A Qualitative and Group Concept Mapping Study to Investigate Service Users’ Perspectives on Strengthening Integration Between Mental Healthcare Services in England

A Qualitative and Group Concept Mapping Study to Investigate Service Users’ Perspectives on Strengthening Integration Between Mental Healthcare Services in England | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A Qualitative and Group Concept Mapping Study to Investigate Service Users’ Perspectives on Strengthening Integration Between Mental Healthcare Services in England Katrina d’Apice, Joe Hulin, Amanda Owen-Smith, Scott Weich, Peter Burton, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7487721/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Integrating mental health and social care services is essential for improving access to quality mental healthcare and for addressing the wider determinants of poor mental health. The UK’s National Health Service, together with its social care and voluntary sectors, is currently undergoing a transformation to achieve this. However, many service users report a lack of integration, long waiting lists, and services that focus on treating symptoms rather than taking a holistic approach. This study aimed to inform an integrated whole system approach to improving mental healthcare and reducing mental health inequalities, from the perspective of service users. Methods We used Group Concept Mapping (GCM) and one-to-one interviews to collect and synthesise the views of 55 service users on integration in the mental healthcare systems in two regions of England. GCM data from the first workshops were analysed using multi-dimensional scaling and hierarchical cluster analysis to create group maps which were then merged into concepts. Interview data were analysed using Framework Analysis which allowed for incorporation of the GCM concepts into the coding framework. Findings were used to form the focus of discussions at the second GCM workshops to produce recommendations. Results Service users described the mental healthcare system as fragmented, opaque, and difficult to navigate—particularly during periods of acute need. Many reported limited awareness of what services were available, how to access them, or what to expect. Service users emphasised the need for a more holistic approach that goes beyond symptom management to address the wider determinants of mental health. We identified 7 recommendations to address some of these issues, which included better information sharing, more connected link workers, and greater provision of tailored community support groups. Further recommendations focused on community hubs, directories of services, and embedding experts by experience and mental health workers across the system. Conclusions Service users want a more connected, navigable, and holistic mental healthcare system—anchored by shared information, consistent support, and community-based care that addresses the wider determinants of mental health. Future work should explore ways to implement our recommendations and evaluate their impacts on mental health support. Mental Health Health Services Integration Systems Approach Mixed Methods Figures Figure 1 Figure 2 Figure 3 Figure 4 Background The demand for mental health services in England is increasing: in 2023, five million referrals were made to mental health services, an increase of 33% from 2019 [ 1 ]. In England, the majority (90%) of adults who receive treatment for mental health difficulties (MHDs) receive this in primary care, including General Practice (GP) and the National Health Service (NHS) Talking Therapies [ 2 ]. Adults who require more specialised treatment may access secondary care, which includes community mental health teams, crisis teams, early intervention teams, emergency care, and inpatient units. Mental health social care, which is commissioned by local authority social care teams but often provided by Voluntary, Community and Social Enterprise (VCSE) organisations, provides vital support for people with MHDs to live well in the community and thus prevent hospital admissions [ 3 ]. MHDs may be caused or exacerbated by wider determinants, such as inadequate housing, financial difficulties, social isolation, and physical inactivity [ 4 , 5 ], many of which are disproportionately experienced within society [ 6 ]. Help to address these wider social determinants of mental ill health is most often provided by VCSE organisations and other social care providers making these sectors vital components of the mental healthcare system [ 7 ]. The current mental healthcare system has been described as fragmented with many people falling through the gap between primary and secondary care due to complexities that are deemed too severe to be dealt with by primary care services and not severe enough to warrant support from specialist mental health services [ 8 ]. Transitioning from one service to another has also been identified as an area for concern, as 20% of service users who move between mental health services never reach their new service [ 8 ]. Furthermore, minoritised ethnic groups experience persistent inequalities in accessing mental health services, in their experiences of services, and in mental health outcomes [ 7 ]. England’s NHS Community Mental Health Framework for Adults and Older Adults, published in 2019, set out a vision for transforming mental health services to deliver whole-person support within local communities by integrating primary care, secondary care, social care, and the VCSE sector [ 8 ]. Integrated care involves different professions working under a single organisational framework to deliver co-ordinated, person-centred care [ 9 , 10 ]. For example, a recent scoping review identified several key elements of effective integrated mental health care within a primary care setting, such as, co-locating mental health and substance misuse services, and proactive case management involving a multidisciplinary team of professionals [ 10 ]. However, several system-level factors influence the implementation of integrated mental health care, including funding, workforce and training, and relationships between organisations and communities [ 11 ]. Uncertainty remains regarding how integration can be achieved in practice [ 12 ], and research is needed to understand how to create an integrated mental health system in which individuals receive timely, holistic, equitable and tailored support for their mental health. Furthermore, it is imperative that service users’ views on integrated care are investigated given the dearth of studies reporting how integrated care impacts the experiences and outcomes of service users [ 13 ]. For example, a systematic review of service users’ experience of integrated care in the United Kingdom only included 16 studies across a 7 year timeframe [ 14 ]. A whole systems approach (WSA) to healthcare improvement considers the healthcare system as a dynamic complex system composed of multiple components that are interacting in interdependent meaningful relationships to produce an outcome [ 15 , 16 ]. Therefore, a WSA addresses complex public health problems in a non-linear way by recognising that a change in one part of the system may produce an effect in an entirely different part of the system due to the interconnectedness of its components [ 17 ]. Taking a systems approach to evaluating mental health service integration involves thinking about the bigger picture (i.e. how different elements are interrelated and influence one another) [ 18 ]. GCM is one type of system evaluation method which can incorporate multiple stakeholders’ views, examine overarching issues pertinent to the system and seek solutions to overcome these issues [ 19 ]. The aim of this study was to inform an integrated whole system approach to mental health improvement and reduction of mental health inequalities, from the perspective of service users. Methods Study design This mixed methods study used both Group Concept Mapping (GCM) and one-to-one interviews, and employed an explanatory sequential design where each phase of the study informed the next phase [ 20 ]. Findings from the first GCM workshops informed our analysis of the interview data, which informed our data collection in the second GCM workshops. GCM is a structured mixed methods approach that aggregates individuals’ qualitative data into a group map that summarises participants’ ideas, and it can be used to identify gaps in mental health services and areas for improvement [ 21 , 22 ]. GCM has several strengths, for example, it elicits a large number of responses to a particular question, enhances participant involvement in analysis and promotes higher-level conceptualisation (as participants sort statements into groups) [ 23 ]. By comparison, strengths of interviews include that they can be personalised to individual participants and provide more depth regarding participants’ lived experience [ 23 , 24 ]. Therefore, using both GCM and interviews in a single study harnesses the benefits of each method. Ethical approval for this study was granted by the London - Camberwell St Giles Research Ethics Committee (22/LO/0835). This study was conducted in accordance with the Declaration of Helsinki. Setting The study took place in two study sites: site 1 is a region in South West England, and site 2 is a city in North England. Participants and Recruitment We recruited participants from organisations that provide mental health services within each study site, for example, GP surgeries and VCSE organisations. The organisations advertised the study to their services users via posters displayed on notice boards, electronic newsletters, and social media. Potential participants contacted the study team directly and were asked to complete a brief online questionnaire (Additional file 1) detailing their demographics and services accessed. Service users were eligible to participate if they were aged 18 or over and had accessed primary care, secondary care, social care, or a VCSE service for mental health support within one of the study sites during the 24 months prior to the workshop or interview. During recruitment we were approached by an advocate from a mental health service who we agreed to include as a participant. Informed consent was taken before each workshop and interview. Service users received a £50 shopping voucher for taking part in a workshop. For participating in an interview, service users received a £20 shopping voucher. Data collection GCM workshops and interviews took place from March 2023 to February 2024. GCM was conducted over two phases of workshops. First phase of workshops We conducted five GCM workshops with 23 participants; four workshops were delivered in person and one workshop took place online. Each workshop comprised 4 or 5 service users. In each workshop, participants individually wrote statements in response to the question “In your experience, what would make mental health services work better together?" Participants shared their statements with other participants in the workshop and discussed if each statement related to one another. Individually, participants then sorted all the statements into conceptually similar groups. In the online workshop, the sorting activity was completed through group discussion because of technical issues that prevented the participants from completing the task individually. Interviews We conducted semi-structured interviews with service users (see Additional file 2 for the topic guide), between May and September 2023. Interviews were predominately conducted remotely via telephone or video call, although 8 took place in person. Interviews lasted between 21 to 102 minutes. Second phase of workshops For the second phase of GCM we held one in-person workshop at each study site lasting for 2 hours, with 26 participants in total. In each workshop participants were asked to suggest actions that could be taken to implement the four key ideas that we identified from the previous workshops and interviews (see Results). A facilitator presented one of the key ideas and guided discussions around specific actions that could be taken. Participants were asked to write their suggestions on Post-it notes according to the prompt “An action that could be taken is …….” After 20 minutes, the next key idea was presented to the group and the participants followed the process outlined above. This process was repeated until each key idea had been discussed. Data analysis First workshops We analysed the CGM workshop data using open source concept mapping software R-CMap [ 25 ] in R (version 4.2.3), which allows statements to be represented as a concept map. We created four concept maps, one for each in-person workshop. To create each map, we performed non-metric multidimensional scaling of the statements to produce a point map, with the statements represented as points on two dimensions. The distance between points on the map refers to the degree to which the participants sorted the statements into the same pile (i.e., a similarity matrix [ 22 ]). We computed stress values for each point map which measures the goodness of fit between the map and its underlying data. Based on the xy coordinates of the point map, we then performed hierarchical cluster analysis, which gives several options for the number of clusters (i.e., cluster solutions) based on how many statements are incorporated into each cluster. KD and JH independently inspected the cluster solutions for each concept map, labelled each cluster, and proposed the cluster solution that made the most conceptual sense. A consensus was reached on the final cluster solutions and labels through discussion with a further two authors JK and PB. During these discussions, some statements were reassigned to other more suitable clusters – see circles on Figs. 1 – 4 . Reassignment of statements is necessary to ensure the clusters represent unique concepts [ 26 , 27 ]. For the online workshop, the participants were unable to individually sort the statements into clusters and therefore it was not possible to analyse these data in R to create a map. Instead, the sorting step was completed by group consensus during the workshop, and the cluster solution and labels were finalised through discussion within the study team. To prepare our data for the next step and because of the large overlap within and between study sites, we merged the clusters across the 5 workshops. KD merged clusters according to the names of the clusters and the statements within each cluster. KD then reviewed each statement within each cluster and reassigned statements that were better suited to another cluster. Consensus agreement regarding the merged clusters and their underlying statements was reached through discussions with a further two members of the research team, JK and JH. This process resulted in 9 concepts. Interviews We analysed the interview data using Framework Analysis [ 28 ], which allows for a combination of inductive and deductive coding [ 29 ]. The audio recordings of the interviews were transcribed and transcripts uploaded to a secure network drive at the study site that conducted the interview. One researcher at each study site read and re-read the transcripts at their respective study site to familiarise themselves with the data. Two transcripts from each study site (i.e., four in total) were randomly selected for double coding. These transcripts were allocated to three researchers (KD, JH, JK) who independently open coded the transcripts. Only anonymised transcripts were shared between study sites. Codes were compared and discussed, and a consensus was reached regarding a coding framework. In addition to the codes identified during open coding, the researchers agreed to include the 9 concepts identified in the first GCM workshops as codes in the coding framework. Within each study site, the researcher that had conducted the interviews applied the coding framework to their respective transcripts in NVivo (Release 1.7.1). They then created a framework matrix for their dataset with each participant as a row, and each code as a column, and summarised the data for each cell in their matrix. At this stage the study team decided to combine the two matrices because similar codes were identified by the researchers at both sites. The first author combined the two matrices and explored the data for patterns to identify sub themes and themes. The study team met regularly throughout the analysis process to discuss emerging sub themes and themes. We used a complementarity approach to combine the GCM and interview data: we used the interviews to expand on the GCM results which enhanced our understanding of service users perceptions of integration in the mental health care system [ 30 ]. Therefore, we aligned the GCM and interview results in a joint display (see Results) to elaborate on the GCM concepts [ 30 ]. Selection of key ideas for the second workshops The study team decided that four key ideas was a suitable number of ideas to discuss during the second workshops to allow for each idea to be discussed in enough depth within the time allocated. To select the four key ideas, two researchers, KD and JH reviewed the sub-themes from the interview analysis, and through discussions with the wider study team, including public collaborators, we selected four key ideas which covered 6 sub-themes. These four key ideas were selected due to several factors: 1) suitability to be discussed during the second workshops – we thought that some ideas would be difficult for services users to comment on how this might be achieved in practice (e.g., sustained funding); and 2) salience in the dataset. Second workshops Participants’ written suggestions about changes to address each idea were typed verbatim into an Excel spreadsheet. KD removed duplicates and collated the suggestions within each key idea which were reviewed and discussed with the research team to identify actionable recommendations. Results We begin by presenting results from the brief questionnaire, including participants’ demographics and the services they accessed. This is followed by findings from the first GCM workshops and then the interviews. Finally, we outline the recommendations that emerged from the second round of GCM workshops. Participants In total 55 unique participants took part in the study (see Table 1 for demographics and Table 2 for services accessed). 23 service users participated in the first GCM workshops (11 in site 1, and 12 in site 2). 25 service users were interviewed (15 in site 1, and 10 in site 2), of whom 2 had previously taken part in a workshop. In the second GCM workshops, 26 service users (15 in site 1, and 11 in site 2) participated, of whom 17 had participated in the first workshop and/or an interview. Table 1 Demographics of participants Demographics Full Sample N55 N (%) Gender Female 35 (63.6) Male 15 (27.3) Age (years) 18–24 9 (16.4) 25–34 15 (27.3) 35–44 13 (23.6) 45 or above 17 (30.9) Ethnicity White British 38 (69.1) Minoritised Ethnicities 16 (29.1) Note. Any value of 5 or less has been suppressed and either omitted or where possible collapsed with another cell to preserve the anonymity of our participants. Table 2 Mental health services accessed by participants Services Accessed Full Sample N = 55 N (%) GP 45 (81.8) VCSE services 34 (61.8) Community mental health team 29 (52.7) NHS talking therapies 26 (47.3) Crisis team 19 (34.5) Inpatient services 13 (23.6) A&E 11 (20.0) Other 9 (16.4) NHS 111 8 (14.5) Social services 7 (12.7) Early intervention team 6 (10.9) Note. Participants were asked to select which services they had accessed for support with their mental health and were asked to tick all that apply. VCSE = Voluntary, Community, and Social Enterprise. First GCM workshops Figures 1 – 4 depict the group concept maps from the four in-person workshops. Stress values, which measure goodness of fit between the map and its underlying data, ranged from 0.187 to 0.236, all within the acceptable range of 0 to 0.369 [ 31 ]. It was not possible to create a group concept map in R for the online workshop because the participants completed the sorting activity as a group rather than individually (see Additional file 3 for statements, cluster solution and names of clusters per workshop, and the merged clusters with their underlying statements). In total, 77 statements were generated across the five workshops and grouped into nine concepts: i) investment in staff and services, and parity of esteem; ii) improve communication and information sharing among service providers and with service users; iii) reduce onus on service users to access and navigate care pathways; iv) holistic and person-centred care; v) improve access to services and access multiple services simultaneously including addiction services.; vi) inclusive, representative, and co-produced services; vii) improve continuity of care; viii) more equitable care; ix) co-located services (see Table 3 for an example statement for each concept). Table 3 Concepts with corresponding example statements Concept N Statements Example Statement 1. Investment in staff and services, and parity of esteem. 10 Mental health could be given more investment from the government - to make users feel valued / important / worthy. Treating mental health equally to physical. 2. Improve communication and information sharing among service providers and with service users. 20 Psychiatry UK to work more with GP - seem to work completely separately and have no communication between the two - results in a lack of support with medication / symptoms. 3. Reduce onus on service user to access and navigate care pathways. 5 Not rely so much on the patient to follow up on care - people find it difficult to remember all the numbers, and are often discharged because they didn't realise deadlines for engagement. 4. Holistic and person-centred care. 15 Allow time to get to know the person so the appropriate service is signposted (e.g. muddling ADHD as a personality disorder). 5. Improve access to services and access multiple services simultaneously including addiction services. 6 Joining addiction services with other mental healthcare. 6. Inclusive, representative, and co-produced services 5 More opportunities for people with lived experience to work in services. 7. Improve continuity of care 2 Quick discharge from crisis team, leading to less detailed discharge notes and dismissal (especially after suicide attempts). 8. More equitable care. 9 More targeted services to reduce inequalities. 9. Co-located services. 5 GP hub. GP and welfare benefits services because mental health will be related to your financial and housing security. Interviews We generated five themes from the data: 1) open, honest, flow of information, 2) equitable access, 3) investment in staff and services, 4) importance of social connectedness and holistic care, and 5) collective responsibility for continuous support (see Table 4 for a list of themes and their corresponding sub-themes). Table 5 displays how the GCM concepts align with and are enhanced by the interview themes. Table 4 Themes and their corresponding sub-themes Themes Sub Themes 1. Open, honest, flow of information Shared patient records Open dialogue 2. Equitable access Timely and long-term access Knowledge of services More equitable care 3. Investment in staff and services Sustained funding Sustainable staffing models 4. Importance of social connectedness and holistic care Social support Relational aspects of care Wider determinants 5. Collective responsibility for continuous support Collective responsibility Bridging gaps Named person to help navigate the system Table 5 Integrated results Group Concept Mapping Concept Qualitative Interview Themes Qualitative Insights i) Investment in staff and services, and parity of esteem 3. Investment in staff and services Qualitative interviews revealed that better funding of services can help keep people in employment, and sustained funding could reduce fragmentation in the VCSE sector. Service users suggested that investment in staff should include valuing staff more, reducing workplace stress, and employing mental health staff in A&E. ii) Improve communication and information sharing among service providers and with service users 1. Open, honest, flow of information Interviews indicated the importance of consent for data sharing, and for clearer and honest communication. Service users suggested that protected time for staff networking, and handover meetings when transitioning between services would aid communication between services. iii) Reduce onus on service users to access and navigate care pathways 5. Collective responsibility for continuous support The interviews highlighted gaps in service provision and recognition that a link worker could help address the wider determinants of mental health. iv) Holistic and person-centred care 4. Importance of social connectedness and holistic care Service users noted the importance of building good relationships between staff and service users to ensure holistic and person-centred care. They described peer support workers as more relatable than other staff, and recognised that social support contributed to their mental health. v) Improve access to services and access multiple services simultaneously including addiction services 2. Equitable access Interviews revealed that waiting for support exacerbated mental health difficulties and led some service users to disengage from services. Short term support was perceived as insufficient in many cases. Improving service users and providers knowledge of services is essential to better understand what services are available. Addiction support in covered under theme 5, see below. vi) Inclusive, representative, and co-produced services 2. Equitable access Service users suggested that the patient advice and liaison service could promote service user voice. vii) Improved continuity of care 5. Collective responsibility for continuous support Service users recommended that services should take responsibility for aftercare to avoid a cliff edge. They noted that integrating services will require courage, trust and time commitment. Integrating addiction services with mental health services was seen as necessary to provide comprehensive support. viii) More equitable care 2. Equitable access Interviews covered all protected characteristics in terms of access and engaging with services. Service users proposed that offering multiple modes and points of access may reduce some of the inequalities to accessing services. Another suggestion was training all healthcare professionals about severe mental illness, being in crisis, and masking, with the aim to reduce discrimination. ix) Co-located services 1. Open, honest, flow of information, and 2. Equitable access Interviews detailed that co-located services could be a way to improve communication among service providers and to reduce inequalities by improving access to services. Open, honest flow of information This theme encompassed two sub-themes, shared patient records, and open dialogue. Service users highlighted the lack of information sharing across services and the desire for this to be improved through shared patient records and better communication among services and also with the service user. Shared patient records Many service users reported that they had to repeat their story to multiple services which was often retraumatising: “that can be so retraumatising because you’re going over this stuff over and over again.” (P6) They suggested that a central database to share patient records could alleviate this burden, for example, patient records could include a readily accessible admissions summary (detailing mental and physical health conditions, a crisis plan/advanced statement) for when service users present at accident and emergency departments or inpatient units: “The mental health unit didn’t know anything about type 1 diabetes it seemed… I certainly know that they can’t see my GP records in secondary care.” (P10) The notion that the service user is the owner of their data and the organisations are data custodians was supported by service users’ desire to access their own data, give consent for their data to be shared between services, and the ability to withdraw consent: “ being able to give informed consent …. Now obviously you can withdraw that at any time but having a central point where all of that data is held, where you can say yes, any parts of the mental health system are allowed to access that ” (P6) A few service users stated that they did not want non-statutory services to have access to their medical history, to avoid stigma or overwhelming non-clinical staff: “it might kind of overwhelm them and make them think, oh, we can't actually cope with this” (P14) Open dialogue Clear and honest communication between service providers and service users regarding what service providers can and cannot offer was deemed vital to manage service users’ expectations regarding the support available to them: “Communication definitely it has to be better. It’s good when they say oh this is what we do but they don’t really specifically say what we don’t do” (P2) Some service users expressed concerns regarding the lack of communication between services: “Like they’re supposed to be the single point of access but … there just doesn’t seem to be clear communication between them but also with the person who’s accessing it, … it’s just so, again, disjointed.” (P23) Service users suggested several ways to improve communication between services, such as, co-located services, protected time for staff to engage in learning forums/informal networking, and handover meetings when transitioning from one service to another: “my CPN communicating with the ward because … if they spoke to my CPN they would get more of a context.” (P5) Equitable access This theme comprised three sub-themes, timely and long-term access, knowledge of services, and more equitable care. Service users acknowledged the negative impact that long waiting lists and short-term interventions had on their mental health. They proposed that knowledge of the different services available was imperative to ensure they were directed to appropriate support, and suggested a variety of ways to make services more equitable. Timely and long-term access Service users reported long waits to access support, leading to frustration, and in some cases disengaging from services: “I know people who’ve disengaged from secondary services because the waiting’s done them more harm than good.” (P12) Most service users stated that waiting for support had exacerbated their mental health difficulties: “when you just get to the point where you actually feel you need help you’ve gone beyond actually needing help and I think having to then wait months to have some sort of contact just is more detrimental.” (P3) Typically, support was short term, lasting 6 to 8 weeks, which was often viewed as insufficient: “I find that there is no long-term support like a one year or whatever everything is six weeks or eight weeks which is not the kind of support you need” (P2) Some service users described experiencing prolonged waiting times for re-accessing services: “I know I can have another 20 sessions, but you got to wait 18 months before you can get referred back on and it’s another probably 18 months. So you’re talking another 3 years!” (P20) Where consistent long-term support had been available, this continuity of care fostered deeper therapeutic relationships between service users and staff, allowing the service user to feel comfortable and for the professional to recognise patterns and respond to needs more efficiently: “So having someone that you can just speak to who gets it … and also how sort of comfortable you feel … having someone as well who can sort of grasp what might be wrong and, and has seen this pattern before or something like that can just pick up on things and act quicker.” (P16) Knowledge of services Service users described that both service users and providers have limited knowledge regarding the myriad of mental health and social care services available, so it can be difficult to know which services are suitable for each person and how to access them: “so there are many things out there but it’s finding if they’re accessible … if it’s appropriate to you, … I think people need to have that information.” [P2] Therefore, increasing awareness of services through better publicity was considered a necessity: “ I think just finding what’s out there and making that simple and clearly available would make a massive difference because the whole system feels really impenetrable ” (P15) Services users stated that they require up-to-date information on what services are available, eligibility criteria, clear referral information, costs, and timings. They suggested several ways to share this knowledge, such as, a centralised website or app, or a phoneline that provides advice about the different services. In addition, outreach and events in other settings (e.g., schools, churches, cafes) could help raise awareness of services to the general public. “a bit of outreach work as well. So, if people from these community groups … could get out to more people and say look this is what we do.” (P20) More equitable care Service users noted that many people may be disadvantaged from accessing or engaging with services due to their socio-demographic characteristics, including, people with limited English proficiency or those experiencing homelessness. Service users reported that individuals with limited English proficiency may experience challenging language barriers which inhibit their ability to access or engage with services: “if there are members of the community where English isn't their first language, … being able to express themselves and … advocate for themselves will become increasingly difficult.” (P15) Service users also recognised that people experiencing homelessness may have minimal contact with services and find it difficult to maintain contact with them: “[I] was homeless for three years following that … when you’re homeless, you don’t really have much contact with them.” (P12) “you might not even have a mobile phone, especially if like you’re sleeping rough.” (P6) For services to be more equitable, service users felt that services need to be representative and co-produced, with service user voice listened to, for example, through the patient advice and liaison service. you ought to point something out or get something sorted without the person having to go and face … the person who’s causing the problem ... PALS … it’s a very good service. Service users proposed that offering multiple modes of access (online, telephone, face-to-face) and multiple points of access (e.g., hubs across the city and non-clinical settings) may reduce some of the inequalities to accessing services. Another suggestion for improving equitability in services was training all healthcare professionals about severe mental illness (SMI), being in crisis, and masking, with the aim to reduce discrimination. “because I am quite high functioning and I can have articulate conversations and I can express myself. They think oh well there’s nothing wrong with you… But then I was using alcohol and drugs to self medicate.” (P20) Investment in staff and services This theme comprised two sub-themes, sustained funding, and sustainable staffing models. Service users recognised the necessity for more and sustained funding in order to keep services operating and improve outcomes for service users. They stated that supporting and valuing staff was vital to ensure better provision of care. Sustained funding Service users reflected on the economic rationale for sustained funding of services: better funding for mental health could keep people in work and contributing to the economy and society, whereas insufficient funding leads to poor support which increases the risk of unemployment and reliance on benefits: “the government wants us to be able to work and contribute to society, … but I've taken so much time off for my mental health and … I don't know how you’re supposed to manage it all really, when there's not that support out there for you.” (P14) According to one service user, the lack of sufficient funding has resulted in a reduction in the level of support services can offer and has also contributed to the fragmentation of the VCSE sector: “statutory services are more to do with maintenance and containment rather than recovery … even the voluntary sector is fragmented and that is because of funding. … they were all fighting for the same funding.” (P17) Sustainable staffing models Service users suggested that investment in more staff would allow for more contact time, improve quality of care, and reduce waiting times. They also recommended employing mental health staff in A&E especially during the evenings and at weekends when people often present in crisis: “It always seems to happen out of hours, and they don’t have any mental health team on duty out of hours.” (P 11) Service users mentioned that reducing staff absence/turnover may be achieved through valuing staff more and taking measures to reduce workplace stress. “you should hold on to them and treat them like a really good employee” (P22) “staff are so stressed. They’re off sick for periods” (P17) Importance of social connectedness and holistic care This theme comprised three sub-themes, social support, relational aspects of care and wider determinants. Social support through family and friends, and good relationships with staff were deemed pivotal for service users’ wellbeing and recovery. Holistic care addressing the wider determinants that contribute to mental health difficulties was also seen as vital for supporting wellbeing. Social support Service users highlighted that the provision of group activities in VCSE organisations can foster a sense of connectedness or belonging. For some service users, having social care support to leave their house to attend appointments, wellbeing groups, or to go shopping, helped reduce feelings of isolation and reliance on mental health services: “I’ve had support through social care … so I think because I’m with them now I don’t have as much contact with mental health services because I get the support I need from them.” (P6) Informal support through family and friends varied among the service users interviewed. Some had a supportive network to rely upon, which they greatly appreciated, although they recognised the burden that this placed on the people in their lives. Others didn’t have family or friends that they wanted to confide in due to the stigma of mental health or not wanting to burden them: “I don’t want them worrying and that cause my family worry … so I didn’t want them knowing” (P22) Relational aspects of care Building good relationships with staff was deemed crucial for service users to benefit from their treatment and engage with the service: “there’s less contact, but the relationship is richer – there’s more to it … and I feel like, in the fact that it is richer, it has much more value to me. I think I’m going to gain much more from it.” (P12) Service users valued compassionate, empathetic, person-centred care, which cultivated trust and enabled open honest conversations. “It worked in a much more holistic way and a lot more compassion … it was a lot more trauma informed, a lot more person centred, … and I believe that’s why it worked better. It was a lot more relational, so you’d build a relationship with the workers”. (P 6) Many service users found peer support workers relatable and thus would encourage services to employ more peer support workers in their services: “if someone who struggles with mental [health] or ever has and they’ve come out of it I think that’s a really good person to be doing that job because they can they relate to the person and what they’re saying” (P 22) Wider determinants Service users recognised that social determinants are often “ the drivers behind people’s mental health ” (P12) and hence the need to focus on the underlying causes of mental health. For example, insecure housing: “obviously when you have unstable housing as well, your mental health is inevitably going to be affected by that.” (P6) In terms of finances, several service users found that the process of applying for benefits was difficult, and help with managing finances was required by some service users: “So, financially – because I got quite ill again last year, I had to stop working, so that’s had quite a financial impact, but my care coordinator helped me look at what my options were. I was able to go onto a [debt solution plan] to not get into trouble with my debts!” (P11) Service users suggested that physical activity being available on prescription, with physical activity guidance being integrated more into services, could potentially reduce waiting lists: “seeing the body and the mind as one and having physical stuff for people to do alongside having talk therapy I think would actually help people heal a lot quicker … potentially get the waiting list down.” (P1) Further suggestions included co-location of services which may help promote holistic care and remove barriers to access: “it was like an absolutely incredible service 'cause it was like five different people for all aspects of stuff that was happening … it was everything in one place and like the access to speak to someone.” (P16) Collective responsibility for continuous support This theme encompassed three sub-themes, collective responsibility, bridging gaps, and named person to help navigate the system. Service users want services to work together to take ownership of their care so that follow on support is in place prior to discharge. Service users identified multiple gaps in service provision, resulting in a lack of support which exacerbated their mental health difficulties. Service users often struggled to navigate the complex mental healthcare system, and many would welcome a named person to help them on their journey. Collective responsibility Service users felt that due to increasing demand many services are under pressure to discharge service users as quickly as possible, often with no follow-on support. When signposting or referrals did occur the initial service rarely received feedback regarding whether the person made it to the next service. Service users suggested that to avoid a cliff edge upon discharge, services need to take ownership/responsibility for aftercare: “what should happen is that that person should remain under their care until they have a plan in place or have the next step in place” (P15) In order to monitor the flow of service users through the system, shared capacity management was noted as essential. Regarding collaborative working, trust was reported to be a key component, along with funding and time to implement sustainable change: “systems have to be courageous enough to work together differently and to do things differently but that requires time investment, it requires a buy-in from those services.” (P6) Bridging gaps Some service users have highlighted gaps in service provision (e.g., between primary and secondary care), resulting in them sometimes being signposted from one service to another without receiving support until they reach the threshold for secondary care: “it's kind of sad that you had to end up in crisis sort of two or three times to get that support and you think, well, maybe if I'd have got that support like five years before that point, then none of that would've happened.” (P16) Other gaps identified were prevention services and paternal support services: “he is also dealing with his own trauma from the event which hasn’t really been resolved because despite the fact it’s almost impossible for the mum to access support, it’s even harder for the dad to access support for something like that.” (P15) Within primary care, most service users were offered Cognitive Behavioural Therapy (CBT) however some stated that CBT was too generic, not personalised, and they would benefit from counselling. Conversely, some people with SMI wanted to access CBT but were unable to do so due to eligibility criteria: “The CBT talking therapies that are available – they run a mile as soon as they know that you have an SMI diagnosis” (P11) A service which addresses both mental health and substance misuse would be welcomed by service users: “if you've got mental health problems and you've not resolved your drug and alcohol issues, mental health services won't touch you. … I think there should be a dual diagnosis team or if somebody's working in mental health teams, they should have knowledge of drug and alcohol substance misuse.” (P17) Named person to help navigate the system Many service users say that a named person (e.g., social prescriber, community link worker, care coordinator) to approach and communicate with services on their behalf, may help them to better navigate the mental healthcare system. Currently, the onus is on the service user to navigate services – which is often difficult to do, especially when they are unwell: “it felt like a bit of a labyrinth to navigate at times really … when I was well enough, I’d sort of have a real like put all my energy and efforts into it and then … when I was unwell again I wouldn’t be able to.” (P1) The named person could act as a bridge between services, help the service user to get onto a pathway, and play a key role in providing holistic, patient centred care which addresses the wider determinants of mental health such as unemployment. Although some service users had received long term support from a named person (e.g., a social prescriber), others had experienced ad hoc or fragmented support due to high staff turnover: “in between each care co-ordinator leaving there’s been like a six month wait at least to get a new one which you know is not supposed to be happening.” (P1) Second GCM workshops Discussions were based around four key ideas covering 6 sub-themes identified from the interviews, 1) information sharing across services (i.e., shared patient records, and open dialogue); 2) named person to help navigate the system; 3) knowledge of services; and 4) holistic care (i.e., bridging gaps, and wider determinants). Participants made 177 suggestions for change across these four key ideas. The suggestions were collated into 7 key recommendations: One Integrated IT System for Shared Patient Records. Service users suggested that one patient record system that all organisations can access would streamline the flow of sharing patient data and may reduce the repetition of assessments across different organisations. Regarding consent for data sharing, service users would like the option of giving consent for either a) any part of the mental health system to access their data, or b) for only services that they specify to access their data. In addition, service users would like to have access to their own records and to see clearly what information is held by whom, with the option to accept/withdraw consent from different organisations. Furthermore, digital clinical management apps such as MyPathway [ 32 ] which assist service users to manage their appointments, access resources, and connect with clinicians, were suggested for use in mental health services. Mental Health Passports In addition to the data recorded by service providers in the shared patient records outlined above, service users recommended that a mental health passport may alleviate the burden of having to retell their story to multiple services. Service users suggested that a mental health passport comprising a written or audio recorded account of their story in their own words would be empowering and allow them to take ownership over their story. The passport could be edited and updated by the service user when needed. In addition, service users would like to choose which organisations they share their mental health passport with. Named Link Worker to Help Navigate the System Service users saw advocacy as an important component of the link workers role (especially when they are in crisis). Other key components included good knowledge of the services available in a community to effectively support service users, and the ability to make social prescriptions (i.e., referral powers). Service users suggested that access to a link worker could be similar to the GP model whereby there is no eligibility criteria or discharge. The link worker could be based in GP surgeries, hospitals, and community services. Consistency of the same link worker to accompany the service user as they moved between services was desired, however, it was noted that this may not be realistic. In cases where the link worker changes, a good timely handover was recommended. Tailored Community Support Groups for People Discharged from Inpatient Care Some service users state that when they are discharged from inpatient care, they struggle to join some support groups in the community because the groups are not catered towards people with SMI. For example, as inpatients, service users receive holistic care such as physical activity groups, art therapy etc., however, these aren’t always available when they leave inpatient care. Service users suggested that the sports therapist in the inpatient unit could deliver physical activity sessions in the community for people with SMIs, which may prevent readmission or escalation of mental health difficulties. Community Hubs and Directory of Services Service users suggested that a community hub (similar to the citizens advice model), which is a front door to a variety of services that address the wider aspects of mental health would be beneficial. The hubs could be in person and/or online/ phoneline, and utilised by both service users and service providers to access information. An online and paper directory of services was deemed essential to increase awareness through better publicity: an example of a services directory is the Sheffield Mental Health Guide [ 33 ]. Key components required in a services directory include, what support is available, what to expect, waiting times (for assessment and for intervention), eligibility criteria, referral routes, timings, and costs. In addition, including testimonies and feedback from people who have used the services would be beneficial for prospective service users. Some service users commented that services may be concerned about being overwhelmed and therefore a lack of visibility could deter people from accessing the service. However, they stated that it is necessary for services to be honest, clear and realistic when explaining their service, especially regarding waiting times and eligibility. Mental Health Workers Embedded in Other Teams Service users recommended having embedded mental health workers in other teams, for example, well-being nurses in GP surgeries, and mental health workers in ambulance crews. A street triage role was also suggested (i.e., dedicated mental health professionals collaboratively working with police officers). Service users highlighted the need for a service which addresses mental health difficulties alongside substance misuse, for example, a service which employs mental health professionals with training in addiction so both issues can be treated simultaneously. Experts by Experience in the Workforce Service users emphasised that they hold lots of knowledge of different services from their lived experience. They recommended recruiting Experts by Experience (EbE) to develop the directory mentioned above. Moreover, they suggested having EbE working in all areas and levels of the system, including being involved in commissioning, service development, management, and being support workers. Service users noted that EbE in the workforce provides role models to service users and may promote greater empathy, care, and compassion in services. However, more training and career opportunities are needed for EbE so that they can develop a career path. Service users valued peer support workers in services, describing them as being easy to relate to, and less judgemental and intimidating than professional staff. Discussion We sought to identify ways to inform an integrated whole system approach to mental health improvement and reduction of mental health inequalities. Throughout the group concept mapping workshops and interviews we encouraged our participants to think about the interconnectedness of different components and services within the whole mental healthcare system and suggest solutions to improve integration among them. Our findings highlight that service users often experience the mental healthcare system as opaque and unnavigable, particularly during periods of acute need. Participants described a lack of clear, accessible information about what services are available, how to access them, and what to expect. As a result, service users were left to navigate a fragmented system with little guidance, often relying on trial and error. Several participants expressed a desire for greater transparency and realism from services—particularly around eligibility criteria, waiting times, and the scope of support available. They also required services that addressed the wider determinants of poor mental health alongside treatment of symptoms. These insights underscore the need for more honest, user-friendly communication strategies, holistic approaches and the implementation of navigational aids such as link workers and service directories to reduce the burden of self-navigation. Our seven key recommendations highlight potential areas where integration among mental health services can be enhanced. Our recommendation for a single, integrated IT system that enables shared patient records is in accordance with several studies that have highlighted how the current lack of ability for IT systems within the NHS to share patient information leads to reduced staff productivity, a lack of antipsychotic medication reviews, and has the potential to retraumatise patients if they have to constantly retell their story [ 3 , 34 , 35 ]. Projects are underway to join up digital patient care records across health and social care within many regions in England [ 36 ]. In addition, the long term ambition is to create a national shared patient record system so that an individual’s record can be accessed anywhere in England [ 37 ]. Our second recommendation regarding information sharing - mental health passports, currently exist for children and young people in paper and digital form, and thus could be extended to adults [ 38 , 39 ]. Mental health passports include a personal account of a service user’s story and could also include tailored preferences (e.g. what to say, what not to say, especially during a crisis) which provide more information to service providers regarding how to interact with the service user than clinical notes alone. Health passports that document details about a person’s disability or health condition are used within the NHS for employees and hence this sets the precedent for mental health passports to also be in put in place for service users [ 40 ]. A link worker (also known as wellbeing coordinator or social prescriber) to help access and navigate the complex ecosystem of mental health services was our third recommendation. This role could not only address difficulties with navigating the system, but could address the challenge of ensuring holistic support for service users. One rapid review of link workers in mental health included 16 papers which reported that people experiencing loneliness and social isolation who were supported by link workers experienced improvements to their wellbeing and social connectedness [ 41 ]. Link workers embedded in a secondary mental health recovery pathway can aid service users’ transition from secondary care to community support groups covering a range of wider determinants, although a person-centred approach needs to be applied to maximise sustained engagement in community support groups for people with SMI [ 42 ]. Our recommendation for tailored support groups for people with SMI is supported by a qualitative study which investigated service users’ views of a physical activity intervention embedded into peer support groups for people with SMI [ 43 ]. The authors found that the social aspect of the support group was very important for fostering a sense of connectedness and that service users preferred informal physical activities, such as walking, rather than sport [ 43 ]. Although the number of link workers in England has increased in recent years in accordance with the NHS long term plan [ 44 ], some authors have suggested that link workers are an inadequate response to the social needs of people with mental health problems, especially those with SMIs [ 45 ]. They note that social interventions require long term support to be effective, and that greater clarity regarding the role and purpose of the link worker is required along with a stronger evidence base of their effectiveness [ 45 ]. Furthermore, placing the onus on the individual to engage in community support groups fails to address the social determinants of mental distress such as unstable housing or lack of employment opportunities, therefore these wider determinants should be the focus of the mental healthcare system rather than solely focusing on treating symptoms of poor mental health [ 35 , 45 ]. In line with our fifth recommendation, one study of four communities in the UK that had better mental health outcomes than their socioeconomic status would suggest, identified community hubs as an important component in fostering community resilience [ 46 ]. Community hubs are buildings that host a variety of different activities for the local community based on their needs, they are led and run by the community, are available to all community members and may evolve over time depending on the changing needs of the community [ 47 ]. Community hubs can reduce mental health inequalities by improving access to services as multiple services are located in close proximity to service users and trusting relationships with local staff reduces fear and stigma [ 48 ]. Libraries could be better utilised to serve as community hubs, as they are considered a ‘safe space’, however greater community awareness of services offered, making service provision more diverse and accessible, and hiring trained staff to deliver activities would need to be considered [ 49 ]. Regarding a directory of mental health services, work undertaken in Vietnam highlighted the importance of involving experts by experience and community groups to ensure the directory is more relevant to the end users [ 50 ]. Two examples of directories, Sheffield Mental Health Guide, and Well Aware (covering Bristol and South Gloucestershire) are run by VCSE organisations and funded by local councils [ 33 , 51 ]. Our sixth recommendation, embedding mental health workers in other teams, is exemplified in a study conducted in Norway, in which psychologists and psychiatrists were placed in GP surgeries [ 52 ]. The study reported many benefits of this co-location model, including better access to mental health specialists and shortening care pathways, however insufficient funding meant the model was unsustainable [ 52 ], therefore, adequate funding for shared care is essential [ 35 ]. Integrating mental health and substance misuse services has been identified as a priority area by the Mental Health Implementation Network [ 53 ]. A realist synthesis which sought to identify how context influences how integrated mental health and substance misuse work, identified three contextual factors, committed leadership, clear staff expectations of the integrated service, and collaborative case management [ 54 ]. Increasing Experts by Experience (EbE) in the workforce is our final recommendation, however previous research has identified the emotional burden that may be encountered by peer support workers given that they utilise their lived experience in their role which may be triggering [ 55 , 56 ]. Good practice should be adhered to when employing peer workers which includes sufficient training and development opportunities, good support and supervision, and regular reviews on defining roles and responsibilities [ 56 ]. Strengths and Limitations A strength of this study was to use both GCM and interviews to explore service users’ views of integration between mental health services. The structured process of GCM organises participants ideas, ensures all voices are heard, and foster consensus among participants. However, the interviews allowed for a more in-depth exploration of participants’ experiences and thus provided greater context to our GCM findings. Because of time constraints it was not possible to explore all our findings in the second workshops which could have led to additional recommendations. Our findings are based on two regions in England and therefore they may not be generalisable to other regions. However, similar concepts arose in both regions suggesting that the issues encountered by participants may not be specific to one locality. The demographics of our participants are not representative of England’s population, for example, women are over-represented in our sample. Future research should explore ways to implement our recommendations within the mental healthcare system and investigate to what extent they improve peoples' experience of service provision. Strategies to enhance integration should incorporate consideration of services that address the social determinants of mental health, including housing and financial insecurity. In addition, investigating the impact of mental health service integration on marginalised groups would be invaluable to understand if service integration reduces inequalities that currently exist. Conclusion Our findings reinforce that service users often experience the mental healthcare system as fragmented and difficult to navigate, particularly during periods of acute need. This underscores the importance of implementing coordinated, person-centred support mechanisms—such as named link workers—to reduce the burden of self-navigation and ensure continuity of care. Such roles could act as a bridge between services, helping individuals access timely, appropriate support while addressing the wider determinants of mental health. The Community Mental Health Framework provides an opportunity to develop an integrated mental health system in which individuals receive timely, holistic, and tailored support for their mental health, and in which the wider determinants of mental health and mental health inequalities are addressed. However, adequate investment, and consideration of how to implement this in practice, is essential to ensure that this vision comes to fruition. Abbreviations CBT Cognitive Behavioural Therapy EbE Experts by Experience GCM Group Concept Mapping GP General Practice MHDs Mental Health Difficulties NHS National Health Service SMI Severe Mental Illness VCSE Voluntary, Community, and Social Enterprise WSA Whole Systems Approach Declarations Ethics approval and consent to participate Ethical approval for this study was granted by the London - Camberwell St Giles Research Ethics Committee (22/LO/0835). The Health Research Authority and Health and Care Research Wales (2/LO/0835) approved for this study to be conducted in the UK’s National Health Service. Consent for publication Not applicable Competing interests SW holds an Honorary Consultant contract with Sheffield Health and Social Care NHS Foundation Trust, which provides specialist NHS mental health and learning disability services for adults living in Sheffield. All other authors declare that they have no competing interests. Funding This Research Award (award number: MH001) was funded as part of the National Institute for Health and Care Research (NIHR) Three Research Schools Mental Health Programme. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. Authors' contributions Conceptualisation and methodology: JK, AOS, SW; data collection: KD, JH, JK, AOS, SW, PB, TR; data analysis and interpretation: KD, JH, JK, AOS, PB, SW; writing—original draft preparation: KD; writing—review and editing: KD, JH, JK, AOS, SW, PB, TR; funding acquisition: JK, AOS, SW, JH, KD. Principal Investigator: JK. All authors read and approved the final manuscript. Acknowledgements We are grateful to the service users that took part in this study and the services that helped with recruitment. Availability of data and materials The transcripts of the interviews generated and analysed during the current study are available in the [data.bris] repository, [PERSISTENT WEB LINK TO DATASETS WILL FOLLOW LATER]. The GCM data generated or analysed during this study are included in this published article and its supplementary information files. 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Ment Heal Soc Incl 29:8–19 Additional Declarations The authors declare potential competing interests as follows: SW holds an Honorary Consultant contract with Sheffield Health and Social Care NHS Foundation Trust, which provides specialist NHS mental health and learning disability services for adults living in Sheffield. All other authors declare that they have no competing interests. Supplementary Files Additionalfile1.Questionnaire.docx Additional File 1. Questionnaire Additionalfile2.TopicGuide.docx Additional File 2. Topic Guide Additionalfile3.GroupConceptMappingData.xlsx Additional file 3. Group Concept Mapping Data Dataset comprising statements, cluster solution and names of clusters by workshop, the merged clusters and their underlying statements. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7487721","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":507406968,"identity":"32bcf6d1-bdcd-4021-a685-60e65e448d4f","order_by":0,"name":"Katrina d’Apice","email":"data:image/png;base64,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","orcid":"https://orcid.org/0000-0002-2117-9498","institution":"University of Bristol","correspondingAuthor":true,"prefix":"","firstName":"Katrina","middleName":"","lastName":"d’Apice","suffix":""},{"id":507406969,"identity":"71544090-ba65-4f71-919a-d4acdf335018","order_by":1,"name":"Joe Hulin","email":"","orcid":"","institution":"University of Sheffield","correspondingAuthor":false,"prefix":"","firstName":"Joe","middleName":"","lastName":"Hulin","suffix":""},{"id":507406970,"identity":"777446b8-7649-4988-ad11-146ba364a8f9","order_by":2,"name":"Amanda Owen-Smith","email":"","orcid":"","institution":"University of Bristol","correspondingAuthor":false,"prefix":"","firstName":"Amanda","middleName":"","lastName":"Owen-Smith","suffix":""},{"id":507406971,"identity":"e410af73-5e84-4cea-81d4-13ce026692db","order_by":3,"name":"Scott Weich","email":"","orcid":"","institution":"University of Sheffield","correspondingAuthor":false,"prefix":"","firstName":"Scott","middleName":"","lastName":"Weich","suffix":""},{"id":507406972,"identity":"fe8334b3-e704-4a2e-94e5-e94614c5b950","order_by":4,"name":"Peter Burton","email":"","orcid":"","institution":"The Independent Mental Health Network","correspondingAuthor":false,"prefix":"","firstName":"Peter","middleName":"","lastName":"Burton","suffix":""},{"id":507406973,"identity":"29dd6bac-531e-4ff7-ace5-cc5b4f738337","order_by":5,"name":"Tammy Raines","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Tammy","middleName":"","lastName":"Raines","suffix":""},{"id":507406974,"identity":"be0233d7-0ab6-49ac-ae1c-dd2e79aac581","order_by":6,"name":"Judi Kidger","email":"","orcid":"","institution":"University of Bristol","correspondingAuthor":false,"prefix":"","firstName":"Judi","middleName":"","lastName":"Kidger","suffix":""}],"badges":[],"createdAt":"2025-08-29 10:24:19","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":true,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-7487721/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7487721/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":90295749,"identity":"c2506bc4-0cde-48f6-8f0e-10ca070dcc0c","added_by":"auto","created_at":"2025-09-01 08:20:24","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":180230,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eWorkshop 1 group concept map\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGroup concept map showing 19 statements arranged in 4 clusters. Circles and arrows show statements reassigned to another cluster.\u003c/p\u003e","description":"","filename":"Figure1.Workshop1groupconceptmap.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7487721/v1/a28a9b51b5fb8a94a067cc7c.jpg"},{"id":90295754,"identity":"40d6720e-b569-43bc-a174-26655724dfa2","added_by":"auto","created_at":"2025-09-01 08:20:24","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":252605,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eWorkshop 2 group concept map\u003c/strong\u003e\u003cbr\u003e\nGroup concept map showing 13 statements arranged in 7 clusters. Circles and arrows show statements reassigned to another cluster.\u003c/p\u003e","description":"","filename":"Figure2.Workshop2groupconceptmap.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7487721/v1/0510cb082bf615d466d58ad6.jpg"},{"id":90295756,"identity":"60d5e2e8-982b-451a-8252-0e7ba5888136","added_by":"auto","created_at":"2025-09-01 08:20:24","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":215454,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eWorkshop 3 group concept map\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGroup concept map showing 18 statements arranged in 6 clusters. Circles and arrows show statements reassigned to another cluster.\u003c/p\u003e","description":"","filename":"Figure3.Workshop3groupconceptmap.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7487721/v1/e20b1e93cabacbf406c82bbd.jpg"},{"id":90295758,"identity":"638e31ff-d889-4d7e-9962-a69cf8cbde6f","added_by":"auto","created_at":"2025-09-01 08:20:24","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":212196,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eWorkshop 4 group concept map\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGroup concept map showing 12 statements arranged in 5 clusters. Circles and arrows show statements reassigned to another cluster.\u003c/p\u003e","description":"","filename":"Figure4.Workshop4groupconceptmap.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7487721/v1/d4dc78e0218e703ec42555d5.jpg"},{"id":90297333,"identity":"4452b944-4c4f-48a7-ad9e-b5f2b3d06b33","added_by":"auto","created_at":"2025-09-01 08:36:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2166691,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7487721/v1/868ccef3-7193-4c96-acbe-25adac04eacc.pdf"},{"id":90297139,"identity":"e330abb9-b5e4-4c81-aff7-91ecd43452db","added_by":"auto","created_at":"2025-09-01 08:28:24","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":81364,"visible":true,"origin":"","legend":"\u003cp\u003eAdditional File 1. Questionnaire\u003c/p\u003e","description":"","filename":"Additionalfile1.Questionnaire.docx","url":"https://assets-eu.researchsquare.com/files/rs-7487721/v1/fc2fccf8ed03f54a3a899833.docx"},{"id":90295752,"identity":"804d498f-b972-4446-84c4-ed02fc243f63","added_by":"auto","created_at":"2025-09-01 08:20:24","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":29162,"visible":true,"origin":"","legend":"\u003cp\u003eAdditional File 2. Topic Guide\u003c/p\u003e","description":"","filename":"Additionalfile2.TopicGuide.docx","url":"https://assets-eu.researchsquare.com/files/rs-7487721/v1/396150db7c0c6b5c483b8c85.docx"},{"id":90295753,"identity":"5facb910-1b26-46b9-bc04-cd9147395edc","added_by":"auto","created_at":"2025-09-01 08:20:24","extension":"xlsx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":30828,"visible":true,"origin":"","legend":"\u003cp\u003eAdditional file 3. Group Concept Mapping Data\u003c/p\u003e\n\u003cp\u003eDataset comprising statements, cluster solution and names of clusters by workshop, the merged clusters and their underlying statements.\u003c/p\u003e","description":"","filename":"Additionalfile3.GroupConceptMappingData.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-7487721/v1/0b08f896c645fd297f23d0d8.xlsx"}],"financialInterests":"The authors declare potential competing interests as follows: SW holds an Honorary Consultant contract with Sheffield Health and Social Care NHS Foundation Trust, which provides specialist NHS mental health and learning disability services for adults living in Sheffield. All other authors declare that they have no competing interests.","formattedTitle":"\u003cp\u003eA Qualitative and Group Concept Mapping Study to Investigate Service Users’ Perspectives on Strengthening Integration Between Mental Healthcare Services in England\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eThe demand for mental health services in England is increasing: in 2023, five million referrals were made to mental health services, an increase of 33% from 2019 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In England, the majority (90%) of adults who receive treatment for mental health difficulties (MHDs) receive this in primary care, including General Practice (GP) and the National Health Service (NHS) Talking Therapies [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Adults who require more specialised treatment may access secondary care, which includes community mental health teams, crisis teams, early intervention teams, emergency care, and inpatient units. Mental health social care, which is commissioned by local authority social care teams but often provided by Voluntary, Community and Social Enterprise (VCSE) organisations, provides vital support for people with MHDs to live well in the community and thus prevent hospital admissions [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eMHDs may be caused or exacerbated by wider determinants, such as inadequate housing, financial difficulties, social isolation, and physical inactivity [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], many of which are disproportionately experienced within society [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Help to address these wider social determinants of mental ill health is most often provided by VCSE organisations and other social care providers making these sectors vital components of the mental healthcare system [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe current mental healthcare system has been described as fragmented with many people falling through the gap between primary and secondary care due to complexities that are deemed too severe to be dealt with by primary care services and not severe enough to warrant support from specialist mental health services [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Transitioning from one service to another has also been identified as an area for concern, as 20% of service users who move between mental health services never reach their new service [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Furthermore, minoritised ethnic groups experience persistent inequalities in accessing mental health services, in their experiences of services, and in mental health outcomes [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eEngland\u0026rsquo;s NHS Community Mental Health Framework for Adults and Older Adults, published in 2019, set out a vision for transforming mental health services to deliver whole-person support within local communities by integrating primary care, secondary care, social care, and the VCSE sector [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Integrated care involves different professions working under a single organisational framework to deliver co-ordinated, person-centred care [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. For example, a recent scoping review identified several key elements of effective integrated mental health care within a primary care setting, such as, co-locating mental health and substance misuse services, and proactive case management involving a multidisciplinary team of professionals [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, several system-level factors influence the implementation of integrated mental health care, including funding, workforce and training, and relationships between organisations and communities [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Uncertainty remains regarding how integration can be achieved in practice [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], and research is needed to understand how to create an integrated mental health system in which individuals receive timely, holistic, equitable and tailored support for their mental health. Furthermore, it is imperative that service users\u0026rsquo; views on integrated care are investigated given the dearth of studies reporting how integrated care impacts the experiences and outcomes of service users [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. For example, a systematic review of service users\u0026rsquo; experience of integrated care in the United Kingdom only included 16 studies across a 7 year timeframe [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eA whole systems approach (WSA) to healthcare improvement considers the healthcare system as a dynamic complex system composed of multiple components that are interacting in interdependent meaningful relationships to produce an outcome [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Therefore, a WSA addresses complex public health problems in a non-linear way by recognising that a change in one part of the system may produce an effect in an entirely different part of the system due to the interconnectedness of its components [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Taking a systems approach to evaluating mental health service integration involves thinking about the bigger picture (i.e. how different elements are interrelated and influence one another) [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. GCM is one type of system evaluation method which can incorporate multiple stakeholders\u0026rsquo; views, examine overarching issues pertinent to the system and seek solutions to overcome these issues [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe aim of this study was to inform an integrated whole system approach to mental health improvement and reduction of mental health inequalities, from the perspective of service users.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design\u003c/h2\u003e\u003cp\u003eThis mixed methods study used both Group Concept Mapping (GCM) and one-to-one interviews, and employed an explanatory sequential design where each phase of the study informed the next phase [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Findings from the first GCM workshops informed our analysis of the interview data, which informed our data collection in the second GCM workshops. GCM is a structured mixed methods approach that aggregates individuals\u0026rsquo; qualitative data into a group map that summarises participants\u0026rsquo; ideas, and it can be used to identify gaps in mental health services and areas for improvement [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. GCM has several strengths, for example, it elicits a large number of responses to a particular question, enhances participant involvement in analysis and promotes higher-level conceptualisation (as participants sort statements into groups) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. By comparison, strengths of interviews include that they can be personalised to individual participants and provide more depth regarding participants\u0026rsquo; lived experience [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Therefore, using both GCM and interviews in a single study harnesses the benefits of each method. Ethical approval for this study was granted by the London - Camberwell St Giles Research Ethics Committee (22/LO/0835). This study was conducted in accordance with the Declaration of Helsinki.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSetting\u003c/h3\u003e\n\u003cp\u003eThe study took place in two study sites: site 1 is a region in South West England, and site 2 is a city in North England.\u003c/p\u003e\n\u003ch3\u003eParticipants and Recruitment\u003c/h3\u003e\n\u003cp\u003eWe recruited participants from organisations that provide mental health services within each study site, for example, GP surgeries and VCSE organisations. The organisations advertised the study to their services users via posters displayed on notice boards, electronic newsletters, and social media. Potential participants contacted the study team directly and were asked to complete a brief online questionnaire (Additional file 1) detailing their demographics and services accessed.\u003c/p\u003e\u003cp\u003eService users were eligible to participate if they were aged 18 or over and had accessed primary care, secondary care, social care, or a VCSE service for mental health support within one of the study sites during the 24 months prior to the workshop or interview. During recruitment we were approached by an advocate from a mental health service who we agreed to include as a participant. Informed consent was taken before each workshop and interview. Service users received a \u0026pound;50 shopping voucher for taking part in a workshop. For participating in an interview, service users received a \u0026pound;20 shopping voucher.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eGCM workshops and interviews took place from March 2023 to February 2024. GCM was conducted over two phases of workshops.\u003c/p\u003e\n\u003ch3\u003eFirst phase of workshops\u003c/h3\u003e\n\u003cp\u003eWe conducted five GCM workshops with 23 participants; four workshops were delivered in person and one workshop took place online. Each workshop comprised 4 or 5 service users. In each workshop, participants individually wrote statements in response to the question \u0026ldquo;In your experience, what would make mental health services work better together?\" Participants shared their statements with other participants in the workshop and discussed if each statement related to one another. Individually, participants then sorted all the statements into conceptually similar groups. In the online workshop, the sorting activity was completed through group discussion because of technical issues that prevented the participants from completing the task individually.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eInterviews\u003c/h2\u003e\u003cp\u003eWe conducted semi-structured interviews with service users (see Additional file 2 for the topic guide), between May and September 2023. Interviews were predominately conducted remotely via telephone or video call, although 8 took place in person. Interviews lasted between 21 to 102 minutes.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSecond phase of workshops\u003c/h3\u003e\n\u003cp\u003eFor the second phase of GCM we held one in-person workshop at each study site lasting for 2 hours, with 26 participants in total. In each workshop participants were asked to suggest actions that could be taken to implement the four key ideas that we identified from the previous workshops and interviews (see Results). A facilitator presented one of the key ideas and guided discussions around specific actions that could be taken. Participants were asked to write their suggestions on Post-it notes according to the prompt \u0026ldquo;An action that could be taken is \u0026hellip;\u0026hellip;.\u0026rdquo; After 20 minutes, the next key idea was presented to the group and the participants followed the process outlined above. This process was repeated until each key idea had been discussed.\u003c/p\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cdiv id=\"Sec11\" class=\"Section3\"\u003e\u003ch2\u003eFirst workshops\u003c/h2\u003e\u003cp\u003eWe analysed the CGM workshop data using open source concept mapping software R-CMap [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] in R (version 4.2.3), which allows statements to be represented as a concept map. We created four concept maps, one for each in-person workshop. To create each map, we performed non-metric multidimensional scaling of the statements to produce a point map, with the statements represented as points on two dimensions. The distance between points on the map refers to the degree to which the participants sorted the statements into the same pile (i.e., a similarity matrix [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]). We computed stress values for each point map which measures the goodness of fit between the map and its underlying data. Based on the xy coordinates of the point map, we then performed hierarchical cluster analysis, which gives several options for the number of clusters (i.e., cluster solutions) based on how many statements are incorporated into each cluster. KD and JH independently inspected the cluster solutions for each concept map, labelled each cluster, and proposed the cluster solution that made the most conceptual sense. A consensus was reached on the final cluster solutions and labels through discussion with a further two authors JK and PB. During these discussions, some statements were reassigned to other more suitable clusters \u0026ndash; see circles on Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. Reassignment of statements is necessary to ensure the clusters represent unique concepts [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. For the online workshop, the participants were unable to individually sort the statements into clusters and therefore it was not possible to analyse these data in R to create a map. Instead, the sorting step was completed by group consensus during the workshop, and the cluster solution and labels were finalised through discussion within the study team.\u003c/p\u003e\u003cp\u003eTo prepare our data for the next step and because of the large overlap within and between study sites, we merged the clusters across the 5 workshops. KD merged clusters according to the names of the clusters and the statements within each cluster. KD then reviewed each statement within each cluster and reassigned statements that were better suited to another cluster. Consensus agreement regarding the merged clusters and their underlying statements was reached through discussions with a further two members of the research team, JK and JH. This process resulted in 9 concepts.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eInterviews\u003c/h2\u003e\u003cp\u003eWe analysed the interview data using Framework Analysis [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], which allows for a combination of inductive and deductive coding [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. The audio recordings of the interviews were transcribed and transcripts uploaded to a secure network drive at the study site that conducted the interview. One researcher at each study site read and re-read the transcripts at their respective study site to familiarise themselves with the data. Two transcripts from each study site (i.e., four in total) were randomly selected for double coding. These transcripts were allocated to three researchers (KD, JH, JK) who independently open coded the transcripts. Only anonymised transcripts were shared between study sites. Codes were compared and discussed, and a consensus was reached regarding a coding framework. In addition to the codes identified during open coding, the researchers agreed to include the 9 concepts identified in the first GCM workshops as codes in the coding framework.\u003c/p\u003e\u003cp\u003eWithin each study site, the researcher that had conducted the interviews applied the coding framework to their respective transcripts in NVivo (Release 1.7.1). They then created a framework matrix for their dataset with each participant as a row, and each code as a column, and summarised the data for each cell in their matrix. At this stage the study team decided to combine the two matrices because similar codes were identified by the researchers at both sites. The first author combined the two matrices and explored the data for patterns to identify sub themes and themes. The study team met regularly throughout the analysis process to discuss emerging sub themes and themes.\u003c/p\u003e\u003cp\u003eWe used a complementarity approach to combine the GCM and interview data: we used the interviews to expand on the GCM results which enhanced our understanding of service users perceptions of integration in the mental health care system [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Therefore, we aligned the GCM and interview results in a joint display (see Results) to elaborate on the GCM concepts [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eSelection of key ideas for the second workshops\u003c/h2\u003e\u003cp\u003eThe study team decided that four key ideas was a suitable number of ideas to discuss during the second workshops to allow for each idea to be discussed in enough depth within the time allocated. To select the four key ideas, two researchers, KD and JH reviewed the sub-themes from the interview analysis, and through discussions with the wider study team, including public collaborators, we selected four key ideas which covered 6 sub-themes. These four key ideas were selected due to several factors: 1) suitability to be discussed during the second workshops \u0026ndash; we thought that some ideas would be difficult for services users to comment on how this might be achieved in practice (e.g., sustained funding); and 2) salience in the dataset.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eSecond workshops\u003c/h2\u003e\u003cp\u003eParticipants\u0026rsquo; written suggestions about changes to address each idea were typed verbatim into an Excel spreadsheet. KD removed duplicates and collated the suggestions within each key idea which were reviewed and discussed with the research team to identify actionable recommendations.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eWe begin by presenting results from the brief questionnaire, including participants\u0026rsquo; demographics and the services they accessed. This is followed by findings from the first GCM workshops and then the interviews. Finally, we outline the recommendations that emerged from the second round of GCM workshops.\u003c/p\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eParticipants\u003c/h2\u003e\u003cp\u003eIn total 55 unique participants took part in the study (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e for demographics and Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e for services accessed). 23 service users participated in the first GCM workshops (11 in site 1, and 12 in site 2). 25 service users were interviewed (15 in site 1, and 10 in site 2), of whom 2 had previously taken part in a workshop. In the second GCM workshops, 26 service users (15 in site 1, and 11 in site 2) participated, of whom 17 had participated in the first workshop and/or an interview.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographics of participants\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e\u003cp\u003eDemographics\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFull Sample N55\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eN (%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e35 (63.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e15 (27.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eAge (years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18\u0026ndash;24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9 (16.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e25\u0026ndash;34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e15 (27.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e35\u0026ndash;44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13 (23.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e45 or above\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e17 (30.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eEthnicity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWhite British\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e38 (69.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMinoritised Ethnicities\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e16 (29.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003eNote. Any value of 5 or less has been suppressed and either omitted or where possible collapsed with another cell to preserve the anonymity of our participants.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMental health services accessed by participants\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eServices Accessed\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFull Sample N\u0026thinsp;=\u0026thinsp;55\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e45 (81.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVCSE services\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e34 (61.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCommunity mental health team\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e29 (52.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNHS talking therapies\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e26 (47.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCrisis team\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e19 (34.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInpatient services\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e13 (23.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eA\u0026amp;E\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e11 (20.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e9 (16.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNHS 111\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e8 (14.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSocial services\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7 (12.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEarly intervention team\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6 (10.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"2\"\u003eNote. Participants were asked to select which services they had accessed for support with their mental health and were asked to tick all that apply. VCSE\u0026thinsp;=\u0026thinsp;Voluntary, Community, and Social Enterprise.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eFirst GCM workshops\u003c/h2\u003e\u003cp\u003eFigures \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e depict the group concept maps from the four in-person workshops. Stress values, which measure goodness of fit between the map and its underlying data, ranged from 0.187 to 0.236, all within the acceptable range of 0 to 0.369 [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. It was not possible to create a group concept map in R for the online workshop because the participants completed the sorting activity as a group rather than individually (see Additional file 3 for statements, cluster solution and names of clusters per workshop, and the merged clusters with their underlying statements). In total, 77 statements were generated across the five workshops and grouped into nine concepts: i) investment in staff and services, and parity of esteem; ii) improve communication and information sharing among service providers and with service users; iii) reduce onus on service users to access and navigate care pathways; iv) holistic and person-centred care; v) improve access to services and access multiple services simultaneously including addiction services.; vi) inclusive, representative, and co-produced services; vii) improve continuity of care; viii) more equitable care; ix) co-located services (see Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e for an example statement for each concept).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eConcepts with corresponding example statements\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eConcept\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN Statements\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eExample Statement\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1. Investment in staff and services, and parity of esteem.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMental health could be given more investment from the government - to make users feel valued / important / worthy. Treating mental health equally to physical.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2. Improve communication and information sharing among service providers and with service users.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePsychiatry UK to work more with GP - seem to work completely separately and have no communication between the two - results in a lack of support with medication / symptoms.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3. Reduce onus on service user to access and navigate care pathways.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNot rely so much on the patient to follow up on care - people find it difficult to remember all the numbers, and are often discharged because they didn't realise deadlines for engagement.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4. Holistic and person-centred care.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAllow time to get to know the person so the appropriate service is signposted (e.g. muddling ADHD as a personality disorder).\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5. Improve access to services and access multiple services simultaneously including addiction services.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eJoining addiction services with other mental healthcare.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6. Inclusive, representative, and co-produced services\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMore opportunities for people with lived experience to work in services.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7. Improve continuity of care\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQuick discharge from crisis team, leading to less detailed discharge notes and dismissal (especially after suicide attempts).\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8. More equitable care.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMore targeted services to reduce inequalities.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e9. Co-located services.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eGP hub. GP and welfare benefits services because mental health will be related to your financial and housing security.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eInterviews\u003c/h2\u003e\u003cp\u003eWe generated five themes from the data: 1) open, honest, flow of information, 2) equitable access, 3) investment in staff and services, 4) importance of social connectedness and holistic care, and 5) collective responsibility for continuous support (see Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e for a list of themes and their corresponding sub-themes). Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e displays how the GCM concepts align with and are enhanced by the interview themes.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eThemes and their corresponding sub-themes\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThemes\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSub Themes\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e1. Open, honest, flow of information\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eShared patient records\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOpen dialogue\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e2. Equitable access\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTimely and long-term access\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eKnowledge of services\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMore equitable care\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e3. Investment in staff and services\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSustained funding\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSustainable staffing models\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e4. Importance of social connectedness and holistic care\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSocial support\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRelational aspects of care\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWider determinants\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e5. Collective responsibility for continuous support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCollective responsibility\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBridging gaps\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNamed person to help navigate the system\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eIntegrated results\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGroup Concept Mapping Concept\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eQualitative Interview Themes\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQualitative Insights\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ei) Investment in staff and services, and parity of esteem\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3. Investment in staff and services\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQualitative interviews revealed that better funding of services can help keep people in employment, and sustained funding could reduce fragmentation in the VCSE sector. Service users suggested that investment in staff should include valuing staff more, reducing workplace stress, and employing mental health staff in A\u0026amp;E.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eii) Improve communication and information sharing among service providers and with service users\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1. Open, honest, flow of information\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eInterviews indicated the importance of consent for data sharing, and for clearer and honest communication. Service users suggested that protected time for staff networking, and handover meetings when transitioning between services would aid communication between services.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eiii) Reduce onus on service users to access and navigate care pathways\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5. Collective responsibility for continuous support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eThe interviews highlighted gaps in service provision and recognition that a link worker could help address the wider determinants of mental health.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eiv) Holistic and person-centred care\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4. Importance of social connectedness and holistic care\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eService users noted the importance of building good relationships between staff and service users to ensure holistic and person-centred care. They described peer support workers as more relatable than other staff, and recognised that social support contributed to their mental health.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ev) Improve access to services and access multiple services simultaneously including addiction services\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2. Equitable access\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eInterviews revealed that waiting for support exacerbated mental health difficulties and led some service users to disengage from services. Short term support was perceived as insufficient in many cases. Improving service users and providers knowledge of services is essential to better understand what services are available. Addiction support in covered under theme 5, see below.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003evi) Inclusive, representative, and co-produced services\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2. Equitable access\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eService users suggested that the patient advice and liaison service could promote service user voice.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003evii) Improved continuity of care\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5. Collective responsibility for continuous support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eService users recommended that services should take responsibility for aftercare to avoid a cliff edge. They noted that integrating services will require courage, trust and time commitment. Integrating addiction services with mental health services was seen as necessary to provide comprehensive support.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eviii) More equitable care\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2. Equitable access\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eInterviews covered all protected characteristics in terms of access and engaging with services. Service users proposed that offering multiple modes and points of access may reduce some of the inequalities to accessing services. Another suggestion was training all healthcare professionals about severe mental illness, being in crisis, and masking, with the aim to reduce discrimination.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eix) Co-located services\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1. Open, honest, flow of information, and 2. Equitable access\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eInterviews detailed that co-located services could be a way to improve communication among service providers and to reduce inequalities by improving access to services.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eOpen, honest flow of information\u003c/h2\u003e\u003cp\u003eThis theme encompassed two sub-themes, shared patient records, and open dialogue. Service users highlighted the lack of information sharing across services and the desire for this to be improved through shared patient records and better communication among services and also with the service user.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eShared patient records\u003c/h2\u003e\u003cp\u003eMany service users reported that they had to repeat their story to multiple services which was often retraumatising:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;that can be so retraumatising because you\u0026rsquo;re going over this stuff over and over again.\u0026rdquo;\u003c/em\u003e (P6)\u003c/p\u003e\u003cp\u003eThey suggested that a central database to share patient records could alleviate this burden, for example, patient records could include a readily accessible admissions summary (detailing mental and physical health conditions, a crisis plan/advanced statement) for when service users present at accident and emergency departments or inpatient units:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The mental health unit didn\u0026rsquo;t know anything about type 1 diabetes it seemed\u0026hellip; I certainly know that they can\u0026rsquo;t see my GP records in secondary care.\u0026rdquo;\u003c/em\u003e (P10)\u003c/p\u003e\u003cp\u003eThe notion that the service user is the owner of their data and the organisations are data custodians was supported by service users\u0026rsquo; desire to access their own data, give consent for their data to be shared between services, and the ability to withdraw consent:\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003ebeing able to give informed consent \u0026hellip;. Now obviously you can withdraw that at any time but having a central point where all of that data is held, where you can say yes, any parts of the mental health system are allowed to access that\u003c/em\u003e\u0026rdquo; (P6)\u003c/p\u003e\u003cp\u003eA few service users stated that they did not want non-statutory services to have access to their medical history, to avoid stigma or overwhelming non-clinical staff:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;it might kind of overwhelm them and make them think, oh, we can't actually cope with this\u0026rdquo;\u003c/em\u003e (P14)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003eOpen dialogue\u003c/h2\u003e\u003cp\u003eClear and honest communication between service providers and service users regarding what service providers can and cannot offer was deemed vital to manage service users\u0026rsquo; expectations regarding the support available to them:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Communication definitely it has to be better. It\u0026rsquo;s good when they say oh this is what we do but they don\u0026rsquo;t really specifically say what we don\u0026rsquo;t do\u0026rdquo;\u003c/em\u003e (P2)\u003c/p\u003e\u003cp\u003eSome service users expressed concerns regarding the lack of communication between services:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Like they\u0026rsquo;re supposed to be the single point of access but \u0026hellip; there just doesn\u0026rsquo;t seem to be clear communication between them but also with the person who\u0026rsquo;s accessing it, \u0026hellip; it\u0026rsquo;s just so, again, disjointed.\u0026rdquo;\u003c/em\u003e (P23)\u003c/p\u003e\u003cp\u003eService users suggested several ways to improve communication between services, such as, co-located services, protected time for staff to engage in learning forums/informal networking, and handover meetings when transitioning from one service to another:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;my CPN communicating with the ward because \u0026hellip; if they spoke to my CPN they would get more of a context.\u0026rdquo;\u003c/em\u003e (P5)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003eEquitable access\u003c/h2\u003e\u003cp\u003eThis theme comprised three sub-themes, timely and long-term access, knowledge of services, and more equitable care. Service users acknowledged the negative impact that long waiting lists and short-term interventions had on their mental health. They proposed that knowledge of the different services available was imperative to ensure they were directed to appropriate support, and suggested a variety of ways to make services more equitable.\u003c/p\u003e\u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\u003ch2\u003eTimely and long-term access\u003c/h2\u003e\u003cp\u003eService users reported long waits to access support, leading to frustration, and in some cases disengaging from services:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I know people who\u0026rsquo;ve disengaged from secondary services because the waiting\u0026rsquo;s done them more harm than good.\u0026rdquo;\u003c/em\u003e (P12)\u003c/p\u003e\u003cp\u003eMost service users stated that waiting for support had exacerbated their mental health difficulties:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;when you just get to the point where you actually feel you need help you\u0026rsquo;ve gone beyond actually needing help and I think having to then wait months to have some sort of contact just is more detrimental.\u0026rdquo;\u003c/em\u003e (P3)\u003c/p\u003e\u003cp\u003eTypically, support was short term, lasting 6 to 8 weeks, which was often viewed as insufficient:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I find that there is no long-term support like a one year or whatever everything is six weeks or eight weeks which is not the kind of support you need\u0026rdquo;\u003c/em\u003e (P2)\u003c/p\u003e\u003cp\u003eSome service users described experiencing prolonged waiting times for re-accessing services:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I know I can have another 20 sessions, but you got to wait 18 months before you can get referred back on and it\u0026rsquo;s another probably 18 months. So you\u0026rsquo;re talking another 3 years!\u0026rdquo;\u003c/em\u003e (P20)\u003c/p\u003e\u003cp\u003eWhere consistent long-term support had been available, this continuity of care fostered deeper therapeutic relationships between service users and staff, allowing the service user to feel comfortable and for the professional to recognise patterns and respond to needs more efficiently:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;So having someone that you can just speak to who gets it \u0026hellip; and also how sort of comfortable you feel \u0026hellip; having someone as well who can sort of grasp what might be wrong and, and has seen this pattern before or something like that can just pick up on things and act quicker.\u0026rdquo;\u003c/em\u003e (P16)\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\u003ch2\u003eKnowledge of services\u003c/h2\u003e\u003cp\u003eService users described that both service users and providers have limited knowledge regarding the myriad of mental health and social care services available, so it can be difficult to know which services are suitable for each person and how to access them:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;so there are many things out there but it\u0026rsquo;s finding if they\u0026rsquo;re accessible \u0026hellip; if it\u0026rsquo;s appropriate to you, \u0026hellip; I think people need to have that information.\u0026rdquo;\u003c/em\u003e [P2]\u003c/p\u003e\u003cp\u003eTherefore, increasing awareness of services through better publicity was considered a necessity:\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eI think just finding what\u0026rsquo;s out there and making that simple and clearly available would make a massive difference because the whole system feels really impenetrable\u003c/em\u003e\u0026rdquo; (P15)\u003c/p\u003e\u003cp\u003eServices users stated that they require up-to-date information on what services are available, eligibility criteria, clear referral information, costs, and timings. They suggested several ways to share this knowledge, such as, a centralised website or app, or a phoneline that provides advice about the different services. In addition, outreach and events in other settings (e.g., schools, churches, cafes) could help raise awareness of services to the general public.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;a bit of outreach work as well. So, if people from these community groups \u0026hellip; could get out to more people and say look this is what we do.\u0026rdquo;\u003c/em\u003e (P20)\u003c/p\u003e\u003cdiv id=\"Sec25\" class=\"Section3\"\u003e\u003ch2\u003eMore equitable care\u003c/h2\u003e\u003cp\u003eService users noted that many people may be disadvantaged from accessing or engaging with services due to their socio-demographic characteristics, including, people with limited English proficiency or those experiencing homelessness. Service users reported that individuals with limited English proficiency may experience challenging language barriers which inhibit their ability to access or engage with services:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;if there are members of the community where English isn't their first language, \u0026hellip; being able to express themselves and \u0026hellip; advocate for themselves will become increasingly difficult.\u0026rdquo;\u003c/em\u003e (P15)\u003c/p\u003e\u003cp\u003eService users also recognised that people experiencing homelessness may have minimal contact with services and find it difficult to maintain contact with them:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;[I] was homeless for three years following that \u0026hellip; when you\u0026rsquo;re homeless, you don\u0026rsquo;t really have much contact with them.\u0026rdquo;\u003c/em\u003e (P12)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;you might not even have a mobile phone, especially if like you\u0026rsquo;re sleeping rough.\u0026rdquo;\u003c/em\u003e (P6)\u003c/p\u003e\u003cp\u003eFor services to be more equitable, service users felt that services need to be representative and co-produced, with service user voice listened to, for example, through the patient advice and liaison service.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eyou ought to point something out or get something sorted without the person having to go and face \u0026hellip; the person who\u0026rsquo;s causing the problem ... PALS \u0026hellip; it\u0026rsquo;s a very good service.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eService users proposed that offering multiple modes of access (online, telephone, face-to-face) and multiple points of access (e.g., hubs across the city and non-clinical settings) may reduce some of the inequalities to accessing services. Another suggestion for improving equitability in services was training all healthcare professionals about severe mental illness (SMI), being in crisis, and masking, with the aim to reduce discrimination.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;because I am quite high functioning and I can have articulate conversations and I can express myself. They think oh well there\u0026rsquo;s nothing wrong with you\u0026hellip; But then I was using alcohol and drugs to self medicate.\u0026rdquo;\u003c/em\u003e (P20)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec26\" class=\"Section3\"\u003e\u003ch2\u003eInvestment in staff and services\u003c/h2\u003e\u003cp\u003eThis theme comprised two sub-themes, sustained funding, and sustainable staffing models. Service users recognised the necessity for more and sustained funding in order to keep services operating and improve outcomes for service users. They stated that supporting and valuing staff was vital to ensure better provision of care.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec27\" class=\"Section3\"\u003e\u003ch2\u003eSustained funding\u003c/h2\u003e\u003cp\u003eService users reflected on the economic rationale for sustained funding of services: better funding for mental health could keep people in work and contributing to the economy and society, whereas insufficient funding leads to poor support which increases the risk of unemployment and reliance on benefits:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;the government wants us to be able to work and contribute to society, \u0026hellip; but I've taken so much time off for my mental health and \u0026hellip; I don't know how you\u0026rsquo;re supposed to manage it all really, when there's not that support out there for you.\u0026rdquo;\u003c/em\u003e (P14)\u003c/p\u003e\u003cp\u003eAccording to one service user, the lack of sufficient funding has resulted in a reduction in the level of support services can offer and has also contributed to the fragmentation of the VCSE sector:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;statutory services are more to do with maintenance and containment rather than recovery \u0026hellip; even the voluntary sector is fragmented and that is because of funding. \u0026hellip; they were all fighting for the same funding.\u0026rdquo;\u003c/em\u003e (P17)\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec28\" class=\"Section2\"\u003e\u003ch2\u003eSustainable staffing models\u003c/h2\u003e\u003cp\u003eService users suggested that investment in more staff would allow for more contact time, improve quality of care, and reduce waiting times. They also recommended employing mental health staff in A\u0026amp;E especially during the evenings and at weekends when people often present in crisis:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It always seems to happen out of hours, and they don\u0026rsquo;t have any mental health team on duty out of hours.\u0026rdquo;\u003c/em\u003e (P 11)\u003c/p\u003e\u003cp\u003eService users mentioned that reducing staff absence/turnover may be achieved through valuing staff more and taking measures to reduce workplace stress.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;you should hold on to them and treat them like a really good employee\u0026rdquo;\u003c/em\u003e (P22)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;staff are so stressed. They\u0026rsquo;re off sick for periods\u0026rdquo;\u003c/em\u003e (P17)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec29\" class=\"Section2\"\u003e\u003ch2\u003eImportance of social connectedness and holistic care\u003c/h2\u003e\u003cp\u003eThis theme comprised three sub-themes, social support, relational aspects of care and wider determinants. Social support through family and friends, and good relationships with staff were deemed pivotal for service users\u0026rsquo; wellbeing and recovery. Holistic care addressing the wider determinants that contribute to mental health difficulties was also seen as vital for supporting wellbeing.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSocial support\u003c/h3\u003e\n\u003cp\u003eService users highlighted that the provision of group activities in VCSE organisations can foster a sense of connectedness or belonging. For some service users, having social care support to leave their house to attend appointments, wellbeing groups, or to go shopping, helped reduce feelings of isolation and reliance on mental health services:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I\u0026rsquo;ve had support through social care \u0026hellip; so I think because I\u0026rsquo;m with them now I don\u0026rsquo;t have as much contact with mental health services because I get the support I need from them.\u0026rdquo;\u003c/em\u003e (P6)\u003c/p\u003e\u003cp\u003eInformal support through family and friends varied among the service users interviewed. Some had a supportive network to rely upon, which they greatly appreciated, although they recognised the burden that this placed on the people in their lives. Others didn\u0026rsquo;t have family or friends that they wanted to confide in due to the stigma of mental health or not wanting to burden them:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I don\u0026rsquo;t want them worrying and that cause my family worry \u0026hellip; so I didn\u0026rsquo;t want them knowing\u0026rdquo;\u003c/em\u003e (P22)\u003c/p\u003e\u003cdiv id=\"Sec31\" class=\"Section2\"\u003e\u003ch2\u003eRelational aspects of care\u003c/h2\u003e\u003cp\u003eBuilding good relationships with staff was deemed crucial for service users to benefit from their treatment and engage with the service:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;there\u0026rsquo;s less contact, but the relationship is richer \u0026ndash; there\u0026rsquo;s more to it \u0026hellip; and I feel like, in the fact that it is richer, it has much more value to me. I think I\u0026rsquo;m going to gain much more from it.\u0026rdquo;\u003c/em\u003e (P12)\u003c/p\u003e\u003cp\u003eService users valued compassionate, empathetic, person-centred care, which cultivated trust and enabled open honest conversations.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It worked in a much more holistic way and a lot more compassion \u0026hellip; it was a lot more trauma informed, a lot more person centred, \u0026hellip; and I believe that\u0026rsquo;s why it worked better. It was a lot more relational, so you\u0026rsquo;d build a relationship with the workers\u0026rdquo;.\u003c/em\u003e (P 6)\u003c/p\u003e\u003cp\u003eMany service users found peer support workers relatable and thus would encourage services to employ more peer support workers in their services:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;if someone who struggles with mental [health] or ever has and they\u0026rsquo;ve come out of it I think that\u0026rsquo;s a really good person to be doing that job because they can they relate to the person and what they\u0026rsquo;re saying\u0026rdquo;\u003c/em\u003e (P 22)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec32\" class=\"Section2\"\u003e\u003ch2\u003eWider determinants\u003c/h2\u003e\u003cp\u003eService users recognised that social determinants are often \u0026ldquo;\u003cem\u003ethe drivers behind people\u0026rsquo;s mental health\u003c/em\u003e\u0026rdquo; (P12) and hence the need to focus on the underlying causes of mental health. For example, insecure housing:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;obviously when you have unstable housing as well, your mental health is inevitably going to be affected by that.\u0026rdquo;\u003c/em\u003e (P6)\u003c/p\u003e\u003cp\u003eIn terms of finances, several service users found that the process of applying for benefits was difficult, and help with managing finances was required by some service users:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;So, financially \u0026ndash; because I got quite ill again last year, I had to stop working, so that\u0026rsquo;s had quite a financial impact, but my care coordinator helped me look at what my options were. I was able to go onto a [debt solution plan] to not get into trouble with my debts!\u0026rdquo;\u003c/em\u003e (P11)\u003c/p\u003e\u003cp\u003eService users suggested that physical activity being available on prescription, with physical activity guidance being integrated more into services, could potentially reduce waiting lists:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;seeing the body and the mind as one and having physical stuff for people to do alongside having talk therapy I think would actually help people heal a lot quicker \u0026hellip; potentially get the waiting list down.\u0026rdquo;\u003c/em\u003e (P1)\u003c/p\u003e\u003cp\u003eFurther suggestions included co-location of services which may help promote holistic care and remove barriers to access:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;it was like an absolutely incredible service 'cause it was like five different people for all aspects of stuff that was happening \u0026hellip; it was everything in one place and like the access to speak to someone.\u0026rdquo;\u003c/em\u003e (P16)\u003c/p\u003e\u003cdiv id=\"Sec33\" class=\"Section3\"\u003e\u003ch2\u003eCollective responsibility for continuous support\u003c/h2\u003e\u003cp\u003eThis theme encompassed three sub-themes, collective responsibility, bridging gaps, and named person to help navigate the system. Service users want services to work together to take ownership of their care so that follow on support is in place prior to discharge. Service users identified multiple gaps in service provision, resulting in a lack of support which exacerbated their mental health difficulties. Service users often struggled to navigate the complex mental healthcare system, and many would welcome a named person to help them on their journey.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec34\" class=\"Section3\"\u003e\u003ch2\u003eCollective responsibility\u003c/h2\u003e\u003cp\u003eService users felt that due to increasing demand many services are under pressure to discharge service users as quickly as possible, often with no follow-on support. When signposting or referrals did occur the initial service rarely received feedback regarding whether the person made it to the next service. Service users suggested that to avoid a cliff edge upon discharge, services need to take ownership/responsibility for aftercare:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;what should happen is that that person should remain under their care until they have a plan in place or have the next step in place\u0026rdquo;\u003c/em\u003e (P15)\u003c/p\u003e\u003cp\u003eIn order to monitor the flow of service users through the system, shared capacity management was noted as essential. Regarding collaborative working, trust was reported to be a key component, along with funding and time to implement sustainable change:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;systems have to be courageous enough to work together differently and to do things differently but that requires time investment, it requires a buy-in from those services.\u0026rdquo;\u003c/em\u003e (P6)\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\n\u003ch3\u003eBridging gaps\u003c/h3\u003e\n\u003cp\u003eSome service users have highlighted gaps in service provision (e.g., between primary and secondary care), resulting in them sometimes being signposted from one service to another without receiving support until they reach the threshold for secondary care:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;it's kind of sad that you had to end up in crisis sort of two or three times to get that support and you think, well, maybe if I'd have got that support like five years before that point, then none of that would've happened.\u0026rdquo;\u003c/em\u003e (P16)\u003c/p\u003e\u003cp\u003eOther gaps identified were prevention services and paternal support services:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;he is also dealing with his own trauma from the event which hasn\u0026rsquo;t really been resolved because despite the fact it\u0026rsquo;s almost impossible for the mum to access support, it\u0026rsquo;s even harder for the dad to access support for something like that.\u0026rdquo;\u003c/em\u003e (P15)\u003c/p\u003e\u003cp\u003eWithin primary care, most service users were offered Cognitive Behavioural Therapy (CBT) however some stated that CBT was too generic, not personalised, and they would benefit from counselling. Conversely, some people with SMI wanted to access CBT but were unable to do so due to eligibility criteria:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The CBT talking therapies that are available \u0026ndash; they run a mile as soon as they know that you have an SMI diagnosis\u0026rdquo;\u003c/em\u003e (P11)\u003c/p\u003e\u003cp\u003eA service which addresses both mental health and substance misuse would be welcomed by service users:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;if you've got mental health problems and you've not resolved your drug and alcohol issues, mental health services won't touch you. \u0026hellip; I think there should be a dual diagnosis team or if somebody's working in mental health teams, they should have knowledge of drug and alcohol substance misuse.\u0026rdquo;\u003c/em\u003e (P17)\u003c/p\u003e\n\u003ch3\u003eNamed person to help navigate the system\u003c/h3\u003e\n\u003cp\u003eMany service users say that a named person (e.g., social prescriber, community link worker, care coordinator) to approach and communicate with services on their behalf, may help them to better navigate the mental healthcare system. Currently, the onus is on the service user to navigate services \u0026ndash; which is often difficult to do, especially when they are unwell:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;it felt like a bit of a labyrinth to navigate at times really \u0026hellip; when I was well enough, I\u0026rsquo;d sort of have a real like put all my energy and efforts into it and then \u0026hellip; when I was unwell again I wouldn\u0026rsquo;t be able to.\u0026rdquo;\u003c/em\u003e (P1)\u003c/p\u003e\u003cp\u003eThe named person could act as a bridge between services, help the service user to get onto a pathway, and play a key role in providing holistic, patient centred care which addresses the wider determinants of mental health such as unemployment. Although some service users had received long term support from a named person (e.g., a social prescriber), others had experienced ad hoc or fragmented support due to high staff turnover:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;in between each care co-ordinator leaving there\u0026rsquo;s been like a six month wait at least to get a new one which you know is not supposed to be happening.\u0026rdquo;\u003c/em\u003e (P1)\u003c/p\u003e\u003cdiv id=\"Sec37\" class=\"Section2\"\u003e\u003ch2\u003eSecond GCM workshops\u003c/h2\u003e\u003cp\u003eDiscussions were based around four key ideas covering 6 sub-themes identified from the interviews, 1) information sharing across services (i.e., shared patient records, and open dialogue); 2) named person to help navigate the system; 3) knowledge of services; and 4) holistic care (i.e., bridging gaps, and wider determinants). Participants made 177 suggestions for change across these four key ideas. The suggestions were collated into 7 key recommendations:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eOne Integrated IT System for Shared Patient Records.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eService users suggested that one patient record system that all organisations can access would streamline the flow of sharing patient data and may reduce the repetition of assessments across different organisations. Regarding consent for data sharing, service users would like the option of giving consent for either a) any part of the mental health system to access their data, or b) for only services that they specify to access their data. In addition, service users would like to have access to their own records and to see clearly what information is held by whom, with the option to accept/withdraw consent from different organisations. Furthermore, digital clinical management apps such as MyPathway [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] which assist service users to manage their appointments, access resources, and connect with clinicians, were suggested for use in mental health services.\u003c/p\u003e\u003cp\u003e\u003col start=2\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eMental Health Passports\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eIn addition to the data recorded by service providers in the shared patient records outlined above, service users recommended that a mental health passport may alleviate the burden of having to retell their story to multiple services. Service users suggested that a mental health passport comprising a written or audio recorded account of their story in their own words would be empowering and allow them to take ownership over their story. The passport could be edited and updated by the service user when needed. In addition, service users would like to choose which organisations they share their mental health passport with.\u003c/p\u003e\u003cp\u003e\u003col start=3\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eNamed Link Worker to Help Navigate the System\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eService users saw advocacy as an important component of the link workers role (especially when they are in crisis). Other key components included good knowledge of the services available in a community to effectively support service users, and the ability to make social prescriptions (i.e., referral powers). Service users suggested that access to a link worker could be similar to the GP model whereby there is no eligibility criteria or discharge. The link worker could be based in GP surgeries, hospitals, and community services. Consistency of the same link worker to accompany the service user as they moved between services was desired, however, it was noted that this may not be realistic. In cases where the link worker changes, a good timely handover was recommended.\u003c/p\u003e\u003cp\u003e\u003col start=4\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eTailored Community Support Groups for People Discharged from Inpatient Care\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eSome service users state that when they are discharged from inpatient care, they struggle to join some support groups in the community because the groups are not catered towards people with SMI. For example, as inpatients, service users receive holistic care such as physical activity groups, art therapy etc., however, these aren\u0026rsquo;t always available when they leave inpatient care. Service users suggested that the sports therapist in the inpatient unit could deliver physical activity sessions in the community for people with SMIs, which may prevent readmission or escalation of mental health difficulties.\u003c/p\u003e\u003cp\u003e\u003col start=5\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eCommunity Hubs and Directory of Services\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eService users suggested that a community hub (similar to the citizens advice model), which is a front door to a variety of services that address the wider aspects of mental health would be beneficial. The hubs could be in person and/or online/ phoneline, and utilised by both service users and service providers to access information.\u003c/p\u003e\u003cp\u003eAn online and paper directory of services was deemed essential to increase awareness through better publicity: an example of a services directory is the Sheffield Mental Health Guide [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Key components required in a services directory include, what support is available, what to expect, waiting times (for assessment and for intervention), eligibility criteria, referral routes, timings, and costs. In addition, including testimonies and feedback from people who have used the services would be beneficial for prospective service users.\u003c/p\u003e\u003cp\u003eSome service users commented that services may be concerned about being overwhelmed and therefore a lack of visibility could deter people from accessing the service. However, they stated that it is necessary for services to be honest, clear and realistic when explaining their service, especially regarding waiting times and eligibility.\u003c/p\u003e\u003cp\u003e\u003col start=6\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eMental Health Workers Embedded in Other Teams\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eService users recommended having embedded mental health workers in other teams, for example, well-being nurses in GP surgeries, and mental health workers in ambulance crews. A street triage role was also suggested (i.e., dedicated mental health professionals collaboratively working with police officers). Service users highlighted the need for a service which addresses mental health difficulties alongside substance misuse, for example, a service which employs mental health professionals with training in addiction so both issues can be treated simultaneously.\u003c/p\u003e\u003cp\u003e\u003col start=7\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eExperts by Experience in the Workforce\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eService users emphasised that they hold lots of knowledge of different services from their lived experience. They recommended recruiting Experts by Experience (EbE) to develop the directory mentioned above. Moreover, they suggested having EbE working in all areas and levels of the system, including being involved in commissioning, service development, management, and being support workers. Service users noted that EbE in the workforce provides role models to service users and may promote greater empathy, care, and compassion in services. However, more training and career opportunities are needed for EbE so that they can develop a career path. Service users valued peer support workers in services, describing them as being easy to relate to, and less judgemental and intimidating than professional staff.\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe sought to identify ways to inform an integrated whole system approach to mental health improvement and reduction of mental health inequalities. Throughout the group concept mapping workshops and interviews we encouraged our participants to think about the interconnectedness of different components and services within the whole mental healthcare system and suggest solutions to improve integration among them. Our findings highlight that service users often experience the mental healthcare system as opaque and unnavigable, particularly during periods of acute need. Participants described a lack of clear, accessible information about what services are available, how to access them, and what to expect. As a result, service users were left to navigate a fragmented system with little guidance, often relying on trial and error. Several participants expressed a desire for greater transparency and realism from services\u0026mdash;particularly around eligibility criteria, waiting times, and the scope of support available. They also required services that addressed the wider determinants of poor mental health alongside treatment of symptoms. These insights underscore the need for more honest, user-friendly communication strategies, holistic approaches and the implementation of navigational aids such as link workers and service directories to reduce the burden of self-navigation. Our seven key recommendations highlight potential areas where integration among mental health services can be enhanced.\u003c/p\u003e\u003cp\u003eOur recommendation for a single, integrated IT system that enables shared patient records is in accordance with several studies that have highlighted how the current lack of ability for IT systems within the NHS to share patient information leads to reduced staff productivity, a lack of antipsychotic medication reviews, and has the potential to retraumatise patients if they have to constantly retell their story [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Projects are underway to join up digital patient care records across health and social care within many regions in England [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. In addition, the long term ambition is to create a national shared patient record system so that an individual\u0026rsquo;s record can be accessed anywhere in England [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOur second recommendation regarding information sharing - mental health passports, currently exist for children and young people in paper and digital form, and thus could be extended to adults [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Mental health passports include a personal account of a service user\u0026rsquo;s story and could also include tailored preferences (e.g. what to say, what not to say, especially during a crisis) which provide more information to service providers regarding how to interact with the service user than clinical notes alone. Health passports that document details about a person\u0026rsquo;s disability or health condition are used within the NHS for employees and hence this sets the precedent for mental health passports to also be in put in place for service users [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eA link worker (also known as wellbeing coordinator or social prescriber) to help access and navigate the complex ecosystem of mental health services was our third recommendation. This role could not only address difficulties with navigating the system, but could address the challenge of ensuring holistic support for service users. One rapid review of link workers in mental health included 16 papers which reported that people experiencing loneliness and social isolation who were supported by link workers experienced improvements to their wellbeing and social connectedness [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Link workers embedded in a secondary mental health recovery pathway can aid service users\u0026rsquo; transition from secondary care to community support groups covering a range of wider determinants, although a person-centred approach needs to be applied to maximise sustained engagement in community support groups for people with SMI [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Our recommendation for tailored support groups for people with SMI is supported by a qualitative study which investigated service users\u0026rsquo; views of a physical activity intervention embedded into peer support groups for people with SMI [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. The authors found that the social aspect of the support group was very important for fostering a sense of connectedness and that service users preferred informal physical activities, such as walking, rather than sport [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAlthough the number of link workers in England has increased in recent years in accordance with the NHS long term plan [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e], some authors have suggested that link workers are an inadequate response to the social needs of people with mental health problems, especially those with SMIs [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. They note that social interventions require long term support to be effective, and that greater clarity regarding the role and purpose of the link worker is required along with a stronger evidence base of their effectiveness [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Furthermore, placing the onus on the individual to engage in community support groups fails to address the social determinants of mental distress such as unstable housing or lack of employment opportunities, therefore these wider determinants should be the focus of the mental healthcare system rather than solely focusing on treating symptoms of poor\u003c/p\u003e\u003cp\u003emental health [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn line with our fifth recommendation, one study of four communities in the UK that had better mental health outcomes than their socioeconomic status would suggest, identified community hubs as an important component in fostering community resilience [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Community hubs are buildings that host a variety of different activities for the local community based on their needs, they are led and run by the community, are available to all community members and may evolve over time depending on the changing needs of the community [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Community hubs can reduce mental health inequalities by improving access to services as multiple services are located in close proximity to service users and trusting relationships with local staff reduces fear and stigma [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. Libraries could be better utilised to serve as community hubs, as they are considered a \u0026lsquo;safe space\u0026rsquo;, however greater community awareness of services offered, making service provision more diverse and accessible, and hiring trained staff to deliver activities would need to be considered [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eRegarding a directory of mental health services, work undertaken in Vietnam highlighted the importance of involving experts by experience and community groups to ensure the directory is more relevant to the end users [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. Two examples of directories, Sheffield Mental Health Guide, and Well Aware (covering Bristol and South Gloucestershire) are run by VCSE organisations and funded by local councils [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOur sixth recommendation, embedding mental health workers in other teams, is exemplified in a study conducted in Norway, in which psychologists and psychiatrists were placed in GP surgeries [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. The study reported many benefits of this co-location model, including better access to mental health specialists and shortening care pathways, however insufficient funding meant the model was unsustainable [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e], therefore, adequate funding for shared care is essential [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Integrating mental health and substance misuse services has been identified as a priority area by the Mental Health Implementation Network [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. A realist synthesis which sought to identify how context influences how integrated mental health and substance misuse work, identified three contextual factors, committed leadership, clear staff expectations of the integrated service, and collaborative case management [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIncreasing Experts by Experience (EbE) in the workforce is our final recommendation, however previous research has identified the emotional burden that may be encountered by peer support workers given that they utilise their lived experience in their role which may be triggering [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. Good practice should be adhered to when employing peer workers which includes sufficient training and development opportunities, good support and supervision, and regular reviews on defining roles and responsibilities [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e].\u003c/p\u003e\u003cdiv id=\"Sec39\" class=\"Section2\"\u003e\u003ch2\u003eStrengths and Limitations\u003c/h2\u003e\u003cp\u003eA strength of this study was to use both GCM and interviews to explore service users\u0026rsquo; views of integration between mental health services. The structured process of GCM organises participants ideas, ensures all voices are heard, and foster consensus among participants. However, the interviews allowed for a more in-depth exploration of participants\u0026rsquo; experiences and thus provided greater context to our GCM findings. Because of time constraints it was not possible to explore all our findings in the second workshops which could have led to additional recommendations. Our findings are based on two regions in England and therefore they may not be generalisable to other regions. However, similar concepts arose in both regions suggesting that the issues encountered by participants may not be specific to one locality. The demographics of our participants are not representative of England\u0026rsquo;s population, for example, women are over-represented in our sample.\u003c/p\u003e\u003cp\u003eFuture research should explore ways to implement our recommendations within the mental healthcare system and investigate to what extent they improve peoples' experience of service provision. Strategies to enhance integration should incorporate consideration of services that address the social determinants of mental health, including housing and financial insecurity. In addition, investigating the impact of mental health service integration on marginalised groups would be invaluable to understand if service integration reduces inequalities that currently exist.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur findings reinforce that service users often experience the mental healthcare system as fragmented and difficult to navigate, particularly during periods of acute need. This underscores the importance of implementing coordinated, person-centred support mechanisms\u0026mdash;such as named link workers\u0026mdash;to reduce the burden of self-navigation and ensure continuity of care. Such roles could act as a bridge between services, helping individuals access timely, appropriate support while addressing the wider determinants of mental health. The Community Mental Health Framework provides an opportunity to develop an integrated mental health system in which individuals receive timely, holistic, and tailored support for their mental health, and in which the wider determinants of mental health and mental health inequalities are addressed. However, adequate investment, and consideration of how to implement this in practice, is essential to ensure that this vision comes to fruition.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCBT Cognitive Behavioural Therapy\u003c/p\u003e\u003cp\u003eEbE Experts by Experience\u003c/p\u003e\u003cp\u003eGCM Group Concept Mapping\u003c/p\u003e\u003cp\u003eGP General Practice\u003c/p\u003e\u003cp\u003eMHDs Mental Health Difficulties\u003c/p\u003e\u003cp\u003eNHS National Health Service\u003c/p\u003e\u003cp\u003eSMI Severe Mental Illness\u003c/p\u003e\u003cp\u003eVCSE Voluntary, Community, and Social Enterprise\u003c/p\u003e\u003cp\u003eWSA Whole Systems Approach\u003c/p\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cp\u003eEthical approval for this study was granted by the London - Camberwell St Giles Research Ethics Committee (22/LO/0835). The Health Research Authority and Health and Care Research Wales (2/LO/0835) approved for this study to be conducted in the UK\u0026rsquo;s National Health Service.\u003c/p\u003e\u003ch2\u003eConsent for publication\u003c/h2\u003e\u003cp\u003eNot applicable\u003c/p\u003e\u003ch2\u003eCompeting interests\u003c/h2\u003e\u003cp\u003eSW holds an Honorary Consultant contract with Sheffield Health and Social Care NHS Foundation Trust, which provides specialist NHS mental health and learning disability services for adults living in Sheffield. All other authors declare that they have no competing interests.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003e This Research Award (award number: MH001) was funded as part of the National Institute for Health and Care Research (NIHR) Three Research Schools Mental Health Programme. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.\u003c/p\u003e\u003ch2\u003eAuthors' contributions\u003c/h2\u003e\u003cp\u003eConceptualisation and methodology: JK, AOS, SW; data collection: KD, JH, JK, AOS, SW, PB, TR; data analysis and interpretation: KD, JH, JK, AOS, PB, SW; writing\u0026mdash;original draft preparation: KD; writing\u0026mdash;review and editing: KD, JH, JK, AOS, SW, PB, TR; funding acquisition: JK, AOS, SW, JH, KD. Principal Investigator: JK. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e\u003cp\u003eWe are grateful to the service users that took part in this study and the services that helped with recruitment.\u003c/p\u003e\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\u003cp\u003eThe transcripts of the interviews generated and analysed during the current study are available in the [data.bris] repository, [PERSISTENT WEB LINK TO DATASETS WILL FOLLOW LATER].\u003c/p\u003e\u003cp\u003eThe GCM data generated or analysed during this study are included in this published article and its supplementary information files.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBritish Medical Association Mental health pressures in England. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/pressures/mental-health-pressures-data-analysis\u003c/span\u003e\u003cspan address=\"https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/pressures/mental-health-pressures-data-analysis\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. 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Int J Environ Res Public Health. ;20\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eThe NHS Long Term Plan (2019) \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.longtermplan.nhs.uk/publication/nhs-long-term-plan/\u003c/span\u003e\u003cspan address=\"https://www.longtermplan.nhs.uk/publication/nhs-long-term-plan/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 4 Apr 2025\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePoole R, Huxley P (2024) Social prescribing: an inadequate response to the degradation of social care in mental health. BJPsych Bull 48:30\u0026ndash;33\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSouthby K, Bidey T, Grimes D, Khor Z, South J, Bagnall A-M (2022) Together through tough times: A qualitative study of community resilience to protect against mental health issues in the UK. 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Front Heal Serv 3:1\u0026ndash;12\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHarris J, Dalkin S, Jones L, Ainscough T, Maden M, Bate A et al (2023) Achieving integrated treatment: a realist synthesis of service models and systems for co-existing serious mental health and substance use conditions. Lancet Psychiatry 10:632\u0026ndash;643\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKlingemann J, Sienkiewicz-Jarosz H, Molenda B, Świtaj P (2024) Peer Support Workers in Mental Health Services: A Qualitative Exploration of Emotional Burden, Moral Distress and Strategies to Reduce the Risk of Mental Health Crisis. Community Ment Health J. ;:629\u0026ndash;638\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRobertson S, Leigh-Phippard H, Robertson D, Thomson A, Casey J, Walsh LJ (2024) What supports the emotional well-being of peer workers in an NHS mental health service? Ment Heal Soc Incl 29:8\u0026ndash;19\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[{"identity":"1dc87a0c-c681-41d6-ba88-e303ebc030e6","identifier":"10.13039/501100000272","name":"National Institute for Health Research","awardNumber":"MH001","order_by":0}],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"University of Bristol","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Mental Health, Health Services, Integration, Systems Approach, Mixed Methods","lastPublishedDoi":"10.21203/rs.3.rs-7487721/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7487721/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eIntegrating mental health and social care services is essential for improving access to quality mental healthcare and for addressing the wider determinants of poor mental health. The UK\u0026rsquo;s National Health Service, together with its social care and voluntary sectors, is currently undergoing a transformation to achieve this. However, many service users report a lack of integration, long waiting lists, and services that focus on treating symptoms rather than taking a holistic approach. This study aimed to inform an integrated whole system approach to improving mental healthcare and reducing mental health inequalities, from the perspective of service users.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eWe used Group Concept Mapping (GCM) and one-to-one interviews to collect and synthesise the views of 55 service users on integration in the mental healthcare systems in two regions of England. GCM data from the first workshops were analysed using multi-dimensional scaling and hierarchical cluster analysis to create group maps which were then merged into concepts. Interview data were analysed using Framework Analysis which allowed for incorporation of the GCM concepts into the coding framework. Findings were used to form the focus of discussions at the second GCM workshops to produce recommendations.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eService users described the mental healthcare system as fragmented, opaque, and difficult to navigate\u0026mdash;particularly during periods of acute need. Many reported limited awareness of what services were available, how to access them, or what to expect. Service users emphasised the need for a more holistic approach that goes beyond symptom management to address the wider determinants of mental health. We identified 7 recommendations to address some of these issues, which included better information sharing, more connected link workers, and greater provision of tailored community support groups. Further recommendations focused on community hubs, directories of services, and embedding experts by experience and mental health workers across the system.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eService users want a more connected, navigable, and holistic mental healthcare system\u0026mdash;anchored by shared information, consistent support, and community-based care that addresses the wider determinants of mental health. Future work should explore ways to implement our recommendations and evaluate their impacts on mental health support.\u003c/p\u003e","manuscriptTitle":"A Qualitative and Group Concept Mapping Study to Investigate Service Users’ Perspectives on Strengthening Integration Between Mental Healthcare Services in England","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-01 08:20:20","doi":"10.21203/rs.3.rs-7487721/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"77cf79b7-04d1-46b3-b1fe-003ca459eb18","owner":[],"postedDate":"September 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-01T08:20:20+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-01 08:20:20","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7487721","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7487721","identity":"rs-7487721","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}