By Natalie Thompson, Aspiring Clinical Psych Content Assistant and Dr Melody Smith, Clinical Psychologist
When working for NHS mental health services, care is structured within a hierarchical system known as the Stepped-Care Model. The first point of contact for mental health concerns is typically the General Practitioner (GP). But what does this structure mean in practice for both practitioners and service users? Is this model a well-designed system, or is it another good idea that, like many NHS services, is struggling to meet the needs of the people it serves.
The stepped care model is used by IAPT services photo credit: MHM 2020].
Understanding the Stepped-Care Model
The Stepped-Care Model of psychological care in the NHS is recommended by the National Institute for Health and Care Excellence (NICE). The model aims to provide the least invasive treatments for mental health difficulties to the largest number of people. The structure resembles a pyramid: the lower steps involve less intensive interventions provided by Psychological Wellbeing Practitioners (PWPs), while higher steps offer specialised and intensive care by highly trained therapists.
At its core, the model promotes early intervention by providing care at the appropriate level based on need, reflecting the idea that “prevention is better than cure.” In theory, this makes sense — delivering simpler, less intensive treatments early should prevent the need for more complex interventions later. However, in practice, several challenges limit its effectiveness.
Gaps in the Stepped-Care Model
Staff Shortages and Recruitment Issues
One of the most pressing issues is the significant shortage of Step 2 PWPs, who form the foundation of the model. Recruitment at all levels is increasingly difficult due to high workloads, emotional burnout, and limited career progression in these roles. The expectation is that most service users will receive treatment at Step 2, helping reduce the need for Step 3 or Step 4 services. However, when these roles remain unfilled, the system collapses, leading to longer waiting lists and more service users presenting at higher steps due to delayed intervention.
Increasing Complexity of Presenting Issues
In practice, many service users now present with severe and chronic mental health conditions requiring Step 3 or higher interventions right from the start. This raises the question: are people waiting until their conditions worsen before seeking help, or are they unaware of the services PWPs provide? A lack of public awareness about the availability of lower-step services could be contributing to this bottleneck.
Service Gaps for Specific Diagnoses
The Stepped-Care Model struggles to accommodate individuals with certain diagnoses, such as Bipolar Disorder or Borderline Personality Disorder. While these conditions are typically managed at higher steps, service users experiencing anxiety or depression alongside these diagnoses may be denied Step 2 or Step 3 care due to exclusion criteria.
In contrast, there are no specific training requirements for treating neurodivergent individuals, such as those with Autism Spectrum Disorder (ASD) or Attention Deficit Hyperactivity Disorder (ADHD). This lack of specialized training means that these service users may be managed by practitioners who are not equipped to address overlapping symptoms, potentially leading to ineffective care.
Transitions from CAMHS to Adult Services
Another critical issue is the transition from Child and Adolescent Mental Health Services (CAMHS) to adult services, which follow the Stepped-Care Model. Adult services start at age 16, meaning that younger service users often require additional safeguarding, care adaptations, and coordination between teams. In my experience, providing effective care for 16-17-year-olds within an adult framework can be challenging, as these services are not designed with younger service users in mind.
Long Waiting Times and Service Pressures
Despite the intended efficiency of the Stepped-Care Model, waiting times for mental health treatment in the NHS often exceed 12 weeks or more. This delay leaves service users without timely support and contributes to worsening mental health conditions. Additionally, high staff turnover in Step 2 roles exacerbates the issue, as many PWPs move on to higher-level training, leaving services perpetually understaffed.
Potential Solutions
While the challenges facing the Stepped-Care Model are significant, several changes could improve its functionality:
Enhancing Career Progression for PWPs
Developing clear career pathways within Step 2 roles could encourage staff retention and reduce high turnover rates. This might include offering specialised training, higher pay, and promotional opportunities within the role.
Increasing Public Awareness
Raising awareness about available services and the benefits of early intervention could encourage people to seek help before their conditions worsen.
Expanding Specialist Training
Providing mandatory training in neurodivergent conditions like ASD and ADHD could ensure more service users receive appropriate care at all steps.
Improving CAMHS to Adult Transitions
Creating dedicated teams specialising in the transition between CAMHS and adult services could ease the process for younger service users.
Investing in Mental Health Services
Ultimately, increased government funding is essential to reduce waiting times, expand recruitment efforts, and improve service delivery.
Conclusion
The Stepped-Care Model has strong theoretical foundations, emphasising early intervention and efficient resource allocation. However, in its current form, significant gaps exist that hinder its effectiveness. Addressing these issues requires systemic changes, including better recruitment strategies, enhanced career development for PWPs, and improved public awareness. Only through such reforms can the NHS deliver the comprehensive, timely mental health care that service users deserve.
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References
Mental Health Matters (MHM). Stepped care. Retrieved 10th May 2023. https://www.mhm.org.uk/pages/faqs/category/stepped-care
