The main idea behind the Fonagy Review is difficult to argue with. People should not have to wait months or years for a diagnosis before they can access every form of help. The review proposes moving from a diagnosis-dependent system to what it calls “needs-led plus diagnosis”, allowing support before, during and after assessment while retaining diagnosis and specialist care for those who need them. The Government has accepted that broad direction and says its forthcoming Mental Health Strategy will focus more on prevention, early intervention and support in schools, colleges and communities across England.
I support that principle. My concern is what happens when it meets the workforce expected to deliver it. The review describes a system under serious pressure, with mental distress and common mental health conditions increasing substantially, particularly among children and young people. Recognition of ADHD and autism has also risen, bringing sharp growth in demand for assessment, while some people with severe, enduring or complex needs still struggle to access specialist care. Earlier support could prevent difficulties escalating and reduce the extent to which diagnosis becomes the only route into help. But putting support into more settings creates practical questions about skills, responsibility and clinical oversight.
Take a young person struggling to attend school while waiting for an ADHD assessment, who is also experiencing anxiety and difficulties in the classroom. Who coordinates the initial response? What can the school reasonably provide? When should primary care become involved, and at what point is specialist assessment necessary? The answers will depend on the individual, but the questions expose the workforce challenge. Staff need to know what they can safely support, what lies outside their competence and where they can obtain specialist advice. Families also need a route through the system that does not leave them moving between services trying to work out who is responsible.
A more joined-up response makes sense, especially when people have several interacting needs rather than one clearly separated condition. Making it work will involve NHS mental health teams, community paediatrics, primary care, education, local authorities and voluntary organisations, all operating under different pressures and with different professional responsibilities. Accountability, supervision and information sharing will need to be clear. Moving responsibility is easy on paper. If the training, supervision and specialist capacity do not move with it, the pressure has simply been transferred.
This is where workforce planning needs to come before recruitment. There is a tendency to respond to every new service ambition by creating a list of vacancies, but organisations first need to understand what work will be delivered, which skills it requires and where responsibility should sit. Some early support may be provided appropriately by trained people in schools, community organisations or other non-specialist settings. Other situations will continue to require diagnostic expertise, clinical oversight or specialist treatment. Recruitment can help build the required capacity once that model is clear. It cannot decide the model on behalf of commissioners and providers.
The King’s Fund, the Royal College of Paediatrics and Child Health and the NHS Alliance have all welcomed the direction of travel while raising questions about workforce development, investment and continued access to specialist care. Taken together, their responses point to the same implementation risk: earlier access cannot rely on schools, community services and other non-specialist settings absorbing additional responsibility while diagnostic and specialist services remain stretched. A needs-led model will only work if both sides of the system have the capacity to do their part.
Diagnosis remains clinically necessary and personally meaningful for many people. The proposed model recognises that while trying to make useful support available sooner. If support outside specialist services is inconsistent, people may still be directed towards specialist teams because there is nowhere else for them to go. If those teams do not have sufficient capacity, early support can become another place to wait rather than a route to the right care.
The forthcoming Mental Health Strategy should give us more detail. Until then, predicting particular workforce shortages or recruitment demand would be premature. The immediate task is more basic: decide what support will be provided, who is responsible for it and how those professionals access specialist expertise when they need it. Get that wrong and earlier intervention may simply move pressure from one overstretched part of the system to another.