The state of health care and adult social care in England 2025/26

Step-down and shared care in the community

As part of our adult community mental health inspection programme in 2025, we held engagement events for providers. These enabled us to learn that it could sometimes be challenging for them when stepping patients down from secondary mental health services into primary care. Attendees told us about their working relationships and mixed experiences of working with GPs. We heard how GPs’ willingness to accept discharged patients, particularly those stable on depot injections, varied widely.

Wim’s Protocol: for the safe prescribing and monitoring of clozapine is the latest guidance from the Royal College of Psychiatrists. Although this recognises that responsibility for prescribing, monitoring and ensuring engagement with monitoring lies with the initiating clinician or clinical service, the guidance highlights the need for appropriate training, funding, formal shared care agreements for GPs, and clarity around responsibilities and liability, including around managing disengagement from clozapine monitoring.

Shared care agreements are important in enabling safe step-down of care, and we heard that where these worked well, it reduced secondary care caseloads and improved patient flow.

One provider described how it had made positive progress around shared care agreements, which resulted in GPs taking over the care for patients on antipsychotics and people with dementia. At another trust where there were strong shared care agreements in place for people receiving oral medications, we heard that GPs were assured that the person would have regular review points from a specialist perspective, and that a relapse plan was in place.

But some attendees at our engagement events told us how prescribing and monitoring were central friction points between primary care services and secondary mental health services. As we reported in last year’s State of Care, attendees described how shared care agreements were frequently contested, inconsistently implemented and under‑resourced, with unclear finance and responsibility arrangements, and lack of national standardisation.

Every year we also proactively engage with chief pharmacists in NHS trusts, to enable us to learn about their arrangements. Some pharmacists told us about the processes they had implemented to mitigate some of the risks with shared care agreements. However, others described how challenges with shared care agreements continued to present one of the biggest areas of risk for people using their services, including delays to treatments, as well as a lack of a single care record.

This echoes the feedback from adult community mental health providers, who told us at our engagement events that the challenges and delays with stepping down care could lead to patients experiencing care that is fragmented rather than continuous, and being at increased risk of deterioration or crisis.

Wim’s Protocol highlights the importance of effective communication between healthcare providers, and of clear roles and responsibilities across the patient's care pathway, including between primary and secondary care services. It also emphasises the importance of physical health monitoring and early recognition of serious adverse effects of medicines.

GPs also have a key role in providing annual physical health checks and support for people with severe mental illness. Many people with severe mental illness have one or more chronic physical health conditions at the same time as their mental illness, and adults living with severe mental illness are almost 5 times more likely to die prematurely compared with those who do not have a severe mental illness. The ‘core’ annual severe mental illness physical health check has 6 elements including:

• alcohol consumption status
• blood glucose or HbA1c test (as clinically appropriate)
• blood pressure
• body mass index
• lipid profile
• smoking status.

In 2025/26, 65% of people with a severe mental illness received all 6 health checks, a fall of 1.3% since 2024/25 and 3.2% less than in 2023/24.

At our provider engagement events, we heard examples of how co-locating mental health staff in GP surgeries, introducing outreach practitioners who rotate between practices, and having medicines optimisation leads has helped to improve handover and monitoring of patients.

Supporting people at high risk

In March 2024 we published our Special review of mental health services at Nottinghamshire Healthcare NHS Foundation Trust. This identified concerns around people with complex needs who presented with a high risk of harming themselves and others being lost in the system and not receiving appropriate support. The Nottingham Inquiry, launched in May 2025, is continuing to build on the findings of our review and others that were published in relation to the Nottingham attacks. It aims to provide a clear understanding and holistic view of the events, acts and omissions that led up to the attacks, and give clear recommendations to prevent this happening again.

We discussed the challenges of supporting people who are at high risk of harming themselves or others at our engagement event for providers. One attendee described people who were identified as high risk as having a complex mental health diagnosis, often also needing support for substance misuse, and described it being very difficult to engage them.

Others spoke about people who are ‘quietly very unwell’ and described how these were not necessarily people who would have been receiving treatment from the assertive outreach team.

To address this challenge, providers told us they use a range of methods to monitor high-risk individuals, including data-driven case-finding and tools such as electronic patient records and regular review of risk levels. They also told us about multidisciplinary working, including community outreach and information sharing across agencies. These approaches aimed to:

• predict if a person may relapse
• manage transitions between services (for example, release from prison or step‑down from high‑intensity care)
• reduce out‑of‑area placements and crises
• identify people who were disengaging with services.

Attendees told us about specific groups of people who were more likely to disengage or whose voices were seldom heard. This was sometimes due to factors such as not wanting to attract attention, cultural or social stigma and/or feeling unsupported (for example, from a lack of commissioned outreach in the area).

Attendees described the different approaches they are taking to identifying and supporting people who disengage from mental health services. A key recommendation from the Nottinghamshire review was that when people had not attended their appointment, flagged as ‘did not attend’ (DNA), this should not be a reason to discharge that person. One provider had recommended to their trust board that nobody could be discharged purely based on DNAs.

A few attendees stressed the importance of engaging people’s families and carers. They told us that family and carer involvement has been strengthened through Triangle of Care approaches and emerging training programmes for carers. One attendee told us that they planned to provide training for all their families and carers in suicide prevention, something that is not typically done, to empower the families and carers to understand what fleeting suicidal thoughts are, and how they can help the person. While a couple of attendees discussed their providers’ initiatives around co‑production with patients, families and carers, they described them as being “a work in progress” and that there was “more to do”.