First reported 17 Dec 2013•Latest report 14 Jan 2026
Definition
What this concern includes
Includes failures of the explicitly identified mental health service system to integrate its sections, teams or care settings, including fragmented inpatient-community arrangements, service silos, unclear cross-service ownership and absent mechanisms for coordinated care.
Not included
Excludes generic communication, information-sharing or coordination failures unless they directly demonstrate fragmentation or failure to integrate mental health services across care settings.
Excludes deficiencies within a single mental health service or clinical intervention where no cross-service integration problem is identified.
Excludes integration failures involving non-mental-health services unless the assertion directly concerns the integration of mental health provision.
Excludes generic staffing, training, documentation or facility deficiencies that are not specifically tied to integration of mental health services.
Reports
33
Distinct published reports
Individual concerns
39
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
53
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
NHS England11
Department of Health and Social Care8
Pennine Care NHS Foundation Trust4
Birmingham Women'S and Children'S NHS Foundation Trust2
Cornwall Partnership NHS Foundation Trust2
Greater Manchester Health and Social Care Partnership2
NHS Birmingham and Solihull Integrated Care Board2
NHS Greater Manchester Integrated Care Board2
NHS Northamptonshire Integrated Care Board2
Northamptonshire Healthcare NHS Foundation Trust2
Office of the Chief Coroner2
Aneurin Bevan University LHB1
Birmingham and Solihull Mental Health NHS Foundation Trust1
Birmingham City Council1
Care Quality Commission1
NHS trust25
Executive non-departmental public body11
Integrated care board11
Ministerial department8
Healthcare site5
Clinical commissioning group2
Coronial office2
English metropolitan district council2
Health-system partnership2
Local health board2
Company limited by guarantee1
English county council1
English unitary authority1
Health and social care service regulator1
National policing body1
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
Dorset
Concerns raised1
Lack of communication between mental-health care teams about patients' care
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester South
Concerns raised1
Lack of a clear system for joined-up discharge planning between primary and secondary mental health services
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Publish best-practice information on coordinated mental-health discharge planning and transition support.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 17 June 2018.
Action
Develop a framework for Community Mental Health Services setting out improved joint working between primary and secondary mental-health services.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 17 June 2018.
Action
Revise the Mental Health Act Code of Practice to set guiding principles for improving patient care, including involving carers and families in care decisions.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 17 June 2018.
London (East)
Concerns raised2
Failure of mental health referral routing between teams
Lack of joint coordination between mental health and primary care services
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Process every NELFT referral and redirect misrouted referrals to the correct team within two working days.
Stated by North East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 16 June 2018.
Action
Continue joint NELFT–Fullwell Cross meetings to agree the process for referrals, prescribing during medication changes and communication, including reconvening to resolve prescribing responsibilities.
Stated by North East London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 16 June 2018.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
Position
NELFT cannot undertake prescribing because prescribers lack an overview of patients’ full medication and may miss interactions or contraindications.
Stated by North East London NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
NELFT cannot undertake prescribing because it lacks arrangements with community pharmacists to ensure frail patients receive medication.
Stated by North East London NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
NELFT cannot use FP10 prescribing for many Older Adult Mental Health Team patients who lack capacity.
Stated by North East London NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
NELFT cannot facilitate compliance aids through local pharmacists, so medication for patients using them must be organised by GPs.
Stated by North East London NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
NELFT cannot undertake FP10 prescribing for many patients in care or sheltered accommodation because those settings will not accept such prescriptions.
Stated by North East London NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Cornwall and Isles of Scilly
Concerns raised1
Lack of clarity about crisis response pathways and service roles
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Update the public website with crisis information explaining daytime and out-of-hours mental health services, helplines and team contact numbers.
Stated by Cornwall Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 7 March 2018.
Action
Develop and provide patients with Safety Plans containing warning signs, coping strategies, crisis contacts, care-team details and carer guidance.
Stated by Cornwall Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 7 March 2018.
Action
Review out-of-hours services to determine whether changes to Home Treatment Teams are needed.
Stated by Cornwall Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 March 2018.
Action
Publish guidelines clarifying community pathways for urgent, emergency and acute mental health services in 2018/19.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 7 March 2018.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Responsibility for reviewing Cornwall-related recommended actions was passed to the new Cornwall Integrated Urgent Care provider.
Stated by Devon Doctors GroupRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Devon Doctors could not implement the requested Cornwall changes because it no longer provided urgent care there.
Stated by Devon Doctors GroupUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Some information-sharing recommendations were beyond Devon Doctors’ control.
Stated by Devon Doctors GroupUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Inner North London
Concerns raised1
Disjointed coordination of care between crisis house and crisis team services
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Work with OneHousing to establish shared access to clinical records and risk assessments for Highbury Grove staff.
Stated by North London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 November 2017.
Action
Introduce joint risk assessments completed by OneHousing and Camden and Islington staff.
Stated by North London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 27 November 2017.
Action
Reinforce detailed feedback to OneHousing staff and agreement of a written action plan when crisis team staff complete risk assessments.
Stated by North London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 27 November 2017.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Information-sharing problems have been rectified through ready access to relevant clinical information and established communication channels.
Stated by North London NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
West Yorkshire Eastern
Concerns raised1
Geographical and operational separation of Acute Medical Wards Mental Health Services
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Preston and West Lancashire
Concerns raised1
Lack of a shared electronic mental health record system across teams
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Birmingham and Solihull
Concerns raised1
Unclear responsibility for patients during transfer between mental health services
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Gloucestershire
Concerns raised1
Failure of services to provide assistance to individuals with addiction and mental health difficulties
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Cheshire
Concerns raised1
Inadequacies in mental health care planning and communication
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Maintain nationally specified integrated stepped mental-health care, including consultant psychiatry, long-term care planning and continuity of care.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 13 June 2016.
Action
Roll out the revised Person Escort Record and provide training so operational staff transfer relevant health information throughout custody transitions.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 13 June 2016.
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Includes failures of the explicitly identified mental health service system to integrate its sections, teams or care settings, including fragmented inpatient-community arrangements, service silos, unclear cross-service ownership and absent mechanisms for coordinated care.
