Greater Manchester Integrated Care Board
Integrated Care Board
Action Planned
NHS Greater Manchester Integrated Care is developing a comprehensive plan to improve access to psychological therapies, with key areas including Workforce Expansion, Enhanced Commissioning Models, and Enhanced Community Crisis Support, including out-of-hours community support, a 24/7 mental health crisis line, and digital support commissioned from Kooth and Qwell. (AI summary)
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Dear Ms Mutch
Re: Regulation 28 Report to Prevent Future Deaths – Robert Leighton Smith
Thank you for your Regulation 28 Report dated 10 April 2025 regarding the sad death of Mr Robert Leighton Smith. On behalf of NHS Greater Manchester Integrated Care (NHS GM), We would like to begin by offering our sincere condolences to Mr. Smith’s family for their loss.
Thank you for highlighting your concerns during the inquest which concluded on the 10 March 2025. On behalf of NHS GM, we apologise that you have had to bring these matters of concern to our attention. We recognise it is especially important to ensure we make the necessary improvements to the quality and safety of future services.
During the inquest you identified the following cause for concern: -
• The inquest was told that Mr Leighton Smith had been assessed as someone who would gain a real benefit from IPT. However, he had not started it at the time of his death due to a significant waiting list. This was caused by the demand for the service being far higher than the capacity. The evidence was that at the time of the inquest the waiting time for IPT was on average 12 months. This was due to the ongoing demand against commissioned capacity.
• The inquest was also told that IPT was not an outlier in relation to its waiting time and that the backlog for all other therapy type services were at a similar level. The consequence of such prolonged waits was that people were having to wait a long time for mental health therapy support that they had been identified as requiring. The Trust (GMMH) indicated they provided the services they were commissioned to provide but unless the additional services were commissioned, they could not increase their provision and waiting lists would remain high.
Private & Confidential
Ms Alison Mutch Senior Coroner for the area of Manchester South Coroner's Court 1 Mount Tabor Street Stockport SK1 3AG
4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk NHS GM has investigated the matters of concern. We acknowledge the seriousness of the issues raised and this response details the current provision of psychological therapies, the strategic action in progress to address waiting times and our pans to enhance support to the people of Greater Manchester.
The current provision and limitations
Recent benchmarking has demonstrated that our commissioned services currently have the capacity to deliver psychological interventions to approximately 14.6% of individuals who require support outside of early intervention services. This figure reflects longstanding systemic underinvestment and financial challenge resulting in capacity limitations within mental health care.
It is also important to note that NHS Talking Therapies, while essential for individuals with mild to moderate mental health needs, are not designed to meet the complex and often intensive needs of those requiring secondary care psychological interventions. This has contributed to a significant treatment gap for people with more severe or enduring mental health difficulties.
Strategic Action to Address Waiting Times
In direct response to these challenges, we are actively developing a long-term strategy to improve access to psychological therapies. This includes:
• Service Mapping and Planning: Our benchmarking exercise has helped us identify current gaps in provision and informed the foundation of our long-term commissioning plans.
• Workforce Development: We are exploring avenues to increase the psychological therapy workforce through targeted recruitment, training, and retention strategies.
• Enhanced Commissioning Models: Work is underway to review and evolve commissioning practices to better align with population needs, recognising that even with improvements, future demand may still exceed current system capacity.
Enhancing Community Crisis Support
To mitigate the impact of these service limitations in the short term, especially for individuals in acute distress, we have significantly strengthened community-based crisis support services:
• Out-of-Hours Community Support: We have introduced enhanced access to community mental health services during evenings and weekends, to ensure individuals in crisis have options beyond core operating hours.
• 24/7 Mental Health Crisis Line: A dedicated 24/7 mental health crisis support line, accessible via NHS 111, has been established, providing around-the-clock access to trained mental health professionals.
• Digital Support commissioned from Kooth and Qwell: We have commissioned online mental health platforms Kooth (for children and young people) and Qwell (for adults), offering free, anonymous, and clinically supervised mental health support. These services expand access to therapeutic support, particularly for those awaiting more intensive interventions.
NHS GM takes the concerns raised in your report very seriously and recognises the pressing need to expand and reform mental health services to meet the growing demand. While we are progressing a long-term improvement plan, we are also committed to ensuring that individuals in need receive timely and appropriate support through strengthened community services and digital resources. We remain fully engaged in efforts to address these gaps and are grateful for your continued oversight in this vital area of public health.
4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk
Best wishes
Re: Regulation 28 Report to Prevent Future Deaths – Robert Leighton Smith
Thank you for your Regulation 28 Report dated 10 April 2025 regarding the sad death of Mr Robert Leighton Smith. On behalf of NHS Greater Manchester Integrated Care (NHS GM), We would like to begin by offering our sincere condolences to Mr. Smith’s family for their loss.
Thank you for highlighting your concerns during the inquest which concluded on the 10 March 2025. On behalf of NHS GM, we apologise that you have had to bring these matters of concern to our attention. We recognise it is especially important to ensure we make the necessary improvements to the quality and safety of future services.
During the inquest you identified the following cause for concern: -
• The inquest was told that Mr Leighton Smith had been assessed as someone who would gain a real benefit from IPT. However, he had not started it at the time of his death due to a significant waiting list. This was caused by the demand for the service being far higher than the capacity. The evidence was that at the time of the inquest the waiting time for IPT was on average 12 months. This was due to the ongoing demand against commissioned capacity.
• The inquest was also told that IPT was not an outlier in relation to its waiting time and that the backlog for all other therapy type services were at a similar level. The consequence of such prolonged waits was that people were having to wait a long time for mental health therapy support that they had been identified as requiring. The Trust (GMMH) indicated they provided the services they were commissioned to provide but unless the additional services were commissioned, they could not increase their provision and waiting lists would remain high.
Private & Confidential
Ms Alison Mutch Senior Coroner for the area of Manchester South Coroner's Court 1 Mount Tabor Street Stockport SK1 3AG
4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk NHS GM has investigated the matters of concern. We acknowledge the seriousness of the issues raised and this response details the current provision of psychological therapies, the strategic action in progress to address waiting times and our pans to enhance support to the people of Greater Manchester.
The current provision and limitations
Recent benchmarking has demonstrated that our commissioned services currently have the capacity to deliver psychological interventions to approximately 14.6% of individuals who require support outside of early intervention services. This figure reflects longstanding systemic underinvestment and financial challenge resulting in capacity limitations within mental health care.
It is also important to note that NHS Talking Therapies, while essential for individuals with mild to moderate mental health needs, are not designed to meet the complex and often intensive needs of those requiring secondary care psychological interventions. This has contributed to a significant treatment gap for people with more severe or enduring mental health difficulties.
Strategic Action to Address Waiting Times
In direct response to these challenges, we are actively developing a long-term strategy to improve access to psychological therapies. This includes:
• Service Mapping and Planning: Our benchmarking exercise has helped us identify current gaps in provision and informed the foundation of our long-term commissioning plans.
• Workforce Development: We are exploring avenues to increase the psychological therapy workforce through targeted recruitment, training, and retention strategies.
• Enhanced Commissioning Models: Work is underway to review and evolve commissioning practices to better align with population needs, recognising that even with improvements, future demand may still exceed current system capacity.
Enhancing Community Crisis Support
To mitigate the impact of these service limitations in the short term, especially for individuals in acute distress, we have significantly strengthened community-based crisis support services:
• Out-of-Hours Community Support: We have introduced enhanced access to community mental health services during evenings and weekends, to ensure individuals in crisis have options beyond core operating hours.
• 24/7 Mental Health Crisis Line: A dedicated 24/7 mental health crisis support line, accessible via NHS 111, has been established, providing around-the-clock access to trained mental health professionals.
• Digital Support commissioned from Kooth and Qwell: We have commissioned online mental health platforms Kooth (for children and young people) and Qwell (for adults), offering free, anonymous, and clinically supervised mental health support. These services expand access to therapeutic support, particularly for those awaiting more intensive interventions.
NHS GM takes the concerns raised in your report very seriously and recognises the pressing need to expand and reform mental health services to meet the growing demand. While we are progressing a long-term improvement plan, we are also committed to ensuring that individuals in need receive timely and appropriate support through strengthened community services and digital resources. We remain fully engaged in efforts to address these gaps and are grateful for your continued oversight in this vital area of public health.
4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk
Best wishes