Patients and GPs are all too familiar with the difficulty of accessing timely and effective NHS support for complex mental health needs. Patients being ‘bounced’ between services who state that an individual is either too complex, not complex enough, or somehow otherwise fails to meet service specifications is a daily reality. This editorial outlines the treatment gap and proposes solutions, based on our collective professional (psychologist, psychiatrist, psychological wellbeing practitioner, GP, charity worker) and lived experience of mental health.

Gaps in mental health provision result from how services are currently commissioned. In 2008, access to evidence-based psychological therapies for common mental health problems (mild to moderate depression and anxiety) was transformed in primary care through ambitious national commissioning of the Improving Access to Psychological Therapies (IAPT) services, now known as NHS Talking Therapies (NHS-TT).1 In secondary care, Community Mental Health Teams (CMHTs) are commissioned to provide support for people with severe and enduring mental illness ([SMI]: psychosis, bipolar disorder, and the most severe ‘personality’ and eating disorders) presenting with high risk to self or others.

Commissioning models in mental health provision leave a significant ‘missing middle’ who have needs between NHS-TT and CMHTs: those who remain unwell after receiving NHS-TT input; those eligible for CMHT input but not accepted due to lack of resource; those out of remit for both NHS-TT and CMHT input; and those discharged from CMHTs as no longer deemed high risk but with ongoing needs. As well as more complex common mental health problems and less severe SMI, the ‘missing middle’ also includes patients with grief, anger, self-harm, co-occurring …