Introduction — the project and evaluation

The final evaluation report for the Community Mental Health Navigator Pilot Programme (CMHN Pilot) presents insights and learning from programme delivery between April 2020 and December 2022, with recommendations for ongoing delivery.

Mental Health UK delivered the CMHN Pilot, with funding from Johnson & Johnson in the UK and the Johnson & Johnson Foundation, in partnership with local healthcare services. They created four new navigator posts based in a healthcare setting in each nation, for two years, aiming to:

• support the non-clinical needs of 240 people experiencing mental illness, for approximately 6 months each.
• reduce demands on the capacity of frontline health and care professionals, freeing up their time for clinical work.

The Tavistock Institute of Human Relations undertook an external, mixed methods evaluation, to help answer whether and how the pilot met its aims. A Theory of Change guided evaluation activity including:

• interviews with navigators, people receiving support, health staff and stakeholders.
• surveys completed by service users and health service staff.
• analysis of monitoring and diversity data collected by navigators on a quarterly basis.

COVID-19, increasing economic pressures and other project-specific challenges contributed to difficulties with engaging people in the evaluation and gathering data from sites. Therefore, caution is advised when drawing conclusions from the data presented.

How was the CMHN Pilot delivered?

Between April 2021 to September 2022, navigators recorded 647 referrals, a 270% overperformance on the anticipated number. Referrals by healthcare professionals, such as GPs, were either triaged by a Mental Health clinician or came to navigators via email, telephone, or team meetings. People referred had a pre-existing mental health diagnosis or were experiencing deterioration in their mental health and needed help with non-clinical issues. As the pilot progressed, people referred were presenting with worse mental health and wellbeing than at earlier stages, perhaps due to effects of the pandemic and cost-of-living crisis.

People saw a navigator for anything from a couple of weeks to over a year, depending on need. On average, people had four appointments each and navigators held caseloads of 31 people per month. However, rates varied over time and between sites. Navigators helped people to access further support such as financial or housing advice, completing benefits applications, accessing food banks, attending groups, taking up volunteering and applying for jobs. Interview data highlighted the importance of proactive support being given when needed, whether by meeting someone at their home, or actively supporting with activities that could be anxiety provoking.

What outcomes did the CMHN Pilot achieve?

Interviewees attributed a range of outcomes to the CMHN roles. For people supported by navigators, there were reports of:

• non-clinical needs being better met.
• decreased anxiety/exacerbation of health or mental health conditions.
• better engagement in and maintenance of positive health behaviours.
• better adherence to clinical and non-clinical treatments.
• access to and engagement in social/ community activities.

Even at a time of increasing demand on frontline services, navigators helped relieve some burden for healthcare professionals. For instance, navigators could offer support to patients who did not meet secondary care thresholds. A cost-utility analysis undertaken, calculating quality-adjusted life years (QALYs), indicates an improvement in QALYs, well within accepted cost thresholds. This was a conservative calculation and further research may find additional financial benefits. Finally, England and Wales partners have now implemented four CMHN posts in England and twelve ‘Social Navigator’ posts in Wales, increasing the likelihood of sustaining outcomes.

What challenges did the CMHN Pilot meet?

Challenges faced in delivering the CMHN Pilot sometimes overlapped with success factors. For instance, the popularity of the service, the ability and commitment shown, and trust generated by navigators, was a success and a challenge, with the potential for navigator overwhelm and burnout. However, in summary, challenges reported included:

• Healthcare system challenges – such as different working styles and processes between different settings, and healthcare service demand pressures.
• Navigator capacity and pilot set up – including a reliance on the individuals fulfilling the role and the high workload of and demand for support from navigators.
• External factors – such as the immediate and ongoing impacts of the COVID-19 pandemic, cost-of-living crisis and increasing complexity of needs faced by people.

Key success factors of the CMHN Pilot

Success factors identified include navigators being based within primary care, but with specialist mental health knowledge and skills. Unlike other services, such as other types of primary care navigation and social prescriber roles, navigators were able to work with:

• a range of mental health needs, from mild to severe and enduring.
• someone for as long as they needed.
• a person’s fluctuating mental health, offering light touch signposting through to proactive, ongoing support, together with check in calls following discharge.

A key aspect was the ongoing emotional support people received. Navigators would sometimes ‘hold’ a client, within a caring, nurturing relationship, supporting self-management of mental health, alongside giving support to access other services and support. This was a unique feature of the role. Finally, the CMHN role seems scalable to a variety of primary care settings. Scalable components include simple, quick referral processes and person-centred focus. Finding the right people to fulfil the role and ensuring appropriate supervision support to avoid burnout, may be the biggest challenges to scalability.

Conclusion

To conclude, the CMHN role is a much-needed service within primary care settings, which can work well in supporting people emotionally and with their non-clinical needs, whilst relieving pressures on clinical services. It complements and is different from existing roles such as care coordinators and social prescribers, providing a cost-effective way of supporting people, which could help prevent deteriorating mental health, escalating of crises, and therefore the need for more expensive healthcare. Attention to ensuring the development of and appropriate support for a CMHN workforce will be key to the success of scaling up, and further research will help better understanding about what works and why in a CMHN service.

Recommendations from evaluating the CMHN Pilot include:

• Clarify referral routes into navigation services, ideally with triaging by a clinician.
• Supervisory oversight that monitors caseloads, supporting navigators to work autonomously and flexibly within their competencies and capacity.
• Implement administrative support for navigators and streamline monitoring and reporting processes.
• Develop peer networking/forums for navigators to share best practice and explore progression routes, such as senior navigator roles.