Despite more than three decades of policy commitment to community mental healthcare, services in England remain organised around a pattern familiar to clinicians, service users and families alike: thresholds, referrals, waiting lists, hand-offs, specialist silos and crisis escalation. Successive reforms have expanded the range of community teams but they have not always delivered continuity of care or a dependable alternative to hospital admission. The result is a system that too often intervenes late, fragments responsibility and leaves people with severe mental illness and complex social needs to navigate multiple entry points at precisely the moment when they most need a stable relationship with a service. ^1,2

The 24/7 Neighbourhood Mental Health Centre (NMHC) model is one response to this impasse. It is being tested through six National Health Service (NHS) England pilot programmes as part of a wider rethinking of community mental healthcare. ^3,4 Birmingham is one of the six national pilots; others are in East London, South London, Sheffield, York and Whitehaven. The premise is simple yet demanding: services should be organised around a defined neighbourhood rather than institutional pathways; be open all hours and easy to access, with no exclusions; be committed to maintaining relationships across crisis and recovery; and address the social conditions that shape mental distress. At its most ambitious, the model seeks to replace episodic, referral-driven care with a continuous, relational, whole-person offer rooted in local communities. ^{5,Reference Mezzina6} The model of care being implemented in Birmingham is based on these foundational principles of NHS England and the Trieste model of community mental healthcare, which is generally acknowledged as one of the best examples of community mental healthcare. ^{Reference Mezzina6,Reference Aria, Sashidharan, Mezzina and Vincent7}

The Birmingham 24/7 NMHC pilot serves an urban population of approximately 50 000 residents across Small Heath, Bordesley Green and Heartlands, areas characterised by ethnic diversity, economic adversity and high levels of need. The service is organised around this geographical population rather than the general practitioner (GP)-registered population. This distinction matters. A neighbourhood model creates direct responsibility to a place and its residents rather than to a set of professional pathways. It also makes visible the wider ecology of care: families, faith groups, voluntary organisations, housing, employment, welfare advice, informal networks and the everyday settings in which people live. These are critical elements of community mental healthcare, often neglected in current services.

Clinical services at Birmingham NMHC commenced in January 2025. The Birmingham model brings together, within a single multidisciplinary team, functions typically distributed across separate services: assessment, ongoing community care, crisis response, intensive home treatment, early intervention, assertive outreach, rehabilitation and recovery work, social inclusion and community partnership. The aim is to avoid the discontinuities that arise when a person moves from one team to another as their level of need changes. The central clinical question is therefore not simply ‘Which pathway does this person fit?’, but ‘What relationship, support and practical help are needed now, and how can these be sustained?’

In Birmingham, the pilot involved establishing a new community mental health team that operates 24 h a day, 7 days a week. It is responsible for all aspects of specialist mental healthcare for the entire catchment population aged 18 years and over. Staffing is drawn from both existing services and new recruits. From the outset, all new referrals from the catchment area, including crisis referrals, were directed to the new team. The 24/7 NMHC team is based in a newly refurbished, open-door community venue designed to provide open access to the local community. The centre also includes six in-patient beds, although these are not yet fully operational due to delays in finalising regulatory approval.

Early implementation shows encouraging signs. In the first year, 712 individuals, representing nearly all eligible cases in the initial cohort, were transferred from local community mental health teams to the new 24/7 service. The process was guided by clinical review and caseload stratification using a locally developed complexity tool. This was associated with a 63% reduction in the community mental health team caseload for the catchment population. This should not be read as a withdrawal of care. Rather, it reflects the redistribution of clinical responsibility to a more integrated local service and marks the beginning of a shift away from legacy team-based arrangements.

There are also early signs of change in crisis care. Compared with the preceding 12-month period, referrals from the catchment population to home treatment teams fell by 51%, and the home treatment team caseload fell by 78%. These are preliminary service-level observations and cannot yet establish causality. Nevertheless, they are consistent with the hypothesis that continuous, accessible and relational community care can prevent some crises from escalating into acute pathways. The Birmingham team has supported people who would otherwise have been transferred to a specialist home treatment team, thereby preserving continuity at the point of crisis. This is a crucial test of the model. If crisis care requires a hand-off to another team, continuity remains an aspiration rather than an organising principle.

Access to care has changed in important ways. Self-referrals account for 18% of all new referrals to the Birmingham NMHC, a significant change from standard secondary care arrangements, where unmediated self-referral is rarely possible, even for people already known to services. In Birmingham, nearly half of referrals to the NMHC are contacted within 72 h, compared with fewer than one-third under standard services, and more than one-third are contacted within 24 h. These data suggest that accessibility is not only a matter of staffing or volume but also of design. Open access, a visible neighbourhood base and a culture of welcome can alter how and when people seek help.

The concept of hospitality, rooted in the notion of accoglienza within the Trieste mental health service, ^{Reference Aria, Sashidharan, Mezzina and Vincent7} has been central to the Birmingham model. By hospitality, we do not mean an informal adjunct to clinical care, but a deliberate reorientation of every clinical encounter. The service aims to receive people as guests rather than as patients. A welcoming, home-style environment, food, conversation, practical help and an open front door are not incidental details; they are integral to the therapeutic model. For people who have experienced services as coercive, bureaucratic or distant, the quality of the welcome may determine whether engagement is possible at all. Hospitality also changes staff practice, shifting attention from assessment as a discrete event to a trusted relationship as an ongoing part of care.

This relational emphasis has begun to reshape clinical practice. Contact frequency and intensity have increased, and staff and patients report a shift away from transactional reviews towards sustained engagement. The model enables clinicians to work with the ordinary texture of people’s lives: medication and symptoms, as well as housing, family conflict, debt, loneliness, work, safety, migration, racism, faith, belonging and hope. For people with severe and enduring mental illness, this work cannot be reduced to signposting. It requires continuity, persistence and a willingness to remain involved when progress is slow. The Birmingham service has developed a ‘Taking Charge’ approach (again, based on the Trieste model of mental healthcare) for individuals with more complex needs, using named workers and small relational networks within the team to coordinate long-term life projects rather than episodic care plans.

Yet the current data also expose the fragility of transformation. At the time of review, only about half of the caseload of more than 1300 people was receiving active clinical input, defined as structured, planned contact at a frequency agreed between the clinician and the service user. Workforce shortfalls, consultant vacancies, infrastructure constraints and the persistence of parallel legacy services have all limited implementation. These pressures create a real risk that the service becomes a rebranded community mental health team: exalted in rhetoric but overwhelmed by throughput, review lists and crisis management. Model fidelity, therefore, requires active protection. Without it, the system will drift back into familiar patterns, as we have seen so often in mental healthcare over the past 30 years.

Community partnership is another defining element of the Birmingham experience. Eleven local voluntary, community and faith-based organisations now work alongside the 24/7 team, providing therapeutic, social and practical support. The aim is not to subcontract ‘non-clinical’ work to the voluntary sector, but to build a distributed system of care in which clinical and community resources are mutually reinforcing. This has included activities and support in social connection, cultural belonging, family work, physical health, welfare, creativity and recovery. For example, community organisations have facilitated peer support groups rooted in shared cultural and linguistic identity and have provided practical accompaniment to welfare and housing appointments that clinical staff alone could not sustain. The partnerships have been strongest where relationships were built early, trust was cultivated and community organisations were treated as equal contributors rather than peripheral providers.

This is particularly important in inner-city areas, such as East Birmingham, where statutory mental health services have not always been perceived as accessible, culturally responsive or trustworthy. A neighbourhood centre must therefore be accountable not only to commissioners and performance dashboards, but also to local people. The Birmingham pilot has begun to establish a Council of Elders, drawing on local cultural traditions of mediation and moral authority, to provide independent, community-rooted oversight. Such arrangements may seem unusual within NHS governance, but they are integral to the model’s ambition. If services are to be genuinely neighbourhood-based, communities must have mechanisms for voice, challenge and co-ownership.

There are, however, unresolved tensions. Statutory procurement, contracting and risk-management processes that currently dominate mental healthcare can easily fracture the trust on which community partnership depends. A service may speak the language of co-production while, in practice, reproducing hierarchical relationships and entrenching epistemic injustice, systematically devaluing the knowledge and experience of service users and community members in favour of professional authority. Similarly, institutional anxiety about safety can undermine openness. The question is not whether safety matters; it plainly does. The question is how safety is understood. A defensive model of safety tends to produce locked doors, exclusions, surveillance and professional withdrawal. A relational model of safety relies on welcome, knowledge of the person, continuity, shared responsibility, relentless negotiation and timely support. The 24/7 NMHC model stands or falls on its ability to sustain the latter without ignoring legitimate risks.

The Birmingham pilot highlights a broader implementation challenge. Innovation in mental healthcare is often treated as a matter of designing a new pathway, appointing new cadres of staff and monitoring activity. The deeper task is cultural. It requires a shift in what organisations value, what they measure, how they tolerate uncertainty and how far they are willing to redistribute authority to frontline teams, service users, families and communities. Implementation outcomes such as feasibility, acceptability, adoption and fidelity are not secondary to clinical outcomes; they determine whether the model under evaluation is the intended one. ^{Reference Proctor, Landsverk, Aarons, Chambers, Glisson and Mittman8}

The findings reported here require cautious interpretation. The pilot remains in transition; local data are still maturing; and robust conclusions about admissions, occupied bed days, coercion, quality of life or longer-term social outcomes cannot yet be drawn. Before-and-after comparisons are vulnerable to confounding, and the absence of the planned beds means the full model has not been tested. A Lived Experience Advisory Panel is in place as a first step towards ensuring the active involvement of service users in shaping and influencing both the model and clinical work, but structured outcome data from a service user perspective are not yet available. Nevertheless, early changes in access, engagement and crisis pathways are important. They suggest that neighbourhood-based care can begin to reshape demand and practice, even before all components are in place. The overall cost of implementing this pilot is estimated at £4.5 to £4.75 million per year (most of it funded by reallocating existing resources), and the original staffing estimate was 60 whole-time equivalent (WTE) posts, although only 46 WTE posts were in place during the pilot.

For national policy, the lesson is clear. The 24/7 NMHC should not be seen as another team in an already crowded landscape. Its promise lies in replacing fragmentation with continuity and local responsibility. That requires aligned investment, estates, workforce, clinical leadership, information systems, governance and community partnership. It also requires the courage to disinvest from duplicative legacy structures as the new model becomes capable of assuming responsibility. Partial implementation may be politically attractive, but it risks discrediting the model by evaluating an incomplete version. ^{Reference Millward9}

The Birmingham experience shows that 24/7 neighbourhood mental healthcare is feasible and acceptable within the English NHS and that it can begin to shift patterns of access, engagement and crisis response. However, its transformative potential to scale up and extend this model across the NHS depends on maintaining model fidelity. The decisive question is no longer whether high-quality, rights-based and person-centred community mental healthcare is possible, but whether and to what extent it can be realised within the English mental health system. International experience and examples of local practice elsewhere show that such care is achievable. ⁵ Early evidence from the Birmingham NMHC confirms this, providing both proof of concept and a practical demonstration of a comprehensive community-based system of mental healthcare. The more difficult question is whether health systems such as the NHS have the willingness, leadership and organisational imagination to change sufficiently, culturally as well as structurally, to allow such care to flourish and succeed.