There’s a version of this conversation that happens in commissioning meetings across the country, and I’ve been in enough of them to know how it goes. Someone flags that a person in the community needs a bit more support — a few extra hours of flexible care a week, some practical help, someone to keep in touch on a regular basis. Then the response, not always but often enough, is “Can we hold off and see how they get on?”
Sometimes that’s the right call, but sometimes it isn’t, and the cost of getting that wrong isn’t a slightly worse outcome. It’s a hospital admission, it’s a placement breakdown, or it’s a secure bed at £185,000 a year or an emergency package put together under pressure that costs three times what a planned one would have.
I want to make a straightforward argument here. Flexible, low-intensity community support (somewhere between one and twenty hours a week depending on what a person needs) is one of the best ways to save money in mental health care but we’re chronically underinvesting in it.
What flexible support actually is
When I talk about flexible support, I don’t mean a rigid care plan with fixed hours and a set list of tasks. I mean support that moves with the person. It’s care that can increase when life gets difficult and reduce when they’re doing well, without needing review, a new assessment, or a commissioner’s sign-off every time the situation shifts.
In practice it might look like:
- Two hours on a Monday to help someone organise their week and deal with anything that’s built up over the weekend.
- An accompanied GP appointment for someone who finds medical settings overwhelming.
- A phone call on a Wednesday evening because that’s when things tend to get harder.
- Help with a benefits form that’s been sitting unopened for three weeks because the anxiety around it is too much.
- A conversation with a landlord on someone’s behalf before the situation becomes really problematic or leads to an eviction.
None of them would appear in a serious incident report, but each of them, done at the right time, might avoid the kind of spiral that ends in crisis.
The maths that commissioners need to do
A medium secure inpatient bed costs around £185,000 a year. A general adult psychiatric bed costs somewhere between £150,000 and £200,000, depending on the trust. An emergency supported living placement arranged under pressure costs significantly more than one planned in advance and often provides worse continuity of care into the bargain.
Now consider what flexible community support costs. Depending on hours and provider, somewhere in the range of a few thousand pounds a year at the lower end, rising to maybe £20,000 to £30,000 for more intensive community packages. Even at the top of that range, we’re talking about a fraction of the inpatient cost — that allows for a person who stay in their community, maintains their tenancy, keeps their relationships intact, and doesn’t lose months of recovery progress to an admission.
The objection I sometimes hear is that you can’t prove these numbers, that you can’t know that someone would have been admitted without the support. That’s true in individual cases. But overall, the evidence is consistent. The evidence shows that strong community support reduces admissions. Bridge Back Home, our hospital-to-home service in Greenwich, has demonstrated this repeatedly, and we have the numbers to prove it.
What is ambiguous — and this is the harder problem — is who gets the savings. The cost of flexible community support sits with the local authority or community mental health budget. The saving from a prevented admission sits with the NHS inpatient budget. Those are different budget lines, sometimes different organisations entirely. It’s this misalignment that’s a structural problem in the system, and it works against the investments that would save the most money overall.
What happens when support isn’t there
I’ve seen the trend more times than I’d like. Someone is coping. Not thriving, but managing. They have some support, some structure, and some connection. Then something changes — a key worker leaves, hours get cut in a review, a relationship breaks down, or the benefits system disrupts payments. The support that was keeping things ticking over is reduced or removed at exactly the moment the person needs it most.
What follows is usually a slow deterioration. Appointments start getting missed. Medication starts getting missed. Sleep gets disrupted. Social contact is reduced. Each of these things feeds the others. By the time it becomes visible to services as a crisis, it’s been progressing for weeks.
The tragedy is that this pattern is almost always interruptible. A support worker who knows the individual, who spots the early signs, who has the flexibility to increase contact for a few weeks — that’s often all it takes. Just a few extra hours of care at just the right time by someone the person trusts.
Why does flexibility matter?
Fixed-hour care packages have their place but people’s needs don’t stay constant, they fluctuate. A person who needs eight hours a week in January might need eighteen in March and four in June. A package that can’t reflect this either over-supports people when they don’t need it or under-supports them when they do.
At Bridge, our community support is designed to flex. That means we need to be talking to commissioners about how this can be done in practice and how changes in hours are authorised, how quickly we can respond when something changes or deteriorates, and how we report on what we’re seeing so that decisions are made on the basis of real information rather than scheduled reviews.
It also means employing people who can work in that way, too. It takes training, it takes good supervision, and it takes a management structure close enough to the front line to support it in real time. The quality of flexible support depends entirely on the quality of the people providing it and the systems behind them.
The ask
I’m not making an argument for unlimited spending on community support. I’m making an argument for spending it earlier, more flexibly, and with a clearer eye on what the alternative actually costs.
If you’re a commissioner reviewing a community package and wondering whether a few extra hours are justified, I’d ask you to look at it from another perspective. The question isn’t whether the person needs those hours badly enough to qualify for them at the moment. The question is what happens if they don’t get them and things deteriorate. What does that cost? And who pays for it?
Most of the time, the honest answer to that question makes the case for preventive support more clearly than any service specification.
We’re happy to have that conversation directly, with any commissioner who wants to think through how flexible support could work for the populations they’re managing. Early conversations are almost always more useful to everyone involved. We’d love to hear from you, and you can get in touch here.
