Last month, a new Churchill Fellowship report called for a radical rethink of palliative care so people with complex mental health conditions get the care they deserve. In this blog, Dr Sarah Yardley, Associate Professor of Palliative Medicine at University College London, reflects on the real world experience and good practice to improve palliative care for people living with complex mental health conditions.
When I asked people living with complex mental health conditions what good palliative care looked like as they faced advanced, incurable, physical illness the answers were quietly devastating “I don’t fit the system”; “When they see mental illness on my notes, that’s it”; “Thank you for thinking we deserve care”.
These are not rare comments, they represent a pattern repeated across the UK, shared by people who know their needs do not neatly align with the structures meant to support them. These are people whose experiences often fall between services, whose distress is misunderstood, and whose physical health needs are overlooked until crisis forces the issue. Their stories shaped every part of my Churchill Fellowship research into how we might redesign palliative care when people are also living with complex mental health conditions.
“When people say, ‘I don’t fit the system,’ it’s the system, not the person, that must change. Rewilding healthcare means putting relationship back at the heart of palliative care.”
These conversations were not simply emotional moments; they revealed systemic truths. When healthcare fails those living in the most structurally vulnerable situations, it fails all of us. And when people with complex mental health conditions are only half as likely to have access to appropriate palliative care, and far more likely to die in hospital following multiple crisis admissions, the consequences are felt across patients, families, communities, and the wider health and care system.
Why this matters for mental health, physical health, and equality
Equally Well UK’s Charter makes a simple but profound assertion: no one should have poorer physical health or worse healthcare simply because they have a mental health condition. Yet evidence shows that people with complex mental health conditions live with longstanding inequalities. They face intersecting disadvantages such as illness, poverty, stigma, unstable housing, isolation, and they encounter systems designed around ‘part‑system efficiencies’ rather than ‘whole‑person need’. These structural vulnerabilities shape patterns of poor health, fragmented care, and reduced choice at the end of life.
The result is predictable: high levels of unplanned care, unmet distress, repeated hospitalisation, and late or absent palliative support. This is not an issue of individual behaviour or non‑engagement; it is a system‑design problem. Systems that rely on rigid criteria, linear processes, or narrow definitions of ‘safety’ often exclude those whose lives do not neatly align with those rules.
What people told me they need
Across the UK, Canada, the USA, and Australia, people described the same fundamentals when navigating serious illness alongside mental health needs:
- Relationship, not assessment, as the starting point.
- Trust, built over time and across settings.
- Choice that is meaningful and not contingent on perfect circumstances.
- Care that holds uncertainty, rather than excluding people because of it.
- Professionals who are connected to each other, not asking the person to repeatedly retell painful stories.
These are not luxuries. They are conditions for good care.
What this means for providers, commissioners, and policymakers
If the stories above show what is not working, global examples point clearly toward what can. Successful models — from Anchorage’s Nuka System to mobile palliative teams in Canada, relational coordination work in the USA, and community‑centred hospice practice in Toronto, all share one core principle: relationship is the mechanism of change.
Across these systems, positive outcomes emerged when:
- Services designed themselves as relational containers, where structures support connection instead of controlling it.
- Boundaries between teams were made more permeable so people could receive support wherever they were.
- Warm handovers enabled trusted individuals to accompany someone across settings.
- Workforce mobility and transdisciplinary collaboration reduced fear of the unfamiliar.
- Distress was assessed for everyone, not just those with a recognised mental health diagnosis.
- Systems asked, at every decision point: How can we be more relational?
These approaches did not require vast new resources, instead, they redirected effort toward what works: coherent care, reduced crisis, and better experiences for people and staff.
A call to action: what UK systems can do now
To meet Equally Well UK’s vision and commitments, and to close the physical health gap in palliative care for people with mental health conditions, we must embed relational working into policy and practice. This means:
- Make it easy to do the right thing: Simplify referral criteria and automate low‑value tasks so practitioners can respond to need rather than navigate bureaucracy. Introduce real‑time dialogue tools that allow teams to connect quickly across organisational boundaries.
- Invest in relational job design: Allocate protected time for connection, coordination, and trust‑building, 15–20% of job plans where possible, so relationship becomes expected, legitimate work.
- Use inclusion quotas and track access: Mainstream services should measure whether structurally vulnerable groups are accessing care. Targets (e.g., hospice admission quotas) can correct historic inequity and promote fairness.
- Build collective social safety: Create conditions where people, service users and professionals, are safe with each other regardless of the situation. This includes positive risk‑taking, shared judgement, community partnerships, and valuing lived experience as expertise.
- Design for whole‑system effectiveness, not part‑system efficiency: Commissioning should reward inclusion, relationship, continuity, and reduced distress — not just speed, flow, or throughput.
Where we go next
People living with complex mental health conditions are a sentinel case for system redesign. If we can get palliative care right for this population, coherent, humane, relational, and fair, we will improve it for everyone. Their stories call us to rewild healthcare: to put relationship back at the heart of systems, and to create structures that support, rather than constrain, the care people need. The question for all of us, providers, commissioners, policymakers, and communities, is not when we should work relationally. It is how we will do it, together.
Summary to connect to Equally Well’s work
People living with complex mental health conditions too often find themselves excluded from the kind of compassionate, coherent palliative care everyone deserves. Drawing on Churchill Fellowship research, this blog explores what people told us they need: relationships that come before assessment, trust built over time, meaningful choice, and care that can hold uncertainty. International examples show that when systems prioritise relational working outcomes improve without requiring vast new resources.
To meet the commitments of the Equally Well UK Charter, the UK must embed relational approaches into policy and practice. By designing for whole‑system effectiveness, building collective social safety, and making it easier to do the right thing, we can create palliative care that is equitable, humane, and truly fit for all.
Author: Dr Sarah Yardley
