Who Decides What Good Mental Health Looks Like?

5-minute read

We were in a meeting recently with the leadership team of a large mental health charity. Smart, committed people doing good work. We were talking about outcomes, about what they track and why, and someone said something that has stayed with us since: "The NHS and government want to see readmission rates drop and fewer hospital beds used. Of course we collect other data, but that’s what matters, that’s what we need to show."

They said it with confidence. And they were not wrong about what the system is asking for. But we left that meeting thinking about a different question: who decided that those were the outcomes that matter?

Because readmission rates and bed usage tell you something about how the system is performing. They do not tell you much about how people are actually doing. A person can avoid hospital and still be isolated, still be struggling, still be living a life that feels smaller than it should. A person can stay out of services entirely and that might mean they are well, or it might mean they have given up trying to get help. The numbers do not distinguish between those two things.

When charities, voluntary and third sector organisations accept the premise that system-level metrics are the ones that matter most, they are doing something they might not realise. They are handing over the power to define what good mental health looks like to the very institutions they exist to challenge.

The framing problem

Most charity, voluntary and third sector leaders we work with are clear about the limits of clinical approaches. They will tell you, quite rightly, that being overly focused on clinical supports and clinical outcomes misses the point. They will argue that community-based work has lasting impact in ways that clinical interventions alone cannot. They will point out that people spend most of their lives outside of services, and that what happens in those spaces, the relationships, the sense of belonging, the feeling of being valued, matters enormously.

All of that is true. And yet many of the same organisations, when they sit down with commissioners or funders, will track and report on outcomes that were designed by the system, for the system. Fewer A&E presentations. Shorter waiting lists. Reduced use of inpatient beds. These are metrics that tell you how well the health system is coping. They do not tell you whether someone feels hopeful about their future, whether they have people around them who care, whether they feel able to make decisions about their own life.

There is a disconnect here that is worth sitting with. Charity, voluntary and third sector organisations have become very good at articulating why community approaches matter. They have been less willing to push for the logical next step: that if community approaches matter, then community-defined outcomes should be what we measure.

What people with lived experience actually say matters

When you ask people who have experienced mental health challenges what recovery means to them, they rarely talk about readmission rates. They talk about things like feeling safe, having purpose, being part of something, being treated as a whole person, having choices, being believed. They talk about hope. They talk about connection. They talk about being able to contribute, not just receive.

These are not soft or unmeasurable things. They are well-documented in recovery literature and in the growing body of peer-led research. They can be tracked, and they should be. But they require a different starting point. They require asking people what matters to them, and then designing your measurement around those answers.

Our paper Shared Power, Shared Recovery: The Promise of Lived-Experience-Peer Leadership, written with peer leaders from twelve countries through the International Peer Leadership Network, makes this case directly. It argues that lived experience expertise must be present across every level of mental health systems: design, delivery, policy, and evaluation. That includes deciding what gets measured and why. As the paper states, if clinicians are the experts in clinical care, then people with lived experience are the experts in community care, and the outcomes they identify should carry equal weight.

This is about power. Who holds it, who sets the agenda, and who decides what counts as success.

The role charities need to play

Charity, voluntary and third sector organisations occupy a unique position in the mental health landscape. They are close to communities. They hear what people actually need. They see what works on the ground, often long before the evidence base catches up. And they are not bound by the same institutional pressures as the NHS or local government. They have more freedom to say what they see.

That freedom comes with a responsibility. Charities and third sector organisations should be the ones pushing the conversation forward, setting the agenda for what good mental health support looks like, and challenging the metrics that currently dominate. That does not mean being difficult in meetings. It means being willing to question the premise of the question. When a commissioner says "we need to reduce readmissions," a charity leader can say: "We agree that is important, and we also want to talk about what is happening for people when they are not in your services. We want to talk about what people themselves say makes a difference. And we want those outcomes to be part of how we all judge success."

This is not about rejecting what the NHS or government values. It is about expanding it. It is about saying: the system's definition of success is incomplete, and we have the knowledge and the relationships to help complete it.

Too many charity leaders go into those meetings ready to demonstrate their value in the system's terms. They prepare data on referrals and throughput and cost savings because that is what they think the room wants to hear. And they are often right, that is what the room has been set up to hear. But the room can be reset. Charities and third sector organisations that lead with what their communities are actually telling them, and present that with the same confidence and rigour as any set of KPIs, start to shift what the whole conversation is about.

What this looks like in practice

If you are a charity or third sector leader reading this and thinking "yes, but how," here are some places to start.

Involve people with lived experience in designing your outcomes framework. Before you agree with a funder or commissioner on what you will measure, bring the people you work with into that process. Ask them what change looks like from where they sit. Use their answers to shape your indicators. If a funder pushes back, that is a conversation worth having, because it reveals whose definition of success is driving the work.

Track what people say matters alongside what the system asks for. You do not have to abandon readmission data or service usage figures. But you can sit those next to indicators that come from your community: sense of belonging, feeling hopeful, having meaningful relationships, being able to make choices, feeling safe. Present both sets of data to your commissioners and funders. Over time, this normalises a broader picture of what success means.

Challenge the premise of questions in commissioning meetings. When someone frames a discussion around reducing demand on services, you can acknowledge that goal and widen it. "We want to understand not just whether people are using fewer services, but whether their lives are getting better. Those are related but they are not the same thing." Saying this clearly and calmly, with evidence, shifts the terms of the conversation.

Build your confidence in presenting community-defined evidence. The reason system-level metrics dominate is partly because they come wrapped in the language of rigour: data, dashboards, statistical significance. Community-defined outcomes deserve the same treatment. Invest in evaluation approaches that capture relational and personal change with the same seriousness. Present your findings in ways that commissioners can use. The data does not have to look clinical to be credible.

Use your advocacy voice. Many charities have become so focused on service delivery and contract compliance that they have forgotten they have an advocacy role. Your closeness to communities gives you insight that policymakers do not have. Use it. Publish what you are learning. Say publicly what you say privately about the limits of current approaches. If charities will not make this argument, who will?

This is a leadership question

I understand why charities and third sector organisations play it safe. Funding is precarious. Relationships with commissioners matter. Saying "your outcomes framework is incomplete" feels risky when your next contract depends on the person across the table. But playing it safe has a cost too. It means the sector keeps measuring what the system values and the things that people with lived experience say actually matter remain secondary, optional, nice-to-have.

The mental health system will not transform itself. The NHS will not one day wake up and decide to measure hope and belonging alongside bed occupancy. That shift has to be led by the people and organisations closest to communities, and that means charities. It means charity leaders who are willing to walk into a room and say: "We have a different view of what success looks like, and here is the evidence for it."

Our work on the Heiloo Declaration and the Shared Power, Shared Recovery paper came from peer leaders across twelve countries reaching the same conclusion independently: that a medical, diagnosis-led way of thinking about mental health has dominated for too long, and that there are centuries of community knowledge, cultural practice, and lived expertise that have been pushed aside by that dominance. The work of shifting this does not belong to peer leaders alone. It belongs to every organisation that says it believes in community-led approaches.

We also know that doing this alone feels exposed. One charity pushing back on a commissioner's outcomes framework can look like they’re being awkward. But when multiple organisations across a system start saying the same thing, when charities, peer networks, and lived experience and peer leaders are all bringing the same evidence about what actually matters to people, it stops being one voice in a room and starts being a message that’s hard to ignore. A coordinated message changes the dynamic. It gives individual organisations the confidence to say what they already believe, knowing they’re not the only ones saying it.

If you believe that what happens in communities matters more than what happens in clinics, then act like it. Measure it. Advocate for it. Lead with it. Changing what gets measured will not happen overnight. But every time an organisation walks into a room and names what their community actually values, the ground moves a little.

Habitus Collective is a lived experience-led consultancy specialising in peer support, co-production, participatory research and community engagement. We work with charities and health organisations who want to lead with community-defined outcomes. If you want to talk about how to shift this conversation in your organisation, get in touch.

Find out more about what we do by clicking the button below.