Plymouth Mental Health and Well-Being Promotion Strategy 2011
Version Control .............................................................................................. 3 Equality Impact Assessment ........................................................................ 3 Acknowledgments ......................................................................................... 3 Introduction .................................................................................................... 4 Promoting Mental Health and Well-being .................................................... 7 Why is mental health and well-being important? .................................... 7 The National Policy Context.......................................................................... 9 The determinants of mental health............................................................. 11 The evidence base for effective interventions .......................................... 13 The local position ........................................................................................ 14 Strategic Aims and Objectives ................................................................... 15 Overall aims .............................................................................................. 15 Specific aims ............................................................................................ 15 Specific Objectives .................................................................................. 16 Relating to the Local Strategic Partnership ....................................... 16 Relating to Information, Intelligence and Mapping of Activity .......... 16 Relating to the development of Mental Health Promotion ................ 16 Relating to Mental Health in the Workplace ....................................... 17 Outcomes .................................................................................................. 17 Initial Priority Actions .............................................................................. 21
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Version Control This Mental Health and Well-Being Promotion Strategy for Plymouth covers the period 2011-14. The strategy was approved by the Plymouth Mental Health Local Implementation Team and the Local Strategic Partnership Health Theme Group in June/July 2011.
Equality Impact Assessment An Equality Impact Screening Assessment will be completed as part of the supporting Action Plan.
Acknowledgments With many thanks to members of the MH LIT and wider stakeholders within mental health and mental health related services for their contributions to the development and completion of this strategy. This Strategy has been written by Sarah Lawson of the Public Health Department within NHS Plymouth.
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Introduction This strategy is a strategy for the promotion of mental health and well-being amongst people living and working in Plymouth. It sits alongside similar strategies for children and young people1 and for older people2, ensuring that a life course approach is taken to recognise the lifelong impact of poor mental health. It has been produced in recognition of the fact that promoting good mental health and well-being is an identified priority for Plymouth in “Healthy Plymouth”, the City’s Health and Social Well-being Strategy and was highlighted as a priority in the Director of Public Health Annual Report 2009/10. It has been and remains a Government priority, as outlined in “New Horizons: A shared vision for Mental Health”3 and in the latest Government’s Mental Health Outcomes Strategy.4 In producing the strategy, a public mental health approach has been taken, which seeks to make sense of the complex interplay between many social, economic and environmental factors that influence individual and community mental health and well-being. It seeks to improve mental health and wellbeing by reducing risk factors and promoting protective factors across 5 areas, as illustrated below; Figure 1:
A Public Mental Health Framework
(Source: Jo Nurse. Department of Health. 2008)
Plymouth Children and Young People’s Trust. 2009. Improving the state or our minds – a Joint Commissioning Strategy for the Emotional Well-being and Mental Health of Children and Young People in Plymouth. 2 NHS Plymouth/Plymouth City Council Adult Social Care Services. 2009. Dementia Strategy 3 HM Government 2009. New Horizons : A Shared Vision for Mental Health. 4 HM Government 2011. No health without mental health : A cross government mental health outcomes strategy for people of all ages. 1
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This approach ensures that the vast breadth of the determinants of mental health and well-being are considered and that the full potential for influencing mental health and well-being is recognised. Key to the public mental health approach is the fact that responsibility for promoting mental health and wellbeing does not lie with any one individual, organisation or sector. This strategy, therefore, has relevance to all individuals, communities, organisations and sectors in Plymouth. Everybody who lives or works in Plymouth has a role to play in improving the City’s mental health and wellbeing, by challenging the determinants that can lead to poor mental health and developing resilience to them. The public mental health approach identifies that improvements in well-being can be achieved through a wide range of evidence-based interventions, from universal measures that apply to the whole population, through to targeted approaches aimed at high risk groups and people with diagnosed mental illnesses. The provision of these interventions is within the remit of many organisations, across the public, private and voluntary and community sectors and engagement from all sectors is essential for the success of this strategy, as illustrated below; Figure 2:
Working Together for Population Mental Well-being
(Source: National Mental Health Development Unit.)
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Throughout this strategy, mental health is considered as more than just the absence of mental illness. The following definitions describe the fuller meaning of mental health: “Mental health is a positive state of mind and body, feeling safe and able to cope, with a sense of connection with people, communities and the wider environment.”5 “Mental health is the emotional and spiritual resilience which enables us to enjoy life and to survive pain, disappointment and sadness. It is a positive sense of well-being and an underlying belief in our own and other’s dignity and worth.”6 “Mental health for each person is affected by individual factors and experiences, social interaction, societal structures and resources and cultural values. It is experienced in everyday life, in families and schools, and at work. The mental health of each person in turn affects life in each of these domains and hence the health of a community or population.”7 “Mental health can be defined as the concept of a process of building a meaningful life, as defined by the people with a mental health problem themselves.” 8 Mental health promotion is taken to mean any action that enhances the mental well-being of individuals, families, organisations and communities. Mental health promotion is concerned with:
How individuals, families, organisations and communities think and feel; The factors which influence how we think and feel, individually and collectively; The impact that this has on overall health and wellbeing.
Mental health promotion works at different interconnected and interdependent levels, each of which may be relevant to the whole population, individuals at risk, vulnerable groups, or people with mental health problems. Mental health promotion programmes and interventions may do any, or all, of the following: Strengthen Individuals
Increase emotional resilience through interventions designed to promote self-esteem, and develop life skills such as communicating, negotiating, relationship and parenting skills.
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HM Government. 2009. New Horizons: A shared vision for mental health. Health Education Authority. 1997. Mental Health Promotion: A Quality Framework. 7 World Health Organization. 2004. Promoting Mental Health: Concepts, Emerging Evidence, Practice. 8 Rethink. 2007. www.rethink.org.uk 6
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Strengthen Communities
Increase social support, social inclusion and participation; improve community safety and neighbourhood environments; promote childcare and self-help networks; develop health and social services which support mental health; promote mental health within schools and workplaces e.g. through anti-bullying strategies and mental health strategies.
Reduce structural barriers to mental health
Develop initiatives to reduce discrimination and inequalities in society as a whole and to promote access to education, meaningful employment, housing, services, and support for those who are vulnerable.
Create mentally healthy environments
Improve neighbourhood environments; ensure safe, people-friendly planning, which facilitates positive social encounters; provide access to green spaces, decent affordable homes and useful, reliable and affordable transport systems. 9
Promoting Mental Health and Well-being Why is mental health and well-being important? Mental health is a growing area of concern globally, nationally and locally. Mental health problems are common and expensive at an economic, personal and community level;
1 in 6 of the adult population experiences mental ill health at any one time. For people with a learning disability this figure is 1 in 4. Mental illness accounts for 23% of the total burden of ill health in the UK and is the largest single cause of disability The NHS in England spends 13.8% of its annual budget on mental health services. Recent estimates put the annual wider economic costs of mental health problems at around £105 billion Poor mental health is both a contributor to and a consequence of wider health inequalities. It is associated with increased health-risk behaviours and increased morbidity and mortality from physical ill health Sickness absence due to mental health problems costs the UK economy £8.4 billion/year and results in 70 million lost working days each year
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Department of Health. 2001. Making it Happen: A guide to developing mental health promotion.
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In addition mental health problems cost £15 billion in reduced productivity each year due to “presenteeism” of people with mental health problems; 10 11 12 13
The benefits of mental health promotion include: 14
Improved physical health and wellbeing;
Prevention or reduction of the risk of some mental health problems; Improved health at work, increased productivity and reduced sickness absence; Assisted recovery from mental health problems; Strengthening the capacity of communities to support social inclusion, tolerance and participation, and reduce vulnerability to socio-economic stresses; Improved mental health services and quality of life for people experiencing mental health problems; Increased ‘mental health literacy’ of individuals, organisations and communities
Against a background of increasing mental health problems and illness, and at a time of severe economic difficulty and austerity in public services, the promotion of mental health and well-being is not only the right thing to do for the health of the population, but it is essential, in order to manage demand on our health and social care services. The economic case for mental health promotion is accepted in the new cross government mental health outcomes strategy, which states; “We spend a great deal of public money on dealing with the consequences of mental health problems. Much of this money could be spent more efficiently, and many of the personal, social and economic costs could be prevented, by addressing the causes of these problems and identifying and treating them if, and as soon as, they arise.” A central aim of the new national strategy is, therefore, to work towards the above and this is also central to this local strategy.
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HM Government. 2009. New Horizons: A shared vision for mental health National Mental Health Development Unit. 2008. The costs of mental ill health. 12 HM Government. 2011. No health without mental health ; A cross government mental health outcomes strategy for people of all ages 13 Sainsbury Centre for Mental Health. 2007. Mental Health at Work : developing the business case 14 Department of Health. 2001. Making it Happen: A guide to developing mental health promotion. 11
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The National Policy Context The latest Government strategy “No health without mental health” has 6 shared objectives for mental health outcomes, which are:
More people will have good mental health More people with mental health problems will recover More people with mental health problems will have good physical health More people will have a positive experience of care and support Fewer people will suffer avoidable harm Fewer people will experience stigma and discrimination
The strategy aims to enable more people of all ages and backgrounds to have better well-being and good mental health and for fewer people to develop mental health problems, by starting well, developing well, working well, living well and ageing well. The strategy accepts that timely access to evidence based interventions will deliver better mental health and so also deliver better physical health, recognising the interdependent relationship between mental and physical health. It also aims to improve public understanding of mental health and, as a result, to decrease negative attitudes and behaviours towards people with mental health problems. The strategy supports the “Time to Change” programme in challenging the stigma of mental health. It aims to empower people of all ages to live the lives they want to lead and to be able to keep themselves and their families healthy, to learn and to be able to work in safe and resilient communities. The strategy has an accompanying document outlining how to deliver better mental health for all. In the relevant sections on Working well and Living Well, which relate to working age adults, the following are listed as areas for focus:
The community and environment in which we live can strongly influence both population and individual mental health and well-being, with sustainable, connected and capable communities having better health Individuals can improve their own mental health by being enabled to e.g. drink alcohol within safe limits, take regular exercise and participate in meaningful activities Addressing mental and physical health in an integrated way delivers multiple benefits Work brings psychological and economic benefits Workplaces are proven to be effective settings for health promoting interventions
It is broadly recognised in the Government’s strategy and elsewhere that work brings other benefits of particular importance to people with a mental health problem. These include:
Social identity and status Social contacts and support A means of structuring and occupying time 9
Activity and involvement A sense of personal achievement15
These points are eloquently reinforced in a personal statement on social recovery made by local person: “I was stabilised on medication some years ago, but I remained unwell. The pills may have controlled many of my symptoms, but they did not change my life. Like most people with sever mental illness, I remained socially isolated, lacked a sense of purpose and had no structure or routine in my life. Wouldn’t that make or keep anyone unwell? Owing to this I still had a smouldering depression, was filled with anxiety and my self-esteem was at an all time low. Only when I began to engage in positive activity, receive some form of meaningful therapy and move on with my life did these “symptoms” pass. Undertaking meaningful employment really was at the heart of my recovery. It provided me with everything I was lacking.” The Government’s Public Health White Paper16 supports a broad definition of mental health and recognises the value of promoting mental health and wellbeing of the whole population and the role this plays in contributing to the wider social and economic goals and to tackling health inequalities. Mental health is accepted as a significant factor across the 5 domains outlined, which are:
Health protection and resilience Tackling the wider determinants of health Health improvement Prevention of ill health Prevention of premature deaths and reduction of health inequalities
This is reflected in the Public Health Outcomes Framework, where mental health indicators are proposed under each of these domains. The White Paper supports the life course approach to health and reinforces the importance of mental health and of dealing with mental and physical health in an integrated way. In particular it recognises that key attributes of mental well-being i.e. self-esteem, confidence and resilience, have very important impacts on health behaviours. The proposed new structures for health and public health could bring opportunities for a greater whole system approach to mental health promotion, prevention and recovery and to put mental well-being impact assessment at the heart of strategic planning to influence the determinants of mental health e.g. housing, transport, environment, education, work, welfare, and community engagement. There are a host of other existing national policies that are important in the context of mental health and well-being including: 15 16
Shepher, G. Psychiatiric Bulletin 13, 231-233. 1989. The value of work in the 1980’s HM Government 2010. Healthy Lives Healthy People: Public Health White Paper.
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Making it Possible: Improving Mental Health and Well-being (2005)  The role of local government in promoting well-being (2010)  Commissioning Mental Well-being for All: A toolkit for Commissioners (2010)  Practical Mental Health Commissioning: A framework for local authority and NHS commissioners of mental health and well-being services (2011)
The determinants of mental health The determinants of mental health are individual, social, cultural and environmental. They relate to life circumstances and to life skills. They are the same determinants as we consider for physical health as illustrated below. Figure 3: The Determinants of Health and Well-being in our Neighbourhoods
(Barton and Grant. A health map for the human environment. 2006)
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In terms of mental health, specific internal and external factors are known to have significant importance: Internal factors Poor quality relationships Feelings of isolation Experience of disharmony, conflict or alienation Physical illness, infirmity or disability Lack of self esteem External Factors Poverty and unemployment Discrimination and social exclusion Poor physical environment Negative peer pressure Experience of abuse or violence Family or community conflict or tension It has been widely established that some health determinants can protect mental health, while some can increase the risk of poor mental health. The key factors are listed in the table below. Table 1:
Risk and Protective Factors for Mental Health
Risk factors for poor mental health
Social isolation Socio-economic disadvantage Bereavement or loss Unemployment Bullying Lack of supportive relationships Existing physical or mental illness Existing physical disability Existing learning disability Social or cultural discrimination Neighbourhood violence & crime Domestic abuse Lack of accessible services or leisure opportunities Caring for someone with an illness Being a teenage or single mum Family break-up & discord Low self-esteem Unsatisfactory job or workplace relationships
Protective factors for good mental health Good social & life skills Supportive friends & family Good quality housing Accessible education & training opportunities Good social networks Feeling safe & included in the community Participation in a community group Strong cultural identity & pride Accessible leisure opportunities Good coping & problemsolving skills Opportunities for success & recognition of achievement Positive working or volunteering experiences Availability of support at major life transitions
(National Public Health Service for Wales, 2008)
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Figure 4:
A model for Mental Health Promotion Evidence Based Interventions (to strengthen protective factors and reduce risk factors)
Individual Level
Improve selfesteem Improve coping skills Improve life skills Improve physical health
Community Level
Improve social support networks Improve participation Improve access to services Improve access to activities and resources
Target Groups
Whole population Vulnerable groups e.g. people with learning disabilities People with mental health problems
Structural/Policy Level
Improve opportunities Improve income Improve equality
Settings
Communities Workplaces Media Primary Care
The above model is one that could be considered to map and structure mental health promotion activity within Plymouth.
The evidence base for effective interventions The evidence base for effective interventions to promote mental health is ever increasing. It is inappropriate to list the entire evidence base within this strategy, but the key documents that provide details of the evidence base are;
NICE Evidence Briefing 2007: Public health interventions to promote positive mental health and prevent mental health disorders among adults HM Government: No health without mental health: Delivering better mental health outcomes for people of all ages HM Government: New Horizons. Confident Communities, Brighter Futures. A framework for developing well-being. Friedli & Parsonage: Mental Health Promotion: Building an Economic Case 13
Mentality: Making it Effective – A guide to evidence based Mental Health Promotion
All interventions that are commissioned to promote mental health and wellbeing should be evidence-based and subject to rigorous, systematic and high quality evaluation. Understanding the evidence base and the economic context of mental health promotion supports the implementation of the relevant interventions, and a shift of resources from treatment to promotion, prevention and early intervention. Broad examples of areas of work that are known to be effective in improving mental health and well-being in working age adults include: Primary care Promoting exercise Social prescribing e.g. time banks, arts, learning Brief interventions to reduce alcohol intake Addressing the physical health of people with mental health problems Access to mental health professionals in GP practices Workplaces Reducing work related stress Listening to and consulting staff during periods of organisational Policies to deal with bullying and harassment Effort and reward balance Supporting staff with mental health problems to continue working Communities and Neighbourhoods Access to green and open spaces Reducing the fear of crime Access to arts and leisure activities and continued learning Open access stress management workshops
The local position The Public Health Development Unit produced an Atlas of adult mental health and related information for Plymouth in 2009. It contains useful information relating to mental health service users within the City and also modelled data on population level mental health needs. Some of the key findings in the atlas are: There is a definite social gradient present in mental health, with those living in the most deprived areas having the greatest needs and making up the majority of service users The mental health needs adjusted population for Plymouth is some 28% above that of the actual population of the City. For the South West locality, the needs adjusted population is 76.4% above that of the actual population. This means that the mental health needs of the local population are considerable and are well above that expected for a standard population of the same size.
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Weighted volumes of anti-depressants prescribed locally are above the national average (as are volumes for other commonly prescribed medications for mental health conditions) In 2008/09 5,700 Plymouth residents came into contact with the local mental health service and the cost of their care was in the region of £7.5 million.
Taking the 2010 GP register population figure of 265,860 and applying the fact that 1 in 6 adults experience mental ill health at any one time, means that in the region of 40,000 local residents could be experiencing mental ill health of some sort on any one day. It is also estimated that 15.5% of the working age population are likely to have the presence of one or more common mental health disorders at any one time, so for Plymouth, this would mean that around 28,000 people are so affected. In 2010, a total of 11,570 Plymouth residents were claiming Incapacity Benefit, not being well enough to work. Of these, 5,485 residents were claiming Incapacity Benefit because of mental health problems. 17 The above help to demonstrate the continuing and growing mental health needs of the local population.
Strategic Aims and Objectives Overall aims To ensure that everyone in Plymouth has equal opportunity to achieve positive mental health and well-being To have a mental health promotion strategy that is agreed, supported and actively implemented by all Local Strategic Partners and by organisations from the public, private, voluntary and community sectors in Plymouth, with involvement from the public and the communities in which they live To promote mental health and well-being for all, working with individuals and communities, and to combat discrimination against individuals and groups with mental health problems and promote their social inclusion Specific aims To raise the profile of mental health and well-being so that it is considered as important, in the same way, and at the same time as physical health and well-being. To tackle the stigma attached to mental illness and the discrimination and social isolation that accompany it To embed mental health and well-being promotion into all policies and activities of Local Strategic Partners, so that they deliver their services in such a way as to benefit the mental health and well-being of those they serve, or whom they have responsibility for, and to tackle stigma and discrimination at every opportunity 17
Department of Work and Pensions, Plymouth Office. May 2010 Data. (Provided by Lucy Stapleton, Job CentrePlus)
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To reduce or prevent the incidence and impact of mental and emotional distress, anxiety, mental illness and suicide To raise awareness of the determinants of mental health and well-being at public, professional and policy-making levels To raise awareness of effective practice in mental health promotion To develop and support inclusive neighbourhoods which value all their members and enable everyone to participate in decisions that affect their lives To ensure adequate support for all people to enable them to manage life stage transitions, especially the transitions from youth to adult and form work to retirement
Specific Objectives Relating to the Local Strategic Partnership To ensure mental health promotion is sustained at a strategic level amongst all Local Strategic Partners To ensure all Local Strategic Partners scrutinise the potential impact of their strategic decision on the mental health and well-being of the community they serve To build capacity for mental health promotion amongst all Local Strategic Partners, through the allocation of adequate resources and comprehensive professional development of staff To integrate the promotion of mental health and well-being into the service delivery plans of all Local Strategic Partners To ensure that mental health and physical health are fully integrated in the minds of all professionals and in the service planning and delivery of all Local Strategic Partners To identify a mental health champion within each Local Strategic Partner To promote and support the development of multi-agency approaches to mental health promotion Relating to Information, Intelligence and Mapping of Activity To ensure mental health promotion activity addresses local needs To draw upon the existing evidence base of interventions that work and to promote the development of new evidence through rigorous and systematic evaluation To build on existing good practice nationally and locally and to disseminate this at all levels To develop a local information strategy and the production of appropriate and accessible information on mental health and well-being To identify and map current work streams amongst Local Strategic Partners that contribute to mental health and well-being Relating to the development of Mental Health Promotion To integrate the promotion of mental health and well-being into all existing health promotion and improvement programmes To develop capacity and capability to enable a mental health promotion approach to wider health improvement activities 16
To ensure all mental health promotion activity is non-discriminatory and promotes inclusion To support a range of resources which promote mental health and wellbeing and challenge discrimination To undertake an annual review of mental health promotion and this strategy, and produce an annual report and action plan, to encourage reflection and continual improvement
Relating to Mental Health in the Workplace To promote mental health and well-being for all employers, employees and volunteers across the City To support staff to remain in work, where appropriate, and in returning to work following a mental health problem To encourage a positive approach amongst all local organisations to the employment of people with mental health problems To undertake an annual review of mental health promotion and this strategy, and produce an annual report and action plan, to encourage reflection and continual improvement Outcomes Within the current proposed new health and public health systems, there are Outcome Frameworks that detail outcomes which would be relevant for this strategy. The outcomes are listed below under the relevant domains of the Healthy Lives Healthy People White Paper. Vision: To improve and protect the nation’s health and wellbeing and to improve the health of the poorest fastest Proposed indicators Increasing healthy life expectancy Reducing the differences in life expectancy and healthy life expectancy between communities and groups, e.g. people with mental health problems. Domain 1: Health protection and resilience: protecting the population’s health from major emergencies and remaining resilient to harm Proposed indicator Comprehensive & agreed inter-agency plans for a proportionate response to public health incidents are in place and assured to an agreed standard. Domain 2: Tackling the wider determinants of ill health: tackling factors that affect health and wellbeing Proposed indicators Children in poverty Truancy rate
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School readiness: foundation stage profile attainment for children starting key stage 1 First-time entrants to the youth justice system Proportion of people with mental illness and/or disability in employment Proportion of people with mental illness and/or disability in settled accommodation Incidents of domestic abuse Statutory homeless households Housing overcrowding rates Fuel poverty Access and utilisation of green space Older people’s perception of community safety Rates of violent crime, including sexual violence Reduction in proven reoffending Social connectedness The percentage of the population affected by environmental, neighbour and neighbourhood noise.
Domain 3: Health improvement: helping people to live healthy lifestyles and make healthy choices Proposed indicators Smoking prevalence in adults (over 18) Rate of hospital admissions per 100,000 for alcohol-related harm Number leaving drug treatment free of drug(s) of dependence Percentage of adults meeting the recommended guidelines on physical activity (5 x 30 minutes per week) Hospital admissions caused by unintentional and deliberate injuries to 5–18-year-olds Under-18 conception rate Self-reported wellbeing. Domain 4: Prevention of ill health: reducing the number of people living with preventable ill health Proposed indicators Hospital admissions caused by unintentional and deliberate injuries to under-5-year-olds Work sickness absence rate Rate of hospital admissions as a result of self-harm Maternal smoking prevalence (including during pregnancy) Incidence of low birth weight of term babies Child development at 2–2.5 years Smoking rate of people with serious mental illness Emergency readmissions to hospitals within 28 days of discharge Health-related quality of life for older people.
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Domain 5: Healthy life expectancy and preventable mortality: preventing people from dying prematurely Proposed indicators  Suicide rate  Mortality rate of people with mental illness These outcomes could be used for the purposes of this strategy, or alternatively, specific mental health promotion measures of success that have been previously developed and used are listed below.
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Table 2:
Measuring Success of Mental Health Promotion
(Source: Care Services Improvement Partnership/NIMHE- Making it possible: Improving Mental Health and Wellbeing in England)
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Initial Priority Actions It is recommended that in the first instance the following areas are considered priority areas for action   
Tackling Stigma Assisting life stage transitions and in particular those from youth to adult and from work to retirement Local Strategic Partners acting as exemplar employers at a time of severe austerity, transitional change and severe uncertainty
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