Take action to improve mental health and reduce substance misuse

England is unusual in having a psychiatric morbidity survey[i] which shows whilst mental ill health is common prevention and treatment resources are not on a par with those for physical illnesses. For example, while 92% of people with diabetes access care, for people with common depression and anxiety, perinatal mental health conditions eating disorders, and other conditions, just around one third can access the specialist care they need. Care provided has too often been for either mind or body, rather based on the person’s specific holistic social, physical and mental health and other needs.

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Due to be published in Autumn 2020 Zero Suicide Alliance (ZSA) is working with NHS Benchmarking to provide a baseline of mental health and substance misuse services to accompany this resource.

With both this ‘take action’ document and the forthcoming NHS benchmarking resource ZSA is promoting a population approach to improving mental health and supporting people with mental ill health.

 

Primary prevention

Secondary and tertiary prevention

Supporting mentally and physically healthier populations across the life-course

When people do develop ill health ensure there is a treatment model that includes:

Health promotion

  • Community, family and individual health education and promotion
  • Life skills for better mental and physical health and citizenship

Partnership with patients/service-users

  • To design systems and individual care that works for population and person
  • To co-produce prevention measures

Local community resilience

  • Local leadership building assets and community strength. See MHF/Local Government Association Mentally Healthier Communities Handbook and Thrive city approaches in London, Bristol and West Midlands.

Early recognition and intervention services

  • In community, primary and specialist mental health

Prevention of avoidable ill health through universal and targeted ‘return on investment’ (ROI) interventions

  • Using dynamic power of digital
  • Workforce and resourcing innovation
  • Evaluating ROI and service demand reduction
  • Partnerships with local leaders and philanthropists  

Recovery-focused

  • Holistic – social, mental, physical
  • Effective evidence-based treatment

 

This section includes:

  • Primary prevention, tackling the avoidable causes of mental ill health including poverty, adverse childhood incidents, ignorance, stigma and lack of family friendly policies such as parenting support, poor employment practices and like sensible alcohol licensing, but also more…
  • Secondary prevention, supporting those at higher risk of experiencing mental health conditions (such as those who have experienced trauma) and…
  • Tertiary prevention - helping people diagnosed with mental ill health recover or stay as well as possible by providing modern accessible mental healthcare: rapid access to kind compassionate, least restrictive crisis care 24/7, early intervention services and recovery focussed rehabilitation, with a true partnership between patients and their therapists

Traditionally the NHS has been mainly in the tertiary area, responding to people who present with symptoms rather than fully using procurement, employment and estates powers to support communities, going out into those communities to educate people about mental health and identifying people who would most benefit from support.

Excellent services seek to move upstream from the traditionally tertiary area concentrated on by the NHS as well as providing rapid, compassionate, recovery-focused support. We must do more than respond to people who present with symptoms and go into the community to identify people who would benefit from support as well as creating the conditions that optimise their chance of staying well in those communities.

For understandable budgetary reasons service access thresholds have often been high, and meant that those people who do access care, often present late with more acute symptoms making recovery more challenging and costly.

Whether its cancer or mental ill health, best practice is to identify risks early and support people holistically to minimise those risks, boost protective factors and intervene with holistic treatment as soon as efficacious.

Prevention and early intervention are financially the most sustainable models, especially in mental health provision which tends to be commissioned on a block contract basis, so that reduction in demand through good preventive work does not necessarily reduce income. The NHS Long Term Plan emphasises the need to prioritise prevention. The welcome movement in acute, community and primary care to provide integrated mind and body care also means that the whole NHS can now play its part in primary and secondary prevention, especially for those with long term (physical) conditions and those who have suffered physical and mental trauma.

Support provided to deliver optimal social and clinical outcomes shares the key components:

  • Rapid access to excellent support when in crisis
  • Early intervention with effective care
  • Recovery-focused support that promotes social, mental and physical health leading to a high quality of living

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1. Ensure your JSNA recognises and prioritises mental health and substance misuse need and uses it to drive evidence-based prevention and treatment.

Effective population mental health relies on:

  • Excellent data about the population and services
  • Co-operation between services and communities
  • Commissioning and provision of evidence-based support and services

The Joint Strategic Needs Assessment (JSNA) process and complete Public Sector Equalities Duty Reports (PSEDR) on key services. The former is mandatory under the Health and Social Care Act (2013) and the latter under the Equalities Act (2010).

Done well the JSNA and PSEDRs create a shared understanding of the population served and with these two baseline pieces of information all partners can agree steps to prevent ill health and commission and provide cost-effective and evidence-based support.

The support we provide our fellow citizens should take account of the cultural, social, mental and physical needs of our population and the individual presenting. We must work to support healthy minds and bodies in healthy communities.   

For services to ensure the most appropriate support for the patient/service-user presenting they also need to understand the context, some of which is set out in the previous sections of this document, that take account of risks and protective factors.

For example, we know that experiencing racism results in poor health outcomes[i], that more than 50% of Black, Asian and Minority Ethnic (BME) people in the UK say they regularly experience racism[ii] and that Black men are more than twice as likely than their White counterparts to experience a psychotic disorder[iii], to name one example of disproportionality affecting BME people.

Therefore, it is vital that services understand the demographics of the population they serve, work with that population to reduce structural racism and other inequalities and provide support that understands discrimination related trauma.

The previous sections have been focused on ‘primary prevention’ that is: stopping mental health problems before they start and promoting good mental health for all by, for example, reducing poverty and adverse childhood events.

HWBs are statutory bodies that every upper tier local authority must host. Typically, members include senior councillors and council officers responsible for public health, children and adult social care, NHS clinical commissioning group leaders, NHS providers and community representation through Healthwatch.

HWBs are responsible for setting the strategic direction of health and care services based on the JSNA.

It is therefore vital, when seeking to reduce suicide and related risks, that the JSNA and resulting strategy takes full account of the demographic and other risks and protective factors relating to mental health and substance misuse.

Your JSNA should not just be a public health information exercise – though reliable public health data is vital – it must be ‘information for action’.

Traditionally, JSNAs are led and developed by public health leaders in each local area. Mental health trusts should be information assets to planners, by sharing knowledge about new evidence for prevention and therapies, including digital innovations and early intervention methods. These can include, from among the patients seen in services, the transgenerational levels of need, which are critical to address if mental health recovery and resilience is to be a reality. These include identified housing and support needs, training and supported employment needs, parenting and green space needs.

In addition to identifying overall levels of need, important considerations include the understanding of the local population demographics and cultures. Equitable access to services is an important goal given the levels of overrepresentation of people from BAME communities in some mental health services and in the use of the mental health act. Under law, every local organisation is required to publish a Public Sector Equalities Duty Report.

The JSNA should compare the demographic characteristics of those most at risk with your own area’s demographic data to see which groups need most focus:

  • Three quarters of deaths by suicide are of men[iv]
  • The 45 to 49-year-old age group has the highest age-specific suicide rate for both men and women[v]  
  • Despite having a low number of deaths overall, rates among the under 25s have generally increased in recent years, particularly 10 to 24-year-old females where the rate has increased significantly since 2012[vi]  
  • Suicide rates are higher among young men of Black African and Black Caribbean origin, and among middle-aged Black African, Black Caribbean and South Asian women, than among their White British counterparts.[vii]
  • Experiences of bullying and violence place LGBT+ people at more substantial risk of suicide[viii]

A good basis for JSNA data is the PHE Fingertips tool that includes Local Alcohol Profiles, Inequality Tools, Wider Determinants of Health and Mental Health data at local authority and CCG level. Having collated and analysed the most useful and accurate data that identifies need in demographic and geography terms, commission support to prevent and intervene as early as possible.

Alliance contracts between NHS, local authority and voluntary and community sector can be useful for this as everyone saves from better outcomes. In the traditional commissioning and providing split there can be ‘perverse incentives’ where those who spend do not gain the benefit and to inpatients beds are valued over good community care.

With an Alliance arrangement it is in all party’s financial interests to reduce demand by appropriately preventing and intervening earlier. The Centre for Mental Health produced a very useful report on creating the best JSNA concluding that there are eight key success factors behind the creation of an effective and impactful needs assessment:

  • Leadership: A ‘championing’ form of leadership to ensure that adequate resources (and expertise and time) are put into assessing mental health needs.
  • Purpose: An actual or perceived need for the JSNA to address a priority.
  • Engagement: Collaborative production with partners inside and outside the local authority.
  • National policy: Policy directives from national bodies having an impact on local decisions
  • Research evidence and data: Using local data and a variety of other sources to gain an accurate picture of the gaps between local need and current provision
  • Voices of experience: Ensuring that people with lived experience of mental health/dementia contribute to the understanding of local need.
  • Presentation: Ensuring that they tell a compelling story and are written in plain English.
  • Follow up: JSNAs being flexible enough to allow for updating as new data emerges.

PHE and the London School of Economics produced another report setting out the barriers and facilitators of commissioning cost-effective services for promotion of mental health and wellbeing and the prevention of mental ill health set out in summary in the table below.

Barriers

Facilitators

Fragmentation and cross-sectoral responsibility for promoting mental health and wellbeing and preventing mental ill-health

 

• Actions to build partnerships across sectors, such as co-locating staff in same premises.

• Development of cross-sectoral actions as part of health and wellbeing strategies.

• Ensure mental health central to JSNA.

 

Lack of local mental health champions or local community involvement

 

• Identify and support potential local champions and relevant local stakeholders that are interested in fostering change

Fragmentation and cross-sectoral responsibility for funding mental health and wellbeing and mental ill-health prevention

 

• Creation of pooled or shared budgets

• Dedicate funding streams for mental health promotion and mental illness prevention

 

Limited incentives in multiple sectors to invest in promotion and prevention

 

• Make use of and/or collect evidence on the benefits of better mental health for funders

• Identifying the interests of a sector and collecting information on outcomes and impacts relevant to it eg education related outcomes for schools, crime and justice

 

 

Sheffield’s JSNA is an excellently designed resource that looks carefully at a range of data to drive action for better outcomes.

There is a whole ‘communities of interest’ section which documents particular risks for various ethnic groups – this is particularly useful where there is disproportionality in outcomes such as Black Caribbean people being overrepresented in acute inpatient mental health services for example.

There is also an A-Z clearly setting out a range of factors. Under ‘A’ there is a section on alcohol, for example, that clearly sets out the current costs of alcohol in the city (currently over £200 million with £38m in NHS costs alone) the demographic and geographic location of misuse using the Local Alcohol Profiles for England and even mapping alcohol attributable mortality by statistical output areas. This is then compared with mapping of treatment provision to check if support is in the right places.

NHS and councils: take action to improve Public Sector Equalities Duty Reports (PSEDR)

Required under the Equalities Act (2010) a thorough PSEDR can help drive more equitable and higher quality support that addresses the needs of your population.

SLAM’s annual Public Sector Equalities Duty Report is an example of a report that sets out the local population profiles, languages spoken, level of access to rapid response, early intervention and recovery mental health services in both inpatient and community settings. It guides the trust’s and its partners’ commissioning of interpreters and Independent mental health advocates, culturally relevant psychological and trauma informed services, its support for employment services and physical health and medicines safety practices