A "public health approach to" ..... mental health

 last week I did a short stint at an event oriented around transforming community mental health. 

I had 10 minutes. It was rapid fire and I oriented my short slot around setting out "a public health approach" to mental health. The speaking notes are here

please steal in any way you want 

these are short form speaking notes. There are no joined up sentences!




1            why should we care about mental health

Miserable lives  ……….

Critical part of healthy life expectancy (the healthy bit and the life expectancy bit – esp wrt to early mortality of those with serious mental illness)

NHS and social care demand. 18% of need - prob a gross under estimate (13% of funding),

Economic productivity. Constraints on econ growth.  

 

2            lets be clear on what we are talking about on "transforming mental health"

Outcome 

Service demand

Need

Causes 

Causes of causes

 how far back do you go. How far upstream do you want to go. Neoliberalism and political ideologies?



Where to look on "the causes"

debt, financial cliff edge / Financial security,

hope and aspiration,

Stable Housing,

stable and safe Early childhood,

quality and quantity of education,

Community connectedness,

terms and conditions of employment, 

Psychological and cultural safety,

Underemployment,  

Civic participation

 

all above are unequally spread  - Gap = a ginormous  Social justice issue. Much to learn from other aspects of social justice (climate?) 

 

3            Framing "mental health" 

is mental health framed in a health service or whole of society context

MH problems will not be solved by adult social care. Norby more or better access to IAPT or community psychiatry. Both necessary but not sufficient 

the narrative is couched in wider determinants, the commitments are put in the framework re investment in mental health SERVICES (ie largely for people who are poorly)

….and in a framework of mental health is “something to do with the NHS”.

Comm Mental Health transformation  - the key word is HEALTH

Individual actions - of either citizens or service delivery vs social, economic context - taking the whole paradigm out of individual framework and into social context

Most mental health is done by people who aren’t “mental health professionals”

anchorage point? - Acute demand working backwards or whole of gov view work forward 

Health v illness 


 We talk about “integration” ……Integration of what ……… well beyond NHS and social care. NHS and welfare, housing, benefits, employment and well beyond 



4             Life course

Biggest impact early on. See the Heckman curve

Not too late to alter life chance later on …… lots and lots of opportunities …..

 

5            Parity of esteem 

 mental  / physical is the usual framing of this 

but also:

Children / adult

Treatment / prevention 

Not just more £ into NHS MH model, integration of “mental health” into totality of NHS (and way beyond)

 

6             No single big idea

Is the big idea

That said look at Donella Meadows and leverage points

 

7            Plenty of frameworks

Thrive NY https://mentalhealth.cityofnewyork.us/

Foresight Mental Capital

SA govt mental wellness 

Resilient Generation https://www.birmingham.ac.uk/research/impact/policy-commissions/mental-health/index.aspx

Positive family, peer, and community, relationships

Minimise adverse experiences and exclusions

Mentally friendly, education and employment

Responding early, and responding well to first signs of distress

Lessons from tobacco control  IMPOWER. Mix of service delivery to individual and structural interventions across govt and international-FCTC

covid swiss cheese model

 

8            Left shift

We all want it / We all know it makes clinical and fiscal sense (wanless and many others)

We've spent 40 years at least doing the opposite. Lancet LSE commission 

Huge vested interests and power in status quo + the challenge if the immediate vs the important

read the stuff from Burstow on chasing demand https://blogs.bmj.com/bmj/2018/09/13/paul-burstow-mental-health-time-stop-chasing-demand-start-tackling-causes/  . the dangers of demand chasing and ever investing in “treatment”.

tier 3 CAHMS vs whole school approach to emotional health and well being

We all want more prevention till it comes to paying for it

"prevention" is always "someone elses problem", I'm just too busy - a common line.  

Population coverage of right interventions, use of QI and service eval, feedback loops

 

9            Some specific areast to focus our minds on 

Housing, leisure, welfare, poverty, employment policy

ACE / Trauma informed-- individual/ service/ place design

Poverty - DWP & UC, CAB & welfare advice,

Poverty…. where the NHS in this  - 1) welfare advice, 2) advocacy, 3) housing, 4) debt

work / health agenda. Lots to be done here. Some stuff not easy. SOHAS type model. IPS type thinking

NHS largely silent on advocacy on welfare system and policy that leads to poverty.

 

10          Going forward…..NHS is about to embark on another round of reform

ICS agenda. How does it connect with prevention, and constructs outside the NHS box. 

investments in services that are essentially SDOH (CAB for eg)

should we be making welfare advice a statutory responsibly (with funding!)

operational sweetspot between NHS delivery and SDOH  - say work fitness model / occ health (IPS type of interventions)

Anchor institutions - economic power. Skills, employment, place based investing, supply chain.  

LA needs to not think of mental health as a “social care problem” - Engagement of wider strategic architecture.

How does this play out in 2 tier areas

 

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