Guilty by Omission In My Opinion...
This Is An Opinion You Decide...The Words Hypocrite Springs To Mind....
Vicky Gray
xxxxxxxx
xxxxxxx
xxxxx
25 June 2007
Andy Hull
Regeneration
Municipal Buildings
Dale Street
Liverpool
L69 2DH
Dear Andy Hull
Re: Guilty by Omission
I received a letter from Ann Gill on the 14 June 2007 concerning a welfare visit. I found the letter extremely stressful. As Head of Trading Standards and Environmental Health I would point out you have a legal duty of care towards your employees? I am currently off with depression I have stated that I do not feel able to meet Ann Gill, as I have been experiencing panic attacks. My job description states that I work for the Enforcement Co ordinator I have continued both before and during my sickness to ask that Stephanie Hudson to manage my sickness, you have full knowledge of this request. Ann Gill continues to add additional stress by insisting she is the only one who can manage my sickness. As you are aware I never signed the contract, which would make me answer directly to Business Support.
Under the Freedom of Information Act I would like to know why you tried to change my contract so that I answered directly to Business Support, when you knew I had extreme problems with Jacquie Whitefield. You stated in the meeting that I had with yourself Allan Auty and Stephanie Hudson it was what the Chief Executive’s Office wanted. The fact that I had put a Grievance in against Jacquie Whitefield and in the Grievance Jacquie Whitefield produced a job description which was nothing like my job description and claimed it was mine, which stated that I answered directly to Business Support and was similar to the new job description that I have not signed. I emailed you on the 18 January 2007 stating that I was extremely concerned about the new job description that Jacquie Whitefield had emailed to myself and other members of staff and that it had not incorporated the amendments that you had agreed to in the presence of Allan Auty and Stephanie Hudson. It did mention Enforcement Work which the staff that it was sent to have either no or limited knowledge of (myself excluded). You never did respond to that email. I am also curious to know on whose authority Jacquie acted upon when she emailed this new job description? I would like to point out that you can be guilty by Omission. In simple English by failing to act and having knowledge of inappropriate behaviour you will be found guilty in any court of law for oppressive arbitory or unconstitutional actions by members of your staff. Please remember this in all future actions or lack of actions.
Yours sincerely
Vicky Gray
Copies to: Colin Hilton
John J Kelly
Berni Turner
Warren Bradley
Jane Kennedy MP
Rt Hon Alistair Darling
_______________________________________________________________________________
In my opinion: I found this website http://www.liverpool.gov.uk/Images/tcm21-160493.pdf A few quotes from the website as I feel they may decide to remove this website…: “Create all the happiness you are able to create: remove all the misery you are able to remove. Every day will allow you to add something to the pleasure of others, or to diminish something of their pains.”
The Joint Strategic Framework
for Public Mental Health 2009–2012
Department of Public Health June 2009
Inspiration
Equality
Independence
Transformation
Picture to come
Banner located in the Main Hall, Blackburne House, Hope Street Liverpool
Mental health is the emotional and spiritual resilience, which enables us to
enjoy life and to survive pain, suffering and disappointment. It is a positive
sense of well-being and an underlying belief in our own and others’ dignity and
worth.
Health Education Authority (1997)
Mental health problems have very high rates of prevalence; they are often of
long duration, and have adverse effects on many areas of people’s lives,
including educational performance, employment, income, personal
relationships and social participation. No other health condition matches
mental ill-health in the combined extent of prevalence, persistence and breadth
of impact.
Mental health problems are more common than asthma. Up to one in six
people suffer from them over the course of their lifetime, while 630,000
people have severe mental health problems at any one time, ranging from
schizophrenia to deep depression. Beyond this, mental health has a far wider
impact on families: there are over 1.5 million carers supporting people with
mental health problems.
Rankin J, (2005) Mental Health and Social Inclusion working paper 2, IPPR/Rethink
In a survey, 84% of people with mental health problems reported feeling
isolated, compared to 29% of the general population.
MIND (2004) Not Alone? Isolation and Mental Distress: www.mind.org.uk
Communities with greater social capital can be shown to have higher levels of
good mental health.
White M, AngusJ (2003) Arts and Mental Health literature review: Centre for Arts and Humanities in medicine
Mental health promotion is both any action to enhance the mental well-being
of individuals, families, organisations and communities, and a set of principles
which recognise that how people feel is not an abstract and elusive concept,
but a significant influence on health.
Friedli L (2000) Mental Health Promotion: rethinking the evidence base Mental Health Review 5 (3) 15–18
It is easy to forget that life is lived in relationships, and the quality of those
relationships has much to do with how life turns out.
Lewis (1998)
Catherine Reynolds (principal author)
With support from the Public Mental Health
Strategy Group:
Andy Kerr
Annette James
Sandra Davies
and with contributions from:
Carole Adebayo
Judy Arslanian
Joan Bennett
Christine Beyga
Chichi Bodart
Tony Boyle
Sue Brennan
Elspeth Bromiley
Maria Cody
Michelle Cox
Jackie Crowley
Julie Curren
John Doyle
Lindsey Dyer
Gary Everett
Susie Gardiner
Julie Hanna
Sue Harvey
Mike Hogan
Louise Holmes
Simon Howes
Teresa Jankowska
Ann Keenan
Tom Knight
Shane Knott
Sarah Lyons
Trish McCormack
Sam McCumiskey
Tesa McGrath
Tommy McIllravey
Lindsey Marlton
John Marsden
Judith Mawer
Clare Mahoney
Irene Mills
Melusi Ndebele
Debbie Nelson
Lisa Nolan
Jackie Patiniotis
Alison Petrie-Brown
Rachel Plant
Taher Qassim
Phil Sadler
Alex Scott-Samuel
Jan Sloan
Gerrilyn Smith
Emma Squibb
Sally Starkey
Julia Taylor
Val Upton
Louise Wardale
Jane Weller
Gary White
Ann Williams
Duncan Young
Particular thanks to:
Jo Nurse
National Lead for Public Mental Health,
Department of Health (DH) in giving
permission to use her ‘Framework for Creating
Flourishing and Well-Being: A Public Mental
Health Approach’ (Nurse J, 2008).
Jonathan Campion
DH, for his feedback on the draft and for his
encouragement.
Jude Stansfield
Public Mental Health and Well-being Lead,
Department of Health/NHS North West; for
being a constant champion for Public Mental
Health across the region.
Andrew Cornes and Linda Richards
Designers, for their inspiration, creativity and
patience in the design of this strategy.
The Public Mental Health Strategy and its aligned Strategic Development Plan has been a
collaborative development drawing upon the strengths, insights and expertise of the following:
Acknowledgements
Foreword 1
Rationale 2
Introduction 2
Strategic Aims 3
Strategic and Operational Integration 3
Underpinning Principles 4
The Social Determinants of Mental Heath and Well-being 5
An Assets-Based approach to mental well-being 8
Mental Well-being Impact Assessment Toolkit (MWIA) 9
Population-based approaches to Mental Health and Wellbeing 10
The Centrality of the Family as a protective factor for mental well-being 11
Young Carers 13
The Economic Case for Investing in Public Mental Health 13
Black and Racial Minorities (BRM) and mental health 15
Framing Public Mental Health Policy and Practice 16
Summary 19
Demographic Trends and Needs Analysis 20
City’s Population Profile and Population Trends 20
Common Mental Health Problems 20
Summary of the Mental Health Equity Profile (2008) 21
Children and Young People 22
Older People 24
Stakeholder Participation 00
Background and context 00
Method 00
Stakeholder Mapping and Analysis 00
Identifying Levels of Participation 00
Identifying methods of participation 00
Resources and implementation 00
Public Mental Health: Commissioning for Health Improvement 00
World Class Commissioning 00
Priorities for Investment 00
Appendices 00
Contents
numbering
This strategic framework is a way of capturing new
and emerging evidence and thinking about the
relationship between individuals and society and
their mental health and well-being. It builds on the
solid foundations laid through the WHO Healthy
Cities initiative through the implementation of
Choosing Health and in the work of Integrated
Commissioning across the city in addressing the
health and social care needs of our population. This
work extends the strategic thinking that was
developed in the Joint Commissioning Strategy for
Adult Mental Health and Well-Being that set out
the relationship between poor mental health and
social exclusion and the challenges that sit with
individuals, families, communities and service
providers in enabling the process of recovery. The
strategy recognises that a consistent and coherent
approach to healthy life expectancy is required
across the life course and over time. It confirms that
for positive mental health and well-being to be a
reality in adult life, the foundations need to laid in
childhood.
Current governmental thinking in health and social
care is increasingly focusing on the need for
preventive approaches to ill health and on the
promotion of well-being. It is timely therefore that
this strategic framework for Public Mental Health is
now able to set out the rationale for building on
the developments already in place and to
strengthen both the resolve and the commitment
of commissioning organisations, their partners and
peer networks to tackle the social determinants of
mental ill-health.
The experience of 2008 has confirmed the
importance of culture in our lives. For Liverpool
residents, and for visitors, the rich variety of cultural
events has been uplifting and has reinforced the
pride Liverpudlians have in their city. The evidence is
growing that engagement in cultural activities is
good for our mental health and well-being and the
developing relationship between Liverpool PCT and
the arts signals the importance of this experience.
The city will continue to embrace change and build
upon its cultural legacy as it moves into 2010,
identified as the ‘Year of Well-Being’ and into 2011
as the ‘Year of Innovation’. The strategy reflects a
growing optimism that we can continue to change
the circumstances that constrain many people’s lives
in this city and that are significant in causing
unhappiness, distress and mental illness. We need
to make effective use of the resources that we
have, to do the things that need to be done, by
supporting people at earlier stages in their lives, by
re-enabling people to engage once more in their
hopes and aspirations and by increasing the
numbers of people who are flourishing and leading
purposeful lives.
This challenge will be met by re-affirming our
commitment to the task by the strong and vibrant
partnerships that exist across this city and by the
growing number of champions that abound in our
communities, organisations and services. Our
endeavour is perhaps best summed up by the
following quote from Ghandi…
Be the change you want to see
in the world…
Gideon Ben-Tovim
Chair LPCT
Paula Grey
Joint Director of Public Health for LPCT and LCC
Andy Hull
Director of Stakeholder Engagement LPCT
Samih Kalakeche
Director of Integrated Adult Health and Social
Care Commisioning for LCC and LPCT
1
“Create all the happiness you are able to create: remove all the misery you are
able to remove. Every day will allow you to add something to the pleasure of
others, or to diminish something of their pains.” 7
7 Bentham J in Layard J (2006) Happiness: Lessons from a New Science. British Journal of Sociology Vol 57 Issue 3 pp535–6
Foreword
This vision statement from the Sainsbury Centre for Mental Health sets a challenging goal for the
direction of this local strategy over the next six years. Promoting mental health for all provides an
opportunity to take a broader view of mental health and to consider the ‘public mental health’ i.e.
the needs of whole communities and that of the city. In particular it is about preventing the onset
of mental ill-health and promoting well-being and enabling a flourishing society. This will require
changes to the levels of investment and commissioning intentions in re-focusing interventions
‘upstream’ and thus reduce the early onset of mental health problems in childhood and their
development into, in some cases, acute mental illness. It will also require commissioning bodies to
consider ways of alleviating the burden of poor mental health that sits within this city’s population
but that remains undiagnosed and unaddressed. In other words, many people are languishing and
are struggling to cope. Current research would suggest that higher levels of the population are
‘languishing’ than was previously estimated with the effect this has on personal and social
functioning and behaviour.
This strategy and the consultation process that supports it, reflects a particular way of working that
is inclusive, empowering, evidence-based and transformational.
2
There is no health without mental health. Mental health is central to the
human, social and economic capital of nations and should therefore be
considered as an integral and essential part of other public policy areas such as
human rights, social care, education and employment. 8
Introduction
The aim of this strategy is to set out an integrated framework for mental health and well-being
for Liverpool that recognises that mental health is a whole-population issue and that it is
everyone’s business.
By 2015, mental well-being will be a concern of all public services.
Undoubtedly there will still be people who live with debilitating mental
health conditions, but the focus of public services will be on mental wellbeing
rather than on mental ill-health. 9
Rationale
Public Mental Health is the art,
science and politics of preventing
mental ill-health and inequalities
through the organised efforts of
society. 10
8 European Ministerial Conference on Mental Health: Facing the Challenges, Building Solutions (2005) WHO, Helsinki
9 The Future of Mental Health: a Vision for 2015 (2008) Sainsbury Centre for Mental Health
10 National Expert Group for Public Mental Health and Well-Being (2008)
Strategic Aims
This strategy aims to promote people’s positive
mental health and ameliorate mental distress,
through the process of earlier intervention and
recovery, by actions that:
_ enhance wellbeing
(i.e. increasing flourishing)
_ prevent mental illness from occurring
_ treat mental illness when it is present
_ enhance wellbeing
i.e. increasing flourishing; and thus
_ improve whole-population mental health;
_ challenge health and wealth inequalities that
impact negatively upon well-being; 11
_ overcome persistent barriers to social
inclusion that continue to affect those with
experience of mental health problems;
_ improve the whole-life outcomes of those
with experience of mental health problems;
_ Support and enable whole system reform.
Strategic and Operational
Integration
The challenge facing the effective
implementation of Public Mental Health is one
of integration. Integration is a key driver within
Liverpool PCT’s Commissioning Plan and relates
to the determination to provide joined up
services. This is a requirement not only of
commissioning within the PCT and City Council
but also of neighbourhood delivery:
This challenge of integrating our services to
best meet need is summed up by the phrase
‘only connect’ 13. It is only through drawing
upon the assets of individuals, groups, peer
networks, agencies and organisations that this
strategy can be made to work and bring
greatest health benefit to the city’s population.
This strategy will draw upon existing national
policy and local strategies across health, social
care and well-being to connect local plans and
commissioning intentions to local needs. In
doing so, it will strengthen strategic
commissioning through Joint Strategic Needs
Assessment and by making clear and explicit
the themes and threads that characterise Public
Mental Health (PMH), namely:
_ The need to focus on positive mental health
and creative health and well-being;
_ The mental health benefits of a healthy
lifestyle;
_ The significance of the family as a protective
factor in children’s lives;
_ The challenges presented by
transition points in people’s lives;
_ The importance of challenging the
experience of stigma and discrimination;
_ The need for advocacy and support for atrisk
individuals and groups;
_ The adoption of the recovery approach
across the spectrum of care;
_ The enabling of self-determination in the
provision of care and support.
3
11 Kagan P (2006) Making a Difference: participation and well-being. RENEW Intelligence Report.
12 A New Health Service For Liverpool: Strategic Commissioning Plan 2009-14, Liverpool PCT, 2009
13 E.M. Forster. (1910) Howards End, Edward Arnold.
It is recognised that we will need to work through local strategic partnerships
(neighbourhood partnerships for health and adult social care) at a level of the
five districts (Alt Valley, City North, Central, Liverpool East and Liverpool
South). The concept is therefore to bring together the existing resources
currently commissioned and delivered by the PCT within a local area to deliver
improved health outcomes particularly in areas where there are issues around
health inequality. 12
Underpinning Principles
The strategy is founded up the principles and
values of the Universal Declaration of Human
Rights. Human rights belong to everyone. They
are a set of basic universal standards that
govern how public authorities treat people.
This human rights-based approach (HRBA)
affirms the importance of a way of working, of
a way of relating and of a way of being that is
predicated upon the following values that
ensure that people are treated with:
_ Fairness
_ Respect
_ Equality
_ Dignity
_ Autonomy
The explicit use of human rights values and
standards in policy, planning and delivery
ensure clear accountability throughout the
strategy and its implementation. It supports
stakeholders in approaches to improving public
mental health that are empowering by
enabling meaningful participation, antidiscriminatory
practice and with specific
attention to vulnerable individuals and groups.
As an underpinning to World Class
Commissioning a HRBA provides NHS Trusts
and their partners with:
_ A practical tool to improve service delivery
_ A framework that can inspire, enthuse and
empower staff and service users
_ Actions that support other health and social
care drivers and targets
This strategy provides a focus for action
through HRB approaches that seek to balance
support for the individual and their families,
the engagement of local communities in selfdetermined
activity, and the re-orientation of
services to best meet individual and collective
needs.
In doing so, the strategy will draw upon
national and local policy drivers15, the insight
and experience of service users and carers,
from community and advocacy groups and
from our partners in the third sector, both
locally and nationally.
4
A HRBA helps to achieve good
practice… but it [also] goes above
and beyond good practice in
providing renewed quality of care
for service users, and staff are
empowered to challenge care
decisions… a HRBA defines a
common shared value base more
effectively than other guidelines
about standards of care. 14
15 Refer to Public Mental Health Strategic Action Plan 2009–12.
16 Choosing health: making health choices easier(2004) DH
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4094550
This approach is essential to promote social
inclusion, the reduction in mental ill-health, the
promotion of positive mental health,
community participation and social cohesion
and is key to the government’s public mental
health agenda16 and is best likely met by actions
and activities that can be undertaken to :
_ Promote and improve mental health through
a focus on increasing key protective factors
and reducing key risk factors. The promotion
of mental health is complementary to
improved physical health, the prevention of
mental illness and physical illness, and to
achieving improvements in the quality of life
of people experiencing mental and physical
conditions and illnesses.
_ Prevent mental health problems, mental
illness, co-morbidity and suicide, with a focus
on key risk and protective factors. This
should include a focus on the prevention of
more common mental illnesses (such as
depression and anxiety), on psychoses, and
in the interaction between mental illness and
other health conditions, such as heart
disease, cancer and diabetes and other longterm
physical conditions.
_ Support improvements in the quality of life,
social inclusion, health, equality and recovery
of people who experience mental illness, to
include further work on addressing stigma
and discrimination, recovery and on
promoting equality of opportunity in areas
such as employment, housing, education,
cultural, sporting and recreational activities.
People with a mental illness are among the
most excluded in our society17.
_ Challenge the stigma and discrimination
faced by people who experience mental
health problems by adopting a social model
of disability that incorporates mental health
problems (including those of a temporary
nature) within the mental health sector,
which refers to human rights, social inclusion
and citizenship.
The Social Determinants of
Mental Heath and Well-being
Any one individual’s mental health sits within
their life experiences of family, friends,
community and broader societal influences. This
is described as an ecological view of health and
wellbeing and is significant to our understanding
of Public Mental Health. It is a way of looking at
the relationship between our individual
experience of health and wellbeing and the
environments in which we live, work and play.
5
17 Towards a Mentally Flourishing Scotland:The Future of Mental Health Improvement in Scotland 2008-11, Scottish
Government, October 2007
18 CSDH (2008). Closing the gap in a generation: health equity through action on the social determinants of health.
Final Report of the Commission on Social Determinants of Health. Geneva, World Health Organization.
Risk factors Protective factors
• Low self-esteem
• Low self-efficacy
• Poor coping skills
• Insecure
attachment
in childhood
• Physical and
intellectual
disability
• Abuse and
violence
• Separation
and loss
• Peer rejection
• Social isolation
• Neighbourhood
violence and crime
• Poverty
• Unemployment/
economic
insecurity
• Homelessness
• School failure
• Social or cultural
discrimination
• Lack of support
services
• Positive sense
of self
• Good coping skills
• Attachment
to family
• Social skills
• Good physical
health Positive
experience of
early attachment
• Supportive caring
parents/family
• Good
communication
skills
• Supportive social
relationships
• Sense of social
belonging
• Community
participation
• Safe and secure
living environment
• Economic security
• Employment
• Positive
educational
experience
• Access to
support services
• Faith
These environments can have a potentially positive or negative impact upon our health at a
number of levels from family relationships and community safety to local and governmental policy.
The model by Dahlgren and Whitehead illustrates these social determinants of health and
wellbeing.
These determinants translate into either risk factors or protective factors for mental health (see
table on previous page). Risk factors increase the likelihood that mental health problems and
disorders will develop and their impact can influence the severity and duration of mental ill-health.
Protective factors help to enhance and protect positive mental health and wellbeing and enable
individuals to be resilient in the face of challenging life experiences.
The most significant impediment to good health, and therefore good mental health is poverty and
often the multiple deprivations and disadvantages that are part of that life experience. The WHO’s
recent final report on social determinants18 and the actions necessary to improve health equity have
identified three principles of action to enable the necessary changes to take place, namely:
_ Improve the conditions of daily life – the circumstances in which
people are born, grow, live, work, and age.
_ Tackle the inequitable distribution of power, money, and resources – the structural
drivers of those conditions of daily life – globally, nationally, and locally.
_ Measure the problem, evaluate action, expand the knowledge base, develop a workforce
that is trained in the social determinants of health, and raise public awareness about the
social determinants of health.
Fig 1 Determinants of health
Dahlgren G, and Whitehead M in the Acheson Report (1998)
6
A key focus for Liverpool PCT is to address health inequalities across the city. This determination has
been further strengthened by the Health is Wealth Commission’s report19 on the Liverpool cityregion
which acknowledges that despite recent economic growth the area continues to evidence a
disparity with regional and national comparitors showing a low life expectancy, a high percentage,
chronic illnesses and a disproportionate dependency on Incapacity Benefit. These risk factors have
been increased by the current economic recession with its impact on unemployment, indebtedness
and the cost of fuel and food. Those in the lower income groups are less cushioned against risk and
hardship.20
“Levels of mental distress among communities need to be understood less in
terms of individual pathology and more as a response to relative deprivation
and social injustice, which erode the emotional, spiritual and intellectual
resources essential to psychological wellbeing. While psycho-social stress is not
the only route through which disadvantage affects outcomes, it does appear
to be pivotal.” 21
The experience of many people living in Liverpool is still one of multiple deprivation. Socioeconomic
stress, resulting from material deprivation gives rise to poor mental health. Such stress
can have physical effects but it can have significant psychological consequences22. The evidence
demonstrates that people living in areas of deprivation with little in the way of community activity,
live with the constant experience of hardship, exhaustion and the daily grind of trying to make
ends meet. Families, in particular, that experience multiple forms of deprivation, face the greatest
hardships. In these circumstances people are prone to ill-health, accidents and relationship
breakdown.
7
19 Health is Wealth: The Liverpool City-region Health is Wealth Commission (2008)
20 Green Well Fair: Three Economies of Social Justice (2009) New Economics Foundation (NEF)
21 Friedli, L (2009) Mental health, resilience and inequalities. World Health Organisation, WHO Europe
22 Appendix 1: Socio-economic stress and its impact on health
23 Wilkinson D (1996) Unhealthy Societies. London. Routledge.
To feel depressed, cheated, bitter, desperate, vulnerable, frightened, angry,
worried about debts or job insecurity; to feel devalued, useless, helpless,
uncared for, hopeless, isolated, anxious and a failure: these feelings can
dominate people’s whole experience of life. . . . it is the chronic stress arising
from feelings which matters, not exposure to a supposedly toxic material
environment. The material environment is merely the indelible mark and
constant reminder of the oppressive fact of one’s failure and of the atrophy
of any sense of having a place in a community and of one’s social exclusion
and devaluation as a human being.23
The model provides a way of considering the
different ways in which the impact of
programmes and interventions, designed to
improve mental health and wellbeing, might be
identified and assessed through forms of
capital, namely:
_ Mental Capital24: cognitive ability and
emotional intelligence
_ Identity Capital: positive self-image,
assertiveness and confidence
_ Human Capital: knowledge, skills and
awareness
_ Social Capital: trust, reciprocity, networks
and inter-dependency
_ Economic Capital: employment, investment,
productivity
Adopting an approach to planned
interventions for mental health improvement
based upon these five forms of capital25 enables
us to view health benefit and quality of life as
related to:
_ The emotional pathways through which
deprivation impacts upon health:
_ Health benefits of participation, involvement
and reciprocity26;
_ Social support as a protective factor for both
mental and physical health:
_ An understanding of mental capital and it’s
contribution across the life course27;
_ A more inclusive model of health that
integrates the medical and social;
8
23 A relatively new concept outlined in: Foresight Mental Capital and Wellbeing Project (2008),Final Project Report -
Executive Summary. The Government Office for Science, London
25 CSIP/NIMHE (2005) Making it Possible: Improving Mental Health and Well-Being in England.
26 ‘A Prospectus for Arts and Health’, Department of Health with Arts Council England, 2007, p13–14
http://www.artscouncil.org.uk/publications/publication_detail.php?browse=recent&id=581
27 Reference Appendix 4
An assets-based approach to mental wellbeing
It is important not to frame the work in Public Mental Health solely from a needs or ill-health
perspective, whilst this is nevertheless central to the work in addressing health and wealth
inequalities. It is vital to integrate into this strategic thinking an asset-based approach to individuals
and communities across the city. This can be demonstrated in the model below which draws from
the research on health outcomes.
Public Mental Health Improvement
_ _ _ _ _
Economic Social Mental Identity Human
Capital Capital Capital Capital Capital
_ _ _ _ _
Health Outcomes
The recent report of the Government Office for
Science ‘Mental Capital through Life’28 outlines
the concept of mental capital as “…the totality
of an individual’s cognitive and emotional
resources, including their cognitive capability,
flexibility and efficiency of learning, emotional
intelligence (e.g. empathy and social
cognition), and resilience in the face of
stress.” It therefore captures those elements
that serve to establish how well an individual is
able to contribute effectively to society, cope
with life’s challenges and to experience a high
personal quality of life.
The extensive set of relationships between
mental capital, biology, culture and
environment are experienced uniquely and
individually but are dependent upon our
personal and social interactions, in particular, in
the early years (These interdependencies are
outlined in the models in the Appendix).
These help to frame not only the major
determinants of mental wellbeing and mental
capital but are indicative of the opportunities
for effective intervention and support across
the life course. By considering the various forms
of capital that are integral to individual, family
and community experience it is possible to reframe
our thinking about planned
commissioning interventions to build upon
these human and structural assets. In doing so
it helps to balance the historic needs-based, or
deficit approach, with one that acknowledges
the strengths and capabilities that already
exists within our local population.
Our deepest fear is not that we are inadequate.
Our deepest fear is that we are powerful beyond
measure. It is our light, not our darkness that
most frightens us. We ask ourselves, Who am I to
be brilliant, gorgeous, talented, fabulous?
Actually, who are you not to be? You are a child
of God. Your playing small does not serve the
world. There is nothing enlightened about
shrinking so that other people won't feel insecure
around you.
We are all meant to shine, as children do. We
were born to make manifest the glory of God that
is within us. It’s not just in some of us; it’s in
everyone.
And as we let our own light shine, we
unconsciously give other people permission to do
the same. As we are liberated from our own fear,
our presence automatically liberates others.” 29
Mental Well-being Impact
Assessment Toolkit (MWIA) 30
Within the context of an asset-based approach
it is recommended that commissioning
organisations and partners consider the
application of this approach to planned
developments.
The Toolkit has been developed as a
collaboration of many partners, including
Liverpool PCT, the Liverpool Culture Company
and IMPACT. The explicit intention in
developing this toolkit was to support policymakers,
planners, people delivering
programmes and services and people living in
communities in understanding how they
currently, and have potential to, improve the
mental well-being of those communities. Using
the toolkit will help to identify how a proposal
will impact on mental well-being and what can
be done to ensure it has the most positive
impact.
Liverpool Culture Company was the first
organisation to pilot the use of MWIA applying
this process to its cultural policies and
programmes . Subsequently, Liverpool PCT has
applied MWIA to a number of local community
projects, funded by the Big Lottery, focused on
activity and nutrition. Work has also been
developed in using MWIA in a school and a
park setting. This work is already beginning to
show results in helping to maximise the mental
health impact of these projects for
beneficiaries.
9
28 Kirkwood T, Bond J, May C, McKeith I, The M (2008) Mental capital through life: Future challenges.
Mental Capital and Wellbeing Project. Foresight, Government Office for Science
29 Williamson M (1992) ‘Our Deepest Fear’ in A Return To Love: Reflections on the Principles of A Course in Miracles.
Harper Collins
30 http://tinyurl.com/mwtphd
The process is stakeholder-based and suggests a basic framework for identifying and assessing
protective factors for mental well-being. It prompts participants, as part of the process, to consider
the following key questions in identifying mental health impact:
How does the proposed development impact on people’s control?
How does the proposed development impact on resilience and community assets?
How does the proposed development impact on participation?
How does the proposed development impact on social inclusion?
These questions reflect the essential characteristics of mental health promotion and help create a
platform for organisations to be mental health aware. The toolkit offers a resource to support
those who choose to promote mental health and it provides the business case for doing so.
Population-based approaches to Mental Health and Wellbeing
Research by Keyes 31 indicates that, across the population, the experience of ‘flourishing’ – people
who have good mental health, enthusiasm for life and who are socially engaged, represents about
17% of the population. In contrast, recent population surveys indicate that about 18% of the
population have a diagnosed mental health problem but that an additional 11% are languishing,
that is ‘a person’s life seems empty or stagnant, a life of quiet despair’. People who are languishing
do not have a diagnosed mental illness.
The Mental Health Spectrum
Keyes has also shown that ‘languishers’ are at greatly increased risk of depression and physical
disorders including cardiovascular disease 32. He also suggests that languishing may be highly
prevalent among young people, many of whom are seeking ways to fill the void of their lives. Sex,
drugs and alcohol are often used in this way, but these only deepen the void and make the person
more dysfunctional. The implications of this research for public health in general demonstrate the
understood, but not clearly articulated relationship, between poor mental health and self-injurious
lifestyles.
10
31 Keyes, C.L.M. 2002. Promoting a life worth living: Human development from the vantage points of mental illness and
mental health. In R.M. Lerner, F. Jacobs and D. Wertlieb (Eds). Promoting Positive Child,Adolescent and Family
Development: A Handbook of Program and Policy Innovations, 4:257-274. CA: Sage.
32 Keyes, C.L.M. 2004. The nexus of cardiovascular disease and depression revisited: The complete mental health
perspective and the moderating role of age and gender. Aging and Mental Health, 8:266-274.
The graphs indicate that a population approach to languishing is needed to address the potential
of this population for developing mental health problems. It would be insufficient to simply focus
on support for those already presenting with poor mental health. This demands a reinforcement of
the argument for, and the determination to increase, the range and scope of earlier interventions
across the life course. The graph below illustrates how a small improvement in population wide
levels of wellbeing will reduce the prevalence of mental illness, as well as bringing the benefits
associated with positive mental health, namely:
• by reducing the mean number of psychological symptoms in the population, many more
individuals would cross the threshold to become flourishing;
• a small shift in the mean of symptoms or risk factors would result in a decrease in the number of
people in both the languishing and mental illness tail of the distribution. 33
The rationale for this approach has been substantiated by work on the prevalence of problem
drinking both nationally and internationally 34, where a small reduction in the mean consumption
of alcohol among light or moderate drinkers will result in a substantial decrease in the prevalence
of problem drinking. 35
The effect of shifting the mean of the Mental Health Spectrum
The Centrality of the Family as a protective factor for mental well-being
A positive childhood environment can be a protective factor in a number of ways. Children who
have had a warm and secure relationship with their parents are more likely to be happy and have
better mental health and wellbeing. Early childhood experiences, particularly in the first year, also
influence later life outcomes and ability to cope with hardship and adverse life events. 36
Recent reviews on the combined effect of multiple disadvantages on outcomes for children and
families, present a correlation between the number of parent-based markers of disadvantage
experienced by a family and the impact on the full range of Every Child Matters outcomes for
children (ECM). 2% of families nationally – equivalent to 140,000 – are affected. (FACS 37)
11
33 Huppert F, (2008) State-of-Science Review: SR-X2: Psychological Wellbeing: Evidence Regarding Its Causes and
Consequences in Mental Capital and Wellbeing: Making the most of ourselves in the 21st century, Foresight
34 Rose G. 1992. The strategy of preventive medicine. Oxford: Oxford University Press.
35 Colhoun, H., Ben-Shlomo, Y., Dong, W., Bost, L. and Marmot, M. 1997. Ecological analysis of collectivity of alcohol
consumption in England: Importance of average drinker. British Medical Journal, 314:1164-1168.
36 Stansfield SA, Head J, Bartley M, Fonargy P (forthcoming) Social Position, early deprivation and the development of
attachment.
37 Families and Children Study (2005) in Reaching Out: Think Family: Analysis and themes from the Families at Risk
Review (2008) Cabinet Office. Social Exclusion Task Force.
This experience is supported by the ‘Families
and Children Study’ that focuses on
disadvantages experienced by families across a
range of areas, reflecting the cross-cutting
nature of social exclusion. These include:
_ Poverty
_ No parent is in work;
_ Family lives in poor quality
or overcrowded housing;
_ No parent has any qualifications;
_ Mother has mental health problems;
_ At least one parent has a longstanding
limiting illness, disability
(including learning disability) or infirmity;
_ Parental drug and alcohol misuse
The impact of these life experiences of
disadvantage for children are illustrated below.
Looked after children, represent a particularly
vulnerable group. Most children (62%) become
looked after as a result of abuse or neglect). A
further 20% are looked after because of family
dysfunction or distress. 39
Early care experiences have long-term
consequences for children’s health and social
development. Entering care is strongly
associated with poverty and deprivation (for
example, low income, parental unemployment,
relationship breakdown) and the outcomes
associated with deprivation often persist into
adulthood. 40 Many children and young people
who are looked after experience significant
health inequalities throughout childhood, and
on leaving care experience poor health,
educational and social outcomes.
12
0
2
4
6
8
10
12
14
16
18
Child admits
running away
from home
before
(2004)
Child spent less
than an hour on
physical activity
in last week
(2005)
In trouble
with police
last year
(2005)
Not seen friends
in last week and
never goes to
organised social
activities (2004)
Child
suspended
or excluded
in last year
(2005)
Well below
average at
English
(2005)
■ No family disadvantages
■ 1 or 2
■ 3 or 4
■ 5 or more
Children from the 5% most
disadvantaged households are
more than 50 times more likely to
have multiple problems at age 30
than those from the top 50% of
households. 38
38 Feinstein, L and Sabates, R (2006), Predicting adult life outcomes from earlier signals: Identifying those at risk, Centre
for Research on the Wider Benefits of Learning, Institute of Education, University of London
39 Department for Children, Schools and Families (2007e) Care matters: time to deliver for children in care: an
implementation plan. London: Department for Children, Schools and Families
40 Department of Health (2002) Promoting the health of looked-after children. London: Department of Health.
“Children from families with
multiple problems are at increased
risk of negative outcomes…”
Reaching Out: Think Family, Analysis and themes from
the Families At Risk Review
Multiple disavantage can cast a long shadow
Young Carers
A significant concern is for those families that
are affected by parental mental ill-health. Over
one third of all UK adults with mental health
problems are parents.
Two million children are estimated to live in
households where at least one parent has a
mental health problem but less than one
quarter of these adults is in work. Nevertheless
most parents with mental health problems
parent their children effectively. 41
Studies show that that a quarter of all women
referred for mental health treatment, have a
child under five years old. Older children
sometimes carry the responsibility as ‘young
carers’ 42 for a parent with severe and enduring
mental health problems. The number of young
carers in the UK is estimated (a likely
underestimate) to be 175,000 and of these
nearly one third care for a parent with a
mental health problem. The census evidence
also indicates that within the total population
of young carers 114,000 are between the ages
of 5–15.
The Economic Case for Investing
in Public Mental Health
There are identifiable economic benefits of
improving positive mental health e.g. below.
While the best outcomes are generally
associated with the absence of mental illness,
the presence of positive mental health brings
additional benefit.
The scale of the economic benefits of
preventing mental illness is considerable:
_ Mental health problems have very high rates
of prevalence; they are often of long
duration, and have adverse effects on many
areas of people’s lives, including educational
performance, employment, income,
personal relationships and social
participation;
_ No other health condition matches mental
ill-health in the combined extent of
prevalence, persistence and breadth of
impact;
_ Mental health problems often begin early in
life and cause disability when those affected
would normally be at their most productive
(unlike most physical illnesses).
The cost to
society of
mental ill-health
has been
calculated as
£110 billion in
2006/7. This is
greater than
the total costs
associated
with crime
across the
UK. 44
13
41 Evans J and Fowler R. (2008) Family Minded: Supporting Children in Families affected by mental illness Barnardos
42 Roberts D, Bernard M, Misca G and Head (2008) SCIE Research briefing 24: Experiences of children and young
people
43 Friedli, L & Parsonage, M (2007) Mental Health Promotion: Building an Economic Case, NIAMH
44 Ibid Friedli & Parsonage
Subjective well-being increases life expectancy by 7.5 years, provides a similar
degree of protection from coronary heart disease to giving up smoking,
improves recovery and health outcomes from a range of chronic diseases
(e.g. diabetes) and in young people, significantly influences alcohol, tobacco
and cannabis use. A positive sense of self also predicts pro-social behaviour
e.g. participation, civic engagement and volunteering. 43
Costs are described and evaluated under three
headings:
(i) the costs of health and social care, covering
such costs as the services provided by the
NHS and local authorities for people
suffering from mental health problems and
also the costs of informal care given by
family and friends;
(ii) the human costs of mental illness,
corresponding to the adverse effects of
mental illness on the health-related quality
of life; and
(iii) the costs of output losses in the economy
which result from the negative impact of
mental illness on an individual’s ability to
work.
Estimates prepared by WHO show that in the
UK mental illness now accounts for more
Disability Adjusted Life Years (DALYs) lost per
year than any other health condition. Thus the
figures for 2002, the latest available year,
indicate that 20.0% of the total burden of
disease in the UK was attributable to mental
illness (including suicide), compared with 17.2%
for cardiovascular diseases and 15.5% for
cancer. No other condition exceeded 10%. 45
Mental illness including suicide accounts for less
than 5% of all premature mortality but for over
30% of all morbidity and disability. 46
The case for prevention of mental ill-health and
the promotion of well-being is compelling from
an economic perspective alone. A snapshot of
the national picture of mental ill-health is
demonstrated in the evidence:
14
45, 46 Ibid Friedli & Parsonage
• Unemployed people are twice as likely to
suffer from depression as people in work;
• Children in the poorest households are
three times more likely to experience
mental health problems than those
children in affluent households;
• Half of the women, and a quarter of all
men, will be affected by depression at
some period during their lives;
• People who have been abused, or who
have been victims of domestic violence,
have higher rates of mental health
problems;
• Between a quarter and a half of people
using night shelters or sleeping rough may
have a serious mental health problem, and
up to half may be alcohol dependent;
• Some BRM groups are diagnosed as
having higher rates of mental health
problems than the general population;
refugees and asylum seekers are especially
vulnerable;
• Severe mental health problems such as
schizophrenia are relatively rare, affecting
one in 200 adults each year. But
depression and anxiety can affect up to
one in five of the population at any one
time with the highest rates in the most
deprived neighbourhoods;
• People with drug and alcohol problems
have higher rates of mental health needs;
• People with physical illnesses have higher
rates of mental health problems;
• Lesbian, Gay, Bisexual and Trans people
have at least twice the risk of suicide than
the general population.
Black and Racial Minorities (BRM)
and mental health
6.4 million people in England belong to ethnic
minority communities. This figure represents
about 1 in 8 of England’s population and in
Liverpool about 11.5% of the city’s population.
The ethnic minority communities in England,
as in Liverpool, share a number of features.
Disadvantage and discrimination characterise
their experiences in this country in almost all
walks of life. This is particularly true in the area
of health and health care. 47 Black, Irish and
other minority ethnic groups experience high
levels of social and material deprivation when
compared with the majority white population.
This is particularly the case for refugee and
asylum seekers. The social exclusion of minority
ethnic groups is complex and varies according
to their economic, social, cultural and religious
backgrounds.
Psychiatric illness rates are generally higher in
minority ethnic groups and they also
experience significant social adversity but have
poorer social networks and support. There are
ethnic differences in access to mental health
services. Most tellingly, there are significant
and sustained differences between the white
majority and minority ethnic
groups in experience of mental
health services and the
outcome of such service
interventions. 48
There are a range of issues that
remain challenging to the
mental health and well-being of
BRM communities across
Liverpool:
_ Populations with high rates of
socioeconomic deprivation (such as
Liverpool’s BRM population) are known to
have some of the highest need for mental
health care, but the lowest access to and
uptake of services. 49
_ Stigma against people with mental health
problems is a major problem in the BRM
community. Research has shown that stigma
and discrimination against people with
mental health problems is informed by
perceptions within the communities
themselves that there is no effective
treatment for mental disorders.
Improvements in the mental health and wellbeing
of BRM populations will be strengthened
by approaches that, for example:
_ Increase involvement of BRM communities in
the assessment of public mental health
needs 50
_ Place emphasis on identifying solutions to
community problems based on local
knowledge and priorities
_ Support cultural adaptation and tailoring of
evidence-based programmes
_ enable BRM communities to identify and
develop appropriate recovery based
indicators
15
47 Inside Outside: Improving mental health services for black and minority ethnic communities in England (2003) DH.
48 Cochrane, R. and Sashidharan, S.P (1996) Mental Health and ethnic minorities: a review of the literature and service
implications. In Ethnicity and Health: Reviews of the literature and guidance for purchasers in the area of
cardiovascular disease, mentalhealth and haemoglobinopathies. CRD Report 5 University of York, NHS Centre for
Reviews and Dissemination
49 http://tinyurl.com/211s5c
50 http://www.raceforhealth.org/members/pcts/liverpool/peer_review
Framing Public Mental Health Policy and Practice
The range of governmental policies and drivers that inform, influence and direct PMH are diverse,
and the challenge at a local level, is to create a sense of direction informing purposeful
commissioned services and interventions that strengthen protective factors and reduce risk factors
at various levels across the population.
The Public Mental Health strategy and the linked Strategic Action Plan are informed by the
framework being developed nationally for the guidance on Public Mental Health. 51
The model below demonstrates the interconnectedness of the key strategic interventions
supporting Public Mental Health:
Create Flourishing, Connected Communities
A Public Mental Health Framework for Developing Well-being
Nurse J 2008
16
51 New Horizons (2008) A Vision for Public Mental Health & Well-Being: A Public mental Health Framework for
Developing Well-Being. Working Draft, Department of Health
Promote
meaning and
purpose
......................................
Develop sustainable,
connected communities
......................................................
Integrate physical and
mental health and well-being
.....................................................................
Build resilience and a safe, secure base
...............................................................................
Ensure a positive start in life
This model provides a simple framework for
thinking about the imperatives – the actions
that need to be taken, to tackle the
impediments to people’s mental health and
well-being. It will help to focus attention on
doing more of the things that are known to
really help people cope with the ups and
downs of life.
It is evident that some of this important work
inevitably focuses on the early years where the
need to ‘ensure a positive start in life’ is a huge
protective factor for mental health through
adolescence and into adulthood. But more than
this, there is a need to connect our thinking and
actions to show the relationship between our
physical health and our mental health. It has
been acknowledged that the last governmental
White Paper: Choosing Health did not make
clear the links between how we think and feel,
our behaviour and subsequent lifestyle. The
Public Mental Health Strategic Action Plan
2009–12 will use the current evidence base to
strengthen that relationship and help inform
what still need to be addressed in this key area
of people’s well-being.
This strategic framework and action plan will
connect work being done on regeneration, on
home improvement, on issues to address fuel
poverty and on developments to support social
cohesion to tackle those factors that militate
against mentally healthy communities.
Importantly, it needs to support actions and
service developments that help those people
who may be struggling with personal or family
hardships to find help, advocacy and a listening
ear. In particular, to reach out to more of
the people experiencing distress who
show this through self-harm and for
those who are at risk of losing hope
and taking their own lives.
Ultimately Liverpool PCT and it’s
strategic partners would wish the
citizens of Liverpool to have meaning
and purpose in their lives to have
raised expectations of better health
and well-being, to have aspirations for
achievement and for more enriched
and fulfilled lives.
It is clearly understood and recognised that in
the years leading up to, and during Liverpool
08, strategic partnerships grew and developed
between the public and third sector health and
social care organisations, and the arts and
cultural sectors. ‘08’ provided the conditions for
culture and health to grow, nurturing
innovation, sustained partnerships, positive risktaking
and a willingness to ‘have a go’.
“Liverpool 08 presented a remarkable
opportunity to enable the lives we
lead, our own culture and the
culture of our neighbourhoods as
having the power to enhance our
health and well-being. Well-being is
not something that you get from
elsewhere but it is something we all
contribute to in what we do, where
we are and who we are with. This
work is about how we deliver health
and how we create the conditions
where we are enabled to be
healthy.”
Creative Communities, of which creative health
was a part, was at the heart of Liverpool 08
and the regeneration of the city. Creative
communities contributed to raised aspirations
and hope and contributed to the realisation of
public mental health.
17
18
Summary
This strategy will provide clear guidance and actions to promote positive mental health & wellbeing
52, prevent the onset of mental health problems, the amelioration of distress and the
inclusion of people, who currently, are socially excluded as a result of their experience of mental
distress. It will align strategic thinking across the life-course, for vulnerable individuals and groups,
for our families, workplaces and communities and for the population as a whole.
In summary the Public Mental Health Strategy and the Strategic Development Plan have the
following objectives:
_ To clarify the landscape of Public Mental Health and specify its key elements and their
relationships, in particular, the social determinants of mental health;
_ To adopt a systematic approach that will help to strengthen the relationship between individual
resilience and the resources available to people in securing their mental health and well-being;
_ To integrate and align current strategic needs assessments, health intelligence and plans across
the public health domain into a seamless approach to public mental health;
_ To inform commissioning intentions across the city’s strategic plans that will contribute to the
achievement of a ‘flourishing’ population 53.
_ To build capacity for Public Mental Health within the Primary Care Trust and the City Council
and through our commissioned 3rd sector organisations across the city.
_ To identify and develop those particular dimensions of mental health and well-being, as yet, not
explicitly articulated in other strategic documents for example, ‘Think Family’, health promoting
settings – workplace health 54;
_ To specify a framework for action that includes promotion, earlier intervention, prevention 55
and protection as the collective means to address mental health inequalities across the city;
_ To provide evidence of effectiveness in public mental health, so that good practice can be
acknowledged, celebrated, commissioned and replicated;
19
52 Our health, our care, our say: a new direction for community services (2006)
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4127453
53 Keyes, CLM ( 2008) A perspective from the U.S.: mental health is a complete state and not merely the absence of
mental illness symptoms or diagnoses in NIMHE Mental Health Promotion Update, January 2008, Gateway Reference
No. 9246
54 Mental health promotion involves any action to enhance the mental well-being of families, organisations or
communities. It is essentially concerned with:
• how individuals, families, organisations and communities think and feel
• the factors which influence how we think and feel, individually and collectively and
• the impact that this has on overall health and well being.
55 Prevention can be defined as:
• Primary Prevention aims to improve the mental health of communities so that people do not become ill.
• Secondary Prevention aims to identify people who are developing early signs of mental illness so that more
serious mental illness can be avoided.
• Tertiary prevention aims to prevent people who have become ill from relapsing, or helps them to recover
City’s Population Profile and
Population Trends 56
In 2001 the city’s population stood at 441,900.
Latest 2006 estimates show that this figure has
now fallen to 436,100 a reduction of 5,800
residents representing a percentage loss of
1.3%. This goes against the national trend
which shows population increasing by 2.5%.
With the exception of 2004–05, levels of
internal out migration are responsible for most
of Liverpool’s annual population decline. This
means those people leaving the City for other
locations within the UK.
The latest data now shows that if the present
trends for the City continue there will be a
further population decrease to 421,700 by 2029
a loss of 20,200 persons since 2001.
In planning and housing terms these estimates
and projections could have some major
implications for future policy. In general (and
common to other policy areas), ongoing
decline in population levels will undermine
sustainable communities through, for example,
falling patronage for shops, schools and other
community facilities.
Since 2001 there has been a decrease in the
number of children (0–15) of 11.9% and a
decrease in the retired age group (65M/60F
and above) of 4.2%, while our working age
population has risen by 2.9% (7,900). The
decrease in the child population is repeated
across all the Merseyside authorities, Core Cities
and at a national level.
The total population in 2001 was 441,900 of
which 36,600 (8.3%) was made up of BRM
groups. This has increased to 10,300 in 2005
giving a BRM population of 46.900 (10.7%)
which includes the White Irish population as
shown in Table 5 below. This represents an
increase of 28.1% from the 2001 figure which is
higher than that of England’s and the North
West which are 18.2% and 23% respectively.
The BRM population in Liverpool is the highest
on Merseyside and higher than the North West
level of 9.7%.
Common Mental Health Problems
The public health importance of common
mental health problems is demonstrated by the
finding that low levels of depression resulted in
51% more days lost from work, than major
depression6. Whereas major psychiatric
disorders such as schizophrenia (which has a
community prevalence of less than 1%) are
certainly more disabling to individual sufferers,
are more distressing for their families and
carers, their rarity means that these conditions
place less of a burden on the public health than
common mental health problems.
_ The most common mental health problems
anxiety and depression, have a combined
prevalence rate of about 18% in the
community 57
_ Around 1 in 6 of all adults reported some
form of common mental health problem 58
_ The highest regional prevalence of any
common mental health problems occurred
in the North West, with a rate of 1 in 5
_ Common mental health problems account
for one third of days lost from work due to
ill-health and 1/5 of all consultations with
general practitioners in the UK
20
56 Briefing Note to RMT/Corporate Regeneration Group, LCC, December 2007
57 Meltzer H, Gill B, Petticrew M. (1995). OPCS Surveys of Psychiatric Morbidity in Great Britain.
58 Report No 1. The prevalence of psychiatric morbidity among adults aged 16-64 living in private households in Great
Britain. HMSO: London.
59 Singleton N, Bumpstead R, O’Brien M, Less A, Meltzer H, (2001) Psychiatric morbidity among adults living in private
households, 2000. The Stationery Office: London.
Demographic Trends and Needs Analysis
The prevalence of mental health problems is
greater amongst people with the characteristics
associated with deprivation 60. There is
abundant evidence that mental health
problems tend to be concentrated in socially
disadvantaged groups within the population,
and that these groups of people have relatively
poor access to mental health care. It was also
evident that in areas defined as deprived,
admission rates to secondary care are three
times higher than the national average. In a
survey of the general population, it was found
that poverty and unemployment increase the
duration of episodes of common mental health
problems.
Compared to those with no common mental
health problems, those with common mental
health problems were more likely to:
_ be separated or divorced (twice as likely);
_ be living as a lone parent family unit;
_ be tenants of the local authority or a
housing association;
_ have a long-term limiting illness;
_ come from a lower social class;
_ be economically inactive and
_ have no formal educational qualifications
Summary of the Mental Health
Equity Profile (2008) 61
Data to support the Adult needs assessment
element of the strategy has been taken from
the Mental Health Equity Profile (MHEP) 62. The
purpose of the equity profile was to examine
equity of access to and provision of services to
meet the mental health needs of the adult
population covered by Mersey Care NHS Trust.
This rapid mental health equity profile,
repeated and updated elements of the
Merseyside Mental Health Equity Audit
undertaken in 2004.
The focus of the profile were services provided
by Mersey Care and relates to the geographical
areas served by Liverpool and Sefton PCTs and
the Kirkby area of Knowsley PCT (i.e. the area
covered by Mersey Care NHS Trust).
All levels of care (primary, secondary, tertiary)
were included in the analysis. The profile used
‘readily available’ performance measures, and
the equity analysis included the following
dimensions: geography; deprivation/socioeconomic
factors; ethnicity; age; sex.
The synopsis is provided in a tabular format
with accompanying mapped data and focuses
on the following key areas:
_ Deprivation
_ G.P. Referrals to Adult mental Health
Services
_ Caseloads with complexity (standard and
enhanced CPA)
_ Hospitalised prevalence of mental health
conditions
_ Hospitalised incidence of self-harm
_ Readmissions within 90 days of discharge
_ A & E Episodes of self-harm
_ Suicide and injury undetermined
_ Suicide amongst people under care
21
60 Rankin, J (2005) Mental Health in the mainstream
61 http://tinyurl.com/211s5c
62 Ubido, J & Lewis,C. 2008) Mental Health Equity Profile of the area served by Mersey Care NHS Trust: Interim Report,
Liverpool Public Health Observatory.
Children and Young People
Surveys suggest that clinically significant
emotional or behavioural difficulties are
restricted to a minority of children and young
people, roughly one in ten 63. Trend analysis
identifies the following as patterns in
adolescent behaviour:
_ Adolescent emotional problems (depression
and anxiety) have increased for both boys
and girls since the mid 80’s;
_ Adolescent conduct problems have showed
a continuous rise for both girls and boys for
the period 1974–1999;
_ The strength of associations between these
problems and poor outcomes in later life
have remained similar over time.
This evidence can be aligned with findings from
a collaboration research project between the
New Economics Foundation 64 and Nottingham
City Council (NCC) which undertook to measure
the well-being of young people in Nottingham
This innovative study surveyed over 1,000
children and young people in Nottingham,
aged 7–19.
_ Just over half of young people scored well
on both categories of life satisfaction and
personal development. Twelve per cent,
however, scored poorly on both.
_ In particular, nine per cent of young people
in Nottingham have ‘very low’ life
satisfaction and can be considered at very
high risk of depression. 23% of young
people who scored ‘low’ in life satisfaction
were also at risk from depression, forming a
large group of 32 % of young people in
Nottingham who are, at the very least,
unhappy in life and may be at risk of mental
health problems. 65
_ Well-being falls substantially as children get
older. When comparing 9–11 year-olds with
12-15 year-olds, average scores for life
satisfaction and curiosity fall by five per cent
and ten per cent respectively.
Some children experience a range of emotional
and behavioural problems that are outside the
normal range for their age or gender. These
children and young people could be described
as experiencing mental health problems or
disorders .Mental health professionals have
defined the problems that children and their
families can be faced with as follows:
_ emotional disorders, e.g. social phobias,
anxiety states and depression that may be
manifested in physical symptoms;
_ conduct disorders, e.g. fighting, bullying,
stealing, defiance, aggression and anti-social
behaviour;
_ hyperkinetic disorders e.g. disturbance of
activity and attention;
The symptoms listed are found, to some extent,
in most children. To count as a disorder they
have to be sufficiently severe to cause distress
to the child or an impairment in his/her
functioning.
In 2004 10% of children and young people
aged 5–16 had a clinically diagnosed mental
disorder 66. Boys are more likely to have a
mental disorder than girls. The prevalence of
mental disorders in children and young people
was greater in those who experienced, lone
families, reconstituted families, parents with no
educational qualifications, families with neither
parent working, families on low income,
families in social or privately rented housing,
families living in deprived areas.
22
63 Time Trends in Adolescent well-being (2004). The Nuffield Foundation
64 Marks N, Shah H & Westall H (2004) The power and potential of well-being indicator: Measuring young people’s
well-being in Nottingham. New Economics Foundation (nef) / Nottingham City Council.
http://www.neweconomics.org
65 This would align with findings form Corey Keyes who has identified significant levels of the population who, in terms
of their mental health and well-being, are languishing.
66 Green H, McGinnity A, Ford T & Goodman R (2004) Mental Health of Children and Young People in Great Britain, ONS
Conduct Disorders
Children and young people with conduct
disorder were more likely than other children
to be boys and be in the age range 11–16. Of
children with this disorder 24% found it harder
than average to make friends and a third found
it harder to keep friends. 59% of children with
conduct disorders were assessed as being
behind with their schooling and with 36%
being two years or more behind their peers.
About half of children with this disorder were
considered to have special educational needs.
As with children with emotional disorder,
children presenting with these behaviours had
high rates of absence from school with 22%
having truanted from school. Children’s parents
were likely to have experienced separation,
financial stress, mental illness or trouble with
the police. Similar behaviours were apparent in
these children, as with those children with
emotional disorders, particularly in respect of
substance use and suicidal ideation 67.
Hyperkinetic Disorders (HKD)
The core symptoms of this disorder are
inattention, hyperactivity and impulsivity.
Children with HKD are predominantly boys
(82%). Almost a third of children with this
diagnosis found it harder than average to make
and keep friends and scored low on a scale
measuring social aptitude. Developmental
delay in academic performance was notable
with 18% being three or more years behind
their peers.
Children with HKD were more than 4 times as
likely to have recognised special educational
needs. In common with children with other
identified disorders many had experienced
parental separation (49%), or had a parent
with a serious mental illness that required a
stay in hospital (23%). The proportions for
other children were 31% and 13% respectively.
The correlation with economic deprivation
mirrored children with other disorders with
31% coming from a household with no parent
working compared to 14%v with nondisordered
children.
Similar behaviours were apparent in these
children, as with those with emotional and
conduct disorders, in respect to substance use
and suicidal ideation 68.
Emotional Disorders
Children with emotional disorders are more
likely to be girls (54%) and to be in the age
group 11–16 (62%). Over 2/5ths of children
with an emotional disorder were behind in
their intellectual development with 23% two or
more years behind. Children with generalised
anxiety disorder and depression had the most
days away from school. 55% of children with an
emotional disorder had experienced their
parent’s separation and 28% of parents had a
serious mental illness. Young people aged 11-16
with an emotional disorder are more likely to
smoke, drink and use drugs than other children
and of concern, 28% said that they had tried to
harm or kill themselves 69.
Autistic Spectrum Disorder (ASD)
Children with ASD are predominantly boys
(82%). Unlike children with the more common
disorders, autistic children tend to have more
highly qualified parents than other children
and were slightly less likely to live in low
income families. Parents here have an unusual
combination of high educational status and
low economic activity rates that reflects their
heavy caring responsibilities. 56% of families
with autistic children were in receipt of
disability benefit.
Just under a third of children with ASD had
another recognised disorder – 16% with an
emotional disorder, usually anxiety related and
19% with conduct disorder. Over 2/3rds of
children with ASD found it harder to make and
keep friends 71% and 73% compared with 10%
and 5% of other children. 42% of autistic
children had no friends compared with 1% of
other children.
23
67, 68, 69 Ibid
Similar behaviours were apparent in these
children, as those with emotional and conduct
disorders, in respect to substance use and
suicidal ideation 70.
Findings from the Adverse Childhood
Experiences Study 71, demonstrate the
relationship between the following childhood
experiences, risk behaviours and problematic
health outcomes as a result of childhood
trauma:
_ Recurrent physical abuse
_ Recurrent emotional abuse
_ Contact sexual abuse
_ An alcohol and/or drug abuser in the
household
_ An incarcerated household member
_ Someone who is chronically depressed,
mentally ill, institutionalized, or suicidal
_ Mother is treated violently
_ One or no parents
_ Emotional or physical neglect
The ACE Study has begun to uncover how
childhood stressors are strongly correlated with
the development of poor health and well-being
outcomes throughout the life course. These
childhood experiences are related to increased
prevalence of smoking, obesity, sexual health,
alcohol, drug use depression, suicidal ideation
and attempted suicide in later life.
Older People
Older people’s mental health is an increasingly
important area of public policy.
Those in later life who have mental health
problems face age discrimination, negative
stereotyping, isolation and low income. This
combination of factors maintains their social
exclusion and increases their vulnerability to
poor physical health 72.
For some older people the transition to
widowhood, the adjustment to living alone and
the loss of close family members, friends and
neighbours feature strongly. Other important
life events include the breakdown of family
relationships, the onset of chronic health
conditions, withdrawal from the labour market,
and the experience of crime. People
interviewed in this study 73 appeared to lack
adequate support when such events occurred,
and some continued to struggle with the
impact of life transitions well after their onset.
Loss of a partner may bring in its wake other
problems such as coping with long-term illness,
financial pressures, and feelings of vulnerability
about living alone in the community. This
highlights the potential need for a new type of
preventive social policy geared towards
providing support to individuals at such turning
points in their lives.
Three million older people in the UK experience
symptoms of mental health problems that
significantly impact on quality of life and this
number is set to grow by a third over the next
15 years. 74 The range of mental health
problems experienced in later life includes
depression, anxiety, delirium, dementia,
schizophrenia and other severe mental health
problems and alcohol and drug misuse.
24
70, 71 Ibid
72 Health Education Authority 1997, Roberts et al 2002, McCulloch 2002
73 Multiple Exclusion and Quality of Life amongst Excluded Older People in Disadvantaged Neighbourhoods. Thomas
Scharf, Chris Phillipson and Allison E. Smith, Centre for Social Gerontology, Keele University, March 2004
74 Age Concern, (August 2007), Improving services and support for older people with mental health problems
Nationally:
_ Depression is the leading risk factor for
suicide. Older men and women have some
of the highest rates of all ages in the UK.
_ Delirium or acute confusion affects up to
50% of older people who have operations.
_ There are approximately 70,000 older
people with schizophrenia in the UK.
_ People aged between 55 and 74 have the
highest rates of alcohol-related deaths in the
UK.
The number of people with Alzheimer’s
dementia (AD) currently exceeds 700,000 in the
UK, which is generally considered to be an
underestimation due to under-reporting 75.
The impact of AD on the mental capital and
well-being of its many sufferers is significant.
The disease progressively causes memory to fail
and memories to fade, with eventual complete
loss of identity. The course of the disease is
unpredictable 76. Periods of rapid decline can be
followed by periods of relative stability of
cognitive function during which awareness of
the progression of the disease causes great
distress both for the individual and their
families.
The majority of patients in the UK live at home,
constantly requiring intensive care from their
spouses and children. Such circumstances have
been shown to cause sadness, grief, guilt and
anger and to increase the risk for depression
and related disorders in family members and
caregivers, thus impacting on their mental wellbeing
77.
The number of Liverpool residents aged 65 and
over is projected to grow from 64,200 in 2007
to 63,500 by 2011 and to 84,700 by 2031
(+30.7%) – 2006 based projections. Within
Liverpool the number of older people with
dementia is predicted to grow by 29.3% by
2030 based on 2006 population i.e. from 4,216
people in 2006 to 5,961 in 2030.
Liverpool has an adult BRM population which is
11.5% of the total adult population and 5.5%
of the 65+ population. Although comparatively
small the BRM community is growing and
ageing. The largest ethnic communities are,
White Other, Chinese and Black African. The
largest ageing communities are White Irish,
White other, and Chinese 78.
25
75 Alzheimer’s Society Demography Policy Position Report. 2007.
www.alzheimers.org.uk/site/scripts/documents_info.php?categoryID=200167&documentID=412.
76 Rabheru, K. 2007. Disease staging and milestones. Can J Neurol Sci, 34:S62-66.
77 Mittelman, M.S., Haley, W.E., Clay, O.J. and Roth, D.L. 2006. Improving caregiver well-being delays nursinghome
placement of patients with Alzheimer disease. Neurology, 67:1592-1599.
78 Estimated resident population by ethnic group, age and sex, mid-2006, (experimental statistics).
Background and context
The prominent place of stakeholder
participation in the development of public
mental health and mental health initiatives has
long been supported by both research and
policy. For many it has become a received
wisdom that participation itself can be a major
vehicle for increasing resilience and mental
well-being, as well as being a prerequisite of
health promotion dating back to the Ottawa
Charter of 1983 79. Involvement in governance
is held by many to be the most important way
of building social capital and developing
community cohesion. 80
The participation of stakeholders in the
development of mental health policy is nothing
new in Liverpool 81. A strong tradition of
participative activities has emerged over the
past 10–15 years. This has included:
_ Development of Joint Forum
_ Development of Patients Council
_ Development of mental health and citizen
advocacy
_ Liverpool Mental Health Awareness Project
_ Liverpool Mental Health Consortium
_ Community Empowerment Network
_ Local Involvement Networks
_ Your Community Matters structures
Many of these organisations have taken
the lead in actively promoting mental
health and well being, raising awareness
and challenging myth and stigma before
there was an explicit policy direction
from central government or from local
health and social care services.
Recent evaluations of mental health
promotion and participatory approaches
have shown, however, that the social and
psychological benefits are not always
straightforward to realise.
There is a view, for instance that barriers have
included difficulty in identifying who the
stakeholders are and a reluctance by the public
to engage with a less than popular cause 82. A
more recent study has gone further to suggest
that the social capital generated by community
participation may not be distributed equitably
across the community, creating a network
dynamic of insiders and outsiders 83.
The strategic approach, therefore, is to build on
those initiatives and structures that have
developed locally, to date, by in the light of
recent evaluations in order to find the way
forward.
Method
The degree of complexity regarding existing
networks and the problematising factors
noticed from some evaluative studies make it
necessary to identify a clear method in order to
establish a strategic approach to engagement.
This would be first of all to establish some key
principles in each of the following areas:
_ Stakeholder Mapping and Analysis
_ Identifying Levels of Participation
_ Identifying Methods of Participation
Stakeholder Participation 26
79 http://www.who.int/hpr/NPH/docs/ottawa_charter_hp.pdf
80 Friedli, L (2008), Resilient Relationships: the influence of public sector policy and practice on social support
(unpublished draft briefing paper, CSIP North West)
81 Joint Commissioning Strategy for Adult Mental Health And Well Being in Liverpool, 2008-2011,
Liverpool PCT & Liverpool City Council
82 Stacey, K, Herron, S (2002), Enacting policy in mental health promotion and consumer participation,
Australian eJournal for the Advancement of Mental Health (AeJAMH), Vol 1, Issue 1
83 Skidmore, P, Bound, K, Lownsbrough, H (2006) Community Participation: Who benefits?,
(Joseph Rowntree Foundation)
Stakeholder Mapping and Analysis
Methods of systematically approaching which individuals, groups and communities may have a
stake in policy/service development have already been identified and are outlined in the Joint
Commissioning Strategy for Adult Mental Health and Well Being in Liverpool (see diagram).
The range of stakeholders in a whole population approach must by definition be broad and varied,
but some initial categorisation as follows might be possible.
_ Everyone
_ Neighbourhood representatives
_ Members of marginalised communities
_ People who have experienced mental ill health
_ People who provide health and social care services
_ People who provide other public services (leisure, education, employment)
A systematic analysis of local groups would enable us to decide to what extent which people will
have an affinity to the aims of the strategy and/or will need to have some awareness raising or
education. Current thinking is informed by the idea of growing the ‘core economy’, namely
realising and strengthening human and social assets that belong to individuals and communities 84.
In this way older divisions that separate people and services are re-fashioned and are characterised
by a new relationship between producers and consumers of services. This idea of co-producing
public services 85, allows public service agencies to become catalysts and facilitators, working
through peer support networks, to better define and meet people’s needs.
27
84 Green Well Fair: Three Economies for Social Justice (2009) New Economics Foundation (NEF)
85 Co-production: A manifesto for growing the core economy (2008), New Economics Foundation (NEF)
Keep satisfied
Engage closely
and influence
actively
Monitor
(minimum effort)
Keep informed
High
Power
Low
Low Interest High
Identifying levels of participation
The implementation of any policy will require
action at a variety of levels and settings. In
public health these have been identified as:
_ Information. The least you can do is tell
people what is planned.
_ Consultation. You offer a number of options
and listen to the feedback you get.
_ Deciding together. You encourage others to
provide some additional ideas and options,
and join in deciding the best way forward.
_ Acting together. Not only do different
interests decide together what is best, but
they form a partnership to carry it out.
_ Supporting independent community
initiatives. You help others do what they
want – perhaps within a framework of
grants, advice and support provided by the
resource holder. 86
Accepting that people will engage according to
their interests, circumstances and skills it will be
important not only to provide a range of
engagement activities, but also to evaluate
levels of engagement to ensure that network
dynamics are managed and a system of insiders
and outsiders does not occur. 87
Identifying methods of
participation
Having established the levels of connectedness
of key stakeholders it becomes possible to find
vehicles for engagement that will be
appropriate to their interests and
circumstances, enabling stakeholders to be
involved in a level that is appropriate to them.
Some methods of engagement are summarised
in the recent Rethink 88 campaign report
(although there are a plethora of varied
techniques available to enable communities
and groups to participate in policy
development). 89 The issue will be to connect
people with the appropriate group.
Resources and implementation
As previously observed, there already exist
resources dedicated to community and
stakeholder engagement both within Liverpool
PCT, as well as Local Involvement Networks and
Community Empowerment Networks, as well
as Liverpool Mental Health Consortium, which
specifically focuses on mental health issues.
A strategic approach would be increase the
profile of the public mental health within these
structures in order to:
_ identify any increased levels of capacity
necessary to support co-ordination
_ evaluate the impact that stakeholder
participation will have both on policy
implementation and on the well being of
the citizens of Liverpool.
28
86 http://www.partnerships.org.uk/pres/fitlog/sld007.htm
87 Skidmore, P, Bound, K, Lownsbrough, H (2006), op cit
88 TIME TO CHANGE (2008) Stigma Shout: service user and carer experiences of discrimination Rethink
89 For a full discussion of principles of participation and an A-Z of how to put theory into practice visit
http://www.partnerships.org.uk
This strategy supports whole systems thinking
in the management of change and system
reform and sees this approach as fundamental
to the meeting of population mental health
needs through integrated commissioning.
Whole system reform characterises the mental
health economy and this presents significant
challenges in managing this constant dynamic.
Managing the implementation of government
policy across well-being, health and social care,
community regeneration and social inclusion at
a local level requires an overarching strategic
approach so that change becomes purposeful,
manageable and coherent. The focus according
to Darzi will need to give:
World Class Commissioning
National consultations 90 have confirmed the
importance that mental health and well-being
has for the public and this is strengthened by
the extensive research evidence that supports
this strategy. The introduction of World Class
Commissioning offers many opportunities to
improve the mental health and well-being of
our local population through earlier
interventions.
The determination to intervene earlier confirms
the vision statement from DH that world class
commissioning will be ‘pivotal in shifting the
focus of care from diagnosis and treatment to
prevention and well-being’ 91. Consideration will
need to be given to longer-term commissioning
plans and intentions to realise this objective
and to maintain a developing equilibrium
between newly commissioned services for
earlier intervention and those that provide
treatment, care support and recovery pathways
for those experiencing mental illnesss.
29
A successful public mental health strategy requires long-term commitment,
multi-agency working and co-ordination, as well as a sense of common
purpose from all stakeholders in Liverpool.
Greater emphasis on prevention
and the responsibility individuals
have themselves. Unhealthy choices
and missed prevention
opportunities are in part the cause
of the growth in the prevalence of
conditions such as diabetes,
depression, and chronic obstructive
pulmonary disease. Working with
their local partners, every primary
care trust will commission
comprehensive wellbeing and
prevention services.
Even with optimal services in place
only 40% of the burden of mental
illness is averted – the need and
determination for the commissioning
and implementation of prevention
services is paramount. 92
90 Our Health, Our Care, Our Say (2007) DH
91 Department of Health (2008) DH/Commissioning, World Class Commissioning. Vision Summary
92 O’Hara K, Stansfield J, Crowson T (2008) World Class Commissioning for improved mental health and well-being in
NIMHE Mental Health Promotion Update. April. Gateway No 9700 pp 10–12
Commissioning for Health Improvement
The saving in costs, (both human and
economic) by reducing, for example, conduct
disorder and in promoting positive mental
health in children through earlier intervention
is evidenced below:
_ Preventing conduct disorders in those
children who are most disturbed would save
around £150,000 per case in lifetime costs
_ Promoting positive mental health in those
children with moderate mental health
would yield benefits over the life course of
around £75,000 per case 93
_ In comparison the intervention cost, per
child, for parenting programmes would be
in the range £1,350 to £6,000.
Using the World Class Commissioning
framework of 11 competencies the table on the
next page outlines how these competencies
relate to key actions for Liverpool PCT and for
the role of Public Mental Health specialists and
partners in this field as ‘Agents for Change’
within the local health economy 94. This helps to
clarify organisational, departmental and
individual objectives in support of public
mental health improvement. It recognises that
World Class Commissioning is a collective
endeavour and not a singular activity and as
such is way of working that relates the parts to
the whole.
30
93 Friedli L (2008) mental Health Promotion: The Economic Case for Investment. In in NIMHE Mental Health Promotion
Update. April. Gateway No 9700 pp 13–14
94 O’Hara K, Stansfield J, Crowson T (2008) World Class Commissioning for improved mental health and well-being in
NIMHE Mental Health Promotion Update. April . Gateway No 9700 pp 10–12
95 Feast D (2008) World Class Commissioning in NIMHE Mental Health Promotion Update. April . Gateway No 9700 pp
15–16
It is unlikely that all the skills
required to achieve World Class
Commissioning performance
already fully exist in any one
organisation. PCT’s, Local
Authorities and wider public service
partners need to work together to
maximise each organisations
contribution to commissioning the
best outcomes for people. 95
31
World-class Commissioning
Vision and Competencies
Role of Public Mental Health Specialists
1 World class commissioners are recognised as the
local leader of the NHS.
Provide leadership for mental health improvement
and build capabilities of colleagues and
stakeholders.
2 World class commissioners work collaboratively
with community partners to commission services
that optimise health gains and reductions in
health inequalities.
Engage key partners in the Public Mental Health
Strategy; integrate mental health promotion across
other health & social care programmes e.g.
improving mental health and well-being of people
with physical illness and long-term conditions;
ensure the needs of people with mental health
problems are addressed within Tackling Health
Inequalities strategies and programmes.
3 World class commissioners proactively seek and
build continuous and meaningful engagement
with the public and patients, to shape services
and improve health.
Advise on and facilitate opportunities for
meaningful engagement; support inclusion of
people with mental health problems into
engagement processes.
4 World class commissioners lead continuous and
meaningful engagement with clinicians to inform
strategy, and drive quality, service design, and
resource utilisation.
Facilitate clinical engagement and support service
improvement in mental health promotion and in
services attaining Care Quality Commission public
health core standards.
5 World class commissioners manage knowledge
and undertake robust and regular needs
assessments that establish a full understanding
of current and future local health needs and
requirements.
Provide advice and expertise to designing and
conducting JSNA that incorporates mental health;
facilitate community needs assessment exercises.
6 World class commissioners prioritise investment
according to local needs, service requirements
and the values of the NHS.
Develop, implement and monitor robust public
mental health strategies, based on need and
stakeholder ownership, that identify priorities for
investment.
7 World class commissioners effectively stimulate
the market to meet demand and secure required
clinical, and health and well-being outcomes.
Build capacity and capability of providers of mental
health improvement interventions; build
knowledge and capability of third sector providers
in evaluating service mental health outcomes.
8 World class commissioners promote and specify
continuous improvements in quality and
outcomes through clinical and provider
innovation and configuration.
Keep up-to-date with emerging good practice
nationally and internationally; explore, develop
and evaluate innovative and creative practice.
9 World class commissioners effectively manage
systems and work in partnership with providers
to ensure contract compliance and continuous
improvements in quality and outcome.
Agree local mental health and well-being outcomes
and indicators and methods for measurement.
10 World class commissioners make sound financial
investments to ensure sustainable development
and value for money.
Develop sustainable practice and partnerships;
keep abreast of emerging evidence based practice;
build links with researchers and economists to
identify, support and influence cost effective
solutions.
Priorities for Investment in Public
Mental Health
Evidence from Friedli 96 confirms the following, as
actions and commissioned activities that can
improve population mental health. The WHO
report, re-affirms the significance of mental
health as crucial to our thinking about sustainable
economic growth and in achieving greater social
cohesion in the face of economic change.
1 Social, cultural and economic conditions that
support family life
• systematically work to reduce child poverty
• support parents and the development of
children in early years through parenting
skills training and high quality pre-school
education
• strengthen inter agency partnerships to
reduce violence and sexual abuse
• increase access to safe places for children to
play, especially outdoors
• make the business case for good work/life
balance and provide adequate
• maternity and paternity leave
2 Education that equips children to flourish
both economically and emotionally
• increase uptake of the health promoting
schools approach, involving teachers, pupils,
parents and the wider community
• support parents to improve the home
learning environment (HLE)
• value social, sports and creative
achievements, as well as academic
performance
3 Employment opportunities and workplace
pay and conditions that promote and
protect mental health
• support efforts to improve pay, working
conditions and job security, notably for the
most vulnerable workers
• make the business case for improving job
control, social support and effort/reward
imbalance
• early referral to workplace based support for
employees experiencing psychiatric
• symptoms or personal crises to avert
employment breakdown
4 Partnerships between health and other
sectors to address social and economic
problems that are a catalyst for
psychological distress
• improve access to non medical sources of
support through social
prescribing/community referral or co
production models e.g. timebanking, to
address basic skills, housing/transport
problems, debt, isolation, limitations in daily
living, opportunities for arts, leisure and
physical activity etc.
5 Reducing policy and environmental barriers
to social contact
• policy responses to personal misfortune e.g.
poverty, unemployment and other
• adversity should not stigmatise or blame the
victims
• develop community transport schemes
• promote volunteering and develop ‘social
outcome’ indicators
• work with planners to introduce/re-introduce
‘stop and chat’ public spaces
• ensure that public spaces such as shopping
malls do not exclude specific groups,
• for example teenagers.
These areas for development are reflected, in
part, in both current achievements and
emerging activity detailed in the Public Mental
Health Strategic Action Plan 2009–12. The
action plan is structured around the three key
imperatives of the strategy, namely:
_ enhance wellbeing
(i.e. increasing flourishing)
_ prevent mental illness from occurring
_ treat mental illness when it is present
32
96 Friedli, L (2009) Mental health, resilience and inequalities. World Health Organisation, WHO Europe
In addition a number of themes have been used to organise and support the Action Plan that have
been informed by the following model developed by Nurse 97.
The Action Plan is integral to the strategic framework and will be a ‘living and working document’
that over the next three years will enable the continuous review and refinement of Public Mental
Health priorities and commissioning intentions within the strategic and operational planning
procedures of Liverpool 1st, Liverpool PCT and Liverpool City Council, its third sector partners and
stakeholder groups.
This development process will reflect a history of effective stakeholder engagement that has been
held up as a model of best practice within the North West Region. In doing so, it will continue to
reach out to its various constituencies by demonstrating that ‘mental health is everyone’s business’.
It will affirm that mental health is fundamental to our well-being. It underpins everything we do,
how we think, feel and behave. It is an essential and precious resource that needs to be protected,
promoted and improved. As such, it sits as much with us as individuals as it does with our families,
communities, our services and our civic responsibilities.
It is perhaps fitting, that in conclusion, it is in the brevity of the following statement that our sense
of direction lies:
“Tend to the social and the individual will flourish.” 98
Catherine Reynolds
Strategic Lead: Public Mental Health
Department of Public Health
Liverpool PCT
33
97 Nurse J (2008) ‘Create Flourishing Connected Communities: A Public Mental Health Framework for Developing Wellbeing.
DH
98 Rutherford J (2008) The culture of capitalism. Soundings: journal of culture and politics 38: 8–18.
(http://www.lwbooks.co.uk/journals/soundings/articles/02%20s38%20%20rutherford.pdf).
Promote
meaning and
purpose
......................................
Develop sustainable,
connected communities
......................................................
Integrate physical and
mental health and well-being
.....................................................................
Build resilience and a safe, secure base
...............................................................................
Ensure a positive start in life
Appendix 1 34
35
36
nef’s ‘Five ways to well-being’
37 Appendix 2
Mental Capital and Well-Being: Making the Most of Ourselves in the
21st Century (2008) Foresight, Government Office for Science
Appendix 3 38
39
40
41
42
 |
| GUILTY BY OMISSION.....YOU DECIDE |
I was extremely disappointed that someone who can treat a fellow human being with a lack of compassion and understanding of their illnesses can have the audacity to have their name associated with mental health issues…. Yet another self-promotion for the Hull…I sent the following letter to Hull in 2007…It apparent from the letter I was suffering from a break down the response to the letter was for one of Hull’s henchwomen (Gill) to respond and threaten me with disciplinary action for breaking Council rules on contacting elected members. No time to heal after major post elective surgery just additional bullying. Then this man promotes the health of the Liverpool people…a very sick joke.
Vicky Gray
xxxxxxxx
xxxxxxx
xxxxx
25 June 2007
Andy Hull
Regeneration
Municipal Buildings
Dale Street
Liverpool
L69 2DH
Dear Andy Hull
Re: Guilty by Omission
I received a letter from Ann Gill on the 14 June 2007 concerning a welfare visit. I found the letter extremely stressful. As Head of Trading Standards and Environmental Health I would point out you have a legal duty of care towards your employees? I am currently off with depression I have stated that I do not feel able to meet Ann Gill, as I have been experiencing panic attacks. My job description states that I work for the Enforcement Co ordinator I have continued both before and during my sickness to ask that Stephanie Hudson to manage my sickness, you have full knowledge of this request. Ann Gill continues to add additional stress by insisting she is the only one who can manage my sickness. As you are aware I never signed the contract, which would make me answer directly to Business Support.
Under the Freedom of Information Act I would like to know why you tried to change my contract so that I answered directly to Business Support, when you knew I had extreme problems with Jacquie Whitefield. You stated in the meeting that I had with yourself Allan Auty and Stephanie Hudson it was what the Chief Executive’s Office wanted. The fact that I had put a Grievance in against Jacquie Whitefield and in the Grievance Jacquie Whitefield produced a job description which was nothing like my job description and claimed it was mine, which stated that I answered directly to Business Support and was similar to the new job description that I have not signed. I emailed you on the 18 January 2007 stating that I was extremely concerned about the new job description that Jacquie Whitefield had emailed to myself and other members of staff and that it had not incorporated the amendments that you had agreed to in the presence of Allan Auty and Stephanie Hudson. It did mention Enforcement Work which the staff that it was sent to have either no or limited knowledge of (myself excluded). You never did respond to that email. I am also curious to know on whose authority Jacquie acted upon when she emailed this new job description? I would like to point out that you can be guilty by Omission. In simple English by failing to act and having knowledge of inappropriate behaviour you will be found guilty in any court of law for oppressive arbitory or unconstitutional actions by members of your staff. Please remember this in all future actions or lack of actions.
Yours sincerely
Vicky Gray
Copies to: Colin Hilton
John J Kelly
Berni Turner
Warren Bradley
Jane Kennedy MP
Rt Hon Alistair Darling
_______________________________________________________________________________
In my opinion: I found this website http://www.liverpool.gov.uk/Images/tcm21-160493.pdf A few quotes from the website as I feel they may decide to remove this website…: “Create all the happiness you are able to create: remove all the misery you are able to remove. Every day will allow you to add something to the pleasure of others, or to diminish something of their pains.”
The Joint Strategic Framework
for Public Mental Health 2009–2012
Department of Public Health June 2009
Inspiration
Equality
Independence
Transformation
Picture to come
Banner located in the Main Hall, Blackburne House, Hope Street Liverpool
Mental health is the emotional and spiritual resilience, which enables us to
enjoy life and to survive pain, suffering and disappointment. It is a positive
sense of well-being and an underlying belief in our own and others’ dignity and
worth.
Health Education Authority (1997)
Mental health problems have very high rates of prevalence; they are often of
long duration, and have adverse effects on many areas of people’s lives,
including educational performance, employment, income, personal
relationships and social participation. No other health condition matches
mental ill-health in the combined extent of prevalence, persistence and breadth
of impact.
Mental health problems are more common than asthma. Up to one in six
people suffer from them over the course of their lifetime, while 630,000
people have severe mental health problems at any one time, ranging from
schizophrenia to deep depression. Beyond this, mental health has a far wider
impact on families: there are over 1.5 million carers supporting people with
mental health problems.
Rankin J, (2005) Mental Health and Social Inclusion working paper 2, IPPR/Rethink
In a survey, 84% of people with mental health problems reported feeling
isolated, compared to 29% of the general population.
MIND (2004) Not Alone? Isolation and Mental Distress: www.mind.org.uk
Communities with greater social capital can be shown to have higher levels of
good mental health.
White M, AngusJ (2003) Arts and Mental Health literature review: Centre for Arts and Humanities in medicine
Mental health promotion is both any action to enhance the mental well-being
of individuals, families, organisations and communities, and a set of principles
which recognise that how people feel is not an abstract and elusive concept,
but a significant influence on health.
Friedli L (2000) Mental Health Promotion: rethinking the evidence base Mental Health Review 5 (3) 15–18
It is easy to forget that life is lived in relationships, and the quality of those
relationships has much to do with how life turns out.
Lewis (1998)
Catherine Reynolds (principal author)
With support from the Public Mental Health
Strategy Group:
Andy Kerr
Annette James
Sandra Davies
and with contributions from:
Carole Adebayo
Judy Arslanian
Joan Bennett
Christine Beyga
Chichi Bodart
Tony Boyle
Sue Brennan
Elspeth Bromiley
Maria Cody
Michelle Cox
Jackie Crowley
Julie Curren
John Doyle
Lindsey Dyer
Gary Everett
Susie Gardiner
Julie Hanna
Sue Harvey
Mike Hogan
Louise Holmes
Simon Howes
Teresa Jankowska
Ann Keenan
Tom Knight
Shane Knott
Sarah Lyons
Trish McCormack
Sam McCumiskey
Tesa McGrath
Tommy McIllravey
Lindsey Marlton
John Marsden
Judith Mawer
Clare Mahoney
Irene Mills
Melusi Ndebele
Debbie Nelson
Lisa Nolan
Jackie Patiniotis
Alison Petrie-Brown
Rachel Plant
Taher Qassim
Phil Sadler
Alex Scott-Samuel
Jan Sloan
Gerrilyn Smith
Emma Squibb
Sally Starkey
Julia Taylor
Val Upton
Louise Wardale
Jane Weller
Gary White
Ann Williams
Duncan Young
Particular thanks to:
Jo Nurse
National Lead for Public Mental Health,
Department of Health (DH) in giving
permission to use her ‘Framework for Creating
Flourishing and Well-Being: A Public Mental
Health Approach’ (Nurse J, 2008).
Jonathan Campion
DH, for his feedback on the draft and for his
encouragement.
Jude Stansfield
Public Mental Health and Well-being Lead,
Department of Health/NHS North West; for
being a constant champion for Public Mental
Health across the region.
Andrew Cornes and Linda Richards
Designers, for their inspiration, creativity and
patience in the design of this strategy.
The Public Mental Health Strategy and its aligned Strategic Development Plan has been a
collaborative development drawing upon the strengths, insights and expertise of the following:
Acknowledgements
Foreword 1
Rationale 2
Introduction 2
Strategic Aims 3
Strategic and Operational Integration 3
Underpinning Principles 4
The Social Determinants of Mental Heath and Well-being 5
An Assets-Based approach to mental well-being 8
Mental Well-being Impact Assessment Toolkit (MWIA) 9
Population-based approaches to Mental Health and Wellbeing 10
The Centrality of the Family as a protective factor for mental well-being 11
Young Carers 13
The Economic Case for Investing in Public Mental Health 13
Black and Racial Minorities (BRM) and mental health 15
Framing Public Mental Health Policy and Practice 16
Summary 19
Demographic Trends and Needs Analysis 20
City’s Population Profile and Population Trends 20
Common Mental Health Problems 20
Summary of the Mental Health Equity Profile (2008) 21
Children and Young People 22
Older People 24
Stakeholder Participation 00
Background and context 00
Method 00
Stakeholder Mapping and Analysis 00
Identifying Levels of Participation 00
Identifying methods of participation 00
Resources and implementation 00
Public Mental Health: Commissioning for Health Improvement 00
World Class Commissioning 00
Priorities for Investment 00
Appendices 00
Contents
numbering
This strategic framework is a way of capturing new
and emerging evidence and thinking about the
relationship between individuals and society and
their mental health and well-being. It builds on the
solid foundations laid through the WHO Healthy
Cities initiative through the implementation of
Choosing Health and in the work of Integrated
Commissioning across the city in addressing the
health and social care needs of our population. This
work extends the strategic thinking that was
developed in the Joint Commissioning Strategy for
Adult Mental Health and Well-Being that set out
the relationship between poor mental health and
social exclusion and the challenges that sit with
individuals, families, communities and service
providers in enabling the process of recovery. The
strategy recognises that a consistent and coherent
approach to healthy life expectancy is required
across the life course and over time. It confirms that
for positive mental health and well-being to be a
reality in adult life, the foundations need to laid in
childhood.
Current governmental thinking in health and social
care is increasingly focusing on the need for
preventive approaches to ill health and on the
promotion of well-being. It is timely therefore that
this strategic framework for Public Mental Health is
now able to set out the rationale for building on
the developments already in place and to
strengthen both the resolve and the commitment
of commissioning organisations, their partners and
peer networks to tackle the social determinants of
mental ill-health.
The experience of 2008 has confirmed the
importance of culture in our lives. For Liverpool
residents, and for visitors, the rich variety of cultural
events has been uplifting and has reinforced the
pride Liverpudlians have in their city. The evidence is
growing that engagement in cultural activities is
good for our mental health and well-being and the
developing relationship between Liverpool PCT and
the arts signals the importance of this experience.
The city will continue to embrace change and build
upon its cultural legacy as it moves into 2010,
identified as the ‘Year of Well-Being’ and into 2011
as the ‘Year of Innovation’. The strategy reflects a
growing optimism that we can continue to change
the circumstances that constrain many people’s lives
in this city and that are significant in causing
unhappiness, distress and mental illness. We need
to make effective use of the resources that we
have, to do the things that need to be done, by
supporting people at earlier stages in their lives, by
re-enabling people to engage once more in their
hopes and aspirations and by increasing the
numbers of people who are flourishing and leading
purposeful lives.
This challenge will be met by re-affirming our
commitment to the task by the strong and vibrant
partnerships that exist across this city and by the
growing number of champions that abound in our
communities, organisations and services. Our
endeavour is perhaps best summed up by the
following quote from Ghandi…
Be the change you want to see
in the world…
Gideon Ben-Tovim
Chair LPCT
Paula Grey
Joint Director of Public Health for LPCT and LCC
Andy Hull
Director of Stakeholder Engagement LPCT
Samih Kalakeche
Director of Integrated Adult Health and Social
Care Commisioning for LCC and LPCT
1
“Create all the happiness you are able to create: remove all the misery you are
able to remove. Every day will allow you to add something to the pleasure of
others, or to diminish something of their pains.” 7
7 Bentham J in Layard J (2006) Happiness: Lessons from a New Science. British Journal of Sociology Vol 57 Issue 3 pp535–6
Foreword
This vision statement from the Sainsbury Centre for Mental Health sets a challenging goal for the
direction of this local strategy over the next six years. Promoting mental health for all provides an
opportunity to take a broader view of mental health and to consider the ‘public mental health’ i.e.
the needs of whole communities and that of the city. In particular it is about preventing the onset
of mental ill-health and promoting well-being and enabling a flourishing society. This will require
changes to the levels of investment and commissioning intentions in re-focusing interventions
‘upstream’ and thus reduce the early onset of mental health problems in childhood and their
development into, in some cases, acute mental illness. It will also require commissioning bodies to
consider ways of alleviating the burden of poor mental health that sits within this city’s population
but that remains undiagnosed and unaddressed. In other words, many people are languishing and
are struggling to cope. Current research would suggest that higher levels of the population are
‘languishing’ than was previously estimated with the effect this has on personal and social
functioning and behaviour.
This strategy and the consultation process that supports it, reflects a particular way of working that
is inclusive, empowering, evidence-based and transformational.
2
There is no health without mental health. Mental health is central to the
human, social and economic capital of nations and should therefore be
considered as an integral and essential part of other public policy areas such as
human rights, social care, education and employment. 8
Introduction
The aim of this strategy is to set out an integrated framework for mental health and well-being
for Liverpool that recognises that mental health is a whole-population issue and that it is
everyone’s business.
By 2015, mental well-being will be a concern of all public services.
Undoubtedly there will still be people who live with debilitating mental
health conditions, but the focus of public services will be on mental wellbeing
rather than on mental ill-health. 9
Rationale
Public Mental Health is the art,
science and politics of preventing
mental ill-health and inequalities
through the organised efforts of
society. 10
8 European Ministerial Conference on Mental Health: Facing the Challenges, Building Solutions (2005) WHO, Helsinki
9 The Future of Mental Health: a Vision for 2015 (2008) Sainsbury Centre for Mental Health
10 National Expert Group for Public Mental Health and Well-Being (2008)
Strategic Aims
This strategy aims to promote people’s positive
mental health and ameliorate mental distress,
through the process of earlier intervention and
recovery, by actions that:
_ enhance wellbeing
(i.e. increasing flourishing)
_ prevent mental illness from occurring
_ treat mental illness when it is present
_ enhance wellbeing
i.e. increasing flourishing; and thus
_ improve whole-population mental health;
_ challenge health and wealth inequalities that
impact negatively upon well-being; 11
_ overcome persistent barriers to social
inclusion that continue to affect those with
experience of mental health problems;
_ improve the whole-life outcomes of those
with experience of mental health problems;
_ Support and enable whole system reform.
Strategic and Operational
Integration
The challenge facing the effective
implementation of Public Mental Health is one
of integration. Integration is a key driver within
Liverpool PCT’s Commissioning Plan and relates
to the determination to provide joined up
services. This is a requirement not only of
commissioning within the PCT and City Council
but also of neighbourhood delivery:
This challenge of integrating our services to
best meet need is summed up by the phrase
‘only connect’ 13. It is only through drawing
upon the assets of individuals, groups, peer
networks, agencies and organisations that this
strategy can be made to work and bring
greatest health benefit to the city’s population.
This strategy will draw upon existing national
policy and local strategies across health, social
care and well-being to connect local plans and
commissioning intentions to local needs. In
doing so, it will strengthen strategic
commissioning through Joint Strategic Needs
Assessment and by making clear and explicit
the themes and threads that characterise Public
Mental Health (PMH), namely:
_ The need to focus on positive mental health
and creative health and well-being;
_ The mental health benefits of a healthy
lifestyle;
_ The significance of the family as a protective
factor in children’s lives;
_ The challenges presented by
transition points in people’s lives;
_ The importance of challenging the
experience of stigma and discrimination;
_ The need for advocacy and support for atrisk
individuals and groups;
_ The adoption of the recovery approach
across the spectrum of care;
_ The enabling of self-determination in the
provision of care and support.
3
11 Kagan P (2006) Making a Difference: participation and well-being. RENEW Intelligence Report.
12 A New Health Service For Liverpool: Strategic Commissioning Plan 2009-14, Liverpool PCT, 2009
13 E.M. Forster. (1910) Howards End, Edward Arnold.
It is recognised that we will need to work through local strategic partnerships
(neighbourhood partnerships for health and adult social care) at a level of the
five districts (Alt Valley, City North, Central, Liverpool East and Liverpool
South). The concept is therefore to bring together the existing resources
currently commissioned and delivered by the PCT within a local area to deliver
improved health outcomes particularly in areas where there are issues around
health inequality. 12
Underpinning Principles
The strategy is founded up the principles and
values of the Universal Declaration of Human
Rights. Human rights belong to everyone. They
are a set of basic universal standards that
govern how public authorities treat people.
This human rights-based approach (HRBA)
affirms the importance of a way of working, of
a way of relating and of a way of being that is
predicated upon the following values that
ensure that people are treated with:
_ Fairness
_ Respect
_ Equality
_ Dignity
_ Autonomy
The explicit use of human rights values and
standards in policy, planning and delivery
ensure clear accountability throughout the
strategy and its implementation. It supports
stakeholders in approaches to improving public
mental health that are empowering by
enabling meaningful participation, antidiscriminatory
practice and with specific
attention to vulnerable individuals and groups.
As an underpinning to World Class
Commissioning a HRBA provides NHS Trusts
and their partners with:
_ A practical tool to improve service delivery
_ A framework that can inspire, enthuse and
empower staff and service users
_ Actions that support other health and social
care drivers and targets
This strategy provides a focus for action
through HRB approaches that seek to balance
support for the individual and their families,
the engagement of local communities in selfdetermined
activity, and the re-orientation of
services to best meet individual and collective
needs.
In doing so, the strategy will draw upon
national and local policy drivers15, the insight
and experience of service users and carers,
from community and advocacy groups and
from our partners in the third sector, both
locally and nationally.
4
A HRBA helps to achieve good
practice… but it [also] goes above
and beyond good practice in
providing renewed quality of care
for service users, and staff are
empowered to challenge care
decisions… a HRBA defines a
common shared value base more
effectively than other guidelines
about standards of care. 14
15 Refer to Public Mental Health Strategic Action Plan 2009–12.
16 Choosing health: making health choices easier(2004) DH
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4094550
This approach is essential to promote social
inclusion, the reduction in mental ill-health, the
promotion of positive mental health,
community participation and social cohesion
and is key to the government’s public mental
health agenda16 and is best likely met by actions
and activities that can be undertaken to :
_ Promote and improve mental health through
a focus on increasing key protective factors
and reducing key risk factors. The promotion
of mental health is complementary to
improved physical health, the prevention of
mental illness and physical illness, and to
achieving improvements in the quality of life
of people experiencing mental and physical
conditions and illnesses.
_ Prevent mental health problems, mental
illness, co-morbidity and suicide, with a focus
on key risk and protective factors. This
should include a focus on the prevention of
more common mental illnesses (such as
depression and anxiety), on psychoses, and
in the interaction between mental illness and
other health conditions, such as heart
disease, cancer and diabetes and other longterm
physical conditions.
_ Support improvements in the quality of life,
social inclusion, health, equality and recovery
of people who experience mental illness, to
include further work on addressing stigma
and discrimination, recovery and on
promoting equality of opportunity in areas
such as employment, housing, education,
cultural, sporting and recreational activities.
People with a mental illness are among the
most excluded in our society17.
_ Challenge the stigma and discrimination
faced by people who experience mental
health problems by adopting a social model
of disability that incorporates mental health
problems (including those of a temporary
nature) within the mental health sector,
which refers to human rights, social inclusion
and citizenship.
The Social Determinants of
Mental Heath and Well-being
Any one individual’s mental health sits within
their life experiences of family, friends,
community and broader societal influences. This
is described as an ecological view of health and
wellbeing and is significant to our understanding
of Public Mental Health. It is a way of looking at
the relationship between our individual
experience of health and wellbeing and the
environments in which we live, work and play.
5
17 Towards a Mentally Flourishing Scotland:The Future of Mental Health Improvement in Scotland 2008-11, Scottish
Government, October 2007
18 CSDH (2008). Closing the gap in a generation: health equity through action on the social determinants of health.
Final Report of the Commission on Social Determinants of Health. Geneva, World Health Organization.
Risk factors Protective factors
• Low self-esteem
• Low self-efficacy
• Poor coping skills
• Insecure
attachment
in childhood
• Physical and
intellectual
disability
• Abuse and
violence
• Separation
and loss
• Peer rejection
• Social isolation
• Neighbourhood
violence and crime
• Poverty
• Unemployment/
economic
insecurity
• Homelessness
• School failure
• Social or cultural
discrimination
• Lack of support
services
• Positive sense
of self
• Good coping skills
• Attachment
to family
• Social skills
• Good physical
health Positive
experience of
early attachment
• Supportive caring
parents/family
• Good
communication
skills
• Supportive social
relationships
• Sense of social
belonging
• Community
participation
• Safe and secure
living environment
• Economic security
• Employment
• Positive
educational
experience
• Access to
support services
• Faith
These environments can have a potentially positive or negative impact upon our health at a
number of levels from family relationships and community safety to local and governmental policy.
The model by Dahlgren and Whitehead illustrates these social determinants of health and
wellbeing.
These determinants translate into either risk factors or protective factors for mental health (see
table on previous page). Risk factors increase the likelihood that mental health problems and
disorders will develop and their impact can influence the severity and duration of mental ill-health.
Protective factors help to enhance and protect positive mental health and wellbeing and enable
individuals to be resilient in the face of challenging life experiences.
The most significant impediment to good health, and therefore good mental health is poverty and
often the multiple deprivations and disadvantages that are part of that life experience. The WHO’s
recent final report on social determinants18 and the actions necessary to improve health equity have
identified three principles of action to enable the necessary changes to take place, namely:
_ Improve the conditions of daily life – the circumstances in which
people are born, grow, live, work, and age.
_ Tackle the inequitable distribution of power, money, and resources – the structural
drivers of those conditions of daily life – globally, nationally, and locally.
_ Measure the problem, evaluate action, expand the knowledge base, develop a workforce
that is trained in the social determinants of health, and raise public awareness about the
social determinants of health.
Fig 1 Determinants of health
Dahlgren G, and Whitehead M in the Acheson Report (1998)
6
A key focus for Liverpool PCT is to address health inequalities across the city. This determination has
been further strengthened by the Health is Wealth Commission’s report19 on the Liverpool cityregion
which acknowledges that despite recent economic growth the area continues to evidence a
disparity with regional and national comparitors showing a low life expectancy, a high percentage,
chronic illnesses and a disproportionate dependency on Incapacity Benefit. These risk factors have
been increased by the current economic recession with its impact on unemployment, indebtedness
and the cost of fuel and food. Those in the lower income groups are less cushioned against risk and
hardship.20
“Levels of mental distress among communities need to be understood less in
terms of individual pathology and more as a response to relative deprivation
and social injustice, which erode the emotional, spiritual and intellectual
resources essential to psychological wellbeing. While psycho-social stress is not
the only route through which disadvantage affects outcomes, it does appear
to be pivotal.” 21
The experience of many people living in Liverpool is still one of multiple deprivation. Socioeconomic
stress, resulting from material deprivation gives rise to poor mental health. Such stress
can have physical effects but it can have significant psychological consequences22. The evidence
demonstrates that people living in areas of deprivation with little in the way of community activity,
live with the constant experience of hardship, exhaustion and the daily grind of trying to make
ends meet. Families, in particular, that experience multiple forms of deprivation, face the greatest
hardships. In these circumstances people are prone to ill-health, accidents and relationship
breakdown.
7
19 Health is Wealth: The Liverpool City-region Health is Wealth Commission (2008)
20 Green Well Fair: Three Economies of Social Justice (2009) New Economics Foundation (NEF)
21 Friedli, L (2009) Mental health, resilience and inequalities. World Health Organisation, WHO Europe
22 Appendix 1: Socio-economic stress and its impact on health
23 Wilkinson D (1996) Unhealthy Societies. London. Routledge.
To feel depressed, cheated, bitter, desperate, vulnerable, frightened, angry,
worried about debts or job insecurity; to feel devalued, useless, helpless,
uncared for, hopeless, isolated, anxious and a failure: these feelings can
dominate people’s whole experience of life. . . . it is the chronic stress arising
from feelings which matters, not exposure to a supposedly toxic material
environment. The material environment is merely the indelible mark and
constant reminder of the oppressive fact of one’s failure and of the atrophy
of any sense of having a place in a community and of one’s social exclusion
and devaluation as a human being.23
The model provides a way of considering the
different ways in which the impact of
programmes and interventions, designed to
improve mental health and wellbeing, might be
identified and assessed through forms of
capital, namely:
_ Mental Capital24: cognitive ability and
emotional intelligence
_ Identity Capital: positive self-image,
assertiveness and confidence
_ Human Capital: knowledge, skills and
awareness
_ Social Capital: trust, reciprocity, networks
and inter-dependency
_ Economic Capital: employment, investment,
productivity
Adopting an approach to planned
interventions for mental health improvement
based upon these five forms of capital25 enables
us to view health benefit and quality of life as
related to:
_ The emotional pathways through which
deprivation impacts upon health:
_ Health benefits of participation, involvement
and reciprocity26;
_ Social support as a protective factor for both
mental and physical health:
_ An understanding of mental capital and it’s
contribution across the life course27;
_ A more inclusive model of health that
integrates the medical and social;
8
23 A relatively new concept outlined in: Foresight Mental Capital and Wellbeing Project (2008),Final Project Report -
Executive Summary. The Government Office for Science, London
25 CSIP/NIMHE (2005) Making it Possible: Improving Mental Health and Well-Being in England.
26 ‘A Prospectus for Arts and Health’, Department of Health with Arts Council England, 2007, p13–14
http://www.artscouncil.org.uk/publications/publication_detail.php?browse=recent&id=581
27 Reference Appendix 4
An assets-based approach to mental wellbeing
It is important not to frame the work in Public Mental Health solely from a needs or ill-health
perspective, whilst this is nevertheless central to the work in addressing health and wealth
inequalities. It is vital to integrate into this strategic thinking an asset-based approach to individuals
and communities across the city. This can be demonstrated in the model below which draws from
the research on health outcomes.
Public Mental Health Improvement
_ _ _ _ _
Economic Social Mental Identity Human
Capital Capital Capital Capital Capital
_ _ _ _ _
Health Outcomes
The recent report of the Government Office for
Science ‘Mental Capital through Life’28 outlines
the concept of mental capital as “…the totality
of an individual’s cognitive and emotional
resources, including their cognitive capability,
flexibility and efficiency of learning, emotional
intelligence (e.g. empathy and social
cognition), and resilience in the face of
stress.” It therefore captures those elements
that serve to establish how well an individual is
able to contribute effectively to society, cope
with life’s challenges and to experience a high
personal quality of life.
The extensive set of relationships between
mental capital, biology, culture and
environment are experienced uniquely and
individually but are dependent upon our
personal and social interactions, in particular, in
the early years (These interdependencies are
outlined in the models in the Appendix).
These help to frame not only the major
determinants of mental wellbeing and mental
capital but are indicative of the opportunities
for effective intervention and support across
the life course. By considering the various forms
of capital that are integral to individual, family
and community experience it is possible to reframe
our thinking about planned
commissioning interventions to build upon
these human and structural assets. In doing so
it helps to balance the historic needs-based, or
deficit approach, with one that acknowledges
the strengths and capabilities that already
exists within our local population.
Our deepest fear is not that we are inadequate.
Our deepest fear is that we are powerful beyond
measure. It is our light, not our darkness that
most frightens us. We ask ourselves, Who am I to
be brilliant, gorgeous, talented, fabulous?
Actually, who are you not to be? You are a child
of God. Your playing small does not serve the
world. There is nothing enlightened about
shrinking so that other people won't feel insecure
around you.
We are all meant to shine, as children do. We
were born to make manifest the glory of God that
is within us. It’s not just in some of us; it’s in
everyone.
And as we let our own light shine, we
unconsciously give other people permission to do
the same. As we are liberated from our own fear,
our presence automatically liberates others.” 29
Mental Well-being Impact
Assessment Toolkit (MWIA) 30
Within the context of an asset-based approach
it is recommended that commissioning
organisations and partners consider the
application of this approach to planned
developments.
The Toolkit has been developed as a
collaboration of many partners, including
Liverpool PCT, the Liverpool Culture Company
and IMPACT. The explicit intention in
developing this toolkit was to support policymakers,
planners, people delivering
programmes and services and people living in
communities in understanding how they
currently, and have potential to, improve the
mental well-being of those communities. Using
the toolkit will help to identify how a proposal
will impact on mental well-being and what can
be done to ensure it has the most positive
impact.
Liverpool Culture Company was the first
organisation to pilot the use of MWIA applying
this process to its cultural policies and
programmes . Subsequently, Liverpool PCT has
applied MWIA to a number of local community
projects, funded by the Big Lottery, focused on
activity and nutrition. Work has also been
developed in using MWIA in a school and a
park setting. This work is already beginning to
show results in helping to maximise the mental
health impact of these projects for
beneficiaries.
9
28 Kirkwood T, Bond J, May C, McKeith I, The M (2008) Mental capital through life: Future challenges.
Mental Capital and Wellbeing Project. Foresight, Government Office for Science
29 Williamson M (1992) ‘Our Deepest Fear’ in A Return To Love: Reflections on the Principles of A Course in Miracles.
Harper Collins
30 http://tinyurl.com/mwtphd
The process is stakeholder-based and suggests a basic framework for identifying and assessing
protective factors for mental well-being. It prompts participants, as part of the process, to consider
the following key questions in identifying mental health impact:
How does the proposed development impact on people’s control?
How does the proposed development impact on resilience and community assets?
How does the proposed development impact on participation?
How does the proposed development impact on social inclusion?
These questions reflect the essential characteristics of mental health promotion and help create a
platform for organisations to be mental health aware. The toolkit offers a resource to support
those who choose to promote mental health and it provides the business case for doing so.
Population-based approaches to Mental Health and Wellbeing
Research by Keyes 31 indicates that, across the population, the experience of ‘flourishing’ – people
who have good mental health, enthusiasm for life and who are socially engaged, represents about
17% of the population. In contrast, recent population surveys indicate that about 18% of the
population have a diagnosed mental health problem but that an additional 11% are languishing,
that is ‘a person’s life seems empty or stagnant, a life of quiet despair’. People who are languishing
do not have a diagnosed mental illness.
The Mental Health Spectrum
Keyes has also shown that ‘languishers’ are at greatly increased risk of depression and physical
disorders including cardiovascular disease 32. He also suggests that languishing may be highly
prevalent among young people, many of whom are seeking ways to fill the void of their lives. Sex,
drugs and alcohol are often used in this way, but these only deepen the void and make the person
more dysfunctional. The implications of this research for public health in general demonstrate the
understood, but not clearly articulated relationship, between poor mental health and self-injurious
lifestyles.
10
31 Keyes, C.L.M. 2002. Promoting a life worth living: Human development from the vantage points of mental illness and
mental health. In R.M. Lerner, F. Jacobs and D. Wertlieb (Eds). Promoting Positive Child,Adolescent and Family
Development: A Handbook of Program and Policy Innovations, 4:257-274. CA: Sage.
32 Keyes, C.L.M. 2004. The nexus of cardiovascular disease and depression revisited: The complete mental health
perspective and the moderating role of age and gender. Aging and Mental Health, 8:266-274.
The graphs indicate that a population approach to languishing is needed to address the potential
of this population for developing mental health problems. It would be insufficient to simply focus
on support for those already presenting with poor mental health. This demands a reinforcement of
the argument for, and the determination to increase, the range and scope of earlier interventions
across the life course. The graph below illustrates how a small improvement in population wide
levels of wellbeing will reduce the prevalence of mental illness, as well as bringing the benefits
associated with positive mental health, namely:
• by reducing the mean number of psychological symptoms in the population, many more
individuals would cross the threshold to become flourishing;
• a small shift in the mean of symptoms or risk factors would result in a decrease in the number of
people in both the languishing and mental illness tail of the distribution. 33
The rationale for this approach has been substantiated by work on the prevalence of problem
drinking both nationally and internationally 34, where a small reduction in the mean consumption
of alcohol among light or moderate drinkers will result in a substantial decrease in the prevalence
of problem drinking. 35
The effect of shifting the mean of the Mental Health Spectrum
The Centrality of the Family as a protective factor for mental well-being
A positive childhood environment can be a protective factor in a number of ways. Children who
have had a warm and secure relationship with their parents are more likely to be happy and have
better mental health and wellbeing. Early childhood experiences, particularly in the first year, also
influence later life outcomes and ability to cope with hardship and adverse life events. 36
Recent reviews on the combined effect of multiple disadvantages on outcomes for children and
families, present a correlation between the number of parent-based markers of disadvantage
experienced by a family and the impact on the full range of Every Child Matters outcomes for
children (ECM). 2% of families nationally – equivalent to 140,000 – are affected. (FACS 37)
11
33 Huppert F, (2008) State-of-Science Review: SR-X2: Psychological Wellbeing: Evidence Regarding Its Causes and
Consequences in Mental Capital and Wellbeing: Making the most of ourselves in the 21st century, Foresight
34 Rose G. 1992. The strategy of preventive medicine. Oxford: Oxford University Press.
35 Colhoun, H., Ben-Shlomo, Y., Dong, W., Bost, L. and Marmot, M. 1997. Ecological analysis of collectivity of alcohol
consumption in England: Importance of average drinker. British Medical Journal, 314:1164-1168.
36 Stansfield SA, Head J, Bartley M, Fonargy P (forthcoming) Social Position, early deprivation and the development of
attachment.
37 Families and Children Study (2005) in Reaching Out: Think Family: Analysis and themes from the Families at Risk
Review (2008) Cabinet Office. Social Exclusion Task Force.
This experience is supported by the ‘Families
and Children Study’ that focuses on
disadvantages experienced by families across a
range of areas, reflecting the cross-cutting
nature of social exclusion. These include:
_ Poverty
_ No parent is in work;
_ Family lives in poor quality
or overcrowded housing;
_ No parent has any qualifications;
_ Mother has mental health problems;
_ At least one parent has a longstanding
limiting illness, disability
(including learning disability) or infirmity;
_ Parental drug and alcohol misuse
The impact of these life experiences of
disadvantage for children are illustrated below.
Looked after children, represent a particularly
vulnerable group. Most children (62%) become
looked after as a result of abuse or neglect). A
further 20% are looked after because of family
dysfunction or distress. 39
Early care experiences have long-term
consequences for children’s health and social
development. Entering care is strongly
associated with poverty and deprivation (for
example, low income, parental unemployment,
relationship breakdown) and the outcomes
associated with deprivation often persist into
adulthood. 40 Many children and young people
who are looked after experience significant
health inequalities throughout childhood, and
on leaving care experience poor health,
educational and social outcomes.
12
0
2
4
6
8
10
12
14
16
18
Child admits
running away
from home
before
(2004)
Child spent less
than an hour on
physical activity
in last week
(2005)
In trouble
with police
last year
(2005)
Not seen friends
in last week and
never goes to
organised social
activities (2004)
Child
suspended
or excluded
in last year
(2005)
Well below
average at
English
(2005)
■ No family disadvantages
■ 1 or 2
■ 3 or 4
■ 5 or more
Children from the 5% most
disadvantaged households are
more than 50 times more likely to
have multiple problems at age 30
than those from the top 50% of
households. 38
38 Feinstein, L and Sabates, R (2006), Predicting adult life outcomes from earlier signals: Identifying those at risk, Centre
for Research on the Wider Benefits of Learning, Institute of Education, University of London
39 Department for Children, Schools and Families (2007e) Care matters: time to deliver for children in care: an
implementation plan. London: Department for Children, Schools and Families
40 Department of Health (2002) Promoting the health of looked-after children. London: Department of Health.
“Children from families with
multiple problems are at increased
risk of negative outcomes…”
Reaching Out: Think Family, Analysis and themes from
the Families At Risk Review
Multiple disavantage can cast a long shadow
Young Carers
A significant concern is for those families that
are affected by parental mental ill-health. Over
one third of all UK adults with mental health
problems are parents.
Two million children are estimated to live in
households where at least one parent has a
mental health problem but less than one
quarter of these adults is in work. Nevertheless
most parents with mental health problems
parent their children effectively. 41
Studies show that that a quarter of all women
referred for mental health treatment, have a
child under five years old. Older children
sometimes carry the responsibility as ‘young
carers’ 42 for a parent with severe and enduring
mental health problems. The number of young
carers in the UK is estimated (a likely
underestimate) to be 175,000 and of these
nearly one third care for a parent with a
mental health problem. The census evidence
also indicates that within the total population
of young carers 114,000 are between the ages
of 5–15.
The Economic Case for Investing
in Public Mental Health
There are identifiable economic benefits of
improving positive mental health e.g. below.
While the best outcomes are generally
associated with the absence of mental illness,
the presence of positive mental health brings
additional benefit.
The scale of the economic benefits of
preventing mental illness is considerable:
_ Mental health problems have very high rates
of prevalence; they are often of long
duration, and have adverse effects on many
areas of people’s lives, including educational
performance, employment, income,
personal relationships and social
participation;
_ No other health condition matches mental
ill-health in the combined extent of
prevalence, persistence and breadth of
impact;
_ Mental health problems often begin early in
life and cause disability when those affected
would normally be at their most productive
(unlike most physical illnesses).
The cost to
society of
mental ill-health
has been
calculated as
£110 billion in
2006/7. This is
greater than
the total costs
associated
with crime
across the
UK. 44
13
41 Evans J and Fowler R. (2008) Family Minded: Supporting Children in Families affected by mental illness Barnardos
42 Roberts D, Bernard M, Misca G and Head (2008) SCIE Research briefing 24: Experiences of children and young
people
43 Friedli, L & Parsonage, M (2007) Mental Health Promotion: Building an Economic Case, NIAMH
44 Ibid Friedli & Parsonage
Subjective well-being increases life expectancy by 7.5 years, provides a similar
degree of protection from coronary heart disease to giving up smoking,
improves recovery and health outcomes from a range of chronic diseases
(e.g. diabetes) and in young people, significantly influences alcohol, tobacco
and cannabis use. A positive sense of self also predicts pro-social behaviour
e.g. participation, civic engagement and volunteering. 43
Costs are described and evaluated under three
headings:
(i) the costs of health and social care, covering
such costs as the services provided by the
NHS and local authorities for people
suffering from mental health problems and
also the costs of informal care given by
family and friends;
(ii) the human costs of mental illness,
corresponding to the adverse effects of
mental illness on the health-related quality
of life; and
(iii) the costs of output losses in the economy
which result from the negative impact of
mental illness on an individual’s ability to
work.
Estimates prepared by WHO show that in the
UK mental illness now accounts for more
Disability Adjusted Life Years (DALYs) lost per
year than any other health condition. Thus the
figures for 2002, the latest available year,
indicate that 20.0% of the total burden of
disease in the UK was attributable to mental
illness (including suicide), compared with 17.2%
for cardiovascular diseases and 15.5% for
cancer. No other condition exceeded 10%. 45
Mental illness including suicide accounts for less
than 5% of all premature mortality but for over
30% of all morbidity and disability. 46
The case for prevention of mental ill-health and
the promotion of well-being is compelling from
an economic perspective alone. A snapshot of
the national picture of mental ill-health is
demonstrated in the evidence:
14
45, 46 Ibid Friedli & Parsonage
• Unemployed people are twice as likely to
suffer from depression as people in work;
• Children in the poorest households are
three times more likely to experience
mental health problems than those
children in affluent households;
• Half of the women, and a quarter of all
men, will be affected by depression at
some period during their lives;
• People who have been abused, or who
have been victims of domestic violence,
have higher rates of mental health
problems;
• Between a quarter and a half of people
using night shelters or sleeping rough may
have a serious mental health problem, and
up to half may be alcohol dependent;
• Some BRM groups are diagnosed as
having higher rates of mental health
problems than the general population;
refugees and asylum seekers are especially
vulnerable;
• Severe mental health problems such as
schizophrenia are relatively rare, affecting
one in 200 adults each year. But
depression and anxiety can affect up to
one in five of the population at any one
time with the highest rates in the most
deprived neighbourhoods;
• People with drug and alcohol problems
have higher rates of mental health needs;
• People with physical illnesses have higher
rates of mental health problems;
• Lesbian, Gay, Bisexual and Trans people
have at least twice the risk of suicide than
the general population.
Black and Racial Minorities (BRM)
and mental health
6.4 million people in England belong to ethnic
minority communities. This figure represents
about 1 in 8 of England’s population and in
Liverpool about 11.5% of the city’s population.
The ethnic minority communities in England,
as in Liverpool, share a number of features.
Disadvantage and discrimination characterise
their experiences in this country in almost all
walks of life. This is particularly true in the area
of health and health care. 47 Black, Irish and
other minority ethnic groups experience high
levels of social and material deprivation when
compared with the majority white population.
This is particularly the case for refugee and
asylum seekers. The social exclusion of minority
ethnic groups is complex and varies according
to their economic, social, cultural and religious
backgrounds.
Psychiatric illness rates are generally higher in
minority ethnic groups and they also
experience significant social adversity but have
poorer social networks and support. There are
ethnic differences in access to mental health
services. Most tellingly, there are significant
and sustained differences between the white
majority and minority ethnic
groups in experience of mental
health services and the
outcome of such service
interventions. 48
There are a range of issues that
remain challenging to the
mental health and well-being of
BRM communities across
Liverpool:
_ Populations with high rates of
socioeconomic deprivation (such as
Liverpool’s BRM population) are known to
have some of the highest need for mental
health care, but the lowest access to and
uptake of services. 49
_ Stigma against people with mental health
problems is a major problem in the BRM
community. Research has shown that stigma
and discrimination against people with
mental health problems is informed by
perceptions within the communities
themselves that there is no effective
treatment for mental disorders.
Improvements in the mental health and wellbeing
of BRM populations will be strengthened
by approaches that, for example:
_ Increase involvement of BRM communities in
the assessment of public mental health
needs 50
_ Place emphasis on identifying solutions to
community problems based on local
knowledge and priorities
_ Support cultural adaptation and tailoring of
evidence-based programmes
_ enable BRM communities to identify and
develop appropriate recovery based
indicators
15
47 Inside Outside: Improving mental health services for black and minority ethnic communities in England (2003) DH.
48 Cochrane, R. and Sashidharan, S.P (1996) Mental Health and ethnic minorities: a review of the literature and service
implications. In Ethnicity and Health: Reviews of the literature and guidance for purchasers in the area of
cardiovascular disease, mentalhealth and haemoglobinopathies. CRD Report 5 University of York, NHS Centre for
Reviews and Dissemination
49 http://tinyurl.com/211s5c
50 http://www.raceforhealth.org/members/pcts/liverpool/peer_review
Framing Public Mental Health Policy and Practice
The range of governmental policies and drivers that inform, influence and direct PMH are diverse,
and the challenge at a local level, is to create a sense of direction informing purposeful
commissioned services and interventions that strengthen protective factors and reduce risk factors
at various levels across the population.
The Public Mental Health strategy and the linked Strategic Action Plan are informed by the
framework being developed nationally for the guidance on Public Mental Health. 51
The model below demonstrates the interconnectedness of the key strategic interventions
supporting Public Mental Health:
Create Flourishing, Connected Communities
A Public Mental Health Framework for Developing Well-being
Nurse J 2008
16
51 New Horizons (2008) A Vision for Public Mental Health & Well-Being: A Public mental Health Framework for
Developing Well-Being. Working Draft, Department of Health
Promote
meaning and
purpose
......................................
Develop sustainable,
connected communities
......................................................
Integrate physical and
mental health and well-being
.....................................................................
Build resilience and a safe, secure base
...............................................................................
Ensure a positive start in life
This model provides a simple framework for
thinking about the imperatives – the actions
that need to be taken, to tackle the
impediments to people’s mental health and
well-being. It will help to focus attention on
doing more of the things that are known to
really help people cope with the ups and
downs of life.
It is evident that some of this important work
inevitably focuses on the early years where the
need to ‘ensure a positive start in life’ is a huge
protective factor for mental health through
adolescence and into adulthood. But more than
this, there is a need to connect our thinking and
actions to show the relationship between our
physical health and our mental health. It has
been acknowledged that the last governmental
White Paper: Choosing Health did not make
clear the links between how we think and feel,
our behaviour and subsequent lifestyle. The
Public Mental Health Strategic Action Plan
2009–12 will use the current evidence base to
strengthen that relationship and help inform
what still need to be addressed in this key area
of people’s well-being.
This strategic framework and action plan will
connect work being done on regeneration, on
home improvement, on issues to address fuel
poverty and on developments to support social
cohesion to tackle those factors that militate
against mentally healthy communities.
Importantly, it needs to support actions and
service developments that help those people
who may be struggling with personal or family
hardships to find help, advocacy and a listening
ear. In particular, to reach out to more of
the people experiencing distress who
show this through self-harm and for
those who are at risk of losing hope
and taking their own lives.
Ultimately Liverpool PCT and it’s
strategic partners would wish the
citizens of Liverpool to have meaning
and purpose in their lives to have
raised expectations of better health
and well-being, to have aspirations for
achievement and for more enriched
and fulfilled lives.
It is clearly understood and recognised that in
the years leading up to, and during Liverpool
08, strategic partnerships grew and developed
between the public and third sector health and
social care organisations, and the arts and
cultural sectors. ‘08’ provided the conditions for
culture and health to grow, nurturing
innovation, sustained partnerships, positive risktaking
and a willingness to ‘have a go’.
“Liverpool 08 presented a remarkable
opportunity to enable the lives we
lead, our own culture and the
culture of our neighbourhoods as
having the power to enhance our
health and well-being. Well-being is
not something that you get from
elsewhere but it is something we all
contribute to in what we do, where
we are and who we are with. This
work is about how we deliver health
and how we create the conditions
where we are enabled to be
healthy.”
Creative Communities, of which creative health
was a part, was at the heart of Liverpool 08
and the regeneration of the city. Creative
communities contributed to raised aspirations
and hope and contributed to the realisation of
public mental health.
17
18
Summary
This strategy will provide clear guidance and actions to promote positive mental health & wellbeing
52, prevent the onset of mental health problems, the amelioration of distress and the
inclusion of people, who currently, are socially excluded as a result of their experience of mental
distress. It will align strategic thinking across the life-course, for vulnerable individuals and groups,
for our families, workplaces and communities and for the population as a whole.
In summary the Public Mental Health Strategy and the Strategic Development Plan have the
following objectives:
_ To clarify the landscape of Public Mental Health and specify its key elements and their
relationships, in particular, the social determinants of mental health;
_ To adopt a systematic approach that will help to strengthen the relationship between individual
resilience and the resources available to people in securing their mental health and well-being;
_ To integrate and align current strategic needs assessments, health intelligence and plans across
the public health domain into a seamless approach to public mental health;
_ To inform commissioning intentions across the city’s strategic plans that will contribute to the
achievement of a ‘flourishing’ population 53.
_ To build capacity for Public Mental Health within the Primary Care Trust and the City Council
and through our commissioned 3rd sector organisations across the city.
_ To identify and develop those particular dimensions of mental health and well-being, as yet, not
explicitly articulated in other strategic documents for example, ‘Think Family’, health promoting
settings – workplace health 54;
_ To specify a framework for action that includes promotion, earlier intervention, prevention 55
and protection as the collective means to address mental health inequalities across the city;
_ To provide evidence of effectiveness in public mental health, so that good practice can be
acknowledged, celebrated, commissioned and replicated;
19
52 Our health, our care, our say: a new direction for community services (2006)
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4127453
53 Keyes, CLM ( 2008) A perspective from the U.S.: mental health is a complete state and not merely the absence of
mental illness symptoms or diagnoses in NIMHE Mental Health Promotion Update, January 2008, Gateway Reference
No. 9246
54 Mental health promotion involves any action to enhance the mental well-being of families, organisations or
communities. It is essentially concerned with:
• how individuals, families, organisations and communities think and feel
• the factors which influence how we think and feel, individually and collectively and
• the impact that this has on overall health and well being.
55 Prevention can be defined as:
• Primary Prevention aims to improve the mental health of communities so that people do not become ill.
• Secondary Prevention aims to identify people who are developing early signs of mental illness so that more
serious mental illness can be avoided.
• Tertiary prevention aims to prevent people who have become ill from relapsing, or helps them to recover
City’s Population Profile and
Population Trends 56
In 2001 the city’s population stood at 441,900.
Latest 2006 estimates show that this figure has
now fallen to 436,100 a reduction of 5,800
residents representing a percentage loss of
1.3%. This goes against the national trend
which shows population increasing by 2.5%.
With the exception of 2004–05, levels of
internal out migration are responsible for most
of Liverpool’s annual population decline. This
means those people leaving the City for other
locations within the UK.
The latest data now shows that if the present
trends for the City continue there will be a
further population decrease to 421,700 by 2029
a loss of 20,200 persons since 2001.
In planning and housing terms these estimates
and projections could have some major
implications for future policy. In general (and
common to other policy areas), ongoing
decline in population levels will undermine
sustainable communities through, for example,
falling patronage for shops, schools and other
community facilities.
Since 2001 there has been a decrease in the
number of children (0–15) of 11.9% and a
decrease in the retired age group (65M/60F
and above) of 4.2%, while our working age
population has risen by 2.9% (7,900). The
decrease in the child population is repeated
across all the Merseyside authorities, Core Cities
and at a national level.
The total population in 2001 was 441,900 of
which 36,600 (8.3%) was made up of BRM
groups. This has increased to 10,300 in 2005
giving a BRM population of 46.900 (10.7%)
which includes the White Irish population as
shown in Table 5 below. This represents an
increase of 28.1% from the 2001 figure which is
higher than that of England’s and the North
West which are 18.2% and 23% respectively.
The BRM population in Liverpool is the highest
on Merseyside and higher than the North West
level of 9.7%.
Common Mental Health Problems
The public health importance of common
mental health problems is demonstrated by the
finding that low levels of depression resulted in
51% more days lost from work, than major
depression6. Whereas major psychiatric
disorders such as schizophrenia (which has a
community prevalence of less than 1%) are
certainly more disabling to individual sufferers,
are more distressing for their families and
carers, their rarity means that these conditions
place less of a burden on the public health than
common mental health problems.
_ The most common mental health problems
anxiety and depression, have a combined
prevalence rate of about 18% in the
community 57
_ Around 1 in 6 of all adults reported some
form of common mental health problem 58
_ The highest regional prevalence of any
common mental health problems occurred
in the North West, with a rate of 1 in 5
_ Common mental health problems account
for one third of days lost from work due to
ill-health and 1/5 of all consultations with
general practitioners in the UK
20
56 Briefing Note to RMT/Corporate Regeneration Group, LCC, December 2007
57 Meltzer H, Gill B, Petticrew M. (1995). OPCS Surveys of Psychiatric Morbidity in Great Britain.
58 Report No 1. The prevalence of psychiatric morbidity among adults aged 16-64 living in private households in Great
Britain. HMSO: London.
59 Singleton N, Bumpstead R, O’Brien M, Less A, Meltzer H, (2001) Psychiatric morbidity among adults living in private
households, 2000. The Stationery Office: London.
Demographic Trends and Needs Analysis
The prevalence of mental health problems is
greater amongst people with the characteristics
associated with deprivation 60. There is
abundant evidence that mental health
problems tend to be concentrated in socially
disadvantaged groups within the population,
and that these groups of people have relatively
poor access to mental health care. It was also
evident that in areas defined as deprived,
admission rates to secondary care are three
times higher than the national average. In a
survey of the general population, it was found
that poverty and unemployment increase the
duration of episodes of common mental health
problems.
Compared to those with no common mental
health problems, those with common mental
health problems were more likely to:
_ be separated or divorced (twice as likely);
_ be living as a lone parent family unit;
_ be tenants of the local authority or a
housing association;
_ have a long-term limiting illness;
_ come from a lower social class;
_ be economically inactive and
_ have no formal educational qualifications
Summary of the Mental Health
Equity Profile (2008) 61
Data to support the Adult needs assessment
element of the strategy has been taken from
the Mental Health Equity Profile (MHEP) 62. The
purpose of the equity profile was to examine
equity of access to and provision of services to
meet the mental health needs of the adult
population covered by Mersey Care NHS Trust.
This rapid mental health equity profile,
repeated and updated elements of the
Merseyside Mental Health Equity Audit
undertaken in 2004.
The focus of the profile were services provided
by Mersey Care and relates to the geographical
areas served by Liverpool and Sefton PCTs and
the Kirkby area of Knowsley PCT (i.e. the area
covered by Mersey Care NHS Trust).
All levels of care (primary, secondary, tertiary)
were included in the analysis. The profile used
‘readily available’ performance measures, and
the equity analysis included the following
dimensions: geography; deprivation/socioeconomic
factors; ethnicity; age; sex.
The synopsis is provided in a tabular format
with accompanying mapped data and focuses
on the following key areas:
_ Deprivation
_ G.P. Referrals to Adult mental Health
Services
_ Caseloads with complexity (standard and
enhanced CPA)
_ Hospitalised prevalence of mental health
conditions
_ Hospitalised incidence of self-harm
_ Readmissions within 90 days of discharge
_ A & E Episodes of self-harm
_ Suicide and injury undetermined
_ Suicide amongst people under care
21
60 Rankin, J (2005) Mental Health in the mainstream
61 http://tinyurl.com/211s5c
62 Ubido, J & Lewis,C. 2008) Mental Health Equity Profile of the area served by Mersey Care NHS Trust: Interim Report,
Liverpool Public Health Observatory.
Children and Young People
Surveys suggest that clinically significant
emotional or behavioural difficulties are
restricted to a minority of children and young
people, roughly one in ten 63. Trend analysis
identifies the following as patterns in
adolescent behaviour:
_ Adolescent emotional problems (depression
and anxiety) have increased for both boys
and girls since the mid 80’s;
_ Adolescent conduct problems have showed
a continuous rise for both girls and boys for
the period 1974–1999;
_ The strength of associations between these
problems and poor outcomes in later life
have remained similar over time.
This evidence can be aligned with findings from
a collaboration research project between the
New Economics Foundation 64 and Nottingham
City Council (NCC) which undertook to measure
the well-being of young people in Nottingham
This innovative study surveyed over 1,000
children and young people in Nottingham,
aged 7–19.
_ Just over half of young people scored well
on both categories of life satisfaction and
personal development. Twelve per cent,
however, scored poorly on both.
_ In particular, nine per cent of young people
in Nottingham have ‘very low’ life
satisfaction and can be considered at very
high risk of depression. 23% of young
people who scored ‘low’ in life satisfaction
were also at risk from depression, forming a
large group of 32 % of young people in
Nottingham who are, at the very least,
unhappy in life and may be at risk of mental
health problems. 65
_ Well-being falls substantially as children get
older. When comparing 9–11 year-olds with
12-15 year-olds, average scores for life
satisfaction and curiosity fall by five per cent
and ten per cent respectively.
Some children experience a range of emotional
and behavioural problems that are outside the
normal range for their age or gender. These
children and young people could be described
as experiencing mental health problems or
disorders .Mental health professionals have
defined the problems that children and their
families can be faced with as follows:
_ emotional disorders, e.g. social phobias,
anxiety states and depression that may be
manifested in physical symptoms;
_ conduct disorders, e.g. fighting, bullying,
stealing, defiance, aggression and anti-social
behaviour;
_ hyperkinetic disorders e.g. disturbance of
activity and attention;
The symptoms listed are found, to some extent,
in most children. To count as a disorder they
have to be sufficiently severe to cause distress
to the child or an impairment in his/her
functioning.
In 2004 10% of children and young people
aged 5–16 had a clinically diagnosed mental
disorder 66. Boys are more likely to have a
mental disorder than girls. The prevalence of
mental disorders in children and young people
was greater in those who experienced, lone
families, reconstituted families, parents with no
educational qualifications, families with neither
parent working, families on low income,
families in social or privately rented housing,
families living in deprived areas.
22
63 Time Trends in Adolescent well-being (2004). The Nuffield Foundation
64 Marks N, Shah H & Westall H (2004) The power and potential of well-being indicator: Measuring young people’s
well-being in Nottingham. New Economics Foundation (nef) / Nottingham City Council.
http://www.neweconomics.org
65 This would align with findings form Corey Keyes who has identified significant levels of the population who, in terms
of their mental health and well-being, are languishing.
66 Green H, McGinnity A, Ford T & Goodman R (2004) Mental Health of Children and Young People in Great Britain, ONS
Conduct Disorders
Children and young people with conduct
disorder were more likely than other children
to be boys and be in the age range 11–16. Of
children with this disorder 24% found it harder
than average to make friends and a third found
it harder to keep friends. 59% of children with
conduct disorders were assessed as being
behind with their schooling and with 36%
being two years or more behind their peers.
About half of children with this disorder were
considered to have special educational needs.
As with children with emotional disorder,
children presenting with these behaviours had
high rates of absence from school with 22%
having truanted from school. Children’s parents
were likely to have experienced separation,
financial stress, mental illness or trouble with
the police. Similar behaviours were apparent in
these children, as with those children with
emotional disorders, particularly in respect of
substance use and suicidal ideation 67.
Hyperkinetic Disorders (HKD)
The core symptoms of this disorder are
inattention, hyperactivity and impulsivity.
Children with HKD are predominantly boys
(82%). Almost a third of children with this
diagnosis found it harder than average to make
and keep friends and scored low on a scale
measuring social aptitude. Developmental
delay in academic performance was notable
with 18% being three or more years behind
their peers.
Children with HKD were more than 4 times as
likely to have recognised special educational
needs. In common with children with other
identified disorders many had experienced
parental separation (49%), or had a parent
with a serious mental illness that required a
stay in hospital (23%). The proportions for
other children were 31% and 13% respectively.
The correlation with economic deprivation
mirrored children with other disorders with
31% coming from a household with no parent
working compared to 14%v with nondisordered
children.
Similar behaviours were apparent in these
children, as with those with emotional and
conduct disorders, in respect to substance use
and suicidal ideation 68.
Emotional Disorders
Children with emotional disorders are more
likely to be girls (54%) and to be in the age
group 11–16 (62%). Over 2/5ths of children
with an emotional disorder were behind in
their intellectual development with 23% two or
more years behind. Children with generalised
anxiety disorder and depression had the most
days away from school. 55% of children with an
emotional disorder had experienced their
parent’s separation and 28% of parents had a
serious mental illness. Young people aged 11-16
with an emotional disorder are more likely to
smoke, drink and use drugs than other children
and of concern, 28% said that they had tried to
harm or kill themselves 69.
Autistic Spectrum Disorder (ASD)
Children with ASD are predominantly boys
(82%). Unlike children with the more common
disorders, autistic children tend to have more
highly qualified parents than other children
and were slightly less likely to live in low
income families. Parents here have an unusual
combination of high educational status and
low economic activity rates that reflects their
heavy caring responsibilities. 56% of families
with autistic children were in receipt of
disability benefit.
Just under a third of children with ASD had
another recognised disorder – 16% with an
emotional disorder, usually anxiety related and
19% with conduct disorder. Over 2/3rds of
children with ASD found it harder to make and
keep friends 71% and 73% compared with 10%
and 5% of other children. 42% of autistic
children had no friends compared with 1% of
other children.
23
67, 68, 69 Ibid
Similar behaviours were apparent in these
children, as those with emotional and conduct
disorders, in respect to substance use and
suicidal ideation 70.
Findings from the Adverse Childhood
Experiences Study 71, demonstrate the
relationship between the following childhood
experiences, risk behaviours and problematic
health outcomes as a result of childhood
trauma:
_ Recurrent physical abuse
_ Recurrent emotional abuse
_ Contact sexual abuse
_ An alcohol and/or drug abuser in the
household
_ An incarcerated household member
_ Someone who is chronically depressed,
mentally ill, institutionalized, or suicidal
_ Mother is treated violently
_ One or no parents
_ Emotional or physical neglect
The ACE Study has begun to uncover how
childhood stressors are strongly correlated with
the development of poor health and well-being
outcomes throughout the life course. These
childhood experiences are related to increased
prevalence of smoking, obesity, sexual health,
alcohol, drug use depression, suicidal ideation
and attempted suicide in later life.
Older People
Older people’s mental health is an increasingly
important area of public policy.
Those in later life who have mental health
problems face age discrimination, negative
stereotyping, isolation and low income. This
combination of factors maintains their social
exclusion and increases their vulnerability to
poor physical health 72.
For some older people the transition to
widowhood, the adjustment to living alone and
the loss of close family members, friends and
neighbours feature strongly. Other important
life events include the breakdown of family
relationships, the onset of chronic health
conditions, withdrawal from the labour market,
and the experience of crime. People
interviewed in this study 73 appeared to lack
adequate support when such events occurred,
and some continued to struggle with the
impact of life transitions well after their onset.
Loss of a partner may bring in its wake other
problems such as coping with long-term illness,
financial pressures, and feelings of vulnerability
about living alone in the community. This
highlights the potential need for a new type of
preventive social policy geared towards
providing support to individuals at such turning
points in their lives.
Three million older people in the UK experience
symptoms of mental health problems that
significantly impact on quality of life and this
number is set to grow by a third over the next
15 years. 74 The range of mental health
problems experienced in later life includes
depression, anxiety, delirium, dementia,
schizophrenia and other severe mental health
problems and alcohol and drug misuse.
24
70, 71 Ibid
72 Health Education Authority 1997, Roberts et al 2002, McCulloch 2002
73 Multiple Exclusion and Quality of Life amongst Excluded Older People in Disadvantaged Neighbourhoods. Thomas
Scharf, Chris Phillipson and Allison E. Smith, Centre for Social Gerontology, Keele University, March 2004
74 Age Concern, (August 2007), Improving services and support for older people with mental health problems
Nationally:
_ Depression is the leading risk factor for
suicide. Older men and women have some
of the highest rates of all ages in the UK.
_ Delirium or acute confusion affects up to
50% of older people who have operations.
_ There are approximately 70,000 older
people with schizophrenia in the UK.
_ People aged between 55 and 74 have the
highest rates of alcohol-related deaths in the
UK.
The number of people with Alzheimer’s
dementia (AD) currently exceeds 700,000 in the
UK, which is generally considered to be an
underestimation due to under-reporting 75.
The impact of AD on the mental capital and
well-being of its many sufferers is significant.
The disease progressively causes memory to fail
and memories to fade, with eventual complete
loss of identity. The course of the disease is
unpredictable 76. Periods of rapid decline can be
followed by periods of relative stability of
cognitive function during which awareness of
the progression of the disease causes great
distress both for the individual and their
families.
The majority of patients in the UK live at home,
constantly requiring intensive care from their
spouses and children. Such circumstances have
been shown to cause sadness, grief, guilt and
anger and to increase the risk for depression
and related disorders in family members and
caregivers, thus impacting on their mental wellbeing
77.
The number of Liverpool residents aged 65 and
over is projected to grow from 64,200 in 2007
to 63,500 by 2011 and to 84,700 by 2031
(+30.7%) – 2006 based projections. Within
Liverpool the number of older people with
dementia is predicted to grow by 29.3% by
2030 based on 2006 population i.e. from 4,216
people in 2006 to 5,961 in 2030.
Liverpool has an adult BRM population which is
11.5% of the total adult population and 5.5%
of the 65+ population. Although comparatively
small the BRM community is growing and
ageing. The largest ethnic communities are,
White Other, Chinese and Black African. The
largest ageing communities are White Irish,
White other, and Chinese 78.
25
75 Alzheimer’s Society Demography Policy Position Report. 2007.
www.alzheimers.org.uk/site/scripts/documents_info.php?categoryID=200167&documentID=412.
76 Rabheru, K. 2007. Disease staging and milestones. Can J Neurol Sci, 34:S62-66.
77 Mittelman, M.S., Haley, W.E., Clay, O.J. and Roth, D.L. 2006. Improving caregiver well-being delays nursinghome
placement of patients with Alzheimer disease. Neurology, 67:1592-1599.
78 Estimated resident population by ethnic group, age and sex, mid-2006, (experimental statistics).
Background and context
The prominent place of stakeholder
participation in the development of public
mental health and mental health initiatives has
long been supported by both research and
policy. For many it has become a received
wisdom that participation itself can be a major
vehicle for increasing resilience and mental
well-being, as well as being a prerequisite of
health promotion dating back to the Ottawa
Charter of 1983 79. Involvement in governance
is held by many to be the most important way
of building social capital and developing
community cohesion. 80
The participation of stakeholders in the
development of mental health policy is nothing
new in Liverpool 81. A strong tradition of
participative activities has emerged over the
past 10–15 years. This has included:
_ Development of Joint Forum
_ Development of Patients Council
_ Development of mental health and citizen
advocacy
_ Liverpool Mental Health Awareness Project
_ Liverpool Mental Health Consortium
_ Community Empowerment Network
_ Local Involvement Networks
_ Your Community Matters structures
Many of these organisations have taken
the lead in actively promoting mental
health and well being, raising awareness
and challenging myth and stigma before
there was an explicit policy direction
from central government or from local
health and social care services.
Recent evaluations of mental health
promotion and participatory approaches
have shown, however, that the social and
psychological benefits are not always
straightforward to realise.
There is a view, for instance that barriers have
included difficulty in identifying who the
stakeholders are and a reluctance by the public
to engage with a less than popular cause 82. A
more recent study has gone further to suggest
that the social capital generated by community
participation may not be distributed equitably
across the community, creating a network
dynamic of insiders and outsiders 83.
The strategic approach, therefore, is to build on
those initiatives and structures that have
developed locally, to date, by in the light of
recent evaluations in order to find the way
forward.
Method
The degree of complexity regarding existing
networks and the problematising factors
noticed from some evaluative studies make it
necessary to identify a clear method in order to
establish a strategic approach to engagement.
This would be first of all to establish some key
principles in each of the following areas:
_ Stakeholder Mapping and Analysis
_ Identifying Levels of Participation
_ Identifying Methods of Participation
Stakeholder Participation 26
79 http://www.who.int/hpr/NPH/docs/ottawa_charter_hp.pdf
80 Friedli, L (2008), Resilient Relationships: the influence of public sector policy and practice on social support
(unpublished draft briefing paper, CSIP North West)
81 Joint Commissioning Strategy for Adult Mental Health And Well Being in Liverpool, 2008-2011,
Liverpool PCT & Liverpool City Council
82 Stacey, K, Herron, S (2002), Enacting policy in mental health promotion and consumer participation,
Australian eJournal for the Advancement of Mental Health (AeJAMH), Vol 1, Issue 1
83 Skidmore, P, Bound, K, Lownsbrough, H (2006) Community Participation: Who benefits?,
(Joseph Rowntree Foundation)
Stakeholder Mapping and Analysis
Methods of systematically approaching which individuals, groups and communities may have a
stake in policy/service development have already been identified and are outlined in the Joint
Commissioning Strategy for Adult Mental Health and Well Being in Liverpool (see diagram).
The range of stakeholders in a whole population approach must by definition be broad and varied,
but some initial categorisation as follows might be possible.
_ Everyone
_ Neighbourhood representatives
_ Members of marginalised communities
_ People who have experienced mental ill health
_ People who provide health and social care services
_ People who provide other public services (leisure, education, employment)
A systematic analysis of local groups would enable us to decide to what extent which people will
have an affinity to the aims of the strategy and/or will need to have some awareness raising or
education. Current thinking is informed by the idea of growing the ‘core economy’, namely
realising and strengthening human and social assets that belong to individuals and communities 84.
In this way older divisions that separate people and services are re-fashioned and are characterised
by a new relationship between producers and consumers of services. This idea of co-producing
public services 85, allows public service agencies to become catalysts and facilitators, working
through peer support networks, to better define and meet people’s needs.
27
84 Green Well Fair: Three Economies for Social Justice (2009) New Economics Foundation (NEF)
85 Co-production: A manifesto for growing the core economy (2008), New Economics Foundation (NEF)
Keep satisfied
Engage closely
and influence
actively
Monitor
(minimum effort)
Keep informed
High
Power
Low
Low Interest High
Identifying levels of participation
The implementation of any policy will require
action at a variety of levels and settings. In
public health these have been identified as:
_ Information. The least you can do is tell
people what is planned.
_ Consultation. You offer a number of options
and listen to the feedback you get.
_ Deciding together. You encourage others to
provide some additional ideas and options,
and join in deciding the best way forward.
_ Acting together. Not only do different
interests decide together what is best, but
they form a partnership to carry it out.
_ Supporting independent community
initiatives. You help others do what they
want – perhaps within a framework of
grants, advice and support provided by the
resource holder. 86
Accepting that people will engage according to
their interests, circumstances and skills it will be
important not only to provide a range of
engagement activities, but also to evaluate
levels of engagement to ensure that network
dynamics are managed and a system of insiders
and outsiders does not occur. 87
Identifying methods of
participation
Having established the levels of connectedness
of key stakeholders it becomes possible to find
vehicles for engagement that will be
appropriate to their interests and
circumstances, enabling stakeholders to be
involved in a level that is appropriate to them.
Some methods of engagement are summarised
in the recent Rethink 88 campaign report
(although there are a plethora of varied
techniques available to enable communities
and groups to participate in policy
development). 89 The issue will be to connect
people with the appropriate group.
Resources and implementation
As previously observed, there already exist
resources dedicated to community and
stakeholder engagement both within Liverpool
PCT, as well as Local Involvement Networks and
Community Empowerment Networks, as well
as Liverpool Mental Health Consortium, which
specifically focuses on mental health issues.
A strategic approach would be increase the
profile of the public mental health within these
structures in order to:
_ identify any increased levels of capacity
necessary to support co-ordination
_ evaluate the impact that stakeholder
participation will have both on policy
implementation and on the well being of
the citizens of Liverpool.
28
86 http://www.partnerships.org.uk/pres/fitlog/sld007.htm
87 Skidmore, P, Bound, K, Lownsbrough, H (2006), op cit
88 TIME TO CHANGE (2008) Stigma Shout: service user and carer experiences of discrimination Rethink
89 For a full discussion of principles of participation and an A-Z of how to put theory into practice visit
http://www.partnerships.org.uk
This strategy supports whole systems thinking
in the management of change and system
reform and sees this approach as fundamental
to the meeting of population mental health
needs through integrated commissioning.
Whole system reform characterises the mental
health economy and this presents significant
challenges in managing this constant dynamic.
Managing the implementation of government
policy across well-being, health and social care,
community regeneration and social inclusion at
a local level requires an overarching strategic
approach so that change becomes purposeful,
manageable and coherent. The focus according
to Darzi will need to give:
World Class Commissioning
National consultations 90 have confirmed the
importance that mental health and well-being
has for the public and this is strengthened by
the extensive research evidence that supports
this strategy. The introduction of World Class
Commissioning offers many opportunities to
improve the mental health and well-being of
our local population through earlier
interventions.
The determination to intervene earlier confirms
the vision statement from DH that world class
commissioning will be ‘pivotal in shifting the
focus of care from diagnosis and treatment to
prevention and well-being’ 91. Consideration will
need to be given to longer-term commissioning
plans and intentions to realise this objective
and to maintain a developing equilibrium
between newly commissioned services for
earlier intervention and those that provide
treatment, care support and recovery pathways
for those experiencing mental illnesss.
29
A successful public mental health strategy requires long-term commitment,
multi-agency working and co-ordination, as well as a sense of common
purpose from all stakeholders in Liverpool.
Greater emphasis on prevention
and the responsibility individuals
have themselves. Unhealthy choices
and missed prevention
opportunities are in part the cause
of the growth in the prevalence of
conditions such as diabetes,
depression, and chronic obstructive
pulmonary disease. Working with
their local partners, every primary
care trust will commission
comprehensive wellbeing and
prevention services.
Even with optimal services in place
only 40% of the burden of mental
illness is averted – the need and
determination for the commissioning
and implementation of prevention
services is paramount. 92
90 Our Health, Our Care, Our Say (2007) DH
91 Department of Health (2008) DH/Commissioning, World Class Commissioning. Vision Summary
92 O’Hara K, Stansfield J, Crowson T (2008) World Class Commissioning for improved mental health and well-being in
NIMHE Mental Health Promotion Update. April. Gateway No 9700 pp 10–12
Commissioning for Health Improvement
The saving in costs, (both human and
economic) by reducing, for example, conduct
disorder and in promoting positive mental
health in children through earlier intervention
is evidenced below:
_ Preventing conduct disorders in those
children who are most disturbed would save
around £150,000 per case in lifetime costs
_ Promoting positive mental health in those
children with moderate mental health
would yield benefits over the life course of
around £75,000 per case 93
_ In comparison the intervention cost, per
child, for parenting programmes would be
in the range £1,350 to £6,000.
Using the World Class Commissioning
framework of 11 competencies the table on the
next page outlines how these competencies
relate to key actions for Liverpool PCT and for
the role of Public Mental Health specialists and
partners in this field as ‘Agents for Change’
within the local health economy 94. This helps to
clarify organisational, departmental and
individual objectives in support of public
mental health improvement. It recognises that
World Class Commissioning is a collective
endeavour and not a singular activity and as
such is way of working that relates the parts to
the whole.
30
93 Friedli L (2008) mental Health Promotion: The Economic Case for Investment. In in NIMHE Mental Health Promotion
Update. April. Gateway No 9700 pp 13–14
94 O’Hara K, Stansfield J, Crowson T (2008) World Class Commissioning for improved mental health and well-being in
NIMHE Mental Health Promotion Update. April . Gateway No 9700 pp 10–12
95 Feast D (2008) World Class Commissioning in NIMHE Mental Health Promotion Update. April . Gateway No 9700 pp
15–16
It is unlikely that all the skills
required to achieve World Class
Commissioning performance
already fully exist in any one
organisation. PCT’s, Local
Authorities and wider public service
partners need to work together to
maximise each organisations
contribution to commissioning the
best outcomes for people. 95
31
World-class Commissioning
Vision and Competencies
Role of Public Mental Health Specialists
1 World class commissioners are recognised as the
local leader of the NHS.
Provide leadership for mental health improvement
and build capabilities of colleagues and
stakeholders.
2 World class commissioners work collaboratively
with community partners to commission services
that optimise health gains and reductions in
health inequalities.
Engage key partners in the Public Mental Health
Strategy; integrate mental health promotion across
other health & social care programmes e.g.
improving mental health and well-being of people
with physical illness and long-term conditions;
ensure the needs of people with mental health
problems are addressed within Tackling Health
Inequalities strategies and programmes.
3 World class commissioners proactively seek and
build continuous and meaningful engagement
with the public and patients, to shape services
and improve health.
Advise on and facilitate opportunities for
meaningful engagement; support inclusion of
people with mental health problems into
engagement processes.
4 World class commissioners lead continuous and
meaningful engagement with clinicians to inform
strategy, and drive quality, service design, and
resource utilisation.
Facilitate clinical engagement and support service
improvement in mental health promotion and in
services attaining Care Quality Commission public
health core standards.
5 World class commissioners manage knowledge
and undertake robust and regular needs
assessments that establish a full understanding
of current and future local health needs and
requirements.
Provide advice and expertise to designing and
conducting JSNA that incorporates mental health;
facilitate community needs assessment exercises.
6 World class commissioners prioritise investment
according to local needs, service requirements
and the values of the NHS.
Develop, implement and monitor robust public
mental health strategies, based on need and
stakeholder ownership, that identify priorities for
investment.
7 World class commissioners effectively stimulate
the market to meet demand and secure required
clinical, and health and well-being outcomes.
Build capacity and capability of providers of mental
health improvement interventions; build
knowledge and capability of third sector providers
in evaluating service mental health outcomes.
8 World class commissioners promote and specify
continuous improvements in quality and
outcomes through clinical and provider
innovation and configuration.
Keep up-to-date with emerging good practice
nationally and internationally; explore, develop
and evaluate innovative and creative practice.
9 World class commissioners effectively manage
systems and work in partnership with providers
to ensure contract compliance and continuous
improvements in quality and outcome.
Agree local mental health and well-being outcomes
and indicators and methods for measurement.
10 World class commissioners make sound financial
investments to ensure sustainable development
and value for money.
Develop sustainable practice and partnerships;
keep abreast of emerging evidence based practice;
build links with researchers and economists to
identify, support and influence cost effective
solutions.
Priorities for Investment in Public
Mental Health
Evidence from Friedli 96 confirms the following, as
actions and commissioned activities that can
improve population mental health. The WHO
report, re-affirms the significance of mental
health as crucial to our thinking about sustainable
economic growth and in achieving greater social
cohesion in the face of economic change.
1 Social, cultural and economic conditions that
support family life
• systematically work to reduce child poverty
• support parents and the development of
children in early years through parenting
skills training and high quality pre-school
education
• strengthen inter agency partnerships to
reduce violence and sexual abuse
• increase access to safe places for children to
play, especially outdoors
• make the business case for good work/life
balance and provide adequate
• maternity and paternity leave
2 Education that equips children to flourish
both economically and emotionally
• increase uptake of the health promoting
schools approach, involving teachers, pupils,
parents and the wider community
• support parents to improve the home
learning environment (HLE)
• value social, sports and creative
achievements, as well as academic
performance
3 Employment opportunities and workplace
pay and conditions that promote and
protect mental health
• support efforts to improve pay, working
conditions and job security, notably for the
most vulnerable workers
• make the business case for improving job
control, social support and effort/reward
imbalance
• early referral to workplace based support for
employees experiencing psychiatric
• symptoms or personal crises to avert
employment breakdown
4 Partnerships between health and other
sectors to address social and economic
problems that are a catalyst for
psychological distress
• improve access to non medical sources of
support through social
prescribing/community referral or co
production models e.g. timebanking, to
address basic skills, housing/transport
problems, debt, isolation, limitations in daily
living, opportunities for arts, leisure and
physical activity etc.
5 Reducing policy and environmental barriers
to social contact
• policy responses to personal misfortune e.g.
poverty, unemployment and other
• adversity should not stigmatise or blame the
victims
• develop community transport schemes
• promote volunteering and develop ‘social
outcome’ indicators
• work with planners to introduce/re-introduce
‘stop and chat’ public spaces
• ensure that public spaces such as shopping
malls do not exclude specific groups,
• for example teenagers.
These areas for development are reflected, in
part, in both current achievements and
emerging activity detailed in the Public Mental
Health Strategic Action Plan 2009–12. The
action plan is structured around the three key
imperatives of the strategy, namely:
_ enhance wellbeing
(i.e. increasing flourishing)
_ prevent mental illness from occurring
_ treat mental illness when it is present
32
96 Friedli, L (2009) Mental health, resilience and inequalities. World Health Organisation, WHO Europe
In addition a number of themes have been used to organise and support the Action Plan that have
been informed by the following model developed by Nurse 97.
The Action Plan is integral to the strategic framework and will be a ‘living and working document’
that over the next three years will enable the continuous review and refinement of Public Mental
Health priorities and commissioning intentions within the strategic and operational planning
procedures of Liverpool 1st, Liverpool PCT and Liverpool City Council, its third sector partners and
stakeholder groups.
This development process will reflect a history of effective stakeholder engagement that has been
held up as a model of best practice within the North West Region. In doing so, it will continue to
reach out to its various constituencies by demonstrating that ‘mental health is everyone’s business’.
It will affirm that mental health is fundamental to our well-being. It underpins everything we do,
how we think, feel and behave. It is an essential and precious resource that needs to be protected,
promoted and improved. As such, it sits as much with us as individuals as it does with our families,
communities, our services and our civic responsibilities.
It is perhaps fitting, that in conclusion, it is in the brevity of the following statement that our sense
of direction lies:
“Tend to the social and the individual will flourish.” 98
Catherine Reynolds
Strategic Lead: Public Mental Health
Department of Public Health
Liverpool PCT
33
97 Nurse J (2008) ‘Create Flourishing Connected Communities: A Public Mental Health Framework for Developing Wellbeing.
DH
98 Rutherford J (2008) The culture of capitalism. Soundings: journal of culture and politics 38: 8–18.
(http://www.lwbooks.co.uk/journals/soundings/articles/02%20s38%20%20rutherford.pdf).
Promote
meaning and
purpose
......................................
Develop sustainable,
connected communities
......................................................
Integrate physical and
mental health and well-being
.....................................................................
Build resilience and a safe, secure base
...............................................................................
Ensure a positive start in life
Appendix 1 34
35
36
nef’s ‘Five ways to well-being’
37 Appendix 2
Mental Capital and Well-Being: Making the Most of Ourselves in the
21st Century (2008) Foresight, Government Office for Science
Appendix 3 38
39
40
41
42
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