Public mental health : implementing in local systems

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Public Mental Health Some key challenges and potential ways forward

Feb 2015UCL Partners

Jim McManus

Director of Public Health

[email protected]

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Experience

• East London

• Birmingham

• Hertfordshire

• “Strategic Opportunism”

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Current Projects

• Public Mental Health Framework

• Veterans

• Year of Mental Health Launching 2015

• CAMHS whole system review

• School Whole System Wellbeing Pilots in 36 schools

• Reframing IAPT

• Do Something Different

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Some “Orientations Events”

• St Albans Cathedral 2015 - day workshop on mindfulness and positive psychology – finding frameworks – for faith communities

• School Heads “Very Brief Intro” sessions

• Police Command

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Getting orientations: Balance in human life

Worldview eg Jewish, Christian, humanistAnthropology: human being as creature or end in itself

Your approach to Psychology – the study of the cognitions and behaviours of the human person eg Positive Psychology

Wellbeing – a concept common to many concerns scientific and spiritual

Mindfulness, just one of many techniques and practices

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Approaching mental health as a DPH

• Making sense of a complicated and contested landscape (various players, various agendas)

• Is it one, several or all of:– Promotion of mental good health– Promotion of resilience? How does that differ from

good mental health?– Primary and Secondary Prevention of mental ill-

health– Tertiary prevention e.g. Prevention of disability due

to mental ill-health? – Making sure mental health services work well?

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Seeking orientation• Speaking to DsPH on public mental health

– “Cinderella” of Public Health– Language – does anyone know what wellbeing

actually means?– Laudable policy intent– Problem with the evidence base – what exactly is it– A lot of (variable quality) science, any actual practice?

• Some level of confusion over what to do– ‘ I have a desire to do something but no idea what‘– ‘I have some idea but no interventions to get there‘– ‘ I have some idea/ framework but not joined up'. – I have loads of indicators of how bad it is, but no tools to make it

any better’

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National Context

• Mental health parity of esteem in CCG guidelines for commissioning strategies

• Under-represented in Better Care Fund

• National Outcomes Frameworks say little on young peoples’ mental health

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Some Premises

• We are facing an (avoidable) epidemiological crisis

• The Policy Context (England) does give us scope to address this

• There are some big tasks we can be getting on with, systems thinking can help

• Some quick wins and delivery tools can help us win politician confidence

• Phasing and Layering across lifecourse

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Systems thinking on public mental health

The wider determinants of Health and Local Government functions (Must adopt a Lifecourse approach!)

The Lives people lead and whether LA functions help or hinder healthy lifestyles (policy, service quality, access, behavioural economics, behavioural sciences)

The services people access such as primary care (high quality, easy access, good follow up, behavioural and lifestyle pathways wrap around)

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Premise 1: We are facing an (avoidable) epidemiological crisis

• Prevalence of mental ill-health

• Prevalence of physical conditions associated with poor mental health

– Chronic disease – poor self management, poor management of sub-clinical risk, must do better on prevention and early intervention

– Some sections of our population at very high risk of avoidable misery and death

– Mental health – intervening too late

– Resilience and Happiness – likewise

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PrimaryPrevention

SecondaryPrevention

TertiaryPrevention

in andOut of hospital

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Premise 2: The Policy Context (England) does give us scope to address this

• Local Authorities – duty to promote and protect health of population

• NHS CCGs – duty to reduce inequalities in health

• Behaviour change is a tool but we need to use it properly and use the right methods

• A balanced strategy using a range of tools and strategies

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Premise 3: There are some big tasks we can be getting on with

1. Analyse the system and identify problems

2. Build a system wide approach to deal with it

3. Be clear on roles, responsibilities and outcomes

4. A more nuanced understanding of mental health and resilience across lifecourse

5. Commission for pathways around people

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Premise 4: Some quick wins and delivery tools

Five big wins

1. Shift up clinical complexity in primary care

2. Shift up preventive and resilience work

3. Step up self care and self management in chronic disease

4. Commission pathways around users

5. Commission primary prevention for key risk groups

Policy and Delivery Tools

• Pathways and structured care approached

• Health and social care integration

• Behavioural sciences

• Health Checks and public health services

• Brief interventions

• Physical Activity

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Premise 5: Phasing and Layering across Lifecourse

Early Years

Childhood Adolescence

Young Adults

Older Adults

Environmental

Structurcal

Social

Behavioural

Biological

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Premise 5: Phasing and Layering across Lifecourse – Adults with Complex Needs

Early Years

Childhood Adolescence

Young Adults

Older Adults

Environmental

•Multi agency

•All commissioners.

•Pathway approach

•“Thrive” focus

•1800 people

Structurcal

Social

Behavioural

Biological

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Healthier Herts: A Public Health Strategy for Hertfordshire

OUR PURPOSEto work together to improve the health and wellbeing of the people of

Hertfordshire, based on best practice and best evidence

OUR VISION:A Healthy, Happy Hertfordshire: everyone in Hertfordshire is born healthy, and lives full, healthy and happy lives. We compare well with England and every area in Hertfordshire compares well against

Hertfordshire

Priority 5: We understand what’s needed and we do what works

Priority 6: We make public health everybody’s business and work together

HOW WE WILL WORK TOGETHER(our strategic priorities: how we do it for

our County)

ThePublicHealthOutcomesFramework(the nationalPHOF willHelp us measureOur success)

WHAT WE WILL ACHIEVE WORKING FOR AND WITH OUR RESIDENTS

(our strategic priorities: what we achieve for our County)

Priority 1: Our Population lives Longer, Healthier Lives

Priority 2: Our Population Starts Life Healthy and Stays Healthy

Priority 3: We narrow the gap in life expectancy and health between most and least healthy

Priority 4: We protect our communities from harm (chemical, biological, radiological and environmental)

BuildingBlocks For the Public Health Family

Strong Leadership

Capable, Skilled People

Co-production with citizens

Effective Partnerships

Evidence and Knowledge Driven

Plan and Deliver for Localism

Whole System Approaches

Making better use of behavioural sciences at individual, interpersonal, community and service levels

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Premise 5: Phasing and Layering across lifecourse

•Think through what we can do short term

•Start work on the medium term

•Set the policy framework for the long term

•Build this understanding among partners

•Get started and realise

•County, District, Parish, NHS, Business and Community Sector working together

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Premise 5: Phasing and Layering

• Phasing across the lifecourse and timeWorking age

AccumulationOf risk inLate workingage

Good early Years outcomesFor lifetimeMental health

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Premise 5: Phasing and Layering across Lifecourse

• Layering levels of action

• Population – resilience – how to thrive

• Sub-Population – self harm work, diversity, bullying

• Individual – school pastoral care frameworks (30 secondaries)

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What it means for NHS Services

• Preventive services in every patient pathway

• Levels and competencies from brief intervention onwards

• Preventive services in clinical services link up to community services (referral for leisure and behavioural interventions)

• Commissioning for self-management in chronic disease

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Making PMH Opportunities a reality -1

• A Framework for DsPH– JSNA to Commissioning remains a

challenge– Domains Model or Prevention Model within

the framework (next slide)– Menu of interventions likely to work across

domains– “Plug and play” tools and strategies

http://www.fph.org.uk/better_mental_health_for_all

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Making PMH Opportunities a reality -2

• Frameworks we might use

– Domains of Public Health Model or Prevention Model?• Health Improvement – layer, scale and phase

• Health Protection – mentally disordered offenders, etc

• Service Quality – CAMHS, MH Pathways etc

– Prevention Model? – 1ry, 2ry, 3ry, Resilience?

– Levels of Public Health (Dettels et al,2009)• Biological, behavioural, social, structural, policy, environmental

– An Evidence Base

http://www.fph.org.uk/better_mental_health_for_all

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The domains model applied to public mental health (a first, partial start at an illustration)

Health Improvement Health Protection Service Quality (often called service public health)

Good JSNA and Equity Audit as a foundational step

Lifecourse approach to building resilience

Protecting people from vulnerability factors (workplace stress)

Best possible evidence

Early intervention Drugs and alcohol work Best possible implementation

Physical activity, social connectedness as well as drugs and therapy

Mentally disorderered offenders work

Best possible evaluation and audit

Tiered approach (severity)

Layering across the 6 layers of public health: biological, behavioural, social, political, environmental, structural (Dettels et al 2009)

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Evidence example – the “S” and “R” words

• Growing evidence base for dual impact of Spirituality and Religion on health

– King et al 2013

– Koenig et al 2012

• Salience of context and outlook

• Important coping and resilience benefits

• Least comfortable of protected characteristics in NHS (McManus, 2008; Cooke 2010)

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Making PMH Opportunities a reality - 3

• Some discrete pieces of work– PMH and wider determinants (resilience, financial

stress and burden)– Using research and academic monies to do

knowledge transfer– Supporting DsPH with knowledge transfer into

implementation• menus of interventions which work• the evidence gap – what’s promising and what does good

innovation look like• evaluations

– Training

[email protected]

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An attempt at a Hertfordshire framework

• Phasing – Lifecourse

• Layering of PMH intereventions (the 6 layers)

– Resilience – how to thrive, carers, lgbt, bullying, community interventions,– physical activity, 5 ways to wellbeing, bibliotherapy, financial stress etc, building social movements and norms

– Prevention – menu of interventions, pathway

– Tiering of services – scale, pace, quality, commissioning, pathways

[email protected]

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Premise 5: Phasing and Layering across Lifecourse

• Layering levels of action

• Population – resilience – how to thrive

• Sub-Population – self harm work, diversity, bullying

• Individual – school pastoral care frameworks (30 secondaries)

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Contributions on Mental Health 1Third sector contributions

Working together PH, NHS, LA contributions

•Activities which improve self esteem and self worth, key skills – recovery, prevention and resilience agenda

•Do more to encourage and enable volunteering – commissioning of services but no funding for volunteer centres. Cost of volunteer centres needs to be considered if volunteering is a proper strategy. Echo this for any frontline org with minimum staffing. Cost of keeping volunteer centres going versus return it brings – if volunteering is an outcome, the infrastructure to support it (vol mgt) needs supporting

•Training front line workers to understand and signpost better

•Evidence for funding (support vcs on getting funding)

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Contributions on Mental Health 2

Third sector contributions

Working together PH, NHS, LA contributions

•CAB transition services are a really good example of third sector working together

•CAB transitions service looking at how we do a referral process and have an activity plan. Sharing data on a small scale.

•Easy to connect with and access especially where there is a fear of accessing services

•Reducing isolation (flexible), trust in the sector, local knowledge, - third sector could promote itself more

•People expect too much from services – people need to be more resilience generally. Services need to promote resilience and taking responsibility for oneself

•Making every contact count is good

•Dealing with alcohol use for self medication – investment has happened but could do more

•Lifestyle prescriptions

•Clearer pathways and being able to move from formal statutory into third sector and less red tape

•Education – get into young people

•A piece of work to support the vol sector demontrate return on investment for their work.

•Commissioners to explain clearly and consistently what they are looking for in return on investment and how vcs reports ROI

•Training offered

•Services are reactive, not flexible enough – need to look at preventive agenda more widely

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Some examples of strategic opportunism in Herts

Population Wide Sub-Populations Individuals

•How to thrive

•Workplace MH Champions

•School Pastoral Care

•£2m investment in Districts

•Anti-Bullying

•Self harm

•Older bereaved

•Adults with complex needs programme

•Health Psychologist working with primary care

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Current Projects revisited

• Public Mental Health Framework for all agencies

• Year of Mental Health Launching 2015

• CAMHS whole system review

• School Whole System Wellbeing Pilots in 36 schools

• Reframing IAPT

• Do Something Different

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Further examples of strategic opportunism in Herts

Population Wide Sub-Populations Individuals

•Lifestyle partnership

–Football clubs

–Leisure offer

–Connection

•Welwyn Hatfield 5 Ways

•LGBT Bullying

•Faith communities and low level interventions

•Extremism and mental health