a pragmatic approach to building a local public mental health progamme
DESCRIPTION
This presentation, given as part of a plenary symposium at the 8th World Congress on Promotion of Mental Health and Prevention of Mental and Behavioural Disorders gives an overview of how one area is trying to develop an approach to public mental health, finding frameworks and tools of useTRANSCRIPT
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Public Mental Health Building the house while living in the foundations
September 26th 20148th World Congress on Promotion of Mental Health and Prevention of Mental and Behavioural Disorders
Jim McManus
Director of Public Health
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Approaching public 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– Dealing with specific challenges – e.g self harm– 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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Strategic Opportunism
• We are facing an (avoidable) epidemiological crisis
• Inadequate policy context
• Needs a systems approach
• 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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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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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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Phasing
• Phasing across the lifecourse and timeWorking age
AccumulationOf risk inLate workingage
Good early Years outcomesFor lifetimeMental health
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• 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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Layering
•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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Phasing and Layering across Lifecourse
Early Years
Childhood Adolescence
Young Adults
Older Adults
Environmental
Structurcal
Social
Behavioural
Biological
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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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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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Strategic opportunism in Hertfordshire
• Layering levels of action
• Population – resilience – how to thrive
• Population – Lifestyle Partnership
• Sub-Population – self harm work, diversity, bullying
• Individual – school pastoral care frameworks (30 secondaries)
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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
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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
•Lifestyle Partnership
•Anti-Bullying
•Self harm
•Older bereaved
•Adults with complex needs programme
•Health Psychologist working with primary care
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Further examples of strategic opportunism in Herts
Population Wide Sub-Populations Individuals
•Lifestyle partnership
–Leisure offer
–Connection
•Welwyn Hatfield 5 Ways
•Health Walks
•Year of Cycling
•LGBT Bullying
•Faith communities and low level interventions
•Extremism and mental health
Working with IAPT on long term conditions and resilience
Suicide and self harm