Economic downturn and reforms to the welfare and housing system:Implications for mental health and wellbeing

HSCF mental health SIG

Vicky HobartPublic Health, City and Hackney

12th July 2012

Mental well being, maintenance and recovery

Promoting mental wellbeing in the population

Maintaining mental health and wellbeing for individuals and families

Aiding recovery

Parenting skills & pre-school education Family environment in early life is a critical to emotional & behavioural

development of children Adverse experiences at this stage e.g. abuse, neglect or harsh parenting,

are strongly associated with onset of MH difficulties in childhood, often persisting throughout the life course

Interventions that reduce risk factors & enhance protective factors in the family show a high level of effectiveness & cost-effectiveness

Parenting skills training (improving MH of parents & the MH/behaviour/life chances of children)

Pre-school prevention programmes, including educational components involving the child & family/parenting support, improve social/emotional behaviour, cognitive function & family well-being with long term improvements in earnings & reduced criminal behaviour

Life-long learning, health promoting schools & continuing education Robust case for strengthening investment in MH promotion in school

settings & for increasing educational opportunities for adults Support for emotional & social development is as important as help with

school work in increasing the chances of educational success, notably for children facing difficulties at home

For primary schools, staff trained to identify signs of emotional problems & a programme to develop children’s emotional & social wellbeing & to help parents develop their parenting skills (NICE)

All secondary schools adopt a whole school approach, encompassing organisation & management issues as well as the curriculum & extra-curriculum provision.

Improving working lives: employment & the workplace 1 in 6 of the workforce is affected by a MH problem Recognition that employment is good for physical & MH

Working conditions & practices in line with the Health & Safety executive’s management standards on work-related stress

Awareness training for line managers, Better access to help & effective rehabilitation

Lifestyle Known effectiveness of lifestyle messages for the promotion of MH e.g.

exercise, diet, learning new skills, creative pursuits & social participation Change in relation to diet, exercise & alcohol has potentially large MH

benefits with low cost interventions, particularly in primary care Behaviour change is influenced by a range of factors. Capacity, motivation

& opportunity to adopt a healthy lifestyle are strongly influenced by MH, as well as by socio-economic factors.

MH & lifestyle advice routinely & opportunistically offered in primary care, with a focus on diet, exercise & alcohol & strengthening social support

Interventions that promote collective opportunities for healthy lifestyles e.g. green gyms, walking groups & self help groups

Supporting communities; environmental improvements Evidence of the MH benefits of the natural environment, including

outdoor urban public spaces MH benefits of contact with nature linked to value of the natural

environment & factors that support psychological wellbeing e.g. physical activity, companionship.

Environmental predictors of poor mental well-being include: neighbour noise, feeling overcrowded, feeling unsafe/fear of crime, damp housing

Protective features include places to escape to (e.g. green open spaces), events to bring people together, community facilities & social & entertainment facilities

Evidence Examples

‘Being without work is rarely good for one’s health, but while ‘good work’ is linked to positive health outcomes, jobs that are

insecure, low paid and that fail to protect employees from stress and danger make

people ill’

Marmot review team

Population health effects of economic crisis

• No ‘typical’ mortality response- some causes increase others fall dependent on populations affected and their characteristics

• Increase in risk factors for poor mental health: low household income, debt, financial difficulties, housing payment problems, poverty, unemployment, job insecurity

• Increase in prevalence of major depressive disorder (Canada/ Hong Kong)• Increase in homicide• Increase in family violence and neglect (WHO report) and reports of

increased domestic violence and relationship breakdown• Associated impacts on wellbeing of children• Worse infectious disease outcomes- living conditions, access to therapy,

poorer retention, reduced immunity.• Little research into longer term impacts

Unemployment- impacts at individual level

• Limiting long term illness• Mental illness• Cardiovascular disease• Higher use of medication• Worse prognosis • Worse recovery rates

Male mortality in England and Wales 1981-1992

Unemployment- material and psychosocial effects

• Reduction in income, lower living standards• Unemployment/fear of as a stressor, triggering distress,

anxiety, depression• And/or worsening physical health• Loss of core role, linked to sense of identity• Reduced social integration, lower self-esteem• Loss of feeling of control – an essential protective feature of

good health• Impact on health related behaviours- increased smoking and

alcohol consumption, reduced physical activity• Wider impacts on families and communities

Simplified cognitive model of unemployment - CBT perspective

Key benefits claimed by residents of Hackney and City of London, May 2011. Percentages are of working age population (NOMIS/DWP)

Hackney The City London

number % number % %

Job seekers 10,660 7.0% 120 1.2% 4.1%

Incapacity benefits and ESA 13,260 8.7% 160 1.7% 6.5%

Lone parents 4,620 3.0% 20 0.2% 1.5%

Carers 1,640 1.1% 20 0.2% 1.2%

Others on income related benefits 1,160 0.8% 10 0.5% 0.5%

Disabled 1,220 0.8% 20 0.3% 1.0%

Bereaved 160 0.1% 10 0.1% 0.2%

Key out of work benefits 29,700 19.4% 380 3.2% 12.4%

Hackney context

• Desirability/ Olympics = increasing rents, less supply

• Increase in employment rate but large cohort remains workless.

• Evidence of real need? ie not people ‘parked’ on IB when manufacturing

declined.

• Large number and % of people rely on means tested benefits including

housing benefit- in work poverty?

• Lone parents

• Larger households- disproportionately affected

• Existing overcrowding

• Hackney Homes working with many Housing Associations

How will people respond to a short fall in income?

• Re-negotiate rents with landlords

• Re-deployment of the household income to meet the shortfall in LHA- reducing spending on food,

heating, travel, leisure.

• Supplementing this income: through financial support from friends/family, through the informal

economy, or by additional non-dependents joining the household that contribute to household

expenses.

• Increased personal debt- through personal loans, or rent arrears. These households may have a

poor credit rating, and be vulnerable to loan sharks and pay day loan companies. This also carries

the risk of repossession, or non-renewal of a tenancy.

• Finding employment-but in the short term this has implications for continued receipt of benefits.

In the longer term Universal Credit may increase work incentives as the cap will not apply to

working households.

• Moving house- either to a smaller/ lower rent property in the same area, or to a cheaper area.

Larger households could split themselves between two properties.

Groups particularly vulnerable to poor mental health: scale of effect, or existing health status

• Incapacity benefit claimants being reassessed

• Single people 25-35 years in private rented sector

• Private rented sector

• Families with 3 + children

• Employment support allowance claimants

• Older people in ‘under-occupied’ properties

• Other?

Priorities to protect the health and well being through these changes

• Advice, advocacy and support- recognising the phasing and complexity of the changes.

• Anticipate an increase in demand for benefits advice and support services, and there is some

evidence of this already locally.

• Prevent overcrowding and homelessness- these are already significant issue in Hackney (see

section) and could be exacerbated.

• Identify and support people who do not engage in the changes or drop out, to prevent

homelessness and/or destitution.

• Establish good links between the new Work Programme and local services to give people the

best chance of good employment or enterprise

• If people have to/decide to move, consider what support they will need and help them plan

eg re-registering with school or GP, access to formal and informal support networks

(including carers), and ensuring good safeguarding procedures for vulnerable children and

adults are maintained through good communication and hand over.

Conditions of those claiming Incapacity Benefit/ Severe Disablement Allowance, Hackney, May 2011 (NOMIS/DWP)

mental and behavioural

disorders, 57%

diseases of the musculoskeletal

system, 17%

diseases of the nervous system, 5%

diseases of the circulatory system,

5%

diseases of the respiratory system,

3%

other, 13%

Work capability assessment/ reassessment

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