The Mental Health Foundation
Changing minds, changing lives
Our vision is for a world with good mental health for all.
Our mission is to help people understand, protect and sustain their mental health.
Prevention is at the heart of what we do, because the best way to deal with a crisis is
to prevent it from happening in the first place. We inform and influence the
development of evidence-based mental health policy at the national and local
government level. In tandem, we help people and communities to access information
about the steps they can take to reduce their mental health risks and increase their
resilience. We want to empower people to take action when problems are at an early
stage. This work is informed by our long history of working directly with people living
with or at risk of developing mental health problems.
The Mental Health Foundation is a UK charity that relies on public donations and
grant funding to deliver and campaign for good mental health for all.
Website mentalhealth.org.uk
Twitter @MHF_tweets
Facebook facebook.com/mentalhealthfoundation
Instagram @mentalhealthfoundation
London Health Inequalities Strategy
We welcome the Greater London Authority’s (GLAs) initiative to review and
reshape its Health Inequalities strategy and its call for evidence.
The Mental Health Foundation has written extensively about the approaches that can
be taken to address mental health inequalities and to prevent mental health
problems from occurring or recurring. Our submission relates to the individual and
local actions that can be applied to address health inequalities in the capital. We
particularly recommend the following Mental Health Foundation resources to inform
the Mayor’s upcoming strategy:
• Mental Health and Prevention: Taking Local Action addresses preventing
mental ill health through delivery in local areas across the UK addressing
needs across the whole of population.
• Better Mental Health for All shows what can be done both individually and
collectively to advance mental health using a public health approach; it
includes recommendations for professionals.
understanding the relationship between poverty and mental health and offers
recommendations to improve outcomes across the life course.
• Mental Health and Housing (PDF) makes a number of recommendations in
relation to the quality of supported accommodation and the need for co-
production and design. It focuses on five approaches to provide supported
accommodation: care support plus, homelessness, complex needs, low-level
step down and later life.
• Fundamental Facts (PDF) offers comprehensive evidence and data on mental
health and the variation in risk and incidence across different groups.
• The Lonely Society? explores evidence on loneliness in society, its impact on
mental health and ways to address it.
• ‘Leaving No-One Behind’ will be published in February 2018 and explores
why some communities and people face much greater risks of mental health
problems and what we can do to improve mental health for all.
• Mapping mental health priorities in London with real-world data, produced in
partnership with Thrive London, applied The Mental Health Foundation’s
mental health inequalities framework to prioritise London Boroughs for action.
This evidence response selects highlights from these publications. Please consult
the full texts for comprehensive detail.
Recommendations and actions to be incorporated into the London Health
Inequalities strategy are highlighted in textboxes throughout our submission.
Should you wish to discuss any aspect of our submission, Isabella Goldie, Director of
Development and Iris Elliott FRSA PhD, Head of Policy and Research, would be very
happy to meet with you.
In responding to the consultation, we are aware some of the information we provide
is duplicated in responses to other questions. We have done this to ensure all
information is considered independently for each standalone question.
Section 1 - Healthy Children
Question 1: Is there more that the Mayor should do to reduce health
inequalities for children and young people?
Yes, the Mayor could do more to reduce health inequalities for children and young
people. Although we recognise some of the recommendations and actions advised in
this section fall outside of the Mayor’s direct authority, we would like to see him
advocate for such changes in order to effectively tackle health inequalities for this
group.
Socio-economic disadvantages place people at greater risk of developing mental
health problems. Children and young people living in these circumstances are two to
three times more likely to develop mental health problems. This sets the scene for a
spiral of disadvantage that all too often accumulates across life. When mental health
problems are established, these can lead to a series of detrimental effects on
people’s life chances. Even when not born into disadvantage, children and young
people who experience mental health problems early in life are more likely to be
workless, to live on benefits and to experience debt all, of which can accumulate to
produce a poorer quality of life that can worsen across the life course.
We recommend the following four key actions:
1. Promoting emotional wellbeing and build resilience through universal and
targeted programmes;
2. Providing the best and most appropriate care and support for young people
experiencing health inequalities;
3. Building the right skills for professionals; and address the adverse impact
that social media and technology can have, while recognising that it also
has many benefits
3
This section sets out each of our proposed actions in more detail.
Promoting emotional wellbeing, building resilience, and establishing and
protecting good mental health
In working to reduce the prevalence and the distress caused by mental health
problems we recognise that to make the biggest difference, we need to start at the
earliest point, focusing a good deal on child development in the early years. The
delay in identifying children at risk and providing effective early intervention means
that many young people enter adulthood with untreated conditions, while for other
symptoms may only develop once they have reached adulthood.
Given the known and emerging neuroscientific evidence on the changes that take
place in the brain from birth through to teenage years, we know that acting to protect
mental health throughout this period needs to be a central priority, as this is a time
when children and young people experience major physical, emotional and social
transitions. As noted by the Children and Young People’s Mental Health and
Wellbeing Taskforce report ‘Future in Mind’: “early intervention avoids young people
falling into crisis and avoids expensive and longer-term interventions in adulthood”1.
1 Department of Health. (2015). Future in mind; promoting, protecting and improving our children and
young people’s mental health and wellbeing. London: NHS England. Retrieved from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/41
We recommend that the Mayor’s actions are underpinned by the following
principles:
spend across London boroughs;
• Risk awareness - tailoring the services and support available to those who
are identified as being at elevated risk of experiencing mental health
challenges and/or distress;
accurately measure success;
• Available - to ensure that community hubs/centres and children’s centres
remain open and have the appropriate resources to meet local demand.
We call for:
• The promotion and protection of mental wellbeing from birth to be at the
centre of the strategy;
• Advice and support to be provided to encourage and support positive
couple relationships;
• Good practice and learning from anti-bullying campaigns to be effectively
shared and encouraged to be adopted;
• Tailored safeguarding measures identifying the most at-risk groups to be
included in the Mayor’s strategy.
This needs to begin in infancy, with advice and support for parents (for example from
midwives, health visitors and GPs) that promotes secure attachment and helps
parents to respond to babies as people, encouraging attunement to their feelings
and their communication of their needs. Parenting support at later ages (including
for foster parents) can also promote attachment and prosocial behaviour, and also
help parents to set clear and consistent boundaries for children in an authoritative
way, rather than using an authoritarian or a permissive style of parenting, both of
which are associated with risks to children’s mental (and sometimes also physical)
health.
The couple relationship is a key early intervention opportunity, with provision of
advice and support that helps parents to nurture their young children in a positive
way. Positive couple relationships can also buffer early insecure attachments for the
parents themselves, and lead to the formation of new working models and patterns
of interaction, which will in turn benefit their children.
We call for universal and targeted programmes to provide support for families and
parents. Our recommendations draw on evidence and knowledge generated by the
Mental Health Foundation and are in line with the recommendations outlined in ‘The
Early Years: Foundations for Life, Health and Learning (PDF)2’, and 'Early
Intervention: The Next Steps' (PDF)3. As a member of the Maternal Mental Health
Alliance4, we call for investment in evidence-based maternal mental health services.
In addition to our calls for specialist clinical services, we strongly advocate for
innovate peer support and self-management approaches for partners and families,
like the evidence based Mums and Babies in Mind5, Young Mums Together6 and
Creating Connections7 programmes.
In light of the increasing number of young people who are experiencing mental
health problems when they leave secondary school, as well as the young people in
further education, targeted approaches that focus on school transitions are needed.
Evidence indicates that support for teenager mental health is almost as important as
focusing on early years, parenting and maternal mental health interventions. Major
neurological changes occur at this stage in the child’s development and it offers one
of the last points at which preventative work is an option. Work undertaken by The
4024/Childrens_Mental_Health.pdf www.gov.uk/government/uploads/system/uploads/ attachment_data/file/414024/Childrens_Mental_ Health.pdf 2 Tickell, C. (2011). The Early Years: Foundations for life, health and learning An Independent Report on the Early Years Foundation Stage to Her Majesty’s Government. Retrieved from: http://www.educationengland.org.uk/documents/pdfs/2011-tickell-report-eyfs.pdf 3 Allen, G. (2011). Early Intervention: The Next Steps: An Independent Report to Her Majesty’s Government Graham Allen MP. Retrieved from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/284086/early- intervention-next-steps2.pdf 4 Maternal Mental Health Alliance. Retrieved from: http://maternalmentalhealthalliance.org/ 5 Mums and Babies in Mind. Retrieved from: https://www.mentalhealth.org.uk/projects/mums-and- babies-mind 6 Young Mums Together. Retrieved from: https://www.mentalhealth.org.uk/news/big-lottery-funding- awarded-scale-young-mums-project-2015 7 Creating Connections. Retrieved from: https://www.mentalhealth.org.uk/projects/creating- connections
the core principles of child development into compassionate school work8.
There is a well-developed evidence base highlighting the link between bullying and
experience of mental health problems during childhood, including higher risks of low
self-esteem, depression and suicide. Findings from the British National Child
Development Study demonstrate the negative social, physical and mental health
effects of childhood bullying are still evident nearly 40 years later, and that the
impact of bullying is persistent and pervasive, with health, social and economic
consequences lasting well into adulthood9. In response, anti-bullying principles need
to be built into school’s practices to shape programmes and guide teachers to
effectively tackle this risk factor.
We now know that childhood adversity has been shown to account for around a third
of future mental health problems: 50% of these are established by the age of 14 and
75% by the age of 2110.The Child and Adolescent Mental Psychiatric Morbidity
Surveys carried out by ONS in 1999 and 2004, covering England, Scotland and
Wales, found that 10% of children and young people (aged 5–16) had a clinically
diagnosable mental health problem11. While these prevalence rates for child and
adolescent mental health problems in the UK are out of date (a new survey, for
England, is due to be published in late 2018), there are more recent statistics that
show prevalence rates are increasing12.
The 2014 survey highlights higher rates of common mental health problems being
found among younger women (aged 16 to 24 years) compared to their male peers.
In 1993, young women of this age group were twice as likely to have symptoms of a
common mental health problem - at 19.2% - compared to young men - at 8.4%. This
increased by 2014, where these symptoms are nearly three times more common in
young women (26.0%) than men (9.1%). The findings also show that nearly 25% of
young women in this age group have self-harmed in their life.
8 Further evidence on the development of whole school nurturing approaches can be found here: https://education.gov.scot/improvement/Pages/sacfi2b-Whole-School-Nurturing-Approaches.aspx 9 Takizawa R, Maughan B, Arseneault L. “Adult health outcomes of childhood bullying victimization: Evidence from a 5-decade longitudinal British birth cohort” is published in the American Journal of Psychiatry 10 Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. (2005). Lifetime Prevalence
and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62 (6) pp. 593-602. doi:10.1001/archpsyc.62.6.593. 11 Department of Health and the Scottish Executive. (2005). Mental health of children and young
people in Great Britain, 2004. Retrieved from hscic.gov.uk/catalogue/ PUB06116/ment-heal-chil-youn- peop-gb-2004-rep1.pdf 12 Health and Social Care Information Centre. (2015). Provisional monthly hospital episode statistics
for admitted care, outpatients and A&E data, April 2013–October 2013: Topic of interest – Eating disorders. Retrieved from gov.uk/government/statistics/hes-for-admitted-patientcare-outpatient-and- ae-provisional-monthly-data-april- 2014-to-october-2014
experiencing health inequalities
The Mayor’s strategy urgently needs to reflect the needs of all children and young
people – whether they are inside or outside the school setting. We are concerned
that policies that look to support the mental health and wellbeing of children and
young people that focus on schools alone will not benefit those who are outside the
school system. We champion the extension of interventions and targeted support for
children who are excluded from school, or otherwise outside the school system, or at
risk of being so. Where possible, a whole-family approach should be taken. This
includes children who are homeless, in the criminal justice system, part of a
travelling community or in immigration detention centres, and who have greater
exposure to factors that negatively affect their mental health, such as poverty and
discrimination. This also includes children who have a parent(s) with a mental health
problem, who are in prison, or have an addiction.
For children and young people to be effectively supported, it is vital that families,
teachers, and care providers, are trained and skilled to provide tailored interventions
for those with mental health problems as well as supporting empowerment of more
vulnerable young people. They also need to be equipped to tackle stigma and
discrimination, including for those who experience intersecting discrimination, such
as young people with disabilities and learning disabilities and those from BAME
communities. The adversity points noted (children with parent(s) with a mental health
problem, who are in prison, or have an addiction) present opportunities to intervene
with the child as services are often already intervening with the parent. A family-
approach underpins how successful such interventions might be, the delivery of this
approach ultimately being determined by upskilling the mental health workforce.
Community leadership can also play an important role guiding and supporting
children and young people. The One Good Adult approach, piloted by NHS Greater
Glasgow and Clyde, emphasises the importance of a having a dependable adult who
can support and protect the mental well-being of a child and/or a young person
available to every child and/or young person13. Time to Change and Black Thrive
13 NHS Greater Glasgow and Clyde. (2017. One good adult. Retrieved from: http://www.nhsggc.org.uk/about-us/professional-support-sites/child-youth-mental-health/the-6-box- model/one-good-adult/
We call for:
• Looked after children, those in contact with the criminal justice system,
children with learning disabilities and children from BAME communities to
receive targeted approaches, which need to be integrated into both the
school setting and the community, to tackle stigma and support them to
thrive and achieve the same academic success as their peers;
• Extending the One Good Adult Approach.
children and young people but also intersectionality.
We champion the adoption of a proportionate universalism approach, with more
progressively targeted interventions to address the specific needs of children and
young people at higher risk and those who are already experiencing a mental health
problem. As stated by the UK’s four Children's Commissioners recommendations in
their 2015 submission to the United Nations Committee on the Rights of the Child,
investment is urgently needed in early intervention children’s services14. Particular
attention needs to be given to those with pre-existing mental health problems, but
also to those who are exposed to factors that place them at higher risk of developing
a mental health problem, for example looked after children and others who are
vulnerable as a result of adverse childhood experiences, very often as a result of
adverse experiences before going into care.
There are more than 68,000 looked after children and young people in England and
according to the Department for Education (2013) 62% of these children15 were in
care because of abuse or neglect, with the majority aged between 10 and 15. This
group require targeted approaches which need to be integrated into the school
setting to ensure they do not increase stigma, but rather support them to thrive,
achieve academic success and to be helped to achieve their potential. Interventions,
for example through peer education, that focus on raising the educational standards
of the most vulnerable children and young people should be rolled out,16 as there is
pervasive evidence linking academic achievement to mental health and wellbeing,
with young people not in education, employment or training (NEETs) being more
likely to report higher anxiety than other young people17.
14 Joint Committee on Human Rights. (2015). The UK’s compliance with the UN Convention on the Rights of the Child Eighth Report of Session 2014–15. London: House of Lords. 15 Department for Education. (2013). Children looked after in England (including adoption and care
leavers) year ending 31 Mar 2013. Statistical First Release. London: Department for Education. Retrieved from: http:///.gov.uk/government/publications/children-looked-after-in-Englandincluding- adoption 16 Faculty of Public Health and Mental Health Foundation. (2016). Better Mental Health for All: A
Public Health Approach to Mental Health Improvement. Retrieved from: https://www.mentalhealth.org.uk/sites/default/files/Better%20MH%20for%20all%20web.pdf 17 Faculty of Public Health and Mental Health Foundation. (2016). Better Mental Health for All: A
Public Health Approach to Mental Health Improvement. Retrieved from: https://www.mentalhealth.org.uk/sites/default/files/Better%20MH%20for%20all%20web.pdf
8
Build the right skills for professionals; and tackle the adverse impact that
social media and technology can have
Protecting and improving the mental health of future generations is a great
responsibility requiring the promotion of personal resilience and wellbeing in those
charged with the care of children, including teachers, childminders and nursery staff,
as well as ensuring they have access to mental health literacy guidance and training.
In the early years parents have the main responsibility of supporting the emotional
and social development of their children, but other care givers play a critical role too.
Families continue to be central to supporting young people across their childhood
and factors such as poor couple relationships, family disharmony, domestic violence
and abuse in the family home can negatively affect the mental health of young
people. However, as they grow older peer relations and the role of the school can
help to balance out challenging family dynamics. Therefore, ideally, there needs to
be a partnership between services and parents in supporting children and young
people’s emotional wellbeing, starting with parenting support in the early years, to
develop secure attachments, reduce the risk of adversity and promote school
readiness; thereafter schools need to work alongside parents where this is realistic
and productive to support good mental health and healthy transitions into adulthood.
It is important to ensure good workplace mental health practices are in place. In
addition to this supporting the ambitions of achieving better mental health for all, it
can help protect pupils from the impact poor mental health and wellbeing of teachers
can have.
Research indicates that good health improvement programmes can mitigate the
impact of suboptimal parenting practices on children18, demonstrating the enormity of
the responsibility schools hold. But this requires teachers to have the space, time
and resilience to take on this pivotal public mental health role. As a matter of urgency
teachers and the pre-school workforce need to be trained to increase their
18 School Mental Health Promotion. (2010). Faculty of Public Health. Available at:
http://www.fph.org.uk/school_mental_health_promotion
We call for:
• Those in contact with children and young people to be trained to increase
their knowledge and skills around the stages of child development and how
this affects cognition, emotions and behaviour (both social and learning) so
they have a better understanding of the needs of young people. The focus
of the training needs to: highlight the importance of creating a nurturing,
compassionate culture that supports learning and peer support; take every
opportunity to build mental health literacy and improve resilience, adopt an
integrated approach to learning and emotional and social development,
and support meaningful engagement and involvement of children and
young people.
knowledge and skills around the stages of child development and how this affects
cognition, emotions and behaviour (both social and learning) so they have a better
understanding of the needs of children and young people and can better support
their wellbeing. This training and awareness will also equip these professionals with
the skills to identify those at an increased risk of developing a mental health problem,
and help them to take early action.
In addition to this training, there is mounting evidence that suggests an increased
focus on exams, and the measures of success applied to schools, can have a
damaging impact on children and young people’s mental health. In addition to the
reality that one in ten children or young people experience mental health problems,
figures from the annual NUT survey of secondary teacher members reported that 85
percent of respondents said that current government accountability measures were
harming the self-esteem, confidence and mental health of their students. 92 percent
argued that accountability measures reduce the quality and time for teacher-pupil
interaction, because of the way these performance indicators and metrics drive
behaviour19. This indicates that if schools focus on supporting good wellbeing and
child emotional and social development, attainment will follow.
Effective protections and improvement around the mental health of future
generations needs to be developed alongside young people themselves. Social
media in particular presents a range of unique challenges and opportunities to this
group, emphasizing the importance of listening to their voices to help understand
and develop approaches for safe navigation of social media. While there is
significant amounts of guidance available, this information needs to be effectively
integrated in training, education and across the curriculum from an early age.
A whole-school approach to mental health
Schools are well placed to support mental health, equipping young people to
progress into adult life as resilient and socially engaged citizens; compassion and
nurture must underpin the culture and ethos of the school to achieve.
As recommended in the Children and Young People’s Mental Health Coalition and
Public Health England resource, ‘Promoting children and young people’s emotional
health and wellbeing: A whole school and college approach’, we call for schools to
19 The National Education Union. (2016). Curriculum and assessment in chaos: a survey of NUT secondary school members. Retrieved from: https://www.teachers.org.uk/news-events/conference- 2016/curriculum-and-assessment-chaos-survey-secondary
We call for:
• Systematic action across the whole school (for example changes to ethos,
bullying policies, involving children and young people in developing school
policies, and programmes to support teacher wellbeing);
• Universal interventions for all pupils (for example curriculum-based social
and emotional education and literacy).
- Outreach programmes for parents and the wider community.
-
children and young people, including provision of proportionate tailored support for
children who need this. Our calls are in line with the Children and Young People’s
Mental Health Coalition and Public Health England’s resource, ‘Promoting children
and young people’s emotional health and wellbeing: A whole school and college
approach’.
As set out in NICE guidance for both primary and secondary schools, whole-school
approaches are best combined with targeted support, namely, providing
progressively tailored approaches that enable timely school-based support for those
at heightened risk of developing mental health problems, such as pupils that
experience bullying or discrimination, have challenging home lives or who are
displaying behavioural problems20.
Question 2: How can you help to reduce health inequalities among children
and young people?
We would be very pleased to work in partnership with the Mayor to share the
experience of our projects which have been working to reduce the health inequalities
experienced by children and young people:
Our Young Mums Together project aims to address the significant challenges that
young mothers often face, which can affect their mental health, relationships,
employment and social engagement. Over the last three years, we have been
working in partnership with local Children’s Centres and other community groups to
develop sustainable hubs of peer and professional support for young mothers (under
25 years) in three London boroughs.
The weekly, drop-in peer support groups for young parents and their children are
designed to enhance young mothers’ life chances and promote maternal mental
health and wellbeing. The sessions address topics of interest to young mothers,
involving guest speakers who can offer specialist information or advice and provide a
signposting route for further support in a relaxed environment that also offers craft
activities and a shared lunch.
Feedback from young mothers has indicated that these weekly sessions have
increased confidence and knowledge, made them feel connected to a supportive
social network and improved their mood.
The project has highlighted the merits of sharing responsibility for mental health
protection and prevention services, particularly for those experiencing or who are
more likely to experience health inequalities, across statutory and non-statutory
services. This shift in responsibility has been identified as particularly beneficial for
groups such as asylum seekers and BAME communities, who are less likely to
access support through primary care services.
20 Adi, Y, Killoran, A, Schrader McMillan, A, Stewart-Brown, S. (2007). Systematic review of
interventions to promote mental wellbeing in primary schools. Report 3. London: National Institute of Health and Clinical Excellence (NICE).
Learning Disabilities and aimed to increase work expectations, aspirations and
opportunities for students with learning disabilities at three schools and colleges in
West Berkshire, Kent and the London Borough of Redbridge.
The number of people with learning disabilities who are in some form of paid
employment has fallen over the past five years to a figure that is well below what
would be expected for people without learning disabilities. The programme aimed to
tackle this issue early on and to raise the aspirations of people with learning
disabilities, and their parents' expectations for them.
The evaluation centred around key recommendations for better supporting children
and young people with learning disabilities into employment. These included:
tailoring individualised employment plans; including employment in all Education,
Health and Social Care Plans; and informing and involving families and/or carers to
support and encourage them to use their own networks to create employment
opportunities.
Question 3: What should be our measures of success and level of ambition for
giving London’s children a healthy start to life?
The Mental Health Foundation advocates that the Warwick-Edinburgh Mental
Wellbeing Scale (WEMWBS) be used across London to identify mental health
inequalities in particular populations and to measure progress. The scale was
developed to enable the monitoring of mental wellbeing in the general population
and the evaluation of projects, programmes and policies which aim to improve
mental wellbeing.
Public Health England and the Anna Freud National Centre produced a toolkit (PDF)
to raise awareness amongst school and college staff of the range of validated tools
We propose that the following indicators should be used to measure success and
that they should be reviewed annually to identify trends.
• School readiness;
• Family homelessness;
• Percentage of children in need due to abuse, neglect;
• Children and young people’s NHS admissions as a result of self-harm;
• Prevalence of eating disorders among young people;
• Percentage of young people who have been bullied in the past couple of
months;
• Numbers of children involved in family court cases.
population21.
School readiness is one of the most significant indicators that can be used to assess
the risk of development mental health problems. While this is an accepted
assessment, it is currently used to measure and record how the child will fit into the
school setting and what adjustments they might require. This indicator provides an
opportunity to intervene not only with the child, but the family as well.
Measurements used in other UK cities
- Goodman Strengths and Difficulties Questionnaire (SDQ)
Glasgow City Council have funded staff at early years establishments (nurseries) to
complete the Goodman Strengths and Difficulties Questionnaire (SDQ) for children
in their pre-school year22;
This SDQ is a behavioural screening questionnaire for children and covers five
areas: Conduct Problems, Hyperactivity/inattention, Peer Relationship Problems,
Emotional Symptoms and Pro-Social Behaviours. The first four of these are rated
negatively (that is, they pick up difficulties in children). The final area, Pro-social
Behaviours, is a positively-scored scale, assessing behaviours such as ‘is helpful if
someone is hurt or upset’.
In Glasgow City, SDQs are currently being collected at 30 months (through Health
Visitors), at age 4-5 in nurseries and in Primary years 3 and 6.
- Child Friendly Leeds
Leeds City Council established its Child Friendly Leeds project that brings together
parents, carers, professionals, organisations and young people to share information,
advice and guidance on a wide variety of issues that affect children and young
people across Leeds23.
- School-Readiness Pledge
The Mayor of Greater Manchester, Andy Burnham, has championed a School
Readiness Pledge to be designed and implemented by the city-region’s schools,
public, private and voluntary sector organisations. This is in response to new
Department for Education figures which showed that 32.5% of children who started
school in the city-region in 2016 were not school ready24.
21 Anna Freud Centre and Public Health England. (2017). Available at: http://www.annafreud.org/media/4612/mwb-toolki-final-draft-4.pdf 22 Glasgow City Council. (2017). SDQ – Pre- School Children. Available at: http://www.understandingglasgow.com/indicators/children/wellbeing/comparisons/within_glasgow 23 Leeds City Council. (2014). Child Friendly Leeds. Available at: http://www.leeds.gov.uk/childfriendlyleeds/Pages/default.aspx 24 Greater Manchester Combined Authority. (2017). The city-region’s schools, public, private & voluntary sector organisations are being urged to sign up to a new pledge to help kids get ready for school. Retrieved from: https://www.greatermanchester- ca.gov.uk/news/article/210/mayor_calls_for_new_plan_to_ensure_no_child_is_left_behind
indicator that assesses a child’s personal, social and emotional development,
physical development, communication skills and language.
Section 2 - Healthy Minds
Question 4: Is there more that the Mayor should do to make sure all Londoners
can have the best mental health and reduce mental health inequalities?
Yes, the Mayor could do more to make sure all Londoners can have the best mental
health and reduce mental health inequalities.
Strategic, system-wide activity is necessary to take advantage of the opportunities to
improve mental health at all stages of life, particularly at times when individuals,
families and communities experience adversity, and during times of transition from
one life stage to another. If we are to rise to the challenge of reducing the prevalence
of mental health problems, we will need to revise the way we view mental health and
where it is owned. We will need to move from a dominant mental health ‘deficit’
model to one which views mental health as a universal asset to be strengthened and
protected.
The model needs to factor in the impact of adversity – Adverse Childhood
Experiences (ACEs) and trauma – which is often set in childhood. We would like to
see the development of a trauma and psychologically informed workforce, parenting
programmes that embed this approach, trauma and psychologically informed
environments in schools, prisons, workplace, statutory sector, welfare system to
We recommend the following eight actions:
- Reaching out and tailoring support for marginalised or excluded groups;
- Developing a social prescribing programme within primary care services in
disadvantaged communities;
using social contact approaches within current anti-stigma campaigns and
initiatives;
members have existing mental health problems, particularly: families in
which a child has moderate or severe behavioural problems; and families
in which a parent has a mental health problem;
- Scaling and testing evidence-based programmes that provide opportunities
for older people in disadvantaged communities to participate in social and
cultural networks and activities, to help reduce their experience of isolation;
- Applying a mental health inequalities framework using routinely available
data to learn where mental health inequalities lie;
- Benchmarking across boroughs and routinely follow up to understand
patterns/trends over time;
- A scaling up of initiatives such as Peer Education that create school
cultures which equip young people with the compassion and emotional
literacy, foster mutual support.
14
reduce harm and chance of re-traumatisation and to promote resilience across the
life course.
We recommend the Mayor takes a universally proportionate25 approach to
preventing the development or worsening of mental health problems.
A central variant that determines the stark health inequalities in London is income;
vast disparities exist between those who have, and those who have not, and this
income differential translates across to health outcomes. The Foundation’s 2016
report, Poverty and Mental Health26 presents the case for taking a universally
proportionate approach outlining evidence for the complex interrelationship between
poverty, marginality and mental ill-health.
People living in poverty are significantly more likely to suffer from mental health
problems27. They are at higher risk of experiencing adverse social, cultural,
economic, and environmental factors affecting mental health, such as living
standards, working conditions, social protection and community social support.
Prevention measures therefore need to be particularly focused on addressing these
circumstances, strengthening community assets as well as addressing individual and
group resilience. The MAC-UK Integrate model for working to improve the mental
health of young people involved in gangs has demonstrated how working in
authentic co-production can have dramatic positive effects.
Black and Minority Ethnic (BAME) communities, for example, experience
disproportionate levels of poor mental health. Black men are significantly over-
represented in prison populations; they are 10% of the UK population, but 26% of the
prison population. They are also likely to experience racialised stereotyping of their
mental distress and cultural insensitivity in services. Detention under the Mental
Health Act is 2.2 times higher for black African people; 4.2 times higher for black
25 Marmot, M. (2009) Fair Society, Healthy Lives, The Marmot Report. 26 Elliott, I. (June 2016) Poverty and Mental Health: A review to inform the Joseph Rowntree Foundation’s Anti-Poverty Strategy. London: Mental Health Foundation 27 Elliott, I. (June 2016) Poverty and Mental Health: A review to inform the Joseph Rowntree Foundation’s Anti-Poverty Strategy. London: Mental Health Foundation
We recommend that the approaches adopted in the strategy should:
- Take into account the cross-cutting agendas of data and research, stigma
and discrimination, and Mental Health in All Policies (MHiAP);
- Reflect life-course stages: perinatal, early years, school-aged children and
young people; working age adults; and later life;
- Adopt a human rights-based approach in recognition of the extensive
human rights violations and discrimination experienced by people with
mental health problems, especially those from excluded communities and
people with learning disabilities.
A universally proportionate approach would involve not only providing more
resources for working with groups that encounter unacceptable risk to their mental
health, but also tailoring interventions in ways that make them more meaningful for
these populations. Co-production is a core principle for achieving this.
People with learning disabilities experience significantly higher rates of poor mental
health and find problems of accessing mental health services that are appropriate to
their needs. In a 2007 UK population-based study of 1,023 people with learning
disabilities, it was found that 54% had a mental health problem. Resources are
available to address this, but there remain significant gaps between learning
disability and mental health-focused services. For people who experience
discrimination, often in multiple forms, effective prevention of anxiety and depression
can often be most effectively achieved through addressing their immediate causes,
such as hate crime or stigma.
Although there remain large gaps in public mental health evidence, we know that
there is now enough evidence on preventing mental health problems to allow us to
act, including for marginalised group. A greater understanding of, and clear plans to
address, inequality are required to ensure a mentally healthier society for everyone.
To achieve this, we support the recommendations made in Public Health England’s
Prevention Concordat for Better Mental Health Programme which aims to facilitate
local and national action around preventing mental health problems and promoting
good mental health. The Concordat, alongside its accompanying documents, for
example the JSNA toolkit29, reiterates the importance of working out how to allocate
public mental health interventions in an evidenced-based, meaningful way to ensure
proportionate investment. The relationship between inequalities related to socio-
economic status and protected characteristics and poor mental health is two-way:
experiencing disadvantage and adversity increases the risk of mental health
problems, and experiencing mental health problems increases the risk of
experiencing disadvantage. Mental health problems can create a spiral of adversity
where related factors such as employment, income and relationships are affected,
and these things in turn are known to compound and entrench mental health
problems.
Given that vulnerable groups are exposed to preventable risks to mental health,
greater attention needs to be paid to mental health problems related to
marginalisation. Mental health is a cross-cutting and mediating factor in public
policy; task shifting to wider public services to ensure that protecting and improving
mental health becomes a collective effort across those parts of the system that have
a key role in determining it. For further details on task shifting, please refer to NYC
Thrive for more information.
28 Confluence Partnerships (February 2014) Ethnic Inequalities in Mental Health: Promoting Lasting Positive Change. London: Lankelly Chase Foundation, Mind and The Afiya Trust Centre for Mental Health 29 Public Health England. (2017). Better mental health: JSNA toolkit. London: Public Health England
prevention, treatment, discrimination, exclusion, care and recovery is needed30. It is
important that decision makers recognise the intersectional dynamics between
mental health and inequality that influence the experience of mental health. The
responsibility for mental health needs to move from sitting solely with health and
social care to other relevant policy areas (including housing, community, work,
income and education. We have worked with LDN Thrive to map mental health
inequalities across London. Please contact and for further information please contact
Antonis Kousoulis, Assistant Director - Development Programmes.
Addressing the root causes of poor mental health will require the integration and
innovation of services as well as piloting new approaches at increasing scales so
investment can then be focused where solutions will have most impact. Investigating
the root causes of inequality in London urgently needs to be a priority for the GLA;
wider data sets, new pilot programmes and forward-looking research projects are
needed to accurately identify patterns of mental health problems and their causes in
the Capital. As the UK lead in the European digital mental health programme eMEN,
we would be happy to meet with the GLA to discuss in this area and how it could
support innovation in tackling health inequalities. Please contact Iris Elliott FRSA
PhD, Head of Policy and Research.
Question 5: How can you help to reduce mental health inequalities?
The Mental Health Foundation is the UK’s charity for everyone’s mental health. With
prevention at the heart of what we do, we aim to find and address the sources of
mental health problems. We provide people and communities with accessible
information about the steps they can take to reduce their mental health risks and
increase their resilience.
The evidence we gather from a range of stakeholders, including those with lived
experience, academics, policy makers and businesses, is focused on how to help to
mitigate risk factors for mental-ill and shape prevention strategies. This work has fed
into government strategies across the UK.
Below are details of two pilot programmes to test the application of the evidence in
UK contexts, with a particular focus on addressing mental health inequalities and
communities at higher risk:
• As one of the two managing partners of the Scottish Programme See Me – a
national anti-stigma programme - we have acknowledged the importance of
addressing mental health stigma in schools to promote early help-seeking and
30 The WHO’s Mental Health Action Plan (2013–2020) has set out four major objectives for mental health: more effective leadership and governance for mental health; the provision of comprehensive, integrated mental health and social care services in community-based settings; the implementation of strategies for promotion and prevention; and strengthened information systems, evidence and research. This would be progressed by the realisation of six cross-cutting principles and approaches: universal health coverage, human rights, evidence-based practice, the life course approach, the multi- sectoral approach and the empowerment of people with mental disorders and psychosocial disabilities.
reduce factors that affect mental health, such as discrimination and bullying.
We have applied public health and community development approaches
which have included applying whole setting approaches within workplaces,
health and social care settings and in schools. For example, in the schools
setting, we have co-designed a curriculum pack with young people that is
currently being piloted in schools across Scotland.
• The Mental Health Foundation has a proposal to develop pilots for 100%
Health Checks. This is an innovative approach, which integrates mental
health check-ups within existing physical health check services. These would
be undertaken at the key transition points in people’s lives when mental health
risks are at their greatest.
With mental health problems reaching record levels, it has never been more
important to intervene early to protect people’s mental wellbeing and help
prevent them from becoming more seriously ill. Levels of stigma often
prevent people seeking help. Rather than wait for people to come to health
services, it is time for health services to seize the opportunities of the contacts
they already have, and to make this a routine element of population health
checks.
Question 6: How can we measure the impact of what we’re doing to reduce
inequalities in mental health?
In accordance with the Marmot Review, we argue that wellbeing should be used as a
measure of the country’s social progress and therefore health inequality targets
should be set in London to measure the impact of health inequality reduction
strategies. Explicit targets have already been set in England, Northern Ireland,
Scotland and Wales, and while some limitations in the scope, methods and
approaches adopted for many of these targets has been documented, there is a
clear case to bring in targets to help focus attention on this issue for London.
The current targets are designed to measure life expectancy and infant mortality.
While these are useful measures, they do not reflect the health status of the
individual or other indicators of health inequalities across the life course. We would
like to see the most up-to-date maps of metal health inequalities across London used
as proxies for certain determinants mirroring the inequalities heatmap that the Mental
Health Foundation has produced for London Thrive. For example, levels of heart
disease would provide an indication of levels of risk to developing mental health
problems since having this particular long-term condition carries a threefold risk of
These indicators include:
2. Unemployment Rates;
3. Crime Rates;
5. Access to mental health services.
developing mental health problems. Likewise, with other areas of adversity, such as
levels of domestic violence, homelessness, crime rates.
The selection of these indicators was guided in part by experts and the 2010 London
Health Inequalities Strategy published by the Mayor of London. We have mapped
these indicators geographically across the 32 Local Authorities of London and The
City of London (where data were available). Further sub-mapping has also been
produced under the headings from the Thrive London Steering Group key lines of
enquiry. Factors were compiled in maps of risk for each issue, providing a map that
prioritises areas of focus based on accumulation of risk factors. Finally, we compiled
an overall heat map of risk combining the information in quintiles across all lines of
the enquiry, following a mixed research methodology of literature review, hand
searches, online searches, and expert advice. For more information on our work in
this area, please contact Antonis Kousoulis, Assistant Director - Development
Programmes.
Section 3 - Healthy places
Question 7: Is there more that the Mayor should do to make London’s society,
environment and economy better for health and reduce health inequalities?
Yes, the Mayor could do more to make London’s society, environment and economy
better for health and reduce health inequalities.
To improve mental health and reduce mental health inequalities, we recommend
applying a socio-ecological approach that takes account of the impact of the social
and physical environment, within homes, settings such as schools and communities.
Alongside this, the impact of wider structural drivers such as welfare, education,
housing and criminal justice policy need to be considered.
The compassionate and inclusive way in which policies are interpreted and
implemented at a local level can set the tone within communities and can have a
significant impact on how empowered people feel in undertaking stewardship of their
neighbourhoods. Evidence tells us that creating pro-social places can do much to
enhance community cohesion and wellbeing31.
The Mental Health Foundation is working with international initiative in mental health
leadership on creating a global principle based urban public mental health network (i-
circle). For further details, please contact Isabella Goldie, Director of Development.
Housing
As the Mayor is directly responsible for London’s housing, there are five key
recommendations we urge him to implement as a matter of priority.
31 What Works Wellbeing. (2015). Community Wellbeing: Creating Pro-social places. Retrieved from: https://www.whatworkswellbeing.org/blog/community-wellbeing-creating-pro-social-places/
would help to tackle inequalities through increasing standards across our built
environment, as well as inclusivity for those with mental health problems and
learning disabilities.
Addressing the health inequalities associated with London’s society, environment
and economy requires changes to social arrangements and institutions. In line with
the World Health Organisation, we recognise that the public sector has an important
role to play in advancing mental health equity.
Reports from the Marmot Review of health inequalities and the Sustainable
Development Commission (PDF) has evidenced how people with mental health
problems experience area inequalities. The populations of deprived areas are
characterised by concentrations of people living with disabilities, including people
with mental health problems, and studies have found that the prevalence of mental ill
health maps closely to areas of deprivation. Poor people are concentrated within
communities that have a poor-quality built environment, housing that is substandard
and insecure, and poor access to open spaces and green environments. The
relationship between the built and natural environment and health, including mental
health, has been established32. Access to green space has a therapeutic benefit as
well as providing access to ‘green exercise’ (that is, exercising in green space) and
play space. The relationship between physical exercise and mental health is well
established, but studies suggest that green exercise can have more positive effects
than other kinds of exercise. Design for mental health, including natural spaces,
should be promoted as good practice for architecture in town and country planning.
32 Pretty, J., Peacock, J., Hine, R., Sellens, M., South, N. and Griffin, M. (2007). Green exercise in the UK countryside: Effects on health and psychological well-being, and implications for policy and planning. Journal of Environmental Planning and Management, 50(2), pp.211-231.
We call for:
• Adoption of co-production with residents, representative groups and other
expert advisers in the design and development of buildings and services;
• Contracts awarded for social and mixed housing bids that have green
space included;
• Investment in the recruitment and continuous professional development of
staff who are committed to creating safe, positive homes for residents.
• Developing and supporting staff to understand and implement the
approaches articulated in policies.
• The provision of safe, and affordable accommodation for those who require
supported accommodation.
services delivering therapeutically innovative, responsive and dynamic
known to increase resilience to stress.
Neighbourhood community development initiatives have been successfully adopted
in a number of disadvantaged communities. This type of approach can lead to long-
term transformative outcomes in health and mental wellbeing. The steps required
are: locating energy for change, creating vision, listening to communities, forming
partnerships, sustaining momentum, taking action and continuing the trajectory of
improvement33.
Co-production with residents, representative groups and other expert advisers
enables residents to participate in the design and development of the built
environment around them, empowering local communities and reflecting the needs
of its residents. The built environment should be a reflection of its overall purpose:
community and individual engagement and support. When homes, buildings and
public spaces stop reflecting this purpose and are unavailable, inaccessible and not
inclusive, there is a clear disconnect in the planning process.
Stigma
We are pleased to see the Mayor lead a citywide campaign to reduce mental health
stigma and discrimination, as part of the health inequalities strategy.
One of the best ways to address stigma and discrimination around mental health is
to return the ownership of mental health to people, families and communities
themselves much as we are doing with physical health. Mental health can be seen
as needing to be dealt with in special places, by specialists, and on occasion this is
true but for the most part, how we think and feel is at the core of who we are, the
33 Gillespie, J and Hughes, S. (2011). Positively Local: C2 a model for community change. University
of Birmingham. Available at: http://www.birmingham.ac.uk/Documents/college-social-sciences/social-
We call for:
• A stepped care approach, which can be valuable in targeting support to
disadvantaged groups. These schemes provide universal services in
disadvantaged communities to avoid stigma, and create a platform to
identify individuals with greater needs;
• A progressive approach to whole-school work to reduce stigma and
discrimination to be adopted, to create an environment conducive to help-
seeking for children and young people in need of higher levels of support,
such as that provided by Cognitive Behavioural Therapy and Acceptance
Commitment Therapy;
services delivering therapeutically innovative, responsive and dynamic
care1.
21
decisions we make and how we behave. It mediates many of our wider social and
health outcomes in life including our attainment levels in school and productivity and
success in work. We need to adopt universally proportionate approaches that create
a conducive culture for all where mental health can be talked about and is viewed as
a universal asset to be protected. Then adapted, modified or tailored versions for
those who face higher risk and more specialised approaches for those who are
already experiencing mental health problems, but whereby they can also benefit
from the universal approaches.
The recent Adult Psychiatric Morbidity (APMS) figures show that two thirds of people
with symptoms of common mental health problems do not receive mental health
treatment. Prevalence rates are rising however figures show people are not either
able to access services or these services feel too stigmatising or not meaningful to
them. These latest figures illustrate a need to find less stigmatising embedded
approaches where mental health is protected and improved in everyday
environments. To achieve this, we need to ‘task shift’ from mental health staff to
teachers, employers by upskilling them to undertake their duties in psychologically
informed ways (e.g. line manager training, teacher training focused on nurture).
Importantly, these approaches needs to be taken as early as possible to prevent
mental health challenges developing, not only because the current system is
struggling to put together viable approaches to helping people recover but to prevent
the misery of mental health problems in the first place.
Stigma and discrimination can be significant factors preventing people from seeking
support for their mental health. Tackling this at an early stage through effective
programmes to enhance mental health literacy and to improve attitudes and
behaviour is critical to enable people to seek help before they experience more
serious mental health problems or reach crisis, including potentially being suicidal.
As mentioned above, the See Me programme, managed by Mental Health
Foundation along with SAMH, has been creating a movement to tackle mental health
stigma and discrimination in Scotland. This programme has adopted a human
rights-based approach to stigma, with the central focus on working to empower
communities to address these issues where we know discrimination can seriously
influence life outcomes, such as schools, workplaces, health and social care and
neighbourhoods.
There is evidence that some initiatives, especially those focused on addressing
stigma and discrimination, and promoting mental health literacy, are most effective if
applied universally (for example across everyone in a workplace or a school). Other
measures are best targeted at those at a particular stage of the life-course (for
example, the perinatal period, teens, or older people). Black and Ethnic Minority
communities, LGBTI groups or people with life histories than increase risk (for
example women who have experienced domestic violence, refugees who have
experienced trauma and care leavers) can benefit from initiatives that are
coproduced, ensuring that these address their particular risk factors.
22
Workplace
Taking a whole-place approach to mental health is the most effective and efficient
way to protect and promote mental health and to prevent mental health problems
from occurring or escalating or becoming a lifelong experience. There is a wealth of
research that demonstrates that there are a number of strategies employers can take
to address this area of inequality.
In our recent report Added Value: Mental health as a workplace asset, published with
Unum, we outline the following:
• The economic importance of safeguarding mental health in the workplace: the
business case for change, including a cost analysis by Oxford Economics.
• The benefits of work to mental health, exploring the extent to which people
feel that their working life is important in protecting and maintaining their
mental health, drawing on both the qualitative interviews and the survey
results.
• People’s experiences of mental health at work, focusing primarily on survey
data to present findings of respondents’ experiences of distress at work, of
absence patterns, and of supporting others.
• Barriers to disclosure, focusing on disclosure of distress and on stigma and
discrimination.
• Supporting mental health at work, exploring the support people with mental
health problems have received in the workplace, looking at what people feel
their employers did well, and what they feel their company could do to
improve the mental health of the workforce.
Question 8: How can you help to reduce inequalities in the environmental,
social and economic causes of ill health?
Early in 2018 the Mental Health Foundation will be publishing a comprehensive,
evidence-based report on tackling mental health inequalities - Leaving No-one
Behind. The report will be exploring why some communities and people face much
greater risks of mental health problems and what we can do to improve mental
We call for:
• Senior managers to develop a culture of openness towards mental health, welcoming disclosure – including their own;
• Line managers being trained to recognise risk factors and behaviours associated with mental distress and to intervene early with confidence;
• Employers undertaking evidence-based anti-stigma activities to create a work environment where staff feel safe and able to talk openly about mental health;
• Employers embracing reasonable accommodation practices to support employees experiencing mental health issues to access their rights.
health for all. It will include evidence on the socioeconomic, relationship, health and
ecological determinants of mental health. The evidence shows that mental health is
a mediating factor affecting the overall health of a city, as it influences a wide range
of social and health outcomes at individual, community and societal levels and has
an impact on all aspects of our lives. Poor mental health contributes to socio-
economic and health problems such as higher levels of physical morbidity and
mortality, lower levels of educational attainment, poorer work
performance/productivity, greater incidence of addictions, higher crime rates and
poor community and societal cohesion. Having good mental health allows us to
access those things that make life meaningful such as: good quality relationships;
active citizenship and being able to contribute to community life; and having access
to work that provides for ourselves and our families. We will make the report freely
available, and hope that it will be helpful for GLA staff working on health inequalities.
We will share a copy with the GLA when it is published.
Question 9: What should be our measures of success and level of ambition for
creating a healthy environment, society and economy?
Housing
Stigma
The Mental Health Foundation have generated a list of scales and developed a
bespoke evaluation framework for the See Me programme (the framework includes
health checks of the workplace). One example of a model applied is the
Discrimination and Stigma Scale. In line with the areas measured in See Me, we
advocate for the Health Inequalities strategy to measure the following four areas:
1. Experienced discrimination;
2. Self stigma;
Indicators to measure housing policies that aim to address the impact of poor
housing and/or homelessness on mental health inequalities should include:
• Family and individual homelessness;
• Areas with high concentration of families with separated or divorced
couples or single parents;
• Overcrowded households (a proxy for poor housing conditions).
Indicators to measure how the Mayor’s initiatives are affecting high rates of
mental health stigma across the capital should include:
• The percentage of people with low scores on self-reported well-being;
• Access to mental health services;
• Access to social care services for people with existing mental health
problems;
• The age-standardised suicide rate.
4. Help seeking.
For more information on the measurements used in the See Me programme, please
contact Isabella Goldie, Director of Development.
Workplace
The Mental Health Foundation has introduced a range of mental health checks with
employers we work with, with the aim of creating benchmarks. For further
information on our work in workplace mental health, please contact Chris O’Sullivan,
Head of Business Development and Engagement.
Section 4 - Healthy Communities
Question 10: Is there more that the Mayor should do to help London’s diverse
communities become healthy and thriving?
Yes, the Mayor could do more to help London’s diverse communities become
healthy and thriving. We recommend he should make strategic, system-wide
changes that are underpinned by a whole- community approach to protecting and
supporting good mental health and wellbeing.
London has particular demographics and structure when compared to the rest of the
UK, which call for targeted approaches. The boroughs that have been shown to have
particularly low levels of community strength and resilience, based on indicators
We call for the following four recommendations to be incorporated into the
Mayor’s strategy:
1. Taking a whole-community approach; 2. Upskilling physical health, care and wider public-sector staff; 3. Providing clear health leadership; 4. Supporting good access to safe and reliable self-management tools online.
Indicators to measure the success of addressing mental health inequalities in the
workplace and, importantly, supporting people with mental ill health into
sustainable employment, should include:
• The number of NEETs (young people not in education, employment or
training);
• The percentage of people with low scores on self-reported well-being;
• The caseload of Employment and Support Allowance claimants.
Tower Hamlets, Newham and Brent34.
Strategic, system-wide activity is necessary to take advantage of the opportunities to
improve mental health at all stages of life, particularly at pressure points when
individuals, families and communities experience adversity and during times of
transition from one life stage to another. If we are to rise to the challenge of reducing
the prevalence of mental health problems, we will need to revise the way we view
mental health and where responsibility lies for improving it. We will need to move
from the currently dominant deficit model to one where mental health is viewed as a
universal asset to be strengthened and protected.
In practice, this approach requires commissioning that is expanded beyond specialist
services to community and settings-based solutions. The Mayor needs to balance
this transition, ensuring high-quality services for those that need them, while also
intervening early to reduce the need for specialist provision and to give individuals,
families and communities, the tools to protect and manage their own mental health.
Taking a whole-community approach
This work can be advanced through a ‘Whole Community Approach’, which provides
a framework that takes account of all the factors that influence mental health at an
individual, family, community and structural level, and allows for mental health to be
considered across a wide range of local policies, services, systems and data that
affect the mental health and wellbeing of communities.
This approach is a social-ecological model of public health and health promotion
which reflects the multidirectional interplay among factors operating within and
across societal and individual levels.
These levels are intersected by four strategies:
1. Task shifting - moving mental health ownership into other aspects of public
sector and beyond, for example schools and workplaces;
2. Making every contract count –embedding mental health at the centre of all
health and social care as a mediating factor driving outcomes;
3. Mental health in all policies – shifting mental health into wider policies
ensuring they are trauma and psychologically informed and impact assessed;
4. Understanding data – using data that produces an understanding of those
factors/outcomes that are in the causal chain in relation to mental health, for
example crime levels, domestic violence, bullying, and absenteeism.
The model is centred around ensuring that high-quality services are available for
those that need them, while also intervening early to reduce the need for specialist
provision and to give individuals, families and communities the tools to protect and
34 Please refer to the Heatmap produce by the Mental Health Foundation for LDN Thrive for further details.
26
manage their own mental health. This will only be achieved through working
alongside communities to understand the influences on their mental health, and
where it is possible, to build on existing strengths, assets and resilience.
Upskilling physical health, care and wider public-sector staff
Upskilling the physical health, social care and wider public-sector workforce is
central to creating a strong prevention strategy. Not only will this focus help the
workforce to learn self- management skills for their mental health, it will also support
them to coach others in basic techniques and develop confidence in having mental
health discussions, and signposting. This includes, for example, midwives, local
Health Visitor Champions and the Family Nurse Partnership staff working with young
first-time mothers; those working with looked after children, and within schools, and
prisons. All need to have basic mental health literacy and the skills to coach those
they work with in how to protect their mental health. This requires a curriculum and
training programme to train the trainers.
An example of good practice can be seen from the Million Minds Programme. The
programme is being developed by Public Health England will see up to one million
people trained in basic mental health “first aid” skills.
Providing clear health leadership
Making this approach a reality across the country requires health leadership
prepared to do things differently and to understand that sharing resources beyond
‘services as usual’ can produce significant health dividends in improved health status
and reduced health funding pressures. Leaders are required who can bring mental
health back into communities, able to co-produce the solutions with those that
understand the challenges first-hand, bring whose insights that will illuminate
practice and build capacity across the system. More and more people are looking to
their own personal resources or to local supports to improve their health and mental
health, but without a different approach this trend will always be strongest for those
with most personal resources, which risks deepening mental health inequalities.
Support good access to safe and reliable self-management tools online
In addition to the provision and support of local community-based solutions, access
to safe and reliable self-management tools online is also required. However, this
should not be left to untested commercial apps nor progressed using procedures that
have been devised for developing medicines and surgical procedures, but are
inappropriate for the fast-moving world of digital innovation.
The Mental Health Foundation is the UK partner in a new European Union-funded
project to improve the quality of and access and availability to e-mental health
support. The €5.3million project, funded through the Interreg North West Europe
Innovation Programme, will run until November 2019. eMEN is a collaboration led by
the Netherlands with partners in Belgium, France, Germany, Ireland and the UK who
combine technological, clinical, research and policy expertise.
27
As demand for mental health services and care continues to outpace provision
across the Capital, and with this entrench inequalities still further, we know that a
new approach is urgently needed.
For more information on our work in this area, please contact Iris Elliott FRSA PhD,
Head of Policy and Research.
Question 11: How can you help to support thriving communities?
The Mental Health Foundation has strong experience on community development
work and working with people and stakeholders to improve mental health outcomes
and build thriving communities. We have been a leader in this field and consistently
doing that through our work in Scotland with various disadvantaged communities,
through international collaborations (e.g. on dementia friendly communities) and,
most recently, in partnership with Thrive LDN on community resilience and
consulting with Londoners to improve the evidence base on what can support
communities to thrive.
The Mental Health Foundation has created a strong research base demonstrating
that appropriately supporting people through different stages of life and
strengthening community ties can improve mental health and reduce illness. Our aim
is to make this research more widely available and demonstrate how it can be
applied in practical ways to support whole communities to enjoy better mental health.
Through our Thrive Programme we aim to be able to offer local authorities and other
key commissioners the expertise to support local needs assessment and a suite of
interventions and community prevention training programmes that will improve
mental health across the whole local population. Our next step, with the support of
Thrive LDN, is to test the impact of applying these kinds of interventions across the
whole life-course in single communities with the hypothesis that it will create a critical
mass of improved health. In the process, we want to work with communities to
develop resilience and capacity to self-manage mental health and offer support to
others through training key individuals. This training will be offered to those able to
support people who are at risk of developing mental health problems and/or cascade
training through a Training for Trainers approach. Once tested will be marketed to
local authorities across the country, including the GLA. We will work with
communities to ensure that this training is co-produced, so that we are helping them
to realise their potential throughout the development process and maximising on the
opportunity this work affords to build links between people. In practice and in the first
instance this will mean co-producing with citizens two key elements: (i) Evidence
based resiliency training programmes and (ii) Citizen-led support packages based on
our tested interventions.
As well as the workshops, the Mental Health Foundation is working with Thrive LDN
to develop ‘whole community mental health’ pilot projects on three London housing
estates. We have already carried out local resident engagement on Clapham Park
Estate in Lambeth and have got funding to begin the pilot in Thamesview Estate,
Barking and Dagenham, in April 2018. We are also looking at obtaining funding for
another scheme on the Rockingham Estate, Southwark. In the pilots, we will be
supporting communities by delivering training to support good mental health across
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the life-course including peer parenting, the Peer Education Project in local schools,
business development for working age adults and loneliness reduction for older and
vulnerable adults. We hope to establish that by supporting communities to look after
themselves and each other more effectively we can reduce mental ill health and
improve wellbeing.
Looking outside of the Capital, the Mental Health Foundation has led an eight-year
programme of work with refugees. The Amaan project, led by the Mental Health
Foundation working in partnership with the Scottish Refugee Council and Freedom
from Torture, raised awareness of the mental health needs of asylum-seeking and
refugee women in Glasgow. The project produced a wellbeing resource designed for
asylum seeking and refugee women. The content and design of the resource was
shaped by asylum seeking and refugee women as part of the project. This resource
aims to help asylum seeking and refugee women to better understand what mental
health is and provide a toolkit to help them have a better understanding of mental
health and ways to help themselves and others.
Question 12: What should be our measures of success and level of ambition
for creating healthy and thriving communities?
Section 5 - Healthy Habits
Question 13: Is there more that the Mayor should do to help to reduce health
inequalities as well as improve overall health in work to support Londoners’
healthy lives and habits?
Yes, the Mayor could do more to reduce health inequalities as well as improve the
overall health of Londoners. A whole-system approach to mental health and
We propose that the following indicators should be used to measure community
strength and resilience and that they are reviewed annually to identify trends.
• Crime Rates;
• Ethnicity (percentage of population from BAME groups);
• Areas with a high concentration of families with separated or divorced
couples;
• All-age prevalence of learning disability;
• Absenteeism from work and school;
• Domestic violence;
• Teenage pregnancy;
wellbeing taken across the life course needs to underpin the Mayor’s strategy35,
using both universal and targeted approaches to address mental health inequalities
across the Capital. Interventions need to target families, parents and children in their
early years and school-age children and young people, working-age adults and
people in later life.
A wide variety of factors underpin people’s ability to sustain mental wellness in the
long term. We need to fully grasp the opportunities to promote wellness in the home,
in schools, in the workplace and in communities, including through the built
environment, rather than treating mental health as the exclusive domain of health
care providers.
We must ensure that prevention work is embedded across the life-course, from the
foundations that are laid down in infancy to the challenges that often come in later
life, and ensure that good mental health literacy is universal across society. Overall,
mental health improvement messages and actions need to be experienced in many
places and at many times during the life course. This sustained reinforcement is vital
for achieving the level of cultural change required. It is important to identify the ways
in which mental health literacy can be improved within the settings where people
spend much of their time and ensure that no-one is left behind in doing so.
Giving people the knowledge, tools and resources to protect and improve their own
and their families’ and friends’ mental health in an easy and readily accessible way
when they need them is of critical importance. Mental health can deteriorate very
quickly, in people’s own homes, workplaces or schools, and support needs to be
there at that time. Public Health England’s Million Minds Campaign and Programme
is a good example of how self-care can be promoted and supported.
The Mental Health Foundation’s online mindfulness course is focused on developing
new approaches that will align with messages of the Million Minds programme. We
currently have a staff member on secondment to Public Health England to develop
the training models for the campaign. For further information, please contact Dr
David Crepaz-Keay, Head of Empowerment and Social Inclusion.
35 MHF are in the process of publishing a paper summarising mental health inequalities and a socio- ecological model to mental health.
We call for the Mayor to integrate the following recommendations into the
strategy:
• Training staff and embedding core mental health guidance in public service and voluntary sector contact opportunities to support all Londoners to live healthy lives;
• Supporting all frontline staff to act as ambassadors, drawing learning from the NHS ‘making every contact count’ programme1;
• Harnessing the power of technology and social media to support
prevention and early intervention.
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A range of evidence-based primary prevention actions can be found within Taking
Local Action (PDF) and Better Mental Health For All. ‘Quick wins’ include training
staff and embedding core mental health guidance in public service and voluntary
sector contact opportunities to support all Londoners to live mentally healthy lives.
For example: health visitors; teachers; housing support workers; charity workers,
faith leaders, care staff and social welfare advisors could all help the people they
work with to understand the steps they and their families can take to increase
resilience. At the same time, they can analyse the most significant risk factors for a
particular group in a particular context, and evidence the need for changes.
Universal preventive measures can be helpful in starting the discussion on mental
health and removing barriers to early help-seeking. However, if only universal
approaches are adopted they risk increasing the mental health inequality gap, as
people who have more personal resources will more readily access these, leaving
those with the greatest challenges and risks further behind.
Applying these principles can have a transformative impact on preventing mental ill
health and therefore tackling mental health inequalities. For example, there is
evidence to indicate that taking an integrated approach, which provides wellness
services for clusters of children identified as being at high risk of multiple poor
behaviours has the potential to achieve more than providing single-issue services
only. The principles for prevention strategies are described in more detail in our
report Better Mental Health for All36.
We know that relationships and feelings of connectivity are good for both our mental
and physical health. Social policy research has called for a shift in emphasis to the
needs of society, arguing that society needs to find a way to reconcile individual
aspirations with shared aspirations for equality. A society that has drifted into
disconnection through self-interest, says neuroscientist John Cacioppo, is storing up
problems for the future: “A rising tide can indeed lift a variety of boats, but in a
culture of social isolates, atomised by social and economic upheaval and separated
by vast inequalities, it can also cause millions to drown37”.
Recent technological advances cannot be ignored when looking to support healthy
lives of Londoners through connectivity. Increased access to information offers an
opportunity for empowerment, although the reliability of the information is sometimes
questionable. The rapid evolution of online technology has created vast new
opportunities for building connections and relationships: 76% of adults in the UK
access the Internet every day38. Studies on use of these online communities have
36 Better Mental Health for All: A Public Health Approach to Mental Health Improvement (2016) London: Faculty of Public Health and Mental Health Foundation. 37 Reported in the Daily Telegraph 18 August 2009; published in the Proceedings of the National Academy of the Sciences o