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
28
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.
30
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