Birmingham Health & Wellbeing Board Summit - July 2012

Birmingham's Way to Wellbeing
Birmingham’s Joint Health and Wellbeing and Social
Inclusion Process Summit
Thursday 12th July, 9am to 2pm
The Bordesley Centre, Birmingham

@bhwbb #bhwbb bhwbb.net

Welcome and introductions

Cllr. Steve Bedser
Cabinet Member for Health and Wellbeing,
Birmingham City Council


Definitions and concepts - what
does it all mean?
Dr Neil Deuchar
Medical Director (Mental Health)
NHS Midlands and East


West Midlands Strategic Health Authority

Wellbeing –
What does it all mean?
Neil Deuchar
Associate Medical Director
NHS Midlands and East
NHS Midlands and East is a cluster of SHAs comprising NHS East Midlands, NHS East of England and NHS West Midlands
Chair: Sarah Boulton Chief Executive: Sir Neil McKay CB

What’s in a name..... West Midlands Strategic Health Authority

mental
positive quality of
health
mental health life

mental
happiness capital
wellbeing

emotional resilience
wellbeing
flourishing



Wellbeing is the subjective experience of
mental, social and spiritual health

It is not merely the absence of illness

It involves a sense of purpose, fulfillment,
agency, belonging and connectedness



Wellbeing is similar to quality of life
Wellbeing derives from and confers
psychological resilience
Wellbeing in enough individuals produces
mental and social capital across
communities
Psychological resilience reduces both
mental and physical illness


There are "Five Ways to Wellbeing" (Foresight/NEF) –

Connect
Give
Notice
Learn
Be Active

Prosocial behaviour enacts the "Five Ways"
This means active citizenship (personal rights and
responsibilities to each other)


Public Mental Health is the promotion of
Mental Health / Wellbeing in communities
and the prevention of mental illnesses in
people at risk
Addressing public mental health reduces
physical illnesses, alcohol and drugs use

Adopting the "Five Ways" improves public
mental health

Understanding the determinants
and what works
Dr Lynne Friedli
Mental Health Promotion Specialist
World Health Organisation


Mental health and wellbeing: understanding
the determinants and what works

Dr Lynne Friedli

Wellbeing Summit
Birmingham Health & Wellbeing

Birmingham

12th July 2012

Source: Ingram Pinn, Financial Times
Birmingham Wellbeing Summit lynne.friedli@btopenworld.com

Summary how we
feel about
&
• Mentally flourishing communities experience
our lives
• Recovery Oriented Communities

• Social Justice, Citizenship & Human Rights

• Commissioning for social value

• Health topics: RIP


What we all need....

To be:
• Heard
• Believed
• Understood
• Respected

Picture Source: http://sarahdrummond.wordpress.com/2010/12/13/an-
assets-alliance-scotland/

Mental health, and the factors that
influence mental health, have never been
more important

Mental
Social S Determinants
Health


Commission on the
Social Determinants of Health
Some living conditions deliver to people a life that is worthy of
the human dignity that they possess, and others do not. Dignity
can be like a cheque that has come back marked ‘insufficient
funds’ Martha Nussbaum
•material requisites
•psycho-social (control over lives)
•political voice (participation in decision
making)
Status Control Relatedness

Best start Quality work
Healthy places

Income Prevention
Education &
skills

Explaining the social gradient:
mental illness journeys...
Most of the experiences that cause mental distress are directly linked
to a lack of money....... powerlessness linked to poverty
Peter Campbell Beyond the Water Tower 2005
• Adverse childhood experiences/stressful life
events
• Racism and other forms of discrimination
• Contact with criminal justice system
• Socio economic status – parental income, tenure,
education, occupation
• Institutional care in childhood

Social Epigenesis: biological embedding *
Status Control Relatedness


Meta analysis: comparative odds of
decreased mortality

The relative value of
social support/ social
integration
Birmingham Wellbeing Summit Source: Holt-Lundstad et
lynne.friedli@btopenworld.com al
2010

Recovery oriented communities
They are saying that they are missing from the community,
they want to give and contribute and that
the community is missing out on their contribution.
PFG Doncaster

People with mental
Full health problems
Quality of have access to
citizenship everyday activities,
life
resources,
Human relationships and
opportunities
rights


Why bother? What works?


Austerity solutions....


Because it’s worth it....
While there are multiple barriers to economic growth, the growth of human
potential is unlimited Coote and Franklin 2010

•Contribution mental wellbeing and mental illness
make to wide range of outcomes
•The ‘unexplained excess’ – classical risk factors do not
account for level of variation in outcomes
•Improving wellbeing saves (a lot of) money
•Improving wellbeing delivers social (as well as
economic) returns
•Improving wellbeing reduces inequalities

Reduce pressure here

NO HEALTH PUBLIC
ADULT
WITHOUT HEALTH NHS
SOCIAL CARE
MENTAL OUTCOMES OUTCOMES
OUTCOMES
HEALTH FRAMEWORK FRAMEWORK
FRAMEWORK

MENTAL HEALTH AND
Get it
WELLBEING right here

Using data and evidence from: Delivering better mental health outcomes;
Economic Case
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicatio
nsPolicyAndGuidance/DH_123766; See also Champs
www.champspublichealth.com

Scope of Action

Material resources Relationships and
Increasing equitable access Respect
to assets that support Social support, collectivity,
mental wellbeing respect for people experiencing
Interventions misfortune
to promote
mental
wellbeing
Inner resources
Meaningful Opportunities to
activity develop senses,
Opportunities imagination,
to contribute reason, thought
(Martha Nussbaum Capabilities)

‘best buys’
•Supporting family life: parenting; HLE; reading ; infant sleep
•Supporting lifelong learning: h/p schools; SEAL; anti-bullying
continuing education; reading recovery
•Improving work: employment/ workplace
•Lifestyle/screening/brief interventions (diet, exercise,
alcohol) social support/integration

Befriending, volunteering, Timebanks, community
development
•Supporting communities: environment/environmental
justice; green space; bridge safety; debt services
Source: Friedli & Parsonage 2009

Net return on investment

Source: Knapp, McDaid & Parsonage 2011

Tentative analysis of economic case:
workplace
400

Extension of Flexible
£s millions per annum avoided

300 Working Arrangements

Integration of
200 Occupational and
Primary Health
Implementing Stress
100
and Wellbeing Audits

0

Source: Mental Capital & Wellbeing: Foresight 2008 – Overhead David
McDaid

Mental health risk and debt
(OR) risk of poor mental health

Unadjuste
d

Income adjusted
Adjusted for
income and socio-
demographic
variables

Number of debts
Source: Jenkins R et al 2008 Debt, income and mental disorder in the general
Population Psychological Medicine 38:1485–1493.

Routes to partnership/joined up delivery
Wild
NHS Commissioning Health & swimming
(for social value) Wellbeing Boards club

Health & Wellbeing Food
Primary Strategies Train
Care Time
Link Integrated
bank
workers Wellness
•Referral Service Community
criteria Garden
•Feedback Community
Referral Hub
loops
Local Area Debt advice/
•Extended
Coordination credit union
consultation Language
Social and
Midnight literacy
Care football

Priorities for moving forward
Innovation is hard. And social innovation is doubly hard. The system will
often absorb new ideas, and then spit them out in forms that their
originators would not recognise... Simon Duffy

ommission for social value – each £ spent also produces
wider community wellbeing

nd health topics: whole life/total place /wellbeing services

oin up delivery: wellbeing, recovery, resources for citizenship

evelop an inequalities imagination (Angie Hart)

Return to the social....
•Wellbeing is produced socially

•Quality of social relationships has a material context

• I am, because we are...


Select bibliography

Warwick-Edinburgh Mental Well-being Scale
www.healthscotland.com/documents/1467.aspx
Cooke, A., Friedli, L., Coggins, T., Edmonds, N., O’Hara, K., Snowden, L.,
Stansfield, J., Steuer, N. and Scott-Samuel, A. (2010) The mental well-being
impact assessment toolkit. 2nd ed., London: National Mental Health
Development Unit
http://www.apho.org.uk/resource/item.aspx?RID=95836
Friedli L (2009) Mental health, resilience and inequalities WHO Europe London/
Copenhagen http://www.euro.who.int/document/e92227.pdf
Friedli L and Parsonage M (2009) Promoting mental health and preventing mental
illness: the economic case for investment in Wales Cardiff: All Wales Mental
Health Promotion Network
http://www.publicmentalhealth.org/Documents/749/Promoting%20Mental%20H


Select bibliography
Knapp M, McDaid D and Parsonage M (2011) Mental health promotion and mental
illness prevention: the economic case Department of Health
Campbell F (2010) Social determinants and the role of local government
http://www.idea.gov.uk/idk/aio/17778155
Newbigging K and Heginbotham C (2010) Commissioning mental wellbeing for all :
a toolkit for commissioners UCLAN
http://www.nmhdu.org.uk/news/commissioning-wellbeing-for-all-a-toolkit-for-comm
DH (2011) No Health Without Mental Health: A Cross-Government Mental Health
Strategy for people of all ages (Feb 2011) gateway reference 14679Solar O and Irwin
A (2011) A conceptual framework for action on the social determinants of health
Geneva: WHO
Dept of Health (2011) The economic case for improving quality and efficiency in mental
health
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digit
OECD 2011 Divided we stand: why inequality keeps rising
http://www.oecd.org/document/51/0,3746,en_2649_33933_49147827_1_1_1_1,0

What makes us healthy?

Jane Foot
Independent Public Policy Adviser


What makes us healthy?

Birmingham Wellbeing Summit
12 July 2012

Jane Foot
www.janefoot.co.uk

www.janefoot.co.uk 38

Reframing our thinking
When we work with people and
communities we focus too much on their
failings, deficiencies, problems and needs.
And we prescribe services to fix those
problems.

We don’t actively look for what creates
health and sustains wellbeing, the things
that are working, the potential for people to
connect their own and others’ assets to
improve their lives.


What are health assets ?
 An asset can be defined as any factor or resource
which enhances the ability of individuals,
communities and populations to maintain and
sustain health and well-being. These assets operate
at the level of the individual, family or community as
protective and promoting factors to buffer against
life’s stresses.
 Skills, capacity or knowledge of individuals
 Passion of families and neighbours that give them energy for
change
 Networks and connections in a community – place, identity,
interest
 Effectiveness of community associations
 Resources of institutions – public, private or third sector
 Physical, environmental and economic resources


What is the evidence?
 Resilience – what are the social factors
that support resilience
 Social networks make you healthier and
happier. Stress and isolation are bad for
you.
 Mental wellbeing and psychosocial factors
– both a cause and a consequence of
inequality
 Good wellbeing makes it possible to ‘get
ill better’.
 Evaluative task is to understand assets
and the dynamics that link assets to
change www.janefoot.co.uk 41

An assets approach
 People are a resource rather than a problem
 Identifies and connects the assets that can
enhance wellbeing
 Values what works well in an area and what has
the potential to improve health
 Sees citizens and communities as co-producers
of their health rather than recipients of services
 Promotes community networks, relationships
and friendships that can provide caring, mutual
help and empowerment
 Supports individuals health and wellbeing
through self esteem, coping strategies,
resilience skills, networks, knowledge,
 Empowers communities to control their futures –
capacity releasing
 Creates tangible resources such as services,
funds, buildings www.janefoot.co.uk 42

1. Health & Wellbeing Boards
 Shared understanding of health as a
positive state and its determinants as those
things that protect and promote good
health
 Prioritise the ‘causes of the causes’
 Whole system – everyone who contributes
to health assets
 Whole life course
 Shift from targeting to whole community
 Commissioning framework – redesign,
support, procurement


2. Asset mapping & mobilising

 Makes us learn to ask what communities
have to offer and care about
 Improves our understanding of HOW
people understand wellbeing and what
helps them cope
 It makes explicit the knowledge, skills,
resources and capacities that already exist
 Helps to make best use of individual skills ,
physical and organisational resources
within the community
 It helps to build trust between
professionals and the local community
 Assets are a resource to meet needs –
influences commissioning

3. Community development – build
social capital

 Core health and wellbeing asset
 Intentional community building
 Work with existing community
networks and activities
 Release the capacity and strengths
 Do not undermine networks and
social support


4. Co-production
 Professionals, service users, families,
neighbours are involved in an equal and
reciprocal relationship
 Planning, design and delivery of agreed
outcomes
 Services do not produce positive health
outcomes – people do
 An awareness of assets in the area
means that residents are valued for
their contribution
 Pooling of different knowledge and skills

5. JSNA + Assets
 A better balance of information
between needs and assets.
 Explore ways of collecting analysing
and understanding assets – not just
the what but also the how.
 Align with data on needs and
resources
 Commission to sustain the health
assets


5. Commissioning for outcomes
 The potential of co-production and asset
approaches is not best served by our
current procurement models
 Co-production + asset-rich communities –
requires a new commissioning framework
 Require providers to identify and build on
assets in the families and
neighbourhoods.
 Intentionally support community
development and social capital
 Do our services undermine health assets?


Health inequalities are driven by underlying
social factors and action is required to
address these ‘causes of the causes’.

“the health and wellbeing of people is
heavily influenced by their local
community and social networks. Those
networks and greater social capital
provide a source of resilience. The extent
to which people can participate and have
control over their lives makes a critical
contribution to psychosocial wellbeing
and to health”
Professor Sir Michael Marmot,
Foreword to What makes us healthy?


WHAT MAKES US HEALTHY ?

The asset approach in practice:
evidence, action and evaluation

Free download at
www.janefoot.co.uk
www.assetbasedconsulting.net

Foot (2012) ISBN 978-1-907352-05-08


Integrating Primary Care Mental
Health and Well Being Services
Dr Ian Walton
Clinical lead for Primary Care Mental Health Services SWB
CCG


‘Integrating Primary Care Mental
Health and Well Being Services’

Dr Ian Walton
GP, PEC chair and mental health lead for Sandwell
and West Birmingham Clinical Commissioning Group
Ian.walton@nhs.net

Complex Patients or complex services

 Low Aspirations
◦ Patients
◦ Clinicians
◦ Statutory sector
 Dealing with Individuals and their families not Populations
 High level needs analysis
 Silo Approach to commissioning and provision
 NICE had led to a disease focussed model
 Wrong care, wrong service, wrong person, wrong time

Needs Analysis

 Breadth and depth of need at whole population
level
◦ GP population and individual
 Large amount of sick people and their carers
◦ Correlated with poor and inadequate housing
◦ Worklessness
◦ Physical and Mental Ill Health and Addictions

The Challenge – To improve the
outcome of the whole population
including……
 Frequent attendees
 Complex needs
 Medically Unexplained Symptoms
 Prevention and early detection
 Those not meeting ‘psychiatry ‘ criteria – sub threshold
 Emotional distressed
 Socially Excluded
 Homeless
 Diverse needs
 Not mentally ill but emotionally distressed eg Sadness , grief,
loneliness– crisis v crysis

Services did not fit the patient

Targeted groups
 Young people at risk of mental ill
health/asbo
 Deaf population
 South Asian women
 Carers
 Men
 People with existing mental health
problems

How did we do it?

 Listened
 Asset mapped locally
 National and international best practice that
works
 Identified a series of pre and post outcome
measures
 Quantitative and Qualitative approaches
 Sourced funding
 Established benchmarks
More pilots than British Airways.......

Human Needs
 Security-a safe territory-a space to grow
 Attention (to give and receive)
 Having a sense of Autonomy and Control
 Emotionally connected to others-intimacy
 Being part of a wider community
 The need for privacy to reflect and consolidate
experience
 Self esteem – via confidence and achievement
 The need to be stretched which comes from a
sense of meaning and purpose.
 Compassion

Books on prescription

A Social Prescribing project
After a successful pilot in Cardiff in 2003, similar schemes have been taken up
across many areas in the UK.

Sandwell first piloted Books on Prescription in 2006, and the service became
mainstreamed across all Sandwell libraries and GP surgeries in 2007.

National Findings
 Patients get more information and a greater understanding of their
condition

 Helps them recover from the problems they are experiencing

 Helps them make informed choices and take a proactive part in
improving their health

 Anecdotal evidence indicates that there has been a low rate of
people returning to their GP once taking up the book prescription

 Patients prescribed books whilst on the waiting list for
psychological therapy resulted in 50% reduction in the number of
sessions they then required

But no-one reads in Sandwell!
 Approximately 1100 book issues per year
 Patients are more likely to access if a GP refers
them to the scheme
 Majority of our current referrals are self-
referrals
 83% of B.O.P. users have applied the techniques
they learnt by reading the books
 83% report improvements in their general
wellbeing and mood as a result of accessing the
scheme

Health Improvement Programmes

Since the services started we have had
over 4,000 people complete prevention,  64 Long Term Conditions
wellbeing and health improvement  58 Relationships
programmes this equates to £800,000  57 Self Defence and Empowerment
prevention costs.  56 Workplace Wellbeing
 50 cCBT
 47 Wellbeing Awareness Training
 1007 Stress Awareness  35 Relaxation
 33 EFT - Emotional Freedom Technique
 769 Health Improvement programme  25 Make Friends with a Book
 351 Food and Mood workshops  22 Yoga (FLW)
 333 Laughter Yoga  17 Stress and Relaxation (FLW)
 305 Happiness and Wellbeing  16 Flourish
 15 Redundancy
 218 Chin-up  12 Laughter Yoga (FLW)
 102 Music and Wellbeing  11 Food and Mood Workshops (FLW)
 89 Yoga  7 Capnography
 70 Positive Mental Training
 2 Maternal Mental Health HIP
 67 Tai Chi Plus over 3,000 people access talking
therapies which using the same formulae
 64 Happiness and Wellbeing (FLW) would be £600,000

Chin up programme
 Aimed at youngsters “at risk of offending”
 Originally given 8 teenage girls
 They told 20 of their mates..
 You can’t have the lads they really are too
much trouble
 Top of our league tables for improving
wellbeing

Conditions Management Programmes
 Long term conditions
 Capnography
 Positive Mental Training
 Wellbeing programmes
 Emotional Freedom Technique

 www.confidenceandwellbeing.co.uk

Local outcomes
3,468 sessions run 2011 -12 for 1,640 patients all programmes show a
measurable difference clinically and also in their wellbeing and social
needs

 Welfare Rights - 240 cases gains of £157,544,
 Reduction in referral to crisis services
 Frequent attenders managed in partnership with probation and A
and E at SWBH
 Access pathways to health for refugees and asylum seekers,
homeless people
 59.5% average recovery rates for IAPT one of top IAPT services
nationally
 Other services are showing comparable results and impact on
wellbeing

Training GPs

basrse

www.primhe.org.uk 70

The magic formula
 Assets V needs
 Starfish
 Collaborative care - warm hands.
 Integrated budgets
 Co- location
 Integrated care across all conditions
 Education and training for all

Conclusion
 Invest in prevention and not in sick
people

 Money talks and there is a business case
for this
KNAPP Martin; MCDAID David; PARSONAGE Michael; (eds.);
Mental health promotion and prevention: the economic
caseLondon: Personal Social Services Research Unit, 2011.
43p
http://www2.lse.ac.uk/businessAndConsultancy/LSEEnterprise

Thanks
 With particular thanks to Lisa Hill,
Primary Mental Health Improvement Lead
Sandwell PCT.
 lisa.hill@sandwell-pct.nhs.uk
 www.confidenceandwellbeing.co.uk
 www.primhe.org.uk
 ian.walton@nhs.net

Question and Answer Session

Plenary Panel


Key Line of Enquiry: Preliminary
Findings
Karen Jerwood
Head of Sport and Physical Activity


Introduction to table-top
workshop
Dr. Jerry Tew
Senior Lecturer, Institute of Applied Social Studies University
of Birmingham


Health and Wellbeing Update- 12th
July 2012 Summit

Alan Lotinga
Director of Health and Wellbeing


Ongoing Top Joint Priorities
• Making the transition to new health and care
systems and structures
– Keeping eye on whole system consequences of change : so
many things starting from April 2013

• Joining up transformation programmes
– e.g. frail elderly, children's services, personal budgets

• Massive efficiency and productivity challenges -
recurring savings
– e.g. joint commissioning


Ongoing Top Joint Priorities
• Maintaining and improving where possible service
quality, safety and performance, with particular
emphasis on personal experience

• Health inequalities


Some important opportunities to build on
• Year 3 of biggest pooled budget, mental health/learning disabilities.
Highly successful – savings, better services. 10% of total City health
and care spend
• Health and care partnership Compact agreed
• “Frail Elderly” transformation programme to build on (and others
commencing)
• Strong support for place-based budgeting approach – e.g. Troubled
families
• Big push towards integration with primary care
• City Council’s Leader’s Policy Statement – “Promoting health and
wellbeing so that older citizens, children and young people are active
and healthy, and live with dignity and independence. We will use the
transfer of public health responsibility…to eliminate health inequality
between the rich and poor and working through the Health and
Wellbeing Board to achieve this.”
• Wellbeing Key Lines of Enquiry - the work and next steps from today.


Next Steps with our Health and Wellbeing
Board
• Next meeting 24 July
• March 2012 review by existing members – what works, what to
improve. Purpose, membership, network of relationships (many
new).
• Labour Council, “no” vote for Mayor, localisation agenda and
determination to address inequality.
• Strategic guide to our health and care system.
• A number of areas where better links sub-structures need
creating, co-opted, to support the work programme eg 3rd
Sector generally, MH/LD joint commissioning, Children's
Services, NHS Provider Forum, Quality and Safeguarding,
Enterprise and Jobs, Crime and Safety.
• Importance of informal meetings and discussion.


Purpose of the Board
• Hold the “centre ground” to prioritising and applying resources
across all agencies, not a magnet for all issues and not a
scrutiny function
• Little direct infrastructure available, therefore need strong
members and networks
• Deliver Marmot objectives, e.g. service integration and joint
commissioning are key means to deliver these ends
• Strategy based on the “big issues” of the city (as defined by
the JSNA), and deliver
• Keep close eye on big changes (Public Health transfer, CCG set
up, Healthwatch) and whole system issues (de-commissioning,
prevention and enablement activity, QIPP activity)


Health and Wellbeing Board – Network of relationships

• National
- Department of Health
- NHS Commissioning Board
- Public Health England
- Care Quality Commission
- HealthWatch England
- Monitor
- NICE


Health and Wellbeing Board – Network of relationships

• Sub National
- Regional “arms” of above
- Clinical Networks and Senates
- Possible HWB federations
- Joint Scrutiny
• Local (providers, partnerships, communities)
- NHS Provider Trusts
- Private Sector
- voluntary and community providers
- other partnerships – children, enterprise, crime and safety,

safeguarding, environment
- Council departments
- Patients, service users, carers, the public


Birmingham Draft
Joint Health and Wellbeing Strategy
• This strategy is an opportunity for us to be clear
about our vision for the health and wellbeing of our
City, and identify what the key partners – the City
Council, NHS and others – will do together to
achieve it. We want our citizens to be able to live
healthier and happier lives, and for the services we
commission to be better at supporting this.


Birmingham Draft Joint Health and Wellbeing
Strategy
• The Strategy is not a statement of everything we need to do
in health, public health and social care in Birmingham but a
statement of what the most important priorities in health and
care should be.
Many of the most challenging health issues in Birmingham are
significantly affected by educational attainment, standard of
living (good employment) and other factors like the places
we live in. This strategy seeks to reflect that.
Making better use of community assets, co-production, more
involvement of local communities, as well as agencies
working better together, will be crucial to delivery (key
themes from today).


Respond by :7th September 2012
Online at
• http://bhwbb.net/joint-strategic-needs-assessment/health
Email by requesting from
• Birmingham.Phi@nhs.net
Or Phone Birmingham Public Health
• Kulwant Ghaleigh, 0121 465 8029


Feedback, conclusions and
proposals
Karen Jerwood
Head of Sport and Physical Activity


All presentations for today can be
found at:
http://bhwbb.net/download/BHWBB%20Sum


Birmingham Health & Wellbeing Board Summit - July 2012

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Editor's Notes