Teaching slides from a University College London Partners and National Co-ordinating Centre for Mental Health Public Mental Health Course in February 2015. This session focuses on building local approaches to public mental health

1. www.hertsdirect.org
Public Mental Health
Some key challenges and potential ways forward
Feb 2015
UCL Partners
Jim McManus
Director of Public Health
Jim.mcmanus@hertfordshire.gov.u
k

2. www.hertsdirect.org
Experience
• East London
• Birmingham
• Hertfordshire
• “Strategic Opportunism”

3. www.hertsdirect.org
Current Projects
• Public Mental Health Framework
• Veterans
• Year of Mental Health Launching 2015
• CAMHS whole system review
• School Whole System Wellbeing Pilots in 36
schools
• Reframing IAPT
• Do Something Different

4. www.hertsdirect.org
Some “Orientations Events”
• St Albans Cathedral 2015 - day workshop on
mindfulness and positive psychology – finding
frameworks – for faith communities
• School Heads “Very Brief Intro” sessions
• Police Command

5. www.hertsdirect.org
Getting orientations: Balance in human life
Worldview eg Jewish, Christian, humanist
Anthropology: human being as creature or end in itself
Your approach to Psychology – the study of the cognitions and
behaviours of the human person eg Positive Psychology
Wellbeing – a concept common to many
concerns scientific and spiritual
Mindfulness, just
one of many
techniques and
practices

6. www.hertsdirect.org
Approaching mental health as a DPH
• Making sense of a complicated and contested
landscape (various players, various agendas)
• Is it one, several or all of:
– Promotion of mental good health
– Promotion of resilience? How does that differ from
good mental health?
– Primary and Secondary Prevention of mental ill-
health
– Tertiary prevention e.g. Prevention of disability due
to mental ill-health?
– Making sure mental health services work well?
Jim.mcmanus@hertfordshire.gov.u
k

7. www.hertsdirect.org
Seeking orientation
• Speaking to DsPH on public mental health
– “Cinderella” of Public Health
– Language – does anyone know what wellbeing
actually means?
– Laudable policy intent
– Problem with the evidence base – what exactly is it
– A lot of (variable quality) science, any actual practice?
• Some level of confusion over what to do
– ‘ I have a desire to do something but no idea what‘
– ‘I have some idea but no interventions to get there‘
– ‘ I have some idea/ framework but not joined up'.
– I have loads of indicators of how bad it is, but no tools to make it
any better’

8. www.hertsdirect.org
National Context
• Mental health parity of esteem in CCG
guidelines for commissioning strategies
• Under-represented in Better Care Fund
• National Outcomes Frameworks say little on
young peoples’ mental health

9. www.hertsdirect.org
Some Premises
• We are facing an (avoidable) epidemiological
crisis
• The Policy Context (England) does give us
scope to address this
• There are some big tasks we can be getting on
with, systems thinking can help
• Some quick wins and delivery tools can help us
win politician confidence
• Phasing and Layering across lifecourse

10. www.hertsdirect.org
Systems thinking on public mental health
The wider determinants of Health and Local Government functions
(Must adopt a Lifecourse approach!)
The Lives people lead and whether LA functions help or
hinder healthy lifestyles (policy, service quality, access,
behavioural economics, behavioural sciences)
The services people access such as primary care
(high quality, easy access, good follow up,
behavioural and lifestyle pathways wrap around)
Jim.mcmanus@hertfordshire.gov.u
k

11. www.hertsdirect.org
Premise 1: We are facing an (avoidable)
epidemiological crisis
• Prevalence of mental ill-health
• Prevalence of physical conditions associated
with poor mental health
– Chronic disease – poor self management, poor management of
sub-clinical risk, must do better on prevention and early
intervention
– Some sections of our population at very high risk of avoidable
misery and death
– Mental health – intervening too late
– Resilience and Happiness – likewise

12. www.hertsdirect.org
Primary
Prevention
Secondary
Prevention
Tertiary
Prevention
in and
Out of hospital

13. www.hertsdirect.org
Premise 2: The Policy Context (England) does
give us scope to address this
• Local Authorities – duty to promote and protect
health of population
• NHS CCGs – duty to reduce inequalities in
health
• Behaviour change is a tool but we need to use it
properly and use the right methods
• A balanced strategy using a range of tools and
strategies

14. www.hertsdirect.org
Premise 3: There are some big tasks we can be
getting on with
1. Analyse the system and identify problems
2. Build a system wide approach to deal with it
3. Be clear on roles, responsibilities and
outcomes
4. A more nuanced understanding of mental
health and resilience across lifecourse
5. Commission for pathways around people

15. www.hertsdirect.org
Premise 4: Some quick wins and delivery tools
Five big wins
1. Shift up clinical complexity in
primary care
2. Shift up preventive and
resilience work
3. Step up self care and self
management in chronic
disease
4. Commission pathways
around users
5. Commission primary
prevention for key risk groups
Policy and Delivery Tools
• Pathways and structured
care approached
• Health and social care
integration
• Behavioural sciences
• Health Checks and public
health services
• Brief interventions
• Physical Activity

16. www.hertsdirect.org
Premise 5: Phasing and Layering across
Lifecourse
Early
Years
Childhood Adolescen
ce
Young
Adults
Older
Adults
Environmen
tal
Structurcal
Social
Behavioural
Biological

17. www.hertsdirect.org
Premise 5: Phasing and Layering across
Lifecourse – Adults with Complex Needs
Early
Years
Childhood Adolescen
ce
Young
Adults
Older
Adults
Environmen
tal
•Multi agency
•All commissioners.
•Pathway approach
•“Thrive” focus
•1800 people
Structurcal
Social
Behavioural
Biological

18. www.hertsdirect.org
Healthier Herts: A Public Health Strategy for Hertfordshire
OUR PURPOSE
to work together to improve the health and wellbeing of the people of
Hertfordshire, based on best practice and best evidence
OUR VISION:
A Healthy, Happy Hertfordshire: everyone in Hertfordshire is born healthy, and lives full, healthy and
happy lives. We compare well with England and every area in Hertfordshire compares well against
Hertfordshire
Priority 5:
We
understand
what’s
needed and
we do what
works
Priority 6: We
make public
health
everybody’s
business and
work together
HOW WE WILL WORK TOGETHER
(our strategic priorities: how we do it for
our County)
The
Public
Health
Outcomes
Framework
(the national
PHOF will
Help us measure
Our success)
WHAT WE WILL ACHIEVE WORKING FOR AND WITH OUR
RESIDENTS
(our strategic priorities: what we achieve for our County)
Priority 1:
Our
Populatio
n lives
Longer,
Healthier
Lives
Priority 2:
Our
Population
Starts Life
Healthy
and Stays
Healthy
Priority 3: We
narrow the
gap in life
expectancy
and health
between
most and
least healthy
Priority 4: We
protect our
communities
from harm
(chemical,
biological,
radiological and
environmental)
Building
Blocks
For the
Public Health Family
Strong
Leadership
Capable, Skilled
People
Co-production
with citizens
Effective
Partnerships
Evidence and
Knowledge
Driven
Plan and
Deliver for
Localism
Whole
System
Approaches
Making better use of behavioural sciences at individual, interpersonal, community and service levels

19. www.hertsdirect.org
Premise 5: Phasing and Layering across
lifecourse
•Think through what we can do short term
•Start work on the medium term
•Set the policy framework for the long term
•Build this understanding among partners
•Get started and realise
•County, District, Parish, NHS, Business and
Community Sector working together

20. www.hertsdirect.org
Premise 5: Phasing and Layering
• Phasing across the lifecourse and time
Working age
Accumulation
Of risk in
Late working
age
Good early
Years
outcomes
For lifetime
Mental
health

21. www.hertsdirect.org
Premise 5: Phasing and Layering across
Lifecourse
• Layering levels of action
• Population – resilience – how to thrive
• Sub-Population – self harm work, diversity,
bullying
• Individual – school pastoral care frameworks
(30 secondaries)

22. www.hertsdirect.org
What it means for NHS Services
• Preventive services in every patient pathway
• Levels and competencies from brief intervention
onwards
• Preventive services in clinical services link up to
community services (referral for leisure and
behavioural interventions)
• Commissioning for self-management in chronic
disease

23. www.hertsdirect.org
Making PMH Opportunities a reality -1
• A Framework for DsPH
– JSNA to Commissioning remains a
challenge
– Domains Model or Prevention Model within
the framework (next slide)
– Menu of interventions likely to work across
domains
– “Plug and play” tools and strategies
http://www.fph.org.uk/better_mental_health_for_all

24. www.hertsdirect.org
Making PMH Opportunities a reality -2
• Frameworks we might use
– Domains of Public Health Model or Prevention Model?
• Health Improvement – layer, scale and phase
• Health Protection – mentally disordered offenders, etc
• Service Quality – CAMHS, MH Pathways etc
– Prevention Model? – 1ry, 2ry, 3ry, Resilience?
– Levels of Public Health (Dettels et al,2009)
• Biological, behavioural, social, structural, policy, environmental
– An Evidence Base
http://www.fph.org.uk/better_mental_health_for_all

25. www.hertsdirect.org
The domains model applied to public mental health
(a first, partial start at an illustration)
Health Improvement Health Protection Service Quality (often
called service public health)
Good JSNA and Equity Audit as a foundational step
Lifecourse approach to
building resilience
Protecting people from
vulnerability factors
(workplace stress)
Best possible evidence
Early intervention Drugs and alcohol work Best possible
implementation
Physical activity, social
connectedness as well as
drugs and therapy
Mentally disorderered
offenders work
Best possible evaluation
and audit
Tiered approach (severity)
Layering across the 6 layers of public health: biological, behavioural, social,
political, environmental, structural (Dettels et al 2009)

26. www.hertsdirect.org
Evidence example – the “S” and “R” words
• Growing evidence base for dual impact of
Spirituality and Religion on health
– King et al 2013
– Koenig et al 2012
• Salience of context and outlook
• Important coping and resilience benefits
• Least comfortable of protected characteristics in
NHS (McManus, 2008; Cooke 2010)
Jim.mcmanus@hertfordshire.gov.u
k

27. www.hertsdirect.org
Making PMH Opportunities a reality - 3
• Some discrete pieces of work
– PMH and wider determinants (resilience, financial
stress and burden)
– Using research and academic monies to do
knowledge transfer
– Supporting DsPH with knowledge transfer into
implementation
• menus of interventions which work
• the evidence gap – what’s promising and what does good
innovation look like
• evaluations
– Training
Jim.mcmanus@hertfordshire.gov.u
k

28. www.hertsdirect.org
An attempt at a Hertfordshire framework
• Phasing – Lifecourse
• Layering of PMH intereventions (the 6 layers)
– Resilience – how to thrive, carers, lgbt, bullying,
community interventions,– physical activity, 5 ways
to wellbeing, bibliotherapy, financial stress etc,
building social movements and norms
– Prevention – menu of interventions, pathway
– Tiering of services – scale, pace, quality,
commissioning, pathways
Jim.mcmanus@hertfordshire.gov.u
k

29. www.hertsdirect.org
Premise 5: Phasing and Layering across
Lifecourse
• Layering levels of action
• Population – resilience – how to thrive
• Sub-Population – self harm work, diversity,
bullying
• Individual – school pastoral care frameworks
(30 secondaries)

30. www.hertsdirect.org
Contributions on Mental Health 1
Third sector
contributions
Working together PH, NHS, LA
contributions
•Activities which improve
self esteem and self worth,
key skills – recovery,
prevention and resilience
agenda
•Do more to encourage and
enable volunteering –
commissioning of services
but no funding for volunteer
centres. Cost of volunteer
centres needs to be
considered if volunteering
is a proper strategy. Echo
this for any frontline org
with minimum staffing. Cost
of keeping volunteer
centres going versus return
it brings – if volunteering is
an outcome, the
infrastructure to support it
(vol mgt) needs supporting
•Training front line workers
to understand and signpost
better
•Evidence for funding
(support vcs on getting
funding)

31. www.hertsdirect.org
Contributions on Mental Health 2
Third sector
contributions
Working together PH, NHS, LA
contributions
•CAB transition services are a
really good example of third
sector working together
•CAB transitions service
looking at how we do a referral
process and have an activity
plan. Sharing data on a small
scale.
•Easy to connect with and
access especially where there
is a fear of accessing services
•Reducing isolation (flexible),
trust in the sector, local
knowledge, - third sector could
promote itself more
•People expect too much from
services – people need to be
more resilience generally.
Services need to promote
resilience and taking
responsibility for oneself
•Making every contact count is
good
•Dealing with alcohol use for
self medication – investment
has happened but could do
more
•Lifestyle prescriptions
•Clearer pathways and being
able to move from formal
statutory into third sector and
less red tape
•Education – get into young
people
•A piece of work to support the
vol sector demontrate return on
investment for their work.
•Commissioners to explain
clearly and consistently what
they are looking for in return on
investment and how vcs reports
ROI
•Training offered
•Services are reactive, not
flexible enough – need to look
at preventive agenda more
widely

32. www.hertsdirect.org
Some examples of strategic opportunism in Herts
Population Wide Sub-Populations Individuals
•How to thrive
•Workplace MH
Champions
•School Pastoral
Care
•£2m investment
in Districts
•Anti-Bullying
•Self harm
•Older bereaved
•Adults with
complex needs
programme
•Health
Psychologist
working with
primary care

33. www.hertsdirect.org
Current Projects revisited
• Public Mental Health Framework for all
agencies
• Year of Mental Health Launching 2015
• CAMHS whole system review
• School Whole System Wellbeing Pilots in 36
schools
• Reframing IAPT
• Do Something Different

34. www.hertsdirect.org
Further examples of strategic opportunism in
Herts
Population Wide Sub-Populations Individuals
•Lifestyle
partnership
–Football
clubs
–Leisure offer
–Connection
•Welwyn Hatfield
5 Ways
•LGBT Bullying
•Faith
communities and
low level
interventions
•Extremism and
mental health