A whole system approach for Mental Health?

Good Mental health is an issue, or set of isues at once both fundamental to our lives and diffuse in the factors which influence it, that it seems a perfect candidate to take a system wide approach to it, from our work/study places to our homes and social environments.  Systems approaches in public health have been a key feature of our public health strategy in Hertfordshire so far.  Chapter three of our strategy outlines our conceptualisation of some of this at the time, though it’s fair to say we have moved on in some of this. http://www.hertsdirect.org/docs/pdf/p/phstrat.pdf

Trying to build a whole systems approach in Hertfordshire

We’re building a systems approach to Mental Health at population level in Hertfordshire, and this week we took a look at what we have already done:

  1. A major Needs Assessment exercise led by Professor Jonathan Campion http://jsna.hertslis.org/top/discondis/menheal/
  2. A major transformation of adult drug and alcohol services
  3. investment into Child and Adolescent Mental Health Services and a trasnformation programme to reshape services, following the whole system review http://jsna.hertslis.org/top/discondis/menheal/
  4. A similar transformation programme just kicking off on drugs and alcohols services for children and young people
  5. A resilience programme in Schools already underway and more work planned
  6. A mental health crisis care concordat with a range of projects under it to improve crisis care
  7. A review to ensure that people with drug or alcohol problems and mental health issues spend less time with police under place of safety orders
  8. A pilot programme for very complex adults
  9. A veterans programme
  10. A suicide reduction programme
  11. A workplace mental health programme run by Business in the Community
  12. Significant increase in uptake of IAPT (psychological therapies)
  13. Developing an approach to recovery – a recovery college
  14. A significant investment in anti-bullying work which has seen us win multiple awards.

All of these are areas of work still underway, and we have much to do still, but a large coalition of agencies in Hertfordshire is working on this. Statutory, commercial, third sector and academic.

Year of Mental Health : Building Leadership

We are in the middle of a Year of Mental Health, which ends in July 2016. The whole purpose of which is to create some focus around this work, to reduce stigma around mental health and to build some political leadership. http://www.hertsdirect.org/your-council/hcc/partnerwork/hwb/hertsyearofmentalhealth/

We signed up to the local government mental health challenge. http://www.mentalhealthchallenge.org.uk/

The County Council has two elected member champions, each District Council has an elected member champion, and we have one MP signed up as a Champion. We are now starting work on parish and town councils.

We have more work to do, obviously, and during this year we will do much more on a number of these.

We have significant Leadership on this issue from our Mental Health Trust and University. But this is not an issue which can be left to them. So building leadership across the system is a task we are all focusing on. I think we’re moving on this.

Work still to be done

There are a range of pieces of work to be done and one of the pieces of work we will be doing this year. Working with the Providers, we will be developing a strategy to improve the physical health of people with mental health problems. We are already working on reducing smoking in this population, and have also made some progress with physical health with people with learning disabilities.

We will also be working mental health more strongly into service specifications for health visiting and school nursing.

Thinking started by our Public Health Conference December 2015

Our rationale for doing all of this is that there is strong evidence that doing it will improve health outcomes and good evidence that it will reduce cost to the public purse.

One of the presentations of the day which got people thinking was looking at a system wide approach to mental health, i.e. taking a population or public health approach to mental wellbeing and mental ill-health. Andy Bell from the Centre for Mental Health http://www.centreformentalhealth.org.uk/ took us through this and gave us prolific advice. I took from my notes of Andy’s session what essentially, with one or two additions from me amount to a 16 point plan, which together forms the basis of a manifesto for population mental health. I’ve augmented this a little with some evidence to back up what Andy was saying. What got me excited about this was that this is one of the most comprehensive and straightforward cross-system manifestos I have ever seen for preventing and reducing mental ill-health in a population.

Andy also gets what I call the overlapping venn diagram of the big population tasks for ensuring we keep people in good mental health . I’ve suggested this in a diagram below. You can add to this the fourth big task of helping people experiencing mental ill health to recover, build resilience wherever possible and get back to the best state of wellbeing they can. Together the sixteen tasks below add up to a manifesto across these four big tasks of population mental health.

mental health diagram

The four big tasks of population mental health

It’s always helpful when working on system issues to get a clear conceptualisation of these. One of the problems with mental health is this can be difficult. So we’ve been testing out since December the four big tasks, which provisionally we have down as below. We may change them but welcome input and comment.

  1. Promoting wellbeing – a good and positive state
  2. Promoting psychosocial resilience – giving people skills to cope with stressors and life
  3. Preventing ill-health – spotting signs, intervening early with basic interventions
  4. Addressing and recovering from mental ill-health – the emphasis on best possible coping, functioning and recovery


The System Must Dos to get good outcomes for good population mental health

I’ve slightly amended my earlier list and now, below, have 18 system must dos which I hope to be working with Andy Bell at Centre for Mental Health and colleagues on. I’ve put these as a lifecourse approach, which should help us put them into our Health and Wellbeing Strategy and also develop a population mental health programme. I’ve also adjusted these so that they each track to one or more outcomes from our Needs Assessment.

  1. Invest in good parenting – reducing the cost of conduct disorder and other problems in later life
  2. Maternal Mental Health during and after pregnancy, including quick access to cognitive behavioural therapy as a priority
  3. Ensuring the key role of schools in mental health is delivered
  4. Primary School is key, and the first major external influence on childrens’ resilience
  5. The whole school approach is the most effective thing you can do
  6. Ensure good adult resilience and early intervention
  7. Workplace interventions pay off – the positive and supportive psychosocial working environment is a key part of this
  8. Early identification
  9. Reducing loneliness – a big task for resilience as well as recovery
  10. Address alcohol issues especially where it’s used for self-medication. You could do the same on drugs and tobaco
  11. Zero suicide – we have to be ambitious
  12. Relapse Prevention especially for psychosis
  13. Support Recovery , always and in every service
  14. Ensure you address physical and mental health –cardiovascular health, smoking, weight and other physical health issues are disproportionately seen in people with mental ill-health. We must address these because they reduce life expectancy, worsen burden of disease and disability and are important in getting people to better mental health
  15. Identify and address unmet need, especially in people with long term conditions
  16. Liaison Psychiatry in every Hospital
  17. Smoking – get people off tobacco,
  18. Make it happen using a system public health approach
  19. Reduce stigma and increase awareness

Systems within Systems

You can articulate systems within systems on this. (Lets not get hung up on semantics or become systems theory nerds, the point is its means to help us change the health of our population for the better, not become experts debating macro, meso and mico system architectures), so within Schools the evidence would point us, Andy Bell suggested, to some issues within the school as a system:

  • Target young people at the greatest risk for mental ill health and reducing resilience. The Good news here is there are lots of interventions which demonstrate value for money
  • Adolescence – ensure good resilience here especially because there is mounting evidence of worsening wellbeing among girls. Involve young people in service design and re-design.
  • Target young people involved in gangs and crime to provide safe and credible routes out and into support. This will pay off later


The System Critical Succes Factors

My reading and working on these issues convinces me that in addition to these must dos within the system itself, there are a number of critical issues which help determine success or failure in getting a systems approach to mental health. I call these Critical Success Factors.  They change, in my experience, depending on your system or the issue you are dealing with. But here, for the most part, are the ones I find which commonly emerge:

  1. A clear shared view of the system
  2. Ability to focus up and down from system to particular issues
  3. Leadership across the system
  4. Understand need using data and peoples knowledge
  5. Set outcomes
  6. Identify and prioritise interventions
  7. A balanced scorecard approach to this
  8. Multiple actors, multiple partnerships, shared vision – a programme approach
  9. Evaluate and iterate

We’ll continue this work, and I hope to write this up in more detail. But having been at this now for around two years, three years for some pieces of work, I believe there are signs we are moving. The issue will be, if the system is complex, how on earth do we evaluate it?  Another blog….

2 thoughts on “A whole system approach for Mental Health?

  1. All very interesting but have you any idea how to join everything up! PH,Housing,Welfare Benefits, Physical and Mental Wellbeing? and where will you start? The obvious place is the GP who will need to know where to sign post. The Carer, the most important member of the TEAM? is important.

    The Community will evaluate it, just as we do at present.

    LA have no money, patients and Carers are left with no services. No ‘Care Plans’ either.

    It is elementary stuff, just made to look complicated, ‘Jargon’ was a know know when I was the Carer representative on the Mental Health National Service Framework’ don’t forget ‘devolution’ will change everything.

    Police 136 ‘Place of safety’ is not happening, because there are no beds, how do you propose to change this?

    Rehabilitation ‘day centres’ have closed for the Mentally Ill,

    Emergency Contact number, is in fact an individual sat on the end of a telephone line, only advice is go to the Police. The Police say it’s not our ‘job’. Join the ‘Merry Go Round’ I have been going around for years.

  2. This is brilliant and something we in Bracknell Forest can aspire to! I’d like to see mental health placed at the very core of Public Health work. It needs to be our primary outcome, as well as consider as an important mediator of the effects of our work. Recent debates on alcohol guidelines show that the Public Health dialogue is still too focused on mortality – giving rise to the “I’d rather die young and have fun” counter argument. If we market healthy lifestyles as having benefits on mental health and the ability to enjoy life (which they of course do) then we may start getting somewhere! Good stuff Jim!

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