Integrating mental well-being into policy and practice in times of austerity. 15 th April 2011

1. Integrating mental well-being into policy and practice in times of austerity.15th April 2011 Mental Well-being Impact Assessment (MWIA)

2. This workshop aims to: • Present an overview of mental well-being and implications for people in times of austerity • Share work in England on the development of a MWIA toolkit and building a national profile and capacity to use MWIA • Offer you a chance to ‘have a go’ with some of the resources for MWIA • Explore how MWIA might support your work and any lessons we can learn from each other

3. What do we mean by mental health? mental illnessAbsence of illness

4. Prevalence of mental illness • Mental ill health accounts for almost 20% of the burden of disease in the WHO European Region • Mental health problems affect one in four people at some time in life. • Nine of the ten countries with the highest rates of suicide in the world are in the European Region. • Estimated 83 million people being affected

5. Mental Health is…… “ a state of well-being in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully and is able to make a contribution to his or her community” (WHO, 2005)

6. The dual continuum Flourishing mental illnessAbsence of illness Languishing

7. Benefits of flourishing • Live longer • Are healthier • Use health services less • Take less days off work • Are more productive • Higher income • More likely to be in long term relationships (Keyes, Lyubomirsky, King, Diener)

8. No Health without Mental Health • Mental Health is the foundation for individual well-being and effective functioning of community (WHO 2010) • The level of mental health and well-being in the population is a key resource for the success of the EU as a Knowledge based society and economy(European Pact for mental health and well-being)

9. Promoting Mental Well-being Protective Factors Unemployment Control Resilience and community assets Poverty Risk factors Poor education Participation Inequalities Inclusion Poor living conditions Individual Community Structural

10. The Development of MWIA: MWIA was first developed by a partnership in Lewisham and Lambeth, including South London and Maudsley NHS Trust, to assist those delivering and monitoring Neighbourhood Renewal Strategy projects to identify and measure their impact on positive mental health and well-being – original toolkit published April 2004

11. “A pioneering methodology for reforming systems to focus on well-being outcomes and determinants” 11 • MWIA provides a structured, evidence based analysis of how policies, proposals, programmes and projects might influence mental health and well-being • It focuses on mental well-being and identifies factors that are having, or have the potential to have, a negative or positive impact on mental well-being. Once identified, actions and indicators are developed to maximise the positive and provide ways to measure this impact going forward. • Mental Well-being Impact Assessment is rooted in Health Impact Assessment methodology and exists to build healthy public policy • With ever increasing policy emphasis on well-being, this tool provides an ideal methodology for supporting system reform to a well-being focus.

12. The Benefits of MWIA include: Engaging a range of stakeholders, including beneficiaries, to increase awareness and understanding of mental well-being Identifying potential positive and negative impacts of a ‘project’ or ‘proposal’ on mental well-being Developing specific indicators (measures) of mental well-being Creating a set of evidence based recommendations and actions to enhance the positive and minimise the negative impact of a project Useful tool to help re-align/commission services to have a well-being focus

14. Figure 2.2: A dynamic model of mental well-being for assessing mental well-being impact

15. Evidence based assessment framework: Population Characteristics & Wider Determinants Population characteristics include: Age, race & ethnicity; gender; socio-economic position & class; physical health; disability; sexuality and other population groups. The wider determinants of mental well-being are: • 1. Physical security e.g. housing, safety at home and in the neighbourhood • 2. Environment e.g. green space, safe play space, quality of the built environment • 3. Meaningful activity e.g. employment, volunteering • 4. Good quality food e.g. affordable, accessible • 5. Leisure e.g. arts and creativity, sport, culture • 6. Education e.g. lifelong learning, pre-school • 7. Financial security e.g. income, credit, assets • 8. Transport e.g. affordable, accessible, sustainable 15

16. MWIA Protective Factors: MWIA is based on 3 key protective factors which promote and protect mental well-being. These are: Enhancing control Increasing resilience and community assets Facilitating participation and promoting inclusion. (Adapted from the Department of Health, 2001)

17. The 6 Stage Process of MWIA: 2 Scoping How will you carry out the MWIA? • Screening • Deciding whether you carry out an MWIA? 3 1 • Appraisal Process • Community profiling • Stakeholder MWIA Workshop • Research – Literature Review 4 Identifying Impact 5 6 Indentifying Indicators The Report & Recommendations (www.hiagateway.or.ukand www.nmhdu.org.uk/mwia-toolkit-2010)

18. Local information: profile of local population, socioeconomic & other determinants from census, NHS, council, police, local reports etc Views and experience of interested parties eg community & vol groups, decision makers, staff, patient groups Epidemiological data & other published & peer reviewed research evidence Collecting, analysing & interpreting information Triangulation

19. Capacity building and use of MWIA in the UK Approximately 500 people have now been trained in most regions of England to carry out MWIAs ranging from Screening to full MWIA Well over 500 MWIAs have been carried out on a wide range of programmes including: Local Area Agreements, Timebanks, carers projects, mental health projects, community arts projects, the European Capital of Culture 08 (in Liverpool), the Well London and NMHDU programme. A National MWIA Collaborative oversees the development and promotion of MWIA and will now be supported by the NHS Confederation and Local Government Improvement Development The former National Mental Health Development Unit funded a national MWIA development and capacity building programme MWIA is becoming mainstreamed in English and UK public policy such as ‘No health without mental health’ and guidance for local government

20. Any Questions?

21. Over to you

22. A case study to illustrate…. Stockport Healthy Lifestyles Service/s • In process of re-commissioning service/s in context of reduced budget and changing demands and feedback • Saw MWIA ‘as a tool to help us realise active engagement from partners in provider organisations’ and a way to focus on mental well-being

23. Stop Smoking Service Alcohol Health Advice Service Health Trainer Service Weight Management Services Mental Wellbeing Services Physical Activity Services Current Lifestyle Services Differential access - some universal, some limited; use of varied support tools and processes Mixed pattern of self referral and GP referral Cross-referral pathways exist, some stronger, some less so Most services issue specific

24. Stop Smoking Service Alcohol Health Advice Service Health Trainer Service Weight Management Services Mental Wellbeing Services Physical Activity Services Single Point of Access Pilot (LAP) Referrals from General Practice managed via single pathway, services remain issue specific. Self-referral unaffected; use of support tools and processes still varied. Current Lifestyle Service

25. Enhanced Basic Offer One-to-one, tailored, personal support over several weeks to identify priorities, plan and carry through change. Community-based “health-trainer” style/ branding; all lifestyle issues Enhanced Specialist Offer One-to-one support over several weeks by skilled staff able to manage complex cases and multiple morbidities. NHS style/branding; all lifestyle issues Limited access Universal Offer Web-based tools to review lifestyle choices and obtain tailored advice Directory of local services/ opportunities to support individual action planning Universal access Integrated Lifestyle Support Model Commissioned direct PARiS; AOP Walking prog; KIOFG Self-health@ library Phase IV Rehab Stressbusters

26. Referral Processes Mediated (individual assisted to access service via web) Social care providers Housing sector Education providers Community development Neighbourhood management Pharmacies Self Open-access to web-based service Via personal computers Via computers in public locations eg libraries, schools Direct (service contacts client in response to professional referral) Primary care Secondary care A&E lifestyle project Mental health service Work Programme Extensive promotion of service to maximise access and uptake across population

27. MWIA of commissioning proposals • Screened proposals using MWIA Screening tool • Identified needed to hear from all interested parties • Had already done a Community Profile and Literature Review • Held four workshops with range of people

28. Findings • Some positives such as offering access to information on healthy lifestyles and other activities including self help through web access – helps sense of control and participation • Likely to be easier for wider range of people to recommend and refer people into the service – control, resilience • May be cost effective as can go to one point of access and use more community based services - control, resilience

29. BUT…. Potential negatives… • Access for people without internet or literacy could reduce access - increase exclusion • Concerns that existing criteria for access to support services is limiting as only to people from ‘deprived area’ - increase exclusion • Concerns that benefits of group activities lost if only 1-1 support focus – participation and resilience • Concern about possible division between individual lifestyle behaviour and wider community based activities - increase exclusion • Need for staff training identified – feeling valued

30. Recommendations • Emphasise the need to high profile publicity and work to help people who do not have access to the internet • Revise proposals to find way to balance 1-1 support with group based activities • Make a case for area served criteria to be changed • Keep staff involved with the proposals as more likely to have ownership • Staff training to be included

31. Reflections form the commissioner • ‘Helped us realise active engagement from partners in provider organisations’ • ‘But it has also been useful in adding depth to discussion about the proposal and highlighting areas of concern and link to mental well-being’ • ‘Also I think it helps me to keep a consistent emphasis on the links between mental wellbeing and successful behaviour change which is useful in considering the nature of the processes and support that the service will need to encompass’ • ‘MWIA is a useful too for co-productive commissioning and helping understand implications for cost savings’

32. Thoughts on relationship to other Impact Assessments…. • Intended to compliment and not replace • Intended to be used as a tool if specific interest is mental well-being & re-alignment to a mental well-being focus • The assessment framework can be integrated into others such as HIA if wanting to strengthen understanding & assessment of mental well-being • Feedback is suggesting it encompasses areas covered by Equality and Race IAs

33. Future application of MWIA in context of re-aligning to a well-being focus in context of austerity measures: • Informing the re-commissioning of services as part of the efficiency drive • Informing the re-focusing of service provision to have a well-being focus and service improvement • As a tool to support the understanding and importance of mental well-being and the contribution that services and programmes (often not part of the NHS) have to make towards this. • As a tool for identifying and measuring impacts and their relationship to outcome measures.

34. For further information on MWIA please contact: Anthea Cooke Email: anthea.cooke@inukshukconsultancy.com; Tel: 00 +44 (0)1428 714485 OR Tony Coggins Email: tony.coggins@slam.nhs.uk Tel: 00 +44 (0)1428 203 228 1688 You can download further information on MWIA and the toolkit from: www.hiagateway.org.uk

35. Any Questions and thoughts about relationship to HIA?