This presentation, given as part of a plenary symposium at the 8th World Congress on Promotion of Mental Health and Prevention of Mental and Behavioural Disorders gives an overview of how one area is trying to develop an approach to public mental health, finding frameworks and tools of use

1. Public Mental Health
Building the house while living in the foundations
September 26th 2014
8th World Congress on Promotion of Mental Health and Prevention of Mental
and Behavioural Disorders
Jim McManus
Director of Public Health
Jim.mcmanus@hertfordshire.gov.u
k
www.hertsdirect.org

2. Approaching public 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
– Dealing with specific challenges – e.g self harm
– 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
www.hertsdirect.org

3. 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’
www.hertsdirect.org

4. 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
www.hertsdirect.org

5. Strategic Opportunism
• We are facing an (avoidable) epidemiological
crisis
• Inadequate policy context
• Needs a systems approach
• 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
www.hertsdirect.org

6. 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
www.hertsdirect.org

7. 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
www.hertsdirect.org

8. 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
www.hertsdirect.org

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

10. • Layering levels of action
• Population – resilience – how to thrive
• Sub-Population – self harm work, diversity,
bullying
• Individual – school pastoral care frameworks
(30 secondaries)
www.hertsdirect.org

11. Layering
•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
www.hertsdirect.org

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

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

14. Healthier Herts: A Public Health Strategy for Hertfordshire
www.hertsdirect.org
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
HOW WE WILL WORK TOGETHER
(our strategic priorities: how we do it for
Priority 5:
We
understand
what’s
needed and
we do what
works
our County)
Priority 6: We
make public
health
everybody’s
business and
work together
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

15. 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
www.hertsdirect.org

16. 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
www.hertsdirect.org

17. The domains model applied to public mental health
(a first, partial start at an illustration)
Health Improvement Health Protection Service Quality (often
www.hertsdirect.org
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)

18. Strategic opportunism in Hertfordshire
• Layering levels of action
• Population – resilience – how to thrive
• Population – Lifestyle Partnership
• Sub-Population – self harm work, diversity,
bullying
• Individual – school pastoral care frameworks
(30 secondaries)
www.hertsdirect.org

19. 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
www.hertsdirect.org

20. Contributions on Mental Health 1
Third sector
contributions
www.hertsdirect.org
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)

21. Contributions on Mental Health 2
Third sector
contributions
www.hertsdirect.org
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

22. 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
•Lifestyle
Partnership
www.hertsdirect.org
•Anti-Bullying
•Self harm
•Older bereaved
•Adults with
complex needs
programme
•Health
Psychologist
working with
primary care

23. Further examples of strategic opportunism in
Herts
Population Wide Sub-Populations Individuals
•Lifestyle
partnership
–Leisure offer
–Connection
•Welwyn Hatfield
5 Ways
•Health Walks
•Year of Cycling
www.hertsdirect.org
•LGBT Bullying
•Faith
communities and
low level
interventions
•Extremism and
mental health
Working with IAPT
on long term
conditions and
resilience
Suicide and self
harm