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Mental Health in the West Midlands Newbigging, Karen; Parsonage, Michael

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Download date: 02. Oct. 2021 MENTAL HEALTH IN THE WEST MIDLANDS COMBINED AUTHORITY

A report for the West Midlands Mental Health Commission JANUARY 2017

Dr Karen Newbigging, Health Services Management Centre, University of Birmingham Michael Parsonage, Centre for Mental Health 2 Mental Health in the West Midlands Combined Authority 3

Foreword CONTENTS TABLES AND FIGURES Acknowledgements 4 Table 1: Cost of mental ill health to the WMCA 31 Executive Summary 5 Table 2: Mean lengths of stay (LOS) for the NHS Rt. Hon. Norman Lamb MP Introduction 12 Trusts 2013–2016 47 The West Midlands Combined Authority 12 Table 3: Place of safety detentions for 2015-2016 47 Policy Context and the West Midlands 12 Table 4: Use of physical restraint 2012-2014 48 The aims and scope of this project 13 Methods 13 Figure 1: A population perspective to improving Good mental health and wellbeing The economic case for action to improve This report 14 mental health 15 is something we should all be able the mental health and wellbeing of our Mental health of the West Midlands Combined Authority 15 Figure 2: Rates of deaths by suicide per 100,000 to experience, but sadly it is not the communities is therefore overwhelming. Population 15 population in the West Midlands 17 case for everyone. Too often people who Prevalence of mental health problems in WMCA 15 Figure 3: Diagnosis of mental illness by equivalised Factors influencing mental health 16 household income and gender 18 experience poor mental health don’t get Allied to this, there is a moral imperative for Populations at risk of poor mental health 17 Figure 4: Estimated numbers and types of the help they need when they need it. The improving the mental health and wellbeing Understanding mental health assets and needs 22 mental health problems for a practice 37 consequences can be long lasting and can of those living in the Combined Authority Co-production and user engagement 23 Figure 5: IAPT referral per 100,000 population have a significant impact on individuals, area. Providing people with the opportunity The economic and social costs of poor mental health in the West Midlands 26 for WMCA CCGs 38 their families, friends and colleagues. to prevent poor mental health, or to recover Estimating costs 26 Figure 6: Percentage of people waiting <28 days should be a central aim of our public Care costs 26 for IAPT in WMCA 38 The West Midlands Mental Health services. We should also focus on how Employment costs 28 Figure 7: Percentage of patients with a Commission asked the Health Services we can reduce the overall impact of mental Human costs 29 diagnosis of SMI having different types of Crime costs 31 physical health checks 39 Management Centre at the University ill health. Aggregate costs in 2014/15 31 Figure 8: Aims of Early Intervention in of Birmingham, in partnership with the Lifetime costs 32 Psychosis services 41 Centre for Mental Health, to develop this Drawing on the evidence and findings Mental health support in the West Midlands 34 Figure 9: Attendances at A&E for a psychiatric report, to provide us with a baseline audit of this report, the Commission will set Promoting public mental health 34 disorder per 100,000 population 44 of the picture in relation to poor mental out a plan of action aimed at making better Other universal services 36 Figure 10: People in contact with mental health health across the region, in terms use of the resources that are available. Primary care 37 services per 100,000 population 46 of services, emerging good practice Early intervention 41 Figure 11: Mental health inpatient beds by Crisis intervention 42 the four main providers in the West Midlands 46 and the economic impact. This report demonstrates clearly why Secondary mental health services 45 Figure 12: No of people detained on we must act to improve the mental Local Authority provision 52 March 31st by NHS provider 47 This report describes some of the health and wellbeing of the region. Third Sector provision 53 Figure 13: MHA Detentions by ethnicity services and initiatives already in place and Specific provision for people from Black Asian and Minority Ethnic communities 54 2015-2016 47 highlights examples of good work already Quality of Life and mental illness 55 Figure 14: Uses of restraint per 1000 bed being done. In doing so it illustrates the Housing 57 days by NHS Trusts in the WMCA 48 high cost of poor mental health on the Employment 60 Figure 15: Proportion of contacts by region. The current financial impact is Criminal Justice System 61 service type for 2014-2015 49 Overall assessment 63 Figure 16: Number of women seen by estimated to be over £12 billion per year. Recommendations 64 community perinatal mental health References 65 services in Birmingham 49 Appendix 1: Audit of Mental Health Activity Commissioned by CCGs Figure 17: Percentage of mental health clients and Local Authorities in WMCA 2014/15 73 receiving a Direct Payment or Personal Appendix 2: Population and socio-economic deprivation in the West Midlands 74 Budget in the WMCA 52 Appendix 3: Mental Health Joint Strategic Needs Assessments for the WMCA 75 Figure 18: Proportion of working age adults Appendix 4: Service user engagement groups in the West Midlands (18-69) recorded as living independently 58 Combined Authority 76 Figure 19: Percentage of adults on the CPA in Appendix 5: Audit of public mental health initiatives being settled accommodation for each CCG in commissioned in WMCA 79 the WMCA 59 Appendix 6: Suggested commissioning priorities for public mental health 83 Figure 20: Percentage of adults on the CPA in 60 Appendix 7: CCG Weighted populations 86 employment for each CCG in the WMCA Appendix 8: Outpatient and community contacts by organisation and team type 87 grouped by LEP Appendix 9: Vanguards 88 Figure 21 The key principles of Individual 60 Appendix 10: The West Midlands Prisons Cluster 90 Placement and Support Abbreviations and acronyms 91

This report should be cited as: Newbigging, K. and Parsonage, M. (2016) Mental Health in the West Midlands Combined Authority. University of Birmingham: Health Services Management Centre. 4 Mental Health in the West Midlands Combined Authority Mental Health in the West Midlands Combined Authority 5

Acknowledgements Executive Summary Mental health in the WMCA

We are grateful for the support that we received from stakeholders in the West „„ There are an estimated 4.032 million „„ People with an increased risk of Midlands, who provided us with information people in 2014–15 living in the West developing mental health problems NEARLY A QUARTER and those who made this possible, often Midlands Combined Authority (WMCA). and/or for whom access to effective within a demanding timescale. The population is culturally diverse, help is problematic are: with over 22% from Black and Asian - Looked after children and young OF ALL ADULTS In particular we would like to thank Minority Ethnic communities, ranging people leaving care Dr Lola Abudu, Paul Sanderson and from 2.3% in Cannock Chase to - Homeless people and people living the team at Public Health England West 42% in Birmingham. in poor quality housing LIVING IN THE WMCA Midlands; Gemma Duggan, National „„ Over half of the population of the - Unemployed people Housing Federation; Professor Jon Glasby, WMCA live in the 20% most deprived - People from Black, Asian and ARE EXPERIENCING A University of Birmingham; Karen Machin, areas in England. There are links Minority Ethnic communities independent service user consultant; Sarah between insecure housing, financial - Lesbian, Gay, Bisexual and Norman, Dudley Metropolitan Council stress, mental health and child Trans people MENTAL HEALTH and lead Chief Executive from the West development, which influence - People with long-term physical Midlands Combined Authority supporting life chances and social mobility. health conditions PROBLEM the Mental Health Commission; Zoe „„ Data from the ONS subjective -People with disabilities, including Page, NHS Benchmarking; Jenny Riley, wellbeing survey points to wide learning difficulties and sensory AT ANY ONE TIME Birmingham City Council; Sean Russell, variations between West Midlands impairments West Midlands Police; Dr Geraldine Local Authorities with rates of - Carers Strathdee, former National Clinical Director wellbeing that are below the national - Survivors of sexual, emotional for Mental Health; Jim Symington, Crisis average for Wolverhampton, Birmingham and physical abuse Care Concordat; Professor Jerry Tew, and Coventry and above average - People experiencing severe University of Birmingham; Helen Wadley, for Sandwell. and multiple disadvantage. THE COSTS OF POOR MENTAL Birmingham Mind; Belinda Weir, University „„ Nearly a quarter of adults living in „„ Detailed profiling of mental health HEALTH TO THE WMCA of Birmingham; and Sarah Yiannoullou and the WMCA are experiencing a mental needs in the WMCA has yet to be colleagues at the National Survivor and User health problem at any one time. The provided. Local Authorities have „„ The aggregate economic and social Network (NSUN). We are also grateful risks of poor mental health are not a responsibility to undertake Joint cost of mental health problems in the to Steve Appleton for his ongoing support uniformly distributed across the Strategic Needs Assessments (JSNAs) WMCA is estimated at around £12.6 and advice; to the West Midlands Mental WMCA population. They are in their localities and these should billion in 2014–15, equivalent to Health Commission for funding this work, influenced by social, economic and provide a detailed picture of the local a cost of about £3,100 per head and to the Rt. Hon Norman Lamb, MP and physical environmental factors and population and their mental health of population. Chair of the Mental Health Commission for social inequalities in particular. needs. The quality of JSNAs across „„ Care costs, covering the costs of his advice and encouragement. Particular „„ Women living in the poorest the WMCA is variable, and poor quality health and other services provided thanks are owed to Liz Haydon, Public households are nearly three times JSNAs will hamper strategic planning for people with mental health problems Services Academy, and Christian Bohm, as likely as men living in the most and understanding of whether progress by the NHS, social services, schools HSMC Library, and Creative Media at the well-off households to be diagnosed is being made on addressing inequities etc,. and also the informal care University, for their support in the final with a common mental health problem in access to effective support, and the provided by family and friends, production of the report. such as anxiety or depression. On the promotion of health and wellbeing. account for 28.0% of the total. other hand, men are more than four „„ Co-production and community times more likely than women to die engagement are central to developing Figure 1 and Appendix 6 are reproduced as a result of suicide. an understanding of the mental health with kind permission of Sage „„ In 2015, there were 477 deaths needs of the WMCA population, recorded as suicide in the West the challenges they face, and the Midlands which at 9.6 deaths per opportunities to strengthen resilience. 100,000 population is lower than the They provide a foundation for rate for England at 10.9 deaths per service transformation. 100,000 population. People living in the poorest socio-economic circumstances are ten times more at risk of suicide than those in well-off households. 6 Mental Health in the West Midlands Combined Authority Mental Health in the West Midlands Combined Authority 7

„„ Mental ill health is estimated to cost „„ The aggregate societal cost of crime - Programmes to improve the physical „„ Annual expenditure on primary care CRISIS INTERVENTION the NHS nearly £2 billion a year in the WCMA is estimated at around health of people with mental health prescribing spend on mental health is „„ The Care Quality Commission has THE AGGREGATE in the WMCA. Only about half of £4.9 billion a year. Assuming that the problems £12 per head in the WMCA, compared recently identified that mental health this represents the direct costs of proportion of offending linked to mental - Suicide prevention with a national average of £13. Spending crisis care provision remains both treatment and care for people with disorders, particularly personality per head by CCG ranges from £8 inconsistent and inadequate. All CCGs COST OF MENTAL diagnosable mental health problems. disorders and substance misuse, „„ Some of these initiatives are short-term to £15.50. in the WMCA have developed action The other half arises mainly because is around 20%, the mental health- projects and at particular risk of „„ Improving access to Psychological plans to improve local access. HEALTH PROBLEMS large numbers of people with long- related cost of crime in the WMCA austerity measures being taken by Therapies (IAPT) is a key strand of „„ Promising initiatives in the WMCA IN THE WMCA IS term physical conditions, such as comes out at just under £1 billion a Local Authorities to reduce overall primary mental health care. The referral include street triage, the redesign of the diabetes and asthma, also suffer year. This figure is, however, subject expenditure. rates for IAPT vary across the country urgent care pathways and crisis houses. ESTIMATED AT AROUND from depression or anxiety and this to a wide margin of uncertainty. „„ Universal services notably, the police, and in 2014, 13% of people with There is emerging evidence that crisis greatly increases the costs of physical „„ Many mental health conditions fire service, libraries and museums anxiety and depression across WMCA houses are more cost-effective than health care. are persistent and recurrent, with have an important role to play in (compared with 12% across England) inpatient care and are more valued by £12.6 BILLION „„ Spending on physical healthcare a particularly high degree of continuity prevention, as front-line services, by accessed IAPT services at any one point. service users but there are currently is also pushed upwards because between adverse mental states promoting awareness of health and The West Midlands was below the only four in the WMCA. IN 2014/15 of medically unexplained symptoms, in childhood and those in adult life. wellbeing and self-management, and national average for IAPT; 621 people „„ The rate of attendance at A&E for people ie, physical symptoms which have no Taking a life course perspective, access to appropriate support. compared with a national average of with mental health problems in the form an alliance under NHS England’s apparent underlying organic cause the total long-term cost of perinatal „„ There is considerable scope to 691 referrals per 100,000 population. WMCA is 180 attendances, per New Care Models Vanguard and are thought to be psychological depression and anxiety is estimated at develop a strategic approach to public Although there has been an improvement 100,000 population which is below the Programme: the Mental Health Alliance in origin. around £0.55 billion for each one-year mental health and prevention, and the in the number of people waiting less national average of 250. The picture is for Excellence, Resilience, Innovation and „„ The cost of Local Authority Care for cohort of births in the WMCA. National introduction of the Prevention than 28 days for therapy, there is similar for self-harm. There is, however, Training (MERIT), which aims to spread children in care because of parental prevalence data suggest that about Concordat offers a critical opportunity considerable variation across the CCGs significant variation across CCGs in the best practice and reduce variations in mental illness mental health and/or 2,600 five-year-old children in the for the WMCA to adopt prevention, in the WMCA and 40% of CCGs are WMCA, from less than ten to more than cost and quality. substance abuse is estimated WMCA are likely to have conduct in a context of a life course approach, below the average for England. 400 attendances per 100,000 „„ The overall bed numbers are broadly at £0.1 billion a year. disorder, and the estimated aggregate as a key focus. population. similar to four years ago, although there „„ The value of informal care provided lifetime cost for this one-year cohort EARLY INTERVENTION has been an increase in the number by family and friends for people in the is over £0.7 billion. PRIMARY CARE of secure beds and a reduction in WMCA with mental health problems „„ Any general strategy for early SPECIALIST MENTAL the number of beds for older adults. is estimated at £1.1 billion a year. MENTAL HEALTH SUPPORT „„ There are 716 GP practices covered intervention should focus mainly on HEALTH SERVICES „„ There was an average of 185 admissions „„ Employment costs, measuring the IN THE WEST MIDLANDS by the 15 CCGs in the WMCA. It has children and young people and aim to psychiatric inpatient beds per costs of output losses in the local been estimated that about one in four to reduce the impact of Adverse „„ At any given point, around 2% of 100,000 population during 2013/14, economy that result from the damaging adults of a GP’s patients will need Childhood Experiences (CACEs), service users in secondary mental compared with an England average of PROMOTING PUBLIC MENTAL HEALTH effects of mental ill health on people’s treatment for mental health problems such as abuse or neglect. health care will be in mental health 227. Admission rates are influenced by ability to work, are estimated at around „„ Local authorities and CCGs are but there is substantial variation in „„ Health and Wellbeing hubs being inpatient beds. The remaining 98% a range of factors including bed numbers £3.9 billion a year equivalent to investing in public mental health practice sizes and the level of mental developed across the WMCA are will be under the care of community and bed occupancy as well as access 31.5% of total costs. These divide initiatives targeted at the general health needs in each CCG. an important strand of enabling people mental health teams. to community support and supported more or less equally between: (i) population or at specific populations. „„ Primary care plays a central role to access appropriate support as early „„ The West Midlands has lower numbers accommodation. the costs of sickness absence and These include: in any prevention strategy because as possible and these need to be of people in contact with specialist „„ Approximately a quarter of people presenteeism among people with - Training and events to promote of its provision of universal services, complemented by initiatives to engage mental health services than other areas admitted were detained under the 1983 mental health problems who are awareness and tackle stigma for eg, to pregnant women and new with socially disadvantaged groups. of England. Mental Health Act. The rates of detention currently in work; and (ii) the costs the general public, front line services mums, sexual health and screening „„ The benefits of early intervention (EIP) „„ In the WMCA, the average spend have been increasing nationally for the of worklessness among those unable and employers, including Mental services, as well as approaches for young people with a first onset on specialist mental health services past 20 years and this is reflected in the to find employment because of Health First Aid for people with long-term physical of psychosis are wide ranging and is £164 per head of population, with figures for the WMCA. In 2014/15, the their mental health condition. - Perinatal and parent/infant health health conditions, and there may be the West Midlands was a pioneer a range from approximately £110 to average rate of detentions was 81.2 per „„ Human costs, representing a monetary and mental health programmes opportunities to strengthen these in implementing early intervention £220, compared with an England 100,000 population, slightly above the estimate of the less tangible but - Parenting programmes, including at a practice level. It is not clear services for this group. Such services average of £154. England average of 77.2. In 2015/2016, crucially important adverse impact of programmes targeted at high risk the extent to which this is happening are provided by three of the four main „„ The four main providers are Birmingham people from Black British/Black/Mixed mental ill health on people’s wellbeing families at practice level or being promoted specialist mental health Trusts and and Solihull Mental Health NHS and British Asian/Asian/Mixed Asian and quality of life, are put at just over - School-based mental health promotion by CCGs. Forward Thinking Birmingham, and Foundation Trust; Black Country together constituted 42% of people £5 billion a year, accounting for and prevention programmes, such „„ There is no single model or agreement the service provided by Worcestershire Partnership NHS Foundation Trust; detained under the MHA and this is 40.5% of the total. This is based on as anti-bullying about what good primary mental health Health and Care NHS Trust has Coventry and Warwickshire Partnership above the expected rate. an estimate of the total number of - Workplace interventions, such care looks like across the WMCA. been identified as positive practice. NHS Trust; and Dudley and Walsall „„ The four NHS Trusts provide a broad quality-adjusted life-years (QALYs) as healthy workplace programmes However, several CCGs are in the „„ Access and waiting time standards Mental Health Partnership NHS Trust. range of outpatient and community that are lost each year as a result of - Targeted initiatives for at risk groups, process of redesigning primary care for EIP services were introduced in Specialist mental health services are also services. Their focus is largely on people mental health problems. including social and community mental health services to strengthen 2015/16 by NHS England and data commissioned from South Staffordshire with a severe mental health condition: „„ The human costs of mental ill health in activities for people from Black and mental health provision in primary on performance against this target and Shropshire Mental Health Trust and early intervention teams; intensive home the WMCA are estimated at just over Asian communities to raise awareness care, early intervention and access is only starting to become available from Worcestershire Health and Care based treatment teams; crisis response £5 billion a year. This is based on of mental health and wellbeing, provide to specialist support. and is not, as yet, comprehensive NHS Trust for residents of Bromsgrove, teams; generic community mental health an estimate of the total number of peer support and promote access for the WMCA. Redditch and Wyre Forest. Forward teams; recovery and wellbeing teams, quality-adjusted life-years (QALYs) to services Thinking Birmingham provides mental enabling daily living, problem-solving that are lost each year as a result of - Tackling violence and abuse, often health services for children and young and coping skills; and assertive mental health problems. through responding to domestic people up to the age of 25. The four outreach teams. violence and abuse main providers have come together to 8 Mental Health in the West Midlands Combined Authority Mental Health in the West Midlands Combined Authority 9

„„ There were a total of 1,284,255 contacts „„ The implementation of personalisation Advice. Such organisations vary in size „„ Housing First, Individual Placement a joined-up approach can save money with community teams in 2014–2015, varies across the WMCA, with and capacity. The types of services INITIATIVES TO and Support and personal budgets and provide a better service to people but the figures on their own do not Warwickshire having the highest rate provided across the WMCA by the third have all been identified as supporting who use mental health services. enable an understanding of the for its use of direct payments and sector include: PROMOTE GOOD recovery because their starting point is relationship between need, referrals and Birmingham for personal budgets. – Well-being hubs and open access accommodating support to individuals, EMPLOYMENT service location or the extent to which There are other Local Authorities, services MENTAL HEALTH rather than vice versa. health and social care needs were met. specifically Walsall and Staffordshire, – Advocacy, both statutory and „„ There are strong links between „„ A mismatch between estimated need where implementation of direct payments non-statutory advocacy to enable HOUSING employment and mental health. and provision has been highlighted for and personal budgets is appearing to be people to have a voice and greater ARE AT RISK OF The DWP-funded Work Choice specialist community perinatal mental lagging behind. choice and control AUSTERITY MEASURES „„ Over 75% of the 1,144,050 homes in Programme for people with mental health health services, with better outcomes „„ There are approximately 420,000 – Carers’ support groups and events the WMCA are either in the private problems has providers in Sandwell, for women of white ethnicity than carers in the WMCA and this figure is to promote their wellbeing BEING TAKEN BY LOCAL rented sector or owned by individuals. Solihull, Coventry, Birmingham, Dudley for women from BAME communities. increasing. The Care Act 2014 placed – Counselling, including bereavement AUTHORITIES Housing Associations, charities and the and Walsall. Employment support, often „„ Organisations in the WMCA have been a duty on Local Authorities to assess counselling and trauma-focused local authorities own over a quarter of a combined with volunteering opportunities pioneers in developing innovative models and provide support to carers in their counselling, IAPT services and million homes, providing social housing and welfare advice, is frequently provided of care and this includes mental health own right. A recent review of this Care stress and anxiety management QUALITY OF LIFE FOR PEOPLE WITH or supported housing for people with by the voluntary sector, sometimes in primary care; early intervention; Act duty found that the implementation courses; A DIAGNOSIS OF MENTAL ILLNESS particular needs. The majority of funded by the Local Authority or CCG. home treatment; street triage; Rapid was poor, with the majority of carers – Creative sessions: art, writing housing provision (out of a care or „„ The international evidence base for Assessment, Interface and Discharge. unaware of their rights. The review and music „„ People with a diagnosis of severe mental hospital environment) is in the form of supported employment, including The WMCA provides an opportunity to highlighted the need to ensure that – Horticulture/conservation/sports illness have a much shorter life supported housing or floating support Individual Placement and Support (IPS), scale these up across the area, and to all social workers and assessors are projects, for example, football expectancy than the population average for those in general needs housing. is very encouraging particularly in reduce variations in access and uptake of appropriately trained, and reflect the targeted at men who would not and high priority should be given to „„ There has not been a strategic enabling people to find jobs more well evidenced interventions. wellbeing principle in assessment ordinarily access mental health addressing this inequality. assessment of mental health needs and quickly to stay in employment for longer, and care and support planning. services „„ Recovery-focused approaches to mental housing and this has not been and in reducing health service costs. LOCAL AUTHORITY – Community development workers health care require a different relationship considered in any detail within the JSNAs. „„ There are currently eight providers of IPS THE THIRD SECTOR to increase engagement with between service providers and service „„ The Local Housing Allowance cap on the in the WMCA, five of which have been „„ The majority of mental health-related particular groups users and Recovery Colleges are amount of housing benefit that can be rated as good or excellent by the Centre spending on mental health by Local „„ The third sector, often referred to – Welfare rights advice, including identified as central to leading this claimed means that there is a substantial for Mental Health in terms of fidelity Authorities is on accommodation as the voluntary sector, comprises benefits, debt and housing; transformation. There are two out of shortfall between the rent for supported to the model. services. Local Authorities also provide charities, social enterprises, and – Recovery-oriented courses a total of 36 listed for England in the housing schemes and the amount social work services and commission community groups, which are typically and workshops WMCA: in Sandwell and Walsall. which will be funded. The delay on the a broad range of mental health services driven by a social mission, are close – A wide range of employment However, Birmingham and Solihull introduction of this cap is adversely from the third sector. The role of social to and have expertise in communities, support Mental Health NHS Foundation Trust impacting upon the development of work in adult mental health includes and involve service users and – A range of support with housing introduced a Recovery College in supported housing and, if introduced, ensuring eligible people can access local people in their governance including accommodation, floating summer 2016 and the Forward will mean that 41% of all schemes will social care resources, including direct arrangements. It occupies a specialist support to enable people to Thinking Partnership, Birmingham, become unviable. payments and personal budgets, niche within a wider ecosystem of maintain their independence, while is also developing a Recovery College „„ In the WMCA, 74% of adults who are in and acting as Approved Mental Health mental health support, reflecting the ensuring that their mental health for young people up to the age of 25 contact with secondary mental health Practitioners, alongside other mental marked involvement of current and needs and daily living skills are to enable them to continue with services and on a Care Programme THE INTELLIGENCE health professionals, and in building former service users. being addressed their studies. Approach (CPA), live in stable and community capacity. „„ This report does not do justice to the – Mental health awareness training „„ Peer support is now widely recognised appropriate accommodation. This ON WHICH TO DEVELOP „„ The Care Act 2014 placed a duty wealth and diversity of the third sector including Mental Health First Aid as helpful in promoting wellness and compares favourably with an England on Local Authorities to promote across the WMCA in relation to mental and suicide prevention training empowerment, with many voluntary and average of 59% but there are some A STRATEGIC wellbeing, physical and emotional, health. This requires further work community organisations encouraging outliers, and it would be useful to identify when carrying out their duties to better understand the sector's Funding sources for these services peer support. The CQC, however, found how to improve their performance. APPROACH TO (Department of Health, 2014). contribution. Third sector services include: CCG and Local Authority that only about half of those people who „„ There is a general dearth of research „„ Increasing thresholds for eligibility, serving individuals with mental health funding; charitable donations; income- felt they would benefit from peer support into housing models for people with MENTAL HEALTH reflecting reductions in Local Authority problems are provided by: specialist generation activities; and awards from were offered it. Many third sector mental health problems. However, budgets, may mean that many people mental health organisations, for example national grant-making bodies, such organisations are organised around promising evidence for improved health IN THE WMCA simply are not getting the support they Mind; organisations primarily concerned as the Big Lottery and Comic Relief. peer support or provide a range of and social outcomes as well as need, with the responsibility for providing with social issues, such as domestic The third sector brings in additional peer support, and there is a wide range economic benefits, is emerging for care shifting to informal carers. violence, for example Women’s resources from various sources external of initiatives in the WMCA including Housing First. Housing First services IS NEITHER „„ During 2014/15, approximately 4,380 Aid, or homelessness, for example St to the WMCA, either on its own or Hearing Voice in West Bromwich; are provided for people who are people (18–64) received Local Authority Mungo’s; those primarily concerned with as a partner with other organisations, BGLAD (Birmingham Gays and sleeping rough and facing multiple COMPREHENSIVE funded Mental Health Support in the a client group, for example SignHealth including the statutory sector. Lesbians against Depression) and First exclusions in Birmingham, Solihull, WMCA: 12.3% received a direct for Deaf people; or with a community, for „„ The short-term nature of much of this Person Plural for people identifying with Coventry and Stratford-upon-Avon. NOR COORDINATED payment and 25% a managed personal example organisations providing services funding potentially jeopardises the complex dissociative identity disorders in „„ There is an active Health, Wellbeing AND THIS HAMPERS budget. The use for mental health to African-Caribbean, South Asian or activity of the third sector and there are Wolverhampton; those provided by the and Housing Group, whose aim is to clients is substantially lower than asylum seekers and refugees; and concerns about the impact of Local six local Mind organisations (Birmingham, promote further partnership working STRATEGIC DEVELOPMENT for other client groups. universal services, such as Citizen's Authority austerity measures. Coventry and Warwickshire, Dudley, Mid between Housing Associations, the AT BOTH A LOCAL AND Staffs, Solihull and Springfield Mind in NHS and local authorities based on South Warwickshire); and Kaleidoscope evidence, from their work to date, that WMCA WIDE LEVEL Plus, in Sandwell. 10 Mental Health in the West Midlands Combined Authority Mental Health in the West Midlands Combined Authority 11

THE MENTAL HEALTH RECOMMENDATIONS 6. A strategy for public mental health 12. Commissioners across the WMCA OF CHILDREN AND needs to be developed for the should aim to reduce the rate of Out YOUNG PEOPLE NEEDS „„ In order to develop a strategic WMCA. Any strategy to improve of Area placements by developing approach to promoting mental health the mental health of the WMCA appropriate local provision and TO BE A PRIORITY, across the WMCA, the following population has to invest in the mental strengthening investment in recommendations are made based health of children and young adults community based services, including on our appraisal of costs and and this will prove to be cost- crisis and recovery houses. provision across the area: effective. This includes attention to parental mental health 13. The evidence for personalised 1. The intelligence for developing a and substance misuse. approaches that give people greater strategic approach by the WMCA choice and control align with what is under developed and the overall 7. There is not a shared understanding service users and carers are asking quality – and indeed availability - of what good primary mental health for and are supported by evidence AS INTERVENTION of current Joint Strategic Needs care looks like and different models that indicates that they lead to better Assessment is very variable. An are emerging across the WMCA. outcomes. Local Authorities should „„ In the WMCA, the average employment the mental health trusts IN THE EARLY YEARS intelligence hub to bring together Identifying the components of good identify action to increase the use rate for people on the CPA was – Prison in-reach teams provided local data to provide mental health primary care mental health would of direct payments and personal 10%, above the England mean of 7%, by the mental health trusts HAS BEEN SHOWN systems intelligence across the facilitate a coherent approach across budgets. but there was considerable variation – Support for prisoners ‘through WMCA should be developed. the WMCA and ensure that the full between the CCGs, ranging from 4–22%. the gate’ TO REDUCE MENTAL potential of primary care is maximised 14. A comprehensive audit of housing „„ There are initiatives underway to promote 2. The approach to intelligence and to support people with mental health provision to support people with health and wellbeing at work. OVERALL ASSESSMENT HEALTH PROBLEMS monitoring needs to encompass problems, including people with mental health problems would both quantitative data on access and co-morbid physical health problems. enable the West Midlands Mental CRIMINAL JUSTICE SYSTEM „„ A considerable investment in mental IN ADULTHOOD outcomes and fine-grained qualitative Health Commission to further health is being made across the WMCA data to understand the real life 8. Organisations and communities investigate the range of provision „„ Offenders and ex-offenders are at and this report provides a starting point adapting the best available evidence. experience of people with mental in the WMCA have pioneered and develop a strategic approach to increased risk of poor mental health for discussion about how well this is Projects designed to strengthen public health problems, their preferences innovative approaches in mental housing and mental health, building and people leaving prison are at an currently deployed. mental health are often short-term for support and the outcomes they health that have been adopted on the emerging evidence for increased risk of suicide and self-harm. „„ If the high costs of poor mental health or at risk of austerity measures. are seeking to achieve. outside the area. There are also Housing First. Persistent offenders are likely to have are to be substantially reduced, the „„ Primary care has a key role to play and examples of promising practice experienced severe and multiple mental health of children and young there are interesting developments at a 3. Co-production should be a where the evidence is incomplete. 15. The wider adoption of high quality disadvantage. Poor mental health and/ people needs to be a priority, both for local level but, as yet, there is no agreed foundation for mental health service Where this is the missing, the Individual Placement and Support or substance abuse increases the risk its immediate benefits and because vision of what good primary care looks transformation across the WMCA evaluation of such initiatives will services should be encouraged. of re-offending, strengthening the case intervention in the early years has been like for the WMCA. and will help ensure that accessible, be an important strand in for effective mental health support, shown to reduce mental health „„ The implementation of promising acceptable and appropriate services understanding the feasibility 16. This is challenging work, systems are including early intervention, family- problems in adulthood. initiatives, with an evidence base, are commissioned, developed and for scaling up across the WMCA. slow to change and it is not a linear based approaches and increasing „„ There are strong links between is patchy, but the West Midlands delivered to meet the diverse needs process. The key issue going capacity across the criminal justice mental health and socio-economic Mental Health Commission is in a of the WMCA population. 9. There is good evidence for a range forward is to ensure the spread of system to identify and respond to conditions and the risks of experiencing good position to promote the scaling of interventions that have yet to be good practice and build on and poor mental health. poor mental health are not uniformly up of these including: perinatal 4. It is essential to understand the adopted on any scale within the strengthen the positive partnerships „„ Integrated offender management is distributed across the WMCA. mental health support; whole school diversity of the WMCA population, WMCA. The implementation of and collaborations, which are clearly a key operating approach within the „„ The intelligence on which to develop approaches to mental health; targeting in terms of inequalities in outcomes; evidence-based practice needs evident. The Commission should, West Midlands Police area and has a strategic approach to mental health families with experience of Adverse conceptions of mental health; barriers to be understood within the therefore, identify the workforce resulted in the West Midlands being in the WMCA is neither comprehensive Childhood Events; wellbeing at work; to access; and preferences in terms WMCA context and prioritised. development implications for within the lowest top ten areas for nor coordinated and this hampers Individual Placement and Support; of service design and support. This achieving the required reoffending for the last two years. strategic development at both a local Housing First; social and emotional needs to include those who do not 10. There are clear variations in system transformation. „„ There are 12 prisons, including one for and WMCA – wide level. learning in schools; early intervention currently access any support and performance across the WMCA women, in the West Midlands. Gaps „„ Personalised approaches that respond in psychosis; street triage and may be further marginalised by an and the factors influencing both in provision relating to primary care to what people say and what they think expanding IAPT provision to socially emphasis on self-management. This is good and poor performance mental health and counselling have needs to happen, are an important disadvantaged groups. central to ensuring that inequalities are requires investigation and action by been identified with a recommendation strand of effectiveness and could save „„ The third sector promotes an ethos not embedded in the approach of the the relevant organisations to improve that IAPT is introduced to address money. Meaningful co-production and of open door and spirit, often supporting West Midlands Mental Health overall system performance. common mental health needs for co-design of services with local people the most marginalised populations. Commission. people in prison. and mental health service providers There are concerns about the impact 11. There should be a commitment „„ Problems in obtaining secure beds are central components of service of budget reductions on this sector in 5. This assessment has identified groups by CCGs and the main mental health for people requiring transfer under transformation but there is a long particular, with valued services having who are at particular risk of poor providers, supported by achievable the Mental Health Act have also been way to go to embed this approach as to be cut or no longer commissioned. mental health and who may be action plans, to reduce the overall highlighted along with a lack of a golden thread in the transformation „„ There is variation between CCGs and in contact with a range of public rate of detentions under the Mental capacity for prison staff to attend of mental health in the WMCA. Local Authorities in terms of the range services, with effort duplicated Health Act and particularly those of relevant training. „„ The approach to public mental health of provision and performance on between them. Improving coordination people from BAME communities, „„ Initiatives in the WMCA to provide and prevention requires strengthening. national performance indicators. and partnership working for these and the use of seclusion and support include: Overall, there is little evidence of a populations should be a priority. restraint. – Criminal Justice Liaison and strategic approach to public mental Diversion Teams provided by health and prevention, utilising the 12 Mental Health in the West Midlands Combined Authority Mental Health in the West Midlands Combined Authority 13

„„ Commissioning for prevention THE AIMS AND SCOPE OF interventions in a broad range of areas. Introduction and quality THIS PROJECT Additional material relating to the costs of „„ Good quality care for all, seven days mental ill health, and promising initiatives a week Against this policy background the West in mental health was also identified from „„ Innovation and research to drive Midlands Mental Health Commission was analysis of key national reports and change established in September 2015 to identify databases (eg, Black Mental Health; The University of Birmingham’s Health communities and local organisations can „„ Services that people receive being of „„ Strengthening the workforce the contribution that the WMCA could Cochrane Collaboration; Crisis Care Services Management Centre (HSMC), promote public mental health and better the highest quality and in which they „„ Transparency and a data revolution make to addressing poor mental health Concordat; Joseph Rowntree in partnership with the Centre for Mental work together to prevent poor mental can have confidence „„ Incentives, levers and payments and wellbeing for adults of working age. Foundation; King’s Fund; Local Health, was commissioned by the West health and provide an efficient and effective „„ Fewer people experiencing stigma „„ Fair regulation and inspection The brief for this project, defined by the Government Association; Mental Health Midlands Combined Authority (WMCA) response to people experiencing mental and discrimination West Midlands Mental Health Commission, Foundation; National Institute for Health Mental Health Commission to undertake health problems, and enable them to realise The 5YFW for mental health makes clear was to identify: and Social Care; National Survivor User a baseline assessment of the costs their ambitions and enjoy a good quality of This policy direction was subsequently that a robust governance framework needs „„ The costs to the West Midlands of poor Network; and the Social Care Institute for of mental ill health and current service life. Devolution also provides an opportunity reinforced by the priorities set out in Closing to be put in place to implement this five-year mental health, including the costs to Excellence) and reports and evaluations provision across the Authority. The main for the WMCA to look longer term and to the Gap: Priorities for Essential Change programme to transform mental health care. public services, employers, and the from key stakeholders in the WMCA. objective of this report is to provide an combine this with early investment to herald to support the transformation of mental Alongside this, attention has also been paid welfare system as a result of mental ill The aim was to identify both published assessment of the current position in a ‘new dawn’ in mental health and tackle health services (Department of Health, to the commissioning and provision of health; current spending on mental and unpublished material. The analysis respect of the mental health and wellbeing inequalities (Social Mobility and Child 2014). A central ambition is for mental accessible support for children and young health by CCGs and local authorities focused on identifying examples of of adults of working age in the WMCA, Poverty Commission, 2015, p.15). health to have parity esteem of with physical people. A Children and Young People’s in the WMCA; and the overall cost promising current and emergent in order to inform work of the Mental health, providing a central focus for NHS Mental Health and Wellbeing Taskforce of mental ill health to the region; directions to be pursued. Health Commission. POLICY CONTEXT AND THE England2. Parity of esteem means valuing was established in September 2014 and „„ An audit of current statutory sector 2. Calculation of broad estimates of the WEST MIDLANDS mental health and physical health equally the strategy, Future in Mind published in (NHS/Local Authority) and voluntary overall economic and social costs for THE WEST MIDLANDS and ensuring that access to appropriate 2015 (Department of Health, 2015). sector mental health service provision the population of the WMCA as a COMBINED AUTHORITY Mental health has been a policy priority treatment and support, early intervention The focus of this is improving access in the WMCA to describe current consequence of mental ill health, using for successive governments and there has and response in a crisis, as well as to care and treatment for young people community and inpatient services nationally and locally available data. The WMCA covers the geography of three been a sustained concern as to whether inequalities in the life expectancy of people to support them to realise their ambitions. provided for adults and young people Data was sought from Local Authorities Local Enterprise Partnerships (LEPs) – people of all ages experiencing mental with a severe mental illness are addressed. and current performance against and CCGs using a bespoke audit form Black Country, Coventry and Warwickshire, health problems are getting the right help It also means that reducing inequalities in These priorities are reflected in the key mental health indicators; to provide detail on expenditure for and Greater Birmingham and Solihull, and support at the right time to support their the levels of resourcing for mental health 2016/2017 CCG performance framework, „„ An audit of current or planned initiatives 2014/15 (see Appendix 1). However, which currently covers 12 councils (seven health and wellbeing. ‘No health without services compared with physical health which includes five indicators for relating to mental health, whether public, as the response was extremely patchy metropolitan and five district councils, mental health’, a cross-government mental services should be a strategic priority. To mental health3: private or voluntary sector to include and incomplete, use was made of NHS within 3 County Councils with a further health strategy published under the promote parity with treatment for physical „„ IAPT recovery rates crisis care; housing and housing related programme budgeting data available five awaiting membership) and 15 Clinical Conservative-Liberal Coalition, made it clear health conditions, two access and waiting „„ People with first episode of psychosis support; employment; recovery colleges; to identify CCG expenditure, for Commissioning Groups (CCGs), some of that mental health is everyone’s business time standards were introduced in April starting treatment with a NICE- service user engagement, and 2013/14 and published data on which have shared arrangements for mental (HM Government, 2011). The strategic 2015 for mental health (Department of recommended package of care treated prevention and promotion. Personal Social Services Expenditure health commissioning with other CCGs or objectives were focused on: Health, 2014), so that: within two weeks of referral and Unit Costs for Councils in England with the Local Authority. The core of the „„ More people having good „„ 75% of people referred to the „„ Children and young people’s mental While recognising that the mental health for 2014/15 for spending by Local WMCA is the seven metropolitan councils, mental health Improving Access to Psychological health services transformation of children and young people is of Authorities. Where local cost data which are Birmingham City Council, City „„ People with mental health problems Therapies (IAPT) programme will be „„ Crisis care and liaison mental health fundamental importance in shaping mental has not been readily available, other – of Wolverhampton Council, Coventry City having a good quality of life with treated within 6 weeks of referral, and services transformation health in adulthood, the scope, determined usually national – sources have been Council, Dudley Metropolitan Borough an emphasis on stronger social 95% will be treated within 18 weeks „„ Out of area placements for acute mental by the Mental Health Commission, is adults drawn upon, and estimates for the Council, Sandwell Metropolitan Borough relationships, employment, stable of referral health inpatient care transformation of working age in the area covered by the West Midlands have been produced by Council, Solihull Metropolitan Borough housing and greater ability to control „„ More than 50% of people experiencing three LEPs. It is also important to recognise making adjustments for such factors as: Council and Walsall Council. Together their own lives a first episode of psychosis will be These policy developments reinforce that that interventions in early and mid-adulthood (i) relative population size; and (ii) these cover approximately 70% of the „„ Ensuring that people with mental treated with an evidence based care mental health is a priority for the NHS. They can also impact upon the prevalence of differences in the prevalence of mental population of the three LEPs. The health problems do not die prematurely package within two weeks of referral do, however, need to be set within a wider mental health disorders for older adults, health problems in the WMCA WMCA also covers Sustainability and and have good physical health context of changes to public services, and including dementia (Heginbotham and compared with the national average in Transformation footprints for Black Country, „„ More people having a positive In March 2015, NHS England established in particular the impact of austerity Newbigging, 2013). the population of working age. In one or Birmingham and Solihull, Coventry and experience of care and support, an Independent Mental Health Taskforce measures on Local Authority budgets, two cases, most notably criminal justice, Warwickshire and parts of Staffordshire, access to timely, evidence-based to develop a five-year strategy for mental which combined with shifting eligibility METHODS important methodological problems Herefordshire and Worcestershire interventions and approaches that health and its report, The Five Year Forward criteria will impact adversely on access to remain unresolved, eg, the exact footprints, established to deliver the give people the greatest choice and View (5YFW) for Mental Health, was services and the range of support available. In summary, this has involved: relationship between offending and Five Year Forward View1. control over their own lives, in the least published in February 2016. This sets out 1. A rapid appraisal of the literature mental health, and in these cases the restrictive environment, and should 57 recommendations, requiring cross- starting with the Centre for Mental best approach may be to offer a range Devolution provides an opportunity to ensure that people’s human rights government action and multi-sector Health publications that have distilled of illustrative figures based on different better understand how public services, are protected collaboration, under the following themes: the evidence on effectiveness and assumptions. cost-effectiveness for mental health

1 www.england.nhs.uk/wp-content/uploads/2016/02/stp-footprints-march-2016.pdf 2 www.england.nhs.uk/mentalhealth/parity 3 www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2016/03/ccg-iaf-mar16.pdf [accessed 150816]. 14 Mental Health in the West Midlands Combined Authority Mental Health in the West Midlands Combined Authority 15

3. An audit of current public sector (NHS/ the WMCA and the quality of local mental Local Authority) and voluntary sector health needs assessments is variable and THERE ARE STRONG Mental health of the West Midlands mental health service provision using: differs in format. While a mental health a bespoke audit form (see Appendix 1); needs assessment was outside our brief, data in the public domain (eg, Health we have provided a brief overview in order LINKS BETWEEN and Social Care Information Centre4; to contextualise the expenditure and data Combined Authority Mental Health Minimum Data Set on provision. Finally, despite support from (MHMDS); Public Health England the Commission’s Steering Group, Public MENTAL HEALTH Fingertips Tools; and Adult Social Health England West Midlands and AND SOCIO-ECONOMIC CONDITIONS. POPULATION the task is sustaining this; the population Any survey of the household population Care Outcomes Framework (ASCOF); Birmingham Mind, some organisations have at risk where the focus becomes reducing is likely to understate prevalence, as and data made available by the NHS been slow to respond or have not provided OVER HALF OF THE There are an estimated 4,032 million avoidable risks; the population with people with psychosis and alcohol Benchmarking Network. These sources the necessary information. Feedback people living in the Combined Authority symptoms and where the need is to dependence are more likely to be have been analysed to identify current suggests that the timing of this exercise, area (2014/15 data) corresponding ensure early identification and intervention; homeless or reluctant to answer questions. community and inpatient services coinciding with the end of the financial POPULATION OF THE to 70.5% of the population in the West and the population with a diagnosed mental provided for adults and young people year and the introduction of Sustainability Midlands Region, 7.4% of the population disorder for whom the focus is on optimal There are strong links between poor mental in the NHS and current performance and Transformation Plans (STPs) for the WMCA IS LIVING in England and 6.2% of the population management and support to promote health, smoking, alcohol and substance use. against mental health indicators. Where NHS, was problematic. However, it may in the UK. The population is projected recovery and inclusion (as depicted People with mental health problems are data from local sources is reported, also indicate a lack of awareness and IN THE 20% MOST to increase by 8% by 20306. Sixty four in Figure 1). more likely to smoke (McManus et al., 2007) efforts to validate this have been made. understanding of, or resistance to the per cent of the population of the WMCA and most people using substance misuse 4. Documentary analysis of key strategic aims of the Commission. DEPRIVED AREAS are adults of working age, aged 16–65 PREVALENCE OF MENTAL HEALTH services have mental health problems, plans and evaluation reports and a small (Appendix 2). Overall, the population of PROBLEMS IN WMCA with co-morbidity being highly prevalent in number of scoping interviews to identify Intelligence about the local system is vital IN ENGLAND the WMCA is culturally diverse and in the community mental health team populations promising initiatives. to developing a strategic plan. There is 2011 Census people from Black, Asian and The National Psychiatric Morbidity Survey (Weaver et al., 2003). In the West Midlands a site hosted by Public Health England's Minority Ethnic (BAME) communities made identified 23.8% of all adults in the West in 2014/15, approximately a fifth of people The work was undertaken from January Knowledge and Intelligence Team (West up 22% of the total population, compared Midlands Region with some kind of mental in contact with mental health services were to July 2016 and provides a rapid appraisal Midlands), which provides health profiles The material on promising practice makes with an average of 20% for England and health problem, compared with 23.0% in also in contact with alcohol (23.4%) and/or Figure 1: A population perspective to improving mental health (Heginbotham and Newbigging, of the current situation, and was limited by for the Local Authorities within the WMCA no claims to comprehensiveness but Wales7. However, the overall figure, England as a whole (McManus et al., 2009)9. substance misuse services (18.5%)10. 2013 adapted from Barry and Jenkins, 2007) the time and resources available. There have and mental health-specific information provides an indication of the breadth of obscures important demographic variations been additional challenges in undertaking is available via the Fingertips Tools and activity and highlights variations in provision. across the WMCA with some Local this work. First, there are different the National Mental Health, Dementia and It raises important considerations for a Authorities having a substantially higher jurisdictions and configurations for public Neurology Intelligence Network, sponsored strategic approach by the West Midlands percentage of people from BAME service delivery in the Combined Authority by NHS England5. This provides a basis Mental Health Commission. First, while communities. For example, Birmingham’s area. Second, there are also different to develop an intelligence hub to bring the research evidence points to promising population, which constitutes a quarter of understandings concerning the focus of the together local data to provide systems interventions, it is clear that their the overall WMCA population, has 42% of WMCA and whether it is solely concerned intelligence across implementation in a WMCA context its residents from an ethnic group other than with the constituent members (ie, the seven the WMCA. is patchy, for reasons that are not always White British8 (and a younger profile than metropolitan councils), includes the clear. Second, the available research the English average) in comparison with non-constituent members or is wider THIS REPORT evidence never provides the full story 2.3% for Cannock Chase and 2.7% for to encompass the areas covered by and there are examples of innovations Stratford-upon-Avon and Tamworth. None three LEPS, recognising that the wider This report provides a baseline of costs, and promising initiatives that are being of the population groups are homogenous partnership with business through the LEPs service provision and initiatives across the developed but have yet to be scaled up and understanding differences within and with neighbouring councils will be WMCA. Our hope is that it provides a living or evaluated. Third, the implementation population groups is important for critical to the success of the WMCA. document for the West Midlands Mental of promising practice raises questions developing approaches to improving the Our brief was to undertake an analysis for Health Commission and its partners to about fidelity to the model and the role mental health of the population (see for this wider area but other key organisations, develop further. The report is organised of contextual factors, particularly example: Newbigging, Bola and Shah, for instance Public Health England West in three sections, which: (1) provide in a context of co-production. 2008) and ensuring that inequalities are not Midlands, have adopted a narrower an overview of mental health in the WMCA; embedded in the development of a strategic definition. Third, there has not been an (2) identify the social and economic costs approach by the West Midlands Mental analysis of the mental health needs across of mental ill health in the WMCA; and (3) Health Commission. provide an overview of current service provision and identify current and emerging In order to conceptualise the mental health Figure 1: A population perspective to improving mental health

promising practice. Inevitably, the service of the WMCA population it is useful to (Heginbotham and Newbigging, 2013 adapted from Barry and Jenkins, 2007) This report provides a baseline data presented in this report is skewed distinguish between: the general population of costs, services provisions and towards specialist mental health provision who have good mental health and for which because this data is most readily available, initiatives across the WMCA. whereas that relating to primary

care is relatively scant. 6 See the Projecting Adult Needs and Service Information tool. Available at: www.pansi.org.uk/index.php?pageNo=407&PHPSESSID=315v74tec3qjl1tbhfmc73ipb5&sc=1&loc=8653&np=1 [accessed 141016]. 7 www.ons.gov.uk/ons/rel/census/2011-census/key-statistics-for-local-authorities-in-england-and-wales/rft-table-ks201ew.xls [accessed 161016]. 8 As above 9 The results of the 2014 survey was published in September 2016 and available at: http://content.digital.nhs.uk/catalogue/PUB21748 [accessed 161016]. 10 4 NHS Digital is the new name for the Health and Social Care Information Centre. See https://digital.nhs.uk [accessed161016].  http://fingertips.phe.org.uk/profile-group/mental-health/profile/drugsandmentalhealth/data#page/0/gid/1938132791/pat/6/par/E120000 05/ati/102/are/E08000025 [accessed 150816]. 5 www.youtube.com/watch?v=c1ZqRmK4DXk [accessed 150816]. 16 Mental Health in the West Midlands Combined Authority Mental Health in the West Midlands Combined Authority 17

20 In the West Midlands, in 2015, there were health problems, including diagnostic 477 deaths recorded as suicide, which at overshadowing; and barriers to accessing THE RISK OF EXPERIENCING 18 9.6 deaths per 100,000 population is lower healthcare including screening (Jones et al., POOR MENTAL HEALTH ARE NOT 16 than the rate for England at 10.911. The rate 2008; Lawrence and Kisely, 2010). for men in the West Midlands was 15 UNIFORMLY DISTRIBUTED ACROSS 14 deaths per 100,000 population, slightly FACTORS INFLUENCING IN 2015 THERE WERE 12 lower than the England average but more MENTAL HEALTH THE WMCA. THERE ARE LINKS All 10 than three times higher than for women at BETWEEN INSECURE HOUSING, Men 4.1 deaths per 100,000, broadly in line with There are a wide range of factors 8 Women national trends. As illustrated in Figure 2, influencing mental health. Social, economic FINANCIAL STRESS, AND MENTAL 477 DEATHS Rate per 100,000 there is a slight downward trend for women and physical environmental influences HEALTH AND CHILD DEVELOPMENT RECORDED AS SUICIDE WITH 6 but an upward trend for men in the number have been shown to be critical, with social 4 of suicides reported from 2010 to 2013, inequalities increasing the risk of many but figures for 2015 point to a slight common mental health problems (WHO distribution were identified as having severe MEN MORE THAN 2 decrease in the rate for men and and the Calouste Gulbenkian Foundation, mental health problems compared with only 0 an increase for women. 2014). From a life course perspective, 4% among those from families in the top 2010 2011 2012 2013 2014 2015 there are risks associated with the inter- fifth. This income-related gradient is much THREE TIMES Socio-economic inequalities in suicide generational transmission of inequality steeper among children than it is among MORE LIKELY TO KILL Figure 2: Rates of deaths by suicide per 100,000 population in the West Midlands risk are evident. A thematic review by the and increased risks of poor mental health. adults and appears to have become steeper (Source: ONS Suicides in the United Kingdom, 1981-2001) Samaritans identified that middle-aged men in recent years (Gutman et al., 2015). THEMSELVES THAN WOMEN in lower socio-economic groups are at The WMCA covers areas of affluence Another recent review of the evidence has particularly high risk of suicide (Wyllie et al., as well as those with significant socio- concluded that austerity measures, which differences in alcohol and substance abuse parents’ (Heginbotham and Newbigging, understanding populaion characteristics 2012). The research evidence indicates economic deprivation and this is reflected have hit poorer people the hardest, have (and suicide) which more adversely affect 2013). However, the causation also runs that may increase vulnerability to poor a complex interplay of factors including in the prevalence data. Eight of the councils damaging psychological consequences, men more than women. the other way, ie, mental ill health leads to mental health. unemployment and economic hardship, have indicators of socio-economic including humiliation and shame; fear and deprivation, eg, because it prevents people lack of close social and family relationships, deprivation that are lower than the average distrust; instability and insecurity; isolation Alternative explanations for these from working. This phenomenon, sometimes 1. Children and young people Mental health restricted notions of masculinity and for England, while over half of the WMCA and loneliness; and feeling trapped and differences point to the differences in social termed social drift, is particularly evident problems in childhood reluctance to access formal support, population is living in areas, which are powerless (McGrath et al., 2015: 1). contexts for women’s and men’s lives: for people with a diagnosis of severe Mental health problems in children and personal crises such as divorce, as well among the 20% most deprived areas in women are more likely to be single parents mental illness. young people can be long-lasting and 50% as a general 'dip' in subjective well-being England namely: Walsall, Wolverhampton, Figure 3 provides an illustration of the and to have experiences of domestic of mental illness in adult life (excluding among people in their mid-years, compared Sandwell (Black Country) and Birmingham relationship between diagnosed condition14 violence, sexual abuse and discrimination POPULATIONS AT RISK OF POOR dementia) starts before age 15 and 75% by with both younger and older people (Wyllie (Greater Birmingham), which constitute and gender and household quintile15 or harassment in the workplace, while MENTAL HEALTH the age 18 (Department of Health, 2013a: et al., 2012). Furthermore, there is emerging part of the core of the WMCA. In these income, from the 2014 Health Survey. men may face unemployment, relationship 177). As outlined in the Chief Medical evidence that this has been exacerbated areas nearly 30% of children are living in They provide a stark illustration of the breakdown and are generally less keen to The message that one in four of the adult Officer’s report for 2012, there are strong by the current post-2008 economic crisis low income households and rates of relationship between household income and seek help and support, as noted before. The population will experience a mental health associations with socio-economic (Wyllie et al., 2012). overcrowding are higher than the average both diagnosis and the type of mental health correlations between Adverse Childhood problem in any given year is now widely deprivation with both mothers and children for England (see Appendix 2). The Social condition. From the 2014 Health Survey Events (ACEs) and poor mental health in promoted and forms an important strand at increased risk of psychological problems People experiencing a severe mental illness Mobility and Child Poverty Commission 22% of women and 12% of men in the adult life are well established, as discussed of shifting the stigma around poor mental and poor general health (Department have a much lower life expectancy than (2015) recently highlighted the links highest income quintile (ie, 20%) reported below, and there is increasing evidence that health19. However, as observed above, the of Health, 2013a). average, with a mortality rate, more than between financial stress, mental health ever being diagnosed with a common the links between childhood sexual abuse risks of developing a mental health problem, three times higher than the general and child development, which influence life mental disorder compared with 4% of and psychosis is particularly strong, as and the nature of that problem, are not This underlines the importance of a life population12. They are four times more chances and social mobility. Gutman et al., women and 7% of men ever diagnosed well as other mental health problems equally distributed across the population. course approach and the early years as likely to die from diseases of the respiratory (2015) using data from the Millennium with a serious or complex mental illness16. (Bebbington et al., 2011). Homogenising the risks in this way may being a critical opportunity for intervention system and digestive system, and two and cohort study, identified that the prevalence For those in the lowest income quintile, result in further inequity. As well as the risks to promote good mental health. Any strategy a half times more likely to die from diseases of diagnosable mental health problems 39% of women reported being diagnosed The relationship between deprivation above, specific populations that are at risk to improve the mental health of the WMCA of the circulatory system13. This reflects in children is strongly related to parental with a common mental disorder and 10% and prevalence is also highlighted by Joint for poor mental health and where access population has, therefore, to address the a variety of influences, including lifestyle education, parental occupation and family with a serious17 or complex mental illness18, Strategic Needs Assessments (JSNAs) to appropriate support may be problematic foundations for good mental health in factors; the fragmentation of services; income. In 2012, 17% of 11-year-olds from compared with 23% and 11% of men. that have examined data at a ward level; and, thus, where targeted action should be adulthood by also focusing on children missed or incorrect diagnoses of physical families in the bottom fifth of the income It is important to note that there are gender for example the Solihull JSNA for 2012 considered, are listed below. There will be and young adults (WHO and the Calouste identified that the rates of mental disorder other groups who are not listed below, eg, Gulbenkian Foundation, 2014; Heginbotham are three times more common in North veterans, where attention should be paid and Newbigging, 2013). There is a growing Solihull than more affluent areas. This to their specific needs. There is always a body of evidence for interventions, to analysis emphasises the importance of danger in drawing attention to people as strengthen parenting, develop emotional 11 Suicides in the United Kingdom, 2013 Registration. This rate is differs from the rate given by the National Confidential Inquiry into Suicides and Homicides See understanding the impact of deprivation having specific needs that they are framed and social learning and respond to mental National Confidential Inquiry into Suicides and Homicides by People with Mental Illness: Annual report and 20 year review, October 2016. Available at; http:// on mental health and its differential effect in problematic terms. The West Midlands health problems in childhood and research.bmh.manchester.ac.uk/cmhs/research/centreforsuicideprevention/nci/reports/2016-report.pdf [accessed 051216]. in terms of demographic characteristics. Mental Health Commission need to be adolescence on which to build this. 12 http://content.digital.nhs.uk/article/2543/Mortality-rate-three-times-as-high-among-mental-health-service-users-than-in-general-population This is clearly important in considering the alert to the this and locate the issues in 13 As above. mental health of future generations in the the situated nature and social context 14 Defined as having a diagnosed mental illness if they reported they had ever experienced a condition and had been diagnosed by a doctor, psychiatrist or WMCA: ‘invest in children, start with of people’s life experiences, as well as professional. There were self-reports of a mental health condition, which had not been diagnosed. 15 A quintile means one fifth of the total ie, 20%. 16 Including attention deficit hyperactivity disorder, seasonal affective disorder and any other mental, emotional or neurological condition. 17 Including psychoses, eating disorder, bipolar disorder or personality disorder. 18 Including attention deficit hyperactivity disorder, seasonal affective disorder and any other mental, emotional or neurological condition. 19 www.time-to-change.org.uk/mental-health-statistics-facts 18 Mental Health in the West Midlands Combined Authority Mental Health in the West Midlands Combined Authority 19

Adverse Childhood Events 45 common mental health problems amongst and providing effective services to meet Many studies have identified that the 40 Black/Black British women (McManus their specific needs. PEOPLE FROM BAME Men (condition number of different risk factors (including 35 et al., 2016). There is also evidence that adverse childhood events (ACEs)) that diagnosed) self-harm is now more common among Asylum seekers and refugees 30 COMMUNITIES ARE chidren are exposed to increases the risk young African-Caribbean women, who The most recent statistics indicate that of poor mental health, and their effects 25 Men (condition are also less likely to be receiving help there are 4,45425 asylum seekers on reported but not MORE LIKELY TO BE appear to be mutliplicative rather than 20 (Cooper, 2010). Section 95 living in the WMCA, with diagnosed) additive. This includes including increased Percentage 15 42% living in Birmingham, including incidence of psychosis, substance abuse, Women (diagnosed) People from BAME communities are more 75 unaccompanied minors under Local DISADVANTAGED IN physical health problems and reduced 10 likely to be disadvantaged in accessing Authority care; 19% in Sandwell; 16% in social functioning and increased likelihood 5 enabling forms of support and overall, Wolverhampton; 12% in Coventry; 6% in ACCESSING ENABLING Women (reported of unemployment and risk-taking behaviour 0 people from these communities have Walsall and 5% in Dudley26. Refugees are but not diagnosed) in adulthood (Rosenberg et al., 2007; Highest 2nd 3rd 4th Lowest particularly low treatment rates (McManus people whose asylum claims have been FORMS OF SUPPORT Varese et al., 2012). ACEs include physical, quintile quintile (i.e. et al., 2016). The focus is often on Black/ accepted and the estimates cited in the sexual or emotional abuse; witnessing (i.e.20%) 20%) Black British men: they are five times more Birmingham City Council equity analysis AND HAVE POORER OUTCOMES domestic violence; loss of a parent; parental likely to be diagnosed and admitted indicate there are approximately 35,000 THAN OTHER PEOPLE WHEN substance abuse and/or mental illness. Figure 3: Diagnosis of mental illness by equivalised household income and gender to hospital for schizophrenia; have refugees living in Birmingham, although Specific groups of children and young (Source: Health Survey for England 201420) disadvantageous pathways into mental these estimates are not based on current THEY DO ACCESS SERVICES people may be at particular risk and looked healthcare; higher than expected rates data. In addition, there will be a number after children are such an example; many of detention under the Mental Health Act of people who have no recourse to public of whom may have been exposed to one Nearly two-thirds of children are placed into 2. People from Black, Asian and (MHA) (see the section on specialist mental funds (ie, whose asylum application has in the WMCA (Birmingham, Coventry, of or more of the ACEs mentioned above care as a consequence of abuse or neglect Minority Ethnic communities health services); are more likely to be been denied), and who may be supported Sandwell, Walsall, and Wolverhampton), but whose care under the Local Authority and over a third have had successive BAME communities across the WMCA prescribed medication; and have difficulties by the Local Authority. living in overcrowded conditions is a provides an opportunity for prevention placements because of behavioural are heterogeneous with the 2011 census accessing services and poorer outcomes significant problem, as measured by and early intervention. difficulties or other mental health needs, identifying that residents born in India when they do (Lankelly Chase, 2014). Black Asylum seekers and refugees have the percentage of households with an which are likely to persist into adulthood represent the most numerous non-UK born Caribbean young men are also twice as mental health needs arising from torture, occupancy rating for bedrooms of 1 or Looked after children and young and may be associated with offending group in the West Midlands followed by likely to die as a result of suicide as White persecution and other adverse experiences less. This is highest in Birmingham with people leaving care behaviour (National Audit Office, 2015). residents born in Pakistan, Poland, Ireland, psychiatric in-patients and there have been pre- and post-migration, including 9.06% of households living in one bedroom According to national data from the Research has indicated that children and Jamaica24. However, China is well- a number of deaths of Black men with stigmatisation by the state and racism or less, nearly twice the national average of Department of Education, 60 per 10,000 in care have a higher prevalence of both represented by the student population and mental health problems while in police (Phillimore et al., 2007). Consequently, 4.8% (see Appendix 2). children under the age of 18 are in Local psychosocial adversity and psychiatric most asylum seekers come from Iraq, Iran, custody (Inquest, 2014). asylum seekers and refugees are at Authority care and overall, the number disorder than the most socio-economically Somalia, Afghanistan, Pakistan, Sudan, increased risk of experiencing post- A recent review for the Joseph Rowntree of looked after children is increasing year disadvantaged children living in private Ethiopia, Eritrea, Congo and latterly Syria. The report of an inquiry into ethnic traumatic stress, depression, perinatal Foundation highlighted strong links between on year21. This includes the numbers of households (Ford et al., 2007). In 2010, The intelligence on the mental health needs, inequalities in mental health (Lankelly mental health problems, suicide and poverty and housing circumstances, with unaccompanied asylum seeking children, 25% of people who are homeless had been access to and preferences for the style of Chase, 2014) summarises a number of psychotic disorders with co-morbidity housing costs having a significant impact which increased by 5% between 2013 in care at some point in their lives; in 2008, mental health support is scant, and that contributory factors contributing including: common (Allsopp et al., 2014; Hollander on poverty and material deprivation (Tunstall and 2014 and by 29% between 2015 and 49% of young men under the age of 21 which is available is often skewed towards „„ Social disadvantage, including living in et al., 2016; Allsopp et al., 2014; McColl et al., 2013). Poor housing conditions 201622. The number of children and young who had come into contact with the criminal specific groups, eg, African Caribbean poverty and homelessness & Johnson, 2006). Despite this, asylum affect the mental health and wellbeing of people in Local Authority care at the end of justice system had a care experience; and in men, South Asian women, and this tends „„ Racism, discrimination and harassment seekers and refugees will face barriers to children and adults and the links between March 2016 was 5,233 in the constituent 2014, 22% of female care leavers became to dominate this agenda such that the „„ Higher rates of exclusion from school accessing effective mental health support, homelessness and poor mental health Local Authority members of the WMCA teenage parents (National Audit Office, needs of other groups may be overlooked, for African Caribbean boys which are similar to those experienced by and substance abuse are well established, (ie, the seven metropolitan councils). 2015). Young people leaving care are four eg, Chinese people, asylum seekers „„ Higher rates of unemployment, with other minority communities but may be although there is debate over the direction Data on whether parental mental illness to five times at greater risk of poor mental and refugees or people from the Somali African and Caribbean men and those further further compounded by their of this relationship. Higher levels of mental or substance abuse was the reason for health and Looked After Children and care community, which is the fastest growing from mixed backgrounds 10–20% citizenship status. wellbeing are associated with living children or young people entering care leavers are between four and five times community in Birmingham. more likely to be unemployed in an area perceived to have an attractive is not routinely recorded, but estimates more likely to attempt suicide or self-harm 3. Homeless people and people living in poor peaceful environment and to have a from these Local Authorities, suggest that in adulthood (Department of Health, 2012; The National Psychiatric Morbidity This disadvantage is compounded housing quality housing good reputation; and being satisfied approximately 37% of children and young National Audit Office, 2015). Despite Survey in 2007 and more recently 2014, by mental health services that are not Having a settled home is vital for good with the house and landlord (Bond, people entering care did so because of mental health and emotional wellbeing (McManus et al., 2007; McManus et designed or may be ill equipped to mental health for everyone and for people 2012). Conversely, poor quality housing; parental substance misuse and/or parental being identified as important issues by al., 2016) found little difference in the deal with the diverse needs of BAME with mental health problems it needs to be overcrowding and noise; multiple mental illness (with estimates ranging from young people leaving care, Local Authorities prevalence rates of common mental health communities, compounded by a lack considered as a core element of support occupancy and temporary accommodation; 10% to 64%)23. It is highly likely that if reported that access to mental health problems between minority ethnic groups of trust in public services, language for recovery (NHS Confederation, 2011). lack of choice over housing; high rise the prime reason recorded is abuse or support was problematic (National Audit and the White population. There is, barriers or previous negative experiences In 2014/15, the mean rate of statutory housing and limited access to green spaces neglect, poor parental mental health Office, 2015). however, an increased prevalence of of those services. People from some homelessness in the WMCA was 3.2 per and opportunities for social participation will be implicated. BAME communities experience difficulties 1,000 households, which is higher than the all contribute to poor mental health (as in accessing appropriate support, although national average of 2.4, with the rate ranging summarised by Boardman, 2015). their issues may not be as visible and, from 0.8 in Dudley to 7.4 in Birmingham

20 http://digital.nhs.uk/catalogue/PUB19295 [accessed 150816]. therefore, overlooked in commissioning (see Appendix 2). In five Local Authorities 21 www.gov.uk/government/uploads/system/uploads/attachment_data/file/464756/SFR34_2015_Text.pdf [accessed 150816]. 22As above, see page 5. 23 Specific request to the constituent members of the WMCA and responses indicated that this information may not be routinely recorded and, thus, the variation in the numbers may reflect this. 25 86% of the total in the West Midlands area. 24 http://www.migrationobservatory.ox.ac.uk/resources/briefings/west-midlands-census-profile/ 26 www.gov.uk/government/publications/immigration-statistics-january-to-march-2016/list-of-tables [accessed 150816]. 20 Mental Health in the West Midlands Combined Authority Mental Health in the West Midlands Combined Authority 21

PEOPLE WITH A DIAGNOSIS OF with mental health problems are more likely 6. Lesbian, Gay, Bisexual and Trans people to be sensitive to the negative effects of A recent systematic review identified that MENTAL ILLNESS unemployment and there is no evidence people who identify as lesbian, gay or that work is harmful to people with a bisexual are twice as likely as heterosexual ARE LIKELY TO DIE diagnosed severe mental illness (Royal adults to experience anxiety or depression, College of Psychiatrists, 2008). suicidality and substance misuse and to 12–13 YEARS YOUNGER have lower wellbeing scores (Semlyen 5. Carers et al., 2016). Depression, anxiety, self-harm THAN OTHER PEOPLE Caring for a family member, partner or friend and suicidality are common among Trans with a mental or physical health condition people, amplified by lack of understanding can be difficult, demanding and potentially by mental health services and experiences isolating. People who are informal carers of harassment and misgendering, social may experience considerable feelings exclusion at work, homelessness and of distress. This has been noted in relation relationship breakdown (McNeil et al., to people whose family members are 2012). subject to compulsion, experiencing 8. People with learning disabilities and/or psychosis or dementia and other complex A survey of Wolverhampton’s LGBT sensory impairments mental health problems as well as long- community highlighted significant mental People with learning disabilities, and term physical health conditions (Boydell et health difficulties including an increased people who are deaf, have higher rates al., 2015). The lack of support or ambivalent prevalence of self-harm, suicidal ideation, of mental health problems than the general attitudes towards informal carers from depression and experience of bullying population, with estimates for people health professionals can compound the amongst the LGBT community (LGBT with learning disabilities, from 25–40%28. People who are homeless are typically of health, only 4% of homelessness services experience of distress (Albert and Wolverhampton, 2013). The role of peer Challenging behaviours (aggression, in a poor state of health and homelessness received any investment from the health Simpson, 2015). support in terms of improving outcomes and destruction, self-injury and others) are has been characterised as ‘the silent killer’ sector (Homeless Link, 2014). Whether facilitating access to care pathways and also evident for 10%–15% of people AUSTERITY because the average age of death for this is the case for the West Midlands The 2011 census results indicated that services within the City was emphasised with learning disabilities29, and, homeless men is 47 years old and even merits further inquiry. there were nearly 600,000 carers in the as important in addressing this. consequently they are over-represented lower for homeless women at 43 (Crisis, West Midlands, equating to approximately in the criminal justice system. People 2011). Homeless people are over nine 4. Unemployed people 420,000 in the WMCA. The percentage 7. People with long-term physical with learning disabilities are also vulnerable MEASURES, times more likely to commit suicide than the Unemployment is technically defined of people providing informal care had health conditions to violence and abuse. As with other general population. They are substantially as not working but actively looking for work, increased by 7% between 2001 and Physical and mental health are socially disadvantaged groups, access WHICH HAVE HIT more likely to have alcohol and substance as distinct from economic inactivity, which 2011 (ranging from 3% in Dudley and interdependent and many risk factors to appropriate services has been abuse problems, with studies indicating that is defined as not working and not looking Wolverhampton to 7% in Birmingham, are common to both, including social problematic and people have typically more than half of the population of homeless for work. Becoming unemployed can Coventry and 8% in Staffordshire and determinants of inequalities; abuse; social fallen between mental health services POORER PEOPLE people are dependent on alcohol or drugs have a negative impact on mental health, Worcestershire and 11% in Warwickshire isolation; poor diet; physical inactivity and and learning disability services. (Fazel et al., 2008). It is estimated that the associated with a loss of income, reduced (Carers UK, 2011)). This may suggest barriers to effective health care (Naylor prevalence of common mental health standard of living, loss of social contacts inequalities in accessing support from et al., 2016). 9. Offenders and ex-offenders THE HARDEST, problems is twice as high and 4–15 times and a loss of self-esteem. There were statutory services in more rural locations. The relationship between mental health higher for psychosis for homeless people 121,400 working age adults recorded About 4.6 million people in England with problems and offending is complex, but HAVE DAMAGING (and 50–100 times greater for people who as unemployed across the three LEPs, These figures will include young carers. a long-term physical health problem also the following broad generalisations are are street homeless) compared with the between January and December 2015. In England, estimates indicate there are have a mental health problem, typically supported by the available evidence: general population (Homeless Link, 2014). The average rate was 6.6% of the 16–64 approximately 166,363 young carers, depression or anxiety, and if left untreated PSYCHOLOGICAL As substance abuse problems are also population ranging from 2.9% for the including 9,371 aged between 5- this can intensify their physical health „„ Most crime is committed by young common, it is estimated that 10–20% of the Coventry and Warwickshire LEP to 8.8% and 7-years-old but this will be an problem, leading to worse outcomes males, many with a history of serious homeless population would fulfil the criteria for the Black Country LEP, compared with underestimate as many young carers and substantially increased costs of care behavioural problems in early life CONSEQUENCES for a dual diagnosis of mental illness and an England average of 5.3%27. go unrecognised by services and receive (Naylor et al, 2012). Medically unexplained „„ The mental health conditions most substance abuse, with nearly half using no support (Becker, 2012). They are just symptoms (MUS), ie, physical symptoms commonly associated with offending drugs and alcohol to cope with mental People who have been unemployed for as likely to be a boy as a girl; one and half with no clear biological basis, are more are substance misuse (alcohol and health problems (Homeless Link, 2014). more than 12 weeks show between four times more likely to come from a BAME common than previously thought and are drugs) and a diagnosis of personality Mental health services have traditionally and ten times the prevalence of depression background and twice as likely not to often long-term, impacting significantly disorder, particularly anti-social been reluctant to provide care and support and anxiety and are also more likely to kill have English as their first language on an individual’s quality of life (Naylor personality disorder to people with a dual diagnosis and this themselves (Waddell and Burton, 2006). (The Children’s Society, 2013). Their et al., 2016). should be a focus for further inquiry by Poverty and unemployment tend to increase needs often go unrecognised, although Multiple diagnoses significantly increase the Commission. the duration of common mental health they may miss school, have lower the risk of offending, for example anti-social problems and debt and financial strain, educational attainment and may themselves personality disorder combined with The rate of rough sleeping has increased which can arise from job loss, are also have a long-standing illness or disability hazardous drinking (Coid, 2010). by 37% since 2010 (Department of associated with common mental health (The Children’s Society, 2013). Communities and Local Government, problems (McManus et al., 2007). 2013) and despite housing being Unemployment is also a risk factor for recognised as an important determinant substance abuse (Henkel, 2011). People

28 www.learningdisabilities.org.uk/help-information/Learning-Disability-Statistics-/187699/ [accessed 1508516]. 29 As above 27 Data available for different areas at: www.nomisweb.co.uk/reports/lmp/gor/contents.aspx [accessed 150816]. 35 www.nepho.org.uk/topics/Offender%20health [1508516]. 22 Mental Health in the West Midlands Combined Authority Mental Health in the West Midlands Combined Authority 23 CO-PRODUCTION People in custody are particularly vulnerable among people living prison are common30. 11. People experiencing severe and multiple to poor mental health. The total prison It is estimated that: disadvantage AND COMMUNITY population in the West Midlands on 31  90% of prisoners have substance Many people experiencing severe and December 2014 was 9,442. Eleven of misuse problems, mental health multiple disadvantage (homelessness, ENGAGEMENT PROVIDE the prisons are for men. Women comprise problems or both substance misuse and offending) have 3.32% of the prison population in the West  9% of the UK prisoner population suffer experienced trauma and neglect, poverty, A SOLID FOUNDATION Midlands, compared with a national average from severe and enduring mental illness family breakdown and disrupted education of 4.51%. Approximately two thirds (64.5%)  10% of prisoners have a learning as children and as adults, and have much of people accommodated in prisons disability higher levels of loneliness, isolation, FOR SERVICE are aged between 21–39. 71% of the  40% of prisoners report no contact unemployment, poverty and mental ill-health prison population are White British, 11% with primary care prior to detention (Bramley and Fitzpatrick, 2015). Both TRANSFORMATION are Black or Black British (equivalent to  People who have been in prison are up Coventry and Birmingham have well above the national average but higher than the to 30 times more likely than the general the national average number of people Some Local Authorities have undertaken CO-PRODUCTION AND USER either initiated by service users or by population percentage of 2.8%) and 10% population to die from suicide in the first experiencing severe and multiple JSNAs on specific mental health themes, ENGAGEMENT commissioners or providers (see Appendix are Asian/British Asian (higher than the month after discharge from prison disadvantage: an index of 216 and 171 for example veterans’ mental health in 4). Such groups provide a foundation for national average of 6%). The rates of respectively, where 100 is the national Warwickshire and mental health needs in Co-production means shifting the balance co-production and are an invaluable source self-harm and suicide within prison are For people leaving prison with poor mental average (Bramley and Fitzpatrick, 2015: primary care in Worcestershire. In addition of power and expertise from public services of expertise and good practice to support on an upward trend (Offender HNA and health and/or substance abuse, the risk of 22), with none of the Local Authorities in a health needs assessment, including and professionals towards local people the mental health system transformation Consultancy Projects, 2015) and young re-offending is increased and there is a the WMCA featuring in the list with the mental health, of the West Midlands prison and service users and carers so issues through the Vanguards and STPs. As well men are 18 times more likely than the clear need for effective mental health lowest prevalence. A workshop in January population was undertaken in 2014/15 and solutions are jointly considered as being involved in service design, such general population to take their own support for this population. 2016, as part of the WMCA scoping work (Offender HNA and Consultancy projects, and solutions co-designed, and may be organisations also provide a range of lives (Offender HNA and Consultancy around Troubled Families, involving experts 2015). Of note is the mental health equity co-delivered (Needham and Carr, 2009). resources, information and peer support, projects, 2015). 10. People experiencing violence and abuse by experience, identified the importance audit being undertaken by Birmingham City This builds on an established tradition and respond to user-defined needs that There are various forms of abuse: emotional, of a holistic approach underpinned by Council to identify how fairly services and of service user and carer involvement do not necessarily align with the interests The Corston Report (Home Office, 2007) physical and sexual, including human partnership working, specifically between resources are distributed in relation to the but is more radical in its ambition and of public services. User and carer groups highlighted the very different needs of trafficking, affecting people of all ages drug and alcohol and mental health mental health needs of different ethnic consequently more challenging for public play an invaluable role for the mental health, women from men in prison. Women and backgrounds. Women are more at risk services, early intervention and prevention groups living in the city. services and local people (Ewert and Evans, and wider, system in agitating for change. with histories of violence and abuse are from sexual abuse and domestic violence and listening properly to what people 2012). The importance of co-production in As well as calling for better access to over-represented in the criminal justice with men more at risk from physical violence need and responding accordingly33. Good practice promotes co-production, commissioning, designing and providing supportive care, improved understanding system; they commit different offences from in public places. There are 48 cases of community engagement and asset mapping mental health support cannot be over- of the realities of poor mental health, and a men; prison is disproportionately harsher for domestic violence in the West Midlands UNDERSTANDING MENTAL HEALTH as ways of understanding the needs, emphasised and is now widely promoted shift in public and professional attitudes, women because they have been designed every day31 with two women killed every ASSETS AND NEEDS system gaps and potential contribution of as enabling public services to address the such groups often take a critical stance to for men, and women are far more likely to be day in England. It is estimated that there communities to health improvement (Public challenges they face in terms of rising initiatives that may be promoted by public primary carers of young children than men, are approximately 400,000 people living Local Authorities have a responsibility Health England, 2015). However, we were demand and expectations, falling investment services as unproblematic. making the prison experience significantly in the West Midlands who are survivors to undertake Joint Strategic Needs only able to identify one JSNA where there and the democratic deficit in public services different for women. Mental health problems of childhood sexual abuse32. The Assessments (JSNAs) of their local was any evidence of asset mapping: (The National Survivor User Network There are ten Healthwatch organisations35 consequences can be long-lasting and population. The purpose of JSNAs is to Coventry and Rugby CCG’s 2015 Mental (NSUN) 2012). across the WMCA, which serve as the debilitating and include a broad range assess current and future health and social Health and Wellbeing assets and needs consumer champion of health and social THE CONSEQUENCES of physical and mental health conditions. care needs within the Health and Wellbeing assessment. The value of co-production lies in care. They were established as a sub- The psychological consequences include Board area, to inform strategic planning, harnessing the expertise of people who are committee of the Care Quality Commission OF SEXUAL ABUSE, anxiety, depression, post-traumatic stress and the guidance makes it clear that they Public Health West Midlands has a role to experts by experience, which will lead to (CQC), to provide information and advice disorder (PTSD), self-harm, suicide, sleep must cover the whole population, and play in developing and promoting guidance better services that enable people to have to government, various NHS bodies and disturbances and emotional detachment. ensure that mental health receives equal and standards to support improvements better lives34. In a WMCA context it would Local Authorities on the views of the local DOMESTIC VIOLENCE Survivors of domestic violence will also priority to physical health (Department of in the quality of JSNAs, to include asset help ensure that the diversity of the WMCA population, and people who use health AND EMOTIONAL ABUSE have needs relating to debt, finances Health, 2013). mapping, and provide tangible examples of is properly considered to ensure that and social care services, on their needs and housing. Survivors of sexual abuse how this intelligence, alongside that from access is equitable for all and that the and experiences of health and social care CAN BE LONG-LASTING are over-represented in mental health As illustrated by Appendix 3, the suicide and other audits, can be used to transformation of mental health is grounded services, and on the standard of health services but may not be able to access comprehensiveness and the quality of the inform commissioning for prevention and in an understanding of what matters to and social care provision and how it should AND DEBILITATING AND appropriate support or may experience JSNAs varies between Local Authorities in quality, and support the wider mental people and what they need from public be improved. Healthwatch organisations re-traumatisation, or further violence the WMCA and, thus, the extent to which health system transformation. services to get on with their lives. across the WMCA are involved in mental ARE ASSOCIATED WITH and abuse, during their contact they provide useful intelligence to inform health system development and have with services. mental health transformation. There are formally constituted independent established networks, and can offer A BROAD RANGE OF service user groups that aim to help people specific expertise in engaging with local who have accessed or are accessing communities. Dudley Healthwatch, for PHYSICAL AND MENTAL services be involved in the way services example, has developed an Activate HEALTH CONDITIONS are planned, delivered and evaluated, approach for involving communities,

30 www.nepho.org.uk/topics/Offender%20health[1508516] 31 www.westmidlands-pcc.gov.uk/news/news-2015/48-cases-of-domestic-violence-crime-every-day-in-the-west-midlands-as-new-standards-are-signed-up-to-for- a-co-ordinated-response/ [accessed 150816]. 34 Glasby, J. (2016). Personal communication. 32 www.pansi.org.uk/index.php?pageNo=407&PHPSESSID=315v74tec3qjl1tbhfmc73ipb5&sc=1&loc=8653&np=1 [accessed 150816]. 35 Birmingham; Coventry; Dudley; Sandwell; Solihull; Staffordshire; Walsall; Warwickshire; Wolverhampton and Worcestershire. 33 Source: Notes from Workshop 2. See www.healthwatch.co.uk/find-local-healthwatch [accessed 030516]. 24 Mental Health in the West Midlands Combined Authority Mental Health in the West Midlands Combined Authority 25

in partnership with Dudley CVS and the „„ Citizens UK Birmingham39, an All Together Better Partnership; recently independent membership alliance of receiving an award for this work from civil society institutions acting together 36 EXPERIENCE- Healthwatch England . for the common good of the city. Founded in 2013, they have trained Many organisations in the WMCA express over 300 leaders on acting in public BASED CO-DESIGN a commitment to co-production and this is life through the method of community particularly challenging for public services organising. Over 1,500 people, drawn IS ONE WAY THAT who are working within a national policy from Birmingham’s faith, education, and a local political context. In a mental trade union and community sectors MENTAL HEALTH STAFF health context, a token commitment to have participated in public action and co-production will perpetuate services building accountable relationships with AND SERVICE USERS that have little efficacy and are perceived those in power in the city. Issues they as unhelpful, controlling or profoundly have focused on include access to CAN WORK TOGETHER damaging (Needham and Carr, 2009). specialist mental health services for Co-production initiatives in the 16–17-year-olds, support for the TO REDESIGN SERVICES WMCA include: Living Wage and resettlement of „„ Every Step of the Way (ESOW), is a Syrian refugees40. AND CARE PATHWAYS key strand of the Changing Futures Together (CFT), a seven-year lottery funded project (£10M) designed to not PROMISING PRACTICE: THE UK’S FIRST MENTAL HEALTH PARLIAMENT only support some of the most complex IN SANDWELL needs of people in Birmingham but also to ensure system change37. Launched by the Members of People’s Parliament (MPs) in Sandwell in July 2015. Birmingham Mind are delivering the The People’s Parliament enables MPs with lived experience of mental ill health to work service user involvement strand of in coproduction with strategic leaders and decision makers to lead policy development, ESOW and this involves training up shape strategy and improve services and support. They have launched a White Paper and 120 Experts by Experience and 30 have developed a set of standards for crisis care with local people with recent experience Involvement Champions each year of crisis care42 that will be embedded locally as a driver to shape what the future looks and matching them with opportunities like. They are aiming to develop employment opportunities with ‘smart’ businesses and within the CFT programme and in community places of safety with the local community across all sectors. There is a launch wider systems. of the Quality of Life standards in October 2016 in conjunction with Sandwell Health and „„ Experience-based co-design of Wellbeing Board. This parliament will be able to check people’s experience against those hospitalisation in early psychosis standards and the CCG and LA are looking at embedding these into commissioning to in Coventry and Warwickshire drive up quality and direct local need. Partnership NHS Trust. This project piloted this collaborative approach The model for the People's Parliament puts people with lived experience at the heart of between service professional and strategic decision making and ensures that local people are working in co-production with service users to identify areas for strategic leaders to find their own solutions. MPs that lead the Parliament are developed by service change. The project identified a Changing Our Lives through a leadership development programme, ongoing supervision range of service improvements that are and an array of opportunities to develop their skills in leadership. Based on this experience, generalisable to other contexts and the time needs to be invested in people to enable them to truly coproduce and be an equal learning both about the process and and reciprocal partners at strategic level. the implementation challenges are informative for future EBCD projects. (Larkin et al., 2015). PROMISING PRACTICE: MAKING A DIFFERENCE (MAD) ALLIANCE IN NORTH „„ 300 Voices38, a partnership between WEST LONDON43 Birmingham and Solihull Mental Health NHS Foundation Trust, West Midlands Founded by the National Survivor User Network (NSUN), the Mad Alliance is formed Police, Birmingham City Council and of 32 leaders representing the diversity of eight London Borough Communities. Time to Change that seeks to engage The experiential knowledge of the Alliance includes seeking asylum, poverty, isolation, with young African and Caribbean men psychological, physical, sexual, relational abuse and trauma, homelessness, racism, aged between 18 and 25 to engage inequality and discrimination. They are involved in Local Authority and CCGs and two with communities and hear experiences NHS Mental Health Trusts and the Like Minded North West London Transformation of inpatient and outpatient care. Board, which involves all system partners, and aims to address unacceptable variations in

Although funding ended in March mental health support and to improve multiagency working. Each Monthly Transformation 36 See: http://healthwatchdudley.co.uk [accessed 270716] 2016, there are a number of legacy board meeting begins with a five- to ten-minute video summary of current service user and 37 The CFT programme is now going to be linked with the Troubled Individuals strand of work for the West Midlands Mental Health Commission. projects being taken forward (see carer experience together with two Alliance advisors attending to represent the Alliance 38 www.bsmhft.nhs.uk/about-us/engaging-with-our-communities/300-voices [accessed 150816]. Appendix 4). expertise. Cultural change is often difficult to measure over short spaces of time but board 39 This is supported by the University of Birmingham so please note the potential conflict of interest. members have said that this brings debate closer to the power of their actions and that 40 www.citizensuk.org/birmingham [accessed 150816]. local decisions have been taken as a result. 41 www.bsmhft.nhs.uk/about-us/engaging-with-our-communities/300-voices [accessed 150816]. 42 www.changingourlives.org/a-uk-first-mental-health-parliament-launched-in-sandwell 43 www.nsun.org.uk/membership/members-platform-mad-alliance 26 Mental Health in the West Midlands Combined Authority Mental Health in the West Midlands Combined Authority 27

In the case of co-morbidities, it is well in England, and an apportionment of these frontline education services such as the The economic and social costs of poor established that, for a wide range of costs on the basis of population numbers, employment of more teaching assistants long-term physical health conditions, a adjusted for differences in the relative (Snell et al., 2013). This increases allocated co-existing mental health problem (eg., prevalence of mental health problems, spending in the WMCA to £0.18 billion. diabetes and depression) leads not only to implies additional NHS spending in the mental health in the West Midlands worse health outcomes but also to greatly WMCA of around £1.09 billion a year. In relation to social security payments, increased costs of treatment for the physical BCG’s national estimate of £7.5 billion complaint. The scale of this increase is 2. Social care costs covers mental health-related spending ESTIMATING COSTS mental health problems are heavily over- CARE COSTS estimated at around 45–75% per case, This component of cost covers spending on on three main benefits: Employment and represented in the criminal justice system based on costs measured after adjustment social care services, including residential Support Allowance, Disability Allowance Mental health problems have high rates of (Ministry of Justice, 2008; Booker et al., 1. NHS costs for the severity of physical disease (Naylor accommodation, funded by local authorities and Carer’s Allowance. Detailed DWP data prevalence; they are often of long duration, 2011), but the nature of the relationship The most comprehensive source of data et al., 2012). Taking 60% as a mid-point, where the primary reason for support is by individual Local Authority allows direct even lifelong in some cases; and they have between mental illness and offending is on the direct costs of NHS treatment for this implies that on average the NHS mental health. According to data for calculation of the amounts spent on these adverse effects on many different aspects complex and further research is needed people with mental health problems is the spends an extra £2,400 a year on every individual local authorities published by the benefits in the WMCA in 2014/15, of people’s lives, including their education, before a fully reliable apportionment of annual NHS programme budget published individual patient who has co-morbid Health and Social Care Information Centre as follows: Employment and Support employment, social participation, personal the societal costs of crime can be made by the Department of Health. This provides physical and mental health problems as (HSCIC), gross total expenditure on these Allowance £410 million, Disability relationships and physical health. No other between mental disorder and other a detailed breakdown of health service against a physical condition on its own. services in the WMCA amounted to £0.115 Allowance £132 million and Carer’s health condition matches mental ill health causal influences. spending between different disease areas (Average costs per patient are estimated billion in 2014/15 (HSCIC, 2015a). Allowance £19 million (DWP, 2016). in the combined extent of prevalence, (infectious diseases, cancers, respiratory at £6,400 a year in the former case and For reasons not explained, the BCG persistence and breadth of impact. Despite Finally, there is a brief discussion of the problems, mental health disorders etc.) and £4,000 a year in the latter.) The annual cost of Looked After Children calculations exclude spending on Housing this, the majority of mental health problems lifetime costs of mental health problems, is available both nationally and by individual as a consequence of poor parental mental Benefit for people who are claiming go unrecognised and untreated (McManus as an alternative to the conventional CCG (Department of Health, 2016). At the aggregate level, given the evidence health and/or substance abuse, based disability benefits because of mental ill et al., 2009). measures which focus on costs in a reviewed in Naylor et al. that there are on the estimates of numbers and costs health. As there seems no obvious logic for single year. For mental health disorders, the bulk of altogether about 4.6 million people in provided by the constituent members of this, DWP data has been used to calculate In assessing the scale of this impact, expenditure relates to the provision of England with a long-term physical health the WMCA, is £0.1 billion. that relevant spending on this benefit in the the approach taken here is to identify All estimates of costs given relate to the specialist or secondary mental health condition and a co-existing mental health WMCA in 2014/15 was £192 million, and quantify all the main costs of mental financial year 2014/15, the most recent year services, such as those provided in problem, extra spending on physical health 3. Other public sector costs resulting in an overall (rounded) total of ill health in the WMCA and then to combine for which all relevant data is available, and psychiatric inpatient units and in the care because of mental health co- A recent national study of the public sector £0.755 billion for the mental health-related these in a single annual total using the they cover the full population of the WMCA, community by specialist mental health morbidities costs the NHS no less than costs of mental ill health carried out for the cost of social security payments. common measuring rod of money. Cost estimated at 4.032 million people in teams. However, the data also includes £11 billion a year, equivalent to 10% of NHS England Mental Health Taskforce is defined broadly to include any adverse 2014/15. Two other pieces of background mental health-related spending in other the total health service budget. identified mental health-related expenditure effect of mental ill health, wherever it falls information, used at various points in the settings, such as Accident and Emergency of around £9.2 billion a year in England on and whether or not it is conventionally analysis, may also be mentioned at this (A&E) departments in acute (non- Medically unexplained symptoms (MUS) public sector programmes other than health THE NHS SPENDS measured in monetary terms or included stage. First, according to the 2007 survey psychiatric) hospitals, and on prescriptions are physical symptoms that do not have a and social services (Boston Consulting in national income. of psychiatric disorder, 23.8% of all adults for mental health problems dispensed by readily identifiable medical cause or are Group (BCG), 2015). Some £7.5 billion of AT LEAST AS MUCH in the West Midlands Region (taken as a high street pharmacists. The one major area disproportionate to the severity of medical this was accounted for by social security Using this approach, costs can be grouped proxy for the WMCA) experience some kind of spending not allocated by disease relates illness, and are assumed to be attributable payments, discussed separately below. ON DEALING WITH together under three main headings: of mental health problem, compared with to GP consultations and for this project it to underlying psychological causes. The The remaining £1.7 billion was made up of Care costs, covering the costs of health 23.0% in England as a whole (McManus et is assumed 25% of all consultations are prevalence of patients with MUS is high relatively small amounts of spending in a and other services provided for people with al., 2009). Prevalence is thus slightly higher mental health-related. Based on the latest in all health care settings and a significant number of different areas including: schools mental health problems by the NHS, social than the national average. Secondly, among available programme budget data, it is proportion of these patients become (spending on Special Educational Needs THE INDIRECT services, schools etc. and also the informal all people in work, average pay in the West estimated that total NHS spending on frequent users of services in both primary (SEN) pupils with behavioural, emotional care provided by family and friends; Midlands in 2014/15 was 7.5% below the mental health problems in the West and secondary care. The overall cost of and social difficulties); criminal justice CONSEQUENCES OF Employment costs, measuring the costs England average and 6.3% below the UK Midlands Combined Authority Area amounts MUS to the NHS in England that results (mental health-related services funded of output losses in the local economy that average (NOMIS, 2016). to around £0.905 billion a year. Of this from the additional use of physical health by the police, courts and prisons); and result from the damaging effects of mental total, £0.207 billion (23%) relates to care services is estimated at around £3.25 Department for Work and Pensions (DWP) MENTAL ILL HEALTH ill health on people’s ability to work; and spending in primary care, including billion a year (update of data in Bermingham employment programmes used by people Human costs, representing a monetary £0.148 billion on GP consultations, et al., 2010). with mental health problems. AS IT DOES ON THE estimate of the less tangible but crucially while the remaining £0.698 billion (77%) important adverse impact of mental ill health covers expenditure in secondary care. Taken together, these estimates for the The allocation of a share of this £1.7 billion DIRECT PROVISION OF on people’s wellbeing and quality of life. aggregate costs of co-morbidities and MUS to the WMCA on the basis of population All of these figures relate to the direct costs imply that in England as a whole the NHS numbers, adjusted for the above-average SERVICES FOR PEOPLE Also provided are some broad illustrative of treatment and care for people with mental spends at least as much on dealing with the prevalence of mental health problems, estimates of crime costs linked to mental Cost is defined broadly health problems. It is, however, clear that indirect consequences of mental ill health results in an estimated annual cost of WITH DIAGNOSABLE disorder including substance misuse. to include any adverse the full impact of mental illness on the as it does on the direct provision of services £0.13 billion. A further adjustment is made, It is well established that people with finances of the NHS goes well beyond for people with diagnosable mental health drawing on evidence not considered in the MENTAL HEALTH effect of mental ill health, these direct costs, in particular because of problems. Overall, the extra costs of BCG study which suggests that less than physical/mental health co-morbidities and physical health care linked to poor mental half of all mental health spending in schools PROBLEMS wherever it falls. medically unexplained symptoms, both of health come to around £14.25 billion a year is SEN-related, with the bulk going on which add greatly to NHS spending on physical health care. 28 Mental Health in the West Midlands Combined Authority Mental Health in the West Midlands Combined Authority 29

4. Costs of informal care EMPLOYMENT COSTS out below, dealing first with mental health adjustments result in an estimate of around Finally, concerning staff turnover, about four Informal care provided to people with problems among people who are currently £130 a day for the cost of sickness million jobs change hands each year in the THE AGGREGATE COST OF mental health problems by relatives and Mental ill health is the dominant health in work and then with mental ill health absence in the WMCA. UK, with mental health problems accounting friends is not generally paid for and so does problem of working age. This is partly among those who are not in work. for up to 5% of the total. Based on evidence LOST OUTPUT BECAUSE OF not feature in GDP. It is nevertheless of because mental health problems are very Allowing also for the above-average on the costs of staff turnover given in the economic significance and the usual common, but also because the burden 1. Employment costs among people in work prevalence of mental health problems in Centre for Mental Health review cited MENTAL HEALTH convention is to impute a monetary value associated with these problems falls mainly Contrary to popular belief, the majority of the West Midlands, the total cost of mental above, it is estimated that the total annual on the basis of what it would cost to provide on people during their working lives. The working-age adults with a mental health health-related sickness absence in the cost of mental health-related turnover an equivalent service if undertaken as prevalence of mental ill health is highest condition have a job and are almost as likely WMCA comes out at around £0.56 billion in the WMCA is around £0.155 billion. paid employment by a homecare worker. when people are in their 20s and 30s and to be working as anybody else. On average, a year. Adding together the above costs of This is the approach taken in the BCG then declines steadily with age. This is in employers should expect to find that at any sickness absence, presenteeism and staff PROBLEMS study, which – when combined with survey striking contrast to physical health, which one time nearly one in six of their workforce Turning now to presenteeism, this is more turnover, it is calculated that the aggregate AMONG EMPLOYED PEOPLE data on the amount of informal care for all major conditions shows a very is affected by a mental health condition difficult to measure, but accumulating cost of lost output because of mental health provided to people with mental health pronounced age gradient going the other such as depression or anxiety, rising to evidence in the international literature on problems among employed people in the IN THE WMCA IS ABOUT problems – results in a national cost way. Indeed, the great bulk of the burden around one in five if substance problems health at work suggests that output losses WMCA is about £1.72 billion a year. estimate of £14.2 billion a year. Based of physical ill health increasingly falls in are also included. The consequences of from this cause are if anything larger, £1.72 BILLION A YEAR on relative population numbers and the the post-retirement years. this may take a variety of forms, but from a perhaps several times larger, than those 2. Employment costs among people prevalence of mental health problems, it is cost perspective the most important relate associated with sickness absence. not in work gives a national cost of £37.6 billion calculated that the cost of informal care in Poor mental health is thus very common to sickness absence, presenteeism (the loss Presenteeism is particularly important in In 2014/15 there were 662,000 working- attributable to mental health conditions. the WMCA is £1.085 billion a year44. The among people of working age and has in productivity that occurs when employees the case of mental health. Among other age adults in the WMCA categorised as Taking into account the numbers of people true costs may well be higher as this only a major impact on individuals and the come to work even when unwell and reasons, this is because workers may be economically inactive, accounting for 26.1% in the WMCA who are long-term sick as a includes direct care costs in the absence economy. For individuals, it can mean consequently function at less than full particularly concerned about being labelled of the overall population in this age group proportion of the equivalent national total of an informal carer – not the wider impact difficulties in finding employment, increased capacity) and staff turnover. as mentally ill by their employers and (ONS, 2016a). Within the total, 143,000 and the lower level of average local pay, on the informal carer. risk of losing a job, frequent or prolonged fellow workers. Fearing possible stigma or (21.6%) were inactive because of long-term it can be calculated that the mental periods of sickness absence and, at worst, Taking these in turn, survey data indicates discrimination, they turn up for work even sickness. Local information is not available health-related cost of worklessness in the 5. Care funded by individuals and charities long-term unemployment and detachment that in 2014 employees in the UK took an if feeling unwell. It also appears that the on the numbers who were long-term sick for WMCA on this method of estimation comes It is estimated in the BCG study that at from the labour market, leading to a average of 6.9 days off work for health productivity losses caused by mental health mental health reasons, but use can be made out at £2.45 billion. Given the number the national level the cost of mental health downward cycle of low income, worsening reasons (CIPD, 2015). Evidence from a problems are more likely to take the form instead of national data on the reasons why of assumptions involved in both cases, services funded by individuals and charities health and social exclusion. The longer range of sources suggests that at least of presenteeism (rather than sickness people claim Employment and Support this is reassuringly similar to the figure amounts to around £1.6 billion a year. This people are out of work, the lower their 40% of these days off are for mental health absence) among white-collar workers Allowance (the main incapacity benefit for of £2.2 billion given above. covers such items as counselling and other chances of ever getting back. For the reasons – and the true proportion may be than they are among blue-collar workers people of working age), and this shows services funded by individuals either out of economy, there are very substantial even higher, for example because it is (Hilton, 2007). that in 2014/15 nearly half (48.8%) did so HUMAN COSTS pocket or through private medical insurance, costs because of the lost production of known that some commonly recorded because of mental health problems (DWP, co-payment for NHS prescriptions, people who are unable to work or whose causes of sickness absence such as back According to one review of the available 2016b). Assuming that this proportion The most widely cited statistics on the employer expenditure on mental health and attendance and performance at work are pain are in reality often best described as evidence, it is conservatively estimated for applies in the WMCA, it follows that the overall burden of ill health and its breakdown non-public sector income to the voluntary disrupted by their mental health condition. medically unexplained symptoms. Taking the UK that among employed people with numbers in the area who were economically between different health conditions are and charitable sector. The share of this total 40% as a conservative estimate, this implies mental health problems presenteeism inactive for mental health reasons total those produced by the WHO in its work on allocated to the WMCA is £0.125 billion There is compelling evidence of a positive an average loss of 2.76 days a year per accounts for 1.5 times as much working around 69,800. the global burden of disease. These figures a year, again based on relative population link between employment and mental health employee for mental health reasons, time lost as sickness absence (Centre are based on a composite health measure, numbers and the prevalence of mental (Waddell and Burton, 2006). People enjoy equivalent to a total of 4.159 million for Mental Health, 2007). In addition, For costing purposes, it is assumed as the disability-adjusted life-year (DALY), health problems. better mental health when they are in work working days lost in the WMCA the average cost of a working day lost before that the appropriate measure of unit which combines years of life lost from and worse mental health when they are out (based on data in ONS, 2016a). because of presenteeism is higher than cost is average total compensation per premature mortality with equivalent years of work. The longer they are workless, the the equivalent cost for sickness absence, employee. National accounts data indicate of life lost from disability and morbidity. more damaging the consequences for their In costing this, it is conventional to assume as the inverse association that is commonly that in the UK as a whole this was £34,100 Conceptually, the DALY is the same as the THE MAJORITY OF mental health, even leading in some cases that absence from work entails a loss observed between earnings and rates of a year in 2014, which reduces to £31,815 quality-adjusted life-year (QALY) which is to suicide. For people with mental health of output whose value in a competitive sickness absence (ie, lower-paid workers a year in the WMCA when allowance is used by NICE and others in this country for WORKING-AGE ADULTS problems, work can be therapeutic. A return labour market equals the money wage, taking more time off than higher-paid made for the lower average level of pay. the evaluation of health service interventions. to work improves mental health by as much or – more accurately – total compensation workers) is not found in the case of Multiplying this by the numbers who were The main practical difference between the as the loss of employment worsens it. Some per employee, ie., the money wage plus presenteeism. A reasonable central economically inactive for mental health two is that the numerical weights attached WITH A MENTAL aspects of the work environment can of on-costs such as national insurance and assumption is that the national average reasons, the annual aggregate cost of to different levels of disability and morbidity course pose a risk to mental health and pension contributions. Using national cost of presenteeism is around £165 per mental health-related economic inactivity are based on the opinions of experts in the wellbeing, for example excessive hours, accounts data for 2014 (ONS, 2015a), day, corresponding to average gross daily in the WMCA comes out at £2.22 billion. DALY and on the opinions of the general HEALTH CONDITION work overload or lack of control, but the this implies an average cost of absence compensation per employee in the UK. As a cross-check on this estimate, a 2008 public in the QALY. Both concepts seek to HAVE A JOB AND ARE ALMOST overall balance of evidence is not in doubt: of around £165 a day at the national level. report on the health of Britain’s working-age combine the adverse effects of ill health on work is good for mental health. The benefits Two adjustments are required to take into Taken together, these assumptions imply population by Dame Carol Black estimated the quantity and the quality of life in a single AS LIKELY TO BE WORKING of employment greatly outweigh the risks, account: first, the fact that rates of sickness that the total cost of mental health-related that the total economic cost of health- measure and they provide a key building which are very small compared with the of absence are higher among workers with presenteeism is around 1.8 times the related worklessness in the UK was £63 block in estimating the human costs of AS ANYBODY ELSE harmful effects of long-term worklessness. below-average earnings than among the corresponding cost of sickness absence. billion in 2007 (Black, 2008). Increased in illness in monetary terms. higher-paid; and second, the lower general Application of this ratio in the WMCA line with money GDP, this is equivalent to a Estimates of the employment-related costs level of earnings in the WMCA relative to context results in an estimated annual cost of £77 billion in 2014. Assuming that Country-specific data from the WHO of mental ill health in the WMCA are set the national average. Taken together, these cost of presenteeism for the area of 48.8% of this is for mental health reasons, work on the global burden of disease are around £1.005 billion. as indicated by the data on Employment available up to 2012 and from these it can

44 Further detail on the cost of informal care available in Buckner and Yeandle (2011). and Support Allowance given above, this be calculated that for the most recent year 30 Mental Health in the West Midlands Combined Authority Mental Health in the West Midlands Combined Authority 31

THE AGGREGATE COST OF CRIME COSTS estimated that over 20% of all crime be regarded as rough ball-park figures. in Britain is committed by people who Much more analysis and much better data The overall level of crime in this country suffered from clinically diagnosable is needed to produce more reliable results. MENTAL ILL HEALTH reached a peak in about 1995 and has conduct disorder in childhood or since been falling steadily at around 2–3% adolescence (Centre for Mental Health, AGGREGATE COSTS IN 2014/15 IN THE WMCA IN 2014/15 a year. All major types of offending have 2009). This is after taking into account declined at broadly comparable rates, other possible influences on offending Pulling together the threads, this section IS ESTIMATED AT including both violent and non-violent crime. behaviour such as socio-economic provides estimates of the overall costs of Despite this welcome fall in offending, crime background and cognitive ability. mental ill health in the WMCA. Three main continues to impose huge costs, most measures are used: £12.6 BILLION, obviously on individual victims but also 2. According to an estimate published by (i) Total costs; on the rest of society. Comprehensive the Department of Health (DH, 2008), (ii) GDP costs, including only those cost EQUIVALENT TO A COST estimates of the costs of crime were first the aggregate economic and social costs components which are covered in national OF AROUND £3,100 PER published by the Home Office in 2000 of alcohol misuse in England in 2006/07 as conventionally measured; and (Brand and Price, 2000) and partially amounted to £18–25 billion. Crime costs (iii) Exchequer costs, representing the HEAD OF POPULATION updated five years later (Dubourg et al., accounted for more than half the total, at overall impact of mental ill health on the 2005). These show, for example, that the £9 - 15 billion. public finances. total cost of crime in England and Wales in available the total number of DALYs lost in 1999/2000 was around £60 billion. This 3. A Home Office study published in 2006 In all cases we leave to one side the the UK because of mental health problems covers not just costs falling on the criminal (Gordon et al., 2006) reported that the costs of crime as discussed above, on was 2.618 million (WHO, 2016). (This justice system but also – and much more economic and social costs of class A the grounds that for the time being these excludes learning difficulties and organic importantly in quantitative terms – costs drug use amounted to £15.4 billion in are best seen as illustrative estimates. disorders such as dementia but includes falling on the victims of crime, including the England in 2003/04, with costs relating alcohol and drug use disorders and value of stolen or damaged property, losses to crime accounting for just over 90% of 1. Total costs self-harm as well as the conditions in earnings associated with crime-related the total. The aggregate cost of mental ill health in commonly described as mental illnesses injuries etc., and an imputed monetary the WMCA in 2014/15 is estimated at such as schizophrenia, bipolar disorder, value of the emotional and physical It should be noted that these estimates are £12.6 billion, equivalent to a cost of depression and anxiety.) impact of crime on victims. The steady fall not independent of each other, as conduct around £3,100 per head of population. in the volume of crime since the mid-1990s disorder in childhood and adolescence is a The breakdown is as follows: To convert this total into a monetary obviously serves to bring down its risk factor not only for offending but also for equivalent, it is assumed that the value of aggregate cost. On the other hand, unit alcohol and drug misuse. Adding together £ billion % of total a DALY or QALY is £30,000. This is at the costs have been rising because of general the above figures would therefore entail an upper end of the £20,000–30,000 range inflation and related pressures, and a broad element of double counting. Care costs 3.59 28.0 used by NICE in assessing whether health assessment is that these two opposing service interventions are good value for influences have largely cancelled each other As noted, the current aggregate cost of Employment 3.94 31.5 money and is also consistent with the rule out, implying that the total cost of crime in crime in England and Wales may be costs of thumb sometimes advocated by the monetary terms is much the same now as estimated at around £70 billion a year. WHO and other international organisations it was in 1999/2000. Assuming that levels of crime are broadly Human costs 5.07 40.5 that the value of a QALY should be broadly the same in the West Midlands as in the the same as each country’s national income Two qualifications should, however, be rest of the country, an apportionment based per head of population, which in the UK is for the QALY, as it clearly represents a been included. And third, an increasing noted. First, there is good evidence that the on relative population numbers implies an Table 1: Cost of mental ill health to currently just under £30,000. substantial increase in society’s willingness body of evidence, both in this country scale and costs of domestic violence are aggregate cost of crime in the WCMA area the WMCA to pay for better health. The recorded view and elsewhere, suggests that the QALY under-recorded in the Home Office figures, of around £4.9 billion a year. On this basis, the aggregate monetary value of the Department of Health is that the value as conventionally measured substantially as documented in an analysis produced in It should be noted that care costs do not of DALYs lost in the UK for mental health of a QALY should rise over time at least under-estimates the value of mental 2004 for the government’s Women and On the conservative assumption that the include the costs of social security benefits reasons is around £78.5 billion a year. in line with money GDP per head and a health, certainly relative to physical health Equality Unit (Walby, 2004). And second, proportion of crime attributable to mental ill paid to people with mental health problems, Taking into account relative population guidance document on quantifying the (Bockerman et al., 2011; Fujiwara and there is also more recent evidence that the health, including personality disorder and estimated earlier at £0.755 billion a year. numbers and the local prevalence of mental health impacts of government policies Dolan, 2014). There are a number of available sources of data on the numbers substance misuse, is around 20%, the This is to avoid double-counting with health problems, this implies an equivalent published by the Department in 2010 put possible reasons for this. One is that the of crimes committed each year understate mental health-related cost of crime in the employment costs. cost estimate for the WMCA of about the value of a QALY in that year at £60,000 dimensions of health used in the QALY are the scale of fraud and cyber-crime (ONS, WMCA comes out at about £0.98 billion a £5.07 billion a year. Sizeable as this figure (Department of Health, 2010). not adequate for capturing the full impact 2015b). A rough allowance for these two year. Based on Home Office estimates for To elaborate briefly, suppose someone is, there are a number of reasons for thinking of mental illness; for example, no allowance factors suggests that the current aggregate the breakdown of crime costs, this includes currently earning £200 a week has to give that it is, if anything, on the low side. Second, the estimates of aggregate cost is made for the stigma and discrimination cost of crime in England and Wales is of costs of £190 million incurred by the up their employment for mental health given above make no allowance for the which add to the burden of many types the order of £70 billion a year. criminal justice system and £22 million by reasons and moves on to out-of-work First, the value of a QALY used by NICE impact of mental/physical health co- of psychiatric disorder. Another is the NHS (for the treatment of crime-related benefits at £80 week. The cost to the has remained unchanged since at least morbidities. As noted earlier, the co- that QALYs are based on hypothetical Some illustrative estimates of the costs of injuries), with most of the remainder falling economy of this change is £200 a week, 1999/2000, despite the fact that between existence of a mental health problem with a preferences of the general public which crime linked to mental health problems are directly on the victims of crime. representing the full value of the output 1999/2000 and 2014/15 the general long-term physical condition is associated may in some cases fail to anticipate as follows: that is lost. Of this cost, £120 is borne by level of prices in the economy increased by not only with increased costs of physical correctly the real impact that different Because of the considerable degree of the individual, whose weekly income falls by 40%, money GDP per head of population health care but also – and indeed because health states may have. In particular, there 1. Drawing on the evidence from uncertainty that surrounds any quantification this amount, and the remaining £80 is borne increased by 60% and NHS spending per of – poorer health outcomes for the physical is evidence that it is much more difficult to longitudinal studies that early behavioural of the share of crime attributable to mental by taxpayers, to fund the new payment of head measured in money terms by no less condition, including higher rates of mortality, adapt to mental illness than it is to most problems are a major risk factor for disorder, these estimates are clearly subject benefits. On this basis, it would clearly than 125%. The last of these in particular is disability and morbidity. These additional physical health problems. subsequent offending, it has been to wide margins of error and at best should be double-counting to include both the hard to square with a fixed monetary value human costs of physical illness have not 32 Mental Health in the West Midlands Combined Authority Mental Health in the West Midlands Combined Authority 33

employment cost of £200 and the benefit LIFETIME COSTS depression or anxiety at some point during 2. Childhood conduct disorder cost of £80. Put another way, there is an the perinatal period, defined as the period Early-onset conduct disorder, defined important distinction to be made between Evidence from longitudinal studies shows during pregnancy and the first year after as persistent disobedient, disruptive and the cost of an output loss and who pays that, in the absence of effective intervention, childbirth. Most attention is given aggressive behaviour, is the most common for it. many mental health problems tend to be to problems in the postnatal period, mental health condition in childhood, highly persistent and recurrent. There is particularly postnatal depression, but affecting 4.9% of all children aged 5–10 2. GDP costs a particularly high degree of continuity data from longitudinal surveys increasingly (Green et al., 2005), and there is strong Total costs as calculated above include two between adverse mental health states in suggests that maternal depression and evidence to suggest that its prevalence major components which are not usually childhood and those in adult life. Most anxiety are at least as common during has increased significantly over the last 30 measured in monetary terms and are children who have mental health difficulties pregnancy as in the year after childbirth. years (Collishaw et al., 2004). Longitudinal therefore excluded from national income as will also have mental health problems as Only a minority of cases of postnatal studies show that the condition is predictive conventionally defined. These are the costs adults and conversely most adults who depression and anxiety are in fact new of a wide range of adverse outcomes in later of informal care and the quality-of-life or have mental health problems will also have cases, arising for the first time after life, including not only continuing mental human costs of mental illness. When these had mental health problems as children. childbirth rather than being a continuation health problems (uniquely, childhood items are excluded, the GDP costs of of conditions which initially developed conduct disorder is a risk factor for all mental ill health in the WMCA work out at To illustrate, the 1946 British birth cohort during pregnancy (Heron et al., 2004). major types of adult psychiatric disorder) £6.355 billion a year, made up of care survey provides data on symptoms of but also poor educational and labour market costs of £2.415 billion and employment depression and anxiety measured in the Perinatal depression and anxiety are of performance, substance misuse, criminality, costs of £3.940 billion. same sample of individuals at various major importance as a public health issue, disrupted personal relationships and even ages between 13 and 53. not only because of their high prevalence reduced life expectancy (NICE, 2013). The aggregate GDP cost of £6.355 billion and their adverse impact on the wellbeing a year is equivalent to an annual cost of A study using this information (Colman et of mothers but also because they have An unsurprising consequence of this around £1,575 per head of population in al., 2007) has shown that, looking forward, been shown to compromise the healthy array of negative outcomes is that conduct the WMCA. In comparison, GDP per head among all children with depression or emotional, behavioural, cognitive and even disorder imposes a very heavy cost burden. in the area is around £22,700 a year (based anxiety as many as 86% continued to physical development of children, with One study which followed a sample of on data in ONS, 2014). Taken together, have these problems in adult life and serious and costly long-term consequences children from age ten until they were 28 these figures imply that mental ill health similarly, looking back, among all adults (NICE, 2014). The risks of these adverse found that the cumulative cost of public imposes a cost in GDP terms which is with depression or anxiety 71% first developmental consequences are roughly services used by those who had conduct equivalent to a loss of about 6.9% a year manifested symptoms in childhood. doubled as a result of perinatal mental disorder at age ten was around £90,000 in aggregate income in the WMCA. illness, after controlling for other influences. per head higher in today’s prices than The importance of continuity as shown among those with no problems, equivalent 3. Exchequer costs by these figures suggests that a valuable A recent study of the costs of perinatal to extra spending of around £5,000 a year The exchequer costs of mental illness way of analysing the costs of mental mental health problems (Bauer et al., 2014) (Scott et al., 2001). About two-thirds of the include all public spending on the care health problems is over the lifetime, as a has found the following: additional cost fell on the criminal justice and support of people with mental health supplement to the annual figures of the type system, with most of the remainder being problems, including social security given so far in this paper. To illustrate this Population data indicate that in mid-2014 divided between the education sector and payments, and also the losses of tax approach, two examples are given below, there were 53,367 children aged 0–1 in health and social services. revenue that result from the adverse the first relating to maternal depression and the WMCA (ONS, 2016b), implying a total effects of mental ill health on employment anxiety during the perinatal period and the long-term cost of perinatal depression and Another study has attempted a broad- and earnings. second to childhood conduct disorder. anxiety of around £0.55 billion for this local based estimate of the lifetime costs of one-year cohort of births, including costs of conduct disorder measured from a societal Publicly funded care costs including social 1. Perinatal depression and anxiety over £80 million falling on the NHS and perspective, covering the costs of adverse security amount to £3,045 million a year. Evidence from a range of sources indicates social services. outcomes relating to mental illness, drug In relation to tax costs, it is estimated in that around 15–20% of all new or expectant misuse, smoking, suicide, earnings and Professor Dame Carol Black’s report mothers suffer from clinically diagnosable crime (Friedli and Parsonage, 2007). on the health of Britain’s working-age Overall, it is calculated that the lifetime population referenced earlier (Black, 2009) cost of these adverse outcomes is around that at the national level the value of tax £275,000 per case in today’s prices, revenue forgone because of working-age measured against a baseline given by ill health is broadly similar in magnitude to THE HIGH DEGREE OF CONTINUITY people who had no conduct problems the social security costs of worklessness. in childhood. Again the bulk of costs Based on the relative figures given in this were found to be crime-related. report, the overall loss of tax revenue BETWEEN ADVERSE MENTAL HEALTH STATES associated with mental health problems in In mid-2014 there were 53,685 children the WMCA may be estimated at around IN CHILDHOOD AND THOSE IN ADULT LIFE aged five in the WMCA (ONS, 2016b). £835 million a year. On this basis, total Based on a national prevalence rate of exchequer costs come to around £3.88 SUGGESTS THAT A VALUABLE WAY OF 4.9%, this would imply a total of 2,630 billion a year. children with conduct disorder in this local ANALYSING THE COSTS OF MENTAL HEALTH one-year cohort and an aggregate lifetime PROBLEMS IS OVER THE LIFETIME cost of around £0.725 billion. 34 Mental Health in the West Midlands Combined Authority Mental Health in the West Midlands Combined Authority 35

Mental health support in the West Midlands

Mental health support in the West Midlands healthy school or workplace initiatives, and Mental Health and Specialist Inclusion Support Service; PROMISING PRACTICE: MENTAL HEALTH FIRST AID (MHFA) is provided by a diverse range of providers community level interventions that may be Wellbeing Awareness Tranquillity Counselling Service; including: primary care; specialist mental below the radar of public services but, This includes events and training courses, Worcestershire Rape and Sexual Abuse A recent meta-analysis concluded that the MHFA programme is effective in increasing health services; acute non-psychiatric nonetheless, are important in shaping the usually aimed at the general public and staff Support Centre; University of Warwick; knowledge about mental health problems, could decrease negative attitudes towards hospitals; community health services; social context for people’s everyday lives. Social working in front-line services. Such events University of Worcester and Walsall people experiencing mental health problems and is effective in increasing help-seeking services; third sector organisations; housing marketing approaches are also popular, and courses have a broader focus than Council. (Hadlaczky et al., 2014). Many of the studies reviewed, however, were Australian and organisations, employment services; the and the Five Ways to Wellbeing are widely Mental Health First Aid training and may the evidence for BAME populations was limited (Wong et al., 2015). Nonetheless, the private sector and as part of front-line promoted, although their evidence base adopt an explicitly social and public health Suicide prevention Thrive programme in New York has set a target of training 250,000 New Yorkers in public services including the police, fire and relevance to a multicultural and diverse focus. For example, Sandwell Council Applied Suicide Intervention Skills Training MHFA in order to change the culture around mental health51. and ambulance services. Each section population is contested. Furthermore, commissions awareness courses for (ASIST) is a recognised two-day Suicide provides an overview of the main types charitable organisations outside the WMCA any individual working within Sandwell, Prevention course, which goes into more A national evaluation of 11,502 course participants reported improvements in their of services available in the WMCA, are providing funding for health and including a range of health, social care detail than MHFA, which only briefly covers knowledge and understanding of how to help others with mental health problems (Jaman current performance against national wellbeing initiatives, for example the Big and voluntary sector services, faith workers, suicide prevention. This training is being et al., 2014). Local evaluations of the immediate impact of courses have been similarly indicators and illustarive examples of Lottery’s Headstart pilots, to identify ways statutory services such as police and fire commissioned and provided for any positive. However, to date, there have been no economic evaluations of MHFA and the promising practice. of helping young people (aged 10-14) deal departments, and workplaces in general. individual working within several Local impact on help-seeking in a UK context and the implications for public service delivery with life’s challenges, in Birmingham and Coventry and Warwickshire Mental Health Authorities (Dudley, Sandwell, Walsall, are, as yet, unexplored. However, there is emerging evidence that with a good mental PROMOTING PUBLIC MENTAL HEALTH Wolverhampton46. Foundation Trust are providing mental and Warwickshire) including a range health strategy (within which MHFA is the literacy component) staff are more willing to health awareness training in A&E to support of health, social care, primary care and report mental health as the reason for absence, it facilitates a return to 1. Provision in the WMCA This analysis, therefore, makes no claims their Crisis Care Concordat. voluntary sector services, faith workers, work and people return more quickly (Bonner, 2016). These interventions are targeted at the to comprehensiveness but provides a basis statutory services such as police and fire general population and designed to promote for further interrogation in order to develop a Mental Health First Aid (MHFA) was departments. Mandatory mental health There are concerns that MHFA can reinforce a narrow biomedical approach and there public mental health and wellbeing, and framework for public mental health to inform introduced to England in 2007 as part of training, that includes suicide prevention, is increasing emphasis on psychological first aid, which reinforces an approach that is tackle stigma surrounding poor mental the strategic commissioning and provision a national approach to improving public is increasingly being promoted for GPs to concerned with 'what happened?' as opposed to 'what's wrong with you?' health. It is recommended that they should of public mental health interventions. mental health and has been provided for enable them to identify patients at risk and adopt a life course approach, and be based young people, in schools, in workplaces and appropriate interventions. on the best available evidence (Davies, The activities commissioned by Local with front-line services as well as members indicates that the overall average for the The Public Health Outcomes Framework 2013). Initiatives to promote public mental Authorities include: of the general public. MHFA is being 2. Performance against national indicators highest levels of personal wellbeing on also provides a number of indicators health may be part of a wider approach, „„ Training and events to promote commissioned in the WMCA by some Local There are two main indicators that are the Life Satisfaction measure49 for West focused on mental illness: those with for example programmes in prison or in awareness and tackle stigma for the Authorities and provided through local Mind currently being used to evaluate mental Midlands Local Authorities on which a diagnosis of mental illness living planning urban spaces and are, therefore, general public, front-line services and associations, for example Coventry and wellbeing: the ONS subjective wellbeing there is data50, range from 14.7% of the independently; mental illness in not always easy to identify. For the majority employers, including Mental Health Warwickshire, and Birmingham. MHFA questions and the Warwick Edinburgh population in Wolverhampton to 28.75% the prison population; those with a of Local Authorities, mental health is „„ First Aid courses are also offered by NHS Trusts and Mental Wellbeing Scale (WEMWEBS). of that in Sandwell, compared with 26.65% diagnosis of mental illness in employment; included as part of Health and Wellbeing „„ Perinatal and parent/infant health West Midlands Employers as well as The ONS subjective wellbeing measure of the overall UK population. Other Local self-harm and suicide; excess mortality of strategies with a small minority having and mental health programmes independent training providers. Deutsche comprises four questions that are included Authorities which were below the national people with a diagnosis of mental illness; developed a public mental health strategy, „„ Parenting programmes, including Bank in Birmingham has trained 16 MH first in the Annual Population survey to assess average are Coventry (19.92%) and suicide and dementia rates. These are for example, Warwickshire45. programmes targeted at high risk families aiders so that there is someone available on the personal wellbeing of the population. Birmingham (21.98%). The highest reported under the relevant section in this „„ School-based mental health promotion every floor of the bank. MHFA England47 WEMWEBS is often used to evaluate levels of Life Satisfaction across the UK report. There are also wider indicators in Examples of public mental health initiatives and prevention programmes, such as has trained 99 instructors across England, the impact of interventions, as for example were reported by Pakistani and Bangladeshi the Public Health Outcomes Framework being commissioned by Local Authorities in anti-bullying and in the WMCA this includes staff the evaluation of the Esteem Team, an communities (29.2% and 27.58% which can be interpreted as a consequence the WMCA are summarised in Appendix 5. „„ Workplace interventions, including from Accord Housing Association Ltd; integrated primary care mental health and respectively), with the lowest levels reported or determinant of poor mental health eg, These may be funded by Public Health Healthy Workplace programmes Birmingham City Council; Birmingham wellbeing service in Sandwell (Thiel et by Black African/Caribbean and Black domestic abuse, homelessness, absence rather than through adult social care or „„ Targeted initiatives for at risk groups Mind; Birmingham and Solihull Mental al., 2013). British People (19.81%) compared with from school or work, social connectedness through children’s services in Local „„ Tackling violence and abuse, often Health NHS Foundation Trust; BITA 26.95% of the White population. There and physically active adults. Authorities and the equivalent information through responding to domestic violence Pathways; Community Wellbeing Using the ONS subjective wellbeing scale, is a similar pattern of results for Local from CCGs was not readily available. It is and abuse Solutions (Own company); Coventry and the ONS reports that personal wellbeing Authorities in terms of the Happiness item, also evident that the voluntary sector plays „„ Programmes to improve the physical Warwickshire Mind; Coventry University; has increased across the UK since the although a much more mixed picture on the an important role in providing preventative health of people with mental health Dudley MBC; Dudley Mind; Kaleidoscope data started to be collected in 201248. other scales (Anxiety and Feeling life is interventions, at an individual, collective problems Plus Group; the Lateef Project; Midlands A summary of the data from 2011–2014 worthwhile). and community level. There will also be „„ Suicide prevention Heart; Sandwell Mind; Severn Trent Water; organisational approaches, for example

48 www.ons.gov.uk/peoplepopulationandcommunity/wellbeing/datasets/measuringnationalwellbeinglifesatisfaction [accessed 150816]. 45  http://publichealth.warwickshire.gov.uk/files/2012/08/MENTAL-HEALTH-AND-WELLBEING-STRATEGY.pdf [accessed 161016]. 49 Source: ONS Reference Tables: Life Satisfaction by Local Authority Districts, April 2011 to March 2014. 46 www.biglotteryfund.org.uk/headstartprojects [accessed 150816]. 50 Birmingham, Coventry, Dudley, Sandwell, Solihull, Walsall, Warwick and Wolverhampton. 47 http://mhfaengland.org/ [accessed 150816]. 51 See https://thrivenyc.cityofnewyork.us/ [accessed 150816]. 36 Mental Health in the West Midlands Combined Authority Mental Health in the West Midlands Combined Authority 37

3. A strategic approach to public  Community empowerment and visits, if the resident agrees, operational 4. Wellbeing Hubs As this suggests, the needs of many people mental health development interventions that firefighters will cover a range of topics that The majority of Local Authorities and/or It is estimated that a practice of presenting with mental health problems in There have been several recent reviews of encourage communities to improve include mental health, weight, exercise and CCGs in WMCA have developed 2,000 patients will have: primary care are relatively straightforward, the evidence base for public mental health physical and social environments, healthy eating, social isolation, loneliness, Wellbeing Hubs to provide the general „„ 352 people with a common mental but there will be a significant cohort whose and there is a consensus that a life course participation and strengthen hoarding and employment52. public with information about health and health problem needs are complex, who have a range of approach is needed with the greatest gains social networks. wellbeing and signpost to appropriate „„ 352 people with a common mental physical and mental health symptoms or being made by promoting the mental health 3. Libraries and museums services (see for example Sandwell’s health problem below the co-morbid conditions, and have associated of parents and children. An example is In the context of the above summary, the Libraries provide access to information Confidence,and Wellbeing Hub). In some diagnostic threshold social difficulties. From discussions during provided in Appendix 6, from a review of the analysis of public health initiatives in the and resources, in different formats and instances, third sector organisations have „„ 8 people with psychosis this project, it is evident that the level of evidence for public mental health to inform WMCA indicates that there is considerable languages, about mental health as well as been commissioned to provide this „„ 120 people with below the support to GPs and, therefore, to such the ten best buys for commissioners to scope for developing a strategic approach non-stigmatising spaces for people to meet alongside peer support or one to one diagnostic threshold for psychosis patients in primary care needs urgent promote public mental health and inform that adopts a life course and multisector to explore health and wellbeing, and to relax support (see for example the Wellbeing „„ 120 people with alcohol consideration by the Commission. commissioning strategies (Heginbotham approach. This should be facilitated by and unwind, providing: Hub provided by Birmingham Mind). dependency and Newbigging, 2013). As with other the national Mental Health Prevention „„ A parents’ collection of books on Information about mental health and „„ 60 people with drug dependency 2. Performance against national indicators reviews, this highlighted the importance of: Concordat programme, which aims to children’s health and wellbeing wellbeing is increasingly available through „„ 176 people with a personality  Promoting good parental mental and support all Health and Wellbeing Boards „„ A partnership for NHS Books on the development of electronic resources disorder Primary Care Prescribing physical health to improve early child (along with CCGs) to have an updated prescription53 (see for example Warwickshire's Health „„ 125 people (out of the 500 on an Annual expenditure on primary care development and wellbeing, maternal JSNA and joint prevention plans that include „„ Mindful mediation sessions and Wellbeing Portal55). average GP practice list) with a prescribing for mental health is £12 wellbeing mental health and comorbid alcohol and „„ Health checks long-term condition with a co- per head in the WMCA, compared  Promoting good parenting skills drug misuse, parenting programmes, and „„ Drop-in sessions with mental health PRIMARY CARE morbid mental illness with a national average of £13 (NHS – universal as well as targeted early housing. In addition, all local areas are experts for people feeling anxious „„ 100 people with medically Benchmarking, 2016)58. This masks intervention programmes for common required to have multi-agency suicide or depressed 1. Current provision in the WMCA unexplained symptoms not variation between CCGs, with Redditch parenting problems and more intensive prevention plans in place by 2017. „„ Volunteering opportunities to The great majority of people experiencing attributable to any other and Bromsgrove spending the least at £8 interventions for high risk families at high encourage people to join the library mental health problems are seen in primary psychiatric problem per person and South Warwickshire the risk of poor mental health(see section OTHER UNIVERSAL SERVICES and provide customer feedback. care and GPs are increasingly seen as most, at £17 per head of population. South on Adverse Childhood Events) being at the centre of ‘providing whole Warwickshire has a higher level of mental  Building social and emotional resilience Many universal services have opportunities Similarly, museums are an important person care to people with overt or covert Figure 4: Estimated numbers and types health need than Redditch and Bromsgrove, of children and young people through for promoting mental health and responding universal public service and there is mental health issues’ (Joint Commissioning of mental health problems for a practice but is substantially lower than the whole school approaches to people who may be experiencing a increasing interest in the role that they can Panel for Mental Health: 2013)56. Primary serving 2000 patients (Source: Joint Birmingham CCGs, (see Appendix 7),  Improving quality of life through mental health crisis and have an important play in contributing to health and wellbeing, care also plays a key role in the emotional Commissioning Panel for Mental which spend between £11–£12 per increasing opportunities for role to play in social inclusion. offering a range of opportunities to wellbeing of people with physical health Health, 2013) head of population. participation, personal development Examples are: participate in cultural or creative activities problems and in preventative strategies. and problem-solving (Camic and Chatterjee, 2013; Dodd and It has been estimated that about one in four  Prevention, identification and 1. Police service Jones, 2014). The Royal Society for Public There are 716 GP practices covered by of a GP’s adult patients will need treatment responding to emotional, physical and/ The police service across the WMCA has Health (2013) advocates that museums and the 15 CCGs in the WMCA, and some of for mental health problems. Figure 4 or sexual abuse been active in changing its approach to galleries have an important role to play in these will be located outside of the WMCA provides an estimation of the numbers  Improving working lives: a) support for people presenting with mental health promoting emotional resilience, coping (see Appendix 7). Based on an index of and types of mental health problems for unemployed b) creating healthy working problems and in particular through the skills, strengthening identity and social mental health need57, the three CCGs in a practice serving 2000 patients. It would environments c) early recognition and introduction of street triage and liaison inclusion (Dodd and Jones, 2014). The Birmingham have the highest level of mental be helpful for the WMCA to have this intervention for those with mental health and diversion services. This is discussed Birmingham Museums Trust has started a health need, with Birmingham South and information for a sample of practices problems d) supported work for those in more detail later in this report. number of health and wellbeing initiatives Central CCG having over 50% more need to test these assumptions. recovering from mental illness across its nine sites, including: free creative than the mean (needs index = 1.56) and  Integrating physical and mental 2. Fire service sessions for carers; gardening for mental Bromsgrove and Redditch nearly 40% less wellbeing through universal access to The West Midlands Fire Service is making health; support for people with dementia; (needs index = 0.64). The populations lifestyle programmes to reduce smoking vulnerable people its priority, with a strong and a day full of activities which offered free covered by CCGs range from approximately PRIMARY CARE PLAYS A CENTRAL ROLE alcohol use, substance use, and obesity emphasis on prevention. While this has taster sessions of a range of therapies54. 113,000 for Wyre Forest to nearly 750,000  Tackling alcohol and substance abuse, been a long-standing aspect of the Fire Museum visits and events can be included for Birmingham Cross City CCG, which including screening programmes and Service’s role through Home Safety checks, as part of social prescribing or recovery increases to just short of a million when IN PREVENTION, EARLY INTERVENTION AND direct measures with those abusing these were extended in 2015 to include college courses, although it is not clear the population is weighted for need (see alcohol. advice to help people improve their health the extent to which this is happening within Appendix 7). ACCESS TO SPECIALIST SERVICES, SOCIAL and wellbeing. Known as Safe and Well the WMCA. SUPPORT AND COMMUNITY RESOURCES HOW THIS CAN BE BETTER RECOGNISED AND SUPPORTED IS A KEY STRATEGIC QUESTION

55 https://apps.warwickshire.gov.uk/PublicHealthDir [accessed 150816]. 56 www.jcpmh.info/wp-content/uploads/10keymsgs-primarycare.pdf 57 52 www.wmfs.net/new-safe-and-well-visits [accessed 150816] See: www.england.nhs.uk/wp-content/uploads/2014/03/d-nph-mental-health.xlsx for data and information on the components of this indicator [accessed120516]. 58 53 http://reading-well.org.uk [accessed 150816] NHS Benchmarking (2016). Report prepared by Zoe Page for this project. See www.nhsbenchmarking.nhs.uk/CubeCore/.uploads/Marketing/ 54 www.bvsc.org/news/health-and-wellbeing-birmingham-museums [accessed 150816]. 201617%20project%20cards/MentalHealth_Benchmark.pdf for information on NHS Benchmarking [accessed 161016]. 38 Mental Health in the West Midlands Combined Authority Mental Health in the West Midlands Combined Authority 39

1400

1200 100 Improving Access to Physical health checks for people 90 Psychological Therapies Mean: 621 with a severe mental illness 1000 80 The Improving Access to Psychological Upper quartile: 734 As noted before, there are serious 70 Therapies (IAPT) programme started Lower quartile: 472 inequalities in mortality rates for people in 2008, originally for adults of working 800 with a diagnosis of severe mental illness, 60 National 2012/2013 age and now extended to older adults with contributory factors including socio- 50 National 2013/2014 and children and young people59. economic circumstances, lifestyle and 40 600 WMCA 2012/2013 medication. 46% of people with a diagnosis 30 IAPT provides Cognitive Behaviour Therapy of mental illness also have a long term 20 WMCA 2013/14 (CBT), and other interventions approved 400 physical illness (compared with 30% in

IAPT referral per 100,000 10 by NICE, to people with common mental the general population). Figure 7 provides 0 health problems, such as mild to moderate 200 a summary of the percentage of physical Blood BMI Blood Alcohol Cholesterol depression and anxiety. There are a range health checks for people diagnosed with Glucose pressure of providers, with 10 services listed on 0 a serious mental illness in the WMCA the NHS Choices website for the West for 2012/13 and 2013/14 compared Figure 7: Percentage of patients with a diagnosis of SMI having different types of Midlands, in addition to those provided with national data. Across the CCGs physical health checks for 2012/2013 and 2013/2014 (Source: NHS Benchmarking, by the specialist mental health Trusts there is generally little variation in these 2016) and in primary care. CCG percentages. Further information on what treatment is subsequently offered, the Referral rates for IAPT vary across the Figure 5: IAPT referral per 100,000 population for WMCA CCGs January - December uptake and its impact on health inequalities country in 2014, and the West Midlands 2014 (Source: NHS Benchmarking, 2016) for this group of patients would be PROMISING PRACTICE: CITY AND HACKNEY PRIMARY CARE PSYCHOTHERAPY was below the national average for IAPT informative. 120 CONSULTATION SERVICE referrals per 100,000 population, with a Mean: 63% mean of 621, compared with a national 100 Median: 68% 3. Redesigning primary care mental City and Hackney Primary Care Psychotherapy Consultation Service (PCPCS), is an average of 691, referrals per 100,000. Upper quartile: 81% health services innovative outreach service provided by the Tavistock and Portman NHS Foundation However, the rate varies by CCG from 80 Lower quartile: 45% Despite its potential and central role, Trust and supports local GPs in the management of their patients with complex mental approximately 250 referrals per 100,000 primary care’s capacity to respond health and other needs that result in frequent health service use. This includes people population in Redditch and Bromsgrove 60 effectively has been problematic and with medically unexplained symptoms, diagnosis of personality disorders or long-term to 1200 plus in Walsall. This raises some consequently relationships with specialist mental health problems, not currently being managed by secondary mental health questions about the relationship between Percentage 40 mental health services have become services, and many of these people have poor physical health and social difficulties. level of need and referral rates. For example, fractious as these services increasingly The PCPCS operates in two distinct ways: (i) as a referral service, ie, providing talking Birmingham South and Central CCG (need 20 focused on people with a diagnosis of therapy interventions to individual patients; and (ii) as a consultancy service for GP and index = 1.56) has a lower rate of referral serious mental illness. Various models have other primary care staff, advising them on the management of patients with complex than Wyre Forest (need index = 0.66). 0 been tried over the past 20 years to improve needs. Forty to fifty GP patients a month are referred to the PCPCS service, over 60% There may be a number of explanations access to mental health support in primary of whom are from BAME groups. A typical course of treatment by the PCPCS lasts for for this, including better overall provision care but there is no clear model for how 12 or 13 sessions at an estimated average cost of £1,348 per patient. and a more developed voluntary sector in such services should be provided. It is Birmingham through which people can clear, however, that the primary care offer An evaluation of the service by Parsonage et al. (2014) found 75% of people using access psychological support. needs to go beyond providing access to the service showed improvements in their mental health, wellbeing and functioning and psychological therapies and physical health 55% were below the threshold for symptoms they had prior to treatment ie, ‘recovered’. CCG Nationally, the number of people waiting checks for people with a severe mental These results compare favourably with IAPT services, which tend to see people with less than 28 days for IAPT, between April Figure 6: Percentage of people waiting <28days for IAPT in WMCA in 2014/15 illness to respond to the broad range of less complex problems. Based on data from a sample of 282 patients, Parsonage et 1 2013 and 2014, rose from 57% to 64% Figure 1: % of people waiting <28days for IAPT in WMCA in 2014/15 mental health need that presents in primary al. (2014) estimated that treatment by the PCPCS reduced the costs of NHS service and to 67% in 2014/15. The WMCA saw 2014/15, broadly similar to the pattern of the presenting issues. Nonetheless, the care, including psychological issues use by £463 per patient in the 22 months following the start of treatment. This

an increase from 56% to 63% in 2013/14 for 2013/14. mean for the WMCA in 2013/14 was on associated with abuse and trauma, significantly offsets the cost of the service. The service performs very well in terms of and to 76% in 2014/15. Figure 6 illustrates this measure is 39% (range 10–70%) in medically unexplained symptoms and cost-effectiveness, with a cost per QALY gained of £10,900, which is well below the the range from 46% to 97% of people This suggests a good fit between the 2014/2015. The highest recovery rate was co-morbidities such as autism and bottom end of the NICE threshold range of £20,000–30,000. Furthermore, a survey being seen in less than 28 days in 2014/15, referral process and capacity to respond, in Cannock Chase CCG (69.4% of 680 accompanying mental health problems, of local GPs using the PCPCS found very high levels of satisfaction with the service, broadly similar to the pattern for 2013/14, whereas in other areas, the capacity may referrals) (HSCIC, 2015b) compared for example. covering such aspects as the referral process and the accessibility and responsiveness not be able to keep pace with the demand. with a national average of 41%. Further of the service. The CCG with the shortest average waiting This warrants further inquiry. interrogation of this data could be helpful As well as responding to expressed time from referral to the first treatment to identify whether the variation reflects need and intervening early, primary Source: Parsonage, M., Hard, E. and Rock, B. (2014). Managing patients with complex appointment was Dudley CCG at 6.7 days The number of people who were above a service user characteristics, organisational care has a central role to play in any needs: Evaluation of the City and Hackney Primary Care Psychotherapy Consultation (HSCIC, 2015b). It is interesting to note diagnostic threshold before treatment and arrangements or effectiveness of the IAPT prevention strategy because of its Service. London: Centre for Mental Health. that despite Walsall having the highest below it following treatment provides a services provided. provision of universal services, eg, to number of referrals per 100,000 population measure of people who are moving to pregnant women and new mums, sexual it is also has one of the highest rates for recovery but does not take account of the health and screening services and people seen in less than 28 days in extent of improvement or the complexity people with long-term physical health conditions and there are opportunities to strengthen these at a practice level.

59 The IAPT programme for children and young people differs from that for adults in being geared towards training staff to embed IAPT in Child and Adolescent Mental Health services (CAMHS). See: www.england.nhs.uk/mentalhealth/cyp/iapt/ [accessed 150816].

1 http://content.digital.nhs.uk/iaptreports [accessed 080916] 40 Mental Health in the West Midlands Combined Authority Mental Health in the West Midlands Combined Authority 41

For example, screening and early attenders to their GP as a consequence and alcohol service; education and Primary care generally relies on people EARLY INTERVENTION partnership between Birmingham intervention to prevent and treat (Merida Associates, 2015). employment and providing quick presenting and this can disadvantage Children’s Hospital NHS Foundation Trust, perinatal mental health problems, access to IAPT; mental health particular groups, particularly if this is The general principle of early intervention Worcestershire Health and Care NHS estimated at affecting up to 20% of All three wellbeing hubs appear to be professionals within primary care; associated with an emphasis on self- in mental health is widely promoted and its Trust, Beacon UK, The Children’s Society, women at some point during pregnancy well regarded and it is interesting to note gateway workers; and support from management, raising issues regarding application can be seen in the Health and Priory Group and a number of CCGs in and for the first year after birth that they have developed independently secondary care services63. equity of access. It has not been possible to Wellbeing Hubs; Mental Health First Aid the Birmingham area. The EIP teams are (Khan, 2015). with the consequence that there is establish this within the scope of this project training; Street Triage; and Liaison and located in Birmingham; Coventry, Nuneaton not a single city wide wellbeing hub. There is a range of other initiatives to but this warrants further consideration. A Diversion schemes for offenders with mental (North Warwickshire CCG), Leamington Sandwell was an early pioneer in  Dudley CCG62 is introducing a new support and develop the capacity of recent study suggests that a multi-faceted health problems. However, the main focus Spa (South Warwickshire CCG); Walsall initiating improvements in primary care model of care – a ‘Multispecialty primary care mental health including: intervention comprising community of any early intervention strategy to impact and Dudley; West Bromwich (West mental health through its introduction of Community Provider’ (MCP), which „„ Health trainers to support lifestyle engagement, high quality primary care and upon adult mental health should be Birmingham and Sandwell CCG) and the Sandwell Wellbeing hub60: offering includes a network of integrated changes psychosocial interventions adapted to the on children. Wolverhampton. Guidance has also been a range of self-help material, group multidisciplinary teams (MDT) „„ Social prescribing, which includes GPs needs of particular groups, can improve developed for GPs on the early identification work and individual support, including consisting of a GP, specialist nurses, prescribing exercise, books, art, access to effective support for under-served 1. Current provision in the WMCA of psychosis (French et al., 2014) but the the Esteem Team supporting people social workers, mental health services museums, computerised Cognitive groups (Dowrick et al., 2013). This model, The West Midlands was a pioneer in terms extent to which this has been implemented with mild to moderate problems (Thiel and voluntary sector link workers to Behavioural Therapy (CBT); educational Improving Access to Mental Health in of early intervention for psychosis (EIP) across the WMCA is unclear. et al., 2013). Other CCGs in the provide mental health and wellbeing activities; green gyms; museums; social Primary Care (AMP) (Gask et al., 2012) is services, which were first introduced to the WMCA are currently in the process of support at a primary care level. A enterprise schemes; time banks; worth considering for implementation and UK in Birmingham (Birchwood et al., 2013; 2. Performance against national indicators redesigning primary care mental health network of young health champions supported employment and volunteering. evaluation in a WMCA context. Lester et al., 2009). These services are a In 2014, the Department of Health and services to strengthen mental health to promote health and wellbeing is A wide range of benefits have been crucial element of improving outcomes for NHS England produced a first set of mental provision in primary care and access also being introduced. identified for social prescribing including This analysis indicates that developments people with severe mental illness and are health access and waiting time standards to wider services to support people  The three Clinical Commissioning increases in self-confidence and have largely been led by the initiative of local typically targeted at people aged 14–35 for introduction during 2015/16 (NHS in the community. These include: Groups (CCGs) across esteem; improvement in psychological primary care services, which may result in experiencing a first episode of psychosis. England, 2015). This included the target  Birmingham: Birmingham South Worcestershire, NHS Wyre Forest wellbeing and positive mood; reduction inequities in access and variations in the The aim of EIP services is summarised in that more than 50% of people experiencing and Central CCG introduced the CCG, NHS Redditch and Bromsgrove in anxiety and depression; improvements range of support available. Above all, the Figure 8. The services provided include a first episode of psychosis will be treated Edgbaston Wellbeing Hub in 2014, CCG and NHS South Worcestershire in physical health and reduction in GP WMCA should foster further development individual psychological therapy, family with a NICE approved care package within and more recently Birmingham Cross CCG, with Worcestershire County and primary care visits; reduction in of a framework of the key components of interventions, vocational and educational two weeks of referral. Data on performance City CCG has commissioned Council, are redesigning the primary social isolation; improved motivation and primary care mental health that is grounded support and case management. A three against this target has only started to be Birmingham Mind to deliver a care mental health service to increase meaning in life and acquisition of new in an appreciation of the wide range of roles year study was undertaken from 2003– made available from January 2016 and at Wellbeing Hub, offering one to one the wellbeing provision for people leaning and skills64. Social prescribing that primary care plays in promoting health 2007 of 14 EIP teams across the West the time of writing this report was only support/signposting and a range of experiencing low mood or anxiety; is, for example, linked to GP Practices and well-being. Midlands and highlighted some of the available for one of the providers in the workshops, groups and courses, reduce variations in access; strengthen in Dudley, while Solihull has a Social difficulties with implementation and variation WMCA. including five ways to wellbeing, partnerships and coordination with Prescribing Team and offers a ’personal across the Region (Birchwood et al., 2007). relaxation, mindfulness, self-esteem and employment services, Local Authorities buddy’ to help people to identify social confidence building and coping with and the third sector; ensure that people activities to improve their health and HOMELESS PEOPLE EIP teams are provided by three of the four anxiety and depression. Services at with more complex mental health wellbeing65. ARE TWICE AS LIKELY main specialist mental health providers with Edgbaston Wellbeing Hub include problems can step up and down „„ A GP to Consultant Helpline to help TO EXPERIENCE A COMMON MENTAL the Early Intervention and Detection Team „„ Prevent psychosis in the ultra- counselling, listening and guidance between primary and secondary care improve the liaison with GPs and transferring from Birmingham and Solihull high risk individuals by identifying sessions, life skills and befriending, services; and to identify potential saving ensure speedy access to clinical HEALTH PROBLEMS AND 4-15 TIMES Mental Health Foundation Trust (BSMHFT) and intervening on cusp of community and practical support, from secondary care to invest in primary advice, introduced by Coventry and MORE LIKELY TO EXPERIENCE PSYCHOTIC to Forward Thinking Birmingham in April psychosis self-help resources and one-to-one care. The proposed model will include a Warwickshire Partnership Trust. SYMPTOMS THAN THE GENERAL 2016. Forward Thinking Birmingham is a „„ Reduce the duration of untreated sessions. The Edgbaston Wellbeing single point of access and provide a „„ A single point of access is run by POPULATION psychosis by promoting early Hub has an Esteem Team, provided by range of wellbeing and psychological Birmingham Solihull Mental Health detection and engagement by Birmingham Mind and based on the therapy services in primary care and Foundation Trust for all CCGs for GPs community agencies and Sandwell model. This Team provides local communities, including wellbeing to refer for secondary care assessment. PROMISING PRACTICE: EARLY INTERVENTION IN PSYCHOSIS comprehensive initial mental health care coordination for people coming courses; personal development; lifestyle „„ Primary care liaison teams to deal with assessments and diagnosis. into the Hub and provides emotional advice and guidance; community non-urgent referrals from primary care, The Worcestershire EIP service has been identified as an example of promising practice „„ Optimise initial experience of and practical support to enable people therapies and helping people to provided by Black Country Partnership by NICE and NHS England (2016) in a resource pack to support the implementation acute care and treatment by to navigate the system. An initial connect with friends and neighbours; NHS Foundation Trust66. of the waiting time standard in relation to: providing ‘Youth friendly’ Acute evaluation suggests that the service recovery colleges; and will join up a „„ Family members of adults with psychosis or schizophrenia being offered Home based/Hospital Treatment can pick up people who may have fallen range or organisations and agencies family intervention. „„ Maximise recovery and prevent through the net of health and social proving relevant support, eg, support „„ Adults with psychosis or schizophrenia being offered combined healthy eating relapseduring critical period by care provision and become frequent regarding violence and abuse; drug and physical activity programmes, and help to stop smoking. providing integrated bio/psycho/ „„ Carers of being offered carer-focused education and support programmes. social interventions; focussing on functional/vocational as well as

60 www.sandwell.gov.uk/info/200222/healthy_sandwell_healthy_you/762/mental_health_and_wellbeing [accessed 150816]. This service (covering Bromsgrove, Redditch and Wyre Forest elements of the WMCA) symptomatic recovery; addressing 61 http://birminghammind.org/services/wellbeing-hub/ [accessed 150816]. comprises two teams covering north and south Worcestershire, with a skill mix in co-morbidity and treatment 62 Dudley is one of 29 areas selected to test a new model of care following the publication of the Five Year Forward View (5YFV) in October 2014. keeping with that recommended for delivery of NICE-recommended care. The service resistance early and supporting See www.dudleyccg.nhs.uk/about-commissioning/integration/ [accessed 040516]. places a strong emphasis on carer support and has a project underway to recruit more carers and network of community 63 www.southworcsccg.nhs.uk/get-involved/pmhs/ peer support workers. It has developed a physical health intervention programme support agencies 64 www.slideshare.net/NCVO/museums-on-prescription-social-prescribing-presentation – Supporting Health and Promoting Exercise (SHAPE); a structured and intensive 65 www.healthexchange.org.uk/services/solihull-social-prescribing/ 12-week course with follow-up, drawing on the expertise of nutritionists, exercise 66 www.bcpft.nhs.uk/services/mental-health/83-for-adults/community-services/21-primary-care-liaison-teams physiologists and health trainers. Figure 8: Aims of Early Intervention in Psychosis services (Source: French, 2016) 42 Mental Health in the West Midlands Combined Authority Mental Health in the West Midlands Combined Authority 43

„„ Four beds for men and women, PROMISING PRACTICE: CRISIS HOUSES PROMISING PRACTICE: managed jointly by the charity P3 and EARLY INTERVENTION Sandwell Crisis Home Treatment team Crisis houses provide an alternative to inpatient wards and there is a growing body of FOR ADVERSE CHILDHOOD EVENTS in Sandwell, with 24-hour support evidence that not only do service users prefer residential crisis houses, mainly provided providing an alternative to hospital by the voluntary sector, they are less stigmatizing and coercive, thus proving a viable A recent review of the evidence by the admission alternative for people not needing close supervision (Howard et al., 2008; Johnson Early Intervention Foundation identified „„ A six-bedded house in Leamington Spa, et al., 2009; Sweeney et al., 2014). The provision of women-only crisis houses enables that the evidence is strongest for provided by Rethink, where people can women to be accommodated with their young children. There is some evidence that they programmes that target children and stay for a maximum of 14 nights, during may be more cost-effective than psychiatric inpatient care (Fenton et al., 2002; Howard parents based on early signals of risk, which time staff will provide emotional et al., 2010), can facilitate effective and timely discharge (Appleton and Appleton, 2014) particularly child behaviour problems, and practical support to assist people and, in building on informal peer support, extend networks and repertoires for crisis insecure attachment, delayed using the service to resolve their crisis management in the event of future difficulties (Sweeney et al., 2014). A recent evaluation development of speech and lack of and focus on recovery of a crisis house in Tower Hamlets found that the cost of a bed in the Crisis House maternal sensitivity (Asmussen et al., „„ A three-bedded house in Cannock, was half that of an inpatient bed in the local mental health Trust (Appleton and 2016). The authors note that universal provided by Housing Plus and Richmond Appleton, 2014). services are vital, therefore, to support Fellowship and providing a short term families and children as a whole and 24-hour Supported Intervention Service as a means to identifying risk and STREET TRIAGE to the appropriate police force to provide accommodation for a three day CRISIS INTERVENTION While primary care and specialist mental targeting support on those who need In Birmingham and Solihull, the immediate crisis intervention if available. placement for people in the South health services form a key strand of the it most. Blackburn with Darwen CCG recognition that mental health relates The focus of their model is to prevent Staffordshire area 1. Provision in the WMCA mental health crisis response across these is using the Routine Enquiry about to about 20% of police activity, and that further crisis through preventative „„ A three-bedded house in in North If not managed well, the experience of domains, the broad range of voluntary Adversity in Childhood (REACH) the service delivered was considered by intervention. Of note is the partnership Warwickshire provided by Friendship a mental health crisis can have a long sector and community contributions is screening tool to identify adults with service users to be poor, Street Triage working across organisational boundaries Care and Housing in partnership with lasting and negative impact not only for the key in promoting resilience, wellbeing, high ACE scores, which may lead to (mental health nurse, police officer and and different sectors to facilitate people Beechdale Community Housing, individual concerned but also their family, empowerment and care for people poorer health and social care outcomes paramedic) was piloted in 201468. receiving an appropriate and timely providing accommodation and support and may influence their capacity for in crisis. The Crisis Care Concordat, and expose their children to risk of Between Jan 2014 and August 2015, response. between 8.00am and 10.00pm for self-management and willingness to seek established in 2014 provides a map of adverse experiences, and is identifying street triage dealt with 4,409 incidents. people living in North East Warwickshire: help in the future. The CQC has identified services and organisations that have agreed interventions to provide support to It prevented 1,160 people attending A&E, There has been no comparison of these Nuneaton, Bedworth, North that mental health crisis care provision is to work together, to make sure that people these families67. prevented the use of 1,654 ambulance different models at a local level but the Warwickshire and Rugby both inconsistent and inadequate (CQC, get the help they need when they are having journeys and 1,025 police resources national comparative evaluation of nine 2015a). Resonating with the findings a mental health crisis, and action plans of being dispatched. Since Street Triage was pilot sites identified a number of factors A review of the current Crisis Care from a survey of service user and families’ the necessary steps needed to improve services. For example, the Staffordshire introduced in Birmingham and Solihull in associated with better outcomes (Reveruzzi Concordat action plans for the core experiences of crisis care (McPin, 2015), local access. The action plans are Crisis Concordat partners are exploring 2014, only two people have been and Pilling, 2016). These include: members of the WMCA identified the the CQC have concluded that many people developed between commissioners, local options for peer support-based hub model. detained in a police cell under s13669 of „„ Joint ownership at senior management following proposals in relation to crisis in crisis are unable to access the help they authorities, mental health and non-mental the MHA 1983. The national evaluation level and regular review of joint working accommodation: need when they need it and are dissatisfied health providers, police, local ambulance The 111 helpline and A&E also play a role reported that approximately a quarter of „„ Effective information sharing between „„ Walsall CCG/Council plans to with the help when they receive it services and voluntary sector organisations in enabling people to access urgent and incidents (26.4%) involved people from services, in particular, access to health develop a specification for social (CQC, 2015a). and it is clear that an effective crisis emergency care in a crisis and for some BAME communities (Reveruzzi and Pilling, information care crisis accommodation. response will only be achieved by all these people will be a first port of call. The 2016). In 2015, the triage team was able „„ Provision of timely advice „„ Birmingham Cross City CCG is The opportunities for crisis intervention organisations working in partnership. Many specialist mental health NHS Trusts also to provide a response to 60% of the to police officers at the point of initial proposing to develop a strategy for identified by the Crisis Care Concordat of the action plans outline steps to develop provide Crisis Resolution Teams (see incidents on site. Of the remainder 41% contact and during the assessment needs of people with non-psychotic (HM Government, 2014) are: a single point of access, the development of Appendix 8). The recent CQC report were taken to A&E, 7% to a specialist process personality issues, which will include „„ Access to support before a crisis an urgent care pathway; Police Custody looking at experiences of crisis care found hospital and the rest to a range of „„ Integration of Street Triage with the non-statutory crisis houses. through provision of information, Liaison and Diversion schemes; improved that people valued the support that they destinations, including home, to a relative’s health service-based crisis pathway preventive activities and supporting support for children and young people and received from volunteers and charities, GPs, home or a place of safety in a voluntary „„ Joint training programmes for Street self-directed care for people from BAME communities. They ambulance staff and the police far more capacity. The service was extended to the Triage staff. „„ Urgent and emergency access to reference other initiatives, particularly in than that received in A&E or from specialist Black Country in September 2014 and a SINCE STREET crisis care relation to early intervention, such as the mental health teams (CQC, 2015b). different model piloted in Coventry (CPN The authors recommended the provision „„ Quality of care during a crisis including provision of IAPT, and to varying degrees and police officer available from 5.00pm– of a 24-hour service seven days a week. alternatives to inpatient admission they emphasise the importance of building 3.00am). West Mercia Police in alliance They identified the co-location of health and „„ Recovery and relapse prevention resilience and capacity building as well with Warwickshire Police have recently police staff (eg, linked to a Control Room) TRIAGE enabling people to stay well as fast tracking through to appropriate commissioned a mental health nurse in the or dedicated phone line(s) as an important control room to support the police in component of effective Street Triage WAS INTRODUCED IN responding to emergency calls and South schemes, which could support a cost- Staffordshire Police have a triage team effective roll out of the programme. BIRMINGHAM AND (police officer and mental health nurse) who provide on the street support and CRISIS HOUSES SOLIHULL IN 2014, phone advice from staff within the Liaison Despite an increase in the number of crisis ONLY TWO PEOPLE and Diversion Programme. The British houses across England in the last two HAVE BEEN DETAINED UNDER S136 67 www.eif.org.uk/case-study/blackburn-with-darwen-ace-adverse-childhood-experiences-screening-pilot/ [accessed 050616] Transport Police have also adopted years, there are only four crisis houses 68 www.heartofengland.nhs.uk/wp-content/uploads/Street-triage-presentation-Dec.pdf a non-mobile model but will route through in the West Midlands: IN POLICE CELLS 69 S136 of the 1983 Mental Health Act allows the police to take anyone, who they believe is mentally unwell and in need of care and assistance, from a public place to a place of safety. 44 Mental Health in the West Midlands Combined Authority Mental Health in the West Midlands Combined Authority 45

450 PROMISING PRACTICE: 400 SECONDARY MENTAL IMPROVING ACCESS TO PROMISING PRACTICE: RAPID ASSESSMENT INTERVENTION AND 350 HEALTH SERVICES APPROPRIATE SUPPORT FOR DISCHARGE (RAID) PEOPLE FROM BAME 300 250 COMMUNITIES 1. Provision in the WMCA The RAID service has been the focus of a number of evaluations all of which have 200 Nationally, approximately 2% of the been positive about its impact including improvements to health and wellbeing as a In recognition of the potentially 150 adult population have some contact with consequence of providing mental health care for people with physical health problems 100 problematic pathways into services per 100,000 population specialist mental health services during in acute hospital (Tadros et al. 2013). There is also evidence that the RAID service is and poor experience of support 50 the course of a year (NHS Benchmarking, good value for money saving money through reduced bed use with a return of £3–4 in a crisis for people from BAME 0 2016). There is, however, considerable for every £1 invested (Parsonage and Fossey 2011; West Midlands CSU). An communities (Race Equality variation across England, as illustrated by evaluation undertaken by Griffith and Glasby (2015) identified the lessons for the Foundation, 2015), some areas are Figure 10, and the West Midlands has roll out of RAID and noted that the key factors influencing its success were the taking targeted action to address lower numbers of people in contact with way in which it was planned, resourced, staffed, and supported. While fidelity to the this. In Dudley, for example, the specialist mental health services than other model was important the role of contextual factors needs to be recognised and Equalities Act provides a framework areas of England, notably the East Midlands, thus sufficient planning and time allowed for successful adaptation of the model for improving the equality of access North West and London. There are four to local circumstances. and outcomes for people from main providers of specialist mental health communities with protected services, providing inpatient and community Figure 9: Attendances at A&E for a psychiatric disorder per 100,000 population characteristics under the Act. This services to the majority of WMCA residents: people living in Coventry, Warwickshire provided predominately to Dudley and (2012/13) (Source NHS Benchmarking 2016) includes: involving people from these  Birmingham and Solihull Mental Health and Solihull. The Trust provides Walsall, with a population of around communities in the commissioning of NHS Foundation Trust (BSMHFT) some specialist services to a wider 560,000, but also to neighbouring crisis services; ensuring the services 2. Performance against national indicators 3. Redesigning the urgent care pathway provides a wide range of inpatient, geographical area, and also provides Trusts in Worcestershire, Staffordshire, commissioned can deliver a range of Nationally, A&E attendances for mental As noted earlier the redesign of the crisis community and specialist mental a wide range of community physical Birmingham and Warwickshire. The care options that meet a diverse health problems or self-harm represent care pathway is a key NHS England target health care to those people living in health services for people in Coventry. Trust employs just over 1,000 health range of needs; empowering people 1.5% of all A&E attendances (NHS for CCGs and likely to be a central theme Birmingham and Solihull who are The Trust employs approximately and social care staff. by providing appropriate information, Benchmarking, 2016). The rate of within the STPs. An example of redesigning experiencing severe mental health 4,000 staff.  Specialist mental health services for access to advocacy services, and attendances at A&E for people with a the crisis care pathway is the work problems, serving a culturally and  Dudley and Walsall Mental Health adults are also commissioned from ensuring that they are engaged in, mental health problem, in the WMCA, was undertaken by BSMHFT, to design an socially diverse population of over a Partnership NHS Trust (DWMH) South Staffordshire and Shropshire and have control over, their care 180 per 100,000 population, below the urgent care pathway to offer comprehensive million. The Trust provides specialist provides a full range of mental health Mental Health Trust and and treatment; commissioners and England average of 250 per 100,000 for crisis support to the population of services for residents outside of the treatment and rehabilitation services for Worcestershire Health and Social providers meeting with community 2012/13 (NHS Benchmarking, 2016). The Birmingham and Solihull. This includes the area including the national deaf mental children, adults and older adults, that Care Trust, particularly for residents leaders to understand any barriers rate for admissions for self-harm was 183 Rapid Assessment, Interface and Discharge health service (Birmingham-based), manage both common and complex of Bromsgrove, Redditch and Wyre that may get in the way of people per 10,000 population for the WMCA, also (RAID) liaison psychiatry service, Psychiatric perinatal mental health, neuropsychiatry mental health conditions. The Trust’s Forest. Forward Thinking Birmingham accessing the help that they need below the national average of 191. It is Decisions Unit (PDU), Street Triage, British and eating disorders. The Trust also range of services spans primary care (FTB) provides a broad range of and reviewing service access data difficult to know, in the absence of other Transport Police, 111 and active bed provides forensic services for children counselling and psychological therapies services for 0–25-year-olds across against demographic and prevalence data, whether this indicates that people management. RAID, an award-winning and adolescents, men and women and for common mental health problems Birmingham and has been fully data to identify gaps in access who would have presented at A&E are well service, available 24/7 to all people aged manages the delivery of all healthcare through to the treatment and care of operational since April 2016. FTB rates for people with protected served by other services, such as primary over 16, provides a liaison psychiatry services at HMP Birmingham. The Trust people detained under the Mental is responsible for all pathways for characteristics. It is very clear that care mental health services, or whether service in acute (non-psychiatric) hospitals. employs approximately 4,000 staff. Health Act and those with severe and 0–25 year-olds, with the exception some communities prefer and will there are barriers to access. Figure 9 It is integrated within five such hospitals  Black Country Partnership NHS enduring conditions. Core services are of place of safety arrangements. use services provided by their illustrates the variation between CCGs in in Birmingham and Solihull, and receives Foundation Trust (BCPFT) provides community, in which they have 2012/2013, which may reflect differences about 1,400 referrals per month. mental health and specialist health higher levels of trust and this has in proximity to A&E departments and/or learning disabilities services to PROMISING PRACTICE: OPEN DIALOGUE implications for commissioning under-development of accessible A notable example of redesigning the crisis people of all ages in Sandwell and these organisations to provide the crisis support. care pathway is also provided by North Wolverhampton as well as specialist Open Dialogue offers a model of crisis response, service delivery and therapeutic necessary support. West London Urgent Care Assessment and learning disability services in Walsall, engagement that has delivered exceptional shorter and longer term outcomes in Care Pathway Redesign in which 8 CCGs Wolverhampton and Dudley and Western Lapland where it has been developed over the last 20 years. A ten-year follow are working together with key stakeholders community healthcare services for up study (Seikkula et al, 2011) found that: on the redesign70. children, young people and families  81% of patients did not have any residual psychotic symptoms in Dudley. The Trust employs  84% had returned to full time employment or studies. approximately 2,000 staff.  Only 33% had used neuroleptic medication  Coventry and Warwickshire Partnership NHS Trust (CWPT) provides a wide Comparable figures for services in other western countries suggest a norm of only ORGANISATIONS range of mental health and learning around one-third of people with psychosis achieving a full clinical recovery. An early disability services for people of all evaluation of the introduction of this approach in the USA found that it could deliver IN THE WMCA HAVE BEEN ages to a population of about 1 million good clinical outcomes, high satisfaction, and shared decision making, although introducing the new service model required a substantial investment in training – an investment that would easily be recouped if outcomes were as good as in Western PIONEERS IN DEVELOPING Lapland (Gordon et al., 2016). Key features of the approach are an immediate crisis response, continuity in the therapeutic team over the course of crisis and recovery, INNOVATIVE MODELS OF CARE and full involvement of the person, their family and significant others in regular network meetings at which difficulties and experiences are discussed and at which any

70 http://16878-presscdn-0-18.pagely.netdna-cdn.com/wp-content/uploads/2014/07/NWL-Urgent-Care-Programme-Overview-for-MIND-Website-020714.pdf decisions regarding treatment are made. 46 Mental Health in the West Midlands Combined Authority Mental Health in the West Midlands Combined Authority 47

1600 Black Country Foundation 1400 Trust The four main providers (BSMHFT; BCPFT; the home rather than on an individual case The mean length of stay (LOS) for acute Trust Mean length of stay (days) CWPT; DWMHPT) have come together to basis (NHS Benchmarking, 2016). There inpatient wards for each of the providers 2013–14 2014–15 2015–16 1200 Dudley and Walsall Mental form an alliance under NHS England’s New was an average of 185 (range 164-230) is provided in Table 2, with the combined BSMHFT 34 36 34 Health Partnership Trust Care Models Vanguard Programme: the admissions to inpatient care per 100,000 average slightly above the England average 1000 Mental Health Alliance for Excellence, population during 2013/14, compared with of 33 days. This excludes people placed out BCPFT 36 37 35 Coventry and Warwickshire Resilience, Innovation and Training (MERIT). an England average of 227 (range 130 – of area and specialist placements, which will 73 800 CWPT 32 43 34 Partnership Trust The alliance will focus on three priority 450). Admission rates are influenced by a have longer LOS, reflecting the complexity DWMHPT 38 47 38 areas to rapidly realise quality and efficiency range of factors including bed numbers, of people’s mental health difficulties. 600 benefits, spread best practice and reduce bed occupancy and access to community Overall mean 35 41 35 Birmingham and Solihull variations in cost and quality through support and supported accommodation. 400 Mental Health Foundation Trust integration across current geographical and Table 2: Mean lengths of stay (LOS) for 71 organisational boundaries . These areas 3. Number and use of inpatient beds the NHS Trusts 2013-2016 (Source: 200 Birmingham Community are seven day working in acute services; At any given point, around 2% of service Trust data 2016) Healthcare crisis care and the reduction of risk; and users in secondary mental health care will 0 promoting a recovery culture. Detail on the be in mental health inpatient beds. The 2011 2012 2013 2014 2015 four Vanguards in the WMCA is provided remaining 98% will be under the care of 4. Use of the Mental Health Act in Appendix 9. community mental health teams. From data In 2013/14, 26% of people admitted to Figure 12: No of people detained on March 31st by NHS provider (Source: KP90, Health and Social Care Information Centre)75 provided by the four main NHS Trusts, there inpatient care were detained under the 2. Number of people in contact with were 1,343 beds available for adults of MHA, slightly above the national average secondary mental health services working age, which includes inpatient, of 23%. In England in 2014-2015, there 01.04.15– 01.01.16– Total This measure uses the number of service rehabilitation and low and medium secure were a total of 25,117 people subject to the 31.12.15 01.03.16 2015–16 72 users registered (on caseload) with mental beds, for 2015 . This compares with 1,322 1983 Mental Health Act (MHA). Of these, The number of section 136 detentions where the person was taken 2 0 2 health Trusts, against wider England beds in 2012, representing an increase 19,656 were detained in hospital and 5,461 directly to a police station population data (NHS Benchmarking, of 1.6% over two years. The data for were being treated under Community The number of detainees under 18 that went to a police station 0 0 0 2016). In the WMCA in 2013, there were 2015/2016 is not entirely clear because Treatment Orders (CTOs). This represents 2,205 people per 100,000 population one of the Trusts (CWPT) amalgamated an increase in the number of people The number of section 136 detentions where the person was taken 764 225 1019 in contact with specialist mental health their services for older people and adults subject to the Act of 1,586 (or 6.7 per cent) directly to a health based place of safety services compared with the national of working age during 2014/15 so that compared to 31st March 2014, and an The number of detainees under 18 that went directly to a health based 19 10 29 average of 2,210. A more detailed analysis services are age independent and the increase of 4,179 (or 20%) compared to place of safety of caseloads indicates that very few people apparent reduction may reflect the different the 31st March 2011 snapshot count. This are registered with specialist mental health way of categorising beds. The main finding national increase is reflected in the increase Table 3: Place of safety detentions for 2015-2016 (Source: West Midlands Police) services if they are living in a residential from this analysis is that while the overall in the numbers of people detained in the or care home. In the WMCA, there is an bed numbers are broadly similar to four main NHS provider Trusts in the West Any Other Ethnic Not Stated average of 31 people in residential or years ago, there has been an increase in Midlands (as illustrated in Figure 12). Group 2% nursing care in touch with specialist mental the number of secure beds and a reduction Differences between providers will reflect 3% health services per 100,000, very similar to in the number of beds for older adults, the size of population covered and provision Chinese the national average. It is suggested that as illustrated in Figure 11. of secure services and national specialist 0% this may reflect a multidisciplinary input to services, with BSMHFT being the main

provider of these services. In the West Black/British 1600 Midlands, in 2014/15, the average rate AfricanCaribbean of detentions was 81.2 per 100,000 /Mixed 1400 population, slightly above the England 20% average of 77.2. However, the rate ranged White British 1200 Figure 10: People in contact with mental from 43.7 for Warwickshire North CCG 54% health services per 100,000 population to 165.4 per 100,000 population74 for Asian British Adult beds (April–June 2013) Source: NHS 1000 Birmingham South and Central CCG. 16% Benchmarking (2016) Low/medium secure This variation is likely to reflect differences 800 in acuity and complexity of people living in CAMHS an urban environment as well as the local Any Other Mixed 600 Older people system configuration and culture. 0% Total White Irish/Other 400 The increased use of the MHA in a context White of stability in the number of beds available 5%

200 raises questions about the number of people that are being admitted to units Figure 13: MHA Detentions by ethnicity 2015-2016 (Source: NHS Trust data 2016) 0 outside the West Midlands. The national 2012 2013 2014 2015 2016 figures show that there has been an has also been increasing (Health and Social USE OF SECTION 136 Figure 11: Mental health inpatient beds by the four main providers in the West increase in use of both Section 2 Care Information Centre, 2015b). Further From data provided by the four main mental Midlands 2012–2016 (Source: NHS Trust data 2016) (on admission) and Section 3 (following analysis is required to establish whether health Trusts, there were over 535 uses of admission). The number of uses of this is the case for the WMCA. Section 136 in 2015-2016. The ethnicity

71 See: www.dwmh.nhs.uk/west-midlands-mental-health-trusts-forge-alliance-to-transform-acute-care [accessed 030316]. Community Treatment Orders (CTOs) recorded for the use of Section 136 72 From April 2016, specialist inpatient beds for 0–25-year-olds are provided by FTB. 73 Includes people over 65 as the service moved to an age independent service from 2014. 48 Mental Health in the West Midlands Combined Authority Mental Health in the West Midlands Combined Authority 49

Provider Name 2012–13 2013–14 Number of Number of Number of uses Number of uses of people of restraint people population because of different catchment to reducing the use of restraint, The figures on their own do not enable an bias in referrals and provision (Randall et al, restraint restrained restrained areas. Nonetheless, this is a trend that which is experienced as traumatic understanding of the service provided or 2015). Figure 16 illustrates the mismatch deserves further investigation alongside and dehumanising and runs counter outcomes for service users. As a minimum, between estimated need and provision, with England 17,358 3,699 23,926 6,380 analysis of the profile of those people to a recovery-focused service there needs to be an analysis of the more referrals coming from the areas closer BSMHFT 1,475 210 1,750 430 detained in secure services and placed (Huckshorn, 2006). relationship between need, service provision to the perinatal mental health unit (located BCPFT 35 15 out of area. and outcomes. A comparison of the by the Women’s Hospital). GPs in the The total number of deaths in inpatient population of women in Birmingham and South of the city were also more likely to CWPT 300 195 495 190 5. Use of restraint and deaths in care for the four main providers between Solihull accessing specialist community make a referral and the community services DWMH 140 55 inpatient care 2013-2016 was 22: 14 as a result of perinatal mental health services over an were achieving better outcomes for women From data provided by the four main suicide and eight unexpected deaths, 18-month period from 1 December 2012–1 of white ethnicity than women from BAME Table 4: Use of physical restraint 2012-201477 providers, the number of uses of restraint for generally attributed to natural causes. August 2013 with census data, indicated a communities (Randall et al., 2015). 2015/2016 was just under 3,000 (2,914): 20 a 25% increase from 2013-2014. These 6. Outpatient and community services figures include all episodes of physical The functionalised model for community 18 restraint, and physical restraint and rapid mental health teams, as described in the 16 tranquilisation. Table 4 provides a summary mental health National Service Framework 14 of the use of physical restraints for the (Department of Health, 1999), emerged 12 Trusts from the Minimum Mental Health from innovations in the West Midlands, 10 2013/14 Data Set (MHMDS). However, the particularly in relation to early intervention, higher rates for BSMHFT reflects that crisis intervention and home treatment 8 2014/15 they are a provider of specialist secure teams. The four NHS Trusts currently 6 2015/16 services, which will have higher uses of provide a broad range of community 4 restraint than acute inpatient service services, which focus largely on people with 2

No of restarints per 1000 bed days because of the greater complexity of a diagnosis of mental illness, personality 0 people’s needs, which is likely to include disorder and co-morbid conditions. BCFT BSMHFT CWPT DWPT substance abuse as well as mental illness. NHS Mental Health Trust The main community teams are:   In order to make more meaningful Early intervention teams, providing Figure 14: Uses of restraint per 1000 bed days by NHS Trusts in the WMCA comparisons between the Trusts, data on assessment and interventions for the use of restraints for acute adult inpatient people with a first presentation of care was obtained and the rate of restraints psychosis; indicates that 55.5% of people were White and Indian), mixed White/Asian or Other calculated per 1000 bed days for each  Intensive home based treatment teams, British and 42% from BAME communities Asian; 21.9% Black British (African/ Trust, as summarised in Figure 14. The providing rapid response and crisis with British Asian and Asian; and Black Caribbean), mixed White/Black and Black mean rate for all types of restraint over the support for service users and family/ British, African, Caribbean and people of other and less than 1% were Chinese, last three years was 14 uses of restraints friends and, potentially, providing an mixed heritage constituting 15% and 15% with the remainder coming from other per 1,000 bed days (range 9–18 restraints alternative to inpatient care; of the total respectively. People of Chinese ethnic groups or for whom ethnic origin per 1,000 bed days).  Community mental health teams, heritage made up less than 1% of the total. was not stated, as illustrated in Figure 13. providing assessment, care planning From data collected by West Midlands From data provided by one of the Trusts, and support; Police, only two people were taken to a The over-representation of people from the use of restraints for people with a  Recovery and wellbeing teams, Figure 16: Number of women seen by community perinatal mental health services in police cell as a place of safety between specific BAME communities, detained learning disability was substantially higher enabling daily living, problem-solving each middle super output layer in Birmingham (2013 data). Source: Randall et al., 2015) April 2015 and March 2016 and none under the MHA, has been consistently and the data in Figure 14 excludes this and coping skills; of these people were under 18; as highlighted by the Count Me In census data and that for secure services, where  Assertive outreach teams, supporting CMHTs summarised in Table 3. reports and subsequently the Care Quality the rates are also likely to be higher. people with severe and persistent Commission annual reports (CQC, 2012; mental health problems and complex Crisis resolution/home MENTAL HEALTH ACT DETENTIONS 2014; 2016). The local data fits this pattern An FOI request by Mind has indicated needs who are hard to engage. treatment teams BY ETHNICITY with people from BAME communities variation between Trusts in the use of General psychiatry accounting for approximately 42% of the restraint and recommended that face down Appendix 8 provides a breakdown of the From NHS Trust data, of the total number number of detentions compared with 22% restraint should be a ‘never event’ (Mind, contacts by organisation and team type. Day services/day care of people detained on a Section 2 or 3 in of the overall population for WMCA. It is 2013). The Mind report reinforces the While information on contacts alone is not Early intervention in psychosis 2015-201676: 57.8% were White British; likely that the detention figures do not need for a proactive and preventative particularly meaningful or illuminating it 14.3% British Asian (Bangladeshi, Pakistani correspond exactly with the WMCA approach by commissioners and providers provides an indication of the balance of Assertive outreach teams activity, as illustrated by Figure 15, which provides a breakdown of contacts between Rehab/recovery services that account for 84% of the total Psychiatric liaison 74 Inpatients Formally Detained in Hospitals under the Mental Health Act 1983 and Patients Subject to Supervised Community Treatment, England – 2014–2015: contacts for adults aged 18–65, for mental 78 http://content.digital.nhs.uk/catalogue/PUB18803 [accessed 160816]. health problems . As this illustrates, Eating Disorder services 75 Birmingham Community Healthcare Foundation Trust provides services to people with learning disabilities. approximately half of the contacts were 76 with CMHTs or Crisis Resolution/Home Excluding people detained in secure services or specialist provision for BSMHFT. Psychol therapy (non IAPT) and 77  Treatment Teams representing 40% of Data source: Health and Social Care Information Centre Mental Health Minimum Dataset (MHMDS) 2012-13 [see http://content.digital.nhs.uk/catalogue/ psychotherapy PUB12745, accessed 141016] and 2013-14 Annu al files [see: http://content.digital.nhs.uk/catalogue/PUB15990, accessed 141016] the total number of contacts. 78 The remainder, not included, are perinatal; forensic; Liaison and Diversion; substance abuse; early onset of dementia and other services that are unclassified or for Figure 15: Proportion of contacts by service type for 2014-2015 which data is missing. (Source: Mental Health Bulletin: Annual Statistics 2014-15) 50 Mental Health in the West Midlands Combined Authority Mental Health in the West Midlands Combined Authority 51

7. Spend on specialist mental health services Based on data from 12 CCGs for admission as the solution to a mental PROMISING PRACTICE: REDUCING THE USE OF RESTRAINT PEER SUPPORT by CCGs 2015/16, the spend by these CCGs on health crisis (Crisp et al., 2016). The contribution of peer support is now Across England, the average CCG OATs was £20 million giving an average Six core strategies aimed at reducing the use of seclusion and restraint have widely recognised as helpful in promoting spend in 2013/14 was £154 per head of spend for CCGs of £1.7 million with a There are initiatives in the WMCA to reduce been identified in the U.S. (Huckshorn, 2006). These strategies are grounded in wellness and empowerment, with many population and there was nearly a threefold range from around £70,000 to over £2.9 the use of Out of area Placements. Solihull a quality improvement perspective using a preventive trauma-informed approach voluntary and community organisations variation in the level of CCG spend on million. This is an underestimate because CCG, for example, has developed a (LeBel et al., 2014) and are: encouraging peer support (National Voices, specialist mental health services when not all CCGs responded and there are step-up/step-down unit within Aviary 1. Continuous involvement of senior organisational leadership (ie, the CEO) 2015). There are many different forms of assessed as a percentage of total CCG differences in the way CCGs collate House, a supported living facility in North 2. Use of data to inform practice at the individual unit level peer support and it is of value across public expenditure. For the same period, the the data on OATs expenditure. The Solihull, with 28 self-contained, one 3. Ongoing staff training and education, including mentoring and supervision, services. In a mental health context, the average spend on mental health in the expenditure covers: bedroom flats proving long term placements focused on primary prevention and intervention key elements include building on shared WMCA was £164 per head of population,  Acute overspill beds for people who to clients. Although a recent development, 4. Use of seclusion/restraint tools: to identify persons with high risk factors for personal experience to focus on strengths with a range from approximately £110 to require an assessment and treatment this is impacting positively on the use of death and injury; use of safety plans; the use of person-first, non-discriminatory and promote wellbeing and recovery, £220 (South Warwickshire CCG). admission but there are no local beds acute overspill beds. In addition, the CCG language; environmental changes to include comfort and sensory rooms; and through self-help groups, mutual peer available is actively supporting three clients to return meaningful treatment activities designed to teach people emotional self- support, formal peer support and online 8. Out of Area Placements  Specialist placements, notably for to Solihull by the autumn and using the management skills (Huckshorn, 2008). peer support (Mental Health Foundation, Individuals may be placed in residential or people with a diagnosis of personality resources released to invest in stronger 5. Inclusion of service users, carers and families in inpatient care as advocates 2012; Faulkner and Kalathil, 2012; inpatient settings within the statutory, disorder, or autism with a comorbid community personality disorder provision. and peers and event oversight National Voices, 2015). voluntary and independent sector, outside mental health problem 6. Debriefing techniques developed from evidence and analysis of incidents. their geographical area of origin (known  Locked rehabilitation beds A repatriation project to bring people with This approach has been implemented in different health care contexts, ADVOCACY as Out of Area Placements or Out of Area  Psychiatric Intensive Care Unit (PICU) mental health problems, and learning particularly mental health, in various countries and has been adapted as a Advocacy, in its various forms, has an Treatments (OATs)). This happens because beds in the absence of local provision disabilities, from Coventry and Warwickshire programme known as REsTRAIN YOURSELF, which is being piloted and important role to play in ensuring that an the provision required is not available in the closer to home has been running for four evaluated for mental health in the North West of England (LeBel et al., 2104). individual’s voice is heard and in promoting specific locality either because there is The variation between CCGs will reflect years. To date 100 people have been empowerment. Many people will be able none or because the demand in the area acuity and the range of local provision. repatriated at a cost saving £12 million80. to advocate for themselves but having outstrips the supply, and is therefore, an Further clarification on how locked This project between CWPT, three CCGs There are also initiatives that are targeted The CCGs, Mental Health Trusts and their someone else to speak on your behalf indicator of performance. The national rehabilitation beds are being used is – Coventry and Rugby, North Warwickshire at specific populations and these include: partners are also actively working on the at a time of crisis can be vital and is one picture suggests that spending on OATs needed as this type of provision lacks a and South Warwickshire and the NHS 300 Voices and community engagement redesign of mental health services as part of measure for ensuring that people’s rights is increasing, reflecting reductions in the clear service description, the people that Arden and Great East Midlands (BSMHFT) (see co-production section) their Transformation Plans to meet national are protected (Newbigging et al., 2015a). numbers of acute hospital beds and these services are designed for and their Commissioning Support Unit, demonstrates  The four mental health Trusts are part policy objectives, particularly in relation to This is particularly important when people’s changes to community services, following interface with low secure beds (Dye the value of multi-agency strategic of the West Midlands Hub, which is a parity of esteem to ensure mental health views are at risk of being discounted the merger of specialist functions into et al., 2016). partnerships and the Trust and the CSU collaboration between eight providers services have the same priority as physical in order to prevent distress and generic community mental health teams recently won an award for this work81. to coordinate, and promote the mental health services across all age groups, and misunderstandings resulting in negative, (King’s Fund, 2015). Out of Area Mental Health Trusts may also be spending The EIP work stream in Wolverhampton health and appropriate care of to ensure that people can access care as and potentially costly, outcomes (Centre placements impact adversely on service money on placing people that require a bed has a focus on reducing OATs for people veterans82. CWPT, for example, close to home as possible. This includes for Social Justice, 2011). Although the user experience and have been associated but cannot be accommodated as the CCG with psychosis. provides a service for veterans to developing better crisis and urgent care evidence base for advocacy is under- with increases in patient suicides (National may have included that requirement within ensure access to priority treatment for and strengthening early intervention,; as developed, a wide range of impacts have Confidential Inquiry into Suicide and a block contract. The CCGs may also be 9. Local initiatives veterans; establishing an enhanced well as building on the positive impact of been identified and are supported by Homicide by People with Mental making a contribution to the specialist Examples of promising practice for standard care pathway tailored for them existing services. practice evidence from advocacy projects Illness, 2015). health component of Local Authority secondary mental health care are described and their carers to be referred to IAPT and service user groups (Macadam et al, spending on out of area placements. in detail under the relevant sections as they and other secondary care services; 10. Changing practice 2013). They include: increasing people’s The data collected for this report relates typically involve partnerships with other developing partnerships with veterans’ As can be seen the majority of these ability to make informed decisions and be to expenditure by the NHS but previous Not being able to accommodate people organisations. They include: charities (Combat Stress, Royal examples focus on the development of new involved in decision-making; being able to research indicates that nearly half of the requiring assessment and treatment in local  Support to primary care – GP crisis British Legion) to pilot a multi-agency services and there is also scope for shifting exercise greater choice and control; better expenditure on Out of Area Placements acute provision is a concern for CCGs and helpline (CWPT) (see primary care ‘one-stop shop’ approach for veterans clinical practice. Given the Care Quality communication and relationships between is made by Local Authorities (Ryan et al., mental health Trusts, as well as individuals section) and their families, and delivering training Commission’s general observations about individuals and professionals, and improving 2007) and, thus, further inquiry as to the and their families, and regulatory bodies.  Early intervention in psychosis (WHCT) for CWPT. the quality of care in acute inpatient settings, access to services, including diversion to Local Authority expenditure in the WMCA National reports, notably the National (see early intervention section) this should be a focus, with a particular less restrictive forms of care (Newbigging is needed. Confidential Inquiry into Suicide and  RAID and redesign of the urgent care  Walsall Carers Support Service emphasis on assessment and treatment et al, 2015b). Homicide (2015) and recent Commission pathway (BSMHFT) (see crisis (DWMHPT) for any carer supporting under the MH Act. The experience of NHS England is responsible for on Acute Adult Psychiatric Care (Crisp et intervention section) someone aged 18 and over living in detention and compulsion can be unhelpful, There is a range of advocacy provision commissioning Tier 4 OATs for children, al., 2016), recommend ending the practice.  Recovery Colleges (BCPT; BSMHFT Walsall who has complex mental health profoundly disempowering and humiliating, across the WMCA, typically based on young people and adults. In 2014/15, NHS There is guidance available79 but realising and FTB) (see quality of life and mental needs: offering a wide range of advice, and whilst some people find it helpful it can a model of independent advocacy and England spent £40 million on OATs, 73% this ambition will require senior level health section) information and support for carers; have a long-lasting impact and is seen as including statutory advocacy (Independent of which was spent on low secure forensic commitment, both clinical and managerial,  Street triage (BSMHFT; CWPT) in and the Child and Adolescent Mental contradicting a recovery focus (Repper Mental Capacity Advocacy (IMCA); beds for adults. In addition approximately and addressing complex, and entrenched, partnership with West Midlands Police Health Services (CAMHS) FLASH and Perkins, 2014). As well as developing Independent Mental Health Advocacy £30 million was spent on two independent problems in other aspects of the mental (see crisis intervention section) team, which has a specific remit to alternatives to in-patient care, there are (IMHA) and Independent Care Act sector providers based in the WMCA. health system that reinforce the use of  Individual Placement and Support support foster carers, adoptive parents, three particular initiatives that can support advocacy). There is a risk that Local (see employment section) and carers to reduce the risk of changes in practice to a more empowering Authorities will increasingly commission placement disruption and/or the stance, and whose potential is not fully statutory advocacy, placing other forms of subsequent need for the child to move realised in the WMCA: 79 See for example: National Mental Health Development Unit (2011). In Sight and In Mind: A toolkit to reduce the use of out of area mental health services. Available into another placement in or outside at: www.rcpsych.ac.uk/pdf/insightandinmind.pdf [accessed060616] of the borough. 80 www.ardengemcsu.nhs.uk/files/7114/3265/7953/Case_Study_-_Mental_Health_Repatriation.pdf [accessed 030316]. 81 https://www.covwarkpt.nhs.uk/our-news/nhs-services-land-national-award-550 82 http://veterans.sssft.nhs.uk/veteranservices/west-midlands-regional-veterans-service [accessed 030316]. 52 Mental Health in the West Midlands Combined Authority Mental Health in the West Midlands Combined Authority 53

advocacy at risk (e.g. generic advocacy and need. This will mean that the responsibility and, as discussed later, are key to a strategy However there is substantial variation blurring between staff, volunteer and ‘user’ predominantly women, affected by abuse community advocacy), such that advocacy for providing care will shift to informal focused on promoting self-determination across the WMCA, as illustrated in Figure roles in the organization, aligned with or domestic violence, including Refuge in becomes increasingly professionalised. It carers. Five years ago, Age UK estimated and recovery. 17 for the constituent Local Authorities. cultures of non-judgementalism, nurture/ Birmingham; Birmingham and Solihull would, therefore, be timely to review this that a 7% cut to Local Authority funding  Personal budgets are the allocation of For direct payments this ranges from 22.9% care, and ‘relational skill’ (Billis and Women’s Aid; Sandwell Women’s Aid; provision; particularly in light of findings would lead to a 25% rise in the hours of funding available to people with eligible (Solihull) to 4.5% (Walsall) and for personal Glennerster, 1998; Macmillan, 2013). The Stepping Stones in Walsall; Coventry that access to statutory advocacy can be personal care provided by carers (Carers needs and the budget can be taken budgets from 70.9% (Birmingham) to 4.5% third sector, therefore, plays an invaluable Haven Women’s Aid; the Haven in problematic for people detained under the UK, 2011). The National Audit Office as a direct payment, or as services (Walsall). There are examples of higher role in mental health, offering an alternative Wolverhampton and Roshni providing Mental Health Act, with the CQC recently (2014) has indicated a 37% real-terms commissioned on the person’s behalf rates of direct payments (Warwickshire) and approach to statutory provision and often support for South Asian women highlighting their finding that 20% of reduction in government funding to local by the council, or by an organisation personal budgets (Worcestershire) in other introducing innovative ways of working that and children. detained patients had not had their rights authorities between 2010/11 and 2015/16. contracted by the Local Authority. In Local Authorities in the WMCA, from which are then adopted by the statutory sector, as properly explained to them (CQC, 2015). While children’s social care has been some cases, part of the budget is taken other Local Authorities can learn. However, is the case with direct payments, advocacy, Such organisations vary in size and Furthermore, a national evaluation of IMHA protected there has been a reduction in as a Direct Payment and the other part further inquiry is needed to understand how peer support and recovery84. The sector capacity, with larger organisations having a provision found that people most in need of adult social care of 9% for this period with managed by the Local Authorities. From meaningful the implementation of direct is particularly adept at identifying and well-developed profile and often offering a advocacy are the least likely to access it further reductions anticipated (National 2015, the expansion of personal health payments and personal budgets is in responding to gaps in provision and in range of services, and there are also many (Newbigging et al., 2015a). Audit Office, 2014: 26). It is inevitable that budgets has been led by CCGS and supporting personalisation. This will involve engaging with people who would not small-scale less formalised groups that this will have had profound implications for people with mental health problems capturing the experience of service users to engage with statutory services. are ’below the radar’ (Mohan, 2011). OPEN DIALOGUE the mental health of carers. whose needs cross health and social be confident that personalisation is being Consequently, any mapping of third sector The potential and evidence for open care boundaries may be able to have implemented as intended. There is a dynamic and extensive third activity is complicated and compromised dialogue was discussed under the previous Local Authorities commission the third integrated budgets across health and sector, which is inevitably more developed by the capacity of smaller organisations to section in relation to crisis intervention. sector to provide a broad range of support care (NHS Confederation, 2015). 2. Support to Carers in urban centres, and it is estimated that support such an exercise. The response to Within the UK a development of the Open (as described below). This includes day  Direct payments are cash payments The Care Act 2014 reinforced a focus there are approximately 450 voluntary the audit from third sector organisations Dialogue model to incorporate peer support services, which were historically provided by and can be made directly to the person, on the needs of carers and providing sector organisations, across the WMCA. was very limited, possibly reflecting their is currently being piloted in four Mental the Local Authority. A further line of inquiry to a trusted third party or to an assessment and support to carers in In addition, there will be small organisations capacity. From the information provided, Health Trusts (North East London for the Commission is whether people with organisation that manages the direct their own right. A recent review of the ’below the radar’ of public services but are the range of third sector across the Foundation Trust – NELFT; North Essex; a diagnosis of severe mental illness have payment on the person’s behalf. implementation of this Care Act duty found an important community asset (Mohan, WMCA includes: Nottinghamshire; and Kent and Medway) been disadvantaged in the modernisation that the majority of carers, responding to a 2011). Third sector services serving and is the subject of a major evaluation of these services and their alignment with During 2014–15, approximately 4,380 survey. were unaware of their rights; nearly individuals with mental health problems  Training on mental health awareness study for which a final funding decision is wellbeing hubs for people with more people (18-64) received Local Authority two thirds had not received an assessment are provided by: specialist mental health including Mental Health First Aid and awaited from the National Institute for common mental health problems. funded Mental Health Support in the and some that had were dissatisfied with organisations, for example Mind; suicide prevention training Health Research. A national one year WMCA: 540 received a direct payment the assessment (Carers Trust and University organisations primarily concerned with a  Well-being hubs and open access in-service training programme is available 1. Direct payments and personal budgets (either in full or in part) (12.3%) and 1105 of Birmingham, 2016). Furthermore, many social issue, such as domestic violence (eg, services providing seven-day-a-week and would be open to practitioners and Direct payments and personal budgets received a Local Authority Managed carers found engagement with the NHS Women’s Aid, or homelessness (eg, St direct access for all to information, teams from West Midlands Trusts. are two specific methods that have been Personal budget (25%)83. The use for problematic. The review concluded that the Mungo’s); with a client group, for example advice and support; peer support/ introduced to give people greater choice mental health clients is substantially Care Act focus on carers was promising SignHealth for Deaf people; or a community, friendships to challenge isolation; and control over the support they receive, lower than for other client groups. and had transformative potential but active for example organisations providing services and the opportunity to engage LOCAL AUTHORITY PROVISION implementation support is required, to African-Caribbean people, South Asian in social/leisure/arts activities as including ensuring that all social workers people, or asylum seekers and refugees; well as access to other services eg, Local Authorities provide social work 80.0% and assessors are appropriately trained, and and universal services, such as Citizen's advocacy, counselling, LGBT and services and commission a broad range of 70.0% reflect the wellbeing principle in assessment Advice. women only support groups, mental health services from the third sector. and care and support planning (Carers employment support etc. The role of social work in adult mental health 60.0% Trust and University of Birmingham, There is a diverse third sector of BAME  Carers support groups and events includes ensuring eligible people can 50.0% 2016: 5). organisations, many of which have their to promote their wellbeing access social care services and resources, foundations in grassroots organisation,  Creative sessions: art, writing and including direct payments and personal 40.0% THIRD SECTOR PROVISION with dissatisfaction with mainstream mental music to enable people to develop budgets, and acting as Approved Mental 30.0% health provision and concern about the creative skills and develop friendships Health Practitioners, alongside other mental Direct payment total The third sector, often referred to as the experience of people from BAME  Horticulture/conservation/sports health professionals. Social workers also 20.0% voluntary sector, comprises charities, social communities, as a possible driver. Mental projects, for example, football targeted Managed personal budget have a role in building community capacity: 10.0% enterprises, and community groups, which health support may also be a component at men who would not ordinarily access ‘working with groups and networks of are typically driven by a social mission, of wider support to BAME communities, mental health services and provides citizens to foster citizen mutual support and 0.0% have a closeness to and expertise on that also provide advice and support. a safe space and route through to social capital’ (Allen, 2014: 15). The Care communities, and because services are other services Act 2014 also placed a duty on Local often provided by volunteers, many of whom Similarly, organisations providing other  Counselling, including bereavement Authorities to promote wellbeing, physical will be peers with lived experience, the welfare services have a mental health counselling and trauma-focused and emotional, when carrying out their power differential between service users component: for example, services counselling, IAPT services and stress duties (Department of Health, 2014). and service providers is reduced. The supporting homeless people; drug and and anxiety management courses aimed However, increasing thresholds for eligibility, third sector, therefore, has a ‘comparative alcohol support; support groups for people at people with common mental health reflecting reductions in Local Authority Figure 17: Percentage of mental health clients receiving a direct payment advantage’ in services for excluded groups with long-term health problems, eg, problems or managed personal budget in the WMCA budgets, may mean that many people because of the relatively flat hierarchies and Parkinson’s UK and service for people, simply are not getting the support they

84 Although the co-option of these methods by public services has been the focus of critique by service user activists as fundamentally alerting them to serve 83 Community Care Statistics, Social Services Activity England 2014-2015. Available at: http://digital.nhs.uk/catalogue/PUB18663 [accessed 100816] professional or organisational interests. 54 Mental Health in the West Midlands Combined Authority Mental Health in the West Midlands Combined Authority 55

 Advocacy, both statutory and non- POSITIVE PRACTICE: ACACIA development approach to tackle the  Chinese Community Centre in support groups: for example Pyari 2. Improving the life span of people diagnosed statutory advocacy, to enable people FAMILY SUPPORT intersecting structural inequalities that limit Birmingham, providing support to Sangat - Asian Women’s Mental Health with a severe mental illness to have a voice and greater choice and life chances'. Therefore, although specific carers and people experiencing mental Support Group; Community Creations Reducing premature mortality and improving control. These services are configured Acacia Family Support, a charity based services are considered, action is also health issues, including outreach – An Interfaith Sewing Group for physical health outcomes for people with a differently but have all sorts of benefits in Birmingham that provides support to required to address the broader social support and workshops covering Women; Migrant Support Group in severe mental illness is a priority for NHS in terms of increasing confidence and women and families affected by antenatal determinants of mental health that Wellness Recovery Action Plans; Walsall. CDWs also help to ensure the capacity to self-advocate; improving and postnatal depression. Acacia disadvantage BAME communities. People Mental Health awareness and a training that the views of the communities that access to services and rights, eg, provides a broad range of emotional and from BAME communities face specific for mental health carers90. they work with are represented in the Over the last five years across the welfare benefits; protecting rights and practical support including befriending; barriers in accessing appropriate support  IAPT services for people from BAME development and delivery of services. West Midlands Time to Change have: shifting the dynamic with professionals psycho-educational group work; CBT and, as noted above, are at greater risk communities are provided by Mind in  Recruited over 500 people as toward co-production (Newbigging and support for fathers. It is an award of detention under the MH Act than Birmingham91. QUALITY OF LIFE AND MENTAL Champions to take action in their et al., 2015a) winning service mentioned by NHSIQ85 people from British white communities.  Freedom from Torture West Midlands, ILLNESS community;  Employment support in a wide range as a model for perinatal support that Consequently, community organisations based in Birmingham, opened in 2009  Facilitated and supported eight of forms, including job-retention; could be transferable to other parts of and the voluntary sector have developed in response to the widespread dispersal A broad range of initiatives are required to campaign groups that have brought negotiating reasonable adjustments; the England. The funding sources for services in response to identified need and of asylum seekers across the UK. improve the quality of life of people with a together people with a lived supporting leaving negative these services include: CCG and Local gaps in provision as well as concerns about Services provided include assessment diagnosed mental illness and who may experience to run campaign activities employment with the most favourable Authority funding; charitable donations; the disadvantageous treatment experienced and psychological therapy for children, be at particular risk of exclusion and in their local area and to challenge outcome; Individual Placement and income-generating activities; and awards by people from their communities. Examples young people, and adults who are discrimination. Underpinning this is stigma stigma in their daily lives Support (which is discussed later under from national grant-making bodies, such across the WMCA include: survivors of torture, including individual associated with having a severe mental  Funded and supported the delivery promising practice); linking people in as the Big Lottery and Comic Relief.  African Caribbean Community Initiative and group work, and a family therapy illness and, as discussed below, people’s of the 300 Voices Programme (see work with other services and training (ACCI)86 in Wolverhampton, providing service to families that have been life chances, including life expectancy are Appendix 4) on workplace wellbeing. comprehensive support service for affected by torture92. drastically reduced. Furthermore people  Run a number of high profile pop  Community development workers and development. A number of respondents people from African Caribbean with a mental illness are at increased risk up Time to Change mental events to increase engagement with drew attention to the impact of Local communities with mental health Initiatives have also been developed by of violent victimisation and a recent study to encourage mental health particular groups Authority austerity measures and this is problems. Services include supported statutory services and these include found that they were three times more conversations; produced an  Advice on welfare rights, including worth focused inquiry. Furthermore, the third housing and advice; day opportunities; Community Development Workers (CDW), likely to be a victim of any crime and five educational pack for professionals, benefits, debt and housing sector is rarely commissioned in a strategic specialist outreach; counselling and a working with different BAME communities times more likely to be a victim of assault. volunteers and youth leaders, with  Recovery-oriented courses and way and the WMCA, in the context of the dedicated Carers’ Support Group. to help prevent mental ill health and support Women with mental health problems were guidance and, materials around workshops, for example: coping with Care Act’s emphasis on market shaping,  The Tamarind Centre in Coventry, access to services. Examples include: particularly vulnerable being ten times more tackling mental health stigma depression, improving confidence and provides an opportunity for Local Authority providing outreach, including support  The community engagement team at likely to be assaulted (Pettitt et al., 2013).  Supported over 20 employers to sign self-esteem, anger management, commissioners, in partnership with CCGs, with mental health Tribunals; BSMHFT who have played a central The study also found that when people a pledge to embed changes in policy mindfulness and tackling sleep to review how they are investing in and counselling and drop-in services to the role in relation to 300 Voices and work reported a crime they felt they were and practice to transform the culture problems developing the capacity of the third sector BAME communities, particularly African closely with Trust staff and community disbelieved or the appropriate action of their workplaces.  A range of support with housing across the WMCA. Caribbean and Asian people87. groups to ensure local people are was not taken. including accommodation, floating  Sandwell African Caribbean Mental consulted and involved in developments Over the next 5 years, Time to Change support to enable people to maintain SPECIFIC PROVISION FOR PEOPLE Health Foundation, providing a range or changes to services provided by the 1. Tackling stigma and discrimination aims to empower communities to lead their independence, while ensuring that FROM BLACK ASIAN AND MINORITY of culturally responsive mental health Trust. They also work with local Shifting negative attitudes and mental and embed local change together by their mental health needs and daily ETHNIC COMMUNITIES services, including counselling, communities to tackle the stigma illness-related stigma is the focus of Time setting up ‘Time to Change Hubs’ In living skills are being addressed; outreach and a Ujima, a user-led service associated with mental health, and to for Change95. The campaign is run by the these Hubs the Campaign will support 24hr nursing care facilities for adults There are various initiatives that recognise providing volunteering, peer support reduce the barriers to getting the right charities Mind and Rethink Mental Illness, partnerships of local organisations and with severe and enduring mental the needs of different groups, as outlined in and mentoring to deliver community help at the right time93. with funding from the Department of Health, individuals to work with people with lived health needs the earlier section of this report, and there meet ups and other social activities88.  Community Development Workers, Comic Relief and the Big Lottery Fund. The experience of mental health problems to is still work to be done to ensure that  Ekta Unity Voluntary Group89, based in who work with people from BAME, campaign has developed a comprehensive convene and coordinate local action. The third sector brings in money and inequalities are not embedded into the Coventry but also covering and increasingly people with an Eastern programme, adopting a strategy of targeting resources to the WMCA either on its own strategic approach adopted by the WMCA. Warwickshire and the West Midlands, European background, including Czech, people through interrelated activities that or in collaboration with public services. promotes a holistic approach to health, Slovakian and Polish people as well as ensure mass reach (social marketing), England and guidance was produced in However, the short-term nature of much of This section considers provision to people mental health and social wellbeing people with protected characteristics empower local people with a lived May 2016 (NHS England, 2016), which the funding for the third sector potentially from BAME communities, to reflect the for Asian and British Asian women, under the Equality Act94. The team experience to lead change (community outlined key action areas: jeopardises its activity and sustainability. diversity of the WMCA. In doing so, it is aged 26 and over. The group provides works in partnership with other leadership) and bringing together people  Support to quit smoking It means that a significant amount of time important, as Tang (2016) has observed in a range of activities, including community organisations to provide with and without experience of mental  Tackling obesity and capacity is spent on bidding and relation to Chinse mental health service yoga and meditation, social and support to individuals, raise awareness health problems to talk openly about  Improving physical activity levels fund-raising, rather than service delivery users: 'to understand cultural fluidity and the wellbeing sessions as well as themed of mental health and wellbeing; provide mental health issues (social contact).  Reducing alcohol and substance use necessity for a transformative community activities such as singing and music. cultural competence training and set up  Sexual and reproductive health

85 Available at: www.nhsiq.nhs.uk/media/2696378/nhsiq_perinatal_mental_health_sml__0915final.pdf [accessed 060616]. 90 www.chinesebirmingham.org.uk/en/supporting_communities/mental_health.htm [accessed 150816]. 86 http://win.wolverhampton.gov.uk/kb5/wolverhampton/directory/service.page?id=TGndY5gVjoI [accessed 060616]. 91 https://web.archive.org/web/20151010110033/http://www.iapt.nhs.uk/silo/files/black-and-minority-ethnic-bme-positive-practice-guide.pdf 87 www.tamarindcentre.co.uk/id2.html [accessed 150816]. 92 www.freedomfromtorture.org/about/15/5252 [accessed 150816]. 88 www.sacmhf.co.uk/user-led.html [accessed 150816]. 93 www.bsmhft.nhs.uk/about-us/engaging-with-our-communities/contacting-our-community-engagement-team/ [accessed 150816]. 89 Awarded the Queen’s Award for Voluntary Service, in June 2016, along with a number of other voluntary sector and community organisations providing support to 94 Singh, K. (2015) Community Development Worker Report 2014-2015 Making Pathways Clear in Mental Health. Available at: www.dwmh.nhs.uk/wp-content/ disadvantaged and marginalised groups in the WMCA. See: www.gov.uk/government/uploads/system/uploads/attachment_data/file/527091/Queens-award- uploads/2013/06/CDW-Report-2014-2015.pdf [accessed 150816]. voluntary-service-winners-2016.csv/preview [accessed 150816]. 95 www.time-to-change.org.uk [accessed 050117] 56 Mental Health in the West Midlands Combined Authority Mental Health in the West Midlands Combined Authority 57

HOUSING  Medicine optimisation PROMISING PRACTICE: RECOVERY COLLEGES There is a range of organisations to provide There is, some limited evidence that peer  Dental and oral health guidance and facilitate the development of support workers can provide value for  Reducing falls The development of Recovery Colleges in England is relatively young and as yet there peer support including Peer2Peer, hosted money through reducing psychiatric 1. Provision in the WMCA are few systematic evaluations of the impact on the quality of lives of people with long by NSUN, an established user-led network inpatient bed use, either by preventing Out of the 1,144,050 homes in the WMCA The analysis of information from Local term mental health problems, although the narrative accounts are promising. A pilot study of peer support experts who share fresh admissions or by shortening lengths of stay the majority (879,260 homes) are in private Authorities on public health programmes in London found that 68% of the students felt more hopeful and 81% had developed approaches to developing and running (Trachtenberg et al., 2013). This review hands, either in the private rented sector identified that most but not all have health their own plans for self-management with those that attend more than 70% of the peer support programmes; the ImROC suggested that more than £4 would be or owned by individuals107. Housing promotion initiatives targeted at people sessions showing a reduction in their use of community mental health services (Cited in programme, which provides support to gained for every £1 invested, although the Associations, charities and the local diagnosed with a severe mental illness North Essex Research Network and South Essex Service User Research Group, 2014). NHS providers and their partners to studies that provided the basis for these authorities own over 264,000 homes, to improve their physical health. A small scale study of Recovery Colleges in Mid Essex found gains in self-confidence, become more recovery-focused; and the calculations were from the US and Australia providing accommodation for people on low motivation, ability to self-manage and improved relationships with others (North Essex Institute of Mental Health, Nottingham, and their generalisability to a UK context incomes (social housing) or with particular As the guidance makes clear, the key to Research Network and South Essex Service User Research Group, 2014). which delivers peer support training may be limited. There is a clear need needs (supported housing). The majority of improving health outcomes for this group accredited with the Open University, and to develop the evidence, focusing on housing provision (out of a care or hospital is better partnership working and the a range of consultancy and evaluation voluntary sector as well as statutory sector environment) is in the form of supported integration of physical and mental health context of people’s lives to be taken into PEER SUPPORT services aimed at developing the role of implementation of peer support roles, and housing or floating support for those in care and as people are likely to experience account and the impact it has on individual A scoping study of mental health peer peer supporters within both the voluntary comparing which achieves better outcomes general needs housing. From 2011-12, the multiple health problems, the coordination health and wellbeing (Forder et al. 2012). support in England identified a range of and statutory sectors. Their recovery- and provides better value for money. ring fence was removed from Supporting of care is vital (Naylor et al., 2016). Personalisation, therefore, sits alongside peer support initiatives in the West focussed training is applicable to a broad People funding and was rolled into the co-production in ensuring that the support Midlands, including user-led initiatives, such range of settings and they have recently RECOVERY AND RECOVERY Formula Grant – a single grant given by 3. Promoting choice, self-determination and services people use recognises their as Hearing Voices Groups, of which there is worked with the Devon & Cornwall police COLLEGES central government to Local Authorities. and recovery strengths and meets their needs to enable one, based in West Bromwich96; BGLAD service to support the development of peer From a national list of Recovery Colleges This means that there is now no specific There is a growing evidence base that them to live their lives. (Birmingham Gays and Lesbians against supporters within the police workforce. (ImROC, 2015), there are two out of a budget allocation for Supporting People self-determination and choice promote Depression), which meets weekly in total of 36 in England for West Midlands services, consequently meaning funding for prevention and early intervention in contrast Direct payments and personal budgets are Birmingham’s gay village area and provides Much of the available evidence relates to residents currently operating, although there supported housing schemes has often been to a traditional model of intervening after two ways in which people can have greater informal peer support97, and the national formal peer support workers (Gillard et al., are other initiatives that provide recovery- diverted, creating gaps in provision and an acute crisis (Alakeson, 2007a; Forder control over their care. The 2013 POET organisation, based in Wolverhampton, 2014) and changing the skill mix of the oriented courses and programmes. The reducing the overall quality of provision et al., 2012). This section considers three survey found that people who took the First Person Plural for people identifying workforce to include peer support workers two Recovery Colleges are in Sandwell, (Homeless Link, 2013; Wadley, 2015). particular strands for a mental health personal budget as a direct payment felt with complex dissociative identity has been identified as the single most provided by the Black Country Partnership strategy for the WMCA that is underpinned more in control and had greater choice than disorders98 as well as those provided important factor in contributing towards NHS Foundation Trust and which started This lack of revenue funding for supported by the principle of personalisation people using a personal budget (Hatton and by the six local Mind organisations changes in more recovery-oriented in October 2015103, and Walsall, provided housing has been compounded by the and autonomy. Waters, 2013). Furthermore, the evidence (Birmingham, Coventry and Warwickshire, services, (Repper, 2013), bringing benefits by Dudley and Walsall Mental Health introduction of a cap (at Local Housing indicates that people experiencing poor Dudley, Mid Staffs, Solihull and Springfield both to those supported by peers and Partnership NHS Trust104. A Recovery Allowance levels) on the amount of housing PERSONALISATION IN HEALTH AND mental health are most likely to benefit from Mind in South Warwickshire). Kaleidoscope to the peer support workers themselves College, provided by BSMHFT, went live benefit that can be claimed. The level of SOCIAL CARE: DIRECT PAYMENTS the choice and control offered by a direct Plus99, in Sandwell, was highlighted for (Repper and Carter, 2011) and also in June 2016105. In addition the Forward this cap means that there is a substantial AND PERSONAL BUDGETS payment of personal budget (Alakeson, being particularly innovative in providing a to mental health services (Gillard et al., Thinking Partnership for young people shortfall between the rent for supported Although the definition of personalisation 2007b); to report a significantly higher range of services with peer support as the 2013). The 2015 Community Mental up to the age of 25 is proposing Recovery housing schemes and the amount which can be open to interpretation and is quality of life than the comparison group focus (Faulkner et al., 2013). Peer support Health Survey, however, found that only Colleges in educational settings to enable will be funded via housing benefit or via the evolving, it is an approach that seeks to (Glendenning et al., 2008); and to also takes many forms and includes: about half of those people who felt they young people to continue with their housing element of Universal Credit. This secure empowerment, citizenship and report improvements in their physical would benefit from peer support were studies106 in Birmingham. There are hits a wide variety of provision, including equality. In a public services context, it is health (Davidson, Gadsby, 2013).  Providing support with recovery and offered it (CQC, 2015), resonating with no evaluation reports of these local mental health services. Research used to refer to ‘recognising people as care planning (eg, South Staffordshire findings relating to access to advocacy developments available, as yet. conducted by the National Housing individuals who have strengths and Integrated personal commissioning (IPC) is Network for Mental Health100) (CQC, 2014).The evidence base in terms Federation found that at the national level preferences and putting them at the centre now being piloted to join up commissioning  Facilitating peer support groups for of delivering outcomes is inconclusive and PRO-RECOVERY WORKING 156,000 units of existing supported and of their own care and support’ (SCIE, at the level of the individual. A national pilot people who hear voices (eg, Hearing where positive findings have been identified PRACTICES sheltered housing would become unviable 2008). Personalisation enables the social is focused on people with complex needs, Voices Network101) they are not replicated across all studies There are other approaches to service and subject to closure. This is 41% of all including people with significant mental  Self-help groups (as above) (Knapp et al., 2015). However, for the role delivery that have been identified as existing schemes. This has resulted in a health needs, ie, people eligible for the Care  On-line peer support to be meaningfully adopted the experiential pro-recovery working practices, which have huge amount of uncertainty amongst THE VOLUNTARY SECTOR PLAYS Programme Approach (CPA), or those who  Peer mentoring (eg, in schools to build knowledge that peer workers bring to their not developed explicitly from a recovery providers and has resulted in 80% new AN IMPORTANT ROLE IN PROVIDING use high levels of unplanned care, but none emotional resilience, Wolverhampton102) work that enables them to engage and perspective but will none the less support developments of specialist housing being of the initial nine IPC demonstrator sites are build qualitatively different relationships recovery. These include: Housing First; put on hold. The government has delayed PREVENTATIVE INTERVENTIONS, in the WMCA. with service users has to be understood, Individual Placement and Support (IPS); the introduction of the cap by 12 months, AT AN INDIVIDUAL, COLLECTIVE AND acknowledged and valued (Gillard and use of ‘personal budgets’ in health and not announced the results of its COMMUNITY LEVEL, AND ACTIVELY et al., 2014). and social care (Perkins et al., 2012). research into supported housing provision PROMOTES PEER SUPPORT

96 www.hearing-voices.org/area/west-midlands/ [accessed 150816]. 97 http://blgbt.org/directory/b-glad-birmingham-gays-and-lesbians-against-depression/ [accessed 150816]. 98 www.firstpersonplural.org.uk/about-first-person-plural/ [accessed 150816]. 103 www.therecoverycollege.co.uk/ [accessed 150816]. 99 www.kaleidoscopeplus.org.uk/ [accessed 150816]. 104 www.wcld.co.uk/kb5/walsall/asch/service.page?id=FKQLHHIRFkw [accessed 150816]. 100 http://ssnmentalhealth.btck.co.uk/ [accessed 150816]. 105 www.bsmhft.nhs.uk/service-user-and-carer/recovery/recovery-college/ [accessed 150816]. 101 www.hearing-voices.org/tag/peer-support/[accessed 150816]. 106 www.bbc.co.uk/news/uk-england-31515884 [accessed 150816]. 102 www.headstart.fm/news/2015/11/18/headstart-schools-evaluation [accessed 150816]. 107 Data provided by the National Housing Federation 2016. 58 Mental Health in the West Midlands Combined Authority Mental Health in the West Midlands Combined Authority 59

100 Percentage on CPA in 90 settled accomodation 100.0 80 or what the future funding for supported 90.0 Housing status and employment status for housing will look like. 70 people on a CPA are taken as a proxy for 80.0 60 the ability of services to help service users There is a general dearth of research into 70.0 50 to optimise functioning and recovery (NHS housing models for people with mental 60.0 40 Benchmarking, 2016). The CPA covers health problems but a mapping study in 50.0 30 approximately 25% of people registered 2009 identified considerable overlap with specialist mental health services. In the 40.0 20 between the characteristics of the clientele Total WMCA as a whole, 74% of adults on a 30.0 10 of residential care; building based support Men CPA were living in stable and appropriate and floating support and significant variation 20.0 0 accommodation. This compares favourably in costs (Priebe et al., 2009). Furthermore, 10.0 Women with an England average of 59% (NHS the majority of the costs were being spent 0.0 Benchmarking, 2016), but as Figure 20 on the housing component suggesting that indicates there are some outliers, and it this population may be underserved by would be useful to understand the factors

mental health services. Watts et al. (2015) Percentage of people on CPA living independetly influencing this variation in performance, argue that psychologically informed including the availability of housing stock environments are crucial in addressing and the collaboration between mental youth homelessness because of the Local Authority health services and housing providers. The high proportion of young people using relationship between the range of housing Figure 18: Proportion of working age adults (18-69) on the the CPA recorded as Figure 19: Percentage of adults on the CPA in settled accomodation for each CCG homelessness services that have complex living independently (with or without support) for 2014-15111 in the WMCA (April –June 2013) (Source: NHS Benchmarking, 2016) provision, the length of stay and use of Out needs, including mental health and of Area Placements needs further inquiry. behavioural problems. Partnership working between housing providers and mental  Develop social networks and use of and food preparation and use of PROMISING PRACTICE: HOUSING FIRST A previous study in Walsall identified health services is, therefore, increasingly leisure facilities mainstream services; linking with the practice of residential sorting from emphasised (NHS Confederation and  Develop peer support and promote community activities and volunteering The evidence from the US and Europe indicates success for the Housing First model anecdotal evidence (Jones and Gulliver, National Housing Federation, 2011). access to universal services opportunities, and wider activities to and is being implemented in Finland as a new national strategy to eliminate long-term 2009) and this requires further analysis. However, the separation between housing  Address housing and tenancy needs promote good health and wellbeing. homelessness (Pleace et al., 2015). A study of nine relatively new Housing First services The location and quality of the and non-housing support, complexity of in England evidenced improvements in physical and mental health for their clientele accommodation is key to people’s funding arrangements and the reduction of SUPPORTED HOUSING STEP-DOWN (Bretherton and Pleace, 2015). There was also evidence of reductions in alcohol or mental health and recovery. available resources, compounded by the Supported housing differs from general Step-down provision is a key component drug use, antisocial behaviour and positive evidence of social integration with differing approaches of housing, health and needs housing because support and care of a mental health housing strategy to neighbourhoods and re-establishing links with families. The Housing First services were 3. Working together social services, has resulted in a lack of a services are provided in addition to housing enable people to live independently and valued by service users for the choice and sense of freedom they offered, as well as the Housing Association providers of services coherent view on the most effective models. management. The people living in supported leave hospital, when there is no suitable intensive, flexible and open-ended support (Bretherton and Pleace, 2015). This study for those with mental health issues have housing have specific needs, often relating alternative. This type of provision will, was relatively small scale and the positive results were not uniform with some instances formed the Health, Wellbeing and Housing People with mental health issues are to mental health problems. Their aim is to therefore, reap benefits to the NHS in terms of deterioration of physical or mental health. There was, however, no evidence of Group. This group’s aim is to promote housed in a variety of stock, both general support people in their recovery and to of cost savings and ensure that people do increased drug use or anti-social behaviour. The study also indicated the potential to further partnership working between need rented accommodation (possibly with live more independently. Some support is not stay as inpatients any longer than is save money and on the assumption that, in the absence of Housing First support, Housing Associations, the NHS and local floating support) and in specific provision targeted at particular groups, for example necessary. There are several providers of people would have required high intensity supported accommodation, the annual authorities based on evidence, from their designed for people with mental health the services provided by the Heantum step-down provision across the WMCA, savings were estimated to be between £3,048 to £4,794 in support costs per person. work to date, that a joined-up approach can needs, notably108 floating support and Housing, based in Wolverhampton, offering including housing associations, charities Factoring in the potential reduction in the use of other services (emergency medical save money and provide a better services to supported housing: supported housing and floating support for and independent sector providers. services and the criminal justice system), the potential overall saving in public users. The WMCA provides an opportunity South Asian men109 and gender specific expenditure was estimated to be £15,000 per person. However, Housing First is not a for a strategic approach to the provision FLOATING SUPPORT support, including supported housing, for HOUSING FIRST low cost option but it may well be more cost effective than the alternatives, although it is of mental health services; providing a All the Local Authorities indicate that they South Asian women110. There is also The Housing First model focuses on rapidly clear that further research is needed (Bretherton and Pleace, 2015; Pleace et al., 2015). consistent approach, and giving housing commission floating support. In general, dedicated provision for women and children finding a permanent home in the community associations and other partners the time the aims of this are to: fleeing violence and abuse, young people for someone without this being conditional and stability to build or expand successful  Promote confidence, reduce anxiety, including care leavers and for offenders on mental health, employment or not There are Housing First services for people with the complex dynamics that can arise services in the region. build resilience and better self- and ex-offenders. abusing alcohol or drugs. It uses a who are sleeping rough and facing multiple as a consequence of trauma and rejection. management of mental health problems client-led approach and is designed to exclusions in Birmingham, Solihull, Coventry A comprehensive audit of housing provision in including safety and risk Accommodation may be on a short-term provide open-ended support to people and Stratford on Avon to help them directly 2. Performance against national indicators to support people with mental health  Provide access to opportunities, basis (ie, up to a year) or a longer term with complex needs, including severe into permanent accommodation, with ASCOF data provides a measure of the problems would enable the WMCA to such as volunteering, education basis. A wide range of support is provided mental health problems, homelessness, comprehensive support tailored to meet proportion of adults using secondary further investigate the range of provision and/or employment in addition to housing, such as building- poor physical health and physical or their individual needs. Many are piloting mental health services on the Care and develop a strategic approach to  Build practical living skills including based or floating support with developing learning difficulties. the use of Psychologically Informed Programme Approach (CPA) who are housing and mental health, building on managing finances, travel training, skills for independence, including budgeting Environments, which recognises the living independently (with or without the emerging evidence on Housing First. potential for change and ensure that staff support) as summarised in Figure 18. are psychologically minded and able to work 108 See for example a summary with case studies developed by a group of housing providers in the West Midlands: Working together in the Midlands to tackle Mental Health issues and Dementia. Available at: http://www.housinglin.org.uk/Topics/browse/HousingMentaHealth/?parent=6081&child=10082 [accessed 150816]. 109 www.heantun.org/?page_id=127 [accessed 150816]. 110 www.heantun.org/?page_id=381 [accessed 150816]. 112 Residential sorting refers to the practice of placing people in local neighbourhoods and housing estates in the same area and leads to increased demand on 111 http://digital.nhs.uk/catalogue/PUB18657/meas-from-asc-of-eng-1415-fin-rpt.pdf[accessed [accessed 150816]. health and social care services and may further disadvantage those individuals and communities. 25 60 Mental Health in the West Midlands Combined Authority Mental Health in the West Midlands Combined Authority 61 20

15 25 2013-2014 10 20 Employment support, often combined with 7%. In the WMCA, the average is 10%, CRIMINAL JUSTICE SYSTEM  A Pathway pack in Dudley for people 2014-15 volunteering opportunities and welfare but there is considerable variation between leaving custody to enable them to 5 15 2015-2016 advice, is frequently provided by the the CCGs, ranging from just under 4% to The Bradley Report (2009) identified that get in touch should the need arise voluntary sector, sometimes funded by the 22% in 2014/15 (see Figure 21). There there are more people in prison than ever  Solihull has a Pathways pack on arrest 2013-2014

Percentage on CPA in employement 0 10 Local Authority or CCG. BITA Pathways, in are striking differences between the LEPs before and that being in custody can for all offenders to help police officers Birmingham, for example, are funded by the with an average employment rate for less heighten vulnerability and increase the risk identify the cause of criminal activity and 2014-15 Birmingham Joint Commissioning Team and than 5% for the Black Country LEP in of suicide and self-harm. It emphasised the signpost to the relevant agencies for 5 provide2015 education,-2016 volunteering and an comparison with around 15% for Coventry importance of early intervention, family- further follow-up work, including mental employment service to adults aged 18-65. and Warwickshire LEP. This data is also based approaches and increasing capacity health as well as substance misuse

Percentage on CPA in employement 0 They provide training and work experience available from ASCOF data at Local across the criminal justice system to identify  Wolverhampton has a well-established with one of their five social enterprises in a Authority level for 2014/15114 and and respond to poor mental health and Youth pathway to support wider variety of industry sectors. demonstrates a pattern, with a reduce re-offending rates. A review of intervention and diversion linked similar range from Birmingham, Dudley, progress on the report’s recommendations through the offender health pathways Individual Placement and Support (IPS) Wolverhampton and Sandwell having concluded that progress needs to be and Youth Offending service has been introduced to enable people who the lowest number of people on CPA sustained and that partnership working is experience severe and enduring mental in employment and Warwickshire, vital to support this effort (Centre for Mental West Midlands Police has recently been health problems to find employment in the Staffordshire and Coventry the highest115. Health, 2014). successful in obtaining funds from the Figure 20: % of adults on the CPA in employment for each CCG in the WMCA grouped by LEP (April 2013–September 2015) open market. Previous approaches for this Home Office Innovation Fund to establish group have largely been based on sheltered It is evident that some areas have made 1. Liaison and Diversion services diversionary programmes for people with work or a ‘train and place’ model. IPS is a progress since 2013/2014, most notably Criminal Justice Liaison and Diversion causal factors, such as substance misuse form of supported employment, which seeks Coventry, which has increased its services exist to identify offenders who have and mental health. The programmes will PROMISING PRACTICE: INDIVIDUAL PLACEMENT AND SUPPORT to place people in open market jobs as percentage of people on CPA in mental health, learning disability or align to the use of conditional cautions and The international evidence base for supported employment, including IPS, is very quickly as possible, with continuing support, employment from 9.8% to 13%, and more substance misuse vulnerabilities when they will include CBT and substance misuse encouraging. A Cochrane review of 14 randomised control trials (RCTs) found that and the specific components of this modestly Dudley, which has increased from first come into contact with the criminal therapies. There is an academic review supported employment and IPS are better than other approaches in enabling people to approach are outlined in Figure 21. 4.3% to 6.2%. However, in many areas, justice system and refer them to appropriate linked to this process to establish what find jobs quicker and be in employment for longer, although issues with the quality of the there has been little change. services for support and therapeutic help. works and ability to evidence a scale evidence were noted (Kinoshita et al., 2013). Similarly, findings for IPS for young people 2. Performance against national indicators Criminal Justice Liaison and Diversion up approach. presenting with a first episode of psychosis indicate that employment outcomes can be The Public Health Outcomes Framework In order to promote the outcomes that have Teams are funded by NHS England as high as 85% (Killackey et al., 2008; Bond et al., 2014). There is also evidence that data indicates that the average employment been identified by research, attention is paid Offender Health. The West Midlands now In 2013, a third of women cautioned for or those on IPS reduce their use of mental health services, including inpatient care, and on rate for people on the CPA in England is to how well IPS is implemented in terms has three pilots covering all of the custody convicted of offences in England and Wales this basis it has been estimated that IPS would pay for itself within a year (cost of of fidelity to the model ie, conformity to the facilities across the West Midlands Police were first-time offenders. Nearly half of all intervention = £2,700, NHS savings = £3,000) (Parsonage et al., 2016). The Australian key principles listed above. The Centre for Force area. New designed 60 cell super the indictable convictions of women were government is currently considering IPS for a much wider group of unemployed people 1. Competitive employment is the Mental Health has carried out independent custody blocks at Oldbury and Perry Barr for shoplifting, compared with just under a with mental health problems (Orygen Youth Health Research Centre 2014). primary goal fidelity reviews and has recognised the provide the mainstay of custody provision quarter of indictable convictions for men. 2. Everyone who wants it is eligible for quality of IPS services in Walsall (provided with smaller custody facilities at Coventry, The next most common offence among employment support by Dudley and Walsall Mental Health Solihull, Bourneville in Birmingham, and women was violence against the person, 3. Job search is consistent with Partnership NHS Trust), Coventry Wolverhampton. The Liaison and Diversion around a third of which was accounted for EMPLOYMENT a new Work and Health Programme to individual preferences (Coventry MBC) and North Staffordshire staff provide an all age service and link by Actual Bodily Harm. Drugs offences support people with long-term health 4. Job search is rapid: beginning within (provider Work4You, Making Space and directly into the local Crown and were the next most common, although the 1. Provision in the WMCA problems, including mental health, into work. one month; covering Lichfield) and Worcestershire Magistrates court to support ongoing proportion of women in prison for these People with severe mental health problems There are currently a number of providers of 5. Employment specialists and clinical (provided by Worcestershire Health and diversion opportunities. The West Midlands types of offences has dropped considerably, have very low employment rates and the DWP-funded Work Choice Programme teams work and are located together Care Trust covering Bromsgrove and is the only Force with 100% coverage from 25.2% in 2009 to 13.8% in 2014117. are at greater risk of falling out of work for people with mental health problems in 6. Employment specialists develop Redditch), as excellent; Sandwell ahead of the national roll out by 2019 which than the general population and other the West Midlands and those listed by relationships with employers based (Sandwell MBC) and Wolverhampton is currently subject to further Treasury Anawim in Birmingham provides a female disadvantaged groups. Although the the British Association for Supported upon a person’s work preferences (Healthy Minds and Wellbeing) as decisions. offender programme which feeds from the majority of people with mental health Employment113, which may not be a 7. Support is time-unlimited and good fidelity; Birmingham (BSMHT) Liaison and Diversion staff. This has been problems want to work, there is a growing comprehensive list, are as follows: individualised to both the employer as fair fidelity; and Wolverhampton The Crisis Care Concordat Action Plans seen as very successful but funding concern about the relationship between  Sandwell Council and the employee; (Wolverhampton MBC) as low fidelity. identify the need to improve access to continues to be an issue for sustainability employment support, entitlement to  Advance Employment, Solihull 8. Welfare benefits counselling supports An inaugural meeting of an IPS network liaison and diversion services and action and the programme may seek to be Employment Support Allowance (ESA)  Hereward College, Coventry the person through the transition from was held in May 2016 with the aim of plans for the constituent members of the included in the wider commissioning and mental health support. In relation to  Pathway First, Momentum and benefits to work. developing a West Midlands IPS strategy WMCA have identified measures, including of female offender health services. the range of employment support, a Shelforce in Birmingham and scaling up provision116. closer working between the police and MH comprehensive mapping of DWP provision  Dudley MBC Figure 21: The key principles of Trusts. Examples of initiatives to support has not been undertaken for this exercise  Seetec and Dudley and Walsall Individual Placement and Support this include: and, in any event, changes are planned Mental Health Partnership NHs Trust (Source: Centre for Mental Health, 2009) for 2017 with the merger of the Work in Walsall Programme and Work Choice to form

114 http://digital.nhs.uk/catalogue/PUB18657/meas-from-asc-of-eng-1415-fin-rpt.pdf [accessed 100516] 115 This is unsurprising because the ASCOF data is drawn from MHMDS. 116 www.wmahsn.org/events/2016/05/11/West_Midlands_Mental_Health_Innovation_Network_Event_-_Individual_Placement_and_Support [accessed 050616]150816]. 117 www.gov.uk/government/uploads/system/uploads/attachment_data/file/457922/Better_Outcomes_for_Women_Offenders_September_2015.pdf 118 113 http://base-uk.org/services-offered/work-choice?page=1 www.westmidlands-pcc.gov.uk/media/371302/06-spcb-07-jul-15-reducing-offending-and-reoffending.pdf 62 Mental Health in the West Midlands Combined Authority Mental Health in the West Midlands Combined Authority 63

Integrated offender management is a Staffordshire and West Midlands CRC key operating approach within the West covering Staffordshire and the West Overall assessment Midlands Police area, being awarded the Midlands, and West Mercia covering the Tilley prize in 2015. The approach has seen Warwickshire and Worcestershire elements the West Midlands within the lowest top of the WMCA. They provide probation ten areas for reoffending for the last services for low and medium risk offenders This exercise has provided a rapid Midlands Public Health, as well as by They are built on an ethos of open door two years118. alongside the national probation service, appraisal of the position of mental its partner Local Authorities. Better and spirit, often supporting the most which serves the most high risk offenders. health in the WMCA, as defined by intelligence will enable a clearer picture marginalised populations. Throughout the 2. Prison This split has increased the complexity the geography of the three LEPs. It is of the current position and the priorities process of gathering data for this appraisal, There are 12 prisons in the West Midlands around information sharing. not comprehensive but provides a for action. We have highlighted the we have heard concerns about the impact and their mental health provision, in addition complement to other work being relationship between inequalities and of budget reductions on this sector in to availability of nursing and emergency 4. Support for prisoners ‘through the gate’ undertaken by the West Midlands Mental mental health and how the risks of particular, with valued services having to be services to people accommodated in prison, ‘Through the gate’ is a National Offender Health Commission and its partners. developing poor mental health are not cut or no longer commissioned. Adopting is detailed in Appendix 10. Approximately Management Service/ CRC led programme evenly distributed across the WMCA. a system-wide and a strategic approach to 3,700 primary mental health referrals of which seeks to identify opportunities to It is clear that considerable investment in It is important that the diverse needs of mental health offers the opportunity of a adult male prisoners are made on an annual resettle individuals as they leave prison. mental health is being made across the different populations, including those that clear-sighted view on what services need basis (Offender HNA and Consultancy Working with providers, plans are put in WMCA and this report provides a starting we identified as being at risk, are properly to be protected and further developed. Projects, 2015: 28). Gaps in provision place to ensure housing, health and social point for discussion about how well this is considered, and what needs to happen to relating to primary care mental health and needs are addressed prior to release. currently deployed. make access to support more equitable. The West Midlands has been a pioneer counselling have been identified with a There is a significant challenge in in many areas and not shied away from recommendation that IAPT is introduced to addressing missed opportunities around The overall conclusion from this appraisal A key message from the emerging innovation, having developed service address low levels of mental health needs pick up of treatment post release especially is that there is considerable scope for the evidence and the promising practice is that models that have consequently been and that innovative approaches to delivering for substance misuse; West Midlands (85% WMCA to improve the mental health of personalised approaches, built on and adopted elsewhere, early intervention for primary mental health support in prisons is missed) compared to the national average working-age adults through a strategic responding to what people with mental psychosis and street triage for example, required. Problems in obtaining secure beds (67% missed). and system wide approach. The framework health problems, their families and and been an early adopter of service for people requiring transfer under the MHA provided in Figure1 in the introduction is communities, say, and what they think models from good quality evidence were also identified by the 2013/14 Health The regional approach to rehabilitation offered as a basis for identifying how action needs to happen, is an important strand elsewhere, Housing First for example. Needs Assessment (Offender HNA and has a governance structure (West Midlands could be taken to provide a systemic of effectiveness and may save money. The establishment of the West Midlands Consultancy Projects, 2015). In addition a Reducing Reoffending Steering Group) approach to future development by It is, therefore, encouraging to see Mental Health Commission reflects this lack of capacity for prison staff to attend supporting housing, employment the WMCA and its partners. a commitment to co-production widely pioneering spirit, and the capacity to work mental health awareness training was and resettlement. expressed by public services in the WMCA together, to work differently and to invest highlighted. and some examples of this being translated resources differently to better effect for There are two key issues that require into action. There is clearly further scope for people living in the WMCA. 3. Community Rehabilitation Companies further consideration by the West Midlands action on this front, drawing on both local In 2014, changes to the delivery of Mental Health Commission and its and national expertise. probation services were introduced, with partners. First is addressing the question responsibilities for most offender being of how children and young people can be It is nevertheless the case that the transferred to 21 Community Rehabilitation better supported to ensure they have a introduction of promising initiatives that have Companies (CRCs). There are two reduced chance of developing a mental the potential to bring social and economic CRCs covering the WMCA population: health problem in later life? This has been benefits is patchy, and the West Midlands outside the scope of the current appraisal Mental Health Commission is in a good but, nonetheless, the evidence strongly position to evaluate these and support their indicates that many children who implementation. Scaling up these initiatives experience mental health problems, often – MHFA, IPS, Housing First, Crisis Houses, in response to adverse childhood events, for example, needs to be actively considered go on to have mental health problems and evaluation of these models in a WMCA PEOPLE IN CUSTODY as adults. Over time, evidence-based context is needed to understand the role STRENGTHENING intervention early in the life course, of contextual factors that may influence ARE PARTICULARLY VULNERABLE including during the perinatal period, is effectiveness and outcomes. There are also TO POOR MENTAL HEALTH AND MORE almost certainly the most effective and areas, particularly in primary care, where AND BUILDING cost-effective means of reducing the different models are being developed and LIKELY TO HAVE EXPERIENCED SEVERE overall prevalence of mental health comparison of these in terms of access THE MENTAL HEALTH AND MULTIPLE FORMS OF DISADVANTAGE problems in the adult population. and impact (eg, patient and economic OF PEOPLE LIVING IN THE WEST outcomes) would be of benefit. Second is the quality of mental health The third sector – voluntary and community MIDLANDS REQUIRES A STRATEGIC related intelligence across the WMCA organisations – play a key role in supporting AND SYSTEMIC APPROACH, THAT footprint. We have found the JSNAs to be people who may not be supported by public RECOGNISES AND DEVELOPS THE of variable quality in terms of how current services, because they are unable to meet and comprehensive they are. This has their needs appropriately or because of ROLE OF ALL ORGANISATIONS IN implications for support from West reluctance to engage with these services. ACHIEVING THIS. 64 Mental Health in the West Midlands Combined Authority Mental Health in the West Midlands Combined Authority 65

Recommendations References

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Tadros, G., Salama, R. A., Kingston, P., Wadley, H. (2015). Correspondence re. Wyllie, C., Platt, S., Brownlie, J., Chandler, Mustafa, N., Johnson, E., Pannell, R. and proposals in the Budget Consultation 2015. A., Connolly, S., Evans, R., Kennelly, B., Appendix 1 Hashmi, M. (2013). Impact of an integrated Birmingham Mind. Available on request. Kirtley, O., Moore, G., O’Connor, R. and rapid response psychiatric liaison team on Scourfield, J.(2012). Men, Suicide and quality improvement and cost savings: the Walby, S. (2004). The cost of domestic Society: Why disadvantaged men in mid-life Audit of Mental Health Activity Commissioned Birmingham RAID model. The Psychiatrist, violence. London: Women and Equality die by suicide. Samaritans. Available at: 37(1), 4-10. Unit, DTI. http://www.samaritans.org/sites/ by CCGs and Local Authorities in WMCA2014/15 default/files/kcfinder/files/press/ Tang, L., 2016. Barriers to recovery for Walsh, E., Buchanan, A. and Fahy, T. Men%20Suicide%20and%20Society%20 Chinese mental health service-users in the (2002). Violence and schizophrenia: Research%20Report%20151112.pdf UK: a case for community development. examining the evidence. British Journal 1. Name of organisation: Community Development Journal. doi: of Psychiatry, 180, 490-495. 10.1093/cdj/bsw025 Details of person completing the audit: Waters, J. and Hatton, C. (2014). The Children’s Society (2013). Hidden Third National Personal Budget Survey from view: The experiences of young Experiences of personal budget holders and carers in England. Available at: carers across adult social care and health. 2. Please provide a breakdown by age for the year 2014-15 below: http://www.childrenssociety.org.uk/ Lancaster University and InControl. sites/default/files/tcs/hidden_from_ Available at: AGE GROUP Spend (£000s) 2014-15 view_-_final.pdf http://www.thinklocalactpersonal.org. Children (0–16) uk/_assets/Resources/SDS/POET_ The King’s Fund (2015). Mental health social_care_FINAL_Oct_24.pdf [accessed Adults of working age under pressure. Available at: http://www. 060616]. (17–65) kingsfund.org.uk/sites/files/kf/field/ Older adults (65-plus) field_publication_file/mental-health- Watts, B., Johnsen, S., Sosenko, F. (2015). Total under-pressure-nov15_0.pdf [accessed Youth Homelessness in the UK. Edinburgh: 040516]. Institute for Social Policy, Housing, Environment and Real Estate (I-SPHERE), Thiel, V., Sonola, L., Goodwin, N. and Heriot-Watt University. Available at: https:// 3. For adults of working age, please complete the table: Kodner, D. (2013). The Esteem Team: pureapps2.hw.ac.uk/portal/ Organisation commissioned Target population Activity specified Expected outcomes Contract value Performance monitoring Co-ordinated care in the Sandwell files/9258335/Youth_Homelessness_in_ (2014-15) details for 2014-15 Integrated Primary Care Mental Health and the_UK.pdf Please attach or provide Wellbeing Service. London: King’s Fund. summary here Weaver, T., P. Madden, V. Charles, G. Trachtenberg, M., Parsonage, M., Shepherd, Stimson, A. Renton, P. Tyrer, T. Barnes et al. G. and Boardman, J., (2013). Peer support (2003). Comorbidity of substance misuse in mental health care: is it good value for and mental illness in community mental money? London: Centre for Mental health. health and substance misuse services. Available at: http://eprints.lse.ac. The British Journal of Psychiatry 183, uk/60793/1/Trachtenberg_etal_Report- no. 4: 304-313. Peer-support-in-mental-health-care-is-it- good-value-for-money_2013.pdf Wong, E. C., Collins, R. L., and Cerully, J. L. (2015). Reviewing the Evidence Base for Tunstall, R., Bevan, M., Bradshaw, J., Mental Health First Aid: Is there support for Croucher, K., Duffy, S., Hunter, C., Jones, its use with key target populations in A., Rugg, J., Wallace, A. and Wilcox, S., California? Rand Corporation Research (2013). The links between housing and Report. Available at: http://www.rand.org/ Please add additional rows as necessary poverty: an evidence review. JRF Report, pubs/research_reports/RR972.html. York: Joseph Rowntree Foundation. WHO and the Calouste Gulbenkian Varese, F., Smeets, F., Drukker, M., Lieverse, Foundation, (2014). Social determinant of R., Lataster, T., Viechtbauer, W., Read, J., Mental health. World Health Organisation. van Os, J. and Bentall, R.P., (2012). Available at: Childhood adversities increase the risk of http://www.who.int/mental_health/ psychosis: a meta-analysis of patient- publications/gulbenkian_paper_social_ control, prospective-and cross-sectional determinants_of_mental_health/en/ cohort studies. Schizophrenia bulletin, 38(4), pp.661-671.

Waddell, G. and Burton, K. (2006) Is work good for your health and wellbeing? London: TSO. 74 Mental Health in the West Midlands Combined Authority Mental Health in the West Midlands Combined Authority 75

% of households with occupancy rating for bedrooms of -1 or less 2011 (England average = 4.81) 6.02 5.19 6.84 3.74 5.63 3.05 1.74 2.65 2.86 2.43 9.06 3.22 2.47 2.64 3.11 2.8 4.44 1.8 2.47 Appendix 3 Mental Health Joint Strategic Needs Assessments for the WMCA

% of adults that have no qualifications or level one qualifications 2011 (England average = 35.76) 45.32 48.31 49.52 44.3 37.22 26.51 31.3 43.2 43.67 32.82 41.53 38.87 36.13 36.31 44.49 44.22 40.91 34.09 42.04 LEP Local Authority Status as of July 2016 Link to JSNA Wolverhampton Refreshed in 2014 https://wolverhampton.moderngov.co.uk/ documents/s5336/Item%2012%20-%20 Appendix%201.pdf

Walsall Refreshed in 2013 http://www.walsallintelligence.org.uk/ Children in poverty: % living in low income households 2013 (England average = 18.62) 29.65 27.19 27.64 21.33 23.53 10.17 8.47 13.92 19.01 12.46 29.16 14.7 12.18 15.67 17.55 17.86 16.79 9.74 18.92 Children and young people emotional wellbeing themedpages-walsall/JSNA JSNA 2015 Adult mental health needs Mental health JSNA Black Country in preparation

Sandwell 0-25 yrs MH JSNA in final draft form Work underway on adult MH JSNA Statutory homelessness: rate per 1000 households 2014/15 (England average = 2.4) 3.21 1.31 4.52 0.76 4.72 2.37 1.6 2.67 3.54 4.66 7.43 2.3 1.28 6.85 0.82 5.2 2.64 1.74 3.24

Dudley Unable to locate http://www.dudley.gov.uk/EasySiteWeb/ JSNA synthesis 2012, no specific section on GatewayLink.aspx?alId=228193 mental health

Coventry 2015. Also covers Ruby but limited information www.coventry.gov.uk/download/.../mental_ Socioeconomic deprivation: people living in 20% most deprived areas 2014 (England average = 20.16) 53.58 48.57 55.67 23.19 33.01 1.02 0 5.35 18.26 1.72 56.65 17.68 3.9 15.72 13.69 17.5 26.41 1.96 22.9 available health_needs_assessment.pdf

Coventry and Warwickshire Warwickshire JSNA 2011-2012 http://apps.warwickshire.gov.uk/api/ Specific mental health needs assessment for documents/WCCC-644-291 veterans in 2015

2011, although specific work done on particular http://birminghampublichealth.co.uk/ Socioeconomic deprivation in 2010 (England average = 21.69) 34.41 31.23 36.97 23.22 28.44 11.47 10.42 16.29 22.74 13.76 37.54 19.14 12.74 16.38 20.64 19.66 21.85 10.38 21.04 themes: employment, equity of access, physical manager/_mods/_ckfinder/userfiles/files/ Birmingham health. Currently undertaking a mental health JSNA%20Mental%20health%20vFINAL(1).pdf equity audit for BAME communities

Staffordshire JSNA for Staffordshire 2012 covers East http://www.eaststaffsbc.gov.uk/ Staffordshire, Lichfield, Cannock Chase and sites/default/files/docs/planning/ Population estimates mid-2014 252,987 274,173 316,719 315,799 337,428 139,396 121,056 62,468 126,174 102,500 1,101,360 115,663 102,093 209,890 98,549 77,112 84,471 95,485 98,960 4,032,283 Tamworth planningpolicy/examination/c/ C39StaffordshireNeedsAssessment2012.pdf

Solihull Planned 2016.17 JSNA Summary 2015 Greater Birmingham and Early Help Needs Assessment March 2016 http://www.solihull.gov.uk/About-the- Solihull Resilience Needs Assessment for School Age Council/Statistics-data/JSNA Children in Solihull February 2016 Dementia Needs Assessment 2016 Physical Health and mental health needs planned for 2016/17 CCG Wolverhampton Walsall Birmingham Sandwell and West Dudley Coventry and Rugby South Warwickshire South Warwickshire North Warwickshire North Warwickshire Coventry and Rugby Birmingham Cross City Birmingham South and Central Birmingham Sandwell and West East Staffordshire SE Staffs and Seisdon Peninsula Solihull Cannock Chase SE Staffs and Seisdon Peninsula Redditch and Bromsgrove Redditch and Bromsgrove Wyre Forest Worcestershire Refresh 2015 covers Bromsgrove, Redditch www.worcestershire.gov.uk/.../id/.../2015_ and Wyre Forest briefing_on_mental_health.pdf 120 120 http://www.worcestershire.gov.uk/ 120 120

120 Primary care mental health needs assessment downloads/file/6527/2015_mental_health_ needs_assessment Council –Metropolitan or County (District or Borough) City of Wolverhampton Council Council Walsall Sandwell MBC Dudley MBC Coventry City Council County Warwickshire Council County Warwickshire Council (Stratford-on-Avon) County Warwickshire Council (North W’shire) CouncilCounty Warwickshire (Nuneaton and Bedworth) County Warwickshire Council (Rugby) Birmingham City Council Council County Staffordshire (East Staffordshire) Staffordshire County Council (Lichfield) Solihull MBC Staffordshire County Council (Cannock Chase) Staffordshire County Council(Tamworth) County Worcestershire Council (Redditch) County Worcestershire Council (Bromsgrove) County Worcestershire Council (Wyre Forest) TOTAL Pink denotes that the LA covers an area outside West Midlands Combined Authority jurisdiction LEP Black Country Coventry and Warwickshire Greater Birmingham and Solihull Appendix 2 Population and socio-economic deprivation in the West Midlands (Source: ONS) 116  76 Mental Health in the West Midlands Combined Authority Mental Health in the West Midlands Combined Authority 77

Appendix 4 Service user engagement groups in the West Midlands Combined Authority

Area Name of Group Description Recent examples of involvement/co-production Area Name of Group Description Recent examples of involvement/co-production

See Me user engagement A project that promotes greater engagement of New Dawn, a comprehensive review of community Experts by A team of eleven expert service users and carers, Urgent care services comprehensive review project at BSMHFT service users in the planning and delivery of mental mental health services, was undertaken with the Experience who use their experience to influence the delivery and and redesign was conducted which led to the health services in Birmingham and Solihull through support of the See Me team to ensure service users Dudley and Walsall quality of services provided by Dudley and Walsall MH development of the Street Triage Service which feedback; ensuring users’ views are represented at and carers could inform and support development of MH Partnership Partnership Trust. The work of EBEs forms a significant has been very well received. all levels of the Trust and See Me user involvement new ways of working. The See Me team have also Trust part of the Trust’s Service User and Carer Involvement workers have a place on all key Trust meetings sought feedback and informed views of service users Strategy, which aims to deliver the vision of involving An overview of the Crisis Resolution and Home Dudley and Walsall and support service users to attend many of these regarding the recent SmokeFree NHS introduction service users and carers in all areas of work. Treatment Service including identifying training meetings as User representatives too. across all teams in the mental health trust. needs for staff. 300 voices A partnership between BSMHFT, West Midlands An evaluation undertaken at the end of the Police, Birmingham City Council and Time to programme (Rowe et al., 2016) identified a number Enhanced care and compassion through the Change that seeks to engage with young African of positive changes from the introduction of 300 introduction of 'Hello my name is' campaign and Caribbean men aged between 18 and 25 to voices, including: Trustwide. hear their experiences of inpatient and outpatient  Engaging a diversity of professionals in training Mental Health The People’s Parliament enables people, with lived White Paper on ‘Alternative Places of safety’ care. 300 Voices was funded by the Big Lottery workshops People’s Parliament experience, to develop into leadership roles as MPs. and are developing a standardised person centred Fund, the Department for Health and Comic  Changing attitudes (particularly among police) These MPs work in co-production with senior leaders Mental Wellbeing Plan and a set of standards Relief, and the funding came to an end in March  Influencing individuals to reflect on and change Sandwell and decision makers from a range of agencies such for crisis care. 2016. Different elements of the programme are their practice. as the local Council or Clinical Commissioning Group, Birmingham being taken forward by BSMHFT (peer support to improve services and support needed to achieve programme) and by West Midlands Police The authors of the evaluation report (Rowe et al., equality, good health and social inclusion. (engagement of workforce with 300 voices). 2016) conclude that there is a clear case to build South Staffordshire An independent charity promoting and developing Succeeded in lobbying and campaigning for a The 300 Voices project adopted a person-centred on the achievement of 300 voices to date in the Network for Mental mental health services from the perspective of people short term nonclinical crisis prevention service. approach to mental healthcare that aims to engage future. Health who have an experience of mental illness throughout Currently exploring partnership working to fund with African and Caribbean men and hear their the six districts and borough of South Staffordshire. and deliver a second service (the current project stories to determine how mental health services Funded by Staffordshire County Council to provide is volunteer led) will be delivered in the future. The project is a mental health participation service called 'Your underpinned by a model of community engagement Voice'. Represent people with experience of mental Succeeded in getting a ring and ride scheme for to create a dialogue and healthy transformative illness within local Healthwatch and local Clinical people living in rural parts of Staffordshire who conversations. Activities include community Commissioning Groups. were having difficulty accessing services. engagement events, the experience booth to Activities include: capture experiences; plays; and the development of  Ongoing qualitative evaluation of five local mental Successful in obtaining National Lottery Funding a practical toolkit aimed at staff. health services and associated care planning to deliver a mental health promotion service aimed Birmingham and Solihull A blog presenting 'an independent, occasionally documentation. at reducing admission into mental health services Mental Health NHS very satirised view' of mental health and Staffordshire  Quarterly high standard newsletter and podcast for next four years. Foundation Trust User Watch NHS issues led and edited by service members. Actively Influencing Mental Independent Mental Health User Involvement Recent and regular consultation with the Care  Four research reports each year covering health services (AIMHS) Service – a registered charity which is user led Quality Commission and Monitor. Co-production topics deciding by members (previous reports and has an entire staff team of people who have of a variety of peer support groups (Mental health have included GP Awareness of mental health, lived experience of mental ill health. and Veterans). Co-production of accredited Experience of Jobcentre Plus, Barriers to  A monthly user forum training packages. Provide local authorities and Employment, Quality of Care in Recovery).  Weekly peer support groups NHS with trained panel members for interview  Ongoing delivery of four workshops promoting Coventry and (mental health and veterans) and selection procedures. Contribute to local and recovery and encouraging self-management Warwickshire  Weekly face to face evaluation of mental national research project, and currently engaged and participation within care planning. health services in the locality with National Mind on a Peer Research Project.  An Investing in Volunteers accredited volunteer Partnership working with Healthwatch. Continue to campaign locally for non-clinical programme providing the opportunity for people changes that affect inpatient care. Successful with experience of mental illness to become in obtaining additional grant funding to set up a community developers. Veterans Peer Support Group. 78 Mental Health in the West Midlands Combined Authority Mental Health in the West Midlands Combined Authority 79

Area Name of Group Description Recent examples of involvement/co-production

Positive Action A service user group, set up by Wolverhampton Introducing a requirement into contracts that for Mental Health Empower Me team at Wolverhampton CVS124 , to services are obliged to have a system in place to (PAMH)123 influence and improve mental health services in respond to issues raised by service user groups. Wolverhampton. Members meet twice a year at Influencing commissioners, along with Hear- our- Appendix 5 membership events to have their say on mental health Voice and other service groups to develop the services, and how they can be improved. Community Wellbeing Hub. There is also a Steering Group, which represents the Audit of public mental health initiatives being commissioned voice of the wider membership at meetings across 125 Wolverhampton on a regular basis, including peer in WMCA (Source: Local Authority Audit responses 2016) support groups that have over 350 members. Hear-our-Voice A Mental Health Action Group that is a completely The group is developing an approach ‘Mental user/ex-user led Registered Charity and Company Health and Physical Health As One’ and aims to Limited by Guarantee, with approximately 150 shift the focus from a biomedical approach members. All members must live within the to one focused on the problems and circumstances Wolverhampton City boundary. The group of people experiencing mental health problems. Wolverhampton Public health intervention Examples Wolverhampton Walsall Sandwell Dudley activities include: It is, therefore, promoting greater access Emotional Health and  Support for recovery by holding monthly Forum to psychological therapies and counselling Self-help stress Wellbeing service Sandwell’s feel good 6 meetings with specific topics; workshops, including in primary care. management resources, Mental health providing one to one wellbeing engagement sessions, such as relaxation, aromatherapy, and 1:1 support and peer awareness/ support; Five Ways campaign from 15/16. educational trips. General public/front support for the general Mental Health First Aid to Wellbeing MHFA, Building resilience  Events to raise public awareness of Mental Health line services to promote public. (MHFA) Youth MHFA and Stress training – training front issues wellbeing, awareness Mental Health First Aid Community wellbeing Management Training. line staff in mental  Communicating members’ ideas to CCGS, Mental and tackle stigma Lite - half-day training services Mental health training for health and wellbeing Health Trusts and the Local Authority to improve the sessions, bi-monthly key workers (eg, health awareness. mental health services and requiring action. over a six month period  A quarterly magazine with a readership of potentially visitors, school nurses 1000 readers which includes all members, Statutory etc.) inc. MHFA. Bodies, Mental Health professionals, Libraries, Perinatal and infant Breast feeding support Breast feeding support Pharmacists, Community Centres, Housing offices, mental health Family Support Family Support and Doctors' surgeries. programmes Services Services Redditch Mental MHAG is made up of individuals and representatives Members have launched a coaching scheme which Health Action Group of organisations from Redditch, who meet monthly works with people to set and achieve their goals. CHANGES local to discuss mental health, raise money for projects They have trained up various coaches to be able Parenting programmes Parenting Team Parenting Programme within the town and host events including an annual to expand the service. (including targeted Parenting team Mellow, Triple P a universal and targeted Wellbeing Week. programmes at high risk Triple P and Solihull offer for parents of Representation on a County Council committee families) children 0–19 Worcestershire to decide what action is taken at a suicide hotspot in the town. Primary Whole School MHAG regularly has speakers from the Health and Approach (WSA) to Care Trust at their meetings, raising concern about Emotional Wellbeing: issues such as the closure of Orchard Place. emotional health and wellbeing audit for SURESEARCH- A midlands network of people who have used and/or Individual Suresearch members collaborate in schools; action planning Service Users survived mental health services and their allies-mental metal health research projects and contribute to to address ‘gaps’ and in Research and health workers, academics, carers. SURESEARCH training practitioners at various institutions including School-based mental Support for teachers implementation of a Education aims to promote service user involvement in mental University of Birmingham social work courses. health promotion and Anti-bullying social and emotional health education, training and research and it has a prevention programmes learning programme membership of over 100. The Suresearch network incorporated into the exchanges information, supports its members and taught curriculum. Audit develops projects and opportunities in education, Includes staff emotional West Midlands research and the creative arts, through its regular health and wellbeing monthly meetings. There are also regular smaller 15/16 Agreed funding meetings: to offer WSA to  Issues for patients and staff on psychiatric wards – Secondary Schools The In-Patient Care Forum  Writing and Reading – The Writers and Readers Group Audit of emotional Workplace wellbeing  Creative Work in the Arts – Survivor Arts Healthy Workplace health and wellbeing initiative led by HR for Workplace Healthy Workplace Programme in schools as above) Dudley MBC staff: interventions Programmes Lifestyle Link includes staff emotional Five Ways to Wellbeing health and wellbeing training course 15/16

123 Funding discontinued 31.3.16.  124 http://wolverhamptonvsc.org.uk/our-projects/mental-health-empowerment/ [accessed 150816]. 125 Some of the public mental health work detailed is developmental or project based and has ended or was under review at the time of data collection. 80 Mental Health in the West Midlands Combined Authority Mental Health in the West Midlands Combined Authority 81

Public health intervention Examples Wolverhampton Walsall Sandwell Dudley Public health intervention Examples Wolverhampton Walsall Sandwell Dudley

Expert Patient Mental health Mental health awareness General public/front MHFA for frontline workers Mental Health First Mental health programme for 18+ awareness/ / mental Health First Aid line services to promote A mental health training Aid training awareness/ living with a long-term Mental Health First Aid for Lifestyles services, awareness and tackle programme for front line Ways to Wellbeing Mental Health First Aid health condition Community wellbeing school staff and stigma professionals e-learning module Mental wellbeing hub Community and Community Development (anxiety/depression) services Community Hub staff social activities workers Community Development UNICEF Level 3 (Full) Addressing social BME Mental Health and Worker Service for accredited Infant Newborn Observational isolation. Access Wellbeing Prevention mental health Feeding Support Service Training for Health Visitors, to education and A community service for Service includes Manmade Dudley Health Visiting support Children Centre workers and employment African/Caribbean/Dual short-term counselling, 9 week course for to mums with perinatal Perinatal and infant Midwives. Targeted initiatives for Support for carers Heritage for people at awareness raising and unemployed men mental health issues mental health Breast feeding support Infant feeding service at risk groups Building confidence risk of developing or practical and emotional 30-50 years of age to Solihull Approach programmes MAMTA – BME service for and self-esteem are recovering from ill support improve mental health Postnatal Plus courses expectant mothers, referring targeted at: mental health. Mental health and wellbeing (pilot Scoping support for and signposting to relevant Young people assessment of all those project), included Five infant mental health agencies BAME groups referred to health trainer Ways to Wellbeing; attachment service from Unemployed men services basic suicide prevention children’s MH provider training; and Mental Parenting Team – Health First Aid Lite. Triple P programme, living Solihull Approach Carers Relaxation Toolkit Parenting programmes Parenting Team with confidence (to improve Antenatal, Postnatal and mindfulness session (including targeted Triple P self esteem), family links and Understanding programmes at high risk nurturing programme, Your Child’s Behaviour families) Parenting Team courses and Tackling violence and Domestic abuse Domestic abuse family Domestic violence Mellow Parenting abuse services hostel perpetrator programme Locality based Acting Early Work with individual Primary Whole-School School-based mental (MDT) teams for School schools to increase Solihull healthy Schools Support for teachers Approach to Emotional health promotion and focusing on various areas emotional resilience Emotional Health Anti-bullying Wellbeing: emotional prevention programmes including mental health and also challenge programme health and wellbeing School Nursing service discrimination Reducing physical Healthy Weight audit, action planning inactivity Services Programmes to improve to address ‘gaps’ and Training and a review of Specialist weight 'Food Dudes' Healthy the physical health of implementation of a processes and pathways for management Eating Programme people with mental social and emotional frontline staff at the Local Smoking cessation Dynamic Dudes health problems learning programme Authority’s employment Screening and adult – physical activity incorporated into the service. Workplace Wellbeing lifestyle services program taught curriculum Charter promoting good Solihull MBC: Agreed funding to offer practice among local Training on mental Workplace Wellbeing Healthy Workplace WSA to Secondary Workplace interventions employers, including training health awareness and Charter and Workplace Programmes Schools Occupational health support on workplace wellbeing Mental Wellbeing a to Council staff. Mental council priority. Forward for Life for Forward for Life for Applied suicide Wellbeing Single Point frontline workers and frontline workers and prevention training Access tool to help managers senior managers senior managers Mental health and in dealing with mental Suicide prevention 4 x half-day SafeTALK 4 x half-day SafeTALK wellbeing 14/15, wellbeing issues in Suicide prevention training basic suicide prevention basic suicide prevention ASIST and SafeTALK the workplace sessions sessions suicide prevention Targeted initiatives 2 x ASIST 2-day suicide 2 x ASIST 2-day suicide Community and social Social inclusion project which Urbrum, a Youth Social training for front line addressing mental prevention accredited prevention accredited activities works with Asian people with Inclusion project, staff from 15/16 wellbeing and target training courses training courses Addressing social mental health needs. for 'hard to reach' groups at risk including isolation Tamarind, a mental health young/BME people in people with mental Access to education resource centre for BME Birmingham Bids invited for mental health issues, isolated and employment groups Community General Art, Craft and health promotion activity individuals, substance Targeted initiatives for Support for carers A variety of social and Development Workers Other Health sessions of 2 reflecting the Five users:- Horticultural at risk groups Building confidence informal educational Community Health hours Ways to Wellbeing (not and Eco projects; social and self-esteem opportunities for young Champions model of continuing) prescribing. Bespoke targeted at: people with ASD recruiting people from Lifestyle Services such Young people ASD group support services. local communities who as Health Trainers, BAME groups Family Nurse Partnership for suffer the worst health Stop Smoking, Weight Unemployed men young parents experience Management target specific groups 82 Mental Health in the West Midlands Combined Authority Mental Health in the West Midlands Combined Authority 83

Public health intervention Examples Wolverhampton Walsall Sandwell Dudley Early Intervention Appendix 6 service for young people in poor/coercive relationships. Suggested commissioning priorities for public mental health Domestic abuse Tackling violence and CDVASS Coventry Domestic abuse services services abuse domestic violence (Source: Heginbotham and Newbigging, 2013) Full references available in source document service providing – single point access to Commissioning area Specific interventions Some examples of the impact or Implementation aspects and References support victims in the outcomes achieved feasibility community  Improved maternal mental  Independent risk factors New recovery services Reducing physical Development of health for conduct and emotional being procured inactivity community-led Health Check Scheme  Improved infant and child Routine enquiry at ante-natal disorders (Meltzer et al., Programmes to improve in 2017, will have Universal routine enquiry Specialist weight initiatives to reduce provided for clients Promote good parental mental wellbeing clinics. Prenatal programmes 2003) the physical health of physical health as key and targeted treatment for management physical inactivity. of community mental mental and physical  Reduced maternal with postnatal follow up in the  Maternal depression, people with mental performance indicator women at risk of depression Smoking cessation Smoking harm health services health to improve early child postnatal depression first year after birth are most especially in teenage health problems – providers to offer with as part of a package Screening and adult reduction and cessation (BSMHFT) development and wellbeing,  Improved parental effective. Interventions with mothers, leads to physical activities to of measures to improve lifestyle services support maternal wellbeing psychological health first-time mothers show best behavioural difficulties. service users perinatal mental health.  Improved mother's effects. (Caan & Jenkins, 2009; Work with owners of employment after NICE, 2007; Karoly et al, car parks/bull ring to ASIST Suicide maternity leave 2005; Olds, 2002) reduces risk of tall Suicide prevention Suicide Strategy draft Prevention Training  Group based parenting Suicide prevention building suicide training has been completed GP Suicide Prevention Universal access to training programmes have a Asist and Safetalk Ensure that parenting Training programmes: positive effect on mental suicide prevention programmes are universal  Community based group health and lead to training  Improved parental efficacy but where targeting programmes; home based improved self-esteem and parenting practice is undertaken match Promote good parenting individual programmes, (Barlow et al., 2003)  Improved maternal programmes to social context skills – universal as well as  Pre-school/ early child  Good parenting skills sensitivity and family circumstances. targeted early intervention education programmes, promote wellbeing and Training in using Big White Wall, a Long term conditions  Reduced use of NHS, 10% of parents with children programmes for common supporting development reduce incidence of WEMWBS, and safe online community programme for people social care, criminal justice with conduct disorders Cancer survivorship parenting problems and more of home learning conduct disorders. (Olds Other secondary research providing peer support newly diagnosed with and third sector provision receive evidence based programme intensive interventions for environment. et al, 1997; Cornah, 2003; of the local household and guided by health arthritis, heart disease  Build social and emotional parenting programmes. high risk families.  Prioritising support for Bywater et al., 2009) survey professionals and diabetes. resilience from an Preschool programmes parents from higher risk  Social and emotional early age that combine high quality groups and with children learning programmes education with parental with emotional and improve skills and self- support are most effective. behavioural problems. esteem (Payton et al., 2008)

 Integrated approach, using universal and targeted interventions in primary school are cost effective.  Improvement in child Healthy schools; extended social and emotional skills, schools including supporting connection to school and families;  Peer-led ‘emotional positive social behaviour. Curriculum should integrate School based mental health intelligence effective  Reduction in conduct development of social promotion. in combatting low problems and emotional and emotional skills within School based Social and self-esteem. Universal Build social and emotional distress. all subjects, delivered by Emotional Learning (SEL) school-wide mental health resilience of children and  Improved family trained teachers supported programmes achieving promotion better than young people through whole relationships and improved by parents. Targeted pupil's core competencies. classroom based brief school approaches parental mental health. approaches to children Self-management and interventions. (Bond et Need a picture  Improved self-esteem. showing early signs of social skills training. al., 2004; Meade & lamb,  Reduced problem emotional and social Build financial literacy. 2007; Schachter et al., behaviour and conduct difficulties are recommended Mentoring programmes 2008; Wright et al., 2006) disorders including Family Intervention Projects substance misuse  Improved financial skills and reduce indebtedness.  Reduced antisocial behaviour reduced domestic violence. 84 Mental Health in the West Midlands Combined Authority Mental Health in the West Midlands Combined Authority 85

Commissioning area Specific interventions Some examples of the impact or outcomes Implementation aspects and References Commissioning area Specific interventions Some examples of the impact or outcomes Implementation aspects and References achieved feasibility achieved feasibility

Workplace screening for risk a) Adopt integrated  Physical and sexual  Increased employment, and of depression followed by interventions which combine violence have direct health reduction in lost employment CBT where indicated. organisational and individual consequences and are risk years due to reduced health Early intervention to reduce level approaches. factors for a wide range of service and welfare costs Multi-component interventions risks of unemployment through b) Job retention and re-  Early diagnosis and long term health problems Improving working  Costs of programme quickly Building life skills in children that integrate skills primary care and Job Centres employment programmes intervention with employees including mental health lives: translate into financial benefits and young people including development and training and promote engagement and which support reemployment with depressive symptoms concerns, alcohol abuse, a) support for mainly in form of cost savings school-based violence of teachers and parents participation for those who and promote the mental health offers good financial return  Reduced levels of mental health unwanted pregnancy, unemployed  Reduction in health costs of Implementation of prevention programmes supported by specialists (see become unemployed. of unemployed people. (Hilton 2005). problems and physical injuries sexually-transmitted diseases b) creating healthy depression and anxiety disorders initiatives to prevent, including sexual abuse and area 1 above) Providing volunteering c) Supported employment  Adults who are economically as a consequence of abuse and risky sexual behaviour. working environments  Improved wellbeing due to identify and respond bullying prevention Key role of primary care and opportunities. programmes and specialist inactive are at increased  Reduced crime, aggression and  Taking a life-course approach c) early recognition reduced financial distress to emotional, Promoting gender equality for the wider health and social Support NHS, LA and Third work schemes are most risk of mental illness (Black, violence. demonstrates the impact and intervention for impacts on reduced housing physical and/or women services to offer a holistic Sector organisations to effective. 2008).  Improved long term self- of childhood abuse on those with mental stress etc. sexual abuse Reducing the availability and approach to abuse with develop interventions to d) Reduce mental health  Lack of income may lead to management of other conditions lifestyle choices and poor health problems  Significant reduction in financial harmful use of alcohol an understanding of the improve healthy working lives stigma and discrimination in increased housing risk and self-management leading d) supported work for distress (M) Victim identification and care contribution of violence and and support occ. the workplace. an increased risk of mental to further problems such those recovering from  Reduction in sickness absence and support programmes abuse to health and social health schemes. e) Support NHS, LA and disorder (Weich & Lewis, as diabetes. (DH, 2010) mental illness  Significantly improved care problems. Stress management third sector organisations to 1998). Bullying has negative employment rate for those on interventions tailored to the develop local interventions consequences on school a scheme needs of the employees. to improve healthy working health and performance  Reduction in rehospitalisation Supported work for those lives, reduce stressors that are (Bond et al., 2001.  Reduced time spent in hospital recovering from mental illness. beyond the individuals’ control. Integrated physical and  Moderate physical activity Universal access to lifestyle mental health behaviour improves mental wellbeing Integrating physical programmes change through brief  Reduced depression and (Harvey et al., 2010) and mental wellbeing Targeting higher risk groups, interventions. Meaningful group activities better self-management of  Exercise of moderate through universal for example people with a Opportunistic health with educational and/or diabetes; reduced dependency intensity has a positive access to lifestyle mental illness or learning promotion interventions for support input based on on primary care effect on physical and programmes to reduce disability, older people and high risk groups through participation of older people.  Improved physical health and Improve the quality of mental wellbeing (NICE, smoking alcohol use, pregnant women. primary care. Befriending services (third  Improved social inclusion Volunteering and peer reduction in obesity. older people’s lives 2008a; NICE 2008b), and substance use, and Target people with diabetes Skilled staff oriented to sector and social care) via  Effective befriending services support programmes for through psychosocial reduces anxiety, enhances obesity. that are known to be at risk of respond to the mental social prescribing to target would generate significant cost to foster contact between interventions which mood and improves self depression. health needs of primary care loneliness and social isolation. savings generations. enhance control, esteem (Egan et al., 2008; patients. Group interventions  Improved quality of life Increasing physical activity in prevent isolation, and Etnier et al., 1997) Falls prevention through  Reduced A&E attendances residential care settings and  Screening and brief enhance physical  Volunteering enhances social support and education and admissions to hospital through social prescribing. intervention in primary care is activity. wellbeing more than in highly cost-effective Ensure staff in leisure centres Screening and brief younger people (Age Tackling alcohol and  Alcohol use reduction has are appropriately qualified to intervention in primary care Concern and MHF, 2006) substance abuse, early paybacks and impacts Multi-sectoral action through provide exercise programmes Target problem drinking  Reduce loneliness and including screening favourably on the NHS multi-agency arrangements for older people. and alcohol abuse through anxiety by providing means programmes and direct reduction in A&E attendances between NHS, LAs, Police, multi-sectoral action (local to stay active. (Lampinen et measures with those and domestic violence Probation, Third sector etc authority, health, police , al.,2006; NICE 2008b) abusing alcohol.  Reduce isolation and ‘hidden education) Build collaborative drinking’ amongst older people  Self help groups and peer  Meaningful occupation and community partnerships  Reduction in crime and support effective in reducing physical activity increases based on existing strengths improved perception of safety social isolation/ loneliness and overall wellbeing (NICE, and resources. Access to social interventions provide meaningful occupation 2008b; Casidy et al., 2008). Community Use of community Use innovative approaches in primary and community locally, leads to increased  Time banks generate empowerment empowerment strategies such as social prescribing care pathways: eg, quality of life through social new social networks and and development  Improve wellbeing and quality based on the active and mutual volunteering Include encouraging active through social prescribing interaction and having practical relationships (Friedli et al., interventions of life and neighbourhood engagement and schemes to engage the travel, reducing effects - specifically volunteering, needs net. 2008). that encourage Outcomes: sense of belonging, participation of local participation of socially of traffic, functionality of Improving quality of including time banks, exercise  Improved mental and physical  Adults who are economically communities to participation in decision community members. excluded groups. neighbourhood, safe green life through increasing arts and creativity, learning health. inactive are at increased improve physical and making, wellbeing/Quality of Create awareness of the Ensure access to education, environments, community arts opportunities for and educational opportunities,  Increased confidence, sense of risk of developing a mental social environments, life, satisfaction with place to impact of the social and learning, arts, leisure, and culture, volunteering participation, personal and green activity. community, social cohesion disorder (Black, 2008). participation and live physical environment on the personal development and development and Signposting to welfare  Increased levels of social  Locating welfare advice in strengthen social community and people’s local support services based problem-solving advice, particularly support and caregiver skills. general practice increases networks . mental health. on consultation with key employment, provision of  Reduced demands on primary benefits, particularly stakeholder groups. support for benefit uptake, care and reduced levels of disability-related benefits Place-shaping by LAs to debt advice, financial literacy antidepressant prescribing. and is an excellent strategy create opportunities for and information and self help.  Self-management and healthy by which primary care people to come together. Debt counselling and advice. behaviours. organisations can influence Primary care can provide  Increase in benefits through their population’s health good access to advice providing access to benefits (Greasley & Small, 2005; services for people in middle advice in GP surgeries Abbott & Hobby, 2003). and old age.

86 Mental Health in the West Midlands Combined Authority Mental Health in the West Midlands Combined Authority 87

Team Type Team Invalid / Missing Missing / Invalid

12,115 10,740 7,485 215 30,555

Attendance Day Care Facility Facility Care Day

Appendix 7 27,180 1,080 33,055 6,040 67,355

– out of scope of PBR of scope of out – Other MH Service Service MH Other

CCG Weighted populations (Mental Health) 16,615 * 40 235 16,890

– in scope of PBR of scope in – Other MH Service Service MH Other 130 755 80 * 965

CCG Weighted Populations (Mental Health) Asylum Service Asylum Number of GP Total Registered Total Need Need index * * * * Practices in CCG Population Weighted

Population Inreach Psychiatric Prison

NHS Birmingham CrossCity CCG 116 739,238 987,078 1.34 * * * *

and Diversion Service Diversion and NHS Birmingham South and Central CCG 45 247,127 386,727 1.56 Liaison Justice Criminal * 2,130 3,315 3,030 8,475

NHS Cannock Chase CCG 27 132,981 91,834 0.69 Substance Misuse Team Misuse Substance NHS Coventry and Rugby CCG 77 474,552 516,732 1.09 760 * * * 760

NHS Dudley CCG 50 312,962 342,340 1.09 Eating Disorders/Dietetics Eating

NHS East Staffordshire CCG 19 136,061 96,632 0.71

8,475 1,100 6,195 4,960 20,730 NHS Redditch and Bromsgrove CCG 22 172,435 111,058 0.64 Illness Mental Peri-Natal NHS Sandwell and West Birmingham CCG 107 542,706 669,742 1.23

4,875 * 1,700 * 6,575

NHS Solihull CCG 32 239,035 252,996 1.06 Service Community Forensic Forensic Community

NHS South East Staffs and Seisdon Peninsular CCG 31 212,546 145,340 0.68 3,270 1,070 * * 4,340 NHS South Warwickshire CCG 36 274,817 267,941 0.97 Service Forensic

NHS Walsall CCG 63 275,130 210,632 0.77 1,340 185 * * 1,525

Psychosis Team Psychosis NHS Warwickshire North CCG 28 184,661 219,213 1.19 in Intervention Early

NHS Wolverhampton CCG 51 261,596 271,167 1.04 27,590 8,480 23,705 6,525 66,300

Service NHS Wyre Forest CCG 12 112,622 74,044 0.66 Disorder Personality

1,585 * 4,240 * 5,825 Young Onset Dementia Onset Young 1,120 * 480 * 1,600

126

Source: NHS England www.england.nhs.uk/wp-content/ (non-IAPT) Service uploads/2014/03/d-nph-mental-health.xlsx [accessed Therapy Psychological

120516] 4,155 * 5,585 * 9,740 Psychotherapy Service Psychotherapy

5,800 * 965 * 6,765 Psychiatric Liaison Psychiatric

20,160 2,885 12,140 4,550 39,735 General Psychiatry General

25,690 51,440 16,160 92,220 185, 510 Rehab. Recovery Team Recovery Rehab.

* * 56,830 * 56, 830 Assertive Outreach Team Outreach Assertive

40,055 5,995 9,130 70 55, 250

Health Team Health Adult Community Mental Mental Community Adult

179, 875 50,200 99,275 4,325 333, 675

Home Treatment Home Crisis Resolution Team/ Resolution Crisis

70,055 18,860 77,490 31,725 198, 130 Day Care Services Care Day

29,435 3,970 2,190 545 36,140 NHS Trust NHS Data source: Health & Social Care Information Centre Mental Minimum Dataset (MHMDS/MHLDDS) 2014/15 [accessed 150816] BSMHT BCPT CWPT DWMHPT Totals Appendix 8 Outpatient and community contacts by organisation team type 126  Source: Mental Health Bulletin: Annual Statistics 2014–15. 88 Mental Health in the West Midlands Combined Authority Mental Health in the West Midlands Combined Authority 89

Appendix 9 Vanguards

MODALITY BIRMINGHAM DUDLEY MULTISPECIALTY THE MENTAL HEALTH ALLIANCE FOR SOLIHULL TOGETHER FOR  Establishment of a Primary Care Centre AND SANDWELL COMMUNITY PROVIDER EXCELLENCE, RESILIENCE, BETTER LIVES within a health and wellbeing campus Patient population: 70,000 INNOVATION AND TRAINING (MERIT) (on hospital site). Patient population: 318,000 The project covers North and South Solihull  Co-location of GP Out of Hours, Urgent The vanguard is made up of a single, local This comprises Birmingham and Solihull and is a partnership between the Heart of Care Walk In / Minor Injury services into GP partnership called Modality Birmingham This Vanguard is led by Dudley Mental Health NHS Foundation Trust, Black England NHS Foundation Trust, BSMHFT, a single Urgent Care Centre. and Sandwell which operates from 15 Multispecialty Community Provider and Country Partnership NHS Foundation Trust, West Midlands Police, Solihull MBC;  Establishment of a GP led step-up / practice sites across Birmingham and includes Dudley Metropolitan Borough Coventry and Warwickshire Partnership Solihull CCG; voluntary and community step-down unit within the hospital. Sandwell and serves a registered Council, Black Country Partnership NHS NHS Trust and Dudley and Walsall Mental sector providers; primary care; the West  Improved access to diagnostics and population of 70,000 patients. Foundation Trust, Dudley Group NHS Health Partnership NHS Trust. midlands academic Health sciences secondary care specialists for primary The vision for the vanguard is to develop a Foundation Trust, Dudley and Walsall Network and representatives of service care / community teams supported by health and social care system accessible Mental Health Partnership NHS Trust, The alliance will focus on three priority areas users, carers and the wider Solihull innovative information technologies. through GP practices, with a care- Dudley Council for Voluntary Services and where the greatest challenges for urban community.  Mental Health services; building on Rapid coordinator to support patients on their Future Proof health Ltd. mental health services exist and where it The vision is to create a maximally integrated Assessment Interface and Discharge, journey. This will be achieved by delivering can rapidly realise quality and efficiency health and social care system that optimises Street Triage, Dementia and Delirium medical services from a number of primary The Multispecialty Community Provider benefits, spread best practice and reduce preventative out of hospital care with rapid Team, Outreach. care centres across Birmingham and model proposed by the partnership in variations in cost and quality through access to specialist care both in and out of  Supporting Patients/ Carers in their Sandwell. Dudley aims to develop a network of integration across current geographical and hospital, when needed, including access to homes and the health and wellbeing integrated, GP-led providers across health organisational boundaries. These areas are other services including charities, leisure campus through open and accessible The larger centres will expand the range of and social care, each working at a level of seven day working in acute services, crisis series, council and police. The ambition is to information and services using various social, mental, community and enhanced 60,000 people, reaching a total population care and the reduction of risk, and extend healthy active life and independence portals, building on the local authority secondary care services on offer to patients of around 318,000 across Dudley. This promoting a recovery culture. Some of the with equal focus on physical and mental “Solihull Connect” service by delivering community outpatient and system will see the frontline of care working specific transformations MERIT will work to health through encouraging lifestyle  Integrated Community Teams, supporting diagnostic services. This will mean that, for as “teams without walls” for the benefit of achieve are: choices, care-coordination and admission avoidance. example, a person who has diabetes and patients, taking shared mutual responsibility  Consistency in services seven days a empowerment for self-management of suffers from high blood pressure will benefit for delivering shared outcomes. week and in pathways, so services fit long-term conditions, reducing pressures on Source: https://www.england.nhs.uk/ from being treated in a familiar environment people’s lives secondary care services and altering the ourwork/futurenhs/new-care-models/ that is close to home and will be supported Under the new provider system patients, for  Less variation in services balance of care provided in hospital and the [accessed 150816] by a care co-ordinator to help manage their example a lady with frailty and long-term  Faster decision making, such as community. This includes: care plan. conditions and registered with a GP in discharges seven days a week and a Dudley, will have her care overseen by a co-ordinated emergency response multi-disciplinary team in the community  A shared care plan, meaning one including specialist nurses, social workers, assessment and only having to tell their mental health services story once and voluntary sector link workers. This will  More likelihood of staying closer to ensure holistic care that better meets all of home if a bed isn’t available in the her medical and social needs at one time in immediate area one place, but allows her to access advice  Less unnecessary time spent in A&E and support for the isolation she can feel at or police cells living alone far from her family, and  More support for recovery in the combatting her episodes of anxiety. When community and less chance of a relapse she needs help urgently there is a 24 hour or return to secondary care services rapid response and urgent care centre  Wider access to clinical trials, leading which provide a single coordinated point to improved treatments, models and of access for her so she doesn’t need to outcomes call 999.  Greater participation in our services across all communities. As a result of the health and care system working better together in this way, patients Key to achieving this impact at scale and are not only receiving the coordinated pace will be shared models for support support necessary for their health needs but services, including research and innovation, they are also linking to the wider network of staffing, workforce planning, information care and social interaction in their technology, equality and diversity and quality community to help them to live more governance. independently for longer. 90 Mental Health in the West Midlands Combined Authority Mental Health in the West Midlands Combined Authority 91

Appendix 10 Abbreviations and acronyms The West Midlands Prisons Cluster

Prison Prisoner Group Mental health provision A&E Accident and Emergency IPS Individual Placement and Support

1,450 adult men Mental health inpatient ward ACEs Adverse Childhood Events JHWB Joint Health and Wellbeing Strategy Primary healthcare is provided through BSMHFT and Birmingham Community NHS Trust ASIST Applied Suicide Intervention Skills Training JSNA Joint Strategic Needs Assessment Birmingham Mental Health In-Reach and Substance Misuse services are provided by BSMHFT. BAME Black, Asian and Minority Ethnic LA Local Authority Psychosocial Services are provided by the South Stafford and Shropshire NHS Foundation Trust Drug Local Enterprise Partnership and Alcohol Recovery Team BCG Boston Consulting Group LEP 569 young adult men 11 bedded mental health inpatient ward providing a regional resource for men up to aged 21 BCPFT Black Country Partnership NHS Foundation Trust LOS Length of stay aged 18–21 Primary healthcare provider is Staffordshire and Stoke-on-Trent Partnership NHS Trust (SSOTP) Birmingham and Solihull Mental Health NHS Foundation Mental Health Alliance for Excellence, Resilience, BSMHFT MERIT Brinsford Mental Health In-Reach services are delivered by South Staffordshire and Shropshire Healthcare NHS Trust Innovation and Training Wolverhampton Foundation Trust CBT Cognitive Behavioural Therapy MHA Mental Health Act Drug and Alcohol service (DARS) is provided by Lifeline and Delphi Medical CCG Clinical Commissioning Group MHFA Mental Health First Aid 1,060 adult men GP, Primary Care, and Integrated Substance Misuse staff are directly employed by Care UK CAMHS Child and Adolescent Mental Health Services MHMDS Mental Health Minimum Data Set Dovegate 12 bedded mental health inpatient ward CIPD Chartered Institute of Personnel and Development MUS Medically unexplained symptoms Staffordshire Integrated Mental Health Services provided by Care UK and South Staffordshire and Shropshire Healthcare NHS Foundation Trust CPA Care Programme Approach NICE National Institute for Health and Care Excellence CPN Community Practice Nurse NOMIS is part of ONS and provides Official Labour 315 women aged 18 The current primary healthcare provider is SSOTP NOMIS Drake Hall Mental Health In-Reach services are delivered by South Staffordshire and Shropshire Healthcare NHS CQC Care Quality Commission Market Statistics Staffordshire Foundation Trust NSUN National Survivor User Network CRCs Community Rehabilitation Companies Drug and Alcohol service (DARS) is provided by Lifeline and Delphi Medical OAT(s) Out of Area Treatment(s)/Placements CJS Criminal Justice System 687 adult men Primary healthcare provider is SSOTP ONS Office for National Statistics Featherstone Mental Health In-Reach services are delivered by South Staffordshire and Shropshire Healthcare NHS CWPT Coventry and Warwickshire Partnership NHS Trust PICU Psychiatric Intensive Care Unit Wolverhampton Foundation Trust DALY Disability-adjusted life-year Drug and Alcohol Recovery Service provided by Lifeline and Delphi Medical QALY Quality-adjusted life-year DWMHPT Dudley and Walsall Mental Health Partnership NHS Trust 1261 adult men 18 bedded inpatient unit for both physical and mental health needs. QOF Quality Outcomes Framework DWP Department of Work and Pensions Hewell Primary healthcare provider is Worcestershire Health Care NHS Trust (WHCT) RAID Rapid, Assessment, Interface and Discharge Redditch Integrated Mental Health Service and Integrated Substance Misuse Service, incorporating clinical and EI Early intervention RCT Randomised Control Trial psychosocial services, provided by WHCT EIP Early intervention for psychosis Staffordshire and Stoke-on-Trent Partnership 622 adult men Primary healthcare provider is WHCT FTB Forward Thinking Birmingham SSOTP NHS Trust Long Lartin 10 bedded inpatient unit for both physical and mental health needs GDP Gross Domestic Product Worcestershire Integrated Mental Health Service and Integrated Substance Misuse Service, incorporating clinical and STPs Sustainability and Transformation Plans HSCIC Health and Social Care Information Centre psychosocial services, provided by WHCT WEMWEBS Warwick Edinburgh Mental Wellbeing Scale HSJ Health Service Journal 1,605 adult men Primary healthcare provider is WHCT WHCT Worcestershire Health Care and NHS Trust Oakwood Integrated Mental Health Service provided by WHCT, with Forensic Psychiatry support from BSMHT IAPT Improving Access to Psychological Therapies Wolverhampton WHO World Health Organization Integrated Substance Misuse Service, incorporating clinical and psychosocial services, is provided by WHCT IMCA Independent Mental Capacity Advocacy WMCA West Midlands Combined Authority 741 adult men Primary healthcare provider is SSOTP IMHA Independent Mental Health Advocacy Mental Health In-Reach services are delivered by South Staffordshire and Shropshire Healthcare NHS Stafford Foundation Trust Drug and Alcohol service (DARS) is provided by Lifeline and Delphi Medical 766 adult and young adult Primary healthcare provider is Shropshire Community Health NHS Trust men aged 18+ Mental Health In-Reach services are delivered by South Staffordshire and Shropshire Healthcare NHS Stoke Heath Foundation Trust Shropshire Substance Misuse Services provided through a partnership between RAPt (Rehabilitation for Addicted Prisoners Trust) and North Staffordshire Combined NHS Trust 654 young men Primary healthcare provider is SSOTP Swinfen Hall aged 15–18 Mental Health In-Reach services are delivered by South Staffordshire and Shropshire Healthcare NHS Lichfield Foundation Trust Drug and Alcohol services provided by Lifeline and Delphi Medical

160 young men Primary care services provided by SSOTP Werrington aged 15–18 CAMHS provision is by ENGAGE (South Staffordshire and Shropshire NHS Foundation Trust) Stoke-on-Trent The Young Persons Drug and Alcohol Support Service is provided by Lifeline and Delphi Medical

Source: Offender HNA and Consultancy projects (2015): West Midlands Prison Health Needs Assessment 2014–15 Birmingham B152RT 40 Edgbaston ParkRoad Park House The UniversityofBirmingham School ofSocialPolicy Centre Management Services Health

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