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Poverty and mental

A review to inform the Joseph Rowntree Foundation’s Anti- Strategy

1 POLICY REVIEW AUGUST 2016 Poverty and : A review to inform the Joseph Rowntree Foundation’s Anti-Poverty Strategy

Iris Elliott PhD FRSA August 2016

Citation

The recommended citation for this review is: Elliott, I. (June 2016) Poverty and Mental Health: A review to inform the Joseph Rowntree Foundation’s Anti-Poverty Strategy. London: Mental Health Foundation.

Acknowledgements

Helen Barnard managed the delivery of the review for the Joseph Rowntree Foundation and co-ordinated input from her colleagues. David Pilgrim, University of ; Professor David Kingdon, University of Southampton; Andy Bell, Centre for Mental Health; and Sam Callan, Centre for Justice were insightful reviewers.

Thank you to the Mental Health Foundation team who supported the writing of this report: Isabella Goldie, Director of Development and Delivery; Marguerite Regan, Policy Manager; and Laura Bernal, Policy Officer.

2 3 Contents

Executive Summary ...... 4

1. Introduction ...... 7

2. Poverty and Mental Health: A Conceptual Framework...... 15

3. Poverty and Mental Health Across the Life Course ...... 22

4. Public Services ...... 32

4.1 Cross-Cutting Themes...... 33

4.2 Health...... 36

4.3 Social Care...... 44

4.4 ...... 45

4.5 ...... 50

4.6 Social Security...... 54

4.7 Advice...... 60

4.8 Planning the Built Environment...... 63

5. Growing the Evidence Base: Data and Research ...... 65

6. Costings ...... 68

7. Recommendations ...... 78

8. Methodology ...... 83

Bibliography ...... 88

Glossary ...... 96

2 3 Executive Summary

Poverty increases the risk of mental discrimination; and policy development) health problems and can be both a at different stages of life and across the causal factor and a consequence of whole of the life course. Attention is mental ill health. Mental health is shaped given to pressure points and transitions by the wide-ranging characteristics throughout life, particularly when (including inequalities) of the social, these are adverse experiences such as economic and physical environments , redundancy and family in which people live. Successfully breakdown, which can be traumatic and supporting the mental health and have cumulative impacts. People with wellbeing of people living in poverty, complex needs are discussed across the and reducing the number of people with review. mental health problems experiencing poverty, require engagement with this In order to strengthen the evidence base, complexity. mental health must be addressed within poverty data and research, and, likewise, The review presents a conceptual poverty addressed within mental health framework for understanding the data and research. A mental health and relationship between poverty and poverty research agenda should be mental health, which draws together: co-produced with individuals, families a life course analysis; a discussion of and communities with lived experience the socio-economic factors (or social of these issues. This research agenda determinants) impacting mental health should include economic research that and poverty; the principles of human has proved persuasive in key areas such rights, equity, anti-stigma and non- as maternal mental health (see Costings discrimination; and the approaches section 6). Implementation science of prevention, self-management, peer methodologies should be employed support, and to scale and test programmes and social movement building. interventions in order to ensure that they are appropriate and effective for people There are a number of imminent living in poverty. opportunities for addressing mental health and poverty across the UK, The review recognises the corrosive including the programmes for impact of stigma and discrimination government of the recently elected on people experiencing mental health devolved administrations in Scotland, problems and those living in poverty. Wales and . It proposes the integration of social contact approaches around mental Recommendations for action are health and poverty within current anti- made across a number of cross-cutting stigma campaigns and initiatives. areas (data and research; stigma and

4 5 The development of Mental Health in treatment for claimants with mental All Policies (MHiAP) at national and local health problems across the social government levels is recommended security system. At a minimum, the for areas of public policy considered Programme needs to be completely within this review (health, education, overhauled. employment, social security, advice and planning the built environment), noting In later life, the evidence base for that this is not an exhaustive list. effective interventions needs to be further developed, particularly for The life course stages are framed within initiatives that facilitate social and this report as: perinatal ( and cultural participation, enhance social the first year following birth), early years, connection and reduce isolation. The children and young people; working age; commissioning of systematic reviews of and later life (from 50 years onwards). evidence would be a valuable first step It is essential that the National Institute in identifying what works with regards for Health and Care Excellence (NICE) to addressing mental health and poverty perinatal care pathway is implemented in later life. Primary care screening for across the UK. Recommended supports mental health problems (particularly for families, children and young people depression and dementia) is one way to are the Family Nurse Partnership, promote early intervention. evidence-based positive parenting programmes (including for families People experiencing poverty and with a parent who has mental health mental health problems would benefit problems), the adoption of the whole- from a number of initiatives across the school approach, and particular supports life course. The creation of accessible, for vulnerable and excluded children, integrated hubs within many of whom may not be in education. deprived communities would provide individuals, families and groups with During working age, policy should timely, appropriate and local support and support people to enter and remain in care. A national programme of primary- work through the adoption of whole- care-based social prescribing within workplace approaches, a national these communities would facilitate individual placement and support (IPS) people’s access to mental health, programme, and development of mental enhancing social, cultural and leisure health and wellbeing programmes for activities that are beyond their economic small and medium-sized enterprise reach. (SME) owner-managers and employees. The social security system needs to be Mental health problems can disrupt leveraged to ensure that claimants with people’s education, training and entry mental health problems receive their into, and progression within, work. Local full social security entitlements, and opportunities for lifelong learning are are the beneficiaries of programmes an important way of addressing the such as Access to Work. There needs disadvantage and exclusion that this to be an improvement in the quality of leads to.

4 5 The use of parity within policy advocacy The Psychologically Informed Planned in order to advance fair investment Environments (PIPEs) approach has in mental health has magnified the been piloted within some criminal false dichotomy between mental and justice settings. PIPEs are a form of physical health. Addressing the mental Psychologically Informed Environment health of children and adults with (PIE). The evidence base is developing long-term physical health conditions but promising, and the report improves their engagement with care recommends the scaling and testing of and treatment, and their prognosis, as PIEs in services for people with complex well as their family members’ and carers’ needs. mental health and wellbeing. Tackling the high levels of physical ill health and This review has synthesised evidence early death among people with serious across a considerable breadth of mental health problems is a priority. The public policy agendas. Although it is development of integrated pathways not a systematic review, the evidence across the life course for people has come from authoritative sources. with co- and multiple morbidities is Where the evidence base is developing recommended. but promising, this is noted (see Methodology). Concerns about the relationship between mental health and criminal It is intended that the review is relevant justice have been raised over many to policy, provision and people across years, each successive report building the UK. The type, quality and scope the case for a complete health and of statistical information and other justice pathway. This report recommends evidence about mental health and the development of such a pathway, poverty varies across the UK. These improved mental health provision variations are noted, but the review’s across all criminal justice settings, and narrative and recommendations have a comprehensive national liaison and been written to be as relevant to each diversion programme. The needs of part of the UK as possible. Black, Asian and Minority Ethnic (BAME) community members, women, and older offenders require particular attention within this work.

6 7 1. Introduction

One in four adults and one in ten mental health and wellbeing of people children experience mental health living in poverty and reducing the problems to some degree in any year;i numbers of people with mental health and the impacts of mental health problems experiencing poverty requires problems ripple out to affect many more engagement with this complexity. people through their social networks of family, education, work and community. There is a growing UK policy consensus The 2015 ‘Monitoring Poverty and that mental health requires substantial ’ report’s comparison attention and investment in order of data between 2005 and 2012 found to address the huge economic and that a greater proportion of women social costs to individuals, families, were assessed as being at high risk of communities and . This agenda mental health problems compared to encompasses addressing the range of men; within the lowest social economic social and economic factors that affect class, 26% of women and 23% of men mental health (referred to as the ‘social were at high risk of mental health determinants of health’), challenging the problems.ii Three-quarters of people stigma and discrimination that continue with a mental health problem do not to impact people with mental health receive ongoing treatment.iii Poverty1 problems and their families in all areas increases the risk of mental health of their lives, removing barriers to full problems, and can be both a causal participation within society – including factor and a consequence of mental ill in education, employment and the health.iv Mental health is shaped by the community – providing public services wide-ranging characteristics (including in a timely manner, and developing inequalities) of the social, economic research and data in order to ensure that and physical environments in which policy and provision are evidence based, people live.v Successfully supporting the and that is tracked.2,vi

1 The Joseph Rowntree Foundation’s definition of poverty is: “When a person’s resources (mainly their material resources) are not sufficient to meet their minimum needs (including social participation).” https://www.jrf.org.uk/report/definition-poverty 2 The Mental Health Foundation’s UK public inquiry into the future of mental health services (December 2012–September 2013) synthesised evidence from twelve oral evidence sessions held across the UK, 1,533 submissions to its call for evidence, three individual interviews, four background papers (‘Inequalities and Mental Health’; ‘A Brief of Specialist Mental Health Services’; ‘Healthcare Informatics for Mental Health: Recent advances and the outlook for the future’; and ‘Mental Health Professional Education and Training in the UK’), and an expert seminar.

6 7 Although mental health problems can policy and services. Such complex affect anyone at any time, they are not needs in adulthood can originate in equally distributed and prevalence ‘complex trauma’ – that is, exposure varies across social groups. The Chief to traumatising events from an early Medical Officer for identified age that lead to complex symptoms a number of groups of young people as and behaviours.vii Complex trauma being at risk of developing mental health can affect people’s ability to form problems, including children living at a trusting relationships and emotional socio-economic disadvantage, children management;viii but, if addressed, with parents who have mental health recovery is possible.ix Trauma-informed or substance misuse problems, and care (TIC) has been described as: looked-after children. Among adults, she identified higher risk among people who “an over-arching framework that have been homeless, adults with a history emphasizes the impact of trauma and of violence or , Travellers, asylum that guides the general organisation seekers and , and isolated older and behavior of an entire system. people.3 Higher rates of mental health Trauma-Specific Services may be problems are associated with poverty offered within a trauma-informed and socio-economic disadvantage. program or as stand-alone services”. Social characteristics, such as , , age, race and ethnicity, sexual Different approaches to TIC have a orientation and family status influence number of common characteristics: the rates and presentation of mental trauma awareness, an emphasis on health problems, and access to support safety, opportunities to rebuild control and services. and a strengths-based approach.x

People who experience several complex The experience of homelessness and interrelated issues, who are referred illustrates the relationship between to as having ‘complex needs’, are at complex trauma and consequent higher risk of mental health problems complex needs. People experiencing and require tailored responses within homelessness, particularly single

3 In her 2013 annual report themed on public mental health, England’s Chief Medical Officer identified particular groups of young people at risk of developing mental health problems: children living at a socio-economic disadvantage; children with parents who have mental health or substance misuse problems; children experiencing personal abuse or witnessing domestic violence; looked-after children; children excluded from school; teen parents; young offenders; young lesbian, gay, bisexual or transgender (LGBT) people; and young black and minority ethnic people. The groups of adults who have higher to experiencing mental health problems were listed as: people with past mental health problems; people who have been homeless; adults with a history of violence or abuse; adults who misuse alcohol or other substances; offenders and ex-offenders; LGBT adults; Travellers, asylum seekers and refugees; adults with a history of being looked after or adopted; people with learning ; isolated older people; and people from BAME communities.

8 9 people4 and women,5 have high levels 1.1 The Impact of the Financial and of mental health problems. High levels Economic Crisis of of neglect, abuse and traumatic childhood experiences were The global financial and economic crisis found in a 2011 census survey of 1,286 has accentuated and reinforced long- participants living in urban homelessness term trends in inequality, low pay and communities.xi Additionally, people who related poverty in Europe. While the are homeless may experience significant initial impact was high rates of male social exclusion and be affected by redundancy, women have experienced substance misuse, which, in themselves, higher wage cuts. Disabled people can be traumatic experiences.xii All (including people with mental health of these experiences and issues are problems), women and ethnic minorities further associated with involvement in have experienced disproportionately the criminal justice system. Promising negative impacts.xv approaches to addressing complex trauma include the development of PIEs The primary health impacts of economic within services used by people with downturns are on mental health complex needs (discussed in section (including the risk of ).xvi People 4.1.4).xiii with no previous history of mental health problems may develop them as a Poverty produces an environment that consequence of having to cope with the is extremely harmful to individuals’, ongoing of job insecurity, sudden families’ and communities’ mental and unexpected redundancy, and the health. The impacts of poverty are impacts of loss of employment (financial, present throughout the life course social and psychological). Keeping (before birth and into older age) and people with mental health problems in have cumulative impacts. However, work and getting people back to work there are evidence-based measures to are key policy and service responses to progress mental health promotion, ill the economic downturn.xvii health prevention, early intervention, and care and treatment that lead A review of UK and international to resilience and recovery and can literature, and two Welsh local be delivered at individual, family, authority case studies by the Cardiff community and national levels.xiv

4 ‘Single homeless people’ is generally understood to be those who are homeless but do not meet the priority needed to be housed by their local authority. They may live in supported accommodation – such as hostels and semi-independent housing projects – sleep rough, sofa surf or live in squats. Many have significant support needs (St Mungo’s (2014) in Breedvelt (February 2016)). 5 Women represent around 30% of people using homelessness accommodation. Women, in particular, may have experienced complex trauma and be further subjected to this through sexual and domestic violence, separation from children, relationship breakdowns, and bereavement. They can benefit from a different – that is, gender-sensitive – approach to meeting their complex needs. (Hutchinson et al. (2014) in Breedvelt (February 2016))

8 9 Institute of Society and Health and 2009 commented: “there is likely to be the Wales Health Impact Support a long tail of human suffering following Unit, found that the health impacts of the downturn”.xxi Longitudinal research recession and its aftermath are likely is required to understand the long-term to be felt directly through uncertainty, impacts of the financial and economic insecurity and lack of control. Within crisis within the UK, both across the labour market, these impacts geographical areas and within population include anticipation of redundancy, groups. In Northern Ireland, such , , research should consider the impacts of changes in expectations of productivity both the UK and Irish recessions. and working practice, reductions in , experiences of debt, financial 1.2 Policy Opportunities tension, and relationship strain. Studies about the rapid de-industrialisation in After many years of advocacy, mental the UK during the 1980s (in Wales, and health is receiving significant attention in the West Midlands and North East from policy-makers across the UK, in of England) found that, although living Europe and globally. Milestone reports in areas of high unemployment may include the national Foresight report protect against some psychological on mental capitalxxii and the World impacts of unemployment (such as Health Organization’s (WHO’s) series stigma and shame), in the long term, of reports: ‘Mental Health, Resilience people living in these communities are and Inequalities’,xxiii ‘Mental Health exposed to other mental health risks Action Plan 2013–2020’,xxiv ‘Social associated with economically deprived Determinants of Mental Health’xxv and areas.xviii The impacts of recession ‘ROAMER: A Roadmap for Mental on such communities highlight how Health and Wellbeing Research in disadvantage accumulates within places Europe’ (ROAMER).xxvi This valuable – for example, the loss of community body of policy and research reports resources and facilities when the local is coalescing around a common, cannot sustain them, and the evidence-based agenda across the life of due to weakened course, combining, firstly, public mental social networks and reduced social health through addressing the social interaction.xix determinants of mental health and advocating a proportionate universalist As signs of recovery emerge within approach in order to reduce health the UK, it is important to distinguish inequalities, and, secondly, integrated between economic recession, which may mental health and social care services be of a relatively short duration, and the that are focused on early intervention consequences that can negatively affect and characterised by access, choice, particular people and places over a quality and timeliness. longer period of time, depending on the interaction of , age, gender For decades, mental health campaigners and the type of work that has been lost.xx have drawn attention to the historical Researchers who looked into the suicide underinvestment and marginalisation of rates in Europe between 2007 and mental health in public policy, service

10 11 provision, research and data. Mental Finally, this advocacy is securing health problems are the largest single significant policy (if not substantial source of disability in the UK, accounting budgetary) successes. In England, there for 23% of the total ‘burden of ’ are policy commitments to parity of (a composite measure of mortality and investment in the ‘No health without reduced ).xxvii However, mental health’ national policy, the NHS it is difficult to get a comprehensive Mandate, the NHS ‘Five Year Forward understanding of mental health, View’ (2015–2020), the Children and including mental health and poverty, Young People’s Taskforce’s ‘Future in due to inadequate research and data. Mind’ 2015 report, and the independent A recent briefing by The King’s Fund Mental Health Taskforce established commented on the challenges of by NHS England (NHSE), which reporting reliable data on the levels of reported in February 2016. The public funding for mental health services in and private sectors are recognising England, and that, consequently, the that the economic and social costs of quality of services cannot be definitely underinvesting in mental health are not assessed;xxviii this is a challenge across sustainable. the UK.xxix With regards to research, mental health receives only 5.5% of the This report is a timely contribution that health research budget (this is discussed can inform the ongoing development further in section 5).xxx of public policy for the Westminster Government and the devolved There is a common agenda around administrations of Scotland, Wales and the development of future mental Northern Ireland elected in May 2016. health services. It will be important to In England, it will be important for the ensure that any additional investment Joseph Rowntree Foundation’s (JRF’s) is used to co-produce progressive Anti-Poverty Strategy to inform the provision with people who have lived implementation of national mental experience of mental health problems health policy and the Mental Health through involving them in the design, Taskforce’s report, ‘The Five Year delivery, monitoring and evaluation Forward View for Mental Health’, and to of services. Over time, mental health support the Prevention Concordat and services should reorient from traditional, proposed mentally healthy communities individualised, biomedical approaches agenda, including Health and Wellbeing towards integrated biopsychosocial Boards’ mental health joint strategic service models that resource self- needs assessments and new Mental management, peer support, and Health Prevention Plans (leveraging the collective leadership by people with lived optimum gains from local authorities’ experience of mental health problems functions). In 2016, and communities with higher prevalence Scotland will progress its new mental of mental ill health.xxxi health strategy and Wales will review ‘Together for Mental Health’. In Northern Ireland, the new Minister for Heath has announced her intention to develop a 10 year mental health strategy.

10 11 1.3 Mental Health in All Policies 1.4 -Based Approach

The WHO recognises the need for a This review uses a human rights- comprehensive and multi-sectoral based approach in recognition of the approach to mental health promotion, extensive human rights violations prevention, treatment, rehabilitation, and discrimination experienced by care and recovery.6 Given that people with mental health problems.7 It households living in poverty are exposed frames mental health problems within to preventable risk to mental health, a social model of disability and draws greater attention needs to be paid on international definitions for mental to mental health problems related to health, mental disorders, psychosocial marginalisation and impoverishment.xxxii disabilities, vulnerable groups and recovery (see Glossary). Although Mental health is a cross-cutting and this review references the authority mediating factor in public policy of the global consensus articulated in supported by the development of MHiAP the UN on the Rights of frameworks and the contributions of Persons with Disabilities (UNCRPD), champions, such as the Westminster it recognises the limitations of relying All-Party Parliamentary Group on on legal instruments to advance the Health in All Policies, which published human rights of people with mental a recent report on , health problems. Therefore, the review health inequalities and reform. considers the importance of collective xxxiii Although JRF cautions against approaches to human rights, such as broadening the definition of poverty in social movements and community order to avoid the risks of diversion or development. dilution, it recognises the intersectional dynamics between poverty and inequality that impact the experience of poverty.xxxiv Integrating a poverty focus into MHiAP should be a priority.xxxv

6 The WHO’s Mental Health Action Plan (2013–2020) has set out four major objectives for mental health: more effective leadership and governance for mental health; the provision of comprehensive, integrated mental health and social care services in community-based settings; the implementation of strategies for promotion and prevention; and strengthened information systems, evidence and research. This would be progressed by the realisation of six cross-cutting principles and approaches: universal health coverage, human rights, evidence-based practice, the life course approach, the multi-sectoral approach and the empowerment of people with mental disorders and psychosocial disabilities. 7 Human rights-based approaches in mental health are described in the British Institute of Human Rights’ publication Mental Health Advocacy and Human Rights: Your Guide, which was developed by its Human Rights in Healthcare project in England and its ongoing mental health and human rights programme, including the Care and Support: a Human Rights Approach to Advocacy programme (https://www.bihr.org.uk/a-human-rights-approach-to-advocacy, accessed 16 February 2016) and Human Rights in a Setting: Making it Work for Everyone, which reported the evaluation of the Scottish Human Rights Commission’s initiative in the State Hospital, which, in turn, provides forensic mental healthcare for Scotland and Northern Ireland.

12 13 A whole-government approach to legislation, policy, strategies, services • preventing people in/experiencing and programmes that addresses poverty 11 from developing mental mental health and poverty needs to health problems; be in line with UK, European and UN commitments to protect, promote and • supporting people in/experiencing respect the rights of people with mental poverty with mental health problems health problems. The UK Government to recover; ratified the UNCRPD in 2009. It is anticipated that the UN Committee • preventing people in/experiencing will review the UK’s realisation of these poverty with mental health problems human rights commitments – including from becoming poor; and Article 28: Adequate and – in 2017. • supporting people in/experiencing Currently, the impact of poverty with mental health problems policies on the UK Government’s to move out of poverty? realisation of CRPD rights has been investigated under the Convention’s The Mental Health Foundation used its Optional Protocol procedure. Further, all Stepwise approach to identify peer- of the UK’s human rights commitments reviewed and grey literature publications are to be reviewed under the UN’s on ‘mental health’ and ‘poverty’, and Universal Periodic Review mechanism in produced a new iteration of its quality 2017. criteria to screen these. The primary limitation of this review is that the time 1.5 Methodology and resources available meant that these documents were not systematically In order to inform the development reviewed. It has drawn together existing of the JRF Anti-Poverty Strategy, this policy and research material and review posed the following question. made recommendations based on the strongest evidence (systematic reviews What public policies8 or services9 have and meta-analyses) and credible sources been evidenced to effectively address (including government, public bodies, mental health and poverty experienced and civil society think tanks and policy 10 by children and adults through: groups).

8 national and international 9 health, social care, education, employment, social security and advice 10 including those with complex needs 11 including individuals, families and communities

12 13 1.6 Summary

The review begins by considering the relationship between poverty and mental health, and proposes a conceptual framework for addressing this. It outlines mental health and poverty across the life course, including its cumulative impacts. The importance of promoting self- management, peer support, community development and movement building is advanced. The review then discusses the significance of public services (health, social care, education, employment, social security, advice and planning) in reducing poverty and mental ill health. The challenges of costings – and the evidence base for investing in mental health as a strategy – are presented. Finally, a set of recommendations are made, informed by JRF’s ‘4 Ps’: Pockets (the resources available to households), Prospects (people’s ), Prevention (stopping people from falling into poverty) and Places (where people live – their homes and communities). These recommendations address cross-cutting themes of data and research, stigma and discrimination, and MHiAP; actions at each stage of the life course (perinatal, early years, childhood, adolescence, working age, and later life); and actions across the life course.

14 15 2. Poverty and Mental Health: A Conceptual Framework

Mental health is a universal asset that we for more people that are in poverty. This all share. mental health supports underlines the importance of preventing us all to reach our potential, individually poverty as well as progressing routes out and collectively. The Mental Health of it.xxxviii Foundation has argued that mental health is a mediating factor between 2.1 Life Course economic and social conditions. Poor mental health experienced by individuals Neither poverty nor mental health is is a significant cause of wider social a static category or experience. So, and health problems, including low what an individual, household, family or levels of education achievement and community needs in terms of protective, work productivity, poor community preventative, and promotional resources cohesion, high levels of physical ill changes. For individuals, these needs and health, premature mortality, violence, resources change over their life course – and relationship breakdown. For some particularly at transition points between of these factors, such as relationship these stages and at pressure points breakdown, the causal relationship runs (for example, during acute and chronic both ways.xxxvi Good mental health, in periods of pressure, such as diagnosis contrast, leads to healthier lifestyles, and management of a long-term health better physical health, improved condition, redundancy, relationship educational attainment and productivity, breakdown or bereavement). Given the and lower levels of violence and crime. cumulative impacts on mental health of xxxvii disadvantage and advantage over the life course, the WHO has stressed the Poverty and mental health problems importance of early intervention.xxxix are not marginal experiences of a separate group in society: anyone can 2.2 Socio-Economic Factors experience either over their lifetime, Impacting Mental Health and there is a clear intersection between mental health and poverty. Whether or Individuals’, families’, communities’ and not someone develops mental health nations’ mental health is determined by problems or moves into poverty, how a wide range of socio-economic factors long this lasts for and its severity, and if (referred to as ‘social determinants’), and how someone recovers their mental which both influence health status health or secures a route out of poverty and the physical, social and personal depends on their access to sufficient resources available for dealing with quality and quantity of resources, and environmental stressors, satisfying the timeliness of this access. Poverty’s needs and realising potential. The dynamic character also means that the social determinants of mental health risk of experiencing mental health exists are not limited to individual attributes

14 15 (emotions, thoughts, behaviours and interactions with others), but also include social, cultural, economic, political and environmental factors such as living standards, working conditions, social protection and community social supports.xl

The following table provides illustrative examples of factors that influence mental health.

Some factors that influence mental health Society Community Family Individual Inequality Personal safety Family structure Lifestyle (diet, exercise, alcohol) Unemployment Housing and open Family dynamics Attributional style levels spaces and functioning (i.e. how events are understood) Social coherence Economic status Genetic makeup Debt/lack of debt of the community Education Isolation and Intergenerational Physical health loneliness contact Health and social Neighbourliness Parenting Relationships care provision

(Adapted from McCulloch and Goldie (2010) in Goldie (2015)) xli

will live in socio-economically deprived Mental health can also be affected by neighbourhoods. It concluded that sudden life events, which are sometimes moves related to difficult life events referred to in the literature as ‘pressure’ could reinforce socio-economic or ‘transition’ points. A recent UK study inequalities in health between areas by explored the relationship between concentrating people with poor health in difficult life events (relationship areas.xlii breakdown, eviction or repossession, and job loss), poor mental health and Studies evidence a social gradient in distinctive patterns of mobility. It found relation to poverty and/or economic that difficult life events appear to harm inequality and poorer mental health both mental health and residential and wellbeing. Populations living in opportunities, increasing the likelihood poor socio-economic circumstances that people with poor mental health are at increased risk of poor mental

16 17 health, depression and lower subjective 2.3 Human Rights wellbeing.xliii Across the UK, both men and women in the poorest fifth of the The UK Government has committed to population are twice as likely to be at risk progressively realise disabled people’s of developing mental health problems as right to an adequate standard of living those on average .xliv,xlv Material and social protection. Under UNCRPD disadvantage (with low educational Article 28, the state commits to ensure attainment and unemployment) was equal access to appropriate and associated with common mental health affordable services, social protection problems (depression and ) in a programmes and poverty reduction review of population surveys in Europe.xlvi programmes (including access for The social distribution of common persons with disabilities and their mental health problems has a social families living in poverty to state gradient and is more marked in women assistance with disability-related than in men;xlvii this is also evident in expenses, such as adequate training, children. A systematic literature review counselling, financial assistance and found that young people aged 10 to 15 respite care). This human right chimes years with low socio-economic status with a number of public policies and had a 2.5 higher prevalence of anxiety sectors covered in this report. JRF’s or depressed mood than their peers with Anti-Poverty Strategy may be one way high socio-economic status.xlviii Socio- in which the UK State could co-ordinate emotional and behavioural difficulties activity across the UK to implement have been found to be inversely UNCRPD. distributed by household as a measure of socio-economic position in 2.4 Equity children as young as 3 years old.xlix ‘Inequalities in health’ refers to Mental health and debt interact with differences between individuals each other. An English study found or groups of people in terms of that, in the general population, half of health status, presence of disease, those with debt have a diagnosis of a and access to healthcare or health , compared to only 14% outcomes, regardless of the cause of people with no debts.l A study by the of these differences. ‘Health equity’ Irish Economic and Social Research refers to the presence or absence Institute found associations between of differences in health, or in the financial exclusions and households major social determinants of health at risk of poverty headed by a person that are unnecessary or unavoidable who is unable to work due to illness or between population groups with social liii disability.li However, it is important not advantages. to pathologise social, economic and financial problems.lii Inequities in health systematically put people who may already be socially disadvantaged at a further disadvantage with respect to their health.liv Inequalities

16 17 in health, including mental health, arise and limiting the horizons of their because of inequalities in society – expectations for health, education, such as the conditions in which people employment and relationships. Social are born, grow, live, work and age. The contact is fundamentally important Marmot Review provides a template for for improving attitudes and behaviours addressing mental health inequities by towards stigmatised groups, and it has tackling the social factors that influence been crucial in building public and mental health in order to achieve explicit political support for prioritising mental policy objectives.12,lv Using an inequalities health policy and services.lvii framework enables us to consider how poverty and mental health intersect with 2.6 Prevention identity. Prevention is a central approach to 2.5 Anti-Stigma and Non- mental health13 and is also a key theme Discrimination in the Anti-Poverty Strategy. Effective mental health prevention requires Stigma and discrimination affect people a multifaceted approach that takes experiencing poverty and people with account of needs at different stages mental health problems.lvi Stigma can be of the life course, differing levels of internalised, which has corrosive effects: risk, the degree to which people may silencing people and preventing them be managing complex challenges (and from seeking and receiving support; perhaps finding it hard to cope), and undermining their sense of self, such the settings in which they can be best as their self-esteem and confidence; reached. Prevention may be focused on different groups of people based

12 1. Give every child the best start in life; 2. Enable all children, young people and adults to maximise their capabilities and have control over their lives; 3. Create fair employment and good work for all; 4. Ensure a healthy standard of living for all; 5. Create and develop healthy and sustainable places and communities; and 6. Strengthen the role and impact of ill health prevention. This will require the combined effort of central and local governments, the NHS, third and private sectors, and community groups. As well as local delivery systems for national policies, individuals and communities need to be empowered to engage in effective participatory decision-making. 13 NHSE (September 2015) The Five Year Forward View Mental Health Taskforce: public engagement findings. A report from the independent Mental Health Taskforce to the NHS in England. Available at: http://www.england.nhs.uk/mentalhealth/wp-content/uploads/sites/29/2015/09/fyfv-mental-hlth- taskforce.pdf [Accessed 2 September 2015]. 14 Universal – for everyone: targeting the whole population, and groups or settings where there is an opportunity to improve mental health, such as schools or workplaces. Selective – for people in groups, demographics or communities with higher prevalence of mental health problems: targeting individuals or subgroups of the population based on and exposure to adversity, such as those living with challenges that are known to be corrosive to mental health. Indicated – for people with early detectable signs of mental health stress or distress: targeting people at the highest risk of mental health problems.

18 19 on their risk profile.14,lviii Prevention can development, and the monitoring and also operate at different phases in the evaluation, of mental health policy.17 This development of mental health problems involvement ranges from peer-support and recovery from them.15,lix and self-management programmes,18 both those within and independent 2.7 Self-Management, Peer Support, of mental health services, to the Community Development and collective organisation of people with Movement Building lived experience in social movement organisations, coalitions and alliances. Individualised, clinical discourses (A recent guide to self-management primarily drawn from the biomedical support by the Health Foundation model of have traditionally usefully outlines the wide range of dominated mental health services. An approaches to self-management for important trend within mental health people with long-term conditions, policy and practice has been the including mental health, and how these growing involvement of people with lived can be put into practice.)lx experience16 of mental health problems, including the establishment of formal structures to include service users in the

15 Primary prevention – aims to stop ill health occurring entirely by using ‘upstream’ approaches for the majority of the population, coupled with selective and indicated interventions focused on people and communities most at risk. Secondary prevention – aims to identify signs of health problems through awareness, self-identification, help from friends and colleagues, etc., ensuring that effective early intervention is provided to minimise progression into a full mental health condition. Tertiary prevention – works with people who have had established mental health problems to prevent relapse and ensure sustainable recovery. 16 The term ‘people with lived experience’ is more frequently used than ‘service user’ or its other variations (including ‘client’ and ‘patient’) in order to recognise that most people who experience mental health problems are not users of health and social care services. Further, concepts of ‘peer’ are problematised by people with lived experience, evolving our understanding of what types of common experience (of mental ill health, services and legislation) create peer relationships and how peer identities intersect with other social identities (including socio-economic status and protected characteristics under equality legislation). 17 In public mental health, this extends to population groups with greater exposure to risk factors associated with mental health problems and lesser access to health-protecting resources. 18 The common underlying principles of self-management in mental health are that people (rather than professionals or clinicians) have control, are life orientated not condition orientated, work together (moving the emphasis from self-management as an individual activity to self-management and peer support as a group activity – independence to interdependence), and that every facilitator is a former participant. Goal setting, problem solving and peer support are key components (Crepaz-Keay, 2015).

18 19 Within the context of human rights- Multiple interpretations of core concepts based approaches, it is important to within mental health, such as self- include both the implementation of management and recovery, highlight these approaches at service levels the importance of co-production as a and the strategic leadership of mental central way for public services, policy- health social movement actors.19,lxi makers and researchers to engage The degree, form and dynamics of with people with lived experience involvement varies significantly and of mental health and poverty. This embodies the power relationships that review proposes the importance of co- operate within mental health between production of meanings and approaches people with lived experience of mental to mental health, ‘peer support’ and health; their families, friends and carers; ‘self-management’ for individuals and clinicians; services; and the state bodies communities living in poverty. that operate mental health and mental capacity legislation. Motivations to promote self- management and peer-support The concept of recovery has been approaches are complex. The critical to changing the power Commission dynamics within mental health from the commented that self-care is a more psychiatric prognosis of lifelong illness, sustainable approach to health service clinically controlled interventions and delivery, and observed that, as well as significant exclusion from ordinary life. empowering people to be in charge of The WHO provides a person-centred their own healthcare, it reduces health definition of recovery (see Glossary). inequalities.lxiii The Scottish Government, in particular, has focused on involving However, research has highlighted that people with experience of mental health varying interpretations of ‘recovery’ problems and mental health services, have developed. In a recent systematic and the importance of self-help, self- review and narrative synthesis of primary referral, self-management, and self- research that explored clinicians’ and directed and peer-to-peer support in managers’ understandings of recovery- service design and delivery.lxiv orientated practice in mental health services, the authors identified three Community development and social descriptive headings: clinical, personal movement building catalyse local and service defined.lxii action, which is necessary for tackling mental health and poverty. Change can

19 Examples of collective organisations are the National Survivor User Network (NSUN) in England and Voices of Experience (VOX) in Scotland. In Wales and Northern Ireland, structures have been established to include service user (and carer) voices in the implementation of mental health policy (the Welsh Service User and Carer Forum, and the Bamford Monitoring Group in Northern Ireland).

20 21 be achieved through the initiatives of based and effective interventions into local public services, but it is important the Creating Nurturing Environments that communities are treated as framework. While this is a theoretical autonomous change agents, and that model, it is a useful resource for individuals, households and communities informing planning-integrated, sustained are empowered to have more control and co-ordinated programmes at a over their lives across the social neighbourhood level.lxviii The Mental determinants of health. The building of Health Foundation is publishing a whole- social capital that creates connections community approach to mental health.lxix within (bonding) and between (bridging) communities can grow resilience, protect Social movement building to advance against health risk factors, provide social mental health involves more complex support, and enable people to access a approaches and the engagement of range of material, social, psychological a wider range of actors, such as the and economic resources, including work decade-long wellbeing movement co- opportunities. Improving community launched by the NHS and Liverpool capital and reducing social isolation Council, which mobilised community, across the social gradient can be voluntary, health, local government and progressed through locally developed business sectors.lxx and evidence-based community regeneration programmes. Such programmes should address barriers to community participation and action, which can be structural and linked to community members’ capacity and capability.lxv

Public Health England (PHE) published a briefing on community-centred approaches, which can inform their inclusion in local public service planning and delivery in areas experiencing material deprivation and a high prevalence of mental health problems. lxvi The English Mental Health Taskforce report proposed the development of mentally healthy communities, including through the use of social movement approaches.lxvii In the US, the Promise Neighborhoods Research Consortium has proposed a community-wide approach for promoting child health and development within high-poverty neighbourhoods by distilling evidence-

20 21 3. Poverty and Mental Health Across the Life Course

The WHO’s report on the social range of policies that can contribute determinants of mental healthlxxi to this higher level goal, but, rather, it highlighted that the effects of focuses on more specific policies that exposure over the life course on both can address mental health needs within disadvantage and advantage accumulate current social conditions.lxxiii over time. The following key factors affect mental health across all stages of This report considers mental health at life, influencing the risk of people having the following stages. mental health difficulties and presenting opportunities to reduce risk. • perinatal (pregnancy and the first year after birth), early years, children • parenting behaviours/attitudes; and young people;

• material conditions (income, • working age, including family access to resources, /nutrition, formation, employment, water, sanitation, housing and unemployment and worklessness; employment); and

• employment conditions and • later life. unemployment; There are a number of evidence reviews • parental mental and physical health; for mental health-related policy, service and and programmatic interventions across the life course, including economic • maternal care and social support.lxxii evidence. However, these mainly focus on pre-natal, perinatal, early These cumulative impacts are evident years, children and young people. individually in a person’s epigenetic, There is a lack of evidence reviews psychosocial, physiological and about mental health in later life, which behavioural attributes, and collectively includes consideration of poverty and in families’ and communities’ social equality. JRF published a report on the conditions. Social and economic relationship between mental health inequities result, and these lead to and child poverty almost a decade inequitable mental and physical health ago.lxxiv The Scottish Government outcomes. Therefore, policies that help published a review of interventions to equalise life chances can be expected to address health inequalities in to have an impact on mental health as the early years.lxxv Health Scotland well as on other outcomes. Recognising produced an evidence summary of this, it is important to note that this public mental health interventions review is not intended to cover the broad for perinatal through to adolescence

22 23 within familial, health and social care, authorities with a commentary on ways community and school settings.lxxvi in which some could be targeted at In England, the Children and Young disadvantaged individuals and groups People’s Mental Health Taskforce drew across the life course.lxxxi together current evidence and made clear and substantial recommendations The case for investing in the prevention in its ‘Future in Mind’ (2015) report. of mental health problems and lxxvii The UK Faculty of Public Health intervening early in childhood and made the case for improving children’s adolescence is overwhelming; this is mental health and wellbeing across the when much of our mental health is themes of pre-school, family , developed. Seventy-five per cent of parenting support, schools, the built mental health problems are established and natural environments, and media by age 24, and 50% by age 14.lxxxii and advertising.lxxviii The UN published One in ten school-age children has a a review of the interventions to clinically diagnosable mental health support the social inclusion of young problem, including depression, anxiety people with mental health problems. or psychosis. A recent English study lxxix (Recommendations based on this on children with severe behavioural evidence are discussed below in section problems reported that about 5% 7.) of children aged 5–10 years have a ‘conduct disorder’ – that is, they 3.1 Perinatal, Early Years, Children display severe, frequent and persistent and Young People behavioural problems20 – and that a further 15–20% who do not reach this The National Equality Panel commented diagnostic threshold display concerning that: “the long arm of people’s origins behaviours. Conduct disorder is twice as [shapes] their life chances, stretching high in boys as in . Rates of conduct through life stages, literally from cradle disorder are higher among children from to grave”.lxxx Mental health problems disadvantaged backgrounds. For about in childhood can lead to reduced life half of these children, serious problems chances by disrupting education and will persist into adolescence and limiting attainment, impacting social adulthood.lxxxiii participation and reducing the ability to find and sustain employment – In the last major British study of the particularly work that provides for an mental health of children and young adequate standard of living. This, in people (Office for National Statistics, turn, can lead to an impoverished and 2004), the rates of diagnosable mental unhealthy later life. The King’s Fund health problems were higher among produced a review of evidence-based children: public health interventions for local

20 Depending on age, these behaviours may include persistent disobedience, angry outbursts and tantrums, physical aggression, destruction of property, fighting, bullying, lying or stealing.

22 23 • whose parent interviewed for 5, 7 and 11), 3.6% could be categorised the study had no educational as such. Comparisons between ethnic qualifications (17%) compared groups found that severe problems to those who had a degree-level were most common among children qualification (4%); from mixed ethnic origins, followed by those of white origin (particularly boys); • in families with neither parent prevalence was lowest among children working (20%) compared to families of Indian origin. Having severe mental in which both parents work (8%); health problems was strongly related to parental education, parental occupation • in families with a gross weekly and family income. Seventeen per cent household income of less than £100 of 11 year olds in 2012 from families in (16%) compared with those with an the bottom fifth of income distribution income of £600 (5%); were identified as having severe mental health problems compared to 4% in the • in households in which someone top fifth.lxxxv receives disability benefit (24%) compared to those that receive no The income-related gradient in benefit (8%); and prevalence appears to have become steeper and is much steeper among • living in areas classed as ‘hard- children than among adults. Seventy pressed’ (15%) compared to those per cent of conduct problems are living in areas classed as ‘wealthy in the bottom two income groups; achievers’ or ‘urban prosperity’ (6% hyperactivity/inattention and peer and 7% respectively).lxxxiv problems have 60% of the cases from the bottom 40% of income; and The prevalence of severe mental emotional problems have 50%. The health problems among 11 year olds 2004 prevalence of severe mental participating in the UK Millennium health problems in children aged 11–16 Cohort Study (MCS) using the was three times as high in the bottom Strengths and Difficulties Scale was fifth of family income as among those 10%; a prevalence of 13% of boys in the top fifth; the MCS suggests a and 8% of girls. In defining persistent fourfold difference.lxxxvi cases of children with severe mental health problems at three or four study Childhood adversity impacts mental points (data was collected at ages 3, health and wellbeing. Adverse childhood

21 Examples of childhood experiences within the family were physical abuse, , emotional abuse, physical neglect, emotional neglect, physical punishment, witnessing domestic violence, household member’s substance misuse, household member’s illness, household member’s incarceration, parental separation/divorce or child separation from family. Examples of childhood experiences within the social context were poverty/socio-economic stratification, racial segregation, political conflict, hospitalisation, community violence, /bullying, maltreatment by teacher or natural disaster.

24 25 experiences have been defined as neglectful parenting, and maltreatment follows. – are particularly important. Loving, responsive and stable relationships “Adverse childhood experiences are with a caring adult that provide social childhood events, varying in severity support and build secure attachment are and often chronic, occurring within the fundamentally important for buffering child’s family or the effects of stressors and coping with that cause harm or distress, thereby them.xcii Familial and community social disrupting the child’s physical or supports, and positive beliefs (optimism, psychological health and development.” self-esteem and a sense of control), 21,lxxxvii continue to act as buffers throughout childhood and into adulthood.xciii Adversity itself tends to be cumulative, with a large-scale US study reporting For children born into poverty, childhood economic adversity in 11% the cumulative impact of poverty of the sample – 84% of which had intersecting with other inequalities is experienced at least one other childhood evident throughout their life course. The adversity. The study also suggests health of children born to mothers in/ that multiple childhood adversities experiencing poverty is more likely to are associated with up to 45% of all be compromised due to their mothers’ childhood-onset mental disorders.lxxxviii poor nutrition, exposure to stress, and The ‘Building a better future’ report poor working conditions,xciv as well as outlines a number of risk factors for limited access to poorer quality public children developing severe behavioural services. Children with lower socio- problems; this illustrates the range of economic status have poorer cognitive adversities experienced by children performance across areas that include and young people, and their cumulative language function and cognitive control impact.lxxxix (attention, planning and decision- making).xcv Stressors such as the In the early years, children’s life chances experience of poverty during sensitive (mental and physical health, social early development periods affect behaviour, educational outcomes and biological stress regulatory systems employment status) are negatively – neural mechanisms by which stress impacted by lack of secure attachment, responses are regulated in the brain – lack of quality stimulation, neglect and the expression of genes related to and conflict.xc Particularly damaging is stress responses.xcvi Cumulative exposure exposure to neglect, direct physical and to stressors over time leads to changes in psychological abuse, and being raised stress responses that have physiological in families where there is domestic effects on the immune system, violence.xci The development of severe cardiovascular function, respiratory behavioural problems is linked to a wide system and other systems, including the range of environmental and genetic risk brain, which damage health.xcvii factors, but adverse familial experiences – such as harsh, inconsistent and

24 25 The effects of poverty on adolescent Having a parent with a mental health mental health are severe and problem can be a risk factor for cumulative. As poverty interacts with a children’s mental health and wellbeing. complex range of social and economic It is difficult to establish the rates of environmental factors, data has not been parental mental health due to factors identified in this paper that attributes including the under-identification of the proportion of child mental ill health mental health problems and incomplete to poverty. However, chronic exposure recording of mental health service users to poverty increases adolescents’ risks as parents.ci The last British study of the for developing conditions such as mental health of children and young depression, and behavioural risks such people found that children with an as substance use, early sexual activity emotional disorder were more than twice and criminal activity.xcviii The awareness as likely as other children to have parents of financial problems in their families also with a score on the General Health negatively impacts adolescents’ mental Questionnaire (GHQ-12) indicative of health and is associated with depression an emotional disorder (51% compared among girls and drinking to intoxication with 23% among other parents). Over in boys, as well as a sense of helplessness half (55%) of children with an emotional and feelings of shame and inferiority.xcix disorder had experienced their parents’ separation, and over a quarter (28%) Children and young people who had a parent with a serious mental experience mental health problems can health problem (for other children, have their education disrupted due to these figures were 30% and 7%). UK missing school during periods of ill health research has identified that parental or being excluded if they have significant mental health problems are a significant behavioural problems. In one study, factor in around 25% of new referrals to children with an emotional disorder had social service departments,cii that more more time off school than other children: than one-third of adults with mental 43% had more than five days’ absence health problems are parents, and it is and 17% had more than 15 days’ absence estimated that two million children live in in the previous term; this compares with households where at least one parent has children with no diagnosed disorder a mental health problem.ciii (21% and 4% respectively). Children with generalised and those Children who have a parent with mental with depression had the most days away health problems can be affected by from school (a quarter had more than 15 spending increased periods of time days’ absence in the previous term). They alone in the family home and becoming then become behind with their learning socially isolated.civ Children may assume and, without additional support to catch a caring role – a responsibility that can up, may not attain their full educational affect their educational experience, potential. This has important impacts including attendance, participation in terms of educational attainment, and attainment;cv however, some young employment and income.c carers regard school as a refuge.cvi The Mental Health Foundation’s study of

26 27 young carers found that, while some parents’ subjective experiences of received social support to provide caring for children in impoverished respite or to enable them to participate circumstances. It found that parents gain in social activities, more intervention material and emotional support from was needed to address difficulties naturally occurring support systems, experienced around school, including but these may not be available and can regular lateness or absence, completing have negative associations. Low-income schoolwork on time, and behavioural lone mothers enjoyed smaller support issues such as their being disruptive, networks and were more reliant on being bullied or having difficulty in mutual support that two-parent families. developing friendships. Young carers The most socially isolated mothers were of parents with mental health problems those least likely to seek professional need to have more information about help; low-income parents’ experiences mental health, support to cope with their of health and social welfare agencies own feelings and additional assistance were mixed. This study concluded to ensure that they attain educational that, while formal support services qualifications.cvii could valuably complement informal support systems, they needed to include There is a clear evidence base around parents’ perspectives in their design, the potential mental health problems development and evaluation.cix that can develop during the perinatal period and a NICE-approved perinatal Parenting programmes, particularly care pathway. The economic case for those that encourage positive parenting, investing in a comprehensive, timely can be very effective across different range of mental health and social care family types and ethnic groups by services for the mother, her partner improving the behaviour of a child with and their family network is discussed in conduct issues, their siblings’ behaviour, Costings (section 6). The UK Maternal and the mental health and wellbeing of Mental Health Alliance has provided parents. However, programmes must leadership across the UK around be implemented with strong fidelity to these issues, including through the the evidence-based model, and must Everyone’s Business campaign (which continue to be evaluated as they are runs until September 2016). The scaled up and transferred for use with Recommendations (section 7) draw on different groups of parents; it is also their ideas as well as on wider evidence. important to learn more about the cviii efficacy of parenting problems over time through longitudinal studies.cx Interventions with a strong evidence base include parenting programmes The UNESCO review on maternal – particularly those for parents in mental health, poverty and children’s disadvantaged areas and who have education outcomes recommended existing mental health problems. A targeted interventions for families meta-synthesis of qualitative evidence experiencing mental health problems from twelve UK studies focused on within existing parenting programmes.

26 27 It referenced child-centred, whole- 3.2 Working Age, Including Family family interventions such as the Formation and Employment Canadian Family Association for Mental Health Everywhere, which helps 3.2.1 Family Formation children to better understand their parents’ mental health problems; the The age, socio-economic context, Australian Simplifying Mental Illness Life capabilities, and personal and material Enhancement Skills (SMILES), which resources of parents significantly supports children in gaining a better influence their experiences of forming understanding of their parents’ mental a family and parenting. The mental health problems, reduces isolation and health of parents can be supported builds their self-confidence; and the from adolescence through whole-school Australian peer support programme programmes, which develop self-esteem, Children and Mentally Ill Parents. These confidence and communication skills programmes have demonstrated positive that support young people to negotiate outcomes such as improved self-esteem positive and safe relationships, to use and coping strategies, and stronger contraception and to be a nurturing family relationships for children and parent. parents. The Family SMILES programme has been adapted and is run in the UK Mothers and fathers with mental health by the NSPCC22 and the Strengthening problems have the right to family life Families Programme has been adapted in under the UNCRPD. Women with the UK and Ireland.23,cxi pre-existing mental health conditions may need support to have a healthy A substantial body of studies has been pregnancy and birth through advice and undertaken regarding the relationship guidance about managing medication, between mental health and wellbeing in and through co-producing an integrated childhood (and their long-term effects perinatal plan with mental health and in adulthood), and the importance of maternity services. This is particularly developing social and emotional skills the case for women with complex needs, among children,cxii including building including those who misuse alcohol and resilience.cxiii Whole-school approaches other substances. Stigmatising attitudes can reach children, staff, parents and among health and social care staff, and communities, and can improve mental family and community members, may health and wellbeing by developing the need to be addressed. Personalising care curriculum, health promotion initiatives, may require negotiation of reasonable support programmes and services.cxiv

22 https://www.nspcc.org.uk/services-and-resources/services-for-children-and-families/family-smiles/ 23 http://mystrongfamily.co.uk/

28 29 accommodations so that parents with Psychosocial health impacts occur mental health problems who are living indirectly through the perception in poverty receive equitable access to of social exclusion and loneliness. services. The high risk of children of Unemployment, ‘bad’ employment and parents with mental health problems in-work poverty are harmful to health going on to develop these too means and are associated with poorer mental that it is important to provide parenting health, psychological distress and minor and from pregnancy and psychological/psychiatric morbidity; throughout childhood. poorer general health; lengthy illness; higher rates of medical consultation, 3.2.2 Employment, Unemployment and mediation and hospital admission; and Worklessness higher mortality.cxvi

It is good work, rather than simply a The Marmot Review set the policy job, that is associated with good mental objective of creating fair employment health. ‘Good’ work and employment is a and good work for all, to be achieved substantial health asset. Work is central through improving access to good jobs to individual identify, and reducing long-term unemployment and social roles. It meets important across the social gradient; making it psychosocial needs in where easier for people who are disadvantaged it is the norm. Socio-economic status in the labour market to obtain and keep is the main driver of social gradients work; and improving the quality of jobs in mental and physical health and across the social gradient.cxvii mortality. Employment is the most important means by which to obtain Employment is central to addressing the adequate economic resources that are relationship between poverty and mental necessary for material wellbeing and full health. Workplaces need to: participation in society. Psychosocial attributes (insecurity, demands, control • promote mental health and prevent and support) and material aspects the development of work-related such as income are ways in which mental health problems; people weigh ‘good’ or ‘bad’ work. Key characteristics of work and employment • make reasonable adjustments that are protective and beneficial for when employees are experiencing health include high levels of supervisor a period of mental ill health (either and peer support and job control, and a one-off event or as a symptom of low levels of insecurity and the absence a fluctuating condition), or when of in-work poverty. cxv Mirroring JRF’s employees have to care for someone concerns about the UK’s high rates of in- with a mental health problem; and work poverty, this review notes that in- work mental ill health is also a concern. • be receptive to supporting people with mental health problems in The interrelationship between poverty, engaging in work. unemployment and mental health problems occurs in a number of ways.

28 29 Whole-workplace approaches are ways Health Foundation defines later life as of drawing together good practices that commencing at 50 years old, as this is can achieve all of these.cxviii the time when many people will begin to experience a mental or physical It is important that the primary decline or deterioration, and many policy goal for people with mental also begin to seriously plan for their health problems should be securing retirement, take early retirement, or employment that provides a living find it difficult to secure employment.cxx wage, combined with providing People who have experienced poverty adequate integrated health and work and inequality during their lifetime may support, focused (with regards to experience the effects of ageing earlier health) on recovery and (with regards in their life course.cxxi This can be the to employment) on retention and case particularly for people who have progression. serious mental health problems, are long- term users of psychiatric medication, or Work, mental health and poverty are have developed one or more long-term discussed in section 4.5, including physical health conditions (see section getting on in work, moving into work and 4.2.2). The lifespan of such individuals self-employment/entrepreneurship. may be shortened by up to 25 years.cxxii

The social security system should There is noticeably less research and provide an adequate standard of living policy material around later life, mental for those who cannot secure or sustain health and poverty. The 2007 UK employment, including the flexibility Inquiry into mental health and wellbeing to respond quickly when someone falls in later life described older people with out of work for either a period of time severe and enduring mental health or permanently. As discussed in Social problems as “invisible in policy, practice Security below (section 4.6), one of and research”.cxxiii However, it is clear the effects of the disproportionately that the cumulative impacts of mental negative impacts of welfare reform on health problems for both the individual disabled claimants is that people with and family are apparent in later life. The mental health problems are concerned lifelong effects of lower educational about trying to enter the labour market achievement, disrupted, low-paid, in case they lose the social security insecure and poor-quality work, and safety net during periods of ill health.cxix reliance on social security payments become evident. The effects include the 3.3 Later Life reduced ability to acquire the material resources necessary for mental health JRF distinguishes between future and wellbeing, such as secure and good- pensioners in age cohorts: ‘younger quality housing, and adequate pension cohorts’ (30–49) and ‘about to retire’ and savings. (50–64); and pensioners today: ‘younger pensioners’ (65–75) and ‘older pensioners’ (over 75s). The Mental

30 31 The inquiry into mental health and maximise salary, pension entitlements wellbeing in later life found that older and savings. Social security may be people with severe and enduring mental an important (or the sole) source of health problems experience and income, and so social security and stigma. Research has found that this advice services need to assist people in group is at a greater risk of receiving maximising their incomes by ensuring inadequate and inappropriate care.cxxiv they receive all of their entitlements.

The combination of poverty and mental A perverse and unintended health problems in later life exacerbates consequence of the welcome attention the risk of social isolation, which is a that is increasingly being given to early significant issue for people with mental intervention is lesser attention being health problems across the life course. given to later life interventions. It is cxxv This is also an issue for people living important to highlight that the Marmot in poverty due to their lack of access to Review – which champions giving every funds for engaging in social and cultural child the best start – also recognises that activities, and the weak social capital there is a wealth of interventions that that can characterise deprived areas.cxxvi can be invested in to improve the health and lives of people at all stages of the life Across all public services, tailored action course. More research is needed in order is required to meet the needs of people to understand what these interventions in later life who are experiencing mental are for people in later life who are health problems or living in poverty (or experiencing (or are at risk of) mental at risk of either of these) in order that health problems and poverty. This is an they can be independent and well.cxxvii important and under-resourced research These actions include: agenda. From the Mental Health Foundation’s mapping of public mental • provision of health and social care, health evidence, it is apparent that much which promotes mental health and of the limited investment in mental wellbeing; health research focuses on children and parenting, with a paucity of research • screening for early detection of being conducted around public mental mental health problems (particularly health in working age and later life.cxxviii depression and dementia);

• support for people at key transitions and pressure points in later life; and

• aids for recovery (as determined by the individual).

Access to lifelong learning opportunities and support to retain, progress in and gain employment is necessary to

30 31 4. Public Services

Addressing health inequalities for member states to advance mental associated with mental health and health. poverty involves changing social arrangements and institutions. The WHO • Service reorganisation and has recognised that the public sector has expanded coverage: shifting the an important role to play in advancing location of mental healthcare into mental health equity.cxxix This review communities, including the provision considers the contribution of a number of supported housing and increasing of public services: health, education, the coverage of evidence-based employment, social security, advice and interventions. the built environment. Although social care is included, it is discussed only • Integrated and responsive care: briefly due to the lack of systematic or integrating and co-ordinating meta-reviews on social care, mental holistic mental ill health prevention, health and poverty. When considering mental health promotion, public services’ potential impact rehabilitation, care and support on poverty and mental health, their that meets mental and physical contributions as purchasers of and health needs and that facilitates services, and as employers, should be recovery across general health considered alongside their provision of and (including public goods in the form of health, social promoting human rights regarding care, education, employment support, employment, housing and social security and advice. These public education) through service-user- goods should be available to the whole driven treatment and recovery plans, population, with targeted support for and the input of families and carers, individuals, families and communities in as appropriate. greatest need.cxxx • Human resource development: It is not possible to present an overview building the knowledge and skills of the current state of provision for of general and specialised health people who experience mental health workers to deliver evidence-based, problems given the broad scope of culturally appropriate and human public services included in this paper, rights-orientated mental health and the paucity of data and research across social care services across the life governments and the UK, and the course through integrating mental current stage within the mental health health into professional curricula policy development cycle. and training and mentoring in practice. The WHO’s ‘Mental Health Action Plan 2013–2020’ provides a set of actions

32 33 • Address disparities: proactively produced a framework for MHiAP for identifying and providing all member states at different levels of appropriate support for groups at governance (local, regional and national). particular risk of developing mental cxxxiii The All-Party Parliamentary Group health problems who have poor on Health in All Policies exemplifies how access to services.cxxxi parliamentarians can champion this agenda.cxxxiv 4.1 Cross-Cutting Themes 4.1.2 Stigma and Discrimination Before moving into the specific areas of public service – health, social The experiences of both poverty and care, education, employment, social mental health are characterised and security, advice and planning the built impacted by social and self-stigma. Fell environment – there are a number of and Hewstone reported that people cross-cutting themes that can address living in poverty show lower levels of mental health and poverty in all areas confidence in their ability to succeed, of provision. These themes are MHiAP, and this can have negative mental and stigma, whole-place approaches and physical health consequences, and service navigators. reduces educational and professional attainment.cxxxv People with different 4.1.1 Mental Health in All Policies mental health problems may experience different forms of discrimination A logical progression from the evidence and stigma, leading to different around social determinants of mental consequences.cxxxvi Stigma is a significant health is the systematic review of all barrier to improving care for people public policies in order to identify how with mental health problems,cxxxvii is positive impacts on mental health and associated with mental health problems poverty can be maximised, and how and is linked to limited life chances in a negative impacts can be minimised and number of areas, including housing and mitigated. The King’s Fund has called employment,cxxxviii social isolation,cxxxix for core government policy reforms, low self-esteem,cxl and delayed help- including social security, to be subject to seeking.cxli The family and friends of macro-level health impact assessments people with mental health problems may (HIAs), and for the delivery of HIAs on experience stigma. local government policies as well.24,cxxxii The European MHiAP Joint Action The Anti-Stigma Programme – European programme (including UK partners) Network (ASPEN) was a three-year European study led through the Institute

24 The King’s Fund notes that there is a range of accessible resources to support the conduct of HIAs, including HIA Gateway (England), Health Impact Assessment in Practice (Scotland), Wales Health Impact Assessment Support Unit, International Health Impact Assessment Consortium (University of Liverpool), and the Spatial Planning and Health Group’s ‘Steps to Healthy Planning’ (2011). The Institute of Public Health in Ireland has developed HIAs across the island.

32 33 of Psychiatry at King’s College London.25 social care settings informed by a series The identified effective approaches to of evidence-based reviews and learnings mental health stigma were addressing from the ASPEN programme.cxliv See mental health stigma generally – for Me is one of the world’s longest running example, by focusing on discrimination national anti-stigma campaigns. cxlv and behaviour change (Thornicroft); The Time to Change campaign runs in using , education and contact England and Wales.27 Both are members (Corrigan); ensuring targeted messages of the Global Anti-Stigma Alliance.28 for different audiences (Byrne); and A Northern Ireland campaign, Change considering structural reform and power Your Mind, was launched in March 2016. (Link and Phelan).cxlii Interventions that use social contact have delivered the 4.1.3 Whole-Place Approaches most consistent results in improving perceptions and recollections about Health-promoting settings programmes individuals with mental health problems are a well-established and evidenced and reducing stigma; approaches that approach to combining interventions combine contact and education lead to to improve the mental health of reduced stigma.cxliii whole populations, those at high risk (or in the early stages) of developing The Scottish national mental health mental health problems, and those anti-stigma campaign, See Me,26 who are in the process of recovering employs rights-based and movement- from a mental health problem.29 building approaches within community, Models include healthy , health- workplace, education, and health and promoting hospitals, healthy schools, and

25 ASPEN used a mixed-method approach to draw together evidence about anti-stigma depression programmes from cross-sectional surveys and face-to-face interviews with (stigma) scales involving a minimum of 1,100 participants; literature reviews regarding best practice, policy-making and legislation; focus groups with non-governmental organisations and service users; and in-depth interviews with government officials. Twenty-six programmes within 18 EU countries were reviewed. The study findings are presented in the ASPEN Network Toolkit. 26 https://www.seemescotland.org/ 27 http://www.time-to-change.org.uk/ 28 http://www.time-to-change.org.uk/globalalliance 29 The Healthy Settings movement originated in the WHO’s Health for All strategy in 1980. A ‘setting’ is defined as a place where people actively use and shape the environment, creating and solving problems relating to health. They are usually identified as having physical boundaries, a range of people with defined roles and an organisational . Settings or whole-place approaches are an effective and efficient way of reaching everyone who is in the setting to tailor and optimise interventions in real- world contexts where people live, work and play, including mental health services and programmes; to make system-level changes, including to structure, administration and management; and to create synergy between health-protecting and promoting activities within the whole system/place. http://www. who.int/healthy_settings/about/en

34 35 healthy communities.cxlvi Whole-place There are opportunities for mental health approaches are discussed in the sections interventions around prevention, care 4.4 and 4.5 below, but can be used to and recovery across the criminal justice develop comprehensive mental . These include the provision of and wellbeing strategies across all public liaison and diversion teams for police services. stations and courts, mental health and wellbeing programmes, and access to Within sectors associated with high NHS-delivered mental healthcare and rates of mental health problems, there support. The use of PIEs is an approach is a case for developing tailored whole- that has developed internationally across place approaches. The criminal justice a range of services – particularly those system is one such sector. Up to 90% for people with complex needs – in order of have some form of mental to maximise the psychological benefits health problem,cxlvii and 10% of male and and mitigate the harms of material and 30% of female prisoners have previously social service environments. Broadly, the experienced a psychiatric acute intention is for a service to be designed admission to hospital.cxlviii The Corston and run with service users’ emotional and Report detailed the high levels of psychological needs as the primary focus. psychological disturbance, daily drug use cli (including illicit drug use) and persistent severe self-mutilation among women in Between 2008 and 2015, a range of UK the criminal justice system. cxlix Mental Government, academic, private and third- health approaches within prisons need sector initiatives within homelessness to take account of the specific needs of services and the criminal justice system groups who are over-represented within advanced the development of PIEs their populations. BAME populations (referred to as PIPEs within criminal are over-represented in prison; they justice).30,31 Examples of PIE pilots are represent 10% of the UK population, but provided in the 2012 Good Practice 26% of the prison population. People Guidance.clii aged 60 and over are the fastest- growing age group within the prison The Royal College of Psychiatrists’ population, and more than 50% have Enabling Environments working group some form of mental health problem clarified the core elements of an enabling often associated with imprisonment.cl environment.

30 PIPEs were piloted in six criminal justice settings by the National Offender Management Service in 2010: three male prisons, two female prisons and two probation-approved services. PIPEs are currently only in prison settings. Within this planned environment, PIPEs support offenders to progress through different stages of an intervention and offender pathways, with awareness of the psychological needs and the effects this might have on the individual (Breedvelt, February 2016). 31 The initiatives included pilot programmes, the Good Practice Guide on Complex Trauma (UK Department for Communities and Local Government and National Mental Health Development Unit, 2010), and Good Practice Guidance (Keats et al., 2012)

34 35 • The nature and quality of a ‘service navigator’ is a valuable one. relationships between participants This is distinct from the public service or members would be recognised ‘key worker’ or ‘care co-ordinator’ roles. and highly valued. During the Mental Health Foundation’s UK public inquiry into the future of • The participants share some mental health services, a case was measure of responsibility for the made for the navigator to have peer environment as a whole, especially experience and be skilled in negotiating for their own part in it, where all the access barriers experienced by participants – staff, volunteers and particular groups, such as members of service users alike – are equally BAME and LGBT communities.cliv valued and supported in their particular contributions. The navigator develops a good sense of the needs an individual and/or their • Engagement and purposeful activity family has, as well as the particular is encouraged. barriers they experience in accessing goods and services. Then, the navigator • Decision-making is transparent, and identifies the range and combination of both formal and informal leadership supports required, signposts appropriate roles are acknowledged. information and other resources in a timely manner, provides consistent • Power and authority is clearly personalised support, and assists the accountable and open to discussion. person in accessing services. These services may include advice and • Formal rules and informal advocacy. expectations of behaviour are clear or, if unclear, there is good reason for 4.2 Health it.cliii “There is very little history of a poverty Although there has been a strong narrative within the NHS to bring interest in the development of enabling together and shape all the levers in its environments, PIEs and PIPEs, and their control, and over which it has influence, further evolution into psychosocially in order to deliver on poverty. The informed environments, the evidence closest the system has is a narrative on base remains promising but under- tackling inequalities.” clv developed. Further research is needed into the gender and life course sensitivity The more affluent and better educated a of PIEs and PIPEs. person is, the greater the health benefits gained from the NHS. Health services 4.1.4 Assistance in Navigating Services need to be developed to ensure that people from lower socio-economic For people who are engaged with a groups and members of socially range of public services, particularly excluded groups gain equal benefits people with complex needs, the role of from public services as higher socio- economic groups.clvi

36 37 England, Scotland, Wales and Northern health services, schools and workplaces) Ireland all have NHS and local authority and for particular diagnoses. provision of mental health (and social care) services, as well as delivery by Lawton-Smith commented that there private, voluntary and community is substantial agreement about what sectors, but with significant variation mental health services should look like in law, service structure, governance, across the UK, summarised by the Mental funding, commissioning and provision. Health Foundation in the 2013 ‘Starting Integration is configured differently Today: Future of Mental Health Services’ within these systems. However, it is a report of its UK public inquiry as: central agenda both between health and other public services, and within the “holistic/integrated and health system itself – horizontally across multidisciplinary/local/community different services, particularly physical based/easy to access/early to intervene/ and mental health, and vertically from recovery based/and co-produced with primary to tertiary care.clvii There is service users and carers”.clx a lack of awareness about the scope and potential to strengthen a focus The future development of mental on mental health and wellbeing within health services must address the services, and it has been proposed that particular needs of communities this should be framed as a quality service and groups that experience health improvement issue with the purpose of inequalities and persistent systemic making every contact count, rather than difficulties in accessing timely, adequate a separate agenda.clviii and appropriate support. BAME communities have poor access to mental The mental health sector has been health services and experience racialised described as a set of interrelated stereotyping of their mental distress. For services (disaggregated as crisis example, black African and Caribbean care, community care, social care service users experience poor or harsh and specialist services) for a range of treatment from primary or secondary conditions that creates a system of mental health services, and detention care.clix It is noted that these services under the Mental Health Act was 2.2 operate alongside peer-support and self- times higher for black African, 4.2 management programmes run by people times higher for black Caribbean, and with lived experience, family members 6.6 times higher for black other ethnic and carers. In turn, these mental health groups than average.clxi services have integral relationships with a broad range of other public Although The King’s Fund’s Mental services, including physical healthcare, health under pressure publication is social security and housing. The NICE limited to England and mental healthcare approves evidence-based interventions provided to those aged 16–65 years, it and treatments that can be provided provides a timely briefing on how the by the NHS and other bodies across the government mandate to realise parity life course in particular settings (such as of esteem between mental and physical

36 37 health has progressed. It sets the context Drawing data from a range of sources, that 17.6% of this population meets The King’s Fund found that funding for the criteria for one or more common adults’ and older people’s mental health mental health problems, and 0.4% has services fell for the first time in a decade experienced a psychotic disorder.clxii In by 1% to £6.63 billion once inflation was 2014/15 there was a 4.9% increase in the taken into account.clxvii Between 2012/13 number of people in contact with mental and 2013/14, 44.8% of mental health health services on the previous year (a trusts had a reduction in income (this total of 1,835,996 people).clxiii proportion fell to 38.6% in 2014/15); however, this data does not take the The King’s Fund reports that – even costs of inflation into consideration. A with ministerial support, inclusion of freedom of information request found parity within the NHS Mandate and the that 44 NHS mental health providers introduction of a rolling programme of experienced a 2.36% reduction in real- access standards for mental healthcare terms funding between 2011/12 and – funding for mental health services has 2013/14.clxviii There appear to be trends been cut, with 40% of mental health in funding moving between different trusts experiencing income reductions types of provision. This is illustrated by in 2013/14 and 2014/15. The national reductions in crisis resolution and home tariff (the fixed standard price for certain treatment (a real-terms reduction of 1.7% NHS services) and planning guidance are between 2011/12 and 2013/14)clxix and two key annual mechanisms by which community mental health teams (a 0.3% funding for mental health services can real-terms reduction across 36 NHS be raised. In 2014/15, Monitor, as sector mental health providers between 2011/12 regulator, reduced the national tariff for and 2013/14), and increased spending mental health and community trusts on out-of-area placements (an increase, by 1.6%. Allowing for the additional according to data from 23 trusts, from funding to uplift tariff prices by 0.35% £21.1 million in 2011/12 to £35.5 million in to support the implementation of the 2013/14).clxx access standards,clxiv in practice, there was a 1.25% reduction in the price paid The complexity and effort of accessing for services despite the requirement funding information that takes inflation in some areas to increase the scope into consideration indicates the need and scale of provision. While the NHSE for transparent, consistent and credible 2015/16 planning guidance instructed reporting of funding for the mental commissioners to increase funding for health system of care, across all types of mental health services in proportion providers, that is disaggregated into its to their annual funding allocation,clxv interrelated sets of services (including a survey of 67 clinical commissioning health and social care) and drilled down groups (CCGs) found that 51% planned to health and local government areas. to increase spending by 1–2% in cash Funding for prevention needs to be terms, 16% planned an increase of less disaggregated across these systems. than 1%, and 31% planned an increase of more than 3%.clxvi

38 39 The quality of care funded in England is This section considers (i) how the NHS poor: only 14% of service users reported as a whole system can maximise its receiving adequate care in a crisis, and impact on poverty, (ii) how integrated, reports of poor community mental whole-system approaches can address healthcare have increased.clxxi Inadequate the mental health of children and young levels of community mental health people from low-income families, (iii) support have resulted in bed occupancy how innovative approaches such as frequently being above recommended social prescribing can support people levels, and high numbers of costly and on low incomes to access social, cultural detrimental out-of-area placements and leisure activities that are beneficial (among 37 NHS mental health providers to their mental health, and (iv) the there was an increase of 23.1% in out- importance of mental health provision in of-area placements: 4,447 people).clxxii the criminal justice system. Further, 30% of delayed discharges from mental health hospital units were The JRF-commissioned paper on associated with the absence of good- poverty and the NHS considered how quality, well-resourced community the NHS could be incentivised and teams.clxxiii Detentions under the Mental assisted to adapt, mitigate, reduce and Health Act increased by 9.8% in 2014/15 prevent poverty, and identified what the compared to 2013/14,clxxiv and a Royal NHS could do more of to make use of its College of Psychiatrists survey indicates economic power, scale and reach in the that detention is being used as a means population. Recognising that people with by which to access care.clxxv mental health problems are at greater risk of poverty, and the high rates of Worryingly, mental health trusts are absenteeism, premature retirement and initiating large-scale transformation long-term unemployment among people programmes around service, with common mental health problems, and corporate infrastructure to deliver The King’s Fund commented that it was cost reductions, reportedly reconfiguring particularly important for the NHS to care pathways and models to use meet and adapt to these people’s needs. approaches with limited evidence, or It identified three areas for service planned evaluation. The King’s Fund action: makes a timely call for stable funding and no more cuts to budgets, and the use of • access to evidence-based mental evidence to improve practice and reduce health interventions, particularly in variations in the quality and access to primary care; care. The NHSE-commissioned Mental Health Taskforce report, ‘The Five Year • appropriate pathways of access Forward View for Mental Health’, outlined to secondary care for BAME a costed blueprint to achieve parity, communities; and providing a mental health agenda that engages all the health (so-called) arms- • access to appropriate physical length bodies to complement the NHSE healthcare. Five Year Forward View (2015–2020).

38 39 The NHS needs to develop a clear, • accountability and transparency; evidence-based narrative centred on a and social model of health that explains the ways in which the NHS can contribute • developing the workforce. to tackling poverty. This would lay out how the NHS can mitigate, reduce Children from low-income families and prevent poverty through service are specifically mentioned within provision, public health measures the chapter on vulnerable children (both health promotion and ill health and young people, and the following prevention), and the use of its economic approach was proposed: power through procurement and employment. Senior managers and • development of a flexible, integrated clinical leaders should be aware of this system to meet the needs of narrative and encouraged to embed it in vulnerable children and young their services.clxxvi people;

The most recent policy development in • development of trauma-focused the UK addressing children’s and young care (including for children who had people’s mental health was the NHSE witnessed or experienced violence, commissioned Mental Health Taskforce’s abuse and/or severe neglect); report ‘Future in Mind’.32 ‘The Five Year Forward View for Mental Health’ • delivery of care to vulnerable groups recommends the full implementation through specific models of provision; of the recommendations of ‘Future in Mind’. ‘Future in Mind’ outlined a number • establishment of a consultation and of key thematic areas for action across liaison service that would advise, the whole system of the NHS, public troubleshoot, and provide formal health, local authorities (responsible for consultation and care planning or education), social care and youth justice assessment and intervention; sectors: • embedding of mental health • promoting resilience, prevention and practitioners within teams early intervention; responsible for groups of vulnerable children and young people, scaling • improving access to effective up the MAC-UK Integrate Model;33 support – a system without tiers; and

• care for the most vulnerable; • reducing of health inequalities and promotion of equality.

32 The Taskforce was established in September 2014 to “consider ways to make it easier for children, young people, parents and carers to access help and support when needed and to improve how children and young people’s mental health services are organised, commissioned and provided”.

40 41 This focus on excluded and vulnerable • include sensitive inquiries about children and young people is echoed in neglect, violence and abuse in NHS England’s ‘The Five Year Forward mental health assessments, and do View for Mental Health’ report, with this routinely for young people aged particular reference to children who over 16 years; are looked after, care leavers, victims of abuse or exploitation, those with • ensure that multi-agency disabilities and long-term conditions, safeguarding hubs have active or who are within the criminal representation by mental health justice system. It proposes that the services for children and young Department of Health and Education people; and should establish an expert group to examine their complex needs and how • strengthen the lead professional these should best be met, including approach to co-ordination of through the provision of personalised services for very vulnerable young budgets. Following the prime minister’s people with multiple and complex announcement of a significant expansion needs in order to prevent them from of parenting programmes, the NHSE falling between services. commissioned Mental Health Taskforce proposes that the government should With additional government funding, integrate the scaling of evidence-based recommended service developments programmes with local transformation were: plans for children’s and young people’s mental health services. • developing staff skills across sectors around trauma and evidence-based ‘Future in Mind’ specified that services interventions; within current funding should: • piloting the rollout of teams • proactively follow up with children, specialising in working with young people and families who did vulnerable children and young not attend appointments, find out people; and why, and offer additional support; • embedding mental health • develop bespoke care pathways practitioners in teams working across education, health, social care with vulnerable children and young and young justice, incorporating people – for example, those in gangs, evidence-based interventions; who are homeless, who have been or are being sexually exploited, looked- • develop multi-agency teams with after children and those in contact flexible acceptable criteria based on with youth justice.clxxvii presenting problems and the level of family or professional concern – and not only on clinical diagnosis;

33 www.mac-uk.org

40 41 Given the historical underinvestment for example, employment, benefits, in mental health provision at primary, housing, debt, legal advice, or parenting secondary and tertiary levels, the main problems.” clxxviii agendas within healthcare include: Usually delivered through primary • securing equitable investment in care, social prescribing has been found mental health services; to provide emotional, cognitive and social benefits for people with mild to • agreeing mandatory waiting times moderate mental health problems, and for NICE-approved mental health reduces social exclusion experienced interventions across the life course; by people with enduring mental and health problems, as well as vulnerable and disadvantaged populations. • ensuring that populations with clxxix It provides an option for health higher risk and prevalence of mental professionals such as GPs to promote health problems have access to a mental health and wellbeing, and choice of appropriate supports in a respond at an early stage to a person timely and flexible manner. who is at risk of developing a mental health problem or expressing mental This includes removing hidden costs of distress. Social prescribing can be an mental health service use, such as having alternative to medication for the 60% of to take time off work or pay for child- or GPs who said that they would prescribe adult care in order to attend inflexible antidepressants less frequently if other appointments, transport costs, and options were available to them.clxxx prescription charges (where applicable). People with complex needs may The principle of whole-system access a range of specialist services for approaches to preventing, treating mental health and/or substance misuse, and supporting recovery from mental including in the criminal justice system. health problems is a recurrent theme In criminal justice settings, a range of within health policy and provision. Social mental health services needs to be prescribing is an example of an effective provided. Liaison and diversion services intervention that provides access to reduce the number of people with appropriate social, cultural and leisure mental health problems in the criminal activities that benefit mental health. It justice system. Preventative and early- has been defined as: intervention mental health programmes for young people and adults within “a mechanism for linking patients with the criminal justice system protect non-medical sources of support within them from developing (or worsening) the community. These might include mental health problems. Accessible, opportunities for arts and creativity, appropriate and good-quality mental physical activity, learning new skills, health supports to manage and recover volunteering, mutual , befriending their mental health should be delivered and self-help, as well as support with, for people in all parts of the criminal

42 43 justice system, including young offender with mental health problems.clxxxiii The institutions, prisons, and secure care, and poor rates of routine health monitoring in community programmes. There is a for this group heighten the risk of relationship between involvement in the physical health conditions being missed criminal justice system, mental health or misdiagnosed. Together, these service and socio-economic status intersected deficits result in lower , with other social identities, including with people with mental health problems gender, race and ethnicity. The Bradley dying up to 25 years younger than Commission Report and its five-year the general population.clxxxiv In order review in 2009 continue to be valuable to reduce these rates of co-morbidity and relevant documents in setting out a and premature mortality, the health policy and provision agenda,clxxxi and the service needs to develop integrated Centre for Mental Health has outlined care pathways that deliver prevention, public mental health approaches to the early intervention and high-quality, non- criminal justice system to promote and stigmatised care for people with mental protect offenders’ mental health and health problems.clxxxv wellbeing.clxxxii Another perspective on co- or multiple 4.2.1 Co-Morbidity morbidities is that many people with long-term physical health problems People with mental health problems (the most frequent users of healthcare experience significant physical health services) commonly also have mental inequalities due to the early onset of health problems, such as depression mental health problems, the effects of and anxiety (or dementia, in the case some psychiatric interventions, and the of older people). It is thought that the high levels of risky health behaviours causal relationship between physical and among people with a diagnosis of mental co-morbidities is two way, and serious mental health problems, such operates through complex mechanisms as smoking, alcohol consumption, combining biological, psychosocial, substance misuse and overeating environmental and behavioural factors. (sometimes as ways of managing the clxxxvi More than 15 million people in mental distress they are experiencing). England alone (30% of the population) Those with mental health problems have one or more long-term conditions. have greater risk (and higher rates), People with long-term conditions are two of heart disease, diabetes, respiratory to three times more likely to experience disease, cancer and . Physical mental health problems than the health conditions are often missed general population, with a particularly because of ‘diagnostic overshadowing’, strong evidence base for a close whereby symptoms are ascribed to the association between mental health and individual’s mental health problem or cardiovascular disease, diabetes, chronic treatment and physical causes are not obstructive pulmonary disease and considered or investigated; this limits musculoskeletal conditions. According to early identification and treatment of The King’s Fund and Centre for Mental physical health conditions among people Health, a conservative estimate is that

42 43 at least 30% of all people with a long- the increased likelihood of their family term condition also have a mental health members providing informal care and problem.clxxxvii,clxxxviii support, involving time off work.cxci (This is discussed in section 6.) • There is a three-way interaction between mental health, physical The institutional and professional health and social conditions. Socio- separation of mental and physical economic deprivation exacerbates healthcare – particularly in countries the relationship between having with non-integrated health and multiple long-term conditions and social care (like England) – increasing experiencing psychological distress sub-specialism and the decline in as follows: generalisationcxcii have all contributed to fragmented approaches and missed • a larger proportion of people in opportunities to improve co-ordination, poorer areas have multiple long- oversight, quality and efficiency in term conditions; and support for people with multiple needs.

• the effect of multiple morbidity 4.3 Social Care on mental health is stronger when deprivation is present.clxxxix Social care encompasses , residential care, domiciliary care, day • A number of studies have found centres and personal assistants.cxciii higher rates of co-morbid mental Provided to individuals and families health problems among women.cxc across the whole of the life course, social care can address a wide range of support The impacts of physical and mental needs – for example, due to disability co-morbidity for the service user (including mental health problems). In include significantly poorer clinical the context of mental health, the Social outcomes and prognosis, adverse Care Institute for Excellence describes health behaviours, poorer self-care and recovery and personalisation as core reduced quality of life. For the health approaches, and outlines the care and social care system, the impacts pathway of holistic assessment leading include increased service use (such as to a care plan, including a crisis and hospital admissions and readmissions, contingency plan led and organised by a and GP consultations) and higher health care co-ordinator.cxciv service costs (such as outpatient clinic attendance, pharmaceutical use and Many of the interventions across the inpatient stays). There are also wider life course that are described in this economic costs, as people with long- paper fall within this broad definition term conditions and mental health of social care. The social care ethos needs are less likely to be employed or, draws on social science analysis of social if in work, are less productive and take structures, systems and relationships, more sickness absence. Co-morbidities which include the dynamics of poverty, reduce economic output due to their disadvantage, inequality, and exclusion. impact on premature mortality and

44 45 Social care services are fundamentally cutting issues for all public services. important in supporting people with This lack of national and international mental health problems, but access to material suggests that the Social Care social care has significantly reduced Institute for Excellence, the NICE, and in England.cxcv Since 2009/10, there training and regulatory bodies across the has been a 25.5% reduction in the UK could valuably undertake evidence number of people receiving social reviews to inform the development of care for mental health problems, with policy, practice and provision, applying no evidence of a reduction in the core principles of social care. These need for such support.cxcvi NHS trusts are personalisation, recovery, rights- have identified local authority budget based approaches, and equity to the cuts as having a negative impact on intersection of mental health and services.cxcvii People with mental health poverty. problems living in poverty are reliant on publicly funded social care. Social From a mental health perspective, care plays a critical role in supporting there has been a historical under- people who experience mental health investment in social care for people with problems to recover, live independently mental health problems. In the current in the community, and gain and retain context of funding cuts and service employment. However, some seldom- retrenchment, progressively higher heard groups experience mainstream thresholds for social care entitlement social care provision as disempowering lead to mental health needs not being and inaccessible.cxcviii met. While urgent and complex social care arrangement may meet these Social care professionals are also thresholds, the importance of low- centrally involved in the implementation level and ongoing social care support of mental health and mental capacity – including supporting people to get legislation. Reports of the undermining out of bed, undertake self-care, go out, of mental health social work are and participate in and contribute to concerning; these include shortages their community – may not be well- of social workers in mental health understood. However, reduction or services,cxcix limited mental health withdrawal of such a service will have content within social work training, a significant impact on an individual’s social workers feeling devalued and quality of life, risk deterioration of their de-professionalised,cc and high levels of mental health, stall or reverse recovery emotional exhaustioncci and work-related and could increase social isolation. stressccii within the profession. 4.4 Education It is striking that the search undertaken for this review did not identify policy Together, the education and health and research texts that addressed sectors have central roles in promoting mental health, poverty and social care. mental health and wellbeing, preventing Therefore, the points made in this mental health problems from developing section are brief and refer back to cross- and escalating, and supporting recovery.

44 45 The ‘Future in Mind’ report outlines the and necessity of whole-system, integrated approaches to children’s and young • providing access to materials and people’s mental health (discussed in relational resources associated with section 4.2). mental health and wellbeing (such as a physicallyccvi and psychologically The Marmot Review found that a central safe space, and consistent positive plank of public policy should be to relationships with adults and peers). enable all children, young people and adults to maximise their capabilities England’s ‘Future in Mind’ report by the and have control over their lives. The Children and Young People’s Mental priority objectives for achieving this Health Taskforce recommended the were reducing the social gradient in use of the whole-school approach. The skills and qualifications; ensuring that King’s Fund’s review of public health schools, families and communities work interventions included the following in partnership to reduce the gradient targeted interventions within the whole- in health, wellbeing and resilience school approach for children and young of children and young people; and people who present with mental health improving the access and use of quality or behavioural problems: lifelong learning across the social gradient.cciii • interventions to reduce drop-out and exclusion rates, focusing on The education sector at primary, raising the educational standards secondary and tertiary levels can make of the most vulnerable children and substantial contributions to addressing young people;ccvii mental health and poverty by: • support and expect schools • providing opportunities for to reduce bullying through education attainment across the implementing evidence-based life course, enhancing prospects for guidance;ccviii securing good work; • support and expect schools to • developing knowledge, skills and reduce the prevalence and impact attributes for mental health and of conduct disorders through wellbeing of all members of the programmes that have been educational community (staff, shown to improve students’ social students, family members and and emotional skills, attitudes, the wider community in which an behaviours and attainment;ccix institution is based); • support schools to develop • providing access to mental health children’s life skills, such as problem supports – for example, school solving, and build self-esteem nursescciv and health visitors,ccv and resilience to peer and media psychological therapies and peer pressure;ccx support, and parenting programmes;

46 47 • develop targeted wellness services • staff development to support their towards clusters of children own wellbeing and that of students; identified as being at high risk of multiple poor behaviours, rather • identifying need and monitoring than providing single-issue services impact of interventions; only. Schools should be encouraged to foster a strong sense of culture • working with parents/carers; and and belonging, and connectedness with teachers;ccxi and • targeted support and appropriate referral. • support the use of resources such as the Department for Education’s Integration with other services within Healthy Schools Toolkit.ccxii and beyond education is an important component of the success of the whole- 4.4.1 Whole-School and College school approach. The promotion of Approach students’ mental health and wellbeing is a shared responsibility, as demonstrated One way to encapsulate many of in the framework of recommended these benefits is to promote a whole- universal and progressive services for place approach. The health-promoting 5–19 year olds in England’s Healthy Child school,ccxiii college and university are well- Programme.ccxv established models, and there is a strong evidence base and body of resources to In its review of public health support implementation. interventions for local authorities, The King’s Fund evidenced the of The whole-school and college approach whole-school approaches and made to promoting emotional health and particular recommendations around wellbeing in schools is founded on eight fostering a strong culture of belonging principles:ccxiv and connection with teachers, and running programmes to develop • leadership and management that problem-solving life skills, resilience supports and champions efforts and self-esteem. Alongside these to promote emotional health and universal interventions, it recommended wellbeing; targeted action around bullying, conduct disorders, reducing school • an ethos and environment that dropout and exclusion, and focusing on promotes respect and values raising educational attainment among diversity; vulnerable children and young people.ccxvi

• curriculum teaching and learning Adopting a whole-school approach to promote resilience and support involves action at systemic, universal and social and emotional learning; targeted levels.

• enabling student voice to influence decisions;

46 47 • Systemic – changes to school ethos, 4.4.2 Children and Young People Who teacher education, working with Are Out of Education parents, community engagement and co-ordination with other Children with mental health problems support agencies. experience disrupted education. According to the last study on the • Universal for all pupils – curriculum- mental health of children and young based teaching of skills for social people (in England, Wales and Scotland problem solving, social awareness in 2004), children with mental health and emotional , delivered problems are more likely to have through active classroom time off school: 17% of those with methodologies such as games, emotional disorders, 14% of those with simulations and group work. conduct disorders and 11% of those with hyperkinetic disorders had been • Targeted – focusing on children with away from school for over 15 days in particular issues, such as behavioural the previous term; these rates compare problems or other signs of mental with 4% of other children. As many as health problems.ccxvii one in three children with a conduct disorder had been excluded from school The Children and Young People’s Mental and nearly a quarter had been excluded Health Coalition, England, produced more than once.ccxxv a briefingccxviii with PHE that described mental health and resilienceccxix and Over two-fifths (44%) of children with an the contribution that a whole-school emotional disorder were behind in their approach can make to promoting development, with 23% being mental health and wellbeing, including two or more years behind (compared building resilience, linked to both with 24% and 9% of other children). Ofsted’s inspection framework,ccxx the Children with an emotional disorder Department of Education England’s were twice as likely as other children to statutory guidance34 and advice,35 have special educational needs (35% and NICE guidance.ccxxi,ccxxii,ccxxiii The compared to 16%). One in five children briefing lists resources that include was diagnosed with more than one of the (Westminster) Government guidance main categories of mental disorder, 72% and advice, evidence reports,ccxxiv data of which were boys. Sixty-three per cent sources (England), curriculum resources, were behind with their schooling and training, organisations, and examples of 40% were more than a year behind. approaches (programmes for children and parents, counselling and helplines). Although education may be delivered primarily through formal education

34 on safeguarding, supporting pupils at school with medical conditions, and promoting the health and wellbeing of looked-after children 35 on mental health and behaviour, and counselling in schools

48 49 settings such as schools and third- entitlements, and legal assistance.ccxxvi A level institutions, education makes an systematic review of case management important contribution when delivered approaches with individuals who in community, health, social care, and experienced homelessness found that criminal justice spaces. Mental health different approaches delivered variable and wellbeing curricula, programmes impacts.36,ccxxvii and supports need to be provided within these places too. Children and young 4.4.3 Lifelong Learning people who are not consistently in formal education often belong to groups that Individual and familial mental health have higher prevalence of mental health problems and poverty can disrupt problems, including homeless children, education and training, and people can young offenders, members of the Gypsy therefore miss out on opportunities and Traveller communities, looked-after for educational and employment children and and asylum-seeking attainment. Young people can fall children. Therefore, public services need between the gaps in services as they to develop innovative ways for reaching transition between adolescent and these children too. adult health, and education, training and employment provision. They can be A systematic review of literature assisted to continue their development about child and and recovery through integrated mental recognised the importance of screening health, education, employment and other for psychosocial stressors at routine services, including IPS (described in the child health appointments and referring section 4.5 below), and the ‘Clubhouse 37 for support; minimising the harm to International Model’ (adapted to ccxxviii mental health while families are in meet their needs). Programmes temporary accommodation (with actions to engage people throughout their life akin to the PIEs approach discussed in course in education and training should section 4.1.4); and ensuring ongoing include mental health and wellbeing support to address psychological components that promote mental health harm caused by the experience of knowledge and skills, resilience, self- homelessness when a family’s situation efficacy, self-management, and recovery. stabilises. Appropriate case management The National Equality Panel recommends support for homeless families could commitments to lifelong learning and address rehousing, health and related training that extend beyond the already ccxxix services, job training and placement, well-qualified.

36 Standard case management was found to improve housing stability, reduce substance use and remove substance employment barriers for substance users. Assertive community treatment improved housing stability and was cost-effective for people with mental health problems, and people with a dual- diagnosis of mental ill health and substance use. Critical time intervention was a promising intervention for housing, substance use and mental health problems, and was cost-effective for people with mental health problems. There was little evidence for the effectiveness of Intensive case management.

48 49 4.5 Employment and costs to the NHS. It reported that mental health was the cause of 40% of Discussions about mental health at work new disability benefit claims each year in policy documents can be framed (representing 1% of the working-age around costs to the economy, costs to population, and the highest of the 34 the public purse and the importance of nations reviewed); it also noted that the good work for mental health. risk of poverty for people with mental health problems was highest in the UK Firstly, in terms of costs to the economy, among the ten OECD countries in a the costs of mental health problems comparative study.ccxxxiii to UK workplaces are estimated to be £26 billion across the economy, or Thirdly, good work for mental health £1,000 per employee per year.ccxxx – as both a protective factor against The main costs are from presenteeism developing mental health problems and (when people are at work, but are also as a valuable route to recovery for underperforming), with sickness people who have experienced mental ill absence accounting for just under a health – is important.ccxxxiv third.ccxxxi However, many employers are unaware of how common mental health 4.5.1 Getting on in Work: Supporting problems are, the impact these have People to Remain in Work and to on their business, and how employees Progress with mental health problems can be supported through simple, reasonable Better mental health and wellbeing accommodations. This lack of awareness among employees has been associated can mean that employers hold negative with higher staff retention, improved views of how a person with a mental productivity and performance, higher health problem could perform at work. levels of collaboration, and reduced ccxxxii sickness and absenteeism.ccxxxv Whole- workplace approaches to mental health Secondly, in terms of the costs to the create a psychosocially informed public purse of people with mental environment in which workers’ mental health problems being unemployed and health and wellbeing is promoted and in receipt of social security, health, social protected.ccxxxvi They incorporate a strong care and housing (and not contributing anti-stigma aspect so that talking about through taxation), a 2014 study by the and dealing with mental health positively OECD costed mental health problems at is part of the workplace’s culture. 4.5% of GDP (£70 billion) each year due to productivity losses, benefit payments

37 A clubhouse is a community of people who are working together to achieve a common goal: recovery from mental illness. Clubhouses are local community centres that provide members with opportunities to build long-term relationships that, in turn, support them in obtaining employment, education and housing. They provide a restorative environment for people whose lives have been severely disrupted because of their mental illness, and who need the support of others who are in recovery and believe that mental illness is treatable. http://www.iccd.org/whatis.html

50 51 The majority of people with mental companies38 as founding members of health problems are already in work. its Mental Health Champions Group. They may have had a pre-existing The initiative outlines the business case problem before getting a job or develop for addressing mental health in the a problem while they are in work. A workplace. The WorkWell Model details whole-workplace approach to mental a range of actions that businesses can health and wellbeing should incorporate take to change organisational culture initiatives, policies, and management around mental health through: providing practices that create a mentally healthy leadership from a boardroom level; workplace culture that: ending the silence around mental health by running mental health events and • promotes and protects the programmes; training line managers mental health and wellbeing of all in mental health and proactively employees; supporting staff who are under pressure or experiencing mental health • intervenes early when an employee problems – for example, by making is at risk or displaying signs of stress reasonable accommodations, investing or distress; in employee assistance programmes and workplace counselling; signing up • enables employees to remain in to anti-stigma campaigns; and publicly work, or return in a timely and reporting on employee engagement and supported manner (including wellbeing using the WorkWell Model referral to the Fit for Work as a framework. WorkWell provides programme); case studies of companies39 that have adopted their approach.ccxxxvii • uses existing government programmes, such as Access to Employers can do a lot to support people Work, to support people with mental to remain in work and to progress in their health problems both in work or careers by: seeking work; and • providing a supportive environment • supports schemes, such as IPS, so that workers feel comfortable and to help people with existing safe to disclose their condition; mental health problems in finding • having trained line managers that employment. can engage appropriately and effectively, using best-practice Examples of whole-workplace procedures to make reasonable approaches are found within Business accommodations; in the Community’s WorkWell initiative, which has a number of national

38 American Express, BaxterStorey, BT, Bupa, Friends Life, Mars, National Grid, Procter & Gamble, Right Management, Royal Bank of Scotland and Santander

50 51 • offering occupational health support groups, health and wellbeing. A study or employee assistance in order for published by the Scottish Government the worker to remain in work; and found that disadvantages in the labour market are associated with negative • proactively supporting return to health outcomes. However, there work so that the individual does not is limited evidence regarding the drop out of employment. reversibility of disadvantage through policy interventions, and some studies There is a wealth of resources and suggest that it is unrealistic to expect initiatives jointly developed by mental a quick reversal of accumulated health organisations, public bodies and health damage from poverty due to an businesses for all sizes of workplace improvement in an individual’s economic (although more needs to be done around or psychosocial situation. A sustained SMEs – particularly micro- and small and significant improvement in material enterprises). and psychosocial health determinants will probably be necessary for reducing The government’s Fit for Work health inequalities, particularly for the programme was rolled out across the most disadvantaged and those worst ccxxxviii UK from 2015. This will provide a affected by the recession.ccxxxix free Fit for Work occupational health assessment for employees who have Work is very important for people with been off sick for four weeks, as well as mental health problems. It provides advice to employers, employees and GPs. income, social status, a sense of achievement and a means of structuring 4.5.2 Moving into Work: Supporting one’s time. Participating in work for People to Enter the Labour Market people with poor mental health has a therapeutic value, as well as indicating Active labour market programmes a successful outcome.ccxl People with (ALMPs) are used to increase mental health problems see work as employability and reduce the risk of a means for helping them recover an unemployment. ALMP interventions ordinary life.ccxli include job search assistance, training, and wage and employment . But, even where proven interventions Research into the effectiveness of are available, there are many barriers ALMPs almost exclusively focuses that prevent people with mental on economic outcomes (earnings, health problems from taking up work. re-employment opportunities and These barriers include stigma and cost-effectiveness), and there is little discrimination, poorly structured social evaluation evidence about how these welfare systems, low expectations, policies and interventions deliver fear of failure, lack of life skills, and health outcomes and affect target

39 Deloitte, Procter & Gamble, National Grid and Mars

52 53 employers’ lack of knowledge in dealing with ongoing support are generally with mental health problems.ccxlii Some more successful in helping people find people who have experienced stigma competitive employment than pre-work and discrimination at work stop looking training; in addition, place and train for a job because they anticipate further models are more cost-effective than incidents.ccxliii vocational rehabilitation approaches. ccxlvi Developed in the US in the 1990s, Absence from work impacts economic IPS is evidenced to be the most effective security and social connectedness. The approach to supporting this group weakening of economic and social ties to get into employment, and service may erode self-confidence and self- user stories illustrate the experience40. esteem in people with mental health Further, IPS can be successfully adapted problems, which exacerbates their to support people with drug or alcohol vulnerability to further periods of ill addictions.ccxlvii,ccxlviii,ccxlix health. People may become trapped in a cycle of exclusion that leads to 1. IPS services have to adhere to eight despair and hopelessness outside the principles. mainstream of economic and social life. 2. Competitive employment is the ccxliv primary goal.

For people with mental health problems 3. Everyone who wants it is eligible for who find it hard to sustain ongoing employment support. employment (perhaps because of 4. Job search is in line with individual the lack of specialist support to help preferences and strengths. them gain employment, or reasonable accommodations during periods 5. Job search is rapid – it begins within of fluctuating ill health to retain four weeks. employment), there need to be other 6. Employment specialists and clinical approaches for enabling and recognising teams work and are located together. the contributions that they make (for 7. Support is time-unlimited and example, through volunteering) so that individualised to both the employee they can live with dignity and respect. and the employer. People with severe and enduring 8. Welfare benefits advice and mental health problems have the lowest information is available. employment rate of all disability groups 9. Jobs are developed with local at less than 10%, but there is strong employers.ccl research about supported employment for this group.ccxlv Placing individuals in open employment and providing them This personalised approach to supporting people to get into work

40 http://www.centreformentalhealth.org.uk/individual-placement-and-support

52 53 is fully integrated with mental health is critical to the of small support services. All referrals are from businesses, yet this sector is least likely people who are already receiving mental to have access to occupational health health support while they are searching or employee assistance support; in for employment and they continue addition, among owner-managers, there to have that support once they are are particular pressures to keep working in employment. Referral is voluntary. even when they are unwell.ccliv IPS has developed the evidence base around the importance of co-locating 4.6 Social Security employment support with mental health services, and of not mandating Social security is a central plank of social or coercing people with mental health protection, defined as: problems into seeking or engaging in employment. This has informed the “policies and programmes designed UK Mental Health Welfare Reform to prevent, manage, and overcome Group’s (MHWRG’s) proposals on situations that adversely affect the well- the fundamental reform of the Work being of individuals and populations”.cclv Programme (see section 4.6). In anticipation of the devolution of 4.5.3 Self-Employment and additional social security powers through Entrepreneurship the Scotland Bill 2015–2016, the Scottish Government published a report SMEs made up 99.3% of the private on its public dialogue on the future of sector in 2014, and accounted for just social security, distilled into a set of under half (48%) of UK private sector principles41 and key messages around employment. The Federation of Small fairness, dignity and respect; universality Businesses has found that 95% of those and take-up; and service design, which moving from economic inactivity into will ground a vision paper and future employment between 2008 and 2011 social security legislation. found work in SMEs.ccli Entrepreneurship programmes can positively impact The calculation of Minimum Income young people’s economic and for Healthy Living includes the level psychosocial functioning and result in of income needed for adequate healthier decision-making, but this needs nutrition, physical activity, housing, to be further tested using integrated social interactions, transport, medical health and microenterprise models.cclii care and hygiene.cclvi The social security Self-employment and entrepreneurship system recognises that having a have the advantages of flexibility in work disability, including a psychosocial hours and location, and allow individuals disability, incurs additional costs paid to capitalise on their unique creativity, through the Disability Living Allowance/ innovate, and pursue their talents.ccliii Personal Independence Payment. Having ratified the UNCRPD in 2009, The mental health and wellbeing of the UK Government has committed to owner-managers as well as employees progressively realising the human right

54 55 of people with mental health problems to damaging for the mental health of an adequate standard of living and social claimants and has raised significant protection. concern about the operation of welfare reform among claimants, the The welfare reform policy agenda has voluntary sector organisations working marked detrimental impacts, both on with them, professional bodies and disabled claimants – including those parliamentarians. The UK MHWRG with mental health problems – and has called for a fundamental reform the mental health and wellbeing of of the new social security system, claimants (Mental Welfare Commission and an integrated assessment and for Scotland, 2013). Claimants find it support system across social security, distressing, inaccurate, unsupportive employment, and health and social care. and counterproductive with regards to engaging them in work. The Scottish Although social security policy is the Parliament’s Welfare Reform Committee responsibility of the Westminster has published a series of reports on the Government, the devolved impact of welfare reform in Scotland, administrations have had a range of which have repeatedly highlighted responses to its implementation – the disproportionate and cumulative including the introduction of mitigating impacts on disabled claimants who are measures and the establishment of affected by several different elements of a Welfare Reform Committee by the the reforms, deprived communities and Scottish Parliament, and a halting of women.cclvii the Welfare Reform Bill in the Northern Ireland Assembly. The public stigmatisation of disabled claimants is considered to have The Mental Welfare Commission weakened social for people for Scotland (MWCS) undertook an with mental health problems, leading investigation into a death by suicide to their feeling silenced, ashamed and following a WCA of a female claimant fearful, and reluctant to seek advice who had long-standing mental health and support (UK MHWRG). The problems and was using mental implementation of the replacement health services.cclviii The investigation’s of the Incapacity Benefit with the methodology included a survey of Employment and Support Allowance psychiatrists in Scotland in June 2013 (ESA) using the Work Capability about the effect of benefit changes Assessment (WCA) has been notoriously

41 Dignity and respect; rights-based; aspirational; person-centred; social investment; adequacy; simple (clear point of access, transparent and accountable) but complex (to meet diversity of needs); choice; accessibility; universal welfare system; flexible, responsive and sensitive; common sense; trusted/honest; preventative; joined up; a system for everyone – not based on ‘them’ and ‘us’; clear outcomes; and tackling poverty and inequality (2013, pp. 10–12). 42 The Mental Health Foundation, Mind/Mind Cymru, Rethink, the Centre for Mental Health, the Scottish Association for Mental Health, the Northern Ireland Association for Mental Health and the Royal College of Psychiatrists

54 55 on their patients; the survey response to provide support. Forty per cent of rate was 70 out of 320 general adult RMOs had at least one patient who psychiatry consultants in Scotland, self-harmed after the WCA. Thirteen including 56 completed by responsible per cent reported that a patient had medical officers (RMOs) whose patients attempted suicide, and 4% (two RMOs) had undergone a WCA. The MWCS stated that a patient had taken his/her reported that 75% of RMOs had not own life. Thirty-five per cent said that been asked for their opinion at any point at least one of their patients had been in the WCA process by the Department admitted to hospital as a consequence for Work and Pensions (DWP) or Atos; of the WCA, and 4% reported a patient 95% had been asked by patients to being detailed under the Mental Health provide medical evidence at some (Care and Treatment) (Scotland) Act point, with 73% being asked as part of 2003. the appeal process against the DWP’s decision. Asked if any of their patients The quality of the WCA experience had been distressed by the WCA reported by psychiatrists to the MWCS process, 96% of RMOs responded “yes”. mirrors issues raised by the UK MHWRG in multiple policy submissions to the The UK MHWRG (whose membership Harrington and Litchfield Independent includes the main mental health reviews of WCA: insensitive assessors organisations in England, Scotland, Wales without the requisite knowledge or and Northern Ireland)42 uses the term skills around mental health problems; ‘displaced expenditure’ to describe the distressing and demeaning experiences costs of welfare reform implementation that left claimants feeling stigmatised to health and social services. This is and victimised; inconsistencies between illustrated in the MWCS report, which what had been said by claimants in a stated that the overall theme of the WCA and what was reported by the survey was patients’ distress and the assessor; and the worsening of mental consequent demands on mental health health symptoms – particularly anxiety services. The MWCS asked RMOs and depression – as well as occurrence about patient experiences following of thoughts of self-harm. the WCA to which the assessment process or outcome contributed (in the The MWCS report, the body of policy RMO’s opinion). Psychiatrists reported work undertaken by the UK MHWRG additional demands on their services and the Scottish Government’s public due to the ways in which the WCA engagement around social security had distressed and destabilised clients have been synthesised into a number of (increased frequency of appointments, recommendations around social security changes to medication, and referral for and mental health. additional support, including intensive home treatment), increased admissions 4.6.1 Benefit Take-Up to hospital (including detention), and increased time involved in mental health There is a need to enhance the take- professionals attending WCAs in order up of benefit entitlements. However,

56 57 the stigma associated with claiming enhance their mental health knowledge benefits intersects with the stigma and communication skills. (social and internal) around mental health. Mental health and advice 4.6.2 Access to Work organisations have expressed concern that government departments and Access to Work is well regarded by agencies do little to inform the public employers and employees and has about the necessity and function of excellent performance results (90% social security. Integrating messages retention rates). In its response to the about the importance of social security 2014 Access to Work Inquiry, the UK to people with mental health problems MHWRG drew attention to the low in social marketing and social contact numbers of people with mental health anti-stigma campaigns is one way of problems who had been supported by addressing the stigma attached to Access to Work’s Workplace Mental claimants. This requires leadership from Health Support Service in England, the media, government departments and Scotland and Wales. Concerns were parliamentarians. raised about the low level of funding (less than 2% of the Access to Work Targeted advertising of benefits should budget), which was unrepresentative of be co-produced with people with lived the number of people with mental health experience of mental health problems, problems in the workforce and applying their families and carers, and the for employment. organisations that work with them. This should be supplemented by take-up Jobseekers with mental health problems campaigns using health and social care may be fearful of disclosing or discussing providers and community gatekeepers. their mental health problem with a Other innovative approaches could prospective employer due to pervasive involve jointly run programmes by societal stigma. It may be hard for advice and mental health organisations them and prospective employers to on social security advice and financial understand what types of support could management. (A Big Lottery-funded be resourced and how this would enable live-and-learn partnership in Northern them to retain and progress in their job. Ireland reduced claimant anxiety, In order to increase the likelihood of promoted an understanding of the securing employment, it is helpful if all social security system and maximised measures can be taken to reduce the incomes.)cclix applicant’s anxiety and support their open communication. Further, claim procedures need to be simplified and the system made more The UK MHWRG proposed the following receptive to, and supportive of, claimants changes to Access to Work in order with mental health problems. This could to increase its reach and benefit to happen by having the same worker claimants with mental health problems. throughout the claim process, and providing training for all levels of staff to

56 57 1. Allow for an agreement of support who have particular difficulties in before someone secures a job and accessing employment – the so- a portable package of support that called harder to help group. Reports travels with the person from job to by the Public Accounts Committee job. (PAC) present several shortcomings of the Work Programme, including 2. Allow for people with mental health the low numbers of people who have problems to discuss the support accessed and sustained employment, they may receive before getting an and commissioned providers’ failure to interview with an employer. engage with the harder to help groups 3. Confirm in the Access to Work despite incentives to do so. The PAC’s eligibility letter the general type 2014 report on the Work Programme and level of support that the reported that only 11% of new ESA jobseeker will receive if they secure claimants achieved job outcomes employment. compared to the DWP’s original 4. Showcase the types of support that (22%) and revised (13%) performance a jobseeker/employer may receive expectations; this means that 90% of through Access to Work, using ESA claimants on the Work Programme cclxi success stories of identifying and had not moved into employment. managing workplace triggers and coping strategies, and developing The substantial problems with the a workplace wellness and recovery WCA discussed above provide the action plan. background to the UK MHWRG’s submission to the Work and Pensions 5. Proactively market the Access to Select Committee Welfare to Work Work scheme to jobseekers with Inquiry (August 2015). The UK MHWRG mental health problems. has described the entrenched fear and 6. Enhance training for all Access to negativity towards the DWP and the Work call handlers on mental health Work Programme felt by ESA recipients. problems and the services offered This negativity is explained by the poor through Access to Work, and arrange support that is offered, the constant for consistent support from one focus on , the pressure person throughout the process.cclx that people are put under and the delays to support that people face. People are anxious about exposing themselves to a 4.6.3 The Work Programme distressing process, receiving sanctions, The policy aim of the Work Programme being pushed into inappropriate work is to help people who have been and disrupting their income by engaging out of work for long periods to find with the Work Programme. This removes and keep jobs, and, specifically, to claimants further from work. increase employment, reduce the time that people spend on benefit, and Attempts to revise the Work Programme improve support for groups, including to date have not delivered substantial claimants, with mental health problems change, and the UK MHWRG concluded

58 59 that fundamental reform is necessary until the full impact of the policy is using the IPS model (described in section understood. Providers and Jobcentre 4.5) and made six proposals. Plus, who continue to show high levels of inaccurate sanction referrals 1. The DWP should offer a new (alongside poor success rates), should programme of support for the be penalised. mental health cohort on ESA. This programme should be locally 5. Health outcomes should be used for provided, with only specialist this cohort. These outcomes should providers at the forefront of delivery. be used to acknowledge progress, but This support should be integrated also to hold providers and Jobcentre with local services such as Improving Plus to account where people’s health Access to Psychological Therapies is negatively affected by support. (IAPT), housing and community 6. People with mental health problems groups. should be directly included in the 2. The DWP should introduce the use design of any new back-to-work of personal budgets in back-to-work support.cclxii support. 3. Support for this cohort should be The ‘Five Year Forward View for Mental delivered within a healthcare setting Health report’ recommends that the similar to the IPS model in order to DWP should ensure that, when it tenders lead to a greater focus on supporting for the Health and Work Programme, someone’s health condition (the it directs funds currently used to main barrier to work), a break in the support people on ESA to commission link between benefit eligibility and evidence-based, health-led interventions support (which, in turn, leads to a that are proven to deliver improved heavy focus on conditionality), and employment and health outcomes at more successful support. Pre-existing a greater rate than the current Work employment indicators for health Programme contract. It has called for bodies could be used in conjunction DWP to invest in ensuring that qualified with this support.43 employment advisers are fully integrated into expanded psychological therapies 4. The use of current conditionality for services. people with mental health problems should be reviewed immediately, with a reduction in conditionality

43 Employment is a key indicator that many health bodies can be held accountable for. This includes the Public Health Outcomes Framework – Indicator 1.8ii: gap in employment rate of people in contact with secondary mental health services versus unemployment rate; the Adult Social Care Outcomes Framework – Indicator I (F): proportion of adults in contact with secondary mental health services in paid employment; the NHS Outcomes Framework – Indicator 2.5: employment of people with mental health problems; and the CCG Outcomes Indicator Set – Indicator C3.17: Improving recovery from mental health conditions.

58 59 4.7 Advice relating to homelessness were 2.8 times as high.cclxiv Using the same data set, Mental ill health is much more common a Youth Access study reported that, among people experiencing welfare among 18–24 year olds, 44% of young problems, and welfare problems are people with mental health problems more common among people who had welfare rights problems (compared have poor mental health. Parsonage with 16% among those who did not have concluded that the causal relationship mental health problems); 62% of those between mental ill health and welfare reporting homelessness also reported problems worked in both directions. having mental health problems; and, among all young people with welfare “Because most live on low incomes, rights problems, 36% said that they people with mental health [problems] worried “all or most of the time”, and are more likely than average to run into 22% said that their problems had led to financial or housing difficulties and their stress-related illness.cclxv capacity to deal with such problems is often compromised by their illness. At The provision of timely, sensitive and the same time, welfare rights problems accessible advice services to people who are a major cause of stress, which can experience cognitive, communication precipitate or worsen diagnosable and emotional barriers is essential mental health conditions. A particular for them to realise their entitlements risk is that welfare problems and mental and protections, and to manage social illness interact with each other, one security issues. People with mental problem aggravating the other and health problems have particularly high leading into a downward spiral into rates of non-claiming. Reasons for this crisis.” cclxiii low take-up of entitlements include the complexity of the system, the lack of Using data from the English and knowledge among claimants, and that Welsh Civil and Social Justice Survey the social security system is not well of 2006–07, the Centre for Mental adapted to the episodic and fluctuating Health found that 56% of people who characteristics of some mental health scored over the GHQ threshold for problems.cclxvi A welfare benefits outreach having a clinically diagnosable mental project for people with diagnoses of health disorder reported one or more severe and enduring mental health welfare rights problems, compared problems provided benefit assessments with 36% of people scoring below the to 153 people and found that only 34% threshold. Among those whose GHQ were receiving their correct entitlement, score indicated a severe mental illness, and the remainder were under-claiming. 83% reported welfare rights problems. Those who were under-claiming who Compared to the general population, accepted help received additional the rates of money or debt problems of benefits of £3,079 (just over £4,000 people who had a clinically diagnosable in 2013 figures). Further, the outreach mental disorder were 2.3 times as high; project found that claimants had been the rates of welfare benefit problems given wrong or inadequate advice by were 2.4 times as high; and problems mental health professionals, highlighting

60 61 the importance of staff training and the mental health conditions. Provision of signposting of specialist advice provision specialist welfare advice for people using within mental health services.cclxvii secondary mental health services cut the cost of healthcare by reducing the People with mental health problems may length of stay (for example, by enabling need advice – and advocacy – in order to discharge through resolving a housing access the range of public services they problem), preventing homelessness (by require; and those with complex needs negotiating with landlords and creditors), may need support in navigating multiple and preventing relapse (by acting on an service systems. They may require legal immediate cause of stress or reducing advice if they are subject to specific vulnerability to future problems). The mental health legislation – for example, study found that only a small number of if they have experienced detention, successful welfare advice interventions some form of deprivation of liberty or by a specialist service was necessary to coercive treatment. They may want to generate sufficient savings to be good formalise their will and preferences in a value for money. (This business case for legal advanced planning document so specialist advice provision is discussed in that their human rights will be protected section 4.7.) if they become unwell. Mental health and mental capacity legislation varies across Advice provision is an important the UK, although all legislation must preventative measure for supporting come into line with the UNCRPD as people who are at risk of developing well as be compliant with the European mental health problems due to financial Convention on Human Rights. The strain caused by debt, housing, services discussed in this review are employment and discrimination. Given subject to equality legislation (noting the body of evidence around debt that Northern Ireland has not updated its and mental health, and the discussion legislation in line with the Equality Act of welfare reform in section 4.6, this 2010). Advice services should be in a section focuses on debt advice. It position to support people with mental considers the lessons that can be learnt health problems to realise their human to support advice-service users with and equality rights, including signposting existing mental health problems, as well them to specialist services. as identifying people who are developing mental health problems. Mental health services should support service users to access advice by 4.7.1 Debt signposting to advice services, or siting specialist welfare provision A clear relationship between debt and within secondary services. A small mental health has been established. exploratory study by the Centre for The last Psychiatric Morbidity Survey Mental Health in 2013 analysed the in the UK showed that one in eleven Sheffield Mental Health British adults was in debt (defined as Bureau, which was one of two such being seriously behind with at least one cclxviii services in England dedicated to the bill or commitment). One in two advice needs of people with severe adults in such debt has a mental health

60 61 condition.cclxix A large-scale UK study • all health and social care found that housing arrears negatively professionals should ask service impacted on mental health in men (if users about financial difficulties in arrears had occurred in the last year) routine assessments; where debt is and among women (if arrears were long reported, primary care professionals term).cclxx Studies have found significant should assess for depression and relationships between consumer debt other common mental health and mental wellbeing,cclxxi and between difficulties; and debt and major depression.cclxxii A high • health and social care professionals proportion of people with mental health should receive basic ‘debt first aid’ problems who are in debt choose not training: knowing how to refer to to tell creditors because they think and support debt counsellors, but creditors will not understand or will not without having to become experts believe them.cclxxiii A large-scale review in debt and money management of evidence concluded that, although themselves. there is an association between debt and mental health problems, there was no conclusive evidence of a causal The Royal College of Psychiatrists relationship; the researchers commented delivered a research programme on that debt “may have indirect effects debt and mental health, which informed on household psychological wellbeing a guide with eight steps for action by over time, as it impacts on feelings of health and social care, summarised as economic pressure, parental depression, ‘CARE’: conflict based family relationships and potential mental health problems among • C – Consider debt as a possible children”. cclxxiv,cclxxv underlying determinant of ill health. • A – Ask about debt – the person 4.7.2 Good Practice in Advice Provision may be too embarrassed to bring it up. The ‘Foresight Review of Mental Capital and Wellbeing in England’ drew together • R – Refer consenting clients to a stakeholders from health and social care, money adviser. money advice, banking and government • E – Engage with financial advisers. agencies in order to address the cclxxvi recession’s impact on mental health, and proposed an integrated framework for action across health, social care, financial A standardised Debt and Mental and advice services, and government. Health Evidence Form was developed in England to inform creditors with the In health and social care, Foresight service user’s consent. Health and social recommended that: care professionals also have a role in signposting service users to appropriate agencies for specialist advice.

62 63 Foresight recommended that financial reduced GPs’ time spent on benefits sector code, as a minimum, should issues by an estimated 15% and resulted recognise the existence of customers in fewer repeat appointments and with mental health problems and define prescriptions. Welfare advice to people ‘best practice’ in working with such who use secondary mental health customers; that these (and mental health services could reduce hospital stays, resources) should be readily available reduce the risk of relapse and prevent to workers and customers; and that homelessness. Within secondary and frontline workers in financial services tertiary care, welfare advice supported organisations should receive regular, discharge planning and freed up clinical appropriate mental health training. staff time.cclxxviii The Council of Europe made recommendations to assist policy- makers in dealing with indebtedness, 4.8 Planning the Built Environment which recognised that indebtedness frequently led to social and health Reports from the Marmot Review of problems, social exclusion of families, health inequalities and the Sustainable and could put children’s at Development Commission have risk. Thus, they called for social, as well as evidenced how people with mental financial, legal and political, solutions to health problems experience area combat poverty and financial illiteracy, inequalities. The populations of promoting social inclusion (including deprived areas are characterised by access to the labour market), attending concentrations of disabled people, to human rights and dignity. Indebted including people with mental health cclxxix households should have effective access problems, and studies have found to impartial financial, social and legal that prevalence of mental illnesses cclxxx advice and counselling.cclxxvii maps closely with deprivation. Poor people are concentrated within A recent evidence review and mapping communities that have a poor-quality study of the role of advice services built environment, housing that is in health outcomes reported that the substandard and insecure, and poor effects of welfare advice on health access to open spaces and green outcomes were significant. These environments. include lower stress and anxiety, better sleeping patterns, improved health The relationship between the built behaviours (smoking cessation, diet and and natural environment and health, physical activity) and more effective including mental health, has been use of medication. It found that direct established. Access to green space has a commissioning of advice services within therapeutic benefit as well as providing health settings was most effective, as it access to ‘green exercise’ and play space. cclxxxi targeted the most vulnerable individuals The relationship between physical and engaged them in trusted settings exercise and mental health is well cclxxxii where their health needs are understood. established, but studies suggest that In primary care, welfare advice provision green exercise can have more positive

62 63 effects than other kinds of exercise. Green space is beneficial for social cclxxxiii Design for mental health, including cohesion through facilitating higher natural spaces, should be promoted as levels of social contact and social good practice for architecture in town integration,ccxcii particularly in deprived and country planning.cclxxxiv The increased neighbourhoods.ccxciii Access to the physical activitycclxxxv and social natural environment creates a meeting cohesioncclxxxvi associated with green space for all age groups and positively space are known to increase resilience to affects their social interaction and stress. cohesion.ccxciv Nearby natural space has been related to crime reductionccxcv This is evident across the life course, and increased neighbourliness.ccxcvi with school-age children’s attitudes Opportunities for socialising and the and behaviours affected by the strengthening of neighbourhood ties quality of the built environment and are provided by community gardens local neighbourhoods, and the poor and club or group green activities. physical condition of neighbourhoods ccxcvii Building communities through adversely affecting schools.cclxxxvii participation in local nature activities The lack of outdoor play has been increases a sense of community pride found to be a causative factor in and strength.ccxcviii increased mental health problems among children and young people. cclxxxviii As for adults, children’s contact with natural environments can reduce stress,cclxxxix enhance their emotional development,ccxc and improve concentration in children with a diagnosis of Attention Deficit Disorder and self-discipline among inner-city girls. ccxci

64 65 5. Growing the Evidence Base: Data and Research

There is much that we already know addressing workplace discrimination and about what works to tackle poverty and effects on productivity), and education mental health in policy and services, (by revisiting missed educational but we need to continue to build the opportunities and changing limited evidence base for change. The historical expectations). It highlights the relevance underinvestment in mental health means of mental health research to the seven that there is an urgent need to invest in EU flagship initiatives, including poverty. broad-based research, evaluation and ccc data agendas that are co-produced with people experiencing poverty and mental The authority and credibility of the health. ROAMER approach and the clarity of its roadmap mean that it is an excellent The WHO’s ‘Mental Health Action resource for developing a mental health Plan 2013–2020’ called on member and poverty research agenda within states to invest in health information JRF’s Anti-Poverty Strategy for the UK, systems44 and evidence and research.45 which will resonate internationally. The ROAMER studyccxcix was published in March 2015. ROAMER outlines a mental health research agenda that 5.1 Research is in alignment with the European Commission’s ‘2020 Vision’, including Because the relationship between its targets on poverty reduction (by poverty reduction and mental health addressing the ways in which mental inequalities has been established, disorders contribute to poverty and ROAMER calls for a broadened scientific poverty exacerbates mental health scope in order to build the public mental problems), social inclusion (by tackling health evidence base and to incorporate stigma that leads to disengagement or socio-economic contexts into new exclusion from society), employment (by models of mental healthcare, including increasing opportunities to work, and recovery.

44 Integrate mental health into the routine health information system and identify, collate, routinely report and use core mental health data disaggregated by sex and age in order to provide data for the Global Mental Health Observatory (as a part of the WHO’s Observatory) (2013, p. 19). 45 Improve research capacity and academic collaboration on national priorities for research in mental health, particularly operational research with direct relevance to service development and implementation, and the exercise of human rights by persons with mental disorders. This includes the establishment of centres of excellence with clear standards using the input of all relevant stakeholders, including persons with mental disorders and psychosocial disabilities. (2013, p. 19).

64 65 ROAMER presents five priority areas 5.2 Data for mental health: supporting mental health for all, addressing societal values Mental health data varies significantly and issues, building research capacities, across the UK. This limits our ability taking a life course perspective, and to compare the prevalence of mental personalised care. It recognises that health problems, service activity and there is a need to address the contextual outcomes, and the degree to which the factors that result in mental health UK Government’s anti-poverty, human disparities, with particular reference rights and equality commitments are to under-researched groups, including being realised. Within the UK, England at-risk, disadvantaged and marginalised has the strongest mental health data populations – specifically relating to administered through the National , and the effects of Mental Health Intelligence Network public and economic policy. (NMHIN), which is hosted by PHE and co-funded through PHE and NHSE. The ROAMER advocates empowering NMHIN manages the Mental Health, service users and carers in decisions Neurology and Dementia ‘fingertips’ about mental health research using online resource.cccii England’s Mental a human rights-based approach. Health Taskforce recommended Mental health research, including its the development of a five-year data dissemination, should enhance service plan. The Health Poverty Index46 is user autonomy, investigate human a web-based tool covering all local rights protection and discrimination, authority districts in England. It allows promote social inclusion, remove stigma, comparisons across geographical areas and advance public awareness and and different ethnic groups, and provides participation in mental health promotion. a high-level visual summary of an area’s ccci Research outcomes should be health poverty, drawing on 60 indicators expanded to include wider outcomes of health and the wider determinants.ccciii linked to the social and economic determinants of mental health, and There is a particular need for investment interventions developed to target these in data improvement, and a welcome directly. interest from governments and public bodies to improve mental health data, NHS England’s Mental Health Taskforce intelligence and dissemination in recommended that the Department of England, Scotland, Wales and Northern Health produce a ten-year mental health Ireland. research strategy by 2017, including a co-ordinated plan for strengthening The key questions facing mental health and developing the research pipeline data are: (i) What qualitative and on identified priorities, and promoting quantitative data are available and how implementation of research evidence. can these be disaggregated? (ii) What is

46 www.hpi.org.uk

66 67 the quality of that data (including how Measurements of mental health and fully data completion requirements are poverty need to be part of a broader complied with)? (iii) What is the scope suite of measurements that relate data for comparison (for example, across to the social determinants, including demographic groups, and geographic economic performance and progress, to and service areas)? and (iv) What realise equity and human rights. Much geographical level can the data be of public policy is focused on growth read to? Many data sets do not ‘talk’ to using the measure of gross domestic each other, and so it is very difficult to product (GDP). However, the use of GDP generate comprehensive presentations has been problematised – for example, of current health statuses, trends and within the Report by the Commission relationships. on the Measurement of Economic Performance and Social Progress.ccciv The poor quality of mental health data The has presents an opportunity to develop it been employed by governments in the with populations that are affected by Global North, including the UK’s Equality poverty and mental health. and Human Rights Commission, as a framework for promoting human rights and equality using capability theory.cccv

66 67 6. Costings

6.1 Challenges of Undertaking such as employment and leisure. By Mental Health Economic Analysis highlighting the cost burden of mental health problems for society, cost of There is a growing body of evidence illness calculations have significantly around both the costs of mental ill health raised the profile of mental health in the for society and the case for investment last decade and secured significant UK in mental health prevention and policy commitments to invest equitably provision. However, robust cost–benefit in mental health.cccvii and return on investment analysis is limited by poor-quality data (discussed The economic impacts of mental health above). Further, it is difficult for voluntary problems are wide ranging and, in and community organisations to make many cases, long lasting because of the the economic case for investment character of the condition and/or the in innovative and novel approaches lack of early and effective interventions. because of challenges involved in They are associated with ability to work, comparing the costs and benefits of personal income and the utilisation of novel approaches in their sectors with health, social care and other support interventions delivered in the public services. These impacts extend beyond sector. the individual experiencing them to encompass family members and wider Cost-effectiveness assessment can be society. Family and friends who care for used for resource allocation across the people with mental health problems may continuum of care, using effectiveness incur significant opportunity and direct measures that extend beyond health costs in doing so. The wider social and outcomes to include quality of life, economic costs to society include higher wellbeing, equity and social justice. unemployment rates, lower participation Resources can include professional, rates and higher health and social care physical, social and psychological costs. For individuals, the costs include interventions, and technological mental distress and the negative impacts treatments.cccvi of treatment – including those of medication, co-morbid physical health Cost of illness studies estimate all the conditions, stigmatisation, reduced social resource consequences associated with functioning, social isolation and reduced a particular mental health problem, self-esteem.cccviii and can calculate the use of health and social care resources, premature Economic evaluation (including cost- mortality, monetary consequences of a effectiveness analysis, cost–utility reduction in quality of life and the loss analysis and cost–benefit analysis) of ability or opportunity to earn income refers to the comparative analysis of or engage in meaningful activities alternative courses of action in terms

68 69 of both their costs and consequences. 6.2.1 Life Course: Maternal Mental cccix Funders often ask for comparisons Healthcccxii with public services from voluntary and community organisations that are The Maternal Mental Health Alliance’s47 innovating new approaches to mental Everyone’s Business campaign health support and treatment. However, commissioned the LSE Personal there are significant methodological and Social Services Research Unit and the capacity barriers to such organisations, Centre for Mental Health to undertake including cost comparisons in their an economic study into the costs of evaluations. Increasingly, there are calls perinatal mental health problems. There for government departments to invest in are NICE-recommended interventions developing accessible cost comparison for perinatal mental health. This report models that can be readily used by the creates the economic base for investing voluntary and community sectors. in NICE-recommended perinatal mental health services. 6.2 Mental Health Evidence Base Perinatal mental health problems affect up to 20% of women at some point The King’s Fund undertook a review during the perinatal period (pregnancy of evidence-based, local public health and the first year after birth). Perinatal interventions, including those for mental mental health problems can include health, and made an economic case ante- and postnatal depression, for each one. Those directly related to anxiety, psychosis, and post-traumatic mental health confirm recommendations stress disorder. In addition to the made elsewhere in this report on adverse impact on the mental health early intervention and whole-place of the woman, perinatal mental health approaches (in education, employment problems compromise the child’s and communities).cccx Health Scotland’s emotional, cognitive and physical summary of effective public mental development, with serious long-term health interventions includes economic consequences. There is a growing body evidence.cccxi A range of studies has of evidence of the adverse effects on developed a good economic case for a the mental health and wellbeing, and number of interventions that are linked economic activity, of fathers. with poverty. Urgent investigation of other promising areas is required in Bauer et al. estimated the costs of three order to establish the evidence base for major perinatal mental health problems: cost-effective intervention. depression, anxiety and psychosis

47 A coalition of over 60 organisations, including professional bodies across the UK http:// maternalmentalhealthalliance.org.uk/

68 69 (mainly bipolar and ). The average birth, compared to the current total long-term cost to society was £8.1 cost of £10,000 to society (£2,100 to billion per one-year birth cohort in the the NHS) of not providing perinatal care UK – just under £10,000 per single in line with NICE guidance. In England, birth – with nearly 75% of the cost this would equate to £280 million a year relating to the adverse impacts on the to bring perinatal care up to the level child.48 A fifth of these costs (£1.7 billion) and standard recommended in national are borne by the public sector, and £1.2 guidance, equivalent to £1.3 million extra billion by the NHS and social services. spending in an average CCG. The cost The cost of one case of perinatal to the public sector of not providing depression is £74,000 (£23,000 adequate perinatal mental healthcare is for the mother and £51,000 for the five times the cost of improving services. child); one case of anxiety is £35,000 (£21,000 for the mother and £14,000 6.2.2 Life Course: Children and Young for the child); and one case of psychosis People is £53,000 (£47,000 for the mother). Conduct Disordercccxiii Only around half of perinatal cases of About 5% of children aged 5–10 years depression and anxiety are detected, display behavioural problems that and many of those detected cases are sufficiently severe, frequent and do not receive the full level of care persistent that they justify a diagnosis recommended by national guidance. of ‘conduct disorder’. This is equivalent Across the UK, 80% of Northern Ireland, to around 30,000 children in each 70% of Wales, 40% of Scotland and one-year cohort in this age range in 40% of England have no specialist England. Boys are more than twice as perinatal care within their health and likely to be affected as girls in the 5–10 social care areas. age range (6.9% of all boys compared to 2.8% of all girls). Conduct disorder is To bring the NHS’s perinatal mental three times as common among children health provision to the level and standard from unskilled and workless households of NICE guidance would cost £400 per as among children from professional and managerial parent groups.

48 The study’s economic modelling looked at the additional costs associated with perinatal mental health conditions – that is, costs over and above those that would have been incurred anyway, such as children’s education costs. These costs included increased use of public services, losses of quality- adjusted life years (QALYs) and productivity losses (measured in 2012/13 prices), and whole-life costs for lives lost through suicide or . For outcomes for the whole family, the study costed for the public sector and society as a whole. Public sector costs covered those that fall on health, social care, education and criminal justice budgets (and included the costs of publicly funded services provided through the voluntary and private sector). Wider costs to society included productivity costs, QALY losses, costs to victims of crime, out-of-pocket expenditure and unpaid care. Costs were either short term (related to the mother during the perinatal period and linked to the child’s pre-term birth) or longer term (typically linked to the children but also the mother’s outcomes linked to long-term remission). The researchers aimed to evaluate lifetime costs, if possible, with the available data.

70 71 Taking into account the extra costs Sixty per cent of the expenditure on falling on health, social care, education parenting programmes is recovered and – from age 10 onwards – the within two years, largely through savings criminal justice system, the broad annual to health and education budgets. In cost per child with severe behavioural order to maximise participation in such disorder is £5,000 to the exchequer. programmes, it is worth investing in From a societal (rather than public measures that enable participation, such sector) perspective, the overall lifetime as free childcare and transport. costs of severe behavioural problems are around £260,000 per case. (The As the estimated number of children in lifetime costs of moderate problems each year cohort with conduct disorder are around £85,000 per case.) Crime- is 30,000, if the government were to related costs are the biggest single provide group parenting programmes to component (more than two-thirds). all of these children’s parents (at £1,270 per child) it would cost £38 million a These figures omit many costs. Bullying year. It is estimated that the societal is a common behaviour of people with benefits of parenting interventions severe behavioural problems; one study exceed their costs by 14:1 over 25 years. estimated that the lifetime earnings of The largest part of this saving would be a single victim of serious bullying are in reduced crime, but savings will also reduced by around £50,000. be accrued by schools (it costs £3,000 a year extra to teach a child with a Parenting programmes that improve conduct disorder), children’s services, the quality of parent–child relationships the NHS and other public sector and the parent’s skill in managing budgets. child behaviour are a recommended intervention. The cost per child of Parenting Programmes: Family Nurse a parenting programme is £1,300. Partnershipscccxiv The aggregate returns from early It is not possible to identify how interventions are underestimated – for much money is spent on parenting example, by the omission of benefits programmes, as this is not recorded such as benefits to parents’ and siblings’ systematically. mental health and wellbeing, and of victims of behaviours such as bullying The Family Nurse Partnership is a and criminal activity. However, the preventive programme for first- relatively low-cost and high-potential time young mothers with particular benefits mean that studies suggest vulnerabilities that provides home that bringing a child below the clinical visiting by trained nurses from early threshold as a result of a parenting pregnancy until the child is 2 years programme is around £1,750 per old. The support addresses a wide case. Every £1 invested in parenting range of issues, including child and programmes yields measurable benefits parent behaviour. The programme was to society of at least £3. developed over 30 years ago in the US and was introduced on a pilot basis

70 71 to the UK in 2007; it will be scaled to parenting programme from one study increase the overall number of families were £1,875 per child in a community- in the programme at any one time to based group parenting programme and 13,000 families in 2015. £1,315 for a clinic-based group parenting programme.cccxv This is set against the Three large, randomised controlled lifetime costs of a child with conduct trials have been conducted in the US disorder and a child with moderate and demonstrated positive results for problems £175,000 (£260,000 minus the mothers and children; longitudinal £85,000). A Cochrane evidence review data continues to be published. The estimated the cost of achieving this for Department of Health published the a child with the highest level of conduct following benefits of the Family Nurse problems at £6,650 (in 2012/13 prices), Partnership programme. meaning that lifetime costs only need to be reduced by 4% to cover the outlays • 48% reduction in verified cases of on the intervention. The Centre for and neglect by age 15; Mental Health concluded that the costs of effective intervention for conduct • 50% reduction in at disorder are very small compared to the 21 months; potential benefits.

• 67% reduction in behavioural and In its review of the cost–benefit analysis emotional problems at age 6; of parenting programmes from both societal and (narrower) public sector • 28% reduction in anxiety and perspectives, the Centre for Mental depression at age 12; Health stressed the importance of retaining fidelity to the programme in • 67% reduction in use of cigarettes, order to gain full benefit, and made the alcohol and marijuana at age 15; and case for resourcing additional supports – such as childcare and travel – to reduce • 59% reduction in arrests by age 15. drop-out. Further research is required to provide a more comprehensive picture Benefits to the mothers include of the long-term benefits of programmes, increased employment, reduced welfare the benefits of programmes to third dependency and reduced offending (61% parties, and the impact of programmes fewer arrests and 72% fewer convictions being scaled up, embedded in service among mothers by the time children systems and transferred to other were age 15). populations. However, the evidence base for certain programmes is already strong. Using a threshold analysis to assess the minimum level of effectiveness needed Conducting cost–benefit analysis for a programme to pass a value for is challenging, as most evaluations money test, illustrative costings for have not collected economic data; bringing a child with conduct disorder characteristically, the benefits of below a clinical cut-off as a result of a programmes accrue over long periods

72 73 and to a wide range of public sector • The development of students’ agencies, and many of the benefits emotional health and social skills of the programmes are not included supports the development of healthy – particularly third-party benefits adults. School-wide anti-bullying (to parents, siblings, and victims of programmes can return almost bullying and crimes). The ‘Building a £15 for every £1 invested through better future’ report provides a detailed higher earnings, productivity and discussion of the economic modelling public sector revenue,cccxvii and conducted on parenting programmes, interventions to address emotional- drawing on UK and US studies, which based learning problems paid for could inform future evaluation design. themselves in the first year through reduced costs to the public sector Within current financial constraints, (social service, NHS and criminal funders may choose to target these justice) and recouped £50 for every programmes. In the case of Family Nurse £1 spent over five years.cccxviii Partnerships, targeting could be towards families where there are risk factors, • School-based behaviour change such as parental mental health problems, programmes are very cost-effective alcohol and drug misuse, family discord in terms of long-term returns. For or domestic abuse. For parenting every £1 spent on contraception to programmes more generally, this could prevent , £11 is be for families where children are saved through fewer terminations displaying severe behavioural problems and savings on antenatal and or where there is one or more adverse maternity care, highlighting the childhood experiences (as discussed in value of sex education within section 3.1). schools.cccxix

Whole-School Approaches Data is not collected on how many The economic evidence reviewed by The schools have adopted a whole-school King’s Fund made the following business approach or components of this case: approach. The challenge of identifying how many schools use a whole-school • Supporting and challenging schools approach is illustrated by a study to achieve social, emotional and commissioned by the Department of health outcomes and to support Education for Northern Ireland, which children to make healthy lifestyle found that fewer than one in five post- choices delivers significant primary schools that responded to a individual, societal and public sector survey used audit tools to measure benefits. Lleras and Culter estimated activity across five domains of whole- the overall health benefits of a good school approaches: school policies, education to provide returns of up school practices, use of established to £7.20 for every £1 invested.cccxvi programmes, school provision for pupils and school provision for teachers.cccxx

72 73 6.2.3 Life Course: Working Age • prevention of mental health problems through workplace Whole Workplace Approachcccxxi conditions and processes; Mental health problems cost the UK economy £26 billion per year – that • better access to help for employees is £1,035 per employee in the UK – particularly with regard to workforce. This figure covers the psychological health; and following costs: • effective rehabilitation. • £8.46 billion sickness absence (seven days of sick leave is the IPS average per worker each year and The IPS approach is an established and 40% of these are reported as mental evaluated model for supporting people health related, accounting for 70 with mental health problems getting million lost working days per year, into work. It is described in more detail including one in seven lost days in section 4.5.2, and case studies from directly caused by the person’s work IPS centres of excellence illustrate its or working conditions). operation.49 The EQOLISEcccxxiii project compared IPS with other vocational/ • £15.1 billion lost productivity rehabilitation services in six European (presenteeism costs 1.5 times countries. It concluded that: as much as working time lost to absenteeism and is more expensive, • IPS clients were twice as likely to as it is more common among senior gain employment (55% versus 28%) staff). and IPS worked for significantly longer than those using other • £2.4 billion replacing staff that leave interventions (which achieve, at due to mental ill health. best, 20–30%);

The whole-workplace approach • the total costs for IPS were generally discussed in this paper includes a wide lower than standard services over range of activities that are supported the first six months; by 2009 NICE guidance and the ‘Promoting mental wellbeing at work’ • clients who had worked for at least a care pathway, and 2015 ‘Workplace month in the previous five years had Health: policy and management better outcomes; and practices’ guidance.cccxxii The Centre for Mental Health assessed that 30%, or £8 • individuals who gained employment billion per year, could be saved through had reduced hospitalisation rates. the following measures: (NICE estimates that supported employed has a QALY of £5,723.) • awareness training for line managers;

49 http://www.centreformentalhealth.org.uk/ips-centres-of-excellence

74 75 Over time, a third of IPS participants estimate is that 10,000–20,000 become regular workers (that is, mostly people benefit (within secondary mental in full-time, sustained employment), a health services). The Centre for Mental third become occasional workers, and Health recommended that everyone a third do not get work. Data about have access to IPS, and called for the earnings was not identifiable. coverage of IPS to double in England to The Centre for Mental Health has reach 40,000 people. outlined the following business case for investment in IPS, stressing the Health: Co-Morbiditiescccxxvi importance of compliance with the IPS Co-morbid mental health problems raise Fidelity Scale.cccxxiv To implement IPS at total healthcare costs by at least 45% the level of provision recommended in (with some studies putting the figure government commissioning guidance at 75%) for each person with a long- would cost around £67 million per year term condition and co-morbid mental in England. This compares with current health problem. This analysis suggests spending on day and employment that between 12% and 18% of all NHS services at £184 million per year, and expenditure on long-term conditions implies that IPS could be implemented is linked to poor mental health and within existing provision but through wellbeing – between £8 billion and diverting resources from less effective £13 billion in England each year (using services. The evidence base and cost 2010 Department of Health figures for implementing the IPS approach is showing that around 70% of total health contextualised by the issues with the spending is on long-term conditions, and Work Programme (discussed in section subtracting for expenditure on research 4.6), including ongoing difficulties in and training). The lower figure equates reaching people with mental health to £1 in every £8 spent on long-term problems. conditions. The presence of poor mental health increases the average cost of Official commissioning guidance NHS service use by each person with a on vocational services for people long-term condition from approximately with severe mental health problems £3,910 to £5,670 a year (using the more recommends caseloads per employment conservative 45% estimate for excess specialist of up to 25 people at any one costs). International research suggests time.cccxxv In broad terms, the cost of that these excess costs are mainly an employment specialist (including associated with people who have severe overheads and support) is thus in the long-term conditions or multiple co- range of £45,000–50,000 a year, and morbidities. recommended caseloads are in the range of 20–25. These figures confirm that As discussed in section 4.2.1, co- an estimate of £2,000 a year per IPS morbid mental health problems costs place is broadly appropriate for financial are incurred through care for their planning purposes. physical health problems – that is, Although it is not known how many increased service use and additional people are currently receiving IPS, the health service costs (accident and

74 75 , primary care, pharmacy, upfront cost);cccxxvii and a Cognitive laboratory, x-ray inpatient, outpatient Behavioural Therapy-based and pharmaceutical). There are wider programme for angina reduced economic costs, including people being hospital admissions and saved unable to work, reduced productivity £1,337 per person.cccxxviii,cccxxix or increased absence at work, and the economic impact on family members Criminal Justice: Liaison and Diversion who provide informal care and support. The Centre for Mental Health has summarised the business case for liaison Based on this evidence, section 7 and diversion for both children and outlines a number of actions regarding young people, and adults within the preventative health checks and criminal justice system. It comments integrated care pathways for people that, although initial upfront investment with co-morbid mental health problems. is required to establish dedicated liaison In their economic analysis, Naylor et al. and diversion teams located in police found that: stations and courts, most, if not all, of these direct costs would be covered by • collaborative care50 arrangements short-term cost savings in the criminal between primary care and mental justice system.cccxxx health specialists can improve outcomes with no, or limited, The Centre for Mental Health outlines additional net costs; the cost comparisons of custodial and community sentences. A • innovative liaison psychiatry typical six-week stay in prison costs approaches that provide support for about £5,000 per case. In comparison, co-morbid mental health needs can a typical one-year community order reduce physical healthcare costs in involving probation supervision and acute hospitals; and drug treatment costs £1,400. A highly intensive two-year community • illustrative examples of savings order, involving twice-weekly contact from integrating mental health with a probation officer, 80 hours support into chronic disease of unpaid work and mandatory management are that: introducing completion of accredited anti-offending a psychological component into a programmes, costs less than six weeks in Chronic Obstructive Pulmonary prison, at £4,200.cccxxxi Disease breathlessness clinic reduced accident and emergency It notes that well-designed interventions presentations and hospital bed can reduce reoffending by 30% or days, and yielded savings of £837 more. The economic and social cost per person (around four times the of crime committed by recently

50 Collaborative care is a NICE-recommended approach for supporting people with long-term conditions and co-morbid depression in primary care (2009). https://www.nice.org.uk/guidance/cg90/ chapter/guidance

76 77 released prisoners serving short • prevented homelessness (costed in sentences amounts to £7–10 billion a the range of £24,000–30,000 per year. Much of this cost falls directly on year to the public sector, including the victims of crime, but 20–30% is the NHS); and borne by the public sector – mainly the criminal justice system and NHS. The • prevented relapse (using the total lifetime cost of crime committed example of schizophrenia with a by an average offender following release probability of relapse of 40% a year from prison is in the order of £250,000. – a cost of £18,000 per episode). cccxxxii Parsonage notes that the about one Liaison and diversion should be available million adults of working age are in all police stations and courts. It would seen by secondary mental health appear that liaison and diversion teams services, and the average annual cost tend to identify needs, including mental of mental healthcare for this group is health and learning disability-related £6,600 per head. He recognises the needs, in about 10% of people who come significant variation around this figure through the criminal justice system. – for example, only about 7% of people receiving secondary mental healthcare Advice: Specialist Provision in spend any time in hospital during the Secondary Mental Health Services course of a year, but, for those who, do The business case for investing in the average cost of inpatient care is welfare advice for people who use £23,000. mental health services was set out in a 2013 Centre for Mental Health study. In addition to reducing health and social cccxxxiii Parsonage analysed the work of care costs, specialist welfare rights the Sheffield Mental Health Citizens advice increased the numbers of people Advice Bureau, which is based in a with mental health problems who are hospital’s grounds and supports about claiming entitlements and receiving 600 people with a diagnosis of a severe the correct amount of entitlement. mental illness throughout the city each Parsonage quoted one study in which year. Just under half of these are seen claimants with mental health problems as inpatients, with the remainder living who were under-claiming, and who in community settings. This is one of accepted assistance following a benefits two such services in England specifically assessment, received an average dedicated to the advice needs of people additional income of £4,000 per year with a diagnosis of a severe mental (in 2013 prices).cccxxxiv illness. The average cost of advice per client was £260 per year.

The study found that specialist welfare advice:

• reduced the inpatient lengths of stay (costed at £330 per day);

76 77 7. Recommendations

Recommendations are made in seven • Implement the ROAMER mental areas: health research agenda with a specific programme on mental • regarding cross-cutting agendas health and poverty. of data and research, stigma and discrimination, and MHiAP; • This work can be informed by the ten-year mental health research • at life course stages: perinatal, early strategy to be developed in England years, children and young people; by 2017. working age; and in later life; and • Undertake a systematic review on • across all stages of the life course. mental health, poverty and social care. 7.1 Investment in Data and Research • Undertake a systematic review on • Develop a UK mental health and mental health, poverty and later life. poverty data plan that addresses data development, intelligence and 7.2 Stigma and Discrimination dissemination, ensuring that this data: • Integrate anti-stigma interventions ▫▫ can be disaggregated by around mental health and poverty demographic characteristics under using social contact approaches equality legislation and compared within current anti-stigma across the UK; and campaigns and initiatives. ▫▫ provides information on mental health service provision across 7.3 Mental Health in All Policies the life course with regards to • Include poverty in MHiAP funding, activity, and access to and frameworks. quality of care across all types of providers, disaggregated into types • Improve planning of the built of health and social care services, environment by including mental and drilled down to service health in all renewal, regeneration, provision areas that reflect the and sustainable development within arrangements for health and social disadvantaged communities. care in England, Scotland, Wales and Northern Ireland. This work can be informed by the development of a five-year data plan in England.

78 79 7.4 Life Course Stages and share this approach with policy-makers in Scotland, Wales 7.4.1 Perinatal, Early Years, Children and and Northern Ireland to inform the Young People development of their mental health strategies. The following work can be informed by the work of the Oversight Boards for • Implement the whole-school both ‘Future in Mind’ and ‘The Five Year approach informed by NICE and Forward View for Mental Health’. Ofsted guidance for schools in disadvantaged communities, with • Implement the NICE perinatal care a particular emphasis on engaging pathway across the UK. parents and caregivers in the school- based mental health and wellbeing This work can be informed by the programmes, and provide targeted implementation of the Five Year Forward supports for children who are at a View for Mental Health target to support high risk of developing mental health 30,000 more women each year to problems or who are experiencing access evidence-based specialist mental mental distress – particularly healthcare during the perinatal period by children with multiple mental health 2020/21. problems, with moderate and severe behavioural problems and those • Provide access to Family Nurse diagnosed with conduct disorders. Partnerships for low-income families. • Include mental health in assessments • Fund evidence-based programmes of needs and support planning for that encourage positive parenting children who are outside of the for parents in disadvantaged areas education system – particularly delivered in community settings, children who have experienced including schools. multiple adverse experiences – for example, homeless children, young • Fund evidence-based parenting offenders, looked-after children, programmes for families whose members of the Gypsy and Traveller members have existing mental communities, and refugee and health problems, particularly: asylum-seeking children. ▫▫ families in which a child has moderate or severe behavioural 7.4.2 Working Age problems; and ▫▫ families in which a parent has a • Develop a national programme mental health problem. of IPS to support people who have experienced mental health • In England, implement the ‘Future in problems in gaining and sustaining Mind’ and ‘Five Year Forward View employment. for Mental Health’ recommendations for vulnerable children, including children from low-income families,

78 79 • Promote the adoption of whole- ▫▫ undertaking a national benefit workplace approaches in all sectors, take-up programme tailored informed by NICE guidance, to people with mental health including: problems; ▫▫ promoting the Access to Work ▫▫ positive human resource and programme for claimants with business policies that support mental health problems, informed the recruitment, retention and by the proposals of the UK promotion of people with mental MHWRG; and health problems and their family members; ▫▫ undertaking a fundamental reform of the Work Programme to develop ▫▫ training for line managers to a tailored programme for claimants identify risks/signs of mental with mental health problems, distress and to intervene early informed by the proposals of the through the use of reasonable UK MHWRG. accommodations and referral to employee assistance programmes and workplace counselling; This work can be informed by the implementation of the Five Year ▫▫ mental health and wellbeing Forward View for Mental Health activities; and recommendations around the tendering ▫▫ use of Access to Work, Fit for Work of the Work Programme, and DWP and IPS programmes. investment in qualified employment advisers who are fully integrated into • Develop mental health guidance expanded psychological therapies and support for owner-managers services. and employees in SMEs, including

access to occupational health and • Improve the DWP’s customer employee assistance schemes. service to people with mental health problems by: This work can be informed by the implementation of the Five Year Forward ▫▫ providing regular mental health View for Mental Health target: that, training to all frontline workers by 2020/21, each year up to 29,000 involved in each stage of the social people living with mental health security process; problems should be supported to find or stay in work through increasing access ▫▫ regularly reviewing and to psychological therapies for common strengthening guidance on mental health problems and expanding vulnerable claimants and audit access to IPS. adherence by DWP staff and contractors; and • Increase the use of social security ▫▫ providing claimants with benefits and programmes by people comprehensive and accessible with mental health problems by: information about what the claim

80 81 process will involve and their rights • Develop a national programme of with regard to information and social prescribing within primary support. care services in disadvantaged communities. • Improve access to advice on social security and wider rights • Provide lifelong learning by providing advice services with opportunities for people whose mental health trained staff in health education, training and entry into and social care settings (including or continuance in employment has secondary mental health services) been disrupted by mental health and in disadvantaged communities. problems.

7.4.3 Later Life • Develop integrated care pathways for children and adults who have • Scale and test evidence-based co- and multiple morbidities (both programmes that provide people with mental health problems opportunities for older people in who develop physical health disadvantaged communities to problems and people with long- participate in social and cultural term physical health conditions who networks and activities, and reduce develop mental health problems). their experience of isolation – particularly at key transitions and This work can be informed by the pressure points in later life, such implementation of the Five Year Forward as redundancy, retirement, caring, View for Mental Health target: that bereavement and moving home. at least 280,000 people living with severe mental health problems should • Screen for mental health problems have their physical health needs met by (particularly depression and 2020/21; its recommendation that the dementia) in primary care services Cabinet Office ensures that recipients within disadvantaged areas and of Life Chances Funding demonstrate provide early intervention support. how they will integrate assessment, care and support for people with co- 7.5 Across the Life Course morbid substance misuse and mental health problems, and be clear about the Establish accessible, integrated public funding contribution required from local service hubs in deprived communities commissioners; and its recommendation that deliver evidence-based that the increased investment to provide interventions across the life course – integrated evidence-based psychological particularly at transition and pressure therapies – for an additional 600,000 points to those individuals, families adults with anxiety and depression and groups who are most at risk of each by 2020/21 (resulting in at least developing mental health problems. 350,000 completing treatment) – should focus on people living with long- term physical health conditions.

80 81 • Develop a national programme of liaison and diversion available to all police stations and courts.

This work can be informed by the implementation of the Five Year Forward View for Mental Health recommendation for a national rollout of liaison and diversion (including for children and young people) by 2020/22, the increased uptake of Mental Health Treatment Requirements, and the development of a complete health and justice pathway.

• Scale and test the development of psychosocially informed environments in services for people with complex needs.

82 83 8. Methodology

This review asked the following question: Step 1: Search for high-quality reviews. Identify areas in which no such What public policies51 or services52 have evidence exists. been evidenced to effectively address mental health and poverty experienced Step 2: Search for other evidence (grey by children and adults53 through: literature, unpublished reports). Identify areas in which no such • preventing people in/experiencing evidence exists. poverty 54 from developing mental health problems; Step 3: Map the evidence into categories and select the best quality and • supporting people people in/ most recent studies for inclusion. experiencing poverty with mental health problems to recover; Due to time and resource restrictions, the identified research and policy • preventing people with mental literature was not systematically health problems from becoming reviewed. Therefore, it is important to poor; and distinguish this paper from the evidence papers that JRF commissioned to inform • supporting people in/experiencing the development of its UK Anti-Poverty poverty with mental health problems Strategy. Through the writing process, to move out of poverty? additional documents were identified in order to strengthen aspects of the paper. It identified evidence using an amended version of the Mental Health Although the focus of the review is Foundation’s Stepwise approach to the UK, current literature in English searching for research evidence. from the European region and other

51 national and international 52 health, social care, education, employment, social security and advice 53 including those with complex needs 54 including individuals, families and communities

82 83 countries (New Zealand, Australia, the US and ) was also included. The transferability of the findings from the literature to the UK context was assessed by considering whether similar contextual circumstances and factors relevant to the paper exist in UK society.55

Step 1: Search for high-quality reviews Relevant databases56 were searched to identify meta-reviews (systematic reviews, meta-analyses, synthesis, literature reviews, etc.) using the strategy outlined in Table A.

Table A: Search Strategy – Meta-Reviews

# Search History (“mental health” or “mental ill*” or “distress” or “psycholog*” or “emotion*”) 1 AND (“poverty”) AND (“review” or “synthesis” or “meta-analysis”) Date range: 2010–2015 Limited to: articles, English only

2 (“mental health” or “mental ill*” or “distress” or “psycholog*” or “emotion*”) OR (“poverty”) AND (“review” or “synthesis” or “meta-analysis”) AND (“criminal justice” or “homelessness” or “substance misuse” or “alcohol misuse”)

3 (“mental health” or “mental ill*” or “distress” or “psycholog*” or “emotion*”) OR (“poverty”) AND (“review” or “synthesis” or “meta-analysis”) AND (“health” or “social care” or “education” or “employment” or “social security” or “advice”)

55 These include cultural characteristics of the population; socio-economic status, geographical context; and current policies, service structures and interventions (and, if not, is there opportunity for innovation?). 56 ASSIA, Barbour Index, CINAHL, Cochrane Library, EMBASE, Emerald, Health Business Fulltext , OVID databases (includes Medline), RefWorks, Transfusion Evidence Library, TRIP: Turning Research Into Practice, Web of Science, EBSCO PsycINFO, WHO Health Evidence Network, Wiley CCTR, Wiley CDSR

84 85 An initial screening by title was care, and a recommendation is made to performed online, and references undertake a systematic review of the were then downloaded into EndNote literature around poverty, mental health bibliographic software and screened by and social care. abstract. Step 2: Search for other evidence After some databases that were In addition to searching for peer- expected to provide results did not, reviewed published literature, a quality check was undertaken by the following internet search was screening for abstracts on these undertaken in order to identify grey databases in order to identify any literature. additional papers missed in the initial title/keyword search. Free Text Search A free text internet search for grey A quality control check was conducted literature using the Google search engine by two Mental Health Foundation was conducted. A set of unique searches staff on a random sample (5%) of the using combinations of terms relating to titles; disagreements in selections were poverty and mental health was used to negotiated and a final list of included recover reports and documents relating references agreed. to social policies and organisations (alliances, coalitions and networks) Following these initial screenings by title working in this area. Due to the large and abstract, and the cross-checking number of returns using this approach, of selections, the full papers of the only the first ten pages of each search references selected as a result of the were scanned. screening were sourced and a final relevance check was made, enabling the Search one: review team to arrive at a final selection “mental health” AND “poverty” AND of papers. (“UK” or “England” or “Scotland” or “Wales” or “Northern Ireland” or All excluded studies from the abstract “Europe” or “Canada” or “USA” or screening stage were recorded and “Australia” or “New Zealand”) the reasons for exclusion noted. These Search two: results are summarised in a QUOROM (“mental health” or “poverty”) statement below. AND “health”

The final selection of articles was Search three: mapped into categories and particular (“mental health” or “poverty”) attention paid to identifying areas AND “social care” where gaps in the evidence emerge. It Search four: was not possible to address these gaps (“mental health” or “poverty”) by searching for primary studies due AND “education” to time and resource constraints. The most significant gap was around social Search five: (“mental health” or “poverty”)

84 85 AND “employment” Contingency Plans Where there were high-quality reviews Search six: in a particular area – for example, a (“mental health” or “poverty”) stage of the life course, protected AND “social security” characteristics and public service – the Search seven: results were synthesised and no further (“mental health” or “poverty”) searches were conducted in that area. AND “advice” The remaining gaps in the evidence Search eight: were noted but given time restrictions. (“mental health” or “poverty”) There was no search for primary studies. AND (“criminal justice” or Particular attention was paid to evidence “homelessness” or “substance misuse” or in areas of particular interest to the “alcohol misuse”) review, such as:

Search nine: • stages of the life course; (“mental health” and “poverty”) AND “strategy” • protected characteristics (intersecting with poverty); and Search of Relevant Websites The websites of up to 25 key • social policies relating to specific organisations identified in the internet public services: health, social care, search were scanned for relevant education, employment, social publications/reports. security and advice.

Finally, the reference lists and In order to produce a high-quality bibliographies included in the review (within the time and resource documents retrieved through Steps limitations), it was necessary to take a 1 and 2 were scanned for additional pragmatic approach to the synthesis of publications. the search results. If there were more than a manageable number of relevant Step 3: Map evidence into categories reviews, these were mapped into and select the best quality and most categories/topic areas of evidence, and, recent texts for inclusion where there were several papers related Following the completion for the to the same topic, the more recent and search phase, data was extracted from highest quality studies were selected for databases using Excel templates (one final inclusion in the review. Excluded for peer-reviewed published (Step 1) and studies were retained in iterations of the one for grey (Step 2) literature). After EndNote software. screening and mapping, the literature was subjected to quality assessment according to explicit criteria, which included methodological quality.

86 87 QUOROM statement

Initial search for reviews: N=669

First screening by title Initial Google free text search and search of key organisations’ websites: Reviews selected: N=137 N=115

Screening by abstract Screening by abstract

Reviews selected: N=56 Papers selected: N=61

Papers mapped then full text retrieved Papers mapped then full text retrieved and data extracted to exclude papers and data extracted to exclude papers not meeting inclusion or quality not meeting inclusion or quality criteria criteria Total peer reviewed papers selected: Total papers selected: N=56 N=22

Total number of documents reviewed: N=76

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94 95 Glossary

Mental health and that individual’s contextual factors (environmental and personal). “is conceptualized as a state of well- (WHO (2011) ‘World Report on being in which the individual realizes Disability’ in WHO (2013) Mental Health his or her own abilities, can cope with Action Plan 2013–2020. p. 38) the normal stresses of life, can work productively and fruitfully, and is able Poverty to make a contribution to his or her community. With respect to children, an is “When a person’s resources (mainly emphasis is placed in the developmental their material resources) are not aspects, for instance, having a positive sufficient to meet their minimum needs sense of identity, the ability to manage (including social participation).” thoughts, emotions, as well as to build (Goulden, C. and D’Arcy, C. (2014) social relationships, and the aptitude An explanation of JRF’s definition of to learn and acquire an education, poverty and the terms used in it. York: ultimately enabling their full active Joseph Rowntree Foundation. p. 3) participation in society.” (WHO (2013) Mental Health Action Plan Psychosocial disabilities 2013–2020. p. 6) refers to people who have received a Mental Disorders mental health diagnosis, and who have experienced negative social factors, “is used to denote a range of mental and including stigma, discrimination behavioural disorders that fall within the and exclusion; people living with International Statistical Classification of psychosocial disabilities, including ex- and Related Health Problems, and current users of mental healthcare Tenth Revision (ICD-10)”. Although the services; and people that identify psychiatric classification system, DSM, themselves as survivors of these services is more commonly used in the UK, the or with the psychosocial disability itself. human rights grounded global disability (Drew, N. et al. (2011) ‘Human rights movement uses ICD-10. violations of people with mental and (WHO (2013) Mental Health Action Plan psychosocial disabilities: an unresolved 2013-2020. p. 6) global crisis’ The Lancet, 378(9803), pp. 1664–75. In WHO (2013) Mental Health Disability Action Plan 2013–2020. p. 39) is an umbrella term for impairments, Recovery activity limitations and participation restrictions, denoting the negative means gaining and retaining hope, aspects of the interaction between understanding of ones abilities and an individual (with a health condition) disabilities, engagement in an active

96 97 life, personal autonomy, social identity, • stigma and discrimination; meaning and purpose in life, and a positive sense of self. Recovery is not • violence and abuse; synonymous with cure. Recovery refers to both internal conditions experienced • restrictions in exercising civil and by people who describe themselves political rights; as being in recovery – hope, healing, empowerment and connection – and • exclusion from participating fully in external conditions that facilitate society; recovery – implementation of human rights, a positive culture of healing, and • reduced access to health and social recovery-orientated services. services; (WHO (2012) ‘QualityRights Tool Kit: assessing and improving quality and • reduced access to emergency relief human rights in mental health and social services; care facilities’. In WHO (2013) Glossary of Main Terms. p. 39) • lack of education opportunities;

Public Mental Health • exclusion from income generation and employment opportunities; is “The art and science of promoting mental well-being and equality and • increased disability and premature preventing mental ill health through death.” population-based interventions to: reduce risk and promote protective, (WHO (2010) ‘Mental Health and evidence-based interventions to Development Report’ in WHO (2013) improve physical and mental well- Mental Health Action Plan 2013–2020. being; and create flourishing, connected p.40) individuals, families and communities.’ (Department of Health (2011) No Health Without Mental Health.)

Vulnerable Groups

“Certain groups have an elevated risk of developing mental disorders. This vulnerability is brought about by societal factors and the environments in which they live. Vulnerable groups in society will differ across countries, but in general they share common challenges related to their social and economic status, social supports, and living conditions, including:

96 97 i Health & Social Care Information Centre xiii Breedvelt, J. (February 2016) Psychologically (2009) ‘Adult psychiatric morbidity in Informed Environments: a literature review. England: Results of a household survey’ cited London: Mental Health Foundation and St in Mental Health Foundation (2015) The Mungo’s Fundamental Facts. http://www.mentalhealth. xiv World Health Organization and Calouste org.uk/content/assets/PDF/publications/ Gulbenkian Foundation (2014) Social fundamental-facts-15-exec-summ. Determinants of Mental Health. Available pdf?view=Standard at: http://www.who.int/mental_health/ ii MacInnes, T. et al. (November 2015) publications/gulbenkian_paper_social_ Monitoring Poverty and Social Exclusion. determinants_of_mental_health/en/ https://www.jrf.org.uk/mpse-2015/mental- [Accessed 18 October 2015] health xv The Scottish Government and Health Action iii Health & Social Care Information Centre Partnership International (16 January 2012) (2009) in Mental Health Foundation Working for Equity in Health. The role of work, (October 2015) Fundamental Facts About worklessness and social protection in health Mental Health 2015. London: Mental Health inequalities. Context, situation analysis and Foundation evidence review. Edinburgh: The Scottish Government iv Fell, B. and Hewstone, M. (June 2015) Psychological Perspectives on Poverty. xvi Elliott, E. et al. (November 2010) Working Available at: https://www.jrf.org.uk/report/ Paper 134: The Impact of the Economic psychological-perspectives-poverty Downturn on Health in Wales: A Review and [Accessed 18 October 2015] Case Study. University of Cardiff: Cardiff School of Social Sciences. Available at: http:// v World Health Organization and Calouste www.cardiff.ac.uk/socsi/research/publications/ Gulbenkian Foundation (2014) Social workingpapers/paper-134.html [Accessed 18 Determinants of Mental Health. Available October 2015] at: http://www.who.int/mental_health/ publications/gulbenkian_paper_social_ xvii Royal College of Psychiatrists, Mental Health determinants_of_mental_health/en/ Network of NHS Confederation and London [Accessed 18 October 2015] School of Economics (2009) in Mental Health Commission (September 2011) The vi Mental Health Foundation (September 2013) Human Cost. An Overview of the evidence on Starting Today: The Future of Mental Health economic adversity and mental health and Services. Final Inquiry Report. London: Mental recommendations for action. Dublin: Mental Health Foundation Health Commission vii Hutchinson, Page, and Sample (2014) xviii Elliott, E. et al. (November 2010) Working and Herman, J. (1997) in Breedvelt, J. Paper 134: The Impact of the Economic (February 2016) Psychologically Informed Downturn on Health in Wales: A Review and Environments: a literature review. London: Case Study. University of Cardiff: Cardiff Mental Health Foundation and St Mungo’s School of Social Sciences. Available at: http:// viii Keats et al. (2012) in ibid www.cardiff.ac.uk/socsi/research/publications/ workingpapers/paper-134.html [Accessed 18 ix Cockersall (2011) in ibid October 2015] x Hopper, E. K., Bassuk, E. L. and Olivet, J. xix ibid (2010) ‘Shelter from the Storm: Trauma- Informed Care in Homelessness Services xx ibid Settings’. The Open Health Services and xxi Stuckler et al. (2011) In Mental Health Policy Journal, 3, pp. 80–100 Commission (September 2011) The Human xi Fitzpatrick, S., Johnston, S. and White, M. Cost. An overview of the evidence on (2011) ‘Multiple Exclusion Homelessness in economic adversity and mental health and the UK: Key patterns and Intersections’ Social recommendations for action. Dublin: Mental Policy & Society, 10(4), pp. 501–12 Health Commission xii Fitzpatrick, S. et al. (2011); Bramley et al. xxii Government Office for Science (October (2015) in Breedvelt, J. (February 2016) 2008) Mental Capital and wellbeing: Making Psychologically Informed Environments: a the most of ourselves in the . literature review. London: Mental Health Available at: https://www.gov.uk/government/ Foundation and St Mungo’s publications/mental-capital-and-wellbeing- making-the-most-of-ourselves-in-the-21st- century [Accessed 18 October 2015]

98 99 xxiii Friedli, L. (2009) Mental Health, resilience xxxvii Mental Health Foundation (2009) in and inequalities. Copenhagen: World Health Sustainable Development Commission Organization Europe (February 2010) Sustainable development: The key to tackling health inequalities. xxiv World Health Organization (2013) Mental London: Sustainable Development Health Action Plan 2013–2020. http://www. Commission. p. 29 who.int/mental_health/publications/action_ plan/en/ xxxviii Goulden, C. and D’Arcy, C. (2014) An explanation of JRF’s definition of poverty and xxv World Health Organization Europe (2013) the terms used in it. York: Joseph Rowntree Review of social determinants and the Foundation health divide in the WHO European Region: executive summary. Copenhagen: World xxxix World Health Organization and Calouste Health Organization Europe Gulbenkian Foundation (2014) Social Determinants of Mental Health. Available xxvi Wykes, T. et al. (2015) ROAMER: A Roadmap at: http://www.who.int/mental_health/ for Mental Health and Well-being Research in publications/gulbenkian_paper_social_ Europe. Available at: http://www.roamer-mh. determinants_of_mental_health/en/ org [Accessed 18 October 2015] [Accessed 18 October 2015] xxvii Department of Health (2011) in Naylor, C. et xl World Health Organization (2013) Mental al. (February 2013) Long-term conditions and Health Action Plan 2013–2020. http://www. mental health. The cost of co-morbidities. who.int/mental_health/publications/action_ London: The King’s Fund and Centre for plan/en/. p. 7 Mental Health xli Goldie, I. (2015) ‘No time like the present’. In xxviii Dorman (2015) in Gilburt, H. (November Crepaz-Keay, D. (ed.) (2015) Mental Health 2015) Mental Health Under Pressure. London: today…And Tomorrow: Exploring current and The King’s Fund future trends in mental health. pp. 3–16 xxix Gilburt, H. (November 2015) Mental Health xlii Tunstall et al. (2015) ‘Difficult Life Events, Under Pressure. London: The King’s Fund Selective Migration – Spatial Inequalities in xxx MQ (April 2015) Mental Health Research Mental Health in the UK’. PLOS ONE, 10(5): Funding Landscape Report. London: MQ e0126567. Doi:10.1371/journal.pone.0126567. Available at: http://www.plosone.org/article/ xxxi Lawton-Smith, S. (2015) ‘The future for fetchObject.action?uri=info:doi/10.1371/ mental health services: some possibilities’. In journal.pone.0126567&representation=PDF Crepaz-Keay, D. (ed.) (2015) Mental Health [Accessed 15 November 2015] Today…And Tomorrow: Exploring current and future trends in mental health. Hove: Pavilion xliii Patel and Jane-Lopis (2005) in O’Shea, E. Publishing. pp. 105–16 and Kennelly, B. (2008) The Economics of Mental Health Care in Ireland. Dublin: Mental xxxii World Health Organization (2013) Mental Health Commission Health Action Plan 2013–2020. http://www. who.int/mental_health/publications/action_ xliv Palmer et al. (2003) in ibid plan/en/ xlv O’Shea, E. and Kennelly, B. (2008) The xxxiii http://www.fph.org.uk/uploads/APPG_on_ Economics of Mental Health Care in Ireland. Health_in_All_Policies_inquiry_into_child_ Dublin: Mental Health Commission. p. 16 poverty_and_health_2.pdf xlvi Fryers et al. (2005) in World Health xxxiv Goulden, C. and D’Arcy, C. (2014) An Organization and Calouste Gulbenkian explanation of JRF’s definition of poverty and Foundation (2014) Social Determinants of the terms used in it. York: Joseph Rowntree Mental Health. Available at: http://www.who. Foundation int/mental_health/publications/gulbenkian_ paper_social_determinants_of_mental_health/ xxxv World Health Organization Europe (2013) en/ [Accessed 18 October 2015] Review of social determinants and the health divide in the WHO European Region: xlvii McNamus et al. (2007) in ibid executive summary. Copenhagen: World xlviii Lemstra et al. (2008) in ibid Health Organization Europe. p. 6 xlix Kelly et al. (2011) in ibid xxxvi Centre for Social Justice (February 2011) Mental Health: Poverty, Ethnicity and Family Breakdown. London: The Centre for Social Justice

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100 101 lxxvii Department of Health and Children (2015) xc Bell, Donkin and Marmot (2013) in World Future in Mind – promoting, protecting and Health Organization (2014) and World Health improving our children and young people’s Organization and Calouste Gulbenkian mental health and wellbeing. London: Foundation (2014) Social Determinants of Department of Health Mental Health. Available at: http://www.who. int/mental_health/publications/gulbenkian_ lxxviii Jolley, R. (ed.) (2011) Thinking Ahead: Why we paper_social_determinants_of_mental_health/ need to improve children’s mental health and en/ [Accessed 18 October 2015] wellbeing. London: Faculty of Public Health xci Fryers and Brugha (2013) in ibid lxxix Division for Social Policy and Development, Department of Economic and Social Affairs xcii Taylor (2010); Shonkoff, Boyce and McEwen (2014) Mental Health Matters: Social (2009); Mikulincer and Shaver (2012) in ibid inclusion of youth with mental health xciii Taylor (2010) in ibid problems. New York: United Nations xciv World Health Organization (2013) ‘Review of lxxx National Equality Panel (2010) An Anatomy social determinants and the health divide in of Economic Inequality in the UK. Report the ’ in ibid of the National Equality Panel. London: Government Equalities Office. p. 398 xcv Fell, B. and Hewstone, M. (June 2015) Psychological Perspectives on Poverty. lxxxi The King’s Fund (2013) Improving the public’s Available at: https://www.jrf.org.uk/report/ health. A resource for local authorities. psychological-perspectives-poverty London: The King’s Fund [Accessed 18 October 2015] lxxxii HM Government (2010) No health without xcvi Taylor (2010) in World Health Organization mental health: A cross-government mental and Calouste Gulbenkian Foundation (2014) health outcomes strategy for people of all Social Determinants of Mental Health. ages. London: the Stationery Office Available at: http://www.who.int/mental_ lxxxiii Parsonage, M., Khan, L. and Saunders, health/publications/gulbenkian_paper_ A. (November 2015) Building a Better social_determinants_of_mental_health/en/ Future: The lifetime costs of childhood [Accessed 18 October 2015] behavioural problems and the benefits of xcvii Shonkoff and Garner (2012); Shonkoff, Boyce early intervention. London: Centre for Mental and McEwen (2009) in ibid Health xcviii Dashiff et al. (2009) in Mental Health lxxxiv Green, H. et al. (2005) Mental health of Commission (September 2011) The Human children and young people in , Cost. An overview of the evidence on 2004. London: The Stationery Office economic adversity and mental health and lxxxv Morrison Gutman, L. et al. (November 2015) recommendations for action. Dublin: Mental Children of the New Century: Mental health Health Commission findings from the Millennium Cohort Study. xcix Frojd, Marttunen and Pelkonen (2006) in ibid London: Institute of Education, UCL and Centre for Mental Health c Green, H. (2005) Mental health of children and young people in Great Britain, 2004. lxxxvi ibid London: The Stationery Office lxxxvii Kalmakis, K. A. and Chandler, G. E. (2013) ci SCIE (2011) and Huntsman (2008) in ‘Adverse childhood experiences: towards Hansson, U., O’Shaughnessy, R. and Monteith, a clear conceptual meaning’. Journal of M. (October 2013) Maternal Mental Health Advanced Nursing, 70(7), pp. 1489–501 and Poverty: The Impact on Children’s lxxxviii Grief et al. (2010) in Mental Health Educational Outcomes. UNESCO Chairs: Commission (September 2011) The Human National University of Ireland Galway and Cost. An overview of the evidence on University of Ulster economic adversity and mental health and cii Tunnard (2004) in Hansson, U., recommendations for action. Dublin: Mental O’Shaughnessy, R. and Monteith, M. (October Health Commission 2013) Maternal Mental Health and Poverty: lxxxix Parsonage, M., Khan, L. and Saunders, The Impact on Children’s Educational A. (November 2015) Building a better Outcomes. UNESCO Chairs: National future. The lifetime costs of childhood University of Ireland Galway and University of behavioural problems and the benefits of Ulster early intervention. London: Centre for Mental Health

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102 103 cxxx World Health Organization and Calouste cxlvii Singleton et al. (1998) in Centre for Mental Gulbenkian Foundation (2014) Social Health (2011) Policy Briefing 39: Mental Determinants of Mental Health. Available Health Care and the Criminal Justice at: http://www.who.int/mental_health/ System. London: Centre for Mental Health publications/gulbenkian_paper_social_ cxlviii Department of Health (2007) in Corston, J. determinants_of_mental_health/en/ (March 2007) The Corston Report: A report [Accessed 18 October 2015] by Baroness Jean Corston of a review of cxxxi World Health Organization (2013) Mental women with particular vulnerabilities in the Health Action Plan 2013–2020. http://www. criminal justice system. London: The Home who.int/mental_health/publications/action_ Office plan/en/,p15 cxlix Corston, J. (March 2007) The Corston cxxxii The King’s Fund (2013) Improving the public’s Report: A report by Baroness Jean Corston health. A resource for local authorities. of a review of women with particular London: The King’s Fund vulnerabilities in the criminal justice system. London: The Home Office cxxxiii http://www.mentalhealthandwellbeing.eu/ mental-health-in-all-policies cl Prison Reform Trust (2009) and HMCI (2008) in Seymour, L. (July 2010) Public cxxxiv http://www.fph.org.uk/about_the_all-party_ health and criminal justice. Promoting and parliamentary_group_on_health_in_all_ protecting offenders’ mental health and policies wellbeing. London: Centre for Mental Health cxxxv Fell, B. and Hewstone, M. (June 2015) cli Breedvelt, J. (February 2016) Psychologically Psychological Perspectives on Poverty. Informed Environments: a literature review. Available at: https://www.jrf.org.uk/report/ London: Mental Health Foundation and St psychological-perspectives-poverty Mungo’s, Broadway [Accessed 18 October 2015] clii http://eprints.soton.ac.uk/187695/1/meeting- cxxxvi Crisp et al. (2000) in Quinn et al. (24 January the-psychological-and-emotional-needs-of- 2013) ‘Nature and impact of European people-who-are-homeless.pdf anti-stigma depression programmes’. Health Promotion International. Doi:10.1093/heapro/ cliii Haigh et al. (2012) in Breedvelt, J. das076 (February 2016) Psychologically Informed Environments: a literature review. London: cxxxvii Zalar et al. (2007) in ibid Mental Health Foundation and St Mungo’s cxxxviii Rosenfeld (1997) in ibid cliv Mental Health Foundation (September 2013) cxxxix Link et al. (1989) in ibid Starting Today: the Future of Mental Health Services. Final Inquiry Report. London: Mental cxl Wright et al. (2000) in ibid Health Foundation cxli Aromaa et al. (2011) in ibid clv Buck, D. and Jabbal, J. (November 2014) cxlii Mental Health Foundation (February 2011) Tackling poverty: Making more of the NHS Tackling the Stigma Against People with in England. London: The King’s Fund. p. depression: a summary toolkit for European 48. Available at: http://www.kingsfund.org. countries. Glasgow: Mental Health Foundation uk/sites/files/kf/field/field_publication_file/ tackling-poverty-research-paper-jrf- cxliii Quin, N. et al. (January 24 2013) ‘Nature and kingsfund-nov14.pdf [Accessed 18 October impact of European anti-stigma depression 2015] programmes’ Health Promotion International. Doi:10.1093/heapro/das076 clvi IPPR (2007) in Sustainable Development Commission (February 2010) Sustainable cxliv https://www.thl.fi/en/web/thlfi-en/research- Development: The key to tackling and-expertwork/projects-and-programmes/ health inequalities. London: Sustainable aspen [Accessed 18 October 2015] Development Commission. p. 52 cxlv https://www.seemescotland.org/about-see- clvii Mental Health Foundation (2013) Crossing me/ [Accessed 18 October 2015] Boundaries – Improving integrated care for people with mental health problems. London: cxlvi The King’s Fund (2013) Improving the public’s health. A resource for local authorities. Mental Health Foundation London: The King’s Fund

102 103 clviii NHS Confederation and National Mental clxxviii Friedli, L., Jackson, C., Abernethy, H. and Health Development Unit (2011) Public Stansfield, J. (undated) Social prescribing for mental health and well-being – the local mental health – a guide to commissioning perspective. London: NHS Confederation and and delivery. Care Services Improvement National Mental Health Development Unit Partnership North West Development Centre. p. 3. Available at: http://www. clix Gilburt, H. (November 2015) Briefing. Mental centreforwelfarereform.org/uploads/ health under pressure. London: The King’s attachment/339/social-prescribing-for- Fund mental-health.pdf [Accessed 15 November clx Lawton-Smith, S. (2015) ‘The future for 2015] mental health services: some possibilities’. In clxxix Bates (2002); Gask et al. (2000) in ibid Crepaz-Keay, D. (ed.) (2015) Mental Health Today…And Tomorrow: Exploring current and clxxx Mental Health Foundation (2005) in ibid future trends in mental health. Hove: Pavilion clxxxi http://www.centreformentalhealth.org.uk/the- Publishing. p. 108 bradley-commission-five-years-on [Accessed clxi Confluence Partnerships (February 2014) 18 October 2015] Ethnic Inequalities in Mental Health: clxxxii Seymour, L. (May 2010) Public health and Promoting Lasting Positive Change. London: criminal justice. Promoting and protecting Lankelly Chase Foundation, Mind and The offenders mental health and wellbeing. Afiya Trust Centre for Mental Health London: Centre for Mental Health clxii McManus et al. (2009) in Gilburt, H. clxxxiii Thornicoft, G., Rose, D. and Kossam, A. (2007) (November 2015) Briefing. Mental health ‘Discrimination in health care against people under pressure. London: The King’s Fund with mental illness’. International Review of clxiii Health & Social Care Information Centre Psychiatry, 19(2), pp. 113–22 (2015b) in ibid clxxxiv Naylor, C. et al. (2012) Long-term conditions clxiv NHSE Strategic Finance Team (2014) in ibid and mental health: The cost of co-morbidities and mental health. London: The King’s Fund. clxv NHSE Strategic Finance Team (2014) in ibid clxxxv Naylor, C. et al. (2012) Long-term conditions clxvi Lintern (2015) in ibid and mental health: The cost of co-morbidities clxvii Mental Health Strategies (2012) in ibid and mental health. London: The King’s Fund. clxviii BBC News (2013) in ibid clxxxvi Prince et al. (2007) in Naylor, C. et al. (February 2012) Long-term conditions and clxix McNicoll (2013d) in ibid mental health. The cost of co-morbidities. clxx McNicoll (2015b) in ibid London: The King’s Fund and Centre for Mental Health clxxi Care Quality Commission (2015c) in ibid clxxxvii Cimpean and Drake (2011) in ibid clxxii McNicoll (2015a) in ibid clxxxviii ibid clxxiii The Commission on Acute Adult Psychiatric Care (2015) in ibid clxxxix ibid clxxiv Health and Social Care Information Centre cxc Thomas et al. (2003); Vamos et al. (2009); (2015a) in ibid Theis et al. (2007) in ibid clxxv Royal College of Psychiatrists (2014c) in ibid cxci Naylor, C. et al. (February 2012) in ibid clxxvi Buck, D. and Jabbal, J. (November 2014) cxcii Finlay et al. (2011) in ibid Tackling poverty: Making more of the NHS in cxciii http://www.skillsforcare.org.uk/Site-Pages/ England. London: The King’s Fund. Available Glossary2.aspx [Accessed 15 November at: http://www.kingsfund.org.uk/sites/files/kf/ 2015] field/field_publication_file/tackling-poverty- research-paper-jrf-kingsfund-nov14.pdf cxciv http://www.scie.org.uk/publications/ [Accessed 18 October 2015] introductionto/adultmentalhealthservices/ waysofworking.asp [Accessed 15 November clxxvii Department of Health and Children (2015) 2015] Future in Mind – promoting, protecting and improving our children and young people’s cxcv Gilburt, H. (2015) Mental health under mental health and wellbeing. London: pressure. London: The King’s Fund Department of Health cxcvi Dormon (2015) in ibid

104 105 cxcvii Appelby et al. (2015) in ibid ccxiv Lavis, P. and Robson, C. (March 2015) Promoting children and young people’s cxcviii Carr, S. (February 2014) Social Care for emotional health and wellbeing. A whole Marginalised Communities: Balancing school and college approach. London: Public self-organisation, micro-provision and Health England and Children and Young mainstream support. Policy paper 18. People’s Mental Health Coalition. Figure Birmingham: University of Birmingham Health 1, p. 6. https://www.gov.uk/government/ Services Management Centre uploads/system/uploads/attachment_data/ cxcix Crosidale-Appelby (2014); Clifton and file/414908/Final_EHWB_draft_20_03_15. Thorley (2014) in Gilburt, H. (2015) Mental pdf health under pressure. London: The King’s ccxv Department of Health (2009) Healthy Child Fund Programme from 5 to 19 years old. London: cc Clifton and Thorley (2014) in ibid Department of Health cci Johnson et al. (2012) in ibid ccxvi Buck, D. and Gregory, S. (2013) Improving the public’s health. A resource for local ccii McNicoll (2014) in ibid authorities. London: The King’s Fund cciii Marmot Review Team (February 2010) Fair ccxvii Goldie, I. (2015) ‘No time like the present’. In Society, Healthy Lives. The Marmot Review Crepaz-Keay, D. (ed.) (2015) Mental Health Executive Summary. p. 18 Today…And Tomorrow: Exploring current and cciv Department of Health and Public Health future trends in mental health. Hove: Pavilion England (2014a) in Lavis, P. and Robson, C. Publishing. p. 10 (March 2015) Promoting children and young ccxviii Lavis, P. and Robson, C. (March 2015) people’s emotional health and wellbeing. A Promoting children and young people’s whole school and college approach. London: emotional health and wellbeing. A whole Public Health England and Children and school and college approach. London: Public Young People’s Mental Health Coalition Health England and Children and Young ccv Department of Health and Public Health People’s Mental Health Coalition. https://www. England (2014b) in ibid gov.uk/government/uploads/system/uploads/ attachment_data/file/414908/Final_EHWB_ ccvi Department of Health and Children (2015) draft_20_03_15.pdf Future in Mind – promoting, protecting and improving our children and young people’s ccxix Children and Young People’s Mental Health mental health and wellbeing. London: Coalition (2012) in ibid Department of Health ccxx Ofsted (January 2015) ‘School Inspection ccvii Parsons (2009) in Buck, D. and Gregory, Handbook’ in ibid S. (2013) Improving the public’s health. A ccxxi NICE (2008) in ibid resource for local authorities. London: The King’s Fund ccxxii NICE (2009) in ibid ccviii Farrington and Ttofi (2010) in ibid ccxxiii NICE (2013) in ibid ccix NICE (2013) in ibid ccxxiv Weare, K. (2015) in ibid ccx McLellan and Perera (2013) in ibid ccxxv Green, H. et al. (2005) Mental health of children and young people in Great Britain, ccxi Jackson et al. (2012); Bond et al. (2004) in 2004. London: The Stationery Office ibid ccxxvi Grant, R. et al. (2013) ‘Twenty-five Years ccxii (2013) in ibid of Child and Family Homelessness: Where ccxiii Langford, R. et al. (2014) The WHO health Are We Now?’ American Journal of Public promoting school framework for improving Health Supplement 2, 103(2): pp. e1–e10. the health and well-being of students and Doi:10.2105/AJPH.2013.301618 their academic achievement. Cochrane ccxxvii de Vet, R. et al. (2013) ‘Effective Case Database of Systematic Reviews 4. Management for Homeless Persons: A CD008958 Systematic Review’ American Journal of Public Health, 103(10), pp. e13–e26. Doi:10.2015/AJPH,2013.301491

104 105 ccxxviii Clark, H. B. and Unruh, D. (2009) ccxxxix Scottish Government and Health Action ‘Understanding and addressing the needs of Partnership International (16 January 2012) transition-age youth and young adults and Working for Equity in Health. The role of work, their families’. In Clark, H. B. and Unruh, D. worklessness and social protection in health (eds.) Transition of youth and young adults inequalities. Context, situation analysis and with emotional or behavioral difficulties: An evidence review. Edinburgh: The Scottish evidence-supported handbook. Baltimore: Government Brookes Publishing. pp. 3–22 ccxl Boardman (2003) in O’Shea, E. and Kennelly, ccxxix National Equality Panel (2010) An Anatomy B. (2008) The Economics of Mental Health of Economic Inequality in the UK. Report Care in Ireland. Dublin: Mental Health of the National Equality Panel. London: Commission Government Equalities Office ccxli Rankin (2005) in ibid ccxxx Centre for Mental Health (2007) Mental ccxlii O’Shea, E. and Kennelly, B. (2008) The Health at Work: Developing the business Economics of Mental Health Care in Ireland. case. London: Centre for Mental Health Dublin: Mental Health Commission ccxxxi Centre for Mental Health and The Sainsbury ccxliii Manning and White (1995); Stuart (2006) in Centre (2007) in Bell, A. (2015) ‘Mental ROAMER: A Roadmap for Mental Health and health and work’. In Crepaz-Keay, D. (ed.) well-being Research in Europe. (May 2015). (2015) Mental Health Today…And Tomorrow: p. 16 Exploring current and future trends in mental health. Hove: Pavilion Publishing ccxliv O’Shea, E. and Kennelly, B. (2008) The Economics of Mental Health Care in Ireland. ccxxxii Bell, A. (2015) ‘Mental health and work’. In Dublin: Mental Health Commission Crepaz-Keay (ed.) (2015) Mental Health Today…And Tomorrow: Exploring current and ccxlv Centre for Mental Health (2013) in Bell, A. future trends in mental health. Hove: Pavilion (2015) ‘Mental health and work’. In Crepaz- Publishing Keay, D. (ed.) (2015) Mental Health Today… And Tomorrow: Exploring current and future ccxxxiii Singh, S. (February 2014) Mental Health and trends in mental health. Hove: Pavilion Work: United Kingdom. Paris: Organisation for Publishing Economic Co-operation and Development. Available at: http://www.oecd.org/els/ ccxlvi O’Shea, E. and Kennelly, B. (2008) The mental-health-and-work-united-kingdom- Economics of Mental Health Care in Ireland. 9789264204997-en.htm [Accessed 15 Dublin: Mental Health Commission November 2015] ccxlvii Centre for Mental Health (2014) in Bell, A. ccxxxiv Waddell and Burton (2006) in Bell, A. (2015) (2015) ‘Mental health and work’. In Crepaz- ‘Mental health and work’. In Crepaz-Keay, Keay, D. (ed.) (2015) Mental Health Today… D. (ed.) (2015) Mental Health Today…And And Tomorrow: Exploring current and future Tomorrow: Exploring current and future trends in mental health. Hove: Pavilion trends in mental health. Hove: Pavilion Publishing Publishing ccxlviii Bell, A. (2015) ‘Mental health and work’. In ccxxxv Census (2011) http://www.ons.gov.uk/ons/ Crepaz-Keay, D. (ed.) (2015) Mental Health guide-method/census/2011/index.html?utm_ Today…And Tomorrow. Exploring current and source=twitterfeed&utm_medium=twitter future trends in mental health. Hove: Pavilion Publishing ccxxxvi National Institute for Health and Care Excellence (June 2015) Workplace policy and ccxlix National Alliance on Mental Illness (July 2014) management practices to improve the health Road to recovery: Employment and Mental and wellbeing of employees. https://www.nice. Illness. Arlington: National Alliance on Mental org.uk/guidance/ng13 Illness ccxxxvii Business in the Community in association ccl Bell, A. (2015) ‘Mental health and work’. In with Mind (undated) Mental Health: We’re Crepaz-Keay, D. (ed.) (2015) Mental Health Ready to Talk. Rethinking the approach to Today…And Tomorrow: Exploring current and mental wellbeing in the workplace. London: future trends in mental health. Hove: Pavilion Business in the Community Publishing. p. 80 ccxxxviii http://fitforwork.org ccli Mental Health Foundation, Work Foundation and Wilson Sheriff (2015) Enhancing mental health in the governance of small enterprises. London: Mental Health Foundation

106 107 cclii Jennings, L. (2014) ‘Do Men Need cclxvii Frost-Gaskin et al. (2003) in ibid Empowering Too? A Systematic Review cclxviii (2007) in Mental Health Commission of Entrepreneurial Education and (September 2011) The Human Cost. An Microenterprise Development on Health overview of the evidence on economic Disparities among Inner-City Black Male adversity and mental health and Youth’. Journal of Urban Health, 91(5) pp. recommendations for action. Dublin: Mental 836–50 Health Commission ccliii National Alliance on Mental Illness (July 2014) cclxix Jenkins et al. (2009) in ibid Road to Recovery: Employment and Mental Illness. Arlington: National Alliance on Mental cclxx Taylor, Pevalin and Todd (2007) in ibid Illness cclxxi , Taylor and Price (2005) in ibid ccliv Mental Health Foundation, Work Foundation and Wilson Sheriff (2015) Enhancing mental cclxxii Fitch et al. (2009) in ibid health in the governance of small enterprises. cclxxiii Mind (2008) in ibid London: Mental Health Foundation cclxxiv Fitch et al. (2009) in ibid. p. 3 cclv Norton, Conway and Foster (2002) in Molnar et al. (2015) ‘Protocol: Realist synthesis of the cclxxv ibid impact of unemployment insurance policies cclxxvi Fitch et al. (2009) in ibid. p. 18 on poverty and health’. Evaluation and Programme Planning, 48, pp. 1–9 cclxxvii Taylor, Pevalin and Todd (2007) in ibid cclvi Marmot Review Team (February 2010) Fair cclxxviii Consilium Research and Consultancy (June Society, Healthy Lives. The Marmot Review 2015) The Role of Advice Services in Health Executive Summary. p. 22 Outcomes. Evidence review and mapping study. Advice Services Alliance and The cclvii Scottish Parliament Welfare Reform Low Commission. Available at: http://www. Committee (April 2013, March 2015, thelegaleducationfoundation.org/wp-content/ July 2015) http://www.scottish. uploads/2015/06/Role-of-Advice-Services- parliament.uk/parliamentarybusiness/ in-Health-Outcomes.pdf [Accessed 18 CurrentCommittees/46339.aspx October 2015] cclviii Mental Welfare Commission for Scotland cclxxix Hills (2007) in Sustainable development: The Investigation Report: Who benefits? (2013) key to tackling health inequalities. London: The benefits assessment and death of Ms DE. Sustainable Development Commission http://www.mwcscot.org.uk/media/180939/ who_benefits_final.pdf cclxxx Royal Commission on Environmental Pollution (2007a) and (2007b) in ibid. p. 16 cclix http://www.beaconwellbeing.org cclxxxi Pretty et al. (2007) in ibid cclx UK Mental Health Welfare Reform Group (2014) Submission to the Work and Pension’s cclxxxii Mental Health Foundation (1997) and (2000); Select Committee Access to Work Inquiry. Abbott et al. (2004); Larson et al. (2006) in ibid cclxi Public Accounts Committee (22 October 2014) Work Programme. Available at: http:// cclxxxiii Pretty et al. (2005) in ibid www.parliament.uk/business/committees/ cclxxxiv Mind (2007) in ibid committees-a-z/commons-select/public- accounts-committee/news/work-programme- cclxxxv Ellaway, Macintyre and Cavier (2005); Cohen report/ [Accessed 15 November 2015] et al. (2007) in ibid cclxii UK Mental Health Welfare Reform Group cclxxxvi Kuo et al. (1998); and Lewis (1996) in ibid (August 2015) Submission to the Work and Pensions Select Committee Welfare To Work cclxxxvii Perpetuity Group (2009) in ibid Inquiry. cclxxxviii Play England (2007) in ibid cclxiii Parsonage, M. (2013) Welfare advice for cclxxxix Wells and Evans (2003) in ibid people who use mental health services. Developing the business case. London: ccxc Kellert (2002) in ibid Centre for Mental Health. p. 30 ccxci Faber, Kuo and Sullivan (2001); and Faber, cclxiv ibid Kuo and Sullivan (2002) in ibid cclxv Sefton (2010) in ibid ccxcii 292 Coley, Kuo and Sullivan (1997); Sullivan, Kuo and Depooter (2004) in ibid cclxvi Cullen (2004) in ibid

106 107 ccxciii Pretty et al. (2007); Sullivan, Kuo and cccxiii Parsonage, M., Khan, L. and Saunders, Depooter (2004) in ibid A. (November 2015) Building a better future. The lifetime costs of childhood ccxciv Bird (2007) in ibid behavioural problems and the benefits of ccxcv Kuo and Sullivan (2001) in ibid early intervention. London: Centre for Mental Health ccxcvi Kuo et al. (1998) in ibid cccxiv Department of Health (2011) ‘Family Nurse ccxcvii Lewis (1996); Maller et al. (2006) in ibid Partnership Evidence Summary Leaflet’ ccxcviii Austin (2002); Inerfield and Blom (2002) in in Parsonage, M., Khan, L. and Saunders, ibid A. (November 2015) Building a better future. The lifetime costs of childhood ccxcix http://www.roamer-mh.org/index.php?page=0 behavioural problems and the benefits of early intervention. London: Centre for Mental ccc European Union (2013) in ROAMER: A Roadmap for Mental Health and Well-being Health Research in Europe (2015) p. 16 http://www. cccxv Dretzske et al. (2005) in Parsonage, M., roamer-mh.org/index.php?page=0 Khan, L. and Saunders, A. (November 2015) Building a better future. The lifetime costs ccci European Union (2013) in ibid. p. 35 of childhood behavioural problems and the cccii http://fingertips.phe.org.uk/profile-group/ benefits of early intervention.London: Centre mental-health [Accessed 18 October 2015] for Mental Health ccciii Campbell, F. (ed.) (March 2010) The social cccxvi (2006) in Buck, D. and Gregory, S. (2013) determinants of health and the role of local Improving the public’s health. A resource for government. Improvement and Development local authorities. London: The King’s Fund Agency cccxvii Knapp, M. et al. (2011) in ibid ccciv Stiglitz, Sen and Fitoussi (2009) in Burd- cccxviii Knapp, M. et al. (2011) in ibid Sharps, S. et al. (2010) Human Development Research Paper 2010/27 Twenty Years cccxix Teenage Pregnancy Associates (2011) in ibid of Human Development in Six Affluent Countries: Australia, Canada, Japan, New cccxx Connolly, P. et al. (May 2011) Pupils’ Emotional Zealand, the United Kingdom, and the Health and Wellbeing: A Review of Audit United States. United Nations Development Tools and a Survey of Practice in Northern Programme Ireland Post-Primary Schools. Belfast: Department of Education for Northern cccv Burds-Sharps, S. (2010) Human Development Ireland Research paper 2010/27 Twenty Years of Human Development in Six Affluent cccxxi Centre for Mental Health (2007) Mental Countries: Australia, Canada, Japan, New Health at Work: Developing the Business Zealand, the United Kingdom, and the Case. London: Centre for Mental Health United States. New York: United Nations cccxxii National Institute for Health and Care Development Programme Excellence (November 2009) Promoting cccvi O’Shea, E. and Kennelly, B. (2008) The Mental Wellbeing at Work. https://www. Economics of Mental Health Care in Ireland. nice.org.uk/guidance/ph22; and Promoting Dublin: Mental Health Commission Mental Wellbeing at Work Pathway. http:// pathways.nice.org.uk/pathways/promoting- cccvii ibid mental-wellbeing-at-work; and (June 2015) Workplace health: policy and management. cccviii ibid http://www.nice.org.uk/guidance/ng13 cccix ibid [Accessed 15 November 2015] cccx Buck, D. and Gregory, S. (2013) Improving cccxxiii http://www.ncbi.nlm.nih.gov/ the public’s health. A resource for local pubmed/19085404 authorities. London: The King’s Fund cccxxiv http://www.centreformentalhealth.org.uk/ cccxi Health Scotland (2012) Evidence Summary: employment-the-economic-case Public health interventions to support mental cccxxv Department of Health and Department for health improvement. Edinburgh and Glasgow: Work and Pensions (2006) NHS Health Scotland cccxxvi Naylor, C. et al. (February 2012) Long-term cccxii Bauer, A. et al. (October 2014) The costs conditions and mental health: the cost of of perinatal mental health problems. LSE co-morbidities. London: The King’s Fund and Personal Social Services Research Unit and Centre for Mental Health Centre for Mental Health

108 109 cccxxvii Howard et al. (2010) in ibid cccxxviii Moore et al. (2007) in ibid cccxxix ibid cccxxx http://www.centreformentalhealth.org.uk/ liaison-and-diversion-the-economic-case cccxxxi ibid cccxxxii ibid cccxxxiii Parsonage, M. (2013) Welfare advice for people who use mental health services. Developing the business case. London: Centre for Mental Health cccxxxiv Frost-Gaskin et al. (2003) in ibid

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