Nottingham Insight

Introduction

Mental health problems are common, disabling and costly.

In 2014, Nottingham Health and Wellbeing Board approved the Nottingham City Mental Health and Wellbeing Strategy, Wellness in Mind. Wellness in Mind brings together the vision for improved mental health and social inclusion across the life course under five priorities.

1. Promoting mental resilience and preventing mental health problems

2. Identifying problems early and supporting effective interventions

3. Improving outcomes through effective treatment and relapse prevention

4. Ensuring adequate support for those with mental health problems

5. Improving the wellbeing and physical health of those with mental health problems.

The use of the term ‘mental health problem’ mirrors that used in the National Strategy (DH2011)  and is therefore used in this chapter as an umbrella term to describe the full range of diagnosable mental illnesses and disorders, including personality disorder.

There are many factors that influence mental health and wellbeing including personal relationships, childhood experience, employment, housing, safety, built and natural environment and experience of discrimination.  At a personal level, the ‘five ways to wellbeing’ (NEF 2008) identified key messages for mental health promotion: be physically active, connect with other people, keep learning, take notice ( based on mindfulness) and give time to other people ( e.g. volunteering). There is a Wellness in Mind training programme which aims to Increase awareness and understanding of mental health and wellbeing across Nottingham. Mental wellbeing is measured each year in Nottingham and the groups with the lowest levels of wellbeing are the unemployed and those with long term health problems.

Mental health problems are very common and it is estimated up to one in two adults will experience problems at some point in their lives (Kessler 2007).   Mental health problems range from severe mental illness, such as schizophrenia to common mental health problems such as anxiety and depression. All these conditions can be highly disabling and affect family, working and social life.

Adults with enduring mental health problems can be one of the most socially excluded groups in society, experiencing stigma and wide ranging social disadvantage as well as poor physical health outcomes. Under the Equality Act people with long term mental health problems may be considered to be disabled, with requirements of all services to make reasonable adjustments to enable them to benefit.   

Mental health and physical health are interlinked.  People with mental health problems experience higher rates of physical illness and a lower life expectancy (De Hert 2011), and those with chronic or long term physical health problems are more likely to experience mental health problems, often unrecognised and untreated. (Naylor 2012).

Mental health problems impact on individuals, families, communities, and society as a whole, with immense social and financial costs.  Mental illness is an important cause of social inequality as well as a consequence. Mental health problems contribute a higher percentage of total ‘disability adjusted life years’ in the UK than any other long term illness (14%, or 23% with drug and alcohol abuse included, compared to cardiovascular disease 12%, cancer 13% and respiratory illnesses 8%) (WHO 2009). Estimates put the full cost of mental health problems in England at £105.2 billion (Centre for Mental Health 2010), and mental illness accounts for about 13% of total NHS spend (Parsonage et al 2012).  In Nottingham the largest proportion of ESA claimants (50.8%) are recorded as having ‘mental and behavioural disorders’, which accounts for over 8,000 adults of working age (Nottingham City Health and Wellbeing Board 2015)

Mental health service improvement is a national priority ( DH 2016), particularly focussing on crisis care, perinatal mental health, ending inappropriate use of police intervention, better access to psychological therapies and parity of esteem (giving equal value to mental and physical health). Building on the NHS Mandate, NHS England has published the Five Year Forward View for Mental Health,  an independent report by the Mental Health Taskforce that sets national aspirations to 2020.In Nottingham, mental health urgent care is included as a local NHS vanguard, there is a Crisis Concordat  partnership, and in 2015 Nottingham City HWBB agreed a Suicide Prevention Strategy .

Unmet needs and gaps

Citizens reported finding the system of mental health services confusing and difficult to navigate and were not always clear where to first turn for support. It is anticipated that the newly commissioned mental health and wellbeing service will serve to meet this need.

• Promoting positive mental wellbeing requires active partnership work across statutory services, non-profit organisations, and voluntary and community services. In addition, communities themselves well placed to tackle the factors that can impact on an individual’s mental wellbeing.
• Broader understanding of mental health needs and the relationship with physical health needs to be improved at all levels within commissioning and provision including in physical health JSNA chapters
• The gap in life expectancy between people with mental health problems and those without needs to be reduced.  This is an important priority for Nottingham City, and particularly with a focus on reducing smoking and improving identification of physical health problems early.
• Official suicide data is being produced earlier than previously, but it does not enable adequate insight or highlight areas needing a more timely response. Further insight should be developed through the Coroner suicide audit and learning from areas that have implemented real time surveillance.
• Care for people in mental health crisis is a partnership priority under the Crisis Care Concordat and Urgent Care Vanguard. This momentum needs to be maintained to ensure services respond to people in crisis based on needs.
• Black and minority ethnic (BME) communities and high-risk groups, such as LGBT groups, offenders and asylum seekers/refugees may have challenges in terms of accessing mental health services. All commissioned services need to ensure they are able to describe the population that use their service so that gaps in access may be identified. Specific services to support community outreach (such as STEPS for BME communities) need to inform wider services how to ensure services meet diverse needs.
• Mental health problems are frequently reported amongst individuals who are homeless or at risk of becoming homeless. Work is needed to ensure the systems of homelessness prevention and mental health support work together to ensure those in need receive adequate treatment, accommodation and support.
• Mental health and employment indicators for the City show very high rates of people on out of work benefits due to mental health problems, and low employment rates for those known to secondary mental health care.
• More understanding is needed for the reason behind the low proportion of people on Care Programme Approach (CPA) in Nottingham compared to other areas.
• More understanding is needed of the needs relating to Personality Disorder.

Recommendations for consideration by commissioners

Ensure all commissioned mental health services:

• Are understood and accessible to all, including groups within the population who currently find services difficult to use for cultural reasons or because they believe the service will not meet their needs;
• Have an emphasis on supporting recovery and promoting ‘safe’ independence;
• Consider each individual’s physical health needs as equally important as their mental health needs;
• Promote seamless referral pathways both within, and between, services ( e.g. between primary and secondary mental services)
• Evaluate the impact of changes to provision for service users and partner organisations.
• Engage and involve service users and carers in service development
• Provide an environment that is smoke free and promotes and supports reductions in smoking.

• Continue to monitor progress towards greater flexibility and choice over accommodation and social support for citizens with enduring mental health needs, in accordance with the principles of self-directed support, and the needs of the local population.
• Consider results of dual diagnosis needs assessment 2015 and draft NICE guidance to make changes to services and pathways as appropriate.
• Develop and implement action plans from the Nottingham city mental health Wellness in Mind Strategy 2014-2017
• Implement action plans from the Nottingham City Suicide Prevention Strategy 2015-18
• Work in partnership to meet the aspirations of the Nottingham and Nottinghamshire Crisis Care Concordat
• Take the opportunity of the duty to promote ‘wellbeing’ in the Care Act to raise the profile of monitoring and improving mental wellbeing.
• Raise the profile of the outcomes for people with mental health problems as an equality issue. This means consideration by all commissioned services (including primary care and physical health services) of the requirement to make reasonable adjustments to enable people with enduring mental health problems to benefit.

Commissioners of other services that impact upon mental health and wellbeing should:

• Consider the impact of all services on citizens’ mental health and wellbeing. For example, planning decisions regarding the use of open spaces and access to community services, arts and leisure services. 
• consider initiatives that address the employment needs of adults with mental health problems, including ways to support adults with enduring mental health problems, and support for people experiencing common mental health problems to remain in or return to work

Liz Pierce, Insight Specialist Public Health, Nottingham City Council,

Liz.Pierce@nottinghamcity.gov.uk

Helene Denness, Consultant in Public Health, Nottingham City Council

Helene.Denness@nottinghamcity.gov.uk

Ciara Stuart, Head of Commissioning - Mental Health, Nottingham Clinical Commissioning Group

ciara.stuart@nottinghamcity.gov.uk

Bobby Lowen, Lead Commissioning Manager, Commissioning and Insight, Nottingham City Council                                                                                

alan.lowen@nottinghamcity.gov.uk