Minded to change The link between mental wellbeing and healthier lifestyles

Transcription

1 SEXUAL HEALTH CLINIC TOWN HALL YOUTH CLUB Minded to change The link between mental wellbeing and healthier lifestyles COMMUNITY CLINIC SPORTS CENTRE Findings from the health trainer service in England November 2015 PHARMACY SCH OOL C ARE H O M E H O SPITA L PRISON GP SURGERY

2 List of contributors Brighton Health Trainer Service Cornwall Health Trainer Service, Health Promotion Service Gloucestershire Community Health Trainers, Independence Trust Hounslow and Richmond Health Trainer Service Herefordshire Health Trainer Service Leicester City Health Trainers, Lifestyle Referral Hub Lewisham Health Trainer Service Liverpool Health Trainer Service Mind in Bexley Health Trainers South East Essex Health Trainers, delivered by Parkwood Healthcare Swindon Health Trainer Service Tameside Health Trainer Service Telford Healthy Lifestyle Team Tower Hamlets Health Trainer Service Walsall Emotional Health and Wellbeing Service Warrington Wellbeing Service Wiltshire Health Trainer Service

3 Contents Section Page Foreword Shirley Cramer CBE 1 Foreword - Tony Coggins 2 Executive summary 3 Introduction 4 Methodology 5 What is a health trainer? 5 Promoting mental health and wellbeing 5 Connection between mental and physical health 9 A growing challenge 13 Conclusion 14 Appendix 14 References 16

4 Foreword There is often a tendency to look at unhealthy lifestyle choices, such as a poor diet or smoking, in isolation without considering the wider factors that may be influencing a person s behaviour. However, to effectively tackle unhealthy lifestyles, we must get to the root cause of these issues. The health trainer service, as a community resource, trusted by their clients, is a valuable tool for achieving this. Positive mental wellbeing is integral to our overall health, a critical ingredient for making healthy lifestyle choices. In spite of this, mental health and wellbeing is often overlooked, seen as an issue of secondary importance, with greater priority given to physical health issues and services. This lack of parity of esteem is mistaken, and hugely misguided if we are to reduce the financial burden of avoidable illness. There is often a tendency to look at unhealthy lifestyle choices, such as a poor diet or smoking, in isolation without considering the wider factors that may be influencing a person s behaviour. However, to effectively tackle unhealthy lifestyles, we must get to the root cause of these issues. The health trainer service, as a community resource, trusted by their clients, is a valuable tool for achieving this. Health trainers are drawn from within the communities they serve and often have first-hand experience of the issues on which they are providing support. Unlike many services, they are also able to offer support over an extended period of time, and are therefore ideally placed to promote mental wellbeing and support clients on issues such as social isolation, anxiety and stress. Using data from the Data Collection and Reporting System, this report highlights the success with which health trainers are doing this. Across a range of wellbeing measures, health trainers are supporting substantial improvements in their clients mental wellbeing. This report however, also highlights that for many services, mental health and wellbeing is a growing issue, with health trainers supporting an increasing number of complex cases. Shirley Cramer CBE Chief Executive Royal Society for Public Health With ever more stringent budgets cuts, public health is facing a difficult time ahead. It is crucial however, that we recognise the importance of promoting mental wellbeing and the valuable role that community-based services such as the health trainer service can play in this. At the same time, it is vital that we recognise the boundaries of the health trainer role and ensure they are provided with the necessary training and support to carry out their role safely and effectively. Page 1

5 Foreword Health trainer services and other community-based interventions are arguably best placed to meet the challenges posed by mental and physical health, and most importantly have the capacity to meet these challenges with a wider, more holistic approach. Or in other words, community-based services are more responsive and connected to dynamic local need. Put simply, our mental health and mental wellbeing is about how we think and feel, which affects what we do and how we function. As such, it is fundamental to leading healthy lives. It is well understood that our mental wellbeing is connected to our mastery of choice and defines our ability to make healthy choices. However, there is a tendency to underplay mental health and wellbeing in approaching physical health viewing physical health as a linear relationship not mediated by other factors. In short, taking a holistic approach to both physical and mental health can engender greater public health outcomes for all. Health trainer services and other community-based interventions are arguably best placed to meet the challenges posed by mental and physical health, and most importantly have the capacity to meet these challenges with a wider, more holistic approach. Or in other words, community-based services are more responsive and connected to dynamic local need. The use of health trainer services and other community-based services creates a feedback loop, in which the service user can bring about better mental health outcomes for themselves, and through the participation of the service and others like it, engender wider communal benefits: indirectly affecting the mental and physical health of those within that community. This report brings additional breadth and depth to the current understanding surrounding health trainer services, as well as the efficacy of community-based services like it. At the initial level, it demonstrates the valuable work of health trainers in improving physical health outcomes. But also, brings to the fore the work of health trainers in improving mental wellbeing and how these two interact within a single intervention. Tony Coggins Head of Mental Health Promotion South London and Maudsley NHS Foundation Trust The report also raises a salient challenge within and facing public health about the current capacity of traditional clinical services, especially that of mental health services. Notably, how do we balance the financial realities of the NHS with the remit and expertise of specific health professionals, such as health trainers? Page 2

6 Executive summary Introduced in 2004, the health trainer service seeks to support the most deprived in society to lead healthier lives, with the core goals of reducing avoidable illness and addressing health inequalities. Health trainers are recruited from within communities to provide support from next door in the form of information on healthy lifestyles, the setting of goals in personal health plans (PHPs) and signposting to local groups and services. In February, we published a report, Indicators of change, the first in a series of six, which demonstrated that the health trainer service has moved beyond its original design as laid out in the White Paper, Choosing Health: Making Healthy Choices Easier. The service is now based in a wide range of settings, with health trainers supporting clients on a vast array of issues from long-term health conditions, financial and housing issues to issues around mental health and wellbeing. This report builds on these previous findings by seeking to understand the types of mental health issues faced by clients, the impact of lower mental wellbeing on their success and the challenges faced by services. Using data from the Data Collection and Reporting System (DCRS), this report demonstrates the success of health trainer services in supporting clients, regardless of deprivation quintile, to achieve substantial improvements across a range of wellbeing measures. Our research also highlights the detrimental impact that lower mental wellbeing can have on the success of clients, thus supporting the case for greater training in this area. The data indicates that clients who do not fully achieve their PHP behavioral goals have a lower average mental wellbeing score at the start of the intervention. Moreover, the data also indicates that, whilst achieving substantial improvements, clients who start with lower mental wellbeing scores on average do not achieve the same level of behavior change success in measures such as consumption of fruit and vegetables as those with higher starting mental wellbeing scores. For a lot of services, mental health is a growing issue. Through the use of semi-structured interviews, we found many services are seeing an increasing number of individuals with mental health issues and feel they are often a dumping ground for more complex cases, partly due to a lack of alternative services. Health trainers offer time and support provided by no other service. It is crucial however, that we recognise the boundaries of this role. To ensure that health trainers are able to work safely and effectively, there is a clear case for greater training in mental health awareness and also, a need for greater support from other services. With more integrated working, there is real potential for health trainers to act as a bridge for those struggling with mental health issues into more specialist services. Page 3

7 Introduction Mental ill health is the main cause of disability in the UK, with an estimated one in four adults and one in five children experiencing a mental health problem each year. 1 This incidence rate, equating to roughly 16.7 million individuals, 2 is higher than that for conditions such as cancer and cardiovascular disease. 1 Mental ill health encompasses a wide range of conditions, ranging from social isolation, anxiety and stress through to more severe conditions, such as bi-polar disorder and schizophrenia. The most common of which is depression with sufferers accounting for between 8-12% of the population. 3 Physical health and mental health are inextricably linked, with poor mental health being both a determinant and consequence of poor physical health. Research has shown that individuals suffering from depression for example, have a 65% increased risk of diabetes, and correspondingly, individuals with diabetes are two to five times more likely to have depression. 4 Mental health problems can be hugely detrimental to the lives of sufferers, as well as that of their family and friends. Poor mental health can make everyday decisions and routines, including healthy lifestyle choices, far more of a challenge. It also places substantial costs on the NHS, welfare system and employers, estimated at an incredible billion per year. 4 To reduce the burden on the NHS, reduce avoidable illness and ultimately, tackle health inequalities, it is crucial that services and communities alike are focused on promoting and supporting mental wellbeing. Defined as a dynamic state in which the individual is able to develop their potential, work productively and creatively, build strong and positive relationships with others and contribute to their community, 5 mental wellbeing is the foundation upon which healthy lifestyle choices are based. The health trainer service, comprised of individuals drawn from within communities to provide support from next door, 6 are an integral part of this and ideally placed to tackle the environmental factors impacting our mental health and wellbeing. Earlier this year, we published the first in a series of six reports produced alongside the Data Collection and Reporting System (DCRS) a team to evaluate the health trainer service. This report demonstrated that the role of the health trainer has expanded considerably, with health trainers now supporting clients on a wide variety of issues, including promoting mental wellbeing and supporting clients with low level mental health issues, such as social isolation and anxiety. Building on our previous DCRS report, this next instalment seeks to dig a bit deeper to understand the mental health issues faced by clients, examine the impact of lower mental wellbeing on their success and understand the growing challenges faced by services in a climate of budget cuts. a. The DCRS is a centralised national database, used by roughly 60% of services, which enables health trainers and health trainer services to report and record the data of their clients, at all stages of an intervention. Whilst simultaneously facilitating the selfassessment of services operational and comparative performance within specific client metrics. Page 4

8 Methodology The research for this report incorporated both quantitative analysis using data collected in the DCRS and also, qualitative research in the form of semi-structured interviews with health trainers and service leads. We analysed the DCRS data collected over a three year period from July 2012 to July We also conducted 31 interviews throughout August and September 2015, 14 with service leads and 17 with health trainers. This was a self-selected sample. For information on which health trainer services took part, please see the list of contributors. What is a health trainer? The introduction of the health trainer service in the 2004 White Paper, Choosing Health: Making Healthy Choices Easier, marked a turning point in public health. Previous public health initiatives had focused on a paternalistic approach, seeking to encourage behaviour change through the provision of advice from on high. 6 The health trainer service was instead to be a workforce drawn from within communities, providing individualised support to clients from a position of understanding. Based on a psycho-social model, 7 health trainers work with their clients over the course of generally 6-8 sessions, setting behaviour change goals in personal health plans (PHPs), providing information on healthy lifestyles and signposting to other services. Health trainers focus on the holistic view of health, seeking to understand and support clients on a wide range of factors that may be impacting their health and wellbeing, be it financial concerns or emotional wellbeing. Since the service was rolled out in 2006, the role of the health trainer has developed considerably, expanding beyond its original remit of physical activity, diet, smoking and alcohol into new areas such as providing health checks and offering support around specific conditions, including diabetes and chronic pain. The service is also now based within a diverse range of settings, including prison and probation, GP surgeries as well as community locations such as libraries and community centres. Despite this adaptation, the core goals of the service remain, which are to reach the most deprived individuals in society, who suffer disproportionately poor health outcomes, and empower them to lead healthier and happier lives. Promoting mental health and wellbeing The central goal of the health trainer service, as articulated in the Choosing Health White Paper, is to reduce health inequalities by reaching out to communities typically seen as hard to engage, particularly those from the most deprived areas. The DCRS data demonstrates that almost ten years later the service remains successful in doing so; from 2012 to 2015, over two-thirds of clients were from the two most deprived quintiles, 43.88% from quintile one and 23.61% from quintile two (quintile one being the most deprived and quintile five being the least deprived). Page 5

9 Promoting mental health and wellbeing As a result of this focus, health trainers often work with clients experiencing a range of complex issues, including physical health issues, problems relating to the wider determinants of health, such as financial, housing and employment concerns and also, mental health issues. Through our interviews, almost all of the health trainers and service leads felt that mental health formed a major part of their work, with many stating that the majority of their clients suffer from such issues. One health trainer, for example, stated that almost in all cases, with all clients, there is a mental health issue alongside it. The health trainer service is an example of humanistic psychology, a service focused on supporting, motivating and ultimately, empowering their clients. Through this method, health trainers are effective in boosting the confidence of their clients, helping them to feel more engaged and supporting them to cope more effectively with the stresses of daily life. This aspect of the health trainer role is important in itself for improving mental wellbeing, and is also crucial for their success in supporting healthy behavior change. Improving clients mental resilience and self-belief is a vital first step to supporting healthier lifestyle choices. One service lead felt that just the process of the intervention can be beneficial for mental wellbeing, people don t always need specific specialist help it s part of this social prescribing agenda people need a purpose to get up and go out. Basic interactions would help a lot of people we see. However, despite this prevalence, for many clients this is not the primary reason they access the service. The DCRS data indicates that diet (55.95%) and exercise (21.84%) are the most popular reasons, with almost three-quarters of clients entering the service for support in these areas. Conversely, mental health and wellbeing accounts for less than 5% of recorded primary issues. This may indicate that for many clients mental health is an underlying issue. Health trainers are unique in the time and type of support they offer, often having first-hand experience of the issues on which they are providing support and being drawn from within the communities themselves. They are therefore, ideally placed to discuss mental wellbeing with their clients. One service lead stated that health trainers have an ability to instigate conversations and to listen... clients feel at greater ease talking about those issues. Similarly, another service lead felt that when you ve spent a long time with somebody, people are saying things they wouldn t necessarily say to a GP... health trainers are more likely to understand those difficult or more complex issues, and are able to effectively signpost. The efficacy of the health trainer service for promoting mental wellbeing is supported by a wealth of data in the DCRS. As the tables below demonstrate, across a range of wellbeing measures, the health trainers are supporting substantial improvements. We have chosen to focus on two mental wellbeing measures, the WHO- 5 and WEMWBS, the self-efficacy measure (the extent to which an individual believes they can achieve) and the general health measure. WHO-5 WEMWBS The WHO-5 Wellbeing Index is a tool for measuring mental wellbeing that looks at the following five areas; the extent to which individuals are feeling cheerful, calm and relaxed, active and vigorous, fresh and rested when waking up, and interested in daily activities. The Warwick-Edinburgh Mental Wellbeing Scale is a tool for measuring mental wellbeing that looks at twelve areas, including for example, the extent to which individuals feel useful, relaxed, confident and optimistic for the future. Page 6

10 Promoting mental health and wellbeing A. Pre and post general health score for all health trainer clients, July 2012 July 2015 General health Before After Change % B. Pre and post WHO-5 scores for all health trainer clients, July 2012 July 2015 WHO-5 Before After Change % C. Pre and post WEMWBS for all health trainer clients, July 2012 July 2015 WEMWBS Before After Change % D. Pre and post self-efficacy scores for all health trainer clients, July 2012 July 2015 Self-efficacy Before After Change % When these measures are broken down according to the deprivation quintiles of clients (tables below), this further demonstrates the success of the service. Despite having a lower starting point, health trainers are able to support clients in the most deprived quintiles to achieve roughly the same WHO-5 and general health scores as clients from the higher quintiles. Given this success and the ability of health trainers to reach the hard to engage, this demonstrates their potential to positively impact health inequalities. Page 7

11 Promoting mental health and wellbeing E. Pre and post general health scores by deprivation quintile, July 2012 July 2015 Quintile Before After Change Q1 Most deprived Q2 Q3 Q4 Q5 Least deprived % % % % % F. Pre and post WHO-5 score by deprivation quintile, July 2012 July 2015 Quintile Before After Change Q1 Most deprived Q2 Q3 Q4 Q5 Least deprived % % % % % G. Pre and post WEMWBS scores by deprivation quintile, July 2012 July 2015 Quintile Before After Change Q1 Most deprived Q2 Q3 Q4 Q5 Least deprived % % % % % H. Pre and post self-efficacy scores by deprivation quintile, July 2012 July 2015 Quintile Before After Change Q1 Most deprived Q2 Q3 Q4 Q5 Least deprived % % % % % Page 8

12 Connection between mental and physical health In response to the mental health needs of clients, many services now provide their health trainers with additional training on mental health awareness and techniques such as motivational interviewing and cognitive behavioural therapy. However, several interviewees felt that this part of the health trainer role is not always recognised and in some areas, the training is insufficient for their work, both in terms of the type of training offered and the immediacy with which it is provided. One service lead felt that the complexity of their work is not always understood, stating that there are a lot of services out there that still don t quite get what the health trainers do... There is a perception that the majority of the work is signposting and making referrals and getting the next one in. The reality is far removed from this. Similarly, another service lead felt that where it is recognised, commissioners have got the impression we just see people who are depressed. Depression isn t a straight forward illness and they don t bare the complexity in mind. Whilst many of the interviewees stressed that they wanted to protect the health trainer role and did not want to become de facto counsellors, they also recognised the importance of having a greater understanding of mental health and called for more training. One service lead felt that without additional training when they (health trainers) get a difficult client, they just become stumped - additional training could boost the confidence of the health trainer. The DCRS data supports this call for additional training. Across a number of mental wellbeing measures (see tables below), it seems that those who do not achieve or only part achieve their goals tend to have lower starting scores than those who fully achieve their PHP. This may indicate that clients with lower mental wellbeing may need additional support and it is therefore, important for health trainers to have greater awareness of these issues. There is also a notable decline in the WEMWBS score and self-efficacy of those who do not achieve, further demonstrating this importance. Page 9

13 Connection between mental and physical health I. Pre and post general health scores of clients that achieve, part achieve and do not achieve their PHP goals, July 2012 July 2015 Plan Outcome Before After Change Achieved Not Achieved Part Achieved % % % J. Pre and post WHO-5 scores of clients that achieve, part achieve and do not achieve their PHP goals, July 2012 July 2015 Plan Outcome Before After Change Achieved Not Achieved Part Achieved % % % K. Pre and post WEMWBS scores of clients that achieve, part achieve and do not achieve their PHP goals, July 2012 July 2015 Plan Outcome Before After Change Achieved Not Achieved Part Achieved % % % L. Pre and post self-efficacy scores of clients that achieve, part achieve and do not achieve their PHP goals, July 2012 July 2015 Plan Outcome Before After Change Achieved Not Achieved Part Achieved % % % Page 10

14 Connection between mental and physical health The DCRS data also highlights the complex issues faced by some health trainer clients. Those who enter the service with a lower starting mental wellbeing score also seem to have poorer starting scores in various physical health measures as well. The data indicates that as the starting WHO-5 score of clients decreases, the average level of moderate physical activity and consumption of fruit and vegetables also decreases, (grouped into four categories in the tables below), whilst average BMI increases. These tables, whilst demonstrating substantial improvements for those with lower starting WHO-5 scores, also demonstrate that these clients still do not achieve the levels of those with greater mental wellbeing. This may indicate that poorer mental wellbeing is acting as a barrier to success and therefore, supports the need for health trainers to have a greater understanding and awareness of mental health. This was a concern shared by many of the people we interviewed, one for example, stated that If a client s depressed or anxious they aren t going to be thinking I must eat my 5 portions of fruit and veg their personal health is hindered. M. Pre and post moderate exercise (30 mins per week) grouped by WHO-5 starting scores, July 2012 July 2015 Starting WHO-5 scores Before After Change (High) (Low) % % % % N. Pre and post BMI score grouped by WHO-5 starting scores, July 2012 July 2015 Starting WHO-5 scores Before After Change (High) (Low) % % % % O. Pre and post consumption of fruit and vegetables score grouped by WHO-5 starting scores, July 2012 July 2015 Starting WHO-5 scores Before After Change (High) (Low) % % % % Page 11

15 Connection between mental and physical health There are similar findings when examining pre and post mental wellbeing scores. As the tables below demonstrate, those who start with lower wellbeing scores, whilst achieving substantial improvements, do not reach the same level as those with higher starting points. This may indicate that health trainers can only support clients to a certain point and that greater time or different types of support would be required to fully address the mental wellbeing issues of these clients. P. Pre and post WHO-5 score grouped by WHO-5 starting scores, July 2012 July 2015 Starting WHO-5 scores Before After Change (High) (Low) % % % % Q. Pre and post self-efficacy score grouped by WHO-5 starting scores, July 2012 July 2015 Starting WHO-5 scores Before After Change (High) (Low) % % % % R. Pre and post general health score grouped by WHO-5 starting scores, July 2012 July 2015 Starting WHO-5 scores Before After Change (High) (Low) % % % % Page 12

16 A growing challenge An integral part of the health trainer role is promoting emotional wellbeing and supporting clients with low level mental health issues, such as social isolation, anxiety and stress. However, a clear theme that emerged from our interviews is that for many health trainers, this is a growing issue. Whilst this has always been a feature of their work, health trainers are seeing an increasing number of individuals with mental health issues. One service lead stated that the nature of the society we live in means that mental health is much more prominent. Welfare changes mean that people are much more stressed, anxious and worried. Alongside this, however, several health trainers raised concerns that they are also seeing an increase in clients with more severe mental health problems, such as suicidal thoughts, severe depression and schizophrenia. One health trainer stated that I have clients who have psychosis, schizophrenia, self-harmed... sometimes I don t know what their diagnosis is. The interviews indicated that this is in part due to inappropriate referrals from other professionals resulting from a lack of familiarity with the health trainer role and the remit of the service. However, several of our interviewees also stated that this is due to service cuts meaning that they are becoming a dumping ground for clients that other professionals do not know what to do with. One service manager stated that clients are being referred to them (health trainers), because other services don t know what to do with them they ve fallen through the net and felt that unless the client is going to make a dangerous decision, there isn t the support there for them. These concerns were shared by another service lead who stated that because of cuts and the reduction of services, without the support of the health trainers there is nowhere for these people to go. For services with good links to specialist mental health teams, their health trainers are able to refer clients and work with them alongside more specialist support. However, in other services, several of our interviewees felt that a lack of integration between the health trainer service and mental health teams was a major challenge. There seems to be real potential for health trainers to act as a bridge for hard to engage clients into mental health services; one health trainer stated that I often feel it would be better to refer those with mental health issues out to services, because there s still a stigma attached to mental health and most clients don t want to go back to their GP and admit they have an issue. The DCRS data clearly demonstrates the effectiveness of the service for promoting mental wellbeing. However, supporting individuals with more severe mental health problems goes beyond the health trainer remit and may not be appropriate support for those clients suffering from mental health issues. One health trainer expressed concern that when we re talking about people with the most severe mental health problems: is the health trainer service really meeting their needs? It can help them for a while, but it isn t behaviour they can necessarily sustain and stressed that the health trainer concept is meant to be empowering people, and not creating a dependency. But the people with the most severe mental health problems are looking for something consistent in their life. Page 13

17 Conclusion The DCRS offers a wealth of data, providing almost a national picture of the health trainer service. Using the DCRS data, this report, alongside previous editions, has clearly demonstrated the effectiveness of the health trainer model for supporting vast improvements in mental wellbeing, as well as positive behaviour change amongst clients. This report however, has gone one step further by seeking to understand the impact of mental wellbeing on the success of clients. The data indicates that those with lower mental wellbeing are less likely to fully achieve their PHP goals. They are also, whilst achieving substantial improvements in health and wellbeing, unable to reach the same high scores across a range of measures as those with greater mental wellbeing. This demonstrates that mental health may act a barrier to success for some clients and strongly supports the case for health trainers to be given greater training in mental wellbeing and understanding mental health conditions. Through our interviews with health trainers and service leads, we have also uncovered a more concerning trend of health trainers increasingly supporting clients with more severe mental health problems and in some areas, becoming a dumping ground for more complex cases. Health trainers provide time and support offered by no other service, they are a trusted community resource and as shown by the DCRS data, hugely successful in reaching those typically seen as hard to engage. We must ensure that the role of health trainer is protected and fully understood by other professionals to avoid inappropriate referrals. It is also vital that where health trainers are supporting those with mental health issues, they are provided with the necessary training and support from other services through more integrated working. Appendix A. Deprivation quintiles of clients, July 2012 July 2015 Deprivation Quintiles Count Percent No fixed abode Q1 Most Deprived Q2 Q3 Q4 Q5 Least Deprived Total % % % % % % % Page 14

18 Appendix B. BMI change for all clients, July 2012 July 2015 BMI Before After Change % C. Weight (Kg) change for all clients, July 2012 July 2015 Weight (Kg) Before After Change % D. Moderate exercise (30 mins per week) change for all clients, July 2012 July 2015 Moderate exercise Before After Change % E. Consumption of fruit and vegetables per day change for all clients, July 2012 July 2015 Consumption of fruit and vegetables per day Before After Change % F. Personal health plan achievement, part achievement and non-achievement rates for all clients, July 2012 July 2015 PHP outcome Count Percent Achieved Not Achieved Part Achieved % % % Outcome Unknown % Total % Page 15

19 References 1.NHS England. A call to action: achieving parity of esteem; transformative ideas for commissioners. Redditch: NHS England, BMJ. Tackling mental health will be central to white paper on public health. Available online at: bmj.com/rapid-response/2011/11/03/economic-burden-mental-illness-cannot-be-tackled-without-researchinvestme%20 (2010, last accessed 12th September 2015) 3. Mental Health Foundation. Mental health statistics: the most common health problems. Available online at: (last accessed 12th September 2015) 4. Mental Health Foundation. Economic burden of mental illness cannot be tackled without research investment. London: Mental Health Foundation, Government Office for Science. Mental capital and wellbeing: making the most of ourselves in the 21st century. London: Government Office for Science, Health Trainers England. About health trainers. Available online at: (Last accessed 3rd April 2014) 7. Bagnall A M, Trigwell J, White J. Health trainers end of year review 1st April st March Available online at: (2014, last accessed 12th September 2015) Page 16

20 For more information, please contact Emma Lloyd, Royal Society for Public Health John Snow House, 59 Mansell Street, London E1 8AN RSPH 2015 Charity Registration Number