Together for Mental Health. Public Health Wales NHS Trust Annual Report

Transcription

1 Together for Mental Health Public Health Wales NHS Trust Annual Report

2 Contents 1.0 Introduction from Public Health Wales 2.0 Mental Health and Wellbeing 2.1 All Wales Mental Health and Wellbeing Needs Analysis 3.0 Delivering Together for Mental Health 3.1 Promoting Better Mental Wellbeing and Preventing Mental Health Problems 3.2 A New Partnership with the Public 3.3 A Well Designed, Fully Integrated Network of Care 3.4 One System to Improve Mental health 3.5 Delivering for Mental Health 4.0 Summary and Conclusions: Looking ahead to 2014 and beyond Annex 1 Public Health Wales NHS Trust Report against Together for Mental Health Delivery Plan Actions Contributors: John Bradley Senior Health Promotion Practitioner, Phil Chick Mental Health Development Lead for Wales, Linda Davies Principal Health Promotion Specialist, Carol Foster Health Promotion Practitioner, Craig Jones Senior Health Promotion Practitioner, Rhiannon Hobbs Senior Health Promotion Practitioner, Su Mably Consultant in Public Health, Mary MacDonald Principal Health Promotion Specialist, Rosalind Reilly Specialty Registrar in Public Health, Pat Riordan Director of Health and Healthcare Improvement, Val Scoley Workplace Health Practitioner, Tracey Taylor Senior Health Promotion Practitioner, Bev Warburton Workplace Health Practitioner, Malcolm Ward Principal Health Promotion Specialist and Sue Wing Principal Workplace Health Practitioner.

3 1.0 Introduction Public Health Wales supports the World Health Organisation (2007), Royal College of Psychiatrists (2010), and Faculty of Public Health (2013) statements that: There is no health, without good mental health, in recognition of the fact that good mental health and a positive sense of wellbeing are central to living a healthy and longer life. Through evidence-based programmes and partnership working, Public Health Wales promotes mental health and wellbeing, supports health professionals and carers, and help to eradicate the discrimination and stigma associated with having a mental health illness. Public Health Wales welcomes this opportunity to report on its work to implement the Welsh Government Strategy Together for Mental Health. The report covers the work of Public Health Wales national teams, including the work of staff formerly based in NLIAH. It is assumed in this report that Local Health Boards reports will cover the work of the Local Public Health Teams. Chapter 1: Promoting better mental wellbeing and preventing mental health problems is structured along the life course, and describes initiatives targeting early years, school aged children, adults and older people. Chapter 2: A new partnership with the public focuses on inequalities in health, and our recent work in relation to offender health, and the health of homeless people. Chapter 3: A well designed, fully integrated network of care Chapter 4: One system to improve mental health Chapter 5: Delivering for mental health These chapters focus more on service improvement, and describe work taken forward by our colleagues who have joined Public Health Wales from NLIAH.

4 2.0 Mental Health and Wellbeing 2.1 Wales and UK data on mental health Mental Health in Wales and the UK Mental health problems are amongst the most common health conditions, directly affecting about a quarter of the population in any one year. Depression and anxiety are the most widespread conditions, while only a small percentage of people directly experience more severe mental illness. Mental health problems are the largest single source of disability in the United Kingdom, accounting for 23 per cent of the total burden of disease, more than cardiovascular disease and cancer (Department of Health 2011b). In Wales eleven per cent of adults have a diagnosed mental health illness. A higher percentage of women (14%) than men (8%) report being treated for a mental illness, (Welsh Government 2012). Socioeconomic group, poverty, poor education, unemployment, social isolation and major life events are major risk factors for mental health problems (Royal College of Psychiatrists, 2010). Figure 1 shows the percentage of adults in Wales treated for any mental illness in by local authority area. It suggests mental health is worse in the more deprived areas of Wales. Figure 1. Age standardised percentage of adults who reported currently being treated for any mental illness by local authority (Source: Welsh Health Survey 2012)

5 The Mental Health Inventory 5 (MHI-5) scale measures mental wellbeing in the population rather than numbers treated for mental ill health. MHI-5 combines the responses to 5 questions in the Welsh Health Survey which ask people about their state of mind and mood. Those with a score of 60 and over are considered to be free from a common mental disorder. Figure 2 shows the percentage of the population free for a common mental health disorder in by local authority area. Figure Proportion 2: Wales of population population free from free a common from a mental common disorder mental (as disorder Age-standardised measured by a Mental percentage, Health Inventory persons 5 score aged > 60), 16+, persons, by local authority. aged 16+, Wales local authorities, (Source: Public Health Wales Observatory, based on Welsh Health Survey data.) Produced by Public Health Wales Observatory, using Welsh Health Survey (WG) 95% confidence interval Wales = 75 Isle of Anglesey Gwynedd Conwy Denbighshire Flintshire Wrexham Powys Ceredigion Pembrokeshire Carmarthenshire Swansea Neath Port Talbot Bridgend The Vale of Glamorgan Cardiff Rhondda Cynon Taf Merthyr Tydfil Caerphilly Blaenau Gwent Torfaen Monmouthshire Newport Mental health has an impact on employment and productiveness. People with a common mental health problem aged between 16 and 74 years are more likely to be economically inactive (39%, compared with 28% of those with no mental health problem), and less likely to be employed (58%, compared with 69%) Stress, anxiety and depression accounted for a third of the 168 million working days lost in the UK for health and related reasons in 2004, translating to a cost of sickness absence of

6 about 4.1 billion. (Mental Health Foundation 2007) The overall cost of mental health problems in Wales in 2007/08 has been estimated at 7.2 billion a year (Friedi and Parsonage, 2009; Faculty of Public Health, (FPH), 2013) In 2011 suicide rates in those aged 15 and over in Wales rose to the highest level since 2004 at 13.9 per 100,000 people, and were higher than England at 10.4 per 100,000. The total number of deaths was 341, most of which were among middleaged men. (ONS 2013) Mental health of specific population groups Whilst mental health issues are common in the whole population, there are some groups who are particularly vulnerable to problems. Some key facts about these population groups are listed below: Children Most mental disorders have their origins in childhood, being evident by the age 14 years. (Royal College Psychiatrists, 2010) Conduct disorders are a serious, but often unrecognised mental health condition in children and young people (National Institute of Health and Care Excellence (NICE), 2013) It has been estimated that promoting mental wellbeing in a single year cohort of children in Wales could lead to benefits worth over 1 billion. Friedli and Parsonage 2009) This figure could be nearly 24 billion for the whole of the UK. Since benefits accrue across the lifecourse, promoting mental wellbeing in children provides more economic benefits than promoting mental wellbeing at other ages (Faculty of Public Health, FPH, 2013). Children of single-parent families are twice as likely to have a mental health problem as children of two- parent families (16%, compared with 8%). Also at higher risk are children in large families, children of poor and poorly-educated parents and those living in social sector housing. (Children s Society 2013) Children and young people growing up in poverty are vulnerable in many ways. They are more at risk of poor health, poor educational attainment, and have lower skills and aspirations. Children growing up in material deprivation have markedly lower wellbeing than their peers. (Children s Society 2013) The Children s Society uses the term materially deprived to describe children who do not have 5 or more items from their 10-item measure of material deprivation. Figure 3 shows the difference between materially deprived children and non-deprived children in relation to various aspects of their lives.

7 Figure 3: Difference between materially deprived children and non deprived children. (Source: Children s Society 2013) Older people The most common mental health problems in older people are depression and dementia. Depression affects 1 in 5 people over the age of 65 living in the community and 2 in 5 living in care homes. However, it is likely that this is an under-representation and only a small proportion of older people with depression are in contact with their GP or mental health services. An estimated 70% of new cases of depression in older people are related to poor physical health (Mental Health Foundation 2007). Other factors leading to depression are loneliness and falls. In the UK, one in three people aged over 65, and half of those aged over 80, fall at least once a year. (Todd and Skelton 2004) Around one in ten older people who fall become increasingly isolated as they are afraid to leave their homes in case they fall again (Age UK 2013). It is estimated that around 10% of those aged 65 and over are lonely all or most of the time. This equates to over 900,000 of the population.

8 (Age UK Oxfordshire, 2012) Loneliness puts individuals at greater risk of cognitive decline (James et al, 2011) and depression (Cacioppo et al, 2006; Green et al, 1992). Loneliness and low social interaction are predictive of suicide in older age (O Connell et al, 2004, Koponen, 2007). Dementia is more common as people age. One in 14 people over 65, one in 6 people over 80, and one in three people over 95 has a form of dementia. In 2011 there were just over 37,000 people living with dementia in Wales. With the changes in demography as people live longer, this number is predicted to increase by 31% by 2021, and by as much as 44% in some rural areas (Welsh Government 2011). Figure 4 shows the predicted increase in the numbers of people with dementia in Wales to This should be treated with caution as it is a prediction based on data published in 2007 and variable factors mean the situation could change. A matter for concern is the apparent difference between the estimated number of people with dementia and the numbers who have been diagnosed and are on the general practice QOF dementia register, as without a diagnosis, people with dementia cannot receive the support, information and treatment that they need to live well with dementia. (Figure 5)

9 Prisoners Prisoners have a higher risk of common mental disorders, suicide, psychosis, personality disorder and alcohol and drug problems (JCPMH, 2013) In a recent Prison Mental Health Needs Assessment undertaken by Public Health Wales, it was estimated that only 8% of the 3,300 prisoners held in Wales at any given time, did not have a mental health problem. An Office of National Statistics (ONS 1997) survey, using clinical interviews, found that 64% of prisoners were likely to have Personality Disorder, 7% psychosis (e.g. Schizophrenia), and 40% neurotic disorders (e.g. depression). Evidence also suggests that some mental health problems, especially depression, are more prevalent in certain types of prisoners, such as those on remand or older prisoners (ONS 1997; Kakoullis, Le Mesurier & Kingston 2010). Homeless people Homeless people have a higher risk of mental disorders with 27 per cent having probable psychosis,10 per cent with alcohol dependence, and 15 per cent with drug dependence (JCPMH, 2013) Comorbidity prevalence in the form of dual diagnosis (major substance disorder and major psychiatric illness) amongst the homeless population can be as high as 50-60% and is up to 5 times higher than that in the general population (JCPMH, 2013)

10 Other vulnerable groups 22 per cent of women have depression a year after birth. Immigrant, asylum seeker and refugee women are at higher risk (JCPMH, 2013) Adults with learning disability have double the risk of depression and have a higher risk of dementia (55 per cent in year olds) (JCPMH 2013) 22 per cent of lesbian, gay, bisexual and transgender people (LGBT) have a common mental disorder and 9 per cent have attempted suicide. Rates are also higher for transgender people (JCPMH, 2013) Black and minority ethnic communities (BMEC): South Asian women have the highest rates for common mental disorder) and black populations have a higher risk of PTSD, suicide attempt and psychotic disorder (JCPMH, 2013). Gender: in women depression, anxiety, parasuicide and self harm are more prevalent, whilst completed suicide and drug and alcohol abuse are more prevalent in men (National MWIA Collaborative, 2011, p23). Refugees and asylum seekers have a higher risk of mental disorders than the general population (JCPMH, 2013)

11 3.0 Delivering Together for Mental Health 3.1 Chapter 1 - Promoting Better Mental Wellbeing and Preventing Mental Health Problems What will this look like for Public Health Wales NHS Trust? As part of its response to the recent report on national health improvement programmes, Transforming Health Improvement in Wales, Public Health Wales has reviewed the evidence for the promotion of mental wellbeing and the prevention of mental disorder across the life course, and compiled an overview of current activity. The conclusions of this review will be taken into account over the coming months as Public Health Wales develops detailed plans to implement the recommendations of Transforming Health Improvement in Wales. Some key findings which will help guide the future direction of programme development and delivery are: Effective interventions There are a number of Tier 0 interventions/services that can make a significant impact on the population. The evidence shows that effective Tier 0 interventions/ services range from actions on the wider determinants of health such as housing interventions to interventions which may be more targeted, consistent with Marmot s proportionate universalism approach. Tier 0 is the stage before the level of primary care. Tier 0 services are accessible to the whole population, and can be accessed via self -referral or by referral from primary care or professionals working in higher tiers. Several high impact areas across the life course were identified from the evidence reviews. These include: Early years interventions, particularly parenting programmes School based mental health promotion programmes Work based mental health promotion Five Ways to Wellbeing Early intervention in psychosis Suicide prevention Ageing well interventions and prevention of dementia. Ongoing research and evaluation Local ongoing innovative Tier 0 interventions/services should be supported in developing evaluation frameworks, including economic evaluation, to build the evidence base for particular interventions. Programme reach Both universal and targeted interventions/services are needed for vulnerable groups across the life course. There is an opportunity for collaborative working arrangements for Tier 0 interventions/services in Wales. Large scale

12 introduction of effective interventions which are co-ordinated at a national level and delivered locally should lead to savings, maximise economies of scale, avoid duplication of resources and improve population mental health outcomes. Integration with other health improvement programmes Public mental health/mental health and wellbeing should be integrated within health improvement interventions across the life course, with specific targeting of vulnerable groups. The links between mental health and substance misuse should be strengthened, to identify opportunities to strengthen integrated approaches and share resources, expertise and networks. Key challenges 1. Implementing the recommendations of Transforming Health Improvement in Wales and subsequent change management of programmes and programme delivery. The Health Improvement Review has set a challenging timescale for the development and delivery of a new Health Improvement Transformation Action Plan by April The development of any new approach to promoting mental wellbeing sits within this framework, and will be influenced by factors affecting it, including the requirement to review the existing Mental Health First Aid programme (MHFA) delivered by MIND Cymru. The current contract for MHFA expires at the end of March MIND Cymru also delivers the Applied Suicide Intervention Skills Training programme. (ASIST) This is funded by the Big Lottery until the end of December Core dataset Work is ongoing to develop a Mental Health Core Dataset for all ages, phase 1is in development for launch in At present, Welsh health information systems are developed to measure mental ill health rather than mental health. However, from a public health perspective, monitoring population mental health is vital, as it concerns the whole population not only the proportion affected by mental ill health. The main challenge is to agree clear definitions for a core dataset which will allow monitoring of prevalence, and estimation of future need in Wales.

13 What have we achieved in the last 12 months? This section lists Public Health Wales achievements under the main headings of early years, school-aged children, adults and older people. 1. Early years programme Public Health Wales Early Years Programme was set up in 2010 to explore how we can bring together expertise from service, academia, policy and others to focus on early years giving every child a healthy start. Since then a number of rapid evidence reviews have been carried out, including one on maternal mental health. This describes the epidemiology and consequences of maternal ill-health, interventions provided in Wales, and the evidence of effectiveness of interventions for prevention and management. This agenda will now be taken forward by the All Wales Perinatal Mental Health Forum with participation from Early Years programme representatives. 1.1 Child Poverty The impact of poverty on the mental wellbeing of children is described in Section 2.1: Wales and UK data on mental health. Public Health Wales has developed a high level Child Poverty Strategy and Action Plan, which draws together activity across the whole organisation aimed at reducing inequities in health. This includes: The Early Years Programme The Newborn hearing screening programme The Newborn bloodspot Screening programme Childhood immunisations The Designed to Smile programme ASSIST (a peer led smoking prevention programme) The Teenage Pregnancy pilot project The development of minimum standards for locally provided Condom Card schemes The Stop Smoking Wales Service The Welsh Network of Healthy Schools Schemes The Sustainable Communities Pathfinder Project Action to promote and protect the health of vulnerable population groups, including those who are homeless, asylum seekers and refugees, gypsy and traveller groups. All of these are considered to be programmes which will reduce inequities and therefore help to reduce child poverty. All are large programmes in themselves and it is not possible to report their progress within this document. If required, further information can be found in Public Health Wales Child Poverty Action Plan update, April 2013, which is available at:

14 2. School-aged children 2.1 Healthy and Sustainable Pre-School Scheme Over the last year Public Health Wales worked with settings involved in the Healthy and Sustainable Pre-School Scheme to achieve the national award criteria for mental and emotional health, wellbeing and relationships by September Over 350 local pre-school settings are now actively involved, and 43 achieved the national award criteria, supported by their local Welsh Network of Healthy School Schemes (WNHSS) Co-ordinators. 2.2 Welsh Network of Healthy School Schemes (WNHSS) 99.9% of all primary and secondary schools in Wales are actively involved in the Welsh Network of Healthy School Schemes. Public Health Wales is currently supporting the local healthy school schemes in implementing the mental and emotional health and well being indicators as part of the Welsh Network of Healthy School Schemes National Quality Award (NQA) by December Estyn has provided new guidance which now includes inspecting well being and this will give more comprehensive detail on children s mental health and wellbeing. 3. Adults 3.1 Healthy Working Wales Programme The Healthy Working Wales programme comprises a number of different schemes to support employers, employees and health professionals to improve health at work, prevent ill health and to support return to work following ill health. These are the Small Workplace Health Award, the Corporate Health Standard Award and Workboost Wales. In addition, Public Health Wales is engaged with health professionals to raise awareness of the health benefits of work and promote the appropriate use of the fit note in primary care. The Corporate Health Standard and the Small Workplace Health Award are the quality marks for workplace health promotion awarded by the Welsh Government. Awards are presented in bronze, silver and gold, with an additional level of platinum for the Corporate Health Standard. Small Workplace Health Award Issues that may affect mental health are introduced at silver award level. Employers are required to consider issues such as engaging employees in consultation, measuring staff satisfaction, and ensuring that staff health and wellbeing is a regular item for discussion with senior managers. They also need to demonstrate how pressure and stress in the workplace is managed, including consideration of the Health and Safety Executive s (HSE) Stress Management Standards, provision of information to employees on prevention of stress and promotion of well-being and creating a culture that does not tolerate inappropriate behaviour between employees.

15 In the past year, with the support of Public Health Wales 165 organisations have committed to work towards at least the bronze level of the Small Workplace Health Award. 108 have achieved an award, 88 bronze, 18 silver and 3 gold. Types of organisation range from children s nurseries to charities and small housing associations. Corporate Health Standard Employers of over 50 members of staff are able to work towards the Corporate Health Standard (CHS), which introduces mental health promotion into the criteria at bronze level and builds on the requirements at silver level. o At bronze level organisations are expected to have a mental health promotion policy in place and risk assess for stress. An improvement plan using the HSE s Stress Management Standards should be developed showing control measures to prevent work related stress disorders. They will also need to demonstrate what policies and procedures they have in place to allow flexible and family friendly working practices. o At silver level, organisations need to evidence their commitment to the principles of the HSE s Management Standards, to have trained managers and staff to identify the signs and symptoms of stress and how to manage them and to make support and counselling available for all staff. The organisation is expected to recognise that mental illness is not necessarily a barrier to effective working and that providing employment and maintaining people in work is a positive way of supporting individuals who are recovering from mental health problems. In the past year, with the support of Public Health Wales 53 organisations have committed to working towards the Corporate Health Standard at bronze level or above. 27 awards have been achieved; 7 bronze, 6 silver, 10 gold and 4 platinum. Organisations range from large employers such as the seven health boards in Wales, to smaller third sector and private organisations employing staff. Workboost Wales Public Health Wales Workboost practitioners provide small businesses with one to one support to develop the systems and processes they need to manage the health, safety and wellbeing of their workforce. Managing pressure and building resistance is one of the four core topics discussed during a Workboost intervention. Workboost practitioners have given information and guidance to 472 organisations employing 5500 employees over the period about a range of topics including managing pressure and building resilience. In Swansea, a pilot workshop for managers and supervisors called How to Manage Stress in the Workplace was very well received. There are plans to repeat the workshop in four other areas; Pembrokeshire, Carmarthenshire, Ceredigion and Neath Port Talbot over the next few months.

16 3.2 Have a Word The Alcohol Brief Intervention Training Programme Although the amount most people drink poses a relatively low risk to their health, an estimated 24% of adults drink a hazardous or harmful amount (The NHS Information Centre 2009). Alcohol is linked to social problems, crime, domestic violence, absenteeism and loss of employment (NICE, 2010). The impact on other family members can be profound, leading to feelings of anxiety, worry, depression, helplessness, anger and guilt. Co-morbid mental health disorders commonly include depression, anxiety disorders and drug misuse, some of which may remit with abstinence from alcohol but others may persist and need specific treatment (NICE,2011). An alcohol brief intervention is a short, evidence-based, structured conversation about alcohol consumption with a client to motivate and support the individual to think about and/or plan a change in their drinking behaviour in order to reduce their consumption. Alcohol brief interventions have been shown to be effective. (NICE, 2010). Public Health Wales has been delivering the evidence-based Have A Word alcohol brief intervention training programme since 31 March 2012, and has trained approximately 3,500 people from a range of different disciplines and professions within the public and third sectors. The number of people trained by Health Board and South Wales Police is shown in Figure 5. Figure 5: The Have a Word Alcohol Brief Intervention Training Programme, 1 st October 2012 to 30 th September 2013 by Health Board and South Wales Police Total ABHB ABMU BCU C&V CTHB HDHB Powys SWP Total 0 0

17 3.3 All Wales Mental Health Promotion Network The All Wales Mental Health Promotion Network was established in July 2007, to provide leadership and support to practitioners working on public mental health in Wales. It presently has approximately 600 members covering all sectors and geographies in Wales. The network is supported by an Advisory Board comprising representatives from key stakeholder organisations. Amongst the routine outputs the network provides a quality assured website; a quarterly electronic newsletter interspersed with e-bulletins; downloadable resources; a national Good Practice Scheme & award; access to training opportunities and an annual National conference. In addition the network facilitates consultations on relevant topics and commissions research, resources and support where indicated, e.g. Promoting Mental Health and Preventing Mental Illness: The Economic case for Investment in Wales by Friedli & Parsonage There are presently 360 different downloadable resources available via the resources database on the network website. The 2013 Annual Conference; Together for Mental Health Promotion: Embedding Mental Health Within Broader Population Health and Wellbeing Approaches, was held at Venue Cymru, Llandudno on Wednesday 19th March 2013 and was attended by 75 delegates. The Conference focused on a key theme within the Together for Mental Health Strategy of linking mental health and wellbeing within the broader health and wellbeing agenda through the life course. The conference was well received with considerable positive feedback and the documents including presentations, evaluation and conference report are available via the website at Work is currently ongoing to provide the next conference on Innovation and Coproduction. 3.4 Mental Health First Aid (MHFA) Public Health Wales oversees delivery of the Mental Health First Aid adult and youth training programme which is delivered by Mind Cymru. MHFA trains participants to recognise the signs and symptoms of someone with mental health problems; to respond to various mental health crises, and to engage with, support and signpost people to appropriate help.the programme is on target to achieve the prescribed numbers of people trained this year, and has exceeded annual targets in previous years. Mental Health First Aid numbers trained YMHFA 463 MHFA 1599 Total trained 2062 Total number of MHFA Instructors trained YMHFA 0 (courses cancelled due to lack of interest) MHFA 20 Total 20

18 3.5 The National Exercise Referral Scheme (NERS) Exercise improves mental health and well-being, reduces depression and anxiety and enhances cognitive functioning. Although exercise can improve the quality of life of those living with mental health problems, its value is seldom recognized by mainstream mental health services. The evidence suggests that exercise may be a neglected intervention in mental health care. The National Exercise Referral Scheme is provided in every county. It provides a service to people suffering from a range of defined health conditions whose health would be improved by increasing their physical activity levels through an evidencebased, structured and supervised exercise programme. Referrals are received from a range of health professionals including community mental health teams, and there is a specific NERS pathway for referral of clients with a mental health diagnosis. All NERS instructors are qualified to a minimum Level 3 on the Register for Exercise Professionals and there are currently 28 instructors with the specialist mental health qualification covering 15 of the 22 local authority areas. The NERS database is being updated and enhanced as data by specific conditions are not currently identifiable. This is being addressed and in the period April to June 2013, 61 people from 4 local authority areas were referred with a primary diagnosis of a mental health condition. The majority of referrals into NERS have multiple morbidities and it is estimated that somewhere between 30-45% have mild to moderate anxiety or depression in addition to their primary physical illness diagnosis. In 2013 there were a total of 26,569 referrals to NERS (for all conditions) of which 18,475 attended for consultations, and 9,185 entered and completed the 16 week programme. 4. Older People 4.1 Over 50s Health and Wellbeing check Welsh Government has asked Public Health Wales to develop the online 50+ Healthcheck, a commitment in the Programme for Government. The aim is to support and empower people over 50 to have greater control over their own health and wellbeing. Health checks are part of a greater shift in emphasis towards improving and protecting health, rather than simply treating illness. The online programme called Add to Your Life asks participants to enter some key details about their health and lifestyle, and based on the response, provides information and links to further support. Third sector volunteers are being trained to support those older people who cannot use an online system or have no access to a computer. The questions are wide ranging and there is a specific section focusing on emotional health and wellbeing. 4.2 Ageing Well in Wales Public Health Wales is working with the Ageing Well in Wales programme, which was launched in November 2012 and is hosted by the Older People s Commissioner

19 for Wales. This is a 5-year collaborative programme which aims to promote positive attitudes and improve the wellbeing of people aged 50+ living in Wales by harnessing, supporting, and scaling up local action through the development of 4 thematic networks focused on: Age-friendly communities Dementia supportive communities Falls prevention Opportunities for employment and new skills There are clear links between these themes and the promotion of mental wellbeing. Age-friendly communities will provide the supportive local context within which older people are valued, are actively engaged with their local community and enabled to thrive as they grow older. Dementia supportive communities pay particular attention to the needs of people living with dementia, for example modifying the physical environment to make it easier to navigate (e.g. through clear signposting and use of colour) as well as providing awareness training for frontline staff in local shops and cafes. Work to prevent falls helps older people to remain independent, and avoids the social isolation and depression that can result from fear of falling. Enabling people aged 50+ to gain new skills and increase their chances of finding work, or engage in meaningful voluntary work, reduces isolation and increases self-esteem. In the last year the programme has gained 3 star reference site status for Wales with the European Innovation Partnership for Active and Healthy Ageing, in recognition of the achievements of the Welsh Government s Strategy for Older People. This will facilitate collaboration with other EU countries and regions on healthy ageing initiatives, and collaborative bids for EU Horizon 2020 funding. 3 initial engagement events have been held on Age-friendly Communities, Dementia Supportive Communities and Falls Prevention, and the networks to advance these areas of work are currently in development. What are our service innovations? The EU Drivers Project The DRIVERS project is a European funded research project that is exploring some key drivers of social determinants of health. Public Health Wales is providing a case study using a retrospective analysis of the Mental Health First Aid programme in Wales to inform a work stream that is looking at fair employment and health. The project, supported by Cardiff University and Welsh Government will also be comparing other mental health interventions in the workplace. These are Mental Health First Aid Lite, Beyond Blue, and a workplace bi-polar resource. The results of this research will also feed into the review of MHFA. (See section on Chapter 1: Key Challenges) NHS Expenditure and Health Tool Public Health Wales Observatory has produced a report and interactive tool that presents NHS expenditure data alongside measures of health and health care.

20 The aim of the work is to highlight issues and provide a public health context to the expenditure data. Whilst it may explain some aspects of the variations in expenditure between health boards, its main purpose is to raise questions for exploration and further consideration. The six budgets included are : Mental health problems Circulation problems Cancers & tumours Musculoskeletal system problems (excluding trauma) Respiratory problems and Healthy individual Where do we require further action? All of Public Health Wales Delivery Plan actions for Chapter 1 are being progressed. Our priorities for the next 12 months Outcome 1: To ensure that mental wellbeing is given equal priority/integrated with physical wellbeing in the development and delivery of policy, programmes and services. Mental Health Promotion Network to continue to disseminate evidence based information. MHPN Board to identify mental health awareness training package including the use of the mental wellbeing impact assessment tool exploring potential for integration with equality impact assessment tool Rollout and evaluation of the online 50+ health check Further consideration is given to the Mental Health First Aid programme. Outcome 2: People and communities are more resilient and better able to deal with the stresses in everyday life and at time of crisis Schools continue to work towards the WNHSS NQA Increased rate in the uptake of Book Prescription Wales (BPW) Public Health Wales to continue to lead the National Suicide and Prevention Self harm Advisory Group (NSSPAG). Production of a draft suicide and self harm prevention for Ministers to consider by January 2014 Outcome 3: Child Welfare and development, education attainment and workplace productivity are improved as we address poverty WG and Public Health Wales to encourage Corporate Health Standard and Small Workplace Health Award employers to share and promote best practice. Ensure that employers have access to information on health and wellbeing.

21 3.2 Chapter 2 - A New Partnership with the Public Public Health Wales believes that inequalities are unjust and will work with partners across Wales to drive strategies, implement policies and advocate, on behalf of those most in need. Public Health Wales supports evidence based programmes that target resources in line with a universal proportionalism approach (Marmot, 2010). What are the key challenges facing us? Austerity and scarce resources 1. The recession and spending cuts have had serious consequences on the Welsh economy. The austerity measures have meant that education and social services, key components of the determinants of health, are under real pressure. 2. Welfare reform is another immediate challenge for Wales. The recent Welsh Government analysis of the impact of the UK Government welfare reforms in Wales highlighted that single parents who are out of work, most of whom are women, are one of the groups that will incur the largest reduction in benefit and tax credit entitlements (Welsh Government 2013) The 2013 Chief Medical Officers Report draws attention to the fact that Wales has a higher dependence on welfare benefits than the UK as a whole, and benefit reform is likely to cause households in Wales to lose 4.1 per cent of their income ( 1,110 per year) on average, compared to 3.8 per cent across the UK. Families with children are likely to lose proportionately more of their income. The income of disabled people has been greatly reduced; some carers of disabled people will also lose some of the support they currently receive as a result of the welfare reforms. What have we achieved in the last 12 months? Reducing inequalities for vulnerable groups 1. Offender health Prison Mental Health Needs Assessment (MHNA) In 2013 Public Health Wales carried out a Mental Health Needs Assessment (MHNA) of Welsh prisons. A key conclusion was that only 8% of the 3,300 prisoners held in Wales did not have a mental health problem. The main findings were summarized into the estimated level of mental health need and the structure, process and outcome of the prison healthcare system. A number of recommendations were made in relation to:

22 Pathways and procedures Staffing Treatment/services Training Assessments SystemOne (Health data collection programme for prisons) Research A task and finish group to implement the recommendations was set up in August and is due to complete its work by April Homeless People Homeless people are 40 times less likely to be registered with a GP compared to the general public, creating a heavy and expensive reliance on A&E departments. Access to primary and secondary care is paramount for effective health care for individuals experiencing homelessness and for people with serious mental illness. In 2012/2013 Public Health Wales produced 3 guidance documents in relation to homelessness: Standards for improving the health and wellbeing of homeless people and specific vulnerable groups This was a revised version of an earlier publication, and was launched in March The Good Practice Guide on Mental Health and Housing The Good Practice Guide for the Health of Homeless Young People In addition, Public Health Wales has continued to host and chair meetings of the All Wales Health and Homelessness Advisory Group 3. Welsh Language In 2013 Public Health Wales undertook a comprehensive Welsh Language Audit, and is rolling out implementation of its Welsh Language Action Plan, to be completed by October Information and support to enable people to improve and self manage their mental health. Public Health Wales Mental Health Promotion Website database of relevant research and evidence is maintained and updated at least weekly. Downloadable resources are available on network website. In addition, a review of the network website is planned, to include new sections on the Five Ways to Wellbeing and revised content for each of the Areas of Interest elements. Public Health Wales oversees delivery of the Mental Health First Aid adult and youth training programme which is delivered by Mind Cymru. The programme is on target to achieve the prescribed numbers of people

23 trained this year, and has exceeded annual targets in previous years. Since the launch in October 2013, 1145 people have been trained in adult Mental Health First Aid (MHFA) and 357 people have been trained in youth MHFA. 5. Workplace Policies Public Health Wales has employment policies to address health at work and stress. In addition, when new policies are being developed their impact on mental wellbeing are considered. An independent counselling service is provided for staff. Public Health Wales has identified a number of issues from the staff survey which are being addressed, e.g. actions relating to bullying and harassment at work. Most HR staff have been trained on MHFA and dignity at work advisers have been identified. Public Health Wales has made a commitment to the Mindful Employer Initiative in Service User engagement The Wales Alliance for Mental Health (WAMH) and Mental Health Action Wales (MHAW) have been working together to develop a mechanism to ensure that service users of all ages and their families and carers are fully involved in service development. National forum members are overseeing the recruitment process for long-term service user and carer members for the National Partnership Board, who should be in place by December Interim members are in place until that point. Quarterly meetings have been established with mental health service user representatives as part of MHAW. In 2013 the annual MHAW conference was run as 3 regional events to facilitate representative service user and care involvement in local Mental Health Partnership Boards and on the Welsh Government National Mental Health Partnership Board, through establishment of a National Forum in partnership with WAMH.

24 Where do we require further action? Outcome 4: People with protected characteristics and vulnerable groups, experience equitable access and services are more responsible to the needs of a diverse Welsh population. 4.1e Public Health Wales to provide guidance and signposting information for LHBs and LAs on dealing with service users with protected characteristics by December Public Health Wales have asked the National Partnership Board to agree to an extension of the deadline to March Our priorities for the next 12 months Outcome 4: People with protected characteristics and vulnerable groups, experience equitable access and services are more responsible to the needs of a diverse Welsh population. 4.1e Public Health Wales to provide guidance and signposting information for LHBs and LAs on dealing with service users with protected characteristics by December See previous box. Outcome 6: People in Wales have the information and support they need to sustain and improve their mental health and self manage mental health. 6.1 To ensure that people of all ages are better informed about mental health and mental illness, with age appropriate information being available. Public Health Wales to expand the range of information on mental health and selfmanagement books to other physical health conditions available to the public and practitioners on the Mental Health Promotion Network Website. Outcome 9: Families and carers of all ages are involved in assessments for support for their caring roles. 9.1 To ensure support for families and carers through implementation of the Carers (Wales) Measure 2011 Outcome 10: People of all ages and communities in Wales are effectively engaged in the planning delivery and evaluation of their local mental health services To ensure that service users of all ages and their families and carers are fully involved in service development. Continue to support work on co-production approaches in mental health, including public health engagement and service user involvement.

25 3.3 Chapter 3 - A Well Designed, Fully Integrated Network of Care Public Health Wales is working with partners and the people of Wales to support the implementation of the Mental Health Strategy. It is also working with partners to tackle the discrimination and stigma associated with having a mental illness. The 1000 Lives Improvement Service is working with LHBs within Wales to ensure that service improvement methodologies drive up the quality of mental health services and the manner in which mental health problems are addressed by acute care services. What are the key challenges facing us? 1. Realising large scale sustainable improvement A key challenge in developing a well designed and fully integrated network of care is that of realising large scale sustainable improvement. The breadth of mental disorders across the life course, the continuum of severity and the range of agencies involved in delivering mental health provision leads to extreme complexity. 2. Problems of reach across a complex system Facilitation, networking and the application of improvement approaches are vital to bringing about closer integration of effective services. The complexity and scale of mental health services lead to problems of reach across the service system. What have we achieved in the last 12 months? The development of integrated services 11.3 To ensure substance misuse co-occurring with mental health problems is managed effectively. Co-morbid substance misuse and mental health problems. To ensure substance misuse co-occuring with mental health problems is managed effectively, local Mental Health Partnership Boards (LMHPB) and Substance Misuse Area Planning Boards (SMAPB) are to ensure that all relevant staff are trained to recognise and respond to people with co-morbid substance misuse and mental health problems. Work is underway to evaluate the number of LMHPB/ SMAPB areas with protocols in place to improve the coordination of services to people with co-occurring mental health and substance misuse problems. Guidance previously issued by WG is being reviewed with a new document planned for publication in Lives Improvement Service is working with the Welsh

26 Government substance misuse branch to undertake this work Lives Improvement Service and Public Health Wales vulnerable adults team are reviewing e-learning materials for their applicability within Wales as a resource to enable SMAPB/LMHPBs to ensure relevant staff are trained in co-morbid mental health conditions To improve physical and mental health care for those with chronic conditions including mental health problems. Dementia Dementia care improvement is now a first order priority for general health care across NHS Wales and the focus of the 1000 Lives+ Improvement programme has moved from a national focus, to bespoke support to individual Health Boards for delivery of their local priorities. Health Board strategies are increasingly focused outwith the NHS, towards partnership working for the development of dementia supportive communities. NLIAH and 1000 Lives + have provided training materials for Health Boards. This training enables HB staff who come in contact with older people, to ensure that they recognise and respond to signs and symptoms of mental illness such as depression, dementia, co-morbid conditions and other functional illness in older people Lives + have developed dementia intelligent targets for Health Boards to implement across Wales. Implementation of these has progressed through pilot sites to wider roll out across Health Boards for dementia care, first episode psychosis and eating disorders. The greatest take up and reliable spread of the improvement measures has been achieved in respect of dementia care improvement, particularly target 1 for Memory Assessment services, target 2 for General Hospital settings and Target 5 for Psychiatric inpatient Units across all Health Boards. The implementation of Target 2 has been integrated and driven through Health Board Action Plans for the Royal College of Psychiatry National Clinical Audit of dementia care. Some excellent pilots of target 3 have been delivered, to improve appropriate use of anti-psychotic medications in community settings. The challenge now is how to spread the improvement methodology to all relevant providers of residential nursing and home care. 12.1: To ensure the expansion of primary care mental health services. Part 1 of the Mental Health (Wales) Measure Lives Improvement Service are leading on or contributing to a number of aspects of the measure. These are outlined below: Chairing of Mental Health (Wales) Measure Implementation group to support service led implementation of all four parts of the Measure s requirements. This includes the development of compliance inventories for all Parts of the Measure and 6 monthly reviews.