Towards a Mentally Flourishing Scotland: The Future of Mental Health Improvement in Scotland 2008-11
This paper outlines the proposed future direction for mental health improvement and population mental health for 2008-11. It builds on the work of the Scottish Government's National Programme for Improving Mental Health and Wellbeing ( www.wellscotland.info).
In setting the future direction, the paper focuses on what Local Authorities, NHS Boards and other key stakeholders can do to support the agenda for 2008-11. It asks for your views on these suggestions and on the support that you think may be required nationally and locally to help meet these suggested actions within the proposed future direction for mental health improvement and population mental health.
Following local and national discussions on these suggested actions and supports, an Action Plan will be developed by the Scottish Government for national and local implementation from April 2008 until March 2011.
Mental health improvement and population mental health work have advanced considerably in Scotland since 2001 and Scotland is now recognised internationally for its work. There are areas of excellence, but we need to build on these and do even more, especially to address inequalities and to ensure that the mental health and wellbeing of Scotland's people flourishes.
This work forms part of the Scottish Government's wider health and wellbeing ambitions for a Healthier Scotland and is integral to addressing health and social inequalities. The future direction also adds to and complements a range of policies, not just on health and wellbeing, but for achieving the wider strategic objectives of the Scottish Government.
We wish to see a Scotland where we all understand that there is no health without good mental health, where we know how to support and improve our own and others' mental health and wellbeing and act on that knowledge, and where our flourishing mental health and mental wellbeing contributes to a healthier, wealthier and fairer, smarter, greener and safer Scotland.
1.1 To achieve this vision we will work across Government and with stakeholders to improve mental health, tackle health, social and economic inequalities, prevent, treat and care for mental illness and improve the quality of life for people living with mental illness.
We believe that people have a capacity for change and are able to achieve productive change in their mental health, both in how they feel and how they live their lives. We also believe that national and local Government and other agencies are able to help set the context, conditions and opportunities for this change in ways that are helpful and supportive to achieving better mental health for all.
3.1 Mental health improvement is an essential part of achieving the Government's social, health, economic and cultural objectives and for addressing health and social inequalities. By concentrating on mental health improvement, considerable progress will also be made in addressing the growing range of problems that manifest themselves where poor mental health exists, for example in excessive drinking, substance misuse, violent and abusive behaviour, self harm and suicide, obesity and poor sexual health.
3.2 Building on the many excellent national and local developments to date, a key objective of the next stages of work is to extend the reach of mental health improvement knowledge and actions into policy and public service delivery, most notably outwith the healthcare system, as part of supporting improved public wellbeing.
4. Concepts and Definitions
There is continuing debate about what mental health and mental wellbeing mean, about the underlying causes of mental health problems and about the best ways to maintain and improve mental health and mental wellbeing. However, the general concepts of what we mean by mental health are becoming clearer and we are now able to define and measure mental health as something positive.
4.1 In this paper, mental wellbeing refers to three main dimensions - emotional, social and psychological wellbeing. This includes our ability to cope with life's problems and make the most of life's opportunities, to cope in the face of adversity and to flourish in all our environments; to feel good and function well, both individually and collectively. Mental wellbeing ranges from good or high mental health, or flourishing, at one end of a continuum to poor mental health, or languishing, at the other end of the continuum.
Mental health problems generally refer to having difficulties with our mental health which affect how we go about our everyday lives. Mental illness refers to clinically identifiable illnesses or conditions that affect our cognitive functioning. Similar to mental health, mental illness can be described as a continuum from high levels of mental illness to low levels of mental illness.
4.2 It is important to recognise that someone can experience signs and symptoms of mental illness and still have good or flourishing mental wellbeing just as people with a physical illness or condition can live positively and flourish and have a good sense of wellbeing. Similarly, someone may have significant mental health problems, but not have a clinically identifiable mental illness. This is because mental wellbeing, mental health/ill health can be identified as being on two different continua. These are represented in the diagrams 1 below.
5. The main themes for population-based mental health improvement
Population mental health addresses the needs of the whole population, covering known risk and protective factors and addressing often underlying structural issues that can help or hinder mental health and wellbeing, such as strong communities and access to meaningful work (help) or discrimination and poverty (hinder). It also involves targeting efforts at people, families, groups, communities and geographical areas that are at greatest risk of poor mental health and who may have complex and multiple needs.
5.1 There is a good evidence base to show that mental health and wellbeing can be promoted, learned, strengthened, developed and sustained and, equally, it can be eroded, undermined or put at risk. This is not just about individuals or about how we behave: it can be undermined or supported by wider factors - our work environment, our physical environment, by what we have available to us, our opportunities and by wider social, health, economic, political or cultural factors.
5.2 We need to enhance people's mental health and wellbeing, so that they are able to flourish. We also need to reduce the occurrence of mental health problems and mental illness and improve the quality of life of people living with on-going mental health problems or illness.
5.3 The work now needs to be taken forward through action on three main themes: promotion, prevention and support.
- Promote and improve mental health through a focus on increasing key protective factors and reducing key risk factors. The promotion of mental health is complementary to improved physical health, the prevention of mental illness and physical illness, and to achieving improvements in the quality of life of people experiencing mental and physical conditions and illnesses. (See also Keep Well)
- Prevent mental health problems, mental illness, co-morbidity and suicide, with a focus on key risk and protective factors. This should include a focus on the prevention of more common mental illnesses (such as depression and anxiety), on psychoses, and on the interaction between mental illness and other health conditions, such as heart disease, cancer and diabetes and other long-term physical conditions. (See also Commitments 3, 5, 7 and 10 of Delivering for Mental Health.)
- Support improvements in the quality of life, social inclusion, health, equality and recovery of people who experience mental illness, to include further work on addressing stigma and discrimination, recovery and on promoting equality of opportunity in areas such as employment, housing, education, cultural, sporting and recreational activities. People with a mental illness are among the most excluded in our society. (See also Commitment 1 of Delivering for Mental Health.)
5.4 Promoting positive or flourishing mental wellbeing applies to each of the above main themes of promotion, prevention and support. Promoting and improving mental wellbeing, encouraging and supporting the factors that enable people to flourish and reducing the risk factors that hamper flourishing, means that this applies equally to people in the top left and the bottom two quadrants of the two continua model for mental health.
6. The main target groups
The underpinning focus for health improvement in 2008-11 is addressing inequalities. We know that good mental health and flourishing mental wellbeing are not equally distributed across the population. Similarly, mental health problems and mental illness are not randomly distributed across populations: although mental health problems will affect one in four people, it will not just be any one in four people.
Those who are subject to discrimination in its many forms (such as racism, sexism, homophobia, ageism, discrimination on the grounds of disability) or are victims of violence or abuse or who are socio-economically deprived are more likely to experience poor mental wellbeing and are more likely to be at risk of developing mental health problems or illness.
Any work that takes a broad approach (rather than individual interventions), as population-based mental health improvement work does, should ensure that particular focus is paid to the actions, accessibility and applicability of messages to a variety of settings and to targeting efforts at those who need it most. This includes work in the promotion of mental wellbeing and in the prevention of mental health problems and illness and improving the quality of life of people experiencing mental health problems or illness.
6.1 Targeted groups for local and national action could include:
- People in institutional settings, such as those in secure care or subject to detention, or people living in care homes or long-term nursing care settings.
- People in non-health care settings, such as veterans or the homeless, who may not otherwise be reached by traditional health care or health improvement approaches.
- People with physical and/or mental illness, people with alcohol problems, people misusing drugs, people who are victims of violence and abuse, people who are perpetrators of violence and abuse.
- Looked after and accommodated children, children whose parents have problems with drugs and/or alcohol, children whose parents have a mental illness.
- People without access to key assets or resources.
- People and groups who experience discrimination.
These above groups are illustrative, and have been identified to highlight the need to be aware of the many groups of people that will need to be targeted for promotion, prevention and support actions.
6.2 Efforts to promote mental wellbeing should also range across the life course from the early years to later life.
6.3 The best research evidence suggests that particular attention and emphasis is given to the early years of life and also to the mental wellbeing of children and young people, especially those who are at greatest risk of mental health problems.
6.4 As well as identifying which people to focus attention and efforts on, and the importance of taking a life stages approach, emphasis also needs to be given to the places and settings where people live, learn, work and play. This will involve giving prominence to work in employment and workplace settings; educational settings - particularly schools, colleges and universities; to sport, recreational and cultural settings; to institutional settings such as prisons and care homes and also to built communities and both urban and rural living.
6.5 Future efforts on promotion, prevention and support are likely to see significant overlap in their target groups and settings.
[See Appendix A for some helpful references on concepts, definitions and evidence for mental health promotion and prevention]
[ Appendix B sets out examples of some key risk and protective factors for mental health]
7. Suggested Actions for Local Areas for 2008-11
7.1 What needs to happen now?
Mental health can be improved, just as physical health can be. Positive mental wellbeing can contribute to positive social, health and economic outcomes. The Government's National Programme for Improving Mental Health and Wellbeing ('the National Programme') and its many partners have made significant strides since 2001 in mental health improvement. We now wish to go further. We now want to help, assist and reach those people, agencies and organisations that are unsure about what the priorities should be, or uncertain if there is a good enough evidence base for action, or are unclear how their particular area of work can make a positive contribution to this agenda as part of work on improving health and wellbeing.
7.2 Since 2001, the National Programme has been focused on national actions and supports with a main emphasis on process and outputs - for example, getting attention to the issues, increasing skills and capacity through training courses, commissioning research and evidence, promoting awareness, carrying out public and community campaigns. We now wish to turn our attention more to outcomes as well as process and ask and assess - what differences are the many programmes of work and linked activities making to Scotland's people? What actions need to be taken forward locally? What national supports would help? And how can progress be tracked and performance assessed?
7.3 People are keen to take this work forward, to contribute and build on the momentum already generated and are asking what the future priorities for action should be now. This paper attempts to provide some suggestions for people to consider. As with Delivering for Mental Health we are keen to engage with a range of national and local agencies and stakeholders to: agree common objectives to be taken forward across Scotland; to suggest and agree commitments for local action; to identify what national supports would help in the achievement of these objectives and commitments; to discuss how best to track and assess performance. This process aims to build a shared and common understanding of what we will do together for the next 3 to 4 years.
7.4 Below we list some proposed main themes for future work - promotion, prevention and support - and suggestions for local actions. These are for you to consider in discussion with your local partners. We then suggest a number of ways in which support for national and local action can be provided to help meet these expectations, again for discussion.
7.5 Based on national and local discussions about these proposals over the next three months or so, we will then develop specific actions, objectives and commitments for implementation from April 2008-11.
8. Broad Themes for Action
8.1 The broad themes for action centre on promotion, prevention and support. Each of these is outlined below.
8.2 Achieving all the following will involve clear local strategic planning in relation to the core responsibilities of local authorities, the NHS and other community planning partners in addressing health improvement, regeneration, social inclusion, education and economic development.
8.3 Promote and improve mental health and promote and improve mental wellbeing
Many of the key risk and protective factors for mental health and mental wellbeing are similar. We therefore suggest that efforts are made to promote and embed the skills, attributes, belief, values and circumstances that increase resilience, self-efficacy, a sense of mastery, coherence and control, individually and collectively. Increasing these attributes enables people to realise their abilities and to flourish, contributing to greater optimism, hope and an ability to cope with the challenges of life. Work in this arena must include the promotion of mental wellbeing for people living with, and/or recovering from, both physical and mental illnesses and should address the specific challenges faced by people who are subject to discrimination in its many forms (see the Fair For All strands).
8.3.1 Work in this arena should draw on the available and developing evidence base and the body of growing experience. More will be done to help make this evidence more readily available, accessible and transferable. Where work is innovative and new, or where work is being tested and piloted, evaluation should be built in from the beginning. This is to ensure that changes and adaptations can be made as the work progresses and also that valuable lessons of learning for future larger scale work can be identified and shared in ways that contribute to the research evidence and practice experience.
8.3.2 Any work should have a population-based approach while addressing specifically those areas of the country and communities and groups where people are more likely to experience poorer mental wellbeing (see Section 6.1, for main target groups)
8.3.3 Part of this approach could include ensuring that key workers (social workers, teachers, healthcare staff, community workers, employment support staff and other key public services staff) are mental health and mental wellbeing literate, so that this becomes an embedded part of their work and practice. Mental health and wellbeing literacy should include a recovery-oriented approach, so that people with a mental illness are enabled to lead and direct their own wellbeing and recovery.
8.3.4 There is evidence to show that concentrating efforts on the early years of life, from before birth to up to 8 years old, and more generally on the mental wellbeing of children and young people, is likely to bring the best long-term outcomes of improved population mental health.
8.3.5 Any work should ensure that it helps foster the social and economic conditions that enable people, families and communities to flourish.
8.4 Prevention: Raise efforts around prevention of mental health problems, mental illness and suicide.
There is a continuing debate around the extent to which nature or nurture affects mental health and mental wellbeing; both have a significant part to play. Work in this arena should therefore promote the determinants of good mental health and mental wellbeing. It should also tackle the main risk factors for mental health problems, mental illness and suicide through increased prevention activities. Disadvantaged and deprived communities experience more mental health problems, illnesses and suicides than more socio-economically advantaged communities, so efforts to redress these inequalities are required.
8.4.1 Issues to address could include greater holistic support for parenting for families who are at risk or struggling; combating poor foetal development, nutrition and early attachment; addressing the cluster of factors associated with social inequalities, such as poor housing, poor employment and educational opportunities, social fragmentation, poor social cohesion and lack of social networks and support. Approaches should be ready to identify where things might go wrong and to engage and support early and address multiple and complex needs, not just isolated issues, within an ethos of promoting self-efficacy.
8.4.2 Good progress is being made on prevention activities where people are at greater risk of developing mental health problems, mental illnesses or where the risk of suicide is greatest, and where people experience significant physical health problems such as heart disease, cancer, or diabetes and other long-term physical conditions. Efforts in this area should re-focus and be raised, linking in with other programmes such as Delivering For Mental Health and Keep Well.
8.5 Support: improve the quality of life, social inclusion, health, equality and recovery of people who experience mental illness.
For too long, people who experience mental illness, whatever their age, have been marginalised, discriminated against, excluded and denied the opportunity to realise their potential. This is beginning to change in Scotland as evidenced by the three biennial Well? What do you think? surveys. But much more needs to be done, especially in tackling deprivation and discrimination, as those in adverse socio-economic circumstances and/or those subject to discrimination are more likely to suffer from mental health problems and illnesses and more likely to experience stigmatising behaviours and prejudice.
8.5.1 Further work is required on addressing stigma, prejudice and discrimination, especially for those who have a diagnosis under the general heading of psychoses. Greater equality of opportunity is also required in areas such as employment, housing, education, and cultural, recreational and sporting activities. Increasing access to mental health and mental illness literacy can also help in enabling people to have the information, education and knowledge they need to keep well and help to support behaviour change in a positive way. Improved mental health literacy can also support, enable and encourage people to seek help earlier and access care, support and treatment earlier, before problems get worse or a crisis arises.
8.5.2 Recovery in the presence or absence of the symptoms of mental illness is possible and will be individual to each person and their circumstances. Belief in recovery is key to tackling stigma and discrimination and improving people's quality of life, inclusion and opportunities.
8.5.3 In developing improved mental health literacy, we wish to see greater public understanding that it is possible to recover, symptom-free from mental illness, and that it is also possible to live life fully and well with a long term mental illness. Valuing people's lived experience of living with mental illness is a key part of this agenda.
9. Proposed actions
The following offers some more detail on proposed actions to enable the main themes for suggested action to be met. We wish to know whether you think these are realistic, appropriate, deliverable, where possible measurable and valuable. We also want to know what support would help you achieve the main themes and suggested actions.
9.1 Action 1 - Promotion of Mental Wellbeing
This could include a focus on:
- Improving 'literacy' around mental wellbeing and mental health, for key agencies, practitioners and the general public.
- Developing a local understanding of individual and community mental wellbeing, building on work in NHS Health Scotland on mental health indicators, to record baselines and assist in assessing effectiveness of programmes of work and changes in local population mental wellbeing.
- Prioritising work in the early years, and children and young people's mental wellbeing, using both population-wide approaches and targeted engagement and interventions, informed by evidence and experience and an understanding of the needs of local populations. Work targeting children should engage parents in any culture of change.
9.2 Action 2 - Prevention: Mental illness
- A focus on addressing more common mental health problems and illnesses, such as depression and anxiety through a population-wide psychosocial response.
- Work on preventing psychoses.
- Early identification and engagement of those at greatest risk of mental health problems and illness, using the health inequalities evidence base and a Keep Well type approach.
- Supporting the 'anticipatory care' agenda, linking to Delivering for Health and Better Health, Better Care.
- Supporting self help, for example, through resources such as Living Life To The Full www.livinglifetothefull.com and other capacity building, training and self-help work aimed at individuals, groups and communities.
- Utilising and supporting a wide range of individual and local population-wide interventions and supports, such as community referrals, social prescribing.
- Taking account of, and addressing, the mental health/mental illness components and consequences of physical illnesses and long-term conditions.
- Understanding and addressing co-morbidity, including substance misuse and mental health problems (see also Commitment 13 of Delivering For Mental Health).
9.3 Action 3 - Prevention: Suicide and Self Harm
- Improving local capacity for suicide prevention, including mainstreaming suicide prevention in social, community, public health, health improvement and mental health care arenas (see also Commitment 7 and Target 2 of Delivering For Mental Health).
- Using the evidence base of health inequalities to tackle the elevated suicide rates in areas of highest deprivation and local, personal and family disadvantage, inequality and deprivation.
- Support to addressing and preventing self harm.
9.4 Action 4 - Support to improve quality of life, social inclusion, equality, recovery and addressing stigma, prejudice and discrimination
- Improvement of attitudes and behaviours within staff groups (in the NHS, local authorities and other public services) to help support improvements in the quality of life, social development, social inclusion, recovery and equality of opportunity for people experiencing mental illness and improve access and use of public services and community resources.
- Social inclusion - further action on implementing Sections 25 - 31 of the Mental Health (Care and Treatment) (Scotland) Act 2003 with its emphasis on social development and wellbeing of people with illness.
- Supporting improved employment and vocational outcomes for people experiencing mental illness, including improved retention rates of people experiencing mental illness in the workforce, increased employment opportunities, the implementation of workplace 'mental health' policies that include retention, support and adjustments at work, promotion of mental health and mental wellbeing, prevention of mental ill health, and proactive disability awareness on mental illness.
- An emphasis given to self care and support for self care, complementary to the recovery message, with work on supporting people's capabilities and assets and on supporting self belief and change, and addressing self stigma.
- Further emphasis given to recovery, with a focus on work outwith services, encompassing relationships, social networks, community, identity, employment, learning and support and addressing prejudice and discrimination.
9.5 Action 5 - Development of a local capability to improve capacity and provide leadership of, and support for, mental health improvement as a core part of mainstream planning and service delivery across each of the key themes
This action could include a focus on:
- Improving local co-ordination as a part of overall public health, wellbeing and health improvement work, regeneration and social inclusion, working on the key determinants of health and mental health in key settings such as the workplace, communities and schools, across the age ranges.
- Making linkages to other key public health and health improvement agendas - especially alcohol, drugs, smoking, obesity (physical activity and diet) and sexual health.
- Making linkages to Delivering for Mental Health targets and commitments, including the health promotion agenda for people experiencing mental illness, suicide prevention, equalities and inclusion.
- Making linkages to supporting improved outcomes for those experiencing physical illness, disability and long-term physical conditions.
- Improving the capacity and capability of practitioners and key stakeholders in awareness, understanding, behaviours and action.
- Building on promoting mental wellbeing, mental health literacy (e.g. Mental Health First Aid), suicide prevention, recovery, stigma and discrimination.
- Increasing public awareness, knowledge, understanding and action.
- Understanding and acting on the evidence.
- Measuring and monitoring progress.
9.6 Action 6 - Support the key role for Community Health (and Social Care) Partnerships in mental health promotion and prevention actions.
This could include a focus on:
- Understanding the local population's needs.
- Finding ways of meeting these needs by providing a range of individual but also group and community engagement and intervention, promotion and prevention programmes and activities.
- Improving capacity and mental health literacy in primary care and in wider community services and local agencies.
- Building on self help and self care programmes.
- Drawing on promising evidence, for example around community referrals / social prescribing.
- Linking with activities targeted at long term health conditions and anticipating where the greatest needs are and where greatest efforts need to be targeted.
- Linking work to Delivering for Mental Health commitments and targets
Actions 5 and 6 (sections 9.5 and 9.6) should be embedded in fulfilling the duties under DDA 2005, including the duty on public bodies to proactively promote equality of opportunity for people with a mental illness.
9.7 For all of the above 6 suggested actions, there is a need to connect local strategic and delivery work with the overall three main expectations and emphasise how inequalities will be addressed.
9.8 Attention could also be paid to local:
- Social marketing and communications activity - reaching out to the general public, communities, targeted populations and other agencies and stakeholders.
- Integrated, coherent and partnership working.
- Understanding, disseminating, using and contributing to the evidence.
- Development and use of key indicators, drawing on the mental health and wellbeing indicators developed by NHS Health Scotland.
- Contributing to improving community wellbeing and more social coherence.
10. National Functions and National Supports for 2008-11
In helping local agencies and stakeholders to meet the broad themes and proposed local actions, we are keen to hear your views on what national functions and support activities would assist you.
Below, we suggest potential areas of support.
10.1 National Support Activities
10.1.1 Research, evidence and evaluation
- collecting and disseminating evidence of what works and what looks promising
- encouraging and supporting development and innovation
- undertaking and commissioning national research
- undertaking and commissioning national evaluation and review work.
10.1.2 Capacity building, skills, competencies and training
- providing evidence-based training, capacity building, skills and competency building programmes
- providing opportunities for networking and learning-
10.1.3 Communications, social marketing and support to the media
- ensuring effective national communications and social marketing and portals to helpful information and advice
- support for national campaigning as one part of an overall social marketing approach
- support for the media on mental health promotion, prevention, suicide prevention and improving the quality of life of people living with mental illness.
10.1.4 National indicators, data and review
- collection, analysis, presentation and development of national indicators of mental health and wellbeing.
[ Appendix C gives examples of National Programme for Improving Mental Health and Wellbeing support activities, agencies, consortia and functions.
Appendix D gives information on National Programme-funded agencies and research work to date]
10.2 National policy and policy co-ordination
Scottish Government Health Directorates will lead on mental health improvement policy. Policy will be co-ordinated across public health and wellbeing, health improvement and mental health. Policy connections and support to other Scottish Government Directorates will also be given.
10.3 National performance management
We will use the process of local engagement on this paper to help agree how we will track progress towards achieving the objectives and commitments and how local performance will be assessed and reported.
11. Discussion Questions and Process
11.1 This paper aims to support and stimulate discussions on the future of mental health improvement across Scotland. The proposals set out here aim to help create the conditions and circumstances for making significant advances in the promotion of mental health and achieve a discernible difference in addressing inequalities in mental health.
11.2 The paper signals a shift in emphasis and focus from national activity to local actions. In making this shift, a number of suggested actions for local areas have been proposed. We want you to consider the three key questions:
What shared objectives and actions for local delivery should be made for 2008-11 that would be deliverable, measurable and valuable?
What national supports would help you to meet these objectives and actions?
How can progress be tracked and performance assessed?
11.3 To assist and take forward the discussion we will take the follow actions:
- Wide distribution of this paper.
- Encouraging and supporting local area discussions on the paper. Small sums of funding will be provided to each Health Board area to help facilitate local discussions. Each area will be expected to submit a written report on their discussions.
- DG Health and Wellbeing, the National Programme and National Programme-funded agencies will offer materials and key people to attend local events.
- There will be other forums and discussion opportunities offered over the next few months on a national basis (please see www.wellscotland.info for further information on these and other relevant and helpful events and forums).
- The independent review of the National Programme and its work, which was commissioned and supported by NHS Health Scotland, will publish its final report soon. This report will also contribute to the discussions on the future of mental health improvement.
- The National Programme, in partnership with NHS Health Scotland and the Scottish Development Centre for Mental Health, will hold a national dialogue event for key stakeholders as a key part of the process.
- The Scottish Government will establish a National Reference Group to consider the outcomes of the discussion process and to help provide advice on the next stages of work.
Following this process, an Action Plan for implementation from April 2008-11 will be issued early in 2008.