On Thursday 4th July I was lucky enough to be live-tweeting from the Public Health England (PHE) event ‘Mental Health, Marginal Communities and Wellbeing: The Public Health Challenge’. You can see a collection of tweets from the day in this storify, which do a pretty decent job of capturing what was said.
The event was an attempt to begin to map what the role of PHE will be in addressing the mental health and wellbeing needs of ‘marginalised communities’. The day addressed two different dimensions of public health; focusing on specific mental health and wellbeing inequalities experienced by particular groups in communities and on the ways that community resilience might be built.
The day was opened and closed by Gregor Henderson, director of public health and wellbeing for PHE giving an interesting insight into the challenges and opportunities that the idea of ‘public mental health and wellbeing’ presents.
These are early days for PHE. It only took up its full responsibilities as an executive agency of the Department of Health on 1 April this year, on the same day that responsibility for public health passed to local authorities.
Gregor Henderson, director of public mental health and wellbeing for Public Health England took the opportunity to begin to outline the boundaries, challenges and opportunities for PHE in defining and defining public mental health practice.
Henderson used both in his framing speech and his summing-up of the day to stress a number of challenges for PHE and for the idea of public mental health and wellbeing. He spoke of the need to find a narrative around public wellbeing that would land effectively with the general public at large. He claimed that the idea of wellbeing as something different from the absence of mental ill-health was in a ‘quiet revolution’; moving from being fluffy to being something that can be measured and which can, and does, influence policy.
Henderson also spoke of PHE as being a kind of interchange for knowledge about both the needs of various communities but also ways in which those needs might be met. He invited those present on the day – and by extension all working with or affected by issues that influence mental health and wellbeing – to work with PHE, stressing that it’s impossible for a large institutional bodies to see and know what’s happening on the ground for people and communities.
Hovering In the background were the massive implications of beginning to think of mental health and wellbeing not as a an individual matter but one where it is possible to take action upon its social determinants. The challenge of this shift was not lost on Henderson, who repeatedly described the event, the recent changes in public health responsibilities and the incorporation of public mental health into PHE as ‘the beginning of a journey’. He claimed that while England might have an arguably effective ‘mental illness service’ we haven’t yet found the right way to build a mental wellness service.
He went to great pains to say that PHE can’t ‘do public mental health and wellbeing’ alone; that it needs everyone with an interest in the wellbeing of communities to “put a bit of skin in the game” and find ways to collaborate and learn from each other. It is the first time that mental health and wellbeing have been included so specifically in public health commitments, and the first time that the responsibility has been positioned outside of medical services.
’Marginalised’ communities, intersectionality, prejudice
The ‘marginalised’ of the event title referred, in the main, to characteristics protected (unlawful to discriminate upon) under the Equality Act 2010. The day itself was an extension of previous Equality Forum events, but the first with PHE. The protected characteristics are; age; disability, gender reassignment; civil partnership; pregnancy and maternity; race, religion and belief; sex and sexual orientation.
Across the day, speakers addressed the mental wellbeing and mental health needs and life situations of a variety of groups of people. These included carers, those with drug and alcohol issues, specific groups within otherwise marginalised groups, lesbian, gay and bisexual people, trans people and older people.
Just how complex the idea of public mental health and wellbeing actually is if we begin to consider it seriously sounded loudly from the majority of the presentations across the day. If we take public mental health and wellbeing as, at a very basic level, the consideration of wider factors and their effect on populations, it becomes clear that the interaction of different factors in the lives of people is a very complex thing.
Interestingly, for those who keep up with the debates that rage across social media, Dr Chris Whiteley, speaking about dual diagnosis and the mental health and wellbeing needs of those using substances (and the substance use issues of those experiencing mental health difficulties), raised the issue of intersectionality. Intersectionality as an concept tries to understand the ways in which different categories (man, woman, disabled, south asian etc) interact with each other to create specific social inequalities.
Whiteley made the point that people with substance use issues and mental health needs often receive far less help and support than they would if they experienced one of the other of those difficulties. For him, siloing drug misuse, alcohol abuse and mental health as different health needs rather than interlinked needs to be challenged. Whiteley’s observation was people’s lives are complex, with people simultaneously belonging to a number of different categories, but that services tend to want ‘simple’ and are often committed to dealing with one particular problem or characteristic. This theme was echoed across the day by a number of speakers.
The effect of prejudice and discrimination of the mental health and wellbeing was also raised by a number of speakers. A number claimed that the stress and other situations that result from outright discriminatory practice and the experience of being labelled other or deviant significantly impacts upon the resilience and wellbeing of individuals and communities. Chris Whiteley suggested in answer to a comment from the floor that discrimination can be a kind of trauma. This may seem like an obvious point, but it points toward one of the prime challenges of public health approaches to mental health and wellbeing. To quote Gregor Henderson, one of the purposes of a public health approach to mental health and wellbeing is to ‘find the causes behind the causes’. In other words, the aim of public health approaches to mental health and wellbeing is to try to influence situations, communities and structures rather than treating the individual for symptoms or situations once developed.
LGB and T
The event very sensibly refused to lump together lesbian, gay and bisexual (LGB) people’s issues with the issues faced by trans people, who in the words of Dr Louis Bailey speaking on trans people’s mental health are ‘often the T that gets knocked off the end of LGBT”. Dr Mike King spoke about the mental health of gay, lesbian and bisexual people.
Bailey outlined many of the findings of the Scottish Trans Mental Health Study 2012, focusing on the ways in which health services are constructed influences the outcomes for trans people. 88% of trans people told the survey they’d felt depressed, 53% had self harmed and 84% considered suicide. Trans people often wrestle with being trans for many years before seeking help and support. The average age of transition (passage from one gender to another) is 43 years. Trans people often wait long periods to be accepted by gender identity clinics (GICs), with average journey to those GICs being in range of 200- 300 miles there and back. Trans people are required to live ‘in role’, which means working, volunteering, studying or training in the gender role they are transitioning to for two years before they are offered access to hormones and surgery, something that Bailey said leaves them open to hate crime as this policy increases their visibility as trans while offering no ways to minimise the response of others to their trans status. There are, Bailey pointed out, a lot of low income and unemployed trans people.
Bailey said that many trans people surveyed felt that medical professionals still had outmoded ideas around gender and behaviour appropriate to gender role and that 27% lied or withheld information from gender professionals and that 33% were concerned about their mental health but didn’t say. For Bailey the conflation of gender dysphoria and mental health difficulty continues to follow trans people, with trans people often experiencing mental health difficulty but having that used as a way of minimising or ignoring their trans status. According to Bailey, gender reassignment reduces suicide risk and improves mental health and wellbeing but is still situated in outmoded models of understanding gender and has significant bottlenecks.
Addressing LGB mental health Dr Mike King pointed out that the UK is top of a table of of 43 countries in terms of legal rights for LGBT people, but that this does not always reflect experience ‘on the ground’. Still, said King, LGBT people are more likely to experience hate crime than straight people but less likely to report it. King suggested that homophobia and prejudice created situations of stress which have an impact on the mental health and wellbeing of LGBT people.
King spoke of research suggesting that the most homophobic children have the most homophobic parents, and that intervention at primary school age in terms of training and teaching was most effective in changing homophobic and prejudicial attitudes. He quote a yougov poll that said that 9 out 10 teachers had no training in ways to tackle homophobia within their classrooms, within their staff team and within the families and communities to which their pupils belong. For King “homophobia, sexism and paternalism travel together”. He did not downplay how deeply rooted homophobia can be, itemising its wellsprings as disgust, religious ideas, fear of infection and corruption and the defence of masculinity.
King pointed out that there is still institutional prejudice against gay people, despite the UK’s strong legal protections. As an example of the ingrained nature of attitudes, King pointed toward that the majority of companies that are recognised Stonewall Top Employers awards choose not to make reference to this on their websites or promotional materials.
King reiterated that gay people have a higher prevalence of mental health difficulties. He quoted a Danish study that showed people were 8 times more likely to kill themselves if in a civil partnership than those who were not, and were twice as likely to die by suicide than a person who was in a traditional marriage.
King saw the idea of public mental health and wellbeing as representing a way in which previously scattershot attempts to challenge prejudice could be drawn together to tackle upstream the attitudes that cause problems. He also saw it as a chance to begin to understand the needs of LGB people to find ways that services might better address their needs. He pointed out that, for instance, we know very little about the mental health and wellbeing of older LGB people.
Older people, carers and ‘compound marginalisation’
Someone who did know about the needs of a variety of older people was Helen Ramsbottom of Age UK. She shared the five key themes that older people had identified for discussion with commissioners: age discrimination, participation, relationships, health and income. She spoke about the need for “robust, upstream interventions’, actions to help people in the present that would prevent more serious problems in future. She pointed out that the most sensible times to give help were at points of transition: from work to retirement, after the lose of a loved one, at the point of a serious illness or loss of independence due to disability. She also stressed that effective interventions were local and specific, rather than generalist and abstracted from lives and communities.
Steve McIntosh of Carers UK gave a presentation that brought together findings around both the impact of caring on carers and also the ways in which carers form a marginalised group themselves. He termed this ‘compound marginalisation’, leaning on similar ideas to Chris Whitely’s use of intersectionality. Again, the reality of life as complex did not fit well with services and support based on considering one characteristic.
According to McIntosh, 6.5million people provide unpaid care in UK. This has risen 600,000 (11%) in last decade. 2million people care for over 20 hours per week. 13 percent of carers care for someone with a mental health difficulty, around 850,000 people. McIntosh pointed out that this is not without its impact: people who are carers can drop out of work, education, community life, socialising. 61% of carers report having experienced depression as a result of caring, with 87% saying that caring had affected their mental health negatively.
McIntosh said that there was a particular challenge for carers for those who experience mental health difficulties, as there is a stereotype of care as being ‘hands on’. Unless carers recognise themselves as carers they cannot access any help of support that is available for carers.
McIntosh also stated that the current way in which social care eligibility is structured, in his words ‘High level needs, low level means’ is storing up a crisis for the future as it actively prevents the commissioning of upstream services with a preventative approach.
Across the day, the focus on population or area based public mental health and wellbeing chimed strongly. To those of us who have been floating around community development or who have involved in the Big Society and its fallout since 2010, the ideas were well established: namely the focus on building the assets and resilience of communities.
Lucy Smith, Public Health Manager – Mental Wellbeing, Lambeth and Southwark, shared a different form of community interaction. She focused on the the work that the London borough of Lambeth have been doing to build up the wellbeing of the area. She reference research that found that social relationships were as beneficial as quitting smoking to a person’s overall health. For her, the next horizon for public health is focusing on social relationships and interconnectedness, rather than individual lifestyle issues
The borough offered small grants to community groups to carry out projects, building in mental health awareness and wellbeing training. More on the borough’s health and wellbeing work can be found here.
Jonathan Lamb spoke about work he’d been involved in Longsight, Manchester. The project targeted specifically Pakistani women and worked by getting to know the community and then finding appropriate ways to influence and support their mental health and wellbeing. To quote Lamb: “Community mapping allowed us to understand local people’s experiences, build trust and develop a database of local assets and stakeholders. Community Focus Groups established strategic agendas and areas for immediate action. Led by a Community Champion the Community Working Group designed, piloted and distributed 3000 multi-lingual calendars addressing mental health literacy and awareness of services. Launching the campaign on South Asian media, they established a Facebook and twitter group reaching over 20,000 users and are producing multi-lingual relaxation CDs.” Lamb commented that lack of identification with western medical understandings of mental health was an issue spoken about more in the literature than was actually expressed ‘on the ground’.
In the project the community focus group helped to identify the issues experienced by the target group while the community working group put into action interventions and developed the actual services. Lamb noted that the traditional mental health promotion model is horizontally targeted, aiming to encourage access for everyone, while the project he had worked upon was targeted very specifically. He also spoke about the ways in which the introduction of Improving Access to Psychological Therapies (IAPT) actually made it harder for some in the community they were working with to access support as it reduced variety and reduced relationships. Lamb suggested that part of the value the voluntary and community sector in mental health is as a bridge between communities and NHS and local authority services, helping communities to trust services, or particular people within services.
Many of the speaker spoke about the need to build mental health and wellbeing literacy. This was strongly confirmed by Poppy Jarman of Mental Health First Aid England (MHFA England), who spoke of their mission to raise the knowledge of mental health amongst individuals and communities as a way of empowering people to take action. MHFA England was set up as a social enterprise in 2009 to offer ‘first aid’ style training to trainers who then train others in the techniques. Their aim is to save lives by training people to train others in ways to sustain good mental health and build resilience.
The final speakers of the day brought home the obligations and responsibilities of PHE as a first responder to events in the same way as emergency services. Richard Amlot and Carla Stanke of Public Health England both addressed the impact of extreme events like terrorist attack or flood on the wellbeing and mental health of communities, and the mechanisms that PHE has been developing to minimise the psychological damage such events cause. Addressing floods, Stanke spoke specifically about the knock-on effects (primary & secondary stressors) on individuals such as loss of possessions, interruption of communications, lack of access to support and difficulty of securing insurance payments. Stanke good social connectedness mitigates against the psychological and physical impacts of events like flood, reinforcing the argument made by other speakers for the vital nature of relationships and community.
While these are early days for Public Health England, there is something genuinely exciting in the optimism present in a new body and a new approach. The intention to get to ‘the causes behind the causes’ will warm the hearts of many long-term activists and campaigners. Henderson noted that there is a tension between local, community based responses and the wish or intention to provide cohesive, comprehensive services.
Henderson repeatedly stated that the broad narrative is not yet there yet to get the public thinking about mental health and wellbeing not just as an individual lifestyle matter but one where community and policy level changes are as, if not more, important.
The reality of this challenge was acknowledged by Henderson, who pointed out that while there is lots of great stuff happening, to make the change that many would like to happen, there will be some outdated structures, practices and organisations that will have to go.
So, the question would go: If we stop thinking about services as being the solution public health and wellbeing challenges and try to look for solutions further ‘upstream’, what can we do to help people have better mental health and greater wellbeing?
As Gregor Henderson says, for PHE at least, it’s early days.
Mark Brown is the editor of One in Four magazine. He is @markoneinfour on twitter
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Thank you for taking the time to share such a full report from the Public Health England event. It is heartening to hear about a broadening acceptance of ‘mental health and wellbeing not as a an individual matter but one where it is possible to take action upon its social determinants’. The points raised about intersectionality and prejudice are really important. From a radical community development perspective, Margaret Ledwith distinguishes between a naive consciousness, in which people ‘engage with single issues rather than the underlying roots of injustice’ (http://communitydevtheories.blogspot.co.uk/2010/11/naive-consciousness.html) and a critical consciousness, in which people are aware of the bigger picture of systems and structures of oppression. I find it incredibly frustrating that in my work with people who are struggling to influence health and social services such people work really hard to keep themselves from connecting with other people also facing difficulties and experiencing issues. They seem to think that their condition or situation is so unique that they won’t get heard if they become part of something bigger. I think the problem is that by perpetuating these divisions, service providers can get away with not listening to anyone properly.
It’s good to read about the different experiences of LGB and T being considered in a helpful way. The statistics you’ve shared in relation to trans people are shocking. We really do need a more understanding culture. This feels as though it has lots of links to the ways that little boys and little girls are bought in to a society which dictates what their roles will be and how they should behave, based on their gender. It’s dangerous stuff for everyone, though given the power which men have in our society, I think women, LGB and trans people are more likely to be negatively impacted by it.
Reflecting on the idea that ‘part of the value the voluntary and community sector in mental health is as a bridge between communities and NHS and local authority services …’, I can’t help wondering whether this is as simple as it seems. The NCIA’s work around voluntary services picks up on something being suggested more widely, that the gap between voluntary organisations and community groups/organisations is so wide now that they don’t seem to be from one sector. The NCIA say in their Inquiry (http://www.independentaction.net/2013/07/01/inquiry-into-voluntary-services-full-briefing-now-uploaded/): ‘With respect to that part of the voluntary sector that has the interest, experience and capacity to offer services to their local communities, a new narrative has been built, in which its role is shaped around the needs of the public services market and subject to shifting fads for service and contract design… This has left many running services in local communities caught between ideologically driven contract requirements of statutory or private commissioners, and the authentic needs of their users and constituents.’ There is no doubt much to be wary of in this arena.
I think you partly answered your question: ‘if we stop thinking about services as being the solution public health and wellbeing challenges and try to look for solutions further ‘upstream’, what can we do to help people have better mental health and greater wellbeing?’ in your mention of building the assets and resilience of communities. Work that I am doing around this in one housing estate in Dudley, with Public Health and Tessy Britton from Social Spaces (http://www.socialspaces.org) is highlighting for me how difficult it can be to shift mindsets from our ingrained ways of thinking and doing as consumers, as representatives, as community volunteers providing services to others in our community and so on. Sharing what we have, connecting it new ways and testing ideas is very different to deciding on a project and applying for funding for it. I plan to blog about my learning so far … though it feels as though we are in the very early stages of this work (despite having begun the thinking nearly 2 years ago!).
In the meantime, the most useful reading to date for a Leadership for Empowered and Healthy Communities programme I am a participant in is this, written by one of the programme facilitators: http://www.thinklocalactpersonal.org.uk/Blog/Community_Capacity_The_evidence/?parent=9376&child=9382, albeit I *really* dislike the term ‘community capacity building’, as it is deficit focused and seems to suggest that ‘professionals’ both have capacity and the ability to transfer it in to people in ‘communities’ (this tends to imply groupings of people who might be unemployed or in jobs which don’t carry professional qualifications), who will be willing vessels for this sort of ‘capacity’- regardless of whether it fits their context or preferred way of operating. (‘You *will* set up a committee and have a constitution and aim to to grow, for that will mean you have capacity in your community, and we can measure it in terms of things we can see and measure and know what they are’!!!!)