Professional Documents
Culture Documents
for mental
health
Discussion paper
The Future Vision Coalition
The Future Vision Coalition
Mind
Rethink
Together
Executive summary 2
Introduction 4
4. C
hange relations between individuals 17
and services
References 20
Discussion paper
Executive summary
This is a discussion paper intended to provoke a
wide-ranging debate about the best direction for mental
health policy. It outlines a vision of change developed
by seven national mental health organisations, who
together make up the Future Vision Coalition. We focus
in particular on four changes that we believe need to
happen to enable those with experience of mental
health problems to enjoy an equal opportunity of a
fulfilling life.
1. A movement away from the dominance of the • A cross-government strategy on mental health,
medical concept of mental health, with an integrated actively coordinated across departments and with a
model driving policy. This model should incorporate champion at Cabinet level
an understanding of the social determinants of mental
health, and implies that mental health is not only a • Specialist services as one element of a spectrum of
Department of Health issue. Whilst an important part of integrated support which makes use of mainstream
the spectrum of care, clinical services should be seen as community services when specialist mental health
one element of a wider whole-life framework of support. input is not required
We should avoid segregation of mental health service • Ensuring that ‘experts by experience’ can take a
users into ‘special services’ where possible: being a strategic leadership role in policy development and
‘service user’ should not define a person. service design
2. Greater importance placed on public mental health • A three-tier public mental health strategy
and recognising mental health as a whole-population incorporating whole-population mental health
issue. It affects everyone and the policy framework promotion, targeted prevention for at-risk groups and
should reflect this. early intervention for children and families
3. For those who need support to cope with a • Full adoption of the ‘recovery approach’ across the
mental health problem, services should be united in spectrum of care
supporting the recovery of a good quality of life and
the achievement of goals and ambitions. • Development of supported employment as a widely
available service to those who want it
4. Power relations need to shift in order to give real • Examination of ways to facilitate increased control by
self-determination over the process and direction of individuals over the types and providers of support
recovery to individuals, their carers and families. This they need and want, including ways to give them
will reflect a move from care as something which is more control over resources
done to service users by the system, towards a system
of support built by the person and their advocates. • Intelligent commissioning which starts from the
viewpoint of an individual’s stated expectations,
Service design should be driven by what those with needs and preferences
experience of mental health problems believe to be an
appropriate spectrum of support – whether or not this • Widening availability of advocacy services
fits with the organisational structures of the past, and • Expanding the role of the voluntary and community
whether or not this includes a large role for traditional sectors to increase accessibility and appropriateness
services.
Discussion paper
Introduction
2009 will be a significant year for mental Our organisations agree that:
health policy in England. • The NSFMH has made a substantial difference to
The Government’s ten-year plan for mental health – the the lives of those suffering mental health problems,
National Service Framework for Mental Health (NSFMH) through raising the profile of mental health, focusing
– will come to an end, signalling a new era. Important resources on vital aspects of the mental health
policy choices must be made to ensure both that its system, and promoting a philosophy of inclusion and
achievements are built upon and its shortcomings independence.
tackled.
• However, some of its recommendations are yet to be
Seven leading national mental health organisations meaningfully implemented and not all new models of
have come together as the Future Vision Coalition to care have yet been fully evaluated.
outline their proposals for a substantial shift in policy
during the next ten years. These organisations are: • Inequalities in access to the system, social exclusion
the Association of Directors of Adult Social Services; and poor life outcomes persist (and by some
the Mental Health Foundation; Mind; Rethink; measures are getting worse).1
the Sainsbury Centre for Mental Health; Together; • These inequalities are reflected in consistently high
and the NHS Confederation’s Mental Health Network. levels of dissatisfaction from service users and
While our organisations come from different other stakeholders about the national variability in
perspectives, we have developed a shared case for standards of care and support.2
the right direction of travel for mental health services. • Communities and groups historically under-served
Our contention is that, to alleviate the burden of poor by the mental health system are still not having their
mental health most effectively, a radical rethink of the particular needs met – for example, many services are
principles underlying policy is required, rather than still provided on the basis of age rather than need.
continued evolution.
• Failure to adequately address the mental health
needs of offenders is a fundamental cause of the
chronic dysfunction of our criminal justice system.
Discussion paper
1. An integrated approach to mental health:
bringing health and social models together
Our vision Historically, mental health policy has
largely been seen from a health service
• a government which recognises the importance of
social and economic factors underpinning mental point of view, underpinned by medical
well-being models and assumptions. This has
created a division between those who are
• all government departments working together to
combat mental ill-health and supporting people to diagnosed as mentally ill and those who
recover from it are not.
• individuals and their families having significant input We believe a more realistic and helpful approach is
into the design of services which meet their needs to position mental health along a continuum where
and take account of what they see as important everyone has varying levels of mental health need at
different times in their life, and where some people
• continued improvement of existing specialist will need formal intervention and support to help them
services, informed by evaluation of differing ways regain a good quality of life.
in which they might be provided.
This approach is more realistic because mental health
status is influenced by factors such as society’s
attitudes and social and economic circumstances. It is
more helpful because the health and illness division
“A model of mental acts to perpetuate ‘us and them’ attitudes which can
contribute to stigma and discrimination.
health which locates Health services alone cannot remove barriers to social
inclusion for those given a mental ill-health diagnosis.
problems solely in the Mental health policy for the coming decade should not
perpetuate this misconception. We would argue that
individual will continue mental health is a whole-population issue and should
be treated as such by government.
to ignore critical factors
Risk and protective factors for mental health
that influence mental A model of mental health which locates problems solely
health and well-being.” in the individual will continue to ignore critical factors
that influence mental health and well-being.
Discussion paper
The actions of all government departments should Inpatient services are a core element of specialist health
be explicitly assessed in terms of impact on whole- services which care for people when they are at their
population mental well-being, and on whether policies most vulnerable. Many improvements have been made
have the potential to create barriers to inclusion or in the last ten years but there is still an urgent need
exacerbate stigmatising attitudes. Equally, many to find evidence-based approaches in this area and to
aspects of government policy have the potential explore alternatives to traditional hospital-based care.
to promote mental health (such as sustainable Further policy attention must ensure that continued
communities, pathways to work, educational attainment improvements to inpatient services are made and that
and social welfare) and these need to be explicitly they are an integrated part of the specialist service care
recognised and coordinated. There should be active pathway for those experiencing acute problems.
coordination of mental health policy across government,
with a Cabinet Minister’s oversight and championing. Users of highly specialised services should not find
This would not only be a symbolic recognition of the themselves cut off from the other things that contribute
whole-population impacts of mental health, but would to mental well-being and a full life, such as good quality
also perform a practical function of integrating and physical healthcare, access to fresh air and exercise,
aligning mental health policy. and family and social contacts.
We acknowledge that:
Discussion paper
2. Focus more attention upstream:
promotion, prevention and early intervention
Our vision The benefits of positive mental health
and well-being are wide-ranging and
• a society where mental well-being is encouraged but
those experiencing mental health problems do not significant for individuals, communities,
feel stigmatised and society as a whole.
• early intervention and support for those who need it Positive mental health not only makes for a better
individual quality of life; it is also associated with
• action to reduce the known risk factors for mental better physical health outcomes, improved educational
ill-health attainment, increased economic participation and rich
social relationships.
• the adoption of measures which reach the whole
population and are aimed at improving mental Mental health is, therefore, a whole-population issue;
well-being. its personal, social and economic impacts affect
everyone.
The case for whole-population mental health In New Zealand, an anti-stigma advertising campaign,
promotion and education led by the Ministry of Health, has had positive effects on
public attitudes towards mental health and illness.15
Aiming to improve the overall level of mental health
in the population may sound ambitious. But there is In England, the Big Lottery Fund and Comic Relief are
evidence that this can be done: supporting Moving people, a four-year, £18 million
programme addressing mental health stigma and
“ Population-level interventions to improve overall discrimination. The programme, which builds on
levels of mental health could have a substantial effect evidence from Scotland, New Zealand and Australia,
on reducing the prevalence of common mental health aims to achieve a measurable change in attitudes and
problems, as well as the benefits associated with behaviour through a range of social marketing and other
moving people from ‘languishing’ to ‘flourishing’ interventions.
(Huppert, 2005). In addition, applying the principle
of ‘herd immunity’, the more people in a community Broad health promotion initiatives should explicitly
(for example, a school, workplace or neighbourhood) address mental health issues because a healthy lifestyle
who have high levels of mental health (i.e. who have can have significant positive effects on mental health.
Discussion paper 11
For example, the link between exercise and good The case for early intervention for children and
mental health is well established. NICE has concluded families
that “there is [robust] evidence… to suggest that
Investment in children’s mental health can help prevent
participation in physical activity, sport and exercise
social and economic exclusion, entry into the criminal
is positively associated with mood, emotion and
justice system, unemployment and deteriorating mental
psychological wellbeing.” 16
health with resulting costs to the individual’s quality of
life, to public services and to the economy.
The case for targeted prevention programmes
Prevention programmes can be tailored and targeted to This approach means early intervention well before
specific groups at increased risk of developing mental child and adolescent mental health services need to
health problems. Such programmes can also work to get involved. Identification of families needing support
reduce risk factors. There are many ways to tackle risk to ensure their child’s mental health – sometimes
factors, for example: even before the birth of that child – is a vital aspect
of promotion and prevention strategies. A report on
• programmes to reduce bullying in schools the evidence base for mental health promotion cited
a study which found that “parenting is the single
• ‘good parenting’ classes
largest variable implicated in health outcomes for
• improving conditions in the workplace to reduce children, notably accident rates, teenage pregnancy,
chronic stress substance misuse, truancy, school exclusion and under-
achievement, child abuse, employability, juvenile crime
• screening workers for early signs of depression and and mental illness.” 19 Early childhood experiences,
offering treatment 17 mediated by a positive relationship with the main
• screening infants at primary care clinics for risk carers, are strongly predictive of later resilience, ability
factors to cope with adversity and, ultimately, mental health.
• carefully attending to the mental health needs of There is considerable evidence that failure to tackle
children in care and children with experience of emerging problems in childhood leads to development
abuse. of adult mental health problems and social exclusion.
One study estimated that, quite aside from costs to
The experiences of later life can pose particular risks the individual, the lifetime costs of public service
to mental health. Age Concern and the Mental Health intervention (including benefits and costs to the
Foundation have highlighted the ‘double whammy’ of criminal justice system) for those children who exhibit
ageism and mental health stigma and discrimination. anti-social behaviour can be ten times as great as for
Bereavement, chronic illness, pensioner poverty and children without such behaviours.20
increased social isolation can all precipitate anxiety and
depression. Their inquiry 18 recommended that a number
of actions were needed to prevent mental health
problems in later life. These include:
Discussion paper 13
3. Focus on improving quality of life, ambition
and hope, not on illness and deficiency
Our vision Our view is that the overarching aim of all
health, social care and voluntary sector
• a system where success is judged by how quality
of life is improved for those experiencing mental mental health services must be to help
health difficulties restore, and then enrich, the quality of life
of those who turn to services for support
• people with mental health problems helped into
employment and once there, supported as long – not simply to aim at removing symptoms.
as appropriate. People with a mental health condition that requires
support beyond their family and friends should be able
quickly to access a range of services which meet their
expectations and needs.
the recovery approach The Sainsbury Centre for Mental Health has defined
recovery as follows:
by mental health and “At its heart is a set of values about a person’s
right to build a meaningful life for themselves,
other support services with or without the continuing presence of mental
health symptoms. Recovery is based on ideas of
offers a framework that self-determination and self-management. It
emphasises the importance of ‘hope’ in sustaining
builds a flexible and motivation and supporting expectations of an
individually fulfilled life.” 23
holistic approach into In other words, the most important goals for all
Tools that can be used to promote this approach include The evidence in support of formal programmes of
the inControl system for self-assessment of need.26 supported employment is strong, both in terms of
This uses responses to simple questions such as “What economics and individual outcomes. McDaid 29 notes
is important to you in your life?” and “What are your that health and social care costs account for only a
hopes and goals for the future?” to guide planning third of the costs to the economy of someone having
of care and support by that individual. The DREEM poor mental health – the other two-thirds is through
assessment tool has been used in Devon to ascertain lost employment. EQOLISE, a six-country European
the levels of recovery orientation in NHS mental health randomised controlled trial,30 has compared the
services and what needed to change to facilitate the employment and non-employment outcomes for
recovery approach. those with severe mental illness receiving individual
Discussion paper 15
placement and support (IPS) with a control group Policy levers: summary
receiving usual rehabilitation and vocational services.
To help improve quality of life for those experiencing
The IPS group exhibited superior employment and
mental health problems, we would suggest:
general functioning outcomes.31
• full adoption of the recovery model ethos and practice
It is important to stress, however, that where full-time
across support services in statutory, voluntary and
employment is not possible, this should not be seen
independent sector services
as a failure to achieve recovery. Options surrounding
part-time working, volunteering and other activities can • thorough exploration of how to systematically
also play a major role in supporting the quality of life of implement supported employment initiatives and
people experiencing mental health problems. alternatives for those who are unable to work
A new understanding of ‘good outcomes’ • a concerted effort to test and implement an agreed
in mental health set of quality-of-life outcome measures so that
services are rewarded for the extent to which they
At present there are few agreed outcome measures for improve quality of life for those using them.
mental health, principally because it is hard to agree
what constitutes a ‘good outcome’. Many concentrate
on psychiatric assessments such as degree of symptom
reduction as measured by clinicians. These may not
take into account how symptoms link to an individual’s
actual levels of distress.
Discussion paper 17
• people needing support can choose interventions • local area agreements, joint ventures, strategic
most likely to reduce their levels of distress, rather partnerships and pooled budgets have the potential
than simply focusing on those symptoms which are to make this happen
traditionally considered to be most important.
• there is a need to extensively pilot and evaluate
The realisation of true self-determination would change the benefits of ways to give individuals control
the dynamics between system and user, between of resources; the Social Market Foundation and
professional and patient, and between purchaser and others have estimated that 25 per cent of mental
provider. There are many barriers to overcome, such as: health spending could be allocated using individual
budgets 34
• the power of the status quo – professional interests
and institutional thinking, and loyalty to different • these pilots should determine both the effectiveness
models of mental illness which do not promote of individual budgets in improving quality of life,
self-determination and their economic viability within a range of
communities. There is international experience to
• low expectations about the competence and capacity draw on: Austria, the Netherlands, France, Sweden,
of those with a mental health diagnosis; perception of several US states and Scotland have established
risk; potential public reaction to individual budgets personal budgets programmes for those with mental
• existing fragmented funding streams, organisational health difficulties 35
boundaries and commitments to block contracts. • training programmes should be piloted to enable
The vision is, therefore, a long way off, but we can start people to participate in commissioning decisions
to make the first steps. in their localities, to commission their own care or
to pool individual budgets in groups, to offset any
threat individual budgets might present to the
Policy levers: summary
collective good
For the Department of Health, we would advocate:
• wider availability of advocacy – which may require
• the programme of system reforms must be funding – is needed to help people develop and
strengthened and fully implemented for specialist implement their own support plan
mental health, as many of these mechanisms will be
a useful foundation for implementing the principles • there is a need to explore the potential for ‘experts by
of self-determination, such as a national tariff experience’ to drive or participate meaningfully
in planning and research; in the US there are
• promoting more intelligent, flexible commissioning, well-developed programmes of support organised
which is required to meet the whole-life needs and run by ‘peer specialists’ 36
of those experiencing mental health problems
(without segregating them in separate services • meeting the needs and preferences of people with a
when specialist input is not required); we would wide variety of backgrounds, cultures, experiences
expect a world-class commissioner from the NHS, for and ages may entail a bigger role for the voluntary
example, not to be constrained by the mindsets and (third) sector in service provision; such organisations
structures of the past, but to start from the viewpoint are often more attuned to people’s needs, and seem
of their population’s stated expectations, needs and more accessible, than statutory services as they are
preferences. frequently small and rooted in the communities
they serve
In terms of resource management to promote
self-determination, we would stress that: • such a diversification of providers will require more
intelligent commissioning, robust quality assurance,
• mechanisms for coordination of funding streams and coordination to ensure that systems of support
already exist and should be better exploited do not become fragmented
– an approach of particular importance to the
implementation of a cross-government approach to • careful consideration of the workforce implications of
mental health the self determination ethos will need to be made.
• What do you think are the top three priorities for the
next ten years of mental health policy?
Discussion paper 19
References
1 Equal treatment: closing the gap, one year on. 11 Friedli, L. (forthcoming) Mental health, resilience
Disability Rights Commission, 2007 and inequalities. WHO Europe and the Mental Health
Foundation
2 No voice, no choice: a joint review of adult
community mental health services in England. 12 Towards a mentally flourishing Scotland:
Healthcare Commission/Commission for Social Care the future of mental health improvement in Scotland
Inspection, 2007 2008–11. Scottish Government, 2007, page 2.
Available at www.wellscotland.info/towards-a-
3 The social and economic costs of mental illness. mentally-flourishing-scotland-resources
Sainsbury Centre for Mental Health, 2003.
Available at www.scmh.org.uk 13 Making it possible: improving mental health and
well-being in England. NIMHE, 2005.
4 See www.who.int/mental_health/en Available at www.csip.org.uk/silo/files/
5 See Together’s Wellbeing approach to involvement. making-it-possible-full-version.pdf
www.together-uk.org/service~user~directorate/ 14 Public health interventions to promote
wellbeing positive mental health and prevent mental
6 Marmot, M. Speech to Fabian Society Health health disorders among adults: evidence
Inequalities Forum, 14 March 2008. See briefing. NICE, 2007. Available at www.library.
http://fabians.org.uk/events/events-news/ nhs.uk/SpecialistLibrarySearch/Download.
marmot-inequalities aspx?resID=236093
Discussion paper 21
This is a discussion paper intended to provoke a
wide-ranging debate about the best direction
for mental health policy. It outlines a vision of
change developed by seven national mental health
organisations, who together make up the Future Vision
Coalition. We focus in particular on four changes
that we believe need to happen to enable those with
experience of mental health problems to enjoy an equal
opportunity of a fulfilling life.
INF14401