joint strategic needs assessment...smi serious mental illness wemwbs warrick-edinburgh mental...

Mental Health & Mental

Illness amongst Adults

of Working Age

Halton Joint Strategic Needs

Assessment 2016/17

Joint Strategic Needs Assessment 2016/17

2 | P a g e

Reader information

Author Sharon McAteer

Contributors James Watson Mark Swift Faye Woodward Lisa Taylor

Reviewer Sarah Johnson-Griffiths

Number of pages 127

Date release September 2017

Description The document describes the policy context, estimated prevalence, risk factors and sub-groups of need, current service provision and national best practice in relation to mental health and mental illness amongst adults of working age (aged 18-64) in Halton

Contact [email protected]

Related documents JSNA Emotional Wellbeing and Mental Health of Children and Young People JSNA Mental Health of Older People JSNA Dementia

Please quote the JSNA

We would like to know when and how the JSNA is being used. One way, is to ask people who use the JSNA

when developing strategies, service reviews and other work to quote the JSNA as their source of information.

mailto:[email protected]


3 | P a g e

List of Abbreviations

5BP Five Boroughs Partnership NHS Foundation Trust

ASCOF Adult Social Care Outcomes Framework

APMS Adult Psychiatric Morbidity Survey

ASPD Antisocial personality disorder

BME Black & Minority Ethnic

BPD Borderline personality disorder

CASSR Councils with adult social services resposibility

CBT Cognitive behavioural therapy

CCG Clinical Commissioning Group

CMD Common Mental Health Disorder

CPA Care Programme Approach. This sets out how secondary mental health services should help people with mental illnesses and complex needs

CQC Care Quality Commission

DLA Disability Living Allowance

DWP Department for Work and Pensions

ESA Employment and Support Allowance

GP General Practitioner

HNA Health Needs Assessment

HSCIC Health and Social Care Information Centre

HSE Health Survey for England

IAPT Improving Access to Psychological Therapies

JSNA Joint Strategic Needs Assessment

LD Learning disability(ies)

LPHO Liverpool Public Health Observatory

LTC(s) Long term condition(s)

MHMDS Mental health minimum dataset

NHS National Health Service

NICE National Institute for Health and Clinical Excellence

ONS Office for National Statistics

PANSI Projecting Adult Needs and Service Information

PHE Public Health England

PHOF Public Health Outcomes Framework

PTSD Post Traumatic Stress Disorder


4 | P a g e

QOF Quality Outcomes Framework

OCD Obsessive compulsive disorder

OCU Opiate and/or crack cocaine drug users

SALT Short and Long term (social care data return)

SMI Serious Mental Illness

WEMWBS Warrick-Edinburgh Mental Wellbeing Scale


5 | P a g e

Contents

Key priorities for consideration by commissioners .............................................................................. 10

Data Summary....................................................................................................................................... 11

1. Introduction ...................................................................................................................................... 12

2. Policy Context ................................................................................................................................... 14

National ............................................................................................................................................. 14

Local .................................................................................................................................................. 14

3. Level of need in the population ........................................................................................................ 16

3.1 Protective factors ........................................................................................................................ 19

3.1.1. Physical activity and access to open space .................................................................... 20

3.1.2. Self-esteem, confidence and ability to manage stress/adversity .................................. 21

3.1.3. Community resilience .................................................................................................... 22

3.2. Risk factors ................................................................................................................................. 26

3.3. Social isolation and loneliness ................................................................................................... 27

3.4. Levels of mental wellbeing ........................................................................................................ 30

3.5. Levels of common mental health disorders (CMD) ................................................................... 33

3.5.1. Estimated prevalence .................................................................................................... 33

3.5.2. Known prevalence ......................................................................................................... 34

3.5.3. Comparisons between predicted and recorded prevalence of CMD ............................ 36

3.5.4. Depression prevalence compared with deprivation ...................................................... 36

3.5.5. Trends in depression prevalence ................................................................................... 37

3.5.6. Anxiety ........................................................................................................................... 38

3.6. Levels of Severe Mental Illness (SMI) ........................................................................................ 38

3.6.1. Prevalence: Estimated ................................................................................................... 38

3.6.2. Known – QOF ................................................................................................................. 39

3.6.3. Correlation between SMI prevalence and deprivation.................................................. 39

3.6.4. Admissions ..................................................................................................................... 40

3.6.5. Detained under Mental Health act ................................................................................ 41

3.6.6. Excess mortality ............................................................................................................. 42

3.7. Other Mental Health Disorders.................................................................................................. 44

3.7.1. Antisocial and borderline personality disorder ............................................................. 44

Prevalence ................................................................................................................................ 44

3.7.2. Eating Disorders ............................................................................................................. 45


6 | P a g e

3.7.3. Post Traumatic Stress Disorder (PTSD) .......................................................................... 46

3.8. Self harm .................................................................................................................................... 47

3.9. Suicide ........................................................................................................................................ 49

3.10. Mental health amongst protected characteristics groups and other vulnerable groups ........ 51

3.10.1. Age ............................................................................................................................... 51

3.10.2.Gender .......................................................................................................................... 51

3.10.3. Race .............................................................................................................................. 51

3.10.4. Disability ....................................................................................................................... 52

3.10.5. Sexual Orientation ....................................................................................................... 52

3.10.6. Marital Status ............................................................................................................... 53

3.10.7. Religion ........................................................................................................................ 53

3.10.8. Sexual identity .............................................................................................................. 53

3.10.9. Pregnancy .................................................................................................................... 54

3.10.10 Homelessness ............................................................................................................. 54

3.10.11 Offenders .................................................................................................................... 56

3.10.12 Refugees and Asylum Seekers .................................................................................... 58

3.10.14 Mental health problems amongst adults with Learning Disabilities .......................... 58

3.10.15 Mental health of ex-Armed Forces personnel (Veterans) .......................................... 61

3.11. Physical illness as a risk factor for mental illness ..................................................................... 62

3.12. Alcohol Misuse ......................................................................................................................... 63

Admissions for mental disorders due to alcohol ..................................................................... 64

3.13 Substance Misuse ..................................................................................................................... 65

4. Service provision ............................................................................................................................... 68

4.1. Settings for Service provision ..................................................................................................... 68

4.2.1. Community Wellbeing Practice Model .......................................................................... 72

4.2.2. IAPT ................................................................................................................................ 73

4.3. Activity levels and Outcomes ..................................................................................................... 75

4.3.1. Health promotion and action to support community and individual wellbeing ........... 75

4.3.2. primary care ................................................................................................................... 76

4.4. Secondary care ........................................................................................................................... 85

4.4.1. specialist mental health treatment ................................................................................ 85

4.4.2. Liaison Psychiatry ........................................................................................................... 87

4.4.3. Early Intervention in Psychosis ...................................................................................... 88

4.4.4. Operation Emblem – Street Triage ................................................................................ 88


7 | P a g e

4.5. Social Care .................................................................................................................................. 89

4.6. Current Assets ............................................................................................................................ 91

5. Impacts of mental wellbeing and mental ill health .......................................................................... 92

Employment and benefits ................................................................................................................. 93

Debt and mental health .................................................................................................................... 96

Housing ............................................................................................................................................. 96

6. Projected levels of need .................................................................................................................. 102

7. User views ....................................................................................................................................... 104

8. Best practice interventions ............................................................................................................. 108

References .......................................................................................................................................... 113

Figures

Figure 1: No Health Without Mental Health – Key Objectives .............................................................................. 14

Figure 2: Model to show the influences to an individual’s mental health and wellbeing ..................................... 17

Figure 3: Schematic overview of the risk factors to mental health over the life course ....................................... 19

Figure 4: Percentage of adults achieving recommended levels of physical activity ............................................. 20

Figure 5: Self-reported well-being: % of people with a low worthwhile score ...................................................... 22

Figure 6: Self-reported well-being: % of people with a low satisfaction score ..................................................... 22

Figure 7: Self-reported well-being: % of people with low happiness score ........................................................... 22

Figure 8: Personal relationships and mental wellbeing, Halton results from the North West Mental Wellbeing

Survey 2012/13 ..................................................................................................................................................... 24

Figure 9: Mean WEMWBS scores for Halton and the North West in 2009 and 2012/13 .................................... 31

Figure 10: Local Authority ranking of mean WEMWBS score 2012/13 ............................................................... 32

Figure 11: Levels of life satisfaction, by self-reported health, April 2014 to March 2015, national results from the

Annual Population Survey, Personal Well-being ................................................................................................... 32

Figure 12: The percentage of respondents to the GP Patient Survey who responded to the question ‘Which, if

any of the following medical conditions do you have?’ who answered ‘Long-term mental health problem’.

Halton CCG compared to 10 similar CCGs and England average .......................................................................... 35

Figure 13: Prevalence of depression amongst Halton GP registered populations, aged 18+, 2015/16 ................ 35

Figure 14: Comparisons between estimated numbers of people with mixed anxiety and depression and actual

numbers of people recorded with depression by general practice 2015/16......................................................... 36

Figure 15: Correlation between estimated prevalence of CMD amongst the 16-74 year old CCG population and

deprivation (IMD 2015) ........................................................................................................................................ 37

Figure 16: Prevalence of CMD (in past week), 1993, 2000, 2007 and 2014, by gender ....................................... 37

Figure 17: Self-reported well-being: % of people with a high anxiety score ......................................................... 38

Figure 18: Prevalence of psychosis at GP practice and CCG level (QOF register), 2015/16 .................................. 39

Figure 19: Correlation between CCG prevalence of severe mental illness (QOF 2015/16) and deprivation (IMD

2015) ..................................................................................................................................................................... 40

Figure 20: Annual trend in emergency hospital admissions due to schizophrenia (ICD10 codes: F20.-, F21.-,

F23.2 and F25.-) .................................................................................................................................................... 40

Figure 21: Hospital admissions amongst people with schizophrenia by ward, Halton 2014/15 .......................... 41


8 | P a g e

Figure 22: People subject to Mental Health Act: rate per 100,000 population aged 18+ (end of quarter

snapshot) 2015/16 Q2, Crude rate - per 100,000 in Halton CCG and its 10 most similar CCGs............................ 42

Figure 23: trend in excess under 75 mortality rate in adults with SMI ................................................................. 43

Figure 24: Treatment, recovery and relapse cycle ................................................................................................ 45

Figure 25: Emergency hospital admissions for intentional self-harm 2014/15, Halton, borough statistical

neighbours and other comparators ...................................................................................................................... 48

Figure 26: Trend in Emergency hospital admissions for self-harm. Directly age-sex standardised rate .............. 48

Figure 27: Hospital admissions for intentional self harm, electoral ward, standardised admission ratio, 2010/11-

2014/15 ................................................................................................................................................................ 49

Figure 28: Trend in suicide rates, 2001-3 to 2013-15 ........................................................................................... 50

Figure 29: Admissions to hospital for mental ill health due to alcohol, 2014/15 ................................................. 65

Figure 30 Estimated prevalence of opiate and/or crack cocaine use, 2011/12, Crude rate per 1,000 population

aged 15-64 ............................................................................................................................................................ 66

Figure 31: Concurrent contact with mental health services and substance misuse services for drug misuse,

Halton statistical neighbours group, 2015/16 ...................................................................................................... 67

Figure 32: Community Wellbeing Practices Model of Delivery ............................................................................. 72

Figure 33: IAPT Clinical Pathway .......................................................................................................................... 73

Figure 34: Precribing items for medication to treat mental ill health .................................................................. 84

Figure 35: Prescribing costs for medication to treat mental ill health .................................................................. 85

Figure 36: Contact with specialist mental health services: rate per 100,000 population aged 18+ (end of quarter

snapshot) .............................................................................................................................................................. 86

Figure 37: Long Term Support clients with a PSR of Mental Health Support for selected LA and adults aged 18-

64, 2015/16 .......................................................................................................................................................... 90

Figure 38: Disability Adjusted Life years (DALYs) in Halton .................................................................................. 93

Figure 39: Percentage of those with a mental illness or learning disability in employment ................................ 94

Figure 40: Gap in the employment rate for those in contact with secondary mental health services and the

overall employment rate: percentage point difference ........................................................................................ 95

Figure 41: Proportion who receive a particular benefit, by type of benefit and by mental health status ............ 95

Figure 42: Individuals Involved in Section 42 Safeguarding Enquiries, by primary support need, 2015/16 ......... 99

Tables

Table 1: Determinants of mental health; factors that adversely affect mental health as well as protective

factors ................................................................................................................................................................... 19

Table 2: Levels of social capital, Halton 2012/13 ................................................................................................. 26

Table 3: General Risk Factors for Mental Health – wider determinants of health. .............................................. 26

Table 4: General determinants of mental health risk in Halton............................................................................ 27

Table 5: Estimated Halton prevalence of loneliness by degree of loneliness felt ................................................. 30

Table 6: Estimated prevalence of Halton residents who feel depressed due to loneliness ................................... 30

Table 7: Estimated prevalence of common mental health disorders (CMD) amongst adults (aged 16 and over) in

Halton, by gender ................................................................................................................................................. 33

Table 8: Estimated prevalence of common mental health disorders (CMD) amongst adults (aged 16 and over) in

Halton, by age group and gender ......................................................................................................................... 34

Table 9: Trend in diagnosed prevalence of depression ......................................................................................... 37

Table 10: Estimated prevalence of SMI, Halton residents aged 16 and over ....................................................... 39

Table 11: People subject to Mental Health Act: rate per 100,000 population aged 18+ (end of quarter snapshot)

.............................................................................................................................................................................. 42


9 | P a g e

Table 12: Excess under 75 mortality rate in adults with SMI: ratio of observed to expected mortalities

(expressed as a percentage) ................................................................................................................................. 43

Table 13: Estimated prevalence of ASPD and BPD in Halton ................................................................................ 45

Table 14: Estimated number of Halton adults (aged 16 and over) who may have PSTD or experienced trauma 47

Table 15: Example of risks and protective factors for suicide []

............................................................................. 50

Table 16: Estimated number of people with learning disabilities who have mental illness ................................. 59

Table 17: Halton CCG population with depression, by age and gender ................................................................ 60

Table 18: Halton CCG population with severe mental illness, by age and gender ................................................ 60

Table 19: Estimated prevalence of alcohol consumption levels in Halton ............................................................ 64

Table 20: Percentage of Halton service users with concurrent contact with mental health services and

substance misuse services for drug misuse, 2013/14 to 2015/16 ........................................................................ 66

Table 21: Commissioned Service Provision ........................................................................................................... 69

Table 22: QOF 2015/16 Depression and Mental Health Indicators ...................................................................... 78

Table 23: Percentage of eligible patients receiving the intervention ................................................................... 79

Table 24: Exception rates ...................................................................................................................................... 80

Table 25: IAPT waiting times to enter treatment, Halton and England 2015/16 ................................................. 81

Table 26: Number of referrals finishing a course of treatment in the year by outcome status, age and gender,

2015-16 ................................................................................................................................................................. 82

Table 27: Number of referrals finishing a course of treatment in the year by stepped care pathway, 2015-16 .. 83

Table 28: Referrals Completing Treatment in Halton and Problem Descriptor, 2015/16 ..................................... 83

Table 29: Percentage of referrals received, entering treatment and finishing a course of treatment in the year

by Indices of Deprivation decile (IMD 2015), IAPT 2015/16 ................................................................................. 84

Table 30: People using NHS funded adult secondary mental health and learning disability services, 2015/16 ... 85

Table 31: People using NHS funded adult secondary mental health and learning disability services by Care

Programme Approach, 2013/14 to 2015/16 ........................................................................................................ 86

Table 32: Bed days by gender, 2013/14 to 2015/16 ............................................................................................. 86

Table 33: Outpatient and community contacts by CCG and attendance type, April to November 2015 .............. 87

Table 34: Number of Halton residents aged 18-64 supported by adult social care due to mental illness, by

various social care packages during the year, 2015-16 ........................................................................................ 90

Table 35: Proportion of Incapacity Benefit/Severe Disablement Benefit and DLA due to mental illness,as at May

2016 ...................................................................................................................................................................... 96

Table 36: Housing hazards and their effects on mental health and wellbeing ..................................................... 97

Table 37: Percentage of adults (aged 18-69) in contact with mental health services who are living in stable and

appropriate accommodation: ............................................................................................................................... 98

Table 38: Conditions cared for person has, 2014/15 .......................................................................................... 101

Table 39: Percentage change in Halton's 18-64 age population, 2014 to 2030 ................................................. 102


10 | P a g e

Key priorities for consideration by commissioners This JSNA describes the mental health and mental illness of working aged people (18-64) in Halton.

This includes those resident in the borough and those registered with a Halton GP. It examines risk

factors for mental health, the burden of mental illness, and the use of mental health, social care

and voluntary services. It assesses the outcomes of mental illness including potential deterioration

to mental health crisis, self-harm or suicide, as well as the relationship between physical health

and mental health, and enablement for people with long term mental illness. With this analysis, it

is possible to identify strengths and weaknesses in the pathway of care for people with mental

illness as well as any unmet need and predictions of future need. The purpose is to help

commissioners to assess where need is greatest in terms of prevention, identification of mental

illness, access to services, support, treatment , recovery and reablement. Commissioners should be

aware that data quality relies on consistent and accurate recording of information, which cannot

always be guaranteed. Therefore, some caution is advised in interpreting the data to ensure that it

accurately reflects the true situation of mental health and mental illness in the population.

Mental ill health is the largest cause of disability in the UK, representing 23% of the burden of illness. At least one in four people will experience a mental health problem at some point in their life and one in six adults has a mental health problem at any one time.[1] . This is reflected by an estimate of over 12,455 adults living with a common mental health disorder (CMD) in Halton. A further 924 are estimated to have a serious mental illness and 5,549 estimated to have two or more psychiatric illnesses. Assuming prevalence rates remain static, this number is predicted to fall by 6.6% for men and 7.7% for women as the working age population is projected to decrease by this amount by 2030. In 2015/6, 1,104 people were diagnosed with severe mental illness (schizophrenia, bipolar affective disorder and other psychoses) and 9,724 with depression. This is an increase on the 2014/15 levels, even taking the lack of data from Windmill Hill practice in 2014/15. During 2015/16 there were 5,110 NHS Halton Clinical Commissioning Group (CCG) registered patients using NHS funded adult secondary mental health and learning disability services, with 6% admitted, slightly higher than nationally. There were 23,795 outpatient and community contacts during the same period.

The information drawn from this JSNA suggests that Halton faces many challenges with promoting

mental health and preventing mental illness. Many of the recognised risk factors for poor mental

health are found at a higher rate in Halton compared with England and the North West. These risk

factors include higher rates of socio-economic deprivation, children in care, violent crime, some

types of drug misuse, relationship breakdown and lone parent households compared with the

North West and England averages. However, some protective factors for mental health are good in

Halton.

A more complex picture is revealed when electoral ward level data on mental health risk factors is

analysed. Many of the more socio-economically deprived areas have associated higher risk factors

for mental illness, whereas the more affluent wards have lower levels of risks associated with

mental illness. Halton also faces challenges with certain vulnerable groups at higher risk of mental

health problems. These include military veterans and those in or returning from the criminal

justice system. Migrants mostly from Eastern Europe as well as the planned introduction of

refugees and asylum seekers is likely to pose particular challenges to a health and social care

system that is not geared up to support an ethnically diverse population, especially one which is

likely to have specific mental health needs.


11 | P a g e

Data Summary


12 | P a g e

1. Introduction

The World Health Organisation describes mental health as

‘a state of wellbeing in which the individual realises his or her

own abilities, can cope with the normal stresses of life, can work

productively and fruitfully, and is able to make a contribution to

his or her community’[2]

No Health Without Mental Health – a cross government mental health outcomes strategy for people

of all ages, 2011[3]described mental health as everyone’s business and that all sectors of society need

to play their part. This is based on a recognition that good mental health and resilience are

fundamental to all other aspects of our lives; physical health, relationships, education, training,

employment and work and in achieving potential. Good wellbeing in the population brings social and

economic benefits.

No Health Without Mental Health made it clear that to realise the benefits of good mental health,

we all need to take action and responsibility for caring for our own mental health and that of others,

challenging stigma and discrimination with the support from Government to do so. NHS England’s

2013 ‘A call to action’ [4]highlights the institutional aim to raise the focus of mental health from any

notion that it be considered ‘secondary’ to physical health. This stated

‘The mandate from the government to NHS England instructs us

to put mental health on a par with physical health, and to close

the health gap between people with mental health problems

and the population as a whole. To value physical and mental

health equality is to ensure equal access to services and equal

quality of those services. The Health and Social Care Act 2012

also secured explicit recognition of the duty of the Secretary of

State towards both physical and mental health.[5]

Mental health as a specialty has led the way in innovation and out of hospital care. From an

institutional hospital based model three decades ago, to one in which most care is provided in

community settings by multidisciplinary mental health teams.[6] Community partnerships are at the

heart of good mental health care with collaboration between agencies to deliver co-ordinated,

needs led care. User coproduction and peer support is highly valued. Digital innovation brings new

opportunities to identify the avoidable causes of ill health and transform the levels of access to

information and treatments.

This JSNA considers mental health in the population of Halton by assessing what factors put this

health at risk and where the challenges are greatest. This will provide evidence to commissioners on

where input and support to individuals is most needed to improve mental health outcomes. In

addition, improving the mental health of those with mental illness will have fundamental benefits to

those individuals, their families and carers, communities and society. It will also help to reduce costs

and pressures on health and social care services. Improving mental health in the population will

reduce the risk of mental health problems and suicide, increase productivity and reduce health risk

behaviour such as smoking and drug and alcohol abuse.


13 | P a g e

Mental illness or disorder refers to a diagnosable condition that significantly interferes with an

individual’s cognitive, emotional or social abilities e.g. depression, anxiety, and schizophrenia.

Common Mental Health Disorders (CMD) are those that affect emotions, causing distress and

interference with daily function but do not alter cognition or insight.[7] CMDs are comprised of

different types of depression and anxiety - mixed anxiety and depressive disorder, anxiety disorder,

depressive episode, panic disorder, phobias, obsessive compulsive disorder. Serious mental illness

(SMI) includes diagnoses which typically involve psychosis or high levels of care, and which may

require hospital treatment. Typically these are long lasting health problems that can significantly

affect quality of life, especially if they are left unrecognised or untreated. SMI includes diagnoses of

schizophrenia and bipolar disorder.[8].

Mental illness causes considerable social, economic and health costs to individuals and to wider

society. At least one in four people will experience a mental health problem at some point in their

life and one in six adults has a mental health problem at any one time.

CMD contributes 12% of the total burden of non-fatal global disease and by 2020, looks set to be

second after Cardio Vascular Disease in terms of the world’s disabling diseases.[9] Mental ill health in

total is the largest cause of disability in the UK, representing 23% of the burden of illness. People

with severe mental illness die on average 20 years earlier than the general population. Mental

disorder costs the English economy an estimated £105 billion a year.[10].


14 | P a g e

2. Policy Context Describe the national and local policy context? Does this include links with other plans e.g. strategic

commissioning plan, sustainable community strategy, health & wellbeing strategy, as appropriate?

National Figure 1: No Health Without Mental Health – Key Objectives

Local The Halton Health and Wellbeing strategy (2013-16)[11] included mental health as one of its 5 priority

areas for action. The 2017-2022 strategy maintains this focus as consultation with the public and

key stakeholders shows that mental health remains a key priority.

Both the overall Health and Wellbeing Strategy and the more detailed mental health strategy

developed as a consequence took a lifecourse approach, with an emphasis on prevention and early

detection. Priorities focussed on working age adults:

Vision from A Mental Health and Wellbeing Commissioning Strategy for Halton 2013 to 2018

Through the implementation of the strategy, Halton aims to ensure the objectives outlined in the

national strategy, those identified in the Halton Health and Wellbeing Strategy 2013-2016, and the

Halton Clinical Commissioning Group Strategic Plan are realised for local people.

People of all ages living in Halton will have a high level of self-reported wellbeing, having happy and

fulfilling lives, being able to contribute economically and socially to their own networks and the

community as a whole.

Those who do experience mental ill health will not feel any stigma attached to the condition and be

able to easily and quickly access appropriate levels of professional support to help them recover.


15 | P a g e

(i) More people will have good mental health: More people of all ages and backgrounds will have

better wellbeing and good mental health. Fewer people will develop mental health problems – by

starting well, developing well, working well, living well and ageing well. We will improve the mental

health and wellbeing of Halton people through prevention and early intervention. We will increase

the early detection of mental health problems which will lead to improved mental wellbeing for

people with mental health problems and their families

(ii) More people with mental health problems will recover: We will improve outcomes for people

with mental health problems through high quality accessible services. More people who develop

mental health problems will have a good quality of life – greater ability to manage their own lives,

stronger social relationships, a greater sense of purpose, the skills they need for living and working,

improved chances in education, better employment rates and a suitable and stable place to live.

(iii) More people with mental health problems will have good physical health: Fewer people with

mental health problems will die prematurely and more people with physical ill health will have

better mental health.

(iv) More people will have a positive experience of care and support: Care and support, wherever it

takes place, should offer access to timely, evidence-based interventions and approaches that give

people the greatest choice and control over their own lives, in the least restrictive environment, and

should ensure that people’s human rights are protected.

(v) Fewer people will suffer avoidable harm: People receiving care and support should have

confidence that the services they use are of the highest quality and at least as safe as any other

public service.

This strategy identifies five priority areas for work to meet the needs of local people.

Priority 1- Improve the mental health and wellbeing of Halton people through prevention and early intervention

Priority 2 – Increase the early detection of mental health problems which will lead to improved mental wellbeing for people with mental health problems and their families

Priority 3 - Improve outcomes for people with identified mental health problems through high quality, accessible services

Priority 4- Broaden the approach taken to tackle the wider social determinants and consequences of mental health problems

Priority 5 - Optimise value for money by developing quality services which achieve positive outcomes for people within existing resources

An external review of adult mental health services provision in Halton has already taken place and a

number of recommendations have been made. There are clear links to both the Alcohol Stratgey

and Substance Misuse Strategy as well as the Suicide Prevention Strategy.

The Mental Health Strategy will be reviewed in light of this and the complementatary JSNAs on child

mental health and older people’s mental health.


16 | P a g e

3. Level of need in the population One of the main aims of a JSNA is to understand the determinants of health in an area and consider

social and contextual factors that affect mental health, such as employment, crime, safety and

housing. The mental health of each individual person is heavily influenced by their social setting,

such as having the ability to earn enough money and feeling part of a community.[12]

It is important to stress that the causes of mental illness are complex, varied and multi-factorial,

including factors such as genetics, childhood experience, characteristics of personality, significant life

events, the quality of relationships, economic and social situation, life-style choices such as alcohol

and other drugs, and aging.[13] Some of these factors are understood to the point of being

acknowledged risk factors for mental illness. Understanding these factors in a local area can

therefore help quantify levels of risk, protection and resilience for the community. It can help to

identify vulnerable groups, consider what interventions could help to develop resilient communities

and indicate where a focus on prevention activities can reduce vulnerability to mental illness.

Greater community resilience has the potential to reduce the prevalence of mental ill-health and

increase the prevalence of good mental health for the whole population, as well as improving

recovery and support for individuals who have become unwell.

Type of questions the JSNA attempts to address include:

What are the social, economic and other factors that promote good mental health? What are the social, economic and other factors that damage mental health? How are these changing over time? How do they affect different groups of people or cause inequalities? What are the community’s main assets and how strong are social networks? What do local people feel about the area and what are they concerned about? How do these wider factors affect the need for mental health services? How can these wider influences on health be tackled by prevention initiatives?

(based on Joint Strategic Needs Assessment: Data inventory)[14 (3)

For the purpose of this JSNA, mental health disorders are grouped and defined as follows:

Common Mental Disorders – (CMDs) are mental conditions that cause marked emotional distress and interfere with daily function, but do not usually affect insight or cognition. They comprise different types of depression and anxiety.

Serious Mental Illness (SMI) – a group of disorders causing serious mental health illness including

psychotic disorders and personality disorders.

Other Mental Health Disorders – there are a range of other mental health disorders not

classified in the two categories above. These include personality disorders, eating disorders,

autistic spectrum disorders, post-traumatic stress disorder.

Self-harm, suicide and mental health crisis - the JSNA will report the prevalence of mental

health crisis by analysing data on self-harm, suicide and use of police powers to remove people

in mental health crisis in the community to places of safety.

The burden of mental illness in a population can be measured in several different ways;

estimates of prevalence of mental illness can be used by applying national data from surveys or

studies to the local population, local survey data can be collected, general practice records and

reporting information can be used to obtain prevalence of recorded mental health disorders,


17 | P a g e

hospital admission information and activity by the mental health trust (5 Borough Partnerships

NHS Foundation Trust – 5BP) can provide detail of demand for services. Each piece of data adds

to the overall picture to understand the epidemiology of mental illness in the population.

The World Health Organisation use a definition of mental health as ‘a state of well-being in which

the individual realizes his or her own abilities, can cope with the normal stresses of life, can work

productively and fruitfully, and is able to make a contribution to his or her community’.[15] Reference

to this definition makes it clear that mental or psychological well-being is influenced not only by

individual characteristics or attributes, but also by the socioeconomic circumstances in which

persons find themselves and the broader environment in which they live. This is conceptualised in

the model below, which shows the groups of contributing factors that influence mental health and

wellbeing.

Figure 2: Model to show the influences to an individual’s mental health and wellbeing

Source: WHO – Risks to Mental Health 2012

[16]

The relationship between deprivation and mental health is complex and it can be difficult to unpick

cause and effect. Experiencing disadvantage can increase the risk of mental illness, and people with

mental illness can be affected by a “spiral of adversity”[17] where related factors such as

unemployment, low income and relationships are impacted by their illness. The other major factor is

access to treatment: people who live in deprived areas are more likely to need mental healthcare

but are less likely to access support and to recover from their symptoms following treatment.[18].

This compounds and worsens mental health problems.

Deprivation is a multi-faceted concept and is about far more than lack of money. It can mean lack of

access to resources, such as inadequate housing, or exposure to negative environmental stresses

such as violence, crime or lack of public green space. It is also noteworthy that a growing body of

evidence suggests that the relationship between deprivation and mental health is not just about

absolute lack of resource for individuals, but that populations with high levels of inequality (large

differences in wealth and resource between individuals) are associated with overall higher levels of

poor health and mental illness for the population as a whole.[19]

There are a wide range of other known associations between lifestyle factors, wider determinants


18 | P a g e

of health and Common Mental Disorders (CMD). These include: being female, work stress, social

isolation, poor housing, negative life events, poor physical health, a family history of depression,

poor interpersonal and family relationships, a partner in poor health, and problems with alcohol.

Links between mental illness and socioeconomic context are also well-established within the

national Adult Psychiatric Morbidity Survey (APMS), with data from the 2014 survey[20]being

consistent with this. It showed that most mental disorders were more common in people living

alone, in poor physical health, and not employed. Claimants of Employment and Support

Allowance (ESA), a benefit aimed at those unable to work due to poor health or disability,

experienced particularly high rates of all the disorders assessed. Overall there has been a rise in

mental health disorders, mostly driven by increases in CMD amongst women. Young women in

particular have emerged as a high-risk group in this latest survey, with the gender gap being most

pronounced in the 16-24 year olds. Women in this youngest age group experience the highest

level of self-reported CMD in the week prior to the survey. Rates of mental illness also increased

in men and women aged 55 to 64.

Reports of self-harming doubled in men and women and across age groups between 2007 and

2014. Greater awareness of what constitutes self-harm and a willingness to admit it may explain

this increase, at least in part.

The survey also showed inequalities in mental health treatment. Among people with CMD, those

who were female, White British, or in midlife were more likely than others to receive treatment. One

adult in ten with severe CMD symptoms asked for a particular mental health treatment in the past

12 months but did not receive it.

Figure 3 shows how factors that impact on mental health influence an individual over the life-

course. It also shows the level these factors operate to influence an individual, whether this is as

part of the culture, within a community or family or directly through individual choice. The

diagram is used as a basis to assess risk factors for mental health disorders for the population of

Halton.


19 | P a g e

Figure 3: Schematic overview of the risk factors to mental health over the life course

Source: Foresight Project, 2008[21][22]

3.1 Protective factors

Factors that promote mental health are most often directly opposed to those that influence poor

mental health outcomes and this is conceptualised in Table 1. It is therefore reasonable to reassess

the data on risks to mental health given above to identify areas with low levels of risk, likely to

promote mental health.

Table 1: Determinants of mental health; factors that adversely affect mental health as well as protective factors

Source: WHO Risks to Mental Health[23]


20 | P a g e

3.1.1. Physical activity and access to open space

Research demonstrates that individuals who engage in regular leisure-time activity of any intensity

are less likely to have symptoms of depression.[24] The context of any physical activity is vital, with

workplace activity having no association with lower levels of common mental disorders. The social

benefits associated with exercise appear to be more important than biological changes in explaining

the associations between physical activity and symptoms of depression.[25] Studies also indicate

physical activity is beneficial for people with other types of mental health problems such as

schizophrenia, as well as conditions such as autistic spectrum disorder[a] and Alzheimer’s Disease and

substance misuse.[26]

Halton level data from the North West Mental Wellbeing Survey 2012/13 shows that those who do

not exercise are most likely to have low mental wellbeing (17.3%) and least likely to have high

mental wellbeing (16%). In 2012/13, 26.3% of Halton respondents had met the physical activity

target of five or more days. There were no differences when compared to the North West.

More recent data on physical activity levels shows that only 48.5% of Halton adults achieving at least

150 "equivalent" minutes of at least moderate intensity physical activity per week in accordance

with UK Chief Medical Officer recommended guidelines on physical activity. This level is statistically

significantly worse than the England level of 57% and the North West level of 53.2%. It also shows

levels have fallen slightly in Halton whereas regional and national trends have improved.

Figure 4: Percentage of adults achieving recommended levels of physical activity

There is significant and growing evidence on the health benefits of access to good quality green

spaces. The benefits include better self-rated health; lower body mass index, overweight and obesity

levels; improved mental health and wellbeing; increased longevity.[27]The natural environment has

been known to provide a number of mental health benefits, such as reduced stress and anxiety,

improvements in mood and concentration, as well as relaxation and escape. The impacts on mental

wellbeing, social networks and sustainable communities probably work through a variety of

mechanisms and it’s in these areas that the strongest evidence is emerging that urban green space

can improve the public’s health. For people living in urban areas, those who have more green or blue

space have better mental health. There is even evidence emerging to suggest that hospital

a The NHS does not regard autism as either a learning disability or a mental health problem on its own. However, some people with autism may have an accompanying mental health problem or learning difficulty


21 | P a g e

inpatients feel better and are discharged sooner when they are able to see greenery outside their

window or enjoy a hospital garden.[28

Estimates deprived from the Natural England Monitor of Engagement with the Natural Environment

(MENE) survey suggest a slightly higher proportion of Halton’s population access the natural

environment for health or exercise purposes (20% compared to 15.8% for the North West and 17.9%

for England). Visits to the natural environment are defined as time spent "out of doors" e.g. in open

spaces in and around towns and cities, including parks, canals and nature areas; the coast and

beaches; and the countryside including farmland, woodland, hills and rivers.

This could be anything from a few minutes to all day. It may include time spent close to home or

workplace, further afield or while on holiday in England. However this does not include routine

shopping trips or time spent in own garden

However, data obtained as part of a North West Coast research programme on community

resilience in deprived neighbourhoods showed substantial variation in the percentage of the

population who access ‘green space’ in the two electoral wards surveyed – just 22.56% in Halton

Castle (the lowest percentage of the 20 deprived wards across the NWC surveyed) compared to

72.1% in Ditton (the highest percentage amongst the areas surveyed). Methodology differences

mean these two datasets are not directly comparable. What this does tell us is that whilst Halton’s

population overall may have access to an use open space to a greater extent than regionally and

nationally, there is likely to be significant variation across the borough.

The 2012/13 Mental Wellbeing Survey showed that respondents from Halton were most likely to

spend their leisure time outdoors ‘several times a week’ (35.2%). They were significantly less likely

to ‘never’ spend time outdoors (0.8%) compared with the North West (2.5%). Frequency of

outdoor leisure time was strongly associated with mental wellbeing; 40.7% of those that

participated in outdoor leisure time ‘less than monthly’ had low mental wellbeing whilst 30.9% of

those who spent time ‘daily or more’ had high wellbeing.[29]

3.1.2. Self-esteem, confidence and ability to manage stress/adversity

Self-confidence: The belief that you can achieve success and competence. In other words –

believing yourself to be capable. Self-confidence might be in reference to specific tasks or a more

wide ranging attitude you hold about your abilities in life.

Self-esteem: Your opinion of yourself and your worth. In other words, your perception of your

value as a person, particularly with regard to the work you do, your status, achievements, purpose

in life, your perceived place in the social order, potential for success, strengths and weaknesses;

how you relate to others and your ability to stand on your own feet.

Both self-confidence and self-esteem relate to perceptions of self, the former relates to perception

of abilities and the latter to perception of worth or value. The concepts are closely related and

those with low self-confidence will often have low self-esteem and vice versa.

The Office for National Statistics (ONS) wellbeing scores from the annual population survey include

measures of people feeling what they do is worthwhile, life satisfaction and happiness. Halton

results show residents have similar or slightly better feelings of being worthwhile and so on.


22 | P a g e

Figure 5: Self-reported well-being: % of people with a low worthwhile score

Figure 6: Self-reported well-being: % of people with a low satisfaction score

Figure 7: Self-reported well-being: % of people with low happiness score

3.1.3. Community resilience

Community resilience is most often viewed as a measure of the sustained ability of a community to

utilize available resources to respond to, withstand, and recover from adverse situations. This

‘survival’ approach to resilience underpins current mainstream understandings of community

resilience. Research by the Young Foundation[30] suggests that community resilience is built primarily

through relationships, not just between members of the community but also between organisations,

specifically between the voluntary sector, the local economy and the public sector.


23 | P a g e

The Young Foundation has developed a holistic understanding of resilience. Our understanding of community resilience is made up of a number of features incorporating cultural, human, political, financial and social resources. These may include ‘hard’ assets such as good transport links, access to services and amenities. Also important are local buildings, organisations that enable communities to come together, allowing people to access support and to have their voices heard in relation to local issues. It includes ‘softer’ assets such as relationships with family, friends, neighbours, colleagues and the support of the wider community. It encompasses links with voluntary and state organisations and the private sector. Most importantly, it not simply about exhorting communities to ‘pull themselves together’ but about giving them the capacity to identify assets and utilise them.

Measures of community resilience should include:

Self: the way people feel about their own lives

Support: the quality of social supports and networks within the community

Structure and systems: the strength of the infrastructure and environment to support people to achieve their aspirations and live a good life.

Thus, various elements of this JSNA will identify measures of community resilience. Section 3.1.2

above considers measures of self. Section 4 on services looks at infrastructure to support people

with mental wellbeing and mental health problems. The measures below on social support, social

connections and social capital focus on support measures.

3.1.3.1 Social support of family and friends

Research indicates that family and friend relationships make unique contributions to the well-being.

This includes both qualitative aspects of family and friend support networks (i.e., subjective

closeness, negative interactions) and structural aspects (i.e., frequency of contact), with the former

likely to be most important as it measures the quality of the support.[31] Whilst positive partner

relationships and family support are predictive of wellbeing measuresfor both genders, where there is

partner strain, friends and family may provide a buffering role more often for women than for men.[32

Halton results from the North West Mental Wellbeing Survey 2012/13 showed:

Personal relationships: There was little variation between Halton and the North West in satisfaction with personal relationships.. Over half (55.2%) of respondents were very satisfied with their personal relationships, whilst only 0.1% were very dissatisfied. Satisfaction with personal relationships showed a strong association with mental wellbeing; those who were very satisfied were most likely to have high mental wellbeing (30.6%) and those who were neutral or dissatisfied were most likely to have low mental wellbeing (43.1%).

Social interaction: over half (52.2%) of Halton participants reported meeting with friends and family (that they did not live with) on most days, a higher proportion than the North West (41.2%). Overall, 9.1% met with friends and family monthly or less (13.4% in the North West). There was a strong relationship between this variable and mental wellbeing; only 7.9% of those who spoke to family and friends on most days had low mental wellbeing compared with 38.6% of those doing so


24 | P a g e

monthly or less.

Social support: Social support was scored based on responses to the questions regarding available

help if the respondent; was in financial difficulty and needed to borrow £100; needed a lift

urgently; was ill in bed and need help at home; and, had a personal crisis and needed support.

Respondents in Halton were more likely to be able to ask for help if they needed a lift urgently

(90.0%) compared with 2009 (77.4%). The majority of respondents felt well supported (63.9%),

with these being most likely to have high wellbeing (33.2%). Respondents with little support were

most likely to have low wellbeing (37.5%).

Figure 8: Personal relationships and mental wellbeing, Halton results from the North West Mental Wellbeing Survey 2012/13

3.1.3.2. Social connections

In the most fundamental ways, social and emotional functioning changes little with age. At no point

in life does the need to feel accepted in larger groups lessen or the negative consequences of social

isolation diminish.[33] Having good social networks and an active social life can reduce the risks of

depression in later life and staying socially connected appears to protect against dementia.[34] It is

very important for older people to maintain a sense of their own self-identity and purpose and the

quality of these social relationships can influence the way the brain processes information.[35]

Research focusing on older people in local communities has reported their sociability and

engagement as central to their conception of wellbeing. Although family – children, siblings,

grandchildren, nieces and nephews are a primary source of comfort and support for many people - it

is often evident that friends and neighbours are the mainstay of most people’s day to day lives.

Friends and neighbours are the people with whom many people share experiences, enjoy

companionship in social activities and support people through life changes such as illness or

bereavement.[36] For many older people, contact declines due to reasons such as being in poor

physical health, having no access to a car and not using public transport, moving into a care home or

becoming a carer. The English Longitudinal Study of Ageing found that participation in social or

recreational activities fell with age and women were more affected than men. The research also

found that around one in ten people aged 50 and over in England in 2006 were not a member of

any political party, environmental or resident group, neighbourhood watch, religious or charitable

association. Sixteen per cent had not participated in social or recreational activities and did not have

a hobby or pastime.[37]

Neighbourhood environments can play a key role in influencing health. Much of the research has

centred on material conditions are area-level effects of socioeconomic status. However,

perceptions of a neighbourhood’s physical and social characteristics can also impact on health

outcomes and can even mediate the impacts of such characteristics, for example, on mental

Mental Wellbeing Category

Low Moderate High

5.6% 63.8% 30.6%

15.9% 64.3% 19.7%

43.1% 51.7% 5.2%

7.9% 64.8% 27.3%

15.0% 63.6% 21.4%

38.6% 45.5% 15.9%

Little support 0-1 37.5% 52.5% 10.0%

2 18.8% 79.2% 2.1%

3 19.5% 71.3% 9.2%

Well supported 4 6.5% 57.7% 35.7%

Source: McHale, Hughes and Jones 2013

Satisfaction with personal

relationships

Social interaction: meet

with family or friends

Social support available

Very satisfied

Fairly satisfied

Neither or dissatisfied

On most days

Once or twice a week

Monthly or less


25 | P a g e

health.[38]

3.1.3.3.Social capital

In general terms, social capital represents social connections and all the benefits they generate. The

benefits for people having these social connections can occur either at an individual level (for

example, through family support) or at a wider collective level (for example, through volunteering).

It is important because of its positive contribution to a range of wellbeing aspects relevant to policy

makers and researchers, such as personal wellbeing and health.

The ONS states that social capital[39:

“represents social connections and all the benefits they generate. The benefits for people having these social connections can occur either at an individual level (for example, through family support) or at a wider collective level (for example, through volunteering). Social capital is also associated with values such as tolerance, solidarity or trust. These are beneficial to society and are important for people to be able to cooperate.”

The ONS methodology for measuring social capital was used for the 2012/13 North West Mental

Wellbeing Survey.[40] The five areas are:

Social Participation: variety and breadth of participation in community organisations.

Social Networks: frequency of contact with friends, relatives or neighbours, social support and social satisfaction.

Social Cohesion: length of residence in local area, sense of belonging to neighbourhood and trust.

Civic Participation: perception of local influence and life satisfaction.

Local Area Views: satisfaction with local area and perception of safety in local area. The overall findings were that over a quarter (27.8%) of Halton respondents were categorised as

having low social capital, 45.7% as moderate and 26.5% as high. There was a similar distribution for

the North West respondents, with 28.4% categorised as low, 47.3% as moderate and 24.3% as high.

The average social capital score was 29.06, similar to the North West average of 28.95. There was a

significant relationship between social capital and deprivation; low social capital most likely in the

most deprived quintile (36.9%) with high social capital most likely in the least deprived. High social

capital was most likely in over 65’s.


26 | P a g e

Table 2: Levels of social capital, Halton 2012/13

3.2. Risk factors

Information on risk factors for mental health is only as good as the data available for analysis.

Data is obtained from a variety of sources including the national census, routine surveys and

social care information. This information is generally available at local authority level and may or

may not be available at ward level. The information varies according to when the data was

collected and collated and is therefore not comparable for any particular year and is usually

between one and eight years out of date.

Based on the evidence of risk factors for common mental health disorders as well as for

serious mental illness, data has been collated based on what is routinely available to analyse

the various risk factors and is presented in Tables 3 and 4.

Table 3: General Risk Factors for Mental Health – wider determinants of health.


27 | P a g e

Table 3 illustrates the link between poverty and other risk factors for poor mental health across the

life course. Wards with higher levels of poverty also have lower levels of education achievement,

higher levels of unemployment and lower life expectancy. Table 4 reinforces this message by

showing higher rates of some other determinants of poor mental health – higher rates of children in

care, violent crime, relationship breakdown, lone parent households, ill health and long-term

unemployment in Halton compared with the North West and England averages.

Table 4: General determinants of mental health risk in Halton

3.3. Social isolation and loneliness Loneliness is a subjective, negative feeling associated with lack or loss of companionship. If you feel

lonely, you are lonely. ‘Social isolation’ is a sociological category relating to imposed isolation from

normal social networks. This can lead to loneliness and can be caused by loss of mobility or

deteriorating health. It is possible to be lonely whilst not isolated, for example amongst those caring

for a dependent spouse with little help.[41]

Societal change including geographic dispersion and fragmentation of extended family networks

mean other forms of local social networks are increasingly important, and there are concerns about

isolation and loneliness among older people. The Lifecourse Tracker national survey[42] asked adults

aged 55 years and over how often they interact with relatives or other adults outside of their

households. Regardless of whether or not they live alone, the proportion of older people saying

they see or speak to a relative or other adult outside their household every day declines with age.

Socio-economic status played a role: Those in higher socio-economic groups (71%) were significantly

more likely than those in lower socio-economic ones (56%) to see or speak to a relative or other

adult outside of their household every day - another example of an aspect of wellbeing correlated

with deprivation.[43]


28 | P a g e

The terms ‘social isolation’ and ‘loneliness’ are often used interchangeably, although they have

different nuances. The concept of social isolation is centered on the level of social integration of an

individual, although the specific definition varies within the literature. It is usually described as the

absence of strong social networks, and therefore as an objective concept distinct from ‘emotional

isolation’ or the subjective and negative emotional experience more usually described as

‘loneliness’.

A recent meta-analysis of 148 longitudinal studies examined data from 308,849 participants with a

mean age at of 63.9 years, and estimated a 50% greater likelihood of survival for individuals with

strong social ties; the health effect for those with poor social relationships and networks was

comparable to smoking 15 cigarettes a day and greater than other established risk factors for

mortality such as physical inactivity.[44]

Studies show a direct correlation between loneliness and poor health outcomes. For example,

lonely individuals have higher blood pressure than their less lonely peers, and this association is

independent of demographics, cardiovascular risk factors, health conditions and depressive

symptoms.[45] Further, while social relationships and conformity to social norms may offer positive

influences on lifestyle, both loneliness and social isolation in older adults are associated with

increased likelihood of multiple unhealthy behaviours such as smoking and physical inactivity, with

the correlated effect on physical health.[46]

Loneliness has a bearing on mental health as well as physical health. The relationship between

loneliness and depression is multidirectional: loneliness can be both a cause and consequence of

depression. Loneliness may affect cognitive behaviours, encouraging a more negative outlook and a

greater focus on self-preservation. Loneliness is often described as a vicious cycle, and these

cognitive behavioural impacts may be the means of mediating this as they hamper social interaction.

Qualitative research suggests loneliness relating to feelings such as ‘anger, sadness, depression,

worthlessness, resentment, emptiness, vulnerability and pessimism’.[47] Lonely or isolated older

people have an increased risk of developing dementia, specifically in developing Alzheimer’s disease,

as self-perceived loneliness doubles the risk.[48]

Due to the nature of loneliness, there are no reliable local sources of data which can tell us how

many people in the borough experience loneliness. It is predominantly seen as a problem that is

particularly associated with old age. Much less attention has been given to examining variations in

loneliness across age groups. One study looking at patterns of loneliness across adults aged 15 years

and older in the United Kingdom used data from the European Social Survey.[49] It found that

loneliness demonstrates a nonlinear U-shaped distribution, with those aged under 25 years and

those aged over 65 years demonstrating the highest levels of loneliness. Depression is associated

with loneliness for all age groups. Poor physical health is associated with loneliness in young adult

and midlife but not later life. For those in mid and later life, the quality of social engagement is

protective against loneliness, while for young adults it is the quantity of social engagement. This

indicates that different factors may endow vulnerability (or protect) against loneliness at different

stages of life and suggests that preventative strategies or interventions that reflect these variations

need to be developed.


29 | P a g e

There are no regular datasets that include measures of loneliness at a population level. The Adult

Psychiatric Morbidity Survey is only conducted once every seven years and does not include measurs

of loneliness. Nor does the The Mental Health Minimim dataset. A 2010 survey of a representative

sample of 2,256 adults in the UK showed:[50]

Loneliness affects many of us at one time or another:

Only 22% never felt lonely and one in ten (11%) felt lonely often

The same number (10%) don’t have company when they want it

A quarter (24%) worried about feeling lonely. This was more commonly felt by those aged 18-34 (36%, compared to 17% of those over 55)

Four in ten (42%) have felt depressed because of loneliness. This was higher among women (47%, compared to 36% men), and higher among those aged 18-34 (53%, compared to 32% of those over 55)

A third (37%) had a close friend or family member who they thought was very lonely. This was higher among women (41%, compared to 33% men) and people aged 18-34 (45%, compared to 31% of those over 55)

Over half (57%) who have experienced depression or anxiety isolated themselves from friends and family

Loneliness in society:

Almost half of us (48%) strongly agree or agree that people are getting lonelier in general.

One in three (35%) strongly agreed or agreed that they would like to live closer to family so that they could see them more often. This was higher among women (40%, compared to 29% of men), and among people living in London (41%, compared to 32% of those living the North West). A third (29%) said they don’t have enough time to spend with friends and family

Two thirds (62%) say technology helps them keep in touch with people they might otherwise lose touch with. One in five (18%) said they spend too much time communicating with family and friends online when they should see them in person. This was higher among younger people (31%, compared to 9% of those over 55)

Seeking help for feelings of loneliness:

One in ten (11%) had sought help for feeling lonely. This was higher among those living in the South West (16%, compared to 12% in the North West and 8% in Yorkshire and Humberside. One in three (30%) would be embarrassed to admit to feeling lonely. This was higher among younger people (42%, compared to 30% of those aged 35-54 and 23% of those over 55)

Applying feeling lonely to Halton’s adult population aged 18 and over indicates 8,439 may often feel

lonely and a further 26,083 feel lonely sometimes. The North West overall prevalence is similar

albeit slightly lower than the UK total although 36% never felt lonely compared to 22% for the UK as

a whole. However, regional levels are not available broken down by age and gender so the UK

prevalence is used for the Halton estimates in Tables 5 and 6.


30 | P a g e

Table 5: Estimated Halton prevalence of loneliness by degree of loneliness felt

Table 6: Estimated prevalence of Halton residents who feel depressed due to loneliness

3.4. Levels of mental wellbeing

The concept of well-being comprises two main elements: feeling good and functioning well. Feelings

of happiness, contentment, enjoyment, curiosity and engagement are characteristic of someone

who has a positive experience of their life. Equally important for well-being is our functioning in the

world.

Experiencing positive relationships, having some control over one’s life and having a sense of

purpose are all important attributes of wellbeing.[b] There are five simple and practical steps that can

be taken to improve wellbeing, called the ‘five ways to wellbeing’ they are:

Connect – connect with the people around you Be active – physical activity is good for the mind and the body Take notice – become aware of the world around you Keep learning – learn new skills and set yourself challenges Give – be a good citizen and help others

In contrast to the negative focus of mental illness, mental health and wellbeing focus on positive

aspects of a person’s attitude and situation that can promote human flourishing (i.e. being happy,

healthy and prosperous). Mental wellbeing is not the absence of negative emotions (e.g.

disappointment, failure, grief) but the ability to manage these emotions.

Across the North West there have been two mental wellbeing surveys, 2009 and 2012/13. Each used

the short Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS) to measure mental wellbeing. The

b) www.fivewaystowellbeing.org

http://www.fivewaystowellbeing.org/


31 | P a g e

seven items included in the short WEMWBS refer to participants’ feelings over the past two weeks.

They are:

I’ve been feeling optimistic about the future

I’ve been feeling useful

I’ve been feeling relaxed

I’ve been dealing with problems well

I’ve been thinking clearly

I’ve been feeling close to other people

I’ve been able to make up my own mind about things

Responses are scored on a five point Likert system, ranging from 1 meaning ‘none of the time’

through to 5 meaning ‘all of the time’. Scores for each item are summed, meaning a respondent can

score between 7 (lowest possible mental wellbeing) and 35 (highest possible mental wellbeing).

Figure 9 shows that the mean WEMWBS score for Halton in 2012/13 was 28.3, which was very

similar to the mean score of 28.5 seen in the 2009 survey[c]. In 2012/13, the mean WEMWBS score

for Halton was significantly better than that for the North West (27.7). Figure 9 shows mean

WEMWBS scores of local authorities across the North West in 2012/13. Halton had the seventh

highest mean score out of all areas surveyed.

Figure 9: Mean WEMWBS scores for Halton and the North West in 2009 and 2012/13

c Note: the 2009 survey used a sample at Halton & St Helens PCT level. Halton data was used in the 2012/13 survey report

but the sample size was too small to be fully representative of Halton’s population


32 | P a g e

Figure 10: Local Authority ranking of mean WEMWBS score 2012/13

Wellbeing and physical health

Adults in the UK who reported very good or good ratings of self-reported health, had higher

proportions of very high life satisfaction when compared with those who reported bad or very bad

ratings of self-reported health in the financial year ending 2015 (Figure 11). Of those that

considered themselves to be in very good health, 37.3% rated their life satisfaction as very high,

compared with 11.1% of those that reported they were in very bad health.

Figure 11: Levels of life satisfaction, by self-reported health, April 2014 to March 2015, national results from the Annual Population Survey, Personal Well-being


33 | P a g e

Wellbeing and work

What Works Centre for Wellbeing,[d] a national organisation funded by central government, has used the ONS personal wellbeing questions and Annual Population Survey data to calculate wellbeing scores by standard occupation code. These scores have been correlated against income using the Annual Survey of Hours and Earnings data to allow for comparisons between wellbeing and earnings.

Headline results:

Chief Executives and senior officials consistently come out as having among the highest levels of well-being. However those in health, welfare, teaching, agriculture and sports report being the most fulfilled – with the highest levels of ‘worthwhile activities’ in life. Hairdressers report high levels of happiness

Those in sales related occupations report lower life satisfaction and worthwhile. Legal associate professionals report high anxiety. Teaching and educational professionals report among the highest levels of ‘worthwhile’ but also higher levels of anxiety. The anxiety question can capture positive and negative aspects of anxiety and there are other examples where we have seen high positive wellbeing coexist with higher levels of anxiety.

3.5. Levels of common mental health disorders (CMD)

3.5.1. Estimated prevalence

Data from the 2014 Adult Psychiatric Morbidity Survey (APMS) shows levels of CMD are high in the

North West for both men and women. Applying these rates to Halton’s mid-year population

estimate 2015 for people aged 16 and over shows an estimated 19,404 people in the borough may

have one or more of this conditions.

Table 7: Estimated prevalence of common mental health disorders (CMD) amongst adults (aged 16 and over) in Halton, by gender

d https://whatworkswellbeing.org/

https://whatworkswellbeing.org/


34 | P a g e

North West data is not broken down by age so it is only possible to use the England rates to produce

estimates for men and women by age groups. This shows a lower overall number compared to the

North West applied rates and so some additional caution is needed in using these estimates.

Table 8: Estimated prevalence of common mental health disorders (CMD) amongst adults (aged 16 and over) in Halton, by age group and gender

3.5.2. Known prevalence

Information obtained from the GP Patient survey provides an insight into the burden of mental

health problems in Halton CCG compared to its 10 most similar CCGs and England. Data is based on

self-reporting of a random sample of the each practice population. So, whilst represtative of the

population, results may be subject to biase to those people responding to the survey and may not

provide an accurate reflection of the burden of mental illness. Data from the survey is available at a

GP practice level. Unfortunately due to small numbers of respondants stating they had long-term

mental health problems, data has been suppressed at this level for Halton GP practices and is only

available at CCG level.


35 | P a g e

Figure 12: The percentage of respondents to the GP Patient Survey who responded to the question ‘Which, if any of the following medical conditions do you have?’ who answered ‘Long-term mental health problem’. Halton CCG compared to 10 similar CCGs and England average

Figure 12 shows that Halton CCG had a statistically significantly higher percentage of respondents

who stated they had a long-term mental health problem compared to the England average

(indicated by the pale blue coloured bars). Most of Halton CCGs comparator CCGs also had

statistically higher levels, apart from Corby, Harlepool and Mansfield CCGs (indicated by the yellow

coloured bars).

Data collected routinely through the Quality Outcomes Framework (QOF) for general practices

includes a measure of the number and percentage of patients aged 18 and over with depression, as

recorded on practice disease registers. There is no data routinely collected to determine the

prevalence of other CMD at the practice level.

This includes all those who have been diagnosed with depression. Therefore it does not include

anyone with depression who has not been diagnosed.

Figure 13: Prevalence of depression amongst Halton GP registered populations, aged 18+, 2015/16


36 | P a g e

As with the GP survey, this shows Halton CCG has a greater burden of mental health problems than

England. It also has a slightly higher prevalence than the North of England. So, whilst the rates may

be different from these two sources, the message remains consistent.

3.5.3. Comparisons between predicted and recorded prevalence of CMD

Figure 14 compares the estimated prevalence of anxiety and depression using the age specific

prevalence rates from the APMS 2014 applied to GP populations for 2016 with the recorded

general practice prevalence of depression (2015/16) for each general practice in NHS Halton CCG.

Although not exactly the same measure, it is possible to use this information to identify practices

with potentially unmet need in terms of recognising and diagnosing depression.

It is possible that general practices differ in terms of how they code depression on their systems

and this could explain the variation in reported rates of depression according to the QOF data.

Practices can record ‘general anxiety’ or ‘anxiety state’ on a patient’s records and this data may

not be represented by the QOF data analysed here.

As the QOF register does not enable an age breakdown, the estimated prevalence has been

calculated at 18+ not 18-64. Therefore the figures are not directly comparable to those shown

earlier in this document which have been calculated at a Halton resident population aged 16/18-

64. It has been done this way to demonstrate possible level of under diagnosis of depression at a

GP practice level. The differences may be more marked as it only takes age in to account not

other contributing factors.

Of the 17 practices in Halton, 8 have more people diagnosed than the estimate, with the

remaining 9 having less than estimated. Overall there are less people diagnosed than estimated.

In 2015/16 there were 9,724 people on the GP register with a diagnosis of depression. This

compares to the estimate of 11,100 for NHS Halton CCG’s 2016 registered population aged 18+. Figure 14: Comparisons between estimated numbers of people with mixed anxiety and depression and actual numbers of people recorded with depression by general practice 2015/16

3.5.4. Depression prevalence compared with deprivation

The 2014 APMS shows that prevalence of CMDs is higher in those who are unemployed or


37 | P a g e

economically inactive and those in receipt of benefits. The difference is more marked in men than

women but is present in both genders.[51]

Local estimates based on the 2014 APMS are not yet available. Estimates based on an earlier,

originally at PCT level and now reworked at CCG level compared to CCG IMD 2015 scores show

however, the strength of the relationship as being only a weak-moderate one at r= 0.35. Some

caution must be used in drawing conclusions from this analysis. Whilst it remains the only

national level analysis, it must be noted that the survey data on which this analysis is calculated is

out of date. Figure 15: Correlation between estimated prevalence of CMD amongst the 16-74 year old CCG population and deprivation (IMD 2015)

3.5.5. Trends in depression prevalence

Data from the APMS shows a steady prevalence rate in men but an increase for women. (Figure

16). The number of people with depression recorded on the general practice register (QOF

data) increased by 60.8% between 2012/13 and 2015/16 for NHS Halton CCG (Table 9). Figure 16: Prevalence of CMD (in past week), 1993, 2000, 2007 and 2014, by gender

Table 9: Trend in diagnosed prevalence of depression


38 | P a g e

3.5.6. Anxiety

Anxiety is not recorded separately to depression by general practice QOF information. However,

it is possible to gain an impression of levels of anxiety in the population using the results from the

Annual Population Survey. Results from the latest available survey data conducted in 2014/15

showed that the proportion of people reporting a high anxiety score in Halton was higher than

comparators but the difference was not statistically significant.

Figure 17: Self-reported well-being: % of people with a high anxiety score

3.6. Levels of Severe Mental Illness (SMI)

SMI is not strictly determined but usually refers to illnesses where psychosis occurs. Psychoses are disorders that produce disturbances in thinking and perception severe enough to distort perception of reality. The main types are schizophrenia and affective psychoses, such as bipolar disorder. Psychosis and the specific diagnosis of schizophrenia represent a major psychiatric disorder in which a person's perception, thoughts, mood and behaviour are significantly altered. The symptoms of psychosis and schizophrenia can be any of the following; hallucinations, delusions, emotional apathy, lack of drive, poverty of speech, social withdrawal and self-neglect. Each person will have a unique combination of symptoms and experiences.

Defining psychosis as severe mental illness does not mean that other conditions are not regarded as

serious - there are others such as schizo-affective disorder, severe clinical depression and personality

disorders.

3.6.1. Prevalence: Estimated

Using the 2014 APMS estimates of the number of Halton adults with SMI can be made.


39 | P a g e

Table 10: Estimated prevalence of SMI, Halton residents aged 16 and over

3.6.2. Known – QOF

General Practice Quality Outcomes Framework (QOF) data records the number of patients with

schizophrenia, bipolar affective disorder and other psychoses as recorded on practice disease

registers Figure 18: Prevalence of psychosis at GP practice and CCG level (QOF register), 2015/16

Unlike depression, diagnosed prevalence rates are lower in NHS Halton CCG than the North of

England and England as a whole. However, with low prevalence rates, the differences are marginal.

There is differences in practice level prevalence rates in Halton, although the overall low to high

prevalence rate is only a 0.9 percentage point difference.

3.6.3. Correlation between SMI prevalence and deprivation

Deprivation is a risk factor for SMI. Nationally, there is a moderate relationship between the


40 | P a g e

prevalence of people diagnosed as having a SMI (CCG QOF prevalence score) and deprivation.

Locally, with only 17 practices, there is insufficient power to detect any relationship with any level of

robustness.

Figure 19: Correlation between CCG prevalence of severe mental illness (QOF 2015/16) and deprivation (IMD 2015)

3.6.4. Admissions

Nine of of ten people with mental illness are cared for within primary care.[52]. However, due either

to their mental illness or their poorer physical health, sometimes an admission to hospital is

necessary. Levels of emergency admissions to hospital due to schizophrenia, overall have been

statistically significantly higher in Halton than in England, and since 2007/08, also statistically higher

than the North West. Against a backdrop of falling rates nationally Halton more closely followed the

North West patten but since reaching a high point in 2011/12 have since started to fall. However,

the rate remains higher than North West or England.

Figure 20: Annual trend in emergency hospital admissions due to schizophrenia (ICD10 codes: F20.-, F21.-, F23.2 and F25.-)


41 | P a g e

The rate of people with schizophenia at any level of the diagnosis code is much higher than those

admitted specifically due to the condition. There is substantial variation across the borough

although it should be noted that this variation in directly standardised rate is based on small

numbers so cuation is needed when drawing conclusions from the analysis.

Figure 21: Hospital admissions amongst people with schizophrenia by ward, Halton 2014/15

3.6.5. Detained under Mental Health act

The Mental Health Act can formally detain a patient for their own safety, or that of other people.

During 2015/16:[53]

The total number of detentions under The Act continued to rise, increasing by 9% to 63,622 compared to 58,399 detentions in 2014/15 This compares with an increase of 10% between 2013/14 and 2014/15 and is the highest number since 2005/06 (43,361 detentions) a rise of just under a half over the period

The use of section 136 of The Act (under which people were brought to hospital as a ‘place of safety’) increased by 18% to 22,965. This rise should be viewed in the context of the fall in the use of police cells as a place of safety over the same period, which was reported in data released earlier this year by the National Police Chiefs’ Council (NPCC)

The data in Table 10 reflects the number of people in NHS funded specialist adult mental health

services at the end of the reporting period who were subject to the Mental Health Act. This number

includes people in these discrete categories (on a single day a person can only be in one category):

people subject to detention

people subject to Community Treatment Order (CTO)

people subject to short term holding powers under sections 4, 5(2), 5(4), 135 or 136 and people subject to Guardianship but not on a CTO

The numbers available from NHS Digital through the Mental Health and Learning Disabilities

Minimum Dataset (MH&LDMDS) have been converted to indirectly/crude rates per 100,000 CCG

registered population aged 18+. This enables comparison between local figures and those


42 | P a g e

elsewhere. Although rates in Halton higher than England but lower than in the North West the

differences are not statistically significant.

Table 11: People subject to Mental Health Act: rate per 100,000 population aged 18+ (end of quarter snapshot)

Compared to NHS Halton CCGs 10 most similar CCGs, the last reporting period shows Halton had the

4th lowest rate. Only Corby CCG had a rate better than England (indicated by the dark blue colour), 5

had a rate simialr to England including Halton (yellow bars) and 5 had a rate higher than England

(pale blue bars).

Figure 22: People subject to Mental Health Act: rate per 100,000 population aged 18+ (end of quarter snapshot) 2015/16 Q2, Crude rate - per 100,000 in Halton CCG and its 10 most similar CCGs

3.6.6. Excess mortality

Men with a SMI die on average 20 years earlier than other people; women 15 years earlier. They have higher rates of cancer, heart disease, respiratory disease and diabetes.[54] This is due to a combination of poorer health-related behaviours, exacerbated for people with mental health problems often living in poverty, having poorer social networks, and more difficulties accessing housing, employment, education and other opportunities. These issues are heightened by the stigma and discrimination still experienced by people living with mental health problems. Both


43 | P a g e

health and social services need to ensure people living with mental health problems have the same levels of access to and outcomes from preventative and support services as the general population. Halton has relatively low levels of excess mortality in adults with SMI compared to its statistical

grouping. Whilst at 402.7, the rate is higher than England, it is not statistically different due to wide

confidence intervals.

Table 12: Excess under 75 mortality rate in adults with SMI: ratio of observed to expected mortalities (expressed as a percentage)

There has been no particular trend in excess mortality, with some minor fluctuations being usual in

annual rates for a small borough.

Figure 23: trend in excess under 75 mortality rate in adults with SMI


44 | P a g e

3.7. Other Mental Health Disorders

3.7.1. Antisocial and borderline personality disorder

Personality disorders are longstanding, ingrained distortions of personality that interfere with the

ability to make and sustain relationships. Antisocial personality disorder (ASPD) and borderline

personality disorder (BPD) are two types with particular public and mental health policy relevance.

ASPD is characterised by behaviour that may include impulsivity, high negative emotionality, low

conscientiousness, irresponsible and exploitative behaviour, recklessness and deceitfulness. As a

result of antisocial personality disorder, people may experience unstable interpersonal relationships

and may disregard the consequences of their behaviour and the feelings of others.[55]

BPD is characterised by significant instability of interpersonal relationships, self-image and mood,

and impulsive behaviour. There is sometimes a pattern of rapid fluctuation from periods of

confidence to despair, with fear of abandonment, rejection, and a strong tendency towards

suicidal thinking and self-harm. Borderline personality disorder is often comorbid with depression,

anxiety, eating disorders, post-traumatic stress disorder, alcohol and drug misuse, and bipolar

disorder.[56].

Prevalence

Difference with how ASPD were assessed in the 2014 APMS mean prevalence cannot be compared

with the previous two surveys. The 2014 survey [57]showed that ASPD was present in 3.3% of adults

aged 18 or over (4.9% of men and 1.8% of women). The highest prevalence was in men aged 25-34

at 6.6% and the lowest in women aged 55-64 at 0.4%.

The overall prevalence of BPD was slightly lower than ASPD, at 2.4% adults aged 16-64. Both highest

and lowest prevalence rates were in women. The highest prevalence was in the youngest age group

the survey covered 16-24 at 7.3%. Prevalence amongst men was also highest in this age group.

Lowest prevalence was in 55-64 females at 0.8% whereas lowest prevalence in men was seen in the

25-34 age group.

Applying the age and gender specific prevalence rates from the 2014 APMS shows a total of 2,255

estimated to have ASPD and 1,907 to have BPD.


45 | P a g e

Table 13: Estimated prevalence of ASPD and BPD in Halton

3.7.2. Eating Disorders

Eating disorders are a group of illnesses defined by the National Institute of Mental Health as being

those in which the sufferer experiences a preoccupation with body weight and shape which disturbs

their everyday diet and attitude towards food. Unusually, compared with other mental health issues,

eating disorders result in both physical and psychological symptoms and can have long term physical

side effects including organ failure. They include Anorexia Nervosa and Bulimia Nervosa as well as

lesser known disorders such as binge eating disorder. The Royal College of Psychiatrists suggest that

a combination of influencing factors (including genetics, age and social pressures) cause eating

disorders and that they are often seen alongside other conditions (most frequently depression or

anxiety disorder). This makes recognition of the underlying eating disorder much more difficult.[58]

Not only may sufferers delay seeking help but the Beat survey of nearly 500 eating disorder sufferes

showed delays of a year or more for a diagnosis with further wating periods for treatment to begin.

As six out of ten people have at least one relapse, total duration can be 6 years or more for about

half of sufferers.

Figure 24: Treatment, recovery and relapse cycle

Source: Beat 2015[58]


46 | P a g e

Prevalence

In 62% of cases symptoms forst occur under the age of 16, 24% between 16-19 and 9% between 20-

24. Very few cases first appear in people older than this. Between 90-95% of cases are females with

5-10% being males. Data from both GP records and hospital admissions indicates the incidence and

prevalence of eating disorders is increasing. The APMS 2014 did not cover eating disorders so the

last national survey was the APMS 2007. It showed that eating disorders remains more common in

females compared with males (9.2% overall prevalence in adult females compared with 3.5% in adult

males). Eating disorders have the highest prevalence in younger adults (20.3% in 16-24 year old

women and 6.1% in 16-25 year old men). 2.5% of adult women will have an eating disorder that has

a significant impact on their life.

These are applied to the population of Halton and show that between 6,320-6,534 adults in Halton

may have an eating disorder (depending on whether using all age prevalence of total of age specific

rates). A smaller but nevertheless significant proportion identify that their feelings about food have

a significant impact on their lives. Applying the age-specific and all-age national prevalence rates to

Halton’s population estimates 16+ for males and females gives an estimate of between 1,558-1,604

of the population having feelings about food that has a significant impact on their life. Halton

commissions its eating disorders service from Cheshire & Wirral Partnership NHS Foundation Trust.

The Warrington, Halton and Trafford Eating Disorders Service offers outpatient support for adults

with an eating disorder. The team, based at the Gateway Centre, near Golden Square in Central

Warrington, provides talking therapies, physical health advice and dietetic expertise. People must be

referred to the service by a GP, social worker or other qualified agency, they cannot self refer.

Activity data was not provided at time of writing so it is not possible to provide any insights into the

volume and demographics of people referred to/attending the service. Between 2010/11 and

2014/15 there were less than 20 admissions to hospital due to eating disorders with just over half in

those aged under 25.

3.7.3. Post Traumatic Stress Disorder (PTSD)

PTSD is characterised by symptoms that have been caused by a traumatic event. Symptoms may

include flashbacks and nightmares, avoidance and numbing, and hyper-vigilance.

Results from the APMS 2014 show that 4.4% of the adult population are screened positive for PTSD

and would warrant clinical assessment of this condition. Screening is done using a trauma screening

questionnaire. 31.4% have experienced trauma. Men and women can equally be affected by PSTD

but prevalence mainly declines with age, although women aged 45-54 have the highest overall

prevalence. Men from mixed/multiple/other ethnic groups and women from black/black British

ethnic groups have the highest prevalence rates. Levels are higher amongst those unemployed or

economically inactive than amongst those who are employed. Applying age and gender specific

prevalence rates for positive screen and trauma experienced to Halton’s population indicates 4,459

may have PTSD to a degree that would result in a positive screen[e] with 31,819 experiencing trauma.

Within the survey a ‘trauma’ is an event of such severity that a person fears for their own or a loved

one’s life or safety. It was defined as: ‘The term traumatic event or experience means something like

e Screening positive for probable PTSD involves both achieving a score of 50 or more on the PTSD checklist

(PCL) and meeting the DSM-IV criteria.


47 | P a g e

a major natural disaster, a serious automobile accident, being raped, seeing someone killed or

seriously injured, having a loved one die by murder or suicide, or any other experience that either

put you or someone close to you at risk of serious harm or death’. A participant could screen positive

for PTSD without reporting having experienced a trauma.

Table 14: Estimated number of Halton adults (aged 16 and over) who may have PSTD or experienced trauma

3.8. Self harm

The incidence of self-harm has risen in the UK over the past 20 years[59] and is one of the top five

causes of emergency admissions to hospital. Those who self-harm have a one in six chance of a

repeat attendance for self-harm at accident and emergency within the year.[60]. Approximately

half of all people who die by suicide have previously self-harmed.[61] However, many people who

self-harm are not seen by NHS services and are not included in statistics.

The term self-harm is used to refer to any act of self-poisoning or self-injury carried out by a person,

irrespective of their motivation. This commonly involves self-poisoning with medication or self-injury

by cutting. Self-harm is not used to refer to harm arising from overeating, body piercing, body

tattooing, excessive consumption of alcohol or recreational drugs, starvation arising from anorexia

nervosa or accidental harm to oneself.[62]

A wide range of mental health problems are associated with self-harm, including borderline

personality disorder, depression, bipolar disorder, schizophrenia, and drug and alcohol-use

disorders. People who self-harm have a 50- to 100-fold higher likelihood of dying by suicide in the

12-month period after an episode than people who do not self-harm.[63

Self-harm results in more than 98,000 inpatient admissions to hospital a year in England, 99% are

emergency admissions. Rates of emergency hospital admissions for self-harm are statistically higher

in Halton than for North West and England (Figure 25). Although rates have fallen, this relative

position remains (Figure 25).


48 | P a g e

Figure 25: Emergency hospital admissions for intentional self-harm 2014/15, Halton, borough statistical neighbours and other comparators

Figure 26: Trend in Emergency hospital admissions for self-harm. Directly age-sex standardised rate

Both Halton as a whole and all but 6 of its electoral wards have admission rates that are statistically

significantly higher than England. The level of admissions for England as a whole is designated as

100, with rates above this showing higher rates and below, lower rates. For the combined years of

2010/11 to 2014/15, Halton had an admission rate over 1.5 times that of England. Halton Lea had

the highest rates, nearly 3 times greater than England.

The Standardised Admission Ratio is a summary estimate of admission rates relative to the national

pattern of admissions and takes into account differences in a population's age, sex and

socioeconomic deprivation. The national figure is always given value of 100. The other levels are

then calculated in related to how many admissions would be expected if the area had the same age-

specific rates as England against the actual fugures. Observed numbers above England are thus

calculated above 100 and figures below as less than 100. It enables an assessment as to the degree

of difference. Figure 27 shows that Halton level is just over 1.5 times that of England with ward level

ratio’s varying from just over 50 to nearly 300 i.e. less than half the England level to three times the

England level.


49 | P a g e

Figure 27: Hospital admissions for intentional self harm, electoral ward, standardised admission ratio, 2010/11-2014/15

3.9. Suicide

Suicide[f] is a major public health issue, and a major cause of years of life lost. Every suicide is an

individual tragedy and a terrible loss to local families and communities. The economic impact of

suicides is also high. It has been estimated that the average cost of a working age adult in England

ending their own is £1.67million.[64]

In times of economic and employment insecurity rates of suicide often increase. This trend has been

observed nationally following the 2008 financial crisis when after a decade of falling suicide rates

they have risen. Locally suicide rates have also increased during 2011 to 2013 compared to previous

years. Although the numbers of people who take their own life in Halton each year are low it is

important to recognise those ending their own life are the tip of an iceberg and locally levels of

distress and suicide attempts are much higher. The recent increase in the number of suicides locally

demonstrates the need for continuing vigilance and action and highlights why a new suicide

prevention strategy for Halton has been developed.

Suicide is not inevitable and can be prevented. Suicide is often the end point of a complex history of

risk factors and events and for many people it is the combination of factors which is important

rather than one single factor. An inclusive society that avoids marginalising individuals and which

supports people at times of personal crisis will help prevent suicides. Evidence-based interventions

exist that if implemented can reduce the risk of suicide.

The reasons why people may take their own life are very complex. The many factors that influence

whether someone may feel like taking their own life can be divided into:

Risk factors: increase the likelihood of suicidal behaviour;

Protective factors: reduce the likelihood of suicidal behaviour through improving a

person’s ability to cope with difficult circumstances.

f Suicide is used here to mean a deliberate act that intentionally ends one’s life.


50 | P a g e

Risk and Protective factors are often at opposite ends of the same continuum. For example, social

isolation (Risk factor) and social connectedness (Protective factor) are at either extremes of a

person’s social support network. Examples of risk and protective factors for suicide are outlined in

Table 14.

Table 15: Example of risks and protective factors for suicide [65]

Risk and Protective factors can occur at different levels:

Individual

Social and community networks

Socio-economic, cultural and environmental level conditions

Figure 28: Trend in suicide rates, 2001-3 to 2013-15

Data from local suicide audits, regional reports and nationally released sources shows that


51 | P a g e

More men die by suicide in Halton than women. This is similar to Cheshire & Merseyside

where 75% suicide deaths were among men.

The number and rates of suicides vary between age groups. In Halton the highest numbers of suicides were observed in the middle age groups: 35-44 and 45-54 year olds

The Cheshire & Merseyside analysis showed that the majority were single (54%) and nearly half lived alone (43%)

3.10. Mental health amongst protected characteristics groups and other vulnerable groups

3.10.1. Age

Common Mental Illness:1 in 10 children aged 5-16 have a clinically diagnosable mental health

problem, with rates of mental illness increasing as they reach adolescence[66] (see mental health of

children and young people JSNA for more details). In adults the 2014 APMS shows rates of CMD are

highest in the 35-44 age group and lowest in the 75+ age group.[67]

Severe Mental illness: Approximately half of all lifetime mental disordersemerge in the teenage

years, with 75% revealed beforethe age of 25.[68][69] The younger the onset, the poorer the

outcome[70]The 2011 Liverpool Public Health Observatory (LPHO) Mental Health Needs

Assessment[71] analysed data on incapacity claimants for mental illness for Merseyside. In each local

authority, numbers of claimants were highest in the 35-44 age group. Rates per thousand population

revealed that those aged 55-59 and 50-54 are most likely to be claimants.

3.10.2.Gender

Common Mental Illness:Women are more likely than men to have CMD. The 2014 Adult Psychiatric

Morbidity Survey shows 1 in 5 women had a CMD during the week before the interview (20.7%,

compared to 1 in 8 men (13.2%).There was less difference in the rates for panic disorders and

obsessive compulsive disorder. Women are also more likley to be treated for CMD than men.[72]

Severe Mental illness: The 2014 APMS shows that nationally prevalence of psychotic disorders is

slightly higher in women than men.[73]However, males are more likely to claim incapacity benefit for

mental illness than females.[74]Similarly, hospital admission rates for psychoses (excluding affective

disorders) on Merseyside were significantly higher for males compared to females. However rates of

admission for affective disorders (which include bi-polar disorder) were lower amongst males

compared to females.

3.10.3. Race

Common Mental Illness:The 2014 APMS showed that there is no absolute pattern but that for men

and women rates tend to be higher for those from Black/Black British and Asian/Asian/British

compared to white and mixed ethnic groups.As with the overall findings, women from Black/Black

British and Asian/Asian/Britishethnic groups are more likely than men to suffer from common

mental disorders.[75] African Caribbean people living in the UK have lower rates of common mental

disorders than other ethnic groups but are more likely to be diagnosed with severe mental illness.[76]


52 | P a g e

Severe Mental illness: Compared to overall population prevalence, levels of psychoses are higher in

men from Black Caribbean and Black African ethnicity but this is not so for women.77 However, they

are less likely to have their mental healthproblems detected by a GP.78 People from these

backgrounds as well as Irish people living in the UK are more likely to be admitted to hospital.

Admission rates for those from Indian and Chinese groups were lower and from Pakistani ad

Bangladeshi groups rates were similar.[79][80] The differences between ethnic groups can be explained

by a number of factors, including poverty, social isolation, racism and cultural differences in e.g.

help-seeking behaviour.[81][82]

3.10.4. Disability

Common Mental Illness: The prevalence of anxiety and depression in people with learning

disabilities is the same as the general population (though higher in people with Down’s syndrome)[83]

Many people with learning disabilities are not able to express their feelings easily in words, which

can mask the clinical presentation of a mental health problem and cause difficulty in making an

accurate diagnosis.[84] Reseach suggests around 30% of people who either are born deaf[85] or aquire

it in adulthood[86] have CMD

Research evidence consistently demonstrates that people with long-term conditions are two to three

times more likely to experience mental health problems than the general population. This is mostly

depression and anxiety, although co-morbidities are also common in dementia and some other

conditions.[87] Overall, it is estimated that 30% of those with long term physical conditions also have a

mental health problem – compared to 20% of the general population. Of those with mental health

problems, 46% are estimated to have a long term physical condition, compared to 30% in the general

population.

Severe Mental illness: Levels of severe mental illness are higher amongst those with learning

disabilities than the general population, for both children (36% compared to 8%[88] and 71% amongst

those with autism[89])and adults (between 25-40%[90][91] and 3% for schizophrenia, 3 times higher

than the general population[92]).The prevalence of severe (psychotic) depression in people with

learning disability is around 3-4%, which is twice as high as the general population.[93]

3.10.5. Sexual Orientation

Common Mental Illness: Research indicates that CMD is 2-3 times higher in gay and bisexual men

compared to men in general, for example 22% experience moderate to severe levels of

depression.[94][95]. Levels of depression are even higher amongst lesbian and bisexual women.[96]

Others types of CMD are also high: low confidence and self esteem (71%), isolation (54%) and eating

disorders (19%).[97]

Severe Mental illness: Although research is limited there would appear to be no difference in rates

of paranoid and schizophrenic disorders between samples of gay men and lesbian women and

general population samples, but increased rates of mood disorders.[98][99][100] However an England

study[101]found evidence of increased levels of ‘probable psychosis’ amongst the non-heterosexual

population with another noting evidence for an earlier age of onset of mental illness amongst the

lesbian, gay, bisexual and transgender (LGBT) population compared to the general population.[102]


53 | P a g e

A Stonewall survey reported that in the year prior, 3% of gay men have attempted to take their own

life. This increases to 5% of black and minority ethnic gay men, 5% of bisexual men and 7% of gay

and bisexual men with a disability. In the same period, 0.4% of men in the general population

attempted to take their own life.[103][104] In the last year, 5% of lesbians and bisexual women say they

have attempted to take their own life. This increases to 7% of bisexual women, 7% of black and

minority ethnic women and 10% of lesbians and bisexual women with a disability.[105][106] Levels of

eating disorders (19%) and self-harm (23%) are also high.[107]

3.10.6. Marital Status

Common Mental Illness:The 2007 APMS found that amongst men, those who were divorced had the

greatest likelihood of having a common mental disorder (CMD). More than 1 in 4 divorced men

(27.7%) had a common mental disorder, compared to 1 in 10 (10.1%) of men who were married.

Amongst women, rates were similarly high for those who were divorced (26.6%), but even higher

(33%) for those who were separated. For men who were separated, rates were similar to those for

married men (10.5%). For men and women combined, rates of common mental disorder were 23.3%

amongst those who were separated and 27.1% of those who were divorced.[108]

(note, this analysis has not yet been done on data from the 2014 APMS)

Severe Mental illness: Those with a probable psychosis are even more likely than those with

neurosis to have many of the characteristics associated with vulnerable family structure, being three

times more likely to be separated or divorced; and three times more likely to be living as a lone-

parent family unit.[109]

3.10.7. Religion

Common Mental Illness:Recent research reviews have concluded that the weight of evidence

suggests that religion is a generally protective factor for mental illness.[110][111] Spiritual beliefs may

help people cope with events and experiences, enabling them to feel that they have more control

over events in their lives.[112] (Mental Health Foundation, 2008). However as noted below in some

cases, religious expressions of spirituality may also become part of the problem, for example

individuals may become burdened by their spiritual activities. People with mental illness may be

vulnerable and may be negatively influenced by certain beliefs and people.[113]

Severe Mental illness: Whilst there is a high prevalence of spirituality and religiousness in patients

with schizophrenia,[114] some studies that suggest religious attendance is lower.[115] This may lead

health professionals toview the spiritual experiences of an individual as manifestations of

psychopathology. However, for many living with mental health problems such as schizophrenia,

religion and spirituality have an important and positive role, providing hope, meaning and

comfort.[116] Unfortunately, somemay become burdened by their spiritual activities, may be

vulnerable and may be negatively influenced by certain beliefs and people.[117]

3.10.8. Sexual identity

Common Mental Illness: Having lesbian, gay, or transgender sexual identities can add extra levels of

discrimination.[118] Transgender individuals in particular are more likely to face social isolation,

discrimination and victimisation.[119] A UK survey found that 66% of trans respondents reported that


54 | P a g e

they had used mental health services for reasons other than access to gender reassignment medical

assistance, suggesting a high prevalence of mental health problems in this group. The study also

found most participants who had transitioned felt that their mental health was better after doing so

(74%), compared to only 5% who felt it was worse.[120] A recent US internet-based survey found

transgender respondents had a high prevalence of clinical depression (44.1%), anxiety (33.2%).[121

Severe Mental illness: A UK survey found that 48% of trans people under 26 said they had

attempted suicide, and 30% said they had done so in the past year.[122] This was higher than an

earlier trans mental health study in 2012, which found that 35% of trans people had attempted

suicide at least once.[123] It is considerably higher than in the general population, where around 9%

of all 16- to 24-year-olds say they have attempted suicide.[124]

3.10.9. Pregnancy

Common Mental Illness: NICE guidance on antenatal and postnatal mental health noted that low

mood after childbirth (sometimes called ‘baby blues’) is very common, occurring in 30 to 80% of

women in the first weeks, but that this needs to be differentiated from clinical depression, estimated

as 12.7% in pregnancy, and between 5.7% to 21.9% postnatally. Around 30% of women remain

unwell beyond the first year after childbirth and there is high risk (around 40%) of subsequent

postnatal and non-postnatal relapse. Levels on anxiety are generally thought to be similar to non-

pregnant women. However there is some emerging evidence suggesting that for generalised anxiety

disorder rates are higher during pregnancy than in the general population. Pregnant or postnatal

women are approximately 1.5 to 2 times more likely to experience obsessive compulsive disorder

than the general population.[125] One recent review found overall prevalence estimates of 1.08% for

women in the general population, 2.07% during pregnancy, and 2.43% during the postnatal

period.[126]

Severe Mental illness: There is limited evidence on the prevalence of severe mental illness amongst

pregnant women. One study used in NICE guidance CG192 showed that whilst childbirth is a risk

factor for the onset of psychosis, it is a very small one.[127] What is more likely is that for women

with a history is severe mental illness, pregnancy and especially the postnatal period increases the

risk of relapse.

3.10.10 Homelessness

The 2014 Homeless Link audit of more than 2,500 homeless people found that 8 in 10 homeless

people self-report some form of mental health issue. The proportion of homeless people with

diagnosed mental health problems (45%) is nearly double that of the general population (around

25%). In particular, the audit found the incidence of depression amongst homeless people is

substantially higher, with 67% reporting feeling depressed and 36% with diagnosed depression

(compared to 3% in the general population, as reported by Homeless Link). The audit also found that

73% of homeless people reported often feeling stressed and 65% were often anxious.[128] This

confirms the findings of the 2009 CRISIS literature review, which reported that that the prevalence

of common mental health problems appears to be more than twice as high amongst the homeless

population compared to the general population.[129]


55 | P a g e

There is strong evidence that those who experience repeat homelessness have severe and enduring

mental health problems.[130] Problems are inter-related, with nearly half of those with a mental

health problem self-medicating by using drugs or alcohol.[131] The prevalence of personality disorders

in the homeless population is thought to be between 60% to 70%[132[133] Psychological disorders such

as personality disorders are often ways of coping with traumatic experiences in childhood and may

lead to homelessness.[134] Homeless Link found that 7 in 10 single homeless people have one or more

mental health condition - 2.5 times the rate of the general population.[135]

The health needs of single homeless people are the most severe and widely documented.[136]. This

group are likely to have complex health needs, including inter-related mental health problems, drug

misuse problems, and alcohol dependence. They are also at risk of injury, pneumonia, tuberculosis,

dental problems and hypothermia.[137] Rough sleeping has been described as the most visible and

damaging manifestation of homelessness.[138] People who sleep rough are likely to have complex

health needs, including mental health problems, drug misuse problems, and alcohol dependence.

They are also at increased risk of injury, pneumonia, tuberculosis, dental problems and

hypothermia.[139] They are most likely to be young males, with 25%-30% having been in local

authority care as children. Rough sleepers have often suffered family breakdowns and other

traumatic experiences.

The report by Shelter[140] examining the impact of temporary accommodation on the health of

homeless families reported that of the 194 families with dependent children that they surveyed,

there were increases in reports of depression (depending on circumstances 50%-64% reported

depression)

The LPHO Health Needs Assessment[141] showed that in Halton there were 280 single homeless

people moving on from Supporting People services in 2012/13 (primary client group). Of these:

62 (22%) had physical health needs (compared to 32% in Liverpool City Region) and 90% had these needs met (87% Liverpool City Region)

56 (20%) had mental health needs (28% Liverpool City Region) and 82% had these needs met (78% Liverpool City Region)

99 (35%) had substance misuse issues (37% Liverpool City Region) and 61% had these needs met (53% Liverpool City Region)

There were 115 homeless families moving on from Supporting People services in 2012/13. Of these:

20 (17%) had physical health needs (20% Liverpool City Region) and 75% had these needs met (89% Liverpool City Region)

34 (30%) had mental health needs (20% Liverpool City Region) and 79% had these needs met (85% Liverpool City Region) (numbers of families with substance misuse issues were too small to include)

Structured drug and alcohol treatment: Of all alcohol and drug clients from Halton commencing

structured treatment during a 9 month period (1/4/13 to 31/12/13), there were 44 alcohol clients

who were homeless (6 Urgent No Fixed Abode) and 62 drug clients (11 Urgent No Fixed Abode).

Halton had the highest proportions of homeless drug and alcohol clients, at more than 1 in 4 of all


56 | P a g e

clients (22% of alcohol clients and 27% of drug clients) – compared to around 1 in 7 across Liverpool

City Region.

3.10.11 Offenders

In a recent Ministry of Justice survey,[142] nearly half (49%) of female prisoners were assessed as

suffering from anxiety and depression, compared with 23% of male prisoners (Ministry of Justice,

2013). Considering each condition separately, 61% of female prisoners were indicated as suffering

from anxiety compared with 33% of male prisoners, and 65% of female prisoners were indicated to

be suffering from depression compared with 37% of male prisoners. This compares to 17% of the

general population (13.2% of men, and 20.7% of women) who were estimated to be suffering from

common mental health disorders.[143]

The Ministry of Justice survey also found that 16% of prisoners had psychotic symptoms, -

considerably higher than the approximately 6% of the general population who reported one or more

psychotic symptoms. Female prisoners were more likely to report symptoms indicative of psychosis

(25%) compared to male prisoners (15%).[144]. The LPHO Mental Health Needs Assessment[145

reported:

the most common mental disorder amongst prisoners is personality disorder, prevalent in 64% of males and 50% of female prisoners

the prevalence of functional psychoses is well above the general population average of 0.4%. In the past year, 7% of male and 14% of female prisoners had suffered from functional psychoses. In addition, up to three-quarters of prisoners with ‘severe’ mental illness are not identified in their prison reception health check

The Halton Health Needs Assessment of offenders in the community notes that female prisoners

also have a 20-fold increased risk of suicide, while males in prisons are at five times higher risk,

compared to general population. Ex-prisoners were at greatest risk of suicide in the period

immediately following release. Among ex-offenders, women have a 36 -fold increased suicide risk

while male ex-offenders have an 8 fold increased risk (SMR 8.3).”[146]

Analysis of the Cheshire Probation Trust data on mental health/Personality Disorder, taken from

OASys assessments of offenders resident in Halton, revealed:

In both 2012 and 2011 the most common mental health illnesses amongst Halton offenders were depression and anxiety. However in 2012 schizophrenia, Attention Deficit Hyperactivity Disorder (ADHD), Post-traumatic Stress Disorder (PTSD), psychosis and personality disorders were also evident but in much smaller numbers. The year before, in addition to depression and anxiety only one other mental health illness was identified; PTSD, with only 1 offender with this diagnosis

There was a fall in the percentage of Halton offenders with a current psychological need between 2011 and 2012 – from 39.7% to 35.1%

In 2012 there was also a smaller percentage of offenders who had disclosed or been assessed with problems with self-harm or suicide attempts, compared to 2011. Down from 36.1% in 2011 to 28.2% in 2012.


57 | P a g e


58 | P a g e

3.10.12 Refugees and Asylum Seekers

Some of the health experiences of asylum seekers may overlap with other disadvantaged and

vulnerable groups in the UK. However, there are physical and mental health issues specific to asylum

seekers which, coupled with the impact of going through the asylum process, places them at risk of

destitution and inequalities.[147][148]

However, some asylum seekers can have increased health needs relative to other migrants. There

are a number of reasons for this:[149] A number have faced imprisonment, torture or rape prior to

migration, and will bear the physical and psychological consequences of this. Health needs of

asylum seekers can be significantly worsened (and even start to develop in the UK) because of the

loss of family and friends' support, social isolation, loss of status, culture shock, uncertainty, racism,

hostility (eg. from the local population), housing difficulties, poverty and loss of choice and control.

Some asylum seekers will have been subjected to torture, as well as witnessing the consequences of

societal breakdown of their home country – with consequences for their mental health. Culturally,

mental illness may not be expressed or may manifest as physical complaints. Stigma may also be

attached to mental ill-health. Furthermore, Western psychological concepts are not universally

applicable to asylum seekers. Mental health problems such as depression and anxiety are common,

but post-traumatic stress disorder is greatly underestimated and underdiagnosed and may be

contested by healthcare professionals. Children are particularly neglected in this area.[g] A shortage

of mental health services for asylum seekers has been recognised.[150]

Refugees and asylum seekers experience a higher incidence of mental distress than the wider

population. The most common diagnoses are trauma-related psychological distress, depression and

anxiety.[151]

3.10.14 Mental health problems amongst adults with Learning Disabilities

The prevalence of psychiatric disorders is significantly higher among adults whose learning

disabilities (LD) are identified by GPs, when compared to general population rates. Challenging

behaviours (aggression, destruction, self-injury and others) are shown by 10%-15% of people with

learning disabilities, with age-specific prevalence peaking between ages 20 and 49. In some

instances, challenging behaviours result from pain associated with untreated medical disorders.

Reported prevalence rates for anxiety and depression amongst adults with learning disabilities vary

widely, but are generally reported to be at least as prevalent as the general population and higher

amongst people with Down’s syndrome. There is some evidence to suggest that the prevalence rates

for schizophrenia in people with learning disabilities are approximately three times greater than for

the general population, with higher prevalence rates for South Asian adults with learning disabilities

compared to White adults with learning disabilities.[152]

Studies into the prevalence of mental health problems in adults with learning disability have found

varying results. The rate is considerably higher than that found in the general population and is

g See Dansokho M. (2016) Unaccompanied Asylum Seeking Children – Health and Wellbeing Needs Assessment a report

looking at the antipicated health and wellbeing needs of UASC coming to Halton and the North West of England http://www4.halton.gov.uk/Pages/health/JSNA/childrens/Asylumseeking.pdf

http://www4.halton.gov.uk/Pages/health/JSNA/childrens/Asylumseeking.pdf


59 | P a g e

probably between 30 and 50%. Its relationship with level of disability, gender, age, epilepsy and

physical illness has not been fully ascertained.[153]

People with learning disabilities have high levels of physical ill health. When combined with other

factors such as poor access to services, this can result in a significant level of inequality of health

status.[154] Physical health problems can also trigger or worsen mental health and behaviour

problems. Some physical problems can have a major impact on mental health and behaviour (e.g.

pain, epilepsy, constipation, infections, and medication).[155]

Table 16: Estimated number of people with learning disabilities who have mental illness

Although there is a new dataset of learning disabilities derived from GP records this only covers 51%

of total England registered patients and 70% of total Halton patients. It is therefore not possible to

use the age-specific numbers to estimate those with mental illness as in Table 16. However, the

dataset does provide two measures: prevalence of LD and non-LD patients with depression and the

same for severe mental illness by age and gender (Table 17).

Depression is a major and treatable cause of distress and disability for people with and without

learning disabilities. In people with learning disabilities, particularly those with limited ability to

communicate, it can be expressed in behavioural ways understood by carers or care staff as

'challenging'. This makes clarity about diagnosis particularly important.

NICE guidelines on the treatment of depression[156] indicates that both medical and psychological

approaches play an important role. Psychological approaches are increasingly being provided

through the NHS Improving Access to Psychological Therapies programme (IAPT). These data provide

some guidance about the numbers of people with learning disabilities likely to need treatment for

depression in local areas.

The overall England rate of having a diagnosis of unresolved depression in adults with learning

disabilities (13.9%) was very similar to that for people without learning disabilities (14.5%).

England rates for both groups rose with age until late middle age and then fell slightly in old age.

Adjusting for the age and sex profile, the number of cases in people with learning disabilities was

4.3% above the number expected if general population rates had applied. 14.2% of CCGs had a


60 | P a g e

standardised prevalence ratio for depression significantly lower than the England figure; 12.6% of

CCGs had a ratio significantly higher. In Halton the Standardised Prevalence Ratio was 75.53% (a

rate of 100% indicated a level as expected, lower than 100% lower than expected and above 100%

higher than expected).

Rates for people with LD in Halton were slightly lower than the England level, for both males and

females. Rates were higher amongst Halton patienst without LD. The gap was especially marked for

females were prevalence amongst non-LD patients were especially high.

Table 17: Halton CCG population with depression, by age and gender

People with learning disabilities are known to suffer more commonly with severe mental illnesses

including schizophrenia, bipolar disorder and other less well defined psychotic conditions. However,

exactly how much more commonly is difficult to assess since diagnosis of these conditions is

substantially more difficult, particularly in those with more severe learning disabilities and little or

no ability to communicate verbally. In people without learning disabilities, psychotic disorders are

relatively uncommon in childhood, appearing usually in adolescence or young adulthood.

Overall, GPs recorded 8.8% of people with learning disabilities aged 18+ as having severe mental

illnesses. This compared to 1.1% of people aged 18+ without learning disabilities. Adjusting for age

and sex profile, the number of people with learning disabilities recorded as having a severe mental

illness was 7.9 times what would be expected if national general population age and sex specific

rates applied. 15.3% of CCGs had a standardised prevalence ratio for severe mental illness

significantly lower than the England figure; 13.2% of CCGs had a ratio significantly higher. Halton’s

standardised prevalence ratio was 673.7%, the same as the England level.

Table 18: Halton CCG population with severe mental illness, by age and gender


61 | P a g e

3.10.15 Mental health of ex-Armed Forces personnel (Veterans)

A rapid Health Needs Assessment[157] of ex-Armed Forces personnel ‘Veterans[h]) health needs in

Halton was commissioned in September 2013 by Halton Clinical Commissioning Group (CCG), to

inform local commissioning intentions and raise the profile of Veteran health needs locally.

A Veteran is “someone who has served in the Armed Forces for at least one day. There are around

4.5m Veterans in the UK”.[i] These men or women, who served as a ‘Regular’ or ‘Reserve’, can have

quite different healthcare needs compared to the average citizen, due to their military service.

There has been a renewed interest in the duty of care the UK owes its Veterans, triggered partly by

media coverage of conflicts in Iraq and Afghanistan. The local ‘Community Covenant’[j] for Cheshire

has shone a spotlight on local Veterans as a group who may have specific health needs. However

there is very little local information relating to the health requirements of Veterans relevant to

Halton service commissioning that is easily accessible.

The evidence-base on the health needs of Veterans in the UK has grown substantially in recent

years. For example, Kings College London’s specialist research centre, Kings Centre for Military

Health Research, have published over 80 reports[158] on military health (including Veteran health)

since 2010. Mental health has been the focus for a considerable number of studies. In 2011,

exploring the mental health needs of the Armed Forces deployed to Iraq and Afghanistan, the Kings

College London study team found Veterans who did report mental health issues tended to be those

who had not served for many years and often left early. Most recently, a report by pressure group

Forces Watch titled ‘The Last Ambush? Aspects of mental health in the British armed

forces‘[159]asserting that the youngest and least educated of the Armed Forces are disproportionately

vulnerable to post-traumatic stress disorder, with resistance to trauma increasing with age and level

of education.

Most Veterans make the transition to civilian life without difficulty. This includes access NHS

provision when they need it. However a significant minority struggle and have needs that differ from

the general population, such as co-morbid or complicating conditions. Some may benefit from

additional support to access services and make the transition as smooth as possible. In particular

where Ministry of Defence budgets increase reliance on a Reserve force that research suggests is

more vulnerable to mental health problems,[160] the potential rise in mental health needs among the

future Veteran population is a distinct possibility in areas with large numbers of Reservists.

Due to the lack of data the rapid health needs assessment used interviews with local Veterans. Some

Veterans interviewed were reluctant to talk about mental health issues and reticent to access care.

Comparative research suggests that this hesitancy appears more pronounced among those with a

service background than the general public. Nationally, the Service Personnel and Veterans Agency

(SPVA) as well as ex-service agencies and charities including Combat Stress, the Royal British Legion

and the Sailors Soldiers and Airmen and Families Association, are trained to signpost to relevant

health services. Local and regional agencies (like Sanctuary For Veterans, Runcorn Veterans

h The term ‘Veterans’ is used for brevity, referring to ‘ex-Armed Forces personnel’ – whilst acknowledging that many ex-service personnel, especially younger people, do not associate themselves with the term Veteran. i : http://www.nhs.uk/NHSEngland/Militaryhealthcare/Veteranshealthcare/Pages/Veterans.aspx j A voluntary statement of mutual support between a civilian community and its local Armed Forces Community, defined as Serving personnel, Veterans, and their families.

http://www.nhs.uk/NHSEngland/Militaryhealthcare/Veteranshealthcare/Pages/Veterans.aspx


62 | P a g e

Association and Live At Ease) also support Veterans in finding adequate care options, however each

may have their own approach and philosophy – particularly towards mental health problems. The

approach of smaller ex-service agencies is sometimes governed by their own members service

experiences rather than specialist expertise or medical training.

3.11. Physical illness as a risk factor for mental illness

‘No Health without Mental Health’[161]states that approximately one quarter of people with physical illness develop mental health problems as a consequence of the stress of their physical condition. Numerous studies have shown that patients with chronic medical illness, compared to those without, have an increased risk of depression. This is so for virtually any long term condition.

In order to estimate the numbers of people in Halton who are living with both long term conditions

(LTCs) and mental health problems, individual level data from Health Survey for England (HSE

2012)[162]has been analysed and applied to the Halton population aged 18-64. The HSE survey

asked people to report long-standing illness of over 12 months. If the long-standing illness reduced

the ability to carry out day-to-day activities, it is considered a limiting longstanding illness. The

mental health status of participants in the survey was measured by GHQ-12[k] with a score of four

or more representing probable mental ill health. 9.8% had two or more LTCs. Based on 2015 mid-

year population estimates this would equate to 7,518 Halton residents aged 18-64.

The HSE 2012 data showed that, of people who had two or more LTCs, 28.4% reported both

limitation in daily life and mental ill health and 3.4% reported mental ill heath as an additional

health problem. These proportions applied to the Halton population aged 18-64 with two or more

LTCs gives a figure of between 2,135 people with LTCs with limitation and mental ill health and

around another 256 people with two or more LTCs without limitation but with mental ill health in

the borough.

Advancing age and being in the routine and manual work social class increase the likelihood

of mental ill health and two or more long term health conditions.

The Chief Medical Officer’s 2013 Annual Report focused on mental health, including a

chapter on physical health and mental illness. It highlighted:[163]

People with a chronic medical condition have a 2.6-fold increase in the odds of having a mental illness, compared to those without a chronic medical condition

Between 12% and 18% of spending on long-term conditions is related to “poor mental health and wellbeing”, translating to between £8 and £13 billion in NHS expenditure in England

Estimates suggest that about 60% of the excess mortality in people with mental illness is avoidable

International evidence shows that people with schizophrenia are about half as likely to receive coronary revascularisation procedures as those patients without a severe mental illness

k The General Health Questionnaire (GHQ) is a screening device for identifying minor psychiatric disorders in the general

population and within community or non-psychiatric clinical settings such as primary care or general medical out-patients. Suitable for all ages from adolescent upwards – not children, it assesses the respondent’s current state and asks if that differs from his or her usual state. It is therefore sensitive to short-term psychiatric disorders but not to long-standing attributes of the respondent. It is available in four lengths, with GHQ-12 being the shortest.


63 | P a g e

Prevalence of smoking among people with mental illness

Those with mental illness are far more likely to smoke and at much higher levels than people in the

general population, and consequently suffer a much-elevated risk of smoke-related harm. There is a

strong association between smoking and mental health conditions. This association becomes

stronger relative to the severity of the mental condition, with the highest levels of smoking found in

psychiatric in-patients.[164][165] It is estimated that of the 10 million smokers in the UK about 3 million

have a mental health condition. Nationally, smoking rates have been falling, from about 27% in the

mid-1990s to 19% in 2014 within the general population. By contrast, smoking rates among people

with a mental health condition have not fallen, with estimates putting the figure at around 40%

throughout the past 20 years.[166]. A 2015 Public Health England and NHS England survey revealed

that 33% of people with a mental health condition smoke compared to 18.7% of people in the

general population.[167] Rates of over 32% are seen among those with common mental disorder, 37%

for those screening positive for PTSD, 40% for those with psychosis, 57% for those attempting

suicide in the previous year, 69% for those with drug dependence and 46% for those with alcohol

dependence.[168] In England there is no longer an exemption for designated rooms for smoking

within mental health institutions.

In addition, people with mental health conditions smoke significantly more, have increased levels of

nicotine dependency and are therefore at even greater risk of smoking-related harm. As such

smoking cessation support needs to recognise the particular smoking behaviours and barriers to

quitting that people with mental health probems face. This may inlcude harm reduction support

where the level of nicotine dependance and/or other issues means the person is not ready to or

unable to quit.[169] For those in contact with mental health services who are ready to quit NICE

recommends the provision of intensive behavioural support, as well as usual advice and provision of

pharmacotherapies.[170]

3.12. Alcohol Misuse

‘Heavy’ drinking of alcohol is associated with mental illness, particularly anxiety and depression. In addition, alcohol problems may occur or become worse in people with depression.[171] Alcohol misuse may also accelerate or uncover a predisposition to other mental illnesses.[172] The use of drugs (illicit or misuse of prescription medication), can affect mental health and for some drugs has been linked to developing serious mental illness. Drug use can also make mental health treatment more difficult.173

‘No Health Without Mental Health and the national drug strategy,[174] both acknowledge the association between mental health and drug and alcohol dependence and that early intervention and effective joint working between drug and alcohol treatment and mental health services can improve successful outcomes.

Dual diagnosis refers to people with mental health problems who also use drugs or misuse alcohol. Research has shown that 75% of users of drug services and 85% of users of alcohol services were experiencing mental health problems. Worryingly, 38% of drug users with a psychiatric disorder were receiving no help for their mental health problem.[175] In another study, dual diagnosis was found in 20% of community mental health clients, 43% of psychiatric inpatients and 56% of people in secure services. People with a dual diagnosis had worse physical


64 | P a g e

health, higher levels of personality disorder, greater levels of disability and lower quality of life than those without a dual diagnosis.[176] Estimated prevalence of alcohol misuse Within Halton there are an estimated 4,833 working age adults drinking alcohol at higher risk levels (over 50 units per week for men and over 35 units for women) with a further 12,811 drinking at increasing risk levels (22-50 units per week for men and 15-35 units for women). However, these figures are based on synthetic estimates[177] and have wide confidence intervals. This means levels may be much lower or much higher, as Table 19 shows.

Table 19: Estimated prevalence of alcohol consumption levels in Halton

Admissions for mental disorders due to alcohol

There are two ways of analysing admissions to hospital for mental health disorders due to alcohol.

The broad definition includes where the primary diagnosis or any of the secondary diagnoses are an

alcohol-attributable mental and behavioural disorders due to use of alcohol code. The narrower

definition includes only where there is an alcohol-attributable mental and behavioural disorders

coded in the primary diagnosis.

In 2014/15 Halton had 830 admissions using the broad definition (600 males and 230 females) and

200 using the narrow definition (130 males and 65 females). Rates in Halton were statistically

significantly worse than both the England for both genders using both definitions. As rates are

higher in the North West than England, compared to the region Halton’s rates were statistically

similar for all but the broad definition in males which was worse.


65 | P a g e

Figure 29: Admissions to hospital for mental ill health due to alcohol, 2014/15

3.13 Substance Misuse The use of drugs (illicit or misuse of prescription medication), can affect mental health and for some drugs has been linked to developing serious mental illness. Drug use can also make mental health treatment more difficult[178] It can both cause or increase symptoms of mental illness and, on the other hand, mental illness can lead someone to abuse substances.[179] For example, people may “self medicate” to block out symptoms or the side-effects of medication.

Substance misuse also contributes to wider social harms - absenteeism, unemployment, domestic

violence, family breakdown, child maltreatment and public disorder.[180] There are many links

between substance misuse and crime, including gang violence and crimes such as theft, burglary,

fraud and shoplifting to get money to buy drugs. The majority of violent offences are committed by

people under the influence of drugs and alcohol, and drunkenness is associated with a majority of

murders, manslaughters and stabbings and half of domestic assaults.[181] Whilst there may be public

perception of a relationship between violent crime and serious mental illness,[182] research suggests

that substance misuse and socio-economic factors are more important.[183]

The national mental health strategy ‘No Health Without Mental Health’ and the national drug strategy[184] both acknowledge the association between mental health and drug and alcohol dependence and that early intervention and effective joint working between drug and alcohol treatment and mental health services can improve successful outcomes. Dual diagnosis refers to people with mental health problems who also use drugs or misuse alcohol. Research has shown that 75% of users of drug services experience mental health problems. Worryingly, it showed that 38% of drug users with a psychiatric disorder were receiving no help for their mental health problem.[185] In another study, dual diagnosis was found in 20% of community mental health clients, 43% of psychiatric inpatients and 56% of people in secure services. People with a dual diagnosis had worse physical health, higher levels of personality disorder, greater levels


66 | P a g e

of disability and lower quality of life than those without a dual diagnosis.[186] People with dual diagnosis often have multiple needs, with poor physical health alongside social issues such as unemployment, debt or housing problems. They are also more likely to be admitted to hospital, to self-harm and commit suicide.[187] It is estimated that there are 701 heroin and/or crack cocaine users in Halton. As a crude rate per 1,000 population aged 15-64, this is the same level as England and the second lowest of the local authorities statistical neighbours group. Figure 30 Estimated prevalence of opiate and/or crack cocaine use, 2011/12, Crude rate per 1,000 population aged 15-64

This is a higher than the number that are in specialist drug treatment services, 587 during 2015/16.

Whilst direct indicators of dual diagnosis are currently largely unavailable, mental health problems

are very common among those in treatment for drug use. It is therefore possible to look at the

proportion of people who, when assessed for drug treatment, were receiving treatment from mental

health services for reasons other than substance misuse. The measure is indicative of levels of co-

existing mental health problems in the drug treatment population. However, it should not be

regarded as a comprehensive measure of dual diagnosis as it only captures whether a person is

receiving mental health treatment at a given point in time.

Table 20: Percentage of Halton service users with concurrent contact with mental health services and substance misuse services for drug misuse, 2013/14 to 2015/16

Considering Halton’s relative position in 2015/16, its rate is statistically lower than England as a

whole. It is one of seven within its statistical neighbours group to have a lower rate than England

(dark blue bars). The rate is lower than its near geographical areas of Knowsley and St Helens and

aslo lower than Liverpool, whose rate at 24.7% is statistically higher than England.


67 | P a g e

Figure 31: Concurrent contact with mental health services and substance misuse services for drug misuse, Halton statistical neighbours group, 2015/16

Recently published NICE guidance[188 (20)for people with coexisting severe mental illness and substance misuse aims to improve care pathways for this group, highlighting the importance of providing coordinated services that address their wider health and social care needs as well as other issues such as employment and housing. Empathy and respect are also vital, as people with dual diagnosis are often stereotyped and stigmatized.[189


68 | P a g e

4. Service provision

4.1. Settings for Service provision Commissioned services for adult mental health and emotional wellbeing services are delivered

across 4 settings:

1. Primary Prevention and Health Improvement consists of:

Health Improvement Team

2. Primary Care Consists of:

Wellbeing Enterprises

Halton GP Practices/Wellbeing Community Practices

3. Secondary & Acute Care consists of:

Halton Assessment Team

Home Treatment Team

Halton Recovery Team

2 Functional Illness Admission Units

4. Community services consist of:

MH Outreach Team

Halton MIND

Veterans in MIND

Improving Access to Psychological Therapies (IAPT) Service

Women’s Relationship Centre

There are a wide variety of 3rd sector organisations which are not commissioned, but provide

services in the community for people with mental health problems

The Adults Mental Health Delivery Group, chaired by the CCG GP clinical lead for Adult Mental Health, is responsible for monitoring progress in implementing the adults element of the strategy through the Adults Mental Health Delivery Action Plan. The Dementia Delivery Group, chaired by the CCG GP Clinical Lead for Dementia, is responsible for the delivery of the older people’s element of the strategy which includes Dementia. These multi-disciplinary working groups include commissioning, provider and other public sector representation. They have been active in developing the strategy to improve mental health and reviewing and coordinating operational progress across a wide range of statutory and voluntary organisations in Halton. Oversight of the action plans monitor progress against the local strategic objectives to improve the health and wellbeing of adults and older people with mental health and emotional wellbeing problems. Examples of work undertaken so far:

Development of a website where all the information about MH services and a calendar of activities is located in one place, i.e. a single point of access.

Embedding liaison psychiatry into the acute hospitals.

Commissioning Operation Emblem, a street triage service established to reduce the use of Section 136, which includes a dedicated patrol vehicle with a Police Officer and a Mental Health Nurse working together responding to incidents as they arise, providing a rapid response with access to both health and criminal justice records.

Procurement of a North west wide Military Veterans IAPT Service, that includes local clinics for assessments – “Veterans in Mind”

Review of the wider health and social care system, pathway gaps that may exist and produce improvements in the provision of mental health services incorporating bed base, and out of area placements – ‘5 Boroughs Footprint Review’, as mentioned under the key recommendations.

Review and re-design of adult community based services


69 | P a g e

Table 21: Commissioned Service Provision

Service Provider Service Description

Health Improvement Team

Halton Health Improvement Team's (HIT) Mental Health Service is part of Public Health within Halton Borough Council.

The aim of the service is to promote positive mental health to improve personal and community wellbeing across Halton.

HIT do this by creating accessible ways for local people to gain understanding and improve their own wellbeing, changing perceptions and encouraging positive behaviours around healthy mental choices.

Hosting local campaigns, raise awareness, design and distribute free resources and offer free and bespoke training relevant to local need.

Offering a range of free awareness and training sessions to Halton's residents and workforce promoting positive mental health, raising awareness of mental health issues and promoting local services and support.

Mental Health Awareness

Suicide Prevention Guidance

The team are currently working on a Self Harm Guidance training package.

All the team’s work helps highlight local provision, pathways and access to services for mental health and living well services available in Halton.

HIT are working with CHAMPS to enable Halton become one of 9 Local Authorities to become accredited as Suicide Safe as part of the No More Suicide strategy.

Halton GP

Practices/Wellbeing

Community Practices

GPs plays a critical role in the care of people with mental illness. This includes diagnosing mental health problems, providing support to the patient and family, prescribing medication and referring to secondary or community services where necessary. Primary care staff have a holistic approach which takes into account the patient’s risk factors, physical and mental comorbidities and domestic and family situation. Training is provided at local CCG led Members Forums for GPs and practice nurses. Halton were the first borough to establish Community Wellbeing Practices, with all 17 GP Practices signing up to the new service model. Practices work with CWOs from Wellbeing Enterprises (above) to provide timely, integrated wellbeing interventions for individuals and communities by adopting a community focused approach.

Halton Assessment

Team (Step 4/5)

The Assessment Team is based at Wakefield House on the Warrington Hospital Site and provides a triage function and act as a single point of access into secondary care services and provides rapid specialist mental health assessment, advice and signposting for adults and older people with moderate to severe symptoms of mental illness. If after assessment people require further care/treatment they will be transferred to the most appropriate team to meet their needs. The service ensures that anyone requiring specialist mental health assessment or advice has ease of access to a timely response. This forms part of a wider Acute Care Pathway provided by the Trust and this service performs a crucial coordinating function to ensure that service users experience a smooth journey through the most appropriate care pathways.

Home Treatment Team (Step 4/5)

The Home Treatment Team provides intensive home treatment for people who have mental health needs that can only be addressed by secondary care mental health services.

The home treatment team will respond rapidly to referrals supporting people at an early stage, actively involving families and carer’s, and offering a flexible approach to people in the least


70 | P a g e


restrictive environments , thus providing an alternative to inpatient admission and will also support an early discharge from hospital.

Halton Recovery Team (Step 4/5)

The Recovery Team are based at the Brooker Centre on the Halton Hospital Site and provide a specialist secondary mental health service that provides individualised person centred care & interventions for adults and older people who have mental health needs that require coordinated support from a secondary mental health service provider. The team promote active participation in treatment decisions and support self-management. The team support patients to relieve their symptoms but also to improve their qualty of life by focusing on building mental strength and resilience and being in control of their own lives using the recovery model. Following assessment a care plan is put in place depending on the need of the individudal. Care plans include treatment such as Cognitive Behavioural Therapy (CBT), physical health screening, Occupational therapy, idependant living skills support, psychological therapy or social worker support. Treatment pathways are dependent on diagnosis and follow the NICE guidance. The service also offers a number of activities to help aid recovery including gardening, walking, exercising and cooking and they offer courses for anxiety, assertveness, depression etc.

Short stay Acute

Inpatient Wards

(step 4/5)

The Halton in-patient service at the Brooker centre provides a multi-disciplinary assessment and where appropriate, treatment and care plans to adults and older people in the borough who due to the complexity of their psychiatric, mental and/or physical health problems cannot be assessed or cared for in any other community setting. They provide assessments and treatment to help patients to achieve optimum functioning to enable discharge to an appropriate setting in the community. There are 2 functional illness wards, Weaver and Bridge, based in the Brooker Centre on the Halton Hospital Site, that are currently occupied by both adults and older people. Occasionally when the Brooker centre beds are full, patients will be sent to other OOA beds, and in situations where they are all full, patients will be admitted to private facilities such as the Priory, until they can be repatriated back to a local bed, when one becomes available or into the community.

Mental Health

Community Outreach

Team (step 2/3)

The service is commissioned by the local authority, and is based at Vine Street Resource Centre in Widnes. It offers 1:1 support in the community for people who have either mental health issues or a physical and sensory disability. It is an enabling service encouraging and supporting individuals around managing their illness / anxieties etc., budgeting issues, educational / vocational and social activities, physical health and home maintenance etc. They refer people onto other appropriate agencies / groups such as Wellbeing, Sure Start and other community groups. They are involved with people for both short and long term interventions depending on their referral route into the service. Short term is usually for those referred in by primary care routes and is up to approx. 6 months. Long term is for those who we have been commissioned to support from a secondary care service and this is for approx. 2 years, however I can be longer if needed. They regularly review all cases and will close when either they feel the person can manage independently or if it is identified they will always require support, then they will organise additional care, PA etc.

Halton IAPT

(Step 2/3)

The service is based in St Johns, Widnes and provides a primary mental health service for adults and older people. It focuses on psychological interventions for mild to moderate common mental health problems. Secondary level psychology includes neuropsychological assessments, psychological interventions such as cognitive behaviour therapy (CBT), Cognitive Analytic Therapy (CAT) psychotherapy, and training and supervision of other staffthe locality teams include mental health nurses, social workers, occupational therapists, psychologists, psychiatrists and support workers. Day therapy focuses on specific evidence-based interventions rather than long-term attendance for social support. Interventions include cognitive stimulation therapy and


71 | P a g e


psychologically focused group therapy for recovery, anxiety and mood management. Some groups take place in local centres but there is also an emphasis on outreach and supporting people to use local community services.

Veterans in MIND (step

2/3/4)

The service is based at Greater Manchester West Mental Health Foundaton Trust (GMW) and provides support to military veterans (MVs) aged 16 or over who are experiencing low to severe mental health problems in Halton. The service offers the same interventions to older people as it does to adults and young people. The service is part of a care pathway working collaboratively in multi-agency partnerships with a variety of statutory, voluntary and private providers to promote recovery. The service adopts a stepped care approach, using screening and assessment processes to ensure the veteran’s needs are addressed by the most appropriate agency. For a referral to be accepted, mental health problems must relate to the veteran’s military service or being linked to difficulties adapting to civilian life post-service.

Halton MIND Mind is linked to the Improving Access to Psychological Therapies programme. The service focuses on helping people with mental health problems to improve their general health and wellbeing. This includes promoting social inclusion and economic productivity. The particular focus of the service is helping people who struggle to access mainstream mental health services provided by NHS statutory providers.

Mind also provides a counselling service in Halton, complementing other local provision for people with mental health problems for whom counselling would be a beneficial intervention. MIND also hosts a befriending service, social & peer support groups and assertiveness courses.

Women’s Relationship

Centre

The womens centre caters for all ages and abilities. Their experience with women who are approaching their mid 60’s is that they can become socially isolated through being widowed, divorced, retired/unemployed, experience physical disability or illness. This can result feelings of loneliness and isolation directly linked to becoming anxious and depressed. The centre work with in partnership with many multidisciplinary agencies in the Halton area for women who would particularly benefit from an integrated co-ordinated approach to promote independence.


72 | P a g e

4.2 Care Pathways

4.2.1. Community Wellbeing Practice Model

Figure 32: Community Wellbeing Practices Model of Delivery


73 | P a g e

4.2.2. IAPT

Figure 33: IAPT Clinical Pathway

4.2.3 The Veterans in Mind service

The service accept referrals from a wide range of statutory and non-statutory organisations such as:

GP’s, nurse practitioners, probation, voluntary agencies, charities, single point of access teams,

counselling services, primary and secondary care mental health services, educational facilities,

relatives (with informed consent) and self-referrals.

Referrals can be made using the on-line referral form on https://www.gmw.nhs.uk/military-

veterans-services or by email to [email protected]. Referrals will also be taken via the

phone on 0151 908 0019. The email address and answerphone will be monitored by administration

https://www.gmw.nhs.uk/military-veterans-services

https://www.gmw.nhs.uk/military-veterans-services

mailto:[email protected]


74 | P a g e

staff in core hours. Any referrals received outside of these hours will be processed the next working

day.

All veterans will receive an initial telephone screening from one of the veterans in mind clinicians

with the first contact attempt being made within 3 working days of referral.

Where appropriate, veterans will receive a face-to-face assessment with a veterans in mind military

clinician, with an assessment appointment being offered within 28 working days of referral.

Referrals that are not suitable for the Service

The specification for the service only encompasses mental health difficulties that are as a direct

result of the veteran’s military service. If a veteran’s mental health difficulties are evidently not as a

direct result of their military service then the Veterans in Mind team will signpost to more

appropriate services e.g. Primary or Secondary Care. If this is unclear at the point of referral, triage

or assessment this is taken to the team meeting for further discussion.

Case management of people with a stable psychosis/severe mental illness will be outside the scope

of this service. However, when an individual with psychosis is being stably managed within

secondary care, veterans may benefit from access to psychological therapies and the service may

provide in reach to secondary care services where clinically appropriate. This would involve regular

liaison with their Care Co-ordinator and feeding into CPA reviews.

People who pose a high risk to themselves, high risk to others or who are at significant risk of self-

neglect that is beyond the remit of the Veterans in Mind military service would be referred onto

specialist or secondary care services. This may include “hard-to-engage” veterans who have

consistently rejected various treatment options offered.

Veterans who have a moderate or severe impairment of cognitive function (eg Dementia); or

moderate or severe impairment due to autistic spectrum problems or learning disabilities must be

referred to specialist services if it is felt to be clinically appropriate. This may also include veterans

who need to be primarily referred for forensic or neuropsychological assessment.

Interventions offered by Veterans in Mind

The Veterans in Mind Service will link closely with other NHS and voluntary veteran service providers

in the North West of England in order (a) to deliver outreach to veterans with mental health

problems and not currently receiving treatment, (b) to provide effective case management of

veterans with a range of different health and social needs, and (c) to provide advice, consultation,

and training to health services working with veterans across the region.

The Veterans in Mind service will provide psychological intervention to address mental health needs

at the following levels:

Specialist preparatory psychosocial support for military veterans who need to acquire pre therapy skills and experiences for Steps 2, 3 and 3+ interventions.


75 | P a g e

Step 2 – Common mental health problems (low severity with greater need). This group of veteran clients have definite but low intensity problems of depressed mood, anxiety or other disorder, but not with any psychotic symptoms.

Step 3 – Non-Psychotic (Moderate Severity). This group of veteran clients have moderate higher intensity problems involving depressed mood, anxiety or other disorder (not including psychosis).

Step 3+: This is specialist psychological care to people between Step 3 and Step 4. This group of veteran clients is characterised by severe intense depression and/or anxiety and/or other disorders, and increased complexity of needs but who do not need to be under secondary care mental health services. They may experience disruption to function in everyday life and there is an increasing likelihood of significant risks.

The Veterans in Mind recovery co-ordinator will take the lead on case managing substance

misuse/dependency issues. This clinician has knowledge of the physical, psychological and social

effects of substance misuse and has experience of working with clients who present with co-morbid

mental health and substance misuse difficulties. Anyone presenting with acute or complex substance

misuse/dependency issues will be signposted to the relevant local services.

4.3. Activity levels and Outcomes

4.3.1. Health promotion and action to support community and individual wellbeing

Halton Health Improvement Team's (HIT) Mental Health Service is part of Public Health within Halton

Borough Council. The aim of the service is to promote positive mental health to improve personal and

community wellbeing across Halton. HIT do this by creating accessible ways for local people to gain

understanding and improve their own wellbeing, changing perceptions and encouraging positive behaviours

around healthy mental choices. This includes awareness campaigns, training, community sessions and

suicide prevention training.

The Community Wellbeing Practices service funded by Halton CCG provides a range of psychosocial

support for patients with mental health problems. This provision includes:

The Ways to Wellbeing social prescribing programme – offering a range of psychosocial educational courses for patients ranging in length from 4 – 8 weeks. Courses include life skills training based on cognitive behavioural approaches, mindfulness introduction, stress management, sleep and relaxation, managing long term conditions, mental health first aid, Triple P positive parenting.

Community navigation support – undertaking social ‘wellbeing’ assessments to address underlying issues that may be impacting on health and wellbeing. We navigate patients to a range of clinical and non clinical community based support to address these needs in a timely fashion.

Social action support – opportunities for patients to volunteer, develop skills, and mobilise strengths and talents to bolster confidence, resilience and provide pathways to meaningful activity and employment. This includes providing grants to patients who want to develop their skills and help others.


76 | P a g e

4.3.2. primary care

The vast majority of depressive and anxiety disorders that are diagnosed are treated in primary care.[190] However, many individuals do not seek treatment, and both anxiety and depression often go undiagnosed. Evidence of probable under diagnosis of CMD in Halton is given in section 8. Some of the treatments and therapies available to people with CMD in Halton are described below.

Many people who experience severe mental illness can and do recover a meaningful and fulfilling quality of life. Treatments and support that address all the person’s needs provide the best chance of recovery. The care of a person with severe mental illness should be discussed, planned and agreed between mental health professionals, GP, patient and carer, if appropriate. Care planning and access to services to support individuals is key to the management and treatment of individuals. Treatment options include anti-psychotic medication, neuroleptics, tranquilisers and antidepressants, hospitalisation and cognitive behavioural and family therapy for the management of psychotic symptoms.

4.3.2.1. Identification and management: QOF

There is a range of evidence to suggest that people with depression and severe mental illness are

more prone to certain conditions, yet are less likely/able to respond to health promotion messages

or access preventative medical interventions such as screening and health checks for cardiovascualr

risk/disease.[191]

Suicide risk is higher amongst those with depression so as part of quality management QOF includes

a number of evidence based interventions. Therefore NICE clinical guideline CG90 on depression in

adults states that patients with mild depression or sub-threshold symptoms be reviewed and re-

assessed after initial presentation, normally within two weeks. CG90 recommends that patients with

mild or moderate depression who start antidepressants are reviewed after one week if they are

considered to present an increased risk of suicide or after two weeks if they are not considered at

increased risk of suicide. Patients are then re-assessed at regular intervals determined by their

response to treatment and whether or not they are considered to be at an increased risk of suicide.

This review could address the following:

a review of depressive symptoms

a review of social support

a review of alternative treatment options where indicated

follow-up on progress of external referrals

an enquiry about suicidal ideation

highlighting the importance of continuing with medication to reduce the risk of relapse

the side-effects and efficacy of medication

Only face-to-face or telephone contact with a GP or nurse practitioner is acceptable to meet the

requirements for this indicator.

The Mental health indicator set reflects the complexity of mental health problems, and the complex

mix of physical, psychological and social issues that present to GPs. Indicators MH002, MH003,

MH007 and MH008 relate to the care of patients with a diagnosis of schizophrenia, bipolar or other

affective disorders. Indicators MH009 and MH010 relate to the care of patients who are currently


77 | P a g e

prescribed lithium. For many patients with mental health problems, the most important indicators

relate to the interpersonal skills of the doctor, the time given in consultations and the opportunity to

discuss a range of management options. This indicator set focuses on patients with serious mental

illness.

Mental health indicators MH003, MH007 and MH008 reflect NICE clinical guidance[192][193]

recommendations that patients receive health promotion and prevention advice appropriate to their

age, gender and health status. The guiadance recommends primary care utilise registers to monitor

the physical health of patients with psychosis, schizophrenia and bipolar affective disorder on a

regualr basis, least annually, including the following health checks:

weight or BMI, diet, nutritional status and level of physical activity

cardiovascular status, including pulse and blood pressure

metabolic status, including glycosylated haemoglobin (HbA1c) and blood lipid profile

liver function

renal and thyroid function, and calcium levels, for people taking long-term lithium MH002: In addition to lifestyle factors, such as smoking, poor diet and lack of exercise, antipsychotic

drugs vary in their liability for metabolic side effects such as weight gain, lipid abnormalities and

disturbance of glucose regulation. Specifically, they increase the risk of the metabolic syndrome, a

recognised cluster of features (hypertension, central obesity, glucose intolerance or insulin

resistance or dyslipidaemia) which is a predictor of type 2 diabetes and CHD.

Patients on the mental health disease register should have a documented primary care consultation

that acknowledges, especially in the event of a relapse, a plan for care. This consultation may include

the views of their relatives or carers where appropriate. Up to half of patients who have a serious

mental illness are seen only in a primary care setting. For these patients, it is important that the

primary care team takes responsibility for discussing and documenting a care plan in their primary

care record. When constructing the primary care record, research supports the inclusion of the

following information:

patient's current health status and social care needs including how needs are to be met, by whom, and the patient's expectations

how socially supported the individual is: e.g. friendships/family contacts/voluntary sector organisation involvement. People with mental health problems have fewer social networks than average, with many of their contacts related to health services rather than sports, family, faith, employment, education or arts and culture. One survey found that 40% of people with ongoing mental health problems had no social contacts outside mental health services

co-ordination arrangements with secondary care and/or mental health services and a summary of what services are actually being received

occupational status. In England, just over 30% of people with mental health problems are currently in work, the lowest employment rate of any group of working aged people. People with mental health problems also earn only two thirds of the national average hourly rate.. Studies show a clear interest in work and employment activities among users of mental health services with up to 90% wishing to go into or back to work

‘Early warning signs’ from the patient's perspective that may indicate a possible relapse. Many patients may already be aware of their early warning signs (or relapse signature) but it is important for the primary care team to also be aware of noticeable changes in thoughts,


78 | P a g e

perceptions, feelings and behaviours leading up to their most recent episode of illness as well as any events the patient thinks may have acted as triggers

the patient's preferred course of action (discussed when well) in the event of a clinical relapse, including who to contact and wishes around medication

MH003: As seen in previous sections patients with schizophrenia have mortality between two and

three times that of the general population and most of the excess deaths are from diseases that are

the major causes of death in the general population. Hypertension in people with schizophrenia is

higher than the general population yet there is evidence to suggest that physical conditions such as

cardiovascular disorders go unrecognised in psychiatric patients. Recording (and treating)

cardiovascular risk factors are therefore very important for patients with a serious mental illness.

MH007: Substance misuse by people with schizophrenia is increasingly recognised as a major

problem, both in terms of its prevalence and its clinical and social effects.

MH008: Research indicates that women with schizophrenia are less likely to have had a cervical

sample taken in the preceding five years compared with the general population. However, this

difference was not so for patients with bipolar affective disorder.

MH009: It is important to check thyroid and renal function regularly in patients taking lithium, as

there is a much higher than normal incidence of hypothyroidism and hypercalcaemia and of

abnormal renal function tests. Overt hypothyroidism has been found in between eight%-15% of

patients on lithium. NICE clinical guideline CG38 recommends that practitioners check thyroid

function every six months together with levels of thyroid antibodies if clinically indicated (for

example, by the thyroid function tests). It also recommends that renal function tests are carried out

every six months and more often if there is evidence of impaired renal function.

MH010: Lithium monitoring is essential due to the narrow therapeutic range of serum lithium and

the potential toxicity from inter-current illness, declining renal function or coprescription of drugs,

for example thiazide diuretics or non-steroidal antiinflammatory drugs (NSAIDs) which may reduce

lithium excretion.

Table 22: QOF 2015/16 Depression and Mental Health Indicators


79 | P a g e

Table 23: Percentage of eligible patients receiving the intervention

Exception reporting applies to indicators in any domain of the QOF, where the achievement is

determined by the percentage of patients receiving the specified level of care. “Exceptions” relate to

registered patients who are on the relevant disease register or in the target population group and

would ordinarily be included in the indicator denominator, but who are excepted by the contractor

on the basis of one or more of the exception criteria. Patients are removed from the denominator

and numerator for an indicator if they have been both excepted and they have not received the care

specified in the indicator wording. If the patient has been excepted but subsequently the care has

been carried out within the relevant time period, the patient will be included in both the

denominator and the numerator (achievement will always override an exception).

Exception reporting is intended to allow contractors to pursue the quality improvement agenda

without being penalised for patient specific clinical circumstances or other circumstances beyond

the contractor’s control which lead to failure to achieve the indicator. For example, where a

medication cannot be prescribed due to a contra-indication or side-effect, where patients do not

attend for review or where secondary care services are not available.


80 | P a g e

Table 24: Exception rates

4.3.2.2. IAPT

People with CMD including anxiety and depression can access IAPT (Improving Access to

Psychological Therapies), often referred to as ‘talking therapies’. This service offers short-term NHS

funded treatment Referrals to IAPT can be made via a GP or directly by self-referral. Treatments

offered through IAPT include:

Guided Self-Help: For those with mild to moderate mood and anxiety problems

Cognitive Behavioural Therapy (CBT) including group-based CBT and online options: CBT is

offered to people with moderate to severe difficulties. It can help with problems such as

depression, panic, agoraphobia, social anxiety, health anxiety, perfectionism, Obsessive

Compulsive Disorder (OCD) and Post- Traumatic Stress Disorder(PTSD)

Other therapy approaches: Interpersonal Therapy (IPT) and Eye Movement Desensitisation

Reprocessing (EMDR). The availability of these approaches may be more limited

IAPT is a government initiative designed to help anyone living in England deal with common mental

health problems. These may include stress, anxiety or depression, as well as panic, phobias, OCD

and PTSD. IAPT delivers a stratified service at steps 2-4 of the NICE pathway for common mental

health problems.[194]

The following analysis is based on the most recent published data for NHS Halton CCG for

2015/16.[195


81 | P a g e

Referrals Received

Between 1 April 2015 and 31 March 2016, Halton IAPT received 4,265 referrals agaed 16+, the

majoriy of which were in the 18-64 age band (4015 or 94%). This was a reduction of 10.4% since the

previous year, in which there were 4,760 referrals.

Referrals amongst 18-64 year olds in 2015/16 show that:

Six out of 10 referrals received were female (59.7%) compared to 36.4% male. This is similar to the England average of 62.7% female and 35.2% males. In 3.9% of referrals the gender was unknown or had an invalid code

Of the referrals amongst men, the highest single number was in the 36 – 64. It accounted for 49.7% of all male referrals received . It was also the most common age group for males entering treatment (53% -535 out of 1010), and completing treatment (54% - 255 out of 470)

Female referrals differ slightly in that females aged 18 - 35 formed the biggest proportion of all female referrals received (48%). However in terms of entering treatment and completing treatment the 36 - 64 age group accounted for the main proportion of female referrals, 52.4% entering treatment and 55.6% completing treatment were in this age group

England shows the same pattern for the main age groups and by gender

Due to small numbers, ethnic breakdown of referrals is unreliable apart from to state that the majority of referrals where White British

Disability was not part of the 2015/16 dataset. This may be due to the poor level of recording in 2014/15 when only 4% of referrals were coded as disabled. The remainder were classed as having ‘no code recorded’. The same proportion (4%) entered treatment with disability being recorded.

Entering Treatment and Waiting Time

The number of referrals amongst those aged 18+ referrals entering treatment during 2015/16 in

Halton was 2,770 (65.3% of all 18+ referrals received). Of these the majority were between 18-64,

2610 or 94.2% of 18+ referrals. The average (mean) waiting time between the referral and the first

treatment appointment was 61.4 days, more than double the England average of 29.4 days.

Table 25: IAPT waiting times to enter treatment, Halton and England 2015/16


82 | P a g e

Table 24 shows that one of the most obvious differences is the substantially lower percentage

entering treatment within 28 days of referral; only 44% in Halton compared to 71.1% for England (an

increase on the 67% in 2014/15). There was alos a lower proportion entering treatment between 29-

56 days. and.

A new IAPT standard was introduced by March 2016 that 75% of people referred to IAPT begin

treatment within 6 weeks of referral, and 95% begin treatment within 18 weeks of referral (NHS

England, 2015). During 2015/16, less than half of referrals had entered treatment within 6 weeks

compared to 8 out of 10 for England and only 85.2% by 18 weeks compared to the England average

of 96.2%. So whilst nationally these two timescale targets were hit, Halton fell short, especially in

relation to the 6 week target.

Finishing Treatment and Recovery Status

The numbers of referrals amongst those aged 18+ in Halton who finished a course of treatmentl was

1,280 of which 1200 were between 18-64. The percentages at each age group who showed reliable

improvementm were similar to England, slightly higher for the 35-64 age bands for both males and

females and slightly lower for the other age bands. Overall 61.7% of Halton patients showed reliable

recovery compared to the England average of 62.2%.There were 1,215 referrals in Halton finishing a

course of treatment that were initially “at caseness”n which equates to 95% (England 90.8%).

Table 26: Number of referrals finishing a course of treatment in the year by outcome status, age and gender, 2015-16

l In order to finish a course of treatment, a referral must have ended in the year with at least two treatment appointments having been attended in the course of the referral m Referrals are classed as having reliable improvement if the patient shows a reliable decrease in anxiety or depression score between the first and last measurement, and the other clinical state (depression or anxiety) either also reliably decreases or shows no reliable change. n “At caseness” is the term used to describe a referral that scores highly enough on measures of depression and anxiety to be classed as a clinical case.


83 | P a g e

The percentage who moved to moved to recovery,o were slightly lower than the England averages

for both men and women in each age group. Overall slightly less Halton people moved to recovery,

42.1% compared to the England average of 46.3%. The government target for recovery, up to 31

March 2015, was that 50% of referrals should move to recovery by the end of their course of

treatment. The percentage entering treatment who achieved this was below target both nationally

(44%) and locally (40.3%).

Treatment recommendations vary with the severity and type of problem. For many mild to

moderate cases NICE recommends a stepped care model, with most people being offered a course

of a low intensity intervention first. People who recover with the low intensity intervention are

discharged, and those with continuing symptoms should be offered a “step-up” to a high intensity

therapy. People with more severe symptoms or with social anxiety disorder or PTSD would normally

be expected to go straight to high intensity therapy.

Table 27: Number of referrals finishing a course of treatment in the year by stepped care pathway, 2015-16

The proportion due to depression and due to axiety where roughly equal.

Table 28: Referrals Completing Treatment in Halton and Problem Descriptor, 2015/16

Deprivation and IAPT

Unlike England were referrals, entering treatment and completion were equally distributed across

deprivation levels, for Halton patients, between 50-60% were from deeprivation deciles 9 and 10,

the most deprived. This reflects Halton’s population distribution and evidence that mental ill health

is linked to living in deprivation.

o Referrals with a completed course of treatment are classed as having recovered if they are classified as clinical cases

when they enter treatment but no longer classified as clinical cases when they have completed a course of treatment. Recovery is measured in terms of the anxiety and depression scores. For a referral to be considered recovered, the patient needs to score below the clinical threshold on BOTH scores at the end of treatment, to ensure that recovery is measured by looking at the welfare of the individual rather than one specific symptom.


84 | P a g e

Table 29: Percentage of referrals received, entering treatment and finishing a course of treatment in the year by Indices of Deprivation decile (IMD 2015), IAPT 2015/16

4.3.2.4. Mental Health Prescribing

CCG mental health prescribing data is available via the electronic ePACT system and can identify the

cost and volume of prescribing at an organisational and practice level, month on month or year on

year, it can also identify prescribing down to drug presentation level. Unfortunately the data does

not break data down to age range and so whilst we can show the trend and level of prescribing of

common mental health drug types we cannot show with any accuracy the prescribing that is taking

place for older people. Much of what we know is based on assumptions informed by prevalence

data, national data and practice level audits. The tables below show the breakdown of items

prescribed over a 3 year period against the actual prescribing costs.

Figure 34: Precribing items for medication to treat mental ill health


85 | P a g e

Figure 35: Prescribing costs for medication to treat mental ill health

In terms of costs, prices have reduced over time as drugs come off patent, therefore figures will

reflect a drop for cheaper prices as opposed to reduced prescribing.

4.4. Secondary care

4.4.1. specialist mental health treatment

Secondary care mental health services provide care for people with serious mental health issues.

The types of services that a secondary care provider is responsible for include in-patient hospital

care, crisis intervention services, recovery services and eating disorder services. Serious mental

health problems include schizophrenia, bipolar disorder or severe depressive disorder. It is

estimated that, nationally, 1 adult in 28 are in contact with secondary mental health services.[196]

In 2015/16, NHS Halton CCG had 5,110 people using its NHS funded adult secondary mental health

and learning disability services. Of these 320 or 6% were admitted. This compared to 5% for 5

Borough Partnership as a whole and 5.6% for England. This gives Halton a higher crude rate per

100,000 adult population compared to England.

Table 30: People using NHS funded adult secondary mental health and learning disability services, 2015/16

Data from the national Mental Health Minimum Dataset includes the numbers admitted to NHS

funded adult specialist mental health services, regardless of a formal diagnosis. It includes use of

community as well as hospital-based services and it can be compared with the levels of health and

illness for a CCG to see whether the use of services is relatively high or low, given the recorded

prevalence of mental illness. It can also be considered in conjunction with other treatment indicators

to show if, for example, the use of inpatient beds is high compared with the use of health services


86 | P a g e

overall. Levels in Halton have been statistically lower than Cheshire & Merseyside since quarter 3

2013/14 but statistically higher than England for the whole period 2013/14 Q1 to 2015/16 Q2.

Figure 36: Contact with specialist mental health services: rate per 100,000 population aged 18+ (end of quarter snapshot)

Halton CCG has consistently had a slightly lower percentage of people using adult mental health and

learning disability services recorded as on a Care Programme Approach.

Table 31: People using NHS funded adult secondary mental health and learning disability services by Care Programme Approach, 2013/14 to 2015/16

Table 32: Bed days by gender, 2013/14 to 2015/16


87 | P a g e

Table 33: Outpatient and community contacts by CCG and attendance type, April to November 2015

Ryan and Hodgetts[197] carried out an independent review of the mental health services across the 5 Boroughs Partnership footprint; Warrington, Halton, Knowsley, St Helens and Wigan. The review examined the acute care pathway for adult mental health services and all the inter-related services that impact upon the pathway, including those not delivered by 5 Boroughs Partnership. The review generated 5 main recommendations for service development or improvement (“big tickets”) as well as an additional suite of further recommendations, some specifically related to the acute care pathway. These were:

1. The interface between primary and secondary care 2. How people with a personality disorder or highly distressed emotional disorders are

supported by the whole system 3. The whole service model across the Borough (including 5 Boroughs Partnership NHS

Foundation Trust services and all others) 4. Step down from in-patient services and the use of out of areas placements in the private

sector 5. The proposed future bed model

The report noted that all of the five are inter-dependent. There is no sequential order to

implementation. They must all be implemented as part of a whole system approach to delivering the

best quality, most efficient and value for money services that are possible within the resources

available across the footprint.

Taking this forward requires a whole system approach – to both commissioning and provision across

each Borough and across the footprint in some cases. This includes primary and secondary health

care, social care, acute hospital services, the criminal justice system, housing, the third sector and

other key stakeholders.

4.4.2. Liaison Psychiatry

This refers to a team of mental health practitioners based within the general acute hospital. The

team provide psychiatric treatment to patients who require it when they attend Accident and

Emergency or as an admitted patient. For patients diagnosed with mental health problems, this

might include those who have suffered self-inflicted injuries, or management of patients presenting

with acute mental health problems. A&E departments have a short stay ward which has the

facilities for the temporary observation of patients who have taken minor toxic overdoses, where


88 | P a g e

more thorough mental health evaluation can be carried out following recovery. Assessment and

management of care would be carried out by the team.

A mental health team providing a service to A&E and inclusive of Ward Liaison Psychiatry, based at

the general hospital, integrated with physical health care can:

Improve patient flow and the appropriate utilisation of resources

Improve patient safety

Increase the quality of care

Improve staff safety

The provision of liaison psychiatry services forms part of the Five Year Forward View for Mental

Health[198] which stipulates that by 2020/21 all acute hospitals will have all-age mental health liaison

teams in place. It is expected that, by 2020/21, 50% of national services will meet the ‘Core 24’

service standard as a minimum. ‘Core 24’ services meet specific staffing criteria but the main

benefits for people accessing services include:

Service provision beyond office hours and for some periods at weekends. Outside of these hours, rapid access to consultant support provided by on-call services using provision already in place

The support and training of mainstream hospital staff

Co-ordination with out-of-hospital care providers and housing services through integration within broader health and social care system.

4.4.3. Early Intervention in Psychosis

Psychosis is characterised by hallucinations, delusions and a disturbed relationship with reality, and

can cause considerable distress and disability for the person and their family or carers. People who

experience psychosis can and do recover. The time from onset of psychosis to the provision of

evidence-based treatment has a significant influence on longterm outcomes. The sooner treatment

is started the better the outcome for the patient and the lower the overall cost of care.

As part of the drive for parity of esteem of mental health conditions and service delivery, national

waiting time standards were introduced in April 2016 that stipulate that 50% of people experiencing

first episode psychosis will be treated with a NICE-approved care package within two weeks of

referral. The standard also extended the eligibility criteria for entry into first episode psychosis

treatment to service users aged 14 – 65 years.

The continued development and investment in early intervention services is outlined in the Five Year

Forward View which sets the goal that by 2020/21 at least 60% of people with first episode psychosis

start their treatment within two weeks of referral.

4.4.4. Operation Emblem – Street Triage

Section 136 of the Mental Health Act is used by the Police to take people to a place of safety if they

consider the person to be mentally ill and in need of care and they are in a public place. In recent

years Section 136 was increasingly being used in Cheshire. Operation Emblem is a service jointly

provided by Cheshire Constabulary and 5 Boroughs Partnership NHS Foundation Trust. It is

commissioned jointly by Warrington CCG and Halton CCG. The aim of the service is to enable police


89 | P a g e

and health care professionals to work together when dealing with members of the public who may

be presenting as a danger to themselves or to other people. The overarching aim of the operation is

to reduce the need to place people on a Section 136 of the Mental Health Act. Operation Emblem

was introduced at the end of 2013.

4.5. Social Care Social care is commissioned through Halton Borough Council for people with mental health

illnesses who are in need of support at home or may require residential care. The Care Act

2014[199] lays down the rules by which care should be provided by local authorities in England. The

Care Act emphasises wellbeing - physical, mental and emotional – of both the person needing

care and their carer, but promotes prevention of the need for social care. At the heart of the Act

is a focus on enabling people to take control of their lives and to manage the care they need. To

achieve this, local authorities should ensure that information and advice on care and support is

available to all when they need it.

The Act includes a statutory requirement for local authorities to collaborate, cooperate and

integrate with other public authorities e.g. health and housing. It also requires seamless transitions

for young people moving to adult social care services. The Act sets out how entitlement to

assessment for social care should operate with national rules on eligibility thresholds for care. A

care and support plan or support plan for carers should be prepared and reviewed regularly. A

personal budget will form part of the care and support plan or support plan. Where a person,

including a carer, has a personal budget, they can have a direct payment. The Act also sets out

rules on safeguarding through a new statutory framework, which should protect adults from

neglect andabuse.

The information provided in this section should be reviewed in light of the responsibilities outlined

in The Care Act, summarised above.

People with mental health disorders who are managed in secondary care (usually with severe

mental illness) can be referred for a social care assessment under the Care Act 2014 to

determine their care and support needs and level of support required.

In addition, there are people with mental health disorders who may not be under the care of

secondary services but require social care support. These people most likely have common

mental health disorders and receive care and support funded in whole or in part by the Local

Authority.

Social Care Data for 2015/16 (Short and Long Term – SALT- return) showed that in total, 175

people with mental health aged 18-64 received long term care and support packages funded in

whole or in part by the Council.

This gives Halton one of the higher rates proportional to its population size within its comparator

group but still just below the comparator group and North West averages


90 | P a g e

Figure 37: Long Term Support clients with a PSR of Mental Health Support for selected LA and adults aged 18-64, 2015/16

Table 34 represents the breakdown of long term care and support funded by the Council by

primary support reason. The table shows that adults with the primary support reason Mental

Health make up 19.23% of all long term care and support packages funded by the Council. A

greater percentage receive Council Commissioned Support only (60%), compared to the average

of 27.5%. Council Managed Person Budgets constitute the second highest category, the same as

for all clients aged 18-64 (20% of clients with mental health support needs; 24.7% of all clients).

Notable also is the low percentage of clients with mental health support needs receiving total or

part direct payments, 19% compared to 41.2% of all clients aged 18-64. Table 34: Number of Halton residents aged 18-64 supported by adult social care due to mental illness, by various social care packages during the year, 2015-16


91 | P a g e

4.6. Current Assets There is growing recognition that, whilst disadvantaged communities have higher health need, they

may also have assets within the community that can improve health and build resilience.[200

Community assets can be anything that improves the quality of the community, including physical

assets such as public green space, play areas and community buildings, as well as social assets such

as volunteer and charity groups, social networks and activity groups. These assets have potential to

protect and increase community wellbeing and thus strengthen resilience.

Greater community resilience has the potential to reduce the prevalence of mental ill-health and

increase the prevalence of good mental health for the whole population, as well as improving

recovery and support for individuals who have become unwell.

We need to consider those aspects of Halton life and local services that are contributing to keeping

people mentally well so that we can build on these for the future. For a robust view of such assets,

there will need to be a longer term investigation and work alongside Halton people. This process

(sometimes called co-production) may itself become an asset as a mechanism for understanding

better what works and for building on the positive things we have. Here are some examples of

important assets for mental health and wellbeing in the borough that could be built on:

a range of community and voluntary sector provision which provides many opportunities, for building and maintaining mental health for communities and individuals

action by people who have experience of poor mental health; to help shape and provide services, to provide mutual support and advocacy, to reduce the stigma of mental ill health and promote paths to recovery

the increasing recognition by agencies and employers across the borough of the importance of staff and customers' mental health and wellbeing, and the impact this has on organisational goals. This reflects the increasing importance of mental wellbeing as a public health priority


92 | P a g e

5. Impacts of mental wellbeing and mental ill health Having poor mental wellbeing or a mental illness can have profound impacts on a person’s life, their

relationships and to society

In secondary care, 11% of the annual health budget is spent on mental health. Nationally more than

£2 billion is spent annually on social care for people with mental health problems.[201] With increases

in the population, and particularly in the older age groups with increasing life expectancy, it is

estimated that the cost of treating mental health problems could double over the next 20 years.[202]

The impact of mental health on peoples wider lives can affect their educational attainment,

employment, housing, family relationships and therefore there are wider costs of mental health

problems than just health related costs. Costs to the individuals, their families and their communities

in lost potential are essentially incalculable. However detailed estimates suggest the overall

calculable cost of mental health problems in England to be around £105 billion and around £30

billion of this estimate is work related.[203] This is largely due to sickness absence and reduced

productivity. There are also large costs associated with the impact on the criminal justice system and

also the housing system and particularly the homelessness services. One of the largest areas of cost

is the benefit system. The most common reason for incapacity benefit claims is mental health, with

43% of the 2.6 million people on long-term health-related benefits have a mental or behavioural

disorder as their primary condition.[204]

Even though so many people are affected by mental illness, there remains a strong social stigma

attached to it. As such people with mental health problems can experience discrimination in all

aspects of their lives. Nearly nine out of ten people with mental health problems say that stigma and

discrimination have a negative effect on their lives. Research shows[205] that people with mental

health problems are amongst the least likely of any group with a long-term health condition or

disability to:

find work

be in a steady, long-term relationship

live in decent housing

be socially included in mainstream society

Mental illness is the largest single source of burden of disease in the UK. No other health condition

matches mental illness in the combined extent of prevalence, persistence and breadth of impact.[206].

The disability-adjusted life year (DALY) is a measure of overall disease burden, expressed as the

number of years lost due to ill-health, disability or early death. It was developed as part of the World

Health Organisations Global Burden of Disease Study for 1990 and in subsequent WHO updates for

2000 to 2004, as a way of comparing the overall health and life expectancy of different countries.[207]

The full impact of mental ill health as described above can be seen in the Halton analysis, with

mental health having the largest DALY lost, higher than cancers (malignant neoplasms) and

cardiovascular disease which are the borough two biggest causes of death (Figure 38).


93 | P a g e

Figure 38: Disability Adjusted Life years (DALYs) in Halton

Employment and benefits Department of Health and the Confederation of British Industry have estimated that 15-30% of

workers will experience some form of mental health problem during their working lives. In fact,

mental health problems are a leading cause of illness and disability.[208]

Work is widely recognised as having a positive impact on mental health, while unemployment has a

negative effect and often leads to deterioration in mental well-being.[209] The importance of

employment in ensuring mental wellbeing is by now widely recognised. People with mental health

difficulties often suffer stigma and discrimination in the workplace, and those who are unemployed,

in an unsatisfactory job, or at risk of unemployment, experience much poorer mental health than

those in stable employment.

People who experience mental ill health remain one of the most disadvantaged groups in the job

market. The Department of Work and Pensions highlighted that:[210]

Only 20% of people with severe mental health problems are employed compared to 65% of people with physical disabilities, and 75% for the whole adult population

In the case of people with more common conditions such as depression, only about half are employed

90% of people with mental health problems want to work compared to 52% of disabled people generally


94 | P a g e

The result is that there are more mentally ill people on incapacity benefits than the total number of

unemployed people on benefit, and 70 million days are lost each year because of mental health

problems. The combined costs of sickness absence, non-employment, effects on unpaid work and

output losses to the UK is £26 billion a year, which is equivalent to £1,035 for every employee in the

UK workforce.[211]

Enablement of people with serious mental illness includes their employment status and ability to work. Evidence suggests that there can be a number of barriers to gaining or retaining employment, for example, the symptoms of the mental illness or discrimination by employers or stigma in the workplace.[212].‘Individual Placement Support’ is one evidenced based method for employment support.[213] The proportion of people with severe mental health disorders, under the care of secondary

mental health services who are in paid employment is provided on a monthly basis. This data

depends on good recording of information during the most recent review or planning meeting

with the patient.

The annual national labour force survey includes questions which enable a calculation on the

number of respondents aged 16-64 years of age who report that they have a mental illness and are

in employment as a percentage of all respondents who report that they have a mental illness. The

indicator forms part of the NHS Outcomes framework. It uses data on the number of working age

respondents to survey who have a health problem or disabilities that they expect will last for more

than a year AND have depression, bad nerves or anxiety, severe or specific learning disabilities,

mental illness, or suffer from phobia, panics or other nervous disorders AND are in employment.

Whilst there are concerns regarding the quality of this data, it nevertheless provides some indication

of how people with mental illness fare in the employment market.

Figure 39: Percentage of those with a mental illness or learning disability in employment

As a small borough there is greater fluctuation in Halton’s rates than regionally or nationally. It

shows, overall a slightly lower percetnage of Halton people with mental illness are in eployment

than across the North West and England as a whole. Confidence intervals have not been calcualted

on this data so it cannot be said if the difference is statistically significant.


95 | P a g e

Data is also available on the gap in employment between those with mental illness and the general

population. It uses employment rates for 16-64 year olds and compares these to the the

employment rate of working age adults who are receiving secondary mental health services and on

Care Programme Approach.

It shows the gap is smaller in Halton than England, although for both there has been a widening of

the gap.

Figure 40: Gap in the employment rate for those in contact with secondary mental health services and the overall employment rate: percentage point difference

This data shows that unlike the general population where most people of working age are in

employment, the majority of people with mental illness are not employed. Those for those who are

economically active there is a heavy reliance on benefits. This is most likley to be the case for those

with severe mental illness as Figure 41 shows.

Figure 41: Proportion who receive a particular benefit, by type of benefit and by mental health status

Data for Halton shows a smaller percentage of residents claiming both incapacity benefits and

disability living allowance (DLA) do so due to mental health problems. This may be due to the high

burden of disease due to other conditions as levels of mental ill health are high in the borough.


96 | P a g e

Table 35: Proportion of Incapacity Benefit/Severe Disablement Benefit and DLA due to mental illness,as at May 2016

Debt and mental health Being in debt and mental health are closely related. Debt may cause or contribute to the

development of mental illness, or it may be that having a mental health problem can lead to getting

into debt, for example, through being unable to work, or through finding it hard to manage money.

A recent report by the Money and Mental Health Policy Institute[214] highlights that a quarter (three

times more than the general population) of people experiencing common mental disorders are also

experiencing financial problems, and that half of adults with a debt problem also have a common

mental health problem. In a survey conducted by Money and Mental Health in April 2015, 86% of

the 5,500 people with mental health problems said their financial situation had made their mental

health problem worse.[215] According to the Royal College of Psychiatrists,[216] one in two people in

debt have a mental health problem – and one in four people with a mental health problem is also in

debt. Personal levels of debt in the UK in 2011 are at a high; in November 2016 it was estimated at

an average debt per person of £29,930, up nearly £100 on the previous month.[217]

313,679 people contacted StepChange Debt Charity for help between January and June 2016, up

11% on the same period in 2015.[218] The average unsecured debt of its clients in the first six months

of 2016 was £13,8261 . Clients had on average 5.7 debts with credit cards continuing to be the most

common unsecured debt. Levels of arrears on essential household bills remained elevated. A

notable growth area for clients’ debt was loans from family and friends; 28% of clients now have

such debts compared to 20% in the first half of 2014. Clients aged under 40 now account for 60% of

all clients advised. Five years ago it was 52%. One in five clients is a single parent, double the

proportion of single parents in the UK population. The proportion of clients who rent their home has

grown from 61% to 77.3% in just five years. The fastest growth in demand has come from those

living in private rented accommodation who now account for almost four in ten clients.

Housing

Type of housing makes an impact on mental health. The evidence for the mental health and

wellbeing impacts of housing, especially poor housing conditions, is less developed than that

supporting physical health impacts. However there is some evidence of pathways that might link

poor housing conditions to mental health outcomes. For example, living in poor housing conditions

has been shown to increase stress, and reduce empowerment and control, each of which have clear

links with mental health outcomes.[219] It is estimated that 19% of adults living in bad housing in

England have poor mental health outcomes.[220]


97 | P a g e

Table 36: Housing hazards and their effects on mental health and wellbeing

Having secured tenure is an important determinant in a person with mental illness being able to

recover. Yet having a mental illness can make this more difficult. People with mental illness are

more likely to live in rented accomodation, fall behind with rent and housing providers often feel

unconfident in how to support people with mental illness. They are often less satisfied with their

hosuing and neighbourhood and find it more difficult to integrate in to their local community.[221]

Information on the housing situation amongst people experiencing mental illness is limited to data

on the percentage of adults (age 18-69) who are receiving secondary mental health services on the

Care Programme Approach recorded as living independently, with or without support. Data shows

that Halton has a higher percentage of people in settled accomodation. The percentage locally and

elsewhere is slightly higher for females than males and this pattern has been consistent over the

past four reporting periods. In 2015/16 there was a slight reduction in the percentage in stable and

appropriate accomodation, both in Halton and elsewhere.


98 | P a g e

Table 37: Percentage of adults (aged 18-69) in contact with mental health services who are living in stable and appropriate accommodation:

Safeguarding of people with mental illness The local adult safeguarding board brings together police, ambulance services, local hospitals and

community and mental health trusts, NHS England and local government. In many places the boards

also include providers and users of services. The boards provide the opportunity for all partners to

be able to share information about the ways in which people in mental health crisis are provided

with the appropriate support and treatment. They are also able to benchmark local services against

the standards published in the Concordat. When people in mental health crisis are not provided with

appropriate and timely support significant harm can occur. A recent analysis of 71 serious case

reviews showed a significant number concerned people in mental health crisis. Some had not

received timely assessments, some had not received appropriate services and some were not

recognised as carers under stress.[222]

For the first time in 2014/15, data was collected on primary support reason. This classification

focuses on the main reason that a person requires social care services at any particular time and

provides a better description of the impairment impacting on the individual’s quality of life and

creating a need for support and assistive care. It may not be related to any underlying health

conditions. From analysing the data, physical support accounts for the majority of cases on a both a

local and national basis with 40% of individuals. Sensory support was the least common group both

in Halton and nationally. The pattern in 2015/16 was the same. In both years Halton had a higher

level due to physical needs and lower due to mental illness, although there has been a slight

increase from 6% due to mental illness in 2014/15 to nearly 9% in 2015/16.


99 | P a g e

Figure 42: Individuals Involved in Section 42 Safeguarding Enquiries, by primary support need, 2015/16

Carers of adults with mental health needs Caring for someone with mental health needs presents different challenges for their carer compared

with a physical illness or disability. These include:[223][224][225][226][227][228]

The fluctuating nature of poor mental health. The need for, and levels of, support may therefore be unpredictable. Dependence on the carer can be really intense and prolonged at times yet minimal at others

Poor mental health is not necessarily as evident as a physical health problem or disability, therefore may be less understanding or support forthcoming for the carer as there is with other health conditions

Because of the stigma surrounding mental ill-health, carers may be less willing to seek support or share with family members and friends. This may mean they have less of a social network to draw on themselves with a resulting risk of poor mental health in the carer themselves

Many people say dealing with the stigma surrounding mental health is worse than coping with the condition itself

Carers play a key role in the recovery of people with poor mental health conditions. This is a significant level of responsibility

Often mental ill-health is associated with other conditions, so this is not the only condition the carer is required to deal with

There are a number of legal and ethical issues surrounding mental health that can make the role of caring even harder

Carers need information, advice and support about carrying out their caring role, but also about understanding and coping with mental health conditions. Carers of people with poor mental health are dealing with taking on a caring role as well as learning how to respond to the behaviours and emotions associated with the condition


100 | P a g e

As a result of these issues, caring for someone with mental health needs may be even more

emotionally draining than any other caring role. Family and friends bereaved by a suicide, or

affected by those at risk of suicide, are at increased risk of mental health and emotional problems

and may be at higher risk of suicide themselves. Keeping family and friends informed and providing

the relevant advice and support in a timely manner can prevent this.[229][230] Suicide prevention

research and recommendations all cite the need to include, support, identify and listen to carers.[231]

The Triangle of Care report[232]emphasises the need for better involvement of carers and families in

the care, planning and treatment of people with mental ill-health with the purpose of supporting

recovery and sustaining wellbeing of both service user and carer. It was developed to address the

clear evidence from carers that they need to be listened to and consulted more closely. The guide

outlines key elements to achieving this as well as examples of good practice. Key elements include:

The carers involved in patient care are identified as soon as possible.

Professionals are ‘carer aware’ and equipped to involve carers effectively

Protocols are in place regarding the sharing of information and confidentiality

Specific professional roles are identified with carer responsibility

Carers are able to meet with staff and are provided with information throughout the care and treatment pathway

A range of support services are provided for carers

Fundamental to the Triangle of Care approach is the importance of understanding what carers need

to carry out their role effectively: skills, information, advice, support, regular breaks. Not just

focusing on the impact of the caring role, but the causes of the stresses in the first place. If the right

information, advice, support and services are not available then a detrimental effect from the caring

role will still ensue.

NICE guideline[233] includes recommendations on the need for mental health services to offer carers

of people with psychosis or schizophrenia an assessment of their own needs, provide information

about the condition (including negotiation with service users about how their information will be

shared), include carers in decision making if the service user agrees and, in addition, advise carers

about their statutory right to a formal carer's assessment. The guidance recommends that all carers

of people with psychosis and schizophrenia should be offered a carer-focused education and support

programme, which may be part of a family intervention, as early as possible. It it likely that the same

applies to people caring with other types of mental illness.

There is often a link between mental health and alcohol dependence. The NICE quality standard on

alcohol dependence[234] recommends that families and carers involved in supporting a person who

misuses alcohol should have the opportunity to discuss concerns about the impact of alcohol misuse

on themselves and other family members.

The Survey of Adult Carers in England is a biennial survey that took place for the second time in

2014-15. The survey covers informal, unpaid carers aged 18 or over, caring for a person aged 18 or

over, where the carer has been assessed or reviewed, either separately or jointly with the cared-for

person, by social services during the 12 months prior to the sample being identified. Carers were

sent questionnaires, issued by Councils with Adult Social Services Responsibilities (CASSRs), in the

period October to November 2014, to seek their opinions on a number of topics that are considered


101 | P a g e

to be indicative of a balanced life alongside their caring role.

A smaller proportion of people cared for by Halton carers have dementia, physical disability and

sight or hearing loss, problems connected to ageing and terminal illness compared to the North

West and England. Conversely a higher proportion have mental health problems, long-standing

illness and alcohol or drug dependency.

Table 38: Conditions cared for person has, 2014/15


102 | P a g e

6. Projected levels of need Prevalence trends for common mental health disorders identified through the APMS show a slight

increasing trend. However, in terms of how many people of working age may have mental health

problems in the future, this increasing population prevalence is likley to be offset by the projected

decrease in the 18-64 age population, by 7% for both males and females in 2030 compared to 2014.

Table 39: Percentage change in Halton's 18-64 age population, 2014 to 2030

Reducing stigma: willingness to come forward and talk about mental illness, may result in increase in

prevalence rates.

IAPT services are based on a robust evidence of effectiveness for common mental health problems and are very successful at reducing rates of these illness when they are sufficiently well resourced according to the level of need in the population, and when they are appropriately supported by secondary care. If primary care services are not sufficiently resourced they must prioritise those with greatest needs, and if secondary care support is insufficient, primary care services can become overwhelmed and stalled with people who are unable to recover successfully because they require secondary care services.

Wellbeing is unique to individuals, at a population level it varies according to measurable trends and improves or deteriorates in response to factors that it is possible to influence. This means there is considerable potential to improve the wellbeing of a local population via the purposeful adoption of a whole system approach supported by local research. Specialist work dedicated wholly to improving the wellbeing of Halton’s individuals and communities is a key part of making positive change across the borough. This work must be supported by organisations across the local health economy with meaningful reference made to local evidence on wellbeing within strategies as well as when taking actions in response.

By addressing the issues identified across the local mental health system in the independent review, there is potential to reduce hospital admissions due to mental ill health. There should be correspondingly increased activity in community services to ensure that people’s health and wellbeing is maximised in relation to adult services.


103 | P a g e

Social and economic changes impact upon the prevalence of common mental health problems, but it is not known to what extent the recent UK economic downturn plus the welfare reforms has affected mental health within the national, or local, population. Generally, income inequality within communities and populations has an adverse effect on mental health at both ends of the spectrum, but with those in the most deprived sectors worst affected.[235] There is also some evidence that adverse situations can increase community cohesion and thus have a positive influence on mental health[236]


104 | P a g e

7. User views National At a national level the Mental Health Taskforce undertook very wide public consultation in 2015 to inform the 5 Year Forward View for Mental Health. Three clear themes emerged – prevention, access and quality. The importance of integrating care and support was also identified as a critical factor to the successful delivery of equitable access and improved outcomes. The need to prioritise equality – particularly for BAME groups, older and younger people – also came out strongly across each of these themes. When asked how people would like things to be different by 2020 the top five areas for change are:

access to services (52%)

choice of treatments (33%)

prevention (25%)

funding (21%)

stigma and discrimination (19%) The Voices from the Frontline report reports the views of people with multiple needs and those who support them and identifies the challenges faced by people when services are not ‘joined up’ or people feel ‘written off’. Online space is being used innovatively to give insight into the real lives and experiences of people with mental health problems, such as the Day in the Life space, where people’s experiences can be read by a wide public. National Survey: 5 Borough’s Partnership NHS Trust results At the start of 2016, a questionnaire was sent to 850 people who received community mental health

services. Responses were received from 211 people at 5 Boroughs Partnership NHS Foundation

Trust. Analysis is via a score out of 10 for the main and sub-indicators. It showed overall the trust

performed similar to the national average across all indicators exept items x and y where they

scored better.

Survey Response

1 Health and social care workers 7.8

1.1 Listening: for the person or people seen most recently listening carefully to them

8.4

1.2 Time: for being given enough time to discuss their needs and treatment 7.8

1.3 Understanding: for the person or people seen most recently understanding how their mental health needs affect other areas of their life

2 Organising care 8.8

2.1 Being informed: for having been told who is in charge of organising their care and services

7.9

2.2 Contact: for those told who is in charge of organising their care, being able to contact this person if concerned about their care 9.9

2.3 Organisation: for those told who is in charge of organising their care, that this person organises the care and services they need well 8.6

3 Planning care 7.5

https://www.england.nhs.uk/mentalhealth/wp-content/uploads/sites/29/2015/09/fyfv-mental-hlth-taskforce.pdf

http://meam.org.uk/voices/

https://dayinthelifemh.org.uk/guide/#main


105 | P a g e

Survey Response

3.1 Agreeing care: for having agreed with someone from NHS mental health services what care and services they will receive 6.9

3.2

Involvement in planning care: for those who have agreed what care and services they will receive, being involved as much as they would like in agreeing this

7.7

3.3

Personal circumstances: for those who have agreed what care and services they will receive, that this agreement takes into account their personal circumstances

8.0

4 Reviewing Care 7.9

4.1

Care review: for having had a formal meeting with someone from NHS mental health services to discuss how their care is working in the last 12 months

8.2

4.2

Involvement in care review: for those who had had a formal meeting to discuss how their care is working, being involved as much as they wanted to be in this discussion

7.5

4.3

Shared decisions: for those who had had a formal meeting to discuss how their care is working, feeling that decisions were made together by them and the person seen

8.0

5 Changes in who people see 6.4

5.1

Explanations: for those for whom the people they see for their care changed in the last 12 months, that the reason for this change was explained to them at the time

6

5.2 Continuity of care: for those for whom the people they see for their care changed in the last 12 months, that their care stayed the same or got better 7.9

5.3

Information: for those for whom the people they see for their care changed in the last 12 months, knowing who was in charge of their care during this time 5.4

6 Crisis care 6.7

6.1 Contact: for knowing who to contact out of office hours if they have a crisis 7.1

6.2 Support during a crisis: for those who had contacted this person or team, receiving the help they needed 6.3

7 Treatments 7.6

7.1 Involvement in decisions: for those receiving medicines, being involved as much as they wanted in decisions about medicines received 7.5

7.2 Understandable information: for those prescribed new medicines, being given information about it in a way that they could understand 6.8

7.3 Medicine review: for those receiving medicines for 12 months or longer, that a mental health worker checked how they are getting on with their medicines 8

7.4

Explanations: for those who received treatments or therapies other than medicine, that the treatments or therapies were explained to them in a way they could understand

8.1


106 | P a g e

Survey Response

7.5

Involvement in deciding other treatment or therapies: for those who received treatments or therapies other than medicine, being involved as much as they wanted in deciding what treatments or therapies to use 7.7

8 Support and wellbeing 5.3

8.1

Help finding support for physical health needs: for those with physical health needs receiving help or advice with finding support for this, if they needed this

5.4

8.2 Help finding support for financial advice or benefits: for receiving help or advice with finding support for financial advice or benefits, if they needed this 4.7

8.3 Help finding support for finding or keeping work: for receiving help or advice with finding support for finding or keeping work, if they needed this 4.1

8.4 Local activities: for someone from NHS mental health services supporting them in taking part in a local activity, if they wanted this 4.6

8.5 Involving family or friends: for NHS mental health services involving family or someone else close to them as much as they would like 7.3

8.6

Information on support from others: for being given information about getting support from others with experiences of the same mental health needs, if they wanted this

4.2

8.7 Support: for the people seen through NHS mental health services helping them achieve what is important to them 6.8

9 Overall views of care and services 7.7

9.1 Contact with services: for feeling that they have seen NHS mental health services often enough for their needs in the last 12 months 6.6

9.1 Respect and dignity: for feeling that they were treated with respect and dignity by NHS mental health services 8.9

10 Overall experience 7.5

10.1 Overall view of mental health services: for feeling that overall they had a good experience

7.5

Source: Care Quality Commission

Further details of the 5BP results can be found at

http://www.nhssurveys.org/Filestore/MH16/MH16_BKReports/MH16_RTV.pdf

Access to all CQC inspection and survey reports available for 5BP can be found at:

http://www.cqc.org.uk/provider/RTV

Local Halton Borough Council have recently undertaken an Experience-based Co-Design project. It

provides a media product (in the form of a video) for services and organisations ( Mental health

organisations including Halton Borough Council, NHS mental health service providers as well as the

voluntary and community sectors) to use to help them shape service development and compliment

staff induction and training sessions.

http://www.nhssurveys.org/Filestore/MH16/MH16_BKReports/MH16_RTV.pdf

http://www.cqc.org.uk/provider/RTV


107 | P a g e

Experience-based co-design (EBCD) involves gathering experiences from patients and staff through

in-depth interviewing, observations and group discussions, identifying key ‘touch points’

(emotionally significant points) and assigning positive or negative feelings. A short edited film is

created from the patient interviews. This is shown to staff and patients, conveying in an impactful

way how patients experience the service. Staff and patients are then brought together to explore

the findings and to work in small groups to identify and implement activities that will improve the

service or the care pathway.[237]

The approach was designed for and within the NHS to develop simple solutions that offer patients a

better experience of treatment and care. However, similar user-centric design techniques have been

used by leading global companies for years.

Some clear themes emerged:

List themes

The film will provide professionals in the mental health sector to hear (and see) service users,

understand the key things that can improve a service users experience of a service and then use this

information when planning and training within services.

8. Best practice interventions

Issue Evidence/Guidance

Address risk factors for mental illness

Reduce Alcohol: NICE PH24 recommends maximising opportunities to provide brief advice on alcohol to more GP practice patients. Debt: Debt advice services save £3 for every £1 spent after 2-3 years. [238]

The missing link – How tackling financial difficulty can boost recovery rates in IAPT (Money and Mental Health Policy Institute, 2016) This report puts forward the case that the IAPT programme should seek to recognise, and develop ways to mitigate, the impact of financial difficulty. Citizens Advice: A debt effect? How is unmanageable debt related to other problems in people’s lives? (2016) Investigates the relationship between high levels of debt and a range of wider issues including unemployment, low pay, physical health problems and poor mental health. Joseph Rowntree: We can solve poverty (2016) Sets out recommendations on actions to solve poverty. Housing and Homelessness: PHE: Homelessness: applying All Our Health (2016) This guidance provides an overview of the issues that are associated with homelessness and highlights interventions that can be implemented at population, community, family and individual levels. Mental Health Foundation: Mental Health and Housing (2016) Report on types of supported accommodation that successfully meet the needs of people with mental health problems - to recommend effective housing solutions. Centre for Mental Health: More than shelter – supported accommodation and mental health (2016) This briefing paper presents a series of key themes for consideration in the future development of supported accommodation for adults with severe mental health problems, including those with multiple needs and substance misuse and those facing homelessness.

https://www.nice.org.uk/guidance/ph24

http://www.moneyandmentalhealth.org/wp-content/uploads/2016/11/Singles-MMH_3273_Our_Report_LiveCopy_DIGITAL_SINGLE.pdf

https://www.google.co.uk/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0ahUKEwj9pL3p4vPRAhUXOsAKHVIuBBQQFggaMAA&url=https%3A%2F%2Fwww.citizensadvice.org.uk%2FGlobal%2FCitizensAdvice%2FDebt%2520and%2520Money%2520Publications%2FThe%2520Debt%2520Effect.pdf&usg=AFQjCNFPoQce6BWNkTyaEbXHsg7avBi3NQ&sig2=AtzGHM_IrVyvd2ZC7J2KWQ&cad=rja

https://www.jrf.org.uk/report/we-can-solve-poverty-uk

https://www.gov.uk/government/publications/homelessness-applying-all-our-health/homelessness-applying-all-our-health

https://www.mentalhealth.org.uk/sites/default/files/Mental_Health_and_Housing_report_2016_1.pdf

https://www.centreformentalhealth.org.uk/more-than-shelter


109 | P a g e


Homelessness Link have lots of useful resources such as Prevention Opportunities Mapping and Planning Toolkit (PrOMPT) http://www.homeless.org.uk/our-work/resources/prevention-opportunities-mapping-and-planning-toolkit-prompt

Promote mental health

Increase Physical Activity Being physically active has an important role in preventing and managing a range of conditions, including mental health problems NICE recommend tailored and structured exercise programmes for the management and rehabilitation from depression. Physical activity can also have a positive effect on mood and provide relief from stress. (NICE PH2, PH8, PH13, PH54) Promote workplace mental health NICE PH22 Mental wellbeing at work recommends interventions to improve mental health within the workplace have been found to be cost-effective for businesses. There is strong evidence that mental health interventions in the workplace can improve people’s wellbeing and there is potential to deliver cost savings

Knapp (2011) found a workplace- based enhanced depression care intervention consisting of the completion by employees of a screening questionnaire, followed by care management for those suffering from, or at risk of developing depression and/or anxiety disorders was cost effective.[239

PHE Guidance: Workplace health: applying ‘All our Health’ (2015): Evidence and guidance to help healthcare professionals encourage people to live healthy lifestyles at work. Also includes a wide range of references to relevant NICE publications and sources of employment indicators. SCIE: Mental health, employment and the social care workforce (2011): This report summarises evidence on what prevents people with mental health problems from working or retaining work in social care and what can be done to enable them to work. It provides a summary of a range of policy and programmes designed to enable people with mental health problems to gain, retain and regain work, with specific focus on employment in social care.

Workplace wellbeing charter: A guide on how to make workplaces a supportive and productive environment. Support and advice to employers who volunteer to sign up

Foresight Project 2008 and New Economics Foundation were commissioned to identify ways of increasing wellbeing. The evidence is incomplete but five ways to wellbeing was recommended:[240][241]

http://www.homeless.org.uk/our-work/resources/prevention-opportunities-mapping-and-planning-toolkit-prompt






https://www.gov.uk/government/publications/workplace-health-applying-all-our-health

http://www.scie.org.uk/publications/reports/report48/index.asp

http://www.wellbeingcharter.org.uk/index.php


110 | P a g e


Five Ways to Wellbeing 1. Connect with others 2. Be physically active 3. Take notice of the world around you 4. Keep learning new things 5. Give to others

The Foresight Project also showed that education and lifelong learning promote mental wellbeing and resilience and reduce the risk of mental illness. Learning is also important in recovery from mental illness.[242]

Community Engagement NICE PH9 Community engagement and the updated NG44 cover recommendations for work with communities and how improved community involvement can contribute towards happier and healthier communities Kings Fund: Strong communities, wellbeing and resilience looks at the role Local authorities can play in helping individuals and communities to develop social capital. What Works Centre for Wellbeing have a number of reports and have been doing systematic reviews on housing and wellbeing, work and wellbeing and wellbeing inequalities:

Prevent mental illness in those with physical illness

NICE CG91 recommends:

The routine clinical management of long term health conditions should include the successful identification of those requiring individual assessment for depression/anxiety. NICE recommend the use of depression identification questions for this purpose and these should be incorporated into the initial patient assessment within pathways of care for long term health conditions.

Offering a choice of psychological intervention dependent on patient preference and assessed severity of depression/anxiety.

Access to commissioned psychological interventions directly from care pathways for long term health conditions should be reviewed to ensure that direct and timely access is available.

Pulmonary Rehabilitation has been shown as an effective management strategy to improve symptoms of depression/anxiety in those with Chronic Obstructive Pulmonary Disease


https://www.nice.org.uk/guidance/NG44

https://www.kingsfund.org.uk/projects/improving-publics-health/strong-communities-wellbeing-and-resilience

https://whatworkswellbeing.org/

https://www.nice.org.uk/guidance/cg91


111 | P a g e


The use of a multi-component cardiac rehabilitation programme for those patients with heart failure and post myocardial infarction will improve quality of life. This should include exercise and psychological interventions to improve outcomes for depression and anxiety

Promote physical health of those with mental illnesses

NICE guidance CG185 recommends that there is monitoring of the physical health of individuals with serious mental illness, and that support should be offered where needed around stopping smoking, weight and lipid management PHE: Wellbeing in mental health: applying All Our Health (2015) gives examples to help healthcare professionals make interventions to promote physical health and wellbeing in mental health. King’s Fund: Bringing together physical and mental health (2016): the NHS five year forward view has highlighted a third dimension – bringing together physical and mental health. This report makes a compelling case for this ‘new frontier’ for integration. It gives service users’ perspectives on what integrated care would look like and highlights 10 areas that offer some of the biggest opportunities for improving quality and controlling costs. DH, PHE, NHS E. Improving the physical health of people with mental health problems: Actions for mental health nurses: This Mental Health workbook was developed by the Health Inequalities National Support Teams (HINST) with 70 local authorities covering populations in England. Local areas could use this approach when analysing whether a population level improvements could be achieved from a set of bestpractice and established interventions. This is offered as useful resource for commissioners RCPsych. Improving the physical health of adults with severe mental illness: essential actions: Top 25 ideas for how members of the Faculty of General Adult Psychiatry (GAP) could take practical steps to improving the physical healthcare of their patients with mental illness. A summary of examples of work to improve the physical healthcare of patients with mental illness – including examples for psychiatrists at all levels, from trainees looking for a local improvement project to examples at team, organisational and strategic levels. Smoking cessation and substance misuse: NICE PH48 guidance aims to support smoking cessation, temporary abstinence from smoking and smoke free policies in all secondary care settings, including mental health services. Smoking cessation in secondary care: mental health settings (2016)


https://www.gov.uk/government/publications/wellbeing-in-mental-health-applying-all-our-health

https://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/Bringing-together-Kings-Fund-March-2016_1.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/532253/JRA_Physical_Health_revised.pdf

http://www.rcpsych.ac.uk/files/pdfversion/OP100.pdf


https://www.gov.uk/government/publications/smoking-cessation-in-secondary-care-mental-health-settings


112 | P a g e


Guidance and self-assessment framework for NHS mental health trusts to develop local action to reduce smoking prevalence and the use of tobacco.

ASH: The Stolen Years: Report by ASH sets out recommendations for how smoking rates for people with a mental health condition could be dramatically reduced NICE NG58 guideline covers how to improve services for people aged 14 and above who have been diagnosed as having coexisting severe mental illness and substance misuse. The aim is to provide a range of coordinated services that address people’s wider health and social care needs, as well as other issues such as employment and housing.

Enablement of those with SMI

Centre for Mental Health: Individual placement and support (IPS) : Supporting people with severe and enduring mental health needs to get back to work, ‘Individual Placement Support’ (IPS) is one evidenced based method for employment support IPPR: Patients in control: why people with long-term conditions must be empowered (2016): IPPR : This report asserts that more should be done to recognise and support the huge amount of self-management done by people with long-term conditions and their carers, and to enable people to work in partnership with healthcare providers to agree the services that fit their needs.

Preventing self harm, suicide and mental health crisis

The NICE self harm pathway incorporates NICE Quality Standard QS34, together with NICE CG16: the short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care and NICE CG133:Self harm: longer term management. PHE: Local suicide prevention planning – a practice resource (2016): This guidance advises how local authorities can: Develop a multi-agency suicide prevention partnership, Make sense of local and national data, Develop a suicide prevention strategy and action plan National Confidential Inquiry into Suicide and Homicide by People with Mental Illness: Provides the latest data and makes recommendations for improving clinical practice and service delivery to prevent suicide and reduce risk. NICE: Self-harm pathway: The quality statement around self-harm includes aspects of suicide prevention advice, particularly in the resource section (with particular reference to the use of risk assessments). This issue of self-harm is a complicated one which spans the life course and occurs in multiple conditions and care settings; the interactive pathway is a useful way to navigate through these

http://ash.org.uk/information-and-resources/reports-submissions/reports/the-stolen-years/

https://www.nice.org.uk/guidance/ng58

https://www.centreformentalhealth.org.uk/individual-placement-and-support

http://www.ippr.org/publications/patients-in-control-why-people-with-long-term-conditions-must-be-empowered

https://pathways.nice.org.uk/pathways/self-harm

https://www.nice.org.uk/guidance/qs34



https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/562280/PHE_local_suicide_prevention_planning_a_practice_resource.pdf

http://research.bmh.manchester.ac.uk/cmhs/research/centreforsuicideprevention/nci/reports/2016-report.pdf

https://pathways.nice.org.uk/pathways/self-harm

References 1. Department of Health (2011) No Health without Mental Health, A cross government mental health strategy 2. World Health Organisation www.who.int/mental_health/en 3. Department of Health (2011) No Health without Mental Health A cross government mental

health outcomes strategy for people of all ages. Supporting document – the economic case for

improving efficiency and quality in mental health. London, Department ofHealth

4. NHS England (2013) A call to action: achieving parity of esteem: transformative ideas for

commissioners https://www.england.nhs.uk/wp-content/uploads/2014/02/nhs-parity.pdf

5. The Health and Social Care Act 2012

http://www.legislation.gov.uk/ukpga/2012/7/contents/enacted

6. Gilburt H., PeckE., AshtonB., Edwards N. and Naylor C. (2014) Service transformation Lessons from mental health London: The Kings Fund

7. NICE (2011) Guideline CG123

8. National Institute of Mental Health (1987) Towards a Model for a Comprehensive Community- Based Mental Health System. Washington, DC:NIMH 9. WHO Global Burden of Disease 10. Brown s, Kim M, Mitchell C. and Inskip H (2010) Twenty-five year mortality of a community cohort with schizophrenia. British Journal of Psychiatry 196:116–121

11. http://www4.halton.gov.uk/Pages/health/PDF/health/Halton_Health_and_Wellbeing_Strategy.pdf

12. Faculty of Public Health, Mental Health Foundation (2016) Better Mental Health for All: A Public Health Approach to Mental Health Improvement http://www.fph.org.uk/uploads/Better%20Mental%20Health%20For%20All%20FINAL%20low%20res.pdf.

13. Fryers T, Brugha T. Childhood Determinants of Adult Psychiatric Disorder Clinical Practice and Epidemiology in Mental Health 2013;9:1-50.

14. Local Government Association (2011) Joint Strategic Needs Assessment Data Inventory http://www.local.gov.uk/health/-/journal_content/56/10180/3511127/ARTICLE.

15. World Health Organisationwww.who.int/mental_health/en

16. World Health Organisation (2012) Risks to Mental Health

http://www.who.int/mental_health/mhgap/risks_to_mental_health_EN_27_08_12.pdf

17. Faculty of Public Health, Mental Health Foundation (2016) Better Mental Health for All: A Public Health Approach to Mental Health Improvement http://www.fph.org.uk/uploads/Better%20Mental%20Health%20For%20All%20FINAL%20low%20res.pdf.

http://www.who.int/mental_health/en

http://www.england.nhs.uk/wp-content/uploads/2014/02/nhs-parity.pdf


http://www4.halton.gov.uk/Pages/health/PDF/health/Halton_Health_and_Wellbeing_Strategy.pdf

http://www.fph.org.uk/uploads/Better%20Mental%20Health%20For%20All%20FINAL%20low%20res.pdf

http://www.local.gov.uk/health/-/journal_content/56/10180/3511127/ARTICLE

http://www.who.int/mental_health/en


http://www.fph.org.uk/uploads/Better%20Mental%20Health%20For%20All%20FINAL%20low%20res.pdf


114 | P a g e

18. Delgadillo J, Asaria M, Ali S, Gilbody S. (2015) On poverty, politics and psychology: the socioeconomic gradient of mental healthcare utilisation and outcomes. The British Journal of Psychiatry 1–2. doi: 10.1192/bjp.bp.115.171017

19. .Pickett K, James O, Wilkinson R. (2006) Income inequality and the prevalence of mental illness: a preliminary international analysis. Journal of Epidemiology and Community Health;60(7):646-7.

20. McManus S, Bebbington P, Jenkins R, Brugha T. (eds.) (2016) Mental health and wellbeing in England: Adult Psychiatric Morbidity Survey 2014. Leeds: NHS Digital. 21. Kieling et al 2011, (foresight project2008)

22. Fisher et al 2011 (foresight project2008)

23 World Health Organisation (2012) Risks to Mental Health http://www.who.int/mental_health/mhgap/risks_to_mental_health_EN_27_08_12.pdf

24. Stathopolou, G, Powers, M, Berry A, Smits, J & Otto, M. (2006) Exercise interventions for mental health: A quantitative and qualitative review Clinical Psychology – Science and Practice 13(2): pp170–193. 25. Harvey S.B.,Hotopf M., Øverland S. and Mykletun A. (2010) Physical activity and common mental

disorders The British Journal of Psychiatry Oct 2010, 197 (5) 357-364; DOI:

10.1192/bjp.bp.109.075176

26. Hull D. (2012) The relationship between physical activity and mental health: a summary of evidence and policy Research and Information Service research paper Paper 198/12, Northern Ireland Assembly 27. UCL Institute of Health Equity (2014) Local action on health inequalities: Improving access to green spaces London: Public Health England 28. Morton S. (2016) Public Health Matters blog Green space, mental wellbeing and sustainable communities https://publichealthmatters.blog.gov.uk/2016/11/09/green-space-mental-wellbeing-and-sustainable-communities/

29. McHale P, Hughes K and Jones A (2013) Mental Wellbeing in Halton: Findings from the North West Mental Wellbeing Survey 2012/13 Centre for Public Health, Liverpool John Moores University

30. The Young Foundation (2012) Adapting to change: the role of community resilience 31. Nguyen, A.W., Chatters, L.M., Taylor, R.J. and Mouzon D.M. (2016) Social Support from Family

and Friends and Subjective Well-Being of Older African AmericansJournal of Happiness Studies; 17:

959. doi:10.1007/s10902-015-9626-8

32. Walen H.R and Lachman M.E (2000) Social Support and Strain from Partner, Family, and Friends: Costs and Benefits for Men and Women in Adulthood Journal of Social and Personal Relationships; 17(1): 5-30


https://publichealthmatters.blog.gov.uk/2016/11/09/green-space-mental-wellbeing-and-sustainable-communities/

https://publichealthmatters.blog.gov.uk/2016/11/09/green-space-mental-wellbeing-and-sustainable-communities/


115 | P a g e

33.Charles S.T. and Cartensen L.L. (2009) Social and Emotional Aging.Annual Review of Psychology,61:383-409. 34.Aked J., Marks N., Cordon C. and Thompson S. (2008) Five ways to wellbeing: the evidence. A report presented to the Foresight Project on communicating the evidence base for improving people’s well-being 35.Carstensen L. and Mikels J. (2005) At the Intersection of Emotion and Cognition: Aging and the Positivity Effect. Current Directions inPsychological Science, 14, 3:117-121. 36.Godfrey M., Townsend J. and Denby T. (2004) Building a good life for older people in local communities 37.Office for National Statistics (2006) Quality of life and social participation fall with age 38.Leslie, E., Cerin, E. (2008) Are perceptions of the local environment related to neighbourhood satisfaction and mental health in adults? Prev. Med. Sep;47(3):273-8 39 ONS. Measuring national well-being: An analysis of social capital in the UK 2015. https://www.ons.gov.uk/peoplepopulationandcommunity/wellbeing/articles/measuringnationalwellbeing/2015-01-29.

40.McHale P, Hughes K and Jones A (2013) Mental Wellbeing in Halton: Findings from the North West Mental Wellbeing Survey 2012/13 Centre for Public Health, Liverpool John Moores University

41. Age UK (2014)Evidence review: loneliness http://www.ageuk.org.uk/Documents/EN-GB/Forprofessionals/Research/Evidence_Review-Loneliness_2014.pdf?dtrk=true

42. GfK NOP Social Research for Public Health England (2013) Lifecourse Tracker - Wave 2 report 43. Lifecourse Tracker has used the six socioeconomic groupings defined from the British National Readership Survey. Further information on this categorisation is available online, including from IPSOS, available at: http://www.ipsosmori.com/DownloadPublication/1285_MediaCT_thoughtpiece_Social_Grade_July09_V3_WEB.pdf 44. Holt-Lunstad J, Smith TB, Layton JB. (2010) Social Relationships and Mortality Risk: A Meta-

analytic Review. PLoS Med, 7:7

45. Social Care Institute for Excellence (2011) Preventing loneliness and social isolation: interventions and outcomes. Research Briefing 39, October 2011.

46. Shankar A, McMunn A, Banks J et al (2011) Loneliness, social isolation, and behavioural and

biological heath indicators in older adults, Health Psychology,30:4. 377-385

47. Oxfordshire Age UK (2012)Loneliness: the state we’re in. A report of evidence compiled for the

Campaign to End Lonelines Available at:

https://www.ons.gov.uk/peoplepopulationandcommunity/wellbeing/articles/measuringnationalwellbeing/2015-01-29

https://www.ons.gov.uk/peoplepopulationandcommunity/wellbeing/articles/measuringnationalwellbeing/2015-01-29

http://www.ageuk.org.uk/Documents/EN-GB/Forprofessionals/Research/Evidence_Review-Loneliness_2014.pdf?dtrk=true

http://www.ageuk.org.uk/Documents/EN-GB/Forprofessionals/Research/Evidence_Review-Loneliness_2014.pdf?dtrk=true

http://www.ipsosmori.com/DownloadPublication/1285_MediaCT_thoughtpiece_Social_Grade_July09_V3_WEB.pdf

http://www.ipsosmori.com/DownloadPublication/1285_MediaCT_thoughtpiece_Social_Grade_July09_V3_WEB.pdf


116 | P a g e

http://www.ageuk.org.uk/brandpartnerglobal/oxfordshirevpp/documents/loneliness%20the%20stat

e%20we%20are%20in%20%20report%202013.pdf

48. Age UK (2014) Evidence review: loneliness

49. Victor C.R and Yang K. (2012) The Prevalence of Loneliness Among Adults: A Case Study of the

United Kingdom The Journal Of Psychology Vol. 146 , Iss. 1-2

50. Griffin J. (2010) The Lonely Society? London: The Mental Health Foundation

51. McManus S, Bebbington P, Jenkins R, Brugha T. (eds.) (2016) Mental health and wellbeing in England: Adult Psychiatric Morbidity Survey 2014. Leeds: NHS Digital.

52. Mental Health Task Force (2016) The Five Year Forward View for Mental Health London: NHS England

53. NHS Digital (2016) Inpatients formally detained in hospitals under the Mental Health Act 1983, and patients subject to supervised community treatment Uses of the Mental Health Act: Annual Statistics, 2015/16 Published 30 November 2016 http://content.digital.nhs.uk/catalogue/PUB22571/inp-det-m-h-a-1983-sup-com-eng-15-16-rep.pdf

54. Social Care, Local Government and Care Partnership Directorate (2014) Closing the gap: priorities for essential change in mental health London: Department of Health

55. NICE (2009) Antisocial personality disorder: prevention and management NICE guidelines CG77, January 2009 56. NICE (2009) Borderline personality disorder: recognition and management NICE guidelines CG78, January 2009 57. McManus S, Bebbington P, Jenkins R, Brugha T. (eds.) (2016) Mental health and wellbeing in England: Adult Psychiatric Morbidity Survey 2014. Leeds: NHS Digital.

58. Beat (2015) The costs of eating disorders: Social, health and economic impacts 59. Royal College of Psychiatrists (2010) Self harm, suicide and risk: helping people who self harm. Final report of a working group. College Report CR158 60. Owens D, Horrocks J, House A (2002) Fatal and non-fatal repetition of selfharm. Systematic review. British Journal of Psychiatry 181: 193–199. 61. Foster T, Gillespie K, McClelland R, Patterson C (1999) Risk factors for suicide independent of DSM-III-R Axis I disorder. Case-control psychological autopsy study in Northern Ireland. British Journal of Psychiatry 175: 175–179. 62. NICE (2013) Quality Standard QS34 Self harm https://www.nice.org.uk/guidance/qs34/chapter/Introduction-and-overview 63. NICE (2013) Quality Standard QS34 Self harm https://www.nice.org.uk/guidance/qs34/chapter/Introduction-and-overview

http://www.ageuk.org.uk/brandpartnerglobal/oxfordshirevpp/documents/loneliness%20the%20state%20we%20are%20in%20%20report%202013.pdf

http://www.ageuk.org.uk/brandpartnerglobal/oxfordshirevpp/documents/loneliness%20the%20state%20we%20are%20in%20%20report%202013.pdf

http://content.digital.nhs.uk/catalogue/PUB22571/inp-det-m-h-a-1983-sup-com-eng-15-16-rep.pdf

https://www.nice.org.uk/guidance/qs34/chapter/Introduction-and-overview

https://www.nice.org.uk/guidance/qs34/chapter/Introduction-and-overview


117 | P a g e

64. Knapp, M., McDaid, D., & Parsonage, M. (2011). Mental health promotion and mental illness prevention: the economic case. London: Department of Health. 65. Living is for everyone (LIFE). Research and Evidence in Suicide Prevention. http://www.livingisforeveryone.com.au/Research-and-evidence-in-suicide-prevention.html 66. ChiMat (2012) Child Health Profiles 2012. Child and Maternal Health Observatory

67. McManus S, Bebbington P, Jenkins R, Brugha T. (eds.) (2016) Mental health and wellbeing in England: Adult Psychiatric Morbidity Survey 2014. Leeds: NHS Digital.

68. Kessler RC, Amminger GP, Aguilar-Gaxiola S, Alonso J, Lee S, Ustun TB (2007). Age of onset of mental disorders: a review of recent literature. CurrOpinPsychiatry., 20:359–64. 69. Memarzia, J., St Clair, M.C., Owens, M., Goodyer, I.M., Dunn, V.J (2015) Adolescents leaving mental health or social care services: Predictors of mental health and psychosocial outcomes one year later. BMC Health Services Research 15 (1), 185 70. Freer M, Shiers D, Churchill D, Friel J (2010) Meeting the mental health needs of young people: a GP’s perspective. In Goldie I (ed) Public Mental Health Today. A handbook (pp. 241-258). Brighton, Pavilion Publishing/Mental Health Foundation. 71. LPHO (2011) Merseyside Mental Health Needs Assessment: Populations at risk of mental health problems amongst working age adults. Liverpool Public Health Observatory Report series number 86, August 2011 72. Mental Health Foundation (2007) Fundamental facts. The latest facts and figures on mental health. 73. McManus S, Bebbington P, Jenkins R, Brugha T. (eds.) (2016) Mental health and wellbeing in England: Adult Psychiatric Morbidity Survey 2014. Leeds: NHS Digital. 74. LPHO (2011) Merseyside Mental Health Needs Assessment: Populations at risk of mental health problems amongst working age adults. Liverpool Public Health Observatory Report series number 86, August 2011 75. McManus S, Bebbington P, Jenkins R, Brugha T. (eds.) (2016) Mental health and wellbeing in England: Adult Psychiatric Morbidity Survey 2014. Leeds: NHS Digital.

76. Mental Health Foundation (online) Black and Minority Ethnic Communities. Mental Health A-Z. http://www.mentalhealth.org.uk/help-information/mental-health-a-z/b/bme-communities/

77. McManus S, Bebbington P, Jenkins R, Brugha T. (eds.) (2016) Mental health and wellbeing in England: Adult Psychiatric Morbidity Survey 2014. Leeds: NHS Digital. 78. Mental Health Foundation (2007) Fundamental facts.The latest facts and figures on mental health. Mental Health Foundation, London 79. CQC (2010) Care Quality Commission Count me in census 2010.

http://www.livingisforeveryone.com.au/Research-and-evidence-in-suicide-prevention.html

http://www.mentalhealth.org.uk/help-information/mental-health-a-z/b/bme-communities/


118 | P a g e

80. BHA (2013) State of Health. Black And Other Minority Groups. BHA Contribution to the Development of a Joint Strategic Needs Assessment (JSNA) .Black Health Agency. 81. Mental Health Foundation (online) Black and Minority Ethnic Communities. Mental Health A-Z. 82. Cooper C, Morgan C, Byrne M, Dazzan P, Morgan K, Hutchinson G, Doody GA, Harrison G, Leff J, Jones P, Ismail K, Murray R, Bebbington P, Fearon P. (2008) Perceptions of disadvantage, ethnicity and psychosis.Br J Psychiatry, 192(3):185-90 83. Burke C-K (2014) Feeling Down: Improving the mental health of people with learning disabilities. London: The Foundation for People with Learning Disabilities

84. Department of Health (2009) IAPT. Learning Disabilities: Positive Practice Guide. http://www.iapt.nhs.uk/silo/files/learning-disabilities-positive-practice-guide.pdf

85. Mental Health Foundation (2007) Fundamental facts. The latest facts and figures on mental health. http://www.mentalhealth.org.uk/publications/fundamental-facts/

86. Cowie R and Douglas-Cowie E (1987) Acquired deafness: the deadly game of hit and miss. British Association for the Advancement of Science, Annual Meeting 24-28 August.

87. King’s Fund (2012) Long-term conditions and mental health: The cost of co-morbidities. The King’s Fund and Centre for Mental Health. February 2012

88. Emerson E, Baines S, Allerton L and Welch V (2012) Health Inequalities & People with Learning Disabilities in the UK: 2012. IHAL, Improving Health and Lives: Learning Disabilities Observatory. 89. National Autistic Society (2012) NAS response to Draft Care and Support Bill. 90. Foundation for People with Learning Disabilities (online) Learning Disability Statistics: Mental Health Issues 91. Smiley E. (2005) Epidemiology of mental health problems in adults with learning disability: an update. Advances in Psychiatric Treatment, 11, 214–222. 92. Koulla Burke C (2014) Feeling Down: Improving the mental health of people with learning disabilities. Foundation for people with learning disabilities. 93. Smiley E (2005) Epidemiology of mental health problems in adults with learning disability: an update Advances in Psychiatric Treatment, 11, 214–222. 94. Stonewall (2012) Gay and Bisexual Men’s Health Surveyhttp://www.stonewall.org.uk/documents/stonewall_gay_mens_health_final_1.pdf

95. Stonewall (2012) Mental Health Briefing: http://www.healthylives.stonewall.org.uk/includes/documents/cm_docs/2012/m/mental-health.pdf

96. Stonewall (2008) Prescription for Change: Lesbian and Bisexual Women’s Health Check. http://www.stonewall.org.uk/what_we_do/research_and_policy/health_and_healthcare/3101.asp

http://www.iapt.nhs.uk/silo/files/learning-disabilities-positive-practice-guide.pdf

http://www.mentalhealth.org.uk/publications/fundamental-facts/

http://www.stonewall.org.uk/documents/stonewall_gay_mens_health_final_1.pdf

http://www.healthylives.stonewall.org.uk/includes/documents/cm_docs/2012/m/mental-health.pdf

http://www.stonewall.org.uk/what_we_do/research_and_policy/health_and_healthcare/3101.asp


119 | P a g e

97. LGF (2012) Findings from the 'I Exist' survey of lesbian, gay and bisexual people in the UK. 2012. The Lesbian and Gay Foundation.

98. Hellman R (1996) Issues in the treatment of lesbian women and gay men with chronic mental illness Psychiatric Services: A Journal Of The American Psychiatric Association, 47, 10, 1093-1098. 99. Sandfort, TGM; Schnabel P, De Graaf R; Bij, RV (2001) Same-Sex Sexual Behavior and Psychiatric Disorders : Findings From the Netherlands Mental Health Survey and Incidence Study (NEMESIS). Archives Of General Psychiatr,: 58, 1 100. Kidd S, Veltman A (2011) Lesbian, Gay, and Transgender Persons with Severe Mental Illness: Negotiating Wellness in the Context of Multiple Sources of Stigma. American Journal of Psychiatric Rehabilitation,14: 13–39. 101. Chakraborty A; McManus S; Brugha TS; Bebbington P, King M (2011) Mental health of the non-heterosexual population of England. British Journal of Psychiatry, 198(2):143-148. 102. Kidd S, Veltman A (2011) Lesbian, Gay, and Transgender Persons with Severe Mental Illness: Negotiating Wellness in the Context of Multiple Sources of Stigma. American Journal of Psychiatric Rehabilitation,14: 13–39. 103. Stonewall (2012) Gay and Bisexual Men’s Health Surveyhttp://www.stonewall.org.uk/documents/stonewall_gay_mens_health_final_1.pdf 104. Stonewall (2012) Mental Health Briefing: http://www.healthylives.stonewall.org.uk/includes/documents/cm_docs/2012/m/mental-health.pdf 105. Stonewall (2008) Prescription for Change: Lesbian and Bisexual Women’s Health Check. http://www.stonewall.org.uk/what_we_do/research_and_policy/health_and_healthcare/3101.asp 106. Stonewall (2012) Mental Health Briefing: http://www.healthylives.stonewall.org.uk/includes/documents/cm_docs/2012/m/mental-health.pdf 107. LGF (2012) Findings from the 'I Exist' survey of lesbian, gay and bisexual people in the UK. 2012. The Lesbian and Gay Foundation.

108. McManus S, Meltzer H, Brugha T, Bebbington P, Jenkins R (eds) (2009) Adult psychiatric morbidity in England, 2007. Results of a household survey. NHS Information Centre for health and social care, National Centre for Social Research and the Department of Health Sciences, University of Leicester.

109. Singleton N, Bumpstead R, O’Brien M, Lee A, Meltzer H (2001) Psychiatric Morbidity among adults living in private households, 2000. London: The Stationery Office. 110. Levin J (2010) Religion and Mental Health: Theory and Research. Int. J. Appl. Psychoanal. Studies, Vol. 7 Issue 2, p102-115 111. Mental Health Foundation (2006b) The impact of spirituality on mental health. A review of the literature

http://www.stonewall.org.uk/documents/stonewall_gay_mens_health_final_1.pdf


http://www.stonewall.org.uk/what_we_do/research_and_policy/health_and_healthcare/3101.asp



120 | P a g e

112. Mental Health Foundation (2008) Spirituality and mental health.Executive briefing, Need 2 Know series. 113. Rethink (2013) Spirituality Factsheet. Web resource, last reviewed June 2013

114. Mohr et al (2011) Spirituality and religiousness as predictive factors of outcome in schizophrenia and schizo-affective disorders.Psychiatry Research, 186, 2-3, 177–182. 115. Grover S, Davuluri T, Chakrabarti S (2014) Religion, Spirituality, and Schizophrenia: A Review. Indian J Psychol Med. 36(2): 119–124 116. Mental Health Foundation (2006) The impact of spirituality on mental health. A review of the literature.Mental Health Foundation. 117. Rethink (2013) Spirituality Factsheet. Web resource 118. Kidd S, Veltman A (2011) Lesbian, Gay, and Transgender Persons with Severe Mental Illness: Negotiating Wellness in the Context of Multiple Sources of Stigma. American Journal of Psychiatric Rehabilitation, 14: 13–39 119. Mustanski B, Garofalo R, Emerson E (2010) Mental Health Disorders, Psychological Distress, and Suicidality in a Diverse Sample of Lesbian, Gay, Bisexual, and Transgender Youths American Journal of Public Health 100, 12 : 2426-2432 120 McNeil J, Bailey L, Ellis S, Morton J, Regan M (2012) Trans Mental Health Study. The Scottish Transgender Alliance. Equality Network. 121. Bockting WO, Miner MH, Swinburne Romine RE, Hamilton A, Coleman E (2013) Stigma, mental health, and resilience in an online sample of the US transgender population American Journal of Public Health, 103(5):943-51.

122. Nodin N, Peel E, Tyler A, Rivers I (2015) The RaRE Research Report: LGB&T Mental Health: Risk and resilience explored. PACE the LGBT mental health charity. 123. McNeil J, Bailey L, Ellis S, Morton J, Regan M (2012) Trans Mental Health Study. The Scottish Transgender Alliance. Equality Network. 124. McManus S, Bebbington P, Jenkins R, Brugha T. (eds.) (2016) Mental health and wellbeing in England: Adult Psychiatric Morbidity Survey 2014. Leeds: NHS Digital. 125. NICE (2014) Antenatal and postnatal mental health. Clinical management and service guidance.Updated edition.National Clinical Guideline Number 192. National Collaborating Centre for Mental Health, commissioned by the National Institute for Health and Care Excellence, published by The British Psychological Society and The Royal College of Psychiatrists 126. Russell E.J., Fawcett J.M., Mazmanian D. (2013) Risk of obsessive-compulsive disorder in pregnant and postpartum women: a meta-analysis. Journal of Clinical Psychiatry. 74:377-85. 127. NICE (2014) Antenatal and postnatal mental health. Clinical management and service guidance. Updated edition. National Clinical Guideline Number 192. National Collaborating Centre for Mental


121 | P a g e

Health, commissioned by the National Institute for Health and Care Excellence, published by The British Psychological Society and The Royal College of Psychiatrists. 128. Homeless Link (2014) The unhealthy state of homelessness: Health audit results 2014. 129. CRISIS (2009) Mental Ill Health in the Adult Single Homeless Population: A review of the literature.

130. Maguire N, Johnson R, Vostanis P, Keats H, Remington B (2009) Homelessness and Complex Trauma: A Review of the Literature. University of Southampton. 131. Homeless Link (2010) The Health and Wellbeing of people who are homeless: Key Findings from the Health Needs Audit Pilot London: Homeless Link 132. Department of Health (2010) Healthcare for Single Homeless People.Office of the Chief Analyst. London: Department of Health 133. Maguire N, Johnson R, Vostanis P, Keats H, Remington B (2009) Homelessness and Complex Trauma: A Review of the Literature.University of Southampton. 134. Maguire N, Johnson R, Vostanis P, Keats H, Remington B (2009) Homelessness and Complex Trauma: A Review of the Literature.University of Southampton. 135. Homeless Link (2010) The Health and Wellbeing of people who are homeless: Key Findings from the Health Needs Audit Pilot Homeless Link, London.

136. DfCLG (2013) Evaluating the Extent of Rough Sleeping. A new approach London: Department for Communities and Local Government. 137. Gavine A (2013) No Second Night Out.Lancet UK Policy Matters. May 17th .http://ukpolicymatters.thelancet.com/no-second-night-out/ 138.DfCLG (2013) Evaluating the Extent of Rough Sleeping. A new approach London: Department for Communities and Local Government. 139. Gavine A (2013) No Second Night Out Lancet UK Policy Matters; May 17th .http://ukpolicymatters.thelancet.com/no-second-night-out/

140. Shelter (2004) Sick and tired- the impact of temporary accommodation on the health of homeless families. http://england.shelter.org.uk/__data/assets/pdf_file/0009/48465/Research_report_Sick_and_Tired_Dec_2004.pdf

141. LPHO (2014) Homelessness in Liverpool City Region A Health Needs Assessment Liverpool Public Health Observatory Report series number 96, May 2014

142. Ministry of Justice (2013) Gender differences in substance misuse and mental health amongst prisoners. 143. McManus S, Bebbington P, Jenkins R, Brugha T. (eds.) (2016) Mental health and wellbeing in England: Adult Psychiatric Morbidity Survey 2014. Leeds: NHS Digital.

http://ukpolicymatters.thelancet.com/no-second-night-out/

http://ukpolicymatters.thelancet.com/no-second-night-out/

http://england.shelter.org.uk/__data/assets/pdf_file/0009/48465/Research_report_Sick_and_Tired_Dec_2004.pdf


122 | P a g e

144. Ministry of Justice (2013) Gender differences in substance misuse and mental health amongst prisoners. 145. LPHO (2011) Merseyside Mental Health Needs Assessment: Populations at risk of mental health problems amongst working age adults. Liverpool Public Health Observatory Report series number 86, August 2011 146. Lloyd M. (2014) Health Needs Assessment (HNA) of offenders in the community in Halton http://www4.halton.gov.uk/Pages/health/JSNA/adults/HNAoffenders.pdf 147. Independent Asylum Commission (2008) Fit for purpose yet? The Independent Asylum Commission's Interim Findings. London: IAC. 148. Lewis H, on behalf of Joseph Rowntree Charitable Trust (2007)Destitution in Leeds: the experiences of people seeking asylum and supporting agencies. York: Joseph Rowntree Charitable Trust 149. Burnett A. (2002) Guide to health workers providing care for asylum seekers and refugees.www.torturecare.org.uk/files/brief27.rtf 150. Haroon S. (2008) The health needs of asylum seekers Briefing statement London: Faculty of Public Health 151. MIND (2009) A civilised society: Mental health provision for refugees and asylum-seekers in England and Wales

152. EmersonE., Baines S., AllertonL. And Welch V. (2012) Health Inequalities & People with Learning Disabilities in the UK: 2012 Improving Health and Lives: Learning Disability Observatory 153. Smiley E. (2005) Epidemiology of mental health problems in adults with learning disability: an

update Advances in Psychiatric Treatment;11(3):214-222

154. Emerson E, Baines S, Allerton L, Welch V (2012). Health Inequalities and people with learning disabilities in the UK: 2012. Improving Health and Lives: Learning Disability Observatory 155. Emerson E. and Einfeld S.L. (2011) Challenging Behaviour. Cambridge University Press. 156. National Institute for Health and Care Excellence (2011) Common mental health problems: identification and pathways to care. NICE guidelines CG123. https://www.nice.org.uk/guidance/cg123

157. http://www4.halton.gov.uk/Pages/health/JSNA/adults/HNAveterans.pdf

158. http://www.kcl.ac.uk/kcmhr/pubdb/

159. http://www.forceswatch.net/sites/default/files/The_Last_Ambush_web.pdf 160. Harvey S.B., Hatch S.L., Jones M., Hull L., Jones N., Greenberg N., Dandeker C., Fear N.T., Wessely S. (2012) The long-term consequences of military deployment: a 5-year cohort study of

http://www4.halton.gov.uk/Pages/health/JSNA/adults/HNAoffenders.pdf

http://www.torturecare.org.uk/files/brief27.rtf


http://www4.halton.gov.uk/Pages/health/JSNA/adults/HNAveterans.pdf

http://www.kcl.ac.uk/kcmhr/pubdb/

http://www.forceswatch.net/sites/default/files/The_Last_Ambush_web.pdf


123 | P a g e

United kingdom reservists deployed to Iraq in 2003 American Journal of Epidemiology; 2012 Dec 15;176(12):1177-84 161. Department of Health (2011) No Health without Mental Health, A cross government mental health strategy

162. Health Survey for England (HSE 2012)http://www.hscic.gov.uk/catalogue/PUB13218

163 Hotopf M. and McCracken L. (2014) Chapter 13 Physical health and mental illness. Annual Report of the Chief Medical Officer 2013, Public Mental Health Priorities: Investing in the Evidence London: Department of Health

164. Royal College of Physicians and Royal College of Psychiatrists (2013) Smoking and mental health. London, RCP 165. Jochelson J, Majrowski B (2007) Clearing the Air. Debating Smoke-Free Policies in Psychiatric Units. London: King’s Fund. 166. Szatkowsk Li & McNeill A. (2015) Diverging trends in smoking behaviours according to mental health status. Nicotine & Tobacco Research 2015; 3: 356-60.

167. Public Health England (2015) Smoking cessation in secure mental health settings – guidance for commissioners

168. McManus S, Meltzer H, Campion J (2010) Cigarette smoking and mental health in England. Data from the Adult Psychiatric Morbidity Survey. National Centre for Social Research.

169. NICE (2013) Smoking: Harm Reduction PH45 https://www.nice.org.uk/guidance/ph45

170. NICE (2013) Smoking: acute, maternity and mental health services PH48 https://www.nice.org.uk/guidance/ph48

171. Alcohol Concern (nd) Fact Sheet 17: Alcohol and Mental Health

www.alcoholconcern.org/publications/factsheets/alcoholand-

172. Eurocare European Alcohol Policy Alliance. www.eurocare.org/resources/policy_issues/mental_health

173. Rethink (nd) Mental Illness Drugs, Alcohol and mental health fact sheet

174. HM Government (2010) The National Drug Strategy: Reducing Demand, Restricting Supply, Building Recovery 175. Weaver, T. (2003). Comorbidity of substance misuse and mental health in community

mental health and substance misuse services. British Journal of Psychiatry, 183,304-313

176. Strathdee, G. Manning, V.and Best, D.(2002), Dual Diagnosis in a Primary Care Group

(PCG) London: Department ofHealth

http://www.hscic.gov.uk/catalogue/PUB13218



http://www.alcoholconcern.org/publications/factsheets/alcoholand-

http://www.eurocare.org/


124 | P a g e

177. Beynon, C et al. (2011) Topography of drinking behaviours in England 178. Rethink Mental Illness Drugs, Alcohol and mental health factsheet www.rethink.org

179. Royal College of Psychiatrists (2012) Mental Illness, Offending and Substance Misuse http://www.rcpsych.ac.uk/healthadvice/problemsdisorders/mentalillness,offending.aspx

180. Department of Health (2014) Annual Report of the Chief Medical Officer 2013 - Public Health Priorities 2014. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/413196/CMO_web_doc.pdf 181. Drugwise (2017) How much crime is drug related? http://www.drugwise.org.uk/how-much-crime-is-drug-related/

182. Mind (2013) At risk, yet dismissed: the criminal victimisation of people with mental health problems https://www.mind.org.uk/media/187663/At-risk-yet-dismissed-report_FINAL_EMBARGOED.pdf

183. Stuart H. Violence and mental illness: an overview. World Psychiatry. 2003;2(2):121-4.

184. HM Government (2010) Reducing Demand, Restricting Supply, Building Recovery: Supporting people to live a drug free life https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/98026/drug-strategy-2010.pdf 185. Weaver, T. (2003). Comorbidity of substance misuse and mental health in community mental health and substance misuse services. British Journal of Psychiatry, 183, 304-313 186. Strathdee, G. Manning, V. and Best, D.(2002), Dual Diagnosis in a Primary Care Group (PCG), London: Department of Health 187. Royal College of Psychiatrists (2012) Mental Illness, Offending and Substance Misuse

http://www.rcpsych.ac.uk/healthadvice/problemsdisorders/mentalillness,offending.aspx

188. NICE. (2016) Coexisting severe mental illness and substance misuse: community health and social care services. NICE guideline [NG58] https://www.nice.org.uk/guidance/ng58 189. NICE. News and features: New NICE guidance on dual diagnosis is 'desperately needed' 2016. https://www.nice.org.uk/news/article/new-nice-guidance-on-dual-diagnosis-is-desperately-needed

190. NICE (2011) Guideline CG 123 191. General Practitioners Committee: BMA, NHS Employers and NHS England (2015) 2015/16 General Medical Services (GMS) contract Quality and Outcomes Framework (QOF) Guidance for GMS contract 2015/16 192. NICE CG178 (2014) Psychosis and schizophrenia in adults: treatment and management http://www.nice.org.uk/guidance/CG178 112 NICE CG185

http://www.rethink.org/


https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/413196/CMO_web_doc.pdf

http://www.drugwise.org.uk/how-much-crime-is-drug-related/

https://www.mind.org.uk/media/187663/At-risk-yet-dismissed-report_FINAL_EMBARGOED.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/98026/drug-strategy-2010.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/98026/drug-strategy-2010.pdf


https://www.nice.org.uk/guidance/ng58

https://www.nice.org.uk/news/article/new-nice-guidance-on-dual-diagnosis-is-desperately-needed

http://www.nice.org.uk/guidance/CG178%20112%20NICE%20CG185


125 | P a g e

193. NICE CG185 (2014) Bipolar disorder. The assessment and management of bipolar disorder in adults, children and young people, in primary and secondary care http://www.nice.org.uk/guidance/CG185 194. National Institute for Health and Care Excellence (2011) Common mental health problems: identification and pathways to care. NICE guidelines CG123. https://www.nice.org.uk/guidance/cg123 195. NHS Digital (2016) Psychological Therapies, Annual Report on the use of IAPT Services. England 2015/16 http://www.content.digital.nhs.uk/catalogue/PUB22110

196. The King’s Fund (2015) Briefing. Mental health under pressure http://www.kingsfund.org.uk/sites/files/kf/field/fi eld_publication_file/mental-health-underpressure-nov15_0.pdf

197. Ryan T., Hodgetts K., Tommis Y. And Clayson A. (2015) 5 Borough Partnership Footprint Review: An independent review of the acute and older adult care pathways

198. Mental Health Taskforce (2016) The Five Year Forward View for Mental Health. https://www.england.nhs.uk/wpcontent/uploads/2016/02/Mental-HealthTaskforce-FYFV-final.pdf

199. The Care Act, 2014: http://www.legislation.gov.uk/ukpga/2014/23/contents/enacted

200 World Health Organisation (2009) Mental Health, resilience and inequalities http://www.euro.who.int/__data/assets/pdf_file/0012/100821/E92227.pdf.

201. Department of Health (2009) Departmental Report 2009: The Health and Personal Social Services Programmes www.official-documents.gov.uk/document/cm75/7593/7593.pdf

202. Mccrone P, dhanasiri s, Patel A et al. (2008) Paying the Price: The cost of mental health care in England. London: King’s Fund

203. Centre for Mental Health (2010) The Economic and Social Costs of Mental Health Problems in 2009/10 204. Department for Work and Pensions (2010) statistical summaries, available at: http://campaigns.dwp.gov.uk/asd/index.php?page=statistical_summaries 205. https://www.mentalhealth.org.uk/a-to-z/s/stigma-and-discrimination 206. Royal College of Psychiatrists (2010) No health without public mental health The case for action Position Statement PS4/2010

207. http://www.who.int/healthinfo/global_burden_disease/metrics_daly/en/ 208. Confederation of British Industry/ Department of Health (1997) Promoting mental health at work London: Department of Health

209. The Marmot Review (2010) Fair Society and Healthy Lives’:Strategic Review of Health Inequalities in England post-2010

http://www.nice.org.uk/guidance/CG185


http://www.content.digital.nhs.uk/catalogue/PUB22110

http://www.kingsfund.org.uk/sites/files/kf/field/fi%20eld_publication_file/mental-health-underpressure-nov15_0.pdf

http://www.kingsfund.org.uk/sites/files/kf/field/fi%20eld_publication_file/mental-health-underpressure-nov15_0.pdf

https://www.england.nhs.uk/wpcontent/uploads/2016/02/Mental-HealthTaskforce-FYFV-final.pdf


http://www.euro.who.int/__data/assets/pdf_file/0012/100821/E92227.pdf

http://www.official-documents.gov.uk/document/cm75/7593/7593.pdf

https://www.mentalhealth.org.uk/a-to-z/s/stigma-and-discrimination

http://www.who.int/healthinfo/global_burden_disease/metrics_daly/en/


126 | P a g e

210. The Centre for Economic Performance’s Mental Health Policy Group. (2006) The Depression Report: A New Deal for Depression and Anxiety Disorders. 211. Sainsbury Centre for Mental Health (2007) Mental Health at Work: Developing the business case

212. Knapp & Lemmi (2014) The economic case for better mental health 213. Centre for Mental Health (2013) Evidence for Individual Placement Support’ (IPS) 214. Money and Mental Health Policy Institute (2016) The missing link: how tackling financial difficulty can boost recovery rates in IAPT http://www.moneyandmentalhealth.org/wp-content/uploads/2016/11/Singles-MMH_3273_Our_Report_LiveCopy_DIGITAL_SINGLE.pdf. 215. The Money and Mental Health Policy Institute (2016) Money on your mind http://www.moneyandmentalhealth.org/wp-content/uploads/2016/06/Money-on-your-mind-full-report.pdf 216. The Royal College of Psychiatrists. Debt and Mental Health 217. http://themoneycharity.org.uk/money-statistics/

218. StepChange Debt Charity (2016) Personal Debt Statistics Yearbook 2016 https://www.stepchange.org/policy-and-research/personal-debt-statistics-yearbook-2016.aspx

219. http://www.cieh-housing-and-health-resource.co.uk/mental-health-and-housing/key-issues/

220. Barnes M, Cullinane C, Scott S, Silvester H. (2013) People living in bad housing – numbers and health impacts

221. National Mental Health Development Unit’s factsheet 2: Mental health and housing

https://www.lancashirecare.nhs.uk/media/Publications/Mental%20Health%20Fact%20Files/nmhdu-

factfile-2.pdf

222. Local Government Association (2015) Note for adult safeguarding boards on the Mental Health Crisis Concordat 223..http://www.carers.org/help-directory/key-facts-and-asks-mental-health-carers

224..http://www.rethink.org/carers-family-friends/caring-for-yourself-guide 225. http://www.rcpsych.ac.uk/healthadvice/parentsandyouthinfo/parentscarers/parentalmentalillness.aspx 226. http://www.carers.org/help-directory/mental-health-factsheets 227. http://rcpsych.ac.uk/campaigns/partnersincare.aspx 228. . http://www.rethink.org/about-us/commissioning-us/carer-support



http://www.moneyandmentalhealth.org/wp-content/uploads/2016/06/Money-on-your-mind-full-report.pdf

http://www.moneyandmentalhealth.org/wp-content/uploads/2016/06/Money-on-your-mind-full-report.pdf

http://themoneycharity.org.uk/money-statistics/

https://www.stepchange.org/policy-and-research/personal-debt-statistics-yearbook-2016.aspx

http://www.cieh-housing-and-health-resource.co.uk/mental-health-and-housing/key-issues/

https://www.lancashirecare.nhs.uk/media/Publications/Mental%20Health%20Fact%20Files/nmhdu-factfile-2.pdf

https://www.lancashirecare.nhs.uk/media/Publications/Mental%20Health%20Fact%20Files/nmhdu-factfile-2.pdf

http://www.carers.org/help-directory/key-facts-and-asks-mental-health-carers

http://www.rethink.org/carers-family-friends/caring-for-yourself-guide

http://www.rcpsych.ac.uk/healthadvice/parentsandyouthinfo/parentscarers/parentalmentalillness.aspx

http://www.carers.org/help-directory/mental-health-factsheets

http://rcpsych.ac.uk/campaigns/partnersincare.aspx

http://www.rethink.org/about-us/commissioning-us/carer-support


127 | P a g e

229.Qin P, Agerbo E, Mortensen PB. (2002). Suicide risk in relation to family history of completed suicide and psychiatric disorders: a nested case-control study based on longitudinal registers. Lancet 360(9340 (Oct)):1126-30. 230..Beautrais AL, Collings SCD, Ehrhardt P, et al. 2005. Suicide Prevention: A review of evidence of risk and protective factors, and points of effective intervention. Wellington: Ministry of Health.

231..Department of Health (2010) Preventing suicide in England. A cross-government outcomes strategy to save lives 232. Worthington A. and Rooney P. (nd) The triangle of care. Carers included: a guide to best practice in acute mental health http://static.carers.org/files/caretriangle-web-5250.pdf

233. http://guidance.nice.org.uk/CG178/NICEGuidance/pdf/English 234.http://www.nice.org.uk/guidance/qualitystandards/alcoholdependence/familiescarers.jsp

235. Pickett KE, James OW, Wilkinson RG. (2006) Income inequality and the prevalence of mental illness: a preliminary international analysis. Journal of Epidemiology and Community Health;60(7):646-7. 236. Friedli L. (2009) Mental Health, Resilience and Inequalities. Denmark: WHO 237 King’s Fund EBCD: Experience-based co-design toolkit https://www.pointofcarefoundation.org.uk/resource/experience-based-co-design-ebcd-toolkit/1-experience-based-co-design/

238 Knapp M, Bauer A, Perkins M, Snell T (2011), Building Community Capacity: Making an Economic case Think Local Act Personal, June 11. http://www.pssru.ac.uk/pdf/dp2772.pdf

239 Knapp M, Bauer A, Perkins M, Snell T (2011), Building Community Capacity: Making an Economic case Think Local Act Personal, June 11. http://www.pssru.ac.uk/pdf/dp2772.pdf

240 The Government Office for Science (2008) Foresight Mental Capital and Wellbeing Project

241 New Economics Foundation (2008). Five ways to well-being: the evidence

242 Kirkwood T, Bond J, May C et al (2008) Foresight Mental Capital and Wellbeing Project. Mental capital through life: Future challenges. London: The Government Office for Science

http://static.carers.org/files/caretriangle-web-5250.pdf

http://guidance.nice.org.uk/CG178/NICEGuidance/pdf/English

http://www.nice.org.uk/guidance/qualitystandards/alcoholdependence/familiescarers.jsp

https://www.pointofcarefoundation.org.uk/resource/experience-based-co-design-ebcd-toolkit/

https://www.pointofcarefoundation.org.uk/resource/experience-based-co-design-ebcd-toolkit/1-experience-based-co-design/

https://www.pointofcarefoundation.org.uk/resource/experience-based-co-design-ebcd-toolkit/1-experience-based-co-design/

http://www.pssru.ac.uk/pdf/dp2772.pdf

http://www.pssru.ac.uk/pdf/dp2772.pdf