Must know: Is your council doing all it can to improve mental health?

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Mental health problems are on the increase, with a rising demand on services and increasing complexity of need. This was happening before COVID-19, but the pandemic has undoubtedly made the situation worse. Local government makes a vital contribution to promoting good mental health and need to continue to invest in this to ensure good mental health in their communities.

Mental health

19 Nov 2021

Why is this important?

Councils play a key role supporting mental health across all ages in their communities. Their role includes maintaining good mental health, prevention of deteriorating mental health, and statutory roles and responsibilities.

A large and growing body of research shows that good mental health is essential for individual wellbeing, for a happy, healthy society and for a prosperous economy.

A recent estimate by the Centre for Mental Health put the cost of mental ill-health at close to £120 billion a year once the cost of health and social care, lost productivity and reduced quality of life is taken into account.

Unfortunately, mental health problems are on the increase, with a rising demand on services and increasing complexity of need. This was happening before COVID-19, but the pandemic has undoubtedly made the situation worse.

Although the government has stated that it has made mental health a priority with the proportion of the overall NHS budget being spent on services increasing before the pandemic – the system is still incredibly challenged in terms of demand, capacity and resourcing. This is especially true for local government which has not seen an equivalent increase in funding for mental health services.

Local government makes a vital contribution to promoting good mental health in individuals and communities. The main ways this happens are through:

System-wide leadership through health and wellbeing boards (HWBs).
Promoting equality and anti-racist approaches.
Public health responsibilities to promote mental wellbeing and prevent poor mental health throughout the life course.
Statutory duties and powers related to mental health for children and young people and for adults.
The overview and scrutiny of mental health provision.
Commissioning of voluntary and community services that support good mental health, including advocacy or youth services.
Provision of wider services that support wellbeing, such as libraries, leisure services and green spaces.

Many local areas are maximising their opportunities by working smartly and imaginatively with health and community partners, to promote good mental health and wellbeing.

System wide leadership

Responding to the pandemic

The full impact of the pandemic on mental health for all ages has yet to be fully realised. But councils are expecting a significant increase in demand for services. The pressure will come from referrals that would normally have been made when services were less restricted in terms of access. Referrals to services are expected to rise as a result of the strain the pandemic has put on families whether because of factors such as job losses, financial insecurity and bereavement. Long covid is also likely to put further pressure on mental health services.

Councils are also working closely with schools which are dealing with a range of challenges, including settling children back into routines, supporting them through pandemic-related anxieties, managing behaviour and re-establishing relationships to enable children to flourish.

Funding has been provided to councils to support schools under the Government’s Wellbeing for Education Return programme which was launched in September 2020 to respond to the additional pressures linked to the pandemic.

The government has also published a Mental Health Recovery Action Plan in 2021 in response to the mental health impact associated with the pandemic. This includes an expansion of Improving Access to psychological therapies (IAPT) and extra funding for the most deprived areas to pay for prevention work, including debt advice, youth projects and support to tackle loneliness and isolation

Integration

Mental health cannot be tackled by any organisation working in isolation. Councils, the NHS, education, and the voluntary and community sector (VCS) must come together with people who use services (children, young people and adults), carers and advocates to ensure that each area has a joined-up and coherent strategy and that services and approaches are delivered in an integrated way.

The 2021 Health and Care Bill is intended to enable local health and care leaders to pursue new and innovative ways of delivering for people and communities working as Integrated Care Systems (ICSs). It will establish Integrated Care Boards as new NHS statutory bodies, enabling the NHS and local government to work as equal partners to reduce health inequalities and improve population health. It will be important to ensure that mental health is given appropriate priority within these new arrangements, working with and in support of local health and wellbeing boards.

Prevention – tackling social determinants and inequalities together

Mental health problems are frequently associated with a range of other factors including poverty, poor housing, homelessness, disability and long-term illness and experience of violence or abuse. Groups who have higher levels of mental health problems include refugees and asylum seekers, veterans, the lesbian, gay, bisexual and transgender community (LGBT), looked after children, and some Asian, black and ethnic minority groups. Though people of all ages and backgrounds can have mental health difficulties at any point in their lives.

Councils, the NHS and the VCS should work closely with partners such as housing, education and employers to improve the social determinants of poor mental health, creating a place-based approach to mental wellbeing. Studies have shown that the following functions have a role in promoting good mental health:

Workplaces that support mental wellbeing – many councils have initiatives, such as awards, that encourage this.
Schools, colleges and universities ensuring they are mentally healthy spaces, running programmes and direct interventions and providing training to promote mental good health. Support to local businesses to help create jobs and training opportunities.
Asset-based approaches to community development – reducing isolation and identifying mental health problems early.
Parks and the natural environment – exercise and green and blue spaces are associated with mental wellbeing.
Sports, culture and leisure services such as swimming pools and libraries – opportunities for exercise and social contacts.
Good standards of housing and support for those at risk of housing insecurity.
Planning the built environment with walkways, cycle-paths and a community focus.
Supporting the financial resilience and wellbeing of communities through providing credit, food or white goods vouchers, council tax support, benefit advice etc.
Bereavement support.

While there is a growing body of research on preventing mental illness, some areas are more advanced than others in evidencing impact. For example, evidence-based parenting programmes are estimated to generate savings in public expenditure of nearly £3 for every pound spent over seven years, with the value of savings increasing significantly longer term.

The health in all policies approach (HIAP) adopted by many councils should cover mental as well as physical health. Many councils have appointed councillors as mental health champions to champion better mental health and tackle stigma. Champions are supported by the Mental Health Challenge, a network where councillors can share ideas, seek advice and receive support with the aim of enhancing the mental health of their local communities.

Best use of funding

With limited funding, it is vital that investment decisions are based on evidence, support innovation and achieve the best outcomes, including tackling mental health inequalities. Through joint strategic needs assessments (JSNAs) and intelligence from public health and the NHS, councils and their partners can target investment in a way which meets local needs and supports the shift to prevention. For example, dependent on data, some areas may focus on reducing suicide, some on tackling bullying in young people and some on men’s mental health.

Questions to consider for all ages system-wide leadership

What work is your Health and Wellbeing Board (HWB) taking forward to improve mental health? Is there a mental health strategy covering prevention, self-help, treatment and support for all ages, signed up to by all partners? How is delivery monitored?
Is the HWB supported by planning structures and implementation plans that promote an integrated approach to mental health for children and young people, and for adults? Do these cover seamless transition from children’s to adult support?
What mechanisms are in place to ensure that people with mental health problems (children, young people and adults), and carers are listened to, and that their views and priorities shape mental health services?
Are the council and other key local partners actively involved in shaping mental health developments in the integrated care system (ICS) footprint?
Does the JSNA help identify local priorities and support effective mental health commissioning and investment?
Do local partners consider the impact of their wider investment decisions on mental health – for example CCG core funding, and council investment in areas such as parks and community assets?
How is mental wellbeing tackled through council functions, such as leisure, planning and housing, and those that are joint with partners, such as education and criminal justice?
What prevention approaches are in place to support groups at risk of mental health inequalities in your area, such as some ethnic minority groups or LGBTQI+?
What measures do the council and key partners have in place to provide mentally healthy workplaces?
How does the council support local employers to create mentally healthy workplaces?
Does HIAP sufficiently cover mental health? What mental health training is given to front line staff in key agencies who work with the public? Is mental health first aid training provided? Is there mental health awareness training for councillors?
Is there an active suicide prevention plan? What progress is being made on this?
What are the council and key partners doing to reduce the stigma of mental health in the local area?
Do the council and key partners have active mental health champions?
Has mental health been included in the overview and scrutiny committee’s programme of reviews?
What more could be done to make your area a mentally healthy place to live?

Adults

Facts and figures

One in six people have a common mental health problem such as depression and anxiety, panic disorders, phobias and obsessive compulsive disorders at any one time.
Mental health problems affect both men and women, but not in equal measure. In England, in 2014, one in six had a common mental health problem: about one if five women and one in eight men. From 2000 to 2014, rates of common mental health problems in England steadily increased in women and remained largely stable in men.
In 2020, there were 5,224 suicides registered in England and Wales. This compares to 5,691 suicides registered in 2019 and 6,507 in 2018. The decrease is likely to be driven by two factors; a decrease in male suicides at the start of the Covid-19 pandemic and delays in death registrations because of the pandemic. Around three-quarters of registered suicides in 2020 were among men, which has been the case since the mid-1990s
Three times as many men as women die by suicide and men aged 40-49 have the highest suicide rates in the UK. Men also report lower levels of life satisfaction than women according to the Government’s national wellbeing survey.
Men are less likely to access psychological therapies than women: only 36 per cent of referrals to NHS talking therapies are for men.
People living alone, in poor physical health or not employed are all more likely to have mental ill health.
Severe mental illness includes conditions such as post-traumatic stress disorder, bipolar disorder and psychotic disorders like schizophrenia. These conditions may require inpatient care and aftercare in the community.
Around one in 20 adults have had Post Traumatic Stress Disorder (PTSD) in the past year and one in 50 bipolar disorder.
Psychotic disorders are much less common with fewer than one in 100 having experienced them (Source: Adult Psychiatric Morbidity Survey, NHS Digital 2014).
Black men are more likely to have experienced a psychotic disorder in the last year than white men and black people are four times more likely to be detailed under the mental health act than white people.
The Centre for Mental Health estimate that 10 million people (8.5 million adults and 1.5 million children and young people) in England will need support for their mental health as a direct result of the pandemic over the next three to five years.

The national picture

The NHS Long Term Plan was published in January 2019 and prioritised mental health for extra investment in England. The plan covers the care of children, young people and adults. By 2023-24 spending will have grown by £2.3 billion a year. While some of this funding will be spent on integrated mental health services, most goes to NHS clinical services.

The plan says that services in the community should be a priority. The goal is to create more integrated, place-based approaches by promoting collaboration between the NHS and local government services, such as social care, drug and alcohol teams, education, housing, employment and public health.

NHS England published the Community Mental Health Framework for Adults and Older Adults in 2019. It provides the framework to support a transformation of community mental health services – one of the key objectives being to “develop a new and integrated models of primary and community mental health care which will support adults and older adults with severe mental illnesses”. Every integrated care system has been required to develop and submit a clear plan setting out their response to the transforming community mental health services framework, with associated NHS funding linked to this.

Changes are also being made to the statutory mental health system and the Mental Health Act. An independent review of the Act found that more than 50,000 people a year are detained under the Mental Health Act, with a disproportionate number among ethnic minority groups and in particular the black community.

The government responded to the to the independent review in 2021 they proposed introducing stronger detention criteria, improved access to advocacy and more frequent reviews of the detention. As well as greater rights to challenge treatment and choice over who can be appointed as a nominated person to look after the detainee’s rights. The government has said that it will draft a revised Mental Health Bill and introduce it when Parliamentary time allows.

Key roles for local government

Councils have statutory duties to provide social care to support people experiencing mental health problems. Section 117 of the MHA requires councils to provide after-care services and support to people moving out of hospitals. Amendments to the Act in 2007 require them to employ Approved Mental Health Professionals (AMHP’s) to contribute to statutory mental health assessments and tribunals.

The National Workforce Plan for Approved Mental Health Professionals is a useful guide to understand the role of the AMHP in mental health services, to coordinate the development of the AMHP role and to aid the recruitment and retention of AMHPs.

Councils also have responsibilities for those who do not have the mental capacity to consent to care or treatment they need when orders are granted under the Mental Capacity Act.

Under the Mental Capacity Act 2005, councils also have a role in agreeing to more restrictive care and support arrangements for who do not have the mental capacity to give consent. As part of the wider reform of mental health, the Liberty Protection Safeguards (LPS) are planned to come into force in 2022 for those aged 16 and over, replacing the current Deprivation of Liberty Standards process. Any restraint and restrictions must be shown to be in the best interest of the individual without capacity and be agreed in advance and reviewed regularly. Under the LPS, it will be a health body playing this authorisation role in most NHS settings. The role will be carried out by councils in care homes, supported living schemes and private hospitals. The LGA is developing a programme of regionally based support to help councils and local partners prepare for implementation as part of the LGA Care and Health Improvement Programme.

While many core mental health services from the IAPT services, NHS talking therapy service, to community mental health teams and inpatient units are run by the health service, local government still plays a key, multi-faceted role, not least.

Health and wellbeing boards provide an important platform through which councils can exert strategic influence over mental health care.
Councils commission a range of services that can be very much considered part of the wider mental health support system, such as drug and alcohol misuse services.
While adult social care, particularly Approved Mental Health Professionals, is a vital part of the crisis response effort along with emergency departments and dedicated mental health crisis teams.

Moreover, local government’s role goes much further, recognising that mental ill health can lead to other problems in people’s daily lives, such as with housing, money, work and benefits. Therefore, a wide range of council and local partner services will play a role in supporting people with mental health conditions as well as the work councils are involved with through social prescribing.

Key points for good practice

The integration agenda requires more co-location of staff, with IAPT therapists and social prescribers, for example, being located together within primary care.
The “no wrong door approach” is key. People should be able to access support and care in a timely manner from many different services, including social workers and housing support staff to social prescribing link workers.
Link mental and physical health by taking steps such as helping people with severe mental health problems to have a physical check-up and putting mental health specialists in emergency departments to divert people from admission. Emotional support services are also being integrated with healthy lifestyle programmes.
Integrated commissioning, particularly involving pooled budgets, supports the delivery of joined-up services. It also has the added benefit of utilising council responsibility for market-shaping to achieve a joint understanding of provision across all sectors.

Case study: The importance of brief conversations

Every day council staff along have countless conversations with local residents. These conversations are opportunities to help improve an individual’s emotional wellbeing. For the past five years Camden and Islington councils in London have been trying to make the most of these opportunities by training frontline workers such as housing officers, leisure centre staff and customer care officers along with NHS, education and voluntary sector colleagues in Making Every Contact Count.

The aim is to help staff recognise when people may need support and have “meaningful conversations” with them to help improve their lives, whether it is boosting their confidence and motivation or helping signpost them to support.

This can be directly related to their health or to other factors such as money worries, employment or housing. Staff are given training on everything from how to initiate conversations, behavioural change techniques and what support is available locally.

Questions to consider for adult mental health

Is there a vision for what constitutes good practice in mental health signed up to by all partners? Is there a strategy for improving quality across all providers?
What arrangements are in place for ensuring an integrated approach to mental health support? For example, integrated mental health teams or mental health pathways?
Does the area operate joint or lead mental health commissioning? Is there a pooled budget? How is the voluntary and community sector involved in integrated arrangements?
Have you a member who is signed up as a Centre for Mental Health mental health champion?
Has your authority signed the Prevention Concordant for Better Mental Health to encourage closer working on mental health?
Is there good awareness and understanding of the prevention concordat in your council?
What measures are in place to intervene early to avoid crises developing? If a crisis develops how are hospital admissions avoided, if possible?
What mechanisms are in place to ensure that people with mental health problems and carers are listened to, and that their views and priorities feed into shaping and monitoring the quality of mental health services?
What range of support is available for people with mental health problems to lead active, fulfilled and independent lives in the community? How are specialist employment services performing?
What are the links between physical healthcare and mental health services? What measures are in place to ensure that the physical healthcare needs of people with mental health problems are picked up appropriately?
Would a mental health equity audit be useful? Is there local information about the numbers of people with mental health problems who may face discrimination, for example because of race, gender or sexual orientation? Are any groups over or underrepresented in mental health services?
What is the age profile of the Mental Health Social Workers in your areas? How many are likely to retire in the next five to 10 years? What recruitment and retention plans do you have in place to meet the needs of your area?

Perinatal, children and young people

Facts and figures

Before the pandemic one in eight children and young people between the ages of five and 19 had a mental health disorder, including emotional, behavioural and hyperactivity conditions.
The highest prevalence was being seen in girls aged 17 to 19.
Follow-up research carried out in July 2020 suggested rates had risen to one in six and maintained at this level in 2021.
Perinatal mental health – problems which occur during pregnancy and the first year of the baby’s life – affect between 10 per cent to 20 per cent of mothers.
Research shows that most (75 per cent) adult mental health problems have their roots in childhood and adolescence.
52 per cent of LGBTQ young people reported self-harming, compared to 35 per cent of heterosexual non-trans young people. Furthermore, 44 per cent of LGBTQ young people reported suicidal thoughts, compared to 26 per cent of heterosexual non-trans respondents.
Half of all mental health conditions begin before the age of 14 and three quarters by the age of 24.

The national picture

Good mental health starts at conception and continues into childhood. Intervening early to prevent problems developing or treating and supporting children, parents and families before problems progress is essential.

As with adults, there is a drive to create a more integrated approach to mental health care for children with a particular emphasis on support in education provision. The mental health needs of children and young people were highlighted in the five-year forward view in 2016 and set out in the 2017 Transforming Children and Young People’s Mental Health proposals.

Central to the drive is the creation of designated leads in schools and colleges for mental health and new mental health support teams for schools, which are currently being rolled out. They are commissioned by the NHS and involve a variety of delivery partners including councils, council-run school nursing services, voluntary and community sector providers and NHS services.

By 2023-24 these should be providing support to an additional 345,000 children and young people. Investment is also being made in community eating disorders services and mental health crisis support to ensure that it is available 24/7, while a four-week waiting time target has been created for access to non-crisis treatment.

There is a focus on what is known as the whole-household approach to provide joined up support to families as well. This includes enhanced support during the perinatal period – pregnancy and the first year after the baby is born – and the Supporting Families Programme, which was previously known as the Troubled Families Programme and includes work to support people to leave abusive relationships, get the right joined-up mental health support and help people to find work.

Key roles for local government

Services for under 18s are known as Child and Adolescent Mental Health Services (CAMHS). There are currently four different tiers to these services ranging from hospital inpatient care at tier four, specialist eating disorder care at tier three to counselling and preventative work at tiers two and one. Although many places are moving to a system that looks at supporting the child holistically, like the Thrive model.

Councils work in partnership with their partners to support children, young people and their families. Councils have a role in direct delivery of universal, targeted provision and working with the NHS to support the most acute mental health needs.

Councils, as corporate parents, have a particular role in the support of children in care, or care experienced young people to ensure they have access to mental health support, where required, this includes unaccompanied asylum-seeking children.

The 0-5 Healthy Child Programme includes health visitors, family nurse partnerships and early years services, while the five to 19 part of the service includes school nurses. All of these are part of the tier one offer as are children’s centres or family hubs. This provision varies in local areas and the method of commissioning will differ too. that are actively commissioned from the voluntary sector. However, provision of these services varies in local areas.

The work of councils in terms of social care and safeguarding is also considered part of the wider mental health system – and will play a crucial role in the COVID-19 recovery.

Key points for good practice

Ensuring a holistic response to emotional wellbeing and mental health such as access to green space.
Investing in early intervention or preventative services such as youth services, play clubs or wraparound support that promotes good wellbeing.
Joining up perinatal and early years support provided by council, the NHS and voluntary sector so that they operate to shared outcomes and standards.
Ensuring frontline staff, such as health visitors and school nurses, are equipped to support children and young people.
Linking councils’ children services, primary care and CAMHS services so that these share a common understanding and operate clear referral pathways.
Ensuring that adult and children’s mental health services work together through transition – both strategically and operational.
Working with NHS to support placements for children with complex or acute needs.
Working with schools to support mental health such as through the creation of school-based mental health teams or encouraging training for designated senior leads in schools.

Case study: How school nurses can support mental health

Walsall's school nursing service has been providing mental health support to children for a number of years. It is based on the FRIENDS programme, which originates from Australia. The programme is cognitive behavioural therapy-based and focuses on key skills such as confidence building, problem solving, resilience and communication.

Every term three eight-week courses are run for primary school children aged seven to 11 and one for teenagers. The sessions are delivered jointly with school staff, helping to increase awareness and skills among the workforce in the process. 

Children work in groups at the sessions, which are run after school in either community venues or the schools themselves – although during the pandemic they have been run online. Referrals are made by GPs, social care, teachers and the families themselves. Those taking part have reported improved confidence.

Walsall has also been one of the pilot areas for the mental health school teams programme with the school nursing service working closely with those teams, sharing referrals.

Questions to consider for perinatal, children and young people

Is there a joined-up strategic approach to mental health from early years, through childhood to adolescence and to the transition to adult services? Does oversight of progress take place at a senior leadership level?
Is there investment in services, or coordination with the voluntary sector, to develop preventative and holistic services that support mental health?
Is there a whole-council approach to ensure children’s wellbeing and emotional wellbeing is central to policy and practice?
Is the council working with schools and early years settings to promote good mental health? Is there an effective interface between services at key transition points, for example midwifery services, health visiting and school nursing services?
Are the council’s 0 to 19 services integrated and closely joined-up with related NHS support and the voluntary sector?
Are expectant parents informed about mental wellbeing alongside advice on physical health? Are they able to discuss any concerns?
Are new parents given information about mental health and wellbeing when they are discharged from hospital, with signposting for further information and help?
Is checking the mental health of families part of the general conversation for health visitors for 0-5s? Are there clear referral pathways where more support is needed?
Do schools and colleges provide lessons on mental wellness and resilience in the same way as physical education lessons?
Is public health supporting schools and colleges to implement initiatives to promote mental wellbeing? Is there a particular focus on initiatives designed by children and young people, peer support and the use of technology to improve access?
If a child or young person begins to experience potentially serious mental health problems is there a clear referral pathway from early years, schools and colleges to GPs and into specialist services where needed?
What is the waiting time for local specialist CAMHS? Are there any delays in specific areas such as support for eating disorders? What is being done locally to tackle this?
Relationship’s education is compulsory in primary schools and sex and relationship’s education in secondary schools. Is good mental health being promoted as part of this?
Do you know how agencies share information about children with the most complex care needs. For example, do you have a Dynamic Risk Register of these children in your area?
Do agencies have clear ways of escalating issues when they arise and ensuring that problems are addressed early?
Do you know what the joint commissioning arrangements are for children with the most complex needs?