Mental health, inequalities and the role of local government
Dr Lynne Friedli
The mental health and wellbeing of communities is both a cause and a consequence of inequalities. This requires local government action at two levels:
- action to address the exclusion and discrimination experienced by people with mental health problems, notably in employment, but also in accessing mainstream services and opportunities, in order to reduce inequalities for one of the most deprived and marginalised groups in society.
- action to reduce income inequalities in order to to reduce the prevalence of mental illness and make improvements to mental health and wellbeing.
Poor mental health contributes centrally to poorer outcomes in many areas of life, often reinforcing inequalities, because those who are most deprived are most likely to experience mental illness and poorer mental wellbeing. Interventions to improve mental health and prevent mental health problems are highly cost effective, deliver social, as well as economic, returns and contribute to reducing inequalities.
Many local authorities are dedicated to reducing the financial and social exclusion experienced by people with mental health problems, and are making progress in improving outcomes in education, employment, access to mainstream services and quality of life. Initiatives like World Mental Health Day, which aim to challenge stigma and discrimination, have become significant local events in many boroughs.
Delivering equality: the contribution of local government
A commitment to equality can be delivered through:
- local government's role as a major employer
- the ‘duty to involve'
- policy and practice which express genuine respect for those facing hardship.
People living in poverty, as well as other vulnerable or excluded groups, consistently describe the pain of being made to feel of no account, which is often experienced as more damaging than material hardship.
It's important to distinguish between efforts to address symptomsof economic inequality, for example the steep social gradients in health and education, and the wider strategic challenge of reducing material inequalities: the gap between rich and poor. The size of the gap is relevant to mental health because many studies suggest that a major impact of inequalities is psycho-social: how stark differences in income and wealth make people feel - about themselves and others and how they impact on social connections, social cohesion and the quality of civic society.
There is strong evidence that inequality is a catalyst for many social problems and that the stress of coping with material deprivation is exacerbated by levels of inequality. The injustice of the differences in life chances and opportunities in Britain today is now widely seen to erode the very characteristics that communities need to survive adversity: resilience and collective efficacy. Although reducing income inequality is a matter for central government, local government can make a contribution through increasing equitable access to assets that support wellbeing, as well as initiatives like London Living Wage (LLW), which directly campaigns to increase low pay. One way of achieving this is to develop an index of multiple assets. This captures the strengths and resources of communities, rather than their deficits, and also identifies inequalities in:
a) access to valued assets
b) opportunities to influence decisions on fair allocation of scarce resources
c) opportunities people have for valued roles and to make a meaningful contribution.
Valued assets might include green space, wild space, blue space (clean rivers, lakes, canals and waterways), gardens, public space, walkability, ‘stop and chat', sporting and cultural opportunities and places to meet, as well as housing, credit, bus services, local shops and markets and works of art. Environmental assets are important stress buffers and contribute significantly to reducing inequalities for communities who may have limited opportunities for peace, space and relaxation. There is growing recognition of the untapped potential of local authorities as ‘place shapers': the spatial vision of environmental justice expressed in a local development framework may be one of the most important long-term contributions to the wellbeing of local communities.
Islington Council Fairness Commission
Islington's Fairness Commission will assess what the council and its partners should do to make the borough a fairer place. Its conclusions will shape the Council's Corporate Plan, Sustainable Communities strategy and budget. The commission's results will also be used to guide the work of the Islington Strategic Partnership and the council's partner organisations. The commission itself is made up of councillors, partner organisations (NHS Islington, Metropolitan Police, local universities and so on), leading experts with a proven track record of fighting inequality and others from the charity sector.
Reducing inequalities in the material circumstances of people's lives and recognising the relationship between relative deprivation and mental wellbeing is part of a wider agenda of strengthening local government action on the social determinants of health, signalled in the Marmot Review. These are challenging issues that are also part and parcel of current debates about fairness - a central theme in the coalition's 'Programme for Government', and will continue to have important implications for local authorities. Those authorities with a visible commitment to social justice, and to greater equity in the distribution of valued assets, will also be those most likely to find creative and successful ways through the economic downturn. While local authorities may find multiple barriers to economic growth, the growth of human potential is unlimited.
Social Exclusion Unit (2004). 'Mental health and social exclusion: Social Exclusion Unit report'. London Office of the Deputy Prime Minister.
Pickett, K. E., James, O. W., Wilkinson, R. G. (2006). Income inequality and the prevalence of mental illness: a preliminary international analysis. 'Journal of Epidemiology and Community Health' 60; pp 646-647.
Prevalence of mental illness is captured through community surveys of psychiatric morbidity; levels of wellbeing are measured using wellbeing scales, for example WEMWBS (Warwick Edinburgh Mental Wellbeing Scale). Trends in mental wellbeing are not identical with trends in mental illness, although both mental illness and mental wellbeing show a marked social gradient.
Friedli, L. and Parsonage, M. (2009). 'Promoting mental health and preventing mental illness: the economic case for investment in Wales'. Cardiff: All Wales Mental Health Promotion Network
Promoting mental health and preventing mental illness: the economic case for investment in Wales - (PDF, 90 pages, 1.5 MB large file)
The London Living Wage (LLW) is supported by the Mayor of London and the Greater London Authority (GLA). It has recently been raised to £7.85 per hour, in recognition of the cost of living in London. LLW applies to suppliers as well as to those directly employed by the GLA and the campaign has also successfully influenced a wide range of major London employers to adopt LLW.
London Living Wage raised - Press release
Wilkinson, R. G. and Pickett, K. E. (2010). 'The spirit level: why equality is better for everyone'. Penguin.
Marmot, M. (2010). 'Fair society, healthy lives: a strategic review of health inequalities in England post-2010' London. The Marmot review
Hills, J. (2010). 'An anatomy of economic inequality' in the UK Report of the National Equality Panel London: Government Equalities Office
An anatomy of economic inequality in the UK: Report of the National Equality Panel
Friedli, L. (2009). 'Mental health, resilience and inequalities - a report for WHO Europe and the Mental Health Foundation' London-Copenhagen: Mental Health Foundation and WHO Europe
Mental health, resilience and inequalities - (PDF, 64 pages, 459 KB)
Mitchell, R. and Popham, F. (2008). Effect of exposure to natural environment on health inequalities: an observational population study 'The Lancet', 372(9650), pp1655-1660
Effect of exposure to natural environment on health inequalities: an observational population study - on 'TheLancet.com' website
The importance of place shaping is explored in detail in the Lyons Enquiry into Local Government (2007)
The Lyons Inquiry into Local Government - (PDF, 46 pages 2.7MB large file)
Programme for Government - on the Cabinet Office website
Coote, A. and Franklin, J. (2010). Transforming welfare: new economics, New Labour and the new Tories, 'Soundings', Issue 44
8 December 2010