COVID-19 Mentally healthier conditions for councillors and communities part two

A transcript from the webinar

Moderator: Hi, and welcome to this local government association webinar on mentally healthier conditions for councillors and communities. This is part two, of a two part webinar, and this bits on mentally healthier conditions for communities. I'm councillor Ed Davie, I've been a Lambeth councillor since 2010, an LGA expert peer since 2013, I'm the longest serving mental health council champion, and you can use that link to check whether your council has a mental health challenge champion. And if not, perhaps you can join me as one, it's a great scheme. I've worked for health charities including the British Medical Association, and the Mental Health Foundation since 2009. And I've got a Masters Degree from King's in Public Health, and I've studied social determinants of health, with Professor Sir Michael Marmot at University College London.


So, I hope you took part one, the webinar that was about mental health for councillors. And in that part one, we learnt that human beings evolved to be hunter gatherers. And hunter gatherers obviously had control over their own lives. They moved their bodies a lot of the time, and were constantly in green space. And this is obviously in contrast to how we live now a lot of the time. Particularly during the various lockdowns that we've had around the pandemic. And so we tend to live less like the picture in the top left hand corner, which is the conditions we evolved to be in. And a bit more like Handforth parish council down there, which is obviously less good for our health. And the last point is having good social contact with our tribes. So, in part two, this webinar, we'll be looking at the context of community mental health. Then we'll be addressing, looking at how we can address social determinants, so that's things like poverty and discrimination. Then we'll be looking at how we can improve the environment to make it more mentally healthy. And finally, we'll look at some psychological insights. And this is largely based on an LGA handbook, that was written by myself, and a clinical psychologist Dr. Katherine Garzonis. Do have a look at that if that's useful. It has some other materials and exercises that would supplement this learning. And during this session, please write down at least three things you're gonna try to improve on. And be as specific as you can. For example, you might wanna work to get more local organisations Living Wage Trust accredited. You might wanna try and tighten your councillors alcohol licensing conditions. You might wanna work with colleagues to create better walking and cycling routes. These are just three examples, there's a lot material in this webinar, you can choose your own three, and they may be different from these ones.


So, a bit of context. Often a conversation about mental health, talks about mental ill health. I'm not going to talk much about mental ill health, more like the conditions for positive mental health. But mental ill health is the major issue. Tens of thousands of people in the U.K die every year related to mental ill health. People will serious mental illnesses die on average twenty years earlier than people without. And it's estimated to cost in financial terms over £100 billion in England alone. That works out about £700 million per upper tier council in lost productivity, in service costs, and human misery. An enormous sum of money. And we can't just treat our way out of this. As Michael Marmot says, 'Medicine is failed prevention'. I think that's a little bit harsh on medicine, but, the points he's trying to make is, we do need good quality mental health, and other services. But such is the scale of the issue, that we do need to be better at prevention, and there are lots of things we can do to help people stay well in their communities.


So what levers do councils have around this area? We're a major employer and contractor. We're the planning authority of housing, active travel, greener community space, and we can implement all of those through our planning decisions. We're the provider and custodian of a lot of resources that our communities need for good health, like parks, and libraries, and leisure centres. We're the licensing authority around alcohol, and gambling, that can have a significant impact on health. We provide social care, and that's particularly important for protecting children, and vulnerable adults, from abuse, neglect, and bullying. Which are all terrible for mental health. We have a role in education through schools and communications with residents. And we're a major influencer. Apart from our formal powers, we also influence partners, and residents, in important ways. So what are the things that influence mental health? On the left, you're going to see the things that influence it positively, we call these protective factors. And on the right, things that influence mental health negatively, we call these risk factors. And the risk factors are pretty much opposite of the protective factors, as you'll see. So having a secure, sufficient, income. Having enough money, really important. Being treated fairly. Having decent housing. Positive parenting, including being securely attached between infants, and at least one parent or carer. Having a positive experience of schooling. Exercise and healthy diet. Access to green space. And as I say, the negative ones, are the kind of inverse of the positive ones, as you would expect. So poverty is really bad. Discrimination. Poor housing and homelessness. Child neglect, abuse, bullying of children and adults. Traumatic events, like being bereaved, or attacked, or you know, severe physical illness. Being isolated. Inactivity, diet, substance misuse. Living in a poor environment. So the World Health Organisation says there are three main factors between health and illness. Social determinants, as I say, things like poverty and discrimination. The environment, things like housing, and access to green space, for example. And individual factors, including psychology, genetics, and health behaviours. And we're going to be looking at these three areas. Social determinants, environment, and individual factors, mainly psychology, in the rest of this webinar.


So, firstly, social determinants. And this determines up to 55% of health outcomes, the World Health Organisation says. So, more than half of health outcomes, are down to things like poverty and discrimination. And there's some interesting books that I love here, that you may wish to read at your leisure about this subject. Yup.


So, poverty and discrimination, anyone can develop a mental health condition, but the risk of developing a mental health condition depends on circumstances. So, obviously, a white, middle class man, heterosexual, able bodied, like myself, I have experience depression and alcoholism, but it's more likely, at population level, if you don't have the advantages that I have talked about. So, those that live in poverty are at greater risk, and those who suffer discrimination are also at greater risk. So just thinking about discrimination, we know that particularly in this country, black and LGBT-plus people have a much higher risk of mental illness. Because of discrimination, and discriminatory practice. And these can manifest in the following ways. So they increase the risk of poverty if you're discriminated against, it's harder to find work, or get an education, or be promoted. Being discriminated against is very stressful, and we know people who experience it have excess stress hormones in their bodies, which is really bad for their mental and physical health. It reduces your sense of control, and increases a sense of powerlessness. And we know having a sense of control, agency, is really important for peoples mental health. If you do become unwell, or you interact with services, your behaviour that may be part of your culture, like gesticulating, or being a bit louder than some other cultures, can be interpreted as disordered, or serious mental illness, and you are treated differently. Which can lead to coercive, inferior, or cultural inappropriate services, that mean you have a worse outcome. And this can all lead to reluctance, understandably, to seek help. Which means that sometimes people from these backgrounds present later. And therefore it's harder to give them the support they need, and they're less likely to have a good outcome. It already increases the risk of self medication, like drinking too much, or taking drugs, and other kinds of risky behaviour. But, I need to stress this, the increased risk is nothing to do with genes, or a cultural flaw, it's to do with structural discrimination, that we all have a role in tackling.


So how do we tackle discrimination? Well part of it is making that all public bodies including local authorities, and mental health trusts, are carrying out public sector equalities duties, under the equalities act. I think it's really important to check your data, for what they call disproportionality. So what is the demographic makeup of the patients in your local mental health trust, for example. Is it mostly men? Is it mostly people who are a particular ethnicity, or a sexuality? These will tell you whether you have a problem with a disproportionate number of any particular group over represented amongst those with the worst health conditions. You should ensure representation at all levels. Make sure your organisation, and your partners, look like the community you serve. And co-produce solutions with people, and communities. Not do things to them, do things with them. Invest in quality anti-discriminatory practice. There are good resources, and training around. And educate yourself and others about the issues. So, I for example, was recommended to read this book by one of my black colleagues. And I found it really useful to think about racism isn't just a binary, the good guys and the bad guys over here, and me as a kind of liberal with a small L is fine. We all have things that we need to learn, and challenge ourselves about in this area. And in Lambeth, just as an example, when I was in scrutiny, I found that whilst 25% of Lambeths residents identify as black, more like 70% of our residents in acute mental health services were black. So nearly three times as many as you would expect. And not, as I say, because of any kind of genetic or cultural issue, but because of poverty and discrimination. So we did this commission, co-producing solutions with our black communities. And we established black thrive, which is a partnership between different public bodies, and the local community, to try to improve prevention, access to appropriate services, and patient experience. We haven't solved it, but we are doing some good work in that area, and you may wish to think about what would be the equivalent in your area. I recognise demographics are different everywhere.


So poverty, which can intersect with issues of discrimination. You can see here in this graph, sections under the mental health act. So when somebody is sectioned, they are forcibly taken into treatment to protect themselves, or others, because they are so unwell. And you can see a very clear link between the least deprived communities, so the most well off people at the top of the graph, have the fewest proportion, the smaller, smallest proportion of people sectioned under the mental health act, per 100,000. And then at the very bottom of the graph, the most deprived communities have the most, and everyone in between is as you would expect. So, it's very clear, the poorer you are, the more likely you are to be sectioned under the mental health act. And similarly these two maps. On your left, you see a map, darker colours indicating higher prevalence, higher rates of common mental health disorders like depression and anxiety. And on the right, a map showing deprivation. Again, darker colours, higher deprivation. You can see they're very closely linked, very closely correlate. And here are deaths around alcohol, and if you flick back to the previous map, you'll see deprivation not only maps very closely to depression, anxiety, but also deaths related to alcohol. And you can also see this in a slightly different way around suicide completions. So the very top line, the blue line, is completed suicides per 100,000 amongst the most deprived 10%, so the poorest people. And the yellow line at the bottom, is the least deprived 10%, and you can see there is a very stark difference in completed suicides. So, depression, anxiety, sections under the mental health act, deaths related to alcohol, and deaths related to suicide, all clearly show that poverty is a serious, serious link. Why is poverty so bad for mental health? Well, for a start, you just can't afford healthy things. From housing to food. Going to the gym is out. Just eating the recommended diet, costs about 75% of disposable income for the most deprived. So just eating well is nearly impossible. It also reduces, what's called mental bandwidth, for good health choices. So basically, if you're worried about how you're going to feed your children, or cloth them, or pay your rent. You just literally have less space in your brain to think about cooking a healthy meal, or taking exercise, or doing other things that might be good for your health. Being poor is really stressful, your body is flooded with excessive stress hormones from worrying about things. It lowers your self esteem and sense of control. And understandably, all of the above can lead to sort of comfort behaviour. You know, eating bad food, inactivity, substance abuse, and risky behaviour. And just to nail one myth around this area. Increasing poor peoples incomes does not encourage bad behaviour, there are many studies on this, this is just one where researchers looked at the impact of increasing child tax credit in the U.K, U.S, and Canada. And it found that when you increase child tax credit, it leads to a large decline in alcohol and tobacco use amongst parents, because most likely, extra income reduces stress, and then reduces consumption of items like alcohol and tobacco.


So, if you wanna improve the mental health of your communities, reducing poverty is key. So I would suggest, and the literature suggests, providing really excellent financial, social security, housing, and child care advice. Councils have a big role in that. Creating as many decent living wage jobs, and apprenticeships as possible. Investing in education and training. Ensuring genuinely affordable housing. Supporting free childcare. For example, the national average in England of parents of two and three year olds, who are eligible for free childcare from national government, is about 70%. Which means three out of ten of those families, are not accessing that free childcare. And councils have a role in encouraging that take up. And be as generous as you can with your council tax support scheme. This is a way of directly putting into the pockets of the poorest people, with a mechanism that you have control over. So, just a little bit more on living wage accreditation. And I make this distinction, obviously national government has a living wage rate, but it isn't the same as the one, the living wage foundation does, which is much more generous. And is changed every year. And only about a quarter of councils, and fewer than 10% if NHS employers, are living wage trust accredited. And sometimes when I bring this up people say, 'Oh, we pay everyone above the living wage rate'. But it's important to get accreditation, because it also covers the staff that are contracted. So those are the cleaners, the rubbish collectors, the carers, the caterers, the administrators, the drivers, the heroic key workers that we've been clapping for helping us during the pandemic, in particular, and they deserve to be paid above a poverty wage limit. And that's been proven to be good for everybodies mental, and physical health. So, just a case study from my own local authority, we've been living wage accredited since 2012, and nearly all of our contractors now pay above the London living wage rate. We've got the first living wage accredited building in an ex-council office block. And we've persuaded, or supported, our two major NHS trusts, our two Universities, and several GP surgeries and schools, to get accredited too. And we have a designated living wage champion, a councillor, who drives some of this activity. So you can look up, using this link, to the living wage trust website, whether your council is accredited, and also other major employers in your area, like your NHS trusts. And if any of them aren't, you know, you can put pressure on to sort that out. Maybe you could think about creating a living wage champion, if you don't have one already. As I said earlier, improving your council tax relief, is another way to put money in the pockets of your poorest residents. Council tax relief is devolved to local government. You can arrange your own scheme the way you want to. And lift people out of paying various proportions, up to 100%. And ideally 100% for your poorest residents. So, Camden, are just changing their council tax reduction scheme, to lift 10,000 people out of work, and low income households, not paying any council tax at all. From the financial year we're about to enter.


And whilst there is a cost to the council because obviously you're taking less council tax, it also means you're taking less people to court, there's less to administer, so the cost is offset by about half a million pounds of savings, which is obviously a positive thing. You may have heard the phrase, 'Anchor Institutions', so that just means, you know, big organisations like the local authority, NHS trusts, Universities, things like that and they can use more of their buying power and their hiring power to support their local economies. So, often these bodies can be very focussed on delivering services, which is totally understandable. But, actually, it's really important to think about their role as major employers and procurers of goods and services, and the more they do that locally, the more they create quality employment and economic benefit for residents which in turn, has an impact on their health. So, Preston in Lancashire has done good work in this area with their partners and across the wider Lancashire economy it's increased local spend but about £200,000,000 and that's helped reduced unemployment, cut it in half and other benefits to the local economy, which in turn has benefits to local health.


And finally, on social determinants and it does sort of cross over into the next subject which is environment, is smoking cessation and if there's a silver bullet in public health, it's probably smoking cessation. Smoking is linked to mental health problems ranging from depression to psychosis and well as obviously, physical health problems we know about and also, the most deprived are twice as likely to smoke as the least deprived and we know that those with a serious mental illness, as I mentioned before, are likely to, or do, live on average twenty years less long than everybody else and part of that's a higher prevalence of smoking. As I say, you're more likely to smoke, the poorer you are and it pushes you further into poverty, and action on Smoking and Health, ASH, estimates that everyone in the UK quit smoking over a million people would be lifted out of poverty as well as immediately enjoying better health. Your public health colleagues can advise you on the best ways of increasing smoking cessation and there are other, you know, sort of, structural mechanisms you have, like banning smoking in public spaces, like playgrounds and parks. The picture shows two children who won our poster competition to display the fact that we were banning smoking in our playgrounds. You can also create smoke free tenancies in tour social housing, and ensure your trading standards teams are enforcing the various laws on displaying cigarettes and clamping down on illegal sales.


Which leads us nicely onto the environment. Excuse me. So, these are some books, obviously, about environmental stuff to do with health. The one in the city-, the middle, happy city is mostly, kind of, North American examples but really interesting ideas about using planning powers to create healthier places. So, we're all products of our environment and planning licensing and influencing powers in local government can be used to improve or worsen mental and physical health, by shaping the environment in which our residents live. And, based on the evidence I would say the ideal mentally healthy environment is one where everyone has a secure, decent home with access-, no more than fifteen minute walk, ideally, obviously, if you're in rural community that can be challenging, but in an urban environment no more than fifteen minute walk via tree-lined safe walking, cycling and electric public transport to high quality employment and training opportunities, communal green and blue space, so, parks, rivers and canals. Free, affordable pro social space, so, pro social just means places where you can meet other people, including libraries, leisure and community centres. Decent affordable childcare and jobs, schools, sorry. Healthy affordable food and the picture on the right is of Utrecht in the Netherlands which is famously somewhere that has-, somewhere that has some of the highest standards of living in the world because they've created a very lovely environment in which to live. A mentally healthy environment also, as well as doing all positive things, it limits crime and antisocial behaviour, air pollution, access to cheap alcohol, harmful gambling and poor quality food. And, I've made a little montage of picture on the bottom to demonstrate those things and I'm afraid my high street looks a lot more like that one that Utrecht. So, there's a challenge for all of us to be more Utrecht and less alcoholic Coral, Morley's there.


So, housing. Housing is a really key part of the environment that influences our mental health. And, I'm sure you've got-, if you're like me you've got a lot of casework about housing to demonstrate that. There is various legislation around what councils have to do around housing, including having an up to date homelessness strategy, so you should check yours and check your local data for success in preventing homelessness and make sure your local planning guidance maximises the number of high quality, genuinely affordable homes in new developments and check what ratio is being achieved. So, I believe it's good practice to try to get at least 30% of social rent levels in any new development as part of a 40% overall, affordable level. Obviously, that would depend on some of your local circumstances, but that's something to aim for to create genuinely mixed communities, which is good for everybody.


Supporting active travel. So, you'll have seen-, if you did the first webinar how important in exercise is for people's mental health and by supporting active travel we can build that into people's everyday life. And, we know that planning decisions over the, sort of, post war period have lead to massive declines in the number of miles walked. So, there's been a 30% decrease since 1980 in the distance that people walk, and that's been mainly driven by planners encouraging suburban housing, out of town shopping facilities, building more roads, obviously, and it makes cars the default mode of transport. And, not only is that bad for people's, kind of, physical activity, but it also damages community cohesion which is another pre determinate of mental health, because it reduces social interaction. So, if you live somewhere, like I do, where I can walk to the shops, my kid's school, the gym, the library, it means that I'm saying hello to lots of different people, which is great for a sense of community as well as my health in walking around. Regular exercise is crucial to mental as well as physical health and it reduces the risk of many diseases and early death by up to half for those who take a reasonable level of exercise. And, it doesn't have to be going to the gym everyday, or doing sports, just moderate exercise for 150 minutes a week, that's just walking at a reasonable pace about, what does that work out as? Twenty minutes a day, max and we can really make a huge improvement to our health.


So, what can councillors do? As I say, the planning process is really critical in this. There's little things that you can do, like, ensuring staircases are places more prominently that lifts in major buildings. You can have an active travel plan, and you should check that-, whether your council has one or not. And, through your planning process, I would recommend discouraging out of town shopping developments that require more car journeys and have a really detrimental affect on town centre high streets as well. There's some good planning guidance from Public Health England through this link and be brave. I know this can be a really noisy issue around low traffic neighbourhoods and cycle tracks, but it's a change that I think needs to happen for people's health and environmental reasons and please try to be brave on this one. Because, this is what you get if you are brave. The Netherlands used to be a car dominated environment like a lot of the UK is, as you can see from the picture on the left and then this is the same street in Amsterdam some years later with trees, with walking, with cycling with outside sitting space, and I know which one I'd rather live in and I know which one is better for mental and physical health. So, let's try to be brave and a bit more like Amsterdam or Utrecht.


So, moving on to increasing green space and access to green space and other leisure facilities. This is really good for people's mental health. They get to meet other people, they get to exercise, they get to be around plants which we know is really good for mental and physical health. And, for fans of Parks and Recreation I've put that little picture up the top, the main character spends many series' trying to get a park built, I hope you have more success than that one. Licensing powers is also a really important lever that local government has, and stricter alcohol licensing reduces consumption which reduces risk to mental and physical health associated with excessive drinking. Excessive drinking is associated with all kinds of terrible outcomes from domestic violence to antisocial behaviour and affects on physical and mental health. And, this is a particular issues for off licence sales as opposed to on license sales, so bars and restaurants and pubs are less of an issue, it's the off licenses we do need to tighten up on. So, you should have an alcohol strategy and some have used a, kind of, public health approach to ensure that this is as tough as it can be to support better health, like, restricting opening hours between 11am and 10pm (inaudible 31.05-31.19) not to grant a license when you have already got a lot of licensees. And, here's a little case study from Newcastle where they've introduced their own local minimum unit pricing scheme. The Scottish government's introduced minimum unit pricing north of the border and it's reduced consumption of alcohol by 25% and that 25% is concentrated amongst the most harmful drinkers and so it's had a really positive health benefit. We don’t have that in England, unfortunately, but Newcastle have adopted their own one with some really positive effects.


So, we're onto the third part of my world health organisation model. We've done, social determinants and the environment and briefly looking at individual factors like psychology and there's three interesting books about psychological processes there, you may want to look them up some time. So, individual and community psychology describes how people think, feel and behave and how these affect each other and how all together they influence health and other outcomes. Psychological insights enable us to design systems that make better outcomes more likely. So, we evolved to conserve energy. We've talked about hunter, gatherer history and whilst we were running around a lot, we also-, our bodies were designed also to try to help us to conserve energy, which was a mechanism to mean that we're ready to escape attack or hunt and forage. So, knowing that, we should use the fact that we know humans can be a bit lazy, frankly, to support better outcomes without too much effort. So, things like changing the defaults on forms that people fill in, and that's been done with organ donation and work place pension schemes, really successfully or building exercise into everyday life or supplying benches in public spaces, so people can interact with each other. These are all ways of, you know, using the insight that people are, frankly, a little bit lazy naturally, to make the healthy activity the default.


So, supporting connections between people is really important and councils can help by designing communal spaces so that people can meet and make friends, ensure that there are nearby quality jobs, accessible public services. We've talked about this in the environments section, but this is the, kind of, psychology of it. Opportunities to gather when we're allowed, social distancing regulations permitting to gather, like, festivals and volunteering, and markets and litter picks and all that kind so stuff that seem like a distant memory now, as I'm speaking to you in lockdown three. Because, when residents are connected to each other and good services, they're much more likely to be happy and successful and in turn, they're likely to support those around them to flourish further. So, community wellbeing when suitably nurtured is a virtuous circle and something that we should think about as, hopefully, we're recovering from the pandemic. Problem solving is another thing that we, that we do collectively and it got our ancestors out of the rain, into caves, then into huts and then into flats and houses, and we only did that collectively by working things out together. So, good problem solvers see ways to make things better, thereby reducing the duration of crisis' or avoiding them all together making this a core skill for promoting resilience, and it naturally benefits everybody. And, the great thing about being a problem solving species is that everyone has the skills to help find solutions. That's why properly managed public consultations can be so useful. The more heads you have on a problem, the better your solution. And, I'm sure we can all think of good and bad examples in our local communities of consultations. When they're done well, they get everyone involved, you get some great ideas, you get buy in. When they're done badly, you tend to alienate residents and you get bad decisions.


And, it links to the sense of control, because human beings really do need to have agency over what happens to them and when they don't, they become unwell in the most extreme case. And, the desire for control includes the ability to choose what happens to us. Having a sense of mastery and knowing that what we do is meaningful, even when we choose not to control something, that is still us making a meaningful decision. So, it's a little psychological insight that can help us think about our practice in local government. So, for example, here's a case study from Northumberland, where the county council used what's called an, 'Asset-based community development model', ABCD, where you try to give power to the residents, and they did that through having world café events, where they brought everyone together and got people to identify local resources and connect people together, to get their ideas. And, people came up with the idea of, kind of, micro grants which they then subsequently established and they funded 75 projects, got over 1,000 people doing positive stuff in a community. Which uses our psychological insights about control, to change the way the county council did things.


So, to sum up. On social determinants, reducing poverty by providing excellent advice, encouraging living wage accreditation, encouraging anchor institutions to employ, train and buy locally. And, examining data for disproportionality, so that's, you know, do you have a disproportionate number of some-, a group with a particular ethnic or other characteristic and to take action to address any discrimination. On the environment, use your planning, licensing powers to work towards everyone having a secure, decent home with access via tree-lined, safe walking, cycling and electric public transport routes to employment green community child care spaces, and limit alcohol pollution and unhealthy food. And, on psychology, by having well designed community spaces, events and consultations you can facilitate people having a sense of control and connection with their community and services.


I've covered a huge amount of material, but there are other things that are important that I haven't had a chance to cover and so you may wish to give it some thought. Your registrars are point of contact for people at moments of upheaval, births, deaths, divorces, you might want to think about how you equip them with the information they need to support people at those vulnerable times. Child protection and development, I've hardly touched on it but it is absolutely crucial, because abuse, neglect and bullying is highly damaging to people's mental health, as is domestic and street violence. So, another area that's important to think about, but slightly beyond the scope of what I've been able to touch on today. Mental health and substance misuse services. Substance misuse is, obviously, part of public health which it devolved to local government and really important and often what's called a, 'Cinderella Service'. I haven't really touched on it today, but it's really important to consider it as well. And, this training I can do with the LGA in your particular council, with local data and more interactive. So, if you're interested in that, do get in touch. Please do complete this very, very short survey, only takes two minutes. Your feedback will help us to improve the service and do get in touch with me if you have any particular issues or you would like to talk about some bespoke training for your council. Have a great day and thanks so much for listening. Please do remember to write down-, I hope you've written down three things that you're going to do as a result of what you've heard today. Thanks very much.