NSPA response to Prevention Green Paper, October 2019

The NSPA worked with policy teams from some of our members to inform our response to the Government’s Green Paper: Advancing our health: prevention in the 2020s – consultation document.

Which health and social care policies should be reviewed to improve the health of people living in poorer communities or excluded groups?

Living in poorer communities and being part of excluded groups is not only detrimental to physical and mental health, but as Samaritan’s ‘Dying from inequality’ report acknowledges, “as area-level deprivation increases, so does suicidal behaviour”. The response to this needs to be cross-governmental and is not solely about reviewing policy; the NSPA believes that there is much good policy across government, but there is little funding to implement it. Any funding review should ensure appropriate funding for local authorities, whose staff provide vital support for many people experiencing poor mental health or at risk of suicide. We also support the Centre for Mental Health’s call, in their ‘Briefing on social care funding’, for any new financial settlement to:
• Provide parity of esteem for mental health with other social service functions
• Secure fair funding for people of working age
• Resolve the confusion between health, housing and social care funding for people with ongoing care needs
• Enable local councils to invest for the future in their workforce and their community.

We also recommend a review of implementation of policy, to ensure that those in poorer communities and excluded groups are enabled and supported to access universal and early intervention services, including GPs, IAPT, Health Visitors, and school health teams. Those delivering these universal services must also have a better understanding of mental health and suicide prevention.

There are many factors affecting people’s mental health. How can we support the things that are good for mental health and prevent the things that are bad for mental health, in addition to the mental health actions in the green paper?

Local authorities and local areas are responsible for many of the things that we know make a positive difference to people’s mental health and wellbeing: physical activity, the physical environment, decent housing, employment and the local economy. Additionally, cuts to local services such as drug and alcohol services and domestic abuse services can have terrible impacts on the mental health and suicidal ideation of those that need them. The government should ensure that money for local authorities and local areas is commensurate to their role, particularly following the Samaritans/University of Exeter report into local suicide prevention plans, which found some ambitious and impressive plans, but that support is needed to enable them to be delivered.

Reaching people in the early years of their life will have an impact on their mental health throughout their lives, and health visitors make a crucial difference here. If they are supported with the time (and money) to make the most of the opportunities of being in people’s homes, to understand the challenges that families are facing and support the parents of very young children, that work would reap benefits for decades.

Have you got examples or ideas about using technology to prevent mental ill-health, and promote good mental health and wellbeing?

Various NSPA members are using technology to support mental health and prevent suicide, including:
• Stay Alive app – www.prevent-suicide.org.uk/stay_alive_suicide_prevention_mobile_phone_application.html
• Good Thinking London – www.healthylondon.org/resource/the-good-thinking-journey/
• Shout crisis text service – www.giveusashout.org/
• Isolutions to isolation – www.keep.eu/project/19362/isolutions-to-isolation
• Samaritans’ web chat service
• Using paid Google ads to target people searching for information around self-harm or suicide and directing them to support pages

However, whatever technological opportunities there are to support good mental health, it’s important to implement them in line with best practice and ethics around technology usage, ensuring that those implementing them are trained, and using them as part of blended care.

Have you got examples or ideas for services or advice that could be delivered by community pharmacies to promote health?

Community pharmacies are already alert to some issues around suicide prevention, including the hoarding of potentially dangerous medication. This could be further enhanced by standardised training in mental health awareness and suicide prevention, enabling staff to be more aware of possible signs of deterioration in mental health and what they could do in response to support or refer people. However, this must be based on strong evidence and consistency of approach. Our member Medicspot is already providing online access to GPs via pharmacies, and this kind of intervention could be further developed to include mental health and suicide prevention.

It would also be valuable to consider the co-location of pharmacies alongside GPs and non-clinical services such as debt advice, housing support, addiction services, and community activities. Communication, referral and social prescribing would be facilitated, all of which would have an impact on suicide prevention.

What could the government do to help people live more healthily: in homes and neighbourhoods, when going somewhere, in workplaces, in communities?

When thinking about helping people live ‘more healthily’, the NSPA would encourage government to ensure that their definition includes mental health as well as physical health.

For suicide prevention, loneliness and isolation can be key issues – both for older adults, but also young people, as DCMS’ Community Life Survey 2016-2017 found that young people aged 16 to 24 report feeling lonely more often than older age groups. This can be particularly problematic in rural communities where the lack of public transport, and high cost of what transport there is, contributes to physical isolation. Further support for local community building work, befriending schemes, and improved local transport would be of benefit.

Workplaces have a large role in supporting well-being and preventing suicide. There is good work being done by many of our members to deliver suicide prevention and mental health awareness training to private employers, and we are keen that growing numbers of employers support their staff. The government can continue to encourage businesses to develop this work, but also has a key role in ensuring that public sector staff nationally and locally, are also supported. This is particularly true in the health service, where some staff, particularly female nurses, are at a higher risk of suicide themselves (www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/articles/suicidebyoccupation/england2011to2015).

What is your priority for making England the best country in the world to grow old in, alongside the work of PHE and national partner organisations?

Older adults have a similar risk of dying by suicide to the rest of the population, but there is little research providing evidence of what the factors might be with this age group; possibilities include increasing physical health problems affecting mental health, lack of purpose post-retirement, bereavement, caring responsibilities, isolation, financial worries, or a complex combination of factors. It would be valuable to investigate this issue, to better inform spending nationally and locally on mental health and suicide prevention in older adults, and ensure that work to increase longevity also prioritises quality of life.

We do know that one in five over-65s is affected by depression yet older adults are less likely to use IAPT services (www.england.nhs.uk/mental-health/adults/iapt/older-people/). It is important for GPs and others in touch with older people to understand “symptoms often attributed to ‘old age’ but where a mental health diagnosis and follow-up is more appropriate” as NHS England recommend in their ‘Primer on Mental Health in Older People’ (www.england.nhs.uk/publication/a-practice-primer-on-mental-health-in-older-people/).

What government policies (outside of health and social care) do you think have the biggest impact on people’s mental and physical health? Please describe a top 3.

Suicide prevention needs a cross-government approach as a crisis can arise from a combination of factors, including poor physical or mental health, changes in employment, living conditions, social isolation, educational attainment and more. Our top three areas of concern are welfare reform, housing and employment, however issues as diverse as education, transport and communities/social inclusion will all affect suicide prevention. We are also aware that wider, international issues can also affect people’s mental health, such as climate change and Brexit, which could have wide-ranging negative impacts on issues connected to suicide prevention, including people’s livelihoods, families, communities and mental health.

Whenever government policies are revised to consider physical and mental health, thought needs to be given to how to measure the impact, and including key indicators in policy to enable that measurement. The idea of a Composite Health Index to track the nation’s health alongside GDP could be of benefit, but careful thought must be given to how it will be implemented and how it will then influence cross-government decisions.

How can we make better use of existing assets – across both the public and private sectors – to promote the prevention agenda?

The public sector workforce is a valuable existing asset, and the Making Every Contact Count campaign has potential to reach large numbers of people and promote the prevention agenda. It is vital, however, that mental health and suicide prevention is part of that, enabling any member of the public sector workforce to be able to have conversations around mental health, self-harm and suicide with anyone they are in contact with.

There is also potential if local and national government shifted towards more progressive use of their land and property; for example, by co-locating clinical services with non-clinical services such as debt advice, housing support, addiction services, as well as community activities. This would facilitate better communication, referral and social prescribing, all of which would have an impact on suicide prevention.

More progress could also be made by effectively implementing existing government policy – for example the Children and Young People’s Green Paper. The plans for school mental health teams could have a very strong impact on suicide prevention, particularly if the staff recruited have a strong understanding of self-harm and bereavement support. The impact would be even greater if the proposals become a universal offer, not just for a small proportion of schools.

What more can we do to help local authorities and NHS bodies work well together?

The Samaritans and University of Exeter report on the progress of local suicide prevention plans shows that local areas are trying to do more with fewer resources, and local authorities also have an important role in reaching the two thirds of people who take their lives but are not in touch with mental health services. They must therefore be given the financial support to do this.

The government could also promote the requirement for the NHS to work together with local areas, for example ensuring that NHS suicide prevention plans are co-produced, that any new NHS structural reform or strategy integrates mental health and suicide prevention, and NHS or government expectations of suicide prevention or bereavement support activity are appropriately funded to enable delivery.

The experience of the NSPA and our members is that health, mental health and suicide prevention are not just the work of local authorities and the NHS, but also benefit from the involvement of police, coroners, the voluntary and private sectors, including rail services. Government communication and funding should encourage and support partnership and co-operation between these diverse groups.

What other areas (in addition to those set out in this green paper) would you like future government policy on prevention to cover?

Suicide is a serious, and preventable, public health issue, and as such the NSPA and our members were disappointed it did not feature more prominently in the green paper. This process presents an opportunity to ensure suicide prevention receives more sustainable public health funding.

As suicide is a cross-government issue decisions made by Departments as diverse as the Treasury, Department for Education and the Ministry of Justice could all impact people’s well-being, however much of the thinking in this green paper seems to take a siloed approach. All new government policy should have tests in place to consider what impact they will have on health and mental health. The effective implementation of the Composite Health Index that is considered across all government departments as policy is made could help with this.

Data collection, including real-time suicide surveillance, can impact the speed and effectiveness of local suicide prevention responses and support for those bereaved and affected, who can be at higher risk of taking their own lives. Additional funding and support, and the exploration of a national data capture system, could allow local areas to further improve their suicide prevention work.

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