Better Health For All

On 24^th January 2023, the Secretary of State for Health announced plans to develop and publish a Major Conditions Strategy in consultation with NHS England and colleagues across government.   This has meant the withdrawal of plans for a standalone 10 Year Mental Health Strategy.  There has been no government mental health strategy since 2011 and England is in danger of not only falling out of line with other UK countries but with the World Health Organisation recommendations.

The forthcoming strategy will bring together mental ill health with cancer, cardiovascular disease, chronic respiratory diseases, dementia, and musculoskeletal conditions. This presents a welcome opportunity to promote an integrated, person-centred and holistic approach to care and prevention. However, there are some key concerns that the Faculty and other stakeholders recognise. Importantly, we are still a long way from achieving parity of esteem for mental health, and particularly prevention – and losing an explicit focus on mental health may limit action on mental health overall.

With this in mind, we propose the following recommendations that will help to maximise the benefits of this new approach and ensure that an explicit focus on prevention and wellbeing promotion are maintained.

1. Resources must be rebalanced towards prevention and early intervention

The field of public mental health is much wider than treatment and clinical services on an individual level. Many people experience short and long-term damage to their mental and physical health as a result of stress, trauma and adversity. It is vital to understand the wider determinants of mental health and wellbeing, and to take preventative action to address the causes of poor mental health across the life course – this means universal action to promote good mental wellbeing in the whole population as well as early and targeted support for those affected by social disadvantage, material deprivation and trauma.

Without fully integrating primary prevention and wellbeing promotion into the prevention and management of long-term health problems, including mental health problems, there is a very real risk that the progress made over the last decade to understand and improve the psychosocial determinants of health[1] will be undermined. Furthermore, shifting focus and funding back to diagnosable conditions at the exclusion of population-level prevention and early help activity would only increase the prevalence of longer-term or more severe problems later on. There is strong evidence that investing in prevention represents good value for money, as well as supporting people to live well for longer.[2]

2. Prevention and early intervention must include action across the life course

People with mental health problems present much earlier than the majority of physical health conditions, with 75% of mental health problems presenting by mid 20s.  Prevention and treatment necessarily takes place earlier in the life course, and there is a risk that the focus on diseases of older age within the government’s Major conditions strategy will shift focus away from the early years and life course approach necessary to improve population mental health.

While action in the early years and childhood are key to early intervention and prevention, it is also important to ensure that people are able to access timely and appropriate support with issues causing stress or distress at any stage of their lives – such as bereavement, financial hardship, abuse or discrimination – whether they are in contact with mental health services or not.

3. Targeted action on preventing and treating major conditions in people with severe and enduring mental health problems

On average, people with severe and enduring mental health problems die 15-20 years younger on average than the general population and two thirds of these deaths are from preventable physical illnesses, including cancer and heart disease (Centre for Mental Health.). The determinants of physical and mental health problems often overlap; mental health problems disproportionately affect people living in poverty, those who are unemployed and who already face discrimination. Poor mental health also has a detrimental effect on health behaviours; for example, 40.5% of adults with SMI in England are smokers compared with 13.9% of the general population.

Recognising these inequalities and the inextricable link between physical and mental health is central to the Equally Well agenda, which is to treat care for mental health needs in the same way as other needs. Integrated Care Systems have a statutory duty to address inequalities and need to be supported by a strategy that gives due value to the relative and historic funding needs for mental health services compared to those for physical health conditions. A more holistic and integrated approach to care and prevention could have major benefits for individuals with severe and enduring mental health problems who have co-occurring health conditions that both contribute to their poor mental health and are exacerbated by it.

4. Promoting person- and community-centred prevention and care

if we are to reduce inequalities in the distribution of the major conditions we need to work with communities experiencing the poorest health, including those with severe mental illness and other inclusion health groups, to tackle underlying issues systemically. Approaches to prevention and care need to be coproduced, starting with good insight on what people’s needs are and how they can best be met.  The NHS statutory guidance on working with people and communities should apply to public health, prevention and the development and implementation of the Major Conditions Strategy.

To conclude, the psychosocial pathways to health have been well established and there are opportunities to be gained from this strategy.  Many factors that underpin good mental health and wellbeing are often the same as for physical health, and many prevention and promotion related policies and interventions could have joint benefit across all conditions. If the UK government is to realise the potential benefits of an integrated strategy, and the commitment to person-centred care, then the Long Terms Conditions strategy needs to be leveraged to assure parity of esteem, embed a psychosocial pathways approach and not lose focus on prevention of mental illness and promotion of mental health.

[1] Stansfield J, Bell R. Applying a psychosocial pathways model to improving mental health and reducing health inequalities: practical approaches. International Journal of Social Psychiatry. 2019 Mar;65(2):107-13.

[2] Policy paper: Prevention is better than cure: our vision to help you live well for longer. DHSC, 5 Nov 2018: https://www.gov.uk/government/publications/prevention-is-better-than-cure-our-vision-to-help-you-live-well-for-longer

Faculty of Public Health Public Mental Health Special Interest Group

February 2023