Redesigning the mental health system around people and communities
Words Nick Webb
Learning from crisis
At Innovation Unit, we take systems seriously. Do they put people and communities at the centre? How and why do they fail to meet needs? Whose needs do they prioritise and who gets left out? How might they be redesigned to deliver much better outcomes for people and communities?
Building on our deep interest in mental health, and drawing on insights from our work managing the National Lottery funded Living Well UK programme, we carried out in-depth interviews to gather perspectives on how the mental health system responded to the Covid-19 crisis and what kind of future system people wanted. We interviewed 28 people – those with lived experience of poor mental health, front line professionals, managers and leaders, and academics and commentators.
The system we have inherited – services in control
While some interviewees told us they received good support during the crisis, most told us of the difficulties they experienced in trying to access services when they needed them most, and how an increased focus on managing risk made services feel more paternalistic and less human. Some people were shut out completely.
We know from our work in Living Well that for a long time the system’s response to overwhelming demand (particularly in the statutory sector) has been to restrict entry to those who are the most unwell. This is done using: narrow criteria, ever higher thresholds, tiers, triaging, waiting lists, rigid pathways, and referrals and handoffs from one service to another. These practices make sense in a crisis, when resources are incredibly stretched, but they prevent access, not mental ill health, and shouldn’t be part of a post-recovery system.
A different and better mental health system – people and communities in control
We heard a powerful case for the importance of personal relationships and social networks in sustaining good mental health, and a compelling vision for the creation of informal, public spaces where vulnerability and suffering are normalised and people can simply be together to share stories of distress and hope.
In this vision, easy to access support is everywhere – talking to a friend, a life coach, going to a peer support group, creating art, enjoying a mindful garden, going to your GP, and, when needed, getting help from a mental health service. Support happens in informal and incidental spaces: pubs, hairdressers, barbershops, cafes, supermarkets as well as in more organised initiatives such as support groups and food banks. All are equally valid and trusted. All forms of support are invitational, and need and demand are embraced, not managed.
Bold and fast paced action to protect community mental health
Staying resilient to everyday suffering is going to be much harder for many people affected by the economic and social impacts of a post Covid-19 world. The rest of 2020 will bring increased mental health distress. Thousands will lose their jobs, possibly their homes, and winter will bring more loneliness due to likely localised lockdowns.
Urgent action is needed.
We think there are two key priorities for protecting community resilience and building mentally healthy communities.
1: Support English localities to deliver the community mental health framework, through new integrated multidisciplinary teams, enabled by technology, powered by staff from primary and secondary care, and the voluntary sector.
The community mental health framework sets out the case for change: too many people across the UK are struggling with their mental health but are not getting the help they need when and where they need it. Services are often highly medicalised and not designed to deal more holistically with the social and economic factors that affect someone’s mental health.
Living Well UK is a leading example of new community based multidisciplinary teams (MDTs) providing ‘easy in, easy out’ holistic, person-centred support, enabled by digital technology. New community models as described by the Framework and brought to life in Living Well systems are the strategically important place to focus local efforts of recovery and renewalI have written about Living Well and the community framework in more detail here.
2: Support local public health leaders and their partners to design and deliver new community-based initiatives
The pandemic has put public health up, front and centre in the national consciousness. As an immediate response, public health leaders pushed the powerful line: “Stay Home, Save Lives, Protect the NHS” and secured compliance with social distancing and separation to reduce risk, illness and death.
The narrative worked, but it has created anxiety and hypervigilance about social contact and the feeling that other people pose a threat to our wellbeing. As lockdown is eased, some people will overcome these feelings and reconnect with the social world. But many people will continue to regulate their proximity to others and worry about repeated spikes.
So what we need now is dynamic leadership in public mental health to deliver a set of new community-based interventions that emphasise connectedness, trust and mutual aid, prevent distress and protect community resilience. This could include:
- Mobilising local communities and civic action to support the most vulnerable groups, as furlough ends and winter approaches. Inspiration can be taken from the Government’s call out for volunteers to help the NHS.
- Helping create new networks of community spaces such as barbers, libraries, and cafes in every locality, that are mental health informed and offer compassionate conversations. These spaces could invite people to talk about their mental health without referrals or thresholds and based on the core principle that communities are made up of people who both give and receive support to one another.
- Investing in programmes that build people’s capacity for self care and care for others. It is clear that we live in a society where people find it difficult to wish themselves and others well. New, evidence-based initiatives for building our internal systems for self care are available, and need to be scaled to new places.
No time to lose
There is no time to lose… we must implement new solutions that can at least limit the damage to come and at best open up meaningful and fulfilling care and support to everyone. These new solutions must embody a new and different system; one that focuses most of all on community resilience and community powered health.
Read the report: From crisis to renewal: redesigning the mental health system around people and communities.
If you share our vision and ambition, please get in touch.