Mental Health and Wellbeing Strategy Meeting Agenda 1.Introductions

Mental Health and Wellbeing Strategy Meeting Agenda 1.Introductions

Mental Health and Wellbeing Strategy Meeting Agenda 1.Introductions Key Stakeholders 2.Strategy Highlights and Key Issues 3.New Partnership Steering Group and Governance Arrangements 4.Service User and Carer Involvement 5.Membership of Work Stream Implementation Groups 6.Next Steps 1 Mental Health and Wellbeing in Gloucestershire CONTENTS 1. 2. 3. 4. 5. 6. 7. Introduction National policy context Local strategic context Local outcomes information Local needs assessment Vision, aims and gaps identified Governance and Implementation Planning Appendices

1 Organisations and individuals involved in the development 2 Service user views 3 References and key supporting documents 4 Examples of vulnerable people 5 Definition of Recovery 2 1. Introduction This document outlines Gloucestershires response to No Health without Mental Health and supports the countys Joint Health and Wellbeing Strategy Fit for the Future and Your Health, Your Care by focusing on plans to improve outcomes relating to the mental health and wellbeing of children, young people and adults in the county. It is an overarching strategy which has been developed with input from representatives of the statutory and voluntary sector in Gloucestershire and incorporates views of users of mental health services and their carers (Appendix 1). It has also been guided by the provisions of No health without mental health: implementation framework which provides recommended actions to bring about improvements in mental health and wellbeing for individuals. The purpose is to provide a set of high level Gloucestershire aims which; - take account of work already in place - identify gaps in planning and; - sets out a governance framework for monitoring both the development of detailed implementation plans where required and progress against them. More detailed action plans or commissioning frameworks are in place for a number of areas or will be developed lead by the relevant organisations where required. These will be mapped in the development of the implementation plans.

This document focuses on the six national objectives to improve mental health outcomes for individuals and the population as a whole. 3 2. National Policy Context No Health Without Mental Health1 sets out six objectives for mental health and wellbeing: 1) More people will have good mental health More people of all ages and backgrounds will have better wellbeing and good mental health. Fewer people will develop mental health problems by starting well, developing well, working well, living well and aging well. 2) More people with mental health problems will recover More people who develop mental health problems will have a good quality of lifegreater ability to manage their own lives, stronger social relationships, a greater sense of purpose, the skills they need for living and working, improved chances in education, better employment rates and a suitable and stable place to live. 3) More people with mental health problems will have good physical health Fewer people with mental health problems will die prematurely, and more people with physical ill health will have better mental health. 4) More people will have a positive experience of care and support

Care and support, wherever it takes place, should offer access to timely, evidencebased interventions and approaches that give people the greatest choice and control over their own lives, in the least restrictive environment, and should ensure that peoples human rights are protected 5) Fewer people will suffer avoidable harm People receiving care and support should have confidence that the services they use are of the highest quality and at least as safe as any other public service. 6) Fewer people will experience stigma and discrimination Public understanding of mental health will improve and, as a result, negative attitudes and behaviours to people with mental health problems will decrease. 4 The No Health without Mental Health: Implementation Framework 1 recommends evidence-based actions for the NHS, other public services and employers. The framework details how success will be measured and how future work on outcomes indicators will be taken forward nationally. It proposes a mental health dashboard which will map the most relevant indicators from the three main outcomes sets (health, social care and public health) to the strategy. The proposed national outcomes indicators are set out below: (1) More people have better mental health (2) More people will recover

(3) Better physical health 1 Self-reported wellbeing (PublicHealthOoutcomesFramework) 2 Rate of access to NHS mental health services by 100,000 population (Mental HealthMinimumDataSet) 3 Number of detained patients (MHMDS) 4 Ethnicity of detained patients (MHMDS) 5 First-time entrants into Youth Justice System (PHOF) 6 School readiness (PHOF) Emotional wellbeing of looked after children (PHOF, Placeholder) 7 Child development at 2-2.5 years (PHOF, Placeholder) 8 IAPT: Access rate (IAPT Programme) 9 Employment of people with mental illness (NHS OutcomesFramework) 10 People with mental illness or disability in settled accommodation (PHOF) 11 The proportion of people who use services who have control over their daily life (AdultSocialCareOutcomesFrame work) 12 Improving Access to Psychological Therapies Recovery

Rate (IAPT Programme) 13 Excess under 75 mortality rate in adults with severe mental illness (NHS OF & PHOF, Placeholder) 5 (4) Positive experience of care and support (5) Fewer people suffer avoidable harm (6) Fewer people experience stigma and discrimination 14 Patient experience of community mental health services (NHS OF) 15 Overall satisfaction of people who use services with their care and support (ASCOF) 16 The proportion of people who use services who say that those services have made them feel safe and secure (ASCOF) 17 Proportion of people feeling supported to manage their condition (NHS OF) 18 Indicator to be derived from a Childrens Patient Experience Questionnaire (NHS OF, Placeholder)

19 Safety incidents reported (NHS OF) 20 Safety incidents involving severe harm or death (NHS OF) 21 Hospital admissions as a result of self harm (PHOF) Suicide (PHOF) 22 Absence without leave of detained patients (MHMDS) 23 National Attitudes to Mental Health survey (Time to Change) 24 Press cuttings and broadcast media analysis of stigma (Time to Change) 25 National Viewpoint Survey discrimination experienced by people with MH problems (Time to Change) 6 The No Health without Mental Health: Implementation Framework also recommends evidence based actions for the NHS: Providers of mental health services Commissioners of mental health services Providers of acute and

community health services Focus on improving equality access and outcomes. Appoint a mental health lead at senior level. Ensure clinical and other staff are able to spot the signs of mental ill health (especially A&E). Implement NICEs quality standard on service user experience in adult mental health and the Youre Welcome standards for young people. Ensure needs of whole population, including seldom-heard groups are assessed and the right services commissioned to meet those needs. Protocols for sharing information with carers. Strengthen clinical practice, risk management and continuity of care. Use NICE quality standards and guidance from the Joint Commissioning Panel for Mental

Health. Orient services around recovery. Effective commissioning in key areas of transition and early intervention. Improve the physical health and wellbeing of people with mental health problems. Support greater choice, including that of treatment and of providers through AQP. Improving mental health of people with long term physical conditions. Commission innovative service models to help improve the mental health of people with long term physical conditions and medically unexplained symptoms. Develop liaison psychiatry services. Support local work to prevent suicide and manage self harm. Primary care providers Improving access to support services, including peer support and

befriending organisations. Improve the identification of people at risk of developing mental health problems. Identify and treat co-morbid physical and mental illness. Increase access for groups with known vulnerability to mental health problems. Good practice in care planning, including transitions. 7 And for other organisations and public bodies: Health and Wellbeing Boards Social Services Childrens services A robust JSNA ensuring mental health needs are properly assessed. Work alongside CCGs to remodel existing support to focus on early intervention, service integration, personalisation and recovery. Work alongside CCGs, schools and wider childrens services to focus on

early intervention and integrated support. Encourage joint commissioning. Better joining up of health, social care and housing support. Improve emotional support for children on the edge of care, looked after and adopted children. Community groups and user led organisations to feed into needs assessment. Ensuring the mental health needs of older people are identified and acted upon. Consider a named Board member as lead for mental health. Healthwatch to ensure that people who use mental health services are recruited as part of their membership. Crown prosecution service Schools and colleges

Public health services Ensure they are aware of the options available to enable treatment for offenders. Support children and young peoples wellbeing. Develop a clear plan for public mental health. (Incorporating three tier approach ; universal, targeted, early intervention). Provide access to targeted evidence based interventions for children with or at risk of developing emotional and behavioural problems. Tackling bullying. Health improvement efforts to include the specific physical health needs of people with mental health problems. 8 3. Local strategic context Two key strategic documents have been developed in Gloucestershire, including elements specifically relating to mental health and wellbeing: Health and Wellbeing Strategy Fit for the

Future Poorly performing (compared with LA family comparators) indicators from the JSNA plotted across life stages and used to identify four priority areas. These are: Promote healthy lifestyles across the life course Reduce long term conditions and premature mortality Improve mental health and resilience Improve the socio-economic determinants of health These are intended to become the work programme for the strategy over the next 20 years. Your Health, Your Care Strategy Recovery focussed approach Support for mental health needs of people with long term conditions Integrated approach to address physical and mental health needs Strategic Initiatives: 1) Primary mental health care and IAPT pathway intermediate care team development 2) Recovery focussed care pop up recovery colleges

3) Extending mental health liaison services 4) Housing and employment In addition the Children and Young Peoples Partnership Plan is in place with a focus on: Looked After Children (LAC) and care leavers Children requiring safeguarding Children subject to the effects of Poverty Children living in challenging circumstances (Including those children, affected by, domestic abuse; young carers; substance misuse; mental health issues; complex needs; those in chaotic families(CCC) Children and Young People with Learning difficulties and Disabilities/ Complex Needs (CYPwLDD) 9 4. Local Mental Health outcomes information A review of the Gloucestershire position against the proposed outcomes measures (measures are not yet available for all indicators) in the Implementation Framework shows: More people will have better mental health Subjective wellbeing (ONS 2012) better than national rates (Life satisfaction 7.54 vs. 7.4; Life worthwhile 7.74 vs. 7.66; Happy 7.3 vs. 7.28; Anxious 2.95 vs. 3.15) Access to NHS mental health services (MHMDS)- rate (2010/11) higher than national (3264/100000 vs. 2789) Formal inpatient detention (MHMDS) - rate (2010/11) lower than national but similar to peers (36.8% vs. 40.9% vs. 37.9%) IAPT access (IAPT Key Performance Indicators)- rates for Q2 and provisional Q3 of 2012/13 are showing some improvement compared to England rates (Q2- 2.2% vs. 2.5% and Q3 2.6% vs. 2.4%) First-time entrants into Youth Justice System (Child Health Profile 2012, ChiMat))- rate lower than national (1120/100,000 vs. 1160/100,000) More people will recover People with mental illness/disability in settled accommodation proportion of adults on CPA receiving secondary MH services in settled accommodation (ASCOF 2011/12 Indicator 1H )is lower than national average - (38.6% vs. 54.6%) Employment of people with mental illness proportion of adults on CPA receiving secondary MH services in employment (ASCOF 2011/12 Indicator 1F) s lower than national average (7.8% vs. 8.9%) IAPT recovery rate: (IAPT Key Performance Indicators): the rate for Q2 and provisional Q3 of 2012/13 are above England rate (Q2 50.7%

vs. 45.9%; Q3 52.7% vs. 44%) Fewer people suffer avoidable harm Suicide rates (2008/10 pooled DSR/100,000)- Rates in the county (10.2) are similar to regional rate (8.9) but higher than national rate (7.9) (especially in males) Rates in females are similar to regional and national rates. (NHS Information Centre) Self Harm Admission rates Hospital stay rates (APHO, 2012) are higher than national rates (244.6 vs. 212))The highest rates are in adolescents and young adults, but there is an increasing trend for 30-34 and 35-39. Rates are strongly associated with deprivation with the highest rates in Gloucester and Cheltenham (Public Health intelligence Unit). Absence without leave of detained patients (Routine Quarterly MHMDS Report) rate of absences in 2FT generally lower than England average (Final Qtr. 4 2011/12 summary 2.8% vs. 3%) Fewer people experience stigma and discrimination Attitudes to Mental health survey- Gloucestershire residents hold more positive and supportive views on mental illness, have better understanding and are better informed that experience nationally (2FT Survey, 2008) 10 5. Local needs assessment 5.1 Mental Wellbeing Available wellbeing measures (ONS subjective wellbeing and self-reported measure of peoples overall health and wellbeing (NI 119)) suggest that Gloucestershire has a higher level of wellbeing compared to the national average, but there are significant variations within the county. 5.2 Risk/protective factors for and determinants of mental health. Generally the county does very well compared with the national experience, but Gloucester and Cheltenham have relatively high rates of many of the risk factors for mental ill-health e.g. deprivation, unemployment, substance misuse, low levels of physical activity, crime etc. Other factors do not follow this trend e.g. Fuel Poverty which is high in FOD, Stroud and the Cotswolds, and LLI which is high in FOD. Rate of young people who are NEET is highest in Cheltenham. Visit the JSNA for more details at: http://jsna.gloucestershire.gov.uk/Programmes/public-health/Mentalhealth/Pages/Library.aspx 11

5.3 Emotional Health and Wellbeing of Children and Young People The most recent national survey of child mental health carried out in 2004 revealed the impact of mental health problems in childhood, with 1 in 10 children between the ages of 5-16 years identified as having a clinically diagnosed mental disorder. Population studies suggest that there may be up to 4,480 children and young people aged 5-16 years in Gloucestershire with Conduct Disorder, 3,634 with Emotional Disorders, 1,183 with Hyperactive Disorders and 1,099 with less common disorders. It is estimated (No Health without Mental Health) that 50% of lifetime mental health disorders are developed before the age of 14 and this can have profound effects on the child, their family and wider society. A growing body of evidence is showing that good parental mental health is significantly associated with good child development outcomes, particularly social, behavioural and emotional development. The quality of the relationship between parents, the quality of care given to a baby, and the attachment that develops between infants and their parents are significantly linked to children and young peoples learning and educational attainment, social skills, self-efficacy and self-worth, behaviour, and mental and physical health throughout childhood and later adult life. Children and young people who are at an increased risk of developing mental health disorders include a number of those that are more vulnerable, who are taking risky behaviours, have long term conditions and both physical and learning disabilities. Emotional Development in Younger Children the Early Years Foundation Stage Profile gives a good indication of emotional development in younger children The percentage of children in Gloucestershire achieving relevant scores was higher than regional and national average scores. However there is considerable variation around the county. Emotional Health and Wellbeing of Children and Young People Survey 1 - Gloucestershire had a higher level of good emotional health and wellbeing compared with regional and national rates . 12 Bullying and feeling safe- bullying can be a cause of mental health disorders such as anxiety and depression, and could lead to self-harm in extreme cases. The latest On Line Pupil Survey 1 showed that the majority of pupils felt safe at school. The trend regarding pupils experience of serious bullying differed between year groups. There was an increase in the proportion of primary school pupils reporting serious bullying between 2006 and 2012 and a decrease among secondary school pupils in the same period. Pupils with a disability, young carers, those entitled to free school meals, pupils with special educational needs and

those from non British-white backgrounds were found to be less likely to feel safe and more likely to have experienced bullying or known of/experienced domestic abuse. The majority of pupils had not thought about deliberately hurting/harming themselves. Several groups of pupils were found to be at higher risk, however. They were those who had experienced bullying, carers, pupils with a disability or special educational needs. A review2 of the emotional health and wellbeing of children and young people in Gloucestershire in 2009 showed that: There are pockets of deprivation where the prevalence of emotional difficulties is expected to be higher than other areas There were some gaps in service provision There was a need for earlier intervention and access to services as well as more focussed community care for those with complex and severe needs. Some more vulnerable groups more prone to mental health difficulties such as Looked After Children, and children with disabilities including learning disabilities had unmet needs Mental health services for children and young people in Gloucestershire were redesigned and recommissioned in 2011 in response to identified needs. Online Pupil Survey 2012 Summary Report, Strategic Need Analysis Team, Gloucestershire County Council 1 Tellus4 survey, 2009/10 http://www.dcsf.gov.uk/rsgateway/DB/STR/d000908/OSF04_2010.pdf 2 13 5.4 Mental Health Problems in Adults Common Mental Health Disorders Rates of anxiety and depression are high in the county with prevalence highest in Cheltenham and Gloucester: Serious Mental Health Problems

As a county, our rates are lower than national averages, but specific wards in the county experience rates that are higher than national ones (i.e. seven in Gloucester- Westgate, Barton and Tredworth, Matson and Robinswood, Moreland, Kingsholm and Wotton, Grange, Podsmead; four in the FoD Cinderford East, Cinderford West, Lydney East, Lydney North;, two in Cheltenham St. Marks, Pitville; , one each in Cotswold Cirencester Watermoor and Stroud districts Central). Dementia The Dementia rate recorded on GP registers is higher in Gloucestershire than regional and national rates. Even with this, it is known that less than half of older people predicted to have Dementia in Gloucestershire in 2011 were on GP registers (3,485 vs. 8,395). Furthermore, the rate in Gloucestershire is set to rise at a higher rate than nationally over the next decade or so. More details can be found in the JSNA at http://jsna.gloucestershire.gov.uk/Programmes/public-health/Mentalhealth/Pages/Library.aspx 14 5.5 Use of Health/Mental Health Services http://www.mhmdsonline.ic.nhs.uk/statistics/ Use of Outpatient and Community Mental health Services measured as specified contacts as a proportion of all contacts over the period 2006/7 to 2010/11: Psychiatrist contacts which had been historically higher than peers is now similar to them CPN contacts which were initially lower have increased in recent years and is now higher than peers Contacts with Psychologists have historically been lower than peers but is now approaching peer experiences Social worker contacts have been varied over the years when compared with peers, with this being lower in 2010/11 OT contacts have been consistently lower than peers Physiotherapy contacts have been historically higher than peers but now similar to peers Psychotherapy contacts which were lower than peers are now higher. For people on Care Programme Approach, over the five year period 2006/7 to 2010/11, the use of various teams has varied compared with peers. This is recorded as activity of specific teams as a proportion of total open cases at the end of the year: General adult psychiatry which was historically higher than peers has fallen below recently Old Age psychiatry has been consistently higher than peers

Substance misuse has been consistently lower than peers Crisis resolution has been consistently lower than peers Assertive Outreach has been mainly higher than peers except for 2008/9 Early Intervention higher than peers Formal detention rates are lower than national rates. There is a great variation in prescriptions of antidepressants and anxiolytics within the county which is not related to need. Gloucestershire has a higher rate of benzodiazepines prescriptions at primary care level compared to regional and national rates. 15 5.6 Stigma Gloucestershire residents generally have a more positive and supportive view of mental illness, and are better informed than the national experience. Females, younger people, married people and professionals were more likely to have a positive attitude to mental health. Fewer people than nationally felt there were sufficient existing services for people with mental illness. Media that are most effective for influencing views locally are TV news, other TV programmes, national newspapers, TV soaps and plays. 16 6. Vision, aims and gaps identified This section sets out the high level aims for Gloucestershire, mapped against the No Health without Mental Health objectives. The aims for each objective incorporate gaps identified through the Steering Group. 6.1 More people will have good mental health Improving mental wellbeing of individuals, families and the general population reducing the social and other determinants of mental ill health across all ages. Starting well, developing well, working well, living well and aging well. In line with the Health and Wellbeing Strategy the vision for mental wellbeing takes a life course approach.

We aim to: Improve the mental wellbeing of vulnerable children Provide more support for parents and families to ensure children get the best start in life School-based mental health promotion initiatives Promotion of work place mental health initiatives Promote good mental wellbeing for all, including the most vulnerable groups, through increasing social connectivity by adopting an asset based approach to community building Affordable Warmth schemes Improve provision and take-up of welfare advice Improve access to psychological therapies throughout the life course Vulnerable* people - improve social networks/support for vulnerable groups including those in rural areas. Strategic approach to volunteering in the county. Improve the population mental wellbeing through the promotion of the Five Ways to Wellbeing 17 *see Appendix 4 for examples Gloucestershire is committed to enabling everyone to have better mental health. Public Health are developing a Public Mental Health Plan that aims to work in partnership with the public, private and voluntary sector to deliver a number of interventions that will improve peoples mental wellbeing and prevent the incidence of mental ill health occurring. 18 6.2 More people with mental health problems will recover Tackling emerging and ongoing problems, as well as acute distress, to help people have a good quality of life. A shared understanding of the meaning of recovery is defined in Appendix 5 Within the context of the understanding of recovery, increase the number of people who recover by: Improving opportunities for education, training and employment and support people to

access these Improving housing choices for people with mental health problems Improving access to services in rural areas e.g. transportation (or community based/provided services) Provide effective support for carers (including young carers) Whole family support where a parent experiences mental ill-health. This is a vulnerable group that frequently remain hidden from services. Services to be effective and recovery oriented Improve the recovery rates from treatment (clinical outcomes measures) Improve support for lifestyle choices and access to mainstream services 19 Case study (Recovery) Sarah is a 49 year old woman who has lived with a severe mental health condition for most of her life. Sarah was connected with an Occupational Therapist who works within a third sector organisation that specialises in supporting people with MH conditions to recover. Initially Sarah was agoraphobic, lacked confidence and all activity was prescribed by others. Sarah was supported to identify her own recovery goals that were important to her and to identify steps that she could take to reach those goals. This process was client led rather than service led and focussed on Sarahs strengths and passions rather than taking the more traditional deficit approach. Sarah is now able to travel independently, makes her own decisions, is independent in all activities and regularly volunteers with a local organisation that requires excellent communication skills. Sarah is able to identify some of the triggers that can make her ill and is able to manage these effectively. 20 6.3 More people with mental health problems will have good physical health Fewer people with mental health problems will die prematurely and more people with physical ill health will have better mental health. Integrate care pathways across primary care, mental health, planned and unscheduled care services

for all long term conditions to reduce physical and mental co-morbidity and ensure a person is considered holistically and as an individual (ensure patient experience is a key measure of the success of integration) Improve access to psychological therapies for medically unexplained symptoms and long term conditions Increase partnership work across statutory, voluntary and community and private sectors (employers) to achieve aims around early detection and access to treatment. Improve access to specialist support and treatment and increase community based alternatives to inpatient care 21 Case study (People with mental health problems will have good physical health) Stuart is a 55 year old man who has had a severe mental health condition throughout his life. He has often managed his emotional issues through comfort eating and has become morbidly obese and is a type 2 diabetic. Stuart was referred to a 6 week Kitchen Challenge programme. The Kitchen Challenge programme uses cooking as vehicle for communicating wider messages such as: team work, improving confidence, daily organisational skills and being exposed to challenges that people havent experienced before. Participating in the Kitchen Challenge enabled Stuart to identify his skills and strengths and recognise his potential. This led to an increased feeling of self worth and confidence which contributed to a sense of improved wellbeing. He felt able to engage in health changing activities and has lost a significant amount of weight, has well controlled diabetes and is physically active. With an improved sense of wellbeing, Stuart was confident enough to work with his living companions and challenge the way in which they ate within the supported housing environment. Supported by the staff, Stuart led the change in how the house ordered, purchased, cooked and budgeted for their meals based upon the healthy eating principles he had learnt during the kitchen challenge programme. Meals are now chosen, cooked and eaten together. 22

6.4 More people will have a positive experience of care and support focusing on choice, control and personalisation; improved experience for children and young people including during transition to adult services; promoting equality and reducing inequality Listen and learn from patient and carer experience and satisfaction monitoring and taking action to improve the service experience Take action to ensure that choices and options in services are fully accessible and understood by people according to their needs Increase the personalisation of care and services Improve the involvement of people experiencing mental ill health and carers (including young carers) in the planning, delivery, monitoring and evaluation of services Ensure appropriate access to comprehensive advocacy services Improve transition from child to adult mental health services 23 6.5 Fewer people will suffer avoidable harm Fewer people suffering avoidable harm from the care and support they receive; fewer people suffering avoidable harm from themselves; fewer people suffering harm from people with mental health problems and improving safeguarding of adults, children and young people. Reduce suicide rates Working in partnership (for instance with planning authorities to reduce avoidable harm from jumping from high places) Reduce self-harm incidents and admission rates Robust Safeguarding and Governance mechanisms across all health and social care commissioned services Improve the reporting of and learning from serious incidents across all health and social care services Improve the processes and understanding / mental health workforce training and development around risk assessment (including the need for self management and positive risk taking)

Training and support for the carers of and people who work with Looked After Children especially related to children who have traumatic experiences, children and young people with disabilities and challenging behaviour. 24 Case study (Fewer people will suffer avoidable harm) Fiona is a 28 year old lady who was referred to the ASPIRE project by her GP. The ASPIRE project is designed to support people who have a long term condition to gain key skills that will enhance their employability. Fiona has a history of childhood and adulthood abuse and repeatedly self harms. She is keen to enter into work but is worried that because she self harms regularly this will make it difficult to find a job. Fiona also faces a number of socioeconomic barriers as a result of being in receipt of benefits that cause her anxiety levels to increase which has a negative impact on her self harming. Staff supported Fiona to navigate her way through the numerous financial barriers that she faced. Fiona worked with the staff at the ASPIRE project to identify the specific issues in her life that led her to feel unhappy and self harm. She was supported to access specialist help to address some of the issues whilst continuing to engage with the ASPIRE project. Working on a one to one basis and taking a strength based approach, the staff at ASPIRE enabled Fiona to identify her skills, talents and passions rather than focussing on the negative issues in her life. Fiona is still working with the staff at ASPIRE and receives specialist support from the mental health services, however she has learnt to manage some of the triggers that have caused her to self harm in the past and has begun a volunteering job that has helped to build her confidence and gain further skills. 25 6.6 Fewer people will experience stigma and discrimination Public understanding of mental health will improve and, as a result, negative attitudes and behaviours to people with mental health problems will decrease. Positive action to influence attitudes towards mental ill health Enable all people to seek help when they need it without fear of stigma or discrimination

Develop initiatives to reduce isolation and improve wellbeing in all our communities Support community development approaches Increase availability of individual employment support services 26 Case study (Fewer people will experience stigma and discrimination) Gloucestershire is committed to promoting the well being and social inclusion of all citizens with mental health problems, their carers and families. Various interventions across all Health and Social care services aim to enable people with mental health problems, their families and carers, to live as full and equal citizens of their local communities, recognising their rights to independence and self determination at the same time as respecting the rights of local communities. Mental Health First Aid is one such intervention and is being implemented across priority groups within Gloucestershire with the aim of raising awareness of how to support someone with a mental health problem with the expectation that increased knowledge leads to reduced levels of misunderstanding and a reduction in stigma. 27 7. Governance and implementation planning The preceding sections set out high level actions across a broad range of objectives. It is important to acknowledge that actions to deliver improvements in many of these areas are already in place in the county. A key objective for the development of this strategy has been to align strategies which impact on emotional health and wellbeing to set out a joined up Gloucestershire approach. This section sets out: a)Proposed governance arrangements. b)Summary of actions and objectives and routes for developing and/or reporting on implementation plans 28

7a) Proposed governance arrangements It is proposed to establish a Mental Health and Wellbeing Group reporting into the Health and Wellbeing Board: Gloucestershire Health and Wellbeing Board Gloucestershire Mental Health and Wellbeing Group Purpose Review and approve implementation plans. Receive reports from implementation leads and track progress. Ensure alignment of plans across organisational boundaries. Proposed Membership: Clinical Commissioning Group Public Health County Council District Councils (Housing / Wellbeing) Voluntary and Community Sector Representative(s) Mental Health Service User and Carer representation Service provider(s) Criminal Justice Employment Education Healthwatch - Chair to be nominated by Health and Wellbeing Board

- Terms of reference for Mental Health and Wellbeing Group to be developed once basic governance structure agreed. - Group to meet quarterly - Many of the work streams impacting on mental health and wellbeing also relate to other areas of wellbeing and it is not intended to create duplicate / multiple reporting routes. - Named senior leads to be nominated by the relevant organisations and be responsible for reporting back to their organisation Underpinned by: - Needs Assessment - Views of service users and carers - Equalities Act Requirements Service user network 29 7b) Implementation planning The development of an implementation plan which sets out all the different organisations key actions and objectives and maps against any current implementation forums is a vital next step in the process. It is proposed that the establishment of a new Mental Health and Wellbeing Group with representation from users and carers and membership from across the range of public and voluntary sector organisations in the county including Healthwatch lead on the implementation of the actions set out in the national strategy and develop the implementation plan for the objectives

identified in this local strategy document. It is proposed that this group develop a number of action cards and track the development of, and progress against these through the relevant implementation groups and report back to the Health and Wellbeing Board on the overall progress against plans. 30 Appendix 1 Organisations and individuals involved in development Gloucestershire VCS Assembly supported a steering group with broad membership of the statutory and voluntary sector: Peter Steel - Independence Trust Gillian Skinner - Gloucester City Council Bren McInerney - Barton and Tredworth Community Trust Hannah Williams - NHS Gloucestershire Di Billingham - NHS Gloucestershire Helen Bown - NHS Gloucestershire Eddie ONeil- NHS Gloucestershire Jane Melton - 2gether NHS Foundation Trust Erica Smiter - People and Places in Gloucestershire CIC Karl Gluck -Gloucestershire County Council Les Trewin - 2gether NHS Foundation Trust Lorna Carter Rethink Mental Illness Mandy Bell - Gloucestershire Young Carers Mark Branton - Gloucestershire County Council Pete Carter - NHS Gloucestershire Philip Booth -Guideposts Trust

Rachel Fisher - Carers Gloucestershire Simon Bilous - Gloucestershire County Council Sophie Reed Rethink Mental Illness Steve ONeil NHS Gloucestershire Sue Cunningham - GL Communities Trish Thomas - Survivors of Bereavement by Suicide Alex Dennison - Gloucestershire Probation Trust Corrine Cooper - Stonham Jem Sweet - Scout Enterprises Sola Aruna - Public Health Tim Poole - Carers Gloucestershire 31 Sub groups were established to consider each of the national strategy objectives: More people with good mental health Hannah Williams Lead Sue Cunningham Peter Steel Karl Gluck Mandy Bell Increase recovery rates Les Trewin - Lead Peter Steel Karl Gluck Steve ONeil Physical health/mental health

Peter Steel Lead Erica Smiter Helen Bown Care and support Karl Gluck Lead Erica Smiter Rachel Fisher Reduce people suffering avoidable harm Sophie Reed - Lead Trish Thomas Sola Aruna Reduce stigma/discrimination Jane Melton Lead Gillian Skinner Bren McInerney 32 Appendix 2 Views of mental health service users in Gloucestershire Rethink were asked to consult with mental health service users across Gloucestershire. In conjunction with Commissioners Rethink developed a series of simple questions based on the overarching outcomes of the national strategy (No Health, without Mental Health). An overview of the themes included in responses* is given below: How can we ensure everyone has good mental health? Professional support Mental Health promotion Intervene early (childhood) Talking therapies

Good housing Education Change at a societal level (Consumerist culture/media images) How can we help people with mental health problems improve their physical health? Better communication with GPs Education on environment Activities e.g. walking and gardening Access to gyms/training e.g. gender specific classes, support to access. Medication e.g. issues related to long term use of medication and side effects. How can we help people recover from mental health problems? Attitudes/Interpersonal skills: Staff attitude towards illness and recovery was not always helpful. Improve training. Medication: Over reliance on medication as main treatment. Not enough information on how long people are required to stay on the medication and what the long term side effects could be Psychological Therapies: Increase availability and types of therapy available. Communication: Need for improved communication between professionals. Carers: Increased support for Carers. Peer Support: Development of a range of peer support (group/individual/expert by experience) Occupation/Work/Activity: Improve access to facilities/services that can support these areas

33 *It should be noted that the overall numbers of people that attended meetings, gave feedback via telephone/web survey are relatively small and largely limited to individuals who use working age services. How can we help people to have better experience of care? How can we help people avoid harm? Knowing what people are entitled to and how to access it (Rights) Better support out of hours Reduce fragmentation of services Improved training for staff Face to face contact Regular contact Social networks, friendship and structure Intervene early How can we reduce stigma and discrimination? Education in schools Work with employers (incl. NHS) Use celebrities to promote positive mental health. Mental Health radio station Overarching Themes Treatment and Psychological Therapies Feedback indicated that people felt that there was still a reliance on medication and that other therapies were not always available in a timely fashion. Peer Support/ Expert Patients Experts by experience programme could provide examples of positive role models to existing Service Users to aid recovery. More

peer groups as a means for Service Users to support each other. Community Support Helping people to develop support networks in their communities. Education in Schools This came across in response to a number of questions in relation to improving mental health, reducing stigma. Employment Improved access to work related activities as a means to improving mental health and aiding recovery. 34 Appendix 3 References and key supporting documents No Health without Mental Health No Health without Mental Health Implementation Plan Gloucestershire Fit for the Future Gloucestershire Your Health Your Care Gloucestershire Children and Young Peoples Partnership Plan Gloucestershire Children and Young Peoples Emotional Well Being Strategy Report to NHS Gloucestershire and Gloucestershire County Council: An Overview of the use of Recovery, Social Inclusion and Wellbeing approaches in the delivery of mental health services for people receiving long-term support, NTDI ,November 2010 Advocacy Strategy 2008-2011 Ageing Well in Gloucestershire (Draft) Barnwood Trust Unlocking Opportunities 2011 2021 Building Recovery in Communities Carers Strategy 2007 Commissioning Framework for the Transition of Social Care 2010-15 Commissioning Framework for Transformation 2010-2015 Commissioning Talking Therapies for 2011-12 County Alcohol Strategy Crime and Disorder Reduction Partnership Three Year Delivery Plan 2008-11.

Delivering Race Equality Draft Transitions Protocol Dual Diagnosis Strategy Early Intervention and Prevention Strategy 2010-2013 Equality Schemes for statutory bodies 35 Extra Care Housing in Gloucestershire a Strategy for the Future (2011 Fair Access to Care Services Gloucestershire Drug Strategy Plan 2010-2013 Gloucestershire Carers and Young Carers Strategy Gloucestershire Carers Multi Agency Strategy Gloucestershire Child Death Review Process Gloucestershire Child Protection Procedure Gloucestershire Children and Young Peoples Plan Gloucestershire Health ad Social Care Community Prevention And Early Intervention Strategy 2010 2013 Gloucestershire Health and Wellbeing Strategy and action cards Gloucestershire Homelessness Strategy 2008-11 Gloucestershire Hospital Carers Policy- developed from Gloucestershire Carers Strategy Gloucestershire Housing and Support Strategy for Offenders 2011-2016 Gloucestershire Public Health Annual Report 2010/11 Gloucestershire Safeguarding Adults Policy and Procedure July 2011 Gloucestershire Self Directed Support (SDS) Operational Policy Gloucestershire Social Inclusion Strategy Gloucestershire Suicide Prevention Strategy 2011 Gloucestershire Supporting People Strategy 2011-2015 Gloucestershires Alcohol Harm Reduction Strategy 2010-13 Gloucestershires Multiagency Mental Health for Social Inclusion Strategy (launched 2009) GSSJC Plan Homeless and Housing strategy in Gloucester

Housing Strategy 2005 2010 Joint Commissioning Strategy for Older People 2007-2016 Joint Strategic Commissioning Plans 2010-13 36 Local Strategy for Employment of people recovering from Mental Illness Market Management Strategy 2009-13 Maternal Depression Strategy 2005-2010 Mental Health and Social Inclusion Strategy for Gloucestershire Mental Health commissioning strategy 2008-12 Preventing Suicide in Gloucestershire A Strategy for Action 2006-10 (Gloucestershire Healthy Living Partnership) Prevention and Early Intervention Strategy 2010-13 Probation Accomodation Strategy Promoting Childrens Mental Health within Early Years and School Settings Safe and Confident Neighbourhoods Strategy: Next Steps in Neighbourhood Policing Safeguarding Adults Serious Case Review Policy Self Directed Support operational Policy Sexual health strategy Shaping our futures 2009-2017- Gloucestershire strategy to support over 50s needs in terms of Gloucestershire Sustainable Community Strategy Smoke-free Gloucestershire Action Plan Strategic framework for improving health in the south west Strategies in development: Strategy for maternal depression (2005 2010) Stronger and Safer Communities Plan 2010-2013 Gloucester Supporting People Strategy Supporting People Strategy 2011-2015 Tackling Obesity Strategy 2007-17 The Bradley Report.

The Corston Report The Dementia Strategy (revised 2009) The Education of Children and Young People with Behavioural, Emotional and Social Difficulties as a Special Educational Need paragraph 72 The Gloucestershire Integrated Economic Strategy 2009-15 Time to Change Transport strategy Tri-Nova Day Service Recommendations 37 Appendix 4 Vulnerable people refer to those who may be more likely to develop mental health problems. These include: Children and young people experiencing poor parenting Those who have suffered abuse and emotional neglect Those in contact with the youth and adult criminal justice system Children and young people underachieving in school Looked after children Early school leavers Young LGBT Homeless children and young people Children and young people who have suffered four or more adverse childhood experiences

Young/Teenage mothers Adults experiencing financial insecurities Homeless adults People misusing substances People experiencing domestic violence and abuse Adults experiencing civil emergencies e.g. floods People experiencing violent crime Adults out of work Older people experiencing social isolation People with long term physical health problems People with caring roles People living in residential care People experiencing Fuel Poverty 38 Appendix 5

A shared understanding of the meaning of recovery Report to NHS Gloucestershire and Gloucestershire County Council: An Overview of the use of Recovery, Social Inclusion and Wellbeing approaches in the delivery of mental health services for people receiving long-term support, NTDI ,November 2010 Recovery embraces the following meanings: A return to a state of wellness (e.g. following an episode of depression) Achievement of a quality of life acceptable to the person (e.g. following an episode of psychosis) A process or period of recovering (e.g. following trauma) A process of gaining or restoring something (e.g. ones sobriety) An act of obtaining usable resources from apparently unusable sources (e.g. in prolonged psychosis) Recovering an optimum quality and satisfaction with life in disconnected circumstances (e.g. dementia) Recovery can therefore be defined as a personal process of overcoming the negative impact of diagnosed mental illness/distress despite its continued presence. Anthony Sheehan, then Director of Care Services, Department of Health (2004), Emerging Best practice in Mental Health Recovery

39

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