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Support for mental health and wellbeing

37. Transforming the NHS from a sickness to a health service is not just a matter of promoting physical health. Understanding how everyone in the NHS can promote mental wellbeing is equally important - and is as much of a cultural shift.

38. A coherent approach to promoting mental health needs to work at three levels:

  • Strengthening individuals: increasing emotional resilience through acting to promote self-esteem, and develop life skills such as communicating, negotiating, relationship and parenting skills.
  • Strengthening communities: increasing social support, inclusion and participation helps to protect mental wellbeing. Tackling the stigma and discrimination associated with mental health will be critical to promoting this increased participation.
  • Reducing structural barriers to good mental health: increasing access to opportunities like employment that protect mental wellbeing. 

39. Other chapters discuss action to support families and children, and set out how strong communities and healthy workplaces can promote mental wellbeing. The NHS's distinctive contribution centres on the close contact that so many staff have with people at times when they may be vulnerable and in special need of support - new mothers, people coping with serious family illness or bereavement, people experiencing domestic violence, or people facing the loss of a job and the loss of self-esteem that can accompany that. We will ensure that standard one of the NSF for Mental Health, which deals with mental health promotion, is fully implemented.

40. The Department of Health will work through the National Institute for Mental Health in England (NIMHE) to ensure that day services for people with severe mental health problems develop to provide support for employment, occupation and mainstream social contact beyond the mental health system. This should include:

  • access to supported employment opportunities where appropriate;
  • person-centred provision that caters appropriately for the needs of all individuals, including those with the most severe mental health problems;
  • developing strong links and referral arrangements with community services and local partners;
  • providing befriending, advocacy or support to enable people to access local services (including childcare services);
  • involving people with mental health problems in service design and operation; and
  • a focus on social exclusion and employment outcomes.

Progress in service redesign will be monitored through the annual review of mental health services (the 'Autumn Assessment') by Local Implementation Teams. NIMHE will publish guidance for commissioners in early 2005.

41. As part of this work, we will ensure that the new training offered to NHS staff helps them recognise times when patients may be particularly vulnerable and strengthens skills and confidence to offer initial support and provide information on the sources of help that are available.

42. People with poor mental health tend to experience worse physical health than the rest of the population. Yet there is evidence that a healthier lifestyle will help improve not just physical health, but also mental health, mood and wellbeing. For example, regular physical activity reduces the risk of depression and has positive benefits for mental health including reduced anxiety, enhanced mood and self-esteem. We need to do more to promote a more joined-up approach to NHS support for people with poor mental health. One early priority for NIMHE's anti stigma and discrimination programme is to address the physical health inequalities experienced by people with mental health problems.

43. We will use the lessons from a new approach being piloted(i) in eight centres in England to extend the new models of physical healthcare for people with mental health problems across all PCTs(ii). Further development of this model will be linked into plans for providing NHS health trainers, outlined in Chapter 5, as health trainers may choose to focus development of their skills in mental health or other specific areas.

Footnotes:
(i) New approaches to the management of physical ill-health among people with mental illness are being piloted by Lilly Pharmaceuticals. (ii) Specialist teams, working in partnership with primary and social care providers, help support people with severe mental illness who are vulnerable to physical ill-health. The teams offer health checks and blood tests, guidance on diet, smoking and exercise, information for the patient and their GP, and the care worker, as well as ongoing support and follow-up. This approach can identify the early signs of disease, such as diabetes or coronary heart disease.

44. We know that people who suffer from mental illness want more information about mental health and illness to help them manage their own care. We will develop new approaches(iii) to helping people with mental illness manage their own care and make available information for them on all aspects of health, both mental and physical wellbeing.

Footnote: (iii) Evidence suggests that this can include electronic self-help options. 

45. For example, the report of the Social Exclusion Unit on Mental Health and Social Exclusion published in June 2004 sets out the action that central and local government will take, working together with different agencies, to strengthen support for people with mental health problems to access employment, as well as the education and leisure facilities that should be available for everyone. There are longstanding concerns about the quality of care and support provided to people from black and minority ethnic groups who have mental health problems. The Department of Health is developing a programme of work to take forward the recommendations in Delivering Race Equality: A Framework for Action, which outlined a whole system approach to tackle the inequalities experienced by people from black and minority ethnic communities in the mental health system of care.

People with severe mental illness (SMI) are 1.5 times more likely to die prematurely than those without; partly due to suicide, but also to death from respiratory and other diseases. Depression is consistently been linked to mortality following a myocardial infarction; it increases the risk of heart disease fourfold, even when other risk factors like smoking are controlled for. People with severe mental illnesses also tend to have a poor diet; they are more likely to be obese; to smoke more; to access routine health checks less frequently, and get less health promotion input than the general population.

Support for smokers

Variation in NHS Stop Smoking Services across PCTs in 2003-04

Note: Quit rate = Number of 4 week quitters (based on self report) per hundred thousand population aged 16 and over in 2003-04 (Source: Department of Health and Office for National Statistics)

Quitting method adoptedNumber of smokers trying this method in each yearSuccess rate one year onNumber of smokers quitting through this route long-term
Willpower: no pharmaceutical or formal professional support1 million3-4%

30,000-40,000

NRT from shop or pharmacy900,0008%72,000
NHS or other professional advice with NRT or bupropion (Zyban) through NHS (e.g. on prescription from GP)600,000 8%48,000
NHS Stop Smoking Services (with NRT or Zyban)300,00015%54,000
Total2.8 million 214,000

Source: Professor Robert West, Cancer Research UK

46. Helping people to give up smoking remains one of the most important ways of preventing avoidable illness and death and reducing health inequalities. Studies have shown that smoking remains the most important cause of ill health in the most deprived areas. We have already set out our plans for action on information campaigns, for restrictions on smoking in enclosed workplaces and public places and for action on sales to underage young people. These actions will boost our wider, comprehensive tobacco control strategy, including the ban on tobacco advertising already implemented and new picture warnings on tobacco packets. The NHS has a special responsibility to back up all these measures with professional support to people who are trying to give up smoking, and to listen to what they want to help them quit.

47. Seventy per cent of smokers say they would like to be able to stop. Every year nearly three million smokers try to quit, although most find it very difficult because tobacco is so addictive. On average, ex-smokers have taken five attempts to quit for good. Achieving the national target to reduce smoking prevalence to 21% or lower by 2010 will not only depend on fewer people taking up smoking but also on large numbers of current smokers successfully quitting. If we hit our new 2010 target this would mean about 2 million fewer smokers in England as a whole, but with relatively higher numbers quitting in routine and manual groups where the target is to reduce prevalence from 31% in 2002 to 26% or less by 2010. We aim to increase the number of smokers who try to quit, and to support them to maximise their chances of sustaining success when they do. 

48. Smokers choose a range of routes to try to quit. Most rely on willpower. Others also try without outside support but with the help of Nicotine Replacement Therapy (NRT) purchased from a shop or pharmacy. Many get NHS help in the form of advice from a health professional, backed by NRT or bupropion (Zyban) (another stop smoking product) supplied under the NHS.

49. Willpower on its own is the least successful approach. There is good evidence that those who receive some formal support are more likely to succeed in quitting. We need to make it easier for people to access forms of help that we know are effective.

50. Increasing numbers of people are using NHS Stop Smoking Services, which provide more structured help for smokers who need or want it. These services use trained advisers to support smokers through the crucial first few weeks of a quit attempt (for example, with practical advice on how to cope with cravings) and help them to access and use NRT or Zyban to the best effect, along with the choice of one-to-one or group support. Since 1999, NHS Stop Smoking Services have helped over half a million smokers to give up for at least four weeks. However, there is currently an unacceptable tenfold variation between PCTs in the numbers of smokers successfully quitting per 100,000 population. These variations are in the numbers of smokers attracted to use the ser vice, not in success rates once people enter a service. Some of the best services are in the most deprived areas. The most successful services:

  • provide easy access through informal locations (community and leisure centres, pubs and clubs) at convenient times (eg outside working hours);
  • encourage primary care contractors, and other NHS, community and workplace contacts to refer people to the service;
  • identify and respond to special local needs, eg running mobile clinics in rural/isolated communities, providing services specifically for particular cultural groups; and
  • make good use of the media, linking to national campaigns like No Smoking Day, and adding targeted marketing for their local services.

51. We will now mainstream and resource this approach, and learn from what works best, driving improved performance through the system, and measuring for sustained success. We also need to gear up services to provide support to people who work in organisations which become smoke-free. New initiatives will need to be specifically targeted at routine and manual groups where the problems are greatest, and services tailored to reflect the needs of these groups. PCTs have a clear target to achieve in diminishing the prevalence of smoking and reducing inequalities and they will be performance managed against it; health trainers will provide extra capacity for stop smoking advice. To help them meet their target:

  • In 2005-06, the Healthcare Commission will examine what PCTs are doing to reduce smoking prevalence among the local population, including their own staff, through tobacco control campaigns, championing smoke-free environments and provision of NHS Stop Smoking Services. Ongoing progress will be assessed against national standards and indicators.
  • We will establish a national taskforce to help increase the effectiveness and efficiency of the NHS Stop Smoking Services and provide practical guidance for local implementation(iv), in particular how to make services more people-centred.
  • We will identify and disseminate good practice on what works through Regional Tobacco Control Managers and the NHS.
  • We will develop pilots on using the electronic booking system to trigger advice for smokers on stopping, with a view to national roll-out.

Footnote: (iv) This includes work with local authorities, all local NHS Trusts and community groups to identify opportunities for referrals to NHS Stop Smoking Services and the role of local clinical networks in prevention and championing Stop Smoking Services by increasing local referrals. 

52. Although the formal NHS Stop Smoking Services may maximise smokers' chances of successfully quitting, not all smokers want to use them. We will expand the choice of help available and provide more support through alternative routes to meet smokers' needs.

53. We have piloted a new programme, Together, which offers ongoing help and support to smokers who want to quit. We will develop the Together programme of support for smokers to quit and roll it out across England from Spring 2005 as part of the range of services that will be linked to Health Direct.

The Together programme will offer smokers support through phone, email and text in quit attempts. The pilot showed an increase in quit rates for those in the programme and very substantial increases among some groups.

54. We want also to widen the use and availability of NRT, which the National Institute for Clinical Excellence (NICE) as identified as among the most cost-effective of health interventions. However, NRT is not as readily available as we would like and both health professionals and smokers need to be more aware of how effective it is.

55. We have a well-established partnership with the manufacturers of NRT, who have an important role in public health and in the promotion of therapies. In 2003 we agreed an innovative deal with the companies involved, under which they provide free NRT patches to PCTs in recognition of the increased investment the NHS is making in stop smoking products. This arrangement will increase the resources available to the NHS to help even more smokers quit.

56. The companies have publicly committed to look at new and innovative ways of making NRT more widely available. They are currently discussing with the Medicines and Healthcare products Regulatory Agency (MHRA) the licensing restrictions around NRT, and are looking at wider access issues and other ways to promote the use of NRT, including:

  • raising awareness among healthcare and related professions by committing resource to that work;
  • new media campaigns;
  • developing new and innovative therapies;
  • promotion of therapies through a wider choice of outlets; and
  • encouraging retailers to allocate more space for stop smoking therapy products and space alongside cigarettes.

57. As part of the strategy outlined in Chapter 2, we will extend our awareness-raising campaigns to promote the use of NRT for people quitting on their own or as part of an NHS-supported attempt.

Case study

In early 2002, Hartlepool's first smoking cessation Drop-in Clinic was established at Greatham, a small village on the outskirts of the town. The success of this initiative led to the subsequent expansion of these community-based clinics across Hartlepool. Drop-in Clinics, staffed by Smoking Cessation Advisers working alongside Nurse Prescribers, offer clients an informal environment with easy access. They provide a holistic package of assessment, advice, information and a prescription of NRT with follow-up support and reviews.

Drop-in Clinics are run across Hartlepool. Perhaps one of the most unusual venues is the Fens Pub, where support is available on a weekly basis between 6pm and 8pm. The Fens Pub is within short walking distance of an area of the town which not only has a disproportionately high number of smokers (70% of adults in some pockets), but also some relatively profound levels of deprivation and health inequality (IMD national rank 25 in Owton ward). Up to 43 smokers wishing to stop have attended this clinic in a two-hour session.

The Drop-in Clinics create an atmosphere of understanding and non-judgmental support, which encourages those who fail to quit to ultimately return and try again. The target set by the DH for Hartlepool was to achieve 1,680 four-week quitters over a three-year period. The three-year target has almost been met within two years. Over 60% of those setting a quit date are smoke free at four weeks. 

Better services to tackle obesity

Understanding the lifestyles of different groups: prevalence of obesity in men and women aged over 16

Source: Health Survey for England 1999

In 2002, almost six out of ten women and seven out of ten men were overweight or obese. Balancing our calorie intake with calories we spend through physical activity is critical. Even eating an extra 10kcals a day can lead to gaining an extra pound in weight per year and gradually over the years this can become a significant problem.

'Overall, it appears that, over the past 20 to 30 years, there has been a decrease in physical activity as part of daily routines in England but a small increase in the proportion of people taking physical activity for leisure. Total miles travelled per year on foot fell by 26% and miles travelled by bicycle also fell by 26% (1975/6-99/01 National Travel Survey). This produced a difference of 66 miles walked per year between 1975-6 and 1999-2001. Twenty-five years ago we walked nearly three marathons a year more than we do now. For a person weighing 65kg this represents an annual reduction in energy expenditure equivalent to almost 1kg of fat.'

At least five a week: Evidence on the impact of physical activity and its relationship to health.
A report of the Chief Medical Officer.
Department of Health.

58. Trends in diet and lifestyle over the last three decades have combined to bring an epidemic in obesity. More sedentary lifestyles, ready access to 'energy dense' food, an increased use of convenience foods, snacking and eating out, have all played their part.

59. In addition to the health risks - diabetes, heart disease and cancer - obesity can have far­reaching psychological and social implications for both adults and children, including reduced self-esteem, increased risk of depression, social isolation and lack of employment.

60. Action on obesity is not just a matter for the NHS: other chapters discuss the role of the food industry, food promotion to children, creating more opportunities for people to be physically active, and opportunities within schools. But a comprehensive response to the threats that obesity poses to individuals and society must include concerted NHS action. The aim must be as systematic and determined an approach to the prevention and treatment of obesity as to other signs/symptoms that signal high risk of disease, for example, high blood pressure. 

Dr Foster survey of obesity services in the UK

The Dr Foster report concludes that:

  • There is significant variation between areas in the UK in terms of primary clinical response to obesity and service provision.
  • Action is focused on obesity as a risk factor for other chronic diseases rather than an illness in its own right.
  • National initiatives to promote healthier behaviours - such as 5 A DAY and exercise on prescription - have been widely adopted and are now almost universal.
  • There is more consistency around second line treatments (surgery and drugs) than first line.
  • There is variation between areas in terms of services available and the communication of services to the public, the way in which the services are organised, and primary responsibility.
  • There is scope for improved information for the public about schemes to tackle obesity - around 10% of areas said they did not provide any form of written information about ser vices available.

61. Recent studies(v) have found clinical services for obesity wanting, with significant variation across England. Although there are examples of good practice, preventive action is often taken only when obesity coexists with other chronic diseases, rather than as a clinical problem in its own right. Research(vi) has found that there is a reticence among health professionals about raising the issue of obesity with patients, a lack of necessary skills to deal with obese patients, and a lack of clear referral mechanisms and services. Around 10% of areas did not have any written information about services available. There is a need for much improved information for health professionals and the public on how to pr event weight gain. 

Footnotes:

(v) Recent studies include those by the Health Select Committee and Dr Foster .

(vi) Report to the Department of Health - attitudes towards and practice of prevention in primary care: a qualitative study, OLR June 2004. 

62. Children are particularly at risk and need a healthy start in life, but about 17% are now obese. We have introduced a national target to halt the year-on-year increase in obesity in under 11 year olds in the context of a broader strategy to tackle obesity in the population as a whole by 2010. The NSF on Children, Young People and Maternity Services includes action on obesity(vii). Chapter 3 outlines what schools and others will do to encourage healthy lifestyles in children and enable early identification and personalised help for those at risk of becoming overweight or obese. 

(vii) National Service Framework for Children, Young People and Maternity Services: Key Issues for Primary Care (September 2004) pages 11 and 12

Body mass index

Formula:

    BMI = weight (kg) divided by (height (m) x height (m))

Classifications:

Body mass index (kg/m2)Classification
Less than 20Underweight
20 to 25Desirable or healthy range
25 to 30Overweight
30 to 35Obese (Class I)
35 to 40Obese (Class II)
Over 40Morbidly or severely obese (Class III)

Source: BMI classifications from the Health Survey for England.

63. The basic messages about how to maintain a healthy weight by balancing energy in and energy out through diet and activity are clear. But there is currently less evidence about effective ways to help people who are obese or overweight to lose weight. Although we need better evidence, the urgency of the problem means developing, rapidly evaluating and implementing new approaches to managing obesity alongside research on what works.

64. We shall build on the good foundations already in place to implement the NSFs for coronary heart disease and diabetes. Guidance for PCTs on priorities and planning includes the need to give advice on diet and activity. The next challenge will be to act on obesity as an issue in its own right using levers such as the new primary medical care contracting arrangements, including enhanced services and through negotiated changes which may be possible in the Quality and Outcomes Framework.

65. We have put action in hand to strengthen the evidence base on effective interventions. NICE has already carried out appraisals and published guidance on the use of drugs and surgery to treat obesity. The DH has also commissioned NICE to prepare definitive guidance on prevention, identification, management and treatment of obesity and this is due to be available in 2007. 

66. We will develop a comprehensive 'care pathway' for obesity, providing a model for prevention and treatment. A typical care pathway for a patient would involve:

A typical care pathway for a patient

67. More specifically the prevention and treatment of obesity will ensure that:

  • we have coordinated activity on obesity prevention and management in each PCT for both adults and children with a range of appropriately trained staff - to include health trainers, school nurses, health visitors, community nurses, practice nurses, dieticians and exercise specialists. Services may also be drawn from the voluntary and independent sector;
  • there are clear referral mechanisms to specialist obesity services which will be staffed by multidisciplinary teams with specialist knowledge and training in obesity management (see paragraph 66); and
  • in addition to specialist services there will also be trained staff who can work in different settings such as schools, leisure services and the community, working alongside obesity prevention and management experts within the overall whole system approach to obesity within a PCT.

68. We will also commission production of a 'weight loss' guide, to set out what is known about regimes for losing weight and help people select the approaches that are healthy and are most likely to help them to lose weight and then maintain a more healthy weight.

69. We will commission further studies to support development of new approaches where there are gaps in the evidence base within the new framework for research discussed in Annex B. This will include production of specific guidelines for children's exercise referral(viii).

Footnote: (viii) In line with National Quality Assurance Framework for Exercise Referral Systems 2001. 

70. We will support the setting up of a 'national partnership for obesity'. The partnership will act to promote practical action on the prevention and management of obesity and as a source of  information on obesity (for both diet and physical activity) and evidence of effectiveness.

71. The NHS will need to act on existing guidance and prepare to be ready to implement NICE guidance. The additional funding that will go to PCTs from 2006 will help them strengthen primary care capacity to prevent weight gain and tackle obesity, and to develop services to respond to patient needs across the whole care pathway. 

Treatment programmes, including:

  • regular weight checks for patients and advice on diet, nutrition and physical activity and weight loss by health trainers and other healthcare professionals;
  • early identification of those at risk, beg opportunistic measuring of patients' BMI, followed by advice;
  • local partnerships between the NHS, local authorities, schools and workplaces to deliver joined up action on nutrition and exercise;
  • local initiatives on healthy eating - eg '5 A DAY' community pilots; and
  • local interventions to promote activity across the population run by PCT, local authority and voluntary sector. 

Treatment programmes, including:

  • specific dietary and activity advice and exercise referral;
  • behaviour change therapy geared to the needs of individuals, for example family-based action for children;
  • long-term support for and review of chronic cases;
  • targeted use of drugs and surgery where appropriate; and
  • regular monitoring of progress and of related disease.

72. The number of people who are overweight and obese means that each PCT area will need a specialist obesity service with access to a dietician and relevant advice on behavioural change. PCTs do not need to commission all these elements from NHS providers, but should develop innovative clinical models that will help support evaluation of different approaches to delivery of obesity services at local level eg quality assured, commercial diet providers and leisure centres. Local partnerships with the voluntary and community sectors, local authorities, the leisure industry and other alternative service providers will be able to enhance capacity and the new primary care contracting arrangements support this. The independent sector may have a key role in providing effective  behaviour change programmes in ways that are more acceptable than traditional NHS care to some groups of patients. We will test this as part of a procurement for a 'year of care' for diabetic patients.

73. Another model we will test is to use the Healthy Communities Collaborative (HCC) principles in the prevention and management of obesity. This will build on existing HCC work on diet and nutrition, and accidents (see chapter 4).

74. As part of the National Health Competency Framework we will allocate new funding for training, management, provision of evidence-based obesity prevention and treatment, based on National Occupational Standards for obesity(ix).A priority will be to ensure that staff get the training they need. 

Footnote: (ix) The Government is funding SkillsActive and Skills for Health - the sector skills councils for leisure and healthcare - to work together to produce common core modules of training on physical activity, diet and obesity which can form part of workforce training across all sectors. This work will be linked with the development of the new competency framework for health trainers discussed in chapter 5. 

75. We also need to help healthcare professionals develop more effective interventions(x)(xi).17,18 We will develop a patient activity questionnaire, which will be available by the end of 2005 to support NHS staff and others to understand their patients' levels of physical activity and assess the need for interventions, such as exercise referral.

Footnotes:
(x) We are also consulting on making sport and exercise medicine a medical discipline.

(xi) Better and more timely information is needed to monitor trends and test the impact of action in all age groups. We will develop the Health Survey for England to monitor body mass index, and utilise data from primary care and schools, and the next round of National Diet and Nutrition Survey to achieve this. 

Case study

The Dorset 'Shape Your Life' programme was devised in 2002. Clients with a body mass index of over 30 with coronary heart disease risk factors and/or diabetes were identified from GPs' registers. If clients were sufficiently motivated, they joined a six-month weight reduction programme, with the aim of losing at least five kilograms. A wide range of options was offered, which included practice-based weight management groups, walking groups, commercial slimming organisations and Weight To Go at local leisure centres. Clients visited their practice nurse on a monthly basis to record weight and blood pressure and complete an evaluation form.

One hundred and forty clients have completed the programme across Dorset: 79% have lost weight, of whom 30% have lost five kilograms or more. Body mass index and blood pressure also reduced in the majority of clients.

Case study

CADISAP is a pilot scheme which is seeking to establish if culturally sensitive cardiac treatment and rehabilitation, designed around the needs of South Asian patients and their families living in the Waltham Forest area, can improve this population's health and quality of life. For the first time, it brings together teams from primary and secondary care to comprehensively manage treatment, support and education along the care pathway in a way which seeks to overcome some of the barriers which may prevent the South Asian population from benefiting from cardiac prevention and rehabilitation services.

Education about cardiac risk factors is provided along with psychological support, nutrition and weight management advice, support on taking lipid-lowering medication, increasing physical activity and blood pressure control. A gradual increase in periods of physical activity to at least 30 minutes most days of the week is encouraged, with practical support given, such as walking up the stairs rather than taking a lift, and walking to the shops rather than driving or taking a bus. Translation services are also available for those who need them.

The scheme, which is supported by the British Heart Foundation and the Department of Health, and partly funded by the Neighbourhood Renewal Fund, has already resulted in a high quit rate among current smokers, improved exercise capacity and changed dietary practices. A formalised, randomised controlled trial is now under way in the second phase of the scheme. 

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