By Steve Griffiths
Ed Miliband’s speech to the Royal College of Psychiatrists widened the reach of political debate about mental health in a way that suggests a coherent strategy that reaches, as Miliband says, ‘beyond the NHS itself’, ‘changing the way our wider society works’, starting in ‘our communities’. If we approach this right, we can create a sustainable flow of policy that integrates mental health, in the true sense of the term, with a project to reduce health inequalities through community empowerment. Miliband’s words, ‘Everybody has a part to play. Only a nation acting together can overcome the challenge we face. That is what One Nation is about’ are not just rhetoric. I start from the experience of a project (HELP – Health Empowerment Leverage Project) that builds resident-led neighbourhood partnerships involving local communities and staff of local public agencies, which can turn around some of the most deprived neighbourhoods. One key of that is the impact on mental well-being of an active, assertive community. The research base is immense: here are just a couple of relevant examples:
- National surveys of psychiatric morbidity in adults aged 16-64 in the UK show that the most significant difference between this group and people without mental ill-health problems is social participation. There is strong evidence that social relationships can also reduce the risk of depression.
- Research also reports significant health benefits for individuals actively involved in community empowerment/engagement initiatives including improvements in physical and mental health, health related behaviour and quality of life.
Consistent with this is the idea that policy is not something that should be done to people. Though this echoes some recent influential thinking about the nature of a ‘relational’ state, it is not new. Marmot and others have established the case for the association between poor mental health and deprivation, and extended it to make an evidence-based case for community empowerment.
An understanding has long been growing that a whole system that addresses the social determinants of health through an energised community can transform the functioning of both provider services, and the well-being of the communities they serve. Its strong economic case arises from a finding with profound implications: that lower levels of social trust are associated with higher rates of most major causes of death, including coronary heart disease, cancers, cerebrovascular disease, unintentional injury and suicide.
Cameron’s reality of a fragmented and marketised society has us running in precisely the opposite direction. Just as high unemployment increases suicides, the bipartisan model of profit-driven welfare reform undermines the mental health of hundreds of thousands.
HELP have developed an outcomes and cost benefit model as a guide for resident-led community partnerships; and have recorded the narrative of such a partnership through the eloquent accounts of residents and service providers. The approach starts with people defining where they are – not having it defined for them – which can then lead to productive dialogue with agencies. The problem of inequality is a multi-dimensional one, but it is no more complex than the way individuals, families and communities people experience it day by day.
It follows that a case can be made for Clinical Commissioning Groups to invest, with local authorities through Health and Well-Being Boards, in whole-system preventive development which creates added value through extension of health pathways into an active community. Inspired strands of such an approach are to be found – and there is an appetite for it, not least among many GPs suspicious of predatory capitalism in their field.
I believe that such partnerships have the potential to reduce some of the sharpest manifestations of inequality. To take one example, small area analysis of the cost of emergency hospital admissions shows extremely high variations between neighbourhoods. Reducing the peaks frees the resources to further enable a strategic shift to prevention and early intervention, to borrow a phrase archived by the Coalition.
I am convinced that if a future Labour Government puts a stop to the marketisation of health, Ed Miliband’s broader and more dynamic understanding of mental health might usefully harness this potential. Why not apply this model to, say, the 1% of most deprived small areas and the neighbourhoods they are part of – 320 of them? The data are there. Northern Ireland is moving in that direction by allocating a minimum percentage of health spend to community development, and Scotland is following a similar path.
Preventing ill health and improving confidence, resilience, and wellbeing through resident-led community partnerships brings together a lot of themes where it matters: it makes social, financial and moral sense.
Steve Griffiths is a writer, researcher and consultant in health and social policy, with a particular interest in reducing health inequalities by addressing the social determinants of health, and campaigning against the erosion of benefits for those who cannot work.