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Towards a Mentally Flourishing Scotland: Policy and Action Plan 2009-2011

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1. INTRODUCTION

MENTAL HEALTH IMPROVEMENT

Our mental health is important to all of us as it affects every aspect of our lives. There is no health without mental health. The Scottish Government is committed to working to improve the mental health of Scotland's people through ensuring that appropriate services are in place, but also by working through social policy and health improvement activity to reduce the burden of mental health problems and mental illness and to promote good mental wellbeing.

The way we talk about mental health, mental wellbeing, mental health problems and mental illness can often be confusing. This policy document deals with mental wellbeing as well as mental illness and mental health problems. The idea of mental wellbeing includes both how people feel - their emotions and life satisfaction - and how people function - their self acceptance, positive relations with others, personal control over their environment, purpose in life and autonomy. Each person's experience differs. Some people who experience mental illness may have a good quality of life and experience good mental wellbeing. Others who do not experience mental illness may nevertheless have poor mental wellbeing and a poor quality of life. Those with depression are also less likely to have a feeling of wellbeing.

Mental health improvement refers to activity to promote good mental wellbeing in the general population; to reduce the prevalence of common mental health problems; and to improve the quality of life for those experiencing mental health problems or mental illness. Our approach is based on a social model of health which recognises that our mental state is shaped by our social, economic, physical, and cultural environment, including people's personal strengths and vulnerabilities, their lifestyles and health-related behaviours, and economic, social and environmental factors.

Mental health improvement is a challenging and complex area of Scottish Government policy, involving different activities, in different settings and working with a wide range of people. In some cases mental health improvement it will be a particular focused intervention, in others it will be about how a policy is implemented. Mental health improvement involves action by Government, including local government, and by the NHS, as well as organisations in the voluntary and private sectors and the choices that people make themselves. Fundamentally it requires that we work beyond health services and providers.

Though it is not under the sole control of the Scottish Government mental health improvement is a key area for Government action because:

  • Mental wellbeing, mental health problems, and mental illness are directly related to an individual's socio-economic outcomes as well as to their health behaviours and physical health and vice versa.
  • Poor mental wellbeing, mental health problems and mental illness are a burden to the economy, both in healthcare costs and lost opportunities. They all have social consequences.
  • There are inequalities in the distribution of mental health problems and mental illness and in the quality of life of those experiencing illness and their carers.

Scotland has already done much to lead the way in mental health improvement and has already been recognised for its work both by other countries and by the World Health Organization. This action plan explains how we will build on our existing success from now until 2011 and beyond, by focusing on strategic priorities for action as well as on the infrastructure support and coordination which the Government will put in place to help facilitate implementation and support delivery.

It has been produced as a result of a review of previous work, evaluations of key areas and an extensive consultation process.

DELIVERY

Under the Concordat between the Scottish Government and COSLA the Scottish Government sets the direction, policy and overarching outcomes for policy, but leaves detailed management of local services to local authorities to develop and deliver in co-operation with Community Planning Partnerships.

In the area of mental health improvement the key roles of the Scottish Government are to:

  • give national leadership to the mental health improvement agenda and foster a culture which encourages mental health improvement;
  • set, in partnership with others, the strategic framework for action and national priorities;
  • support delivery organisations to develop and implement interventions and approaches;
  • take forward wider policies that will contribute towards mental health improvement goals.

Most council services, including education, community care, employment and social inclusion, are directly relevant to mental health improvement. The key roles of local government in this area are to:

  • give local leadership to the mental health improvement agenda;
  • develop, with Community Planning Partners and Community Health Partnerships, local plans for delivery;
  • develop and implement local interventions and approaches;
  • embed mental health improvement approaches into other services, building on the learning from implementing the Mental Health (Care and Treatment) (Scotland) Act 2003 and the guidance in With Inclusion in Mind.

NHSScotland has a lead role in health improvement as 'every healthcare contact is a health improvement opportunity'. The key roles of the NHS mental health improvement are:

  • through NHS Health Scotland to provide national support and leadership for the delivery of mental health improvement;
  • through local NHS Boards to support and deliver local plans for delivering mental health improvement in conjunction with Community Planning Partnerships and Community Health Partnerships;
  • to embed mental health improvement into all NHS activity, but in particular in respect of those who are at risk of developing mental health problems as a result of substance misuse or other lifestyle issue, and those experiencing mental illness.

All public sector employers should demonstrate a commitment to mental health improvement and leadership in the way that they discharge their role as employers.

The Third Sector makes a significant contribution to the mental health improvement agenda both nationally and locally. Its key roles are to:

  • deliver services which directly or indirectly promote mental health improvement;
  • innovate in the development of new service approaches and interventions;
  • act as a catalyst in promoting active citizenship and social capital to develop community capacity;
  • advocate change and improvement for service users and the general population.

The actions of individuals and communities are also central to this agenda. We know that 'intentional' activities (activities over which we have control) are important drivers of mental wellbeing. Improvement may be achieved through interventions that change our behaviour, for example, taking regular exercise; our cognitions, for example, interpreting events in a positive light; and our motivations, for example, focusing on goals that reflect deeply held values rather than external rewards, as a method of improving mental wellbeing.

Such an approach acknowledges human agency. However, individuals do not make choices in isolation from the broader social and physical environment of which they are part and there is a clear role for Government in creating the social and environmental context in which individuals and communities are able to act on their own behalf. Advocating for individual responsibility and self-help in mental health improvement is therefore set within a framework with equal attention to the creation of mentally-healthy environments within which individuals and communities are empowered.

There is no single solution to achieving outcomes in mental health improvement and no single sector, agency or programme can deliver this agenda on its own. Partnership working through Community Planning Partnerships, Community Health Partnerships and other organisational structures will be key to delivering mental health improvement at local and national level.

STRATEGIC PRIORITIES

Our work on mental health improvement is being taken forward in the context of the Scottish Government's National Performance Framework, which is supported by action to promote solidarity and cohesion, and Government action in key policy areas such as other health-related policies on alcohol, substance misuse, physical activity and health inequalities, and areas such as early years, education, older people, homelessness, poverty and social inclusion.

Mental health improvement is relevant to and involves a wide range of variables, including life stages, settings, interventions and approaches and populations. While there are certain approaches which are likely to have benefits across all of these domains, such as improving people's understanding of how to look after their mental health, there are also activities which are particular to one or more.

In setting strategic priorities for action we have focused on those areas which are likely to have the largest impact and where action is likely to be cumulative in supporting and reinforcing other Government priorities for action.

The six strategic priorities we have selected are:

  • Mentally Healthy Infants, Children and Young People
  • Mentally Healthy Later Life
  • Mentally Healthy Communities
  • Mentally Healthy Employment and Working Life
  • Reducing the Prevalence of Suicide, Self-harm and Common Mental Health Problems
  • Improving the Quality of Life of those experiencing Mental Health Problems and Mental Illness

OUTCOMES APPROACH

There has been a move to an outcomes approach to public sector accountability with the Concordat and the National Performance Framework. In this environment 'logic models' are a useful tool which link activities with outcomes. Logic models have three main uses: policy development, tracking progress, and communicating pathways to outcomes. Outcomes within logic models are time-sequenced. The rationale behind this is that if short-term outcomes are achieved this will lead to intermediate and then long-term outcomes being realised.

Logic models are developed using a collaborative methodology in which stakeholders participate to ensure the models are evidence informed, logical and achievable. The Scottish Government and NHS Health Scotland have begun working with key stakeholders to develop a series of logic models and other evaluation tools to identify the relevant short-term, intermediate and long-term outcomes in the mental health improvement field, the evidence base supporting them and the activities which will achieve them. A simplified illustrative model is presented on page 11 using the priorities set out in this document.

Illustrative logic model for mental health and wellbeing

Illustrative logic model for mental health and wellbeing

LOCAL DELIVERY

In developing local delivery plans and approaches in support of these strategic priorities and locally identified priorities, community planning partnerships and community health partnerships will want to:

  • identify the local population's needs in relation to mental health improvement;
  • agree local actions to address the key determinants of mental wellbeing, mental health problems, mental illness, suicide and self-harm - in key settings and across life stages;
  • make explicit linkages to relevant Single Outcome Agreements and NHS targets and commitments;
  • improve local capacity and awareness of practitioners and stakeholders;
  • increase the local population's understanding and awareness of mental wellbeing and mental health problems and illness, focusing, in particular, on disadvantaged communities;
  • develop local mechanisms to measure and monitor progress and outcomes.

Actions are likely to include population-based approaches as well as more focused activities to address health inequalities and identified risk and protective factors. Opportunities will exist to embed mental health improvement into other service delivery approaches. Equally, the participation and engagement of individuals themselves in activities has a clear wellbeing benefit.