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Five things we learned in Liverpool

Though the terraces were empty, 'You'll never walk alone' played in my mind throughout our recent Prevention Concordat learning event at Anfield Road. It seemed a fitting accompaniment to our conversations, which addressed some suitably grand topics about the role of community and place in promoting positive mental health.

From a day that didn’t shy away from polemics, here are five big ideas that stayed with me.

1. We need to reframe how we understand mental health
It’s now clearer than ever that there are evidence-based interventions that can improve the mental health of the population. From this, we might conclude that the task ahead is simple – we just need to commission those interventions that bring the greatest benefits for local people. While doing so is, of course, critically important, discussions in Liverpool pointed to something else that needs to take place, something more fundamental about how we understand mental health. There has been some real progress in recent years on public attitudes and stigma, but mental health is still seen largely in negative terms – as an illness or deficit. Achieving the Prevention Concordat’s goal of better population mental health will involve thinking much more about mental health as a resource that we all possess, shaped by our relationships and the communities we live in.

2. We can make much better use of the skills and resourcefulness of frontline staff of all kinds
Emotion is part of being human, but so too is the fear of dealing with it. One of the challenges facing us is understanding how to support staff to overcome that fear. At the event we heard how training programmes such as Connect 5 have been used to give people the skills they need to listen, to sensitively enquire, and to offer advice about mental health and wellbeing. Taking a public health approach to mental health means empowering frontline staff across public services, employers and community groups to have supportive conversations of this sort. This isn’t just about ‘awareness’ – important though that is. It is about challenging the assumption that only specialists can help someone with their mental health.

3. In commissioning, high standards of proof can be counter-productive
Having an impact is one thing; proving it is another. There was no shortage of examples in Liverpool of services or interventions that were seen to be delivering wide-ranging benefits for the community, but that were struggling to demonstrate this definitively within the timescales required by commissioners. Measuring outcomes can be very challenging, particularly in relation to financial returns on investment. We need to have an approach to commissioning that draws on evidence and ensures that public money is well spent, but that also allows room for creativity and local flavour. Or as one person at the event put it, we need to understand how we can measure something without killing it.

4. National policy can help or hinder local attempts to focus on prevention and promotion
Several people argued that local efforts to give greater priority to prevention and promotion were sometimes in tension with national policy. For example, the introduction of national access standards for some mental health services means there is now greater parity with other forms of health care, and that should be welcomed. But if we hold the system to account primarily for delivering faster access to specialist care, should we be surprised if more upstream work takes a back seat? National policy has made bold commitments to ‘get serious about prevention’. Doing so in mental health will require significant changes in terms of how policy is constructed and which agencies are involved in overseeing its delivery. A key question that remains is how prepared national bodies are to lead that change.

5. Health improvement has to build on local history and values
There were several comments on the theme of local identity, history and values – and the importance of harnessing these as part of efforts to promote positive mental health. Towards the start of the event, Andy Kerr from Liverpool Clinical Commissioning Group argued that the city has a rebellious spirit that stretches back into its history and is part of its identity. That spirit was evident during the day, and long may it continue. Improving population mental health isn’t solely about the technocratic application of data and evidence – it will involve challenging conversations, cultural change, and building a community of champions.

Which takes me back to my starting point – never walking alone. How’s that for an outcome measure?

Chris Naylor is a Senior Fellow in health policy at the King’s Fund.

Chris Naylor6 April 2018

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