At the start of the Sixth Senedd, our key issues article highlighted the main challenges and opportunities for improving mental health and wellbeing in Wales. A key message was that ‘mental health’ doesn’t just sit within the NHS – it’s a much broader public health issue. Improvements to mental health services are necessary, but we also need to be looking much further upstream.
The determinants of mental health
Our mental health is, to a great extent, shaped by the social, economic, and physical environments we live in. While mental health problems can affect anyone, some groups of people are disproportionately at risk. This is often linked to inequalities in society, including those related to protected characteristics and other factors such as income, housing, access to education and employment. Our March 2022 article focused on poverty as one of the key contributing factors to poor mental health.
For good mental health, people’s ‘relational’ needs (i.e. having safe and supportive relationships with families, friends, and communities) must also be met. Connection and a sense of belonging are key. Unfortunately, for many people there are still significant barriers to accessing services, opportunities, and taking part in everyday activities. The impact of loneliness and isolation is a growing public health concern.
Health and Social Care Committee inquiry
The Health and Social Care Committee’s December 2022 report on tackling mental health inequalities calls for a clearer, more coherent narrative – ‘mental health’ is about more than the presence or absence of mental illness. We need much greater focus on the causes of poor mental health and the building blocks of wellbeing. The report concludes that the mental health of the population won’t improve (and will continue to get worse) without effective action to address the impact of trauma, and tackle inequalities in society and the wider determinants of mental health:
This message, combined with a clear ambition to reduce mental health inequalities, must be at the centre of Welsh Government’s new mental health strategy.
While the Welsh Government accepted this, its response to this key recommendation is very brief and the extent to which the Welsh Government shares the ambition of the Committee’s report isn’t clear. The mental health and social change charity Platfform believes this is a “missed opportunity”:
This could have been another bold watershed moment in our country, to set a new direction in public services and beyond. Instead, it feels like the depth of the report, and the implications for Wales, were missed. We need clear vision and leadership to drive the shift needed here.
A lived experience advisory group has worked alongside the Committee during this inquiry. The group has also shared its disappointment at the Welsh Government’s response, which participants felt lacks clarity, commitment, and understanding of the issues experienced by people subject to mental health inequalities.
Medical model
In evidence to the Committee’s inquiry, stakeholders described an outdated model for mental health which fails to address people’s broader needs. Mental health services tend to be based on a ‘medical model’ of illness. The diagnosis leads the support/treatment provided, but the human needs underlying a person’s mental health difficulties are often ignored or under-explored.
People with co-occurring conditions or ‘dual diagnosis’ can find it very difficult to access support. This may be a particular issue for neurodivergent people, people with learning disabilities, and for people with substance misuse issues. The neurodiversity charity ADHD Foundation for example, reports that children who reach the threshold for child and adolescent mental health services (CAMHS), including because of self-harm, eating disorders, or attempted suicide, are denied counselling support - "Because it's their ADHD".
The Committee’s report sets out 27 wide-ranging recommendations, including actions to:
- improve the accessibility of services;
- build the capacity of the mental health and wider workforce to meet diverse needs;
- develop social prescribing: and
- strengthen provision for neurodivergent people, people who face language/communication barriers, and people with severe mental illness.
Powers to tackle mental health inequalities
To understand exactly how far the Welsh Government can go in improving the mental health and wellbeing of the population, the Committee asked for a “frank appraisal” of which policy, legislative, and financial levers for tackling poverty and other social determinants of mental health are within the Welsh Government’s control.
The Welsh Government’s response makes the point that its ability to tackle poverty is limited - “To substantially reduce poverty levels would require a radical change in the approach taken by the UK Government”. However, the response lacks reference to other determinants of mental health, including those it does have more control over (for example housing, transport, community cohesion, access to education and employment).
Implementation is key
During the Committee’s inquiry, stakeholders described Wales as ‘leading the way’ with its Future Generations legislation and whole-school approach to emotional and mental wellbeing.
A number of relevant frameworks have also been produced or are in development – a trauma-informed framework, the NEST/NYTH framework (a planning tool for developing mental health support services for children), and a social prescribing framework. Stakeholders have welcomed these, but call for clarity about how they will translate into meaningful change on the ground.
To address some of the concerns about an ‘implementation gap’, a number of the Committee’s recommendations are aimed at improving monitoring and accountability for the Welsh Government’s action on tackling mental health inequalities, e.g. through developing outcome measures and regular reporting on progress.
The Welsh Government’s response indicates that a consultation on the successor to its Together for Mental Health strategy will be published at the end of 2023. The new strategy is expected to be comprehensive, and the Welsh Government has said that reducing mental health inequalities will be a “fundamental principle”. Even so, stakeholders question whether a mental health strategy on its own will be enough to turn the tide on the growing levels of mental ill health among the population. As described in the Committee’s report, what’s needed is a truly cross-Government approach to tackling inequality and creating the conditions for people to thrive, and the governance and accountability structures to ensure whole-system change is implemented.
The Senedd will debate the Health and Social Care Committee’s report on Wednesday 3 May 2023. You can watch this on Senedd.tv.
Article by Philippa Watkins, Senedd Research, Welsh Parliament
