Putting prevention at the heart of national and local systems in England: our policy perspective

This short policy summary is part of a series setting out the major changes that are needed to improve mental health. Local health systems differ across the UK; this paper focuses on England. It draws upon Mental Health Foundation research and analysis which can be found in the 'further reading' section.  

Contents:

• Why we need health systems to focus on prevention
• The future of public mental health
• Evidence for prevention-focused interventions
• What are the core principles of preventative mental health care?
• Policy recommendations for preventing public mental ill health
• Further reading

Why we need health systems to focus on prevention

We have a health and care system that is geared towards late intervention and crisis management. This current model of waiting for people to develop mental health problems and then seeking to treat them is an ineffective way of improving the population’s mental health. Instead, we must reorientate national and local systems towards prevention.

Poor mental health remains the biggest contributor to overall population ill health in the UK. Levels of poor mental health are unacceptably high and have been rising since 2000.^[1] Mental ill-health has an economic and social cost of £117.9 billion a year, approximately 5% of UK GDP, with the majority of costs falling outside the health care sector, most notably through lost employment and informal care costs.^[2]

The economic and social inequalities and adversity that manifest in our communities have a direct bearing on the physical and mental health of the population. The only way this can effectively be addressed is through a more cohesive and co-ordinated approach in which these social determinants of mental health are prioritised by national and local systems, with shared outcomes measures, clear encouragement and guidance and sharing of good practice from government. 

These inequalities are spread across many areas of our lives including poverty, income and food insecurity,  housing, experience of abuse and neglect, employment, education, and access to public transport. Often, they intersect with injustices such as racism, misogyny and homophobia. All these have an impact on the mental health and wellbeing of the population.

The future of public mental health

Despite the urgency for action, the public health system is under greater pressure than at any time in living memory, with a 26% cut in funding for the Public Health Grant, on a per head basis, since 2015/16. ^[3]

The Health and Care Act 2022 put Integrated Care Systems (ICSs) on a statutory footing, with the Government making it an explicit requirement that Integrated Care Board mental health representatives should also be focused on prevention. But such work remains the exception.

The future of public mental health will depend on clear definitions, agreed priorities, effective structures and systems, improved levels of investment, and collaborative working that goes beyond traditional stakeholders. Achieving this will yield a significant return on investment and save future expenditure on health, social care and criminal justice services.

Evidence for prevention-focused interventions

The evidence is clear that it is the places and circumstances in which people are born, grow, study, live and work that have a powerful influence on their mental health. Good evidence exists for a range of public mental health interventions, including parenting programmes, anti-bullying programmes and the right support for women in the perinatal period.^[4]

These well-evidenced interventions should be widely available and provided at scale, as they can reduce the risk or severity of mental health problems, enhance mental wellbeing, and support the delivery of a broad range of outcomes relating to health, family relationships, education and employment.^[5]

Our own evidence review with the LSE indicates that there is an ever-growing evidence base of studies supporting cost-effective interventions to prevent mental health problems, many of which have been carried out in a UK context and show a positive return on investment.^[6]

What are the core principles of preventative mental health care?

National work on public mental health should be:

1. Cross-sectoral, with responsibility shared across government, structures and systems
2. Systemic, prioritising the inequalities that lead to mental health problems
3. Holistic, considered also as integral to physical health and wellbeing
4. Informed by a high-quality data and informatics infrastructure to inform decisions at every level, and to bring about transformation on the ground
5. Carried out in partnership with public agencies, the private sector, the third sector, people with lived experience, and communities. In particular, it must foreground the views of people with experience of mental health problems and the risk factors that can lead to them.
6. Resourced with dedicated and transparent finance, and a stable and planned workforce

Most of the substantial costs associated with mental health conditions do not fall on health care systems.^[7] Investment in preventing mental health conditions therefore has the potential to be highly cost-effective; the challenge is to facilitate more investment in prevention across the UK, within and beyond public health and health care systems.

Policy recommendations for preventing public mental ill health (England):

Financial

1. National government and local authorities must increase investment in evidenced interventions for public health and the prevention of mental health problems. The Government should also invest in developing the evidence base for promising interventions so that they can be rolled out widely if shown to be effective.
2. There should be improved and sustained investment in public health that matches the rate of budget increase of the NHS, with a proportion earmarked for public mental health. At a minimum, the government must reverse the nearly £1bn real-terms cut since 2015^[8] of the public health grant.
3. There should be a dedicated long-term funding stream, supported by DHSC, the Office for Health Improvement and Disparities (OHID), and the Treasury to enable integrated care partnerships (ICPs) to build on the most effective elements of the Better Mental Health Fund programme in the most deprived communities, as identified in its evaluation.^[9]
4. The Department of Health and Social Care should establish a requirement that the NHS actively invests a specific percentage of its budget on well-evidenced preventive and early intervention work in communities. 
5. There should be national reporting on the levels of funding allocated to public health and prevention within and beyond the NHS and local government, and on how funding is spent.

System change

1. The UK government should commit to developing a national mental health and wellbeing strategy that takes a cross-departmental approach incorporating action beyond health and public health systems.  This must include a strong focus on preventing mental health problems and supporting good mental health, recognising the benefits of improved preventive work in mental health for other life outcomes. 
2. ICSs should have clear accountability to central government for outcomes, with targets shared at a minimum between health, adult and children’s social care, and public health. As the effects of poor mental health are experienced in wider local systems, ICPs should also recognise the interests of, for example, the police and criminal justice systems in preventing mental ill-health. Targets should address the ‘what’, not the ‘how’; that is, they should relate directly to the outcomes that local systems should be seeking to achieve. Central targets are necessary if systems are to be pushed to deliver the public mental health approach needed by the NHS for its long-term sustainability.
3. The Government must ensure ICSs use their power as a convener and co-ordinator of local partners to support the development and roll-out of evidence-based public mental health interventions.^[10] ICSs must also use their status as a local ‘anchor institution’ to take actions which will improve their population’s mental health, including implementing the Real Living Wage for all its employees and supporting its communities through purchasing decisions.^[11]
4. All ICSs should become signatories to the Prevention Concordat for Better Mental Health.^[12]
5. UK and devolved governments must invest in research that considers the long-term costs and benefits of prevention and not just its short-term impacts, embedding future generations' considerations in public policy.
6. Many ICSs struggle to fund public mental health interventions, even those with a good evidence base. Given the lack of central government funding, ICSs are in the challenging position of needing to think creatively about how they can focus funding on prevention. These approaches will look different in each area, but ICS leaders should ensure that they are learning from their peers. 
7. Beyond the replicable interventions that currently have a good evidence base, local decision makers should be listening to the specific needs of their communities to develop support from the ground up. This will involve combining expert knowledge of what has proven effective in other contexts with the knowledge of the community about their own needs. 

Published: November 2023 / For review: May 2024