Poor mental health remains the biggest single contributor to disability in the UK. There is strong evidence that preventative mental health work leads to social and economic benefits across society. Yet public health is poorly funded, and public mental health even more so.
The 42 Integrated Care Systems (ICSs) in England represent an important opportunity to achieve a shift towards prevention.
This report examines the extent of the commitment to public mental health activity in the 42 ICS areas across England, by analysing their statements of intent in their 2023 Integrated Care Strategies and their Joint Forward Plans (JFPs) for the period 2023–28.
Read the executive summary of the report below, or download either the summary or the full report as PDFs.
Overview
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 20001.
There is strong evidence that preventative mental health work leads to social and economic benefits across society. Our 2022 report with the London School of Economics, The economic case for investing in the prevention of mental health conditions in the UK, put the economic and social costs of poor mental health at a conservative £118bn a year and set out some of the best value-for-money public mental health interventions. It is a human and an economic necessity that these be made widely available in our communities.
Yet public health is poorly funded, and public mental health even more so. Despite some welcome growth in investment in recent years, it receives only around 3 per cent of specific local authority public health funding. The 2023 Hewitt Review noted a failure to realise the ‘best health value’ from current investment in the NHS and concluded that greater value can be achieved by investing in primary and secondary prevention, and by shifting care from acute to community and primary care settings.
The 42 Integrated Care Systems (ICSs) in England connect local authorities, the NHS, the voluntary sector and others. Now placed on a statutory footing by the Health and Care Act 2022, their remit is to improve the health and wellbeing of their populations. In commissioning and providing services, NHS bodies and their partners must also address inequalities and have regard to the sustainable and efficient use of resources.
ICSs represent an important opportunity to achieve a shift towards prevention.
Despite its welcome and thorough guidance on Integrated Care Strategies, there is very limited action by central government to make this a reality. Neither is it scrutinising the extent to which ICSs' strategies and plans set out actions to improve the public’s mental health with work to prevent mental health problems, reduce their associated impacts and promote mental wellbeing and resilience.
Aims and methodology
In the absence of scrutiny from the centre, our project aimed to examine the extent of the commitment to public mental health activity in the 42 ICS areas across England, by analysing their statements of intent in their 2023 Integrated Care Strategies and their Joint Forward Plans (JFPs) for the period 2023–28.2
The strategies and plans were evaluated against criteria specifying or indicative of public mental health-related activities: the strategies for their intent to engage in public mental health activity, the plans for determining if they took a public mental health approach by addressing the social determinants of mental health and/or proposing mental health prevention work.
We also had a particular focus on the four population groups at heightened risk of poor mental health that are current strategic priorities for the Foundation: children and young people at risk of developing mental health problems, vulnerable families, asylum seekers and refugees, and people with long-term conditions.
Findings
Our report does not aim to ‘call out’ poor performance. It makes a broad assessment of the extent of public mental health activity in the 42 ICS areas, and highlights where particular ICSs have been able to make progress, for the purpose of sharing it with policymakers and others.
Our analysis found that many ICSs, but not all, are taking real steps towards preventing mental health problems and their associated impacts and promoting mental wellbeing and resilience.
The nature and extent of public mental health activity is variable, and it was rare for their Joint Forward Plans to set out explicit actions on prevention and early intervention. Indeed, even the best plans and strategies we reviewed would have benefited from more clarity on their approach to preventing mental ill-health.
We also set out in the report how England lacks a public mental health infrastructure: there is no real plan from central government that sets out what the expectations are from all parts of the system, national and local, and provides the funding, leadership and knowledge-sharing to allow this to happen.
Overall, we identified six Joint Forward Plans (14%) as being excellent and eight (19%) as being poor. The majority – 28 (67%) – had good features but either did not constitute a detailed plan or were limited in the population groups they sought to support.
In relation to our priority population groups, we found that:
- every Joint Forward Plan includes at least some content on improving the mental health of children and young people;
- 37 (88%) spoke about supporting vulnerable families;
- 20 (48%) spoke about supporting people with long-term conditions;
- only 11 (24%) spoke about supporting the mental health of asylum seekers; and
- only 6 (14%) spoke about all four of these at-risk groups.
Encouragingly, racial inequalities in mental health were broadly understood within five-year forward plans. Less positively, only a minority had clear actions for addressing racial inequalities as a route to improving population mental health: 14 (33%) met this criterion.
We found that only three (7%) ICSs mentioned specific mental health needs assessments (beyond the Joint Strategic Needs Assessments (JSNAs) that all local authorities carry out). Of these, two (5%) described how the assessment was being used to determine their planning. None stated how they would monitor the outcomes of public mental health interventions related to the mental health needs assessment. While JSNAs may in some areas contain substantial content on preventative mental health, a specific mental health needs assessment could be of value in areas where such content does not exist in order to galvanise action.
Discussions and recommendations
NHS Confederation research has found a strong desire on the part of system leaders to move towards greater integration and a preventative model, but it has also identified that systemic issues around funding, social care delivery, workforce and capital are holding them back.
Given these challenges, it is not reasonable to expect local systems to excel at public mental health delivery when they are struggling to deliver on other core responsibilities.
One of the most effective basic steps that central government could take to improve public mental health provision would be to address the funding and workforce issues that understandably occupy so much bandwidth for local decision-makers. This would free their hands to engage in the long-term, innovative prevention work that system leaders want to achieve.
To achieve a sustained shift towards prevention work, we recommend the following:
1. ICSs should develop rigorous plans on public mental health
These should explicitly talk about public mental health and make this central to their strategic approach and mental health-related practice. Their plans should commit to well-evidenced programmatic work and embedding a trauma-informed approach across the system. They should be informed by and responsive to community needs, especially for those most at risk of poor mental health. Delivery of these plans must be supported by sufficient, long-term funding from central government (see Recommendation 5).
2. Better sharing of effective practice
As public mental health work in ICSs develops, it will be critical for ICSs to share information about what is working most effectively in their areas. NHS England (NHSE), the Department of Health and Social Care (DHSC), the Ministry of Housing, Communities and Local Government, other central government departments, the Local Government Association, the Association of Directors of Public Health, the NHS Confederation and others should consider how they can facilitate effective sharing of good practice.
3. ICSs need a stronger focus on minoritised communities
They should develop clear plans to improve the mental health of all the minoritised communities in their areas, including the inclusion health groups.
4. Central government must create a new public mental health infrastructure
This must address the determinants of mental health and enable delivery of evidence-based public mental health work in a planned, sustained, accountable way, with clear targets and a roadmap for delivery. Details of the necessary components of such an infrastructure are set out in the full report.
5. Central government must increase funding for prevention
Long-term funding is needed for public mental health work. The government should introduce a full national needs assessment of the implementation gap in public mental health, and ensure funding is in place to deliver the work needed to address this. Part of this will involve the restoration of the public health grant to at least the 2015 level.
As the Hewitt Review (2023) recommends, this requires a shift in resources; we support the review’s proposal that the share of total NHS budgets at ICS level going towards prevention should be increased by at least 1 per cent over the next five years. This requires national funding support.
We are supportive of Demos’ call for a new category within Departmental Expenditure Limits – Preventative Departmental Expenditure Limits – which has the potential to rebalance the way we consider expenditure as a country and allow us to take longer-term decisions. Funding for prevention should be ring-fenced, with oversight to ensure that it is genuinely used for that purpose.
6. Better collaborative working between the centre and ICSs
We need more co-production of national policies and guidance, with ICSs and NHSE working together to develop them. They should recognise the deep impact of inequality on mental health, and prioritise action aimed at minoritised communities, people living in poverty and others, such as the ‘inclusion health groups’, whose needs
have historically been underserved. Such collaboration must be fully inclusive, involving the voluntary, community and social enterprise sector and other sectors, communities and people with lived experience.
7. Mental health and wellbeing policy and spending impact assessment
The UK government must fulfil the commitment made under the previous government’s interim Major Conditions Strategy report (for England) to develop a Mental Health and Wellbeing Impact Assessment Tool to support policymakers to consider the mental health and wellbeing effects of their policies.
In addition, the mental health implications of spending decisions should be introduced as new criteria in the Treasury’s Green Book and accompanying guidance.
8. An increased focus on children and young people
Half of all mental health problems have been established by the age of 14, rising to 75 per cent by age 24. Well-evidenced prevention and early intervention programmes exist to prevent a range of adverse outcomes, including having mental health problems as an adult. DHSC, OHID and NHSE should work with local systems to ensure widespread availability of these cost-effective programmes shown to improve infants’, children’s and young people’s mental health. This should include digital interventions; children and young people need the option of
accessing effective support in ways that work for them, at any time.
Every parent and carer should have access to effective support, including evidence-based parenting programmes, and every school and college should be a mentally healthy place for children and young people.
9. A national cross-departmental inequalities strategy
The government should develop a cross-departmental strategy to reduce health inequalities, focusing on reducing inequalities in the population that cause people to become unwell in the first place, and preventing the range of inequalities that can arise from having a mental health problem.
10. Action to address wider systemic issues
System leaders have a strong desire to move towards greater integration and a preventative model, but issues around funding, social care delivery, workforce and capital are holding them back. To help enable the move to more preventative work, the government must address these wider challenges facing the NHS and local authorities.
The report also sets out recommendations for further research that the government should undertake to support this work, including research that improves the evidence base on public mental health interventions and quantifies the current resource allocation for such interventions, and promotes a better understanding of mental health inequalities and levels of need.
Footnotes
- For further information about levels of poor mental health and its impact on population disability see the NHS website: https://www.england.nhs.uk/mental-health/adults/ (accessed September 2024) and BMA analysis: https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/pr… (accessed September 2024).
- When the research took place between March and December 2023, two Integrated Care Strategies were not publicly available for review.
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