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Policy and mental health

Building healthy public policy is, as discussed earlier, integral to health promotion. Links can be established between all major policy areas and mental health although these are of differing strengths and some are more direct than others. A few policy areas may apply more directly to certain periods of the lifespan but most have relevance across the lifespan. A division can be drawn between policies explicitly labelled as mental health policy and policies which have the potential to impact on the determinants of positive mental health and prevention of mental ill health, whether or not these impacts are made explicit.

Where mental health policy is concerned comments have been made in a number of countries about the extent to which it has largely been about mental illness, prevention and treatment rather than the promotion of positive mental health. WHO (2001:1) said that ‘national mental health policies should not be solely concerned with mental illness but recognize and address the broader issues affecting the mental health of all sectors of society’. WHO is taking a leading role in making statements about mental health policy. World Health Assembly Resolutions have urged Member States to take actions to promote mental health and prevent mental illness. In 2002 the Assembly asked the Director General to provide information and guidance on suitable strategies towards these ends and Resolution (WHA55.10, in Herrman et al. 2004: 11) called for WHO to:

‘facilitate effective development of policies and programmes to strengthen and protect mental health’. Its most recent contribution has been a Declaration and Action Plan for Mental Health (WHO 2005).

In most countries the traditional focus of specific mental health policy has been on illness and the responses to it. In the UK, for example, Rogers and Pilgrim (1996) noted this illness focus of mental health policy and stated that to date it had not been influenced by the broader traditions of health promotion. By contrast, they saw that USA had taken a broader focus since the 1960s and suggested three reasons for the differences between the two countries over this period: the radical politics of the 1960s; the community care focus of mental health policy makers; and the nature of psychiatry in the USA which included a strand dedicated to social epidemiology. In a number of countries there is evidence that policies are now broadening and examples will be included in the following chapters.

In addition to looking for specific mental health care policy to include not only mental illness but also primary prevention and, ideally, the promotion of positive mental health, what is also needed is a greater emphasis on public health policy and recognition of the links between its various aspects and mental health. The UK provides an illustrative example of the gradual development of public health policy and attention to mental health. The Government’s generation of documents on prevention in the 1970s was noted earlier (DHSS 1976, 1977). While making brief mention of the range of determinants of health the documents emphasized strongly the role of individual behaviour and lifestyle. What has been described as the first public health document since the setting up of the NHS in 1948, The Health of the Nation appeared in 1992 (DoH 1992). Although the stated strategy was on improving and maintaining health the targets set were ill health outcomes and the socio-economic determinants of health were neglected. Mental health was one of five key health areas specified but the focus was solely on mental illness. This document was seen as too closely linked with the Department of Health and insufficiently shared by other policy areas which also had important contributions to make to public health. As a result the healthy alliances which were called for in the document were slow to develop (Hunter 2003). Notwithstanding its shortcomings the Health of the Nation provided a basis for the developments which followed. With a change of Government in 1997 a Minister for Public Health was appointed and an explicit commitment made to the creation of a more socially equitable and cohesive society. The responsibility for achieving this was clearly stated to cut across policy areas. A Social Exclusion Unit was set up to focus on narrowing the health gap. Several important initiatives were set up in disadvantaged areas, for example Sure Start, a programme for pre-school years which will be discussed in the next chapter and Health Action Zones discussed in Chapter 6. An Independent Inquiry on Inequalities in Health examined health inequalities and identified effective actions (Acheson 1998). Of its 39 recommendations only three were directly related to the NHS reinforcing the fact that addressing inequalities involved actions across departments. A Consultative Document ‘Our Healthier Nation’ (DoH 1998) emphasized the need to address inequalities and social exclusion through cross government action but was criticized for maintaining a focus on disease outcomes.

Mental health was included but the only target was a reduction of the suicide rate. Comments in response to the consultation requested that a target of ‘increasing wellbeing’ be added and relevant measures identified. Efforts to address inequalities continued with Tackling Health Inequalities (DoH 2001a) and From Vision to Reality (2001b). An important series of documents entitled National Service Frameworks (NSFs), drawn on in subsequent chapters, developed standards for health for various aspects of health and population groups. One NSF was specifically on mental health and others on children and older age also included much that is relevant to mental health promotion, including reference to its social determinants (DoH 1999b, 2001c, 2004a). Finally, Choosing Health (2004b), a public health White Paper, illustrated a shift in the direction of public health policy – towards partnerships with populations in achieving health. The three main principles of its ‘New Public Health’ approach were informed choice, personalization and working together. The White Paper stated that information and practical support would be provided to get people motivated and to improve emotional well-being.

On the basis of earlier consultation with the public various priorities were identified, including that of mental health. The report gave supporting reasons for improving mental health: because it was crucial to physical health and making healthy choices, because stress was the commonest reported cause of sickness absence and because mental ill health can lead to suicide. An important task is to try and assess the nature and extent of impact of key policy areas on mental health both singly as well as in interaction. Increasingly the health impact of policies is brought out but it can be asked whether the implications for mental health are always recognized as fully as those for physical health. The relations between key policy areas and health will be discussed in the following lifespan chapters but we can offer introductory comments on selected areas. Policy which impacts on economic status is widely seen as a major priority in promoting all aspects of health. At the global level there is growing recognition of the damaging impact of poverty on whole regions of the world and consideration of strategies that may ameliorate the issues. The links between poverty and mental health will be raised frequently in subsequent chapters. Make Poverty History had a high profile in 2005 and campaigning to address world poverty is an ongoing and sustained campaign. Achieving global policies on trade that will impact on the poverty of poorest nations and communities is slow to achieve. Millennium goals were agreed but progress towards these is slow (see Box 3.3). A second policy area with major significance for mental health is that of education. By this we mean education as a whole rather than specific education for health. While the links between education and mental health have been widely recognized with respect to children the contribution of education to health throughout life has not always received the same attention. For example, the Acheson Report (1998) recommendations on education were confined to pre-school and school aged children. Those involved in the encouragement of lifelong education have, however, recognized its importance. Adult involvement in education has the potential to impact on mental health directly and indirectly through, for example, increasing employability, and enhancing economic status and social inclusion.

Currently, in the UK, resources for post-school education are being targeted towards increasing skills for work in young adults which is clearly important. Similar provision for older adults is also needed but is being reduced along with education for personal development not directly related to work and recreation (Tuckett 2006). The significance of education for promoting positive mental health has been acknowledged, as Tuckett points out, in national mental strategy. Initiatives such as a project to issue doctor’s prescriptions for education on the same lines as prescriptions for exercise have been developed in recognition of this link . The current reductions in adult learning provision illustrate a lack of joined up thinking between education, health and economic policy.

A third area of policy with strong influences of mental health is that which relates to work and employment, including policies which increase opportunities for securing employment, which ensure that work takes place in health promoting settings, and which support prompt return to work following involuntary unemployment or illness. Other policy areas with significance for mental health include housing, transport, leisure and recreation, environment, nutrition and neighbourhood renewal. One policy area where there is growing interest in its links with health is that relating to the arts. While people have always reported the positive impacts on mental health of participation in music, dance and other arts activities this has not always been reflected in policy making. In some countries there are now a growing number of evaluations of arts for health projects generating evidence to support relevant policy actions (see the arts for health network:

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