Belfast_Health

‘Have Your Say Belfast’ Emotional Health & Wellbeing in Belfast Part 1: (1100 words – should be 900) The public health intervention I am proposing involves carrying out a Belfast-wide questionnaire to ascertain how people rate their own mental health and wellbeing and what steps can be taken to improve their lives and that of their family. A process such as this has never been done before in Belfast, but the need to review current service delivery is a case that cannot be ignored any longer. In this economic climate with purse strings tightening, how we spend what money we do have is ever more important. By carrying out this ‘upstream’ intervention (Core Text p29) I believe that health practitioners will be better informed and better able to direct available resources to those that need assistance the most. The questionnaire in essence will act as the ‘glue’ that sticks everything together in the right place. My reason for choosing this intervention is based on quantitative data which shows Belfast urgently needs a ‘positive mental health’ intervention. Belfast is the capital city of Northern Ireland and it has a population of 280,962 according to Census 2011 figures. The city is broadly divided into 4 quarters (based along Westminster parliamentary boundaries) North, South, West and East Belfast. Anecdotally it is estimated that the Belfast Health and Social Care Trust receives 20,000 referrals per year for mental health services. Suicide levels according to the Northern Ireland Statistical Research Agency (NISRA) across Northern Ireland have risen dramatically in recent years with Belfast recording very high levels year on year. In 2010 there were 313 suicides with the highest figure being recorded in North Belfast. Substantial health inequalities exist across the city. For example a man will live 4 years longer if he lives in the more ‘affluent’ part of the city such as South Belfast compared to West Belfast (Dr Raymond Russell Health Inequalities in Northern Ireland by Constituency May 2012). More people from North and West Belfast will die from cancer, circulatory and respiratory diseases than any other part of NI while people living in North and West Belfast also have the highest rates for self harm and the highest proportion of individuals using prescribed medication for mood and anxiety disorders. These statistics are compounded even further by severe social and economic deprivation issues with North and West Belfast topping the league (http://www.nisra.gov.uk/deprivation/nimdm_2010.htm). It is well recognised, not least via the 2010 Marmot Review, that the incidence of common mental health problems rises expeditiously among communities with high levels of social deprivation and with a worsening economic climate it is expected the gap will widen. The intervention I am proposing will centre around the development of an ‘emotional health and wellbeing questionnaire’ that would be sent out to every household in Belfast so that an assessment can be made on current views and experiences. This would be underpinned by a series of targeted focus groups as well as community engagement sessions in order to increase responses from key demographics. In Belfast where health and social services management is largely localised, this questionnaire represents a powerful vehicle for active participation of civil society in planning and evaluating services. Like many public health interventions, especially ones designed around reducing existing health inequalities, this is reactive. Using Nutbeam and Harris’ 5 step model (Core Text p255) together with Hawe et al’s (Core Text p 257) emphasis on evaluation, the process as outlined above should give health practitioners the necessary tools to intervene in the right places. The overall aim of this intervention is to identify the emotional health and wellbeing needs of people in Belfast. The objectives are as follows: Firstly, to obtain views and attitudes of as many as possible residents and community, voluntary and section 75 groups on what should be included in an implementation plan to improve mental health and emotional wellbeing in Belfast; Secondly, to understand residents’ perspectives and attitudes towards themselves, their home life, and their local area by December 2012 and thirdly to gather sufficient data to identify and prioritise actions to be included in a draft emotional resilience and wellbeing plan for Belfast in April 2013. This questionnaire would be spearheaded by the Belfast Strategic Partnership (BSP), which is a meaningful partnership made up of stakeholders from the community, Belfast City Council (BCC), Public Health Agency (PHA), and Belfast Health and Social Care Trust. It was set up in 2011 to address life inequalities across the city of Belfast, with an emphasis on improving health and wellbeing and reducing health inequalities. I am a community activist who jointly chairs the BSP’s Emotional Health and Well Being (EHWB) Group as well as the founder of a community based programme called Bridge of Hope which works to support and empower victims and survivors of the conflict. The target population of my intervention is broad, which for the purpose of this assignment may make the issues at hand more complex. The levels of poor mental health being experienced by individuals in this city span across all age groups, a fact I see every day in my role as Head of Victims Services at Ashton Community Trust. In fact recent research on suicide levels in Belfast (ref Mike Tomlinson) has altered the general consensus that young men are more vulnerable to suicide than any other age demographic. Professor Mike Tomlinson’s research instead showed that children of the ‘Troubles’ i.e. men aged 35-44 were more prone. Examples of taking this ‘survey/questionnaire’ approach would include the May 2011 report published by Queen’s University Belfast into emotional health and wellbeing of post primary students. This work took both a quantitative and qualitative approach in that it used both the postal survey as well as extended interviews with individuals to reach its recommendations on the way forward. The Guernsey Emotional Wellbeing Survey of 2010 also involved the use of a postal survey. It is important to note the level of resources already dedicated to this field. There are already significant structures in place to support individuals, especially those affected by suicide and self harm. For example within PHA alone, they administer 21 separate contracts in Belfast under the government’s suicide prevention strategy ‘Protect Life’. Resources in Northern Ireland and responsibilities are changing. In 2015 local district council will assume the power for much more governance than they do now. This includes control of public health. The BSP is a huge resource and well placed to deliver this intervention as it involves people at local as well as statutory level. It has the capacity to involve stakeholders from a multi-disciplinary range as well as community representatives in a process that will ultimately affect a significant population. Part 2: (1014 words – should be 900) This intervention is aligned to the more complex social model of health as it is explicitly embraces the concept of resilience in a health context. Resilience has been identified as the ability to cope in adversity and is linked to protective factors in childhood such as good health, sufficient resources and coping with challenges (Luthar et al 2000 p19 Core Text). This ties in with the questionnaire’s overall focus which is to find out what people living in Belfast think will make it easier for them to cope with life’s ups and downs, in other words to enable them and their communities to be more emotionally resilient. The scale of mental health problems in Belfast is growing year on year. As outlined in Part 1, morbidity statistics, suicide rates, the amount of mental health referrals and social and economic deprivation figures in relation to Belfast taken together represent a powerful case for change. “Effective planning requires information about the needs of the target population,” (Core Text p246) and to this end the questionnaire, driven by the BSP’s EHWB sub group, should provide this. This EHWB partnership approach embraces the rules of transparency, accountability, respect and agreed ethical principles of mutual understanding (core Text p392). It further aspires to Glasby et al’s assumed benefits. In relation to community engagement, the representatives are fully engaged members if Scriven’s wheel of participation is considered. Expectations that we can help reduce health inequalities must be managed. The Transtheoretical Theory of Change identifies five stages of change that people will engage in. Examination of the complexity of behaviour change is based on a range of constructs and diversity of factors but the fact remains changing people’s behaviours is difficult. There is no quick solution. In relation to ethics a balance must be struck. With the government pushing the message that individuals must learn to self manage their health (as recommended within the DHSSPS Transforming Your Care 2011 report) this must run in parallel with the guidance from Nuffield Council of Bioethics (Core Text p409) which suggests the state has a “duty to look after the important needs of people individually and collectively” (Core Text p141). Implementation of this intervention would flow from the BSP’s EHWB group and would firstly draw up the contents of an emotional health and wellbeing questionnaire taking into consideration benchmark psychometric questions on thoughts and feelings as defined by the 2008 Warwick Edinburgh Mental Well-Being Scale. Questions around the wider social determinants of health (Dahlgren and Whitehead 1991) will also be referenced in tandem with WHO’s definition of public health as a “state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity”. The questionnaire content would be approved and a projected deadline for return of responses would be set. The paper questionnaire would be posted to 130,000 households in Belfast. To encourage as much feedback as possible, questionnaires can be completed on a dedicated website. The questionnaire would be launched in the press with messages from both community and statutory members emphasising the importance of feedback. A detailed press release will include the vision behind the questionnaire and how it has the capacity to shape services in local areas in the future. To encourage participation community engagement sessions and a number of focus groups, including a sample from Section 75 minority groups will be organised. Attention to school leavers aged 16 and over will also be given priority. Once responses have been collated, the data will be analysed for patterns. The findings will firstly be presented to EHWB and then BSP’s Executive Programme Group. These identified local priorities will help the EHWB draft an Emotional Resilience Strategy for the city of Belfast and accompanying action plan. This group will also devise a planning framework for the implementation of the Emotional Resilience Strategy which all BSP partners should agree to. Within this, resources will be allocated and existing pathways/configurations for commissioning of services reviewed. The final stage in this intervention will be to take this plan back to the people in an extensive consultation. The target population will be 130,000 households in Belfast. According to Creative Research Systems, the confidence rating size needed for the survey is 384 responses. This means that we can be 95% confident (confidence level) that if we asked everyone in Belfast the same questions, we would get the same answers, plus or minus 5% (confidence interval or ‘margin of error’). 95% confidence level with a 5% confidence interval is the industry standard. In Belfast we have a wealth of quantitative evidence to support the case of investing in areas that suffer from poor health. This evidence comes from a raft of places including the latest census figures which include statistics on social class which in itself has “long been identified as a major indicator of health” (Core Text p178). Useful quantitative data from NISRA comes into play when considering epidemiology which is regarded as the “scientific foundation for public health” (Core Text p184). However there is a lack of locally-based evidence on which to plan a mental health intervention. The questionnaire aims to capture this data. The questions broadly mirror Bhopal’s three categories (Core Text p195) of questions that need answered if agencies are to understand why a certain condition/disease persists. They also follow Punch’s principles (Core Text p208) of designing good questions. Evaluation will play a pivotal role whilst collating the responses to the questionnaire. It is anticipated that there will be an element of programme redesign and reimplementation as advocated in Hawe’s planning and evaluation cycle if for example a certain demographic is poorly represented in returned questionnaires (Core Text p.257). At this juncture the process will have the flexibility to adapt to any gaps. This may take the form of carrying out further focus groups. The EHWB will regularly monitor and evaluate progress whilst measuring achieved targets as outlined in Part 1. They will also evaluate the impact and the outcome of the questionnaire (Core Text p.258) and take responsibility for participatory feedback and consultation with local people in February 2013. Part 3 (648 words – should be 600) Good population health outcomes, including reducing health inequalities, depend on a wide range of issues including political which inevitably are driven by policy from the government of the day. Currently in NI a new strategy by the Chief Medical Officer (CMO) to replace the ‘Investing for Health’ 10 year strategy is nearly complete. In July 2012 Michael McBride supplied some detail to the NI Assembly at Stormont about the new draft framework, ‘Fit and Well: Changing Lives,’ which he said has been particularly influenced by the Marmot report, 'Fair Society Healthy Lives'. The CMO’s new plan is designed along the life course approach: pre-birth to early years; children and young people; early adulthood; adults; and later years. The policy implications of this questionnaire will be far reaching as they will supply evidence about people along this life course and what stage they are at. The results I anticipate will require action from many departments, not just health. Improving the mental health of a city will require a cross-sectoral approach linked into appropriately-led resources. In Belfast the locus of power is changing and currently all relevant agencies are gearing up for 2015 when responsibility for public health will transfer to councils under the Review of Public Administration. As joint chair of EHWB it is clear to see that statutory partners are willing to look towards a dynamic shift in policy as they estimate 70 per cent of all resources are diverted towards crisis responses. It stands to reason then that this mental health questionnaire will ultimately throw up many challenges if the focus towards early preventative work is a key finding. The recent first draft population plan for the Belfast Local Health Economy states that health care in Belfast must address the stark difference in life outcomes between people living only a few hundred yards apart. It says: “However we recognise that health and social care services have only a 10-20 % impact on this ‘inequality gap’ and that we must work with services users, their carers, local communities and with other agencies in the BSP to improve the life outcomes of those most in need.” In effect the remaining 80% of change required must be taken on by individuals themselves. It further adds that the health service must be reshaped in light of the current financial outlook. For example it states that the health care service in Belfast must save £232 million in 12 months during 2014-2015. In light of such changes coming down the line, instigated by the Stormont government initially via the December 2011 Transforming Your Care report, communities must be ready to face the challenges and ethical dilemmas ahead. Working with communities and ‘bringing them with them’ to address life and health inequalities will be crucial in the time ahead. Community empowerment lies at the very heart of the Beacon Estate. Hazel Stuteley and Philip Trenoweth brought about transformational change via democratic processes and engagements when seeking to address public health issues at a local level. The challenge in Cornwall was about getting public health leads to address the problems in tandem with the people who were experiencing the health outcomes. The message was one of empowerment, ie that local people are the experts on their own community and their expertise must be listened to by agencies tasked with addressing the gaps in health. As Hazel Stuteley reflects: “They are the victims of their education, social and environmental circumstances, not the architects of them” (Reader p287). The Marmot Review endorsed empowerment as being at the ‘centre of action to reduce health inequalities’ (Marmot, 2010, p34). The BSP has already stated that the move towards and emotional resilience strategy must be “people and community focused”. They also generated these valued goals: a common agreement or call to action for all agencies to intervene early; to be practical and rooted in community and finally; be person centred. 1. Critically reflect on your work, identifying what you consider to be its main strengths and weaknesses (around 600 words). Part 4: talk about weaknesses of survey, 387 responses is low. Reference Healthy Cities: A boy born into the most disadvantaged conditions can expect to live 6 years less than a boy born in the last deprived area and a girl 3 years less Who Ottawa charter for health promotion 1986 page 9 core text The need for joined up policies which address the wider socio economic determinants of health so strong a feature of the Marmot Report in 2010 are signalled clearly the Black Report 30 years earlier p27 Core Text. Community engagement strategies page 167 Beattie’s model of health promotion (Core text p.154) Interestingly participants also advocated the need to get on with the job of making a difference, rather than spending a huge amount of time assessing needs and strategising. Feedback also indicated that a population wide approach with a specific target on disadvantaged groups should not be adopted - rather efforts should be focused at an area based community or locality level. Make the point that together “demography, epidemiology and survey research are powerful and essential tools in efforts to promote public health” Core Text 212). Ultimately we need the results from the survey as evidence to plan and evaluate how we intervene in this public health matter. Note that assessing local health needs is not a straightforward matter – although local people may share common problems or interests they may have different agendas and express different needs. In order to overcome engagement issues health practitioners have adopted a number of other strategies to overcome difficulties in order to tap into the most comprehensive local voice possible. These include using key informants, focus groups etc. The challenge I maintain is for mental health care professionals and service delivery models to determine how best to engage with individuals and meet their needs more effectively at an earlier stage. Reference page 34 Core Text health inequality is framed as an issue of social justice References Belfast Local Commissioning Group, Belfast Health and Social Care Trust (22nd June 2012) Belfast Local Health and Social Care Economy: First Draft Population Plan 2012-15 Connolly, P., Sibbett, C, Hanratty, J., Kerr, K., O’Hare, L. and Winter, K. (2011) Pupils’ Emotional Health and Wellbeing: A Review of Audit Tools and a Survey of Practice in Northern Ireland Post-Primary Schools Belfast: Centre for Effective Education, Queen’s University Belfast. (http://www.qub.ac.uk/schools/SchoolofEducation/CentreforEffectiveEducation/FileStore/Filetoupload,248710,en.pdf) Department of Health, Social Services and Public Safety NI (2011) Transforming Your Care http://www.dhsspsni.gov.uk/transforming-your-care-review-of-hsc-ni-final-report.pdf Douglas, J. Earle, S. Handsley, S. Jones, L. Lloyd, C. E. Spurr, S. (eds) (2010) A Reader in Promoting Public Health: Challenges and Controversy, (2nd edn), London/Milton Keynes, Sage/The Open University. Guernsey Emotional Wellbeing Survey - A Cross-Sectional Survey of Mental Wellbeing and Common Mental Health Disorders in Guernsey and Alderney http://www.gov.gg/CHttpHandler.ashx'id=4825&p=0 Jones, L Douglas, J. (2012) Public health: building innovative practice. London, Sage/The Open University. www.nisra.gov.uk/Census/pop_press_release_2_2011.pdf). NISRA (www.nisra.gov.uk/demography/default.asp31.htm). Russell, R (May 2012) Health Inequalities in Northern Ireland by Constituency, Northern Ireland Assembly Research and Information Service Briefing Paper Tomlinson, M (2012) The Trouble with Suicide, Mental Health, Suicide and the Northern Ireland Conflict: A Review of the Evidence. School of Sociology, Social Policy and Social Work/Queen’s University Belfast Census 2011 Confidence Ratios: (http://www.surveysystem.com/sscalc.htm#one) Warwick Edinburgh Mental Well-Being Scale http://www.healthscotland.com/documents/1467.aspx Who constitution page 1 Marmot Fair Society Healthy Lives'. Investing For Health