Mental Health JSNA | Boltons Health Matters
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Mental Health JSNA

Abstract

This is the JSNA chapter on mental health. Theme chapters summarises implications for commissioning, who is at risk and why, the level of need in the population, service provision and use, unmet needs, what works in terms of evidence, community views and priorities, any related equality impact assessments, unmet service needs/gaps and recommendations for further needs assessment work. 

Introduction

 

Mental illnesses are conditions defined by diagnostic criteria and often treated within mental health services; they appear in approximately one in four of the population at some point in their lives.  One in six adults has a mental health problem at any one time.  Common mental disorders such as depression and anxiety are not considered as serious or disabling as psychotic disorders such as schizophrenia or bipolar disorder.  However, as the former are much more common and so affect more people they have a much greater impact on local communities.  This chapter summarises aspects of mental health in Bolton across primary care, secondary care, and dementia.  Mental wellbeing is an element of everyone’s health and will be touched upon here but for more detail on mental wellbeing in Bolton see the specific wellbeing chapter of the JSNA.

People with mental illnesses are far more likely to lead unhealthy lifestyles; for instance, many people with schizophrenia smoke, have very poor diets, are obese, and take little exercise, but they are also less likely to be asked about these factors and offered support when they encounter health services.  Consequently, people with mental illnesses are far more likely than the general population to die from coronary heart disease (CHD) and respiratory diseases as well as suffer chronic conditions such as diabetes.  There are also many social factors associated with poor health outcomes for people with mental illness including social isolation and stigma and discrimination, particularly in the workplace such that gaining and maintaining employment is made more difficult for people with mental illness.  Finally, mental wellbeing is essential to everyone’s health, including people with mental illness.

The cost of mental health problems to the economy in England has recently been estimated at £105 billion, and treatment costs are expected to double in the next 20 years.  We know from Mental Health Strategy Reports and programme budgeting which are collected annually by the Department of Health, that Bolton is below both national and regional benchmarks in adult mental health but on a par for older adults across health and social care.  Total spend across health and social care in Bolton in 2011/12 was £47.8million.

 

Implications for Commissioning

1. Since 2007, there has been a programme of needs assessment, public consultation with key stakeholders, particularly service users and carers, which has resulted in a draft joint mental health strategy (‘It’s My Life’) which had, as its main priorities, the treatment of anxiety and depression and dementia.  Public consultation strongly supported these priorities which the new Clinical Commissioning Group has also adopted.  Within the draft all-age strategy the following priorities were identified:
Acute
• Development of Improving Access to Psychological Therapies (IAPT);
• Improved care pathways;
• People with complex needs, including Asperger’s Syndrome;
• Dual Diagnosis mental health/substance misuse and mental health/learning disability;
• Delivering equalities in mental health;
• Military veterans;
• IAPT services.
Dementia
• A Memory Assessment Service;
• Development of the community dementia service;
• Increased use of the voluntary sector;
• Improved involvement of service users and carers in decision making.

2. As part of the implementation of ‘It’s MY Life’ NHS Bolton commissioned Dr Tony Ryan to undertake an independent review of local mental health services in Bolton (primarily secondary care services) in 2011 and this report has been published (available here) and universally accepted by all key stakeholders.  This report makes many and detailed recommendations for commissioning of local secondary care services that are to be implemented as necessary in Bolton as well as recommending the transfer of primary care psychological therapies to the principal secondary care provider.  The key recommendations in the first instance were:
• Establishment of a Memory Assessment Service for dementia in Bolton and increased integration of older people’s mental health services;
• Local partners must work together to establish a Mental Health Liaison Service at the Royal Bolton acute trust (RAID – Rapid Assessment Integration and Discharge);
• Agree and define a pathway for adults with urgent mental health needs which sets out more clearly the levels of need that service users will have to gain access to services and also time frames for services to respond;
• Improve the involvement of service users and carers in the ongoing development of local services.
3. Further areas for development identified in ‘It’s My Life’, some of which were also picked up in Tony Ryan’s Review were:
• Develop the health and wellbeing agenda to support self-care/management through preventative/early identified initiatives and clearly defined care pathways;
• Target services more equitably to respond to essential need particularly amongst South Asian communities and deprived areas in Bolton, including greater focus on physical health needs;
• Address to a greater extent the needs of people with dual diagnosis, personality disorder, and other complex conditions;
• Develop an eating disorder service that reflects the whole care pathway;
• Develop understanding of need in relation to primary care and preventative mental health services to inform future commissioning;
• Suicide prevention to include coordination and contributions from several areas including public services and organisations, voluntary groups, the private sector, and individuals.

 

Who's at Risk and Why?
    From national evidence  and the findings of the Bolton Health & Wellbeing Survey 2010, we know that those at greatest risk of common mental health problems such as depression and anxiety include:
    • More deprived populations (including those living with increased burdens such as poor housing conditions, fuel poverty, and financial difficulties);
    • The unemployed;
    • The Asian Pakistani and Black population;
    • People with learning disabilities;
    • Older people;
    • The lesbian, gay, and bisexual (LGB) population;
    • People with substance misuse problems.
    Women are more likely to have been treated for a mental health problem as well as suffer from depression and anxiety.  The extent of this difference is likely influenced by the difficulty of engaging men with health services and under diagnosis in the male population.  Men are however much more likely to have an alcohol or drug problem and so are overrepresented in the associated conditions.
    The White British group have a high rate of self-harm, while South Asian and Black groups have a lower level than average compared to the general population.  Women are more likely to self-harm than men and young people are also at increased risk (research suggests that nationally 10% of 15-16 year olds have self-harmed).
    Depression affects 1 in 5 older people living in the community and 2 in 5 living in care homes.  Older people are more vulnerable to many of the risk factors that can cause depression such as being widowed or divorced, being retired/unemployed, physical disability or illness, and loneliness and isolation.  In addition, older people may develop depression because of neurobiological changes associated with ageing, prescribed medication for other conditions, as well as genetic susceptibility which increases with age.  Furthermore, alcohol problems are common in older men and are more likely to go unnoticed among older people; mental health problems associated with alcohol abuse include anxiety, depression, hearing voices, confusion, and dementia.
    Dementia is almost invariably a disease of ageing.  Rates of dementia vary between men and women and age groups, but in general risk increases with age for both genders.  Dementia under the age of 65 is known as early onset and is relatively rare but has a disproportionate impact upon both the individuals and their families.  The most common form of dementia is Alzheimer’s disease and while it is not known what causes Alzheimer’s it is known that ageing is the main factor.  The second most common type of dementia is vascular and this is caused by mini strokes that constrict blood flow and oxygen to the brain.  Some lifestyle changes are believed to help prevent dementia such as a healthy diet, regular exercise, and keeping your mind active (for example by doing computer games, crosswords, and puzzles).
The Level of Need in the Population

 

Mortality

The latest standardised mortality ratio (SMR) for suicide and injury undetermined in Bolton is higher than both the regional and national average for both sexes.  It is also higher than the majority of our statistical peers.  On average between 20 and 30 people commit suicide in Bolton each year.  The majority of suicides in Bolton are seen in men; however, while the male rate is higher the female in Bolton, the male rate is 40% lower than that seen in all men in England, but the female rate in Bolton is 117% higher than we see in all women in England.  Suicide in Bolton is significantly higher in the most deprived fifth of Bolton’s population.

Despite the higher male suicide rate and number of deaths, a greater number of women suffer from mental health problems.  However, in line with the national picture men are far less likely to present to a health practitioner with such problems.

People in treatment with mental health providers represent the group at greatest risk of suicide, for which there will be one such death in 1,000 patients every year.

Prevalence and Incidence

When asked a series of questions (GHQ12) to screen for possible non-psychotic mental health problems in 2010, 26.5% of the adult population of Bolton showed evidence of such problems.  This equates to approximately 54,000 people and is an increase from 48,000 when previously surveyed in 2007.  The more deprived areas around the Town Centre display the highest local rates of poor mental health.  This pattern is also seen for hospitalised prevalence of mental health problems (that is, people who are admitted to hospital for a mental health condition), where Bolton’s admission rate is 23% higher than England, which is better than average for the North West region, but in some deprived parts of Bolton the admission rate is 290% higher.  Also, the disabled and the LGB populations have some of the highest rates of poor mental health we see locally (over 40% with possible mental health problems (GHQ12)).  Finally, in Bolton there is a gradient across deprivation quintiles and the Asian Pakistani ethnicity should be of particular concern given their very high rate of poor mental health.

There are 2,276 people on the primary care (QOF) register for mental health (psychotic disorders).  There are 24,058 people registered with depression at any time, with 2,298 new cases registered in the last year (2011).  From the Bolton Health & Wellbeing Survey 2010 it is estimated that 53,400 people perceive themselves to have suffered nervous trouble or depression in the last 12 months.  This suggests that there is underreporting/diagnosis of mental ill health in Bolton.  Self-perceived depression in Bolton is much higher in the most deprived fifth of the population, in the Asian Pakistani population, and in the disabled and LGB populations.

In Bolton, 664 people aged 18-64 years are estimated to have a psychotic disorder, 26,735 to have a common mental disorder, and 11,947 people with some psychiatric disorder are predicted to be co-morbid (have more than one disorder).  In Bolton, 9,935 people aged 18-64 are predicted to have alcohol dependence, the majority of which (7,186) are male.  Moreover, 5,633 of those aged 18-64 are estimated to be dependent on drugs, the largest proportion of whom are again male (3,717).  Of the latter, approximately 1,700 will be in effective treatment.  For local people aged over 65 years, 3,852 are expected to have depression, with 1,210 predicted to have severe depression.

Severe mental illnesses such as schizophrenia and manic depression (psychotic disorders) are less common.  Whilst a quarter of routine GP consultations are for people with a mental health problem the most common are anxiety or depression.

The South Asian population in Bolton show some of the lowest levels of self-perceived nervous trouble or depression but are amongst the highest for possible mental health problems as measured by the GHQ12.  This may suggest people in some communities find it more difficult to admit to suffering from mental health problems due to stigma or social pressures – which in turn is indicative of unmet need in these communities in Bolton. 

When combining a range of mental health indicators the following areas in Bolton exhibit the greatest level of mental health need: Tonge Moor & Hall i’th’ Wood, Halliwell Road, Breightmet N & Withins, Victory, Lever Edge, Highfield & New Bury, and the Town Centre.

Since 2006/07 there has in general been a year on year increase in secondary care outpatient and community activity for local mental health services.  Total contacts with members of different professional staff groups have increased from 60,196 in 2006/07 to 97,293 in 2010/11.  All categories of contact have increased over this period so that in 2010/11 there are 10,757 psychiatrist contacts (attendance at an outpatient clinic), 40,474 CPN contacts, 7,655 psychologist contacts, 11,853 occupational therapist contacts, 9,183 physiotherapist contacts, 188 psychotherapist contacts, and 17,183 social worker contacts.  There were also 694 people who spent at least one day as an inpatient during 2010/11, this accounts for 11.3% of all activity which is the lowest proportion in recent years but is still higher than the England average (8.1%).

The Mental Health Observatory ranks Bolton twentieth in England when looking at mental health indicators.  The top four are the most deprived in the country (Manchester, Liverpool, Knowsley, and Salford) and Bolton is ranked lower than six of its fifteen statistical peers.

Dementia

It is estimated that there are 3,026 people in Bolton who have dementia (diagnosed and undiagnosed).

There are currently 1,601 people on the primary care (QOF) register for dementia in Bolton (52.9%).  Numbers of people in need of care due to dementia will rise significantly as the overall elderly population increases because of the disproportionate rise in the number of people aged 85 years and over.  This will mean an estimated total of 3,601 people with dementia in Bolton in 2020, increasing further to 4,877 in 2030.  A significant proportion of this population will have very high needs.

Key JSNA Indicator Sheets

 

Current Services in Relation to Need

 

Primary Care

The greatest level of under doctored areas generally falls in those parts of Bolton with the most people who are at increased risk of suffering common mental health problems such as anxiety and depression.

From comparisons with estimates, there is likely to be significant under reporting of both depression and dementia in primary care.

GPs account for the majority of referrals into Bolton’s psychological therapy services for common mental health problems, including anxiety and depression, however other health professionals are increasingly making referrals and more people are self-referring to these services as a result of staff training and community education initiatives. 

There are two services for common mental health problems, such as anxiety and depression, in Bolton that currently record their activity as part of the Improving Access to Psychological Therapies (IAPT) programme.  These services provide for different ‘steps’ of need that increase to describe the severity of people’s symptoms.  At ‘step 3’ is the Primary Care Psychological Therapy Service which is an established service.  The ‘step 2’ service, named Think Positive, is currently a pilot service and within this pilot there are fewer staff than is required for a fully operational service to fully provide for the population and level of need in  Bolton.  The data from these services demonstrate that there are approximately 39,361 people with common mental health problems, and therefore eligible for these services in Bolton.  This figure is taken from the National Psychiatric Morbidity Survey and is the official measure for IAPT services.  Other measures of similar elements of mental illness are referred to elsewhere in this chapter and these figures may vary because of the differences in precisely what they measure.  The number of people accessing these services was expected to be around 2,682 for the annual period April 2012 to March 2013.  Think Positive commenced in the second half of this period, in October 2012.  As discussed this service is a pilot with limited staff numbers, and from the offset access was initially low but has consistently increased as the service has become known.  Despite these limitations, Think Positive is resulting in an expected increase in access by around 544 people before 31st March 2013, taking the annual access rate for Bolton from 7.9% to 8.2%. 

For the next annual period from April 1st 2013 – March 31st 2014 these two services combined have the potential to provide access to psychological therapy for approximately 4,870 people with common mental health problems, taking the access rate up to 12.4% of the population in need.  This is a generous estimate as it assumes that the Think Positive pilot service will continue at full capacity, plus recruiting four additional trainee staff members which have been offered by the national IAPT programme.  If Think Positive is not permanently funded beyond the pilot, the numbers seen will reduce over this period as the service closes down and the trainees cannot be accepted, and as a result, the access rate will be closer to 11%.  In order to comply with national guidance and evidence and to perform favorably in comparison to other similar areas, the target that should be achieved for access in Bolton is 15%.  If Think Positive is allowed to develop to have the staff numbers that should be expected for Bolton within 2013/14, projections indicate that the target of 15% access is likely to be exceeded within the subsequent annual period.

Secondary Care

Bolton is significantly higher than average for England for emergency hospital admissions for mental health conditions (322.01 per 100,000), unipolar depressive disorders (44.41), and admissions for schizophrenia, schizotypal and delusional disorders (88.17).  Emergency admissions to hospital for a mental health condition should be avoided wherever possible through the use of community based mental health services.  Bolton does however have a significantly lower rate of emergency hospital admissions for Alzheimer’s and other related dementia.

Bolton has a significantly higher rate of in year bed days for mental health (196.28 per 1,000 population) compared to England (192.85) and is much higher than average for the North West (177.64).

Though there is no perceived polarity, Bolton has a higher number of people using adult and elderly NHS secondary mental health services (3.40 per 1,000 population) than the England average (2.55), a higher number of people on a Care Programme Approach (CPA) (10.83 per 1,000 population) than England (6.39), and a higher number of contacts with a Community Psychiatric Nurse (CPN) (198.55 per 1,000 population) than England (168.53).  Around 300 people are detained under the Mental Health Act 1983 in Bolton each year, with another 400 being admitted as voluntary patients.

For 2010/11 the Crisis Resolution Home Treatment Team (CRHT) received 2,916 referrals, which is over ten times more than are triaged through the Single Point of Access (SPoA) to secondary care.  The recent independent review of acute mental health services in Bolton concludes that the lack of an effective triage system, lack of an A&E liaison service, and inappropriate expectations faced by the CRHT all contribute to this high number.

Over the same period, A&E to CRHT was the most common referral route across the service system.  In addition, virtually all referrals made by A&E are to the CRHT.  As elaborated in the independent review, this confirms the views of people working in the services that the CRHT is being drawn away from its primary role of working with secondary care service users to reduce their inpatient usage and is drawn into assessing people who are unlikely to require secondary care mental health services.  Similarly, only 56.4% of all CRHT service users had been given a primary mental health diagnosis at their last contact.  This may suggest that the CRHT is assessing a significant number of service users who may not have a mental health problem.

The majority of service users who have been subject to Section 136 have contacts with other mental health services (84.5%).  However, this does mean that over 2010/11 there were almost 100 individuals who have been the subject of Section 136 and not ended up in a service.

There are a small number of people who utilise a significant proportion of the inpatient bed days in Bolton (n = 106).  These people are likely to have experienced movement between three services over a two-day period.  They are also likely to have had contact with the Assertive Outreach Team and minimal contact with the CRHT.  Finally, they are also likely to have complex needs as indicated by their lengths of stay, time on CPA, frequency of contact, and primary diagnosis of psychosis.

Dementia

As of 2012 dementia services are being redesigned and developed to address the 17 objectives in the National Dementia Strategy and the 13 recommendations in the independent review of dementia services in Bolton carried out by Doctor Tony Ryan.  At time of writing the proposals aim to integrate services in Bolton for older people with dementia and to assess the finer details associated with developing Firwood Dementia Centre as an assessment and respite facility.  The intention is for this to act as a ‘hub’ to direct people to the most appropriate service, whether that is statutory, voluntary, or independent.  Also, a new Memory Assessment Service opened in October 2012 to improve the early detection of people with dementia, which currently stands at 52.9%.  This service does reflect whole system redesign with a primary care limb as well as the clinic itself; the key change is that GPs use validated tools to assess patients memory prior to referral.  This figure has increased over the past year from 43.0% (as identified by the Alzheimer’s Society), so the hard work undertaken by Bolton stakeholders in paying dividends.  It is anticipated that the 52.9% figure will increase significantly now the newly commissioned Memory Assessment Service is fully operational.

 

Projected Service Use and Outcomes

 

The proportion of people with common mental disorders is projected to decrease by 2.1% in Bolton by 2029, compared with increases in the North West (1.2%) and in England (6.9%).  The proportion of people with psychosis is projected to decrease by 2.0% in Bolton between the 2009 baseline and 2029, compared with a 3.0% increase across the region and a 7% increase across England as a whole, with the fastest increase seen in the 55-64 age groups.

The implication for local services is that there are around 4,250 people who are likely to be affected by severe mental disorders who require high levels of support from secondary mental health services.  An additional 800 are predominantly affected by substance misuse and will require high levels of support from substance abuse services as well as mental health services in some cases.

The prevalence of self-reported anxiety (nervous trouble) and depression is greater than the often quoted 1 in every 4 people in Bolton.  This has increased, from 23.9% of the population in 2007 to 26.4% in 2010.  Wellbeing is a significant factor in the prevalence of common mental health problems.  People with low wellbeing in Bolton are almost three times more likely to experience common mental health problems.  Conversely, only 3.7% of people with high wellbeing in Bolton experience common mental health problems.  There are approximately 56,116 adults reporting common mental health problems in Bolton, there are an additional 16,000 individuals In Bolton experiencing a low level of wellbeing which places them at significant risk of developing common mental health problems.

IAPT services are based on a robust evidence of effectiveness for common mental health problems and are very successful at reducing rates of these illness when they are sufficiently well resourced according to the level of need in the population, and when they are appropriately supported by secondary care.  If primary care services are not sufficiently resourced they must prioritise those with greatest needs, and if secondary care support is insufficient, primary care services can become overwhelmed and stalled with people who are unable to recover successfully because they require secondary care services.

Wellbeing is unique to individuals, at a population level it varies according to measurable trends and improves or deteriorates in response to factors that it is possible to influence.  This means there is considerable potential to improve the wellbeing of a local population via the purposeful adoption of a whole system approach supported by local research.  Specialist work dedicated wholly to improving the wellbeing of Bolton’s individuals and communities is a key part of making positive change across the borough.  This work must be supported by organisations across the local health economy with meaningful reference made to local evidence on wellbeing within strategies as well as when taking actions in response.

By addressing the problems across the local mental health system identified in the independent review, hospital admissions should reduce to national norms.  There should be correspondingly increased activity in community services to ensure that people’s health and wellbeing is maximised in relation to adult services.

The economic downturn is likely to have an impact on the number of people with mental health problems over the next few years.  This is particularly relevant in terms of mental wellbeing amongst the whole population, which may well be lower in the upcoming Bolton Health & Wellbeing Survey 2013 compared to the baseline 2010 figure.  This is a vital measure for the future of local preventative services such as the Think Positive service that aims to build resilience in the population and reduce the demand on all services, including primary and secondary care.

 

Evidence of What Works

 

Bolton’s Health Matters has created a collection of evidence and intelligence to ensure best practice in decision within this area. To view this collection, please click here

 

Community Views and Priorities

There have been routine exercises in assessing service user and carer views and a ‘Top 10’ wish list has been compiled from this work:
1. GP training in general and GPs specialising in mental health;
2. Listening/talking time;
3. Information;
4. Appointments/home visits;
5. Accessing services;
6. Continuing support/follow up after discharge;
7. Support with benefits and daily living skills;
8. Courtesy and respect;
9. Reduced waiting times;
10. Day services.
Feedback on the current system from Bolton Link’s Mental Health Group
Members report experiencing difficulties accessing psychological therapies (IAPT) and that referral processes amongst GPs appear inconsistent.   This links to the issue of under-doctored areas in Bolton in that it may be useful to support one system where every patient a GP considers will benefit from psychological therapies should be referred to a clinician who could make the initial assessment and then from there be directed to either IAPT or counselling services based on assessed need. A concern was also expressed about the step prior to this where in under-doctored areas there may be a risk of people not being referred efficiently because of the time constraints within a GP.

Equality Impact Assessments

No recent local equality impact assessments have been carried out that we are aware of.  If you are aware of any such work locally please let us know at Bolton Health Matters

 

Unmet Service Needs and Gaps

Primary Care
As above, there is local evidence of unmet need in primary care with numbers on QOF primary care registers for depression and dementia not meeting estimates and self-reported measures surveyed in the population.
It is acknowledged nationally that depression in older people is a widely under-recognised and under-treated condition.  Historically, many health professionals, including GPs, have failed to identify depression in this population, viewing it as an inevitable feature of ageing and so have not offered the treatments and support available to other age groups.  It can be difficult to diagnose depression in older people as it often occurs alongside other illnesses, both mental and physical such as dementia, stroke, and diabetes.  In addition, many older people do not seek help from their GP for depression.
The Primary Care Psychological Therapy Service offers general advice, signposting, support, and treatment for people aged 16 years and over experiencing mild to moderate mental health problems at ‘step 3’ as discussed.  When analysed for equity, the use of the service broadly matches the level of need in the populations of Bolton.  However, there remains a gap in primary care mental health provision for people aged over 65 and those with dual needs (e.g. depression/substance misuse or dementia or mild learning disabilities).
Think Positive is open to anyone over the age of 16, living in Bolton, or registered with a Bolton GP.  The service has been built according to a public health model focused on having maximum impact in the population by targeting the service according to intelligence on local needs accompanied by the development of upstream initiatives to preserve wellbeing and prevent needs.  The range of interventions offered focus on coaching and facilitating self-help using Cognitive Behavioural Techniques (CBT) to provide patients with skills required to achieve recovery, which they may use again to provide resilience in the future.  According to calculations supported by the IAPT programme the Think Positive pilot is currently resourced to around 57% of what is needed to meet needs in Bolton.  As it stands, the pilot can provide access to these services for around 1,968 people per year, if the number of staff were appropriate to the level of need, this would increase to around 3,616 people per year, which in combination with the ‘step 3’ service, would enable Bolton to exceed the access rates that are expected for the borough, even if activity at ‘step 3’ remained the same.
The funding for this pilot was agreed by the Extended Professional Executive Committee further to a business case presented by the Public Mental Health lead and the pilot will be fully evaluated against outcomes throughout 2012-2014 to demonstrate the value of the service and evaluate the case for future investment.
Another very important contribution to meeting mild to moderate needs is 1Point which is a grouping of voluntary sector providers who have worked together utilizing a single point of access and signposting to a menu of interventions.  The voluntary sector sees significant numbers of people and work to national IAPT standards.

Secondary Care
Regarding secondary care, the recent independent local review of acute mental and dementia services identifies a range of service gaps that are to be addressed in relevant local strategies and service redesign.  See the full document for more detail, but in brief the key gaps identified are:
1. The lack of a Mental Health Liaison Service at the Royal Bolton acute trust to better manage emergency admissions for mental health conditions and improve the appropriateness of referrals;
2. The lack of a clear pathway for people with urgent mental health needs that clearly defines the levels of need that service users require to gain access to services and time frames for services to respond;
3. More involvement of service users and carers in the ongoing development of local services is required.

Recommendations for Further Needs Assessment Work

• Assessment and regular monitoring/analysis of the Public Health Outcomes Framework indicators linked to mental health are necessary.  These are: 1.6 People with mental illness/disability in settled accommodation; 1.7 People in prison with mental illness; 1.8 Employment for those with long-term health condition inc. learning disability and mental illness; 2.8 Emotional wellbeing of looked after children; 2.10 Hospital admissions as a result of self-harm; 2.23 Self-reported wellbeing; 4.9 Excess <75 mortality in adults with serious mental illness; 4.10 Suicide; 4.16 Dementia and its impacts.
• Understanding of need in relation to primary care services and preventative public mental health initiatives needs further development as part of formal needs assessment to inform future commissioning.  As demonstrated above, this aspect of the mental health pathway has been touched upon in needs analysis and public consultations related to other services in Bolton, but has not been the focus of dedicated needs assessment work to date.  Furthermore, although individual primary care services and preventive initiatives communicate regularly with their patients and involve them in service development and evaluation, people who use these services have not been formally and intentionally consulted by commissioners.  It is important to note that a lot of valid data and research does exist, and should be combined and factored into any such needs assessment.
• With the ageing population and current ongoing changes to older people’s mental health services in Bolton, and especially considering the proposal for the new Memory Assessment Service, there should be a chapter specific to dementia in Bolton’s JSNA.  A new JSNA Indicator Sheet has recently been added that focuses on dementia, and a summary chapter of its own will allow us to go into more detail than is afforded here.
• Whilst this chapter focuses on the need on adults, there is an acceptance of the fact that more work is needed to understand the mental health and emotional wellbeing needs of children and adolescents in Bolton.
• There is need for improved and consistent data collection in relation to mental health disorders to improve our understanding of service usage and unmet needs.
• Develop understanding of need in relation to primary care and preventative mental health services to inform future commissioning.

Key Contacts

• Heather Fairfield – Assistant Director of Commissioning for Mental Health
• Jayne Wood – Public Health Improvement Specialist (Mental Health)

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