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Wellbeing JSNA

Abstract

This is the JSNA chapter on wellbeing. 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

The most recent Government mental health strategy, 'No health without mental health', defines wellbeing as "a positive state of mind and body, feeling safe and able to cope, with a sense of connection with people, communities and the wider environment" . The strategy pushes heavily for increased focus on the wellbeing of the population and sets out evidence based recommendations for approaches that are effective in bringing about change and improving the nation's wellbeing. These findings and recommendations have been used to inform this chapter.

People with poor wellbeing ('languishing') are in a state of significant distress that impacts feelings (e.g. sadness), thoughts (e.g. 'what's the point?'), social functioning (e.g. isolating self) and life satisfaction (e.g. worthlessness). Importantly, languishing is different from mental illnesses, which are a range of conditions that are diagnosed according to the severity and duration of a set of symptoms, and as such low wellbeing without mental illness is experienced by a significant proportion of the population. However, low wellbeing is also commonly experienced by people with mental illness and can inhibit recovery. The converse, high wellbeing ('flourishing'), comprises of positive feelings (e.g. happiness), thoughts (e.g. 'I can do it'), social functioning (e.g. supporting others) and life satisfaction (e.g. contentment). Flourishing is protective across a range of health outcomes; it is more commonly experienced by people without mental illness, however people with mental health problems can achieve flourishing wellbeing and this is known to facilitate recovery and future resilience.

Mental illness is experienced by approximately 1 in 4 people in Bolton. Between 30 and 40 people take their own life in Bolton each year. Self-harm is a significant challenge and the exact scale of the problem is unknown. All of these factors impact the lives of many more than those directly affected. These factors are touched upon here but for more detail see the specific areas of Bolton's Health Matters.

Improving wellbeing prevents illness and reduces costs for the NHS, local authorities and for society in general over the next two to five years. Strategic commissioning for better wellbeing leads to lower demand on services, and improvements in population health.

Furthermore, wellbeing approaches include a focus on assets, aiming to empower people to take action by mobilising existing strengths and resources, to generate health outcomes.

Implications for commissioning

A recent report entitled Wellbeing in Bolton is the most detailed analysis of the ways in which wellbeing acts across the geography of Bolton, and interacts with other elements of health, lifestyle and society. The key recommendations are:

  1. Our approach to Joint Strategic Needs Assessment (JSNA) should be re-thought to include an asset based approach rather than just measuring deficits
  2. Future local strategies should give greater prominence to wellbeing; this is especially relevant to health strategies developed by the Health and Wellbeing Board
  3. Mental Wellbeing Impact Assessment (MWIA) can be used to achieve focus on Wellbeing in Bolton within strategy and service design and ensure maximal positive impact on wellbeing
  4. Wellbeing interventions should be built into care pathways for physical and mental ill health for individuals and into community health improvement initiatives

These recommendations are mutually supportive and no one in isolation will be as successful as it would be if all of them were adopted holistically.

NHS and Public Health commissioners in Bolton have examined the evidence and agreed to develop the wellbeing agenda and to support preventative initiatives. This has resulted in a pilot programme, known as Think Positive, to develop progress towards the following objectives:

  1. Improve the capacity of the general public to manage their mental wellbeing as a life skill, and to support others in their community
  2. Support communities to work together to achieve better wellbeing
  3. Improve the confidence of people in helping roles, including health professionals, and volunteers, in improving the mental wellbeing of the people they support
  4. Improve the confidence of people in helping roles, including health professionals, and volunteers, to recognize and respond appropriately to mental health problems and risk
  5. Improve access to psychological intervention for people with the first signs and symptoms of common mental health problems
  6. Help to develop referral pathways and clinical leadership across the mental health system on behalf of all people who experience mental health problems, particularly those with primary care needs
  7. Deliver a service for people with common mental health problems, according to a public health approach, according to known needs intelligence and as part of community engagement to reduce barriers and inequalities

Think Positive includes a service for people with the first signs and symptoms of anxiety and depression as well as a Public Mental Health Team focusing on the wellbeing and mental health of the general population, particularly those at increased risk of low wellbeing. Initial evaluation indicates that Think Positive is making strong progress towards all of these objectives, plus many other positive outcomes that are included in the evaluation framework. This programme of work is currently undergoing a monitoring and evaluation process with reports published on Bolton's Health Matters. Commissioners have the opportunity to mainstream, develop and permanently fund this programme to ensure continued progress on these outcomes many of which are requirements of the NHS, Public Health and Adult Health and Social Care outcomes frameworks and the NHS Operating Framework.

The wellbeing agenda in Bolton must connect more comprehensively with the increasing Public Health focus on approaches relevant to whole families, and across the life course. The wellbeing and mental health of children and young people and of older people warrants particular consideration and strategic development.

The specific mental health and wellbeing needs of expectant mothers, new babies and parents, children and young people warrants particular attention. Such needs in Bolton are not as well understood as they could be, and there may be significant gaps in service provision, particularly in relation to post-natal wellbeing.

A great deal of work to improve wellbeing occurs across Bolton; evidence shows that the impact of community level initiatives have a profound collective impact. This work should be taken stock of and more fully understood to enable wellbeing initiatives to connect, share examples of effective working, and potentially work jointly to maximize use of resources.

These recommendations are cross cutting and require a clear high level mandate for large scale change set forward, in response to the evidence, by Bolton Health and Wellbeing Board, Bolton Clinical Commissioning Group and wider partners involved in planning, influencing and commissioning the local health economy. The Public Health Department (PHD) have advanced the local agenda in terms of both intelligence on wellbeing and development of evidence based strategic initiatives that make a difference and as such are well placed to support and inform this mandate.

Who's at risk and why?

Some risk factors for low wellbeing can be pre-existing and unchangeable but may still reveal opportunities for action targeted at particular groups. The modifiable risk factors which are most significant in determining poor wellbeing in adulthood include:

  • Inequality and social injustice
  • Lack of control
  • Exclusion, isolation, loneliness
  • Unemployment
  • Low income, financial insecurity, debt
  • Violence
  • Exposure to stressful life events (e.g. bereavement, breakdown of relationship)
  • Inadequate housing, fuel poverty

In order to have good wellbeing, individuals need to feel:

  • Respected
  • Related to others, a sense of belonging
  • Valued
  • In control, able to influence their life
  • Connected
  • Equally able to access resources and opportunities

It is also helpful to understand wellbeing in the context of protective factors that can be supported and encouraged to improve wellbeing. Support networks, valued social roles, positive relationships and opportunities for valued participation are protective of wellbeing across the life course. Factors that can encourage this protection include:

  • Neighbourhood cohesion, perception, and security
  • Community activity and local involvement
  • Local leisure
  • The quality of local environments
  • Transport
  • Opportunities for learning
The level of need in the population
Mortality and morbidity

Wellbeing interacts with health and it's determinants in a causal and consequential cycle. Wellbeing is influenced by our social circumstances and health, and it plays a pivotal role in our contribution to both4. It is well evidenced that by increasing wellbeing, outcomes improve across the board, even if other risk factors (e.g. socioeconomic inequalities) remain. From the literature the following beneficial outcomes can be expected from improvements in population wellbeing2:

  • Increased life expectancy (approximately 7.5 years)
  • Improved overall health
  • Prevention of chronic physical disease
  • Prevention of mental health problems
  • Improved recovery from mental health problems
  • Stroke incidence and survival
  • Protection from heart disease (poor mental health is a greater risk factor for cardiovascular disease than smoking)
  • Improvements in pain and limitations in daily living

Wellbeing in Bolton

Wellbeing in Bolton was first measured in 2010 and will be measured for the second time in 2013; the mean wellbeing score for the Bolton population is 25.4 which is lower than both Greater Manchester (27.0) and the North West (27.7).

There is a clear inequality gradient in wellbeing in Bolton; the most deprived group in the population have significantly fewer people who are flourishing (13.3%) and many more people who are languishing (25.5%) compared to the least deprived group (22.6% flourishing, 8.9% languishing). This pattern is also reflected geographically across Bolton; wellbeing is lowest in the more deprived areas around the Town Centre and towards the South East. Furthermore, the Town Centre and Breightmet N & Withins are amongst the most deprived areas in Bolton and are also the only areas in Bolton where less than 10% of the population have high wellbeing. This demonstrates plainly the association between socioeconomic status and wellbeing is at work in Bolton.

Despite the strength of this association, it is important to avoid concluding that wellbeing in Bolton is simply a 'side effect' of socioeconomic status. In general, as deprivation increases wellbeing deteriorates, however this relationship is not uniform. Some areas of Bolton that are matched on socioeconomic deprivation have significant differences in wellbeing, and where wellbeing is better, other outcomes are also improved (e.g. social cohesion). This supports the evidence demonstrating that a range of risk and protective factors are at play in determining wellbeing, not socioeconomic status alone. It also indicates that wellbeing affords resilience to adversity by acting in measurable and significant association with factors such as social cohesion in a causal and consequential way (e.g. people with closer communities feel better and more able to contribute positively to their community).

Improved wellbeing is particularly important to the most deprived section of Bolton's population. We know this because, when we look at all people in Bolton with moderate wellbeing across the deprivation scale, we see that health inequalities are much reduced both in terms of the overall prevalence of poor outcomes, and the extent of difference between the most and least deprived. This means that if everyone in Bolton had moderate wellbeing, then health inequalities would reduce even if socioeconomic inequalities remained. This demonstrates the resilience that even moderate levels of wellbeing offers4.

The wellbeing of the disabled population demonstrates one of the most serious inequalities in wellbeing in the borough. Of those classified disabled, just 3.8% report high wellbeing, whilst 47.2% of all disabled people in Bolton are 'languishing', this is group has profoundly deteriorated wellbeing compared to Bolton overall. The key factors that influence the mental health and wellbeing of people with disabilities are decreased life chances (particularly education, employment, and housing), social inclusion, support, choice, control, and lack of independence. Being a carer also has a negative influence upon a person's wellbeing. Whilst not as dominant an influence as being disabled, 19.4% of all carers are 'languishing' and just 13.3% 'flourishing'.

Furthermore, it is clear that wellbeing is critical to health; people with good wellbeing are nine times more likely to have 'excellent health' than people with poor wellbeing. These differences continue into individual physical health conditions. For many chronic health conditions, languishers have a higher prevalence of disease than both flourishers and the Bolton average. However, improvements to wellbeing are also protective of physical health and improve outcomes and recovery rates - from wider literature we know this to be especially true for coronary heart disease (CHD), stroke, and diabetes4. Furthermore, poor wellbeing is also associated with poor self-management of chronic illnesses.

It has been well demonstrated that many negative health behaviours bring immediate social and emotional gains, and as such are practiced as an attempt to boost individual wellbeing. This is reflected in the data we have for Bolton. For instance, 30.2% of Bolton's languishers smoke compared to just 11.5% of flourishers. Smoking prevalence doubles across groups of increased deprivation, but it trebles across groups of deteriorating wellbeing in Bolton. Regarding alcohol behaviours, binge drinking (drinking with the intentional purpose of getting drunk) is the type of drinking most strongly associated with levels of wellbeing; 48.6% of languishers binge drink compared to 34.7% of flourishers. Interestingly low wellbeing does not seem to be a factor in regularly drinking over the safe limit (below the level classed as 'binging'). This is perhaps connected to regular drinking as a behaviourassociated with affluence and celebration amongst some UK social and cultural groups, whilst binge drinking is more associated with coping with difficult circumstances.

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. The prevalence and incidence of mental health problems in Bolton are covered in detail a separate mental health JSNA chapter. Mental illness and wellbeing are highly correlated but belong to separate continua. The absence of mental illness is not an appropriate indicator of good wellbeing in individuals or populations. Some approaches to reducing the symptoms of common mental health problems (e.g. cognitive behavioural therapy), can promote positive change and skills that also facilitate wellbeing, resilience and positive lifestyle change and as such psychological therapeutic approaches have a great deal of Public Health relevance. For example, the Improving Access to Psychological Therapies Programme (IAPT) has resulted in psychological intervention services (known as step 2) that can work with high volumes of people at the juncture between low wellbeing and milder common mental health problems using low intensity interventions. These services have the potential to operate as primary/secondary prevention Public Health wellness services with significant population level impact on wellbeing. Overall reductions in mental illness prevalence however, are not sufficient to improve population wellbeing, whilst conversely, better wellbeing in the population is significantly associated with reductions in mental illness prevalence plus improvements across a range of other outcomes.

Key JSNA Indicator Sheets
DISEASE AND ILL HEALTH: Wellbeing
DISEASE AND ILL HEALTH: Depression
DISEASE AND ILL HEALTH: Mental Health Problems
DISEASE AND ILL HEALTH: Self-harm
DISEASE AND ILL HEALTH: Dementia
MORTALITY: Suicide

Current services in relation to need

Wellbeing is a cross cutting issue. There are necessarily many initiatives happening across Bolton that contribute, intentionally or indirectly, to the wellbeing of the population. This section does not set out to identify them all. The Public Mental Health Team and Think Positive are given as examples of servicesdesigned specifically to improve wellbeing locally.

The Public Mental Health Team

The Bolton Health & Wellbeing Survey 2010 indicates that 16.8% of the adult population in Bolton have low wellbeing, this equates to approximately 34,000 people at significant risk of deteriorating health and social outcomes due to the condition of their psychological health. This deterioration is largely preventable through evidence based initiatives that focus on improving wellbeing and building emotional resilience. This is the focus of the Public Mental Health Team, and consists of one specialist and two practitioners in Public Health who currently deliver a number of initiatives towards this aim. In the time that this team have been delivering (August 2012-March 2013) they have engaged with approximately 4,000 people in Bolton on the topic of improving wellbeing through various initiatives. This work has the potential to impact on many people as a number of these initiatives are about skilling people up to look after their own wellbeing and to support others. This work impacts across the life-course and is being delivered within communities, workplaces, health providers, GP Practices, schools and other education settings.

Think Positive

Bolton has a 15-74 population of 192,759. The prevalence of anxiety and depression within this population is 39,261, equating to 20.4% of the actual population (according to the measures used by the IAPT programme). Bolton currently has two IAPT Service Providers to meet this need in the population (Think Positive and Primary Care Psychological Therapy Service).

The Think Positive service is a focus of this chapter, the Primary Care Psychological Therapy Service is for people with more advanced needs and features within the JSNA chapter on Mental Health

Think Positive sits alongside the Public Mental Health Team within a programme funded for a pilot period until the end of March 2014. This programme is led and provided within the PHD and is focused according to a Public Health/preventive model ensuring that it supports accessible recovery for people with the first signs and symptoms of common mental health problems such as anxiety and depression, and also promotes resilience and wellbeing for everyone in Bolton. Initial evaluation indicates that Think Positive and the Public Mental Health Team are making strong progress towards the intended outcomes. The service has been set up with a keen focus on improving accessibility and targeting resources to reduce inequalities. It is too early in the life of the pilot to identify inequalities and inequities in provision but the evaluation framework is set up to enable identification of such issues so that they may be addressed.

At its current capacity, around 500 people can access the Think Positive service every three months. As the service is new, the data must be treated with caution however early signs are that the proportion of people who complete treatment and are moving to recovery is 45.0% in Think Positive. This is higher than the IAPT expected performance for a step 2 service in its first quarter (40.0%).

An independent report conducted by the Regional IAPT team indicates that Think Positive has insufficient capacity to meet the level of need in Bolton appropriately. This analysis suggests that the current clinical capacity of the service is approximately half what it should be. The report indicates that this capacity issue must be resolved for Bolton to meet the two key targets for recovery and access that feature in the government framework 'Everyone Counts: Planning for Patients 2013/14'.

Cost-effectiveness

Analysis of wellbeing interventions which focus on returned investment and cost effectiveness is a growing area of research. Such analysis can often only be applied to interventions that generate particular data and that have been systematically applied to large populations over longer time periods. Newer initiatives and those that are delivered with specific sections of communities using innovative or creative approaches are often excluded. Qualitative and subjective analysis of impacts is valid and important in measuring the impacts of wellbeing interventions. This can be supported by the wealth of literature demonstrating that improvements to wellbeing boosts health outcomes and reduces costs for local economies, regardless of the nature of the intervention.

That said, there are a range of interventions that have been analysed and shown to have a particularly powerful impact on wellbeing, as well as being measurably cost effective:

  • Health visiting and reducing postnatal depression
  • Parenting interventions for children with persistent conduct disorders
  • School-based social and emotional learning programmes to prevent conduct problems in childhood
  • School-based interventions to reduce bullying
  • Early detection for psychosis
  • Early intervention for psychosis
  • Screening and brief intervention in primary care for alcohol misuse
  • Workplace screening for depression and anxiety disorders
  • Promoting wellbeing in the workplace
  • Debt and mental health
  • Populationlevel suicide awareness training and intervention
  • Bridge safety measures for suicide prevention
  • Collaborative care for depression in individuals with Type 2 diabetes
  • Tackling medically unexplained symptoms
  • Befriending of older adults

In light of present economic pressures, commissioners need to consider the evidence base for cost effectiveness when designing solutions to improve wellbeing.

Projected service use and outcomes

We know that in Bolton older people (45-64) currently carry the greatest risk of low wellbeing in the most deprived communities of Bolton, and we know that in the future, the older age groups will make up a significantly larger proportion of the population of Bolton. As a result the wellbeing of older adults, particularly those living in deprived communities must continue to be afforded increasing priority in order to prevent a range of negative outcomes for this group, as well as a significant deterioration of wellbeing in Bolton overall. As we continue to monitor wellbeing in Bolton we will understand more about what wellbeing needs will be like in future.

The economic downturn is also 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. The impact of the economic downturn on suicide rates has been nationally reported; the impact is felt particularly amongst men facing unemployment.

Evidence of what works

As well as the interventions and approaches described throughout this chapter, sources for information on effective interventions and evidence-based policy are highlighted on Bolton's Health Matters by clicking here. In particular, a strategy for wellbeing in Bolton is being drafted as an expansion of this chapter.

Drawing on the strongest evidence available, the six areas that can enable good early progress in improving the overall health and wellbeing of individuals and communities are below :

  1. Pre- and post-natal interventions to improve early child development and wellbeing, maternal health and wellbeing and parent-child social interactions with each other, and with others
  2. Pre-school programmes to improve the relationship between parent andchild, to improve child behaviour and early social/emotional skills and to prevent and treat conduct problems
  3. Build social and emotional skills and resilience of children and adolescents, to support the development of good relationships with peers, friends and family; and to promote child's self-awareness, ability to manage feelings, motivation, empathy and social skills
  4. Support to get people back to work, including psycho-social support and use of psychological therapies
  5. Work based programmes on health and wellbeing (including stress management) and reasonable adjustments and support to help people retain employment
  6. Programmes for older people to increase social support, prevent social isolation, maintain physical and mental wellbeing and strengthen sense of meaning and purpose

In order to achieve the outcomes that these interventions have the potential to deliver, they need to be embedded in mainstream provision, rather than delivered as isolated interventions.

Community views and priorities

A health needs assessment was conducted in three of Bolton's NRS Areas to ascertain peoples' understanding of health, their experiences, expectations, and engagement with services and to allow comparison with other data sources.

The findings show that there is a gap between peoples' aspirations to adopt 'healthier' behaviours and them taking action to do so and that this can be explained by their lived situations. The impact of situations on behaviours occurs via the impact that those situations have on wellbeing and its constructs such as self-esteem, self-efficacy, and aspiration, which subsequently determine behaviour choices. These elements of wellbeing warrant particular attention when aiming to design effective and appropriate interventions to improve health. Asset based community development provides the ideal framework for understanding and unlocking the unique capabilities of communities to work together to improve their collective wellbeing.

The report includes analysis from questions asked regarding wellbeing and wider health outcomes and the full report is available on Bolton's Health Matters

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 needs and service gaps

Referrals into the mental health system are not systematic or uniform. This is being addressed through restructure of the acute care pathway and points of access. This needs to include referral to and from Think Positive and be supported by systematic communication of the system to the general public and referring individuals to attempt to improve the appropriateness of referrals. This work must also take stock of the many public mental health and preventive initiatives occurring within Bolton services and communities and ensure that pro-active and supportive signposting occurs so that people who are referred to mental health services, have their psychological, physical and social healthaddressed with parity of esteem.

The Staying Well Project aims to improve health, wellbeing and quality of life, enabling adults 65 and over to stay healthy, happy and promote independence in their own homes by reducing risk and preventing future crisis. Individuals are systematically identified using GP practice registers. Those clients that are eligible are offered a person centred, home-based conversation and active support to find and take up appropriate services, information, advice and support. This project is truly holistic, taking physical health, mental health, social support, physical living environment and economic difficulties into consideration and connecting people with appropriate support.

The Open Bolton website provides an ideal opportunity for people in helping roles to link the people they support with social, physical and emotional health support. This website remains under development due to lack of resources, however once complete (Summer 2013) large scale promotion and education of its proper application would have significant impact on the wellbeing agenda in Bolton.

The evidence underpinning the social capitol movement explains that in many cases, it is the quality and strength of social connections within a community, that mitigate the impact of adversities such as material inequality. Valuable social relationships bring resilience and sustain wellbeing in the face of adversity, and enable us to flourish towards positive outcomes. There a great many initiatives in Bolton which strive to support and build social connections.

The local TimeBank project at time2communtiies CIC take an innovative approach to setting up opportunities for individuals and groups to 'trade' in their time and unique skills. The outcomes of this approach are cross cutting, people benefit from the exchange of favors and services, but of equal importance to TimeBankers are the connections, networks and relationships that result.

Health Development Workers based in Bolton's communities also make profound impacts on health outcomes for local communities through health promotion and education programmes but also through creative approaches to bringing people together. Connections are often made between people with similar interests or in some cases people who have shared experience of particular difficulties, to support one another in making positive changes for themselves and for the good of the community.

These services need support and development to enable them to be more widely available so that the outcomes that they have the potential to deliver can be fully realised.

More capacity can be built amongst mental and physical health professionals to provide a holistic health and wellbeing orientated approach focused on the quality of life of individuals with mental health problems beyond the direct treatment and maintenance of symptoms of mental illness.

Prescribing of anti-depressants is no longer recommended by NICE as first line response to emotional distress . Training and awareness as to the alternative social options for GPs and other prescribers is essential in ensuring evidence based care is being delivered.

Health professionals need to receive training on providing psychologically minded consultations with their patients, and allowances made within the specifications of their role, their service, and the associated care pathways to enable them to practice these techniques. This is particularly important in primary care preventative services and in the management of long term conditions where the evidence base demonstrates strongly that attention to wellbeing improves outcomes.

Inappropriate use of medication with regard to treating emotional distress is an issue, especially amongst certain ethnic minority communities - a structured patient education, self-management and collaborative care planning approach is required.

UCAN Centres commonly encounter individuals experiencing emotional distress. Staff in these settings require training and resources to assist in response to these needs.

The library service have a great deal of resource and skill to provide individuals with information and self-help materials associated with wellbeing; this should be coordinated according to a singular self-help signposting system.

There is currently very little data in relation to the level of need in Bolton in terms of wellbeing and mental health for new parents in the period preceding and following the birth of a child. This is a critical stage for the lifelong wellbeing of both children and parents. Nurturing environments produce offspring with greater tolerance to adversity whilst pre- and antenatal stress can cause genetic changes in a child that increase vulnerability and reduce resilience across the lifecourse. Anecdotal evidence collected from professionals involved in the care of new parents and babies in Bolton suggests that the services to address this issue are not what they should be. Midwives, health visitors, and staff in Children's Centershave direct experience of lack of services that can offer support, limited information on where to refer, and concerns about assessing people for fear that there is no service to signpost them on to.

The health of the general public faces increased risk in coming years due to continued economic adversity and associated pressures (e.g. reduced income, less employment, fewer opportunities). We know that under such circumstances people tend to see traditional definitions of 'health' as somewhat of a luxury and less important than simply getting by as best as possible9. There is a need to engage people on the topic of 'getting by' and talking to people about 'wellbeing' can help them to articulate the total impact of the challenges faced as well as what it means to take good care of yourself during difficult circumstances. A conversation focused on wellbeing, rather than a health assessment, allows broader exploration of health including consideration of opportunities to connect with others, to be open to opportunities to learn, to be mindful of things that make us feel good, to contribute and partake in community activities as well as being more active and looking at health behaviours. Wellbeing conversations should be a part of every contact between a community member and a person in a helping role.

Conversations about wellbeing are equally important at the community level. Traditional approaches to assessing intelligence on needs have a limited focus on deficits and can only usefully inform what is 'done to' communities to 'meet needs' through service provision and intervention. Assessment of wellbeing in communities leads to valid and holistic intelligence on how communities are coping which can deepen our understanding of health inequalities, complement provision and inform how services respond. But crucially, talking about wellbeing allows for identification of community assets, pockets of strength, and hot spots of community action where people are coming together in the face of adversity to support each other. This intelligence can inform how the local health economy can work with communities to support development of assets and enable communities to improve outcomes.

Recommendations for further needs assessment work

Assessment and regular monitoring/analysis of the Public Health Outcomes Framework indicators linked to wellbeing are necessary. At a recent conference held by Public Health England ('Mental Health in the New Public Health System') these were identified to be: 2.8 Emotional wellbeing of looked after children; 2.10 Hospital admissions as a result of self-harm; 2.23 Self-reported wellbeing; 4.10 Suicide; 4.11 Emergency re-admission within 28 days of discharge from hospital; 4.3 Mortality from causes considered preventable; 1.9 Sickness absence rate; 1.16 Utilisation of outdoor space for exercise; 1.18 Social connectedness; 1.19 Older people's perception of community safety; 4.9 Excess <75 mortality in adults with mental illness.

Understanding of need in relation to primary care services and preventative wellbeing and public mental health initiatives needs further development as part of formal needs assessment to inform future commissioning. 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.

Key contacts

Jayne Wood - Health Improvement Specialist (Mental Health and Suicide Prevention)

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