Joining the dots: a social model for

mental health

Claire Driffield, Health and Social Care Lead

Citizens Advice@ClaireDriffield

Dr Janet BlissClinical Vice Chair

Liverpool CCG

Who we help

Citizens Advice clientsJazz is a single parent with mental health problems. She works part time and has a number of debts, including Council Tax. Bailiffs have been called to recover the council tax debt.

Jazz received an aggressive letter from the bailiffs stating that, unless Jazz paid off the full debt within 7 days, they would recommend that the local authority took her to court. Jazz spoke to the bailiff on the phone, hoping to arrange a repayment plan, but they refused anything below full payment.

The bailiff dismissed Jazz’s mental health problems and Jazz found him aggressive and threatening, which led to her having a panic attack. Jazz was really scared that the bailiff was going to arrest her and that she would lose her child as a result. This caused her mental health to further deteriorate. To try to solve the problem, she booked an emergency appointment at Citizens Advice, which meant she had to miss work.

Our clients’ health

● Nationally, 41% of clients disclose they have a disability and/or long term

health problems.

Mental health is the number one health issue for clients

● Clients experiencing a mental

health problem tend to have

more complex advice needs.

● We also know clients with

mental health problems have

more advice issues than an

average client.

[Data source - National Citizens Advice 2017]

Our clients tell us practical problems make their health worse.

As a result of their practical problems:

Our evidence shows clients with a mental health problem are:

● twice as likely to be behind on a household bill

● almost twice as likely to need advice on council tax arrears

● three times more likely to be homeless due to repossessions from

housing associations

● 60% more likely to need advice on accessing jobs

Practical problems impacts on health

4 in 5 of our clientsfelt stressed, depressed or anxious

3 in 5 of our clientsfelt their physical health had got worse

[Data source - Citizens Advice Research, 2017]

Housing clients with a mental health problem

What is the impact?

[Data sources - Money and Mental Health Policy Institute 2017 and National Citizens Advice 2018]

Pressure on the health system

● Nearly 20% of GP time is spent on non-clinical problems.

● Over 70% of GPs report demand for non-health queries is increasing.

● Recovery rates are significantly lower for people who have problem debt

Nationally, the IAPT recovery rate for people with both depression and

problem debt is estimated at 22%, less than half that of those who have

depression but no financial difficulties (55%).

● IAPT practitioners face a ‘Vicious cycle’ of practical problems

● 98% said they had dealt with a patient’s non-health problems during an

appointment in the past month.

● 8 out of 10 said dealing with a patient’s practical issues left them with less

clinical time to treat their mental health issues.

… and patient mental health suffers

Pressure on local government

● Poor mental health exacerbates problems navigating local government services.

- Multiple contacts- Straight forward issues escalate to complex problems- Complex problems take longer to resolve

● Confusion:- Which services are provided by the Council?- Which Council department can help? - How do I get in touch with them?

● Giving up: - People often gave up before they reached the correct level and type of help

… people need support regardless

Coping day to day

And what should be done?

Developing a Social Model of Health in Liverpool

Dr Janet Bliss

Clinical Vice Chair Liverpool CCG

Design Principles• Accessible via a single responsive gateway• Developing and embedding ‘link workers’ within

health services• Developing a framework for service provision with

trusted partners• Building on existing resource within LCC and VCSE• Systematising Asset Based Community approaches• Reversing the inverse care law

Design challenges• The ‘inverse care law’ – those who need our support and care the most are

typically least likely to access it

• Asset-based approaches- culture change for commissioners

• Salutogenesis vs Pathogenesis: building a ‘sense of coherence’

• Our sense of coherence is based on our ability to understand the systems we live in, our perceived ability to influence them and having a sense of purpose

• We need to design something that avoids disempowering individuals and communities…too easy for health to default to a deficit model

First Steps-Advice on Prescription

• Liverpool Advice on Prescription in Primary Care project (Liverpool APP) set up in 2014 in order to alleviate poverty and hardship among people with LTCs and/or co-morbid mental health problems.

• Provides a social treatment option for primary care teams in respect of: benefits, financial hardship and insecurity, homelessness, debt, relationship breakdown, bereavement, domestic abuse, unemployment, fuel poverty.

• 50 advice clinics in health settings every week

Advice on Prescription outputs 2017/18

• 730 interventions pcm• 75% of referrals are from GPs• 50% had not used an advice service before • £6.7m secured in additional income for vulnerable

patients• £2.6m reduction in household debt• 80% of users report increase in wellbeing• Funding secured to look at linked data sets

Linking multiple data-sets

Study Cohort• 7,402 clients over the period April 2015 to October 2018

• 29,702 enquiries - for example a PIP application, a housing problem, specialist debt,

court hearing

• 55.5% female

• 47% single person households

• 14% single parents

• Largest age group 40–65years

• 45% with household income below £800 pcm ( falling to 24% after CAB intervention)

Household Income

Numbers of unique clients grouped by the secondary presenting advice issue.

(Issues with less than 100 clients are omitted for clarity)

Long-term conditions in the study cohort

Number of different long-term conditions per client

Utilisation of health and social care services

Advice on Prescription Plus

• Funding from Department of Health

• 5 link workers across city and counting

• Links to general practice, mental health and social care

• Non-clinical

• Provides motivation and support

• Supports patient until social prescription activated

Activity: e.g. green therapies, gardening, allotments, city farms, falconry, bowling,

angling, bicycling for beginners, bicycling with a disability, yoga,

tai chi, walking groups –different levels, active ageing

Resilience: building personal & economic

resilence, e.g. financial management skills,

confidence-building, adult skills and lifelong learning, pathways to

employment, volunteering, Enterprise

Hub.Creativity: e.g. arts & crafts, music, orchestra,

pottery, knit & natter, Made –Up-To-Meet,

acting, cookery classes, woodwork

Volunteering & connecting: eg Liverpool Re-connect, community development, community groups, befriending, lunch clubs, circles of

support, drama, local history clubs, cookery, intergenerational groups, walk and talk groups, bereavement support, peer support, Back to Life,

WAYS TO WELL-BEING GATEWAY MODEL

Simple referral, initial assessment

via phone call within 2 working

days

TRUSTED PARTNERS

GPs

Mersey Care

PSS Wellbeing Centres

Liverpool Re-connect

WHISC

Live Well

Healthwatch

Carers

Cancer services

Macmillan/Wellbeing

Stroke Association

Respiratory

Liverpool Domestic Abuse Services

YPAS

Barnardos Young Carers

Age UK

And more….

Practical: e.g. income maximisation, welfare

benefits, debt management, help with prescription, fuel, food

poverty, housing, employment, tribunals,

bereavement, relationship breakdown

“I will remember that I do not

treat a fever chart….but a

sick human being, whose

illness may affect the person's

family and economic stability.

My responsibility includes

these related problems, if I

am to care adequately for

the sick”

Questions?

Claire Driffield, Health and Social Care Lead

Citizens Advice@ClaireDriffield

Dr Janet BlissClinical Vice Chair

Liverpool CCG