Mental Wellbeing Director Of Public Health Annual Report 2018

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Mental WellbeingDirector ofPublic HealthAnnual Report2018

Contents03Introduction05 Mental Wellbeing in the Home09Mental Wellbeing in Educational Settings16 Mental Wellbeing in the Workplace20 Mental Wellbeing and City Spaces2

Introductionimpacts of new technologies on young peopleis also increasingly linked to health issuesincluding anxiety and sleep problems.Mental illness is the biggest source of burdenof disease in the UK. Mental health problemsoften begin in childhood and have lifelongimpacts. Improving childhood mental healthwill reduce inequalities, improve physical healthand reduce health risk behaviour. Improvedmental health can contribute to increasedlife expectancy, economic productivity, socialfunctioning and quality of life. Helping peopleto thrive in a rapidly changing environment is amajor challenge we must overcome to ensurethat the benefits of protecting and promotingmental health are felt across generations in allareas of Leicester.There is growing recognition that while manypeople have poor emotional health, they alsohave social and community assets whichcan strengthen resilience to mental healthproblems. Support can start in schools,libraries, workplaces and communities. Acrossthe city, there are schemes, such as mentalhealth champions, ‘books on prescription’ inlibraries, volunteering in parks and museumsand community walks which can be beneficialfor health and wellbeing. These can reducesocial exclusion and social isolation andcontribute towards healthier lifestyles, bettereducational attainment and employment.Adverse childhood experiences, such asneglect, substance misuse, domestic violenceand physical or sexual abuse are associatedwith future mental illness. The right supportfor children and families in the early yearsis therefore critical. We need to ensure thatservices are there for everyone, with moreattention focused on the parts of the city withhighest levels of need and deprivation.With many services under immediate pressuretoday, investing to reduce tomorrow’s problemsis challenging and may require one organisationto invest now for another to save in the future.We have good economic evidence of theimpact of some things we can do today, whichwill save money in 2-5 years’ time. Otherareas, such as investment in city design and theurban environment have a less strong evidencebase but equally haveimportant immediatebenefits beyond improving health.Specialist mental health services are underpressure. Only a minority of those who needhelp get support. The NHS Five Year ForwardView for Mental Health recognises that we needto put greater energy into prevention, ratherthan waiting until people reach crisis point.Even with planned expansion of mental healthservices, those for children will still only reach35% who need support.If we want to turn the tide, we need tothink differently about how we mobiliseresources from the NHS, local government,the voluntary sector, local communitiesand business. Only by drawing on the widerresources in society can we reduce theeconomic and social burden of mental illnessthrough prevention and early interventionChanges in how we live and work havecreated new pressures. Social isolation is nowrecognised as a health issue, with importantconsequences for mental health and wellbeing.Technology has created both opportunitiesand barriers: social media has allowed peopleto connect to each other in new ways, but theRuth Tennant (2015 – 2018)Director of Public HealthLeicester City Council, 20183

Mental and Emotional Wellbeing17%Low worthwhile score(% of 017/18Low happiness score(% of 8.92015/162016/17Never/rarelyfelt usefulSource:LeicesterEngland12.1Never/rarely feltoptimistic aboutthe future14%LeicesterEngland22.1Never/rarelyfelt relaxed19%High anxiety score(% of people)2011/12Reported poormental health2014/154.3LeicesterEngland12%Never/rarely felt theywere able to deal withtheir problems well4.2Low satisfaction score(% of people)5.3Never/rarely felt closeto other people2013/144.2No DataAvailable3.8No DataAvailableThe Facts7.3Leicester Health andWellbeing Survey, 2018.10.32017/18Annual PopulationSurvey 2016/17

Mental Wellbeing in the HomePositive relationships build a sense of belongingand self-worth. Good mental health is linked to asafe home life, and the opportunity to take partin activities which enable people to thrive. TheWhitehall II study found that people who reportthat they have low control at homehave a higher risk of depression1. Poor mentalhealth is linked to difficult relationships and poorenvironmental circumstances.together, these factors impact on people’sability to manage parenting issues.The importance of mental wellbeing at homecan be seen when considering the times whenpeople are vulnerable in their family life; suchas leaving home, bereavement, separationand divorce. All such occasions may result infeelings of isolation. Although people havedifferent social needs, and feeling lonely isn’titself a mental health problem, most peopleneed some kind of social contact to maintaingood mental wellbeing. Conversely, having amental health problem increases the chance offeeling lonely.For children, the strongest driver of poorwellbeing occurs when they experience weakand uncaring relationships. The 1001 CriticalDays2 is an All-Party Parliamentary Groupinitiative to emphasise the importance of theperiod from conception to age 2 in shapingbrain development, in the lifelong impact onemotional health and on a person’s life chances.Responses to the Leicester Health andWellbeing Surveys generally reflect theevidence. They show that loneliness impactson people of all ages. People who are sociallyisolated are more likely to have poor mentalhealth and wellbeing and are less able to askfor help from people around them. Between aquarter and a third of respondents to the surveyfelt lonely and were left out of activities.Poor mental health has an intergenerationalimpact. Many adults with a mentalhealth problem in Leicester are likely to beparents and that is in addition to the number ofmothers with perinatal mental ill health. TakenPoor(7 - 20)Average(21 - 30)Good(31 - 35).excluded, lonely or alone?30%8%5%.that you lack companionship?21%9%3%.left out of activities/events that youwould enjoy or like to go to?22%9%5%.isolated from others?22%5%3%% often / all of the time:Significantly higher than the overallSignificantly lower than the overall5

ApproximatelyMental health problems are higher inchildren who experience poverty anddomestic violence. For adults of working age,the breakdown of relationships, and adversecircumstances, such as risk of falling into debt,all have a detrimental impact on people’smental health. Local Health and WellbeingSurveys bear out these factors. With longer lifeexpectancy, protecting the mental wellbeingof older people is becoming more of a problem.Mental wellbeing in old age is affected bydeprivation, bereavement, isolation andphysical illness.25%9,700 6,400Will be parentswith a mentalhealth problemin Leicesterof adults in mentalhealth care are likelyto be a parentSocialisolation inolder people isassociated withincreased risk ofdeath from anycause in the UK;13%Support for Familiesundergraduates havemental health symptomslinked to stress and anxiety,equivalent to aboutSupporting new parentsThe occurrence of mental health problemsduring pregnancy can have a significant impacton women, children and families. Children’sservices are involved in the prediction anddetection of mental health problems in theperinatal period. They ask questions aboutexperience of mental illness, previous treatmentby specialist mental health practitioners, andself-reported measures of mental wellbeingsuch as the Edinburgh Postnatal DepressionScale. Effective intervention can improvethe quality of life for new mothers and havea positive impact on reducing postnataldepression.5,000studentsat the 2 universities inLeicesterIn Leicester, based on5,000 births per year thereare likely to be10cases of postpartum psychosis,500-700cases of mild to moderatedepression linked topregnancy and150cases ofsevere post-nataldepressionbereavement, retirement and declining healthall of which are recognised risk factors. Peopleliving with multiple illnesses are more likelyto be isolated and this in turn further impactsnegatively on their health. Therefore, for olderpeople, having social connections and beingpart of society is particularly important. TheHealthy Aging section of Leicester’s new JointHealth and Wellbeing Strategy emphasisesthe need to support the mental and physicalhealth of older people. It also emphasisesthe importance of ‘aging confidently andcomfortably’ and the need to ensure that olderpeople continue to feel valued and useful partof society.Supporting older peopleLoneliness and isolation for older people maybe physical isolation, lack of companionship,and sometimes the lack of a useful role insociety. If schemes to target loneliness in olderpeople are to be effective, they should involveolder people at every stage, including planning,development, delivery and assessment.Befriending schemes have proved one of themore effective services for combating bothisolation and loneliness, but they are bestused in conjunction with other services. Groupsupport, including intergenerational activities,can be useful in helping older people out ofloneliness and isolation.Those who aresocially isolatedare more likely tohave poor mentalhealth and wellbeingOlder people tend to experience more socialisolation and loneliness as they are morelikely to have experienced life events such as6

The most effective way to help people managesocial isolation and loneliness is throughbefriending schemes and by encouragingattendance at social activities. However, thereis also a need to intervene before peopleexperience it, this can be achieved by targetingpeople when they become at risk. Examplesof where this could be effective include therecently bereaved, carers, recently retired, peoplediagnosed with a second chronic illness. Thelocal authority is in the process of exploringthese ideas to ascertain how to best supportthose with or at risk of being isolated and lonely.Identifying people at risk of lonelinesscan be difficult but targeting thosedisproportionately affected by loneliness– lower socio-economic groups, thewidowed, the physically isolated, peoplewho have recently stopped driving, thosewith sensory impairment and the very old– has proven most effectiveKey prevention opportunitiesBuild relationships for wellbeing means:Strengthening your relationships withpeople who are close to you, such asfamily and friends;Broadening your relationships in yourcommunity and the wider world.Personal action plan:If possible, take time each day to be withyour family. This could include a fixed“family time” each day;Arrange a day out with friends you haven’tseen for a while;Switch off the TV and play a game withthe children, or just talk (see some tips ontalking to children about feelings andtalking to teenagers);Make the effort to phone peoplesometimes – it’s all too easy get into thehabit of only ever texting, messagingor emailing people;Speak to someone new today; Have lunchwith a colleague;Visit a friend or family member who needssupport or company;Volunteer at a local school, hospital orcommunity group;Make the most of technology by usingvideo chat apps to stay in touch withfriends and family7

Case studyThese supportive visits meant that togetherthey were able to build on the new mum’sstrengths in the interactions with her baby.Steadily her confidence in her parenting skillsgrew. By the time her baby was 2 years old,her patient was able to provide, and enjoymost, of the baby’s care. Their bond wasevident and her patient was feeling wellenough to engage in community groupsfor familiesA pregnant 24-year-old woman of SouthAsian ethnic background was referred to EarlyStart by her midwife. Before her pregnancy,she had been in hospital because of bipolardisorder. She was closely monitored buttowards the end of her pregnancy her mentalhealth had started to deteriorate once more.As part of the Early Start offer, she wasassessed by a Public Health Nurse in theantenatal period. Her care included a jointapproach with mental health nurses andweekly supportive visits.After her baby was born the patient wasdischarged home. However, her mentalhealth worsened, and both mother andbaby were admitted to a postnatal mentalhealth unit. This was a difficult time, duringwhich the new mum experienced recoveryand relapses. In baby’s first year she washad several inpatient episodes, sometimes indifferent parts of the country and sometimessectioned under the Mental Health Act.The Public Health Nurse felt that whenshe was well, her patient was excited tobe a mum and very enthusiastic. But thedisruption in the first year of baby’s life meantthat she needed all possible support to helpher to bond with her child.This was complex work, covering differentsettings. For instance, the nurse visited herpatient in the mother and baby mentalhealth unit. This helped to develop a trustingrelationship which meant that supportivevisits could easily continue when the patientwas back in the home environment. Inaddition, there were some periods wherethe patient was unwell, and the baby’sgrandmother provided most of the care.Home visits helped the nurse to buildrelationships with her patient’s extendedfamily.8

Mental Wellbeing inEducational SettingsBy supporting childhood emotional healthschools can influence cognitive development,learning and physical health. Poor mental healthin childhood is likely to lead to lifelong mentalhealth problems. The extent of the problem isshown by the average UK classroom which has3 children with a mental health problem, 7 whoare being bullied and 6 who self-harm.the more adverse experiences people facein childhood the higher the risk of diabetes,respiratory and cardiovascular disease.3Such experiences are associated with anincreased risk of disruption to education. Longterm outcomes include poor educationalattainment and employment prospects.Children who fall behind with work and do lesswell in exams can have reduced life chances.The more time children spend with each other,whether in the classroom or as part of a teamor club, the more chance they have of makingfriends and feeling included, boosting socialskills, confidence and self-esteem.Social disadvantage and adversity increasethe risk of developing mental health problems.Children and young people from the pooresthouseholds are 3 times more likely to have amental health problem than those growingup with no experience in of adversity. Thisissue goes far beyond mental illness, becauseLeicester - Children & Young People’s Health and Wellbeing Survey 2016/1770%46%More thanof children aged 10-15 havereservations about talkingabout feelingsof 10-15 year olds haveexperienced bullying23%SIXTY EIGHT PERCENTONE IN FIVEof 10-15 yearolds in Leicester haveexperienced bullying inthe last 12 monthshave an adult they can trust to talkabout problemsIn 2017/181 in 4Children aged 10-15 yearsfelt sad or upset alotChildren wouldbe there for afriend for support5%of half days were misseddue to school absence(4.8% nationally)**PHE fingertips9In 2017, 7.2% of16-18 year oldswere not ineducation,employment ortraining in Leicestercompared to6.0% nationally*

Our Young People’s Health and Wellbeing Survey showed that about 25% of Leicester childrenhave experienced bullying in the last 12 months and 20% feel sad or upset a lot. However, 30%find it hard to trust people, more than 70% have reservations about talking about feelings, and66% of 14-15 year olds did not agree that school teaches them how to deal positively withfeelings. When it comes to supporting people, 25% said they would be there for a friend and 68%have an adult they trust to talk about problems.In a short questionnaire of Headand Deputy Head teachers,most believed there is anincrease in childhood mentalhealth problems, especiallythose which are beyond theskills of teaching staff, but whichdo not meet the thresholdfor referral to specialist Childand Adolescent Mental HealthServices. Evidence also suggeststhat nearly half of teachershave poor mental health.4Taken together these findingsshow that there are higherthan average rates of bullyingin Leicester, and while someyoung people are supportiveand know trustworthy friendsor adults, they are generallyunlikely to talk about theirfeelings. More should be done,beyond specialist mental healthservices, to protect the youngpeople’s mental health.Eight principles to promote a wholeschool and college approach toemotional health and wellbeingAn ethos andenvironment thatpromotes respect andvalues diversityTargetedsupport andappropriatereferralCurriculum,teaching andlearning to promoteresilience and supportsocial and emotionallearningLeadershipand managementthat supports andchampions efforts topromote emotional healthand wellbeingWorking withparents/carersThe diagram here summariseshow whole school engagementin prevention and promotionis an effective way to buildresilience to mental illness.5This approach advocates thatthe ethos of the school shouldpromote respect and valuediversity. This will be properlyestablished though leadership,policy development, curriculumbased social education,programmes for parents andteachers and targeted supportfor children at high risk of poormental health.Identifyingneed andmonitoring impactof interventions10Enablingstudent voiceto influencedecisionsStaff developmentto support their ownwellbeing and thatof students

Future in MindA key message is that promoting wellbeing inschool has the potential positively to influencepupil’s readiness to learn. By facilitating pupilsuccess schools can help children to be resilientand mentally healthy. As the demands ofteaching can also have a detrimental impacton a teacher emotional wellbeing, protectingteachers’ health is also important7Future in Mind is a national initiative, led by theNHS with other local organisations to improvechildren and young people’s access to mentalhealth care and support. Across Leicester,Leicestershire and Rutland, this programme hasput in place a new service, Route to Resilience.This service helps schools to promote positivemental health, support vulnerable families andindividuals, and offer advice as to how andwhere to get help. It is developing a network ofschools which can approach emotional healthwith confidence and clarity.Improving emotionalwellbeing ineducational settingsTime to Change LeicesterTackling bullying in LeicesterschoolsTime to Change Leicester is a key publicmental health campaign to stimulate broadconversations about mental wellbeing. Raisingawareness of mental wellbeing in schools isan important way of challenging stigmatisingattitudes for the benefit of young people.Experience of bullying is a strong predictorof poor emotional wellbeing and lowereducational attainment. A child’s sense ofbelonging to a school is higher where there arelower levels of bullying. Such schools are morelikely to be high achieving.In order to tackle bullying, Leicester CityCouncil worked with schools and governorsto develop an anti-bullying strategy8 and ananti-bullying alliance.9 The key strands of thiswork are leadership, best practice, and bettercommunication, participation of young peopleand data management. The strategy recognisesthat schools can promote pupil emotionalhealth through better social interactions, andthat these can benefit academic performance.It encourages schools to tackle behaviour whichundermines relationships and to involve pupilsin decision making so that they have a stake inschool life.Using information taken from the Health andWellbeing Survey of Young People in Leicester,Time to Change Leicester has highlighted theproblem of bullying in Leicester and hasworked with schools and universities to helpimprove understanding about young people’smental health.Experience of bullying is a strong predictorof poor emotional wellbeing and lowereducational attainment. A child’s sense ofbelonging to a school is higher where there arelower levels of bullying. Such schools are morelikely to be high achieving.11

Healthy Child ProgrammeHealthy Together [see diagram below] is theHealthy Child Programme for 0-19 year olds,delivered by Leicester Partnership NHS Trustfor children and families. Public Health Nursessupport positive mental health of children andparents by monthly drop-ins in primary schooland weekly drop-ins in High School. HealthyTogether also offers a digital service for parents,which is helpful at moments of anxiety suchas children starting school, transition betweenprimary and secondary school and at times whenpressure of exams can take a toll [such as in Year11]. Young people in secondary school can accessdigital support from Public Health Nurses throughthe ChatHealth Text Service. There is a web-basedsupport for primary and secondary age children,with useful information about emotional healthand wellbeing. Healthy Together offers thematicWeb Chats which cover topical issues such asbullying and exam pressures2017/1895% of infantsreceived anew birth visitwithin 14 daysof birth2017/18174 familiesparticipated inthe Early Startprogramme2017/18433 vulnerablemothersattended supportsessions12

ranlTcia aloS gitDionr(ars neYe titio2c/ a2 1 P Pr sHC min45B4ricea lin1Y @C snHV mi45.nlyro)sefhfB4toron - 1 or3M4 oup o r (BGr P SWioneHC actitPrsekWe86sHV min45thBir omewNe @ HrHV Hou1lata eten HomiesnA @ rabHV Hou s to B1 mpBusition)13SafeguardingSelf-harmAnxietyCSE AwarenessGP informed on completionof package of careHCP Practitioneror Support Workerliaise with SCPHN oncompletion of packageof careEarly StartUp to 25 children in each districtIntensive home visitingObesityDevelopmental delayBrief intervention (EHWB, sexualhealth, smoking, drugs, eatingdisorders)Long-term conditionsContinence - up to 12 weeksUniversal Partnership PlusChildren in needTailored package, delivered in con junction with partner agenciesComplex needsLooked after childrenTravelling familiesCSEPerinatalFamily supportToiletingDiet and nutritionMinor illness / hospital dischargeSmoking / oral health / home safetyBlood spot testsTime limited package of care - max 4 in clinic / school or 2 at home (advice and review)Pathways:BreastfeedingBehaviourTwo can talkCONIGrowthNNUWeb Chatswww.healthforteens.co.uk)Universal PluspticeRe 3)(MP (BNC co.uk6ar(YeB3)P(MNC PSWHCChatHealth Text Service (City and County)Generic advice0-19: 1 HV and SN on duty 9.00-17.00Document on record and tasked to teamTravelling Families have separate arrangements7arYe gitalDiNurse TriageEstimate 10% need follow up records review or contactFollow up - signpost / SN assessment9arYe gitalDiSCPHN - ledOversight planningfor deliveryHigh impact area health campaignsAsset based community development work11arYe gital nly)iD ity o(CAdvice Clinics inNeighbourhoodCommunityBuilding community capacityHealthy profilesHealth fairsHealthy TogetherDrop ins Primary: Monthly(HCP Nurse orSCHPN)Secondary: Weekly(SCPHN)Diagram of Healthy Together the 0-19 Healthy Child Programme

Case studyschool approach. Additional enhancedprofessional development has been accessedby individuals, with two Mental Health FirstAiders trained in 2018, to further aid staffthrough peer support programmes.Eyres Monsell Primary School is located inan area with high rates of deprivation andchildren born into poverty. There is a historyof disrupted education and low social mobilitywhich cuts across generations. Children oftenenter school with poor concentration levels,emotional and behavioural issues and specialeducational needs.OutcomesSchool academic outcomes haveimproved. In 2017 the school achievedin the top 10% nationally for its readingresults at the end of Key Stage 2 and wasone of the top 3 most improved schoolsin Leicester City.The school has worked to address thesebarriers with a holistic approach, creating avalue based culture which actively promotesand supports mental wellbeing and trainingfor staff and pupils, to encourage mentalwellbeing.Improved attendance rates with areduction of pupils who are persistentabsentees.School leadership has promoted core valuesof resilience, respect, aspiration, honesty,co-operation and reflection. Children areencouraged to articulate their feelings andemotions and have a greater understandingand ability to cope with situations andchallenges they encounter in daily life.Improved behaviour and reducedexclusion rates.Reduced stigmatisation across the wholeschool community of mental health.Reduction of staff absence relatedto mental health and a reduction in theassociated costs of absence management.Pupils now have yoga and meditation as partof their daily lives, through planned Mini MeYoga sessions. Children learn ‘calm down’strategies and develop an awareness of howto regulate their bodies through methodssuch as breathing techniques. Every childaccesses weekly opportunities to improveresilience, communication, self-confidence,self-awareness and emotional regulation aspart of the curriculum. Children have time tocalm down after playtimes. There is a moreopen culture aimed at reducing stigma andanxiety around speaking about concernsand worries. Additional services such asRELATE counselling are sourced through PupilPremium Funding, to provide specialist earlyintervention for pupils needing additionalexpertise and professional support.The first Primary School in the EastMidlands to have all teachers trained inYoga and Meditation, receiving theMini Me Yoga Accreditation.The first school in the UK to be awardedCarnegie Centre of Excellence for MentalHealth in Schools School Mental HealthAward at Gold standard.The more we placed emphasison the wellbeing of pupilsthe more we also began torecognise the need to supportour staff too. For staff toperform to their best they needto have a positive mindsetEmpowerment of teaching staff hasbecome a key driver. Staff members areencouraged to develop self-awareness tomanage their own mental wellbeing. All staffhave received training and developmentin Creating a Culture of Well-Being, toensure the sustainability of our wholeK Hill, Headteacher14

Future actionThe school is committed to further supportingthe wider school community through providingparental engagement and support. The schoolhas recently received a Time to Change LeicesterCommunity Grant for a parents’ mental HealthGroup called “Chatter Matters”. This hopes tosupport parents and carers in developing theirown well-being strategies and providing a forumwhere parents and carers can build connectionsand relationships to support their own mentalhealth.The school continues to develop its ownwell-being and mental health provision andis committed to encouraging further staffdevelopment. The school has recently appointeda dedicated Mental Health Lead to the leadershipteam, who is receiving training through LeedsBeckett University’s Mental Health in SchoolLeads programme. A further member of staff isundertaking Mental Health First Aid for Youths.The school is also participating in an academicresearch study in 2018 – 2019, looking at applyingpositive psychology to grow character strengths –the VIA Youth Project.15

Mental Wellbeing inthe WorkplaceMental health problems including anxiety, stress and depression are common and aleading cause of absence from work. In 2016, more than 15 million working days werelost because of mental health problems in the UK, with the estimated annual cost ofsuch problems at work estimated as over 70 billion.10Health and WorkSpotlight on Mental HealthAlmost1 in 6people of working agehave a diagnosablemental healthconditionin 2015 someMental health conditions are a leading causeof sickness absence in the UKOVERwere lost todaysan increase of 24% since 200915m19%long-termsicknessabsencein England attributedto mental ill health48% ofEmployment and SupportAllowance recipientshad a ‘Mental or Behavioural disorder’as their primary conditionEach yearmental ill-healthcosts the economyan estimatedstress, depressionand anxiety’ in2014 70bn through lost productivity, social benefits andhealth care.Work can be acause of stressand common mentalOf people withphysical long termconditions,1 in 3also havemental illness,most often depressionor anxietyhealth problem:in 2014/159.9m dayswere lost towork-relatedstress,depressionor anxietyIn 201642.7%employment ratefor those who report mental illnessas a main health problem (Mentalillness, phobia, panics, nervousdisorders including depression, badnerves or anxiety. Compared to74% of all populationSources: Adult Psychiatric Morbidity in England, 2007; Health and wellbeing at work: a survey of employeres, 2014; Cimpean & Drake 2011; Nayloe et al; OECD, 2014; Labour Force Survey, various years16

Employment is a strongly evidenceddeterminant of mental health. There is adistinction between good work, characterisedby fair treatment, autonomy, security andreward, and bad, in which individuals do notfeel valued, supported or stimulated. Betteremployee mental health is associated withhigher staff retention, improved productivityand performance, higher levels of collaborationand reduced absenteeism.Marmot11 identified people with mental healthproblems as being among the most likely tobe in low-quality, low-status and insecurework. They are also more likely to beunemployed. The employment ratefor people living with mental healthproblems is 10-35%, depending onthe problem, compared to 59% forpeople with a general health problemand 77% for people who do not hav

have poor mental health and wellbeing Mental health problems are higher in children who experience poverty and domestic violence. For adults of working age, the breakdown of relationships, and adverse circumstances, such as risk of falling into debt, all have a detrimental impact on people's mental health. Local Health and Wellbeing

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