National Assembly for Wales / Cynulliad Cenedlaethol Cymru
Health and Social Care Committee/ Y Pwyllgor Iechyd a Gofal Cymdeithasol


Public Health (Wales) Bill / Bil Iechyd y Cyhoedd (Cymru)


Evidence from Mental Health Foundation – PHB 88 / Tystiolaeth gan Y Sefydliad Iechyd Meddwl – PHB 88



Response of the Mental Health Foundation to Committee’s call for evidence on the general principles in the Public Health (Welsh) Bill


The Mental Health Foundation


The Mental Health Foundation (MHF), incorporating the Foundation for People with Learning Disabilities (FPLD), is the leading UK charity working in the field of mental health and learning disability. We combine policy, research, campaigning and service development to promote good mental health and to improve services for anyone affected by mental health problems or with a learning disability.


Our contribution is based on our experience, over 60 years, of advocating for improved mental health for all, applied research on effective interventions on mental health and learning disabilities and influencing reform in policy and practice.


Emily Wooster

Head of Development Wales



We are urging the Welsh Assembly to introduce a clause in the Public Health Bill recognising the importance of mental health. Our response will be limited to the question regarding what other areas the Bill needs to address (Question 21). It is imperative that the Bill includes mental health and wellbeing as key determinants of physical health, beyond smoking. Mental health must be part of any Public Health Bill. Mental health is a universal asset that we all share, it enable us to reach our potential as individuals, as communities and as a society. Conversely poor mental health can lead to a cycle of disadvantage. This can involve higher levels of physical morbidity and mortality, lower levels of educational and work performance, and poor community and societal cohesion.


Placing mental health at the heart of public health policy will lead to healthier lifestyles, reducing health risk behaviour and physical illness. This aligns to the aims of the Welsh government to reduce the risk and occurrence of mental and physical illness, disability and premature death.[1]


Table of contents

1.    Mental health as a public health issue

2.    Mental health equity


3.    Mental and non-communicable diseases

4.    Prevention




1.    Mental health is a public health issue:


1.1  Mental health is a public health issue, and therefore it must be at the core of any public health strategy. Ill-health in the UK, carries huge financial costs . It is been estimated that NHS Wales’ largest single programme budget category is mental health problems, which amounts to 11.4% of the £5,560.1 million total.[2] Cancer and diabetes cost NHS Wales £380.1 million and £95.2 million respectively.[3]  In terms of welfare, mental health problems attributes to 43% of the 2.6 million people on long-term, health-related benefits.[4] In 2013/14, Wales experienced 25,000 lost working days due to work-related stress, depression or anxiety; more than for any other illness.[5]


1.2  No other health condition matches mental ill-health in prevalence, persistence or breadth of impact.[6] In Wales, one in four adults experience mental health problems at some point during their lifetime and one in six will experience symptoms at any one time.[7] Additionally, Wales needs to provide sufficient mental health services, as only one in nine adults requiring treatment in 2011 were in fact being treated.


“There is no public health without mental health…investment is needed to promote public mental health.”[8]


2.    Mental health equity: giving to every person the best chance to achieve in life


2.1  By addressing mental health in the Public Health Bill, the Welsh Government will be able to address deep social, economic and health inequalities.[9] The relationship between inequalities and poor mental health and wellbeing is a two-way process. Experiencing disadvantage and adversity increases the risk of mental ill health, and experiencing mental ill health increases the risk of experiencing disadvantage. Living with mental health problems can create a cycle of adversity where related factors such as employment, income and relationships suffer.


2.2  Mental ill health is not evenly distributed across society.People from certain groups are more likely to experience mental health problems, and therefore face significant disadvantages in life. Evidence shows there are strong relationships between factors such as poverty, disability, gender, sexual orientation, age and ethnicity, and mental ill health. The Green Paper itself recognises the “social and economic determinants of health,”[10] including, income and education, lifestyle, physical environment and access to quality care.[11]


2.3  To reduce health inequalities, the Welsh Government needs to take into consideration the different characteristics and circumstances of each individual in the development of any public health regulations.Mental health problems are more than a health issue, they have a broad range of influences and determinants. We know that, for example, people’s gender, age, race, sexual orientation, work status, home and neighbourhood –to name a few- have a, positive or negative, effect on people’s mental wellbeing. Unsurprisingly, in Wales people who, for example, live in poverty are at higher risk of developing a mental health problem. This evidence strongly suggest that only by closing health inequalities will we be able to live in a society where every person -regardless of their gender, sexual orientation, race, socio-economic background, religion or belief, disability or age- can flourish and achieve the best of their potential in life.


“Without addressing the promotion…of a diverse population’s mental health across government, not only are individuals poorly served, but many government goals and commitments on physical health, social cohesion and productivity are simply not achievable. Investment across the board will more than pay for itself…through a reduced need for public services and an increased opportunity for people with mental health conditions to contribute socially and economically.”[12]



2.4  To reduce the prevalence and associated social and financial costs of mental health problems, mental health must be embedded across the public policy spectrum, and be recognised in the Public Mental Health Bill. The mediating role of mental health in improving health and socio-economic outcomes needs to be better understood, and entrenched as a central aspect of all health and public service delivery. Parity in public mental health is essential to better understand the determinants and influencing factors of mental health, and to enable early diagnosis and support.  Delivering on parity of esteem requires working to achieve equal funding and prioritization for mental health services, for public mental health programmes, and within wider public policy.


3.    Addressing mental health will help to tackle non-communicable diseases:[13]


3.1  The Bill needs to recognise that the mind and body are intrinsically linked.Having poor physical health causes stress. Likewise, experiencing a mental health problem places people at greater risk of developing a long term condition, and produces poorer outcomes for those that do. Despite many years of aspiring to person-centred care, there is still much to do before fully integrated and holistic support is standard. Working collaboratively across physical and mental health services will not only achieve better outcomes for individuals, but has the potential to be cost effective. This can be achieved by using the points of service access to improve mental health for those experiencing physical ill health, and by promoting the health of people with mental health problems.


3.2  There is a significant link between non-communicable diseases and mental health. Mental health issues can onset physical ailments and vice versa. Rates of depression are doubled in those with diabetes, hypertension, coronary artery disease and heart failure[14]. In addition, the prevalence of depression among those with two or more chronic physical conditions is almost seven times higher than healthy controls.[15] Depression almost doubles the risk of coronary heart disease[16] and increases death by a cardiovascular disease by 67%.[17] The trend continues: schizophrenia is associated with a three-fold increase in death rate of respiratory diseases and four fold by infectious diseases.[18]


3.3  Failing to recognise the link between the two will perpetuate the unacceptably large mortality gap. People with mental health problems die prematurely compared to the general population. On average, men and women with mental health problems die 20 and 15 years earlier respectively[19] .Those living with schizophrenia and bipolar disorder have a 25-year shorter life expectancy, largely due to the increased risks from smoking. The majority of deaths arise from preventable causes and could have been avoided by timely medical intervention.[20]


“Individuals with mental illness experience increased levels of physical illness and reduced life expectancy.”[21]


3.3 The Welsh Government recognises that “mental health is as important as physical health in a long, happy and active life.”[22] In doing so, the Government will be better equipped to address its primary non-communicable disease concerns of smoking, alcohol consumption, diet and physical activity,[23] and minimise obesity, alcohol misuse, cancer, cardiovascular diseases and diabetes.[24]


Key statistics: inequality, mental health and non-communicable diseases


·         20-25% of the British population that are either obese or smoke experience the highest prevalence of anxiety and depression.[25]

·         Obesity is more common for those living with depression, bipolar disorder, panic disorder and agoraphobia.[26] 

·         Not only are low-income households disproportionately affected by physical and mental health conditions, but evidence suggests that they are more likely to have their physical health needs unrecognised, unnoticed and poorly managed.[27]

·         Smoking is the largest single cause of preventable death and health inequality, which disproportionately impacts people with mental ill health. 70% of people in in-patient mental health units, compared to 21% of the general population, smoke,[28] and almost half of total tobacco consumption and smoking-related deaths occur in people with mental health problems.[29]















4.1 It is understood that it will not be possible to absorb the rising costs of providing care and support for mental health problems in the long term, and the economic case for working to prevent mental health problems has been clearly stated. [30] If we are to rise to this challenge then we will need to act decisively as we have in the past when faced with significant risks to public health.


“The preventable nature of many of the related physical and mental health conditions also reinforces the need for an increased focus on preventative action, particularly to safeguard the future health of our children and young people.” [31]


4.2 Our first waves of public health improvements whilst significantly reducing mortality were rightly centred on curing illness and responding in crisis. This has left a legacy of services designed to fix deficits. Although it will be crucial to continue to improve access to good quality service provision, we have to do this alongside working to improve health so that illness is a rarer event.



[1]Welsh Government (2014) A consultation to collect views about whether a Public Health Bill is needed in Wales. Available at:

[2] NHS expenditure programme budgets: 2013-14. Available at:

[3] NHS expenditure programme budgets: 2013-14. Available at

[4] Department for Work and Pensions (2010) Administrative Data in Public Health Framework. Department for Work and Pensions. In p.19.

[5] Health and Safety Executive (2014) Stress-related and Psychological Disorders in Great Britain 2014. Available at:

[6] Friedli, L., Parsonage M (2007) Mental Health Promotion: Building the Economim Case. Northern Ireland Association for Mental Health

[7] Welsh Government. Together for Mental Health A Strategy for Mental Health and Wellbeing in Wales. Available at; p12.

[8]RCPsych. No Health Without Mental Health. The case for action. Available at: p. 11.

[9] Sainsbury Centre for Mental Health (2007) Mental Health at Work: Developing the Business Case (Policy Paper 8). SCMH. In p.18.

[10]Welsh Government (2014) A consultation to collect views about whether a Public Health Bill is needed in Wales. Available at:

[11] Welsh Government (2014) A consultation to collect views about whether a Public Health Bill is needed in Wales. Available at:

[12]  Future Vision Coalition (2009) A Future Vision for Mental Health. Future Vision Coalition. In p. 33.

[13] Welsh Government (2014) A consultation to collect views about whether a Public Health Bill is needed in Wales. Available at:, p.4.

[14] Egede LE (2007) Major depression in individuals with chronic medical disorders: prevalence, and correlates and associates of health recourse utilisation, lost productivity and functional disability. General Hospital Psychiatry, 29, 409–416. In p.21.

[15] Moussavi S, Chatterji S, Verdes E, et al (2007) Depression, chronic disease and decrements in health: results from the World Health Surveys. Lancet, 370, 851–858. In p.21.

[16] Hemingway H, Marmot M (1999) Evidence based cardiology. Psychosocial factors in the aetiology and prognosis of coronary heart disease: systematic review of prospective cohort studies. BMJ, 318, 1460–1467 in p.14.

[17] Mykletun A, Bjerkeset O, Dewey M, et al (2007) Anxiety, depression and causespecific mortality: The HUNT study. Psychosomatic Medicine, 69, 323–331. In

[18] Saha S, Chant D, McGrath JA (2007) Systematic review of mortality in schizophrenia: is the differential mortality gap worsening over time? Archives of General Psychiatry, 64, 1123– p.14.

[19] Department for Health. Choosing Health: Supporting the physical health needs of people with severe mental illness.

[20] British Medical Association. (2014). Recognising the importance of physical health in mental health and intellectual disability.,d.ZGU

[21] RCPsych. No Health Without Mental Health. The case for action. Available at: p.14.

[22] Welsh Government (2014) A consultation to collect views about whether a Public Health Bill is needed in Wales. Available at:,

[23] Welsh Government (2014) A consultation to collect views about whether a Public Health Bill is needed in Wales. Available at: p4.

RCPsych. No Health Without Mental Health. The case for action. Available at: p.8

[25] Melzer D, Fryers T, Jenkins R (2004) Social Inequalities and the Distribution of Common Mental Disorders. Maudsley Monographs Hove, Psychology Press.

 In p 13.

[26] Simon GE, Von Korff M, Saunders K, et al (2006) Association between obesity and psychiatric disorders in the US adult population. Archives of General Psychiatry, 63, 824–830. In p 15.

[27] Department of Health, Choosing Health: Supporting the physical health needs of people with severe mental illness

[28] RCPsych. No Health Without Mental Health. The case for action. Available at: p.15.

[29]  RCPsych. No Health Without Mental Health. The case for action. Available at: p.15.

[30] Marmot Review. Fair Society, Healthy Lives: Strategic Review of Health Inequalities in England Post 2010. London: Marmot Review; 2010.

[31] Welsh Government (2014) A consultation to collect views about whether a Public Health Bill is needed in Wales. Available at: p.5