Maggie’s Centres: wellness through building design and the environment

In March 2017, the 20th Maggie’s Centre was opened in the grounds of Forth Valley Royal Hospital in Falkirk. Designed by architects Garbers & James, it is expected to receive 3000 visits in the first year.

Maggies Centre Forth Valley, Garbers and James

Maggie’s provides free practical, emotional and social support to people with cancer and their family and friends, following the ideas about cancer care originally laid out by Maggie Keswick Jencks and co-founded by her husband Charles, who is a landscape architect. Among Maggie’s beliefs about cancer treatment was the importance of environment to a person dealing with cancer.

She talked about the need for “thoughtful lighting, a view out to trees, birds and sky,” and the opportunity “to relax and talk away from home cares”. She talked about the need for a welcoming, reassuring space, as well as a place for privacy, where someone can take in information at their own pace. This is what Maggie’s centres today aspire to.

A number of high profile architects have designed Maggie’s Centres across the UK – from the late Zaha Hadid to Frank Gehry, Richard Rogers and Rem Koolhaas.

The Maggie’s Centre in Kirkcaldy, Zaha Hadid Architects

Promoting wellbeing through the natural environment and effective design

Drawing on research which considers the significant impact that environment can have on wellbeing, Maggie’s Centres are designed to be warm and communal, while at the same time being stimulating and inspiring. The interiors are comfortable and home-like. Landscape designers and architects are encouraged to work closely together from the beginning of a project as the interplay between outside and inside space, the built and the “natural” environment, is seen as an important one.

A building, while not wholly capable of curing illness, can act as “a secondary therapy”, encouraging wellness, rehabilitation and inspiring strength from those who move around it.”

Each of the centres incorporates an open kitchenette where patients can gather for a cup of tea, airy sitting rooms with access to gardens and other landscape features, and bountiful views. There are also private rooms for one-on-one consultations; here Maggie’s staff can advise patients on a range of issues relating to their condition, whether that is dietary planning, discussing treatment options (in a non-clinical setting) or delivering classes such as yoga.

Spaces to promote mental wellbeing as well as physical healing

Maggie’s Centres are also about offering spaces to people to help improve their mental wellbeing. As well as quiet tranquil spaces for reflection and meditation, there are also central areas, focused on encouraging the creation of a community between the people who use the centre. Wide-open spaces, high ceilings and large windows, with lots of opportunities to view the outside landscaping and allow natural light to enter are a key feature of many of the Maggie’s Centres.

The locations also try as far as possible to provide a space free from noise and air pollution, while remaining close enough to oncology treatment centres to provide a localised base for the entire treatment plan of patients.

Fresh air, low levels of noise and exposure to sunlight and the natural environment, as well as designs that provide spaces that promote communal interaction to reduce feelings of isolation and loneliness, have all been shown to improve mental as well as physical wellbeing. In this way, the physical attributes and design of the Maggie’s buildings are helping to promote mental as well as physical wellbeing of patients and supplement the care being given by the cancer treatment centres located nearby.

Interior of the Maggie’s Centre in Manchester, Foster and Partners

Award-winning architecture and design

In 2017 Maggie’s Manchester was shortlisted for the Architects’ Journal Building of the Year award. And many of the individual centres have won regional design awards for their innovative use of space and incorporation of the natural environment into their designs.

A Maggie’s garden was also featured at the 2017 Chelsea Flower show, highlighting the importance of environment, and the role of the natural environment in rehabilitation and promoting wellness among those who are ill.

Final thoughts

How design and landscape can aid and empower patients is central to Maggie’s Centres. They are a prime example of how people can be encouraged to live and feel well through the design of buildings and the integration of the surrounding natural environment. These environments are the result of a complex set of natural and manmade factors, which interact with one another to promote a sense of wellness, strength and rehabilitation.

They demonstrate how the built environment can contribute to a holistic package of care – care for the whole person, not just their medical condition. Other health and social care providers can learn from them in terms of supporting the wellbeing of patients, carers and their families.


You can find out more about Maggie’s Centres though their website.

Keep up to date with what is interesting our research officers on Twitter.

Read more about innovative building design in our other blog articles.

Zero suicide cities: learning from Detroit in the UK

Suicide is the biggest killer of men under the age of 45. Yet people still experience stigma when seeking help for mental illness, despite high-profile discussions of mental health issues such as those by members of the royal family and sportspeople. And a report into the Government’s suicide prevention strategy in March 2017, suggested that although 95% of local authorities now have a suicide prevention plan, there is little or no information about the quality of those plans, or whether adequate funding is available to implement them.

The lack of progress made on improving suicide and general mental health provision has led to a growing frustration among professionals and resulted in attempts to create new approaches to tackle mental health issues, and in particular to improve access to support for people in crisis or at risk of suicide.

The idea of a “zero suicide city” was first adopted in Detroit in the late 2000’s, with others following its lead in subsequent years. With reports finding that around 14 Londoners a week took their own life in 2015 (735 in total), an increase of a third from the 2014 statistics, a report in February 2017 by the London Assembly Health Committee suggested that London too should take this approach.

So what can London, and other areas of the UK, learn from Detroit’s approach? And how can services act to reduce the number of people taking their own lives?

Zero-suicide cities

Poverty and high unemployment in Detroit are contributing factors to high levels of depression among city residents. As a result of these high rates of depression and very high suicide statistics, Detroit-based mental health professionals adopted a new approach to tackle the stigma around mental illness and use identifiers to highlight cases of crisis, or potential crisis. The focus is on preventative care, encouraging professionals to act upon signs of mental illness before a suicide or attempted suicide takes place.

Patients attending health clinics for other illnesses, including diabetes or heart failure, are also now screened for depression and other mental health issues before they are released. This allows people deemed to be ‘at risk’ to be identified as soon as they come into contact with medical professionals, who can then refer the patient to a mental health specialist if needed, rather than reacting to mental illness once it reaches crisis point.

In order to support this approach, a centralised IT system was created which means results are traceable, and surveys and information are standardised so they can be used and accessed across clinics throughout Detroit. Coordination with non-medical practitioners, including social workers, employers and family members, has also been key in identifying people at risk and signposting them to help at every possible opportunity. There has also been additional training for staff to improve recognition of identifying factors. Patients can email their clinicians or liaising staff directly and attend regular drop-in appointments. Up to 12,000 patients using mental health facilities are tracked each year in the city and some statistics suggest that the clinics reduced suicides by over 80%.

There have been some criticisms of the system however, despite the reduction in the number of suicides in the city. Critics highlight the fact that many of the poorest and most severely in need of help are not reached as they do not have health insurance and so do not attend those clinics involved in the scheme.

Ultimately, however, the scheme seeks to provide better preventative, coordinated and targeted care to those who are at risk or show some signs of mental health crisis. And some in the UK have suggested there are lessons that could be learned from this approach.

Whole system approach to suicide prevention in the East of England

Four local areas in the East of England (Bedfordshire, Cambridgeshire & Peterborough, Essex and Hertfordshire) were selected in 2013 as pathfinder sites to develop new approaches to suicide prevention based in part on the Detroit model.

Since then, Mersey Care, Cambridge and Peterborough Clinical Commissioning Group and Teesside councils have also become aligned with the programme and are continuing with their approach towards improved suicide prevention. The Centre for Mental Health evaluated the work of some of the sites during 2015.

The evaluation found there were a range of activities that had taken suicide prevention activities out into local communities. They included:

  • training key public service staff such as GPs, police officers, teachers and housing officers
  • training others who may encounter someone at risk of taking their own life, such as pub landlords, coroners, private security staff, faith groups and gym workers
  • creating ‘community champions’ to put local people in control of activities relating to promoting positive mental health and signposting to help services
  • putting in place practical suicide prevention measures in ‘hot spots’ such as bridges and railways
  • working with local newspapers, radio and social media to raise awareness in the wider community
  • supporting safety planning for people at risk of suicide, involving families and carers throughout the process
  • linking with local crisis services to ensure people get speedy access to evidence-based treatments.

However, subsequent research also highlighted some of the challenges. The marketing of the pilots was seen to be damaging and misleading with regards to creating “zero suicide areas”, rather than suicide prevention areas. It has also been suggested that although the campaigns serve to raise publicity and awareness, there is little evidence that the schemes actually reduce the number of suicides in an area any more than “traditional campaigns” to better signpost people to available support.

In addition, many of the projects struggled past the initial implementation stage to have long-term impact, as the buy-in from local GPs and other service professionals was not as high as was expected.

Final thoughts

Widening and improving access to support and services for people at risk of mental ill health or suicide is a big challenge for health and social care professionals. Identifying those people at risk is one of the key barriers and taking inspiration from schemes like those trialled in Detroit is one way for professionals in the UK to adapt their approaches in order to overcome these barriers.

Providing more opportunities for people to get help, and better training for professionals who may come into contact with people with mental illness are some of the ways that current schemes are trying to address mental health and suicide in particular.

However, as many of the evaluative studies from test sites in the UK have found, going beyond that to take mental health into the community, in order to create whole system pathways of care across multiple settings and professions, remains a challenge.

As the London Assembly report pointed out, another key aspect is creating an open environment for people to talk about how they are feeling. This week is Mental Health Awareness Week 2017 and the theme is ‘surviving to thriving’ – and emphasising that good mental health is more than the absence of a mental health problem. Whether in the workplace or in the home; with friends, family or colleagues; it’s important that everyone feels that they have a space where they can talk, and to cultivate resilience and good mental health.


If you enjoyed this blog, you may also be interested in our other articles on mental health in the workplace.

To see what other topics our researchers are interested in, follow us on Twitter.

Beating the back to work blues

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The first journey into work after the Christmas break has to be one of the most painful journeys of the year. Overfed, possibly hungover, still angry at that sly comment your distant relative made across the dinner table a week ago, you and many others return to work at the start of January with the glow of the next set of bank holidays seeming very far in the distance (FYI the next bank holiday is Good Friday on 14th April – yes, APRIL *sobs*).

It’s no surprise then, that January is the time of the year that sees the highest rates of divorce. This is the month heralding some of the highest stress rates of the year, and is the lowest point in the calendar for many people who face daily battles with mental health. A researcher at Cardiff University, Dr Cliff Arnall has even created a formula to work out that 24th January is the “most depressing day of the year”.

Mental health takes centre stage at work

It’s therefore apt that as many of us spend much of our time at work, there has been an increasing recognition of the role of employers in supporting mental health.

In October 2016, Business in the Community published its 2016 Mental Health at Work report, which included a toolkit for employers. The report highlights the damage that concealing their condition can do to people with mental health problems, as well as the level of support that should be made available to employees to help promote positive mental health and wellbeing in the workplace.

Recommendations made in the report include:

  • Talk – Organisations and employers should break the culture of silence that surrounds mental health, particularly in the workplace by talking the Time to change employers pledge
  • Train – Organisations and employers should invest in training to ensure basic mental health literacy for all employees in all areas of the business
  • Take action – Organisations and employers should “close the gap” by asking all staff about their experiences of their own mental health at work and how any issues have been dealt with. Understanding the perceptions that staff have of how the company supports mental health generally across the organisation, can help identify steps to improve/ change practice if necessary.

Employers role in removing stigma

Ensuring good mental health in the workplace affects all levels of staff, from senior management to the newest members of staff who are still training or serving a probationary period. Multiple reports, including those by ACAS, CIPD, MIND and The Work Foundation, have stressed the importance of employers setting an example to their staff. That includes senior staff recognising when they need to take time to support their mental wellbeing too.

The Chartered Institute of Personnel and Development’s (CIPD) Absence Management Report for 2013, showed that stress is one of the biggest causes of long-term absence in the workplace. The report also showed that it impacts staff at all levels:

  • 40% of respondents said that stress-related absence increased over the past year for the workforce as a whole
  • 20% said it increased for managers
  • 1 in 8 reported a rise for senior managers
  • Only 44% would feel confident enough to disclose unmanageable stress or mental health problems to their current employer or manager.

The report suggested that if senior managers acknowledged their own mental health issues, it would remove some of the stigma associated with asking for help with mental health in the workplace. However, doing this requires a significant culture shift in how many organisations are run – which could take years. The Work Foundation, commenting on the 2016 version of the CIPD report, found that:

“Effective management of mental health in the workplace can save around 30% of costs felt by employers.  Line managers have a really important role to play in creating an environment where employees feel safe to disclose with the knowledge that the organisation will do something to help them.  Managers need to have a positive employment relationship where open and honest conversations can be had to discuss any required adjustments and provide that supportive environment.”

Using “blue Monday” to initiate conversations on mental health

This year “Blue Monday” falls on the 16th January. It may be called the worst Monday of the year, but employers are being encouraged to use the publicity around it to create opportunities for employees to discuss mental health in the workplace.

Questions to ask could be: what makes them stressed, what makes them anxious, how can the office environment be changed to improve the wellbeing of employees? There are also ideas for activities to help staff “beat the blues”, including lunchtime exercise, healthy eating and talking to colleagues about things other than work.

Specific sectors have also begun to initiate schemes to try to improve mental health and well being. Mates in Mind is a programme to be launched in early 2017 by the Health in Construction Leadership Group with the support of the British Safety Council. Modelled on an Australian programme, it is a sector-wide programme intended to help improve and promote positive mental health across the construction industry in the UK.

In social work, too, informal peer mentoring schemes have sprung up organically in many offices, with co-workers giving each other support when they need it, often in an informal capacity. More formal schemes have been set up to help social workers monitor and feel safe when talking about their mental health to colleagues and superiors. Feedback indicates that the low rate of retention of social workers is, in part, due to stress caused by secondary trauma or excessive caseloads.

 

So, as we trudge back to our desks for the first working days after Christmas, it is perhaps worth keeping some of these ideas in mind. Employers are keen to talk about mental health, but they also need the input of staff in order for them to work.

Putting some of these ideas into practice, may also go some way to improving the situation of many with hidden mental health conditions in the workplace who don’t feel confident enough to speak openly about it. We needn’t wait for the next bank holiday to improve our mood, small changes can make a big difference to wellbeing in the workplace!


Follow us on Twitter to see what developments in public and social policy are interesting our research team. If you found this article interesting, you may also like to read our other workplace mental health articles: 

Managing mental ill health in the workplace

Ending the stigma around anxiety

Planning for an ageing population: designing age-friendly environments

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In the UK, increased life expectancy means that people can expect to live longer than ever before.  While this is clearly good news – and has a number of potential economic benefits – the shift in demographic structure towards an increasingly elderly population has a number of significant implications.

Following Wednesday’s blog post on the implications for planning of the ageing society, today we highlight some of the ways in which planners can help support the creation of age-friendly environments by influencing the design of the urban environment, transport, housing and the wider community and neighbourhood.

The importance of an age-friendly environment

Age-friendly environments are underpinned by three key factors:

  • Safety
  • Accessibility
  • Mobility

Such environments impact positively upon the quality of life of older people by enabling and encouraging physical activity and social connection.  This in turn has a beneficial impact upon their physical and mental health, and helps to tackle social exclusion – which can be a particular problem among older people.

Conversely, as the World Health Organisation (WHO) notes, poor design can have a negative impact:

“older people who live in an unsafe environment or areas with multiple physical barriers are less likely to get out and therefore more prone to isolation, depression, reduced fitness and increased mobility problems”

Creating an age-friendly environment

There are a number of areas in which planners may have an influence on the provision of age friendly environments:

  • the design of the urban environment
  • supporting appropriate transport options
  • the provision of age-appropriate housing
  • adequate neighbourhood and community facilities

Urban environment

In terms of the urban environment, green spaces are an integral aspect of age friendly environments.  Access to green spaces supports the physical activity of older people, makes a positive contribution to their health and wellbeing, and provides opportunities for social interaction.

Research has found that green spaces that are poorly maintained, perceived as unsafe, or contain potential hazards resulting from the shared use of parks and walkways are less likely to be used by older people.  Suggestions for improvement include the creation of small, quieter, contained green spaces and improved park maintenance.

Paths, streets and pedestrian areas are also a key planning consideration. Older people have greater reliance on pedestrian travel and are more likely to be physically active in areas that are pedestrian friendly.  The perception of safety also influences use – therefore, lighting and road safety measures can help to enhance this.

Adequate public toilet provision will also become an increasingly important issue.  Recent cutbacks have resulted in many public toilets being closed – in their review of public toilet provision in the UK Help the Aged noted that provision was sporadic. They found that the majority of older people had experienced difficulties in finding a public toilet, and even when toilets were found, they were often closed.

Transport needs

Responding to the transport needs of different groups will also present a key challenge. For example, an analysis of major European cities  by the Arup engineering consultancy found that older people typically make fewer journeys, use private cars less, public transport more (trams and buses in particular) and walk more.  In addition to this, older people’s typical walking speed – as well as the average length of walking trips – were lower than younger people’s patterns.  These differences must be considered when designing age-friendly environments.

The growing population of older people in rural and semi-rural areas, and the reliance on cars in areas with limited public transport options were also identified by Arup as important issues.

Age-appropriate housing

There will be increased demand for age-appropriate housing that meets the needs of older people as the population ages. People are likely to have longer periods of retirement and possibly longer periods of ill-health. As noted by the Future of an Ageing Population Project, unsuitable housing can damage individual wellbeing and increase costs for the NHS.

In order to meet demand, it will be necessary to both adapt existing housing stock, as well as ensure that new housing can adapt to people’s changing needs as they age.  Age-appropriate housing that supports independent living can reduce demand on health and care services, and positively enhance the lives of older people.

Thinking ‘beyond the building’

There is also a need to think ‘beyond the building’. It is thought that interventions that improve homes are likely to be less effective without similar improvements in the neighbourhood.  The ability to socialise and to access services is considered to be particularly important.

Therefore, planning for the provision of local shops and other community facilities such as GP surgeries, post offices and libraries, in tandem with an increased focus on walkable neighbourhoods and public transport provision, will help older people to be physically active and more independent.

Raising awareness

Despite a pressing need for action, the provision of age friendly infrastructure in the UK has been constrained by a lack of resources, and assigned a relatively low priority.  However, there is growing recognition of the need to raise awareness of the potential effects of the ageing population and its implications for the design of cities, towns and villages across the UK.

Planning departments cannot address these implications in isolation.  However, for their part, knowing and understanding the potential implications of the UK’s ageing population is a positive step towards the creation of a successful age-friendly built environment.


For further information, you may be interested in our other blog posts on the creation of age-friendly towns and cities and the economic opportunities presented by an ageing society.

We have also published two members-only briefings on Ageing, transport and mobility and Meeting the housing needs of older people.

Planning for an ageing population: some key considerations

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On average, the UK’s population is becoming older and living longer, healthier lives.  This is due to historically low fertility rates and reduced mortality rates.  Between 2014 and 2039, the government predicts that over 70% of UK population growth will be in the over 60 age group. Although this trend is partially countered by migration, by 2037 there will be 1.42 million more households headed by someone aged 85 or over.

The implications of population ageing for society are so complex and far reaching that they are impossible to fully predict. However, a key priority is the provision of age-friendly environments.  This is where local government, and planning departments in particular, have a crucial role to play.

In this blog post – the first of two on the implications of population ageing for planning – we highlight some key areas for consideration.

Some areas will be more affected than others

While headline-grabbing statistics paint a very clear picture of the significant growth in the number of older people that is predicted, often they obscure the subtleties of the way in which population ageing will occur across the UK.

In reality, it is likely that population ageing will not occur equally in all areas of the UK.  The degree to which some local authorities – and therefore planning departments – will be affected varies considerably.

The impact of population ageing is measured by a ‘dependency ratio’ – the number of people aged over 65 for every person between 16 and 64.

Recent research has found that coastal localities are likely to have higher dependency ratios than urban areas.  Urban areas will, however, experience a larger overall number of older people.

Dependency ratios will vary considerably between local authorities.  On average, it is predicted that by 2036, there will be over four people aged over 65 for every 10 people aged between 16-64.  However, local figures are likely to vary – from just over 1 in 10 in Tower Hamlets, up to 8 in 10 in West Somerset.

You can see how your own area is likely to change in an interactive map created as part of the Future of an Ageing Population Project.

Differences between the ‘young old’ and ‘older old’

And while there is awareness of the growth in the overall numbers of ‘older people’, another complexity is that ‘older people’ are not a homogenous group. 

As life expectancy increases, the differences between different age groups become more significant.  For example, there are variations in the needs, tastes and lifestyles between the ‘older old’, i.e. those aged over 80, and the ‘young old’ who are just approaching retirement age.

Some planning departments are already taking this into consideration.  Northumberland County Council – who have a higher than average number of older people within their population – use a three phase definition as part of their strategy to prepare for the ageing population. They categorise ‘older people’ into three distinct groups: older workers; ‘third agers’; and older people in need of care.

Understanding social impact and interpretation

The physical environment is commonly understood to be a ‘societal context’ in which ageing occurs.  This is reflected in the term ‘physical-social environment’ – it suggests that there is no physical environment without social interpretation.

However, recent research has found that while planners were reasonably aware of the physical needs of older people, they were less aware of the social and economic contexts of older people’s lives.  This included the links between wellbeing and attractive environments, green space, activity and health, and the positive impact of place attractiveness on social interaction.

Related to this, older people’s social interpretation of the built environment – including the importance of place meanings, memories and attachments ­– is likely to become an increasingly important consideration for planners.  As too is the potential effect of redevelopment on older people – which may include feelings of insecurity and alienation, disorientation, loss of independence, and social exclusion.

Involving older people in the planning system

How to effectively involve older people in the planning system in an increasingly technology-dependent age will pose a number of challenges.

Planners will need to think creatively about options for engagement.  Increasingly, social media platforms and other online media have been used to engage with users.  However, these technologies may not be readily accessible or easily used by older people due to a lack of technological skills or access to the internet.

Older people may also need certain adaptations to support them to become involved – either online or in person – if they have physical or other disabilities.

Negative assumptions about technology’s usefulness held by some older people may need to be challenged or worked around.

Supporting healthy and happy lives

There is no way to fully predict the impact that population ageing will have across all sections of society.  Developing our understanding of the way in which the built environment can help to support and enable older people to live happy and healthy lives – and the implications of this for planning towns and cities across the UK – is increasingly important.

In our next blog post we will look at some of the ways in which planners can help support the creation of age-friendly environments through their influence on the design of the urban environment, transport, housing and the wider community and neighbourhood.


For further information, you may be interested in our other blog posts on the creation of age-friendly towns and cities and the economic opportunities presented by an ageing society.

Mobilising healthy communities: Bromley by Bow Health Partnership

Ian Jackson of the Bromley by Bow Health Partnership was the guest speaker at the first Glasgow Centre for Population Health (GCPH) seminar series of the year.

The Bromley by Bow Health Partnership (BBBHP) is a collaboration between three health centres and other non-primary care partners in the Tower Hamlets area of London. The aim of the partnership and the new primary care delivery model which comes with it is to transform the relationship between the public and primary health care. This means considering the wider determinants of health when the partners plan and deliver care, rather than treating healthcare in a purely biomedical way.

Edited image by Rebecca Jackson. Map via Google Earth

Edited image by Rebecca Jackson map via Google Earth

Effect of social determinants on health

In the 1890s Charles Booth created a map of London which categorized areas of the city of London depending on their levels of deprivation. The most recent Indices of Multiple Deprivation Report showed that those same areas considered deprived in the1890s are still facing the highest levels of multiple social deprivation and health inequality today. It is no secret that disadvantage has a negative impact on people’s ability to make the best choices when it comes to health. And disadvantage at a social level can have a significant influence on poor physical and mental health across a range of conditions.

More recent research conducted by Michael Marmot looked more closely at what determines health outcomes in populations, and the extent to which other factors influence people’s health, or rather their ability to be well.

He produced what is known as the 30/70 model: 30% of what determines your health is your genetics and improvements in pharmacology, the other 70% is related to other “external factors” including poverty, environment, culture, employment and housing. BBBHP has used this as the foundation for their primary care model, arguing that primary care providers are not just dispensers of medical products, but have a responsibility to contribute to people living healthier lives in their community.homeless

Social prescribing

One issue highlighted by the BBBHP was the significant number of people presenting at GP surgeries with “non-medical” ailments, or medical ailments triggered by “non-medical stimulus”. People were arriving at the practices and booking appointments because they were lonely and it gave them somewhere to go. Others were presenting with symptoms of depression, which on further investigation were found to have stemmed from issues around debt or domestic violence. A social prescribing service was set up by the partnership to try to tackle some of these non-medical conditions and improve the health of the general population by non-pharmacological means.

The social prescribing service, where GPs refer people to other local services for help, can be used as a replacement for pharmaceutical interventions, or be supplementary to them. GPs, or other primary care staff, may refer any adults over the age of 18 to one of over 40 partnership organisations. These range from walking groups to formal sessions with advisors in debt or domestic violence agencies, as well as art classes, community gardens and companionship services to combat loneliness. The organisations can provide help and advice on issues such as employment and training, emotional well being and mental health.Ölfarbe

The challenges of quality and funding

Maintaining quality in the provision of social prescribing is a particular challenge for BBBHP. They work regularly with trusted partners, particularly the Bromley by Bow Centre. However, there is no consistent quality check for many of the services from the health partners themselves. Evaluative studies and feedback sessions are used to assess quality and impact, and consider the scale of demand. And while it is acknowledged that more formal frameworks for assessing quality and impact of social prescribing services are preferred in formal assessments, in reality, word of mouth, participant feedback and uptake rates are used as a standard for quality as much as official feedback in a localised community setting.

A second issue is funding. BBBHP identified that finding long term funding was their main issue in providing security for providers and service users, as well as for GPs referring to services. Funding is vital not only to ensure the survival of the community groups who provide some of the referred services, but also to allow them to develop longer term partnerships and build capacity within the social prescribing service. The BBBHP works closely with the Bromley by Bow Centre, a key provider of support services for the local community, but like many services which rely on funding, they increasingly have to plan for tighter budgets.

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A final challenge for the staff at BBBHP was changing people’s expectations of primary care, and what it means to live well. Some patients were suspicious and reluctant to be recipients of “social prescription”, as this did not fit with the traditional expectation of what GPs should do to make people well. This can be a big change in mindset for some people, according to Ian Jackson, when people come expecting to be prescribed antidepressants but are instead “prescribed” a walking club or a debt advice service. He noted that the reaction from patients can sometimes be confused or hostile, and some patients do not even turn up for referrals.

Improving patients’ understanding of the benefits of social prescription, ensuring people attend referral appointments, and that social prescriptions have a long term impact is something which BBBHP are hoping to research further. They feel that looking at the long term impact of non-pharmaceutical interventions and how these feed back into the wider agenda of tackling inequalities is important to allow the partnership to continue to build healthy communities and save on primary care costs in the long term.

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Creating positive social connections to improve community health

Social prescribing and other associated projects have sparked new social connections. Members of the community have come together to form their own support groups. The Children’s Eczema support group run by local GPs and the DIY health scheme, which sought to educate and support parents who were anxious about minor ailments in children, have helped parents in the area to set up WhatsApp groups, organise coffee mornings and go to one another for support. Such initiatives are regarded by BBBHP as important in tackling wider, systemic social inequality in the area.

Currently, primary health care in communities is focused on illness. This needs to change, according to BBBHP, with local community-based health delivery based as much around social health as biomedical issues. Through its social prescribing and other services BBBHP has aimed to focus on supporting people in a holistic way, tackling health inequalities as well as biomedical illness, to allow them to make good choices to improve their health.


If you’ve enjoyed this article, you might also like more of our blogs on health and wellbeing:

The Men’s Sheds revolution spreading around the world

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by Stacey Dingwall

Last week I attended ‘Men’s Sheds: the movement in Scotland and the big picture internationally’, an event, organised by the Centre for Research & Development in Adult and Lifelong Learning (CR&DALL) at the University of Glasgow.

Our blog on the Men’s Sheds movement was one of our most popular last year. The movement originated in Victoria, Australia in the 1990s, as a place for men to socialise and take part in practical activities. 23 years later, there are now close to 1,000 such spaces in Australia. Sheds have also proven popular in Ireland (350 Sheds and counting) and Scotland (at least 38 up and running, with 30 in the start-up phase).

Research has indicated that loneliness and isolation are a particular issue for certain groups of men, which is reflected in higher suicide rates. Evaluations of Men’s Sheds have found participation to have a range of positive effects for these groups of men, predominantly in terms of their mental health and wellbeing.

The movement in Scotland …

The first speaker of the day was Willie Whitelaw, Secretary of the Scottish Men’s Sheds Association (SMSA). Willie highlighted two key points, which were themes throughout the rest of the afternoon:

  • The importance of Sheds not being regulated by outside agencies, e.g. government – this was something that those involved in Sheds felt particularly strong about. As noted by Professor Mike Osborne, the Director of CR&DALL, at the start of the afternoon, the reduction in government support for adult education has created a need for people to organise themselves in order to access lifelong learning opportunities. Thus, those who attend Sheds feel strongly about preserving the independence of the space, as well as its democratic dynamic.
  • How to ensure the sustainability of Sheds, and community projects in general – Willie described how the SMSA can support Sheds across Scotland by offering advice on applying for funding, how to keep things like rental costs low, and using mechanisms such as the Community Empowerment Bill and Community Asset Transfers to their advantage. Noting the difficulty that many community projects face in sustaining themselves long-term, Willie highlighted the Clydebank Independent Resource Centre (CIRC), which has been running for over 40 years, as a rare but good example of how sustainability can be achieved.

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…and the big picture internationally

The second speaker of the day was Professor Barry Golding from Federation University Australia. Barry is the most prolific researcher in the area of Men’s Sheds, and published The Men’s Shed Movement: The Company of Men last year. Barry described the origins of the movement in Australia, and suggested it took off due to its provision of the three key things that men need: somewhere to go, something to do, and someone to talk to.

Barry also emphasised the importance of not formalising Men’s Sheds, and particularly not promoting the spaces as somewhere where men with health issues go (not a very attractive prospect to an outsider!) This point was also picked up by David Helmers, CEO of the Australian Men’s Shed’s Association. David described the experience of one Australian Shed who had a busload of patients arrive after being referred by health services. The point of the Shed is to create a third space for men (other than home or work) where they can relax and socialise with their peers. Any learning or health improvements that arise from this is coincidental and not forced.

Barry and David were followed by John Evoy of the International Men’s Shed Organisation (IMSO). John focused on the experience of Sheds in Ireland, noting the impact of the recession as a particular reason why the movement has taken off in Ireland. The IMSO’s aim is to support a million men through Sheds by 2022.

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Strengthening the movement and using evidence

To finish the afternoon, two panels comprising Shed members and researchers considered the questions of how to strengthen and sustain the Men’s Sheds movement, and how research might be beneficial to this.

Shed members on the panel and in the audience suggested that changing the stereotype of Sheds as spaces for older men with health (particularly mental) issues is important. In fact, men of any age are welcome to attend their local Shed, and current members are particularly keen to encourage this in order to support the intergenerational transmission of practical skills that are otherwise at risk of being lost.

In terms of available evidence, it was noted that research on Men’s Sheds is still scarce, and focused on the Australian experience. Catherine Lido, a lecturer in psychology in the university’s School of Education, discussed the pros and cons of carrying out a systematic evaluation of the movement in the UK. Again, the importance of the democratic nature of Sheds was raised – allowing outside agencies, particularly government, to come in and carry out research would involve the loss of some control. Any research conducted would have to be participatory, in order that Shed members did not feel like they were the subject of an ‘experiment’. Barry Golding highlighted, however, that there is currently almost no data on UK Sheds available; rectifying this could strengthen Sheds’ chances of being successful in applications for funding to support their running costs.

If you enjoyed reading this, you may also be interested in our previous blog on ‘makerspaces‘, which have drawn comparisons with the Men’s Sheds movement.

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Mindfulness in schools: does it work?

by Stacey Dingwall

Over the last couple of years, the concept of being mindful has almost become a buzzword. However, mindfulness has actually been around since the 16th century, before being developed as a modern day western Buddhist practice from the 1970s.

Transform your life?

On the 17th of March, along with almost 400 other people, I attended the Transform Your Life event at Glasgow’s Trades Hall. The event was organised by the Kadampa Meditation Centre (KMC) in Glasgow, a Buddhist temple which opened in 2013 with the aim of providing a space for people to learn how to meditate and practise Buddhism.

The talk was delivered by Gen Dao, a senior Kadampa teacher who has been ordained for over 20 years, teaching at centres in America and Australia before taking up her current post as principle teacher at KMC Liverpool. Its focus was on equipping attendants with the ability to cope with everyday stresses and anxieties, by applying some simple meditation and mindfulness techniques.

After demonstrating a basic breathing technique, Gen Dao opened her talk by commenting on how prevalent mindfulness has become, noting that it is now used as a management technique and as a means of selling women’s magazines. She spoke about the benefits of using mindfulness not only on a personal level, but also how actively improving your mind can awaken the potential to bring benefit to others. Mindfulness, she explained, was essentially just remembering to breathe, and trying to focus on experiencing only positive states of mind.

The remainder of Gen Dao’s talk concentrated on the importance of mastering the ability to ‘oppose’ negative thoughts, and making the decision to be content and happy, without the intervention of others. Also highlighted was the need to strive for ‘patient acceptance’, or the ability to give up on the feeling that things in your life should be different – instead, we should learn how to view our feelings from a more detached perspective, and not identify with painful feelings, or “bad weather” in the mind.

Speaking to Gen Dao after the talk, I raised the point that, although not a physical pursuit, mindfulness is something that you have to train in, and learning to adapt to a new way of thinking is something that could take some time. Essentially, adopting a mindful outlook could mean changing the habits of a lifetime.

Mindfulness in the classroom

This could explain why some schools are now incorporating mindfulness exercises into classes, in order to prepare young people for the future. Last July, BBC News reported on the first large-scale trial of mindfulness exercises in schools across the UK conducted by the Wellcome Trust, during which researchers will look at whether introducing mindfulness at an early age can help build psychological resilience. The exercises, which will include deep breathing and a practice called ‘thought buses’ in which participants will be taught to see their thoughts as buses that they can either get on or allow to pass by, are designed to show children how to live in the present and eventually, equip them with the ability to solve problems while under stress.

The study will involve around 6,000 children and young people; a considerably larger amount than have taken part in previous evaluations of the impact of mindfulness in schools. While the existing evidence is currently described as limited, these smaller studies have indicated that mindfulness interventions with children and young people do have some success in generating lower stress levels and a greater sense of wellbeing among participants. These findings are important, given that a recent survey of school leaders by the Association of School and College Leaders found that 55% of respondents reported a significant increase in the number of young people in their schools who are dealing with anxiety and stress.

Case study: Mindfulness in Schools Project

The Mindfulness in Schools Project (MiSP) was founded in 2007 by former teachers Richard Burnett and Chris Cullen. Having experienced the benefits of mindfulness themselves, they developed “.B”, a 9-week course that aims to make mindfulness accessible, and fun, for secondary school pupils. The course, which has also been adapted for younger children as Paws B, is now being taught in twelve countries, including the UK. Teachers and pupils who have used the programme report on its ability to restore calm to a class after break, for example, or to calm pupils down at times of particular stress, such as exams or performances. It has also been suggested that the programme can help to improve pupils’ ability to concentrate.

Critics of the impact of mindfulness in the classroom argue that these results cannot be relied on, due to the experiments taking place outside of the boundaries of a randomised controlled trial. They also point to the possibility that participants’ ability to concentrate may only have improved due to their being informed that this is what the exercises are designed to do. Richard Burnett has openly recognised the limits of mindfulness himself, emphasising that it cannot replace the fact that some people require medication and clinical care to deal with their condition, and is more effective in smaller groups supervised by medically trained professionals. Trainers delivering the programme are also open about the fact that mindfulness is not something that will work for every child. What it can do, however, is provide a reminder to breathe when things get too much – something that can surely only be a positive for everyone.

If you enjoyed this post you may be interested in our previous commentary on mental health issues:

Ecotherapy in practice: nature based mental health care

Ecotherapy, also known as nature-based or green care is an alternative therapy for people suffering from mental health issues. It can be delivered as an individual treatment or in combination with traditional medicinal and talking-based treatments. Charities and research has suggested that it can reduce depression, anger, anxiety and stress as well as improving self-esteem and increasing emotional resilience.

Spessartbach

The mental health charity MIND emphasises the positive health benefits, commenting that ecotherapy:

  • is accessible
  • can take place in both urban and rural settings in parks, gardens, farms and woodlands
  • works through people either working in nature or experiencing nature

It can be structured or more informal, with some areas providing therapist led classes while elements of ecotherapy, such as taking walks or gardening, can also be done without specialist supervision, on your own or with family members and friends.

AAT and AAI (Animal Assisted Interventions and Animal Assisted Therapy)

This form of therapy uses guided contact with animals such as horses or dogs. It is becoming increasingly popular in university settings, with dog cafes or dog rooms during student mental health weeks or during exam times to help alleviate student exam stress. Pet therapy has also been shown to be effective with children and young people who suffer from anxiety or who have experienced trauma, and for elderly people suffering from dementia.

Therapy could be one to one or in a group and could also be delivered to people who are in residential care setting. AAT can also be used to assist mobility and coordination or simply to spend relaxed time with animals where patients can feed or pet them. This interaction can promote bonding between the individual and animal which has been found to reduce stress and anxiety.

Nature Arts and Craft Therapy

Nature based art therapy takes inspiration from nature to create and provide materials to create art work. This type of therapy can also include social and therapeutic horticulture (STH). This can be a particularly effective form of nature based intervention as it can be adapted to suit a wide range of mobility and abilities and could potentially lead to work experience or the sale of goods created, which in itself can build self-confidence and transferable skills.

Adventure Therapy

This therapy focusses on using physical activities to encourage psychological support, It includes activities such as rafting, rock climbing and caving. Often done in a group, this type of therapy aims to build trust and raise confidence. While it can be strenuous, less able individuals can take part in green exercise therapy, which largely includes walks and rambling, or wilderness therapy (which includes physical group and team activities such as making shelters and hiking).

Effectiveness of ecotherapy

In February 2016, Natural England published A review of nature-based interventions for mental health care, which considered the benefits and outcomes of approaches to green care or ecotherapy for mental ill health.

One of the main challenges the report highlights is to increase the availability of green therapies in order to make the practice more normalised within treatment. The authors also speak about the importance of standardising the use of terms such as ‘ecotherapy’, ‘green care’ and ‘nurture based interventions’ to allow people to fully understand what different interventions entail. The report makes nine recommendations, including:

  • expanding the evidence base around green therapy
  • increasing the scale of commissioning of green care initiatives
  • increasing collaboration between the green care sector and health and social care practitioners

Ecotherapy is still not widely accepted as a mainstream approach to mental health treatment. However, it is increasingly being offered as a combination therapy alongside traditional drug-or talking-based interventions. Advocates of ecotherapy hope that this will lead to wider acceptance of the approach and the positive effect it can have on people who suffer from mental ill health.

Advocates emphasise the holistic and person-centred benefits of ecotherapy, which has been shown to improve physical health as well as mental wellbeing. As the video below demonstrates, it increases social skills and in many instances can help people build new or develop existing skills which can help them enter, or re-enter employment. Potentially this may also reduce the burden on care and community mental health services.


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Hoarding and housing: person-centred approaches to a growing problem

Most people have possessions in their homes that they can’t bring themselves to throw out, from clothes and furniture to photographs, books and ornaments. But the growth of clutter around the house can sometimes escalate to become so severe that it causes significant risks to the health and wellbeing of residents and their neighbours.

For housing providers, problematic hoarding has become a serious and costly issue. In 2014, Inside Housing magazine reported an increase in the number of social housing landlords seeking injunctions to inspect homes where they suspected the resident of hoarding. But a housing management solicitor highlighted underlying difficulties with taking legal action against problematic hoarders.

“Even if the housing association wins and costs are awarded against the tenant, the chances of the tenant paying are slim. It’s a problem because it’s a huge expense.’

The nature of hoarding

A 2012 paper from the Chartered Institute of Environmental Health (CIEH) provided an overview of hoarding, and observed:

“As a behaviour, it is quite common and most people who hoard possessions do not suffer from any psychiatric disorder. However, in some cases the problem may progress to become so severe that it causes significant distress and impairment.”

The CIEH paper noted that three components have been identified with problematic hoarding:

  • acquisition of and failure to discard possessions that appear to be of little use or value
  • living spaces sufficiently cluttered so as to preclude activities for which those spaces were designed
  • significant distress or impairment in functioning caused by the hoarding

The problems and risks for housing providers and their tenants

For housing providers, residents and neighbours, hoarding presents particular problems and risks, including:

  • overcrowding issues
  • health and safety hazards, including fire risks and falling /tripping
  • environmental health concerns, including infestation and vermin
  • properties falling into disrepair

Tackling the problem

Under mental health and environmental legislation, local authorities and health agencies can take action where hoarding constitutes a statutory nuisance or health and safety risk. Social landlords may also resort to legal action against tenants. But taking an enforcement-only approach raises tricky ethical questions, especially if a resident is mentally unwell. And, as the Inside Housing article reported, taking tenants to court can be ineffective and expensive. Housing organisations, therefore, are increasingly developing person-centred approaches to help compulsive hoarders understand and change their behaviour.

Orbit Housing: support and advice

For some years, the Orbit housing group has been collaborating with Coventry University and the Knowledge Transfer Partnership to tackle the growing problem of hoarding.

In 2013, Orbit launched a toolkit designed to support practitioners and organisations working with people who compulsively hoard. The toolkit was developed with input from mental health support organisations, environmental health bodies and service users. It addresses environmental and social isolation issues and includes advice on the assessment process, intervention tools, improvement measures, relapse prevention, and sign-posting.

In 2015, Orbit obtained funding for two specialist case workers, enabling the launch of a new hoarding support and advice service. In addition, Orbit has also developed a hoarding policy setting out the aims, principles and values to be adopted in the housing group’s approach to individuals with hoarding tendencies.

Derbyshire:  Vulnerable Adult at Risk Management

Because problematic hoarding can require responses from different agencies, including social housing providers, environmental health and fire and rescue services, a multi-agency approach is helpful in tackling the issue.

In Derbyshire, this kind of multi-agency policy has been established to develop a risk management plan for people who would not necessarily fall into the responsibility of adult social care direct service provision.

Vulnerable Adult at Risk Management (VARM) is managed by Derbyshire County Council and Derby City Council, with support from the Fire and Rescue Service, police, social housing providers, environmental health and others. The policy aims to support vulnerable adults who are at risk of serious harm through self-neglect and risk-taking behaviour, and it has already been applied in cases of hoarding.

Last year, the Chief Fire Officers’ Association highlighted a case where the VARM policy helped a Derbyshire social housing provider to support an elderly man who was putting himself at risk due to hoarding behaviour.

“His care package was adjusted, to include assistance with household chores; he was visited and helped by health practitioners; his home was cleared allowing his central heating to be repaired. Fire risks were mitigated down to an acceptable level without the need to revisit and upset him.”

Similar approaches have been developed by Circle Housing Association in the London borough of Merton, and by Knightstone Housing in the West of England.

Positive outcomes

Hoarding is one of many resource-intensive problems facing social housing landlords. But, as these examples demonstrate, a collaborative, sensitive and supportive approach to problematic hoarding can achieve positive outcomes for housing organisations and their tenants.


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Read some of our other housing blogs: