Mental Health and Wellbeing Strategy

4 June 2024

The Older People’s Commissioner for Wales (OPCW) welcomes the opportunity to respond to the Welsh Government’s consultation on the draft mental health and wellbeing strategy for Wales 2024 to 2034.

Wider determinants of mental health

The Commissioner welcomes the Welsh Government’s involvement of older people in the development of the draft strategy. In March 2024, research was conducted on behalf of the Commissioner with over 500 people aged 60 and over living in Wales, covering a wide range of subjects, including mental health.[i]

Two-thirds of respondents said that a ‘strong sense of community’ was the best thing about growing older in Wales, highlighting the crucial role our friends and neighbours, as well as the amenities in our communities, often play in supporting our health and well-being, and enabling us to age well. It is positive to see the role of communities in promoting and protecting good mental health across the life-course given significant focus and value within the Welsh Government consultation document, along with the recognition of the wider determinants of health in informing the strategy.

As older people are identified in the draft strategy as a population group who may require additional support in protecting their mental health, a clear strategic connection with the Welsh Government’s Age-Friendly Wales: Our Strategy for an Ageing Society should be established, with its associated action plan included as part of the focus on inequality and promoting equity.

Of particular relevance within this context is the shared strategic importance of the World Health Organisation’s Age-Friendly Cities and Communities model. Its current implementation in Wales is a key mechanism by which communities are supported to participate in collaborative planning and delivery with public and voluntary stakeholder agencies, thereby including them in efforts to promote and protect good mental health for all. Continued investment in and engagement with this approach to coordinating community participation is essential and should be more explicitly recognised and supported within the final strategy and delivery plan.

Experiences of discrimination also form part of the wider determinants of mental health. Ageism has the potential to impact both an individual’s mental health and the kinds of support and treatment offered/received for mental health problems. Discrimination can have a damaging impact on people’s mental health as is shown by existing studies, mainly focused on racism or experiences of perceived discrimination in general. There is substantial evidence of the harmful effects of discrimination on mental health.[ii] On ageism specifically, a study of older people (50+) in England found that perceived experience of ageism was linked to a higher likelihood of depressive symptoms. Of the older people who formed part of the study, over a quarter reported they had experienced age discrimination, with 41% reporting receiving poorer service or treatment in medical settings.[iii] The research concluded by emphasising “the importance of tackling age-related discrimination, the potential benefits of which include improved mental health and wellbeing, maintenance of physical health, and prevention of disease in older adults”.[iv] The Welsh Government strategy needs to explicitly address ageism as a societal problem but also in terms of the specific issues older people may face as a result of ageist attitudes from mental health professionals and services.

Older people’s mental health

The opportunity to participate in the Independent Review of Together for Mental Health was appreciated and it is good to see that the issues highlighted during the review are referenced in the Equalities Impact Assessment accompanying the consultation document. This includes data from the Royal College of Psychiatrists and from the Equalities and Human Rights Commission on the prevalence of mental health conditions among older people, the impact of life events and the wider determinants of mental health on older people, along with the Commissioner’s response to the Senedd Health and Social Care Committee inquiry into mental health inequalities.

Since the review, research undertaken on behalf of the Commissioner in March 2024 showed that levels of optimism among older people in Wales are declining sharply. Only 39% of participants were optimistic about the future, while 37% were pessimistic. This is a significant change from 80% and 8% respectively in 2021. The same research showed that 17% of respondents expected to struggle with their mental health in the coming year. Extrapolating this result to national level would mean that almost 150,000 older people older people in Wales are expecting to struggle with their mental health, without taking account of factors such as the high prevalence of depression and anxiety among older people living in care homes or the higher likelihood of experiencing a common mental illness such as anxiety or depression among Black women when compared with white people.[v]

The Welsh Government needs to ensure that the variety of evidence on older people’s mental health, including that set out above, is used to inform the proposed plans for additional support for older people.

Older people’s rights

The Commissioner supports the vision statements and principles set out in the draft strategy, particularly the rights-based approach, and encourages public bodies to adopt a rights-based approach as a way of working to safeguard and promote older people’s human rights in public services planning and delivery in Wales. This means that public bodies should work to the following principles:

Embedding older people’s human rights
Empowering older people
Non- discrimination and equality
Participation

The principles are in line with the rights-based priorities cited in the strategy.

Social isolation and digital exclusion

The intention for the strategy to support the roll out of social prescribing to tackle social isolation is particularly welcome. 21% of older people who took part in research conducted for the Commissioner in March 2024 expected to face social isolation in the coming year. This would equate to 184,000 older people nationally. In December 2023, the Commissioner issued a briefing paper on loneliness and isolation among older people and called on the Welsh Government to review its 2020 loneliness strategy.[vi]

In January 2024, the Commissioner warned that increased use of digital technology is putting older people at risk of social exclusion.[vii] 33% of people aged over 75 and 13% of people aged 65-74 do not use the internet, including Smart TV and handheld devices.[viii] Technology and digital solutions can support many older people to look after their health and wellbeing. However, the recognition in the draft mental health and wellbeing strategy that there is also a need to focus on digital exclusion and on providing alternative channels and offline resources for those people who cannot, or choose not to, access services digitally (many of whom are more frequent users of health care) is welcome. This needs to be a reality rather than an aspiration. Offline access to services, including mental health and wellbeing, should be included from the beginning as part of a user-centred design approach.

Delivery plans and indicators

The draft strategy includes a number of measurable indicators that the Welsh Government will monitor as part of the implementation of the strategy. It will be important to assess the detail of short-term targets when this is set out in delivery plans and further indicators identified to support the evaluation of the strategy when commissioned. The strategy, delivery plans and indicators should address the areas below.

Given the all-ages approach in the strategy, there needs to be clarity on how implementation will actively avoid ageism and age discrimination and the actions and measures which will ensure this. The Commissioner’s evidence to the Senedd Health and Social Care Committee inquiry into mental health inequalities[ix] set out examples (from the Royal College of Psychiatrists) of what constitutes age discrimination within a service. These are generalisable to other contexts. Delivery plans and indicators should incorporate this framework.

The deficiencies in data collection on mental ill-health in the older population in Wales highlighted in the Commissioner’s response to the Senedd Health and Social Care Committee inquiry into mental health inequalities need to be addressed, and data must be segmented by age (ideally, in five-year age bands) and other protected characteristics to reflect the diversity of the older population.

Older people’s access to mental health services is a longstanding concern. The Welsh Government’s Together for Mental Health Delivery Plan 2019-22 included measures to improve older adults’ access to psychological therapies and crisis and out of hours care. It would be helpful to see evidence of any improvements so far in older people’s access to services as a result of these measures. The new strategy and delivery plan must ensure that the Welsh Government can evidence the availability of and access to appropriate mental health services to meet older people’s needs.

The draft mental health and wellbeing strategy highlights the impact which transitions between services can have on mental health. Moving into a care home, for example, can have huge emotional consequences for many older people and their unpaid carers.[x]At times of transition, older people and their unpaid carers need trauma-informed, relationship-based approaches to practice, which recognise the emotional impacts of transition experiences, and which seek to promote emotional and mental wellbeing.

There is evidence to show that some older people are reluctant to talk about mental health / mental wellbeing, because they associate such terms with “mental illness”, which remains highly stigmatised. It may be helpful to use different language / terminology when approaching the issue of mental health with older people (some authors have suggested that the term “emotional well being”, for example).[xi] However, it is important not to be prescriptive and to recognise that different older people, will have different preferred ways of discussing issues related to mental health. Welsh language terminology also needs to reflect the words older people are more likely to feel comfortable using. Older people whose first language or preference is to use Welsh need to be supported and able to access mental health services in the Welsh language.

It will be essential that the delivery plan, indicators and evaluation are designed in a way that makes it possible to demonstrate whether the strategy is making a clear difference to older people’s mental health and wellbeing.

Conclusion

Consideration of the above areas and the areas highlighted in the Equalities Impact assessment is integral to the development of the delivery plan and the proposed plans for additional support for older people. In addition to the areas set out in the ‘Delivery plans and indicators’ section above, the Mental Health and Wellbeing Strategy and associated delivery plans should:

Explicitly address ageism both as a societal problem but also the specific issues older people may face as a result of ageist attitudes from mental health professionals and services.
Demonstrate a clear strategic connection with the Welsh Government’s Age-Friendly Wales: Our Strategy for an Ageing Society.
Ensure that all available evidence on older people’s mental health, including that related to other protected characteristics, is used to inform the proposed plans for additional support for older people.
Consistently adopt a rights-based approach.
Recognise that while technology and digital solutions can support many older people to look after their health and wellbeing, offline access to services, including mental health and wellbeing, needs to be included from the beginning as part of a user-centred design approach.

The Commissioner and her team would be happy to discuss this response further.

Notes

[i] OPCW, Support offered by strong Welsh communities hugely valued by older people, finds Commissioner, May 2024 https://olderpeople.wales/news/support-offered-by-strong-welsh-communities-hugely-valued-by-older-people-finds-commissioner/

[ii] Sarah E Jackson, Ruth A Hackett, Andrew Steptoe, Associations between age discrimination and health and wellbeing: cross-sectional and prospective analysis of the English Longitudinal Study of Ageing, Lancet Public Health 2019; Vol. 4, e200. Available at: Associations between age discrimination and health and wellbeing: cross-sectional and prospective analysis of the English Longitudinal Study of Ageing – The Lancet Public Health

[iii] Sarah E Jackson, Ruth A Hackett, Andrew Steptoe, Associations between age discrimination and health and wellbeing: cross-sectional and prospective analysis of the English Longitudinal Study of Ageing, Lancet Public Health 2019; Vol. 4, e203. Available at: Associations between age discrimination and health and wellbeing: cross-sectional and prospective analysis of the English Longitudinal Study of Ageing – The Lancet Public Health

[iv] Sarah E Jackson, Ruth A Hackett, Andrew Steptoe, Associations between age discrimination and health and wellbeing: cross-sectional and prospective analysis of the English Longitudinal Study of Ageing, Lancet Public Health 2019; Vol. 4, e207. Available at: Associations between age discrimination and health and wellbeing: cross-sectional and prospective analysis of the English Longitudinal Study of Ageing – The Lancet Public Health

[v] Rethink Mental Illness, Black, Asian and Minority Ethnic (BAME) mental health https://www.rethink.org/advice-and-information/living-with-mental-illness/information-on-wellbeing-physical-health-bame-lgbtplus-and-studying-and-mental-health/black-asian-and-minority-ethnic-mental-health/#:~:text=Compared%20to%20white%20people%3A,likely%20to%20experience%20psychosis%2C%20and

[vi] OPCW, Briefing: Tackling Loneliness and Isolation in Wales – December 2023, https://olderpeople.wales/resource/briefing-tackling-loneliness-and-isolation-in-wales-december-2023/

[vii] OPCW, Access Denied: Older people’s experiences of digital exclusion in Wales, January 2024 https://olderpeople.wales/wp-content/uploads/2024/01/Access-Denied-Older-peoples-experiences-of-of-digital-exclusion-in-Wales.pdf

[viii] OPCW, Understanding Wales’ Ageing Population: Key Statistics, March 2024 https://olderpeople.wales/wp-content/uploads/2024/03/Understanding-Wales-ageing-population-March-24-.pdf

[ix] OPCW, Consultation Response – Mental Health Inequalities, March 2022 https://olderpeople.wales/resource/consultation-response-mental-health-inequalities/

[x] Age Cymru. 2023. Preserving What Matters: Integrating Mental Health into Care Home Transitions. Available at: https://www.ageuk.org.uk/globalassets/age-cymru/documents/care-home-guide/preserving-what-matters-report-v5.pdf

[xi] Williamson, T. 2011. Promoting Older Men’s Mental Health and Emotional Wellbeing. Working with Older People.