Recap

In the UK, one in four of us experience a mental health problem each year, a number that has only grown since the start of the covid pandemic nearly five years ago. At the same time, 75% of all mental health conditions begin before a person reaches the age of 24, and half of all conditions start by the age of 14. Life stressors such as work, relationships, financial pressures, illness, and the loss of loved ones can also contribute to mental health problems throughout a person’s life. 

It’s clear that we need a mental health approach that spans the entire lifetime and considers how to prevent, treat and provide ongoing mental health support - a case we recently made in our article arguing for a whole population approach to mental health support.This is the joined up provision of inclusive, accessible and effective mental health services for an entire population. 

A whole population approach places individuals at the centre of service design, and aims to meet the needs of the entire population rather than focusing solely on treating individuals with diagnosed conditions. It also involves creating comprehensive care pathways for clinical support and acute intervention when necessary.

Valuable in a number of ways, a whole population approach:

• Encourages a broader perspective on intervention design
• Considers resources beyond traditional clinical commissioning
• Harnesses the power of partners - like community groups and digital solutions providers - to achieve positive outcomes
• Measures success not only by symptom reduction, but also by considering wider determinants of health as both mediating and success factors.

With over 20 years of experience partnering with the NHS and local authorities to provide mental health services, Kooth has seen the impact of a whole population approach across four key pillars: individual, community, system and whole population. 

Action across all four is vital to ensuring success.

If you’d like to hear about the successes and learnings of real-world whole population approaches first-hand from commissioners who have implemented them, register to receive the full report by clicking here.

Here we focus on the first level: how to keep individuals at the heart whole population approach.

Four Elements for Healthier, Happier Individuals

In a successful whole population approach to mental health, we've found four key elements support individuals to live mentally healthier, happier lives: 

1. Taking A Holistic View of Each Person

The foundation of a whole population approach is that people are empowered to make positive changes in their own lives and reach goals that improve their mental wellbeing and functioning, before, during and after episodes of poor mental health. 

This contrasts to traditional service design that focuses on intervention when acute, diagnosable problems occur and prioritises symptom reduction or cure. While this approach has huge benefits for those that are unwell, a whole population view provides opportunities for self-management and supported management at any time. The key is to shift thinking and approaches from ‘treating an illness’ to also ‘empowering the person.’

By placing the whole person at the centre of services, mental health providers can consider both the presenting issues, and also the wider context that may be contributing to - or even creating - poor mental health. Considering a person’s holistic needs involves listening to their input, involving them in decision-making, and empowering them to take an active role in their own care, where appropriate.

At Kooth, this means working with the i-THRIVE model to ensure we adjust our offer to someone’s level of need. In this way individuals can access appropriate, relevant help and feel as though they are active decision-making partners on their journeys. 

As a result, individuals are more likely to engage with support and achieve positive outcomes, as well as feel more confident in self-management, which in turn equips them to keep themselves healthier, for longer. 

2. Prioritise Inclusion and Accessibility 

The second key element of the ‘Individuals’ pillar focuses on prioritising inclusivity and accessibility. This is vital as both directly impact the effectiveness of the support provided. For example, 58% of young people report their conditions worsened as they waited for mental health support, and long wait times have strongly been associated with deterioration of clinical outcomes - improved accessibility could mitigate this. So what does this look like in a whole population approach?

Inclusivity

Inclusivity in a whole population approach ensures that everyone is considered as part of intervention design, with particular attention paid to include groups or communities most likely to fall through the gaps or experience more barriers to accessing traditional services. 

A whole population approach consciously takes action to make interventions more inclusive by including service users in service design and employing engagement approaches and practitioners that reflect the communities they serve - whether that’s in terms of sex, gender identity, ethnicity, religion or belief, age, cultural background, socioeconomic group or neurodevelopmental condition. This helps services to meet the needs of those using them and to reach those less-likely to engage or most in need. Three tips we recommend to build inclusivity:

1. Identify service user access preferences and representation needs through community engagement and consultations

2. Embed service user feedback into service outcome measures and conduct periodic reviews to inform service transformation needs

3. Where clinically appropriate, adopt a strengths-based approach that recognises  patients’ knowledge, capacities, strengths, abilities and cultural preferences within their own mental health care delivery.

Accessibility

Accessibility considers possible physical, psychological, practical and clinical barriers restricting users’ access to a service. These might include services being located far from an individual’s place of residence, unreliable or irregular public transport options, lack of disabled access, limited opening hours, digital access needs, neurodevelopmental needs, or minimum eligibility thresholds.

Four tips to build accessibility:

1. Co-locate services in community settings

2. Have digital and non-digital routes into existing pathways

3. Embed digital interventions into existing pathways

4. Implement wraparound services with no minimum thresholds for access

More commissioners are looking at ways of co-locating and promoting services within community settings such as schools, places of worship, and community centres. Having a presence within local communities can help reduce stigma and anxiety around requesting help, normalise mental health conversations and lead to awareness and engagement campaigns that leverage existing community assets. Examples include training Black Barbers to be mental health ambassadors, or partnering with local transport services to promote offerings to local people.  

Introducing both digital and non-digital entry routes into existing pathways, and embedding digital interventions into existing pathways can be a helpful way to widen access. We’ve seen this greatly impact the accessibility of mental health pathways. Since Kooth’s Children and Young People’s (CYP) and adult service, Qwell, are accessible 24 hours a day, everyday of the year, service users can access self-management tools whenever they need. Adding to this, Kooth’s mental health practitioners are available until 10pm, providing digital ‘out of hours’ options for existing mental pathways. Feedback has been productive;

"For some young people it means they are not just left feeling they have no support once CCETT discharges."

Lincolnshire Partnership Foundation Trust CAMHS Crisis and Enhanced Treatment Team (CCETT) Practitioner

Eligibility criteria and thresholds for clinical support are necessary in many contexts, so providing wraparound, ‘ungated’, early intervention services is instrumental to improving accessibility in a whole population approach. Wraparound support allows for prevention and earlier intervention, as well as providing a pathway for escalation, de-escalation and signposting to appropriate services across the mental health system. In this way, individuals receive support at the earliest point in their episode of poor mental health, reducing the likelihood of developing complex presenting issues, and reducing pressure on acute and specialist services. All of this combined unlocks capacity to provide proportionate care to higher acuity cases - a topic we will discuss more in a few weeks’ time.

3. Adopting a Wider Definition of Effectiveness

Kooth is committed to continuous research and development ensuring that we take account of the existing evidence base (with its emphasis on traditional delivery models) with our understanding through decades of experience of working with CYP and adult users in the digital mental health space. Contributing to innovation and dissemination of knowledge in the field of mental health and digital interventions through robust, inclusive and objective research combines well with all our experience in delivering services.

But our view of effectiveness doesn’t only consider traditional delivery models and standard outcomes, in a whole population approach, our wider definition ensures service user perspectives are a core part of measurement. Using goals-based outcomes (GBO) alongside standard clinical measures (e.g CORE-10, GAD, PHQ, WSAS) and working hand-in-hand with users is key to gaining deeper insight into the impact of a particular intervention. 

4. A Blended Approach of Prevention, Early Intervention, and Treatment to Supports Mental Health Needs as They Arise

A comprehensive and holistic approach to mental health provides support at every stage. Help is not just focused on “sick care” for people with mental health conditions, but also on mental health promotion and maintenance.

Individuals are provided with support earlier to help head-off diagnosable mental health conditions before they emerge, prevent emerging issues from getting worse, as support is provided when it’s needed. To do this, a whole population approach considers prevention, early intervention, treatment and self-management principles together.

Prevention focuses on reducing the risk of mental health problems before they arise, by enabling individuals to proactively support their own mental health and utilising their own strengths. This can be done through mental health education within schools, awareness campaigns about support available, and providing support to self-manage the everyday ups and downs of life and maintain healthy wellbeing practices. 

Early intervention identifies and addresses emerging mental health concerns before they escalate into more severe problems. Providing health information, single session support or signposting those with mild, temporary or ongoing fluctuating difficulties allows users to manage their own health, but also the flexibility to engage with a professional if needed. Ultimately, the goal is to empower users to find the best ways of supporting themselves without intensive support from a health practitioner.

Treatment provides a range of therapeutic interventions focused on achieving agreed mental health outcomes and goals. Here extensive system resources may be required to alleviate symptoms of poor mental health, promote recovery, and improve functioning. A whole population approach would consider softening the impact of ongoing poor mental health by helping users manage long-term problems through ongoing support, wrap-around care and step-down pathways. 

Self-management, like prevention, focuses on empowering individuals but focuses on maintaining mental and emotional wellbeing beyond the length of any intervention. This might necessitate providing individuals with tools and coping skills post intervention, support to understand self-identity or triggers and creating boundaries, or recommending a supportive network and signposting to local or digital support groups.

Kooth Provides Support for Those in Need

At Kooth, accessibility, inclusivity and effectiveness are at the very core of what we do.

Kooth provides safe, anonymous digitally-enabled mental health care for children and young people aged 10-18, and Qwell for adults aged 18+.  Both services offer a full mental health-toolkit and give individuals the opportunity to choose the kind of support that works for them. Choose from;

• Structured or responsive professional support with one of our 180 mental health practitioners
• Self directed support through our expert therapeutic content and activities
• Or pre-moderated community support through forums and discussion boards. 

Figure 1: Pathways of engagement on Kooth and Qwell Platforms

Positive Clinical and Experiential Outcomes 

We’re proud of our impact and continue to strive for the best outcomes for our service users and commissioners. Since April 2021, we’ve seen extremely positive engagement.

• Almost 400,000 goals based outcomes set
• 62% of young people and 71% of adults achieved their goals based outcome
• 75%  felt their needs were met in just a single session
• 90% found Kooth and Qwell to be a useful resource
• 87% would recommend Kooth and Qwell to a friend

Everything we do can be commissioned across a whole populations so everyone has access to;

• Local health promotion and prevention 
• Early intervention and prevention services
• Targeted CAMHS waitlist or crisis step-down services
• And seamless transition from children and young people's support to adult support.
  
  
  

It's been a lifeline for me... For the first time in years, I've reached out and already I've been given the opportunity to live chat, I've talked to many practitioners and got so much support.”
- Young person using Kooth

“It [Qwell] has helped me through some very difficult times. They are very knowledgeable, caring and supportive. I don't know what I would have done without it sometimes.”
- Adult using Qwell

We’re excited to continue sharing our learnings on the impact of a whole system approach and hope you stay with us as we explore the remaining three pillars and share examples of success from across the UK. 

We’ll be publishing more about each pillar in coming weeks, with our next article focusing on Pillar 2: How a whole population approach leads to healthier communities.

In the meantime, if you'd like to learn how other commissioners are pioneering a more joined up approach to mental healthcare provision, we're publishing a full report showcasing their experiences, challenges, and share practical advice in the coming months. Pre-register to secure your free report: 

To get in touch with us directly, contact on of our teams;

London and South Team

Midlands and North Team

Scotland, Wales & Northern Island Team