Speaking at The King's Fund Annual Conference on29 November 2017, Gary Belkin, Executive Deputy Commissioner, New York City Department of Health and Mental Hygiene, shares lessons from New York City’s public health approach to changing the way people think about mental health, and how the government and local partners provide care.
So this is where we launched what we call Thrive NYC. At that point it was just a report. Now we have 54 initiatives up and running, a first four year of course of about a billion dollars. You can’t solidify the workplace, secure neighbourhoods, figure out your prison problems, graduate everyone you want to graduate, reduce your healthcare burden if you’re not taking on mental health in its fullness. Maybe one out of five Americans who have major depression will get evidence based care for it.
So there are two realities we wanted to take on. The mismatch between the size of the problem and the approach, and the mismatch between our reliance on a treatment system that just wasn’t reaching people and living up to the challenge.
There was the diligence to with widespread community input to decide what were our North Stars? What were our guiding principles? Change the culture included everything from training a quarter of million New Yorkers mental health first aid, to training half the New York Police Department in how to manage behavioural emergencies on the street.
Act early, with whole new investments in social emotion learning of course are public pre K and day care centres that touch 100,000 kids every year and social emotion learning skills, close treatment gaps and we identified some key gaps we wanted to close such as universalising, screening and treatment for pre and postpartum depression. Partnering with communities, doing pace based work for this ensemble of stuff to really work and to really be sustained and permanent and to see their impact, use data better. Created a whole new thing called the Milhove Innovation Lab in our health department to come with new sources of data and we’re exploring crowd sourcing and learning about gaps and needs through push surveys and pooling data sets that never talk to each other and then finally position government to lead.
For government to do these 54 new initiatives and to do this approach, it has to change. In the skill sets it has, and the structures it has and the data it has, in the way it engages with the communities that it oversees, that it governs. And so we created new structures. We’ve created a mental health planning council that brings multiple city agencies together, so you have parks department, probation, police, child welfare, economic development all talking about how they are all working toward shared aims around mental health.
So what I just described to you is sort of where we started with the commitment for a principle-driven, public health approach to mental health. By public health I mean what also informed the initiatives were looking across the population; who is affected, where are our key risk opportunities to intervene, but there are three other things I just want to briefly mention that we learned as cross-cutting ways of implementing this stuff. They are Explode the Work or Explode the Workforce. To do those initiatives we have to totally rethink the workforce; who’s in it, what skills they have, how they relate to each other. We need to Engage the City and I mean that in a very deep way and I’ll talk a little bit more what I mean by that, and we have to Learn. It’s not the external party coming to do the three year evaluation that’s get reported at the end, that’s not where learning happens. Learning happens in the day to day effort to make this work and that’s where we lose most of the really precious data about how to do this.
So we have to equip our frontlines to be laboratories, through improvement practices, through other embedded and facilitated supports for them to do that and we saw that as a mission of the city. It’s engaging the city into this work at all levels. It’s not just the business of the health department and it’s not just the business of government. Most of the Thrive initiatives that are funded, the 54 initiatives actually are owned or co-owned by agencies other than the health department, and we found in New York that also if you go, if you travel, if you step out you start to find what the healthcare system is not finding.
So, the data at the bottom right is from a colleague of mine who did a convenience sample of churchgoers one day in a black church in Manhattan and used the PHQ9 and found these depression rates which are higher than you find in primary care, about three times what you find in the general population. So if I’m a public health planner, if I’m coming in from a public health perspective, my priority is making sure priests know what to do, is to go to churches to find, to find the people that we’re missing and so if you put all these things together, you really have a very different topography of how you are thinking about your mental health system. It’s not in your centres, it’s partly in your centres, but they have a different role. They’re in task shifting mostly to skill build, coach and mentor others to be frontlines as well as to get more serious folks who need specialised care.
My last message to you is if you’re going to think about to think at a population level is to have permission, to speak exceptionally about the completeness of the work that you need to do to succeed and the strategic anchors you have to be honest to, if you’re going to succeed before things get unleashed. It’s proven very helpful to us, it’s kept us honest as sprawling and as nerve racking and I can tell as many crises every day we have on each of these 54 initiatives to keep track of, but it keeps us on a strategic direction and a hope of strategic fidelity to these kinds of transformative possibilities.