Supporting people with chronic conditions: the intersection between physical and mental health

Callum Young, Andy Bell

Centre for Mental Health calls for a cross-government mental health plan that tackles the wider determinants of ill health. It is essential that mental health support is available to all who need it, especially those with chronic conditions. Additionally, people with severe mental illness must enjoy the same standard of physical health as those without such conditions, and we must bring a reduction in the life expectancy gap within the next 10 years. To achieve this, we advocate for a whole-person model of care, where people are treated as holistic individuals by their healthcare teams.

Introduction

Living with a chronic condition can have a devastating impact on people’s mental health. Much of the written evidence submitted to the first consultation of this inquiry shows how diagnosis of, and living with, a chronic condition can be a major risk factor for mental ill health. Our own work, with Kidney Research UK, shows that chronic kidney disease is a risk factor for poor mental wellbeing (Wilton, 2023), and that poor mental wellbeing worsens physical outcomes for people with kidney disease. Moreover, 48.5% of people with COPD report anxiety (Asthma + Lung Cymru, 2024), and 81% of people with MS report worsening mental health after diagnosis (MS Society Cymru, 2023). A similar observation is made across most chronic conditions.

Despite this comorbidity, people with chronic conditions are rarely offered mental health support (Centre for Mental Health, 2021). People regularly report that their mental health is not taken as seriously as their physical health, and that they are not asked about their mental health by health professionals. Indeed, over 60% of people with Inflammatory Bowel Disease report not being asked about their mental health (Crohn's and Colitis UK , 2023), and only 20% of people with COPD are offered access to mental health services (Asthma + Lung Cymru, 2024). This is exacerbated by siloed care, which means that people with multimorbidity are treated for each condition independently, and often at the expense of holistic support. Regularly, people are returned to primary care and asked to wait for many months, in order to access mental health support (O'Shea, 2019).

Long wait times, and medical uncertainty, worsen this. Less than 80% of people are met within 26 weeks of referral to care services. Even after being met, people can continue to face uncertainty about their conditions; 45% of people with unexplained medical symptoms report deteriorations in their mental health (Royal college of psychiatrists Wales, 2023). This, alongside other medical trauma, can further contribute to mental ill health (Wilton, 2020). Moreover, for young people, major illness and medical treatments can serve as adverse childhood experiences (ACEs), which have a long-term impact on mental and physical health (Khan, 2016).

As well as these medical issues, the mental health of people with chronic conditions is exacerbated by social factors. For example, when chronic conditions deteriorate, people’s capacity for work can change. This can result in job insecurity, and subsequent financial hardship (Centre for Mental Health, 2023). When illnesses are poorly understood, such as in the case of PMOD, up to 17% of people report losing their job due to their conditions (Women's Health Wales Coalition, 2023). This insecurity can create financial anxiety, contributing to the mental health risks associated with chronic conditions (Murray, Holkar, & Mackenzie, 2016).

In cases where chronic conditions have put families under financial hardship, all family-members are at increased risk of poor mental health. Recent research from the Centre shows that children’s mental health is threatened by mounting financial pressures, linked to the cost-of-living crisis (Davie, Khan, & Abdinasir, 2023). Parents report their struggles in supporting their children’s wellbeing while working long hours or living in insecure housing. The risk of housing insecurity rises for people with chronic conditions (Charkhchi, Dehkordy, & Carlos, 2018), as does the likelihood of poor or unstable working conditions (Haagaard, 2020). As such, living with a chronic condition can increase the mental health harms that children experience. This is especially true in cases where living with chronic conditions has put someone under threat of poverty. For example, many people who feel unable to work are faced with a social security system that sanctions unemployment, and provides insufficient support (Abdinasir, 2023). This can exacerbate the mental health burden associated with financial hardship, and does little to get people into work.

In addition, social determinants like family circumstances, education, poverty, housing, work and racism can all contribute to ill health. Wales has the highest poverty rate in the UK, with 34% of children in Wales living in poverty. Poverty is a major risk factor for mental ill health, and is also a determinant of chronic conditions (Davie E. , 2022; Kivimaki, et al., 2020). Moreover, race inequality can drive poor mental health, and further exacerbate access to mental health support (McHayle, Obateru, & Woodhead, 2024).

There is also overwhelming evidence that mental ill health contributes to poorer physical health. For example, people with severe mental illness die up to 20 years earlier than average life expectancy (Lugton et al, 2023). Most of these deaths are due to preventable physical health conditions. For example, people living with severe mental illness (SMI) face difficulties in managing healthy weight (Bailey, 2020). Stigma around mental ill-health and obesity can impair people’s ability to manage their weight (Rand, et al., 2017); this is exacerbated by a lack of wellbeing support in conjunction with weight management, and people’s variable motivation in response to mood fluctuations (Wilton, 2020).

Even for those without chronic conditions, mental ill-health can be a barrier to preventative practices like healthy eating, physical activity, and alcohol control (Melton & Meader, 2020). Illustrative of this point, smoking rates in people with long term mental-ill health is 26.8%, vs 14.5% in the general population (Li, et al., 2020). This rises to 40.5% in people with SMI, and these rates have increased since the pandemic (Equally Well UK). Despite this, people with SMI are far less likely to be offered smoking cessation support than the general population (Sinclair, 2020).

This is part of a wider network of commercial determinants that disproportionately affect people from deprived areas (Centre for Mental Health, in prep). People who live in low-income postcodes, who are at disproportionate risk of mental ill-health, are less likely to have good access to cheap and heathy supermarkets (Which?, 2022). This increases reliance on local shops, which provide less access to nutritious food options.

This evidence illustrates a circular relationship between physical and mental health. People with chronic conditions are especially vulnerable to poor mental health, but there is insufficient mental health support available to them. Moreover, people with mental health conditions are at greater risk of chronic conditions, but physical health initiatives are often inaccessible.

The wider determinants of ill health apply to both physical and mental ill health. It is therefore imperative that the Welsh Government tackles these, by placing mental health at the centre of all policy decisions. Additionally, people with chronic conditions must be treated as holistic individuals: their mental and physical health should be of equal priority, and their needs should be met in a coordinated manner.

To achieve this, we recommend:

- Putting mental health at the heart of all policies and decision making.

- Protecting the physical health of people with severe mental illness.

- Providing holistic, person-centred care for people with chronic conditions.

- Adopting a social model of health and care.

Mental health in all policies

The population’s health depends on all government departments. As such, we advocate for a ‘mental health in all policies’ approach to decision making. Similar to the ‘health in all policies’ approach, we suggest that all policy proposals should be assessed for their potential mental health impact. This is because, although progress has been made, mental health still experiences a lack of parity of esteem. As such, mental health is often neglected in the course of decision making. This is despite the role of mental ill-health as a catalyst for deteriorating physical health. Indeed, the development of mental ill health is a common early step in the cascade of chronic conditions that is common in people with multimorbidity (Kivimaki, et al., 2020).

To prioritise mental health in this way, the Government must have the ‘machinery for a mentally healthier nation’. This is a tripartite system of cross-government checks and balances which ensures that all departments are acting in the interest of people’s mental wellbeing. The features of this machinery include:

- A mental health policy test

- A mental health commissioner for Wales

- A national mental health strategy.

These are explored below.

A mental health policy test

Policy testing is the process of assessing the potential impacts of prospective policies (National MWIA Collaborative, 2012). We propose that a mental health policy test should become an integral part of the policy production process. To do this, civil servants and decision makers should come together, provide and curate evidence, and discuss what the likely effects of proposed policies could be. This evidence can be collected from similar policies proposed at a local or international level. Alternatively, they could come from the perspectives of potential stakeholders. Ideally, only policies with positive mental health impacts should be implemented. Once this information is collected, it must be made publicly available, so that government agencies can be held accountable for their mental health impacts (Erkkilä, 2020). Transparency is integral to the successful implementation of a mental health policy test, helping to ensure the quality and efficiency of policy testing, and preventing it from becoming a ‘tick-box’ exercise (Sabur et al., 2024).

We suggest that a mental health policy test should be based on the Mental Wellbeing Impact Assessment (MWIA; National MWIA Collaborative, 2012) framework. The full MWIA can be time and resource intensive, but the screening process is an easy-to-implement version of the full MWIA (Centre for Mental Health, in prep). It can be used in tandem with some MWIA tools to achieve substantial mental health benefits in all policy decisions. The MWIA toolkit (National MWIA Collaborative, 2012) provides comprehensive guidance on how to implement this.

The Welsh Government should implement a cross-government policy test, which is woven into the policy production pipeline for all departments.

· This could be run as a pilot project initially, with later legislation to embed it into the machinery of government.

· A cross-department team of senior policy officers should develop a sustainable implementation framework, making use of existing resources and expertise to facilitate this process.

· Each department should guarantee public transparency of its own policy testing process, by publishing the findings online. This will provide a benchmark against which government departments and their executive agencies can be held accountable for their mental health impact.

· The cross-department team should produce resources to encourage and support similar policy testing processes in regional and local government across Wales.

A mental health commissioner for Wales

A statutory mental health commissioner is a nebulous role, which exists in different capacities internationally. In the main, a mental health commissioner for Wales would offer sustained leadership for mental health, complementary to existing roles and structures in government (Bell and Wilton, 2023). By helping to put mental health at the heart of government, the commissioner could change the ways decisions get made – in part by monitoring the outcomes of a mental health policy test.

Our vision for a mental health commissioner is of a statutory role with relative independence from government. In this sense, the commissioner is free to criticise government policy, and offer contrasting views to that of central messaging. They should work in a cross-government fashion to secure better mental health and wellbeing for the public, by scrutinising policy decisions and their likely impact. We encourage that the commissioner is as role legislated for in perpetuity, ensuring that mental health will be prioritised by successive governments. By enshrining the role in statute, it allows the commissioner to respond freely and with impunity to harmful policy decisions.

Legislation for a mental health commissioner could be part of a new Mental Health Act in Wales. Alternatively, it could be legislated for on its own, or as part of a package alongside the policy test. This is especially relevant, given the opportunity for the policy test to be used as a tool by the mental health commissioner (Centre for Mental Health, in prep).

The Welsh Government should legislate for an independent mental health commissioner,

· This could be done in conjunction with legislation for a policy test.

· The mental health commissioner must be established in perpetuity to ensure long-term focus on mental health.

· The mental health commissioner must be independent from the government, and free to criticise harmful policies.

A national mental health strategy

To ensure that mental health is at the heart of decision making, the Welsh government should commit to its plans to update the long term mental health strategy (Welsh Government, 2023). This strategy should adopt a cross-governmental approach, that attributes responsibility for mental health across all departments. This should begin as soon as possible, and incorporate key suggestions from our manifesto: A Mentally Healthier Nation (Centre for Mental Health, 2023). There should be statutory requirements associated with key outcomes, and funding commitments where appropriate.

To tackle the health inequalities facing people with chronic conditions, a specific section should be dedicated to provision for people with long-term health problems. This should incorporate the recommendations in this memo, and pay special attention to the minimisation of the life-expectancy gap.

Protecting the health of people with severe mental illness

People with mental ill health experience worse physical health than those without. In severe cases, people’s life expectancy can be up to 20 years shorter (Lugton et al, 2023) and, for many, this greater risk of mortality comes alongside many years of poorer quality of life (Equally Well UK, 2018). We believe that no one should have poorer health or healthcare due to mental ill health. To achieve this, we encourage Welsh government to sign up to the Charter for Equal Health (Equally Well UK, 2018), and take the actions we outline below.

Equally Well

Equally Well UK was setup in response to the severe health inequalities facing people with long term mental health conditions. People with SMI are more likely to face health risks associated with smoking, lack of physical activity, poor weight management and nutrition, infectious disease, poor dental health, and cancer (Equally Well UK, 2024). Given this plethora of risks, it is essential that people with SMI have access to physical health checks. Indeed, NHS England’s Quality and Outcomes Framework specifies a physical health check should be undertaken for patients with SMIs every 12 months (NHS England, 2024). Similar provision should be available in Wales, and made universally accessible to all people with SMI.

However, our own research shows that provision of these health checks is insufficient to meet the need of people with SMI (Hutchinson, 2024). Many people with SMI face barriers which prevent access to physical health checks. For example, many people with SMI have experienced medical trauma (including compulsory treatment), which causes distrust of medical professionals. It is therefore essential that promotion of these checks are coproduced, and that health checks are trauma informed.

As well as regular health checks, people with SMI should be supported to access vaccines at the earliest opportunity. During COVID, vaccines were made accessible to people with SMI (Equally Well UK, 2022). As part of this programme, people were supported to make an informed decision about their health. This is especially valuable for people who may be vulnerable to medical misinformation. This empowerment facilitates people to take responsibility for their physical wellbeing, and attenuates long-term physical harms associated with mental ill health.

It is critical that access to physical healthcare is equally available to people with mental ill health. There is a major risk that the physical needs of people with mental ill health are ignored due to their conditions. Often, psychiatrists are (wrongly) called to meet patients who present with physical symptoms, due to their history of mental health problems (Centre for Mental Health, in prep). This is especially prevalent in people with SMI. The physical needs of people with mental ill health should be met with equal priority to their mental health needs, and this care should come from the appropriate professionals.

The Welsh Government, and NHS Wales, should minimise the physical health inequalities for people with mental ill health, by signing up to the Charter for Equal Health,

· People with a mental health condition should be offered effective and empowering support, information, and advice to support their physical wellbeing.

· Mental health service providers, and primary care, should ensure annual health checks are provided to people with SMIs.

· Primary care should secure equitable access to high quality, evidence-based physical care, using tailored and proactive approaches and shared decision-making.

· All health and care workers should be trained, supported and equipped to support the physical health of people with mental health conditions. This should not be limited to mental health services.

Accessible Prevention:

Support for preventative services– like smoking cessation – should be available and accessible to people with mental ill health (Sinclair, 2020). This should not be withheld due to siloed care or diagnostic overshadowing, which is part of the reason that existing programmes are underserving people with SMI (Wilton, 2020).

It is important to tailor preventative and self-management programmes to cater to the needs of people with mental ill-health. A key first step would be to tackle stigma associated with mental ill-health and obesity (Rand, et al., 2017). This can be done by making weight-management programmes more inclusive, and shifting public-health focus away from weight as a measure of healthy living (Bailey, 2020; Wilton, 2020). Weight obsession can be harmful for mental health, proliferate eating disorders, and stigmatise obesity (Centre for Mental Health, 2023; Wilton, 2020). Instead, by focussing on healthy lifestyle, people feel empowered to engage with weight management in a more person-centred way.

To improve accessibility of primary health-management services, there is great value in the primary care provision of psychological medicine (O'Shea, 2019). This support was originally developed to tackle high use of primary health services due to unexplained physical symptoms. The rationale was that psychological intervention would improve mental health, and thus alleviate physical symptoms. In its first year, psychological provision was shown to save £524 per person, post-discharge. The overall savings far outweigh staffing costs. It is likely that providing psychological support in primary care will improve self-management of chronic conditions, by removing psychological barriers to self-management programmes (Wilton, 2020).

To tackle the harm of commercial determinants, supermarkets must be incentivised to improve provision to more deprived areas (Which?, 2022). Alternatively, a similar effect can be achieved by supporting local businesses to expand their selection of affordable and nutritious food (Langellier , et al., 2014). Such interventions may also help to tackle the over-population of fast-food restaurants in deprived areas (Wise, 2018).

The Welsh Government, and Public Health Wales, should make preventative and self-management support universally accessible,

· Public health services should be supported to reach out to people with long-term mental health conditions: identifying those at risk, intervening early, preventing problems whenever possible, and offering extra support when needed.

· Smoking cessation support should be available to people, regardless of their mental ill health.

· Providers of weight-management programmes should make their services accessible, and should shift their metrics of success away from a numbers-based approach.

· Primary care services should provide psychological medicine practitioners, and commissioners should incentivise this provision.

Holistic care

A recurrent theme from the first consultation is that people do not benefit from siloed care provision. Indeed, from our own research with Kidney Research UK, we find that people with chronic kidney disease have little access to psychosocial support (Wilton, 2023). By treating single conditions in isolation, the overall holistic needs of the individual are not met. To counter this, we propose a person-centred approach to care provision. In this model, people’s overall needs are considered and accordingly met. It can help to overcome the issues associated with diagnostic overshadowing, whereby a ‘primary condition’ takes priority over all other healthcare requirements. Moreover, it ensures that people with condition-related emotional distress can get this assessed and addressed according to its severity. This will improve the quality of life for people with chronic conditions, and may prevent the deterioration of people’s mental wellbeing into a state of mental ill health.

Person centred care

There are four key principles which underpin person-centred care (Morton and Sellars, 2019):

1) Care is delivered with dignity, compassion and respect.

2) Care is well coordinated.

3) Care is personalised, taking into account clinical, social, emotional and practical needs.

4) Care enables people to take an active role in their own treatment.

It is critical for person-centred care to be coproduced with the people being treated. This ensures people experience autonomy in their programme of care, and empowers them to make clear what their needs are. This builds trust between patients and their care team, and mitigates harms associated with medical trauma - especially prevalent in racialised communities and those with SMIs (Equally Well UK, 2024; McHayle et al, 2024). The process of shared decision making is iterative, and facilitated by a set of skills and values held by health care professionals (Wilton, 2023). Despite the relative slowness of this coproduction, it is critical to reduce the negative impact of chronic conditions on people’s wellbeing. Moreover, it helps to shift care away from a disease-specific approach.

Centre for Mental Health launched the #AskHowIAm campaign, calling for health practitioners to ask patients how they are feeling, at every opportunity (Centre for Mental Health, 2021). Central to this campaign is the need for health practitioners to show compassion. Small gestures of care can be a major boon to people struggling with their mental and physical health. This includes regular emotional check-ins, and the availability of continual support between appointments. In conjunction with this, practitioners must be proactive in the information and advice they provide regarding self-management of chronic conditions. This proactivity ensures that people are fully aware of the support available to them, and can access it at point of need. This can help to reduce the initial harm of diagnosis.

The British Psychological Association highlight the importance of medical psychologists in the management of chronic conditions. They make the argument that such support should be available at all levels of care. Our own work has shown that inclusion of psychological support in primary services is of net health- and economic-benefit (O'Shea, 2019). Indeed, in England, primary care networks are now incentivised to hire mental health practitioners (Bell, 2021). This is a major step, and one that should be mirrored in Wales. As part of the Strategic programme for primary care, NHS Wales is building professional collaboratives which form cluster footprints across different services in a region (NHS Networks, 2023). There is currently no specific call to include mental health professionals in these collaboratives. To meet the goal of treating patients holistically, and removing division between physical and mental health services, mental health professionals should be actively and explicitly sought in these professional groups. Moreover, as well as improving access to mental health practitioners, it is important to upskill other health professionals regarding mental health (Marks, 2019). This is essential to meet the demands of #AskHowIAm (Centre for Mental Health, 2021).

Additionally, Project Future’s work shows that mental health services can be of benefit outside of traditional care settings (Centre for Mental Health, 2022): psychological support in youth services are greatly effective at tackling mental health stigma and improving mental health literacy in young people. Alternatively, the family hubs scheme provides mental health support to children, young people, and their carers via a drop-in format (DHSC, 2023). These hubs can also assist families with medical, financial, and parenting advice. This is a great example of holistic, de-siloed care, and should be fully funded and rolled out across Wales.

The Welsh Government, and NHS Wales, should prioritise person centred care for the treatment of people with chronic conditions,

· Healthcare professionals should coproduce care plans, prioritising the holistic needs of the patient.

· Healthcare professionals should be trained to provide compassionate care during appointments, and should proactively offer emotional support at the earliest possible opportunity.

· Primary care networks should be incentivised to employ mental health practitioners, and incorporate mental health support into primary care settings.

· Welsh government should invest in family hubs, accelerating roll out of this initiative across the country.

A social model of care

Living with chronic conditions can put people at greater risk of various social inequalities. In turn, these social inequalities serve as wider determinants of physical and mental ill health. This circular relationship illustrates how being diagnosed with a chronic condition can precipitate a further cascade of illness (Kivimaki, et al., 2020). It is therefore important to tackle the social harms that befall people with chronic conditions, and reduce the health inequalities associated with certain risk-factors.

A major step toward achieving this is the adoption of a mental health policy test. This ensures that all prospective policies will be of net benefit to the public’s mental health. However, there are more immediate ways to tackle health inequalities that exist now. A major part of this is aiming to eradicate poverty, as deprivation greatly increases risk of mental ill health (Davie E., 2022).

Employment and IPS:

The risk of poor or unstable working conditions rises for people with chronic ill health (Haagaard, 2020). As such, living with a chronic condition can increase the mental health harms associated with deprivation. To counter this, it is vital that people with chronic conditions are supported to find work which is suitable to them. Work can be protective for mental health, but only if it is tailored to meet the individual needs of the worker. One good way to support people into work is IPS (Centre for Mental Health, 2022). The focus of IPS is to get people into paid employment, related to their personal preferences and skill-set. Critical to its success is the provision of support to employers, so that the needs of prospective employees can be met. The goal is to get people into long-term employment, which can stabilise their finances and support their mental health.

Inclusion of IPS in health care can help people find stable and suitable work. This is a significant step in reducing the risk of further comorbidity, by removing the immediate risk of poverty and financial insecurity. This has the knock-on effect of improving access to secure housing, and creating a sense of independence. Work can be protective for mental health, by providing income, purpose and routine. This is only true, however, in workplaces with good conditions and fair treatment (Centre for Mental Health, 2024). As such, as well as supporting people with chronic conditions into work, workplaces must be supported to provide suitable environments for people with chronic conditions. IPS can help with this, but the Welsh Government must also ensure that employers are held to an appropriate standard for the workplace.

The Welsh Government, and NHS Wales, should incorporate IPS into healthcare provision for people with chronic conditions,

· Health care providers should provide access to IPS for people diagnosed with all mental health and/or chronic conditions.

· The Welsh Government should establish workplace standards, and enforce these standards, to ensure that people have access to supportive and safe work environments.

A mentally healthier nation

The conditions for a mentally healthier nation are within reach (Centre for Mental Health, 2023). To achieve them, social inequalities must be tackled as a matter of priority. This is not just a desirable outcome, but is critical to reduce NHS wait times and prevent ill health. The simplest, and most urgent, step is to end poverty. The Welsh Government could take steps to end poverty in Wales, with a duty enshrined in legislation to foster concerted action.

We advocate for a Minimum Income Guarantee, ensuring that everyone has enough money to afford a healthy life. The incomes of the most deprived, and the most vulnerable (including those with chronic conditions), can be increased by increasing minimum wage in Wales – rising with inflation. Moreover, Welsh Government should encourage and incentivise wealth building schemes where anchor institutions (like local authorities, NHS trusts and universities) use social value procurement to buy goods and services and recruit their workforce locally. Such a scheme in Preston, Lancashire, reduced anti-depressant prescriptions by nearly 10% (Rose et al, 2023).

Another way to reduce poverty is to lower costs for people with chronic conditions. This can be done by providing more social housing, with greater energy efficiency; extending free childcare and council tax exemption; providing access to cheaper (or free) public transport. The latter of these can also help to improve access to green spaces, shown to be protective for mental and physical health by promoting outdoor physical activity (McNally, 2017).

Another important step is to address mental ill health in children and young people. Over 50% of mental health conditions are established by the age of 14. This rises to 75% by the age of 24 (CYPMHC, 2023). Therefore, to tackle mental ill health in the adult population, interventions must be targeted at this demographic.

Loneliness and isolation are two major determinants of mental ill-health. Indeed, loneliness increases mortality by a third (McNally, 2017). If people lack the skills and experience to form meaningful relationships, this can have devastating impacts on their mental health. In contrast, healthy and meaningful relationships can be protective for people’s mental health – especially mental health resilience in children and young people (Snell, 2022). This highlights the importance of early intervention, and the enhancement of social ‘scaffolding’ around children at risk of mental ill-health. This is especially true for children experiencing multiple deprivation. Successful relationship building depends on fun and happiness, easy and flexible access, creative self-expression, and safe spaces for openness.

Such an approach can be observed in the Welsh Government’s ‘Whole School’ policy. The rationale of the Whole School Approach is that every part of the school community is included in pupils’ health and wellbeing. This includes teachers, parents, and students. In theory, this approach should ensure that no student gets left behind – that everyone’s needs are met. Although the whole school approach is part of Welsh Government’s ‘Health and Wellbeing in Schools’ strategy (Education Wales, 2021), there is still some way to go before this is a reality in all schools across Wales. The roll out and evaluation of this must therefore be accelerated.

There is also evidence that physical environments can determine people’s mental health outcomes (Roberts et al, 2019). Factors like air pollution, noisy neighbourhood, and lack of access to safe outdoor space, can increase risk of depression and psychosis. Typically, people with multiple deprivation are more likely to live in high-risk physical environments (Centre for Mental Health, 2023). To overcome the harms associated with these environments, we suggest that Wales should take steps to improve the physical environments people live in, especially in the most disadvantaged neighbourhoods, and tackle air pollution.

These are some of many recommendations made in our manifesto: A Mentally Healthier Nation (Centre for Mental Health, 2023). We encourage the Welsh Government to adopt all the recommendations made therein. These form the basis for a national mental health strategy, as outlined above.

Recommendations

Chronic conditions are intimately linked with mental ill health. People diagnosed with long term health conditions are much more likely to experience poor mental wellbeing, and people with mental health conditions are at greater risk of developing chronic conditions. To tackle the intersection of these issues, we encourage Welsh government to prioritise person-centred, holistic care. We call on the government to adopt a ‘mental health in all policies’ approach to decision making, and to tackle the wider determinants of ill health.

To achieve this,

· The Welsh Government should implement a cross-government policy test, which is woven into the policy production pipeline for all departments.

· The Welsh Government should legislate for an independent mental health commissioner.

· The Welsh Government, and NHS Wales, should minimise the physical health inequalities for people with mental ill health, by signing up to the Charter for Equal Health.

· The Welsh Government, and Public Health Wales, should make preventative and self-management support universally accessible.

· The Welsh Government, and NHS Wales, should prioritise person centred care in the treatment of people with chronic conditions.

· The Welsh Government, and NHS Wales, should incorporate IPS into healthcare provision for people with mental health problems and those with chronic conditions.

· The Welsh Government should adopt the recommendations made in A Mentally Healthier Nation.

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