How can you solve problems in mental health with entrepreneurship if people who live with mental ill-health always end up poor?

Mental health, social entrepreneurship and inequality

The following is the text of lecture ‘Mental health, social entrepreneurship and inequality’ given by Mark Brown to Goldsmith College Social Enterprise MA students via Zoom on 21st July 2020.

In one way or another, all of my adult career has been about asking the question ‘where does the money come from to make things happen in mental health?’

The global cost to people’s lives of mental ill-health, trauma and distress is immense. We might tend to only see the national balance sheet of the amount of work days missed or the cost of hospitals or care, but the real cost is in the things that people never get to do or be, the years lived in discomfort. People with more severe mental health difficulties tend to die 20 years younger than those who don’t have those difficulties. The cost of people finding themselves with nowhere to turn and unable to trust what’s happening in their own mind is almost too large to contemplate.

In this talk I’m going to try to share some lessons I’ve earned from trying to ‘do’ social enterprise in the area of mental health, then lead you through a bit of a discussion of the overall market for mental health in the UK and try to tease out some lessons for social entrepreneurship looking to make mental health better.

My career in doing mental health stuff began in around 2006 when I has the stupid/clever idea to try to publish a national mental health magazine written by people with mental health difficulties, for people with mental health difficulties. It was a social enterprise project that we managed to keep going until 2014, and one that I hope made some kind of difference to people. But it’s one that in some ways, in hindsight, is a great example of what not to do. Not because it wasn’t a great idea. But it wasn’t necessarily a great business. The idea was that the magazine should be a lifestyle magazine: a magazine that covered the same kinds of issues as other lifestyle magazines — leisure, finance, health, family, consumer-issues, holidays, culture, jobs, relationships — but from the perspective of a section of the population who shared a variety of defining characteristics. In this case, the defining characteristic was the experience of mental ill-health, distress or trauma. This, we reasoned at the time, was enough of a wide demographic to contain lots of different kinds of people, but who would all also experience common challenges created by the ways in which society is structured to meet the needs of those who do not share the experience of mental ill-health, distress or trauma.

What we thought was that any lifestyle issue would have different dimensions based on the way that mental-ill health, distress and trauma might change the way in which either society viewed those with mental health difficulties in relation to it; or the way that different constraints or different needs that people who live with mental ill-health, trauma and distress have would alter the experience of the issue in question. So, going on holiday might include different things to plan like maintaining sleep patterns or seeking out a specialist travel insurer. Achieving work-life balance might be different if depression, fatigue or difficulty concentrating were a day to day experience. Shopping from bras might be different if anxiety prevented you from having a proper fitting. We reasoned that a shared store of knowledge of how to ‘hack’ a world not designed with you in mind might generate an almost endless variation on standard feature articles.

At the time we were planning this, the overall media environment around mental health looked very different. In the last 14 years, in the english speaking world at least, mental ill-health and the way it shapes people’s lives has risen further and further up the list of public concerns. There are more column inches, more web pages, more minutes of television, online content, podcasts and other media about what it’s like to live with mental health difficulties than ever before. Millennials are more conversant in ideas around mental health and far more likely to consider their mental health and the mental health of others. This seems to be even more true for Generation Y. Where once mental health difficulty was the preserve of hard hitting documentaries and lurid dramas, it now features more than ever in the general too and fro of popular culture. It’s a thing now. When we were planning the magazine, this wasn’t the case at all. What there was at the time was: newspaper stories every time there was a scandal; a fair amount of very miserable first person books released in the wake of Elizabeth Wurtzel’s Prozac Nation; some very good blogs and websites; some stuff from the beginning of Mad Pride and Guardian articles about NHS staff. Of course, there were lots of other things happening. There always is. But the point was that these things were only available if you knew about them. And the only way to find out about them was to know about them. Which meant that most people who lived with the daily reality of mental ill-health, distress and trauma didn’t know about them.

The magazine, which we eventually called One in Four, was launched in 2009 after a pilot issue in 2007. Me and my business partner David Floyd made some assumptions in the way hot shot young-ish social entrepreneurs do. We assumed that because the magazine was so good and so useful, it would be paid for by the people who have the largest responsibility in the UK for the provision of help and support for people experiencing mental ill-health: The National Health Service. We came up with a bulk subscription model where organisations could buy multiple copies of the magazine on behalf of the people who use their services. We pictured piles of our glossy, well-written, exciting and interesting magazine sitting in GPs surgeries, mental health centres, inpatient wards, therapists waiting rooms.

We were wrong. Or at least, from a business point of view, we were wrong. We received charitable funding to produce our pilot issue and to distribute about six thousand copies. People wanted it when it was free. We decided that ‘free to the end reader’ was the business model we would use. It’s the model we use now for our four community newspapers (Waltham Forest Echo, Tottenham Community Press, Enfield Dispatch and EC1 Echo). During the pandemic lockdown we’ve been delivering our newspapers for free to the doors of our communities and doing OK-ish selling adverts. We’re not quite breaking even, but we think it’s worth it. Back in 2007, we knew that the people who most needed good quality, interesting and useful mental health information were people who tended to not have that much money, so we reasoned that we would have to find other ways to fund the magazine’s four 36 page issues each year. We took out a loan, we received some charitable funding and we came up with an organisational subscription model. We also hoped to sell a bit of advertising. That was the plan, at least. But what actually happened was a bit different, and informs all of my work since and will inform the second half of this talk.

All of the things we learned are hard social enterprise lessons, not specific only to mental health related activity, but with their own quirks and wrinkles. The first thing we learned was that, for the most part, the National health Service didn’t want to buy a magazine written by people with mental health difficulties, for people with mental health difficulties to distribute instead of their own publications. We had lots of meetings where we told people in the NHS that our information was better, more relevant and more interesting than the information they created. We told people whose job it was to write and create mental health material that our mental health material was better, cheaper and more effective than theirs. Surprisingly, being told that their materials were shit didn’t make the NHS more likely to buy ours and being told that we wanted to put them out of a job didn’t make people more likely to buy our materials either. The lesson we learned was that you can’t disrupt your customer. It’s their money.

No one had quite done a publication like ours at the time we started it. We were breaking new ground. I got interviewed and got a full page in The Guardian. We were new, fresh, maybe even a little bit exciting. So we thought. What an advantage! Pioneers! What that actually meant was that we were trying to create a market and a use case for what we had made. What we found out was that even if we could convince an NHS organisation to purchase our social enterprise produced magazine, filled with the voices of lived experience, the chances were that when it was delivered, the person signing for it wouldn’t know what was suppose to happen with it and it would end up still in its boxes undistributed. What we found out was that being first to market without the resources to really educate that market through advertising, corporate partnerships, through media and through general resource-based kicking really hard at the door meant that we had made the cardinal mistake of assuming that the value of our product was self-evident to the customer. We were out there, alone, being compared to other products that we didn’t even resemble. We assumed that what our product was (information written by people who’ve lived through things!) and how it was made (by a social enterprise that pays its writers and is trying not to screw anyone over!) would answer the primary question any customer has: what is the point of this product and why would I want it? Fourteen years on, what we had made would make more sense to people. They still might not buy it, but they’d probably understand better what we were trying to do. Social enterprise, mental health, lived experience: all have a better toe hold in the consciousness of people who have money in their pockets now.

Other mistakes we made were the classic ones that everyone makes at least once. We ended up growing the staff team who worked on the publication far quicker than we grew revenues from the publication. In fact, our team grew because we spent more and more money on people time to try to make it make more money. We paid people to sell advertising. We paid people to publicise and market us. We spent money to chase money, but the money spent was far more than the money raised. We weren’t a start up, burning through capital and waiting to sell to the highest bidder before the whole house of cards collapsed. We were spending our money in wages not taken, our youth and good looks in working round the clock on other projects to prop this one up, and in my own case, a growing sense of burn out, crisis and existential exhaustion. The lesson we learned was that sweat equity is a real thing, but it’s worth nothing if you can’t cash out. When the only resource to hand is your own time and labour; you will eventually reach a point where there is no more of you to go around. in 2012 I took home, in total about seven thousand pounds in wages despite working sixty hours or more week. My business partner took home even less. We kept going because what we were doing felt important. But we also were subject to the sunk costs fallacy. We also kept going because during the hard years of austerity, there weren’t many other prospects that directly offered us a chance to use our skills and abilities. David became an expert in social investment during that time. I ate a lot of economy beans.

We also made a fairly massive error that wasn’t quite within our control. We chose to launch our publication, to be paid for by public services, just at the point that the global financial crisis happened. We’d conceived of it in 2006, an historic high point for spending on public services. We went into regular production almost at the same time as Lehman Brothers collapsed in 2008. We had developed a business model that relied upon the public purse as its main customer at exactly the time it became clear that we would be entering the biggest period of public spending contraction, and on the horizon looming, the election of a government committed to cutting spending as a principle. And we financed part of the launch with a loan. If we had held back, we’d have never had the seven years of publication that we did. We’d have never done it at all. But as we were doing it, the marketplace changed around us. And, as importantly, the lives of our readers changed, too.

We responded to the fall in public sector spending in a few ways, none of them quick enough. At our high point we had managed to sell 60 thousand copies of One in Four to the NHS, to charities and to other organisations like public libraries. The amount we made in advertising was always negligible, not for want of trying. We cut our staff team, we halved the amount we paid contributors, we reduced our page count which hit a sweet spot of losing four pages but making each copy a third less expensive to print and reducing the amount it cost to ship and post them. We got better at guessing how many copies we would need to print. We cut a very cheeky deal with the person who distributed goods to a national chain of charity shops who was up for including the magazine in the shipments. We stopped trying to secure advertising. And we began to offer individual subscriptions.

It was offering individual subscriptions than taught us some interesting lessons about how people regarded mental health and who should pay for it and also how the lives of our intended readership had been gutted by government austerity policies. We kept our subscription price low. It was ten pounds for four issues delivered to your door. Some people were highly critical of this, accusing us of profiting off the back of people living in poverty. We weren’t. We barely broke even on the offer. But we found that because the thing we were doing was mental health, people assumed that someone was paying for it. The public sector delivers the majority of mental health care and support in the UK, with the charity sector providing most of the rest. People didn’t feel like individuals should pay for things that were mental health related.

This was understandable. Austerity has absolutely hammered many people in the UK who experience mental ill-health, distress and trauma. Benefits were cut, services not funded, charities shut up shop, unemployment rose. Disability benefits, paid to people to offset the costs of having being disabled because of their mental health were cut drastically, then cut again. The Work Capability Assessment was an impersonal interview that could lead to your income from social security benefits payable because you could not work reduced by hundreds of pounds each month. The Spare Room subsidy, for people who lived in council housing, meant that the amount of rent that was paid for you in the form of housing benefit was calculated on whether you had any spare rooms. If you lived alone, you suddenly had to find the money to pay for any ‘extra rooms’, reducing the money you had in your pocket. Benefits sanctions, where you benefits might be stopped if you missed an appointment or were judged to not be trying hard enough to find work, could reduce someone income to zero for weeks. In the face of things like that, a yearly direct debit of £10 pounds could capsize you. The people we most wanted to get our magazine to couldn’t afford our magazine, no matter how cheap we made it.

By the end, in 2014 we found a way of making each quarterly issue and getting 20 thousand copies out to the high street via charity shops for under 3 thousand pounds an issue if we didn’t pay ourselves. That was based on giving them away for free. And this was where we learned our final lesson. When we presented this case to funders, they didn’t see that this was a victory and the result of seven years of learning. They saw it that we had failed because, as a social enterprise, we hadn’t made it work as a business. Of course, charitable funding *is* a business model, and what we were achieving, while still paying our contributors, was incredible value for money. But it hadn’t succeeded in its initial intention of becoming sustainable as a business in itself. So, with heavy hearts we decided to end the magazine after seven years. In the time we were running it I had to do all manner of different mental health related work to subsidise the magazine. It changed my life. During that time we watched mental health rise up the agenda until at times in the UK it felt like everyone was talking about it. We saw others launch mental health magazines with different business models, ones we’d decided against, come and go.

And we learned a lot about the landscape of mental health and how it relates to entrepreneurship and to inequality.

The second half of this talk is some more broad observations about the challenges of trying to use social entrepreneurial approaches to solving issues in mental health. As I said at the beginning, mental health isn’t one thing. It’s not synonymous with wellbeing, though wellbeing influences mental health and mental health influences wellbeing. Think of this as a bit of market analysis.

It’s very easy to get excited about the causes of mental ill-health in a very abstract way, spending ages discussing nature versus nurture, biography versus biology, environment versus genetics, chemistry versus emotions, prevention versus cure and so on. All of those things are huge issues where there are very real areas of disagreement and very real antagonistic discourses. You’ll have heard some people claim that mental illnesses ‘don’t exist’ or that all mental ill-health results from disruption of brain chemistry. You’ll have heard people say that all mental ill-health results from trauma, or childhood mistreatment or from social conditions. You’ll have heard people who say it’s all in people’s heads and they should just pull their socks up and stop being silly, or that mental ill-health is only an affliction of the decadent west, and that people in other cultures don’t experience mental ill-health. Everyone has a pet theory that sounds about right to them. Some think that you can cure mental ill-health through exercise alone, or eating lots of kale or doing meditation or being mindful. The reality is that mental health is incredibly complicated and multi-factorial. Your own mental health is a combination of how your body and brain works, what has happened to you in your life and the effect it has had on you and the environment you find yourself in.

For me, the route to exploring whether entrepreneurship can offer anything to support people who live with difficult stuff is to focus on their lives, their feelings, the conditions they live in and what they really want to happen. This is a variety of understanding the problem before arriving at the solution. The question is: what might be done to sustainably help people have the best life they can have?

Roughly speaking, approaches to improving people’s mental health can be trying to change how their body works, how their understanding of their thinking, feeling or perceptions is or what their situation is like.

If you haven’t already spent the last ten years studying psychology or psychiatry or neuroscience, it is unlikely that you as an entrepreneur are going to stumble across a miracle cure for anything, never mind something that will change directly at the level of biology what people think, feel or perceive. The barriers to entry to such things are, quite rightly, very, very high. New drugs are incredibly expensive to develop and even more expensive to license and prove to be effective. The pharmaceutical industry has actually, to a great extent, disinvested from the development of new drugs in mental health because the cost far outweighs the potential return. Their current dominant business model is trying to broaden the range of experiences for which their existing drugs might be prescribed. Generally speaking, any time you see an entrepreneur trying to sell a new ‘cure’ for anything from anxiety to hearing voices to depression they are either trying to sell something that doesn’t work or they are trying to sell something that is dangerous. There’s a name for that and it’s quackery. That isn’t to say someone won’t make a big breakthrough in future, but it’s probably not going to be you knocking together something in your kitchen or shed.

I get to go to a lot of research conferences and there are amazing things being found out all the time about the ways that people’s brains and bodies work. I’ve come across academics who have formed companies to market things like Virtual Reality as a means to overcome phobias, academics trying to take new ways of monitoring people’s real time physical and emotional state to market so that treatment can be improved. Academics trying to sell advanced algorithms that can help predict when someone may be becoming unwell. There is certainly an entrepreneurial function in taking such findings to market, and academics are not always the best entrepreneurs. They often end up with a product for which they can’t find a market. Finding a great product is what inventors do. Finding a way to leverage value from that product is what entrepreneurs do. In the UK, you are still likely to run into the problem that we had with our little magazine. The people who might most benefit often don’t have money; and the organisations and bodies that have money are not always very open to using that money to spend on people’s behalf on a new or untested product or service. In fact, in the UK, there is a growing movement in the NHS of intrepraneurs under the banner of Quality Improvement who describe themselves as people who rock the boat but don’t get out of it, people who already work for the NHS but who seek funds and resources to develop new things within the existing structures. Organisations like the School for Health and Care Radicals claimed to be doing entrepreneurial work but within healthcare systems not outside them. They tend to like having conferences, drawing diagrams and describing themselves as ‘change agents’. Your mileage may vary as to whether you feel it’s correct that entrepreneurs should risk their own time and money to develop things and then give it to the NHS or not. Certainly in the circles of mental health doers that I mix in there is a lot of suspicion that other people take all of the risks, while those ‘within the system’ get all of the credit and also get to pay their rent.

Across the world, mental health care and support differs greatly in its availability and its quality. Some of this is down to the individual healthcare systems of various countries, with some countries having socialised healthcare systems like the NHS in the UK or the healthcare systems of the majority of western Europe. Some have insurance based healthcare systems where greater emphasis is placed upon individual choice. Some countries have hybrid systems where some things are provided according to need and others are available to those with the money to pay for them. Some countries have little to no mental health care and support at all. Global wealth inequality has a huge impact on how the lives of people who experience mental ill-health, trauma and distress turn out, as do inequality within countries.

As Michael Marmot found in the groundbreaking Whitehall II study, there is a social gradient to health. A longitudinal cohort study conducted between 1985 and 1988, Whitehall II examined the health of 10,308 civil servants aged 35 to 55, of whom two thirds were men and one third women. What it found was that there was a strong association between pay grade and mortality. Men in the lowest grade (messengers, doorkeepers, etc.) had a mortality rate three times higher than that of men in the highest grade (administrators). This effect has since been observed in other studies and named the “status syndrome”. Basically, the poorer you are and the less control you have over your life, the more likely you are to become ill. While much of the current popular rhetoric around mental health and mental illness tends to focus on the idea that ‘mental illness doesn’t discriminate’ and ‘it can happen to anyone’ this is true in an abstract rather than practical sense. While it is true that anyone might hear voices, begin to believe things that other don’t hold to be true, become depressed, experience mania or have intense distress or trauma responses, these experiences and the extent to which they interrupt people’s wellbeing in major ways tend to interact in more pronounced ways the fewer choices and resources people have available to them.

One of the greatest challenges for all healthcare, mental health included, is what Julian Tudor Hart, a GP, called the Inverse Care Law. Put very simply, those most in need of healthcare are least likely to get it. This is true within countries and it’s true on a global scale. People who are ill tend to end up poor, and people who are poor tend to end up with little power, little access to resources and slender access to those in power. In this sense, mental health often operates in a condition of market failure, which makes entrepreneurial approaches to solving problems people have around their mental health a challenge. As we found with our magazine, the people who might benefit most from something are often the people who can least afford it and also have the least resources available to find out about it.

In 2013 The World Health Organisation (WHO) published Investing in mental health: Evidence for action, an excellent paper which in their own description examines: “potential reasons for apparent contradiction between cherished human values and observed social actions.” The paper examines the case for governments across the world to invest in mental health by acting upon avoidable risks, providing essential care and enforcing fundamental rights. It also examines why governments do not make these investments despite convincing evidence to encourage them. As the report has it; there are a “number of barriers that continue to influence collective values and decision-making — including negative cultural attitudes towards mental illness and a predominant emphasis on the creation or retention of wealth (rather than the promotion of societal well-being).”

It’s worth looking at what WHO regards the justification for state intervention in mental health. The UK, even with our currently falling level of investment, still has one of the best funded systems of social support for people with mental health difficulties in the world. The report states: “ there is ample international evidence that mental disorders are disproportionately present among the poor, either as a result of a drift by those with mental health problems towards more socially disadvantaged circumstances (due to impaired levels of psychological or social functioning) or because of greater exposure to adverse life events among the poor.”

The WHO feel there are a number of key actions, not limited to treatment, requiring state intervention to promote mental health:

-provide better information, awareness and education about mental health and illness;

-provide better (and more) health and social care services for currently underserved populations with unmet needs;

-provide better social and financial protection for persons with mental disorders, particularly those in socially disadvantaged groups;

-provide better legislative protection and social support for persons, families and communities adversely affected by mental disorders.

This recognises that for many people, the market alone will not provide the things they need to have the best mental health possible.

So where does social entrepreneurship fit in? Mental health is about far more than treatment, therapies and drugs. It isn’t an abstract problem, it’s a problem that people live through.

Broadly speaking, there are three ways you could look to change people’s lives of people living with mental ill-health, distress and trauma through social entrepreneurial approaches:

-The thing you do directly helps people and you are paid directly for it

-How you do the thing you do helps people and that thing generates income through being done

-The thing you do doesn’t directly help people but it does make money or create resources which can then be used to help people

So in the first case, you provide a goods or service that directly addresses a need that people who live with mental ill-health, distress or trauma have any you are paid either by them or others on their behalf for the service or goods in question. This is closest to a traditional sale or service. It might be selling directly to people, or it might be selling to bodies or organisations that purchase on people’s behalf. Big White Wall is a mental health app which NHS trusts and local authorities purchase on behalf of their citizens. Headspace is a mental health app that people take subscriptions to for themselves.

In the second case, the thing you do involves the people you are trying to help by providing employment, training, experience or something else and the resultant product or service raises money. An excellent example of this is Timpson the keycutters and cobblers who employ people who might otherwise find it difficult to find work. Or Greenwich Leisure which does similar. The Big Issue is probably another.

In the third case, you are just doing something that is profitable then giving the proceeds to other activities of your choice. This was once a popular model, aspired to by many, succeeded at by few.

A lot of things described as being ‘for’ mental health in the open marketplace are really about providing marginal gains for people at the top end of the scale of being well, rather than sorting out problems for those who really are having current difficulties. Most apps describing themselves as creating positive mental health are really doing one of five things: they are coaching a particular behaviour, encouraging people to record data, teaching a particular technique or approach, connecting people with ‘a community’ or providing information and ‘inspiration’. There are very few apps or online services which are providing clinically measurable outcomes or actually solving a practical living problem people have. This is mainly because the barriers to entry for something claims ethically to have a large effect are similar to those for a medication. To have spent the time and money to create something that has a measurable effect on people’s mental ill-health means that the likely only way of recouping costs is to sell in bulk either to health services or health insurers because the people most likely to be helped are people who, again, are least likely to have access to the resources, access to knowledge and potentially high enough spec technology to to make use of it. If you are wondering if you are going to eat today or tomorrow, six quid on an iphone app and a contract that costs enough to get you a latest model iphone aren’t always going to be top of your list, even if you really want them.

There’s lots that needs to change in UK mental health care but there are serious ethical and practical considerations to be made about trying to disrupt the health marketplace in a situation where socialised heathcare exists. Babylon Health’s GP at Hand app, which allows those signed up to it to have video consultations with a GP via their mobile is a pretty popular proposition and one well liked by those who have signed up for it. It is a genuinely disruptive service. It’s also a service that when the NHS began to offer it, led to huge costs for one Clinical Commissioning Group who was the virtual host of the virtual GP surgery which meant that they had to look at whether they could still afford their actual non-virtual patients registered at flesh and blood GPs. The ethical considerations of testing things that might change people’s lives for better or worse are not to be sniffed at. Trying to muck about with what’s inside someone’s head is serious business.

We did a bit of research for Power to Change a couple of years ago on whether community businesses might provide some of the help and support that people with mental health difficulties that caused them greater difficulties weren’t getting now that local authority and NHS budgets had been cut. The idea was that community owned businesses who gained at least fifty percent of their revenue from trading might provide either services to people experiencing difficulties or opportunities for people experiencing difficulties. A hypothetical example of this might be a farm shop staffed by people who have been having difficulties which pays a living wage and also involves other people with difficulties in picking, sorting, marketing. Another example might be a community pub where all of the staff have lived experience of mental health which does all of the normal pub stuff, but also provides quiet hours, community events and mental health drop-ins. What we concluded was that for such enterprises to be sustainable they would either need to be really good at providing their service or would need to be subsidised by someone interested in the added value they brought. In short, we concluded that unless there was a strong commercial base of selling people things they actually wanted to buy, the business itself would find it difficult to stay afloat long enough to provide the added benefit it intended.

Entrepreneurs generate value by organising and combining resources into something that has a value greater than its constituent parts. Entrepreneurship in mental health can often feel like an impossible task given the lack of a specific marketplace to enter or the barrier to entry to the marketplaces that exist.

Things go in and out of fashion. Once there was great money to be made ‘coaching’ workplaces to be more inclusive of people who have mental health difficulties. Mental Health First Aid is a good example of this. Individual accredited trainers deliver a standardised curriculum as a franchise. They are selected because of their lived experience. There was a glut of mood tracking apps and mindfulness meditation apps. Virtual reality will still have its moment. There was a moment where bakeries and cafes staffed by people who live with mental ill-health, distress and trauma were all the rage. Ideas get inspirational ted talks from muscular start-uppers. Then as soon as they seem to be everywhere, they’re nowhere, packed up, shuttered, burned through. The thing I’m most often asked is ‘can you find me some people who have mental health difficulties to test this thing I’m working on with?’ This for me is emblematic of the largest challenge and the largest opportunity for social entrepreneurship in mental health.

For me, the best ideas really happen when someone understands intimately the problem they have identified, and then check, check and check again what that problem actually means with the people who have it. What people in mental health services think about the challenges of living life with mental health difficulties are not always what people who actually do the living think they are. Far too much activity falls into the category of teaching: teaching people who are poor how to budget rather than finding ways to make sure they aren’t poor, for example.

Social entrepreneurship approaches to improving mental health, for me at least, are most likely to be successful when they address the problems and challenges in people’s lives, rather than trying to fix people. Given the market conditions, poverty, discrimination, lack of choice of where you live and with whom, the fact that people around you do not face the same challenges, it feels to me that focusing relatively low cost products or services or on giving a mental health spin to already existing successful models of business will be where the opportunities lie.

I can’t stop thinking about a project I heard about in Africa that was looking to prevent HIV infection and progression in young women. These women often contracted HIV from transaction sex or rape. Retroviral drugs work. But they need to be taken at the same time every day. They found that depression, anxiety and the after effects of trauma made keeping up the drug regime difficult. So they developed an emotional support group. When they could regularly spend time with their peers having a bit of a laugh and talking about difficult stuff things felt easier to deal with. And with that came the stability to take the medication.

I’ve recently been involved in a grant making making panel for a mental health community action and mutual aid microgrants fund. We funded very pragmatic action to support people’s mental health. One of my favourites was a group that gives clothes and furniture to women escaping domestic violence and abuse. They asked us for some cash to pay for their storage room for a couple of months. That feels to me like a meaningful bit of social entrepreneurship to create better mental health for people. There is certainly a gap in the market. The next stage would be finding the market in the gaps.

Mental health and inequality intertwine in many unexpected and deep ways. Global mental health needs local boots on the ground and solutions specific to the market and environment in which people live. I’ve never been more embarrassed than when I was at a Global Mental Health Summit organised by the Westminster government, talking to colleagues from across the world while being lectured by a load of white british people as if we were the best in a country that operates a hostile environment, has waiting lists that last for years and has an active policy of making it as hard as possible for people with mental health difficulties to get the money they need to live. Your mental health shapes your environment and your environment shapes your mental health. Social entrepreneurship needs to look at how it makes material things better for people. Ideas are great, but problem solving is better. Better mental health is about making people’s lives better. I’m sure that you’ll all be better than me at finding ways of making that happen and finding the way to make that sustainable. If you can’t be a therapist or nurse or a social worker, find something that will help, not cure.

I’m sorry I still haven’t got a better answer for where the money comes from.

@markoneinfour