APPENDIX 19
Memorandum submitted by the Royal College
of Psychiatrists (EDP 28)
SUMMARY
Employment rates and mental illness
— Unemployment rates for people with
all mental disorders are high, but particularly so for those with
Severe Mental Illness with rates for this latter group being between
60-100%.
— People with long-term psychiatric
disabilities are even less likely to be in employment than those
with long-term physical disabilities.
— The high rate of unemployment in
those with mental illness is as much a product of social factors,
as of the personal consequences of mental illness.
— Barriers to work for people with
Severe Mental Illness include structural factors, stigma and prejudice,
attitudes and approaches of the mental health services and the
lack of well run employment schemes.
— The overwhelming majority of mental
health service users want to be employed, or at least be engaged
in meaningful work.
The importance of work
— Work is important in maintaining
and promoting mental and physical health and social functioning.
Being in work creates a virtuous circle; being out of work creates
a vicious circle.
— Work is important in promoting the
recovery of those who have experienced mental health problems
and is a key factor in social inclusion.
— The longer that a person is off work
for illness reasons, the less chance they have of returning to
work.
Health Policy Issues
— Recent Government documents, eg the
National Service Framework for Mental Health and Our
Healthier Nation, contain components important to the employment
of those with psychiatric disabilities.
— There is no specific mention of rehabilitation
or vocational services for mental illness in any of the current
official government documents relating to Mental Health Services.
Services: key components and research evidence
— The extent of work schemes in the
UK is not known for certain. The availability of schemes varies
across the country.
— A "spectrum of opportunity"
for work, training and support should be available in a comprehensive
mental health employment service in a given locality. This spectrum
may include: Prevocational Training, Supported Employment,
Sheltered employment, Social Firms,
— Supported employment is more effective
than prevocational training at helping people with Severe Mental
Illness to obtain and keep competitive employment.
Developing comprehensive local services
— CMHTs and specialist Rehabilitation
services are the main components of the Mental Health Services
that have a role to play in assisting users into work and supporting
them there.
— Partnerships and interagency working
are crucial to developing employment services for people with
psychiatric disabilities.
— There are few links between Members
of Community Mental Health Teams (CMHTs) employment agencies and
employers to assist in getting people into work and supporting
them whilst there.
— Specialist Vocational Workers are
required in CMHTs.
— Vocational services must be supported
by other suitable, quality Mental Health Services to improve the
functioning of the mentally ill and to offer a spectrum of inpatient,
day patient and other community services.
— Specialist Rehabilitation Services
can act as providers of employment opportunities.
1. INTRODUCTION
1.1 For most people work forms a central
part of their lives, offering rewards beyond that of income. This
is the case for people with psychiatric disabilities, for whom
work and meaningful activity give a sense of identity and other
therapeutic benefits including increased self-esteem, enhancement
of sense of worth and improved functioning.
1.2 For people with severe mental illness
the rates of unemployment are high, higher than for their fellow
citizens with physical disabilities. Mental disorders are one
of the three commonest medical causes for being in receipt of
Incapacity Benefit.
1.3 Employment is linked to Social Inclusion.
Employment for those with mental illness gives opportunities for
them to participate in society as active citizens and barriers
to them doing so are linked to stigma, prejudice and discrimination.
1.4 Employment opportunities for people
with mental illness are an important concern for those working
in mental health services, not least because they form part of
the rehabilitation and reintegration efforts associated with these
services. There are however a range of other bodies who are concerned
with employment opportunities for the disabled, thus making a
large array of partnerships possible in this area.
1.5 Unemployment is high is those with mental
disorders, particularly severe mental disorders, and there are
a range of social and economic barriers that impede employment
in these groups. In general there is a lack of vocational rehabilitation
services in the United Kingdom, for people with both physical
and mental illnesses. There is a need for a coherent strategy
for vocational rehabilitation that involves employment and health
services and covers both physical and mental disorders. For those
with severe mental illness the services for employment should
be considered along with the need to devise a coherent strategy
for psychiatric rehabilitation that takes into account the current
evidence base for employment schemes and other developments that
can improve the care and outcome for those with psychiatric disabilities.
2. WORK, EMPLOYMENT
AND LEISURE
2.1 The American novelist William Faulkner
observed, work is "just about the only thing that you can
do for eight hours a day". The traditional definitions of
work emphasise that it is an activity that involves the exercise
of skills and judgement taking place within set limits prescribed
by others. Work is therefore essentially something you "do"
for other people. By contrast, in most leisure activities you
can "please yourself".
2.2 "Employment" is work you get
paid for. Most childcare, housework, looking after elderly or
sick relatives—is clearly "work", in the sense
that the tasks and outcomes are defined by others, but they do
not, at present, usually attract formal payments. This distinction
between "work" and "employment" is very important
in the context of mental health problems because the overwhelming
majority of people with mental health problems want to be employed,
at the very least they want to "work", ie to be engaged
in some kind of meaningful activity which uses their skills and
meets the expectations of others. However, not all wish to be
"employed" with all the additional stresses and responsibilities
that entails.
3. THE PREVALENCE
OF MENTAL
ILLNESS
3.1 The 1995 Office of Population Censuses
and Surveys' household survey of 10,000 adults aged 16-65 in Great
Britain confirmed the presence of widespread psychological symptoms
in the general population.
3.2 The major findings of the OPCS survey
were:
— About one in seven adults had some
sort of neurotic health problem in the week prior to the interview.
— Women were far more likely to suffer
a neurotic health problem than men.
— The four most common neurotic symptoms
were fatigue (27%), sleep problems (25%), irritability (22%) and
worry (20%).
— The most prevalent neurotic disorder
in the week prior to interview was mixed anxiety and depressive
disorder (77 per 1,000) followed by generalised anxiety disorder
(31/1000), depressive episode (21 per 1,000), obsessive compulsive
disorder (12 per 1,000), phobia (11 per 1,000) and panic disorder
(eight per 1,000).
— Functional psychoses (what is considered
by some as "Severe Mental Illness") had a prevalence
rate of four/1000 in the past year.
— The rates of alcohol and drug dependence
were 47/1000 and 22/1000 in the past year.
— Men were three times more likely
than women to have alcohol dependence and twice as likely to be
drug dependent.
— Alcohol and drug dependence were
most prevalent among young adults, particularly young men aged
16-24 years.
3.3 The bulk of people with common mental
disorders (anxiety and depression) are seen and treated in General
Practice. Approximately 90% of people with diagnosed depression
are treated entirely within primary health care.
3.4 General Practitioners provide the main
source of care for most people with psychiatric disorders, the
bulk of whom have non-psychotic syndromes. These groups place
a high demand on General Practice and about a third will have
morbidity persisting for over many years.
4. EMPLOYMENT
IN PEOPLE
WITH COMMON
MENTAL DISORDERS
4.1 The OPCS survey found significant levels
of unemployment and sickness absence in those with neurotic disorders:
— Adults with neurotic disorder were
four to five times more likely than the rest of the sample to
be permanently unable to work.
— Overall, 61% of men with one neurotic
disorder and 46% with two disorders were working, compared with
77% of those with no disorder. The equivalent figures in women
were 58%, 33% and 65%.
— The lowest rates of employment among
people with neurotic disorders were found in those with phobias.
43% of men and 30% of women with phobias were working.
— Among the sample with any neurotic
disorder who were unemployed and seeking work, 70% had been unemployed
for a year or more (that is 7% of all people with a neurotic disorder).
— Compared to the general population,
adults with neurosis were twice as likely to be receiving Income
Support (19% compared to 10%) and four to five times more likely
to have invalidity benefit (nine per cent compared to 2%).
4.2 Employee absenteeism is a familiar characteristic
of the current labour market and "depression, bad nerves
or anxiety" was ranked eighth out of 13 self reported chronic
health problems as a cause for non-attendance at work. Recent
statistics illustrate that mental health problems have, within
the last five years, become the leading reason for claims to incapacity
benefits.
4.3 Women with mental disorders and people
from black and ethnic minorities have even greater problems accessing
employment.
4.4 The unemployed consult their GPs more
often than average and those who have been unemployed for more
than 12 weeks show between four and 10 times the prevalence of
depression, anxiety and somatic illness, with an association between
unemployment and suicide.
4.5 About 50% of patients receiving incapacity
benefits have musculoskeletal or mental health problems. There
is some evidence that those patients that are initially certificated
as having back pain, receive diagnoses of depression or anxiety
after some months off sick. One diagnosis may often transmute
into another.
5. EMPLOYMENT
IN PEOPLE
WITH LONG-TERM
MENTAL ILLNESS
5.1 National figures show that rates of
unemployment in people with long-term mental illness are high.
5.2 The Labour Force Survey, a continuous
household survey carried out in Great Britain provides figures
on those with long-term disabilities. They classify individuals
as long-term disabled with a mental health problem as main difficulty.
5.3 The long-term disabled with mental health
problems as the main difficulty represent 8% of the long-term
disabled of working age. 18% of this group were in employment
in 2000. The long-term disabled with no mental health difficulties
represent 84% of the long-term disabled of working age. Fifty
two per cent of this group were in employment in 2000 (Labour
Force Survey—Great Britain Spring 2000).
5.4 The Labour Force Survey figures demonstrate
that people with long-term mental health problems are much less
likely to be economically active than those with physical or sensory
impairments. Other studies indicate that between 30-40% of this
group of people with mental illness are capable of holding down
a job.
5.5 Figures from the OPCS survey of adults
with psychotic disorders living in the community support these
findings. Half the sample of people surveyed was classified as
unable to work, one in five were in employment and one in eight
were unemployed.
5.6 In 1990, of 1,000 people with mental
health problems of at least two years standing using community
mental health teams in a south London borough, 20% were in paid
employment. By 1999 this had dropped to only 8%. The situation
was worse for those community mental health team users with a
diagnosis of schizophrenia: among this group the proportion in
paid employment fell from 12% in 1990 to only 4% in 1999.
5.7 These figures compare poorly with the
general population of disabled people whose employment rate, although
half that of their non-disabled counterparts, remained constant
at around 40% between 1985 and 1996.
6. COSTS OF
MENTAL ILLNESS
AND UNEMPLOYMENT
6.1 Mental health difficulties can affect
an individual's function in numerous ways and, depending on the
age at onset, a person's working capacity can be significantly
reduced. In the workplace, this can lead to absenteeism, sick
leave, and reduced productivity.
6.2 The cost of disabilities arising from
mental health problems, can be viewed as arising from three components:
— direct costs of welfare services
and treatment including indirect costs of carers etc;
— costs of state benefits;
— costs of income relinquished as a
result of incapacity.
6.3 In the United Kingdom mental health
problems are a leading cause of distress, illness and disability
and carry a significant financial cost. It has been estimated
that 80 million working days are lost every year in the UK due
to mental illness costing employers £1.2 billion.
6.4 An average of 3,000 British people move
onto Incapacity Benefits each week. The economic costs of this
are high, about £10 billion a year. The leading causes are
musculoskeletal (28%) and psychiatric disorders (20%).
6.5 The estimated annual total cost of mental
illness in England at 1996/7 prices is £32.1 billion; the
component costs include £11.8 billion in lost employment,
£7.6 billion in Department of Social Security (now Department
for Work and Pensions) payments and £4.1 billion in National
Health Service costs.
7. WHY IS
WORK IMPORTANT?
7.1 Work plays a central role in all our
lives. This has been recognised since ancient times, for example,
the Greek Philosopher Galen 172AD, described employment as "nature's
best physician" and "essential to human happiness".
The 18th century poet William Cowper, who himself experienced
periods of mental illness throughout his life and was confined
to an asylum for over a year, said "The absence of occupation
is not rest, a mind quite vacant is a mind distressed".
7.2 There are five main arguments for the
promotion of employment for people with mental health problems:
(i) Social and health benefits.
(ii) Demand from service users.
(iii) Ideological argument.
(v) National policy and the desire to deliver
mental health care in non-custodial settings.
7.3 Work as a social issue.
7.3.1 Employment provides a monetary reward
and is inseparable from economic productivity with its profits
for the employer and its material benefits for society. In addition
employment provides "latent benefits", non-financial
gains, to the worker.
7.3.2 These additional benefits include
social identity and status; social contacts and support; a means
of structuring and occupying time; activity and involvement; and
a sense of personal achievement.
7.3.3 Work tells us who we are and enables
us to tell others who we are. It is typically the second question
we ask when we meet someone—"What is your name?",
"What do you do?"
7.3.4 While work is important for everyone,
it is particularly crucial for people who experience mental health
problems. People with such difficulties are particularly sensitive
to the negative effects of unemployment and the loss of structure,
purpose and identity which it brings. Being in work enhances quality
of life. Already socially excluded as a result of their mental
health problems, this exclusion is aggravated by unemployment.
Loss of work is a key factor in social exclusion.
7.3.5 Work is extremely important both in
maintaining mental health and in promoting the recovery of those
who have experienced mental health problems. Enabling people to
retain or gain employment has a profound effect on more life domains
than almost any other medical or social intervention. The costs
of unemployment are large.
7.4 Work as a health issue
7.4.1 Employment is important in health,
as well as in social functioning. There is voluminous research
on the links between unemployment, physical health and psychological
well-being. Although, working in an unsuitable environment can
also be stressful (see below) the negative impact of unemployment
generally exceeds that of stress at work.
7.4.2 Unemployment has been linked with
increased general health problems, including premature death and
there is a particularly strong relationship between unemployment
and mental health difficulties.
7.4.3 Unemployment is associated with increased
use of mental health services and is known to increase the risk
of suicide.
7.4.4 Unemployment can exacerbate the mental
health difficulties of those with more serious psychiatric problems.
People with serious mental health problems have been found to
experience lower levels of symptoms when they are in employment
and clinical deterioration among people with a diagnosis of schizophrenia
is associated with lack of occupation.
7.4.5 Employment may lead to improvements
in outcome through alleviating psychiatric symptoms, increasing
self-esteem and reducing dependency.
7.4.6 Unemployed people do not exploit the
extra time they have available for leisure and social pursuits.
Their social networks and social functioning decrease, as do motivation
and interest, leading to apathy. Social isolation is often particularly
problematic for people who experience mental health problems and
work is more effective than occupational therapy in increasing
social networks.
7.5 Work preferences for those with mental
illness
7.5.1 Mental health service users clearly
say that they want to have the opportunity to work. Studies indicate
that as many as 90% would like to go back to work.
7.5.2 Assisting people to gain and sustain
employment should be considered an important "treatment"
in its own right. It is central to achieving many of the targets
for mental health services which have been set over the last decade,
for example the Health of the Nation Targets (Department of Health,
1992) and the Mental Health National Service Framework (Department
of Health, 1999).
7.6 Work as a rights issue
7.6.1 The right to work is enshrined in
Article 23 of the United Nations Declaration of Human Rights,
which states that "everyone has a right to work, to free
choice of employment, to just and favourable conditions of work
and to protection against unemployment". The majority of
people who experience longer-term mental health problems continue
to be denied this right.
7.6.2 People with a psychiatric disability
should be valued in the same way as those without and they deserve
respect, self-determination, and empowerment. This means a community
"presence" (inclusion), choice, competence, status and
participation.
7.6.3 Discrimination on the part of potential
employers is undoubtedly a major obstacle to people with mental
health problems gaining work, especially those with diagnoses
of schizophrenia.
7.6.4 It is important to remember that the
NHS is the largest employer in Europe. When combined with the
social services and voluntary sector, the pool of potential jobs
becomes very large indeed. Therefore initiatives designed to increase
access to employment within these services are likely to be as
important as those directed towards private sector employers.
7.7 Work as an economic issue
7.7.1 Each year over £20 billion of
public money is spent on supporting people out of work in the
form of social security payments: almost 25% of incapacity and
disablement allowances are paid to people with mental health problems.
If some of this resource could be redirected towards enabling
people to maintain and/or regain employment then the social, psychiatric
and economic gains are likely to be large.
7.8 National policy and the new context
of mental health care
7.8.1 In the past, most work projects in
the UK for those with long-term psychiatric disabilities were
run from or by the large psychiatric hospitals. The run down of
the large hospitals has placed most mental health services and
their users in community settings. Recent government policies
have stressed risk minimisation, the containment, monitoring and
supervision of people with mental illness and a mixed economy
of care. Some argue that work may provide such non-custodial supervision
whilst at the same time promoting therapeutic ends.
8. BARRIERS TO
EMPLOYMENT AND
TO THE
DEVELOPMENT OF
EMPLOYMENT SERVICES
8.1 Several factors make up the barriers
to employment for mental health service users:
— Historically, the employment of disabled
people has depended on economic growth, overall rate of employment
and times of labour shortage.
— The welfare system has built in disincentives
to returning to work. The so-called "benefits trap".
There is a fine balance between supporting people who are unable
to work and the creation of disincentives to returning to work
for those who can.
— The disadvantages faced by people
with a history of mental illness in the open employment market,
including stigma, a reluctance to employ them, the risk of failure
faced by them and the benefits trap.
— There has been a tendency for mental
health professionals and others to underestimate the capacities
and skills of their clients and to possibly overestimate the risk
to employers. This may extend to GPs and employers who give insufficient
attention to helping people return to their jobs.
— The dominance of a model of mental
illness that emphasises episodes and "cure" as opposed
to one that focuses on the disabilities of people with long-term
mental illness.
— The shift in mental health services
from large asylums to community based services. What work schemes
that did exist in the past were based in, or run by, hospital
services. Current responsibilities for people outside of hospitals
are not clearly allocated amongst state organisations dealing
with health and employment.
— Lack of expertise in business development
among mental health professionals.
— The lack of evidence and ignorance
of the existing evidence relating to the types of services and
approaches that are effective in getting those with mental illness
to work and keeping them in employment.
8.2 Assumptions of unemployability by
professionals
8.2.1 Service users often report that their
psychiatrist has told them "You will never work again".
Whether or not this actually happens as frequently as is reported
is open to question, but most mental health professionals acknowledge
that more emphasis should be given to people's employment aspirations.
However, the professionals often go on to suggest that the people
that a particular clinician works with are at the very severe
end of the spectrum and either could not or do not want to work.
Research calls into question both these statements, but they are
such a fixed part of clinical culture that frequently no one even
asks users whether or not they want to move towards employment.
8.3 Inappropriate early interventions
8.3.1 When a person develops a mental illness
it is important that they retain their job. After some months
on certified sickness absence the risk to the patient of losing
their job increases greatly with consequences for self-esteem,
confidence and motivation. The longer that a person is off work,
the lower the chance of returning to work. After six months of
certified incapacity for back pain there is about a 50% chance
of returning to work, which falls to 25% at one year and 10% at
two years. Few individuals return to work after one to two years
absence, irrespective of further treatment.
8.3.2 Many people with mental illness lose
their jobs unnecessarily and others fail to be re-employed in
less demanding work, thus allowing them to descend into the downward
spiral of long-term unemployment.
8.3.3 The role of the General Practitioner
is crucial to appropriate early intervention.
8.4 Loss of motivation/confidence
8.4.1 Recent research has shown that "self
efficacy", a collection of internal characteristics and feelings
including motivation, work adjustment, self confidence and self
belief, is an important indicator of employability. The corollary
of this is that the catastrophic loss of self-confidence that
often comes as a consequence of mental breakdown is a key factor
in making people reluctant to go back to work. The same effects
have been observed among people who have been made redundant or
become long-term unemployed. What makes this a difficult problem,
is that once a person has lost confidence in their own employability,
it is very difficult to restore it unless they can get a job.
8.5 Stigma, discrimination, attitudes
and lack of knowledge by employers and the general public
8.5.1 Service users regularly put employer's
attitudes at the top of their list of barriers. Recent surveys
of employers tend to confirm that many will not even entertain
the thought of employing a disabled person, much less someone
with a history of mental ill health.
8.5.2 It is often said that employers need
"educating" about mental illness. Whether knowing more
makes people discriminate less is open to question, but changing
employer attitudes is certainly important. Work by the Employers
Forum on Disability suggests a totally different approach to the
usual tack of "give this poor person a chance". Unlocking
the Potential suggests that agencies supporting disabled people
should offer to help employers solve their recruitment problems
and arrange opportunities for them to meet and talk to disabled
people face to face.
8.6 The perceived risks to income from
coming off benefits
8.6.1 The "benefits trap" is usually
first or second on users' lists of obstacles to returning to work.
Indeed the term itself may be a further barrier because it deters
people from exploring ways in which they could, with safety, improve
their income through employment. However, the evidence is that
for very many disabled people the risks and difficulties of trying
to come off benefits are only too real. Government attempts to
deal with this problem (see Chapter 2) have as yet only made marginal
improvements and more improvements are needed.
8.6.2 People of working age with enduring
mental health problems can find themselves trapped on state benefits
by a range of factors. A person who suffers from a mental health
problem and is unable to work may receive replacement income from
a number of sources including the state benefit system. In financial
terms the level of this replacement income may act as a "barrier"
to alternative activity such as steps towards rehabilitation or
a return to work because earnings, particularly for part-time
work, may not compare favourably with the income replacement from
benefits.
8.6.3 People can be trapped on benefits
by other factors including the advice they receive from health
professional and lay "work focused" advisers. Too often
health professionals have low expectations for their patients
in regard to rehabilitation and eventual employment and their
advice is often "this person should never work again".
Similarly advisers may not possess the experience or expertise
to promote work or work-related activities to people with mental
illnesses.
8.7 Negative attitudes and lack of knowledge
of key staff, friends or carers
8.7.1 This is another dimension of the self-confidence
issue. The attitudes and expectations of significant others may
also be critical to an individual's self-belief. For example,
people leaving prematurely from vocational rehabilitation programmes
tended to have smaller social networks and less perceived support.
As in other areas of psychiatry, the need to develop good working
"partnerships" between services focused on the individual
and those focused on his/her "significant others" is,
once again, underlined.
8.8 Inter-agency problems
8.8.1 Employment opportunities cut across
several agencies. The problems that arise are partly a consequence
of deinstitutionalisation and the move towards community services
provided by a mixed economy of care. It has been a constant source
of irritation to disabled people that the various agencies, Government
and independent sector, who provide vocational rehabilitation
rarely seem to work together or provide "maps" by which
individuals can navigate the system. The present Government has
given great emphasis to "joined up thinking" and joint
working. However working in partnership, avoiding duplication
and enabling the individual journeys through the system to be
clearly sign-posted are easier said than done.
8.9 Employees—barriers to work
8.9.1 A recent report by the Scottish Council
Foundation found three main causes that prevent work resumption:
— The nature of the incapacity (including
adaptations to the workplace, particularly flexibility of working
conditions);
— Local labour market opportunities;
and
— Benefit traps that make work a financial
risk.
8.9.2 A consistent theme throughout the
Scottish Council Foundation report is the need for earlier and
better forms of rehabilitation and, while the Disability Discrimination
Act, 1995 (DDA) outlaws discriminatory practices and places responsibilities
on employers to make reasonable adjustments, a weak labour market
enables employers to be selective about whom they recruit.
8.9.3 Too often people with mental health
problems remain on long-term state benefits because they are unable
to obtain timely access to appropriate treatment eg counseling,
cognitive behaviour therapy, treatment for substance misuse and
rehabilitation.
9. HEALTH SERVICE
INITIATIVES
9.1 In the last 10 years there has been
no specific national mental health services initiatives to examine,
improve or promote employment opportunities for people with psychiatric
disabilities.
9.2 Three major documents have set out targets
and plans that have implications for the employment of those with
mental disorders: the Health of the Nation and Saving Lives:
Our Healthier Nation documents and the National Service
Framework for Mental Health.
9.3 Recent developments in mental health
policy have focused on risk reduction, containment and the improvement
of follow-up and monitoring. The emphasis for new services has
been on the development of crisis/home treatment teams, assertive
outreach teams and services for first onset psychosis. Whilst
these are of importance to the care received by those with long-term
and severe mental illness, there has been no mention of the development
of rehabilitation services, in which vocational services would
play an important role. This silence regarding such schemes is
an important omission in government policy regarding the long-term
mentally ill.
9.4 A further key strand of health policy
has been the initiatives to develop a "primary care based"
service. Of central relevance are the changes in commissioning
that are a key part of this. The development of Primary Care Groups,
and now Primary Care Trusts, will alter the balance of commissioning.
Such new developments should be closely monitored to ensure that
the needs of the mentally ill are not lost in the move from Health
Authorities to Primary Care Trusts.
9.5 Our Healthier Nation had a single
target for mental illness: to reduce the death rate from suicide
by at least a fifth by 2010. The document acknowledged the importance
of the National Service Framework in achieving this.
9.6 The National Service Framework for
Mental Health (Department of Health, 1999) sets out standards
for a range of mental health service provision, including the
mental health needs of working adults, from primary through to
specialist mental health services to help to ensure that people
with mental health problems receive the service they need.
9.7 Efforts to enable people with mental
health problems to work are likely to be important in achieving
three of the seven Mental Health National Service Framework standards:
Standard one requires Health and Social Services
to "combat discrimination against individuals with mental
health problems and promote their social inclusion". Work
is central to promoting social inclusion.
Standard five requires that care plans for people
with more serious mental illness include "action needed for
employment, education or training or another occupation".
This means that work must be central to the care provided by clinical
teams.
Standard seven requires that local health and
social care communities minimise suicides among people with mental
health problems. Given the link between unemployment and suicide,
enabling people to gain and sustain work may make an important
contribution to decreasing suicide rates.
9.8 The National Service Framework for
Mental Health places particular emphasis on the role of users
and carers as partners. It expects that services will "involve
service users and their carers in planning and delivery of care"
and "be properly accountable to the public, service users
and carers".
9.9 All the seven standards in the National
Service Framework specifically highlight the role of users and
carers as partners alongside social care and health agencies.
Users and carers must ensure that they have input into the local
service planning and delivery, as well as playing a central role
in service evaluation.
9.10 The NHS plan (Department of
Health, 2000) puts both employment and occupational activity squarely
into the mainstream tasks for general psychiatric services by
setting a target that by March 2002 the written care plans of
all individuals on enhanced CPA must include plans "to secure
suitable employment or other occupational activity". It is
perhaps a missed opportunity that it does not differentiate between
employment and "other occupational activity" as the
failure to distinguish between these in recent years has perhaps
been one factor in bringing about the current position where so
few people with severe and enduring mental health problems are
in employment.
9.11 Workforce Action Team (WAT)
9.11.1 Following on the publication of the
mental Health National Service Framework, a number of underpinning
areas of work have been set in train. One of these was the setting
up of the Workforce Action team (WAT) to consider the workforce
implications of the programme of mental health service modernisation.
The planned changes crucially depend on the availability of a
sufficiently large, well-trained, and well-led workforce.
9.11.2 The Workforce Action Team adopted
a set of principles that might be summarised as:
— a user focus and user and carer involvement;
— guided by strategy (the NSF and NHS
Plan);
— taking a holistic approach considering
the total skill mix available in the statutory and non-statutory
sectors;
— with orientation to competencies
and continuing skills and knowledge development; and
— integrating this Human Resource perspective
in both delivery and planning.
9.11.3 The work was carried out by a number
of sub-groups, one of which specifically considered the role of
non-professionally affiliated workers. They point out that these
are key people in the workforce who give direct support to users
by spending time with individuals. They will be accessible to
users, and when necessary they will help users to get access to
other appropriate staff and services. Their focus will be on respecting
their clients' needs as seen by the user, providing dignity and
enabling client independence because the focus will be on recovery.
They suggest that these workers be called STR workers (support,
time, recovery) and go on to suggest that one source of recruits
to these posts would be users themselves.
10. VOCATIONAL
SERVICES FOR
THE MENTALLY
ILL
10.1 The use of "constructive occupation"
has formed a part of the care for the mentally ill since the development
of the mental hospitals.
10.2 Vocational rehabilitative and reintegrative
efforts for the mentally ill have varied historically and this
variation is linked to changes in the economic cycle and the availability
of employment. The mentally ill have been the marginal elements
of the "Industrial Reserve Army". High levels of unemployment
are associated with limited efforts at rehabilitation and a consequent
low recovery rate for those with mental illness.
10.3 In Britain, early sheltered work schemes
were set up after the 1914-18 war. In 1927 the first "sheltered"
factory, making "Thermega" electric blankets, was set
up by the Ex-Services Mental Welfare Society to employ the convalescents
under their care. Work for "ordinary" psychiatric patients
remained in the mental hospitals and the 1930 Mental Treatment
Act stated that hospitals should provide employment (and entertainment)
in addition to medical attention.
10.4 The 1950s and 1960s witnessed an increase
in employment schemes, mainly based in hospitals. By 1967, 100
out of 122 hospitals surveyed had some form of industrial therapy
provision.
10.5 The Disabled Persons Act, passed in
1944, led to the provision of a number of facilities. Industrial
Rehabilitation Units that offered courses of training in industrial
skills and work habits; Sheltered Employment factories and workshops
were subsidised to allow for a lower productivity, and offered
permanent or interim employment; and Disabled Resettlement Officers
at every Employment Exchange were responsible for helping disabled
people to find work. In addition, local Industrial Therapy Organisations
(I.T.O.) were set up by interested parties—psychiatrists,
relatives, organisations, local employers and charities—to
provide various types of sheltered employment. Most went on in
factories, but some also provided services in the community, for
instance the car-wash group connected to the Bristol I.T.O.
10.6 The success of these schemes was limited.
They did not lead to many people returning to open employment,
and they were not adaptable to changing industrial conditions.
Only a small proportion of patients moved on to open employment.
They did however succeed in providing a small number of mentally
ill people with a "real job" and many more were offered
the opportunity to work, even though the financial rewards might
be limited.
10.7 As unemployment increased during the
1970s and 1980s, so paid employment opportunities for people with
mental illness became limited and schemes that existed were mainly
based in or run by hospitals. The bulk of these were based around
sheltered work or employment. This period also coincided with
increasing run down of the large mental hospitals and the eventual
closure of many during the 1990s. The development of community
based mental health services was not always commensurate with
the loss of hospital services and less emphasis was placed on
work schemes, which became fragmentary.
10.8 An alternative to sheltered work, supported
employment (ie placing the person in a "real" employment
setting and providing direct support to the, and their employer,
while in the workplace) had been espoused in the USA since the
1960s. These ideas took force in the 1980s as it was thought that
sheltered workshops isolated people from mainstream society. By
the late 1980s, supported employment had begun to attract attention
in the field of psychiatric rehabilitation. However, the use of
these approaches has been slow to develop in the UK.
10.9 During the last two decades there has
been an expansion of employment schemes for the mentally ill.
These have shifted in location from hospital to community, and
are often run by non-statutory agencies. They fall into three
broad categories: sheltered employment, "open" supported
employment and Social Firms.
11. KEY SERVICE
COMPONENTS
11.1 There is a large proportion of people
with psychiatric disabilities who want jobs and who have the potential
to get and keep them provided that there are available schemes
and opportunities and that reasonable adjustments are made in
the workplace.
11.2 There will be people whose disabilities
are too great to be supported in open employment (at least for
a part of their illness career) regardless of the extent of available
support. For these people other approaches to work and structured
activity will be needed. It is however very difficult to predict
in advance of trying out employment just who this group might
be. It is therefore important not to let people's hopes and aspirations
have a premature closure.
11.3 No one model of service is right for
everyone and each approach may help different people at different
times in their recovery and reintegration. Ideally people should
have access to a range of work, training and support which is
relevant to their changing needs. They should have the opportunity
for progression towards paid employment, but they should not be
forced to move on to situations of greater stress and responsibility
if they do not wish to.
11.4 It is generally agreed that a comprehensive
mental health employment service in any given locality should
contain a "spectrum of opportunities", with possibilities
to access this spectrum at any point and to move, or stay, according
to individual needs.
11.5 Such a "spectrum" is important
not just because individuals have different needs: they may also
choose different pathways into work. Careful consideration needs
to be given to the component parts of this spectrum and their
co-ordination. The consequences of making wrong choices can tie
up resources in ineffective services for years.
12. WORK SCHEMES
FOR THOSE
WITH MENTAL
ILLNESS
12.1 There are several types of schemes
that may be included in the spectrum of opportunities.
12.2 Sheltered employment
12.2.1 Traditional sheltered workshops and
sheltered employment factories (Remploy etc.) do not provide employment
in the open market. They may be of value for those who find open
employment difficult and as a means of introducing people to the
work situation. They tend to have very low rates of movement into
open employment they often find it difficult to be commercially
viable.
12.3 Prevocational Training
12.3.1 Prevocational training is one way
of helping people with severe mental illness return to work. Prevocational
training assumes that people with severe mental illness require
a period of preparation before entering into competitive employment.
This preparation includes sheltered workshops, transitional employment
(working in a job that is "owned" by a rehabilitation
agency), skills training, work crews and other preparatory activities.
Some individuals may need to get back into a working regime through
a graduated activity programmes; others may find it helpful to
have short period of confidence building and developing coping
strategies such as that offered by PECAN Employment Agency in
Peckham, South London. These approaches are not ends in themselves.
12.4 Supported Employment
12.4.1 Supported employment places clients
in competitive jobs without extended preparation and provides
on the job support from employment specialists or trained "job
coaches". The concept is very simple. A person is hired and
paid by a real employer. The job meets both the employee's needs
and skills and the employer's requirements. The employee is entitled
to the full company benefits and from the beginning the employee
and the employer receive enough help from a support organisation
to ensure success.
12.4.2 There are a number of different supported
employment programmes such as the Assertive Community Treatment
Model, transitional employment (for example, the clubhouse approach)
and the Job Coach Model. The model that emerges from the literature
as the most promising programme so far is known as Individual
Placement and Support (IPS). In IPS the emphasis is on rapid placement
in work with intensive support and training on the job.
12.5 The Clubhouse Model
12.5.1 Clubhouses aim to assist people with
long term mental health problems to address issues such as low
self-esteem, low motivation and social isolation. They promote
social inclusion and support people in leading productive and
meaningful lives within the community. The clubhouse model is
based on principles of meaningful activity and psychosocial rehabilitation,
and work is a central factor in its operation.
12.6 Social Firms
12.6.1 A possible solution to the problem
of providing high quality sheltered work and employment, which
is being developed in many parts of Europe, including the UK,
is the social firm. These are sometimes described as "modern"
versions of sheltered employment, but there are crucial differences
that go beyond repackaging and changing the name.
12.6.2 In a Social Firm the emphasis is
on creating a successful business that can support paid employment.
The social firm operates entirely as a business but its methods
emphasise participation by employees in all aspects of the enterprise.
Although it may offer training on a commercial basis, it is not
primarily engaged in "rehabilitation" and its core staff,
whether or not disabled people, are paid the going rate for the
work. It is also not a "ghetto", as usually around half
the staff will be disabled people. Members from the disabled workforce
may be in managerial positions.
12.6.3 Co-operatives can operate like social
firms or social enterprises but are owned and managed democratically
by the members. Social Enterprise is a name that has been adopted
for a small business which operates semi-commercially, but which
has a training or rehabilitation function (Grove et al, 1997).
12.7 Opportunities for volunteering
12.7.1 For many people making a contribution
in a voluntary capacity, particularly to an activity that they
regard as socially worthwhile, may also be a valuable part of
their lives. For disabled people there is often added value in
volunteering to help others as "experts by experience".
There are many opportunities for volunteering and many agencies
that can act as brokers between the need and the people who can
meet it.
12.7.2 The volunteer role, and the process
needed to enable disabled people to become volunteers, requires
exactly the same kinds of support as paid employment.
13. WORK SCHEMES
IN THE
UNITED KINGDOM
13.1 It is uncertain as to how many different
types of work scheme operate in the UK and how many people are
receiving services. Recent surveys of provision estimate that
there are at least 135 organisations offering sheltered employment,
77 providing open employment and about 50 Social Firms. A survey
in the northwest of England found high variation in provision
and a poor relationship between the schemes identified and the
needs of the areas in which they operated. There was a more than
forty-fold variation in provision across health authority areas,
and the highest level of provision was in the area with the lowest
deprivation and unemployment levels.
14. EFFECTIVENESS
OF WORK
SCHEMES
14.1 There have been several reviews of
the effectiveness of work schemes and most evidence comes from
studies conducted in the USA. Several randomised controlled trials
have compared prevocational training to supported employment.
Prevocational Training assumes that people with severe mental
illness require a period of preparation before entering into open
employment. Supported Employment places people in competitive
jobs without extended preparation, and provides on-the-job support
from employment specialists or "job coaches". In general,
supported employment is more effective than prevocational training
at helping people with severe mental illness to obtain and keep
competitive employment. Sheltered employment schemes have been
largely unsuccessful at achieving open employment for those with
severe mental illness.
14.2 The conclusions of cost-effectiveness
research mirror those of effectiveness research. Although the
literature on the effectiveness of vocational rehabilitation is
convincing, a limitation is that the published studies have examined
intervention strategies individually rather than in combination.
Consequently, we do not know which combinations and amounts of
interventions produce optimal effects for which subjects, nor
do we know what the additive effects might be. In addition, studies
of supported employment have not identified client characteristics
that predict success or failure other than prior work history.
14.3 More work needs to be done on the effectiveness
of such schemes, particularly in the UK as most of the studies
have been carried out in the USA. Of particular importance are
their cost-effectiveness, the clinical and social outcomes, and
job retention.
15. DEVELOPING
COMPREHENSIVE SERVICES
15.1 The main parts of the Mental Health
Services that deal with employment issues are those that see adults
of working age. In the main, these are General Adult Psychiatry
services. Specialist services such as those providing for people
with substance misuse problems also have a role. For people with
Severe Mental Illness, it may be the Specialist Rehabilitation
Services or the Community Mental Health Teams (CMHTs) who have
an input into employment and vocational schemes.
15.2 Community Mental Health Teams have
developed in all parts of the country since the 1980s and have
increasingly given priority to those with Severe Mental Illness.
They are seen as playing a central role in the delivery of the
standards of the National Service Framework along with Crisis
teams, Assertive Outreach teams and Services for those with First
Onset Psychoses. All these components of the new community services
have some role to play in assisting with activity and employment
for those with psychiatric disability.
15.3 Associated with these community services
are inpatient services, in which many people with Severe Mental
Illness will be placed at some time in their episodes of acute
illness during their lives. It is recognised that acute inpatient
psychiatric services in Great Britain are often inadequate, both
in terms of numbers and quality. Such services can be improved
and there are good examples of associated residential units which
may form an important part of the rehabilitation process following
an acute episode of illness. Acute Day Hospitals also play a part
in providing meaningful activities for patients recovering from
acute episodes as well as in treating these episodes. They can
play a part in rehabilitation and be part of the process of getting
people into work.
15.4 The severity of symptoms and impaired
social functioning are not per se barriers to employment. The
changes in delivery and expectations of mental health care have
led to a change in the population served and in the locus of care
to the community.
15.5 There are a significant number of people
with severe mental illness who can work, given the appropriate
opportunities, and who want to work. There are also increasingly
more opportunities for meaningful employment. Mental Health Services
need to be aware of this and alter their own attitudes and approaches
accordingly.
15.6 There is a need to prepare people with
psychiatric disabilities for employment. This means the effective
use of appropriate treatments including medication. Care needs
to be exercised regarding the side-effect profile of medication,
which may place barriers in the way of certain types of work.
The use of the newer antipsychotic drugs, including Clozapine
may be considered appropriate. The use of psychosocial interventions
for people with enduring mental illness may be useful in building
up ways of coping with enduring symptoms. The evidence regarding
the concept of self-efficacy opens up a potential therapeutic
area for cognitive restructuring. The development of Cognitive
Remediation Therapy may assist in improving concentration and
other intellectual tasks. Psychological therapies for affective
disorders may be useful in addressing cognitive barriers to work.
15.7 Barriers to employment exist both within
and outside of the mental health services. Those within the services
need to be recognised and corrected. Those outside the services
need to be recognised and, if possible steps within services should
be instituted to reduce the likelihood that these will impede
the progress of service users.
16. MENTAL HEALTH
SERVICES AND
THE BARRIERS
TO WORK
16.1 Barriers may be part of the process
of assessment and treatment. The assessment and facilitation of
employment should be seen as part of the role of all mental health
professionals. Staff need to recognise the potential for employment
in many of the users and to overcome assumptions of unemployability.
Staff should also recognise the conflict between activity as a
treatment and employment as both a right and a choice. Employment
opportunities should be considered for all service users and staff,
and users need to come to a shared agreement on goals, which may
require that the service user needs to develop self-efficacy.
16.2 The Care Programme Approach may be
of assistance in highlighting vocational needs in the patients
care plan. The Department of Health's Implementation of the Mental
Health Policy requires that by 2002 all Care plans in the Care
Programme Approach for people with more serious health difficulties
must show plans to secure suitable employment or other occupational
activity.
16.3 Community Mental Health Teams (CMHTs)
are ideally placed to take a lead in co-ordinating the vocational
rehabilitation of those with psychiatric disabilities. They can
however only do this if appropriately funded. The NSF implementation
plans place CMHTs in a central position for the co-ordination
of local services (Department of Health, 2001). CMHTs see the
bulk of those with Serious Mental Illness in any one area and
provide for direct referral from Primary Care.
16.4 However, in most local areas that are
covered by CMHTs there may be no work schemes for people with
mental disability and such schemes are patchy throughout the country.
The same will apply to rehabilitation services. There is a need
for all CMHTs to have access to a range of work schemes and these
should be based along the lines indicated by the available evidence.
This central role of CMHTs in local services for the severely
mentally ill can only be achieved through the improvement of rehabilitation
and day care services in the areas that these teams operate in
and by enhancing the skills of members of the teams. There is
also the need to identify vocational specialists within the CMHTs.
16.5 At present, members of the CMHTs are
not adequately trained to deal with the delivery of vocational
services. They will need additional training to assist with the
delivery of such services. This will require the introduction
of the concepts of rehabilitation and work in the training of
psychiatrists, nurses and others in the multidisciplinary team.
In addition, the development of training opportunities for staff
working in Community Mental Health Teams including information
on Disability Discrimination legislation; skills; awareness; information
on resources available.
16.6 The National Plan also requires that
welfare benefits advice is part of the Care Programme Approach
and this needs to be integrated. The Welfare to Work Scheme for
which the lead agency is the local authority social services department
also requires that benefits advice be integrated with employment
assessment. Each CHMT may in due course need to identify a benefit
lead and a vocational lead who would work closely together. The
use of welfare and benefits advice workers can assist users in
achieving the range of benefits that are available to them and
can give appropriate advice on benefits and work.
16.7 Whilst the CMHTs provide a central
pivot and focus for local delivery of psychiatric care, the difficulties
faced by such teams should not be underestimated. Many CMHT workers
have large caseloads and the demands placed upon them are great,
often exceeding their capacity to deal adequately with such pressures.
These demands compromise the delivery of quality services and
stretch the team members' ability to make use of any training
opportunities. Recruitment and retention of staff is difficult
and, for example, there are presently 188 vacancies for Consultant
Adult General Psychiatrists in England (12.7% vacancy rate). Present
funding is directed at the NSF initiatives of Home Treatment Teams,
Assertive Outreach and First Onset Psychosis, which may take staff
away from CMHTs and leaves no available funding to strengthen
the activities of CMHTs.
17. THE SPECIALIST
VOCATIONAL WORKER
IN THE
COMMUNITY MENTAL
HEALTH TEAM
17.1 One approach to improving outcome in
terms of getting users into and maintaining them in employment
is for CMHTs to identify Specialist Vocational workers. While
in some teams it may be that an individual with an Occupational
Therapy background is best placed to take on this role, it is
not a role exclusive to Occupational Therapists and it is reasonable
for individuals to develop this role who come from nursing or
social work or from backgrounds outside health and social services,
including industry, education and employment services.
17.2 A significant part of the work would
be to identify local resources and a network of employment opportunities
available locally. The vocational specialist would develop systems
for reviewing wishes and expectations of those in non-vocational
day care. He or she would carry a message of individualising care
and recognising "reasonable adjustment" and facilitating
employment.
17.3 Many CMHTs contain Occupational Therapists,
who may be able to provide vocational expertise, guidance, information
and support to clients, care co-ordinators and professionals within
the team with support from the vocational specialist. Their skills
base would suggest that this is an appropriate choice; however
this role should not be in isolation nor exclude other team members
from helping clients with support to access employment. Ideally
the emphasis on work needs to be an integrated approach with the
whole team focused on employment.
18. LONGER TERM
MAINTENANCE IN
WORK
18.1 In addition to getting people back
into work, the mental health services also have a role to play
in keeping people in work. Maintaining people in work is likely
to be more challenging than entering work.
18.2 The evidence from the research studies
suggests that close liaison between employers and CMHTs is an
important factor in achieving good employment outcomes. The systems
for supporting people in maintaining work are not widespread and
models vary. Issues do arise regarding who should provide the
support both to the employee and to the employer. User preference
has to be taken into account. Both mental health professionals
and employers need to be flexible in making reasonable adjustments
and access to support.
18.3 The issue of retention has been highlighted
by the Department of Health in the implementation of NSF standard
one, which promotes social inclusion. There is increasing emphasis
on the importance of enabling individuals with mental health problems
to remain in their jobs wherever possible.
19. SPECIALIST
MENTAL HEALTH
SERVICES
19.1 Day care can play a part in the rehabilitation
of those with psychiatric disabilities and can increase the spectrum
of services available within a local area. The concept of day
care needs to be expanded to provide a range of facilities, all
of which have close working links with CMHTs, and provide a range
of services, both acute and chronic, both therapeutic and supportive.
They all need to have rehabilitation as a central aim and have
work, activity and employment as central goals. The Club House
model is one example of this expanded concept.
19.2 At present the Mental Health Services
place insufficient emphasis on returning people to work and there
are few specific provisions for work schemes or work liaison schemes
in CMHTs. The National Service Framework for Mental Health and
its associated documents, whilst implicitly offering opportunities
for Mental Health Services to develop employment schemes, does
not give direct emphasis on developing rehabilitation services.
There is a need to develop such rehabilitation services alongside
the others that place an emphasis on acute care and the traditional
illness model.
19.3 There is a need to review the current
structure and delivery of rehabilitation services. The change
in service delivery that has been consequent on the move away
from large institutions to expanded community facilities has meant
that general adult community services have taken over some of
the roles that have previously been part of rehabilitation services.
The new structure must take into consideration the overlap between
Rehabilitation and Adult Community Services and adapt the delivery
of rehabilitation accordingly. In addition, the role of the Social
Services and the Voluntary Sector must be built into the emerging
picture of services. Vocational Rehabilitation will inevitably
take a significant place in the delivery of such services. The
goal of open employment must be a part of the rehabilitation process,
but other forms of meaningful activity must not be ignored and
will form part of the spectrum of services.
19.4 There are currently few Rehabilitation
Consultants in the UK and a significant number of vacancies. In
England in 2000 there were 2,816 a total of consultant psychiatrists
in post with 371 vacancies (Royal College of Psychiatrists, 2001).
46 of these consultants were Rehabilitation Consultants and there
were 13 rehabilitation consultant vacancies (this is probably
an underestimate). There were only nine applications for Specialist
Registrars to obtain endorsements in Rehabilitation between 2000
and 2004, so it appears that insufficient numbers of rehabilitation
psychiatrists are being trained. This may reflect the current
training state in General Adult Psychiatry. It is recommended
that there should be 0.4 Full-time Equivalents Consultant Rehabilitation
Psychiatrists per 100,000 population.
19.5 While facilitation of employment opportunities
is now fundamental to general community mental health services
compared to past times when it would have been seen as a role
of specialist rehabilitation services, there is still some place
for Specialist Service provision.
19.6 In some areas Specialist Rehabilitation
Services have developed as providers of employment opportunities.
Additionally the specialist service providers do have a special
role in meeting the needs of the most disabled. This would include
the population now served by specialist services where they do
exist and also individuals with additional disadvantage in the
labour market such as the Mentally Disordered Offender Population.
Unfortunately while the research evidence tells us that severity
and complexity of psychiatric disability is not a barrier to successful
employment, in practice in most areas the most severely disabled
population of mental health service users remain the least likely
to be in employment.
20. HEALTH SERVICE
MANAGEMENT AND
COMMISSIONING
20.1 The introduction of new commissioning
arrangements involving Primary Care Trusts are yet untested, but
may provide potential threats to the delivery of services for
those with Severe Mental Illness. In thinking about local strategies
for commissioning vocational rehabilitation services the following
need to be included:
— principles of non exclusion and active
employment of users of mental health services;
— support for local social economy
(eg using local catering social enterprise, or printing service);
— benchmarking of services available;
— examining the interface with day
activity services;
— obtaining user feedback throughout
planning and service delivery;
— funding support to social firms especially
early on; and
— participation with other stakeholders
in joint provision (discussed below).
20.2 There is always a danger in pan-disability
initiatives that people with mental health needs will be forgotten
or excluded from the definition of disability. Mental health service
managers and planners need to contact their local authority to
find out who is putting the WtW JIP together and ensure that someone
who knows about mental health services locally, this may be a
service user, is on the steering group. It may be useful to convene
a meeting of mental health service and employment stakeholders
in the local authority area to ensure that the input into the
JIP reflects all views and experiences of the route into work.
Included in the considerations should be people who are already
in work but are at risk of losing their jobs through mental illness.
21. THE GENERAL
PRACTITIONER AND
PRIMARY CARE
21.1 General Practitioners (GPs) are in
a key position to affect and sometimes determine a patient's trajectory
through the employment system. GPs provide medical advice to their
patients on fitness for work and this advice initiates most spells
of incapacity for work lasting over a week. Medical statements,
such as form Med 3 and form Med 4, which doctors use to record
this advice, are official documents and may be used by a patient
as evidence to support a claim to a financial benefit. Quite apart
from their use by employers as medical evidence to support a claim
to company sickness benefits or Statutory Sick Pay, medical statements
form a key part of the claim process for state incapacity benefits.
Psychiatrists also provide sick certificates but less frequently
than GPs.
21.2 GPs need to see themselves as taking
active decisions about certification as part of patient management.
Particularly in the field of mental illness, there is a close
correlation between a better prognosis and the ability to find
and keep work. There are many options for support for the patient
and GP in conjunction with the Department of Work and Pensions.
Where there is scope for rehabilitation and seeking work, the
GP should encourage the patient in that direction if possible.
21.3 GPs manage the vast majority of people
with mental health problems, including those with mild and moderate
mental illness. Although many patients with Severe Mental Illness
are managed in secondary care, the GP often has significant input,
often concerning certification. For those patients with common
mental illness, the problems often centre on confidence and performance
anxiety. For those with Severe Mental Illness there are frequently
problems of cognition and motivation.
21.4 Research on employment and mental health
problems and the General Practitioner is less readily available
than that quoted on in other parts of this report. Much of the
evidence that is available is generic, but some offers insight
into mental illness and employment.
21.5 GPs carry out a number of functions
with regard to sickness, disability and certification. These processes
are rarely regarded by the practice as important, but the decision
to issue a certificate of incapacity may have profound long-term
consequences for the patient and their family. Certification is
often used as a simple, rapid way of closing a consultation rather
than a significant intervention affecting a patient's life and
potential job prospects.
22. INTERAGENCY
WORKING
22.1 The statutory, voluntary and private
sectors can and should be involved in partnership working. Statutory
agencies do not merely appear as funders or commissioners. Some
of the largest government organisations—for example the
Employment Service and NHS Trusts in Avon and West Wiltshire—have
found new ways of working together for the benefit of users. Some
recent government initiatives, such as New Deal for Disabled People
and Health Action Zones, have been utilised to support new and
original forms of partnership.
22.2 Many of the partnerships will include
the Health and Social Services, Employment Services and the Voluntary
Sector, but there were some unusual players. There have been notable
successes in working with groups operating way outside the mental
health sphere—for example supermarket chains, railway preservation
societies and conservation groups. Where mental health service
users have teamed up with "green" groups, mutual enthusiasm
for a common cause has pre-empted any concerns about difference.
This should give confidence to others who hesitate in approaching
community agencies in their locality for fear of prejudice and
intolerance.
22.3 The evidence for this section is drawn
largely from Working Together by Adam Pozner, Judith Hammond and
Mee Ling Ng of Outset Consultancy Service. Two major lessons can
be drawn from this research:
(i) Successful partnerships do exist and
can generate real benefits for service users. Many individuals
previously excluded from education and training are now learning
new skills. Opportunities for work and meaningful occupation have
been opened up in creative ways. Securing open employment is becoming
a reality for many who never believed it possible.
(ii) The possibilities for partnership are
almost endless. The range of agencies that are encountered working
together is huge. The extent to which organisations outside the
mental health field are involved is both surprising and encouraging.
22.4 The role of employers in this process
is important and the cost of mental ill-health on industry is
a legitimate concern and should be placed firmly on the business
agenda. For example, reduction of staff absenteeism would reduce
costs significantly. Engaging with employers and identifying the
advantages to business of working to improve the workplace and
to engage with other organisations to prepare people with psychiatric
disability to rejoin the labour market is an essential part of
this process.
22.5 Contributors to the research project
highlighted key factors in successfully developing and sustaining
partnerships, as well as some of the problems faced. Agencies
setting out on the partnership path need to be aware of these:
— Developing a user focus.
— Commitment from the top.
— Achieving a professional approach.
— Understanding the local business
scene.
23. WORKING IN
PARTNERSHIP WITH
COMMUNITY MENTAL
HEALTH TEAMS
23.1 For health services, the importance
of working in partnership is provided by the example in the Bristol
East and Bath District, where occupational therapists from community
mental health teams (CMHT) are working in partnership in an Employment
Service New Deal for Disabled People (NDDP) pilot scheme. In this
scheme NDDP Personal Advisors were paired with front line workers
from CMHTs to enhance the employability of mental health clients.
The employment staff particularly emphasised the value of working
with the occupational therapists on this scheme and occupational
therapists reported increased skills. This collaborative approach
was positively regarded by the clients who appreciated the holistic
working. It is important in these projects, where a member of
the team is focussing on vocational needs, that the rest of the
team acknowledges this in terms of giving it priority and freeing
up sufficient time for the vocational "lead" to fulfil
this role effectively.
23.2 Where occupational therapists have
worked closely with employment service staff and vocational specialists,
it has resulted in a useful exchange of skills and expertise.
The clients benefit from bringing together the vocational expertise
and the understanding of the impact of the psychopathology on
work performance.
24. RECOMMENDATIONS
24.1 National policy
— The Government should urgently review
the organisation and delivery of psychiatric rehabilitation services,
including vocational rehabilitation, and the resources committed
to such services.
— Whilst recognising the lead role
played by the UK Departments of Health, the issues raised by employment
and psychiatric disability are much wider involving, for example,
the Department for Work and Pensions, Local Governments and the
Regions. We recommend the creation of a Government interdepartmental
working group to monitor the cumulative impact of employment policies
and initiatives on people with mental health problems. This group
should contain independent experts.
24.2 Development of Vocational Services
— Employment services for those with
mental illness should contain a spectrum of approaches and involve
a range of agencies with a co-ordinating body.
— The institution of a nationwide rehabilitation
programme that psychiatrists and General Practitioners can access
on behalf of their patients, so that users can be put in touch
with effective interventions early.
— A work development and co-ordination
team should be established in every local Mental Health Service.
— Rehabilitation services for those
with mental illness should be focused on getting people back into
employment or other meaningful activity.
— Employment services for those with
severe mental illness should be aimed at getting those people
who wish to start or return to employment into open employment.
— Vocational rehabilitation services
should allow for a rapid response to those who develop mental
illness whilst in work with an aim to allow a return to work.
— Strategies for the prevention of
work-related mental illness
— Strategies for the support of those
who develop mental illness whilst working and systems of liaison
with mental health services.
— Policies to facilitate the employment
and to maintain the employment of those who have or develop
mental illnesses.
— Communication between mental health
services, General Practitioners and the employers needs to be
improved and all agencies should be aware of the needs and the
ways of working of the other.
— There should be greater partnership/joint
working between the Jobcentre Plus and other employment agencies,
and Mental Health Teams and service providers.
24.3 Psychiatrists and Community Mental
Health Teams
— Mental health workers should be aware
of:
— the implications of the Disability
Discrimination Act;
— the evidence base related to employment
opportunities for those with psychiatric disabilities; and
— what vocational services are available
locally and how these can be accessed.
— The enhancement of employment services
for those with mental illness will require mental health workers
with dedicated sessions.
— There needs to be an examination
of the numbers of available posts for specialist rehabilitation
consultants and associated teams, with there being at least 0.4
Full-time Equivalents Consultant Rehabilitation Psychiatrists
per 100,000 population.
— Awareness of the need to get people
into work or back to work should begin soon after initial contact
with psychiatric services, whether this is in outpatient clinics,
community teams or in-patient units.
— Psychiatrists and others working
in mental health teams should develop a more positive attitude
to the employability of those with mental illness.
— Community Mental Health Teams should
be considered as central to the health service provision of vocational
rehabilitation for those with mental illness.
— Vocational and welfare specialists
should be employed in CMHTs.
— The Care Programme Approach should
be used for those in contact with secondary mental health services
to record a person's vocational needs and to plan for their rehabilitation.
24.4 Primary Care
General Practitioners should:
— always consider how clinical management
would support a patient back into work;
— review before the first six weeks
of certified incapacity to reduce the chances of long-term sickness;
— try to keep positive expectations
about patients' return to work;
— emphasise progress and offer appropriate
therapy where possible;
— differentiate between the risk of
losing an existing job and the problems of getting back into work
after a long absence; and
— communicate as clearly as possible
with the employer within the constraints of ethics and confidentiality.
24.5 Training/education
— Training in adult psychiatry should
involve opportunities for experience in psychiatric rehabilitation,
and the visiting educational approval teams should note such opportunities.
— Mental Health Services should offer
training to employment agencies, including Jobcentre Plus, other
employment services and organisations and the Benefits Agency.
— An educational initiative should
be launched in order to:
— ensure that certifying medical practitioners,
particularly GPs, are fully aware of the range of management
options available;
— inform GPs and other healthcare professionals
of the factors interfering with a return to work;
— inform GPs and other healthcare professionals
of the factors hastening a return to work;
— help GPs and other healthcare professionals
to provide better advice to their patients of working
age and to the patients' employers; and
— ensure that other Mental Health practitioners,
including nurses and consultants, are aware of the process
of certification and contribute appropriately to it;
— An initiative should be launched
to ensure that patients are informed about all the options available
to them in relation to work retention, job search and benefits;
and that they have access to appropriate advice at every stage.
24.6 Commissioning
— Primary Care Trusts (and Groups)
should organise to work with local DEAs and the employment agencies,
including Jobcentre Plus, to facilitate local responses to these
challenges.
24.7 Research
— Priorities for research on employment
and psychiatric disability should include:
— the extent, type and availability
of work schemes in the UK;
— cost effectiveness of vocational
rehabilitation models and how much mental state and social outcome
are improved by working; and
— schemes and approaches to the rehabilitation
of those who do not have severe mental illness
— the role of primary care services
in the vocational rehabilitation of those with non-psychotic mental
illness.
— Research should be directed at efforts
to enhance job tenure and long-term vocational careers.
— A body of research literature should
be developed that examines the need to keep people in work when
they develop mental health problems (as opposed to the placement
of people with pre-existing mental health problems).
Andrea Woolf
Committee Manager—Policy
6 January 2003
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