APPENDIX 20
Memorandum submitted by the Scottish Development
Centre for Mental Health (EDP 29)
SUMMARY
This paper has been prepared on the basis of
on-going work in Scotland on mental health and employment issues,
involving discussion and consultation with a wide range of stakeholder
interests.
Its points and recommendations are specific
to the situation of people with mental health problems, and it
does not aim to address the needs of all disabled people.
Historically, this group has not had the attention
of other disability groups in respect of policy development, and
financial support for and involvement in national programmes has
been well below that of other groups.
The increasing numbers of people with mental
health problems as a proportion of all those in receipt of Incapacity
Benefit, combined with the much higher unemployment rates amongst
this group as opposed to disability groups in general, point to
the need for separate targets and dedicated initiatives in the
mental health and employment field.
The paper points out where some barriers are
operating with this group that may not apply to all disability
groups, particularly in relation to financial disincentives in
the current welfare benefits system.
The nature of mental ill health also has a more
serious impact on motivation and confidence, which needs to be
recognised in national programmes, whose timescale for achievement
cannot be matched by this group.
This has been seen as a failure of this group,
rather than a result of lack of understanding amongst programme
designers.
Some practical recommendations are made, which
could be implemented at local level, and monitored for their value
in increasing employment access.
Many of these revolve around developing the
lead role of Job Centre Plus, and how it may need to change its
structure and practice if it is to deliver its share of the PSA
target in relation to people with mental health problems.
1. INTRODUCTION
1.1 The Scottish Development Centre for
Mental Health has been running an employment programme since 1999,
funded by the Scottish Executive Public Health Division. The programme
has involved collection and dissemination of good practice, networking
support for employment and mental health projects and practitioners
across Scotland, and support for strategic planning and service
development in different areas of the country.
Our practice database highlights 70 dedicated
employment and mental health projects in Scotland, with a contact
list of over 250 practitioners and mental health service users
who are involved with these issues.
1.2 We have mounted consultation exercises
over the last year, to determine what more could be done at a
policy level to promote the employment of people with mental health
problems, and where responsibilities should lie in developing
more comprehensive services in local areas. As well as involving
the above network in this, we have engaged with mental health
service users in two specific areas (both rural, isolated ones),
and have also discussed issues with a wide range of stakeholder
interests, represented on the Employment Programme Advisory Committee.
This committee includes medical practitioners, NHS Board officers,
health promotion staff, social work managers, Scottish Enterprise,
STUC and voluntary sector organisation members.
1.3 SDCMH is also a partner in "EQUAL
Access"—a European-funded Community Initiative to facilitate
the access of disabled and disadvantaged people to employment.
EQUAL Access is a partnership of 14 organisations with experience
of many disadvantaged groups, which is developing pilot activities
and research into the barriers and solutions to employment access
problems. One of the underpinning work programmes (which SDCMH
is leading) is on the financial, motivational and informational
barriers within the current benefits system that act to deter
individuals on long-term benefits from actively seeking work.
1.4 Thus the responses to the Committee's
questions, contained in this paper, are based on discussions with
a wide range of organisations and individuals, but are informed
primarily by the experiences and needs of people with mental health
problems.
2. EXCLUSION
FROM THE
LABOUR MARKET
AND HIDDEN
UNEMPLOYMENT
2.1 There have been a number of studies
which highlight the high unemployment rates of people with mental
health problems, especially those with severe and enduring problems.
For example, a study in 2000 showed employment
rates of 8% amongst a sample of people with a range of diagnoses
attending a Community Mental Health Team, while those with psychotic
problems were even lower, at 4% (Huxley 2000). The Labour Force
Survey 2000 has reported that people with mental health problems
are much less likely to be economically active than those with
other disabilities.
Reported rates of unemployment have varied between
studies, but the Disability Rights Commission estimates the overall
national figure for people with a mental health problem to be
an unemployment rate of 72% (DRC 2000). This compares very unfavourably
with disabled people in general, whose unemployment rates are
between 30-40%. This figure is itself significantly above the
rate for unemployed people in general.
2.2 People with a "mental or behavioural
disorder" now constitute the single largest group of Incapacity
Benefits claimants in the UK, with 33% of all IB claimants falling
into the group. The social security bill in the UK for unemployment
amongst mental health service users was estimated in 1999 as £7.6
billion (Mental Health Foundation), and with the increasing size
of this group on Incapacity Benefit, is likely now to be even
higher.
In overall terms then, if you are unemployed
and have a mental health problem which impacts on your day to
day life, you are extremely unlikely to be in a job, and will
find it very difficult to get into work.
2.3 This contrasts strongly with the studies
which show willingness to work by people with mental health problems.
Not all people who have been surveyed mean "I want to be
employed full-time in the open labour market", but their
preferences are overwhelmingly in favour of work. Studies have
shown as many as 90% would like to go back to work (Secker et
al 2001).
That so many are unemployed whilst wanting to
work, demonstrates that the "system" designed to help
unemployed people into work is not helping individuals with mental
health problems realise their aspirations, and that in the case
of mental health service users, there is "hidden unemployment".
3. ARE THE
NEEDS OF
PEOPLE WITH
MENTAL HEALTH
PROBLEMS ADEQUATELY
CATERED FOR
AND WHY
IS THE
CURRENT SUPPORT
SYSTEM INTO
WORK NOT
WORKING IN
MENTAL HEALTH?
3.1 The above information suggests that
the needs of people with mental health problems are not being
addressed, and that the size of this group in relation to the
overall Incapacity Benefit claimant population will continue to
grow unless their needs are recognised and addressed.
3.2 There are five commonly agreed barriers
which operate to deter people with mental health problems from
accessing employment:
— The lack of focus of the medical
system on employment issues.
— The nature of mental ill health and
its impact on confidence and motivation.
— Difficulties with accessing information
and services, and the general distance of people with mental health
problems from the Job Centre Plus set up.
— Discrimination amongst employers
towards this group, bourne of lack of awareness and stigma.
— The financial disincentives in the
current benefits system.
3.3 The employment focus of the NHS
3.3.1 At a strategic planning level, the
involvement of the NHS, in particular the mental health service,
with employment issues, and their responsibilities in ensuring
employment services are available, is not universally agreed.
Individual Boards and Trusts have different views of their responsibilities,
and different funding priorities. Until there is some clarification
from government, resource allocation and practice changes will
not be implemented at local level.
3.3.2 People with more serious problems
will receive support in the community from community mental health
teams. Research has shown that staff in these teams know little
about employment issues, and do not ask questions of new referrals
as to their employment status or to their goals in relation to
employment. It can be some time before employment is raised with
individuals, if at all, and by that time, an individual is likely
to have lost confidence in their working abilities and see a return
to work as a daunting prospect. This is shown by the IB statistics
that after two years, a claimant has only a 5% chance of returning
to work.
3.3.3 A focus on medical treatment, and
the maintenance of an individual's stability, are the primary
aims of the mental health service, and service users report that
they are often told that employment will threaten this status
quo, and they should not consider it.
3.3.4. Models of vocational rehabilitation
in this country, which have now been tested and found to work,
show that for individuals to succeed in gaining employment, the
responsibility for supporting those who want to work must be transferred
as quickly as possible from the mental health service, to other
employment specialists. The NHS must still however have primary
responsibility for supporting an individual's mental health.
3.4 The impact of mental illness on individuals
3.4.1. Many disadvantaged groups report
a loss of confidence as a result of unemployment. In the case
of people who experience mental health problems however, loss
of confidence, self-esteem and lack of motivation is more severe
and can have a lasting impact on the ability of an individual
to work.
3.4.2. Most employment projects focus on
addressing this issue, by engaging an individual in meaningful
work or training. Thus many projects are aimed at developing employability,
rather than directly trying to place individuals into employment.
This accounts for the low exit rate into employment reported by
many employment projects.
3.4.3. The characteristics of mental illness
reduce an individual's willingness to take risks. Involvement
in stressful situations is seen as too much of a risk, one that
will precipitate a recurrence of psychiatric symptoms. Work is
seen as stressful. The attitudes of the mental health service
therefore reinforce the individual's perceptions of what will
be risky or stressful, and will restrict their willingness to
think about going back to work.
3.4.4. Mental ill health can also be a fluctuating
condition. Many people with a diagnosis of schizophrenia or manic
depression expect to become ill in the future, and this adds to
the risk of taking a job, especially when people do not have the
confidence that appropriate support will be provided to enable
them to retain their job.
It is important to understand how mental illness
impacts on individuals, as these internal barriers are powerful,
and influence whether individuals will take up an offer of assistance
or not.
3.4.5. It also informs how best to shape
services in future. One of the consequences is that services must
be based on individual need, but design of services for this group
has proved particularly challenging, as the range of individual
circumstances, in terms of education, qualifications and previous
work experience, is extremely wide, much wider than say those
with a learning disability.
3.4.6. In terms of providing services which
focus on one client group, the opinion of people who use mental
health services is divided. Some want to be involved in projects
with people who have experienced similar difficulties and who
can offer peer support. Others want to be just like anyone else.
3.4.7. The key questions are not whether
specialist employment projects should be more inclusive, rather
how these projects work together with other agencies such as Job
Centre Plus, whether their funding is adequate to support the
required activity and how they fill in the gaps in services and
support that can be found in any local area in the country one
cares to choose.
3.5. Difficulties with accessing information
and services
3.5.1. Research has demonstrated a large
gulf between the likely level of people with mental health problems
who want to work and the availability of specialist services to
help them—in Scotland in 1999, only one in 14 people with
mental health problems who wanted to work were estimated to have
a place in an employment project. (Durie, 1999). Availability
of employability projects is patchy, there are few places available
in rural areas and places within eg voluntary sector projects,
are unstable due to funding.
3.5.2. This would not matter if people with
mental health problems were taking up places in mainstream Job
Centre Plus programmes, and their needs were being catered for
that way. Statistical information has proved difficult to obtain,
but evidence suggests that many people with mental health problems
are largely unaware of mainstream programmes such as Workstep
and Access to Work. A survey in Glasgow recently showed that less
than 5% of individuals involved in employability development projects
had heard of a Disability Employment Advisor (Durie and Gortmans,
2002).
3.5.3. Anecdotal evidence from NDDP brokers
in Glasgow suggests however that NDDP is actually attracting people
with mental health problems in significant numbers, which is attributed
to the letters sent out to IB claimants and the provision of direct
information to people about the programme.
This would suggest that people with mental health
problems will respond to offers of help with employment access.
What NDDP brokers however are reporting anecdotally, is that the
majority of this group are not ready to engage with the programme,
and need more preparation and development support before being
"job ready".
3.5.4. Problems of access to information
is most clearly a barrier in the welfare benefits system. Many
employment projects do not have in-house expertise on benefits,
and therefore individuals are not receiving eg better-off calculations
that explore all the in-work benefits to which they are entitled,
and which might encourage them to seek work. The complexity of
the current system is discouraging projects from training staff
to give advice, instead they are relying on the CAB or independent
advice network, which is severely stretched, and unavailable in
many areas.
3.5.5. The evidence from service users is
that they will not seek such information directly from Job Centre
Plus staff. There is research currently underway in Scotland through
EQUAL Access to examine this issue in more detail, but early information
suggests that service users believe that if they raise questions
about in-work benefits with Benefits Agency staff, they will put
their current benefit entitlement at risk. In the absence of a
clear information service to this group, what appears to happen
is that "urban myths" circulate, about people who engage
with limited work and lose their benefits, or who find themselves
worse-off as a result. This serves to reinforce the risks of moving
into employment.
3.5.6. In terms of the types of services
available in local areas, there are huge inequalities. Most urban
areas possess more services than rural areas. Few areas possess
work experiences programmes such as social firms, social enterprises
and clubhouses. In some areas, Access to Work cannot be accessed
for people with mental health problems. In Scotland, there is
only one specialist mental health organisation with a national
Workstep contract.
3.5.7. In all areas, the missing service
is job retention. The support needs of people who experience or
develop mental health problems while at work, and the needs of
their employers, are largely ignored at present. The majority
give up work, thus fuelling the rising level of IB claimants with
mental health problems. We consider that more work on job retention
for mental health should begin now, even though the national pilot
is still in its infancy.
3.6. Discrimination amongst employers
3.6.1. Surveys of employer attitudes towards
people with mental health problems show that discrimination is
real. In a survey of employers in Fife for example, 35% said they
would dismiss someone who was shown not to have disclosed their
mental health problem at interview (Reid Howie, 1999). Other studies
have shown discrimination in terms of recruitment, poor retention
rates of staff with mental health problems and negative attitudes
from work colleagues. 34 per cent of mental health service users
report being dismissed or forced to resign from their jobs as
a result of their mental health status (Read & Baker, 1996).
53 per cent of people with mental health problems in employment
have not disclosed their status to their employer for fear of
dismissal ((MIND, 2001).
3.6.2. This merely reflects the attitudes
of society in general towards mental illness. Fear, prejudice
and lack of understanding act within individuals, whether they
be managing directors, middle managers or work colleagues, to
create discrimination towards this group which results in lack
of workplace support.
Changing this situation will not be easy. There
are however examples of where mental health awareness training
is being successfully delivered to employers, with some change
in work practices and in-house support for individuals who have
mental health problems, or develop them while at work.
3.6.3. The impact of the DDA in terms of
mental health has not been studied. Observations and experiences
of those involved in mental health and employment issues however
suggest there may be some unintended consequences of the legislation
in terms of mental health.
The DDA does offer an opportunity for employment
and mental health specialists to engage with employers, and to
offer mental health awareness training which addresses some of
the concerns employers might have in recruiting this group. On
the other hand, some employers may be seeing workplace mental
health initiatives, and more open discussion of mental health
issues, as leading to an increased risk of legal action from employees,
whether related to work-related stress or under the DDA.
The Act is open to considerable interpretation
in relation to mental health. The concept of "reasonable
adjustment" when it relates to someone with a mental health
problem is not clear, and the eligibility of individuals for protection
under the Act has been placed in doubt by some tribunal decisions.
The expectations placed upon employers by the Act are consequently
unclear, and until they are, employers will act to minimise risk
to themselves.
3.7. Financial disincentives in the
welfare benefits system
3.7.1. The disincentives mainly revolve
around the interaction of housing benefit with earnings, and loss
of other benefits when entering work.
For someone on Incapacity Benefit, who is also
in receipt of Housing Benefit or Council Tax benefit, earnings
are restricted to £20 per week. Above that limit, HB administrators
have the right to reclaim 85% of earnings, and in practice, individuals
do not earn more than this. Under the term of the National Minimum
Wage Act, this effectively restricts individuals to paid work
of four hours per week. This affects both employment projects
who wish to pay people for engagement in work experience projects,
eg social firms, and the ability of individuals to gain meaningful
work placements with employers as a precursor to gaining a job,
as can be seen in the Transitional Employment Placements offered
by clubhouses.
3.7.2. Many people with mental health problems
are living in social rented housing, often with care packages.
In a Scottish survey, 95% of individuals involved in employment
and training activity were in receipt of housing benefit and limited
to paid work of £20 per week (Forth Sector, 1999). Seventy
five per cent reported that they would work more hours if their
benefit was unaffected, and 31% identified themselves trapped
by the housing benefit earnings disregard rules.
In practice, this restricts people who are on
IB to working four hours per week, with no transitional flexibility
to allow them to work more paid hours as a precursor to working
full-time. Those who are eligible for Permitted Support Work,
who in theory can work up to 16 hours per week and earn £67.50,
in practice find that HB restricts them to working four hours
per week.
3.7.3. This situation appears to affect
mental health service users disproportionately to other groups,
and there appear to be three main reasons for this:
— People on constant medication to
control their psychiatric symptoms have real problems in building
up their physical and mental stamina required to work full-time,
and need to do it gradually over a period of time, which the current
system does not allow beyond four hours per week. This "gap"
is currently unbridgeable unless the HB disregard rules are waived.
— The attitude towards risk, and the
belief that people will only remain healthy if they do not change
their situation and put their benefit entitlement at risk.
— The fear of a recurrence of mental
health problems in future, resulting in loss of employment, the
need to reclaim benefits (stressful in itself) and the fear of
not being eligible a second time for IB or DLA because they have
been working.
3.7.4. The other benefits issue regularly
reported by people with mental health problems as a concern is
entitlement to Disability Living Allowance when entering work.
In terms of the legislation, entitlement to
DLA is not dependent on employment status. Mental health service
users however anecdotally report that gaining employment will
trigger a review, with a consequent loss of benefit. The individual's
needs however may not have changed because they are employed,
and they may have been able to access employment through Workstep
or Access to Work, and have found employers willing to accommodate
their disability. Someone who is blind, and receives DLA for this,
will not be under a similar threat if an employer adapts their
premises and practices with Job Centre Plus help and employs them,
as they are still clearly blind and require help with everyday
living. This is less clearcut when an individual has a serious
mental health problem, and the current review procedures seem
unable to make consistent decisions.
DLA is important because for most people it
is their disposable income while on benefit, and if lost will
make a significant difference to their better-off calculation
and their perception of the risks involved. Many individuals have
reported that its probable loss does make a difference to their
attitude towards work.
3.7.5. Combined with the lack of access
to accurate welfare benefits advice highlighted above, the current
system is holding back those individuals who may use Permitted
Work as a vehicle to move towards employment, and is not properly
addressing their financial concerns about whether work will be
economically viable for them.
4. THE ROLE
OF JOB
CENTRE PLUS
AND GOVERNMENT
PROGRAMMES
4.1. The Green Paper "Pathways to Work"
published in November 2002 indicates an increased role in the
future for Job Centre Plus in tackling unemployment amongst disabled
people, in partnership with other organisations.
Job Centre Plus is the only organisation that
can deliver national funding support for programmes that aim to
overcome the barriers to work for people with mental health problems.
It is the only body in a position to ensure equality of access
across different areas, it does not have a medical focus, its
services are now based on personal action planning and analysis
of individual need (consistent with the needs of mental health
service users) and it does have experience in partnership working.
These are all positive features for Job Centre Plus taking a lead
role in increasing the employment rates of people with mental
health problems.
4.2. The size of the IB population who have
mental health problems, and the nature of some of the barriers
that are operating, will however pose a set of challenges for
Job Centre Plus in taking this lead role in mental health.
The Employment Service historically did not
have significant uptake amongst their programmes from people with
mental health problems, and understanding amongst many staff,
even DEA's, of mental health issues, is consequently low.
4.3. For the Job Centre Plus network to
be successful in increasing access of people with mental health
problems to employment, a number of issues need to be addressed:
— Lack of current partnership working
between Job Centre Plus and NHS staff.
— Lack of awareness within Job Centre
Plus of mental health issues.
— A need to recognise and involve specialist
mental health employment providers.
— The need for adaptation and increased
flexibility in the delivery of programmes if they are to increase
uptake by people with mental health problems, including addressing
some of the key barriers in the welfare benefits system.
4.4. Even if the Job Centre Plus network
was to undertake a universal programme of mental health awareness
training of staff, it would still find difficulty in adequately
supporting individuals in the process of employment access. Relying
on the NHS mental health service to provide support to individuals
would not work in the near future, until the NHS mental health
service has been given and accepted employment as a clear responsibility,
and until staff have embraced it.
4.5. There is a case for a more active partnership,
at least in the short- to medium-term, between specialist employment
support agencies and Job Centre Plus, where national programme
funds are more flexibly used to support individuals along a particular
pathway to work.
Examples of increased flexibility that might
be needed in order to increase the uptake and value of Job Centre
Plus programmes for this client group are:
— Increased timescales for outcome
achievement, recognising the issue of gradual increase in physical
and mental stamina.
— Measurement of achievement by "distance
travelled towards the labour market" rather than simply getting
a job.
— Packaging together individual programmes
such as Workstep and Work Preparation into more coherent pathways
in a local area.
— The active engagement of employers
in these developments, the direct tackling of lack of employer
awareness and increased guidance to employers of mental health
and the requirements of the DDA.
— Allowing earnings of £67.50
per week for those engaged in Permitted Work, irrespective of
housing status.
5. CONCLUSIONS
AND RECOMMENDATIONS
5.1. Unfortunately, the evidence base for
delivering these increased flexibilities on a national scale does
not exist. Although more research is now being undertaken in the
mental health and employment field, it is still the case that
we do not know how many people with mental health problems would
move into employment if these barriers were removed. The Department
of Work and Pensions research programme does not recognise small-scale
studies or those not based on experimental methodology, which
makes it difficult to argue for change on the evidence to date.
Information obtained to date however, combined
with consultations with a wide range of practitioners and mental
health service users, leads us to suggest that the following recommendations
if enacted would make a difference at local level, which could
then be evaluated.
5.2. Enhance the capacity of the medical
system to focus on employment issues
5.2.1. Issue instruction to the NHS and
the mental health service to engage with partners in planning
and resourcing employment services in each area.
5.2.2. Their input should be to establish
referral links of individuals with mental health problems from
primary and secondary care and to part fund dedicated vocational
rehabilitation teams, in partnership with the DEA service of Job
Centre Plus.
5.3. Promote awareness of the nature
of mental ill health and its impact on confidence and motivation
5.3.1. Adequate funding for confidence-building
programmes, and work experience programmes such as social firms
and clubhouses, should be established.
5.3.2. Their effectiveness should be judged
by new measures and tools, developed and accredited at a national
level, to determine "distance travelled towards the labour
market".
5.4. Develop access to information and
services
5.4.1. The DEA service should be developed
into teams of vocational rehabilitation specialists, with at least
one specially trained mental health DEA team per district, and
should involve mental health service staff seconded into post
eg occupational therapists and community psychiatric nurses.
5.4.2. This team should undertake a case
management role, as the main contact point for individuals referred
from the mental health service, primary care or other sources.
5.4.3. This lead role of Job Centre Plus
and the DEA service should be undertaken in partnership with a
network of local service providers, colleges, economic development
agencies and employers.
5.4.4. Marketing the service should focus
on the support and help available, and the service should not
be, or perceived to be, coercive.
5.4.5. Job Centre Plus should pilot a staff
training and development initiative with local statutory and voluntary
organisations, that would allow individuals to access accurate
welfare benefits information through community routes.
5.4.6. DEA's should have budget flexibility
to buy in specialist local employment services for individuals,
over and above existing contracts.
5.4.7. DEA's and local service providers
should be able to negotiate packages of funding based on combining
existing national programmes into coherent local pathways, which
can extend existing parameters such as length of stay, expected
outcomes, eligibility etc..
5.4.8. Funding for Workstep and Access to
Work should be increased so that supported employment initiatives
for this client group should be made available across the UK.
5.4.9. Marketing and promotion of Workstep
and Access to Work to individual IB claimants should be improved.
5.5. Tackle discrimination amongst employers
towards this group, born of lack of awareness and stigma
5.5.1. Job Centre Plus should develop a
mental health at work promotional programme, aimed at overcoming
stigma and providing comprehensive mental health awareness training
to employers.
5.5.2. Employers representative organisations,
local service providers and statutory agencies should develop
local forums to facilitate links with employers and access to
real jobs.
5.5.3. A national policy initiative should
be undertaken to clarify the DDA in terms of mental health, both
in terms of eligibility for people with mental health problems
and in terms of guidance on "reasonable adjustment".
5.6. Dismantle the financial disincentives
in the current benefits system
5.6.1. Allow all those entering Permitted
Work to gain earnings of £67.50 per week, irrespective of
housing status, and to ensure that Housing Benefit administration
receives appropriate guidance on this waiver.
5.6.2. Examine the issues around loss of
DLA following work, and clarify the guidance, to ensure that only
those whose disability has fundamentally changed as a result of
going back to work will lose DLA altogether.
5.6.3. Investigate further the financial
relationship between current benefit levels, part-time earnings,
in-work benefits, costs of working (eg loss of free prescriptions)
and housing benefit, with a view to reform of housing benefit,
DLA, IS and other relevant benefits, to ensure that individuals
are able to move off IB and into part-time work, without financial
penalty.
5.6.4. Simplify the system to enable individuals
to work out for themselves what they need to earn.
5.6.5. Create a new transitional benefit
to bridge the gap between 16 hours work per week and full-time
work, which reduces in line with earning capacity.
5.6.6. Institute a reclaim process for IB
that guarantees a turnaround of one week after loss of employment.
6. CONCLUSION
6.1. Action to reduce unemployment levels
amongst people with mental health problems will only be prioritised
by other agencies if Government sets separate targets for achievement
for this group. The aim should be to bring their unemployment
levels down to at least those for other disability groups, in
line with the Public Service Agreement target.
Sheila Durie
Employment Programme Director
6 January 2003
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