Memorandum submitted by The Royal College
of Psychiatrists
SUMMARY
Principles for the new Benefits System Relevant
to People with Mental Illness
— The system must be fair.
— The system must provide security.
— The system must be socially
inclusive.
Employment Rates and Mental Illness
— Unemployment rates for people
with all mental disorders are high.
— The largest single group of
people receiving Incapacity Benefit have a common mental disorder,
which may be complicated by substance misuse.
— People with Severe Mental Illness
have exceptionally high rates of unemployment—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 Mental Illness include structural factors, the benefits system,
stigma and prejudice, attitudes and approaches of the 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 activity.
— Disincentives to work include:
the medical review process, permitted work rules, disruption of
income, fear of drop in income, 52-week linking rule, difficulties
in getting financial support for practical needs at work, lack
of expert, independent benefits advice on return to 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.
Work for People with Mental Health Problems
— It is important to consider
two matters: keeping people in work and getting people back to
work.
— The attitudes of employers,
the issuing of sickness certificates, the personal capability
assessment and incapacity questionnaire (IB50) all require examination
to assist in keeping people in work.
— Aspects of the benefits system
may inhibit a return to work: linking rule, permitted work, incentives
to return to work, work focused interviews, moving back to work,
medical reviews, losing out on means-tested benefits.
Services: Key Components and Research Evidence
— Overall there is a paucity of
good vocational schemes in England for people with any form of
mental illness.
— For people with Common Mental
Disorders there is a paucity of good quality evidence for prevention,
retention and rehabilitation of these disorders, but among the
existing evidence: brief individual therapy (mainly CBT) is beneficial
and booster sessions may be subsequently needed. When people are
off work due to mental disorders an early return to work is aided
by line managers keeping in touch at least once every two weeks.
— Employers, line managers, occupational
health professionals, Jobcentre Plus, GPs and mental health professionals
need to work together. There is a need to commission services
that require joint schemes between these agencies.
— Results from the Pathways to
Work pilot projects are promising. Two matters require attention:
the selection of claimants taking part in the pilots and the longer
term outcome of the projects.
— There is strong evidence that
Supported Employment schemes (particularly Individual Placement
and Support (IPS)) are effective in getting people with severe
mental disorders into open employment.
— The extent of work schemes in
the UK is not known for certain, but there are few Supported Employment
schemes and 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.
— Jobcentre Plus Advisors require
training to deal with people with severe mental health problems,
better knowledge of the highly complex benefits system and disabilities
and better working arrangements with Community Mental Health Teams.
— The commissioning of vocational
rehabilitation services needs to be improved and to include cross
agencies working and partnerships.
1. MENTAL HEALTH
PROBLEMS AND
INCAPACITY
Mental health problems are the largest single
reason for people being in receipt of Incapacity Benefit, representing
some 29% of all IB claimants (this is an underestimate since many
other individuals on IB will have co-existing or unrecognised
mental disorders). Mental health services receive approximately
12% of the NHS budget, the majority of which is devoted to funding
inpatient services for those with the most severe illnesses and
in acute distress.
2. SCALE OF
MENTAL ILLNESS
For the purposes of considering employment and
mental health problems, it is instructive to divide those with
mental disorders into two groups: those with common mental health
problems (mainly depression, anxiety and adjustment disorders
that are reactions to psychosocial stress) and those with chronic
and severe mental health problems (for example severe and chronic
depression and anxiety, schizophrenia and bipolar disorders).
Whilst these groups overlap, the latter group is more likely to
have contact with secondary mental health services and may require
different approaches to get into work. The problems of those with
substance misuse and learning difficulty will be considered separately.
Common Mental Disorders
Figures from both National Survey of mental
disorder in GB (Meltzer et al, 1995a; Singleton et al,
2001) show a prevalence of common mental disorders in working
age adults of about 16%. Thus about 5,000,000 people in this age
group in England suffer from these problems at any one time. About
6% of this population, 1,900,000 people, will develop one of these
disorders in the course of a year (Singleton and Lewis, 2003).
There are significant levels of unemployment
and sickness absence in those with common mental disorders (Meltzer
et al, 1995b):
— 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 (9% compared to 2%)
The vast majority of those receiving Incapacity
Benefit as a result of an identified mental health problem will
be suffering from a common mental disorder, not uncommonly complicated
by substance misuse. In addition many individuals who are identified
as being incapacitated by a physical illness or complaint will
have co-existing or primary mental health problem. Somatisation
disorders and conditions such as Chronic Fatigue Syndrome are
an important cause of disability.
Chronic and severe mental health problems
Figures from the Labour Force Survey, suggest
that the long term disabled with mental health problems as the
main difficulty represent 8% of the long-term disabled of working
age. This represents about 2.5 million people of working age in
England. About 1% of the population suffer from Schizophrenia,
about 320,000 people.
People with long-term disability due to mental
health problems are much less likely to be economically active
than those with physical or sensory impairments. 18% of the former
group were in employment in 2000, compared to 52% of the latter
group (Labour Force Survey—Great Britain Spring 2000).
Of the students who graduated in 2003, less
than 30% of graduates with mental health problems were in full
time paid work, compared with 48% of disabled graduates and 55%
of non-disabled graduates. (Association of Graduate Careers Advisory
Services (2005) What Happens Next?)
Figures from the OPCS survey of adults with
psychotic disorders living in the community support these findings
(Foster et al, 1996). Half the sample of people surveyed
was classified as unable to work, one in five was in employment
and one in eight was unemployed. These rates do not improve over
time, for example in one London Borough, unemployment rates for
residents with long-term mental illness increased during the 1990s
from 80% in 1990 to 92% (Perkins and Rinaldi, 2002). For those
with schizophrenia the rates of unemployment increased from 88%
to 96% during the same period. These changes occurred despite
an overall fall in unemployment rates during this period.
These low rates of employment should be considered
against the facts that at least 30-40% of people who are significantly
disabled by enduring mental illness are capable of holding down
a job (Ekdawi and Conning, 1994). Many wish to be in some form
of employment and more have a need for meaningful activity, which
will often include working in a voluntary capacity.
3. SUBSTANCE
MISUSE
2.1% of the population suffer from Alcohol Dependence,
30% of men and 15% of women drink above recommended limits Meltzer
et al (1995a; 1995b). 1.5% suffer from Drug Dependence
Meltzer et al (1995a).
Drugs of misuse include: opiates (eg heroin
and illicit methadone); stimulants (eg amphetamines, cocaine and
crack-cocaine); and alcohol misused by drug misusers. Many drug
misusers, however, take a cocktail of drugs and alcohol including
hallucinogens, cannabis and prescribed drugs such as benzodiazepines.
The use of heroin together with cocaine or crack-cocaine is also
becoming increasingly common.
Drug misuse may be a chronic relapsing condition
(Task Force to Review Services for Drug Misusers 1996). While
many drug misusers do successfully recover from drug dependency
or addiction, most make several attempts to do so, lapsing or
relapsing into drug misuse in intervening periods.
Deprivation and social exclusion are likely
to make a significant contribution to the causes, and complications
of drug misuse. Similarly, poor housing, or lack of access to
affordable housing, educational disadvantage, criminal involvement,
unemployment and low income (ACMD 1998).
Alcohol problems have an impact on ability to
work productively and hold down a job. Alcohol problems contribute
to problems at work and unemployment. A one day census (2003)
noted of 10,000 receiving help 36% were unemployed.
In England many people with neurotic disorders
are also likely to have alcohol problems Meltzer et al
(1995b):
— Adults with neurotic disorder
were more likely than those without disorder to have used drugs
in the past year, including misuse of prescribed medicines.
— Men with neurosis were more
likely to drink over 50 units of alcohol a week than those with
no disorder.
— Among regular drinkers, alcohol
dependence was twice as common among those with a neurotic disorder
than those with no disorder.
— Regular drinkers with a neurotic
disorder were more likely to have experienced an alcohol related
problem in the past year than those without.
— Drug dependence was twice as
common among drug takers with neurotic disorder than among those
with no disorder.
Thus a significant proportion of those with
common mental disorders who are receiving IB may have substance
misuse. This may be apparent, but in many may be undetected. These
problems in this group will require detection and appropriate
treatment in addition to that of their mental disorder.
4. LEARNING DISABILITY
Studies of the employment situation of people
with learning disabilities in the UK have revealed results which
are profoundly disappointing.
For most people in the general population, the
transition to adult life is characterized by a diminution of parental
control and parental involvement in the child's life. But for
many people with learning disabilities, "reality suggests
a greater reliance on parental resources", rather than any
reduction of the dependence on the young person on their parents
(Thorin et al 1996). Furthermore, for most people of normal
intelligence, the transition period from education onwards is
not so much a shift from child to adult services, as it is a move
from school life to the workplace. Most studies of the extent
to which this is true for people with learning disability have
yielded disappointing results, in that the employment levels among
people with learning disability are not high (O'Brien 2001). Given
the clear association which has been found, between a successful
employment placement and a better quality of life for people with
learning disability (Kraemer et al 2003), this is a most
disappointing state of affairs.
In their long term follow up of young adults
growing up in the Aberdeen area of Scotland, Richardson and Koller
(1996) noted that times of high employment in that locality—when
the oil industry was at its peak—resulted in high employment
rates for young men with learning disability, but that, as soon
as the oil boom began to wain, these people were first to be laid
off. This set of findings speaks clearly of the negative attitude
which sadly prevails in the employment of people with learning
disability.
5. EVIDENCE FOR
EFFECTIVE TREATMENTS
Against the scale of the problem should be considered
the availability of effective treatments. Many people with common
mental disorders do not have access to treatments, such as Cognitive
Behavioural Therapy (CBT), that are known to be effective. Probably
less than 10% of those with common mental disorders will receive
psychological therapies. About 30% of people attending their GPs
with depression who need CBT have actually received it (Boardman
et al, 2004). The currently understood effective means
of treating common mental disorders are enshrined in NICE guidelines
and guidance. These cannot be implemented within the current level
of resources of people and money devoted to mental health services.
Perhaps 10,000 additional CBT therapists are needed to deliver
adequate access to psychological therapies (Layard, 2005). Psychological
treatment services for people with physical complaints are particularly
poorly developed.
NICE guidelines for the treatment of schizophrenia
and bipolar disorders also exist, but their implementation is
incomplete and variable across the country.
6. SOCIAL AND
HEALTH BENEFITS
OF WORK
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. 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 (Warr, 1987). 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?"
While work is important for everyone, it is
particularly crucial for people with mental health problems. People
with such difficulties are especially sensitive to the negative
effects of unemployment and to the loss of structure, purpose
and identity which work brings (Bennett, 1970; Rowland and Perkins,
1988). Consider the additional burden that lack of meaningful
activity brings to those with mental ill-health: 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 that occupational
therapy in increasing social networks.
Being in work enhances quality of life (Hatfield
et al, 1992; Hill et al, 1996). Work links the individual
to society; already socially excluded as a result of their mental
health problems, this exclusion is aggravated by unemployment.
Unemployment has been linked with increased
general health problems, including premature death (Brenner, 1979;
Bartley, 1994). There is a particularly strong relationship between
unemployment and mental health difficulties (Warr, 1987; Warner,
1994), with increased use of mental health services (Wilson and
Walker, 1993; Warner, 1994) and increased risk of suicide (Platt
& Kreitman, 1984).
For many people, work is a vital part of therapy
and of the recovery process. In addition, despite the high rates
of unemployment among people with mental health problems studies
indicate that as many as 90% would like to go back to work (Grove,
1999; Rinaldi and Hill, 2000; Secker et al, 2001). There
is increasing policy emphasis on the importance of service users'
preferences and wishes in the provision of services and mental
health service users clearly say that they want to have the opportunity
to work. Assisting people to gain and sustain employment should
be considered a valid "treatment" in its own right which
assists in achieving many of the targets for mental health services
(Posner et al, 1996).
7. BARRIERS TO
WORK
Mental health service users face more significant
barriers to work than other disabled people. Only people with
a severe learning disability find it more difficult to get paid
work. The high rates of unemployment in those with mental illness,
coupled with the desire to obtain work, suggests that work projects
that do exist are only providing a limited and restricted service.
Barriers to employment for mental health service
users include:
— Historically, the employment
of disabled people has depended on economic growth, overall rate
of employment and times of labour shortage (Warner, 1994).
At present there may be a lack of available jobs.
There are about 600,000 jobs presently available, but about 800,000
people with identified mental health problems receiving incapacity
benefit. Thus there are not sufficient jobs to move this entire
group receiving IB into jobs. In addition many of those who have
been out of the job market for a considerable period will require
some retraining: they will commonly lack both confidence and appropriate
skills for the contemporary labour market.
— The impact of mental health
problems on the individual.
The personal, family and social problems associated
with mental illness are considerable and should not be underestimated.
— The welfare system has built
in disincentives to returning to work—the so-called "benefits
trap".
People will often gain little or nothing by returning
to poorly paid work. The "benefits trap" has particularly
adverse consequences for an individual with a recurrent, relapsing
disorder as opposed to a stable level of disability, however severe
this may. This is a consequence of the difficulties people experience
should their attempts to return to work fail.
— The disadvantages faced by people
with a history of mental illness in the open employment market.
These include stigma, a reluctance to employ
them, the risk of failure faced by them and the "benefits
trap".
— 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 extends to GPs, employers and Occupational
Health professionals, who may give insufficient attention to helping
people return to their jobs. The vast majority of individuals
who leave the labour market due to mental health problems do so
before they have any contact with mental health services.
— The dominance of a model of
mental illness that emphasizes episodes and "cure" as
opposed to one that focuses on overcoming the disabilities of
people with long-term mental illness.
A social model of disability and a rehabilitation
philosophy may be more beneficial.
— Lack of expertise in business
development among mental health professionals
— The limitations of evidence
relating to the types of services and approaches that are effective
in getting those with mental illness back to work and keeping
them in employment.
8. DISINCENTIVES
TO WORK
These include:
— Medical review process.
There are concerns that engagement in voluntary
work, education and training—which can help get back to
work—may trigger the medical review process.
These may deter people, who will be at risk of
losing incapacity benefit and associated benefits.
— Transition to work may disrupt
income.
People returning to work will lose housing benefit.
Should the return to work fail they will be at risk of losing
their home.
— Fear of drop in income.
The time period may not be long enough for people
whose illness has a relapsing and remitting course. (For example
the average time to clinical relapse for people being treated
for schizophrenia is approximately two years.)
— Difficulties in getting financial
support for practical needs at work.
Access to Work system may be difficult due to
delays.
— Lack of expert, independent
benefits advice on return to work.
9. WORK FOR
PEOPLE WITH
MENTAL HEALTH
PROBLEMS
Two matters should be considered: First keeping
people in work and second getting people back to work. The implications
of these two matters are different and may be linked to the two
general groups of people with mental health problems outlined
above.
Keeping people in work
When a person goes off work for sickness reasons
they are likely to visit their GP for a sickness certificate.
The decision to issue a certificate of incapacity may have profound
long-term consequences for the patient and their family.
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 (Clinical Standards Advisory Group, 1994; Niemeyer
et al, 1994). 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.
Apart from dealing with certificated sickness
absence, the GP also intervenes by responding to employers' queries
about illness and disability. Medical responses to these queries
can make a significant difference to the outcome of the negotiation
between worker and employer. Most GPs have received little training
in dealing with these demands appropriately and evidence research
suggests that as a consequence the advice given may be often inadequate
and sometimes even unhelpful (Hiscock and Ritchie, 2001).
These medical reports may also be given by secondary
care doctors who are also asked to comment on return to work.
Important in considering return to work are not only appropriate
therapeutic interventions, but also the suggestions for a strategy
for return to work and the provision of "reasonable adjustments".
There is little agreement as to what these strategies and adjustments
may be and studies are required to delineate these.
In addition the attitudes of employers need
consideration:
— Fewer than four in ten employers
would consider employing someone with a history of mental health
problems (Manning and White, 1995).
— 98% of companies surveyed said
they thought the mental health of employees should be a company
concern: less that one in 10 had an official policy on mental
health. (Mind (2005) Stress and mental health in the workplace.)
— 69% of people with mental health
problems were put off applying for a job because they thought
they would be unfairly treated (Read and Baker, 1996 Not Just
Sticks and Stones Mind).
— 52% had had to conceal their
psychiatric history for fear of losing their job (Read and Baker,
1996).
— 38% had been teased or harassed
at work (Read and Baker, 1996).
— 34% had actually lost their
job because of a mental health problem (Read and Baker, 1996).
— 47% people with mental health
problems reported discrimination in the workplace (Mental Health
Foundation, 2000 Pull Yourself Together).
There is a need to:
— Enhance the role and responsibility
of employers in recruiting and retaining.
— Improve the links between employers
and health services.
— Improve the capacity of Occupational
Health services to provide appropriate advice and (if necessary)
treatment in relation to mental health problems.
— Question the assumptions of
health professionals about the value of keeping people in work
when they have suffered a mental health problem.
— Consider measures to maintain
people in work after they have returned and if they suffer a further
episode of illness.
Attention needs to be given to employers' fears
about taking on people with a mental health history and should
look at both how these fears can be minimised and if there is
a role for incentives for employers
Claiming benefits
The first 28 weeks of incapacity are assessed
under the "own occupation test" which looks at a person's
ability to do their usual job and is based on medical certificates
from a GP. After this time, the personal capability assessment
(PCA) applies which involves completing an incapacity questionnaire
(IB50) that assesses ability to do any work.
Forms are difficult to understand and complete.
There may be an "institutional bias" against people
with mental health problems in the incapacity benefit questionnaire
which does not establish information about fluctuating conditions.
The DWP uses a system that allocates points to certain activities
and tasks, with 10 points needed to determine a person's eligibility
on grounds of mental incapacity. Mental health descriptors are
not itemised in the same detail as physical descriptors and a
client is therefore less likely to answer in the way most helpful
to a successful outcome in their case.
The Incapacity Benefit Questionnaire (IB50)
should be Redesigned to ask Specific Questions on Mental Health
Problems.
Getting back to work
Many people with chronic mental health problems
will not have worked for many years and many with severe mental
illness may never have worked, especially if the disorder began
in the early adult years, as is common for people with schizophrenia.
The prospect of returning to work or beginning work is daunting
and the provision of skills and opportunities is important.
In addition, aspects of the benefits system may inhibit
a return to work:
1. LINKING RULE
People with mental health problems have difficulty
getting benefits reinstated if their return to work fails. They
are often not treated sympathetically by the benefit system, in
spite of the linking rule 51 allowing people back onto incapacity
benefit. They also fear disability living allowance (DLA) will
stop if they begin work.
Thus:
— People considering moving back
into work are always and clearly advised about linking rule entitlements
and how to secure them.
— People need not fear the consequences
for their benefit income should their move back into work fail.
— Re-instatement to benefit entitlement
under the linking rules is prompt.
— Joining and completing training
courses as a first step to work should not affect people's entitlement
to benefits.
2. PERMITTED
WORK
Many people with mental health problems cannot
return directly to full time work, and undertaking permitted work
whilst continuing to claim benefits is a route back to employment.
Permitted work allows people who receive incapacity benefit or
income support on the basis of being incapable of work, to work
without losing entitlement to their benefit. The rules and "in
work" benefit entitlements are complicated and clients depend
on advice and help to understand and use them.
Permitted work rules assume that people will
move into full or part time work after 52 weeks. After a year,
an individual has to take on sufficient work to meet their income
needs or reduce their work to something paying less than £20
per week, the permitted work lower limit, perhaps losing out on
any progress they have made. People with mental health problems
may need more time.
Permitted work rules also fail to recognise
that some people will never be able to move into full-time work
and would benefit from doing a small amount of work on a part
time basis indefinitely. The DWP might consider making permitted
work rules into transitional arrangements that are not finite
and which allow people to earn up to the limit for a two year
period after which they could apply for a one year extension at
a time. People who can gradually move into full time employment
could be allowed to earn above the limit and have their incapacity
benefit income tapered to take account of earnings.
The permitted work rules lock people into returning
to work via very low paid work. Thought needs to be given to helping
people back to part time skilled work with higher rates of pay.
3. INCENTIVES
TO RETURN
TO WORK
These are often poor especially as many people
return to work part-time and, for example, lose their additional
benefits (see vi below). Working Tax Credits are open to those
working 16 hours a week or more, but are often complicated. These
may need to be available for those working less than 16 hours
per week.
4. WORK FOCUSED
INTERVIEWS
People with severe mental illness are exempt
from these, but not those with less severe illness.
5. MOVING BACK
TO WORK
Low benefit income means people with mental
health problems usually have no spare funds to cushion themselves
through the transition back to work and the gap between benefits
ending, which are paid on a weekly basis, and work pay starting,
usually on a monthly basis. The piloted Adviser Discretion Fund
will help with travel costs and buying clothes but it will not
help address the difficult interim period between benefit payment
and employment income. The Return to Work credit does not help
people who need help to cover the transitional period from benefits
to employment income, which a run-on of benefit would achieve.
It does not benefit to people who continue working beyond 52 weeks
and who have little prospect of higher rates of pay because they
lack training and skills, which may be the case for many people
with mental health problems.
Maintaining Incapacity Benefit Payment for People
with Mental Health Problems for a Month During their Move Back
into Work should be Considered.
6. MEDICAL REVIEWS
The problems clients face with personal capability
assessments conducted by Medical Services fall into the following
areas:
— doctors not listening to clients;
— poor recording of clinical findings;
— incorrect assumptions based
on information from the client and from the medical examination;
— effects of mental illness not
appropriately taken into account by the scoring system employed;
and
— difficulties in arranging home
visits for some clients.
Regular Training should be a Priority for Medical
Services and the Assessment Tool Currently used needs Revision.
7. LOSING OUT
ON MEANS-TESTED
BENEFITS
Other benefits including means tested benefits
can provide people with assistance at times of extreme hardship
so that people are able to keep a roof over their head and pay
for the essentials of daily living. These include:
10. EVIDENCE
FOR THE
EFFECTIVENESS OF
VOCATIONAL SCHEMES
The present evidence for getting people into
work or keeping them in work may again be divided into evidence
for those with common mental disorders and for those with severe
mental illness.
Evidence for vocational schemes for people with
common mental disorders
A recent review of workplace interventions for
people with common mental health problems, commissioned by the
British Occupational Health Research Foundation (BORFH), revealed
the there is a paucity of good quality evidence for prevention,
retention and rehabilitation of these disorders, but among the
existing evidence:
— Stress management techniques
improve people's ability to cope with stress and to avoid stressful
situations at work. Useful techniques are: teaching problem solving
skills, exercise and rehabilitation.
— For people who have common mental
disorders that are affecting their work, brief individual therapy
(mainly CBT) may be beneficial. Booster sessions may be subsequently
needed.
— There is insufficient evidence
that organisational approaches are effective.
— There is no firm evidence that
stress management techniques can help once people have developed
common mental health problems.
— When people are off work due
to mental disorders an early return to work is aided by line managers
keeping in touch at least once every two weeks.
This evidence combined with the observations
about health services and employers outlined above suggest that
employers, line managers, occupational health professionals, GPs
and mental health professionals need to work together on these
matters. To this we may add the input of Job Centre Plus. This
points to the need to commission services that require joint schemes
between these agencies.
In addition there is a need for more research
in this area, particularly work using job retention as a main
outcome variable, examination of other interventions and organisational
approaches and the effects on different members of the workforce.
At present the results from the Pathways to
Work pilot projects are promising, the statistics suggesting returns
to work are up by 10%. The pilot projects wisely target the organisations
that need to liaise: employers, health services and Jobcentre
Plus, but two matters require caution. The first concerns the
selection of subjects for the pilots. It must be borne in mind
that claimants taking part in the pilots are either new claimants
or long term claimants who have volunteered to take part in the
pilots. By definition these two groups are respectively, close
to being job ready and/or self-motivated. Other claimant groups
may not have these features. The second is the longer term outcome
of these projects, for example do the people who return to work
remain in work?
Evidence for vocational schemes for people with
severe mental disorders
The strongest evidence for vocational schemes
for people with severe mental disorders comes from Supported Employment
schemes. These schemes place clients in competitive jobs without
extended preparation and provide on the job support from employment
specialists or trained "job coaches" (Becker et al
1994). A person is hired and paid by a real employer. 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. The core principles of supported
employment are:
— The goal is competitive employment
in work settings integrated into a community's economy.
— Clients are expected to obtain
jobs directly, rather than after lengthy pre-employment training.
— Rehabilitation is an integral
component of treatment of mental health rather than a separate
service.
— Services are based on client's
preferences and choices.
— Assessment is continuous and
based on real work experiences.
— Follow-on support is continued
indefinitely.
There are several types of supported employment
programmes, for example, the Assertive Community Treatment Model,
transitional employment (for example, the clubhouse approach)
and the Job Coach Model (Bond et al, 1997). The model that
emerges from the literature as the most promising programme so
far is known as Individual Placement and Support (IPS)
(Becker et al, 1994). In IPS the emphasis is on rapid placement
in work with intensive support and training on the job.
There have been several reviews of the effectiveness
of work schemes and most evidence comes from studies conducted
in the USA (Bond et al, 2001; Crowther et al, 2001).
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.
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. As yet we do not know how effective
these approaches will prove to be within the UK, which has both
a radically system of social welfare and a markedly different
job market to the USA. Of particular importance are the cost-effectiveness,
the clinical and social outcomes, and job retention of Supported
Employment schemes.
There are several critical components of successful
employment schemes:
— The agency providing supported
employment is committed to competitive employment as an attainable
goal for those with severe mental illness.
— Supported employment programmes
use a rapid job search approach to helping clients obtain jobs
directly (rather than providing lengthy pre-employment assessment,
training and counselling).
— Staff and clients find individual
job placements according to client preferences, strengths and
work experiences.
— Follow-up supports are maintained
indefinitely.
— Supported employment programmes
are closely integrated with mental health teams.
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.
11. THE ROLE
OF JOBCENTRE
PLUS
Jobcentre Plus should have two main objectives
for all disabled people, including those with or those with mental
health problems:
— to help people get work or improve
their chances of getting work, including advice on in-work financial
help; and
— to make sure that people are
aware of all the benefits and other help available, are helped
to access them and receive their entitlement quickly and accurately.
We are aware that Advisors are not sufficiently
trained to deal with people with severe mental health problems,
they often have an inadequate knowledge of the highly complex
benefits system as it affects people with disabilities and there
are inadequate working arrangements with Community Mental Health
Teams. These issues must be addressed.
12. HEALTH SERVICE
MANAGEMENT AND
COMMISSIONING
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).
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.
11. ROLE OF
MENTAL HEALTH
SERVICES
Mental Health Trusts have a role to play in
getting people back to work. This may be as exemplar employers
with clear policies and schemes to employ mental health users,
such as the St Georges Mental Health Trust. In addition, their
work places may be designed to be conducive to mental health and
to supporting those who develop mental health problems. The organisation
of their services, such as the Community Mental Health teams (CMHTs)
and rehabilitation services need to develop systems aimed to introduce
users to benefits advice, employment opportunities and pathways
into meaningful activities.
12. PRINCIPLES
FOR THE
NEW BENEFITS
SYSTEM
The system must be fair. It must recognise the
importance of a wide range of return to work activities and must
be tailored to meet the needs of individuals. In addition to examining
the needs to retain people in work and help in returning to work,
it specifically needs to cater for those for whom full-time work
would never be a realistic option, and those with diminishing
or fluctuating work capacity. It should also recognise the needs
of those disabled people who have never worked before. Full-time
work, part-time work, voluntary work, starting work and work retention
activities all need to be included in the scope of the system.
The system must not prejudice one disabled group over another.
This may be a reason for re-examining the assessment for benefits
system to ensure that people with mental health problems are not
unjustly prejudiced.
The system must provide security. The risks
associated with moving into work, or even just trying out work,
can be a major disincentive for people with mental health problems.
For example, many disabled people report that one of their biggest
fears is that trying out work will result in their Disability
Living allowance (DLA) being reviewed. DLA is payable to people
in paid employment but for some groups of people with mental ill-health,
a move into work can be taken by the DWP as a signal that their
condition has improved, and prompt a review of their DLA. For
some people this may be true but for many others the first few
weeks or so in a new job can be more stressful that remaining
on benefit. The possibility of loss of DLA, during this period,
can be a major disincentive, especially if people are worried
about their ability to cope with paid employment. A period of
say, six month as a "settling-in guarantee" may be necessary
under which disabled people are guaranteed that their DLA will
not be reviewed. This allows time to settle into a new job, and
to ensure that it is going to be sustainable.
The system must be socially inclusive. People
with mental health problems require a decent income, good social
and health care, as well as access to education, and training,
in order to play their full part in society according to their
abilities. Comprehensive benefits advice is crucial to this. Consideration
must be given to those who do not get into work and chances and
opportunities must be open to them that allow them to participate
in other ways.
A number of the problems experienced by people
with mental health conditions are shared to an extent by other
groups of disabled people. The side effects of medication or treatment,
adjusting to changes in dosage levels, or fluctuating/deteriorating
physical health, will all affect an individual's ability to be
consistent in their approach to work-related activities. There
needs to be flexibility around targets and an understanding of
reasons for non-compliance by people in these groups.
Agnes Wheatcroft
28 September 2005
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