Select Committee on Work and Pensions Minutes of Evidence

Memorandum submitted by The Royal College of Psychiatrists


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.


  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.


  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.


  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.


  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.


  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.


  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).


  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.


  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.

    —    Permitted work rules.

    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.

    —    52-week linking rule.

    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.


  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:


  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.


    —    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.


  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.


  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.


  People with severe mental illness are exempt from these, but not those with less severe illness.


  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.


  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.


  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:

    —     housing benefit;

    —     the social fund;

    —     income support; and

    —     prescription charges.


  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.


  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.


  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.


  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.


  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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