Select Committee on European Union Fourteenth Report

CHAPTER 6: Social exclusion, stigma and discrimination

141.  The Green Paper[44] states that, despite improved treatment options and positive developments in psychiatric care, people with mental health problems still experience social exclusion, stigmatisation, discrimination, or their fundamental rights and dignity are not respected. Many of our witnesses reinforced this point. With the exception of sexually transmitted diseases, no other health problem appears to attract the same public response. Ignorance, stigma and discrimination are commonplace. These issues are obviously closely linked to the denial of basic human rights, as discussed in the previous chapter. There are also close links to promotion and prevention, which we discuss in Chapter 7.

Social exclusion—the challenge

142.  The term "social exclusion" was initially used as a simile for poverty, but has grown to acquire a wider interpretation. It would now encompass unemployment, poor quality housing or homelessness, limited social networks, and restricted participation in social, economic and political life.

143.  The 2004 report from the Government's Social Exclusion Unit clearly set out the connections between mental health problems and social exclusion. It suggested that there were five main reasons why mental health problems too often led to and reinforced social exclusion, stigma and discrimination: low expectations of what people with mental health problems can achieve; lack of clear responsibility for promoting vocational and social outcomes; lack of ongoing support to enable them to work; and barriers to engaging in the community.[45]

144.  Some or all of these same dimensions were identified in evidence submitted to us (for example: pp 120-123; pp 60-63; pp 140-144). Mind strongly advocated a strategy that addressed the deprivation and marginalisation experienced by people with mental health problems as essential within the European Union's broader commitment to solidarity, community and social justice (pp 54-60).

145.  Rethink emphasised the need to focus on social cohesion, dependent in turn on the fulfilment of individual human rights and social inclusion as a citizen, as well as community acceptance of individual difference. They warned that some groups were more vulnerable than others, identifying: women who were single parents or who experienced domestic violence; Black, Asian and other ethnic minority groups; the homeless; and unemployed people (pp 60-63). The NHS Confederation (pp 144-145) also emphasised the centrality of social cohesion.

146.  As noted in Chapter 3, people with mental health problems experience above-average mortality rates. If an early death is the ultimate form of social exclusion, then denial of basic human rights is not far behind. The summary of evidence on rights in Chapter 5 shows that a large number of people with mental health problems in many European countries are still denied some of the most basic rights generally enjoyed by the rest of the population. Most fundamentally, those people who spend large parts of their lives incarcerated in asylums or other institutions, separated from the normal opportunities to socialise, to work, to travel, to have personal relationships and to live in a family, are among the most socially excluded people in Europe today.

147.  As we also described in the previous chapter, many organisations and individuals called for the Commission to put greater emphasis on deinstitutionalisation. The Open Society Mental Health Initiative thought there was insufficient emphasis in the Green Paper on the need to ensure that all Member States both commit to, and implement, policies to eliminate to the extent possible the practice of holding people with mental health problems in institutions (deinstitutionalisation). This meant not only closing the large dehumanising institutions but also (and indeed ahead of closure) developing comprehensive community-based services. They took the view that to segregate people, bar them from access to education and employment or deny them the right to choose where and how they lived and with whom they associated, solely on the basis of a mental disability label was unacceptable. The nature of institutions was, in itself, dehumanizing; and the existence of institutions was anathema to the concept of a civil and open society in which the rights of all citizens were respected (pp 155-159).

148.  The Mental Disability Advocacy Center (MDAC) in Hungary also criticised the Green Paper for failing to give an unequivocal commitment to the closure of all institutional services. Their interpretation of the Green Paper's encouragement to Member States to assess "how the Structural Funds can be better used to improve long-term care facilities and health infrastructure in the field of mental health" was that it supported the existence of institutions and long-term social care homes. It should be noted that the MDAC employs the latter term in the way it has been used in discussions of large, substandard facilities run by social welfare agencies in many central and Eastern European countries—see the discussion of this terminology in Chapter 5 of this report. Instead, the MDAC wanted structural funds to be used to create good community-based services orientated towards recovery, self-help, integration and crisis management (pp 134-140).

149.  Ms Camilla Parker (a legal and policy consultant working on the field of mental health disability and human rights) argued that, if the Commission and national governments were to be serious about promoting mental health, then they needed to tackle the extreme social exclusion of people placed in institutions for years on end, sometimes for life. The first step in a European-wide strategy, she argued, had to be to close the long-stay institutions and build good community-based alternatives (Q 173).

150.  However, as the NHS Confederation stated, people with mental health problems suffer from community isolation even after deinstitutionalisation. They suggested that to receive treatment and care in the community guaranteed very little (pp 144-145). The European Public Health Alliance wanted the Commission's strategy to encourage better access to social housing and greater efforts to help homeless people with mental health problems to be "socially reinserted" (pp 115-117).

151.  The Minister also called for better access to supported housing, especially for those people who have been living in institutions for many years (Q 234). At the same time, she argued, there was a need to try to tackle the stigma and discrimination that many people faced from an uninformed general public when placements in the community were being considered. This would not be easy. As the NHS Confederation remarked, there was public concern about risk, and it was a reality that many criminal offenders had diagnosable mental health problems. Whether public perceptions of the size of the risk were accurate was another matter (pp 144-145). We discuss below the role of the media in the portrayal of mental health problems.

152.  Some people with mental health problems—indeed it would appear to be a growing number—are in prison. The Mental Disability Advocacy Center suggested that prisoners and people in (long-stay, institutional) social care homes with mental health problems were vulnerable to abuse and mistreatment (pp 134-140). Mind wanted people in prison to be added to the Green Paper's list of marginalised groups that should be targeted in the strategy. They cited the Social Exclusion Unit's estimate in 2002 that 72 per cent of male prisoners and 70 per cent of female prisoners suffered from two or more mental disorders, proportions that were 14 and 35 times, respectively, the levels found in the general population (pp 54-60).

153.  Although most of our evidence referred to the social exclusion experienced by people as a result of their mental health problems, the case was also made that social exclusion could itself be a risk factor for poor health, including mental health. Mind drew our attention to Annex 7 of the Green Paper which summarised material from the World Health Organization identifying key risk factors. These included:

• exposure to drugs and alcohol;
• displacement, isolation and alienation;
• lack of education, transport and housing;
• neighbourhood disorganisation;
• peer rejection;
• poor social circumstances;
• poor nutrition;
• poverty;
• racial injustice and discrimination;
• social disadvantage;
• urbanisation;
• violence and delinquency;
• war;
• work stress; and
• unemployment.

Mind was therefore concerned that a "medical model of mental health"—which they saw as still dominant in many countries—would obscure the social causes and contexts of mental distress (pp 54-60).

154.  Rethink noted the close link between unemployment and mental health problems, and referred to the Social Exclusion Unit report that social isolation was an important risk factor for deteriorating mental health and suicide; and that two-thirds of men under the age of 35 with mental health problems who died in the UK by suicide were unemployed (pp 60-63).

155.  Dr Marcus Roberts from Mind returned to this theme. He found it interesting that the Commission should have become more concerned about mental health problems as awareness has grown about their social and economic causes. He said that the EU did not have competence in the mental health field as such, but that once the social and economic causes and consequences were recognised, then it would become a matter of great interest and relevance. The EU might then want to approach other policy areas in ways that were "mental health-proofed", i.e. checking legislation and reports for their likely impact on mental well-being. He suggested that the EU might go further. When investing in measures to tackle, for example, social exclusion or employment, some proportion of resources might be specifically identified for projects that promote better mental health (Q 141).

Social exclusion—need for action

156.  Department of Health officials described to us the national, cross-departmental social inclusion programme that was part of the wider approach to mental health, built upon the work of the Social Exclusion Unit that we quoted earlier in this chapter. Government departments and delivery agencies, working with local authorities and different tiers of the NHS, were endeavouring to coordinate initiatives in the areas of housing, employment, welfare benefits as well as health and social care, with particular targets including homeless people, offenders, asylum seekers and other marginalised groups (Q 96).

157.  The Green Paper[46] in contrast, does not go into any detail when discussing action to combat social exclusion, except for the recommendation—welcomed by many of our witnesses—that through the consultation process it would be hoped to identify best practice for promoting the social inclusion and protecting the rights of people with mental health problems.

158.  The Mental Disability Advocacy Center was critical of the Commission's proposals for action, which, they said, were weak and needed to become more concrete and tangible. They were also critical of the top-down approach, and suggested that the achievement of long-term impact required guidance "on all levels" (pp 134-140).

159.  The Mental Health Foundation wanted an EU mental health strategy to cover discrimination, employment, mental health promotion and access to fundamental rights such as decent housing and education (pp 140-144). The International Longevity Centre also supported a European strategy that sought to improve both the health and social inclusion of people with mental health problems. They pointed to the critical role played by patient/family engagement in advancing social inclusion and human rights. This led them to recommend the joint training of patients, family members, professionals and policymakers in advancing social inclusion and in countering stigma and discrimination. The EC-supported LEONARDO programme and other initiatives offered an example of such an approach (pp 120-123).

160.  Liz Sayce and Claire Curran[47] review the limited progress with the promotion of social inclusion. They find that, to date, there has been no national or European initiative strong enough to make a significant system-wide impact on rates of exclusion faced by people with mental health problems or psychiatric disabilities. As they point out, this is despite an EU Directive on employment in 2000 that required governments to outlaw discrimination on grounds including disability, and a promised but not yet delivered Directive on disability discrimination.

161.  We conclude that social exclusion is itself a risk factor for poor health, including mental health problems. We think therefore that action to address the mental health needs of the population should recognise the social causes and contexts of mental distress. We strongly support the Commission's proposals to address this social exclusion.

162.  We recognise that the Government has arguably done more than most Member States to recognise the problem of social exclusion of people with mental health problems, and has taken a number of initiatives to address the problem. Nevertheless, there is still a long way to go, and we recommend that the Commission should support concerted efforts by Member States and others to counter the social exclusion of people with mental health problems, who experience disadvantage in many areas, including housing, employment, access to services, income and participation.

163.  We accept that a particularly difficult challenge is the number of people with mental health problems who are in prison, where their mental health needs may not get recognised or appropriately treated. We recommend that the Commission should encourage Member States urgently to examine the services available to recognise and to treat those with mental health problems in prisons.

Stigma and discrimination

164.  Professor Graham Thornicroft of King's College London, Institute of Psychiatry, suggested an agenda for mental health policy. His starting point was the widespread discrimination experienced by people with mental health problems "at home, at work, in personal life, in social activities, in healthcare, and in the media". He made the distinction between ignorance (the problem of knowledge), prejudice (the problem of attitudes) and discrimination (the problem of behaviour). Stigma stemmed from these three: from the widespread misunderstanding of mental health; from the fear, anxiety and avoidance of the general public and of people with mental health problems ("self-stigma" because they anticipated rejection and discrimination); and from the evidence that discrimination blighted the lives of many people (pp 22-27).

165.  In its Green Paper[48] the Commission recognised these problems, stating that people with mental health problems met fear and prejudice from others, often based on misconceptions. They also recognised that stigma increased personal suffering and social exclusion, and could impede access to housing and employment.

166.  Dr Marcus Roberts of Mind noted the high costs of stigma: "...it is stigma that keeps people out of work, it is stigma that stops them approaching services when they need help, and it is stigma that keeps people isolated because they do not integrate into their community, and therefore it perpetuates in a vicious circle [the] wider causes of mental health" (Q 149).

167.  Many others reiterated these concerns to us. Rethink reported how the stigma surrounding mental health problems could prevent people from forming close personal relationships, which compounded their isolation, adding to the vicious cycle that connects social exclusion and mental heath (pp 60-63). One of the recommendations they suggested was education to improve public awareness of mental health. The King's Fund commented that stigma was a major barrier to recovery (pp 124-127); but the Royal College of Psychiatrists suggested that stigmatising attitudes—or at least "negative attitudes or indifference"—were often displayed by health care staff (pp 161-164).

168.  The Open Society argued that tackling stigma was essential if Member States were to make progress in pursuing the first three priorities identified by the Green Paper, i.e. promoting mental health; preventative action; and improving quality of life through social inclusion and protection of rights and dignity (pp 155-159).

Action to tackle negative attitudes and discrimination

169.  Professor Thornicroft helpfully set out a number of suggested actions to counter the negative attitudes and stigma experienced by people with mental health problems. He distinguished action to support individuals and their families, action to support people with mental health problems at their place of work, actions needed at the local level, and actions needed at the national level. In Table 3, at the end of this chapter, we detail the actions suggested by Professor Thornicroft. He also described action to support service user advocacy groups (pp 22-27).

170.  Among Professor Thornicroft's recommendations were a number of specific actions that should be taken at international level. He noted the standards set out by the World Health Organization as a guide to countries that were producing for the first time or revising their mental health laws. These covered areas such as involuntary treatment, restraint, privacy and seclusion. At European level, action should be taken to enforce anti-discrimination laws in relation to employment (see the next section of this chapter). European health ministers should also ensure that they implement the Mental Health Declaration and Action Plan to which they gave their assent following the 2005 Helsinki discussions. The priorities set out there included the need to foster awareness of mental health problems, and the commitment to tackle stigma, discrimination and inequality.

171.  Others drew our attention to the need for the Commission and national governments to recognise that a number of pieces of legislation already existed that should guard against stigma and discrimination. The Mental Health Foundation made this point, and referred specifically to the Disability Discrimination Act in the UK that stated that people should not be discriminated against on the grounds of disability, including disability stemming from poor mental health. Enforcement of anti-discrimination legislation was clearly to be encouraged, but would be unlikely to be sufficient unless backed up by other initiatives (pp 140-144).

172.  Mind and Rethink also referred to existing legislation, and wanted mental health to be "mainstreamed" as a core disability rights issue. However, they warned that language was important and that it might not be helpful simply to assimilate mental health within disability as it could confuse the issue (QQ 143-146).

173.  The NHS London EU Unit urged the Commission to promote "one-stop shops" to provide information about, and assistance with, mental well-being in non-stigmatising settings, and to encourage Member States to share best practice examples of how to challenge stigma and discrimination (pp 145-148). The Scottish Association for Mental Health recommended that other countries learn from the award-winning "See me" anti-stigma campaign in Scotland, which was showing early signs of success. Mind and Rethink noted that this campaign was funded by the Scottish Executive from revenue raised through a tobacco levy in Scotland. They applauded this link (Q 148).

174.  In England, the Department of Health has established Shift, a national anti-stigma and discrimination programme launched in 2004. Shift is a communications-driven programme that works with the media, schools, private and public organizations to reduce stigma and discrimination. Shift endorsed the key priorities of the Green Paper, which corresponded to the key objectives of the National Social Inclusion Programme (NSIP) which built on the Social Exclusion Unit report. The NSIP worked across government departments to influence policy and raise awareness of the non-health needs of people with mental health problems, and also worked with partners in the health field to promote better social inclusion. Shift recommended that mental health needs should be addressed within broader EU strategic policy objectives. The illustration they offered was in relation to employer practice that can have a large impact on the mental health of employees (p 171).

175.  However, Mind and Rethink lamented the small budget allocated to Shift: £873,000. This was, they said, about one twentieth the size of the budget for the successful anti-stigma campaign in New Zealand, which had significantly changed attitudes. Expenditure per head of population on their anti-discrimination work in New Zealand was 34 pence, compared to 13 pence in Scotland and just 1.44 pence in England. The New Zealand campaign was also long-term (funded for five years) whereas Shift was funded from year to year, and delivered by a coalition of voluntary organisations (QQ 146-149).

176.  Referring to the European Parliament's response to the Green Paper,[49] Mr John Bowis MEP identified defeating stigma as the most important of the specific areas of action set out in the document (Q 112). Stigma was a wholly unnecessary added burden to an illness which had to be tackled as a human rights abuse. Individuals need legal protection in access to work, leisure and services, and the public needed to be educated to get a better understanding of mental health problems, which would—he argued—improve tolerance. He also argued that better coordination between agencies (health, social work, housing, employment service, social security) would help to defeat stigma (Q 127).

177.  The Mental Health Foundation identified the central role played by the media in influencing public perceptions of mental illness, but lamented the way the media generally reinforced negative misperceptions (pp 140-144). Whether the media could ever be persuaded to challenge stigma was an open question. Department of Health officials referred to the "discriminatory attitudes" of the media (Q 94). The Samaritans organisation was critical of the Green Paper's failure "to engage the need for media to be engaged both as a group to influence and a channel to utilise". They explained that the Samaritans themselves produced media guidelines on the representation of suicide and monitor media output in an attempt to encourage "positive, non-stigmatising and alternative messages on the portrayal of mental ill health and suicide" (pp 164-167).

178.  The Minister (Q 224) also identified the need to try to work with the media to alter how they portrayed mental health problems. She pointed to some of the successes achieved by the Shift programme (Q 237), suggesting that work with the media had been "quite successful", and that some of the campaigns by the BBC, targeted at young people, had also been effective. Work with employers, mentioned in Shift's own submission to the Inquiry, was encouraging.

179.  Mr John Bowis MEP (Q 112) referred to some of the high profile cases involving people with mental health problems that had attracted a lot of media coverage. He was concerned that every such incident gets reported three times by the media—once when the incident occurred, a second time when there was a court case, and a third time when the conclusions of any formal inquiry were published. This could mislead the public into thinking there were three separate incidents. He referred to the tabloid headlines that generated letters to Members of Parliament and to local councillors from "frightened or worried constituents". More needed to be done, he argued, to undermine the widespread ignorance about mental health.

180.  A number of witnesses argued that one way to change attitudes, break down stigma and counter discrimination was to help people with mental health problems to be empowered in ways which help to address their problems. Professor Thornicroft noted that "empowerment" had been described as the opposite of "self-stigmatisation". He made a number of recommendations to help to empower people with mental health problems, including: participation in formulating care plans and crisis plans; using therapy to reverse negative self-stigma; collecting consumer satisfaction ratings of services; creating user-led and user-run services; developing peer support worker roles in mainstream services; advocating for employers to give positive credit for experience of mental health problems; and participating in research on treatment and care (pp 22-27).

181.  Rethink called efforts to support the greater involvement of mental health service users by giving them the correct medication, adequate support in accessing services, and reducing barriers to accessing services, not only in mental health services but all services, particularly housing and education. The voices of service users and carers needed to be heard. They argued that enabling participation, and maintaining involvement, in society helped people with mental ill health to remain active citizens (pp 60-63).

182.  The International Longevity Centre (pp 120-123) and the London NHS EU Unit (pp 145-148) saw empowerment and social integration as being at the heart of initiatives to improve the health and quality of life of people with mental health problems. Mind (pp 54-60) urged the Commission to ensure that any efforts to promote mental health included a substantial input from those who had experienced mental distress.

183.  Department of Health officials emphasised the difficulties of tackling stigma and discrimination, and hence the value of learning from the experiences of other countries. They referred to a small and growing body of expertise on what worked, but considered that this did need nurturing and helping by contacts. They also reinforced what others had said, that defeating stigma required action from a range of sectors and was not exclusively a health sector responsibility. They mentioned the launch by Ministers of the Action on Stigma campaign on World Mental Health Day in October 2005, which sought to engage major employers in fighting stigma. The campaign had started with NHS employers, to "get our own house in order first" (Q 94).

184.  We are persuaded that to improve public understanding of mental health problems would help to counter the negative attitudes that are often expressed. To achieve this, we recommend that efforts should be continued and reinforced to raise public awareness as to the extent, causes, characteristics and impact of mental health problems (sometimes called improvements to "mental health literacy").

185.  While we recognise that different approaches might work best in different countries, we believe that Member States should be encouraged to make a commitment to tackling stigma and discrimination and to promoting the social integration of people with mental health problems. Member States should also be encouraged to work towards a code of good practice and to share examples of successful initiatives.

186.  Our view is that mental health problems should be recognised as coming within the scope of anti-discrimination legislation relating to disability and that, to the extent that such legislation exists already, it should be enforced and its impact should be monitored. Member States that do not have such legislation should be encouraged to introduce it.

Employment problems

187.  While most people with mental health problems, even severe problems, want to work, employment rates can be extremely low, as we saw in Chapter 3. But a Healthcare Commission survey in 2004 of 27,000 mental health service users in England found that a third had not received any help with finding work.[50] Loss of employment can equate to severely reduced income, as well as losses to social networks, pension and other entitlements. Work is also a normalising experience, allowing people to participate more fully in society and can promote self-esteem and quality of life. In short, it considerably enhances the chances of social inclusion.

188.  Mr John Bowis MEP as we noted earlier, cited the defeat of stigma as the most pressing issue for a mental health strategy (Q 112). Another key priority he identified was the need to educate employers and the trades unions about the importance of mental health in the workplace. The welfare of people at work, he noted, had been a very direct responsibility of the EU since the Treaty of Rome. While accident prevention at work had received a lot of attention, the mental health needs of the workforce had been neglected (QQ 112, 130).

189.  Many other witnesses also emphasised the central role played by discrimination in employment. The London NHS EU unit noted that stigma, discrimination and exclusion from employment affect economic prosperity (pp 145-148). The NHS Confederation urged national governments to make commitments to raise employment rates of people with mental health problems, similarly pointing to the compelling business case for increased labour market participation. The Confederation saw this as instrumental to efforts to tackle discrimination and "the myths of mental illness" (pp 144-145).

190.  Mind saw stigma as a barrier to employment for people with experience of mental health problems. Lack of flexibility among employers was also an issue. Mind referred to the Social Exclusion Unit report on mental health and social exclusion, which found that fewer than four in ten employers would consider employing someone with a history of mental health problems, compared to more than six in ten for physical disability. They referred also to the more recent survey by the Chartered Institute of Personnel and Development that found that more than 60 per cent of employers disregarded applications from people with drug or alcohol problems, criminal records, and a history of mental health problems or incapacity. Half the employers surveyed said that nothing would persuade them to recruit from these "core jobless" groups. Despite these reports indicating the need for improvement in the attitudes of employers in the UK to mental health issues, Mind worryingly thought that employers' attitudes to mental health were probably more progressive in the UK than in some other EU countries (pp 54-60).

Action to address employment problems

191.  A number of appropriate actions were identified by witnesses. West Sussex County Council described how they were endeavouring to encourage more progressive attitudes and approaches by employers. One approach they were using was to train employers to have a better understanding of the challenges of employing people who experienced mental health problems (pp 174-176).

192.  Professor Thornicroft recommended a number of actions to support people at work (see Table 3 at the end of this chapter). Just as workplace modifications were made for people with physical disabilities, so it was necessary to make "reasonable adjustment" (as the Disability Discrimination Act requires) for people with mental health-related disabilities. Among the examples he offered were the following measures: flexibility in work hours so that people could attend appointments for treatment, or could work when they were not impaired by their medication; more gradual induction phases for people returning to work after a prolonged absence or for people with some cognitive impairment; reallocation of marginal job functions which caused an individual anxiety; and efforts to raise disability awareness among all employees to reduce stigma (pp 22-27).

193.  This point was also made by Ms Camilla Parker. She noted that people often interpreted the "reasonable accommodation" requirement of the European Directive on employment[51] simply to mean making buildings accessible to people with physical disabilities, but it needed to be extended to include the more challenging task of flexibility for people with mental health problems. She wanted the Commission to use its proposed platform to engage with employers and with individuals—improving awareness of obligations and rights—so as to encourage better working practices (QQ 185-186).

194.  Both the Minister (Q 224) and Department of Health officials (Q 94) referred to the Government's Health, Work and Wellbeing strategy on which the Department for Work and Pensions, the Health and Safety Executive and the Department of Health were collaborating. The aim was to get employers to play their part in acknowledging and dealing with mental health problems in the workplace, while ensuring that people did not feel excluded or that they have to leave work.

195.  The Minister also described the work done with employers as part of the Shift campaign, encouraging greater openness about mental health. She cited the efforts of big employers such as Royal Mail and BT to share their experiences of how they have dealt with those issues, and particularly how they had taken responsibility to adapt working environments. She referred, also, to "changing the culture", partly through the Pathways to Work projects that were trying to help people with mental health problems back into the workforce—"to maximise everyone's potential and skills and keep them at work"—and partly through exploration of a code of practice for employers, that would aim to develop a healthier workplace. At this stage, the Government was working with voluntary guidance and was monitoring how much progress could be made in that way (Q 238).

196.  Ms Winterton MP also drew attention to the guidance issued to employers in October 2005, some of it voluntary and some of it reminding them of their obligations under the Disability Discrimination Act (p 107).

197.  At a European level, Professor Thornicroft noted that anti-discrimination laws were now mandatory under the EU's Article 13 Directive,[52] making it illegal to discriminate in the workplace on grounds that include disability. Member State governments had also to enforce these laws. He suggested that it would be timely to share experience on how successful such laws had been in reducing discrimination against people with mental health problems. This could provide a basis for identifying the need for further or amended legislation (pp 22-27).

198.  The Mental Health Foundation also wanted employers and employees to be made aware of their duties and rights under European and national legislation. They suggested that "If Member States' laws were inadequate in this regard, they should be encouraged and supported to introduce legislation". The Foundation suggested that the European Commission might lead by example by implementing positive and proactive employment initiatives for its own staff with experience of mental health problems (pp 140-144).

199.  Dr Matt Muijen (Regional Adviser for Mental Health at the European Region of the World Health Organisation) warned against the risk, if mental health problems were singled out for special attention in a legal framework, that employers might seek to avoid employing people with mental illness altogether. Including mental health within mainstream disability would help to avert this danger (Q 212). He did not support legislation that would require employers to employ a certain percentage of people with mental health problems, as he saw this as unenforceable. Instead he suggested that incentives to employers would be more helpful for example giving subsidies or tax breaks for good practice. It was important to support people in the workplace, including support for people wanting to get back to work (Q 219).

200.  Dr Marcus Roberts from Mind (Q 150) floated the idea of a European Directive or similar instrument that would require businesses above a certain size to have proper mental health policies. He referred to the UK Access to Work scheme which provided funding to employers to make workplace adjustments to help people with disabilities, including mental health problems, thus removing the financial barrier. Applications were made by individuals. For small businesses it could be hard to introduce flexibility, and it might be that government needed to provide compensatory funding. He also supported social enterprise models as good vehicles for reintegrating people into work.

201.  Mr Paul Corry from Rethink (Q 150) agreed that there were particular issues for small employers. He wanted to stress, however, that people with mental health problems, when they were actually in work, had higher productivity rates than the general workforce because their motivation was higher.

202.  Not everyone will be able to work, even with better flexibility and other reasonable adjustments. As Mind suggested, people who were not able to get into paid employment should be encouraged to get involved with voluntary work because of the many benefits that could follow. Mind felt that these kinds of projects made a vital contribution to the well-being and social inclusion of people with mental health problems, and that it was important that they were properly funded as part of a comprehensive European mental health strategy (pp 54-60).

203.  We recognise that a key area of exclusion and stigma is employment, and that disadvantage in employment has major economic and social consequences. We recommend that the Commission should encourage Member States to work with employers to help them to recognise the economic benefits of mental health promotion/prevention, and to agree a code of practice.

204.  We understand why small businesses might find it economically difficult to put in place the flexible working arrangements that can help people with mental health problems. We urge Member States to seek practical means of helping small businesses to comply both with the legislation and with any voluntary codes of practice.

205.  We recommend also that the European Commission should consider introducing a "reporting obligation" for Member States to monitor how employers are performing in relation to the employment of people with mental health problems.

TABLE 3

Suggestions by Professor Thornicroft (Consultant psychiatrist at the South London and Maudsley NHS Trust) for actions needed to form a strategy for mental health

Action to support individuals and their families

Action	By
Develop new ways to offer diagnoses Have information packages for family members that explain causes, nature and treatments of different types of mental illness Actively provide factual information against popular myths Develop and rehearse accounts of mental illness experiences which do not alienate other people	Mental health staff Mental health staff, consumer and families Mental health staff Mental health staff and consumer groups

Actions needed at the local level

Action

By

Introduction of supported work schemes Psychological treatments to improve cognition, self-esteem and confident Health and social care explicitly give credit to applicants with a history of mental illness when hiring staff Provision of reasonable adjustments/accommodations at work Inform employers of their legal obligations under disability laws Deliver and evaluate the widespread implementation of targeted interventions with targeted groups including school children, police and healthcare staff Provide accurate data on mental illness recovery rates to mental health practitioners Implementation of measures to support care plans negotiated between staff and consumers

Mental health services with specialist independent sector providers Mental health and general health services Health and social care agencies Mental health providers engaging with employers and business confederations Employers' confederations Education, police and health commissioning and providing authorities Professional training and accreditation organisations Mental health provider organisations and consumer groups

Actions needed at the national level

Action

By

Use a social model of disability that refers to human rights, social inclusion and citizenship Apply the anti-discrimination laws to give parity to people with physical and mental disabilities Inform all employers of their legal obligations under these laws Interpret anti-discrimination laws in relation to mental illness Establish service user speakers' bureaux to offer content to news stories and features on mental illness Provide and evaluate media watch response units to press for balanced coverage Share between countries the experience of disability discrimination acts Understand and implement international legal obligations under binding declarations and covenants Audit compliance with codes of good practice in providing insurance Providing economic incentives rather than disincentives to disabled people ready to return to work Change law to allow people with a history of mental illness to serve on juries with a presumption of competence

Governments and non governmental organisations (NGOs) to change core concepts Parliament and government Employment ministry or equivalent Judiciary and legal profession NGOs and other national level service user groups Statutory funding for NGOs to provide media watch teams Legislators, lawyers, advocates and consumer groups NGOs to communicate legal obligations of all stakeholders, and health and social care inspection agencies to audit how far these obligations are respected in practice Associations of Insurers with Service User organisations and mental health NGOs Employment Ministries to introduce new and flexible arrangements for disabled people to work with no risk to their income Justice Ministries to amend the law relating to jury service

Taken from evidence submitted by Professor Graham Thornicroft (Consultant psychiatrist at the South London and Maudsley NHS Trust)

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44   op. cit. p. 5 Back

45   Mental Health and Social Exclusion-Social Exclusion Unit Report, ODPM 2004 Back

46   op. cit. p. 12 Back

47   Page 34 of their chapter "Tackling social exclusion across Europe" in Mental Health Policy and Practice across Europe (edited by Martin Knapp et al., Open University Press, 2007) Back

48   op. cit. p. 11 Back

49   European Parliament resolution on Green Paper 2006/2058(INI)-adopted 6/9/2006 Back

50   Healthcare Commission (2004) Patient Survey Report 2004-Mental Health, Healthcare Commission. Back

51   We understand this to be a reference to Article 5 of Council Directive 2000/78/EC of 27 November 2000 establishing a general framework for equal treatment in employment and occupation [2000] OJ L 303/16. Back

52   We understand this to be a reference to Council Directive 2000/78/EC of 27 November 2000 establishing a general framework for equal treatment in employment and occupation [2000] OJ L 303/16. Back