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If mental health trusts did this, they would enable people to go through the route of voluntary work within their trust and ultimately perhaps to jobs within it, or indeed elsewhere. Again, this employment support should be linked to the provision of evidence-based therapies. They have to go together. It is no good having one and not the other. In East London we have employment coaches and psychological therapists in all our community teams, but I have to confess that this has happened only within the past 12 months due to a thoroughgoing push from certain people within the trust. Does the Minister know to what extent this is now common practice across all mental health trusts? It is probably unreasonable to ask him that, but it certainly would be very interesting to know because that should be the case.

The Healthcare Commission now has a target for local authorities, through their mental health trusts, to increase the proportion of mental health service users in employment year by year. Although there is no specificity there, the idea that you will be marked “good” only if you increase the proportion each year is pretty promising and a good start. There is good evidence that the initiatives discussed here are the best way to achieve that target.



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Again, I recognise that this is somewhat outside the Minister’s remit, but cross-departmental work on these matters will be essential if the target of a 1 million fall in the number of benefit claimants over 10 years is to be achieved. Therefore, what progress has been made with the Department of Health in progressing those agendas?

I had not planned to mention the role of the foundation trust model in all this, but I think I will. Others may be aware that we now have something called a board of governors or a member’s council elected by our community. We also have thousands of members, many of whom are service users of our trust. We have had to think how to involve our membership. Our trust has come up with precisely the solution that we are talking about today—it seems eminently sensible for every other mental health trust to do the same—the members need to be invited and encouraged to become involved in voluntary work and, ultimately, in employment. We are right at the beginning of this; we became a foundation trust only on 1 November; but we feel that there is a lot of interest in this and it may be something that we need to encourage nationally. It could be quite a significant way forward for people in the secondary sector. I realise that large numbers of people are not in the secondary mental health sector, they are in the primary care sector, but we could really make progress through that foundation trust model that, when we started, we had not thought of as a major issue.

My final point is one that I raised during our debates on the Welfare Reform Bill last year. The Minister may guess what I am going to mention. I hope that his heart will not sink to hear me mention the words “linking rules” again, but the issue remains as pressing as ever. For noble Lords unfamiliar with this territory, the aim of the linking rules is to ensure that anyone on incapacity benefit who finds a job and who, within two years loses the job, can restore those benefits, supposedly without delay—unless things have changed since I was involved in those matters.

I am concerned that in such circumstances, someone still needs to complete a form, and there are inquiries to be made, before benefits are restored. Also, housing benefit is considered quite separately. In reality, those procedures can take weeks, perhaps months, especially for people with mental health problems who are likely to have fallen out of a job because of a recurrence of those problems. They will be lying in bed, they will not be picking up the phone, answering letters, making sure that they are filling in forms or getting someone else to do it for them.

When we last debated these issues, the DWP was considering the possibility of aligning the reclaim process for housing benefit with that for employment support allowances. I have not completely given up hope of further improvements to the linking rules themselves for employment support allowances. It may be reasonable to limit those special provisions to people with mental health problems, because if your mind is working all right, you can probably deal with those matters, even if you have to sit in a wheelchair; but if your mind is not helping you at all, the linking rules do

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not answer the problem. Has the Minister managed to make any progress since last summer with those matters? I look forward in anticipation to his reply.

4.28 pm

Baroness Linklater of Butterstone: We must all be grateful both to my noble friend Lady Neuberger for introducing this debate on this very important issue and to the Sainsbury Centre for Mental Health for producing its report and highlighting so graphically the real crisis that we are facing in this country: how issues of mental ill health are costing this country dear. Although the noble Baroness's Question focuses on the cost and the need for support to business, there are the other inevitable costs incurred by the range of agencies to pick up the pieces of fragile or broken lives; the human cost to those who are ill, to other individuals, families and communities; and the urgent need for support for them as well.

One of the real ironies is the extent to which mental illness is the object of so much fear, stigma, ignorance and even cruelty when it is such a common feature of our society, and the evidence shows that it is getting worse. With one in four of us experiencing mental ill health at some point in our lives, there will be very few individuals anywhere who do not know directly of someone who has been mentally ill. I declare an interest here. I have a wonderful son who is now 37. He has had severe manic depression since he was 15, a fact which has had a huge impact on all who have had the good luck to know him. Indeed, it has inevitably involved times of great distress, anxiety and, indeed, fear for us all, and which in his case has meant that long-term real employment has not been possible. We are a society that fears any deviation from what is normal, particularly when mental illness and other disabilities significantly affect and damage the normal, strong or successful in our communities. I believe that we are getting it badly wrong, both materially and morally, where the mentally ill are concerned. The Sainsbury report not only points out graphically the costs of our failure, but also, very usefully, how to begin to deal with the problem.

My noble friend Lady Neuberger has already gone through the detail of the report, and I hope noble Lords will forgive me if I repeat some of it. The cost to business alone of mental illness is vast. The figure of £26 billion annually is hard to get our heads around, unless we think of it as over £1,000 for every single employee, everywhere, each year. Of these employees, the report tells us, at any time one in six will be experiencing a neurotic disorder such as depression, anxiety or stress-related problems. That is different from the group of people who, like my son, suffer from long-term severe mental disorders. The former group is by far the larger and represents the chief concern in the report because people in that group are more able to work and their illness is less likely to be permanent.

We have discussed that ghastly word, presenteeism, which along with absenteeism and high staff turnover, are the main costs. Presenteeism suggests a sort of ghostly figure drifting around the workplace, and I am sure it should not be difficult to find a better word.

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Being present but unable to work properly is a reflection of the fear felt by the employee of being mentally ill or being found out because of the stigma the illness generates, and the stigma itself is rooted in fear. Furthermore, most employers hugely underestimate the prevalence of mental illness in their workforce, partly because they are simply unaware of it and partly because, I suspect, they do not want to recognise it. That is fear once again. Yet we all know that work is good for business, good for individual self-confidence and self-esteem, good for health, and of course, as the husband of the noble Baroness, Lady Meacher, knows, good for happiness.

Apart from the stark detailed calculations of the cost of mental illness, we see that appropriate, constructive and effective ways of dealing with mental ill health at work is not rocket science and can save thousands in pounds and people. It is crucially to do with the attitude towards staff of managers, which should be free of prejudice. Managers who are properly informed about the nature of mental illness and trained accordingly are able to facilitate early recognition and swift access to appropriate help. As we know, most fear and prejudice is rooted in ignorance. Much stress can be mitigated by having realistic expectations of staff, dealing effectively with bullying in the workplace and giving people more say over how they work—all of which amount to strategies that lead to a positive working environment. Training is important, so that a manager can feel confident about dealing with someone who is showing signs of mental illness that could otherwise be quite threatening. Knowing where to go for the appropriate help is essential. In this way, appropriate and effective interventions, such as CBT—although sometimes I think that can be exaggerated—can prevent the loss of a job or facilitate an early return to work.

Proper support to stay in or return to work can be crucial. It all seems quite obvious, but it is still sadly lacking and is a real challenge to the Government. My experience over the past few years is that it is not the Government who are leading the way here, but the voluntary sector and the world of social enterprise, with the growing and very exciting development of social firms. They are businesses with a moral compass, where not only do the usual criteria apply for any successful business—such as a proper business plan, a healthy profit at the end of the year, top-class service to the customer and a budget showing future growth—but there is an overarching rationale of meeting a particular social need in the people whom it employs and in the service that it gives.

Social firms are by no means exclusive to the mental health field, but they employ, among many others, people with severe and/or enduring mental health problems. They provide a supportive working environment that recognises and responds to the needs of individuals and, where appropriate, challenging environments where people can carry out real work in real businesses. That may be a stage in recovery in the sometimes long journey to sustained, meaningful employment, or perhaps a place where the individual can be sustained and supported over many years.

I declare a second interest, as my daughter is a beneficiary of just such a firm in Scotland, which I commend to the Committee. It is called Forth Sector,

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and it is based in Edinburgh. It runs a group of small businesses, including a small guest house where the trainees all have mental health issues of some kind. It is a delightful place, where the highest standards apply, the service is excellent and the occupancy rate is high. I cannot sing its praises highly enough.

The Freud report in 2007 suggested that the true cost to the state of a person on incapacity benefit was around £64,000 a year. The cost of sustaining a person in one of Forth Sector’s social firms is a 10th of that, without including a calculation of the personal, family and social capital that such a placement creates. By trading as they do, not only do social firms provide real work experience, but they effectively substitute for and subsidise the state provision of care. I suggest that the Government take a sustained and real interest in the support and development of this approach and of the work of social firms.

Finally, I quote the example of the National Schizophrenia Fellowship in Scotland, of which I am a patron. It has been supporting people with a range of mental illnesses for years in a variety of areas, including employment. Sometimes clients start by volunteering with a large organisation, such as the National Trust for Scotland, with which there is a long-standing relationship, and sometimes with small businesses. In this and many other ways, its work is invaluable to many people and their families. Typically, it may intervene when a person has become ill and before too long has perhaps lost his home and job, while the employer was simply not aware of illness or the reality of the situation. The outcome of the intervention is a negotiation with the employer and a return to work, home and stability. That is immeasurable. Without NSF, such a person is to be found on the state’s very expensive scrapheap. Its work with young people may involve starting with volunteering, often working alongside them, to experience the working environment, before graduating to real work. That is something that the Government should be encouraging and developing.

The marvellous work of such social firms and voluntary organisations is the beacon in what is still a dark world for so many of the mentally ill. Of course the noble Baroness, Lady Neuberger, is right to challenge the Government to follow their lead, which is now so overdue and so pressing. I sincerely hope that they will take this latest report from the Sainsbury Centre very seriously, for literally none of us can afford to ignore its message any longer.

4.40 pm

Lord McColl of Dulwich: I, too, would like to thank the noble Baroness, Lady Neuberger, for initiating this important debate. At the outset I would like to contrast West Africa with this country in several respects. My clinical practice is in West Africa for several months every year with a charity known as Mercy Ships. Many of the patients that my wife and I operate on have been rejected by their fellow countrymen because they are assumed to have some sort of curse. This leads to throwing stones at children with hare lips, cataracts, squints and many other conditions. Women who have been rendered incontinent through disasters in childbirth are completely ostracised by society.



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Before we adopt too critical an attitude to such behaviour in Africa, it is worth remembering that in this country the all too common attitude towards those with mental ill health can be very strange, to say the least. Even highly intelligent, educated people will use terms like “nutty”, “barmy” and “bananas” to describe those who are mentally ill. The same people would never dream of using such language to describe those with heart failure, pneumonia or cancer. Some have tried to explain this inappropriate behaviour in terms of fear or ignorance of mental illness, or that it acts as a kind of protective carapace. The strange thing is that doctors have also used these derogatory terms, but what is even more surprising is that psychiatrists have done the same. A medical student spent an hour carefully assessing a patient in a psychiatric outpatient clinic and then presented the case history to a distinguished psychiatrist, who started laughing. “What’s the joke?” asked the student. “The joke is that he is a psychopath”, was the reply. “Yes, I know that he is a psychopath”, said the student, “but what is the joke?”. “The joke is that there is nothing we can do for him”. The student thought that the consultant’s response constituted what psychiatrists call incongruity of affect, which is a well known symptom of schizophrenia. That was a few years ago, and hopefully things are improving.

These things are always difficult to judge, but my impression is that there is now less prejudice and ignorance about mental illness, but unfortunately, as has been mentioned already, recent surveys suggest that tolerance towards those with mental health problems is now lower than it was in 1994, which is very discouraging. A survey of members of the Depression Alliance showed that 79 per cent of them were fearful that revealing their condition at work would be damaging. That is a sad state when one bears in mind how common mental illness is in the population as a whole. As the noble Baroness said, one in four in the nation will suffer from mental ill health during their lifetime and at any time one in six workers will be experiencing anxiety, depression or problems related to stress.

Mental ill health is normal in every workplace. We have heard the figures about how much it costs, so I will not repeat them. We have heard the term “presenteeism”, which I do not like at all. I would prefer to use the Latin phrase, labore sed aeger, which means labouring but ill. The Latin word “aeger” covers mental as well as physical ill health. The phrase could be abbreviated to LSA, and would certainly be better than presenteeism.

The figures we have heard are probably underestimates because many people present with medically unexplained physical symptoms that are due to mental health problems. These are not recognised by patients themselves or by their doctors. Indeed, these symptoms can be difficult to diagnose. To make matters worse and even more complex, a patient’s symptoms may be due to mental health problems and concomitant physical disease. It is important to state the obvious that, as has already been said, mental illness does not make a person unemployable. There have been many recent examples of this: one in the form of the Norwegian Prime Minister, Kjell Magne Bondevik. My Norwegian friends in Norway said that people were amazed when he

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admitted publicly his illness and then took six months off, but his openness was so impressive that he was elected for a second term. Such openness is a great inspiration for those with the same condition.

Mental ill health can be cut by the good management of staff, and there are several excellent examples. BT, as has been mentioned, has reduced its mental health sickness absences by one-third through its Work Fit programme. There is also good evidence that being in work keeps people healthier, both physically and mentally. Unemployment reduces life expectancy by 10 years, as the noble Baroness, Lady Neuberger, pointed out.

Work-related mental stress can be reduced by creating more pleasant working conditions, giving staff more say over how they work, and dealing with bullying. I remember some years ago in a hospital how some secretaries got very angry with the way they were being bullied and mistreated by people who should have known better. I suggested to them that the next time it happened they should just look the guy in the eye and think to themselves, “Poor chap, he’s not having enough roughage in his diet”. The only problem with this was that it would make the secretaries smile, which sometimes inflamed the situation even more.

Managers should be, and are being, trained in how to deal quickly and effectively with these problems and how to get people to take up psychiatric therapies and effective rehabilitation. On the subject of rehabilitation, it is helpful if managers keep in contact with people when they are off sick and help them to return to work earlier.

There is no doubt that this is a very neglected subject due to the lack of public awareness, the persistent stigma of mental illness and a lack of training among management. Much needs to be done. The Department of Health’s commissioning of the Sainsbury Centre for Mental Health to tackle stigma and discrimination around mental illness is a welcome development, and I look forward to hearing what more the Minister is going to do.

4.48 pm

The Parliamentary Under-Secretary of State, Department for Work and Pensions (Lord McKenzie of Luton): I start by expressing my gratitude to the noble Baroness, Lady Neuberger, for calling this debate today and to all noble Lords for devoting their time to this very important issue. I fear that 12 minutes is too short to do full justice to the weight of noble Lords’ contributions, but I shall try. I am also indebted to the Sainsbury Centre for Mental Health for its policy paper on developing the business case and for all its ongoing work on the mental health agenda, particularly in its links with employment.

The Government are committed to ensuring that 2008 marks a step change in the way we approach the health of the working age population and in particular support for people with mental health conditions. It is central to our aspiration of achieving an 80 per cent employment rate that we improve the health of our working age population, reduce sickness absence and drive down the number of people falling out of work and on to welfare benefits. This success will mean healthier and more productive employees and a stronger economy.



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We recognise the changing dynamic of British business and the corresponding shift in the nature of ill health and sickness absence for working age people. Mental ill health is now the greatest single cause of sickness absence. As the noble Baroness, Lady Neuberger, explained, the Sainsbury Centre for Mental Health estimates that it accounts for 40 per cent of all sickness absence—some 70 million days a year. The impact on business is more than £25 billion a year, including £15 billion from—I hesitate to say—presenteeism, with employees staying in work but performing below par.

Mental health conditions are also the single biggest cause of people claiming incapacity benefit—a higher figure than the number of people claiming jobseeker’s allowance. Dame Carol Black’s recent review of the health of Britain’s working age population rightly drew attention to the challenges. An accompanying report from the Royal College of Psychiatrists highlighted that mental health problems cost the British economy more than £40 billion each year.

The evidence is clear that work is generally good for health, and that is true for mental health as well as physical health. The Government have made considerable progress in working to address those challenges—as the noble Baroness, Lady Linklater, said, it is not rocket science—but we must go further. We must help all employers to manage mental health conditions at work by tackling the stigma associated with mental ill health; and wherever possible prevent such conditions developing in the first place. The noble Lord, Lord McColl, graphically challenged us on some prevailing attitudes and on the prejudices which, sadly, still persist. We must further improve the access to mental health support services for those who develop conditions, helping people to stay in work or to return to work as quickly as possible.

We have been looking at ways to improve the support that is available to employers, both to ensure that they understand what they can do to prevent mental ill health being caused by work and to help them manage staff with mental health conditions, whatever the cause. The Health and Safety Executive developed its excellent management standards for identifying and managing the risks so that work-related stress can be prevented. The HSE is also supporting employers by developing improved information and guidance through its website.

As part of Dame Carol Black’s review, PricewaterhouseCoopers considered the economic case for business investment in wellness. The evidence from 50 employer case studies suggests that the initial programme costs can quickly be translated into financial benefits. PwC is now working on developing a toolkit that will allow employers to quantify the financial benefits of their wellness interventions. We intend to pilot this toolkit in the summer, and we will encourage employers in both the public and private sectors to take part in this pilot and to use the toolkit to move towards reporting on health and well-being in the boardroom.


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