Creating mentally healthy workplaces

What can employers do to help tackle the major challenge of mental ill health?

The issue of managing employees' mental health is gaining in significance - recent official figures show that absences from work due to stress alone account for the largest number of days lost to work-related ill health, 13.4 million days in 2001/02. Mental illness is also contributing to a general lengthening of the duration of absences in Britain - an absence due to mental ill health typically lasts twice as long as one caused by other reasons.

Widespread coverage of stress at work is prompting a more open attitude towards mental health issues generally and job retention and rehabilitation programmes are growing, spurred by campaigning groups such as Mind Out for Mental Health and some of the more proactive NHS health authorities.

Macro costs are huge

The total economic and social costs of mental illness were estimated at £77 billion in 2002/03, more than the £60 billion costs of crime, according to a study by the Sainsbury Centre for Mental Health¹.

The impact on individuals represents the largest proportion of these massive costs, including the adverse effects of mental illness on people's health-related quality of life. However, the next biggest group of costs involves "output losses" worth £23.1 billion.

Output losses (see table 1 ) arise from the fact that those with mental health problems are more likely to be unemployed, and for longer, and that this group of workers takes more time off sick or, most gloomily, "exit" from the workforce prematurely due to suicide. The Sainsbury Centre points out that 39% of people with mental health problems are unemployed.

The researchers accept that this is a high estimate, and recognise that some of those with mental health problems may be unemployed for physical or other reasons. However, to balance this out, the Sainsbury Centre research takes no account of the impact of mental illness on the productivity of those in work who may be operating below full capacity. (See box 1 on the reasons why employees with mental health problems lose their jobs.)

Work is good for mental health

Despite the growing incidence of work-related stress, depression and anxiety, work remains crucial to the maintenance of an individual's mental health. A job brings self-esteem and identity for people with mental health problems, providing opportunities for scheduled activity, and enables them to better manage the symptoms of their condition.

There is growing evidence of the strong business case for effectively managing employees' mental health, through the use of good policies and practices and training line managers to help staff with problems. According to research² from the Work Foundation and Mind Out for Mental Health, employers with good mental health and job retention policies benefit from better productivity, greater staff retention and a reduced risk of litigation from breaches of employment and disability legislation. Effective policies on maintaining mental health at work also foster a culture of acceptance and diversity in organisations.

Yet managers' awareness of and ability to manage an employee with mental health problems is often poor (see box 2 ). The Work Foundation research finds that only 2% of those it surveyed know exactly how to handle such a situation, while most employers (58%) say they would try to deal with it, but were not sure they would improve the situation. Managers talked of problems maintaining an individual's confidentiality when dealing with the responses of his or her colleagues, and of not finding out about the problem soon enough.

The sensitive issue of how to deal with mental health problems caused by factors outside work was also raised by managers in the Work Foundation research, who often feel that they do not have enough support from their organisation to manage mental health at work. In one case described in the research, two members of a team developed work stress as a result of not effectively managing the mental health problems of a third member.

Managers have difficulty recognising the signs of potential mental ill health in employees, resulting in them occasionally using inappropriate procedures, such as disciplinary ones, to manage cases of employees in mental distress. Only 30% of participants in the Work Foundation research have adequate information to manage mental health at work and an even smaller proportion (7%) considers that the information is tailored to them specifically.

Guidance at hand

The Mind Out campaign has produced guidance³ for line managers on supporting employees with mental health problems, largely as a result of the need for this being identified in its joint research with the Work Foundation. The Mind Out campaign is designed to prevent stigma and discrimination surrounding mental health and is managed by the Department of Health and the National Institute for Mental Health in England.

The pack is written for managers, particularly those in small organisations, and covers the recruitment process, the need to talk to employees at an early stage in an illness to prevent it getting worse, and maintaining contact during sickness absence. It gives tips on successful rehabilitation after mental illness and on managing the continuing mental health problems of people at work. A separate section provides information for employees with mental health problems.

The section on maintaining contact with employees on sickness absence stresses that appropriate contact is essential - and not harassment, as some line managers fear it will be construed. During contact, it is important to let the employee know they are not forgotten and to reassure them about practical issues such as the job and income.

The role of an employee's GP is covered: "GPs have no responsibility to the company and cannot be forced to provide advice to the employer." But the information pack adds that some GPs will respond to requests for help and guidance, especially if channelled through the patient. Employers should provide an employee's GP with copies of any rehabilitation policies or phased return-to-work plans for comment, and offer to pay for the GP's time.

The guide suggests that managers' discussions with individuals about their phased return to work should be broadened to cover changes or adaptations to work-related factors that might have contributed to the employee's absence. But, it adds, managers need to be honest about factors that cannot be changed.

Employers are bound by disability legislation to consider making adjustments for those covered by the law, which could include allowing a person to work at home, or the provision of a quiet place to go if they feel anxious on return to work. Managers also need to discuss with the employee what colleagues should be told about the illness and prepare to be guided by individuals' wishes. The person returning from an absence due to mental ill health must be treated in the same way as one with ill health problems having a physical cause.

The issue of managing ongoing mental health problems, such as manic depression, is a difficult one and employers need to strike a balance between exercising their duty of care to assess risk and take action to minimise it, and making special (possibly discriminatory) arrangements for employees with mental health problems. The Mind Out guide describes how some people with ongoing mental health problems draw up a document to be used in the event of episodes or bouts of ill health at work, setting out symptoms to look for, people to contact and what employers can usefully do to support the individual.

Job retention key

Dr Bob Grove, director of the employment programme at the Sainsbury Centre for Mental Health, says that occupational health "is all about mental health". He believes that the difficulties a person faces returning to work after a long-term absence due to a physical or mental illness often spring from psychosocial issues connected with lack of confidence or disengagement with the workplace, rather than any continuing long-term physical ill health.

His programme focuses on early intervention and the prevention of long-term disability due to mental health problems, and job retention is at its heart. The Sainsbury Centre seeks to influence government and employers by using best evidence on the importance of job retention and the fostering of mentally healthy workplaces. For example, the employment programme is currently focusing on the role of GPs as possible job retention advice workers - most employees do not have access to occupational health, and those with mental health problems are most likely to approach their GPs for help.

Dr Grove believes that employers often react differently to an employee who is off work with a mental health problem compared with the way they treat a person absent with a physical condition, and often do not know what to do or say. He believes that a good mental health policy, including the need to make and maintain early contact "perhaps using a script", can help.

He recognises that there are resource implications in managing mental health at work, "but, for the most part, it's about how managers handle the situation". They need to be able and willing to make adjustments to allow a return to work, and to ask employees what they need to make this possible.

"The need to make reasonable adjustments should apply to all those returning from a mental health-related absence, not only those covered by the Disability Discrimination Act," Bob Grove suggests. "We need to replace the 'all-or-nothing' approach to rehabilitation." This can mean that an employee who returns to work full time and on full duties immediately comes under pressure and disappears on sick leave again all too soon.

Case management works

Dr Grove was recently involved in evaluating a job retention and rehabilitation pilot project in the Avon and Wiltshire NHS region. The project seeks to prevent job loss among those with mental health problems by using job retention case managers to work with employers, GPs and individuals to manage a return to work. Five employers, 13 clients and six GPs took part, in addition to the job retention team case managers.

The project was successful and is continuing - three-quarters of the original group of employees involved retained their jobs or found new ones at a similar level, and only two people lost employment. The job retention team used a combination of client- and work-focused interventions. Work interventions include acting as an advocate for the client at work, helping with legal issues, negotiating adjustments and return-to-work plans, helping to develop support mechanisms at work and providing information to employers.

"Negotiations with employers around problems at work and adjustments were perceived to be particularly helpful at a time when clients themselves lacked the confidence to do this for themselves," says the project's evaluation report⁴. Both the clients and GPs believe work plays a significant part in the "genesis of mental ill health", and employers acknowledged that they are ill equipped to deal with mental health issues, although most were supportive of the principle of doing so.

The evaluation of the Avon and Wiltshire pilot identifies the following factors as crucial to the success of job retention programmes for people with mental health problems:

Dr Grove believes that the case management approach to helping people with mental illness stay in employment could be more effective if case managers and advice workers offered even more support to employers about how to manage people with mental health problems, and provided more general information on fostering healthy workplaces. They could also be more proactive in using the disability legislation to "ensure the employees' rights are maintained where employers are not willing to engage with the service," the evaluation concludes.

The Avon and Wiltshire model is being extended to other areas, including Derbyshire and Devon, where the mental health services recognise that "keeping people in work keeps them out of their offices", according to Dr Grove. He accepts that a national case management service to help people with mental health problems keep their jobs is unlikely, but believes that the role of personal advisers in jobcentres could expand to include elements of the job retention manager's work: "The Treasury is also gradually understanding that failing to do anything to keep people in work produces costs in benefit terms further down the line." Work must be seen as central to the process of recovery from mental ill health, "not as something to be postponed pending clinical recovery", Dr Grove adds.

1. The economic and social costs of mental illness, Sainsbury Centre for Mental Health, 2003, tel: 020 7827 8300, www.scmh.org.uk .

2. Managing mental health: research into the management of mental health in the workplace and the information and guidance available to managers, Ceri Diffley, the Work Foundation/Mind Out for Mental Health, 2003, www.theworkfoundation.com .

3. Line managers' resource: a practical guide to managing and supporting mental health in the workplace, Mind Out for Mental Health, 2003, tel: 0870 443 0930, www.mindout.net .

4. Getting back before Christmas: Avon and Wiltshire Mental Health Partnership Trust job retention pilot evaluation, Dr Bob Grove, Dr Jenny Secker and Dr Tina Thomas, Avon and Wiltshire Mental Health Partnership Trust, 2003.

Source: "The economic and social costs of mental illness", Sainsbury Centre for Mental Health.

This article was written by Sarah Silcox, a freelance writer and trainer on employee health issues, sarahsilcox@waitrose.com.