Work can help beat mental health social exclusion

Employers are to get more help to recruit and retain individuals who have mental health problems under a new government action plan to tackle social exclusion.

"Finding and retaining employment is one of the most important and difficult issues facing people with mental health problems," concludes a new report by the government's Social Exclusion Unit (SEU)¹.

What more might be done to enable adults with mental health problems to enter and retain work was one of two key questions the unit's project on mental health sought to address, and has led to a 27-point action plan focusing on six areas, including employment.

The action plan aims to bring together the work of government departments and other organisations to improve the employment outcomes and opportunities for people with mental health problems (see box 1 ). For example, the government intends to expand its Pathways to Work pilot schemes, which encourage people to move off incapacity benefit into work. It will improve employment support through other programmes, including a scheme to better engage employers in the issue.

The SEU project on mental health involved a written consultation and roadshow (during which people with mental health problems were encouraged to share their experiences in and out of work), a literature review, and four local area research studies looking at "delivery" issues, including employment.

Employment supports mental health

Only 24% of people with long-term mental health problems are in work in the UK, compared with 58% of a similar group in the USA, where rehabilitation support tends to be more widespread and effective. A strong link exists between unemployment and the development or worsening of mental health problems.

GPs can play a crucial role in job retention by suggesting work adjustments or referring patients to vocational advisers, the SEU report suggests.

Vocational advisers, based in primary care settings, such as GP surgeries, can give advice on benefits and liaise with employees and employers to manage an individual's return to work.

However, the report notes, GPs often issue sickness certificates without discussing these other options with patients because of "constraints on their time". Many GPs see a conflict of interest in their role as issuers of sickness certificates, and make the patient's request for a note a priority - half would rather not have to perform the role.

Just under half of employees have access to some form of occupational health (OH), usually because they work in the public sector or for large organisations, the report notes, adding that OH services should support job retention and act to remove unnecessary barriers to work.

OH providers and GPs, however, should talk more to each other to ensure that all available support is mobilised. Those without in-house OH support are able to call on external services, including NHS Plus or those offered by the Employers' Forum on Disability, the report notes; but it does not mention the barriers to greater access, including the employer's willingness or ability to pay for OH help.

Low healthcare priority

Mental health trusts spend £140 million a day on employment services, including projects focusing on helping people with mental health problems find work in mainstream settings as quickly as possible. However, 35% of those participating in the project consultation considered that trusts and other social care services place a low priority on employment for people with mental health problems, and only 6% believed that such providers give work a high priority.

The low expectations of many health and social care staff can be a big barrier to the employment of people with mental health problems. In particular, the report found that Jobcentre Plus staff - working in the offices of the state employment agency - can have poor awareness of mental health issues, leading to a culture of low expectations and the belief among those charged with supporting people that "they'll never work again".

Employer attitudes are a barrier

Many employers are still reluctant to employ people with mental health problems and "occupational health departments might also raise concerns that the individual would be unable to cope or would take too much time off sick," the report finds. The following two quotations from participants in the local area research studies clearly illustrate the barriers faced by those with mental health problems:

Around 40% of employers say that they would recruit a person with mental health problems, compared with around 60% who say they would recruit from those with a physical health problem and nearly 80% say they would do so from among those who are long-term unemployed. Three-quarters of employers believe it would be difficult to employ someone with schizophrenia, even though this condition usually requires no adaptations to the work environment. Some employees interviewed for the research were concerned about a perceived link between this condition and violence.

Other research among personnel managers suggests that they would be much more likely to employ a diabetic person than someone with depression, all other factors being equal. One-third of people with mental health problems report being dismissed or forced to resign from their job, according to the SEU research, while four in 10 felt they were denied a job because of their previous psychiatric history.

More than two-thirds had been deterred from applying for a job for fear of unfair treatment, while anecdotal evidence uncovered by the SEU suggests that severe mental ill health is being specified in some employment contracts as grounds for instant dismissal. For example, dismissal will be instant "if you become of unsound mind or a patient under the Mental Health Act 1983".

Making the business case

Overcoming employer resistance to the employment of people with mental health problems can best be done by making the business case, the SEU report suggests. It quotes the chief executive of Braintree District Council as saying: "To support our staff when mental health goes wrong means that we support them in the whole of their lives, which, in turn, means we get the best out of them at work."

The SEU project presents the business case as follows:

The DDA is viewed as a "milestone" by the SEU in terms of reducing discrimination against people with disabilities, 10% of whom have mental health problems. The report notes that the legislation will be extended to smaller employers from October 2004. It adds that the Disability Rights Commission (DRC) has recommended making other legislative changes relating to mental health, including amending the requirement that mental impairment should last for at least 12 months to be covered by the legislation, so that short-term depression might be covered.

The SEU suggests that "awareness amongst employers about how the DDA applies for people with mental health problems does not appear particularly strong", and that 23% of employment cases brought by the DRC are related to mental health. Employment tribunal applicants raising issues of work-related depression, bad nerves and anxiety have a success rate of only 18%, compared with 39% in respect of diabetics, the most successful health-related applicant group.

Job retention and sustainable work

Employers have a vital role to play in tackling mental health issues by creating a healthy workplace, the SEU project concludes. Two-thirds of those with mental health problems believe that unrealistic workloads, long hours and bad management caused or contributed to their mental health problems.

The role of managers in job retention is of paramount importance, and the SEU quotes Work Foundation research into the low proportion of managers who feel competent to manage an employee with problems. It says that "the lack of support for managers or employers when an employee has mental health problems can be a particular concern for small and medium-sized enterprises." Such organisations rarely have a dedicated HR or OH function, and can lack advice and the financial capacity to keep a job open for extended periods if an employee is off sick, the SEU concludes.

Supporting employees with mental health problems needs sensitivity. For example, such people often do not want colleagues to know their situation, so "having someone sit with them in the workplace would not always be appropriate", the project finds. More effective support could include buddying schemes, job coaching and OH services, while others may need external and ongoing support, which extends to working with the employer to raise awareness and provide advice on making reasonable adjustments to the work or workplace.

People with mental health problems often return to work into a job with lower pay and responsibility than previously. One participant in the consultation told the SEU researchers: "At present, the glass ceiling that women have identified is more like a concrete ceiling for mental health service users. Many of us cannot even see through to the possibility of senior roles or wider influence." The culture of low expectation - which extends to those charged with helping people with mental health problems - can mean that individuals with mental health probems do not progress beyond entry level jobs.

Sainsbury Centre wants firm dates

The Sainsbury Centre for Mental Health, an organisation that campaigns for better employment opportunities for people with mental health problems, welcomes the Social Exclusion Report into mental health. Dr Bob Grove, director of the centre's employment programme, says the analysis in the report is "spot on", but wants to know "what happens now", in both the short and long term.

In the short term, Dr Grove would like the government to be more precise about when more people with mental health problems will have access to an employment adviser, and dates for when a government statement will appear on tackling people's fear of moving off benefit into work. But he still believes the report could be a "landmark" in the approach to mental health in the workplace, and hopes that in the longer term it will prompt a review of the national service framework for mental health.

Dr Grove believes that employers are "no better or worse" than the general public in their perceptions of mental ill health, and need to be given the right information and a chance to prove themselves in the employment of people with mental health problems. He believes that disability legislation has been effective in persuading employers to think twice before sacking people, but that it has done little to encourage their recruitment.

Case study: BT

The mental health strategy of telecommunications giant BT has three elements - primary prevention; secondary intervention and tertiary rehabilitation - each of which is used to recruit and retain people with mental health problems.

Paul Litchfield cites the example of an employee with a phobic anxiety state who has particular problems with team meetings and open plan offices. The employee has been set up to work at home. However, to avoid potential social isolation, he is required to dial in to team meetings and to have regular one-to-one meetings with his line manager at the office, where he is also encouraged to chat to colleagues.

In response to this, BT has jointly developed with the trade unions a computerised stress risk assessment management tool, called STREAM. The tool asks individuals 30 "pressure" questions and also incorporates General Health Questionnaire 12. A line manager can encourage an employee to take the STREAM test if they have concerns about how they are coping with pressure.

The test places individuals in a red, amber or green zone, according to the risk factors present. Around 5% of people doing the test come out in the red zone, while typically two-thirds are in the green zone. Line managers with employees in the red zone are required to carry out a structured interview with the individual within a fixed timescale to assess whether or not further action is needed.

STREAM took 18 months to develop, including undertaking two pilot programmes involving 2,500 BT staff. The finished version was rolled out in spring 2004. BT collects information on which businesses have issues with the particular stress factors measured by STREAM - for example, demand and control or relationships. And senior management receives regular reports mapping how their operating business is performing on stress compared with BT as a whole. This analysis also enables BT at corporate level to compare similar large operations across its organisation, for example call centres in different parts of the UK.

Data on the incidence of work stress factors collected from the STREAM process is supported by the annual BT employee attitude survey, which provides figures on prevalence. Information on sickness absence due to mental health problems also feeds into information gathering at BT, although Paul Litchfield recognises that there is bound to be an element of under-reporting of mental health problems from this source. However, BT's external OH service uses more sophisticated diagnostic codes to provideinformation on employee clients, and also attempts to assess whether or not BT employees' mental health problems are work-related.

Once in employment, according to BT's chief medical officer, "we can run into issues of confidentiality" when trying to retain employees with mental health problems, particularly if they choose not to talk about their medical history to their line manager.

There are various sources of help at BT for employees having problems with their mental health including access to an employee assistance programme (EAP). The BT service differs from other EAPs in that, in addition to counselling, there is an employee assistance management team of around a dozen people that acts as an interface between the employee and the line manager.

The line manager is able get help and advice by speaking to the management team, whose members are very experienced in dealing with mental health issues. Employees who are off work for more than 10 days and have a mental health diagnosis will also be invited in for a chat by the OH service.

At this point, the individual's line manager is emailed a general fact sheet on managing people with mental health problems, explaining the team member's diagnosis and stressing the importance of maintaining contact. A formal referral to the OH service happens after around four weeks' sickness absence due to mental health problems. The STREAM test is often used as a way in which the employee and line manager can talk about effective rehabilitation once a return to work is considered.

Success criteria

Most of the mental health cases at BT are related to anxiety and depression, although some employees experience bipolar affective disorder (manic depression) and a few have schizophrenia. Both of these more serious forms of mental illness are underrepresented in the BT workforce, as is the case in most employers, and Paul Litchfield believes BT "still has work to do" here.

But BT also measures its success in terms of how many people are helped back into work after at least six months' absence due to a mental health problem - a rate that is running at around 55% compared with national estimates of nearer 24%, according to Paul Litchfield. Data from the SEU report suggests that BT's job retention activities have led to an 80% cut in early retirement rates for people with mental health problems at the company.

1.Mental health and social exclusion, Social Exclusion Unit, June 2004, www.socialexclusionunit.gov.uk.

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