Psychiatric Disability Employment in the UK by Michael Burville

Employment opportunities and psychiatric disability

Council Report CR111 October 2002

Royal College of Psychiatrists London Due for review: 2007 1

Contents

Membership of the Working Group Executive summary Introduction 1. Work, employment and psychiatric disability: the scope of the problem and key background issues 2. Work, employment and psychiatric disability: the policy context 3. Services: key components and research evidence 4. Developing comprehensive local services Appendix 1. Statistics on long-term disability Appendix 2. Terms used in disability assessment Appendix 3. Disability Discrimination Act 1995 Appendix 4. An example of a format for a vocational assessment (suitable for use in a CMHT) Appendix 5. Comparison of costs of supported employment and pre-vocational training Appendix 6. Requests for reports on employment Appendix 7. Inter-agency working: key factors for putting partnerships into practice References

4 5 13 15 38 52 72 95 98 100 104 110 111 113 117

Membership of the Working Group

Royal College of Psychiatrists (Chairman) Department for Work and Pensions, Sheffield Rehabilitation Section, Royal College of Psychiatrists Department Psychiatry, St Thomas’ Hospital, London General practitioner/Royal College of General Practitioners, London Dr Jim Ford Department for Work and Pensions, Sheffield Keith Foster Department of Health, Mental Health Branch, Leeds Sue Godby College of Occupational Therapists, London Bela Gor Employers’ Forum on Disability, London Dr Bob Grove Institute for Applied Health and Social Policy, King’s College London Dr Anna Higgitt Department of Health, London Professor Peter Huxley Institute of Psychiatry, London Dr Paul Litchfield Faculty of Occupational Medicine Eileen McDonald Rethink, London Dr Nick Niven-Jenkins Department for Work and Pensions, London Dr Rachel Perkins Springfield Hospital, London Dr Brian Robinson Rehabilitation Section, Royal College of Psychiatrists, London Dr Philip Sawney Department for Work and Pensions, London Professor Geoff Shepherd Health Advisory Service, London Dr Jim Strachan General and Community Faculty, Royal College of Psychiatrists, London Ronnie Wilson First Step Trust, London Dr Jed Boardman Mike Buckley Dr Sue Cope Professor Tom Craig Dr Brian Fisher

Other contributors Dr Jim Birley Dr Laurence Measey Liz Sayce Dr Kam Bhui Dr Fiona Ford The Working Group also met with the following members of voluntary and user/carer groups Mike Calver Manic Depression Fellowship Julie Downs Hearing Voices Network Graham Estop Voices Forum, Rethink Harold Jones Rethink Andrew Webster Independent user adviser Christina Young UK Advocacy Network 4

Executive summary

This report has been produced by a working group of the Royal College of Psychiatrists. The group aimed to: • •

•

review the existing employment and vocational opportunities and the barriers to these for people with psychiatric disabilities; consider the range of current employment and vocational schemes for people with psychiatric disabilities and their capacity to assist in retaining and regaining employment; review the existing evidence for the need for employment and the effectiveness of schemes for those with psychiatric disabilities.

Key findings The scope of the problem • • •

• • •

• •

There is a need to distinguish between work, employment and leisure. Work plays a central role in people’s lives and is a key factor in social inclusion. Work is important in maintaining and promoting mental and physical health and social functioning. Being in work creates a virtuous circle; being out of work creates a vicious circle. Work is important in promoting the recovery of those who have experienced mental health problems. The overwhelming majority of mental health service users want to be employed, or at least be engaged in meaningful work. Unemployment rates for people with all mental disorders are high, but particularly so for those with severe mental illness, for whom rates are between 60 and 100%. People with long-term psychiatric disabilities are even less likely to be in employment than those with long-term physical disabilities. The high rate of unemployment in those with mental illness is as much a product of social factors, as of the personal consequences of mental illness. Barriers to work for people with severe mental illness include structural factors, stigma and prejudice, attitudes and approaches of the mental health services and the lack of well-run employment schemes. Women with mental disorders and people from Black and ethnic minorities have even greater problems accessing employment. A social disability model of illness offers a more helpful and constructive approach to addressing the difficulties of employment for those with mental illness than one centered on episodes of illness.

The policy context •

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The Health and Safety at Work Act 1974 imposes a statutory duty to safeguard the health, safety and welfare of staff – this applies to both mental and physical well-being. Under the Disability Discrimination Act 1995 it is unlawful for employers with 15 or more employees to treat someone less favorably for a reason related to their disabilities (from 2004 the Disability Discrimination Act will cover almost all employers, not just those with 15 or more employees). Under the Disability Discrimination Act 1995 a ‘disabled person’ is someone with physical or mental disability. Mental disability includes clinically recognised conditions that have lasted or are expected to last longer than 12 months. The Disability Discrimination Act also makes it illegal for providers of any services to treat someone less favorably for a reason related to his or her disability. The Disability Discrimination Act has important implications for psychiatrists and others working in mental health services. Current social inclusion strategies are aimed at breaking the cycle of unemployment, poverty and poor health (including mental health). There are several linked policy initiatives under the rubric of ‘Welfare to Work’ that are designed to encourage and support disabled people in obtaining paid employment, for example new benefit regulations can permit more work experience while still remaining on benefits. Recent government documents, including the National Service Framework for Mental Health (Department of Health, 1999a) and Saving Lives: Our Healthier Nation (Department of Health, 1999b), contain components important to the employment of those with psychiatric disabilities. There is no specific mention of rehabilitation or vocational services for mental illness in any of the current official government documents relating to mental health Services.

Services: key components and research evidence •

• • •

Historically, occupation has formed an important part of the care of those with mental illnesses, but rehabilitation efforts have varied over the past two centuries, linked as they are to the economic cycle and availability of employment. Work schemes in the UK have been principally in the form of ‘sheltered employment’ and have been linked to the large asylums. In the UK the broad choice is now between sheltered employment, open supported employment and ‘social firms’. A ‘spectrum of opportunity’ for work, training and support should be available in a comprehensive mental health employment service covering a given locality.

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Pre-vocational training assumes that people with severe mental illness require a period of preparation before entering into open employment. Supported employment places people in competitive jobs without extended preparation, and provides on-the-job support from employment specialists (‘job coaches’). Supported employment is more effective than pre-vocational training at helping people with severe mental illness to obtain and keep competitive employment. Sheltered employment schemes have been largely unsuccessful at achieving open employment for those with severe mental illness. Social firms, which emphasise creating successful businesses that can support paid employment, can help to create suitable jobs. The extent of work schemes in the UK is not known for certain. Sheltered schemes still seem to predominate and the availability of schemes varies across the country. The elements of successful work projects can be spelled out to ensure fidelity to models of known effectiveness and adherence to accepted quality standards.

Developing comprehensive local services •

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• • • •

Partnerships and interagency working are crucial to developing employment services for people with psychiatric disabilities. The possibilities for partnerships are manifold and successful partnerships can create real benefits for service users. Key factors for putting partnerships into practice include: developing a user focus, finding partners, communication, oiling the wheels, commitment from the top, addressing boundary problems, achieving a professional approach, being tuned in, understanding the local business scene, and evaluation of schemes. Members of Community mental health Teams can successfully work in partnership with non-health agencies, but at present there are few links between CMHTs, these agencies and employers to assist in getting people into work and supporting them while there. General practitioners (GPs), through their clinical management and provision of advice on fitness to work, are in a key position to influence and sometimes determine a patient’s trajectory through the employment system. The longer that a person is off work for illness reasons, the less chance he or she has of returning to work. It is likely that a rapid response and assistance into rehabilitation can help the return to work. Attitudes of mental health services and lack of effective schemes act as barriers to getting people with psychiatric disabilities into work. CMHTs and specialist rehabilitation services are the main components of the mental health services that have a role to play in assisting users into work and supporting them there. 7

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Mental health services currently place insufficient emphasis on returning people to work and there is no specific provision for work schemes or work liaison schemes in CMHTs. CMHTs are ideally placed to take the lead in coordinating the vocational rehabilitation of those with psychiatric disabilities, but they presently lack sufficient expertise in welfare advice and vocational work. Specialist vocational workers are required in CMHTs. Since March 2002 the Care Programme Approach has had to include plans to ‘secure suitable employment or other occupational activity’. Vocational services must be supported by other suitable, quality mental health services to improve the functioning of those with mental illnesses and to offer a spectrum of in-patient, day patient and other community services. Maintaining people in work is important and close liaison between employers and CMHTs plays a key role in achieving good employment outcomes. Specialist rehabilitation services can be providers of employment opportunities. Occupational therapists are currently the only member of CMHTs who have specialist training in the assessment of function and activity, and they are well placed to play a central role in employment schemes. The occupational health team plays a key role in assessment of people with mental illnesses who are entering or who are already in work. The bulk of the people whom they see have non-psychotic illnesses. Communication and liaison between GPs, mental health professionals and occupational health staff is an essential part of keeping people with psychiatric disabilities in work or getting them back to work.

Recommendations National policy •

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The Government should urgently review the organisation and delivery of psychiatric rehabilitation services, including vocational rehabilitation, and the resources committed to such services. In the UK, the Departments of Health play the lead role in addressing the issues raised by employment and psychiatric disability, but these issues have much wider implications involving, for example, the Department for Work and Pensions, local government and the regions. It is recommended that a government interdepartmental working group be established to monitor the cumulative impact of employment policies and initiatives on people with mental health problems. This group should contain independent experts.

Development of vocational services •

Employment services for those with mental illnesses should contain a spectrum of approaches and involve a range of agencies with a coordinating body. 8

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There should be instituted a nationwide rehabilitation programme that psychiatrists and GPs can access on behalf of their patients, so that users can be put in touch with effective interventions early. A work development and coordination team should be established in every local mental health service. Rehabilitation services for those with mental illnesses should be focused on getting people back into employment or other meaningful activity Employment services for those with severe mental illness should be aimed at getting individuals who wish to start or return to employment into open employment. Vocational rehabilitation services should allow for a rapid response to those who develop mental illness while in work, with the aim of enabling a return to work. Employers should have: • strategies for the prevention of work-related mental illness; • strategies for the support of those who develop mental illnesses while working and systems of liaison with mental health services; • policies to facilitate and maintain the employment of those who have or develop mental illnesses. Communication between mental health services, GPs and employers should be improved and each agency should be aware of the needs and the ways of working of the others. There should be greater partnership/joint working between the Jobcentre Plus and other employment agencies, and mental health teams and service providers.

Psychiatrists and community mental health teams •

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Mental health workers should be aware of: • the implications of the Disability Discrimination Act 1995; • the evidence base related to employment opportunities for those with psychiatric disabilities; • the vocational services that are available locally and how these can be accessed. The enhancement of employment services for those with mental illness will require mental health workers with dedicated sessions. There needs to be an examination of the numbers of available posts for specialist rehabilitation consultants and associated teams, to ensure at least 0.4 full-time equivalent consultant rehabilitation psychiatrists per 100 000 of the population. Awareness of the need to get people into work or back to work should begin soon after initial contact with psychiatric services, whether this be in outpatient clinics, community teams or in-patient units. 9

•

• • •

Psychiatrists and others working in mental health teams should develop a more positive attitude to the employability of individuals with mental illnesses. CMHTs should be considered as central to the health service provision of vocational rehabilitation for those with mental illness. Vocational and welfare specialists should be employed in CMHTs. The Care Programme Approach should be used for those in contact with secondary mental health services, to record a person’s vocational needs and to plan for rehabilitation.

Primary care General practitioners should: • • • • • •

always consider how clinical management would support a patient back into work; review the patient before the first 6 weeks of certified incapacity, to reduce the chances of long-term sickness; try to keep positive expectations about patients’ return to work; emphasise progress and offer appropriate therapy where possible; differentiate between the risk of losing an existing job and the problems of getting back into work after a long absence; communicate as clearly as possible with the employer within the constraints of ethics and confidentiality.

Training/education •

• •

Training in adult psychiatry should involve opportunities for experience in psychiatric rehabilitation, and the visiting educational approval teams should note such opportunities. Mental health services should offer training to employment agencies, including Jobcentre Plus and other employment services and organisations. An educational initiative should be launched in order to: • • • • •

ensure that certifying medical practitioners, particularly GPs, are fully aware of the range of management options available; inform GPs and other health care professionals of the factors interfering with a return to work; inform GPs and other health care professionals of the factors hastening a return to work; help GPs and other health care professionals to provide better advice to patients of working age and to the patients’ employers; ensure that other mental health practitioners, including nurses and consultants, are aware of the process of certification and contribute appropriately to it. 10

•

An initiative should be launched to ensure that patients are informed about all the options available to them in relation to work retention, job search and benefits, and that they have access to appropriate advice at every stage.

Commissioning •

Primary care trusts (and groups) should organise to work with local disability employment advisers (DEAs) and employment agencies, including Jobcentre Plus, to improve local responses to these challenges.

Research •

• •

Priorities for research on employment and psychiatric disability should include: • the extent, type and availability of work schemes in the UK; • the cost-effectiveness of vocational rehabilitation models and the extent to which mental state and social outcome are improved by working; • schemes and approaches to the rehabilitation of those who do not have severe mental illness; • the role of primary care services in the vocational rehabilitation of those with non-psychotic mental illness. Research should be directed at efforts to enhance job tenure and long-term vocational careers. A body of research literature should be developed that examines the need to keep people in work when they develop mental health problems (as opposed to the placement of people with pre-existing mental health problems).

Introduction

For most people, work forms a central part of their lives, offering rewards beyond that of income. This is also the case for people with psychiatric disabilities, for whom work and meaningful activity give a sense of identity and other therapeutic benefits, including increased self-esteem, enhancement of sense of worth and improved functioning. For people with severe mental illness the rates of unemployment are high, higher than for their fellow citizens with physical disabilities. Mental disorders are one of the three most common medical causes for being in receipt of incapacity benefit. Employment is linked to social inclusion and forms part of current government initiatives to improve the fabric of society. Employment gives those with mental illness opportunities to participate in society as active citizens, and barriers to participation are linked to stigma, prejudice and discrimination. Employment opportunities for people with mental illnesses are an important concern for those working in mental health services, not least because they form part of the rehabilitation and reintegration efforts associated with these services. A number of other bodies are also concerned with employment opportunities for disabled people, thus making a wide range of partnerships possible in this area. The Working Group was set up to examine employment opportunities for those with psychiatric disabilities. It consisted of members of the Rehabilitation and Social Section and the General and Community Faculty of the Royal College of Psychiatrists, of experts working in the field of employment and mental illness from outside of the College, a GP, representatives from three key government departments (the Department of Health, Department of Social Security,1 Department for Education and Employment1) and a number of voluntary organisations. The Working Group also consulted with members of several national user groups. The Working Group was principally concerned with adults with severe mental illness. However, it was inevitable that the problems of people with affective, anxiety, neurotic and other disorders should be included, as they are at increased risk of absence from work and often find it difficult to get back into work if they are off sick for prolonged periods. The problems of people with learning disabilities were not considered.

1. In June 2001, just before the final meeting of the Working Group, the Department for Education and Employment and the Department of Social Security were restructured and their employment functions were combined within the new Department for Work and Pensions.

The Group was mainly concerned with secondary health care services but, given the importance of the GP as a filter into both secondary care and the welfare and employment arenas, it was thought that the position of primary care services in relation to employment and mental illness should be prominent in the report. The Working Group did not review in detail work-related stress or the harmful effects of work (a large body of work exists on this area). The Group aimed to: • •

•

review the existing employment and vocational opportunities and the barriers to these for people with psychiatric disabilities; consider the range of current employment and vocational schemes for people with psychiatric disabilities and their capacity to help individuals to retain or regain employment; review the existing evidence of the need for employment and the effectiveness of schemes for those with psychiatric disabilities.

The Working Group focused on two major concerns regarding employment: the problem of getting people into work (employment opportunities) and the problem of keeping them in work (employment retention). In 2001, the British Society of Rehabilitation Medicine produced a report on vocational rehabilitation that examined all areas of disability (British Society of Rehabilitation Medicine, 2001). Inevitably, they examined the issues of mental disorders and work. Their report covers some of the ground of the present report, but did not consider severe mental illness specifically. The conclusions and recommendations of the present report overlap with those of the Society’s report and it is worth referring to that document in conjunction with the present report.

1. Work, employment and psychiatric disability: the scope of the problem and key background issues

This chapter examines the concepts of work, employment and leisure and the particular importance of work. It reviews the figures relating to mental illness and the workforce and looks at the needs of certain special groups (ethnic minorities and women). Finally, it considers reasons why work schemes for the people with mental illnesses have been given a low priority and the advantages of utilising a disability model of mental disorders.

What is work? Work, as opposed to leisure, has some very distinct characteristics. The traditional definitions of work emphasise that it is an activity that involves the exercise of skills and judgement, taking place within set limits prescribed by others (Bennett, 1970). Work is therefore essentially something you ‘do’ for other people. By contrast, in most leisure activities you can ‘please yourself’. Thus, reading a book, watching or playing sport, collecting stamps – are all activities you choose to do and if you do not want to do them, you do not have to. (Of course, there are people who get paid for such activities, but they are therefore ‘working’ or, in some senses, ‘employed’). So what is the difference between ‘work’ and ‘employment’? It is simple: ‘employment’ is work you get paid for (Hartley, 1980). Most child care, housework, looking after elderly or sick relatives are clearly ‘work’, in the sense that the tasks and outcomes are defined by others, but they do not, at present, usually attract formal payments. This distinction between ‘work’ and ‘employment’ is very important in the context of mental health problems because the overwhelming majority of people with mental health problems want to be employed, at the very least they want to ‘work’, i.e. to be engaged in some kind of meaningful activity that uses their skills and meets the expectations of others. This is the fundamental value of work and employment. However, not all wish to be ‘employed’, with all the additional stresses and responsibilities that entails. Bennett (1975) has characterised work, in contrast to occupational therapy, as the performance of a task within prescribed limits to achieve goals set by others who then reward the person, thus linking the individual to society. This is not to say that leisure is not also important. But an endless diet of ‘leisure’ is as stultifying and corrosive as enforced employment. What we all need is a balance between work and non-work activities; this is one of the fundamental lifechallenges.

Why is work important? As indicated, work plays a central role in all our lives. This has been recognised since ancient times (Rowland & Perkins, 1988). As long ago as 172 AD, the Greek physician and philosopher Galen described employment as ‘Nature’s best physician’ and ‘essential to human happiness’. Freud noted that work ‘binds the individual to reality’, and Thomas Szasz described it as ‘the closest thing to a panacea known to medical science’. The 18th-century poet William Cowper, who himself experienced periods of mental illness throughout his life and was confined to an asylum for over a year, said ‘The absence of occupation is not rest, a mind quite vacant is a mind distressed’ (Rowland & Perkins, 1988). Work was a central element in the therapeutic programme provided by the old asylums (Rothman, 1971; Chapter 3, this report) and, as Wing & Brown (1970) showed in their classic study of institutionalism and schizophrenia in three hospitals, the strongest factor associated with high levels of both positive and negative symptoms was the amount of time that patients spent inactive and unoccupied. There are five main arguments for the promotion of employment for people with mental health problems (Schneider, 1998): 1 2 3 4 5

the social and health benefits; the demand from service users; the ideological argument; the economic argument; national policy and the desire to deliver mental health care in non-custodial settings.

Work as a social issue Employment provides a monetary reward and is inseparable from economic productivity, with its profits for the employer and its material benefits for society. In addition, employment provides latent benefits – non-financial gains – to the worker. These additional benefits include: social identity and status; social contacts and support; a means of structuring and occupying time; activity and involvement; and a sense of personal achievement (Jahoda et al, 1933; Bennett, 1970; Warr, 1987; Rowland & Perkins, 1988; Shepherd, 1989; Pozner et al, 1996; Grove, 1999). Some have argued that it is working itself, rather than its financial benefits, that improves well-being (Bartley, 1994). Work tells us who we are and enables us to tell others who we are (Galloway, 1991): typically, the first questions that we ask when we meet someone are ‘What is your name?’ and ‘What do you do?’ Although work is important for everyone, it is particularly crucial for people who experience mental health problems. People with such difficulties are particularly sensitive to the negative effects of unemployment and the loss of structure, purpose and identity which it brings (Bennett, 1970; Anthony & 16

Shepherd, 1984; Collis & Ekdawi, 1984; Rowland & Perkins, 1988; Shepherd, 1984). Being in work enhances quality of life (Hatfield et al, 1992; Hill et al, 1996). The social exclusion that results from having mental health problems is exacerbated by unemployment. Loss of work is a key factor in social exclusion, a fact recognised in various government ‘new deal’ policies, including the New Deal for Disabled People, which explicitly includes those with mental health problems. Work is extremely important both in maintaining mental health and in promoting the recovery of those who have experienced mental health problems. Enabling people to retain or gain employment has a profound effect on more life domains than almost any other medical or social intervention. The costs of unemployment are large. Work as a health issue Employment is important in health, as well as in social functioning. There is voluminous research on the links between unemployment, physical health and psychological well-being (for a review see Bartley, 1994). Although working in an unsuitable environment can also be stressful (see below), the negative impact of unemployment generally exceeds that of stress at work. Unemployment has been linked with increased general health problems, including premature death (Brenner, 1979; Beale & Nethercott, 1985; Smith, 1985; Bartley, 1994) and there is a particularly strong relationship between unemployment and mental health difficulties (Warr, 1987; Warner, 1994). Unemployment is also associated with increased use of mental health services (Brenner & Bartell, 1983; Wilson & Walker, 1993; Warner, 1994; Steward, 1996) and is known to increase the risk of suicide (Moser et al, 1987; Philippe, 1988; Lewis & Sloggett, 1998). Unemployment can exacerbate the mental health difficulties of those with more serious psychiatric problems. People with serious mental health problems have been found to experience lower levels of symptoms when they are in employment (Warner, 1994), and clinical deterioration among people with a diagnosis of schizophrenia is associated with lack of occupation (Wing & Brown, 1970). Hospital admission rates among those who are in work are reduced (Warner, 1994), although this could be a consequence of people with less severe symptoms being more likely to secure employment. Anthony (1994) and Anthony et al (1995) found no relationship between symptomatology/disability and the outcomes of vocational rehabilitation. Employment may lead, therefore, to improvements in outcome by alleviating psychiatric symptoms, increasing selfesteem and reducing dependency (Cook & Razzano, 2000). As suggested above, the existence of work in a person’s life is a necessary counterpoint to leisure (Rowland & Perkins, 1988). Thus, unemployed people do not exploit the extra time they have available for leisure and social pursuits (Jahoda et al, 1933). Their social networks and social functioning decrease, as do motivation and interest, leading to apathy. Social isolation is often particularly 17

problematic for people who experience mental health problems, and work is more effective than occupational therapy in increasing social networks (Miles, 1971, 1972). Work preferences for those with mental illness There is increasing policy emphasis on the importance of service users’ preferences and wishes in the provision of services (Department of Health, 1999a, 2000), and mental health service users clearly say that they want to have the opportunity to work. Studies indicate that as many as 90% would like to go back to work (Grove, 1999; Rinaldi & Hill, 2000; Secker et al, 2001). This supports the conclusion of Pozner et al (1996) that assisting people to gain and sustain employment should be considered an important ‘treatment’ in its own right. It is central to achieving many of the targets for mental health services which have been set over the last decade, for example the Health of the Nation targets (Department of Health, 1992) and the National Service Framework for Mental Health (Department of Health, 1999a) Work as a rights issue The right to work is enshrined in Article 23 of the Universal Declaration of Human Rights, which states that ‘everyone has the right to work, to free choice of employment, to just and favourable conditions of work and to protection against unemployment’ (United Nations, 1948). The majority of people who experience longer-term mental health problems continue to be denied this right. An important influence on thinking of work as a ‘right’ has been the principles of normalisation and social role valorisation (Wolfenberger, 1972, 1983). These principles value people with a disability in the same way as those without. It is argued that they deserve respect, self-determination and empowerment. This means a community ‘presence’ (inclusion), choice, competence, status and participation (O’Brien, 1988; Ramon, 1991). The disability rights movement has taken this up and promoted empowerment for people with disabilities, including mental health problems. Discrimination on the part of potential employers is undoubtedly a major obstacle to people with mental health problems gaining work, especially those with a diagnosis of schizophrenia (Wansborough & Cooper, 1980; Manning & White, 1995). However, if people are to gain employment, it is necessary to view employers as an important resource that should be supported and nurtured, rather than attacked for their prejudice. When considering employers, it is important to remember that the National Health Service (NHS) is the largest employer in Europe. When combined with the social services and voluntary sector, the pool of potential jobs becomes very large indeed. Therefore, initiatives designed to increase access to employment within our own services are likely to 18

be as important as those directed towards private-sector employers (see Perkins et al, 1997, 1999; National Health Service Executive, 2000). Attention needs to be directed not only to helping people to regain employment after they have lost it, but also to preventing them from losing it in the first place. In these endeavours, primary health care services, as well as secondary mental health services, play a critical role. By the time people reach secondary services it may be too late to help them to retain the employment they had when their problems began, therefore intervention at an earlier stage of the primary-care pathway to psychiatric care is important. Work as an economic issue The costs of mental illness and unemployment are substantial (see p. 23). Each year in the UK over £20 billion of public money, in the form of social security payments, are spent on supporting out-of-work people; almost 25% of incapacity and disablement allowances are paid to people with mental health problems. If some of this resource could be redirected towards enabling people to maintain and/or regain employment then the social, psychiatric and economic gains are likely to be large (Schneider, 1998). National policy and the new context of mental health care In the past, most work projects in the UK for those with long-term psychiatric disabilities were run from or by the large psychiatric hospitals (see Chapter 3). The run-down of these hospitals has placed most mental health services and their users in community settings. Recent government policies have stressed the minimisation of risk, the containment, monitoring and supervision of people with mental illness, and a mixed economy of care. Some argue that work may provide such non-custodial supervision while at the same time promoting therapeutic ends (Schneider, 1998). Mental health and the workplace Work has both negative and positive effects on mental health. Work and ‘stress’ – the negative effects The workplace and the nature of work are changing rapidly and this appears to be increasing the psychological demands on workers. All forms of work bring unavoidable responsibilities, problems, demands and pressures and, although some people are motivated by the challenges and difficulties, for others these things take their toll, causing work-related mental heath problems. Several factors are thought to be responsible for this. Work has intensified in recent years because of organisational changes, particularly downsizing and the

concept of ‘lean production’. Job insecurity has increased in the UK, predominantly in manufacturing industries but also in the service industries and small- to medium-sized firms, particularly in the information technology sector. Although many of these changes appear to give workers more autonomy and a decrease in working hours, they may also have resulted in increasing demands with unrealistic deadlines and lack of clear instructions and decision-making; increased monitoring; and isolated working conditions. These problems (hazards) in the workplace are strongly influenced by other variables, including home life, the provision of (occupational) health services and even broader issues such as legislation. ‘Job stress’ (or ‘work-related stress’), which may be defined as an adverse reaction excessive pressures or other demand made of them, is now recognised as a major challenge. Like other occupational health problems, work-related stress can be managed by application of risk management strategies. Developing measures for the assessment of the psychosocial hazards and evaluation procedures for interventions has become a priority for employers and health and safety organisations (Health and Safety Executive, 2001). Although in many countries, including the UK, there is no specific legislation addressing the impact of work-related mental health problems, future research will inform policy development, legislation and guidance on best practice. Because of the stresses associated with work, the transition from unemployment (or lack of regular structured activity) to being engaged in work or employment may be particularly difficult. For example, Donnelly et al (2001) found that around 10% of new entrants who prematurely terminated attendance at vocational rehabilitation programmes did so for reasons of deterioration in their mental health. This underlines the stresses faced by people with mental health problems entering or re-entering the workforce. It has obvious implications regarding the need to have good links between vocational and clinical services. Work and health – the positive effects It is not possible to quantify the impact of work alone on mental well-being or social and self-esteem, but there is a growing awareness that work is at the centre of life for most people, providing financial security and personal identity and enabling them to make a meaningful contribution to society. Studies over the past 60 years have shown consistently that up to 40% of unemployed people suffer psychological distress. They also suffer from poverty and low incomes, as well as poorer mental health. The available research literature supports the view that work improves the mental health of people with serious mental health problems (Dewa & Linn, 2000). It appears that people who become unemployed have over twice the risk of mental health problems, particularly depression, compared with those who remain employed. Re-employment is one of the most effective ways of promoting the mental health of the unemployed. 20

The scope of the problem Overall prevalence of psychological disorder in the population The 1995 Office of Population Censuses and Surveys’ (OPCS’) household survey of 10 000 adults aged 16–65 years in Great Britain confirmed the presence of widespread psychological symptoms in the general population (Meltzer et al, 1995a). The major findings were that: • • • •

• • • •

about 1 in 7 adults had had some sort of neurotic health problem in the week prior to the interview; women were far more likely to suffer a neurotic health problem than were men; the four most common neurotic symptoms were fatigue (27%), sleep problems (25%), irritability (22%) and worry (20%); the most prevalent neurotic disorder in the week prior to interview was mixed anxiety and depressive disorder (77 per 1000) followed by generalised anxiety disorder (31 per 1000), depressive episode (21 per 1000), obsessive–compulsive disorder (12 per 1000), phobia (11 per 1000) and panic disorder (8 per 1000). functional psychoses had had a prevalence rate of 4 per 1000 in the previous year; the rates of alcohol and drug dependence had been 47 per 1000 and 22 per 1000 in the previous year; men were three times more likely than women to have alcohol dependence and twice as likely to be drug dependent; alcohol and drug dependence were most prevalent among young adults, particularly young men aged 16–24 years.

Mental health problems in general practice Approximately 90% of people with diagnosed depression are treated entirely within primary health care. General practitioners provide the main source of care for most people with psychiatric disorders, the bulk of whom have non-psychotic syndromes. These groups place a high demand on general practice and about a third will have morbidity persisting for over many years (Lloyd et al, 1996; Craig & Boardman, 1997). The unemployed consult their GPs more often than average (Beale & Nethercott, 1985) and those who have been unemployed for more than 12 weeks show between four and ten times the prevalence of depression, anxiety and somatic illness, with an association between unemployment and suicide (Claussen et al, 1993). About 50% of patients receiving incapacity benefits have musculoskeletal or mental health problems. There is some evidence that those patients that are initially certificated as having back pain receive diagnoses of depression or anxiety after some months off sick. One diagnosis may often transmute into another. 21

Employment in people with common mental disorders The OPCS survey found significant levels of unemployment and sickness absence in those with neurotic disorders (Meltzer et al, 1995b): • •

•

adults with neurotic disorders were four to five times more likely than the rest of the sample to be permanently unable to work; overall, 61% of men with one neurotic disorder and 46% with two disorders were working, compared with 77% of those with no disorder; the equivalent figures for women were 58%, 33% and 65%; the lowest rates of employment among people with neurotic disorders were found in those with phobias; 43% of men and 30% of women with phobias were working; among the sample with any neurotic disorder who were unemployed and seeking work, 70% had been unemployed for a year or more (that is, 7% of all people with a neurotic disorder); compared with the general population, adults with neurosis were twice as likely to be receiving income support (19% v. 10%) and four to five times more likely to receive invalidity benefit (9% v. 2%)

Employee absenteeism is a familiar characteristic of the current labour market, and the category ‘depression, bad nerves or anxiety’ has been ranked eighth out of 13 self-reported chronic health problems as a cause for non-attendance at work (Almond & Healy, 2000). Recent statistics illustrate that mental health problems have, within the last five years, become the leading reason for claims to incapacity benefits (Department of Social Security, 1999). Employment in people with long-term mental illness The Labour Force Survey, a continuous household survey carried out in Great Britain by the Office for National Statistics provides figures on those with longterm disabilities. Data for 1998–2000 are shown in Appendix 1. One survey category concerns individuals with long-term disabilities whose main difficulty is a mental health problem (‘long-term disabled with a mental health problem as main difficulty’). In 2000, this category accounted for 8% of all unemployed people of working age with long-term disabilities. Eighteen per cent of people in the category were in employment, 4% were looking for work and an estimated 78% were unemployed. Long-term disabled people for whom a mental health problem was not the main difficulty represented 84% of the total population of working age with long-term physical and/or mental disabilities, and 52% of these people were in employment in 2000 (Office for National Statistics, 2000). The Labour Force Survey figures demonstrate that people with mental health problems are much less likely to be economically active than those with physical or sensory impairments. Other studies indicate that between 30 and 40% of this group of people with mental illness are capable of holding down a job (Ekdawi & Conning, 1994). 22

Figures from an OPCS survey of adults with psychotic disorders living in the community support these findings (Foster et al, 1996): 1/2 of the sample were classified as unable to work, 1/5 were in employment and 1/8 were unemployed. These national figures show that rates of unemployment in people with mental illness are high. Separate surveys support these findings of low rates of employment. In surveys of around 500 users of community mental health services, Thornicroft et al (1998) showed that only 16% were in paid employment and Stott et al (2000) reported a figure of 14%. Other surveys have presented an even more worrying picture. In 1990, of 1000 people with mental health problems of at least 2 years’ duration who were using CMHTs in a south-London borough, 20% were in paid employment. By 1999 this had dropped to only 8% (Perkins & Gentle, 1999). Perkins & Gentle found that the situation was worse for CMHT users with a diagnosis of schizophrenia: among this group the proportion in paid employment fell from 12% in 1990 to only 4% in 1999. This is consistent with Manning & White’s (1995) finding that employers were more inclined to take on people with depression than those with a diagnosis of schizophrenia. These figures compare poorly with the general population of disabled people, for whom the employment rate (although half that for their non-disabled counterparts) remained constant, at around 40%, between 1985 and 1996 (Burchardt, 2000). Even though the unemployment rate for individuals with disabilities due to a mental health disorder is high, mental health promotion remains one of the most underdeveloped areas of health promotion in the UK: ‘Whilst mental ill health constitutes one of the biggest health, social and economic issues this country faces, its prevalence remains inadequately analysed and documented, and, as a result, woefully misunderstood and under-resourced’ (J. McKerrow, Director of the Mental Health Foundation, cited in Bird, 1999). Costs of mental illness and unemployment Mental health difficulties can affect an individual’s function in numerous ways and, depending on the age at onset, a person’s working capacity can be significantly reduced. In the workplace, this can lead to absenteeism, sick leave and reduced productivity. The cost of disabilities arising from mental health problems might be viewed as comprising three components (Saraceno & Aro, 2001): • • •

the direct costs of welfare services and treatment, and indirect costs of carers, etc. the costs of state benefits the costs of income relinquished as a result of incapacity.

In the UK, mental health problems are a leading cause of distress, illness and disability and carry a significant financial cost. It has been estimated that 80 million working days are lost every year in the UK because of mental illness, costing employers £1.2 billion per year. 23

An average of 3000 British people move onto incapacity benefits each week. The economic costs of this are high – about £10 billion a year (Gordon & Risley, 1999). The leading causes are musculoskeletal (28%) and psychiatric disorders (20%) (British Society of Rehabilitation Medicine, 2000). The estimated annual total cost of mental illness in England at 1996/1997 prices is £32.1 billion; the component costs include £11.8 billion in lost employment, £7.6 billion in Department of Social Security (now Department for Work and Pensions) payments and £4.1 billion in NHS costs (Patel & Knapp, 1998). Employment and mental illness in Black and other minority ethnic groups Black and other minority ethnic people living in the UK are a diverse group that includes first-generation people who migrated in search of work opportunities, refugee communities, and second and subsequent generations who now consider themselves British. The ability of each of these groups to negotiate barriers to social inclusion, finding work and acquiring new work skills may differ depending on their personal resources and the impact of migration on mental well-being. Thus, for traumatised refugee communities, resettlement and finding work may be undermined by their traumatic migration experiences, social isolation, discrimination, linguistic isolation and mental illness. It is likely that those migrating to find work fare better, having the personal resources to migrate in order to establish a better life. Unemployment in the UK is known to be high among Black people (Trades Union Congress, 1995). In terms of the ethnic groups listed in the 1991 census, unemployment affects 10% of the White group; over 30% of the Bangladeshi and Pakistani; over 20% of the Black Other and Black African groups; between 10 and 15% of the Irish, Indian and Other Asian; and nearly 20% of the Other-other and Black Caribbean groups (Peach, 1996). The fourth National Morbidity Survey showed that, of the economically active adult population, 11% of White people are unemployed, compared with 24% of Caribbean people, 38% of Pakistani and 42% of Bangladeshi people (Nazroo, 1997). Although second and subsequent generations can be expected to be more able at securing work because of bi-cultural competencies, the experience of Black and other minority ethnic groups is that the effects of social exclusion and discrimination traverse generational boundaries. Although a great deal of attention has focused on higher rates of schizophrenia among African–Caribbeans, and possibly all immigrant groups, there has been little attention to employment and work among people with mental illnesses from Black and other minority ethnic groups. Similarly, service development to meet the needs of these groups has not included the impact of illness on their ability to retain employment and to find new work opportunities. The absence of attention to retaining work might reflect the already low levels of employment among all users of psychiatric services, but especially among African–Caribbean men, who are the most conspicuous users of mental health services in inner-city areas. The evidence suggests that African–Caribbean people, particularly young men, are 24

especially disadvantaged, in part because of racial discrimination, but also because of poverty and lack of formal qualifications and training opportunities. At one level, opportunities for securing employment should be made available to all socially excluded groups, and this is the responsibility of local authority and multiple agencies, including health services. The difficulties of securing employment, finding realistic employment opportunities and retaining jobs affect self-worth, identity, status and, ultimately, mental well-being. Recovery from mental illness involves a re-appraisal of ones worth and abilities. Mental illness reinforces the sense of powerlessness and makes it less likely that Black and other minority ethnic groups can avoid social exclusion. Unemployment and mental illness are stigmatised both by the majority society and by minority ethnic groups. These factors might also perpetuate the existing spiral of social exclusion. Refugees and newly immigrant communities are known to have appropriate qualifications in their home countries, but have great difficulty finding employment in the UK, securing professional requirements to practice in the UK, developing language skills and social networks, and recovering from traumatic migration and resettlement experiences (National Asylum Support Service, 2001). Consequently, employment projects are a crucial part of the Home Office’s plan for integration of refugees. Employment interventions might be more appropriate and acceptable among such groups than the existing mental health service interventions for post-traumatic stress disorder (Eastmond, 1998; Summerfield, 2001). Why have employment opportunities and work schemes been neglected for those with mental illness? Barriers to employment and to the development of employment services From the figures on employment and mental illness quoted above it appears that mental health service users face more significant barriers to work than do other disabled people. Only people with severe learning disabilities find it more difficult to get paid work. The high rates of unemployment among those with mental illnesses suggests that work projects that do exist are providing only a limited and restricted service. Several factors contribute to these barriers to employment: •

•

Historically, the employment of disabled people has depended on economic growth, overall employment rates and times of labour shortage (Warner, 1994). The welfare system has built-in disincentives to returning to work (the socalled ‘benefits trap’). There is a fine balance between supporting people who are unable to work and creating disincentives to returning to work for those who could. Many problems face people with a history of mental illness in the open employment market, including stigma, a reluctance to employ them, the risk of failure and the benefits trap. 25

•

• •

There has been a tendency for mental health professionals and others to underestimate the capacities and skills of their clients and, perhaps, to overestimate the risk to employers. This may extend to GPs and employers who give insufficient attention to helping people return to their jobs. The dominant model of mental illness emphasises ‘episodes’ and ‘cure’ as opposed to one the disability of long-term mental illness. Mental health care has shifted from large asylums to community-based services, and the few work schemes that existed in the past were based in, or run by, hospital services. Current responsibilities for people outside of hospitals are not clearly allocated among state organisations dealing with health and employment. Mental health professionals lack expertise in business development. There is a lack of evidence (and ignorance of the existing evidence) relating to the types of services and approaches that are effective in getting those with mental illness into work and keeping them in employment.

Professionals’ assumptions of unemployability Service users often report that psychiatrists have told them ‘You will never work again’. Whether or not this actually happens as frequently as is reported is open to question, but most mental health professionals acknowledge that more emphasis should be given to people’s employment aspirations. However, they often go on to say that their patients are at the very severe end of the spectrum and either could not or do not want to work. Research calls into question both of these beliefs, but they are such a fixed part of clinical culture that frequently no one even asks users whether or not they want to move towards employment. Inappropriate early interventions The proposal to set up the New Deal for Disabled People Job Retention pilot (see Chapter 2) recognises that insufficient attention is given to helping people in work retain their jobs. There are concerns that people with illness or disability might lose their jobs without sufficient efforts being made to keep them in employment or to make adequate adjustments to their job or working environment. The subsequent loss of a job allows them to descend into the downward spiral of long-term unemployment. The role of the GP is crucial to keeping people with sickness in work (see Chapter 3). Loss of motivation/confidence Recent research has shown that ‘self-efficacy’, a collection of internal characteristics and feelings that includes motivation, work adjustment, self-confidence and selfbelief, is an important indicator of employability. The corollary of this is that the catastrophic loss of self-confidence that often comes as a consequence of mental 26

disorder is a key factor in making individuals reluctant to go back to work. The same effects have been observed among people who have been made redundant or become long-term unemployed. What makes this a difficult problem is that once individuals have lost confidence in their own employability, it is very difficult to restore it unless they can get a job. The attitudes and ignorance of employers and the general public Service users regularly put employers’ attitudes at the top of their list of barriers. Recent surveys of employers tend to confirm that many will not even entertain the thought of employing a person with a physical disability (Rinaldi & Hill 2000), much less someone with a history of mental ill health. Following on from this it is often said that employers need ‘educating’ about mental illness. Whether knowing more makes people discriminate less is open to question, but changing employer attitudes is certainly important. Work by the Employers’ Forum on Disability suggests a totally different approach to the usual tack of ‘give this poor person a chance’. Unlocking the Potential (Zadek & Scott-Parker, 2000) suggests that agencies supporting disabled people should offer to help employers solve their recruitment problems and arrange opportunities for them to meet and talk to these people face to face. The perceived risks to income from coming off benefits The ‘benefits trap’ is usually first or second on users’ lists of obstacles to returning to work. Indeed, the term itself may be a further barrier because it deters people from exploring ways in which they could, with safety, improve their income through employment. However, the evidence is that for very many disabled people the risks and difficulties of trying to come off benefits are only too real (Betteridge, 2001). Government attempts to deal with this problem (see Chapter 2) have made little difference and more significant improvements are needed. People of working age with enduring mental health problems can find themselves trapped on state benefits by a range of factors. A person who suffers from a mental health problem and is unable to work may receive replacement income from a number of sources, including the state benefit system. In financial terms, this replacement income may act as a barrier to alternative activity such as steps towards rehabilitation or a return to work because earnings, particularly for part-time work, may not compare favourably with the remunerations from income-replacement benefits. However, people can be trapped on benefits by other factors, including the advice they receive from health professionals and lay ‘work-focused’ advisers. Many health professionals have low expectations for their patients with regard to rehabilitation and eventual employment, and advisers may not possess the experience or expertise to promote work or work-related activities to people with mental illnesses. 27

Negative attitudes and ignorance of key staff, friends or carers This is another dimension of the self-confidence issue. The attitudes and expectations of significant others may be critical to an individual’s self-belief. For example, people who prematurely leave vocational rehabilitation programmes tend to have smaller social networks and less perceived support. As in other areas of psychiatry, the need to develop good working partnerships between services focused on the individual and those focused on the ‘significant others’ is highlighted. Inter-agency problems Employment opportunities cut across several agencies (see Chapter 4). The problems that arise are partly a consequence of deinstitutionalisation and the move towards community services provided by a mixed economy of care. It has been a constant source of irritation to disabled people that the various government and independent agencies that provide vocational rehabilitation rarely seem to work together or provide ‘maps’ by which individuals can navigate the system (see Grove et al, 1997). The present Government has given great emphasis to ‘joined-up thinking’ and joint working. However, working in partnership, avoiding duplication and ensuring that individual journeys through the system are clearly signposted are easier said than done (see Chapter 4). Addressing the mental health needs of employees Individuals with mental illnesses, including severe mental illness, may want to find mainstream employment, or to retain their jobs after a period of treatment, but they are frequently discouraged by a range of environmental, institutional and attitudinal barriers. Some of the hardest obstacles for them to overcome are associated with feelings of shame, fear and rejection. There appear to be two main problems when employers attempt to address the mental health needs of their employees. The first of these is employers’ poor recognition (and acceptance) of mental health issues concerning their workforce. The second is the lack of easily accessible, expert preventive treatment and rehabilitation programmes. In addition, there needs to be effective implementation of anti-discrimination legislation. Some large companies in the UK have developed policies consisting of key elements of good practice that address mental health issues in the workplace. Workers’ and employers’ organisations have also been active in promoting equal opportunities, codes of good practice and employment of people with disabilities. The Trades Union Congress (TUC) and the Confederation of British Industry (CBI) are the principal organisations representing workers and employers, while the Employers’ Forum on Disability encourages good practices among employers in an attempt to remove barriers to the employment of people with disabilities.

The CBI has worked jointly with government agencies and the TUC to tackle stress-related problems in the workplace and has produced guidelines on stress management that address stress as a human resource and as an occupational health and safety issue. Barriers to work A recent report by the Scottish Council Foundation (McCormick, 2000) identified three main reasons why people who have been off work because of illness do not return to employment: (a) the nature of the incapacity, including any workplace adaptations and requirements for flexible working; (b) local labour market opportunities; (c) benefit traps that make returning to work financially disadvantageous. A consistent theme throughout the Scottish Council Foundation report is the need for earlier and better forms of rehabilitation. Furthermore, although the Disability Discrimination Act 1995 outlaws discriminatory practices and places responsibilities on employers to make reasonable adjustments to accommodate those with disabilities, a weak labour market allows them to be selective about whom they recruit. Too often people with mental health problems remain on long-term state benefits because they are unable to obtain timely access to appropriate treatment, for example counselling, cognitiveâ&#x20AC;&#x201C;behavioural therapy or treatment and rehabilitation for substance misuse. Employment and women whose primary disability is psychiatric A growing body of literature suggests that mental health services see work and employment as more important for men than for women. Women tend to be under-represented on vocational programmes, especially those designed to facilitate access to open employment. Showalter (1987) has shown, in the relatively closed society of the old asylums, how the priority accorded to work for male patients meant that they occupied more powerful, higher-status positions. Men, for example, looked after less able patients and worked in the bakery or on the farm, whereas women were directed towards more domestic pursuits such as sewing, cleaning and laundry work. Since this time, attitudes towards the employment of women have changed, but there remains a relative lack of attention to the work needs of women. Bachrach (1985) has described how, in the USA, community care programmes for men with psychiatric disabilities are based on higher expectations of performance than are those for women, who often continue to be stereotyped as passive, emotional and childlike. These differential expectations have resulted in different patterns of placement in community services for men and women, and work is typically

seen as less important for women (Bachrach, 1985; Goering et al, 1988; Perkins, 1991, 1992; Perkins & Rowland, 1991). Data from the UK indicates that women are under-represented in vocational programmes designed to enable people with psychiatric disabilities to gain access to work opportunities. In their study of over 2000 longer-term clients of CMHTs in two South-London boroughs, Perkins & Gentle (1999) found no difference between the proportion of men and women in open employment, but a significant difference in the proportion of men and women served by the range of specialist mental health vocational programmes available in the area that were designed to provide work rehabilitation, training and access to open employment. Women comprised 50.4% of the population of longer-term clients, but only 32% of the people using these work/employment programmes. Similar figures have been found in two other studies. Pozner et al (1996) described 29 work/employment schemes, which included work rehabilitation/ sheltered work, club-house and vocational training programmes as well as supported employment programmes and social firms/cooperatives. Women comprised an average of only 36% of the people using these programmes. Hallam & Schneider (1999) studied seven works schemes, and found that only 30% of the people using them were women. These figures indicate that women are underserved by vocational programmes for people with mental health problems. However, there are also data to suggest that low expectations of women result in their being differentially disadvantaged within such programmes. Perkins & Rowland (1991) studied a rehabilitation service that offered four sheltered workshops designed for people with different levels of disability. Although the functioning level of the population of men and women using them did not differ, there was a significant difference in the proportion of men and women in the different workshops. Women comprised 72% of those using workshops designed for those with the most disabled people but only 25% of those using workshops designed to prepare more-able clients to move on to sheltered or open employment outside the health services. The available data therefore suggest that, in comparison with men, mental health services place less emphasis on employment for women, and have lower expectations of them in the vocational arena. Men are more likely to use vocational services than are women and the under-representation of women is most marked in services directed towards enabling people to gain and sustain open employment. This means that women with psychiatric disabilities face not only the employment discrimination outside mental health services experienced by everyone with mental health problems, but also additional discrimination within mental health vocational services because of their gender. If services have lower employment expectations of these women then a vicious circle may result that exacerbates the low expectations that the women often have of themselves. If few women use a vocational programme, then it can readily become a largely male environment in which women feel unwelcome and out of place, making it less likely that they will want to join it. 30

If women with psychiatric disorders are to enjoy the health, social and psychological benefits of work then it is important that vocational programmes are acceptable and accessible to them. This might involve the explicit challenging of the often implicit assumptions that women are less able than men in the vocational arena and that work is less important for them; the specific targeting of women with psychiatric disabilities to encourage them to use vocational services; and the removal of potential barriers to their engagement by, for example, considering child care arrangements and women-only sessions. Illness or disability? The common model applied to long-term mental disorders is the ‘illness’ model, which emphasises the episodic nature of the disorders. This is less appropriate in the present context than a model that emphasises the disabilities (i.e. enduring problems) associated with mental illness, i.e. a ‘disability’ model. The illness model The illness model assumes that an episode occurs for which treatment is available and a cure can be achieved. Such a model may be useful when applied to acute mental illness, especially in the context of acute in-patient services, or to many of the problems seen by mental health services. It is less useful in the context of rehabilitation services and employment opportunities. Illness is often assumed to be short-lived; it can come and go quickly. Illness removes the expectation of, and often the capacity for, fulfilling normal social roles – the patient is excused from work, active parenting and other duties. In most cases this is temporary and the focus of attention is on ‘getting better’. Health professionals are expected to assist by providing treatments and cures and the patient is generally expected to cooperate with these, by taking what sociologists refer to as the ‘sick role’ and engaging in ‘illness behaviour’ (Parsons, 1951; Mechanic, 1962). The disability model Disabled people, however, cannot normally expect a ‘cure’. However, they can usually adapt to changed circumstances and can increasingly expect adjustments in the world around them to enable them to participate. For example, a woman with a major spinal injury following an accident may use an electric wheelchair, have her home made accessible through a local authority grant, continue to work by using voice recognition software provided by her employer and learn to drive an adapted car. She fulfils social roles by learning new skills, being provided with special adaptations and support (both physical and social). She can expect contributory action from others, rather than waiting to ‘get better’. 31

The World Health Organization (WHO) used to distinguish between impairments (abnormalities at the level of the organ), disabilities (functional disturbances, at the level of the individual) and handicaps (interaction of the individual with the environment). But after two decades of use this classification was revised and it now places a stronger emphasis on social, as opposed to biological, factors (Appendix 2 outlines the terminology used by the WHO in assessing disability). An alternative to the WHO view is a two-part typology – impairment/disability. Disability is understood by the UK disability movement, and to an extent by British disability policy, to mean the interaction between an impairment (being blind, or unable to walk, or having long-term cognitive difficulties as a result of schizophrenia) and the social structures and barriers that exclude the person from full participation. This means that use of the term ‘disability’, unlike ‘illness’, automatically brings into focus the need to remove barriers in social attitudes, practices, policies and the built environment. This Social Model of Disability views disability as an interaction between a person’s impairment and the social barriers they face. Arguments for adopting a social model of disability There are a number of reasons why the use of a social model of disability is more useful in the present context than is a traditional illness model. 1. It offers a more helpful conceptual basis for understanding and promoting employment opportunities for people who use mental health services and offers more hope of recovery of social roles. The term ‘disability’ captures more of the experience of being a long-term mental health service user than does the term ‘illness’ and it makes more sense of the experience of seeking or keeping work. For those with long-term or recurring mental illnesses, such as recurrent depression, manic depression or schizophrenia, the concept of ‘disability’ may be much more relevant than that of ‘illness’. Although there are physical, psychological and social treatments available to reduce symptoms, there are no cures. Acute periods do have some of the characteristics of ‘illness’, but the overall pattern is usually longer term. If the individual waits to ‘get better’, or pins all hopes on cure, the likelihood is that all social roles, from employee to parent, will be withheld until some elusive future moment of positive mental health. Yet why should a mental health service user wait to be free of major symptoms in order to work? A deaf person could legitimately expect employers and service providers to adjust their workplaces, procedures and practices to enable access and participation. What hope remains to the individual mental health service user when, despite treatment, the symptoms and/or adverse effects of medication remain disabling? Clinicians can use the model to explore with clients their individual strategies for recovery and for managing the effects of disability and discrimination. For 32

example, following a first episode of psychosis, a professional might support the client to maintain, or change, his employment, education and social networks – perhaps helping him to think through what, if anything, he intends to say to others and how he will deal with any negative reactions. This can encourage the client to begin the active process of creating a fulfilling life, in changed circumstances. This model enables practitioners to avoid the twin dangers of raising potentially false hopes of cure through treatment or of conveying no hope at all. The concept of ‘illness’ may be of very limited use as a basis for planning improved employment opportunities for people who experience ongoing or recurrent impairments (physical or mental). Employers do not think in terms of enabling ‘ill’ people to work. Ill people should not be at work, almost by definition. They should be tucked up at home, or in hospital. If, however, a person is ‘disabled’, for example is a wheelchair user or is blind, then employers usually recognise that adjustments may be needed to enable that individual to get or keep a job. It is also important to develop the research base on social inclusion, using a disability paradigm. This will help ensure that the aim in the first standard of the National Service Framework for Mental Health, to ‘combat discrimination against individuals and groups with mental health problems, and promote their social inclusion’, is rooted in a growing evidence base. 2. It better captures the experience of discrimination and exclusion that is central to the lives of many mental health service users and it addresses the barriers to employment. The emphasis on disability as an interaction between impairment and social barriers adds the important dimension of the social context in which we live and adds the component of social inclusion, which is absent from traditional illness models. The disability model also focuses attention on appropriate challenges to discrimination. Mental health professionals can use their influence and expertise to counter popular stereotypical interpretations of gross diagnostic categories, by providing detailed understanding of the individual implications of conditions: for example, by assisting a person to get work, or giving evidence in the judicial system or contributing to media debates. The disability model appears to offer much greater opportunities to achieve social inclusion in general, and labour market participation in particular, than any other available conceptualisation. It also has the potential to unite mental health professionals and service users in a common pursuit of social justice. 3. It is consistent with current government policy. The impairment/disability typology is in common use in UK disability policy and for that reason it is helpful to adhere to it in order for service users to benefit from the anti-discrimination provisions of current disability rights policy. It underpins the Disability Discrimination Act 1995 and the Disability Rights Commission (DRC) set up in 2000 to enforce the law and promote 33

equality of opportunity for disabled people. A ‘disabled person’ is defined by the Disability Discrimination Act 1995 as having an impairment lasting, or expected to last, for at least 12 months (either episodically or continuously). This typology also avoids the term ‘handicap’, which some find offensive. The UK Government, as well as governments in the USA and a number of other countries, has defined disability to include long-term conditions not always associated with ‘disability’ in the public mind. In Britain these include cancer, AIDS, epilepsy, diabetes – and ‘mental illnesses’, provided they are ‘clinically well recognised’. 4. It is consistent with the views of users and people with disabilities. The majority of people with disabilities consequent on physical and mental disorders wish to be in some form of meaningful employment. In general, the British disability rights movement supports the notion of disability and of the equivalence of physical and mental disabilities, and it generally subscribes to the social model of disability. None the less, the language of disability is highly contested. In the USA, the preferred language is a ‘person with a disability’: the person comes first, as he or she is not synonymous with the disability. The British disability rights movement rejects this conceptualisation, on the grounds that, under a social model of disability, people are ‘disabled’ by society: hence they are ‘disabled people’. The disability rights movements also support a revised concept of ‘recovery’. Proponents of ‘recovery’ in the USA have proposed a source of hope far more profound than that of ‘cure’, by arguing that recovery for people with ‘psychiatric disabilities’ is about establishing a satisfying and meaningful life with the impairment – not waiting or hoping to be without it. Deegan (1993) sees this as fundamentally similar to the experience of people with physical impairments: ‘Recovery does not refer to an end-product or result. It does not mean that my friend [with quadriplegia] and I were “cured”. In fact, our recovery is marked by an ever-deepening acceptance of our limitations. But now, rather than being an occasion for despair, we find that our personal limitations are the ground from which spring our own unique possibilities’. Recovery is active and purposeful; it requires civil rights, so that opportunities are available for disabled people; and it rests on a notion of long-term disability, not illness. Not all users of mental health services identify with the term ‘disabled’. Sayce (2000) addresses the most common reasons for rejecting the term and puts many of them down to a lack of full mutual understanding between people with different experiences of disability or mental health problems. For instance, mental health service users sometimes believe that ‘disability’ implies being ‘born that way’, when in fact the incidence of physical impairments increases dramatically with age; or that disability is permanent and 34

unchanging, whereas many impairments, such as multiple sclerosis, are as episodic as bipolar disorder. Many people with physical or sensory impairments also see their disability as socially constructed, ‘in the eye of the beholder’, as do many mental health service users: both challenge the notion of perfection in relation to which their presumed ‘imperfections’ are defined. For example, some in the deaf community see deafness as a matter of linguistic and cultural identity, not of impairment. The different specific experiences and the real common strands can best be understood through shared discussion and exploration. This is beginning to occur. For example, a project at Greater London Action on Disability (GLAD) brings together mental health service users and other disabled people to create a ‘common agenda’. This convergence seems set to grow and deserves the widest debate. 5. It assists in achieving dialogue with employers. The social model of disability also offers more promise at a pragmatic level, because of developments in British disability rights policy in the past 5 years that create a new opening for dialogue with both employers and service users. The spread of good employment practice under the Disability Discrimination Act creates a significant new opening for discussion with employers, if framed in terms they understand: ‘psychiatric disability’ or ‘psychiatric impairment’, not ‘mental illness’. Employers understand the term ‘disability’ and terms like ‘reasonable adjustment’ are becoming common currency. It is relatively straightforward for them to transfer lessons learnt from, say, flexible working practices for someone with dyslexia or multiple sclerosis, to adjustments for someone with mental health problems. Employers also know that government policy encourages them to recruit and retain more disabled employees – and that doing so can give their company an edge in the corporate social responsibility stakes. Employing people who are ‘ill’ brings no such resonance. It would be counterproductive in the extreme to approach employers to encourage them to employ ‘mentally ill’ people. The term ‘illness’ is likely to suggest high sickness absence - wrongly, in the case both of supported employees with mental health problems (Perkins et al, 1999) and disabled people in general (Zadek & Scott Parker, 2000). The Disability Discrimination Act 1995 (Appendix 3) Mental health staff can capitalise on the fact that most employers now realise their obligations not to discriminate and to provide reasonable adjustments, but may need help to understand the application of these concepts to the employment of people with psychiatric, rather than physical, impairments. Mental health professionals play a key role in defining ‘reasonable adjustments’ in the workplace 35

that might enable a person with mental health problems to work successfully, supporting them to negotiate the adjustments and providing additional treatment and support outside the workplace, if needed. The law (the Disability Discrimination Act 1995) promotes this approach, and employment practices are beginning to follow suit – in relation to people with mental health problems as well as those with physical impairments. Some large companies make attempts to retain employees who develop mental health problems. These might involve adjustments to working practices, working hours and the tasks involved in an individual’s job. It might involve setting up support to help the person on a day-to-day basis – all the kinds of adjustments you would expect to make under the Disability Discrimination Act (Mind, 2000). Although the Disability Discrimination Act has limitations in relation to people with mental health problems (Department for Education and Employment, 1999) there have been a number of dismissal cases successfully contested by people with psychiatric impairments. The Disability Rights Commission’s goal is a society in which all disabled people can participate fully as equal citizens. ‘All’ disabled people explicitly include those with psychiatric impairments. The Disability Discrimination Act provides a legal framework that is beginning to be understood by employers. They are required not to treat an individual less favourably on grounds of disability and to make adjustments, where ‘reasonable’, so that disabled people are not disadvantaged. For many people with psychiatric impairments, the only change needed from the employer is an end to discriminatory practices. If managers recruiting staff stopped screening out people with a psychiatric history, or gaps on their curriculum vitae, then more people with psychiatrically disabilities could be working. But although some people need no ‘adjustments’ or just make their own privately, for instance by taking short breaks when voices are troublesome, others need to negotiate with the employer. These negotiated adjustments for people with cognitive and emotional impairments have been defined and tested (Employers’ Forum on Disability, 1998; Sayce, 2000). Employers may need help to understand what the relevant ‘reasonable adjustment’ is for someone who hears voices or is nervous of social interactions: it may seem less obvious than for the person who is blind. But they are beginning to recognise that the law places the same obligations on them in relation to psychiatric as to physical impairments. Key points of Chapter 1 • • •

• • •

• •

Work is important in promoting the recovery of those who have experienced mental health problems. The overwhelming majority of mental health service users want to be employed, or at least be engaged in meaningful work. Unemployment rates for people with all mental disorders are high, but particularly so for those with severe mental illness, for whom the rates are between 60 and 100%. People with long-term psychiatric disabilities are even less likely to be in employment than those with long-term physical disabilities. The high rate of unemployment in those with mental illness is as much a product of social factors as of the personal consequences of mental illness. Barriers to work for people with severe mental illness include structural factors, stigma and prejudice, attitudes and approaches of the mental health services and the lack of well-run employment schemes. Women with mental disorders and people from Black and ethnic minorities have even greater problems gaining access to employment. A social disability model of illness offers a more helpful and constructive approach to addressing the difficulties of employment for those with mental illness than does an approach centered on episodes of illness.

2. Work, employment and psychiatric disability: the policy context

This chapter sets out examples of recent and current government policy and legislation, which have implications for the employment of those with psychiatric disabilities. Of central importance is the Disability Discrimination Act 1995. The chapter has been divided into three main parts: legislation, Welfare to Work initiatives and health service reforms. Legislation Health and safety at work The basis of British health and safety, the Health and Safety at Work Act 1974, sets out the general duties that employers have towards employees and members of the public, and employees have to themselves and to each other. Modern health and safety law in this country, and also much of that in Europe, is based on the principle of risk assessment. The Health and Safety Executive expanded its activities on work-related stress in the early 1990s and commissioned an independent review of the scientific literature on stress, which resulted in its current guidelines on work-related stress (Health and Safety Executive, 1995). The guidelines provide a flexible framework for action that employers can adapt to their organisational needs. All employers have a common-law duty of care to protect their employees from harm arising from activities in the workplace and there is no differentiation between harm to physical or to mental health. Furthermore, a higher standard of care is owed to a person who is known (or ought to be known) to be vulnerable. This common-law duty is supplemented by a statutory duty imposed by the Health and Safety at Work Act 1974 to safeguard the health, safety and welfare of staff; again the legislation applies equally to mental and to physical health. The Health and Safety at Work Act has been augmented by the Management of Health and Safety at Work Regulations 1999, which represents the UKâ&#x20AC;&#x2122;s implementation of the European Union Framework Directive on health and safety. The Regulations require employers to undertake a risk assessment of all work to identify hazards, including those to mental health, and to ensure that risks are adequately controlled. The Management of Health and Safety at Work Regulations 1999 require employers to take suitable and sufficient advice from competent sources when discharging their legal duties. Many employers seek to meet this requirement by seeking advice from occupational health professionals, both when assessing risk and when determining fitness for employment. However, access to occupational 38

health advice is patchy and, while common among large employers in both the public and private sectors, is less usual for small and medium-sized enterprises. The Government is seeking to address this inadequacy but, at present, there is no certainty that a company will have an occupational health professional to assist with the placement or rehabilitation of patients with mental health problems. The larger organisations, which might be better placed to make any adjustments required, often do have access to appropriate expertise, but the downsizing of many companies has had a deleterious effect on the provision of occupational health services. Many large organisations, though few small and medium-sized enterprises, have developed mental health policies subordinate to their overarching health and safety policy, which is a statutory requirement. Such policies aim to educate management and the workforce alike to recognise the prevalence of mental illness and to help destigmatise these conditions. They are often linked to equal opportunities policies and may well incorporate the management of psychosocial risks in the workplace. Drug and alcohol policies, which are also common, are usually separate documents and their tone tends to reflect the nature of the industry in which the company operates; support for rehabilitation is a frequent feature but there is less scope for this in safety-critical work. The Disability Discrimination Act 1995 The legislative requirements of health and safety law are complementary to those imposed by employment law. The Disability Discrimination Act 1995 applies a very broad definition of â&#x20AC;&#x2DC;disabilityâ&#x20AC;&#x2122; such that many individuals with chronic mental health problems fall within its scope. Discriminating against disabled people is unlawful and employers are specifically required to identify obstacles to employment and to implement adjustments to overcome them, provided that these are reasonable. Government guidance and the case law that has developed since the act came into force dictate that a good deal is expected of employers when dealing with those affected by mental illness. The Disability Discrimination Act has been responsible for a marked change in attitudes towards the employment of disabled people including mental health problems. People with a physical or mental impairment which has a substantial and long-term adverse effect on that ability to carry out normal daily activities are now covered by the employment provisions of the Disability Discrimination Act. The act makes it unlawful for employers with 15 or more employees to treat an applicant or an employee with a disability less favourably than others because of that disability and provides protection at the recruitment stage as well as for those already in work (from 2004, the provisions of the act will apply to nearly all employers, not just to those with 15 or more employees). Mental health problems, current and recovered, ranging from schizophrenia and bipolar disorder to panic disorders and depressive conditions, fall within the remit of the Disability Discrimination Act. An employer with more than 15 39

employees is responsible for making a reasonable adjustment if an applicant with a disability at a substantial disadvantage in relation to others. Although the act contains some examples of adjustments, the list is not comprehensive and companies often need to take advice about the type and reasonableness of adjustments they are required to make (Employers’ Forum on Disability, 1998). Such adjustments might include: • • • • •

part-time work alternative work, for example in a different environment more supervision and training regular meetings with supervisors/managers mentor support.

The Disability Discrimination Act is designed to protect ‘disabled people’ and those with a history of disability from discrimination. This act, despite limitations, offers significant new protections and opportunities for a wide range of disabled people, including those with mental health problems. The law sets a benchmark for the behaviour that society deems acceptable, which can give service users a basis on which to negotiate their rights, often without recourse to law. The key provisions of the act are: 1 2 3

a definition of who is ‘disabled’ protection from discrimination in employment protection from discrimination in the provision of goods, services and facilities

Further details of the Disability Discrimination Act are outlined in Appendix 3. Issues relating to Black and other ethnic minorities The importance of gaining, retaining and sustaining employment following the onset of psychiatric disorder might be promoted by mental health teams, but it is also a responsibility of an employer. The Human Rights Act, the Disability Discrimination Act and the Race Relations Act offer some assurance of a change in prevailing attitudes to prevent an institution’s procedures and practices from acting to the disadvantage of Black and other minority ethnic groups with mental disorder. Public and private bodies are now accountable in law should their procedures and practices discriminate against ethnic groups and disabled people. However, there is an absence of pragmatic schemes to support employers in their endeavours, let alone guidelines for mental health teams in promoting employment in groups among whom unemployment is especially prevalent. Employers could be helped to support work schemes for mentally ill Black and other minority ethnic groups and other socially excluded groups by encouraging their closer liaison with local authorities, business schemes and employment schemes and by the attention of the latter to each employer’s 40

organisational culture. Employers’ attention to discrimination and to the fit between employees’ abilities and the demands of work, and the impact of these demands on mental well-being, should be monitored. Avoiding unrealistic attempts to find employment that compound hopelessness must be balanced with maximising the therapeutic benefits of challenge, which include hope, improved self-esteem and greater financial security. Government Welfare to Work initiatives Mental illness should be perceived and accommodated in the workplace like any other illness or disability. Two important employment barriers faced by people with mental health problems are lack of flexibility at work and the attitudes of employers, particularly the low priority of employing people with mental health problems. Some employers recognise that mental health at work requires a higher profile and are developing good practice guidelines and workplace training on mental health issues to counter discrimination against staff and customers with mental health problems. Current social inclusion strategies are aimed at breaking the cycle of unemployment, poverty and poor health, including mental health. However, these strategies will succeed only within a framework that recognises the need for integration of the individual with mental health problems into normal employment settings. An effective framework requires networking of appropriate agencies (health service, employment and benefit agencies in particular) and an appreciation that individuals have differing needs and aspirations that require distinctive levels of support (Scottish Development Centre for Mental Health, 1999). In July 1997 the then Chancellor of the Exchequer set aside £195 million to improve the opportunities for disabled people and those with long-term illnesses to enter work and training, through the Government’s Welfare to Work approach. The fundamental premise of social welfare for the present Government is ‘work for those who can, support for those who can’t. Hence, there are a number of linked policy initiatives, under the umbrella of Welfare to Work, that are designed to encourage and support disabled people in obtaining paid employment. New policies and initiatives are appearing all the time. Among the most important changes and issues that affect people who use mental health services are the following: 1 2

changes to welfare benefits; special initiatives on disability and employment: • • • •

Welfare to Work Joint Investment Plans New Deal for Disabled People extension New Deal for Disabled People Job Retention pilots WORKSTEP 41

(1) Changes to welfare benefits Administrative changes Significant changes to the administration of welfare payments are underway. The Government has piloted ‘ONE’, which was at first called the ‘Single Work-Focused Gateway to Benefits’. In essence, ONE personal advisers are charged with making sure that people applying for long-term benefits are counselled about the options for remaining in employment or taking on other employment before they lose touch with the labour market. ONE provides a single point of entry into the benefit system for those of working age, to help them achieve their potential and independence. The ONE pilots complement the New Deal for Disabled People by bringing together Jobcentre Plus (see below), local authorities and private and voluntary sectors to give people help and advice on a range of work-related topics that include information about work, training, benefits and child care. There are also changes aimed at encouraging people on long-term benefits to consider moving towards employment. In 2001, the Department for Education and Employment and the Department of Social Security merged to form the new Department for Work and Pensions. In 2002, Jobcentre Plus replaced the Government’s Employment Service and Benefits Agency for people of working age. By bringing together employment support and the delivery of benefits the Government hopes to ensure that everyone receives periodic counselling about the options and opportunities for them to come off benefits and take up employment. Mental health service users, as with others on long-term benefits, will therefore periodically be called in to see an adviser for a work-focused interview. Although they will not be compelled to take up employment, they may risk losing benefits if they fail to attend the interviews. Care coordinators and clinicians will need to be aware of these changes in order to ensure that service users who receive a summons to a work-focused interview will be given appropriate support. Changes to in-work and out-of-work benefits The thrust of all the changes to benefits is to make it easier for disabled people to move from benefits into work. Because of the complexity of the system, the proposed changes do not always have the effects intended. Hopefully, these problems will be worked out over the coming years. The main changes to out-ofwork benefits are as follows. •

•

The period of the ‘linking rule’ that enables people trying out employment to return to the same benefits they were on before if the job does not work out has been extended from 8 weeks to 12 months. New permitted work rules introduced in April 2002 mean that any person receiving a state incapacity benefit can: (i) work for less that 16 hours a week and earn up to £60.50 per week for up to 6 months, with a 6-month extension for those working with a personal adviser, job broker or disability employment adviser. 42

(ii) work for maximum earnings of £20.00 a week with no time limit and no hours limit. People who undertake sheltered work or are undergoing a hospital treatment programme that includes work continue to be able to earn up to £60.50 a week (April 2001 rates) with no limits on the number of hours they work. Changes made to benefit regulations enable people in the programme to retain their benefits for the first year of employment, and the introduction of the Disabled Person’s Tax Credit, which replaced the Disability Working Allowance, guarantees a specified level of income from work, designed to make work pay for people working more than 16 hours per week on very low incomes. To encourage work retention, the Government introduced a new ‘fast-track gateway’ for Disabled Person’s Tax Credit. (2) Special initiatives on disability and employment In addition to these structural changes there are a number of initiatives designed to test out better ways of supporting disabled people in getting and retaining employment. Joint investment plans: Welfare to Work for disabled people Joint investment plans originated as part of the Department of Health’s ‘Better Services for Vulnerable People’ initiative. They are 3-year planning tools designed to reshape local services best to meet local needs. As with other joint investment plans, the Welfare to Work joint investment plans are part of an initiative to ensure that government and other agencies work effectively together at a local level to provide better services. The initiative is led by the Department of Health, in partnership with the Department for Work and Pensions. The department responsible for supporting the development of joint investment plans is the Department of Health Joint Unit. At a local level the lead agency responsible for drawing up the joint investment plan is the local authority. The purpose of Welfare to Work joint investment plans is to help disabled people to find, retain or move closer to the world of work. To achieve this a number of local agencies have to work together. These include: health, social and employment services; local pilots and initiatives (including the New Deal for Disabled People, ONE, health action zones, etc.); Jobcentre Plus; local education authorities; Connexions (careers advice agencies); and learning and skills councils. Together they will assess need, map current provision and pathways into work, decide where the gaps are and draw up plans to meet the needs identified. The aims of joint investment plans are to: • •

promote independence for adults; use the plan to determine local targets and enable the development of responsive services to meet the needs of the local population; 43

â&#x20AC;˘ â&#x20AC;˘

improve the use of resources to meet joint objectives for health and social care; maximise transparency in health and local authority investment by charting this systematically.

Initial plans were submitted to NHS regional offices in April 2001. A Department of Works and Pensions workshop was held in September 2001 attended by 21 randomly selected local authorities. The aim of the workshop was to support the joint investment plan process by giving local authorities the opportunity to review what has already been achieved, and to share experience and to identify good practice. Early indications show that people with learning disabilities or mental ill health are benefiting more than those with a physical or sensory impairment. National extension of the New Deal for Disabled People The main labour market programme for people on incapacity benefits is the New Deal for Disabled People (NDDP). The Department for Work and Pensions manages the programme. Disabled people are seven times more likely to be unemployed than non-disabled people. There are over 2.6 million people claiming incapacity benefits, and the NDDP is designed to help this group. The Labour Force Survey (Appendix 1) indicates that one million disabled people who are not working would like to work, and that around 400 000 of these both want to work and feel that they could start work within two weeks. The NDDP is voluntary and builds on previous pilots (which have helped over 8200 people into work), by exploring and testing further innovative ways of helping sick and disabled people receiving incapacity benefits to achieve their full potential through work. The NDDP aims to help clients overcome the barriers that prevent them from finding and keeping a job. Clients on qualifying benefits in England, Scotland and Wales will have access to a network of job brokers. The first job brokers (drawn from the private, public and voluntary sectors) became operational in July 2001 and a national network was in place by September of that year. Job brokers work with employers to match their clientsâ&#x20AC;&#x2122; skills to vacancies, help clients to understand and compete in the labour market and support them in finding and keeping employment. They also actively promote to employers the advantages of employing disabled people. In addition to the network of job brokers, clients whose entitlement to incapacity benefits was established on or after 2 July 2001 are offered a gateway interview with an employment service adviser. The adviser will discuss with them the best way forward, submit them for a suitable job if they feel ready, tell them about the job brokers in their local area and encourage them to register with a broker. One of the main barriers to employment faced by people on incapacity benefits is fear of being worse off when they move off benefit. Because of this, Jobcentre Plus advisers and job brokers will provide in-work benefit and tax credit calculations to help clients to understand the implications of moving into work. 44

The 52-week linking rule introduced in October 1998 as part of Department for Work and Pensions’ programme of welfare reform also means that clients can try work in the knowledge that if the job falls through within a year, they can return to the higher rates of benefit without having to serve any waiting period. In designing the way in which job brokers will work, the national NDDP has taken account of lessons learned from the NDDP pilot schemes, which finished at the end of June 2001. These found that many people in this client group needed considerable support to find work and many also felt that they needed support to retain work. So once clients register with a job broker, there is no fixed limit to the time for which the job broker will work with them. Rather, it is for the job broker and client to agree on the client’s needs and how those will be met, recognising that this will take longer for some than others. Job brokers are also required to support clients through their first 6 months of employment to help them make the transition from benefits to work, and the funding arrangements allow for this. The NDDP national extension will be evaluated. Random assignment was originally selected as the means of evaluation. However, when the first new Jobcentre Plus service ‘pathfinder offices’ opened in October 2001 it was decided that this service would include mandatory work-focused meetings for new customers claiming incapacity benefit. These meetings are a gateway for NDDP, and therefore random assignment is no longer an appropriate evaluation tool. The Government has therefore abandoned plans for its use and is reviewing options for alternative approaches. The Job Retention and Rehabilitation pilot The Job Retention and Rehabilitation Pilot (JRRP) originated within the NDDP. The pilot will deal with employed (and self-employed) people whose jobs are at risk because of health or disability problems. The JRRP is a demonstration project led by the Department for Work and Pensions and the Department of Health, with input from the Health and Safety Executive, the National Assembly for Wales and the Scottish Executive. The pilot follows NDDP initiatives, including 24 innovative schemes and 12 personal adviser pilot areas, although their primary focus was not on job retention. Neither current statistical sources nor research findings provide a full picture of the influence of different factors on job retention rates, or potential target groups and areas. The JRRP aims to test the overall impact of job retention and rehabilitation services (including their cost-effectiveness) and relative impact of different employment and/or health strategies, to inform any longer-term decisions about public investment in job retention services. Each week in 2001, some 3000 people moved from statutory sick pay to incapacity benefit, and up to 80% of these people are then out of work for several years, risking economic and social exclusion. Their former employers lose employees with expertise and experience, who have to be replaced, often at considerable cost. 45

The client group for the pilot are individuals who have been absent from work due to prolonged illnesses and disabilities and might otherwise end up in receipt of long-term incapacity benefits. Any ‘live’ pilot services for clients with a wide range of disabilities and illnesses, physical and mental, will operate in areas drawn from the following health authority/health board areas: West Kent, East Kent, Wiltshire, Leicestershire, Birmingham, Sheffield, Tees, Newcastle and North Tyneside, Iechyd Morgannwg and Greater Glasgow. The JRRP aims to test, using random assignment as the principle evaluation methodology, the overall impact and cost-effectiveness of job retention services, and the relative impact of strategies to boost the help available through one of the following: 1

2 3

workplace advice or support for individuals or their employers (taking account of the employers’ responsibilities under the Disability Discrimination Act); health care services (e.g. by focusing more on job retention as an objective of health interventions, by enhanced rehabilitation services and by advice); a combination of the above two.

One-quarter of recruited clients will be randomly assigned to each of the three intervention groups or to a control group (which will not receive any help from the pilot service). Robust evaluation of the impact is a fundamental aim of the pilot, which has brought together delivery and evaluation organisations from an early stage. The feasibility phase of the pilot ended on 18 January 2002. WORKSTEP: the modernised Supported Employment Programme Established in the 1940s, the Supported Employment Programme (SEP) has been providing employment for many thousands of people who, because of their disabilities, found it hard to secure work. In 2001, over 22 000 people were employed through this programme and it had a budget of over £161 million. Over 10 000 of these individuals were employed by Remploy in its factories and on the Interwork programme. A further 12 000 people, who were employed through supported employment programmes run by local authorities and voluntary bodies, were working in supported jobs with mainstream employers and in supported factories and supported businesses. Even though it was designed for people with more severe problems, it was also expectated that some would move into open employment. Historically however, few have. In fact, the average is as low as 2% a year. Since the demand for employment far outstrips supply, many disabled people facing significant barriers to work and for whom supported employment could be a bridge from benefits to work never have the option of taking up paid work. In 1998/1999, the entire programme was reviewed. A wide-ranging process of consultation was embarked upon. The process of supported employment was 46

divided into sections and each section became the subject of a focus group. The focus group sessions were held at several venues throughout the UK and the findings published by the Employment Service in August 1999. Since that time various other documents and papers have emerged and steering groups have been set up to develop various instruments such as quality evaluation documents. Some of this work is continuing, but prototypes will be implemented, reviewed and adapted over this period. The new programme, known as WORKSTEP, was launched in April 2001. Its primary focus is on eligibility criteria. Disability employment advisers use the definition of disability as set out in the Disability Discrimination Act. WORKSTEP plans to identify disabled individuals who face the greatest barriers to working and who need additional support to work. Those eligible will include those on incapacity benefits, longer-term unemployed disabled people, disabled people needing support to retain a job, and previously supported employees who still need support. The programme will no longer use an estimate of potential productivity in determining eligibility. In an attempt to encourage progression from WORKSTEP into open employment the new programme will set progression targets. These will be 10% for existing employees and 30% over 2 years for new supported employees recruited after 1 April 2001. Progression is defined as no longer needing support. These targets are not mandatory, although progression will be monitored with a view to setting more realistic progression targets in the future. In the remodelling of WORKSTEP it has been recognised that agencies associated with employment schemes come into contact with potential workers from many different sources. However, every potential worker will have to meet with a disability employment adviser, who will ensure the eligibility requirements are met. New funding arrangements are being put into place to make payments to the agencies involved at crucial points in the supported employment process. For example, it will be a requirement that everyone referred to WORKSTEP will make a development plan with the agency (this plan will combine a vocational profile and an action plan setting out what an employee would like to achieve and when he or she expects to achieve it). The agency will be paid £500 per client for this process (agencies will not be able to claim for any planning work done with their existing employees). Once a client is in work, the agency will be paid £320 per month for as long as the client is receiving active support. When it is agreed that a supported employee no longer requires active support the agency will be paid an ‘outcome payment for progression’ of £500. When the worker has sustained this progression for 6 months the agency will receive a further outcome payment of £500. For supported workers on the scheme prior to 1 April 2001, the agency will continue to receive the annual payment of £4760, instead of the monthly payment of £320. However, for existing supported workers progressing to open employment the agency will also still be able to claim the outcome payment of £500. 47

It is of concern that mental health service users should benefit from the new programme: they took up only around 6% of the available places on the Supported Employment Programme. It is hoped that the new flexible of WORKSTEP will make it more beneficial to individuals ready to work more than 16 hours a week. However, there remains a problem for people who want support and the possibility of earning extra income from part-time work of less than 16 hours a week. The WORKSTEP funding system now gives providers a financial incentive to help supported workers to progress to open employment, where appropriate. This benefits both the disabled people who can take up mainstream work and those who are waiting to take up a place on WORKSTEP as part of the process of moving back into paid work. Health service initiatives In the past 10 years or so, there have been no health services initiatives specifically to examine, improve or promote employment opportunities for people with psychiatric disabilities. However, three major Department of Health documents have set out targets and plans that have implications for the employment of those with mental disorders: The Health of the Nation (1995), the National Service Framework for Mental Health (1999a) and Saving Lives: Our Healthier Nation (1999b). Recent developments in mental health policy have focused on risk reduction, containment and the improvement of follow-up and monitoring. The emphasis for new services has been on the development of crisis/home treatment teams, assertive outreach teams and services for first-onset psychosis. Although these are of importance to the care received by those with long-term and severe mental illness, there has been no mention of the development of rehabilitation services, in which vocational services would play an important role. This silence regarding such schemes is an important omission in government policy regarding longterm mentally ill people. Another important strand of health policy has been the initiatives to develop a ‘primary care based’ service. Of central relevance are the changes in commissioning that are a key part of this. The development of primary care groups, and now primary care trusts, will alter the balance of commissioning. Such new developments should be closely monitored to ensure that the needs of people with mental illnesses are not lost in the move from health authorities to primary care trusts. The Health of the Nation and Our Healthier Nation From 1992 to 1997, the Health of the Nation strategy was designed to be the central plank of health policy in England and it formed the context for the planning of services provided by the NHS (Secretary of State for Health, 1991; Department of Health, 1995). The Government described it as ‘the first explicit attempt ... to provide a strategic approach to improving the overall health of the population’ (Department of Health, 1995). 48

The Health of the Nation Targets for mental illness were three-fold: to improve the health and social functioning of mentally ill people; to reduce the overall suicide rate and to reduce the suicide rate among severely mentally ill people. It is clear from the research evidence that employment has a significant impact in all of these areas. In July 1997, the then Secretary of State for Health appointed Sir Donald Acheson to lead an independent inquiry into inequalities in health care provision and provide a report to include a strategy for improvement. The report (Acheson, 1998) and its recommendations formed the basis of a White Paper Saving Lives: Our Healthier Nation, which was described as an action plan to improve the health of everyone and ‘the health of the worst off in particular’ (Department of Health, 1999b). Our Healthier Nation had a single target for mental illness: to reduce the death rate from suicide by at least a fifth by 2010. The document acknowledged the importance of the National Service Framework for Mental Health in achieving this. The National Service Framework for Mental Health The National Service Framework for Mental Health (Department of Health, 1999a) sets out standards for a range of mental health service provision, from primary through to specialist mental health services, to help to ensure that people with mental health problems receive the service they need. These standards also cover the mental health needs of working adults. Efforts to enable people with mental health problems to work are likely to be particularly important in achieving three of its seven standards: Standard 1, which requires health and social services to ‘combat discrimination against individuals with mental health problems and promote their social inclusion’ – work is central to promoting social inclusion; Standard 5, which requires that care plans for people with more serious mental illnesses include ‘action needed for employment, education or training or another occupation’ – this means that work must be central to the care provided by clinical teams; Standard 7, which requires that local health and social care communities minimise suicides among people with mental health problems – given the link between unemployment and suicide, enabling people to gain and sustain work may make an important contribution to reducing suicide rates. The National Service Framework for Mental Health places particular emphasis on the role of users and carers as partners. It expects that services will ‘involve service users and their carers in planning and delivery of care’ and ‘be properly accountable to the public, service users and carers’. All seven standards in the National Service Framework highlight the role of users and carers as partners alongside social care and health agencies. Users and carers must ensure that they have a say in local service planning and delivery, 49

and that they play a central role in service evaluation. This is already happening in some localities, where, for example, some user groups are offering mental health awareness training to health and social care professionals. The NHS Plan (Department of Health, 2000) puts both employment and occupational activity squarely into the mainstream tasks for general psychiatric services by setting a target that by March 2002 the written care plans of all individuals on enhanced care programme approach must include plans ‘to secure suitable employment or other occupational activity’. It is perhaps a missed opportunity that it does not differentiate between employment and ‘other occupational activity’, as the failure to distinguish between these in recent years has perhaps been one factor in bringing about the current position where so few people with severe and enduring mental health problems are in employment. There is a risk that individuals in both non-vocational day care and transitional employment schemes such as clubhouses become trapped in the system and do not have the opportunity to progress into paid employment (see Chapter 3). The Workforce Action Team (WAT) Following on the publication of the National Service Framework for Mental Health, a number of underpinning areas of work have been set in train. One of these was the setting up of the Mental Health Workforce Action Team to consider the workforce implications of the programme of mental health service modernisation. The planned changes crucially depend on the availability of a sufficiently large, well-trained and well-led workforce. The Workforce Action Team brought together a range of high-level representatives from education and training, the professions, users, carers, employers, civil servants, primary and secondary care services, social services and the voluntary sector and was chaired by Sue Hunt, an experienced mental health trust chief executive. The committee was asked to take a national perspective on workforce, education and training issues for all involved in the delivery of mental health services (health, social care and voluntary sector) and to take account of and reflect the reality of what was happening nationally, regionally and locally. The establishment of a special programme to look at workforce, education and training issues was ‘a first’ in policy development terms and reflected the recognition of the centrality of workforce issues to the delivery of new policies. In considering its remit, the Workforce Action Team adopted a set of principles that might be summarised as: • having a user focus and user and carer involvement; • being guided by govenrment strategy (the National Service Framework and NHS Plan); • taking a holistic approach that considered the total skill mix available in the statutory and the non-statutory sectors; • being concerned with competencies, continuing skills and knowledge development; • integrating this human resource perspective in both delivery and planning. 50

The findings of the team and its full report can be accessed from the team’s homepage at http://www.doh.gov.uk/mentalhealth/wat.htm. The study was carried out by a number of sub-groups, one of which specifically considered the role of non-professionally affiliated workers. The report points out that these would be key people in the workforce, who would give direct support to mental health service users by spending time with them. They would be accessible to users and, when necessary, would help users to gain access to other appropriate staff and services. Their focus would be on respecting the needs of users (as the users themselves see them), providing dignity and enabling independence through recovery. It is suggested that these workers be called STR workers (support, time, recovery) and that one source of recruits to these posts would be users themselves. Key points of Chapter 2 •

•

• • • •

•

The Health and Safety at Work Act 1974 imposes a statutory duty to safeguard the health, safety and welfare of staff – this applies to both mental and physical well-being. Under the Disability Discrimination Act 1995 it is unlawful for employers with 15 or more employees to treat someone less favorably for a reason related to a disability (from 2004, the Disability Discrimination Act will cover almost all employers, not just those with 15 or more employees). Under the Disability Discrimination Act a disabled person is someone with physical or mental disability. Mental disability includes clinically recognised conditions that have lasted or are expected to last longer than 12 months. The Disability Discrimination Act makes it illegal for providers of any services to treat someone less favorably for a reason related to disability. The Disability Discrimination Act has important implications for psychiatrists and others working in mental health services. Current social inclusion strategies are aimed at breaking the cycle of unemployment, poverty and poor health (including mental health). There are several linked policy initiatives under the rubric of Welfare to Work that are designed to encourage and support disabled people in obtaining paid employment, for example new benefit regulations permit individuals to gain more work experience while remaining on benefits. Recent government documents, including the National Service Framework for Mental Health and Our Healthier Nation, contain components important to the employment of those with psychiatric disabilities. There is no specific mention of rehabilitation or vocational services for mental illness in any current official government documents relating to mental health services.

3. Services: key components and research evidence

This chapter is concerned with the types of employment, vocational rehabilitation schemes and associated services that might make up a comprehensive range of opportunities for those with psychiatric disabilities. The historical background to the development of these services is outlined as well as the current spectrum of services. The evidence for the effectiveness and cost-effectiveness of vocational rehabilitation schemes is examined, using reviews of randomised controlled trials where available. Historical background As indicated in Chapter 1, the use of ‘constructive occupation’ has formed part of the care of people with mental illnesses since the development of the mental hospitals. At the Retreat in York (Tuke, 1813), work formed an important part of the regime and at the Hanwell Asylum in Middlesex the majority of patients were actively employed in running the hospital (Connolly, 1847). However, vocational rehabilitative and reintegrative efforts for those with mental illnesses have varied historically and this variation is linked to changes in the economic cycle and the availability of employment (Warner, 1994). Mentally ill people have been the marginal elements of the ‘industrial reserve army’. High levels of unemployment are associated with limited efforts at rehabilitation and a consequent low recovery rate from mental illness. The development of work schemes and rehabilitation has also varied internationally. During the 19th century there was little emphasis on rehabilitation in British psychiatry. In contrast, in the USA rehabilitative efforts were more common and work therapy was strongly emphasised in state hospitals (Rothman, 1971). In Britain, during and after the Frist World War, the treatment of thousands of soldiers with ‘shell-shock’, who were less stigmatised than people the ‘mentally ill’, led to innovations in psychological approaches. But it was not until 1927 that the first ‘sheltered’ factory, making electric blankets, was set up by the Ex-Services Mental Welfare Society to employ the convalescents under their care. Work for ‘ordinary’ psychiatric patients remained in the mental hospitals and the Mental Treatment Act 1930 stated that hospitals should provide employment (and entertainment) in addition to medical attention. Important changes were made in some hospitals, influenced by the work of Dr Herman Simon at Gutersloh in Germany. His own crucial experience had occurred much earlier, in 1905 at Warstein, when he had taken over a new asylum in a very derelict and unfinished condition. He recruited the patients to finish off the works and noted that there were significant improvements in the condition of many of them, notably the most disturbed (Burleigh, 1964: pp. 30–32). 52

For Simon, the most important ingredient in this process was that the work was real. It was essential and had an obvious and urgent purpose, which was shared by the staff and the patients, who were valued as workers and contributors. To produce such a situation under ordinary asylum conditions, run by its own staff and not dependent on any contributions from the patients, was more difficult. Simon’s approach (he deliberately avoided calling it a system) was ‘active therapy’, aiming to ‘return the patient to life in the community by nurturing the residual healthy parts of a formerly healthy being and the removal of any environmental conditions in the asylum which were likely to impede recovery’ (cited in Burleigh, 1964). This was noted and imitated elsewhere in Europe and in the USA, notably by Abraham Myerson in Boston, who set up a ‘total push programme’. In the 1930s, efforts were made to introduce these schemes into British psychiatric hospitals, but these were largely unsuccessful, probably owing to the high levels of unemployment experienced during this period. In these years occupational therapy emerged as an accepted form of treatment in the UK, but implementation was patchy (Clark, 1974) The Second World War generated a high number of civilian, as well as military, casualties and this led to a greater interest in the rehabilitation of diverse groups of disabled people. In addition, ‘deinstitutionalised’ psychiatrists returned to hospitals that had stagnated for 6 years, to be joined by younger men and women who had witnessed other grim institutions – concentration and prisoner of war camps – and found certain parallels in their hospitals. They were determined to make changes. The 1950s and 1960s witnessed an increase in employment schemes, mainly based in hospitals. In the early 1950s Tizard and O’Connor showed that, when rewarded by money, institutionalised people with ‘mental handicaps’ could do skilled and productive work. Later they obtained similar results with in-patients who had schizophrenia. Rudolf Freudenberg, Superintendent of Netherne Hospital in Surrey, developed rehabilitative schemes that emphasised the importance of work. Local employers set up satellite workshops in the hospital and every attempt was made to ensure that all patients did some paid work every day. By 1967, 100 out of 122 hospitals surveyed in England had some form of industrial therapy provision (Wansborough & Miles, 1968). The classic studies of Wing and Brown mentioned in Chapter 1 found that at Netherne there were many fewer cases of severe schizophrenia, compared with less ‘active’ hospitals (Wing & Brown, 1970). The ’natural history’ of schizophrenia, with its decline into inactivity and ‘negativism’, thus proved to be highly dependent on the opportunities provided for meaningful activities and the most malignant element was ‘the amount of time doing nothing’ – a rediscovery of Simon’s experience 50 years previously. The Disabled Persons Act, which was passed in 1944, led to the provision of a number of facilities: industrial rehabilitation units offered courses of training in industrial skills and work habits; sheltered employment factories and workshops, 53

subsidised to allow for a lower productivity, offered permanent or interim employment; and ‘disabled resettlement officers’ at every employment exchange were responsible for helping disabled people to find work. In addition, local industrial therapy organisations (ITOs) were set up by interested parties – psychiatrists, relatives, organisations, local employers and charities – to provide various types of sheltered employment. Most were in factories, but some also provided services in the community, for instance the car-wash group connected to the Bristol ITO (Early & Magnus, 1968). The success of these schemes was limited. They did not lead to many people returning to open employment and they were not adaptable to changing industrial conditions – automated car-washes soon displaced the group armed with buckets and cleaning rags. Mentally ill individuals appeared to present particular problems owing to their fluctuating mental states, dependency and lack of confidence and to stigmatisation. Only a small proportion of patients moved on to open employment. They did, however, succeed in providing a small number of mentally ill people with a ‘real job’ and many more were offered the opportunity to work, even though the financial rewards were often limited. As unemployment in the UK increased during the 1970s and 1980s, so paid employment opportunities for people with mental illnesses became limited and schemes that existed were mainly based in or run by hospitals. The bulk of these offered sheltered work or employment. This period also coincided with increasing running down of the large mental hospitals and the eventual closure of many in the 1990s. The development of community-based mental health services was not always commensurate with the loss of hospital services and less emphasis was placed on work schemes, which became fragmentary. The nature of employment also changed, with a loss of manufacturing and a growth in service industries. An alternative to sheltered work, ‘supported employment’ (i.e. placing people in a ‘real’ employment setting and providing direct support to them and to their employers while in the workplace) had been espoused in the USA since the 1960s (Newman, 1970). These ideas took hold in the 1980s as it was thought that sheltered workshops isolated people from mainstream society (Wehman, 1986). By the late 1980s, supported employment had begun to attract attention in the field of psychiatric rehabilitation (Mellen & Danley, 1987). However, the use of these approaches has been slow to develop in the UK. During the past two decades there has been an expansion of employment schemes for mentally ill people. These have shifted in location from hospital to community, and are often run by non-statutory agencies. They fall into three broad categories: sheltered employment, ‘open’ supported employment and ‘social firms’ (O’Flynn & Craig, 2001). Key service components The findings reported in the previous chapters suggest that a large proportion of people with psychiatric disabilities want jobs and have the potential to get and 54

keep them provided that there are available schemes and opportunities and that reasonable adjustments are made in the workplace. Of course, there will be people whose disabilities are too great to be supported in open employment (at least for a part of their illness career) regardless of the extent of available support. For these people other approaches to work and structured activity will be needed. It is, however, very difficult to predict who these individuals are. It is important to give everyone the opportunity to achieve their employment potential. No single model of service is right for everyone and each approach may help different people at different times in their recovery and reintegration. Ideally people should have access to a range of work, training and support that are relevant to their changing needs. They should have the opportunity for progression towards paid employment, but they should not be forced to move on to situations of greater stress and responsibility if they do not wish to. Thus, it is generally agreed that a comprehensive mental health employment service in any given locality should contain a ‘spectrum of opportunities’, with access at any point and the opportunity to move, or stay, according to individual needs (Grove, 1999). Such a ‘spectrum’ is important not just because individuals have different needs: they may also choose different pathways into work. Careful consideration needs to be given to the component parts of this spectrum and their coordination. The consequences of making wrong choices can tie up resources in ineffective services for years. When thinking about a comprehensive range of work opportunities, we need to consider not just the setting, but also the characteristics of the individuals placed in them and the desired outcomes. As with other areas of psychiatry, outcomes will be determined by a combination of ‘historical’ factors (work history, skills, previous work performance); ‘individual’ factors (confidence, motivation, personal aims and objectives); and ‘setting’ factors (expectations of staff, opportunities for training and development, links to other programmes, etc.). The assessment process must therefore begin by examining these variables. Assessment, action-planning, vocational guidance There is scope for improvement in our common understanding of ‘assessment for employment’ across professional fields with an interest in psychiatric disability and employment. First, we must recognise the predictive importance of historical factors. As in other areas of social functioning, there tends to be a strong relationship between work history and future occupational functioning (Strauss & Carpenter, 1977; Watts, 1983). Of course, this is not to say that the past always predicts the future as far as work is concerned, but it does provide some guide. Detailed work histories are certainly generally much more useful than most clinical measures such as diagnosis (Anthony & Jansen, 1984) or traditional psychometric testing 55

such as IQ or aptitude measures, which have very limited predictive value when it comes to occupational performance (Wiggins, 1973). Second, we must recognise the importance of personal factors such as motivation, confidence and personal objectives. They have consistently been shown to be highly predictive of outcomes and are generally superior to traditional skills or IQ assessments. Thus, if the person really wants to do the job, then this is clearly very important (conversely, if she is not interested, if it does not fit into her personal agenda, it does not matter how skilled she is or how well she appears to be suited, she is unlikely to be successful) An example of an assessment and planning schedule that may be suitable for those working in adult psychiatric services is shown in Appendix 4. So, how can we best assess ‘employability’? Employability has many aspects, two major dimensions of which are worth highlighting: •

•

job readiness – being ready to work in the sense of having job-retention behaviours (e.g. fitting in with work colleagues, persisting at tasks, not requiring unacceptably high levels of supervision); recruitment readiness – being both ready to work and likely to negotiate normal recruitment processes successfully (able to present positively and reassuringly in written applications and at interview).

It should be noted that motivation is contingent and is linked to success, mastery and other factors. Getting a job can change a person’s whole outlook and attitude to work, so the premature exclusion of apparently unmotivated individuals may deny them the chance they need to move on in life. Assessment is therefore a highly skilled task and should be considered as an intervention in its own right. Both the research evidence cited above and common sense suggest that it is important to find out if an individual wants (or has) a job as early as possible in their contact with health services. It is important to consider both job retention and job placement at this time. One vital service component is therefore a system that covers both primary and secondary care services and has as its main objective finding out whether someone experiencing mental illness has a job or wishes to remain employed. Once this is established, the next challenge is to find ways of working with them and their employer (that is, create an action plan) either to keep the job open, or to arrange rapid redeployment into a less stressful job as soon as they are well. Work is currently going on with general practitioners in Merseyside and Tyne & Wear health action zones to develop such systems and job-retention services. For people in contact with psychiatric services who have lost touch with the labour market, there also needs to be a system of assessment and planning, linked to the care programme approach, which meets the requirement to have ‘action for employment, education and occupation’ on all care plans . The vocational assessment and action planning system pioneered by the Work Development Team of the Avon & Western Wilts NHS Trust (for which it became 56

a ‘beacon’ site) is a good example of such a system. The people who do the assessment are mostly occupational therapists who belong to the community teams, but they also meet regularly as a group for mutual learning, support and system maintenance. A work development team, through a work development officer, can call on specialist advice or training as required in the action plan. In the assessment and planning process the main components are: • • •

whether people really want to work what their skills are what they are interested in doing.

Once these are established each individual can have a programme of support and training designed for them, which is aimed at achieving their personal goals and ambitions. Pre-vocational training Pre-vocational training is one way of helping people with severe mental illness to return to work. It assumes that such individuals require a period of preparation before entering into competitive employment. This preparation includes sheltered workshops, transitional employment (working in a job that is ‘owned’ by a rehabilitation agency), skills training, work crews and other preparatory activities. Some individuals may need to get back into a working regime through graduated activity programmes; others may find it helpful to have short period for confidence-building and developing coping strategies such as is offered by the PECAN employment agency in Peckham, south London. Neither of these approaches is an end in itself and each is linked from the very beginning with the individual’s goals and action plan. People wishing to find employment can begin job search process as soon as they feel ready to do so. Supported employment Supported employment places clients in competitive jobs without extended preparation and provides on-the-job support from employment specialists or trained job coaches (Becker et al, 1994). The concept is very simple. The client is hired and paid by a real employer. The job meets both the employee’s needs and skills and the employer’s requirements. The employee is entitled to full company benefits and, from the beginning, both employee and employer receive enough help from a support organisation to ensure success. The core principles of supported employment, set out by Becker et al (1994), Bond et al (1997b, 2001a) and Crowther et al (2001b), are as follows: • •

the goal is competitive employment in work settings integrated into a community’s economy; clients are expected to obtain jobs directly, rather than after lengthy preemployment training; 57

• • • •

rehabilitation is an integral component of treatment for mental health problems, rather than a separate service; services are based on each client’s preferences and choices; assessment is continuous and based on real work experience; follow-on support is continued indefinitely.

As we shall see below, the research evidence suggests strongly that the supported employment model of vocational rehabilitation has been most effective in helping service users to get and keep paid employment. There are several types of supported employment, for example, the assertive community treatment model, transitional employment (such as the clubhouse approach) and the job coach model (Bond et al, 1997b). The model that emerges from the literature as the most promising so far is known as individual placement and support (Becker et al, 1994). In this programme, the emphasis is on rapid placement in work, with intensive support and training on the job. The assessment and planning system and pre-vocational training mentioned above fit well with the characteristics of individual placement and support. The additional feature required is time-unlimited support in the workplace. This need not mean that professional spend huge amounts of time at employers’ premises. Indeed, many employment support workers develop ‘natural’ support with the cooperation of the employer and the client’s work colleagues. However, work situations change, people change, symptoms return. The important thing is for support to be available to both employer and employee in a timely fashion and for it to be just as much as is needed and no more. In the UK, supported employment agencies find it very hard to get funding for this postplacement work, but it is vital for success in the longer term. When a client is placed in work the job of the support worker is not finished – it may have only just begun. User employment programmes The principles of supported employment have been used to great effect in a number of schemes across the UK in which NHS trusts have committed themselves to the employment of service users. Personal experience of mental health problems is thus specified as either a desirable or an essential qualification on person specifications for posts. In these schemes, the first of which was pioneered by South West London and St George’s Mental Health NHS Trust, people with mental health problems are employed in existing posts on the same terms and conditions as other employees and a programme of support for those who need it is built into the normal employment practices of the trust. The effect of the scheme has been interesting on a number of levels, not only creating jobs, but also challenging many of the barriers and misconceptions about employing people with mental health problems (Perkins et al, 1997, 1999). 58

The clubhouse model

Level of clubhouse involvement

High

Low

Another popular model with an employment component is the clubhouse (Beard et al, 1982). Clubhouses aim to assist people with long-term mental health problems to address issues such as low self-esteem, low motivation and social isolation. They promote social inclusion and support people in leading productive and meaningful lives within the community. The clubhouse model is based on principles of purposeful activity and psychosocial rehabilitation, and work is a central factor in its operation. A strong clubhouse focuses on building pathways for members to move back into the community by the means of their choice. These include help and support with employment opportunities in the local community. There are four major variants of supported employment, differing in terms of the organisation and intensity of the support provided. These are set out in Fig. 1. In all of these employment initiatives, members are paid the going rate for the job and all work is undertaken at the employerâ&#x20AC;&#x2122;s workplace. The exact balance and mix of support elements will depend on the resources available within the clubhouse and within other services locally. Historically, clubhouses have focused on transitional employment placements to the exclusion of all else and this has often led to a criticism that too much reliance is placed on basic, entry-level positions. Clubhouses in the UK are now looking closely at whether there is a â&#x20AC;&#x2DC;rightâ&#x20AC;&#x2122; mix and balance. Some are placing education as an equally high priority for resources and are developing pathways for members to move into education. Others are focusing on securing more complex transitional employment, which in many cases results in members remaining in the companies

Group placements

Transitional employment

Supported employment

Independent employment 6 months Duration of clubhouse involvement

Fig. 3.1 Level and duration of clubhouse involvement in the four main variants of supported employment.

in which they were first placed, in positions similar to their first placements. Clubhouses are also seeing a greater use of supported employment opportunities. These newer developments may meet some of the criticism levelled at the clubhouse model and transitional employment (Hill & Shepherd, 1997). However, clubhouses remain somewhat exclusive, ‘segregated’ facilities that appeal to only a proportion of people with mental health problems. It remains to be seen whether the UK clubhouse model will become widely established, with a broad appeal and many of the programme characteristics necessary to support members in a variety of work and employment options. Sheltered employment Traditional sheltered workshops and sheltered employment factories (such as those run by Remploy) do not provide employment in the open market. They are now widely seen as unsatisfactory for a number of reasons. First, they are generally seen as ‘institutional’, offering only low-grade, unvaried, repetitive work, often paying hourly rates that are well below the going rate for the job. The National Minimum Wage Act 2000 has begun to force changes in the rates paid to those in sheltered employment, but at present this often means that they simply work fewer hours to avoid exceeding the earnings threshold above which their benefit payments will be cut: changes to these thresholds are urgently required. There is also evidence that there are very low rates of movement from sheltered into open employment and sheltered placements are often therefore substitutes for employment rather than stepping stones towards it. Sheltered employment shemes also face the problem that most now have to be commercially viable. Thus, they have to select and retain only the most able workers, who could in many cases hold down a job in the open labour market. Social firms A possible solution to the problem of providing high-quality sheltered work and employment is the social firm, which is being developed in many parts of Europe, including the UK (Grove et al, 1997). Social firms are sometimes described as modern versions of sheltered employment, but there are crucial differences that go beyond repackaging and changing the name. In a social firm the emphasis is on creating a successful business that can support paid employment. Social firms operate entirely as a businesses but their methods emphasise employees‘ participation in all aspects of the enterprise. Although they may offer training on a commercial basis, they are not primarily engaged in ‘rehabilitation’ and their core staff, whether disabled people or not, are paid the going rate for the work. Usually about half the staff are disabled and members from the disabled workforce may be in managerial positions. Much of the evidence about the costs, benefits and effectiveness of social firms comes from Germany. However, there is evidence from the UK to suggest that 60

here, too, social firms can create sustainable jobs and that employees find them empowering places to work (Grove & Drurie 1999). Cooperatives can operate in the same way as social firms or social enterprises, but they are owned and managed democratically by the members. There are a number of UK examples of cooperatives that include people with mental health problems. The best known are probably Daily Bread and Castle Project Printfinishers, both in the East Midlands. Social enterprise is the name adopted by small businesses that operate semicommercially, but have a training or rehabilitation function (Grove et al, 1997). At their best, social enterprises provide a range of work opportunities, which can include supervisory, sales, information technology and administrative work experience. These go beyond the entry-level tasks traditionally associated with sheltered work. The business is conducted in a setting appropriate to its trading requirements (e.g. a café in a high street) and staff, although mostly on benefits, are trained to National Vocational Qualification (NVQ) standard in that trade if that is what they want. The management style of social enterprises emphasises participation, teamwork and mutual support in meeting the genuine challenges of producing goods and services to a commercial standard. Some social enterprises also offer limited permanent employment on their workforce if the business is sufficiently profitable. However, the extent to which social enterprises succeed in enabling disabled people to move on to further employment is variable and it often depends on the availability of and links with high-quality local supported employment schemes. Opportunities for volunteering For many, making a contribution in a voluntary capacity, particularly to an activity that they regard as socially worthwhile, is a valuable part of their lives. For disabled people there is often added value in volunteering to help others as ‘experts by experience’. There are many opportunities for volunteering and many agencies that act as brokers between the need and the people who can meet it. The volunteer role, and the process needed to enable disabled people to become volunteers, requires exactly the same kinds of support as does paid employment. Thus, a supported employment agency may have volunteering as one option for its clients; if it does not, a volunteer support agency is often created to fulfil the role. Some volunteers’ bureaux have started something akin to supported employment schemes for the purpose of enabling people with learning disabilities or mental health problems to have access to volunteering opportunities. Work opportunities and vocational rehabilitation schemes should be seen as part of a spectrum of rehabilitation services for those with severe mental illness. They are not the only services needed to allow people with mental illness to engage in meaningful activity and should be placed in the context of other day and community-based services (see Chapter 4). They are important in allowing 61

people with psychiatric disabilities to obtain employment in the open job market, with the associated gains that this entails (see Chapter 1). The extent of work schemes in the UK The full extent to which work schemes for disabled people operate in the UK is not well understood. It is not known how many different types operate and how many people are receiving services. Surveys of the provision of such schemes in the UK estimated that, around 1999, there were 135 organisations offering sheltered employment, 77 providing open employment and about 50 social firms (Grove & Drurie, 1999; Crowther et al, 2001b). The European Economic Interest Grouping (ERMIS) (Reynolds & Higgins, 1997) database contains the most comprehensive and recent record of work schemes in the UK, but inclusion in the database is voluntary. It uses 12 definitions of work schemes and three categories of employment model. The three categories are: vocational models (including vocational guidance, rehabilitation and vocational training); sheltered models (including adult training centres, sheltered employment and sheltered workshops); and supported models (including supported employment, work placement and sheltered placement). Schneider (1997) experienced considerable difficulties in producing a typology of schemes from the database and found considerable overlap between categories. Schneider found that 45 (38%) of the 120 schemes fell into all three categories and attributes this overlap to failures in programme fidelity, pragmatic responses to local opportunities or deliberate planning. Crowther & Marshall (2001) also used the ERMIS database to establish the number of schemes operating in the north-west of England. Their results confirm Schneiderâ&#x20AC;&#x2122;s reservations about its comprehensiveness. They identified 15 schemes, and by visiting these 15 a further 35 were identified. Most (52%) were traditional industrial therapy or sheltered workshops, and 44% were in the mixed category identified by Schneider. Only one scheme offered transitional employment and only one offered supported employment. This pattern may not be typical of the whole country. For instance, there were no clubhouses in the region at the time of the study. Crowther & Marshallâ&#x20AC;&#x2122;s survey also found high variation in provision and a poor relationship between the schemes identified and the needs of the areas in which they operated. There was a more than forty-fold variation in provision across health authority areas (from 0.4 per 1000 population to 17.6 per 1000), and the highest level of provision of places was in an area with the lowest deprivation and unemployment levels. Research: the effectiveness of work interventions The pattern of traditional provision in the north-west of England is very similar to that described by Pfammatter et al (2000) in Germany. Most vocational 62

rehabilitation programmes in Germany are either of the therapeutic or sheltered variety and supported employment programmes are not common. This may account for the disappointing results of a 3-year naturalistic follow-up study of 471 users of these services in Westphalia-Lippa (Reker et al, 2000). After 3 years, only 11% of the patients were in competitive employment, 67% were still in sheltered employment, 7% in out-patient work therapy programmes and 15% were unemployed. This was in spite of the fact that 74% achieved their subjective rehabilitation goals expressed at baseline. These disappointing outcomes of traditional patterns of service are also found in studies in the USA, where the effectiveness of different types of work scheme intervention has been reviewed (Bond et al 1997b, 1999). Bond et al (1997b) examined the effectiveness of supported employment for people with severe mental illness. They report that all studies suggested significant gains in obtaining employment for persons enrolled in supported employment programmes. In experimental studies, a mean of 58% of clients in supported employment programmes achieved competitive employment, compared with 21% for control subjects, who typically received traditional vocational services. Employment outcomes relating to time employed and employment earnings also favoured clients in supported employment. There was no evidence that supported employment led to stress levels that resulted in higher rehospitalization rates (although detailed changes in individual symptomatology were not monitored). They concluded that the two features of many supported employment programmes with the most empirical support were the integration of mental health and vocational services within a single service team, and the avoidance of pre-placement training. Crowther et al (2001a,b), in the only systematic review of vocational rehabilitation on the Cochrane database, report essentially similar results (many of the studies reviewed are the same as those considered by Bond et al). Eleven randomised controlled trials met Crowther et al’s inclusion criteria. Five (1204 subjects) compared pre-vocational training with standard community care, one (256 subjects) compared supported employment with standard community care, and five (484 subjects) compared supported employment with pre-vocational training. The main findings were as follows. •

• •

Supported employment was superior to pre-vocational training in finding competitive employment. Five randomised controlled trials including 484 clients found that those in supported employment were significantly more likely to be in competitive employment at six time points across 18 months. This significant difference also applied to mean hours worked and mean monthly earnings. The most effective trial of individual placement and support managed to find competitive employment for 61% of participants (Drake et al, 1999b). Clients in pre-vocational training programmes (three trials involving 887 individuals) were significantly less likely to be admitted to hospital than clients receiving standard community care. This finding should be 63

• •

interpreted with caution, since two of the trials were over 25 years old, and all trials also included comprehensive psychosocial rehabilitation. There was some evidence that payment improved engagement with vocational rehabilitation programmes and enhanced their effectiveness. There was no evidence that the success of the work schemes was due to the selection of the most able or most easily placed people.

Drake et al (1999b) came to similar conclusions about individual placement and support schemes (enhanced vocational rehabilitation, EVR), finding them superior to standard vocational rehabilitation (SVR), even for inner-city clients with poor work histories and multiple problems. In their 18-month study, Drake et al found that participants in the individual placement and support programme were more likely to become competitively employed (60.8% v. 9.2%) and to work at least 20 hours per week in a competitive job (45.9% v. 5.3%). EVR participants had a higher rate of participation in sheltered employment (71.1% v. 10.8%). Drake et al (1999a) suggested that there is no evidence that the rapid-jobsearch, high-expectations approach of individual placement and support produces untoward side-effects. They also concluded that individual placement and support positively affects satisfaction with finances and vocational services, but probably has minimal impact on clinical adjustment. This latter conclusion has been disputed by Crowther et al (2001b) and there is some indication that in at least two studies (Bell & Ryan, 1984; Clark et al, 1998) symptomatic improvement may have been taking place in people who were in work. Programme fidelity As in other areas of psychosocial research, it is important that programmes achieve ‘fidelity’ to models of known effectiveness. Without this it is unlikely that the outcomes achieved in systematic research trials will be replicated. Bond et al (1997a, 2000a,b, 2001b) reported on the development and use of scales to measure fidelity for vocational rehabilitation programmes. They argued that (as with assertive community treatment) the active ingredients of the model run the risk of becoming diluted if there are no clearly mandated programme elements and no standards to follow for those who design and implement the work schemes. To assess whether programmes follow the individual placement and support model, they developed and applied a fidelity scale to 123 vocational rehabilitation programmes in the USA. They found that 90% of the individual placement and support programmes were consistent with the fidelity scale and the other 10% were ‘partially consistent’. In contrast, only one third of ‘other supported employment’ programmes and none of the ‘other vocational rehabilitation’ programmes were consistent with the standards. A factor analysis of the content of the fidelity scales from the 123 programmes produced four factors that provide further insight into the difference between the individual placement and support approach and the others. The first two factors were job selection and job development (emphasising client choice, individualised 64

job search and avoidance of extended pre-placement preparation), which individual placement and support shares with other types of supported employment programme. The other two factors – integration with the treatment team and the use of staff who are employment specialists who do not provide other services – may distinguish individual placement and support from other approaches and may be critical ingredients (Bond, 1998) to include if the model is to succeed. Job preferences Mueser et al (2001) examined the relationship between job preferences, job satisfaction and job tenure in a sample of 204 unemployed clients with severe mental illness. The clients were randomly assigned to individual placement and support, to a psychiatric rehabilitation programme and to standard services. In the individual placement and support group, people whose jobs matched their pre-employment preferences reported higher levels of job satisfaction and longer job tenures than clients whose jobs did not match their preferences. Job-matching may be particularly important for people who are more ambivalent about working. Long-term job tenure Becker et al (1998) point out that, for people with severe psychiatric disabilities, maintaining a job is often more difficult than acquiring a job. They explored job terminations among 63 persons with severe mental illness who participated in competitive work through supported employment programmes. More than half of the job terminations were ‘unsatisfactory’, defined as the person concerned quitting without having other job plans or being fired. Baseline ratings of demographic and clinical characteristics, pre-employment skills training, and early ratings of job satisfaction and work environment did not predict unsatisfactory terminations. People with better work histories were less likely to experience unsatisfactory terminations. In addition, unsatisfactory terminations were associated retrospectively with multiple problems on the job that were related to interpersonal functioning, mental illness, dissatisfaction with jobs, quality of work, medical illnesses, dependability and substance misuse. Future research on effectiveness The main limitation of the Crowther et al (2001a,b) review, and of all the research to date, is that the most compelling evidence all comes from the USA. This adds weight to the argument that systematic trials in the UK, especially of individual placement and support, are long overdue. Crowther et al conclude that future research in the UK should establish the cost-effectiveness of vocational rehabilitation models, their effects on hospital admissions, and how far mental state and social outcome are improved by working. 65

Further research is needed into who does or does not get into a scheme, and who stays in and who leaves. This should help people to devise employment schemes that match approach and work experience to the needs of those served. Donnelly et al (2001) compared people who completed a vocational rehabilitation programme with those who did not. One-third of those who left a programme early found work experience too ‘pressured’ or showed a deterioration in their mental health. However, 40% of the early finishers felt insufficiently challenged by the work. The results of the research summarised here suggest that supported employment programmes also need to address the issue of job retention for those who are placed by the scheme. The organisers of work schemes need to identify and address the range of difficulties that can arise on the job. Drake et al (1999a) argue that future research should be directed at efforts to enhance job tenure and long-term vocational careers. There is no corresponding body of research literature that examines the need to keep people in work when they develop mental health problems (as opposed to the placement of people with pre-existing mental health problems). Research: the cost-effectiveness of work interventions There are relatively few studies of the cost-effectiveness of work schemes for people with severe mental illness. Those that have been published have been reviewed by Clark & Bond (1996), Schneider (1997) and Barton (1999). In general, it seems that work and employment schemes, particularly supported employment, offer good value for money when compared with traditional day care or vocational services. Schneider (1997) and Hallam & Schneider (1999) compared the costs of work schemes with alternative forms of day care, using data adapted from Personal Social Services Research Unit (PSSRU) studies of psychiatric service provision in London (Knapp, 1995). The average weekly costs of work schemes were higher than those for day care, although the difference partly attributable to the greater attendance requirements in the work schemes. When daily costs were considered, the unit cost of day care was higher than that of a work scheme placement, but since case-mix was not included in the analysis it may be that more disabled patients went to day care services than to work schemes. None of the seven work schemes whose costs were assessed by Schneider made a profit. The net profit margins (i.e. the net profit divided by the income) were all negative: they all made a loss, ranging from –73% to a massive –2686%. Another way of looking at the figures is to divide the income by the expenditure to give the income ratio, or the proportion of expenditure covered by sales. These ranged from a low of 4% in a clubhouse scheme to a high of 51% in an industrial therapy unit. There are few studies of the cost-effectiveness of work schemes, and those that do exist are not all of the highest quality. Clark & Bond (1996) reviewed a number 66

of these studies, only two of which (both undertaken in the early 1980s) were peer-reviewed and published (Weisbrod et al, 1980; Bond, 1984). Almost 1000 individuals participated in the studies reviewed, but the two published studies had fewer than 250 particpants between them. Costs were assessed comprehensively in only two of the studies, only one of which has been published (Weisbrod et al, 1980). Both of these were actually investigations of assertive community treatment, in which work was a component part and it is therefore hard to separate out the specific contribution of each component. Clark et al (1998) considered the net benefits of two approaches to supported employment compared in a randomised trial: individual placement and support and group skills training. The costs and benefits were analysed from societal, government and user perspectives. Although a previous analysis showed that individual placement and support participants were significantly more likely to find work, worked more hours and had higher earnings, the net benefits of the two programmes were not significantly different. Crowther et al (2001a) provided a summary of the cost data from a number of more recent studies comparing supported employment and pre-vocational training. They also summarised the mean hours in competitive employment. Their findings are shown in Appendix 5. The overall costs of control services are greater than the costs of immediate placement, and in three of the four studies people in supported employment earned significantly more per month than people in pre-vocational training. The mean hours in competitive employment shows a striking advantage for supported employment over pre-vocational training. Barton (1999) reviewed experimental and quasi-experimental outcome studies of psychosocial rehabilitation interventions for people with severe and persistent mental illnesses. The psychosocial rehabilitation domains reviewed were skills training, family psychoeducation and supported employment. Supported employment programmes increased earnings by an average of 125% and the number of clients in employment by an average of 42% compared with controls. The mean benefit-to-cost ratio was 1.78:1. Although agreeing that supported employment appears to be effective and cost-effective, Barton argues that it may be precipitate to replace all skills training (which he reports as showing an average effect size of more than 0.56) with supported employment. He suggests that other findings have shown that 40â&#x20AC;&#x201C;78% of clients end a supported employment placement within 6 months. He also notes that the effects of supported employment do not appear to generalise to other outcomes. An approach that integrates mental health services with vocational services and outreach tends to produce better results. The conclusions of cost-effectiveness research mirror those of effectiveness research described above. Although the literature on the effectiveness of vocational rehabilitation is convincing, a limitation is that the published studies have examined intervention strategies individually rather than in combination. Consequently, we do not know which combinations and amounts of interventions 67

produce optimal effects for which subjects, nor do we know what the additive effects might be. In addition, studies of supported employment have not identified client characteristics that predict success or failure other than prior work history. Quality issues It is possible to bring together a number of the themes discussed above and to set out a quality framework for social firms analogous to the ‘fidelity’ criteria of supported employment projects (Pozner et al, 1996; Grove et al, 1997). This framework is based on the Charter of the Confederation of European Social Firms, Employment Initiatives and Social Co-operatives (a pan-European network aimed at encouraging the development of work and employment opportunities for people with mental health problems) and has been reformulated in terms of the following ‘standards’ and ‘possible indicators’. It might be a useful checklist for local services. Quality framework for social firms: standards and possible indicators Standard 1: The project has clear aims, which are understood by all stakeholders (staff, commissioning agents, workers) Possible indicators 1.1 The aims and objectives of the project are clearly set out. 1.2 The aims strike a suitable balance between ‘commercial’ and ‘caring’ concerns. 1.3 The aims are understood and agreed by all relevant stakeholders. 1.4 The balance between commercial self-sufficiency and subsidy funding for the project is clearly described and understood by funders. 1.5 The status of employees (paid, not paid) is defined. 1.6 Workers are given clear ‘terms and conditions’, which specify their rights and responsibilities.

Standard 2: The rules for paying workers are clearly set out Possible indicators 2.1 It is clearly set out whether employees will be paid at ‘market rates’ or given some form ‘reward for effort’. 2.2 If payment is not according to market rates, then the rules by which rewards are calculated (attendance, effort, etc.) are clearly described. 2.3 If systems of payment ‘in kind’ are used, then the rules for these are described. 68

Standard 3: The project is closely integrated with the local business community, both physically and organisationally Possible indicators 3.1 The project is physically located on a ‘commercial’ (as opposed to a ‘health’ or ‘social services’) site. 3.2 The project depends on regular, face-to-face contact with the local business community for its successful operation. 3.3 Members of the public and local businesses are encouraged to visit the project as they would any other commercial venture. 3.4 The project advertises itself through ordinary, commercial outlets.

Standard 4: The project involves participants in day-to-day management decisions Possible indicators 4.1 Workers are encouraged to attend daily meetings with supervisers to influence decisions about how work will be organised and carried out. 4.2 There are regular ‘workers meetings’ (e.g. monthly or quarterly) to review progress, business targets, methods of operation and so on. 4.3 Workers (and supervisors) are clear about their sphere of authority and the nature of the influence that they can exert. 4.4 Workers feel that they have some degree of choice over what they will do and influence over the operation of the project. 4.5 Workers are given clear information regarding performance, progress towards business targets, etc.

Standard 5: The project aims to offer a range of work and employment opportunities to suit a range of skills and abilities Possible indicators 5.1 There are opportunities for both clerical and manual workers. 5.2 There are equal opportunities for females and males. 5.3 The project has sought to balance the need for investment in capital and investment in labour (i.e. high capital investment/low labour input v. low capital investment/high labour input). 5.4 The project has tried to avoid overdependence on routine, sub-contract work (attempts to diversify, create a range of locally relevant products and services). 69

5.5 Decisions regarding the range of work undertaken take quality, appeal and opportunities for community integration into account, as well as strictly commercial factors.

Standard 6: The project has a clear, local focus and an effective marketing strategy Possible indicators 6.1 The projects fits in well with the local business community. 6.2 The project has undertaken local marketing surveys and used this information to inform its business plan.

Standard 7: The project attempts to create a ‘real’ work setting and to minimise stigma Possible indicators 7.1 The project employs a majority of staff with experience in business (as opposed to health or social care). 7.2 The project markets itself as an ordinary business (not as catering for people with special needs) 7.3 The project involves some non-disabled people in the workforce. 7.4 There are clear opportunities for career progression for all staff (e.g. nonpaid to paid workers). 7.5 Workers are valued for their skills and abilities, rather than their problems and deficits.

Standard 8: The project has good links with local services and similar work projects Possible indicators 8.1 The project has good links with local specialist services (e.g. CMHTs) so as to ensure that the health and social needs of workers are effectively addressed. 8.2 The project has good links with local primary care teams. 8.3 The project has good links with other local work projects so as to offer ‘move on’ opportunities for those that are interested. 8.4 The project does not demand ‘throughput’ progression (move on) as evidence of effectiveness. 70

Key points of Chapter 3 •

• • • • •

• • • •

•

Historically, occupation has formed an important part of the care of mentally ill people, but rehabilitation efforts have varied over the past two centuries owing to their links to the economic cycle and availability of employment. Work schemes in the UK have been principally in the form of sheltered employment and have been linked to the large asylums. In the UK the choice is now broadly between sheltered employment, open supported employment and social firms. Each locality should offer a ‘spectrum of opportunity’ for work, training and support within a comprehensive mental health employment service. Pre-vocational training assumes that people with severe mental illness require a period of preparation before entering into open employment. Supported employment places people in competitive jobs without extended preparation and provides on-the-job support from employment specialists or job coaches. Supported employment is more effective than pre-vocational training at helping people with severe mental illness to obtain and keep competitive employment. Sheltered employment schemes have been largely unsuccessful at achieving open employment for those with severe mental illness. Social firms, which emphasise the development of successful businesses that can support paid employment, can help to create suitable jobs. The extent of work schemes in the UK is not known for certain. Sheltered schemes still seem to predominate and the availability of schemes varies across the country. The elements of work models of known effectiveness can be translated into quality standards, so that all projects can be assessed to ensure fidelity to and adherence of these standards.

4. Developing comprehensive local services

The provision of employment opportunities for people with psychiatric disabilities inevitably involves working across a variety of different agencies and professional groups. The key health service agencies are occupational medicine, general practice and general adult psychiatric services (mainly community mental health teams (CMHTs) and rehabilitation services). This chapter examines the roles of these three agencies in employment and psychiatric disability and explores the essential area of wider inter-agency working. The role of mental health services The sections of the mental health services that deal with employment issues are those that see adults of working age. In the main, these are general adult psychiatry services. Other agencies that have a role include specialist services such as those providing for people with substance misuse problems. Specialist rehabilitation services or CMHTs may be the who have an input into employment and vocational schemes for people with severe mental illness. Since the 1980s, CMHTs have been set up in all parts of the country and they have been giving increasing priority to those with severe mental illness (Sayce et al, 1991; Onyett et al, 1994). These teams are seen as playing a central role in the delivery of the standards of the National Service Framework, together with crisis teams, assertive outreach teams and services for those with first-onset psychoses. All these components of the new community services have a role to play in assisting with activity and employment for those with psychiatric disabilities. Associated with these community services are in-patient services: many people with severe mental illness will be in-patients at some time, owing to episodes of acute illness. It is recognised that acute in-patient psychiatric services in Great Britain are often inadequate, in terms of both numbers and quality (Sainsbury Centre for Mental Health, 1998). These services can be improved and there are good examples of associated residential units that can form an important part of the rehabilitation process following an acute episode of illness (Boardman & Hodgson, 2000; Boardman et al, 1997, 1999). Acute day hospitals also play a part in providing meaningful activities for patients recovering from acute episodes (Creed et al, 1990; Harrison et al, 1999) and, through rehabilitation, can be invloved in the process of getting people into work. Implications for general adult psychiatry services The previous chapters have been written from the specialist point of view of employment and mental illness. What are their implications content for general adult psychiatry services? Several matters are of note. 72

•

The severity of symptoms and impaired social functioning are not in themselves barriers to employment. This evidence flies in the face of previous received wisdom based on earlier research and is in conflict with the mindset commonly instilled in mental health professionals. Earlier evidence was based on studies on an institutionalised population, often in specialist rehabilitation work projects. Changes in delivery and expectations of mental health care have led to a change in the population served and a shift of the locus of care to the community. Additionally, adopting the disability model offers significant benefits to people with mental illness. A fundamental premise of the National Service Framework for Mental Health is social inclusion. The implications are that mental health professionals need to espouse assessments and interventions directed at minimising discrimination and at empowering users. This is beginning to be reflected in the language and philosophical approach being adopted in specialist rehabilitation psychiatry, where the concepts of ‘recovery’ and ‘reintegration’ are replacing ‘rehabilitation’. There are a significant number of people with severe mental illness who can work and, given the appropriate opportunities, who want to work. There are also increasing opportunities for meaningful employment. Mental health services need to be aware of this and to alter their attitudes and approaches accordingly. There is a need to prepare people with psychiatric disabilities for employment. This means the effective use of appropriate treatments, including medication. Care must be exercised regarding the side-effect profile of medication, which may place barriers in the way of certain types of work. The use of the newer antipsychotic drugs, including clozapine, may be appropriate. Psychosocial interventions for people with enduring mental illness may be useful in building up ways of coping with chronic symptoms. The evidence regarding the concept of self-efficacy opens up a potential therapeutic area for cognitive restructuring. The development of cognitive remediation therapy may assist in improving concentration and other intellectual tasks (Wykes et al, 1999; Wykes & van der Gaag, 2001). Psychological therapies for affective disorders may be useful in addressing cognitive barriers to work. Barriers to employment exist both within and without the mental health services. Those within the services need to be recognised and corrected. Those without also need to be recognised and, if possible, steps should be taken within services to reduce the likelihood that these will impede the progress of service users.

Mental health services and the barriers to work Many people with acute episodes of psychosis and other presentations of severe mental illness will have some contact with an acute psychiatric ward (or, in the 73

future, a crisis or home-treatment team). Many of these individuals will have the objective of achieving the passage from in-patient status to independent living. Others will take a different route, or even multiple routes, through various services at different times in their illness career. Barriers to getting work have been discussed in Chapter 1. The transition through services from in-patient care to open employment has multiple stages, each of which can contain barriers if not managed effectively. The key barriers encountered are: • • • •

assumptions of unemployability the dominance of the medical model (which emphasises cure) as opposed to a disability model (which emphasises recovery) The lack of expertise in CMHTs The lack of appropriate local services.

Barriers to gaining work may be erected during the process of assessment and treatment. The assessment and facilitation of employment should be seen as part of the job of all mental health professionals. Staff need to recognise any potential for employment in service users and to overcome assumptions of unemployability. They should also recognise the conflict between activity as a treatment and employment as both a right and a choice. Employment opportunities should be considered for all service users, and both staff and users need to come to a shared agreement on goals. This may require them to develop self-efficacy. The care programme approach could be used to highlight vocational needs in patients’ care plans. Since 2002, all care plans in the care programme approach for people with more serious health difficulties have had to include plans to secure suitable employment or other occupational activity (Department of Health, 2001). Community mental health teams are ideally placed to take a lead in coordinating the vocational rehabilitation of those with psychiatric disabilities. The National Service Framework implementation plans place CMHTs in a central position for the coordination of local services (Department of Health, 2001). CMHTs see most people with serious mental illness and they accept direct referrals from primary care. However, in many areas covered by CMHTs there are no work schemes for people with mental disability and the provision of schemes is patchy throughout the country (see Chapter 3). The same applies to rehabilitation services. There is a need for all CMHTs to have access to a range of work schemes, which should be based models shown to be effective (see Chapter 3). This central role of CMHTs in local services for severely mentally ill people can be achieved only through the improvement of rehabilitation and day care services in the areas in which the teams operate and by enhancing the skills of team members. There is also the need to identify vocational specialists within teams. At present, most members of CMHTs are not adequately trained to deal with the delivery of vocational services. They will need additional training to assist with the delivery of such services. This will require the introduction of the 74

concepts of rehabilitation and work in the training of psychiatrists, nurses and others in these multi-disciplinary teams. Team members should have training on information disability discrimination legislation; and information on resources available. The National Plan also requires that welfare benefits advice be part of the care programme approach and this needs to be integrated into care plans. The Welfare to Work Scheme, for which the lead agency is the local authority social services department, also requires that benefits advice be integrated with employment assessment. In due course, each CHMT might need to identify a ‘benefit lead’ and a ‘vocational lead’, who would work closely together. Welfare and benefits advice workers can help service users to achieve the range of benefits available to them and can give appropriate advice on benefits and work. Although CMHTs provide a focus for local delivery of psychiatric care, the difficulties faced by these teams should not be underestimated. Many CMHT workers have large case-loads and the demands made of them are great, often exceeding their capacity to deal adequately with such pressures. These heavy demands compromise the delivery of quality services and stretch team members’ ability to make use of any training opportunities. Recruitment and retention of staff is difficult: for example, in 2000 there were 188 vacancies for consultant general adult psychiatrists in England (a 12.7% vacancy rate) (Royal College of Psychiatrists, 2001). Present funding is directed at the National Service Framework initiatives of home treatment teams, assertive outreach and first-onset psychosis, which may take staff away from CMHTs and leaves no available funding to strengthen the activities of CMHTs. The specialist vocational worker in the community mental health team One approach to improving outcome in terms of getting users into and maintaining them in employment is for CMHTs to identify specialist vocational workers. A team member with an occupational therapy background might be best placed to take on this role, but individuals from nursing or social work or from backgrounds outside health and social services (including industry, education and employment services) might also take it on. A significant part of the work would be to identify local resources and a network of local employment opportunities. Vocational specialists would develop systems for reviewing the wishes and expectations of clients in non-vocational day care. They would advocate individualised care and the need of employers to recognise ‘reasonable adjustment’ and facilitate employment. Many CMHTs contain occupational therapists who, with support from the vocational specialist, could provide vocational expertise, guidance, information and support to clients, care coordinators and professionals within the team (Perkins, 1999; Perkins & Sollman, 2000). However, this role should not be undertaken in isolation nor should it exclude other team members from helping clients to gain access to employment. Ideally, an integrated approach should be 75

taken, with the whole team focused on the employment potential of service users (Creegan & Williams, 1997; Perkins, 1999). Current government plans (Department of Health, 2001) emphasise the importance of early intervention in psychosis, stating that ‘every effort must be made to provide an effective pathway to valued education and occupation.’ There is recognition that ‘the longer an individual remains out of work or education the harder it becomes to gain employment later on’. Occupational therapists in Coventry have initiated an early intervention service where integrated provision of psychosocial therapies have emphasised the importance of occupation and meaningful activities. The capabilities required by staff to implement the National Service Framework standards include the commitment to support and facilitate service users’ opportunities to obtain meaningful and independent work, and the ability to maximise user strengths and interests, promote independence and enhance autonomy, to sustain a therapeutic relationship and to reduce social exclusion. Occupational therapists are involved in ‘place and train’ based services based on individual placement and support, and supported employment models such as the job clinics in Antrim, Northern Ireland. In this service, the community occupational therapist, disability employment adviser and an industrial therapy organization placement officer work in partnership to provide careful assessment and placement in education or employment (McCrum et al, 1997). In the South West London and St George’s Mental Health Trust occupational therapists act as the vocational lead within the clinical team, linking with and supported by the vocational services manager (Rinaldi & Perkins, 2001). In Bristol, an integrated scheme involves occupational therapists as part of a specialist rehabilitation prevocational training unit and as link workers in all general adult CMHTs to ‘place and train’ services with the employment service. Central to the success of the Bristol scheme has been the development of the ‘occupational action plan’, a shared assessment tool, with a shared language, which is used by both the health and the employment agencies. This plan has becomes part of the care programme approach documentation. Longer-term maintenance in work In addition to getting people back into work, the mental health services have a role to play in keeping people in work. The evidence from the research studies quoted in Chapter 3 suggests that close liaison between employers and CMHTs is an important factor in achieving good employment outcomes. The systems for supporting people in work are not widespread and models vary. Issues do arise regarding who should provide the support both to the employee and to the employer. User preference has to be taken into account. Both mental health professionals and employers need to be flexible in making reasonable adjustments and access to support. Maintaining people in work is likely to be more challenging than getting them into work. 76

The issue of retention has been highlighted by the Department of Health in the implementation of Standard 1 of the National Service Framework, which promotes social inclusion. There is increasing emphasis on the importance of enabling individuals with mental health problems to remain in their jobs wherever possible. At least one company in the UK employs an occupational therapist who has the specific role of ensuring job retention among staff. Occupational therapy practice within the workplace is more developed in Canada, Australia and the USA, demonstrating the potential for the future. Kearns (1997) described a model in which occupational therapists work alongside human resources staff to support job retention and rehabilitation in open employment. Here again, the attitudes of mental health professionals must be challenged. Although evidence undeniably shows that most mental health problems have a relapsing, intermittent course there often remains an expectation that people should stay well. Therefore when relapse occurs, the professional may look for alternative solutions to the situation, for example recommending a change of work or accommodation that is not necessarily justified or indeed wanted by the service user. The potential of occupational therapy The role of the occupational therapist has been partly considered above. Often, these individuals are the only members of CMHTs with specific training related to the assessment of service users’ functioning and activity. Occupational therapists consider occupational roles to be a fundamental aspect of their work. Working as team members, they can play a key role in vocational programmes. The education and training of occupational therapists equips and qualifies them to assess the impact of a disability on an individual (Cullum, 1997). Occupational therapy plays a role in enabling people to make vocational choices following illness (Stokes, 1997). A scoping review of the literature by Mountain & Carmen (1999) identified how the core skills of occupational therapists enable them to play a specific role in work rehabilitation by: • • •

limiting the effects of illness and disability through occupation assessment of functioning, job analysis and restructuring work tasks creation of enabling work environments.

The approaches and core skills of occupational therapists that might help clients towards employment include: • • • • • •

functional assessment of work ability pre-vocational assessment identification of needs job analysis/task analysis goal-setting offering a holistic approach 77

• • • • •

problem-solving teaching of skills managing lifestyle changes adaptation of work environments knowledge of psychiatric conditions.

Ergonomics involves the process of matching the workplace with the people who work there. In describing the interface and closer working between the professions of occupational therapy and ergonomics, Berg-Rice (1998) wrote that ‘the practice of ergonomics-for-one, with an individual client focus, in rehabilitation ergonomics is really occupational therapy by another name’. Occupational therapy for those with more enduring problems Mountain & Carmen (1999) noted the strength of occupational therapy in enabling individuals with more intractable or complex problems to identify their work needs and help them to achieve their goals, taking into account the residual effects of illness and disability. Some clients with enduring mental health problems feel that to overcome the barriers to employment of stigma, loss of role and low self-esteem, they need help with time management, problem solving, confidence building, planning and goal setting (Bassett et al, 2001). These are all skills and approaches that occupational therapists can develop in them. The occupational therapy focus on work practice Recent trends in occupational therapy have placed greater emphasis within the profession on the importance of occupation and its relationship to health. A current benchmarking exercise on academic and practitioner standards specifies as a key aspect of the occupational therapy process the importance of restoring opportunities, for example through training in employment skills followed by negotiation and advocacy in seeking work. International therapy literature rooted in the study of occupation and occupational science has ‘permeated occupational therapy, become embedded in it, influencing the profession’s thinking, education and research’ (Ilott & Mounter, 2000). British occupational therapists have contributed to the expanding knowledge about work practice, and the growth of interest in this field is reflected by the establishment in 2000 of a specialist section of the College of Occupational Therapists entitled Occupational Therapy in Work Practice and Productivity (Mountain & Carmen, 1999). Training and research implications for occupational therapists include the development of employment skills such as job finding, negotiation and placement together with increasing training opportunities which focus on the ‘place and train’ approach and provision of services in open employment settings. Evaluation of recent employment initiatives would go some way in addressing the 78

requirement for evidence-based practice. The National Vocational Rehabilitation Association (NVRA) has instigated a mapping exercise looking at current vocational skills training and is suggesting development of NVQ-type training. Arrangements for flexible and collaborative working with a range of public, private and voluntary sector organisations are emerging within the profession in line with new employment initiatives. Occupational therapists are moving into new employment-based territories, including working in partnership with, or employed directly in, occupational health departments, insurance companies and other businesses. Specialist mental health services Long-term day care facilities have been criticised for providing understimulating and restricting environments, which might reinforce the low motivation and withdrawal seen in many with long-term psychoses. However, day care can play a part in the rehabilitation of those with psychiatric disabilities and can increase the spectrum of services available within a local area. The concept of day care needs to be expanded to provide a range of facilities, all of which have close working links with CMHTs, and provide a range of services, acute and chronic, therapeutic and supportive. They all need to have rehabilitation as a central aim and have work, activity and employment as central goals. The clubhouse model is one example of this expanded concept. It remains the case that although evidence suggests that symptom severity is not itself a bar to open employment, in practise there are likely to remain some people for whom open employment may be an unrealistic goal for the foreseeable future. An expanded concept of day care will need to be developed to meet the needs of such individuals. At present, the mental health services place insufficient emphasis on returning people to work and there are few specific provisions for work schemes or work liaison schemes in CMHTs. The National Service Framework for Mental Health and its associated documents, although implicitly offering opportunities for mental health services to develop employment schemes, does not place direct emphasis on developing rehabilitation services. There is a need to develop such rehabilitation services alongside those that concentrate on acute care and the traditional illness model. There is a need to review the current structure and delivery of rehabilitation services. The change in service delivery that has been consequent on the move away from large institutions to expanded community facilities has meant that general adult community services have taken over some of the roles that have previously been part of rehabilitation services. The new structure must take into consideration the overlap between rehabilitation and adult community services and adapt the delivery of rehabilitation accordingly. In addition, the role of social services and the voluntary sector must be built into the emerging service structure. Vocational rehabilitation will inevitably take a significant place in the 79

delivery of such services. The goal of open employment must be a part of the rehabilitation process, but other forms of meaningful activity must not be ignored and will form part of the spectrum of services mentioned in Chapter 3. There are currently few rehabilitation consultants in the UK and a significant number of vacancies. In England in 2000 there were 2816 consultant psychiatrists in post, with 371 vacancies (Royal College of Psychiatrists, 2001); 46 of these consultants were rehabilitation consultants and there were 13 vacancies for rehabilitation consultants (this is probably an underestimate). Between 2000 and 2004, there were only 9 applications for specialist registrars to obtain endorsements in rehabilitation, so it appears that insufficient numbers of rehabilitation psychiatrists are being trained. This may reflect the current training state in general adult psychiatry. The College recommends that there should be 0.4 full-time equivalent consultant rehabilitation psychiatrists per 100 000 population. Although facilitation of employment opportunities is now fundamental to general community mental health services whereas in the past it would have been seen as a role of specialist rehabilitation services, there is still some place for specialist service provision. In some areas specialist rehabilitation services have developed as providers of employment opportunities. Indeed, several such services have been given ‘beacon’ status as examples to other districts. Additionally, specialist service providers have a particular role in meeting the needs of the most disabled people. This would include the population now served by such specialist services as do exist and also individuals with additional disadvantage in the labour market, such as the mentally disordered offenders. Unfortunately, although the research evidence tells us that severity and complexity of psychiatric disability are not necessarily a barrier to successful employment, in practice in most areas the most severely disabled mental health service users remain the least likely to be in employment. Two examples of good practice in the UK are Surrey Oaklands NHS Trust and Bristol Assessment and Training Unit and Work Development Team. Surrey Oaklands NHS Trust The Priority Enterprises division of Surrey Oaklands NHS Trust is a ‘beacon’ site providing a range of training, rehabilitation and employment services for people with mental health problems and/or learning disabilities. Services have evolved from pre-existing vocational and sheltered work projects into social enterprises in partnership with the voluntary sector. The service recognises the importance of providing a wide range of opportunities to give each person a real choice in how he or she achieves employment. Users can gain access to the service at any point according to preference and need. The spectrum of pre-vocational options includes garden centres, information technology and office work, woodwork, picture framing, a craft studio, a high street shop and two social firms (a printing business and a travel agency). A key feature of the service is the development of a ‘work links’ based on the supported employment model. The vocational services of the trust are integrated with the specialist rehabilitation services, and residents of a long-term ward have been successfully integrated into open employment. The rehabilitation service has 80

developed the practice of working closely with service users to support them in work. The service obtains the consent of individuals (when they are well) to allow it to contact employers if there are concerns that extra support in the workplace is needed or if signs of change in mental state require action to ensure that the employment position is not lost. The specialist rehabilitation service considers they it plays an important role in setting an example to CMHT staff to consider employment opportunities and not to assume that all service users with severe mental health problems should be advised to avoid the stress of employment. Bristol Assessment and Training Unit and Work Development Team This service was established as part of a wider development plan for comprehensive specialist rehabilitation services including in-patient, residential, vocational and social support. It provides a community-based pre-vocational assessment and training environment, staffed mainly by occupational therapists but closely associated, geographically and culturally, with a small, community in-patient unit staffed by nurses. The unit is available for people with severe and enduring mental health problems who may move, after a period of training, to local colleges, supported employment places, voluntary work or supported workshops. It assumes that all people can enter employment or work, if they choose to, with the correct level of support. The unit also houses and is closely linked to a work development team that uses the ‘place and train’ model and is a designated ‘beacon’ project. This team works closely with the employment services, local employers (including NHS trusts), local colleges and social services departments. They provide a support network for vocational specialists (mainly occupational therapy staff) placed in general adult CMHTs who use occupational action plans (see above) as part of the care programme approach. A recent development is a small group of vocational staff who help employees and employers to develop job-retention programmes. This group uses the network already established with the mental health services, employment services, social services, occupational health departments and local employers. Health service management and commissioning Newly introduced commissioning arrangements involving primary care trusts are as yet untested, but they may threaten the delivery of services for those with severe mental illness. In thinking about local strategies for commissioning vocational rehabilitation services the following need to be included: • • • • •

principles of non-exclusion and active employment of users of mental health services support for the local social economy (e.g. using local social enterprises for catering and for printing services) benchmarking of services available examining the interface with day activity services obtaining user feedback throughout planning and service delivery 81

• •

provision of funding support to social firms, especially early on participation with other stakeholders in joint provision (discussed below).

There is always a danger in pan-disability initiatives that people with mental health needs will be forgotten or excluded from the definition of disability. Mental health service managers and planners need to contact their local authority to find out who is putting the Welfare to Work Joint Investment Plans together and ensure that someone who knows about mental health services locally (this may be a service user) is on the steering group. It may be useful to convene a meeting of mental health service and employment stakeholders in the local authority area to ensure that the input into the plans reflects all views and experiences of the route into work. Included in the considerations should be people who are already in work but are at risk of losing their jobs through mental illness. The general practitioner and primary care General practitioners (GPs) are in a key position to affect, and sometimes determine, a patient’s trajectory through the employment system. GPs provide medical advice to their patients on fitness for work and this advice initiates most spells of incapacity for work lasting over a week. Medical statements (such as the forms Med 3 and Med 4) which doctors use to record this advice are official documents and may be used by patients to support claims to employers for financial benefit such as company sickness benefits and statutory sick pay. Medical statements also form a key part of the claim process for state incapacity benefits. Psychiatrists also provide sickness certificates (‘doctor’s notes’), but less frequently than GPs. General practitioners need to see themselves as taking active decisions about certification as part of patient management. Particularly in the field of mental illness, there is a close correlation between a better prognosis and the patient’s ability to find and keep work. There are many options for support for the patient and GP, in conjunction with the Department for Work and Pensions. Where there is scope for rehabilitation and seeking work, the GP should encourage the patient in that direction if possible. The vast majority of people with mental health problems, including those with mild and moderate mental illness, are managed by their GPs. Although many patients with severe mental illness are managed in secondary care, the GP often has significant input, often concerning certification. For those patients with common mental illnesses, problems often centre on confidence and performance anxiety. For those with severe mental illness, there are frequently problems of cognition and motivation. Little research evidence is available on the GP’s role in assisting in the employment of patients with mental health problems, and much of what has been published is not sufficiently specific, but some offers insight into mental illness and employment. 82

General practitioners and sickness certification General practitioners carry out a number of functions with regard to sickness, disability and certification. These processes are rarely regarded by GP practices as important, but the decision to issue a certificate of incapacity may have profound long-term consequences for patients and families. Certification is often used as a simple, rapid way of closing a consultation rather than a significant intervention affecting a patient’s life and potential job prospects. After 6 months on statutory sick pay, sick workers may be entitled to incapacity benefit or, if they have insufficient national insurance contributions, to a meanstested benefit. The GP may be asked to complete a Med 4 statement, which the patient must pass to the Department for Work and Pensions and patients may be examined by approved physicians to confirm incapacity for work in general. The medical assessment process used to determine entitlement to state incapacity benefits is known as the personal capability assessment. New assessment schemes are being piloted, and in one pilot area, the examination carried out by the doctor approved by the Secretary of State to perform these assessments also encompasses an assessment of functional work-related capability as well as an assessment of incapacity. After some months on certified sickness absence the risk to patients of losing their job increases greatly, with consequences for self-esteem, confidence and motivation. The longer individuals are off work, the lower is their chance of returning to work (Clinical Standards Advisory Group, 1994; Niemeyer et al, 1994). After 6 months of certified incapacity for back pain there is about a 50% chance of returning to work, which falls to 25% at 1 year and 10% at 2 years. Few individuals return to work after 1–2 years’ absence, irrespective of further treatment (Clinical Standards Advisory Group, 1994). Apart from dealing with certificated sickness absence, GPs also intervene by responding to employers’ queries about illness and disability. Medical responses to these queries can make a significant difference to the outcome of the negotiation between worker and employer. Most GPs have received little training in dealing with these demands, and recent evidence from research on behalf of the Department for Work and Pensions suggests that as a consequence the advice given is often inadequate and sometimes even unhelpful (Hiscock & Ritchie, 2001). General practices are increasingly providing counselling services in their surgeries, which might be helpful to people whose jobs are under threat as well as to those who are unemployed. Group cognitive–behavioural therapy has been shown to be beneficial for long-term unemployed individuals (Proudfoot et al, 1997). Addressing mood and associated cognitions can lead to a better outcome. GPs can also guide their patients to take advantage of new ‘permitted work’ rules for recipients of a state incapacity benefit (see Chapter 2). Some of the key decisions that a GP might be expected to face are summarised in Fig. 2. 83

If referred to a hospital or therapist:

Should patient be on a certificate while waiting? Which will work better – work or inactivity?

Med 3 or Med 5 (first completion for mental health problem)

?Vague diagnosis

?Send Med 6 to BA/ Jobcentre Plus

Med 3 or Med 5 (second completion in same episode)

Think! Is this likely to lead to long-term sickness?

Filling in Med 4 (and IB113)

Is early return to work possible? Consider therapeutic earnings or disabled person’s tax credit (I Rev)

Remind Jobcentre Plus that special help may be needed to return patient to work. Make it clear if there is severe mental illness or severe learning disability

This is likely to lead to long-term sickness

Return to work ?Liaison with occupational health department or via occupational health project, with or without comment on Med 3

Refer to disability employment adviser ?Suggest disability living allowance

Filling in medical report for incapacity benefits

Check whether patient has own personal adviser Make contact

Fig. 2 Flow chart - mental health incapacity, benefits and work advice.

Doctors’ attitudes to certification In a review of the literature, Hiscock & Ritchie (2001) noted that patient characteristics such as age, attitude and job prospects are reported to be a major influence on the ways that GPs approach sickness certification. GP characteristics such as age, level of training and the extent of involvement in occupational health were reported to have an impact on both the approach to and rates of certification. It has already been mentioned that the doctor might regard certification as an easy conclusion to a consultation. This concept is supported by a Spanish study (Gensana-Lopez et al, 1995). Many older doctors feel that they should focus on treating the illness, whereas younger doctors tend to question certification and may more frequently consider rehabilitation. Thus, many GPs may collude with their patients’ sick role. 84

From in-depth interviews of 33 GPs, Hiscock & Ritchie (2001) identified three main views regarding the GPs’ role in sickness certification. Some would prefer to play no role at all, some think that the responsibility for sickness certification sits with the GP, but feel that some modifications of the role are necessary, and some value their participation in sickness certification and think that the GP is best placed to play this role. The more patients exhibit illness behaviour that drifts away from the traditional passive role, the more inappropriate doctors’ responses can become. For example, Vandereyken & Meerman (1988) in Belgium have shown that doctors may respond to patients who show chronic illness behaviour by arguing with them, threatening them, and sometimes by referring on. There are more constructive ways of managing sick-role behaviours, for example by identifying care-eliciting behaviour and responding with therapeutic interventions (Blackwell, 1992). Furthermore, GPs can suggest employment alternatives to patients that will mean they will not lose financial support. It is possible that in times of high job availability, certification may be less necessary as it is more likely that employment can be achieved.

The characteristics of patients and their work One key determinant of long-term sickness is the coping style and skills of the individual patient (Grossi et al, 1999). Emotional distress, avoidant or emotionfocused coping styles and perceived disability seem to be the important factors. Studies of back pain have revealed predictors of poor outcome that include social problems, psychological distress, physical inactivity, post-traumatic stress disorder, dissatisfaction with work, compensation claims and poor localisation of pain (Waddell et al, 1984; MacFarlane et al, 1999). At work, high psychological demand and low control over working conditions, with poor social support are related to high rates of mental health and physical problems (Stansfield et al, 1995). Job strain has been shown to increase musculoskeletal problems in workers (Hemingway et al, 1997). Job resumption is more likely if the patient sees the work as meaningful and has good relationships in the workplace (Gard & Sandberg, 1998). However, the strongest predictors of return to work are the patient’s intent to do so and the availability of work (Fishbain et al, 1999). It also seems clear that some of the secondary problems can be improved by psychological intervention. Both social support and problem-solving or cognitive– behavioural training can improve mental health and employment outcomes for the unemployed (NHS Centre for Reviews and Dissemination, 1997). However, illness for less than 12 months has a better prognosis (Jankus et al, 1995), suggesting that early intervention by all agencies is likely to be in the best long-term interest of patients. Evidence is also clear that the adverse health effects of unemployment are largely reversed by re-employment (Kessler et al, 1998).

Responding to employers Both GPs and psychiatrists frequently receive requests for reports from employers. Inadequate responses can prejudice job retention. It is helpful if those writing the reports can do so in such a way that supplies employers with what they need to know in order to support a return to work, if that is what the patient wants. It is possible to write such reports without creating problems for patient confidentiality. Permission to supply the information should be obtained from the patient and they may have the right to see a copy of the report. Guidelines on responding to employersâ&#x20AC;&#x2122; requests for reports about patients are set out in Appendix 6.

The role of the occupational health team Occupational health services The discipline of occupational health has grown up largely outside the NHS and the majority of staff have undertaken their specialist training in public (e.g. social services) or private-sector businesses. The NHS is playing an increasing role in both training and the provision of services to other organisations but it remains a minority stakeholder in both activities. Perhaps as a result of this cultural difference, professional demarcation is less rigid than in most other medical specialities and team working has been the norm for many years. Occupational physicians and occupational health nurses remain at the heart of those teams but many other skills are routinely employed as determined by the nature of the business and the hazards that have to be controlled. Ergonomists, occupational hygienists, safety practitioners and physiotherapists may well form part of the group and, increasingly, the services of organisational and clinical psychologists are being used. The great majority of services are preventive in outlook and where treatment is offered it is very much on an emergency basis until care can be transferred, usually to the patientâ&#x20AC;&#x2122;s GP. However, rehabilitation into work is seen as a core component of most services, not just for the benefit of the patient but also because of the direct benefit to the business. Both occupational physicians and occupational health nurses work to specific ethical guidance in addition to the general ethics applicable to all doctors and nurses. This guidance recognises that occupational health staff play roles uncommon for other health care workers in that there are duties both to the employing organisation and the employee. It emphasises the requirement to give impartial advice that safeguards the health of employed people and others who may be affected by the work activity. Occupational health staff usually therefore need to look more widely than the individual patient when formulating professional advice and give consideration, for example, to the safety implications of employing an individual with a given health problem in a particular role. 86

Organisation of provision The majority of occupational health provision falls outside of the NHS. Virtually all NHS Trusts provide some form of occupational health support for their own staff and the majority now also have access to an accredited specialist. A government initiative is currently in train to extend cover to primary care and, in some areas, NHS units will offer services to local employers on a repayment basis. However, most organisations that have an occupational health service provide it either by using their own employed professional staff or by purchasing outsourced services. In-house services vary in size and complexity, from departments with many specialists, dozens of nurses, a variety of other professionals and associated support staff to a single, part-time occupational health nurse. In general, the larger the organisation or the more hazardous its activities the more sophisticated its occupational health service is likely to be. The roles of occupational health services for those with mental illness Occupational health services have two main roles in dealing with people with mental health problems: (a) assessment; and (b) management of the psychological problems of those in employment. Assessment The first contact that most employees have with occupational health staff is at recruitment. The sophistication of medical checks at entry is broadly aligned with the requirement for special physical or mental attributes, the nature of potential hazards to which the employee might be exposed and the value of the role to the organisation. Most potential employees complete a health declaration at the pre-employment stage. Occupational health practice has changed significantly since the introduction of the Disability Discrimination Act 1995 and most employers focus on capability and the impact of any health problem on an individual’s ability to discharge the proposed duties effectively. If obstacles are identified, it is usual to undertake an occupational health assessment to define adjustments that might be made to facilitate the individual’s entry to employment. It is then for the employer to determine whether it is reasonable to implement the adjustments and, if necessary, to justify any decision to an employment tribunal. This approach differs from the traditional illness-oriented assessment and should be less threatening to candidates who have had mental health problems. The health declaration should be completed after provisional selection, and not as part of the ‘sift’ process, so that good candidates are not disadvantaged because of a history of mental illness. Some jobs require particular psychological qualities and employers may, in such cases, include psychological profiling in the pre-employment assessment process. Individuals should be made aware in advance of any such special requirements and the nature of the assessment process, so that they can make an informed choice about whether to submit an application. The identification of 87

such requirements does not override employersâ&#x20AC;&#x2122; Disability Discrimination Act duties and they must be able to demonstrate that adjustments, which can be extensive, to allow an individual with a chronic or recurrent mental health problem to fill the post cannot reasonably be put in place. Occupational health departments also have a role in helping employers to assess the capability of vulnerable individuals entering employment even when the physical or psychosocial risks are not exceptional. In such cases any adjustments that are recommended are the same as any control measures to prevent harm accruing to the individual or others as a result of the work activity. Management of psychiatric disability in employment Psychiatric illness is common and people in work have no immunity. People with major psychiatric conditions are underrepresented in employment but psychotic episodes in the workplace usually generate significant concern and high emotion in all concerned. Occupational health staff are usually alerted as a crisis develops and should take charge of the patient until care can be transferred to an appropriate external authority. Reassurance of colleagues is critical, not least because of the common fear, fuelled by media characterisations, that violence against others is a significant risk. Many occupational health departments maintain a long-term supportive relationship with employees with psychoses and this is easiest to achieve if there is a dedicated on-site resource or a regular peripatetic cycle of visits. Contact is also usually maintained with the individualâ&#x20AC;&#x2122;s line manager, partly to provide him or her with support but also to help identify early signs of deterioration. With the consent of the patient, advice can be given to managers and human resources staff about the impact on performance of psychiatric conditions, which can be hard for lay people to identify. Non-psychotic disorders are far more prevalent in employment and constitute the great majority of cases seen. The principles for managing individuals at work are the same, but support is usually shorter term and, depending on the severity of the condition, less intensive. Welfare and counselling services are far more likely to deal with this group and occupational health staff would normally become involved with a person still at work only if approached by that individual or by management in relation to related employment problems. In general, during an acute episode in which the employee remains at work, occupational health advice is likely to centre on reducing workload, moderating the complexity of activities, more regular management support, assistance in prioritising tasks and emotional support. Encouragement would also be given to individuals to seek advice from their GPs and the effect of any prescribed medication on safety-critical tasks such as driving would be assessed. Many individuals with acute mental health problems absent themselves from work and this is often the trigger for occupational health involvement. Current good practice dictates an early assessment to help determine whether work is an adverse factor and to help maintain contact with the employer, since length of 88

absence is itself associated with diminished success in rehabilitation. Early occupational health assessment is indicated even when it is clear that the individual is some way off being fit to return to work. Demonstrating the employer’s commitment to supporting the absence and eventual rehabilitation can also give the individual much-needed reassurance. It is good practice for line managers to maintain regular contact throughout absences and this may be augmented by welfare or counselling services. Monitoring by occupational health staff need not be as frequent but should occur often enough to assess progress and to maintain the impetus for a return to work. In some cases, access to treatment considered likely to be beneficial (e.g. cognitive–behavioural therapy) may be difficult through the NHS. Some employers fund private treatment in such circumstances, even where health insurance is not offered, in order to speed recovery. Occupational health services would normally be the conduit for such action but no treatment should be initiated unless endorsed by the doctor with primacy of clinical care responsibility. Sometimes the severity of the patient’s condition dictates that it is inappropriate for an occupational health assessment to be carried out in the early stages of an absence. In such situations occupational health staff should monitor progress remotely, provided informed consent can be obtained, by liaising with those charged with the patient’s clinical care. Considerable reliance is then placed on the judgement of the treating clinician, usually a psychiatrist, about the timing for an approach and the perceptions of the patient about an eventual return to work. Individuals who have experienced an acute breakdown in mental health are rarely fit for the full range of their duties by the time they return to work. Planned rehabilitation into work, with a careful definition of recuperative duties, is therefore essential to maximising the chances of success and, critically, to avoiding the precipitation of a recurrence. Most employers are amenable to a graduated return to work with restricted hours. In general, after any significant mental health absence (of 1 month or more) a programme of up to 1 month of increasing hours starting at a base of approximately half-time will be beneficial. Open-ended arrangements are counterproductive because they can fuel the loss of confidence that often characterises such illnesses and it is better to set a time limit and extend it if progress is slower than originally anticipated. In some schemes the company occupational physician determines whether pension scheme criteria are met, whereas in others the trustees instruct their own medical adviser, who would normally have a specialist qualification in occupational medicine. Individual scheme criteria vary, but in general there has to be incapacity from the job previously undertaken (and/or all work) and that incapacity must be permanent. Difficulties can arise in some mental health cases where a substantial functional recovery is expected, even if that may be some years off. Medical retirement often requires a history of chronic or relapsing illness with a statement of poor 89

prognosis from a psychiatric specialist. Positive harm to individuals can result from ill-advised recommendations about medical retirement from clinicians who have no knowledge of the work undertaken or the pension scheme criteria. Communications with occupational health services The interests of patients with mental health problems who are in work or actively seeking employment are usually best served by a dialogue between those responsible for clinical care and those providing occupational health advice to the employer. Clearly such communication is dependent on the informed consent of the individual concerned and this should be obtained in writing. Unfortunately, such dialogue is the exception rather than the rule and communication is often limited to occupational health staffs’ requests for medical reports from GPs or psychiatrists. Good relations can develop between occupational health staff and CMHTs, GPs and others when the company is geographically compact and professional contact with the same people is frequent. Some occupational health services invite colleagues from both primary and secondary care to visit the workplace and discuss common issues (although the response rate is sometimes disappointing). On occasions, and particularly when trying to get a patient back into employment, mental health teams may wish to establish contact with occupational health colleagues without knowing if a company has access to a service. Patients who are already employees will usually know if there is an occupational health service and may well know contact names and addresses. If they do not, or for potential employees who are unlikely to have such knowledge, it is most appropriate to enquire through the human resources department whether occupational health support is available and, if so, how it might be accessed. Although occupational health usually lies within human resources, confidentiality should be strictly maintained and it is prudent when making enquiries not to reveal the name of the patient. Occupational health services will expect that the patient’s consent has been obtained before any contact by the psychiatric services is made. Inter-agency working The evidence for this section is drawn largely from Working Together by Adam Pozner, Judith Hammond & Mee Ling Ng (2000). Among the agencies involved in their research were: • • • • • •

user/disabled peoples’ organisations NHS mental health trusts social services voluntary and independent-sector providers employers regional disability services 90

• •

training and enterprise councils local authority regeneration departments

The statutory, voluntary and private sectors can and should be involved in partnership working. Statutory agencies do not merely appear as funders or commissioners. Some of the largest government organisations – for example the Employment Service (still in existence at the time of the research) and NHS trusts in Avon and West Wiltshire - have found new ways of working together for the benefit of users. Some recent government initiatives, such as the New Deal for Disabled People and health action zones, have been utilised to support new and original forms of partnership. Many partnerships include health and social services, employment services and the voluntary sector, but some have unusual players. There have been notable successes in working with groups operating outside the mental health sphere – for example supermarket chains, railway preservation societies and conservation groups. Where mental health service users have teamed up with ‘green’ groups, mutual enthusiasm for a common cause has pre-empted any concerns about difference. This should give confidence to those who hesitate in approaching local community agencies for fear of prejudice and intolerance. Two major lessons can be drawn from Pozner et al’s (2000) research. First, successful partnerships do exist and can generate real benefits for service users. Many individuals previously excluded from education and training are now learning new skills. Opportunities for work and meaningful occupation have been opened up in creative ways. Securing open employment is becoming a reality for many who never believed it possible. Second, the possibilities for partnership are almost endless. The range of agencies that are encountered working together is huge. The extent to which organisations outside the mental health field are involved is both surprising and encouraging. Working with people from different backgrounds can be immensely stimulating and the bringing together of different perspectives can be very fruitful. Some mental health professionals who tend to see service users just as patients develop broader views. Avenues for transfer of skills and exchange of information have opened up, for example organisations with commercial expertise can pass this on to others within trading consortia. How partnerships emerge varies enormously. In one locality, joint working developed through strategic planning. In some cases, professionals from different agencies identified a gap in provision and lobbied their respective agencies to fill it. In others, agencies who had been working alongside each other for some time formalised the arrangement, obtaining funding for shared workers. Frequently, the tireless persistence of one person with a vision was crucial. Individual champions played a central role either in linking individual agencies or persuading service commissioners of the merits of partnership. Many of those consulted by Pozner et al (2000) pinpointed the initial development phase of partnership as critical. At its heart must be shared values and, chief among these, a commitment to service development for the benefit of 91

the user. The danger of setting up partnerships merely to fulfil funding criteria, frequently in haste because of deadlines, is that the partners may not have enough in common to work together effectively. This could be because their services are not really complementary or they have a different ethos. Partnership working is not easy. Most of those surveyed had negotiated a long learning curve. Relationships and personalities can be crucial factors in success or failure. However, difficult though it might sometimes be, the benefits make it worthwhile. The role of employers in this process is important and the cost of mental ill health on industry is a legitimate concern and should be placed firmly on the business agenda. For example, reduction of staff absenteeism would reduce costs significantly. Engaging with employers and identifying the advantages to business of working to improve the workplace and to engage with other organisations to prepare people with psychiatric disabilities to rejoin the labour market is an essential part of this process. Key factors for putting partnerships into practice Contributors to Pozner et al’s (2000) research project highlighted key factors in the successful development and sustainment of partnerships, as well as some of the problems faced. Agencies setting out on the partnership path must be aware of the following: • • • • • • • • • •

developing a user focus finding partners communication ‘oiling the wheels’ commitment from the top boundary problems achieving a professional approach being tuned in understanding the local business scene evaluation

These factors are discussed in Appendix 7 Working in partnership with community mental health teams For health services, the importance of working in partnership is exemplified by the experiences of the Bristol East and Bath District, where occupational therapists from CMHTs worked in partnership in an Employment Service New Deal for Disabled People (NDDP) pilot scheme. In this scheme, NDDP personal advisers were paired with front-line workers from CMHTs to enhance the employability of mental health clients. The employment staff particularly emphasised the value of working with the occupational therapists on this scheme and occupational therapists reported increased skills. This collaborative approach was positively 92

regarded by the clients, who appreciated the holistic approach (Grove, 2000; Gordon & Mills, 2001). In these projects, if one member of the team is focusing on vocational needs it is important that the rest of the team acknowledges this by giving it priority and freeing up sufficient time for the vocational ‘lead’ to fulfil this role effectively. Where occupational therapists have worked closely with employment service staff and vocational specialists, it has resulted in a useful exchange of skills and expertise. The clients benefit from this bringing together of vocational expertise and understanding of the impact of psychopathology on work performance (Perkins, 1999). Interagency working in the future Although working in partnership is not a panacea for all problems, there is no doubt that it can provide real benefits for service users, commissioners and providers. The survey by Pozner et al (2000) demonstrated a range of possibilities and may provide ideas and inspiration. Some of the approaches described may be particularly relevant to an individual locality without too much modification, but sometimes there will be a need to think laterally to develop quite new ways of working together. One important influence (and opportunity) for future working is the rapid development of information technology. The internet creates the opportunity for virtual partnerships to develop, allowing agencies and individuals separated geographically to work collectively. Of relevance to this is the emergence of teleworking, the growth of the call centre industry and the explosion in ecommerce. Key points of Chapter 4 •

•

Partnerships and interagency working are crucial to the development of employment services for people with psychiatric disabilities. The possibilities for partnerships are manifold and successful partnerships can create real benefits for service users. Key factors for putting partnerships into practice include developing a user focus, finding partners, communication, oiling the wheels, commitment from the top, boundary problems, achieving a professional approach, being tuned in, understanding the local business scene, evaluation. Members of CMHTs can successfully work in partnership with non-health agencies, but at present there are few links between CMHTs, these agencies and employers to assist in getting people into work and supporting them while there. General practitioners, through their clinical management and provision of advice on fitness to work, are in a key position to influence and sometimes determine a patient’s trajectory through the employment system. 93

• • • •

•

• • •

•

The longer that a person is off work for illness reasons, the less chance there is of a return to work. It is likely that a rapid response and assistance into rehabilitation can help the return to work. Attitudes of mental health services and lack of effective schemes act as barriers to getting people with psychiatric disabilities into work. CMHTs and specialist rehabilitation services are the main components of the mental health services that have a role to play in assisting users into work and supporting them there. Mental health services currently place insufficient emphasis on returning people to work and there is no specific provision for work schemes or work liaison schemes in CMHTs. CMHTs are ideally placed to take the lead in coordinating the vocational rehabilitation of those with psychiatric disabilities, but they presently lack sufficient expertise in welfare advice and vocational work. Specialist vocational workers are required in CMHTs. Since March 2002 it has been required that the care programme approach contain plans ‘to secure suitable employment or other occupational activity’. Vocational services must be supported by other suitable, high-quality mental health services to improve the functioning of mentally ill people and to offer a spectrum of in-patient, day patient and other community services. Maintaining people in work is important and close liaison between employers and CMHTs plays an important role in achieving good employment outcomes. Specialist rehabilitation services can act as providers of employment opportunities. Occupational therapists are currently the only member of CMHTs who have specialist training in the assessment of patients’ function and activity, and are well placed to play a central role in employment schemes. The occupational health team plays a key role in assessment of people with mental illness who are entering or who are already in work. Most of the people whom they see have non-psychotic illnesses. Communication and liaison between GPs, mental health professionals and occupational health staff is an essential part of keeping people with psychiatric disabilities in work and getting them back to work.

Appendix 1. Statistics on long-term disability

Tables A1.1 and A1.2 show data from the Office for National Statisticsâ&#x20AC;&#x2122; UK Labour Force Survey. The Labour Force Survey is a continuous, household survey that provides a wide range of data on labour market statistics and related topics such as training, qualifications, income and disability. The data from the survey are used extensively both within and outside government. The survey has been running since spring 1992 in its present form. Before this, between 1973 and 1983 a biennial survey was carried out during the spring, and in 1984 the survey became annual. As well as Office for National Statistics, government users include the Department for Education and Employment and the Department for Trade and Industry. The survey sample of addresses is taken from the Postcode Address File (an Office for National Statistics database). In addition, a small sample of addresses

Table A1.1 Long-term disability, mental health problems and employment from 1998â&#x20AC;&#x201C;2000 Survey category Total UK population of working age (n) Long-term disabled (n) % of working age population In employment (n) Employment rate (%) Long-term disabled with mental health as main difficulty (n) % of all long-term disabled of working age In employment (n) Employment rate (%) Long-term disabled with mental health difficulties as an associated health problem (not main problem) (n) % of all long-term disabled of working age In employment (n) Employment rate (%) Long-term disabled with no mental health difficulties % of all long-term disabled of working age In employment (n) Employment rate (%)

Spring 1998

Spring 1999

Spring 2000

35 022 000 6 071 000 17 2 643 000 44

35 166 000 6 393 000 18 2 957 000 46

35 295 000 6 573 000 19 3 076 000 47

484 000

483 000

519 000

8 70 000 15

8 77 000 16

8 95 000 18

641 000

565 000

561 000

11 97 000 15

9 95 000 17

9 101 000 18

4 946 000

5 344 000

5 493 000

81 2 475 000 50

84 2 785 000 52

84 2 880 000 52

Source: Office for National Statistics, 1998, 1999, 2000.

of NHS and health trust accommodation is included; individuals aged 16 or over and at boarding school or living in a hall of residence are included in their parent’s household. The survey has a stratified random sample and within any continuous 13-week period every postcode sector is sampled. This feature allows representative results to be produced for any 13-week period and has been utilised in the Office for National Statistics’ Labour Market Statistics First Release. From April 1998 the Labour Force Survey figures have provided headline UK unemployment and employment figures each month for the preceding quarter. The survey uses a panel design, and each sampled address is interviewed for five waves. Interviews take place at 3-month intervals, and the fifth interview at each address takes place 1 year after the first. Each quarter, interviews are achieved at about 59 000 addresses with about 138 000 respondents. During 2000 a response rate of 79% was achieved for the first wave of the survey. All first interviews (with the exception of a very small sample located north of the Caledonian Canal) are carried out by a team of face-to-face interviewers who work exclusively on the Labour Force Survey. If the informant is willing, subsequent interviews are carried out by telephone from a telephone interviewing unit at the Office for National Statistics’ Titchfield office. Over 60% of all the interviews are conducted by telephone.

Table A1.2

Main type of long-term disability and associated mental health problem: spring 2000 (Office

for National Statistics, 2000); bt, below threshold of 10 000

Long-term disabled, by type of main disability n

Base Arms, hands Legs or feet Back or neck Difficulty in seeing Difficulty in hearing Speech impediment Skin conditions, allergies Chest, breathing problems Heart, blood pressure, circulation Stomach, liver, kidney, digestion Diabetes Epilepsy Learning difficulties Progressive illness Other problems, disabilities

% of all longterm disabled

6 573 596 408 349 719 977 1 229 871 114 504 120 706 bt 131 686 901 303 770 112 300 296 136 153 267 492

Long-term disabled with associated mental health problem n

% with main type of disability 9 10 10 11

2 14

561 394 42 013 68 728 137 805 bt bt bt bt 51 142

73 293

37 15 15 21 26 48

12 5 11 14 10 10

6 11 19 2 2

022 978 643 676 012 633

5 5 2 2 4 7

067 631 232 333 691 980

A similar quarterly survey is conducted in Northern Ireland by the Central Survey Unit of the Northern Ireland Statistics Research Agency. The Social Survey Division processes results from this survey for the Department of Economic Development. The results are combined with those from the Great Britain survey to produce UK figures. All disability information is based on a set of health-related questions answered by the respondents themselves or by proxy respondents. They are therefore based on self-report of impairments and of their impact on work and day-to-day living, rather than on a clinical assessment of impairments. Long-term disability is defined as a health problem or disability that is expected to last more than a year, which has a substantial adverse impact on an individualâ&#x20AC;&#x2122;s day-to-day activities (related to the Disability Discrimination Act 1995) or limits the kind or amount of work that the indivudal can do. The definition includes people with progressive conditions, but may exclude some who feel that their progressive conditions and/or severe disfigurements do not limit their work or have a substantial adverse impact on their day-to-day activities. Respondents are also asked to describe their health problems or disabilities in terms of a pre-set list; those with more than one health problem or disability are asked to identify their main one. For mental health problems, the list includes the following descriptions: depression; bad nerves or anxiety; mental illness; phobias, panics or other nervous disorders. It is therefore possible to identify those with a mental health problem as their main disability from those who have an associated mental health problem (i.e. it is not their main disability).

Appendix 2. Terms used in disability assessment

In 1980 the World Health Organization (WHO) published the first version of the International Classification of Impairments, Disabilities and Handicaps (ICIDH) as a manual to accompany their ICD publications. The ICIDH was described as a classification of the consequences of disease, which could be viewed at three levels (Fig. A2.1): Impairment ‘Any loss or abnormality of psychological, physiological, or anatomical structure or function.’ Disability ‘Any restriction or lack (resulting from an impairment) of ability to perform an activity in the manner or within the range considered normal for a human being.’ Handicap ‘A disadvantage for a given individual, resulting from impairment or a disability, that limits or prevents the fulfillment of a role that is normal (depending on age, sex, and social and cultural factors) for that individual.’ The ICIDH was originally developed as part of a WHO initiative to compare health systems. However, it soon became clear that a classification based on diseases and their consequences fails to capture and distinguish the variety of experiences of people who live with health conditions. After two decades of use, the ICIDH required revision because of the new social understanding of disability and changes in health care provision. ICIDH–2 (World Health Organization, 1998, 1999) was developed to an international consensus to provide a unified and standard language and framework for understanding the dimensions of disablement. It is an attempt to integrate the ‘medical’ and ‘social’ models of disability by classifying human functioning at the level of the body, the whole person and the person within the complete social and physical environmental context. A physical or mental condition is termed a ‘health condition’ and is defined as a disease, disorder or injury, regardless of its exterior manifestation. ICIDH–2 does not cover functional states that are not health related, for example states brought about by socio-economic factors independent of health conditions.

Disease or disorder

Impairment

Disability

Handicap

Fig. A2.1

The three levels of the consequences of disease.

Within ICIDH, environmental and personal features are described as contextual factors. ICIDH–2 provides a description of situations with regard to the range of human functioning and disability and covers any disturbance in terms of ‘functional states’ associated with health conditions at the three levels described previously: (a) the body level (b) the individual [person] level (c) the societal level. These three levels are called ‘dimensions’ and have been named: (a) body functions and structure (b) activities at the individual level (c) participation in society. These dimensions replace the terms impairment, disability and handicap, and extend their meanings to include positive experiences. Definitions of dimensions (a) Problems in body function and structure = impairments (b) Difficulties with activities = limitations (c) Problems with participation = restrictions

Appendix 3. Disability Discrimination Act 1995

The key provisions of the Disability Discrimination Act are: • • •

to define who is ‘disabled’ to protection disabled people from discrimination in employment to protection disabled people from discrimination in the provision of goods, services and facilities.

Defining who is ‘disabled’ A disabled person under the Act is someone ‘with a physical or mental impairment, which has a substantial and long-term adverse effect on a person’s ability to carry out normal day-to-day activities’. Even if treatment mitigates the adverse effect, the person is still classified as disabled. In addition, mental health service users (unlike people with physical impairments) have to demonstrate that they have a ‘clinically well-recognised’ condition (this requirement is included because the law is not intended to cover ‘moods or mild eccentricities’). Case law to date shows that people found to be disabled under this definition include those with schizophrenia, clinical depression, clinical anxiety, bipolar affective disorder, agoraphobia, post-traumatic stress disorder and bulimia nervosa. ‘Longterm’ is defined as having lasted, or expected to last, for at least 12 months (episodic conditions in which each episode lasts less than 12 months is covered provided the overall condition has lasted or is expected to last for more than 12 months). This definition of disability has implications for clinicians, who can: • •

•

inform clients who are likely to have rights under the Disability Discrimination Act; give advice to courts and tribunals about what is a ‘clinically wellrecognised’ condition and give expert evidence on the adverse effect of an impairment on the ability to carry out normal day-to-day activities; contribute to national debates about whether the current definition should be changed.

The Disability Rights Task Force recommended in 1999 that the definitions be reviewed to ensure comprehensive coverage of people with mental health problems and to explore whether the requirement to have a ‘clinically wellrecognised’ condition should be removed. Guidance pertaining to the Act currently defines ‘normal day-to-day activities’ in ways that underplay cognitive and emotional activities, which can mean that mental health service users have to put forward tortuous arguments in order to qualify as disabled: for instance, claiming that agoraphobia has an adverse effect on mobility. 100

Protection from discrimination in employment The Part II of the Disability Discrimination Act makes it illegal for an employer to treat someone ‘less favourably’ for a reason related to his or her disability, unless this can be ‘justified’ under the provisions of the Act (less-favourable treatment is justified only for a reason that is both material to the individual case and substantial). It is also illegal to fail to make ‘reasonable adjustments’ to ensure that a disabled person is not at a substantial disadvantage. Adjustments for employees with psychiatric impairments might include additional support provided by the employer; arrangements for the employee to access off-site support (e.g., permission to make calls to a mental health support worker); and changes in working hours to avoid rush hour travel for someone who has panic attacks in crowds (see Employers’ Forum on Disability, 1998). Employers with fewer than 15 employees are currently exempt, but this exemption is set to end in 2004. Other current exemptions include prison officers, firefighters, police officers and the armed forces, although, with the exception of the armed forces, this is due to change in 2004. The law does not debar positive discrimination in favour of disabled people; and allows disability-specific (e.g. mental health) charities and supported employment agencies to discriminate positively in employing people with specific impairments (e.g. psychiatric impairments). This has the following implications for clinicians. First, they can contribute to making the NHS an exemplar in employing people with mental health problems effectively, for example by ensuring that human resources and management colleagues have access to best practice information on reasonable adjustments for people with mental health difficulties. They can also promote the new Department of Health guidance on employing mental health service users in the NHS (Department of Health, 2002). This guidance, influenced by the Disability Discrimination Act, states categorically that the NHS would no longer apply the ‘2-year rule’ which, following the Clothier report into homicides by nurse Beverley Allitt, had been used to screen out from nursing and other professions individuals who had received psychiatric treatment in the preceding 2-year period. This blanket exclusion is illegal under the Disability Discrimination Act. Clinicians can also spread knowledge in the service about the Disability Discrimination Act and about what ‘reasonable adjustments’ are, so that staff can inform clients of their right to ask for adjustments at work and to challenge outright discrimination. Furthermore, they can ensure that staff are aware of how to support service users in deciding whether and how to challenge discrimination in their lives. People may need space and support to think through whether and how to speak openly about their mental health condition to an employer, if this is the only way to seek redress or to secure a reasonable adjustment at work. They may need support to think through whether they wish to identify themselves as ‘disabled’.

101

When assessing a person’s suitability for work, clinicians should always consider whether he or she might be able to do a specific job with the right adjustments or support. Remember that it is illegal for an employer to refuse someone a job, or to terminate employment, on mental health grounds without first seeing whether a ‘reasonable adjustment’ would make it possible for the person to do the job. Clinicians should also encourage a culture that never underestimates people’s ability to work and they can raise awareness about the value of work to people’s mental health. By ensuring that occupational health colleagues are fully versed in the law, clinicians increase the likelihood that they will look for ways to overcome barriers to employing someone with mental health problems. Clinicians can also ensure that health and safety issues are not used as an excuse to discriminate: both the Disability Discrimination Act and health and safety law require employers to make individual assessments and to explore adjustments before refusing someone work on health and safety grounds. Finally, clinicians should ensure that psychiatric reports written for employment tribunals and courts are fully informed by the Disability Discrimination Act, for example by addressing whether the person is (a) ‘disabled’ enough to be covered by the Act and (b) potentially able to work, with adjustments as necessary. It is important to take the opportunity to educate tribunals and courts, which may be unaware, for example, that many people with schizophrenia can work effectively. Protection from discrimination in the provision of goods, services and facilities Part III of the Disability Discrimination Act makes it illegal for providers of any services – from banking to ballet – to treat someone ‘less favourably’ for a reason related to his or her disability, unless this is ‘justified’ under the provisions of the Act. Less-favourable treatment might be justified if it were necessary, for example, to avoid endangering the health and safety of any person, or if an individual lacked capacity to enter into an agreement about a service to be provided. The Act also makes it illegal not to make ‘reasonable adjustments’ to enable a disabled person to use services, again unless this is ‘justified’. Public, private and voluntary sector service providers of all sizes are covered, including GP surgeries, NHS trusts and local authorities. Thus, someone with schizophrenia given a lower quality of physical health care than other patients could bring a challenge under the Act, as could someone asked to leave a shop, or not given time to explain his or her financial needs at a bank. From 2004, stronger requirements will apply in terms of making physical adjustments to premises and facilities. For example, the NHS will have to take reasonable measures to ensure access of wheelchair users to its facilities. This has implications for psychiatrists, who are in a position to ensure that health professionals are aware of their legal obligations and of good practice, for

102

example, by ensuring that there is no discrimination on mental health/disability grounds in decisions on GPs’ lists. Psychiatrists can also try to ensure that people with all types of impairment (such as deafness or learning difficulties) can use mental health services on an equal basis. One way of encouraging other health services to provide fair treatment to mental health service users is, correspondingly, to demonstrate to deaf or learning disability services that their clients will have fair access to mental health services. It is important that psychiatrists let service users know that they have the right to be served equally in such places as shops and banks and in such things as seeking housing. Explore with them whether they want to request a ‘reasonable adjustment’ in order to use any services. For example, they might want an advocate with them when discussing financial issues at a bank, or that information be provided in writing as well as orally in anxiety-provoking situations such as a doctor’s appointment.

103

Appendix 4. An example of a format for a vocational assessment (suitable for use in a CMHT)

Advice that might be helpful to clinicians assessing patients may be found in Perkins (1999).

Work/education assessment interview with client Note: This is not a blueprint for an interview. The aim is to collect as much information as possible in order to be able to construct an employment plan. Feel free to ask additional questions and to omit parts that are irrelevant.

Name: Address: Type of accommodation: Living arrangements: Date of Birth: Keyworker: Date of Interview: Interviewer: The purpose of this interview is to think about you work/education preferences, goals, experience and skills, and work out ways in which we might help you. It is not a job interview or a test and the information is confidential â&#x20AC;&#x201C; it will not be given to potential employers without your permission.

CURRENT GOALS Have you thought about working? What sort of work would you like to do? What interests you about this job? What do you think it involves? Have you tried to do it? If so, what happened? If not, what has been holding you back? Have you thought about going to college, studying or training? What might you like to do?

104

What interests you about this? What do you think it would involve? Have you tried to do it? If so, what happened? If not, what has been holding you back?

How do you feel about? Getting an ordinary job (open employment)? Voluntary work in the local area? Working in a place specially designed for people with mental health problems? Going to college or doing a training course?

WORK AND EDUCATION BACKGROUND Tell me about school: What subjects did you like? What subjects did you dislike? What were you good at? Did you like school in general? Did you have any difficulties at school? Did you pass any exams? At what age did you leave? Have you done any courses, education or training since you left school? What did you do? When? Did you like it? Did you have any difficulties? Did you finish the course? Did you get any qualifications? Tell me about any jobs that you have had (include paid, voluntary and sheltered work) Company and job/position Start date/Finish date What did you like/do well at? Did you have any difficulties/things you disliked? Why did you leave?

105

Tell me about any hobbies or interests you have had in the past What were they? When did you start/stop doing them? Why did you stop? What did you like/dislike about them? Have you ever been a member of any clubs or organisations? Which ones? When did you start/stop? Why did you stop? What did you like/dislike about them? Any other achievements?

CURRENT ACTIVITIES AND ADJUSTMENT What do you do on an average day at the moment? Where and when do you go out? Tell me about any hobbies or interests you have now What? How long have you done it? What do you like/dislike about it? Have you ever been a member of any clubs or organisations? What? How long have you been a member? What do you do? What did you like/ dislike about it? Do you have any physical health problems? If so, what are they? How do they affect you? What do they stop you doing? Are you receiving treatment for them? Is this treatment effective? Do you have any mental health problems? If so, what are they? How do they affect you? What do they stop you doing? Are you receiving treatment for them? Is this treatment effective? Do you know when you are becoming unwell? How do you know? What do you do? Do you have many friends or family members you are in contact with? Do you find them understanding/supportive? What do you think they would feel about you trying to get a job/going to college?

106

WORK SKILLS AND INTERESTS There are lots of skills that you needs when you go to work or college. I want to go through some of them now. How good do you think you are at this?

Do you think you need to improve this?

Literacy: reading, writing, spelling Numeracy: adding up, dealing with numbers Physical fitness Communication: getting on with other people, talking to people you know, talking to strangers Using the telephone Time keeping: getting to work on time, leaving on time Endurance: sticking at things Reliability: doing what you say you will do on time Concentration Making decisions Being supervised, told what to do Learning new things Looking after yourself, dressing smartly Coping with pressure or stress

How would you prefer to work? On your own or in a group (any preferences about with whom â&#x20AC;&#x201C; gender, age, etc.) Indoors or outdoors? In a large or a small workplace? Sitting down, standing up or moving around? In a noisy or a quiet place? With familiar tasks or with new and varied tasks? Being told what to do, or left to your own initiative? Doing practical tasks, working with machinery, working with people, other? Behind the scenes or in the public eye?

107

Part-time or full time? Regular hours or shift work? Any other work preferences? What sort of problems do you think you would have: Getting a job? Keeping a job? Getting on a course? Finishing a course? How might you go about trying to find work or a college course? Would you like any help in finding and getting work/a course? What sort of help would you like? If you were to get a job, or start on a course, would you need any help to do the job/ course? What sort of help would you like? OTHER WORK-RELATED FACTORS How confident are you about: Using public transport? Do you have a bus pass/travel card? Going out alone in familiar areas? Finding your way in new places? Do you have a car/driving licence? Do you drink or use drugs? If so, when? How much? Might it interfere with your work? What would you expect to get from work/studying? (money, meeting people, qualifications, something worthwhile to do, confidence, a sense of satisfaction and personal fulfillment, etc.)

ANY OTHER COMMENTS What sort of things do you enjoy doing? What sort of things are you interested in? What sort of things do you dislike? What are you good at? What are you not so good at?

108

Individual employment plan Name:

Date:

Overall work/education goal:

Summary of strengths and problems related to achieving the goals: Strengths

Problems

Overall plan for moving towards goal:

Objectives

Action

People responsible

Objective 1

Objective 2

Objective 3

Review date:

109

Appendix 5. Comparison of costs of supported employment and pre-vocational training

Table A5.1 summarises cost data from recent studies of supported employment and pre-vocational training (Crowther et al, 2001a).

Table A5.1 Cost data, mean monthly earnings, mean hours in competitive employment Study

Intervention

Bond et al, 1995

Immediate placement Control Immediate Placement Control

Clark et al, 1998

Study

Intervention

Bond et al, 1995

Supported employment Pre-vocational training Supported employment Pre-vocational training Supported employment Pre-vocational training Supported employment Pre-vocational training

McFarlane et al, 2000 Clark et al, 1998 Drake et al, 1999

Study

Intervention

Clark et al, 1998

Individual placement Pre-vocational training Individual placement Pre-vocational training Individual placement Pre-vocational training

Drake et al, 1999b Gervey & Bedell, 1994

Mean monthly costs (US$)

Other health costs (US$)

Overall costs (US$)

251.6 132.0 313.1 307.3

263.0 586.5 801.6 928.5

514.6 718.5 1114.7 1235.8

Mean monthly earnings (US$)

t or F

99.9 60.7 41.9 11.8 188.5 59.9 111.1 111.4

Mean hours in competitive employment (US$) 33.7 11.4 17.9 1.5 69 9.9

110

2.75

<0.01

2.35

<0.05

3.34

<0.001

4.29

t or F

3.7

<0.001

4.4

<0.001

3.7

<0.03

Appendix 6. Requests for reports on employment

Before replying to any request for an employment report from an employer, any medical expert, including psychiatrists and GPs, should ask for a detailed description of the personâ&#x20AC;&#x2122;s duties or proposed duties at work. It is not possible to provide a useful report without such a job description. It is also good practice to check with the individual concerned that the job description is realistic assessment of his or her day-to-day duties and to ask which are core duties and which are carried out infrequently or are of lesser importance. Requests from employers for medical information often concentrate on whether an individual meets the definition of disability contained in the Disability Discrimination Act 1995. Such requests might ask for the name and nature of the diagnosis, details of any treatment and medication being taken and how long the condition is likely to last. Medical advisers should ascertain why the employer wants the report, so as to be as helpful as possible. If the report is to be used to help the employer retain or recruit an individual by making reasonable adjustments to the job, comprehensive details of diagnosis and treatment will not be necessary. Reports for legal advisers involved in tribunal proceedings might, however, need this information. A report from a psychiatrist (or other mental health professional) written to assist an employer wishing to recruit or retain an employee should contain the following information. 1 2

Confirmation that the individual does have a mental health problem. Any effect that this mental health problem might have on the individualâ&#x20AC;&#x2122;s ability to carry out any of the activities necessary for the job (e.g. ability to concentrate for long periods). Whether the person is receiving any treatment that might have an impact on his or her ability to carry out the jobâ&#x20AC;&#x2122;s duties (e.g. might the sideeffects of drugs lead to greater fatigue in the morning or is time required during the working day for treatment?). Any adjustments that the employer could make, for example: (a) giving time off during the working week for rehabilitation, assessment or treatment such as counselling or other medical appointments; (b) accepting that the employee may need to take time off sick if the disability is episodic; (c) allowing the employee to have a support worker or providing additional supervision; (d) allowing the employee extra time to carry out certain tasks; (e) providing additional training;

111

(f) acquiring or modifying equipment (e.g. room dividers, partitions or other soundproofing, or visual barriers if the person has difficulties with concentration or memory); (g) allowing occasional or permanent working from home or assigning the person to another location; (h) reducing noise in the working environment; (i) modifying the mode of giving the person instructions (e.g. by providing instructions in writing rather than orally); (j) modifying procedures for testing or assessment (e.g. in writing rather than orally or by allowing more time); (k) offering flexible working hours (e.g. a later start if side-effects of medication mean that the person is groggy in the morning); (l) training for co-workers on mental illness to build tolerance and understanding of aspects of the personâ&#x20AC;&#x2122;s behaviour that may be unusual but does not affect his or her ability to carry out the job effectively; (m) allocating to someone else some duties that are particularly difficult for the individual; (n) allowing the individual to reduce his or her working hours either temporarily or permanently; (o) transferring the individual to another more suitable vacancy (this may be something that the employee suggests if questioned).

112

Appendix 7. Inter-agency working: key factors for putting partnerships into practice

Contributors to the research project on inter-agency working carried out by Pozner et al (2000) highlighted the following key factors for successfully developing and sustaining partnerships, as well as some of the problems faced. A user focus Central to any partnership development must be the needs of service users. At every stage, the question of whether users will benefit must be posed, and answered, by users. To ensure that users and carers can play a meaningful role as partners, they need to be supported to do so. In many localities, the user movement and its infrastructure is still weak and underresourced. Many partnerships are dependent on a small number of users for a growing number of local initiatives; this can cause significant pressures on individuals, as well as creating a tendency for partnerships not to consult more widely. Strategies must be adopted to ensure that the local user infrastructure is continually being strengthened and supported. Finding partners Whether a single agency is looking for a partner to develop its services or an established partnership is trying to fill an identified gap, the same thing applies: it is necessary to identify in detail the skills or service needed. These might already be possessed by an existing partner or it might be possible to develop them within the partnership. In many cases, looking around for others with appropriate skills and experience may be the answer: it will be much quicker, and cheaper, to instil awareness of mental health issues into a college lecturer than to train a mental health worker to teach catering to NVQ Level 3. In general, agencies should do what they are good at and find others to do the things they cannot do. In that way they might avoid giving service users second best. The fact that an organisation does not operate within the mental health arena does not mean that it lacks relevant skills. For example, the techniques developed by the group Theatre in Prisons and Probation proved highly effective in the mental health sphere. New partners need to take on board the values of the partnership as a whole. If they do not, users might not experience the same quality of service throughout, one of the most important benefits of partnership working. The roles of each partner need to be clearly defined right from the start. Some might need to reshape their provision to avoid duplication: others might need to 113

take on a wider role, perhaps managing the partnership. Failure to agree clear roles and responsibilities can lead to ongoing friction and poorer services for the user. Communication Good communication between all partners and their service users is vital. There must be an efficient flow of information and this should be properly resourced. Regular management meetings can help to keep key aims in view and development priorities on target. They can also provide support, particularly for smaller agencies with only a few workers, who can sometimes feel isolated or undervalued. These meetings also give users the opportunity to influence development. Most partnerships described in Pozner at elâ&#x20AC;&#x2122;s survey reported that users were represented on their management committees. â&#x20AC;&#x2DC;Oiling the wheelsâ&#x20AC;&#x2122; Making partnerships work requires time, and all services are stretched. This is less of a problem for small partnerships operating in close physical proximity, but larger partnerships identified this as one of their biggest problems. If there is no funding earmarked to underpin the partnership, it can be difficult for agencies to fulfil their roles satisfactorily, in tandem with their other responsibilities. Wherever possible, bids should include some costs for running the partnership. Commitment from the top It is vital that there is commitment at the highest management levels to partnership working. Some partnerships include a commitment to partnership working in job descriptions. Commitment needs to be continuous. When a partnership is well-established, senior managers can sometimes think that it can carry on under its own momentum and regular meetings are seen as a waste of time. This is a serious misjudgement. Regular communication between partners is absolutely crucial. Without ongoing input of ideas and review, the collaboration will ossify, start to fail its users and ultimately disintegrate. Boundary problems A problem that some partnerships have to wrestle with is that of cross-boundary working. With more than one local authority, NHS trust or Employment Service2 area, the number of people required to attend meetings multiplies (thus rendering

2. The research was carried out before Jobcentre Plus replaced the Employment Service.

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the chances of finding a date suitable for all virtually nil). The partnership will also be confronted with multiple priorities, different ways of working and levels of commitment. Serious thought should be given to whether the difficulties outweigh the benefits. A professional approach The way a partnership presents itself and its services to the world can also be a factor in its success. For trading partnerships and those dealing with the private sector, a professional image is crucial. The image must be backed up with professional delivery. For example, if there are deadlines or targets to meet, then it is important to meet them if the private sector employers or supporters and partners are to take the scheme seriously. These agents generally expect everyone they deal with to deliver the required outcome or standard, and may not do business if these cannot be met. Siting of premises is also an important factor. High street or business park locations are preferable to more traditional sites, particularly for more employment- or business-oriented projects. It emphasises integration into ordinary community life and engenders more dignity and self-esteem in service users. Being â&#x20AC;&#x2DC;tuned inâ&#x20AC;&#x2122; Keep in touch with policy developments at a national and local level. One partner could take responsibility for that and for reporting to others. There is advantage in knowing in advance about forthcoming initiatives such as health action zones or the New Opportunities Fund. It allows time to investigate the scope for meeting user need through that route. It also enables new partners to be identified, particularly community agencies operating outside the mental health area, and the feasibility of multi-agency funding bids and shared posts can be assessed. Understanding the local business scene If an awareness of new policy initiatives enhances flexibility and creativity in service development, so also does an awareness of the local economic scene. Knowledge of employer demand for skills results in appropriate vocational training. Supported employment services need up-to-date information about which sectors are expanding and which employers have labour shortages. Social firms need market research to identify viable products and services. Many agencies lack the expertise or resources to carry out this type of work themselves. Useful partners can be the local chamber of commerce, local authority economic development departments, business skills units and any other agencies with easy access to labour market information and commercial intelligence.

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Evaluation To keep the partnership vital, evaluation is crucial and without it services can stagnate; elements that no longer serve a useful purpose or have become inefficient can continue indefinitely, burning up precious resources. All partners, particularly service users, should be involved in this exercise. An evaluation report that clearly demonstrates the benefits of partnership and the quantifiable gains for service users could prove useful when trying to ensure continued support from senior managers.

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