Tucked away on page 60 of the Budget documents, was a commitment to invest in mental healthcare for the working-age population. This is well warranted and long overdue – at any one time an estimated one in six of the working-age population is experiencing a mental health condition.
Mental illness is estimated by the OECD to cost the UK around £70 billion annually – roughly 4.5% of GDP. Costs are not only felt by the health system; the costs of lost productivity at work, unemployment and welfare benefits are also considerable. With an estimated four out of ten new disability benefit claims relating to mental illness, it’s clear that managing and preventing mental ill health is not just a job for the Department of Health.
The Budget measures focus on increasing access to evidence-based psychological therapies. This will be done in two ways: by providing online Cognitive Behavioural Therapy (CBT) to claimants of Job Seekers Allowance and Employment and Support Allowance, as well as users of the new Fit For Work (designed to support people who are on long periods of sickness absence to stay in work); and co-locating NHS psychological therapy services in 350 Jobcentres across the country.
Given that waiting times for NHS psychological therapies (known as the IAPT programme in England), are reported to be more than a year in some parts of the country, anything that improves access is good news.
So, this all sounds pretty positive – but what does the evidence say?
From pilot to practice
In 2014, the government commissioned a report to explore the evidence on what works in improving psychological well-being at work. Four interventions were recommended and pilots were then commissioned by the Department of Health and the Department of Work and Pensions to measure their effectiveness and to test their feasibility for national roll-out.
The interventions included the provision of online CBT with a vocational element within Jobcentres, and the integration of employment support (in particular, a model of supported employment known as Individual Placement and Support) with NHS psychological therapy for people with common mental health conditions. It seems likely that these two interventions influenced the Budget measures.
Unfortunately an evaluation of the online CBT did not happen; research was instead conducted with service users to inform its development. We can have some confidence in this approach, given that promising evidence already exists for online CBT – particularly in terms of job retention. A recent Cochrane review (focusing on depression) found “moderate-quality evidence that enhancing primary or occupational care by providing workers with a structured telephone or online cognitive behavioural therapy reduces sickness absence compared to regular care”.
The second intervention, assessing the effectiveness of integrating employment support into NHS psychological therapy, was given a six-month pilot. This was run in four areas of England; and the service was offered to Employment and Support Allowance claimants with mental health conditions. An evaluation, which we conducted at The Work Foundation, showed positive results – 15 service users found paid work and many others achieved a range of other positive outcomes.
However some caution is warranted when relating this pilot to the one proposed in the Budget. While the pilot was developed around integrating employment support into NHS psychological therapy services, this is in fact a significant step away from the Budget commitment to co-locate NHS psychological therapy services in the Jobcentre.
Our evaluation of the pilot suggests that integrating mental health support within the Jobcentre may present some issues.
The Individual Placement and Support (IPS) model of supported employment, is based on eight principles, including the integration of employment specialists within clinical teams. The approach is already used in various parts of the UK (commissioned locally in response to recognised need), and there is substantial evidence that it is effective in improving employment outcomes for people with severe and enduring mental health conditions (including schizophrenia).
The IPS model of employment support is usually delivered in the community, often by third-sector providers – using a very different setting from the pressurised environment of a Jobcentre. In our evaluation of the pilot, service users spoke specifically about the value of being able access employment support outside of the Jobcentre.
Concerns came from within the Jobcentre as well, with one adviser fearing that effectively putting a Jobcentre “stamp” on the provision of therapy, would have a negative effect on claimants perceptions of the service and its potential health benefits.
Such concerns are only heightened by reports of poor treatment by some Jobcentre staff of people with mental health conditions, as well as worrying media reports that have suggested that therapeutic support would be mandatory and that people’s welfare benefits would be dependent on uptake.
The evaluation showed that integrating employment support and psychological therapy has positive outcomes. My concern is negative perceptions of the Jobcentre, and indeed the culture found within it, will form a barrier to effective treatment in a way that community and health service-based IPS services avoid. To me, the key is in the integration of health and employment services – and the awareness that this is about much more than co-location. It is about the shared values, and the shared objectives of IPS providers and the NHS. Unfortunately, even with the best intentions, these will be fundamentally different from those of the Jobcentre.
Having the government take the issue of mental illness and employment so seriously is nothing to be sniffed at, and I do not wish to appear negative – there are many people who will benefit from having faster access to evidence-based psychological therapy in a way that might help them to stay in or to find a job. Roll-out is not due to begin until the summer – lets hope the DWP uses this time wisely to address some of the barriers to providing helpful and effective support for people with mental health conditions who want to work.