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Getting people with mental health issues and learning disabilities into employment

There are significant barriers to employment for people with mental health issues and learning disabilities. With effective support, they can access the proven benefits of long-term work. But that means more co-operation between employment services, social workers and health professionals, from psychiatrists and mental health nurses to psychotherapists and occupational therapists.

Work is good for us. There's strong evidence that it not only helps us financially, but also emotionally, improving our general quality of life and wellbeing. However, it seems that accessing the world of work is far from easy for the people who would most benefit from these positive outcomes: those with poor mental health or learning disabilities.

It's not just the self-limiting nature of their conditions that can prevent people from accessing paid work. Employers often discriminate against people with mental health conditions or learning disabilities. As a result, health professionals can have low expectations and there is a reluctance to invest in proper support resources or to work closely with social care and employment professionals to provide a coherent and cohesive strategy. The following is a summary of the results of a report entitled Clinicians attitudes to the employment of people with psychosis (Marwaha, Balachandra and Johnson, 2009):

"Clinicians believed that many more people with psychosis were capable of working than were actually doing so. Nevertheless they believed that about two thirds of their caseloads were either incapable of working or able only to do voluntary or sheltered work. The work roles they saw as suitable tended to be ones requiring lower levels of technical skills. Clinicians saw helping people get back to work as a core part of their role, but felt they had little relevant training and limited confidence in the vocational services currently available for their clients."

Good intentions

Of course, many mental health professionals take a more positive attitude to their patients' ability to work. However, where no defined support structure exists, this positivity is unlikely to lead to more people finding jobs. A review of a London community mental health service found that, while mental health staff rated 18.9% of their clients as capable of open market employment, only 5.5% were actually in work (The nature and correlates of paid and unpaid work among service users of London Community Mental Health Teams, Lloyd-Evans, Marhawa, Burns, Secker, Latimer, Blizard, Killaspy, Totman, Tanskanen and Johnson, 2012).;

Psychological Wellbeing and Work, a 2014 study jointly commissioned by the Department for Work & Pensions and Department of Health, found that, although there is a range of public services that could support people with mental health problems in finding work, there are a number of obstacles, including three key issues:
  • Assessment is difficult and there are low rates of diagnosis or referral to specialist health and employment support.
  • Services often work independently, addressing only the mental health problem or the employment need individually.
  • There's often a delay in service provision, which means health and employment problems can get worse.

Worrying figures

The statistics speak for themselves.  According to a recent report by the Organisation for Economic Co-operation and Development (OECD), people with severe mental health conditions are six to seven times more likely to be unemployed than people with no mental health condition, with an employment rate for all people with mental health conditions of just 37% (Labour Force Survey, Quarter 2, 2013). Even those with a mild-to-moderate condition can be 2 to 3 times more likely to be out of work.

The picture for those with learning disabilities is even bleaker. In 2010/11 only 6.6% of adults with learning disabilities were reported to be in some form of paid employment (Foundation for People with Learning Disabilities). They even fare badly in comparison with disabled people in general, for whom the employment rate has steadily increased in recent years, and now stands at 48% (Labour Force Survey, Office for National Statistics, 2008). And while 1 in 10 people in England are self-employed, there's a negligible amount of people with learning disabilities represented in that figure.

The economic costs of not helping those with mental health issues and learning disabilities back into work are substantial. 40% of people who are unable to work because of poor mental health are claiming incapacity benefit, costing the taxpayer millions of pounds each year. A single person working for a full year, rather than claiming benefits, contributes £20,000 to the Exchequer and over £33,000 into the economy (Oxford Economics 2007). The total bill for mental ill health in England, including the costs of health and social care, lost economic output and the human costs of reduced quality of life, is estimated at an amazing £105.2 billion every year (Centre for Mental Health).

Major challenges

All this presents huge challenges not just for social workers, but for a wide spectrum of health professionals, including psychiatrists, psychologists, mental health nurses, occupational therapists, learning disability nurses, and speech and language therapists. They are best placed to help their patients understand the value of paid work, and to work closely with social care managers to put in place robust support strategies. However, the main focus of health professionals is inevitably on primary care. To be more involved in putting employment at the heart of support planning for their patients, they need appropriate time and resources, not to mention encouragement from senior management. In general, resources are already stretched; in 2012/13 1.59 million people were in contact with specialist mental health services and there were 21.7 million outpatient and community contacts arranged (NHS Confederation).

Occupational therapists who work with mental health patients provide a good example of positive intervention. The website of the British Association of Occupational Therapists and College of Occupational Therapists cites a randomised trial from 2007, which found that occupational therapists can enable people with mental health problems to return to work three months earlier, and work for longer hours, than in standard psychiatric interventions. The same survey also found that 50% of service users with mental health problems who returned to work as a result of occupational therapy intervention were still in employment 42 months later.

Government initiatives

Given the economic case, it's no surprise that the Government has prioritised the improvement of employment rates for those with mental health problems and learning disabilities. "Research has shown that at least 70% of NHS Trust mental health clients want to work and can work," says the Centre for Mental Health. "However, they need the support of their clinical team and specialist employment workers to help them through the process of finding suitable work, attending interviews and management of their condition once they are in work."

Two successful government initiatives have shown the way forward...

Individual Placement and Support (IPS) is an evidence-based approach to supported employment for people who have a severe mental health illness. It's based on eight key principles:
  1. It aims to get people into competitive employment
  2. It is open to all those who want to work
  3. It tries to find jobs consistent with people's preferences
  4. It works quickly
  5. It brings employment specialists into clinical teams
  6. Employment specialists develop relationships with employers based upon a person's work preferences
  7. It provides time unlimited, individualised support for the person and their employer
  8. Benefits counselling is included
There has been unanimous approval of IPS from service users, their families, clinicians and researchers. Evidence shows that this 'place then train' model is much more effective in getting people into work than traditional approaches, such as vocational training and sheltered work.

"The outcomes can be surprisingly good," observed Dr Geraldine Strathdee, National Clinical Director for Mental Health, in a recent interview on the NHS England website. "IPS even works well in areas of high unemployment or during times of recession because success relies on the development of trusting relationships between the employee, employer and employment specialist."

Jobs First was set up to encourage people with learning disabilities to use their social care personal budgets, along with appropriate funding streams such as Access to Work, to buy the support they need to get and keep a job. It was announced within the Government's New Opportunities white paper in 2009 and was a key commitment in the same year's Valuing Employment Now strategy. In a review of the scheme carried out by King's College London in 2013, Jobs First was 'consistently described as a spur for sites to progress efforts to change attitudes and to promote employment'. However, ensuring that there was enough money behind the scheme was seen as a key challenge.

Employers can show that they encourage applications from disabled people by displaying the 'Two Ticks' symbol. This is something Sanctuary supports and is one of the hundreds of companies across the UK that are already using the symbol, including local authorities and academic institutions, as well as major retailers and big brands, such as Barclays Bank, British Airways, BT and McDonalds.

In its Disability and Health Employment Strategy, the Department for Work & Pensions expresses a clear desire to improve the employment support for people with mental health issues: "We need a co-ordinated and joined-up approach between employment and health services in order to improve the opportunities and outcomes of people with a mental health condition". To help achieve this aim, the department has set up a Mental Health and Employment Task and Finish Group, which has defined a clear strategy for ensuring that employment is a key focus for mental health service users.

The target date to see major improvements is 2025. More than a decade may seem plenty of time to make a difference. But it's no easy task. As well as additional time and resources, there needs to be a sea change, firstly in the way health professionals think about getting their mental health and learning disability clients into work, and secondly in the way they interact with employment services. Only then will we see this unfairly marginalised section of society really begin to benefit from their right to work.
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