Information for clinicians

No one is intrinsically unemployable: studies show that, given the right conditions and support, the vast majority of people who are out of work and use mental health services want to return to or to start work.

We know that many people with a mental health condition do not participate in key activities of society, they are socially excluded, and that being in work can reduce the likelihood of this. The right work, with the right support from employers, colleagues, carers and health and care professionals can actually aid recovery for people with mental health problems.

However, people with mental health problems do face significant challenges when trying to access employment. Some of these challenges are shared with other people such as the need to adjust the physical environment, or to mitigate language difficulties or the need for extra support or training. However, often these obstacles are less tangible owing to some differences between mental health problems and other impairments:

• They are not immediately obvious and can develop at any time in a person’s life
• They attract fear and prejudice e.g. myths of incompetence or danger
• They typically fluctuate and it can be difficult to predict when these fluctuations will occur
• They affect a person’s ability to negotiate the social, rather than the physical world of work.

Work, and particularly paid employment, can be beneficial to health and well-being. Not only does it provide financial reward it also:

• Is central to personal identity.
• Provides structure and purpose to the day.
• Gives opportunities for socialisation and friendship.
• Increases social networks - a core component of social capital
• Can offer a role valued by society

Remember that unemployment is bad for health and well-being:

• Rates of common mental disorders such as depression and anxiety are higher among the unemployed than among those in work
• Suicide rates are up to three times higher in the unemployed compared to those in work, especially among the long-term unemployed
• The risk of attempted suicide is also greater in the long-term unemployed than those unemployed for a shorter time
• Job loss can lead to problematic alcohol consumption for around 1 in 5 men and 2 in 5 women
• These relationships are found in cross-sectional and longitudinal studies and it seems reasonable to conclude that there is a causal association between losing employment and subsequent mental distress and ill health.
• Be aware that not all types of employment are beneficial. Bullying in the workplace is a pernicious problem. Jobs with poor psycho-social quality can be as bad for a person’s mental health as unemployment. These include those with high job demands and complexity, low job control, job insecurity and unfair pay.

Key messages for mental health services are:

• Helping people to gain or retain good and appropriate work is a valid recovery goal and that health services should play a role in facilitating this.
• Supporting people into employment or other valued activities can improve their sense of hope and agency as well as offering them important opportunities, all of which are key components in personal recovery.

Resources:

• The Mental Health Five Year Forward View (PDF)
  An independent Mental Health Taskforce formed of health and care leaders, people who use services and experts created a Five Year Forward View for Mental Health for the NHS in England. It set out plans to improve mental health care and contained recommendations for improving supported employment. NHS England’s accompanying Implementation Plan committed additional funding and a timetable of action.

• No health without mental health: a cross-Government mental health outcomes strategy for people of all ages
  No health without mental health: a cross-Government mental health outcomes strategy was published in early 2011. It sets out six shared objectives to improve the mental health and well-being of the nation. It stresses the interconnections between mental health, housing, employment and the criminal justice system.

• Realising ambitions: Better employment support for people with a mental health condition (PDF)
  Rachel Perkins, Paul Farmer and Paul Litchfield
  Department for Work and Pensions, December 2009
  This review (also known as the Perkins Review) was commissioned by the Secretary of State for Work and Pensions to look at mental health and employment and to identify how Government could help people with mental health conditions fulfil their employment ambitions. It is predicated on the conclusion that appropriate work is good for you: it improves your mental health and protects against relapse.

• Social Inclusion and Mental Health
  Jed Boardman, Alan Currie, Helen Killaspy, Gill Mezey
  Royal College of Psychiatrists, June 2010
  This book reviews the ways in which people with mental health problems are often excluded from participating in society. It examines the steps that psychiatrists and mental health workers can take to facilitate the social inclusion of people with mental health problems.

Mental health and work

• Royal College of Psychiatrists OP101. Employment and mental health (PDF)
  This report outlines the main priorities and activities of the Royal College of Psychiatrists in the area of mental health and employment. Sayce, L. (2011)

• Getting in, staying in and getting on. Department for Work and Pensions.
  An independent review of specialist disability employment programmes commissioned by the Department for Work and Pensions and written by Liz Sayce’s then the Chief Executive of RADAR.

• New Economics Foundation (2014) Well-being at work A review of the literature.
  A review of the literature on Well-being at work. The evidence also shows that people who achieve good standards of well-being at work are likely to be more creative, more loyal, more productive, and provide better customer satisfaction than individuals with poor standards of well-being at work.
  

• Working for a healthier tomorrow
  Dame Carol Black's Review of the health of Britain's working age population, 2008

• Working our way to better mental health: a framework for action
  Department for Work and Pensions, 2009
  This cross government strategy is built on the conclusion that there is a positive link between employment and mental health. Research shows that people generally enjoy better mental health when they are in work. In contrast, the longer individuals are absent from or out of work, the more likely they are to experience depression or anxiety. Work can therefore play a vital role in improving everyone’s well-being and mental health.

• Is work good for your health and well-being?
  Gordon Waddell and Kim Burton, 2006
  This review collates and evaluates the scientific evidence on the link between work and health. The review focused on adults of working age and the common health problems that account for two-thirds of sickness absence and long-term incapacity (i.e. mild/moderate mental health, musculoskeletal and cardio-respiratory conditions).

Clinicians can help or hinder the process of getting people with mental health problems into work, or keeping them there.

Clinicians are often a barrier for people with mental health problems getting into work.  Unfortunately, by omission or commission, physicians and other health or social care workers have contributed to the belief that employment is not a realistic possibility for many people with mental health conditions.

People with mental health problems often speak about the negative attitudes of people they encounter in health and social services. Realising Ambitions, the Perkins review of employment support, highlights the experience of some users of mental health services when faced with the attitude of health and social care professionals to the issue of employment for people with mental ill-health. It concludes that many health and social care workers have not seen employment as part of their remit and do not ask patients about their work or employment status.

The Centre for Mental Health briefing ‘Removing barriers: the facts about mental health and employment (PDF)’, draws on a variety of research studies and surveys of users of mental health services.  It shows that the low expectations and lack of knowledge of healthcare professionals constitutes a major barrier to the employment of people with mental ill-health.

You should consider an occupational history as part of your comprehensive assessment.  There is now compelling evidence that appropriate work is good for patients; it helps their recovery and protects against relapse.  In addition, there is an increasing body of evidence that shows certain approaches can help people with mental health problems to remain in or gain open employment.

This means that health and social care workers need to play a key role in facilitating employment, or employment related activity such as training or education.  Your occupational history should include information about the patient’s employment status, the type of work environment and support mechanisms that are in place.

Remember, that for those in work, the stressors that may cause problems at work may often not be related directly to the workplace, such as marital or family problems.  However for others the stressors may be part of their working environment and may cause or exacerbate their condition.

Steps can be taken in the workplace to mitigate these factors.  If the issues in the workplace are not resolved then it is unlikely that a period of sickness absence on the part of your patient will make any positive difference to his/her long-term health and well-being.

What might these work related stressors be?

What are the possible sources of work related stress?

Six areas of work that can have a negative impact on employee health if not managed properly.

An occupational history may also help you to identify the factors in the workplace which may cause or exacerbate neuropsychiatric symptoms.  Some of these factors may include exposure to substances such as lead and manganese which are known to cause both temporary and long-term psychiatric symptoms and illnesses.

An incomplete occupational history may lead to a missed occupational diagnosis and inappropriate management.  If the link between work and health is not recognised and the causal factors are not managed effectively, including ongoing review, then the patient’s condition is unlikely to improve.

Resources:

Creating a healthy work environment

Employer module

• Realising ambitions: Better employment support for people with a mental health condition (PDF)
  Rachel Perkins, Paul Farmer and Paul Litchfield
  Department for Work and Pensions, December 2009
  This review was commissioned by the Secretary of State for Work and Pensions to look at mental health and employment and to identify how Government could help people with mental health conditions fulfil their employment ambitions.  Chapter 4 includes a summary of the 4Rs (raise, respond, recommend, refer) for primary care and mental health professionals when addressing the employment needs of people with a mental health condition.

• ACAS (Advisory, Conciliation and Arbitration Service)
  Health, work and wellbeing, 2012
  This booklet includes checklists to help you to evaluate how healthy the workplace is and to identify situations where action is needed.

• Health and Safety Executive (HSE)
  The mission of the HSE is to prevent death, injury and ill health in Great Britain’s workplaces.  HSE resources on mental health conditions are focussed on work related ‘stress’.
  This is the link to a step by step approach to implementing the HSE management standards  which represent a set of conditions that, if present, reflect a high level of health well-being and organisational performance.  This approach is supported with specific guidance and tools to see whether the organisation is ready to change and how to secure the commitment across the organisation needed to effect change.  This may help in any discussion or evaluation of the conditions in your patient’s workplace.

The HSE has produced a simple questionnaire (PDF) which links questions about the nature of a person’s work and workplace environment to the six categories or causes of stress. 

MIND

• How to be mentally healthy at work booklet
  Explains how people can be mentally healthy at work, giving practical suggestions for what to do and where you can go for support.

National Institute for Health and Clinical Excellence (NICE)

• Promoting mental wellbeing through productive and healthy working conditions: guidance for employers, November 2009
  This public health guidance was developed by NICE using rigorous methodology including reviewing the available academic evidence, economic analysis and engagement with various stakeholders.  The guidance includes recommendations for action in the form of ‘who should take action’ and ‘what should they do’.

Institute for Children’s Environmental Health, Learning and Developmental Disabilities Initiative, November 2008

• Mental health and environmental exposures (PDF)
  This fact sheet discusses the connections between environmental exposures to physical and chemical agents with mental health symptoms and conditions.  While it is recognised that environmental exposures to toxic substances can lead to disease, disability and other medical conditions, the connections to psychiatric conditions are not as well known.  However, there is a substantial amount of scientific evidence that certain exposures can lead to both temporary and long-term psychiatric symptoms and illness.

• eLearning for health 
  This is an eLearning resource for primary care professionals. It aims to improve their knowledge, skills and confidence when dealing with issues relating to work and health. Health e-Working offers six interactive sessions of e-learning with practical examples and guidance on how to improve patient care. One of the six sessions is called “Making the occupational link”.  This resource has been developed by a steering group led the Faculty of Occupational Medicine in partnership with the Royal College of General Practitioners, the Society of Occupational Medicine and e-Learning for Healthcare.

• Healthy working UK
  This website has been developed in collaboration with the Royal College of General Practitioners, the Faculty of Occupational Medicine and Society of Occupational Medicine and is based on the Healthy Working Wales pilot developed by Cardiff University and the Welsh Assembly Government. It provides GPs and other primary healthcare professionals with timely access to information, training and decision aids to support the management of health and work.

Regaining occupational function should be an explicit goal in the patient’s care plan.

How long should people with mental health problems be off work?

It is difficult to predict how long a person who develops a depressive or anxiety disorder should be off work. We know that many people with these disorders make a slow recovery, whilst for others they are transient. People often quote a natural recovery rate of only 20% for depression and 5% for anxiety disorders and the majority of people need support to achieve recovery from these common mental health problems.

Importantly, what we do know is that the longer a person is off work, the less likely they are to return to work. For people who are off sick from work owing to mental health problems for six months the chances of them returning to work within two years is small, with only about 10% achieving this. This is similar to the rates of return for those who go off work owing to back pain.

It is important that people's mental health problems receive early recognition and intervention. Two things are important to remember:

• People do not have to be entirely symptom free to remain in or return to work successfully.
• It is not enough just to provide early and effective treatment; efforts to assist the patient back to work should be carried out at the same time.

For those people who develop mental health problems whilst in work it is important to try and help them keep their job. Clinicians working in primary care play a key role in this and should, in addition to providing access to medication and psychological therapies, work with the patient at an early stage on a return to work plan. For those working in Secondary care it is important to discover among new patients referred to the clinics and community teams or admitted to inpatient units whether they are in work and liaise with their GP and employers. They may also need to be linked in to the local vocational scheme and given appropriate benefits advice.

Many people with long term mental health problems, particularly those with a diagnosis of psychosis, will not be in work and may not have worked for many years, if ever. These people can and do work, but may need greater support to find them suitable employment. For these groups there is ample evidence that well organised supported employment schemes can be successful in helping them find jobs.

Working with your GP, community health services, occupational health service and specialist mental health services

The people involved in treating your mental health condition are important in helping you to stay in work, and to keep working well.

Health professionals should see supporting you in being in work as an important part of your care and treatment.  Your GP can help you to look at your work and to plan any changes that might be helpful.

Rethink Mental Illness

Rethink Mental Illness has useful information on:

• Discrimination and mental illness - Equality Act 2010 – Employment 
  (questions that an employer can ask you before and after they offer you a job)
• Money issues, benefits & employment

WorkSmart
Advice about occupational health from WorkSmart which is provided by the Trades Union Congress (TUC).

Mental health services and teams in the community 
Our mental health factsheet.

Department for Work and Pensions – Sick note to Fit Note 
From the 6 April 2010 the sick note was replaced by the fit note. This section of the DWP website includes guides for employees, employers and health professionals on the new system.  

Information on Taking Sick Leave

GPs now give a 'may be fit for work' statement if they think that someone’s health condition may allow them to work - as long as they are provided with the right support.

As of April 2010, the sick note was replaced by the fit note (a statement which identifies the type of work than can be carried out with appropriate support).  This signalled a shift in emphasis from how long an employee cannot be or must not be at work to providing more useful information on how a person’s condition affects what they do and how they might be able to return to work.  GPs now give a 'may be fit for work' statement if they think that someone’s health condition may allow them to work - as long as they are provided with the right support.  This support could be a phased or graduated return to work as well as the ‘reasonable adjustments’.

The 6th National General Practitioner Worklife Survey found that almost 90% of respondents felt they had a proactive role to play in helping patients to stay in or return to work and two thirds agreed they had a responsibility to society to facilitate a return to work.   The survey found that the fit note helped GPs to improve the quality of discussion with their patients about returning to work and had helped patients make a phased return to work.

GPs can help their patient’s to play an active role in this process by ensuring that they discuss the occupational health provision (if any) in the workplace and the level and quality of support that is actually in place at work and outside.  It might be worth asking your patient and the employer about the policies and practices of the organisation as well as the level of expertise and training of the line managers as appropriate.

Recent evidence suggests that maybe fit for work box on the Fit Note is typically not completed and that maybe fit for work is less frequently completed in people with mental disorders.   The DWP is currently reviewing the Fit Note.

Developing good policies and practices to support your employees to remain productive at work.  A key shift in the mindset that the fit note brings is that sickness absence is in effect an intervention; it needs to be applied carefully, reviewed regularly and be a part of a broader treatment plan.  Like any intervention, it is not a ‘cost free’ option; it may have side effects which are detrimental to the employee.

• Department for Work and Pensions – Sick note to Fit Note
  From the 6 April 2010 the sick note was replaced by the fit note.  This section of the DWP website includes a guide for employers, employees and health professionals on the new system.

• Information specifically for doctors and other health professionals
• Statement of Fitness for Work
  The Med 3 and Med 5 medical statements were replaced with the Statement of Fitness for Work. This page sets out the scope of the changes and what has stayed the same as well as how the new system is of benefit to doctors.  This page contains links to practical tools such as desk aids, the guides on the statement of fitness for work for GPs, hospital doctors and occupational health professionals as well as guides to completing medical (factual) report for the DWP and the Health and Work Handbook.

• Statement of Fitness for Work: A Guide for General Practitioners
• Statement of Fitness for Work: A guide for hospital doctors
• Statement of Fitness for Work: A guide for Occupational Health professionals

• General Practitioners’ attitudes towards patients’ health and work (PDF)
  This is a summary of the research findings from the 6th National General Practitioner Worklife Survey which asked a sample of GPs in England, Scotland and Wales about the role of GPs in patients’ health, work and well-being.  The summary also draws out similarities and differences in the views of GPs in England and Wales compared with Scotland.

Developing good policies and practices to support your employees to remain productive at work.

The Health and Safety Executive recommend that organisations develop a mental health policy which is integral to the health and safety at work policy. In this way you show that you recognise and accept that mental health is an important issue and it emphasises your commitment to promoting the mental health of your workforce.

There are a number of organisations which can help you to develop good policies and embed good practice in your workplace.  Developing and implementing these policies will vary according to the size and resources available to you, but given the importance of mental health you could ask ‘Can you afford not to invest in taking a proactive approach?’.

• ACAS (Advisory, Conciliation and Arbitration Service) 
  Provides advice and guidance on a range of workplace issues.  In addition to written resources, ACAS provides consultancy services which aim to help you understand what needs to be done to address a range of issues related to health and wellbeing and then work with you to develop practical solutions. There is a work programme which is specifically for small businesses as well as resources for new employers. Many of ACAS’s publications include sample policies.
• Managing attendance and employee turnover
  This booklet includes a sample managing absence policy.
• Work-related stress: What the law says
  This guide summarises the legal duties that employers have to reduce, and where possible prevent, work-related stress impacting on the health of their employees. It has been produced by the HSE, ACAS, CIPD and Health, Work and Well-being.
  
• Stress and mental health at work, 2010
  Chartered Institute of Personnel Development (CIPD)
  
• Realising ambitions: Better employment support for people with a mental health condition - Rachel Perkins, Paul Farmer and Paul Litchfield
  Department for Work and Pensions, December 2009
  This review was commissioned by the Secretary of State for Work and Pensions to look at mental health and employment and to identify how Government could help people with mental health conditions fulfil their employment ambitions. Appendix 5 summarises an example of good practice from British Telecom (BT). BT has a mental health framework which underpins one of five key themes in its ‘people strategy’.  

 Useful Check Lists for Organisations

• Checklist 1 (PDF) 
• Checklist 2  (PDF)

Try to ensure that any clinical interventions support a return to work.

Many people with mental ill-health can, and do, continue to work successfully.  In fact, working can be part of the recovery process and in some people it can help prevent a mental health condition from getting worse. But, most people will need some type of support to stay in work and to continue to function well at work.

Clinicians play an important role in changing how patients and their employers think about the relationship between recovery from mental ill-health and starting or returning to work.  The message for employers and patients is different from returning to work after a surgical procedure for example, where guidance quoted for returning to physical tasks may be six weeks to three months for most people depending on the nature of the work.  It is difficult to give such precise predictions for many mental health conditions, but we do know that the longer a person is off work the less likely they are to return.

For people with mental health problems it is important to begin preparations to return to work early in the treatment process.  Treatment and return to work efforts should be done in parallel and not sequentially.  It is important therefore to identify what type of tasks your patient can do and how work patterns can be changed to accommodate this.

It makes good business sense for employers to ensure that they implement policies to support people with mental health conditions to work appropriately.  A healthy workplace protects and increases the productivity of employees by reducing staff absence as well as staff presenteeism where staff turn up to work but perform below their best.

Business case for supporting employees

Whether you work in primary care settings, occupational health or in secondary care you have a key role to play in ensuring that the right adjustments are in place for people with a mental health condition to participate in work.  The first part of this support is the place that getting into or returning to work has in your patient’s care plan.  This section also includes information on how long people with mental health problems may be off work.

• Centre for Mental Health has undertaken a number of projects on Recovery which aims to change the way in which mental health services and practice can be changed to help  people recover their lives. The project has produced 10 top tips which are steps that each professional can take to move towards recovery-oriented practice.
• The Implementing Recovery Organisational Change (ImROC) project carried out with the NHS confederation is concerned with the redesign of mental health services.
• The Centre for Mental Health has also produced research identifying the benefits of work on mental and physical health and well being as well as effective interventions to place and support people with established mental health problems in the workplace.
• Rethink Mental Illness has resources on recovery, including a guide for mental health professionals on supporting recovery, reflections and testimonies from mental health service users on their experiences of recovery.
• Mental Health Foundation is a leading mental health research, policy and service improvement charity.
• Research into Recovery and Wellbeing contains information about the work of the Recovery Research Team at the Institute of Mental Health, University of Nottingham.

"The Health and Wellbeing of our employees is critical to the success of our business.” Andrew Main, CEO, Aramark. Quoted on Business in the Community health and wellbeing programme.

Poor mental health is very common. At any one time, one in three of the working-age population may be experiencing some kind of distress or mental health condition such as depression or anxiety.

Research by the Centre for Mental Health in 2007, estimated that the cost of mental health problems to business was over £1,000 per employee per year. This took into account lost working days through sickness absence, reduced productivity by employees underperforming at work (also known as ‘presenteeism’) and the cost of replacing staff who leave their jobs due to mental ill-health.

The cost to the wider economy is even greater since mental ill-health is now the most common reason for claiming health-related benefits and 86 per cent remain on the benefits for more than three months (compared to 76 per cent for all other claimants).  In addition, there is the cost of lost production and the cost of treatment and care which could be as high as £30-40 billion per year.

Even though these figures are bleak and should be of concern in the current economic climate, most senior managers underestimate the effect of mental ill health in their workplace.

It follows then, that if senior management do not think that mental ill health is an issue, then they are probably also failing to recognise that there are key steps they can take to support and promote good mental health and wellbeing in the workplace.

"All organizations say routinely 'People are our greatest asset'.  Yet few practise what they preach, let alone truly believe it." (Peter Drucker 1995 p77, Drucker P.F. (1995) Managing in a Time of Great Change, Butterworth-Heinemann,) 

• Mental Health at Work: Developing the business case - Centre for Mental Health, 2007
  This paper examines the importance to employers of mental health problems in the workforce.  It draws on UK and international evidence to quantify the costs of mental ill health at work.  It concludes that it makes good business sense to develop good policies and practice to improve the management of mental health in the workplace.

• Working our way to better mental health: a framework for action - Department for Work and Pensions, 2009
  This cross government strategy is built on the conclusion that there is a positive link between employment and mental health.  It draws on the work of Dame Carol Black, National Director for Health and Work, as well as others.

• Realising ambitions: Better employment support for people with a mental health condition - Rachel Perkins, Paul Farmer and Paul Litchfield Department for Work and Pensions, December 2009
  This review was commissioned by the Secretary of State for Work and Pensions to look at mental health and employment and to identify how Government could help people with mental health conditions fulfil their employment ambitions.  Appendix 4 summarises the business case for employment and people with a mental health condition.  

• Building the case for wellness - Pricewaterhouse Coopers LLP, 2008
  This report was commissioned by Government Health Work Wellbeing Executive to carry out research into the business case for workplace wellness programmes in the UK.  The report’s findings are based on a mixture of systematic literature reviews, case studies and follow up interviews.