The Government is challenging employers to increase their efforts to get people with common mental health problems back to work. But what support can organisations expect from the new Health and Work Service (HWS)? Sarah Silcox reports.
The Government has thrown down the gauntlet to all those involved in implementing its national mental health strategy, including employers through their wellbeing at work initiatives, to keep their eye on the ball and accelerate the pace of change. A document published in January 2014 recognises that employers have a vital role to play in promoting the psychological health of employees, by helping those with common mental health problems return and stay in work after sickness absence, and in the recruitment of people with ongoing mental health issues.
Why has the pace of change in the mental health field been slower than the Government would wish, and how can employers be persuaded to play their part in promoting the employment of people with mental health problems – particularly during cash-strapped times? Will the new HWS scheduled to be launched in parts of the country later this year speed things up? And what needs to be done to ensure that those absent from work with mental health issues are treated equally to those with physical health problems?
Further and faster change
Two years on from the publication of the Government’s mental health strategy, the lives of many people dealing with mental health problems have not significantly improved. This is the context for Closing the gap, a rallying cry for the health and social care community and employers to go “further and faster” to transform the support and care available.
“Closing the gap” identifies 25 aspects of mental healthcare and support where the Government, working with a range of agencies and organisations, expects to see tangible change in the next couple of years. A section on supporting employers to help people with mental health problems stay or move into work makes the point that “good work” is generally good for people’s health and wellbeing, including those with common mental health problems. It also stresses that return to work can improve psychological health and be part of therapy, as long as it is “suitable”.
Andy Bell, deputy chief executive of the Centre for Mental Health, welcomes the challenge issued in “Closing the gap”: “We need to recognise that this document is not creating new policy, but is designed to add impetus to the Government’s existing mental health strategy.”
He adds that “it would be nice if the extra profile it generates for the issue increases employers’ awareness”, but points out that the document is not designed to cover “everything on everything”.
Common mental health problems remain a significant cause of long-term sickness absence, making the management of employees’ mental health “clearly a big topic” for the Government, according to Dr Sayeed Khan, chief medical adviser at the manufacturers’ organisation EEF.
The Government recognises that helping current and potential workers with mental health issues is a “big challenge”, and that services must work together more effectively. It wants to support employers to promote workplace wellbeing, and recognises that doing so is a “vital element of our overall prevention strategy”.
The “Closing the gap” wake-up call implicitly acknowledges that poor management can contribute to work-related mental ill health, stating that “many employers want to build the managers’ capacity to organise work to enable all staff to contribute and be recognised”. The document adds that NHS England is working with the Department for Work and Pensions (DWP) to identify best practice in the employment of people with mental health issues, such as recruitment and retention, tackling stigma and effective work-based support. It also talks about improving the information available to line managers, particularly on developing their “soft skills”, and recognising signs of stress and mental health problems in teams.
“All the evidence shows that prevention and early intervention is important in supporting employees with mental health problems, and most employers, in our experience, want to help,” Bell says.
Resilience at work is a fashionable topic, and the document picks up on the need to encourage employees to build their ability to “bounce back” as a defence against unmanageable stress.
Khan is cautious about the current vogue for resilience training: “I don’t like the subtle shift towards increasing individuals’ resilience, perhaps at the expense of tackling the organisational causes of stress and pressure. It kind of assumes that people with work-related stress are ‘wimps’ and not able to cope, when most can cope perfectly well if the sources of stress are removed.”
He sees the promotion of wellbeing as a hierarchy, with an organisational approach at the top, the identification of those needing support in the middle and appropriate individual treatment below.
“Only after all this is done should employers be looking at building employees’ resilience – for example, by helping them build stability zones in their private lives, at church, in clubs or through hobbies,” he says.
Why such slow progress?
Employees’ mental ill health is “a massive issue”, according to president of the Society of Occupational Medicine (SOM) Dr Alistair Leckie, and one that “won’t be fixed overnight”. Attitudes from all involved in its management, including employers, will take time to shift. Leckie argues that the term “mental ill health” covers a huge gamut of conditions and that there is never a “one size fits all” solution.
Anna Harrington, an occupational health (OH) nurse focusing on mental health issues, is more forthright: “Provision is dire, absolutely diabolical. I struggle to suggest to employees that they embark on the route of obtaining NHS mental health services because they have to wait so long.”
She argues for closer working between employers and secondary-care professionals at an early stage: “Often, it’s too late to build relationships with treating psychologists at the crisis point – for example, when someone goes off sick.”
On the flip side, she has seen a “real transition” in the attitude and approach of employers in the past few years, many of which are far more open and determined to tackle the issue.
A lack of coordination between different agencies and support services for those with mental health problems is undoubtedly a barrier to progress in the management and treatment of mental ill health (van Stolk et al, 2014). But why is it so difficult to get joined-up working in this area? Bell argues that part of the reason is that joined-up working requires health and social care professionals to work in different ways, and that often funding flows create perverse incentives, pulling different public-sector agencies apart when they should be working together.
“But this is changing – for example, GPs are more aware of the role work plays in mental health. Schemes like Access to Work are very important as they enable people to come back, often with only minor adjustments or with just the support of good management. Work then becomes part of recovery,” he says.
Khan echoes the Centre for Mental Health’s concerns about the need for agencies to work together: “The NHS tends to just deal with medication and the clinical management of people, services that often don’t extend to providing outpatient services when employees return to work. Rehabilitation professionals don’t link with hospitals and all the support and care agencies are offering different types of advice.”
Progress with the mental health strategy has been slower than hoped because mental health is often hidden and invisible. It also exists on a spectrum, according to Andrew Kinder, chief psychologist at provider OH Assist.
“The use of a single label – mental ill health – for this spectrum of conditions confuses people and doesn’t help tackle stigma,” he says, adding that he favours a biopsychosocial model that recognises the role played by other factors in the treatment of mental health, such as the support of family and friends.
How can more employers be persuaded to put resources into managing workplace wellbeing?
According to Bell, this is the “£1,000-per-person question”. He believes the Government, and particularly the NHS, can lead by example and act on the recommendations of the Boorman review (an independent review into the health and wellbeing of NHS staff) to implement top-level initiatives and interventions.
Access to OH support remains a big issue, Leckie says: “Seventy per cent of employees still have no access to OH, and even among the rest fewer than 10% have comprehensive support.”
Advocates need to make the “spend to save” arguments effectively to demonstrate to employers that simple interventions can help keep good people at the organisation, Leckie adds: “We also need to invest in line manager capability – particularly their ability to spot and talk with people who may be beginning to experience mental ill health before they go off sick.”
“Closing the gap” also stresses the need to increase employment opportunities for those with mental health problems, although it is not specific about whether or not it is referring particularly to those with more severe mental health issues.
“We need to talk more about giving work opportunities to this group, who are often denied work through not having the right individual support. There are too many places where there is no individual and placement support service, which is proven to be effective for this group,” Bell says.
Employers need to be flexible in the employment of workers with common mental health problems, according to Khan, but he adds that this can only go so far and only in some occupations: “For example, some workers with common mental health problems will have periods when they might not be able to perform effectively, which can make it difficult for them to be employed in certain occupations.”
On the other hand, he says that people with common mental health problems can be very creative in suggesting solutions to workplace barriers to working with mental ill health, and employers need to tap into this and get them on board: “These employees can be very solution driven when it comes to tackling work-related barriers.”
Health and Work Service challenges
The new HWS is set to be launched in some parts of the country later this year with a national roll-out in 2015, providing employers with advice on work retention when health problems arise. The DWP has announced that the service will focus on mental health and musculoskeletal disorders, and will be available once an employee has been off work sick for four weeks.
The new service will need to be led and influenced by what employees and employers want, rather than what the public-sector agencies responsible for implementing the HWS assume they want, according to our sources.
“The new service needs to be flexible and support both parties equally,” says Bell, adding that it also needs to recognise the link, or co-morbidity, between physical and mental ill health and tackle them both holistically, rather than treat them separately – as so often happens.
The supply of appropriate professionals will be crucial to the success of the new service, according to many commentators.
“[It] will need to be staffed by the right people, who will also need to be accessible,” Khan says. “This is a huge challenge on a national basis when we are struggling with the supply of OH nurses generally. Staffing will determine whether or not the service is fit for purpose; otherwise, it could end up being a barrier, rather than an aid, to rehabilitation if people are waiting too long to be assessed.”
Those employed by the HWS should have experience in the work context, Kinder says: “The professionals working in the new service need to understand the role of commercial and business factors in workplace health, and need to bear these in mind when recommending interventions – the service also needs to extend beyond just assessments to actual interventions.”
Harrington is “worried” that people will only receive an initial contact with the new service, when mental ill health often requires repeated contact. The focus of the service is also likely to be on giving advice, leaving employers to manage cases in the best way they can and in the context of often only limited knowledge and experience of the issues.
How can we ensure that mental health is treated equally to physical conditions in the HWS? Leckie believes a start would be to first identify those needing support. This would require the assessments carried out by the service to focus on the possibility of mental health issues.
“This can be difficult in a phone-based assessment, as it is easy to miss the non-verbal clues of a psychological problem,” he says, adding that the initial assessment by the new service needs to be followed up by the right approach, which may be simple signposting or the full range of clinical therapies.
Department of Health (2014). Closing the gap: priorities for essential change in mental health.
van Stolk C et al (2014). Psychological wellbeing and work: improving service provision and outcomes. Department for Work and Pensions and Department of Health.