Published: 15/12/2005 Volume 115 No. 5986 Page 24 25 26

As one of society's most marginalised groups, most mental health service users struggle to return to employment. But a new series of initiatives is helping trusts lead by example. Emma Forrest reports

While many of us have been basking in what chancellor Gordon Brown likes to boast is Britain's longest period of sustained economic growth - and the falling levels of unemployment that go with it - those with mental health problems have been unable to share in the 'good times'.

There are now over 1 million people with mental health problems claiming incapacity benefit - more than the 890,000 claiming unemployment payments. Put starkly, once you have been signed off work for mental health problems, it is unlikely you will ever go back. The mentally ill are three times more likely to be unemployed than other disabled people.

Bob Grove, director of employment support at the Sainsbury Centre for Mental Health, says that although 90 per cent of new incapacity benefit claimants expect to work again, only around 35 per cent do. 'If you do not go back to work in the first year, you do not go back at all.'

Mr Grove says the Department for Work and Pensions pilot scheme Pathways to Work, which works with those who have been claiming incapacity benefit for up to two years, has proved successful with mental health service users, who make up around half of the pilot's candidates.

The scheme includes a compulsory interview to access suitability for work. Claimants receive tailored advice on how to get a job from a specialist adviser, and NHS rehabilitation support to help them manage their condition.

'We are talking about people who should never have been on benefits, those who have depression and anxiety, but are in a retractable situation. Of the others, a lot have succumbed to depression after being off work for six months with something like a back problem, says Mr Grove.

He says Pathways to Work is not designed to deal with people with severe and enduring mental illness, who will need continued support if and when they go back to work.

'It assumes that once you are back in work you will be OK, ' explains Mr Grove. 'Much greater resources will be needed to work with people with severe mental illness, although it is small in comparison.' Although a number of trusts are putting together effective programmes, Mr Grove fears many mental health trusts are yet to face up to the fact that helping service users get back into work 'is their responsibility'.

This is despite the fact that the national service framework for mental health states that employment needs should be part of a service users' care pathway approach.

With changes to the benefits system widely expected (see box, page 26) there is a growing sense of urgency around helping service users stay in - or find -employment, training or education.

'I have been beating the drum about this for 20 years and there is a definite sense of momentum now, ' says Mr Grove, who is confident that the message is getting through. 'There is research building around the benefits of being in employment, that work can help make you well.' Commissioners need to be convinced of the validity of employment schemes, too. Many are currently funded by European money. Guidelines for commissioners are expected soon.

The period of time service users have been out of work varies. Three to four years is typical, but some may have been jobless for anything up to 15 years, leading to terrible isolation, financial hardship and social exclusion.

The relatively new and rare post of vocational services manager in trusts has been instigated to do something about this.

South West London and St George's Mental Health trust is regarded as the leader in this field.

The trust has had a vocational services manager in post since its clinical director of general adult services, Dr Rachel Perkins, saw similar schemes running successfully in the US in 1995.

The trust tried to lead by example with its user employment programme, and is regarded as a model by many other trusts.

'None of the posts where service users have found jobs have been specially created, they have been employed on the same terms and conditions as everyone else, whereas some trusts create roles, ' says vocational services manager Miles Rinaldi.

For the past four years the scheme has also been looking at employment opportunities in two more of the boroughs in the trust's patch.

'We have implemented the individual placement and support approach, with an employment specialist working with each community-based team [including services such as early outreach], ' says Mr Rinaldi. 'This involves working with employees on an individual basis and going out to see who will recruit someone with a mental health problem. It is about matching the skills and abilities of the client, and the role they want, with opportunities.' 'We are now working with the other boroughs to implement this; it is clearly the most effective approach to getting people back into work.' South Essex Partnership trust has secured EU funding to pay for its first vocational services manager, Jan Hutchinson, appointed earlier this year.

The trust has placed an emphasis on broadening opportunities with local employers for service users. It recently held a breakfast meeting with around 30 local firms, hosted by chief executive Patrick Geoghegan, to advertise its ability to provide a consultancy service for employers wanting support for staff with mental health problems, and to argue that mental health service users are valid potential employees.

Ms Hutchinson says a post such as hers, in the heart of the health system, can make it easier for employees to get information about a service user's condition.

'All employers need is evidence that a condition is being managed and treated, ' says Ms Hutchinson. 'I can put a report together on that in a week, instead of it taking several months because information has to be gleaned by company occupational health from GPs, specialist mental health services and the voluntary sector.' With two employment advisers now in post, the aim is to have one in each of the four primary care trusts covered by South Essex Partnership.

'Advisers can tell colleagues in community teams about how to make employment part of the care package, ' says Ms Hutchinson.

Vocational advisers at West Kent NHS and Social Care trust are 'getting out there and coldcalling employers, saying that they have someone with these skills and abilities and asking if there is something suitable, ' says trust vocational services manager Heather Penn. Her post has only been in place since August and one service user has already found paid employment.

'It is new territory for some employers, but we can give more support than if someone with mental health problems requests a job off their own back after being out of work. Offering the right support makes for a more successful experience. Community mental health teams need to embrace work as being as important for service users as accommodation and benefits, ' says Ms Penn.

At other trusts the emphasis is on finding roles for service users in the trust itself. 'There were pockets of good work going on around the trusts but these needed more consistency and to be more proactive, ' says Lynne Miller, vocational services manager at Central and North West London Mental Health trust.

Ms Miller says that even in a mental health trust there were concerns about what would happen if a service user given a job through the user employment scheme became unwell.

'Clinicians are used to working with people only when they are unwell. But there is evidence that services users take less time off than the general population. We wanted them to realise that experience of mental health problems and services can be an asset; if they have been through the system they can give a different perspective. For some roles it could be an essential requirement, ' she says.

Her trust works with a number of voluntary agencies already working on improving employment opportunities for service users and as referrers into the service.

Ms Miller says this partnership-working means the trust does not seek to find service users work with other local employers to avoid duplication of work by agencies elsewhere.

Instead, work placements in a huge variety of roles, from gardening to occupational therapy, have been found within the trust for service users, after receiving vocational counselling to identify what they want to do. Three employment advisers are also being piloted across the trust.

'The advisers' primary role is to help service users retain their jobs, and find job opportunities for users by working with our partner agencies, ' says Ms Miller.

Although studies have shown that fewer than four out of 10 employers would take on someone with a mental health problem, and one third of people with mental health problems said they had been forced to resign or been dismissed from a job, many managers report that their clients have faced less discrimination than might have been feared.

'There are clearly issues with stigma in the workplace; some people have no experience of mental health and do not know what it could mean; they want to know what the dangers are, can someone be unpredictable?' says Ms Hutchinson. But she adds that employers are generally sympathetic. 'The majority of people do now know someone with some sort of mental health problem and these issues are generally being talked about more.' Ms Miller says that when a service user is found a job or a placement, details of their condition are not revealed; what is important is stressing that support will be available for both employee and employer.

'The amount of information we give depends on what the client is comfortable with, ' she says. .


If users of the Sheffield user employment and support service need convincing that the scheme works, they need look no further than its user volunteer coordinator, Andrew Wright, a former client of the service.

Mr Wright attended one of the service's Back into Training and Employment (BITE) sessions after it was suggested by his key worker and an occupational therapist at the acute day hospital he attended.

A former sales manager, Mr Wright had been out of work for three years: 'I had really been quite successful but had totally lost confidence in myself and it was difficult to start again, ' he says. 'I had previously tried going back to work but had no support and lasted three weeks.' At first, Mr Wright was unsure that BITE was for him. 'I even found getting public transport difficult, but it was made clear that the workshops were about looking at opportunities, not necessarily having to find work.' With encouragement from the service's managers, Mr Wright became more involved in running workshops. He had initially been considering finding manual work, but was encouraged to take on research for the service.

His confidence began to grow, particularly after he became chair of the trust's user and carer forum, a role that involves attending trust board meetings, clinical governance meetings and interview panels.

'I was only doing what I wanted to do, but I still used to go home and think that I would done a rubbish job. My confidence is still quite low but is getting better all the time, ' he says.

Realising he wanted a career in mental health, Mr Wright took on voluntary placements in several areas of the trust, and considered a position in occupational therapy before deciding that he did not want to take on the necessary training. He then saw an advertisement for his current job.

'Sally Bramley [trust clinical lead for vocational rehabilitation] and the trust chief executive both gave me a reference and I had phenomenal levels of support. I still get a lot of support and without it I would not have lasted, ' says Mr Wright. 'I have had practical help too; I have a small office of my own where I can sit and be quiet and get on with my work without being disturbed, as I still find it difficult to acknowledge that I can do a good job.' He works to place service users throughout the trust, achieving around 40 placements in the last two years.

'My job is to find out the clients' interests and thoughts on the future and find opportunities.

Voluntary work gave me experience and a place for me to be myself, so having been through the service gives me a lot extra. I know it worked for me.'


Could service users be forced to go back to work before they are ready? That is the fear of one source close to the Department of Health, who estimates that the green paper on incapacity benefit will now be out in the New Year. It is likely to be highly controversial - with MPs and the public.

The source says that three former Work and Pensions ministers (David Blunkett, Alan Johnson and Alan Smith) have already made it clear that they liked the balanced support offered by Partnership to Work in contrast to any suggestion of coercing people into work.

'It is thought the green paper could include a two-tier benefit that will sort out the employable from the unemployable and make the conditions much more severe, ' he says.

'There are also rumours that it could be time limited. Anything that would limit the amount of time you could spend claiming the benefit would be counterproductive for those working with vulnerable people, as it would affect those who need the ability to move on and off benefits if they become ill again [such as with severe mental illness].

'If mental health service users are forced to move at a pace they are not comfortable with they are just going to get ill again.'

Key points

There are over 1 million people currently claiming incapacity benefit because of mental health problems.

Statistically, those that have been signed off work because of mental health problems are unlikely to return.

South West London and St George's Mental Health trust is working on strategies to employ service users and improve their employment prospects.

For further details and more information on mental health issues, visit www.goodmanagement-hsj. co. uk/mentalhealth