Report 48: Mental health, employment and the social care workforce

What helps people with mental health problems gain and retain employment?

[There is a] need for management priorities that value worker wellbeing with a balance between productivity and a healthy work climate (74).

NICE commissioned an evidence review to find out whether healthy and productive working conditions promote mental wellbeing among employees (73). This review informed NICE guidance on mental health and work (36).  The Health and Safety Executive also produce standards to help management promote healthy workplaces (62) (see Law, policy and guidance).
 
There are a number of programmes and interventions designed help people of working age to gain and retain competitive employment that utilises their skills and knowledge, regardless of mental health problems.  These types of services can work equally well for people from ethnic minority communities, as long as employment staff are skilled and confident in addressing issues associated with racism (75).

• Reasonable adjustmentOpen

  The public sector duty of the Equality Act 2010 provides legal safeguards for employees with mental health problems. Employers must demonstrate that they have introduced adjustments that allow disabled employees to do their job (76).

  Work resumption and a change in work tasks, as well as other adaptations, such as flexible work times, working from home, gradual return to work after ill health or part-time working or job shares, have been shown as effective in enabling employees with mental health problems to remain in work (77), (78), (18).

   Each person’s skills and the challenges they might face at work will differ, so any adjustments should fit the individual’s needs, not be standardised.

  The mental health charity Mind has produced joint guidance with the Federation of Small Businesses on reasonable adjustments for employees with mental health problems (79).

  Actions include good communication - especially with staff working in isolation - informal mentoring for new staff and involving employees, wherever possible, in planning their own workload and setting reasonable agreed deadlines. These guidelines are particularly relevant to the small businesses that comprise the majority of social care workplaces (4).

• Interventions to support mental health at workOpen

  Preventative interventions aim to create workplace systems, structures and processes that can support employees’ mental health regardless of any specific issues they might bring with them into the workplace.

  A common feature of many of the preventive interventions is a cognitive behavioural therapy (CBT) approach, with a focus on return to work rather than merely trying to improve mental health problems.

  Talking therapies such as CBT have been widely recognised as helpful treatments for mild to moderate mental health problems such as depression or anxiety (36), (80) Government commitment to extending the range of and access to talking therapies should benefit those with mental health problems who want to work  (81).

• Case studiesOpen

  The health and wellbeing of NHS staff was reviewed as part of the Health, Work and Wellbeing Programme (49).

  The review encourages NHS organisations to provide staff health and well-being services centred on prevention, fully aligned with wider public health policies and initiatives. It states that these services should be seen as a real and tangible benefit of working in the NHS, and managers should be given the skills and tools to support staff with mental health problems. 

  The report includes ac case study of an initiative to promote health and wellbeing among staff at Cambridge University Hospitals NHS Foundation Trust through a varied programme of physical and non-physical activities, social events and clubs:

  ‘Staff enjoy physical health activities, including: a staff inter-departmental football tournament, supported by Cambridge United Football Club; Walk to Work, sponsored by Stagecoach and Cambridgeshire County Council; free stretch and Pilates classes for staff alongside a campaign to increase staff activity and exercise levels; and monthly de-stress days where, in partnership with Cambridge Regional College, staff can receive either a 20-minute manicure and hand massage or a relaxing back massage’  p.9

  The Increasing Access to Psychological Therapies (IAPT) programme offers treatment for depression and anxiety disorders, combined where appropriate with medication.

  The economic case has demonstrated that talking therapies could help people come off sick pay and benefits and stay in or return to work. 
  An action plan on IAPT for the current parliament reiterates a key goal of improving social and economic participation, including employment, for working-age people (81).

• Individual placement and support (IPS) for serious mental health problemsOpen

  There is now strong evidence that IPS models (which place people in jobs and then train and support them while working) have better success rates than more traditional approaches such as vocational training and sheltered work, in getting people with severe mental health problems into paid jobs (82), (83), (84), (85), (86).

  Key aspects of this Individual Placement and Support (IPS) approach include rapid job search based on individual preference, and ongoing support by an employment adviser, working within mental health services, to individuals and employers. Complete recovery from mental health problems is not a prerequisite as long as a job seeker wants to work and is confident they can do so.

• Early intervention initiativesOpen

  There are a number of studies that look at early intervention. Researchers looked at how to identify employees with mental health problems so that suitable support or signposting to appropriate treatment could begin as soon as practicable.

• Case studiesOpen

  Postal intervention:

  Researchers (87) looked at the results of sending letters to people within two weeks of the start of sickness absence. Participants in the trial were sent a letter offering return to work with adjusted job on sickness benefits; a questionnaire about sick leave; and a consent form.

  This randomised controlled trial (RCT) included a one-year follow-up, and showed a significant reduction in length of sick leave.
  
  Critical success factors included early intervention, within one month of the start of sick leave, and also a focus on return to work regardless of mental health problems.

  Telephone screening:

  A randomised controlled trial (RCT) of a telephone screening, outreach and care management intervention in the United States for depressed workers showed a positive impact on clinical and work productivity outcomes. Employees of a large company were surveyed and those who had symptoms of depression were invited to join the study, then randomly assigned to a telephone intervention group or a non intervention group.

  The intervention group were telephoned by qualified mental health clinicians who assessed their needs and recommended suitable treatment (or offered to talk to them on the phone if treatment was refused). Depression severity and work performance were the outcomes measured.
  At the end of the trial, the intervention group had significantly lower self-reported depression scores, higher job retention and more hours worked (88)

• Getting back to work initiativesOpen

  CBT focused on Return to Work
  A randomised controlled trial (RCT) in the Netherlands assessed a brief intervention, that started 2-3 weeks after start of sick leave and was based on cognitive behavioural therapy (CBT) principles combined with graded activity and a phased return to work.

  Those who received the intervention returned to either full or part-time work within a shorter time than those in the comparison treatment group or the control group (89).

  Return to Work Co-Ordinators
  Intervention by Return to Work co-ordinators study were compared with care as usual by occupational physicians in a Netherlands study. The Return to Work coordinators offered support to employees who had been off work for 2-8 weeks with distress. They acted as brokers between employees and their workplaces, holding separate one-to-one interviews with the employee and employer, and then arranging a joint meeting for all parties (90).

  The intervention had a positive effect for those employees who intended to return to work at baseline, despite any psychological symptoms, but was less effective for those employees who did not intend to return to work at baseline. Cost effectiveness similarly showed a benefit (cost savings) for the subgroup of employees who intended to return to work at baseline, over and above care as usual, though no overall cost savings for the whole group (91).

  The Retain/Regain Service
  Intervention by employment advisers (EAs) was researched in Cambridgeshire, England and found to improve employment outcomes. The EAs worked in three localities alongside or within various GP surgeries. GPs could refer to the EAs anyone with mental health problems whether in work or off sick (Retain clients) or unemployed due to mental health problems (Regain clients). Tailored brief interventions were offered either face-to-face or via telephone or email contact. They included careers guidance and skills to negotiate with employers for the Retain clients; or practical assistance in job search, CV writing and interview technique; careers guidance; and assertiveness training for the Regain group (42).

• Assessing what worksOpen

  The intervention studies on mental health and employment cover a range of different approaches, delivered by varying types of practitioners, to participants with a wide spectrum of mental health problems.

  Some of the narrative and qualitative studies describing personal experience of stigma and discrimination included include employees from social care, but none of the intervention studies were conducted in social care, even though their findings are relevant for that sector.

  Some important studies, such as those on line manager training, employment advisers, OH audit of NICE guidance and IPS, have been conducted and implemented in the UK. It would help if the implementation of these studies in social care could be evaluated, fill knowledge gaps about how best to recruit and retain employees with mental health problems in social care.

  Strengths
  The interventions reviewed in this briefing focus on work outcomes, not just clinical improvement. In other words they supported the principle that people with mental health problems do not have to be completely recovered to be in or to return to work.

  Several of the interventions reported in this review have been undertaken in the UK. They offer the possibility of applying these research findings to practice in social care workplaces.

  Weaknesses
  It is hard to compare data from the various studies as the participants are from a wide range of groups and backgrounds. As a rule participant sample sizes are small and follow-up on interventions’ effects are usually of short duration, and may have a high drop-out rate, resulting in even smaller sample sizes on which to base conclusions.

  None of the studies showed evidence of the involvement of people with mental health problems in their design and delivery. People with mental health problems were the subject of the research, not the authors, even though their needs and experiences are the pivot around which the interventions revolve.

• Economic evaluation of what works Open

  Only one of the intervention studies in this review included an economic evaluation. It showed that there was an economic benefit, over and above care as usual, for those employees who benefited from the intervention (91).
  An assessment of the economic case for mental health promotion and mental illness prevention (92), gives two examples of the potential cost effectiveness of workplace interventions for mental health problems.  Their first example refers to the telephone intervention included in this review (88).

  The authors conclude that this type of intervention would be cost-saving from a business and health perspective, as long as all costs are borne by business. Intervention costs are more than outweighed by gains to business because presenteeism and absenteeism both reduce. Public sector employers could benefit from investing in such a universal screening intervention (92).

  Their second example is a model intervention on promoting mental wellbeing at work, mirroring the recommendations in the NICE guidance (36). The authors argue that workplace well-being interventions can be significantly cost-saving in the short term. The public sector could benefit as an employer from improved investment in workplace well-being programmes. Smaller companies and organisations may need public support to implement such schemes (92).