Psychological Wellbeing and Work

Key Messages

We know that being in work is good for wellbeing and that mental health problems are an increasing issue for the nation and so the Minister for Welfare Reform and the Minister for Care and Support jointly sought to expand the evidence base on common mental health problems.

A number of Government programmes assess and support those with mental health difficulties to work, but it is internationally recognised that the evidence base for successful interventions is limited.

The Contestable Policy Fund gives ministers alternative avenues to explore new thinking and strategies that offer cross-Government benefits. This study was commissioned through this route; these are our key findings:

1. Common mental health problems are different forms of depression or anxiety disorder. They are common among the working-age population and their costs to Government, employers and individuals are considerable.
2. This study investigates how the employment outcomes of people with common mental health problems can be improved and what policies and interventions could help them maintain or gain work.
3. A range of public services are provided for people with mental health problems that could potentially support participation in employment but there are significant challenges with provision for this purpose. The study found that:
   • The assessment of employment and health needs of people with mental health problems is difficult and there are low rates of diagnosis or referral to specialist health and employment support;
   • The services often work in isolation and tackle either the mental health problem or the employment need discretely; addressing both is important as there is no systematic evidence that better health treatment alone will deliver employment outcomes;
   • Service provision is often delayed and both health and employment problems can worsen as a result, whereas early access is important to prevent people from falling out of work or bringing them back into work;
   • Although there is some evidence for what works to help employees retain work when mental health problems arise, evidence of what works for people in the benefit system is limited;
   • The interaction between mental health and employment is complex and unlikely to lend itself to a “one size fits all” solution.
4. A longlist of policy options was generated for the Government to consider. They include workplace interventions, influencing the behaviour of key gatekeepers, improving assessments of employment and wellbeing needs of people with common mental health problems, building up employment advice in current programmes, and more.
5. Four shortlisted options propose models of service delivery that:
   • Provide earlier access to specialist services;
   • Address both employment and mental health needs; and
   • Introduce more integration between current services or propose new or innovative applications of existing evidence-based models.

   Option 1: Embed vocational support based on the Individual Placement and Support (IPS) model in primary care settings. The key principles of IPS are specified and the model has been tested in secondary care settings for people with severe mental illness. This intervention would be accessed through services offering psychological therapy or even through GP practices.

   Option 2: Use group work in employment services to build self-efficacy and resilience to setbacks that benefit claimants face when job seeking. This intervention would be based on the JOBS II programme that has been tested in several countries but not yet in the UK. It would be accessed through Jobcentre Plus but delivered in neutral settings.

   Option 3: Provide access to online mental health and work assessment and support. This intervention would build on models of online mental health assessment and Cognitive Behavioural Therapy (that have been tested). It would include a vocational element, which would have to be developed, and it could be open to the general population.

   Option 4: Jobcentre Plus commissions third parties to provide a telephone-based specialist psychological and employment-related support. Telephone based services offered through this intervention would be very similar to the support provided by Employee Assistance Programmes and models designed for the Work Programme. It would be offered accessed through Jobcentre Plus.

6. The study concludes that these policy options are complementary—they serve slightly different objectives and client groups. They imply different models of integration, commissioning and funding. They have different estimated costs per participant but for most the benefits to Government are estimated to exceed the costs, providing a case for investment. The effectiveness of each option should be tested to build an evidence base in this area.

Executive Summary

This study has been developed to support policy development and has been funded by the Department of Health, the Department of Work and Pensions and the Cabinet Office Contestable Policy Fund. It aims to examine the existing evidence on mental health interventions and propose new approaches to develop the evidence base for future policy development. In commissioning this, Ministers sought further understanding of how employment outcomes of people with common mental health problems such as anxiety and depression can be improved. This study suggests and develops a range of approaches to improve the alignment of mental health and employment services for people with common mental health problems. The intention is to contribute to building a stronger evidence base and improving service delivery in this area, through the piloting of one or some of these approaches by the Government.

Mental health and behavioural disorders are common. At any point, up to 18 per cent of the working age population has a mental health problem (McManus et al., 2010). More pressing, the prevalence of mental health problems among sickness benefit claimants is increasing with over 40 per cent of sickness claims recording a mental or behavioural disorder as a primary condition.* The costs to the Government and employers of sickness benefits and sickness absence respectively are considerable. Moreover, more effective treatment and employment advice may reduce healthcare utilisation and improve the general health and wellbeing of the population.

A range of government services are already involved in mental health and employment. These include employment services and the benefit system (i.e. Jobcentre Plus), the Work Programme and its providers, health services and in particular general practitioners (GPs) and the Improving Access to Psychological Therapies (IAPT) service (in England) and occupational programmes such as the Fit for Work Service pilots (now concluded) and the English Occupational Health Advice Services aimed at employers among others.

There remain significant challenges in current service provision. It has already been recognised that multiple access points and separate services add to the challenge of effective delivery. Our consultations for this study revealed that service provision is often delayed and protracted and the problem can worsen as a result. In line with worldwide trends, the UK's assessment of the employment and health needs of people with common mental health problems by service providers is often poor, with relatively low rates of diagnosis and referral to specialist services (see, eg, Gask et al., 2009). Even with the introduction of the IAPT service, expert interviewees indicated that there remain challenges around access to services for people with common mental health problems and significant variances in access times between locations. Finally, the employment outcomes for this group can be disappointing, with relatively few placed into employment compared to other client groups.

As part of this study, we reviewed the evidence of interventions that work for employment and wellbeing in this area. The conclusion of this review is that the evidence base is limited and there is no systematic evidence that better health treatment alone will deliver employment outcomes. We undertook a range of consultations with: researchers whose areas of interest include psychology, mental health and wellbeing, occupational health, health at work, and reemployment; representatives of healthcare services and mental health services in England, Scotland and Wales; and representatives of the DWP and Work Programme providers with responsibilities for employment support. The aim of these consultations was to gauge what stakeholders thought would be effective in improving employment outcomes for people with common mental health problems.

On the basis of the evidence review and consultations, we produced a longlist of policy options for the Government to consider. For each of the policy options we, together with our project partners, scored the policy options on how acceptable they are likely to be to stakeholders, how feasible they are to implement, and how suitable they are in terms of effectiveness and efficiency. We included over 30 policy options covering a range of different areas including workplace interventions, influencing the behaviour of service gatekeepers, improving employment and wellbeing assessments of people with mental health problems in the benefit system, building capacity in IAPT for employment advice and innovative interventions.

We tested a number of these options in workshops and meetings. In arriving at the shortlist of four options, we looked in particular at new evidence-based models of service delivery that combine addressing employment needs and mental health treatment, more integration between existing mental health treatment and employment services, new applications of existing evidence-based models in this area, or indeed a combination of all three. Furthermore, we looked at options that provided earlier access to specialist services than is the case currently. Finally, we selected options which could be capable of being tested, given the need to build an evidence base in this area.

We provide business cases for each option, outlining the proposition and the benefit-cost ratio. Our estimates are conservative and only include monetisable benefits. It is envisaged that there will be wider benefits in terms of improvements in self-efficacy, wellbeing and job readiness that we could not quantify. In all business cases, we see an employment outcome as a person moving from sickness or unemployment benefits into employment for a period of at least six months.

The four policy options combine different approaches: intensive individual case management; group support; online; and telephone-based intervention. They are:

1. Embed vocational support based on the Individual Placement and Support (IPS) model in IAPT or other suitable psychological therapy services.

IPS is a fidelity/specified model and has been tested in secondary care settings for people with severe mental illness. IPS would be offered through IAPT (as currently is the case in some locations) and referrals to the IPS service would be made by IAPT therapists. A greater group of individuals with common mental health problems would be able to access to evidence-based support that addresses both their mental health problem and supports them into employment. This option would also place more employment advisers (EAs) in primary care, and increase the number of EAs overall.

On the basis of available evidence, we estimate a benefit-cost ratio of 1.41. This means that for each £1 spent to achieve an employment outcome, the Government would save about £1.41. This option has a relatively high cost per participant (about £750) and appears particularly effective in terms of achieving an employment outcome compared to the other options proposed.

2. Use group work in employment services to build self-efficacy and resilience to setbacks that benefit claimants face when job seeking.

This intervention would be based on the JOBS II model (also known as the 'Winning New Jobs' programme). The focus of JOBS II is to build resilience and inoculate the participant against setbacks in the job searching process. The approach has a supporting evidence base as to its effectiveness. The intervention could be offered through Jobcentres, whose advisers could assess participant suitability using an employment strengths and needs assessment tool or, if necessary, other agreed criteria. Other referral paths could be considered such as IAPT and the Work Programme. The intervention would target the Jobseeker's Allowance (JSA) group or the Employment and Support Allowance (ESA) group before they enter the Work Programme. The programme will need to be modified for the ESA group.

JOBS II costs around £875 per participant. The annual net benefit to the Government would be about £280 per employment outcome with an estimated benefit-cost ratio of 1.07. This means that for each £1 spent to achieve an employment outcome, the Government would save £1.07. This policy option has the highest estimated cost per participant of all options. It appears reasonably effective in terms of achieving employment outcomes compared to the other policy options proposed (though less effective than the estimated effectiveness of Option 1).

3. Provide access to online mental health and work assessments and support.

This option would build on eHealth models of online mental health assessment and Cognitive Behavioural Therapy (CBT) (which have been tested) with a vocational element, which would need to be developed. The service could potentially be opened up to the general population (including the in-work group). People with common mental health problems often find it difficult to actively seek and obtain support. Providing online assessments and interventions will enable greater access to specialist services which have an inbuilt vocational element. This in turn could lead to better health and employment outcomes for these individuals.

Careful consideration would need to be given to where the platform would be hosted and to its functionality. It could be hosted in the NHS. The platform could combine assessment of common mental health problems with signposting and potentially treatment (such as Computerised CBT). There is very little information on likely costs of the intervention. We estimate the cost between £200 and £400 per participant including set-up and licensing fees, though this per participant ratio is likely to fall as scale is increased. There are challenges with measuring employment impacts.

This intervention is the least costly per participant, and is less effective in achieving employment outcomes compared to the other options.

4. Jobcentre Plus Districts procure third party telephone-based psychological and employment-related support.

Telephone-based services offered through this model would be similar to Employee Assistance Programmes and interventions designed for specialist service provision in the Work Programme. In this case, the intervention would be used for the JSA group or ESA group before they enter the Work Programme. Jobcentres would assess claimants using an assessment tool and refer them to the service.

We estimate a benefit-cost ratio of 1.12. This means that for each £1 spent to achieve an employment outcome, the Government would save £1.12. Compared to other options proposed, this option has a low cost per participant (about £ 250), is not as effective in terms of achieving employment outcomes, but can potentially reach a good number of people with common mental health problems.

Improving the employment outcomes of those with common mental problems is a complex issue. There is no single 'one size fits all' solution. It is likely to need a variety of interventions. The policy options proposed are complementary. Where we have data, the benefits to the Government are estimated to exceed the costs. They have slightly different aims and client groups. They offer different approaches, some more intensive than others. They have different estimated costs per participant and levels of effectiveness. They imply different models of integration, commissioning and funding. The aim should be to test of the effectiveness of each.

References

Gask L., Lester H., Kendrick T., and Peveler R., “Primary Care Mental Health,” RCPsych, 2009.

McManus S, Meltzer H, and Campion J., “Cigarette smoking and mental health in England. Data from the Adult Psychiatric Morbidity Survey,” London: National Centre for Social Research, 2010. As of December 2013: http://www.natcen.ac.uk/study/cigarettesmoking—mental-health

Note

* Own calculations based on 5% sample of administrative data and the Work and Pensions Longitudinal Study, available from the DWP tabulation tool: http://83.244.183.180/5pc/tabtool.html. IB, SDA and ESA claimants are included.

The research described in this article was conducted by RAND Europe.