the rationale behind the need for an employment strategy

an examination of the main issues for improving employment outcomes

developing a model for delivering effective vocational services

a focus on key concepts to take into account for delivering efficient and effective support

a range of products for delivering vocational services

suggestions for future policy development and taking work forward

It concludes with a detailed examination of the process of effective job search and a case study on integrating vocational rehabilitation into mental health recovery services.

Two versions of the framework document are available on the NSIP website.

For the full version of the framework document please click here.

For a shorter summary version please click here.

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Welfare Reform Green Paper

DWP published a Welfare Reform Green Paper – No one written off, reforming welfare to reward responsibility on 21st July 2008. It is intneded to be a wide ranging consultation on the future of welfare and sets out plans for improving support and work incentives to create a system of additional rights and which rewards responsibility. The majority of people of working age, those capable of work now or at some point in the future, will have to take steps to prepare for or seek work but the aim is to give greater choice and control over the support provided.

Many of the proposals are relevant to people with mental health conditions, and include:

a) Skills

• Basic skills screening for Employment and Support Allowance (ESA) at start of claim, with later mandatory skills health check (when appropriate) are to be tested, then rolled out nationally. DWP is consulting on a requirement to attend mandatory training

b) Conditionality

• The new Work Capability Assessment (replacing the Personal Capability Assessment when ESA for new claimants is introduced in October 2008) will be used to reassess the work capabilities of all existing IB claimants. This reassessment process will take place between 2009 and 2013 and once a person’s work capabilities have been assessed they will become subject to the ESA regime.
• Current plans are to extend a Pathways to Work regime to existing customers under 25. A light touch Pathways regime will also be extended to everyone under 50.
• The Work Capability Assessment (WCA) will be reviewed to take account of adaptation to a health condition or disability and to look at some of the measures used to make assessment of work capabilities.
• From 2010 new ESA claimants will be subject to a mandatory regime (compulsory engagement) for up to two years. From 2010 new ESA claimants, in the work related activity group, will be required to undertake work related activity.
• A Work Focussed Health related Assessment (WFHRA) will follow the WCA. An individual will discuss work options, steps they can take to prepare for work and support needs. It will be used to help develop an action plan. The WFHRA will be repeated during the lifetime of a claim
• The maximum interval between medical assessments will be two years.

c) Support

• In return for increased responsibility to look for work in line with capabilities Government will look to provide personalised support for everyone.
• Access to Work budget to be doubled by 2014 and used to improve the way it is delivered. This will include more flexibility and timely delivery to make it more responsive to fluctuating conditions – including mental health conditions.
• Specialist disability employment programmes to be focused on those furthest from the labour market. New contracts (to be commissioned later this year following response to the earlier consultation on specialist programmes) will ensure provision meets needs of those requiring greater help.

d) Response to Dame Carol Black's report: Working for a healthier tomorrow.

• Although it confirms a response to the report is currently being developed the green paper contains commitments to:
  • Continue to pilot and promote the Business Health Check tool (for measuring and reporting on the benefits of investing in health and well being of staff)
  • Reform the sick note and testing of an electronic note
  • Pilot Fit for Work services in City Strategies areas
  • Encourage adoption of Back to Work action plans
  • Explore effectiveness of Employment Retention Assessments.

e) People with mental health conditions

• The Green paper confirms need to:
  • Improve support for people with mental health conditions
  • Tackle stigma and discrimination
  • Help people manage condition
  • Provide support to managers

• Also confirms that
  • Employment support advisers will be tested as part of the Increasing Access to Psychological Therapies service
  • A national strategy for mental health and employment is being developed

f) Benefits

• With all disabled customers migrating to ESA (and Lone Parents to JSA) looking for Income Support to be abolished leaving two working age benefits; ESA for those with disabilities or health conditions (who meet the assessment criteria) and JSA for all other groups

g) Devolution and individualisation

• Want to increase individual choice. This is being tested in the three Pathways areas where there are two provider to choose from
• Two Jobcentre Plus areas will pilot allowing their advisers more flexibility in the support they provide customers.
• A ‘black box’ approach to be adopted for service providers with freedom in way they deliver programmes. Contracts will specify the outcomes and funding agreements with DWP.
• To test its effectiveness DWP, as part of Flexible New Deal, will pilot a single programme that covers both ESA and JSA customers. There will be a single conditionality regime for both groups.
• Providers will be given a Right to bid. If they have an innovative proposal which they think will improve outcomes there will be a process where their ideas will be considered for potential funding.

The Green Paper contains a number of questions on the full range of proposals and the consultation period runs until 22 October 2008. For information on the Green Paper and to obtain copies please click here

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National Strategy for Mental Health and Work

The Secretaries of States for Work and Pensions and Health have announced the intention to develop a National Strategy for Mental Health and Work. It aims to ensure a better coordinated response across government to the challenges faced by people of working age with mental health conditions and to improve their employment chances.

The Strategy will look at issues, like stigma and discrimination, which often prevent people with mental health problems from finding or keeping employment and will be overseen by a high-level group from business, the medical profession, academia, the third sector and stakeholder groups. It will be chaired by the National Director for Health and Work, Dame Carol Black.

The announcement, on 27th November 2007, also contained a number of measures to ensure that mental health and employment support is delivered in a more holistic way and provides more advice and support to healthcare professionals and employers. This includes:

• Wherever possible the roll out of Pathways to Work and Improving Access to Psychological Therapies programmes will be linked up. This is to allow customers to take up a fuller range of support available and obtain better back to work and healthcare support as part of a seamless package.
• Establish a mental health forum to bring together all those involved in delivering Pathways to Work support, to share evidence and experiences in relation to support for people with mental health conditions.
• Pilot an advice and support service for employers, especially smaller businesses, to help them to manage and support people with mental health conditions to remain in or return to work. Government will explore the possibility of using the service to provide support and advice for GPs as part of efforts to better align employment and healthcare services.
• Treble the capacity of the Pathways Advisory Services pilots. These are testing the effectiveness of placing Jobcentre Plus advisers in GP surgeries.
• Roll-out of educational programme for GPs on health and work issues, focusing specifically on mental health and employment.
• Explore ways to improve communications between GPs and employers to improve the likelihood of people working. This aims to ensure that the process for GPs to issue medical certificates will allow them to be more positive moving to a well note instead of a sick note. This will make it easier for GPs to provide more helpful advice to patients and their employers about their fitness for work, especially for those with mental health conditions.

In a speech at the British Health foundation on 20th February Alan Johnson spoke more about the plans to replace a sick note culture with a well note culture. For an article on the announcement please click here

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Vocational Services Guidance

Publication of Vocational Services for people with severe mental health problems: Commissioning guidance, which provides a framework to commission evidence-based vocational services and the tools to monitor the effectiveness of such services.

To download the guidance click here

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Dame Carol Black maps the path to a healthier future

Following a wide-ranging research and consultation exercise alongside a call for evidence Dame Carol Black, the National Director for Health and Work, published (17 March 2008) the first ever review into the health of the working age population. In her report Working for a Healthier Tomorrow Dame Carol suggests that creating a healthier Britain requires radical changes to work-related health services - if appropriate support is to be made available for all.

The review found that ill health was costing the country £100 billion a year and the human cost to families was immeasurable. Dame Carol said the key challenges facing the country include insufficient access to good work-related health support in the early stages of sickness, including mental health conditions. In addition provision is currently disproportionately concentrated among a few large employers, leaving the vast majority of small employers without support. A range of other issues identifed included the current sick note process which concentrates on what people can't do, instead of what they can.

 Some interesting findings relating to mental health (MH) include:

• An acknowledgement that Pathways to Work has had a more limited effect on people with MH problems this comes from the College of Psychiatrists report (see below). It suggests that Pathways should explore how to better target and meet the needs of the MH group.
• Recognition that more needs to be done to help the MH group if Government is to meet the 1million off IB target and 80% employment aspiration.
• The Mental health and employment strategy, currently being developed, will need to urgently look at how to best meet the needs of MH people who are workless. This should include review of current policies on the MH group.
• Specialist MH provision should be available as part of employment programmes for all working age benefit groups
• A multidisciplinary Fit for Work work related health service should be available in early sickness absence. It should be available for all people needing help and open to those on out of work benefits
• The health professionals consensus statement includes the need to tackle stigma and discrimination - especially around MH.
• Highlights the importance of early intervention using a holistic approach based on bio-psycho-social model.
• More evidence is needed on impact of early intervention on MH group

The recommendations contained in the report focus on proposals to keep people healthy at work and help them return to work if they get ill. They include:

• Paper-based sick note should be replaced with an electronic fit note, stating what people can do, not what they can't
• Occupational health should be brought into the mainstream of healthcare provision
• A new Fit for Work service should to be piloted for patients in early stages of sickness. When appropriate models for the Fit for Work service have been established access should be open to those on incapacity benefits and other out-of-work benefits.
• Government should fully integrate health support with employment and skills programmes, including mental health support where appropriate.
• Government should expand the provision of Pathways to Work to cover all incapacity benefits claimants as soon as resources allow, including appropriate provision for those with mental health conditions.
• To support the development of its proposed mental health employment strategy, Government should review mental health support within current policies and seek to determine the most effective method of assisting this group of people back into work.
• Government should consider offering advice and limited funding to help local partnerships kick-start health and work activity.
• Government should encourage the provision of vocational rehabilitation services by employers, building on the findings of their ongoing vocational rehabilitation review and providing guidance for employers.
• Government should consider the use of incentives for employers to support the employment of those with disabilities or health conditions.

An important development linked to Dame Carol's work is a consensus statement signed, on 5 March 2008, by more than 30 health professional bodies. In the statement they pledged to help people enter, stay in or return to work - whenever this is appropriate.

For further information see following links:

• Dame Carol Black's review - Working for a healthier tomorrow
• Summary of evidence received for the review
• Report on mental heath and work commissioned from Royal College of Psychiatrists
• Consensus statement signed by healthcare professionals

The review is currently being jointly considered by the Secretaries of State for Health (Alan Johnson) and Work and Pensions (James Purnell). A response will be published later this year.

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Individual Placement and Support Model

People with severe mental health problems can and do want to work but over half who are in contact with mental health services do not receive any help to find work, although they would like to receive it.

The Individual Placement and Support (IPS) approach is an evidence based practise that involves assessing vocational skills and preferences relatively quickly and then attempting to place people in employment settings, which are consistent with their abilities and interests, where they can develop their skills in the work environment while being provided with ongoing support. Support is also provided to the employer and direct to the workplace if necessary in order to ensure maintenance of the job.

This approach to vocational rehabilitation for people with severe mental health problems has been shown to be more effective than other approaches to help people with mental health problems gain and retain employment. Research into the effectiveness of this approach shows there are six principles:

• Services should be focused on paid employment with a primary goal of paid employment in integrated settings
• Programmes should involve rapid job search and minimal pre-vocational training
• Employment specialists should be integrated into clinical teams, with employment an integral part of the overall care plan
• Job search should be driven by client preference and choice
• There should be continual assessment of people's needs with support adjusted as necessary and assistance in career progression
• Access to time unlimited support once in work

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Employment Outline and Key Action Areas

Paid work gives people a real sense of their own value, improves their self-esteem and gets them out of their illness.

Action on Mental Health: Factsheet 4

Key Action Areas

• Support on employment and social issues for people with severe mental health problems
• Advice on employment and social issues through primary care
• Improving access to employment programmes
• Supporting and engaging employers of all size

The Mental Health and Social Exclusion report identified employment as a key area for improvement for people with mental health problems. People with long term mental health problems have the lowest employment rate of any of the main groups of disabled people – only 24% are currently in work in England however with the right support, many more would be able and would like to work. Indeed unemployment is associated with worsening health with the barriers to employment including low confidence, low expectations among health professionals, employer attitudes and difficulties moving from benefits to work. There can also be a lack of support to help people retain jobs.

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The Really Useful Book of Learning and Earning

The second edition of The Really Useful Book of Learning and Earning (2008) has been published by National Institute of Adult Continuing Education (NIACE) and is result of close collaboration between NIACE, NSIP and other partners to provide a comprehensive range of information and advice for people with a health condition or disability who are considering a return to work.

The book is designed to be easy to read and, although aimed at all disabled people, will be of particular interest to people with mental health problems and those who support them. It is full of information and advice to help people in their journey into work and there are blank action plans to help people set out goals. It contains a diary, hints and tips for job hunting, information about learning opportunities, a FAQ section on different kinds of employment programmes and provision available and how taking up work might affect benefits. There are also inspiring stories of people who have moved off benefits into work.

Details of how to order copies can be found on the NIACE website please click here

To download a pdf version please click here

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Regional Employment and Education Teams

Because they tend to face a greater range, and intensity, of obstacles for obtaining or retaining employment an important factor for helping more people with mental health problems achieve their work aspirations is to ensure, no matter what their starting point, or wherever they live, everyone is able to access tailored support for overcoming the particular issues they face.

It has long been recognised that partnership working is essential for the delivery of effective vocational support and the Prime Minister's Social Exclusion Task Force report Reaching Out: An Action Plan on Social Exclusion (September 2006) reiterated the importance of employment as a key factor in tackling social exclusion and the need for better partnership working for meeting the full range of individual employment needs. Action 23 in the report states: Building on current guidance and legislation, the Government will develop dedicated regional teams to provide further support for the implementation of good practice around the employment of those with severe mental health problems.

Implementing good practice around the delivery of vocational support for those with more severe mental heath problems needs an holistic, strategic approach to the development of local services for people with mental health problems and the regional teams will look at creating a coherent, flexible approach that ensures national policy objectives connects with regional and local activity and encourages better joined up working for the delivery of employment related services.

A key part of NSIP's work is to oversee the development of these dedicated regional teams and, because the value and importance of providing better vocational services for the mental health group is being increasingly recognised by health, employment and education service providers, this activity will integrate with existing networks, and take account of the development of the city strategies concept.

Planning activity on the design of this strand of work has been completed and NSIP is currently working with colleagues in the Care Services Improvement Partnership development centres to establish employment and education teams in each of the 9 English regions. Activity is now well advanced and NSIP is engaging with key stakeholders, such as Jobcentre Plus, Government Office, Regional Development Agencies and Learning and Skills Councils, to agree shared objectives and priorities.

An example of what is already being achieved in joining up activity is provided by the North East, Yorkshire and Humber Regional Development Centre which with other regional agencies have assembled a team to promote the mental health and employment agenda. The team has representatives from the Government Office, Regional Development Agency, Jobcentre Plus, Strategic Health Authority and Learning and Skills Council, among others.

They have jointly commissioned research, including a policy map, and an ethnographic study to determine how policy is interpreted into delivery as well as several pieces of supporting work. Using this research they have developed a jointly held strategy, including a statement of priorities, which has been consulted on prior to its official launch.

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Vocational Advisors in Primary Care

NSIP organised a one-day seminar in April 2005 on vocational advice in primary care. The aims of the event were to bring together key stakeholders to share thinking on best practice and lessons learned, and to consider the way forward.

The Mental Health and Social Exclusion report states that NIMHE will test models for providing vocational and social support in or linked to primary care, working in a partnership with Department for Work and Pensions, and the Department for Constitutional Affairs.

People in work experience better health than those out of work, and so the medical profession may consider its therapeutic value. People who become sick whilst in work generally visit their GP at some point and the longer someone is out of work, without receiving appropriate advice and support, the less chance there is of returning to employment. In many respects this has potential for job retention and might be seen as a preventative measure.

The model has already been tested, albeit with a slightly different focus, in the DfES project on Learning Prescriptions, and also with an employment focus in Lewisham and Camden. Sheffield Occupational Health Advisory Service and Health@Work in Liverpool have also been working in this area.

DWP received £1.3million from the 2004 Pre-Budget Report to test appropriate models, and after working alongside NIMHE in the development of this work began testing vocational advisers in GPs surgeries services in 5 of the original Pathways to Work areas. The pilots began in the spring of 2006 and will run until March 2008.

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Pathways to Work

Following the initial seven pilots (which commenced October 2003 and April 2004) Pathways to Work has been adopted as the national model for all new IB claimants and the service was expanded to cover 40% of the country, including those areas with the highest concentration of IB recipients, by December 2006. The Pathways approach has also been tested on some existing IB claimants in the original seven pilot areas and it has been announced that mandatory Pathways to Work interviews and the New Work Capability Assessment will be introduced nationally to all existing claimants aged under 25 in 2009. Any claimant not required to attend work focused interviews in a Pathways to Work area can access the service on a voluntary basis.

DWP are hailing the pilots as a success. Research suggests that Pathways significantly increased the probability of being employed about a year and a half later by 7.4 percentage points. They also indicate a good take-up of the choices package - 20% take up some provision by twelve months with the condition management programme and New Deal for Disabled People being particularly popular. Based on its success Pathways to Work is currently being made into a national offer with all of the country to be covered by April 2008. Roll out is in two phases (phase one started December 2007 and phase two will commence April 2008). Private and voluntary sector providers will deliver the service in the remaining 60% of the country and to see a full list of contactors please click here.

When looking at the encouraging results from Pathways to Work it must be borne in mind that claimants taking part are either new claimants or longer term claimants who have volunteered to take part, who may be more self-motivated and ready to work. Initial research seems to suggest people with mental health problems have not benefited from the introduction of the service as well as some other groups of people with a health condition or disability. Information on Pathways to Work research can be found on the DWP website. Please click here

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Stress in the Workplace

In May the mental health charity Mind, published its report into work-related stress in which is was reported that 20% of respondents to a Health and Safety Executive survey described their work-related stress levels as very or extremely stressful. A CBI survey also cited in the report found that 98% of companies surveyed said they thought the mental health of employees should be a company concern, yet less that one in ten had an official policy on mental health. The report identified the most stressful types of jobs, which included customer services roles, call centre jobs and clerical/admin roles.

Further information can be found here.