Betting the budget on mental health

Sneaking its way onto p60 of the Budget 2015 documents, my colleague alerted me with some excitement to the ‘package of measures to improve employment outcomes for people with mental health conditions’.  Not traditional Budget fare – the inclusion of measures supporting mental health and employment emphasises just how far we have moved forward with this agenda, demonstrating  the increasing weight given to the health of the working age population (and particularly the mental health)  across portfolios, and I suspect also the hard work of some Liberal Democrat MPs.

 “Starting from early 2016, the government will provide online Cognitive Behavioural Therapy (CBT) to 40,000 Employment and Support Allowance and Jobseeker’s Allowance claimants and individuals being supported by Fit for Work. From summer 2015, the government will also begin to co-locate Improving Access to Psychological Therapies (IAPT) therapists in over 350 Jobcentres, to provide integrated employment and mental health support to claimants with common mental health conditions.”

Increasing access to psychological therapies (the principle, not the NHS program) through increasing access to computerised CBT is definitely something to be pleased about. Still too few people get access to evidence based treatment, and despite recent announcements of waiting list targets for IAPT (the program, not the principle), waiting times remain considerable in many areas of the country. Indeed, concerns around Fit For Work have reflected on whether it would result in people, having already been absent from work for 4 weeks, being placed at the back of a very long IAPT queue – to the detriment of both health and work outcomes.

Evidence for computerised CBT for treating depression in particular is promising, and it has been demonstrated to reduce levels of sickness absence.  A recent Cochrane review found  “moderate quality evidence that enhancing primary or occupational care by providing workers with a structured telephone or online cognitive behavioural therapy reduces sickness absence compared to regular care.”

And that is not the end of the good news.  As many in the field will know, co-location of health and employment services has been shown to be an important element in programmes which improve employment outcomes for people with mental health conditions. Research on schizophrenia and employment (as discussed in our 2013 report) highlights the importance of a model of employment support known as Individual Placement and Support  (IPS). This approach intrinsically requires integration between health and employment services – with employment specialists from the IPS service working as part of the secondary mental health care team. Currently IPS services are available only sporadically around the UK, driven by local commissioning decisions. The poor availability of IPS support, which research has shown to be highly effective in getting one of the most vocationally and socially disadvantaged groups into work, is an ongoing concern for those of us who work in the field.

Today’s budget announcement reflects a recent shift in focus to whether the IPS model is effective for people with common mental health conditions in primary health care settings. On the basis of strong anecdotal evidence (as highlighted in the RAND Europe report on Psychological Wellbeing and Work), the integration of IPS in IAPT services was recently run as a 6 month pilot project, with an integrated IPS and IAPT service offered to longer term ESA claimants and Work Programme returners in 4 areas of England. An evaluation of outcomes and feasibility is due for release in the very near future (sorry can’t give anything away yet!). What I can say is that, as shown by the repeatedly poor Work Programme outcomes for people with mental health conditions, it is difficult to see that maintaining the current model of employment support (even when integrated with therapy) will be sufficient. The IPS model is about more than just co-location of employment support and therapy – it is about integration of services, requiring shared values and goals. While for service users, it is about choice and trust – words that are perhaps not commonly associated with the Job Centre.  As suggested by a series of spurious  articles in the media last year, it may be hard for people to break the link between something being provided by the Job Centre to help with job seeking, and something which is mandatory and which may affect welfare benefits.

We simply do not know how well this will work, and apparently we are not waiting to find out – another project running as we speak, the “DWP/IAPT Employment Initiative “, is looking specifically at the effects of integrating IAPT services into the Work Programme at 8 locations. the results of which will not be due out until the end of 2015, so after the planned summer 2015 roll out of IAPT in the Job Centre.

Still, such considerations shouldn’t take away from the overall positive nature of this announcement for the 1 in 6 of us of working age who experience a mental health condition every year. It is fantastic to hear that more people will be getting access to some form of treatment, and that policy makers have listened to messages about the importance of integrated health and employment support to achieve the best employment outcomes for people with mental health conditions. However, the ability for the Job Centre to provide appropriate support for those with mental health conditions is still very much up in the air. If we can support more people with mental health conditions who want to work, into work, there are substantial gains to be made not only for individual health and societal wellbeing, but also in terms of the considerable economic returns of a reduction in welfare spending and better use of human capital. The stakes are high – I just hope that adding support onto existing services, rather than making some fundamental changes to the way employment support is provided, isn’t making too small a bet.