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Karen Steadman

Raising expectations - what can we learn from the German employment support system for people with disabilities? Lessons from our two reports

Authors: Karen Steadman

09 June 2015

Employment rates for people diagnosed with schizophrenia are extremely low – at around 8% in the UK – they are among the lowest associated with any health condition. Such data obscures the reality that many people with schizophrenia are motivated and able to work, and are actively engaged in job seeking; seeing a return to employment as indicative of their recovery and consequently as a goal to aspire to. Many people have also found work to have benefits for their health and wellbeing – something which is reflected in the academic literature. So what is the reason for the considerable vocational disadvantage experienced by people with this diagnosis?

Between 2012 and 2014 we conducted research in the UK and in Germany to better understand what the barriers and enablers to employment are for people with a diagnosis of schizophrenia, and to identify ways that employment outcomes might be improved. The two reports are available here (UK) and here (Germany).

Accurate condition-specific employment data is hard to come by – what exists though shows that although numbers are still low, people with schizophrenia in Germany are more likely to be in paid employment than they are in the UK (19-26% versus 5-15%). People with schizophrenia in the UK also fare worse than those in Germany on a range of other health and social measures, with a higher likelihood of homelessness, suicide, and worse health behaviors (see the table below).

When making a comparison, it is important to be aware of the much greater reliance on sheltered workshops in Germany. People with mental health conditions make up a large proportion of sheltered workshop employees (around a fifth), and an estimated 4 out of every 10 employed people with schizophrenia in Germany are actually working in sheltered workshops or as volunteers rather than the open labour market. This is a very different picture from the UK, which has little by way of sheltered work nowadays and what remains (having been redeveloped into ‘supported businesses’) are not a common option for people with mental illness.

Even discounting the sheltered workshop population however, employment rates remain higher in Germany, both for those working independently of benefits, and for those who still received some. So, what else does our research tell us as to why this might be?

The expert professionals and individuals with lived experience that we spoke to in both countries largely agreed about the potential health benefits of working and the value it often has for people with schizophrenia. Several German expert participants went further, describing work as a basic right. This is illustrative of a major difference – the presence of a legal framework supporting this ‘right’ to employment. Social security provision is outlined in the German social code, which underpins both vocational rehabilitation support as well as the duties placed on businesses to employ people who are registered as having a severe disability – managing both the supply of able employees and of appropriate jobs (again, including sheltered jobs).

German vocational rehabilitation includes many different types of programme, varying in cost and intensity, and the extent to which they focus on the goal of open employment. The BTZ model, which was identified as a common route for people with schizophrenia, provides 12-18 months focused rehabilitation and retraining to the end of returning someone to their previous job or one in a related field (for more detailed information on German programmes refer to appendix 3 of the report).

In terms of managing job supply they maintain an employment quota, wherein all businesses with over 20 employees must have at least 5% of employees who are registered as severely disabled. The UK had a similar policy in place until the 1970s, though it was always poorly implemented – perhaps reflecting the UK ideological commitment to individual responsibility over social responsibility (this paper may be an interesting read). For those that do not meet the quota, a levy must be paid, funds from which are directed into vocational rehabilitation programmes. Disabled employees are also provided protection from dismissal – employers have to apply to a government body to justify the decision. Where an application is unsuccessful the employer is referred to the IFD who provide support and advice to the employer and employee (in some ways similar to the UK’s Access to Work). Wages may also be subsidized to account for reduced productivity of an employee. Disabled employees are also encouraged to self-advocate – with disabled employee representatives often found in larger companies.

The extent to which such support benefits people with schizophrenia specifically is unfortunately not clear – data is very limited, with what does exist referring only to ‘severe disability’ status rather than a specific condition. In terms of entry into vocational rehabilitation programmes, discussions with experts suggested that people with schizophrenia might be seen as riskier prospects by insurers who pay for programmes, as well as by service providers, and by those who might refer someone to a service. This was seen as a barrier to accessing support more focused on employment in the usual labour market, with the suggestion that in reality people with schizophrenia are increasingly directed towards sheltered work, rather than other, more inclusive supported employment vocational rehabilitation options.

In the UK we see a different picture – arguably a much more ‘hands off’ approach. Employer engagement is an individual matter, with no incentives for employers and minimal protections for individual employees. Vocational rehabilitation services which focus on employment in the open labour market are limited in supply outside of the welfare to work system. Even though in the UK evidence-based Individual Placement and Support services are available through some secondary mental health care services, provision is highly variable nationally with services commissioned locally, driven by local knowledge and interest.

Perhaps the observation I was most struck by in conducting this research, was in the difference in the quality of the jobs of participants with schizophrenia in both countries. While the British participants by and large were unhappy in their jobs, most of which were insecure and not related to their interests, skills and qualifications, their German counterparts appeared much happier, with long tenures and several stating their current role was their ‘dream job’. Though there was some concern from experts that young Germans may find entering the workforce today more difficult than older generations, it seems likely that they would have a much better start than their counterparts in the UK.

The above provides but a brief, simplified overview of the respective situations in both the UK and Germany in regards to employment support for people with schizophrenia. There are many other issues to be considered and comparisons to be made – I hope to have the time to examine these more thoroughly and think about the implications for both UK and Germany policy in this area.

From the UK perspective, I think there may be lessons around shifting the onus for finding employment away from the individual, and looking how we might encourage employers and others to take more responsibility and play a more active part. The ‘free market’ approach to support and services in the UK seems to be resulting in a lack of them! I believe the German example should also give policy makers and other stakeholders cause to raise their expectations about work and what it can mean for people with schizophrenia – not only in terms of improving the staggeringly low employment rates, but also in terms of improving the quality of the employment.

 

Table A: social and vocational data on schizophrenia in the UK and Germany

From a comparative perspective, figures from two countries should be taken with a pinch of salt – they are worked out in very different ways with varying data quality.

   UK/England  Germany
 Population  220,000 (0.41%) [5]
 500,000 (est 0.62%) [8]
 Health factors:    
 Smoking  62.5% [6]
 58% [1]
 Suicide rate
 48.6% [2]
 35% [2]
 Alcohol/drug dependence
 35% [7]
 21%[7]
 Social Factors:
   
 Being homeless
 32.8% [2]
 8.4% [2]
 Been to prison
 14.6% [2]
 7.1% [2]
 Live alone
 36.1% [2]
 33% [2]
 Married  13.2% [2]
 18.9% [2]
 Living with partner/children
 16.9% [2]
 27.5% [2]
 Employment:    
 Employment rate
 8% (5-15% [5]
 22.5% (19-26%) [1,3,4]
 Unemployed  87.1% (80.9-93.3) [4]
 63% (40-75.9%) [4]
 Never employed
 8.3% (1-16%) [4]
 7% (3-11%) [4]
 Employed supporting self
 8.9% (3-15%)
 14.1% (9-18%)
 Employed and receiving benefits
 4% (4%)
 22.7% (8-45%)
 Sheltered/voluntary
 5% [4]
 38% [4]

 

 Employment status of people with schizophrenia

 Data from:

[1] Papageorgiou, Cañas, Zink, & Rossi, 2011 - Country differences in patient characteristics and treatment in schizophrenia: data from a physician-based survey in Europe. European Psychiatry, 26(1, Supplement 1), 17-28.

[2] Bebbington et al., 2005 – The European Schizophrenia Cohort (EuroSC). A naturalistic prognostic and economic study. Soc Psychiatry Psychiatr Epidemiol, 40, 707-717.

[3] Haro et al., 2011 - Cross-national clinical and functional remission rates: Worldwide Schizophrenia Outpatient Health Outcomes (W-SOHO) study. The British Journal of Psychiatry, 199(3), 194-201.

[4] Marwaha et al., 2007 – Rates and correlates of employment in people with schizophrenia in the UK, France and Germany. The British Journal of Psychiatry, 191(1), 30-37.

[5] The Schizophrenia Commission, 2012 - The abandoned illness: a report from the Schizophrenia Commission. London: Rethink Mental Illness.

[6] Brown, S., Birtwistle, J., Roe, L., & Thompson, C., 1999 - The unhealthy lifestyle of people with schizophrenia. Psychol Med, 29(3), 697-701.

[7] Carra, G ; Johnson, S ; Bebbington, P ; Angermeyer, MC ; Heider, D ; Brugha, T ; Azorin, Jm ; Toumi, M, 2012 - The lifetime and past-year prevalence of dual diagnosis in people with schizophrenia across Europe: findings from the European Schizophrenia Cohort (EuroSC). European Archives Of Psychiatry And Clinical Neuroscience, 2012 Oct, Vol.262(7), pp.607-616.

[8] Frey, 2012 - PMH16 Analysis of the Economic Burden and Cost Structure of Schizophrenia in Germany Using Observational Sickness Fund Data. Value in Health, 15(7), A336

[9] Bebbington, P., Angermeyer,M., Azorin, J.-M. et al., 2005 - The European Schizophrenia Cohort (EuroSC): a naturalistic prognostic and economic study. Social Psychiatry and Psychiatric Epidemiology, 40, 707-717.