increasing access to employment within mental health services for ...

Diversity in Health and Care 2010;7:13–21

# 2010 Radcliffe Publishing

Research paper

Harnessing the expertise of experience: increasing access to employment within mental health services for people who have themselves experienced mental health problems Rachel Perkins Director of Quality Assurance and Service User Experience

Miles Rinaldi Head of Recovery and Social Inclusion

Joss Hardisty User Employment Programme Manager South West London and St George’s Mental Health NHS Trust, UK What is known on this subject . People who have personal experience of mental health problems often experience discrimination when applying to work in the NHS. . Managers often lack confidence when employing a person who has personal experience of a mental health problem, based on stereotypes of people with mental health problems being unpredictable and dangerous. . The employment of people who have personal experience of mental health problems within mental health services can actively improve the quality of those services. What this paper adds The NHS can be an exemplar employer in employing people with mental health problems, not just in entry-level positions but at all levels and across all professions within an organisation. . For many people who have experienced mental health problems, the only barrier to employment is employers’ unwillingness to consider them because of their psychiatric history. . The adoption of charters can only be realised if they are translated into behavioural changes by line managers who actually deliver the change along with the routine collection of data. .

ABSTRACT The User Employment Programme, which was established in 1995, was designed to increase access to employment within mental health services for people with mental health problems. This paper describes the individual and organisational outcomes of the programme between 1995 and 2007. Demographic, clinical and employment data were collected. Confidential equal opportunities monitoring data enabled an evaluation of the effectiveness of the programme. The results showed that between 1995 and 2007, 142 people were supported in 163 posts within the trust, of whom 86% continued to work or were engaged in professional training. At the time of appointment, people with schizophrenia had been unemployed for significantly longer periods. There was no significant association between length of time for

which support was provided, job type, job grade or success in sustaining employment. In 2007, 23% of all recruits to the trust had experienced mental health problems. The data indicate that recruits with mental health problems were more numerous among those recruited to higher-grade positions in the organisation. In conclusion, it seems that mental health services have a major role as employers as well as service providers in enabling people with mental health problems to access employment. This is particularly important in relation to the public-sector duty to promote disability equality. Keywords: employment, mental health, public services, social inclusion

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R Perkins, M Rinaldi and J Hardisty

Introduction The User Employment Programme at South West London and St George’s Mental Health NHS Trust (formerly Pathfinder Mental Health Services NHS Trust) was established in 1995 with the intention of increasing access to employment within mental health services for people who have themselves experienced mental health problems (Perkins et al, 1997). Drawing on successful initiatives in the USA (Sherman and Porter, 1991; Mowbray et al, 1997) and the effectiveness of the Individual Placement and Support Programme (Becker and Drake, 1993) approach to supported employment in enabling people with mental health problems to gain and sustain employment, it was argued that employing people with personal experience of mental health problems in mental health services could actively benefit both individual employees and the quality of the mental health service provided. The importance of work for people who have experienced mental health problems has been widely documented (see, for example, Royal College of Psychiatrists, 2002), yet only 21% of people with longerterm mental health problems are in employment (Office for National Statistics, 2009). Research has repeatedly shown that employers are cautious about employing people with mental health problems (BacaniOropilla et al, 1991; Rinaldi and Hill, 2000; Chartered Institute of Personnel and Development, 2006; Future Foundation, 2006). In the case of schizophrenia, there is an additional prejudice arising from the negative portrayals by the media of people with this illness (Campbell, 1997; Angermeyer and Schulze, 2001). This no doubt plays a role in the general public’s perception of people with schizophrenia as being unpredictable and dangerous (Crisp et al, 2000; Social Exclusion Unit, 2004; Thornicroft, 2006). Glozier (1998) found that people with a diagnosis of depression had significantly reduced chances of employment, a finding consistent with earlier research in which employers were found to discriminate against those people who disclosed a history of mental ill health (Sinclair, 1986). In many respects the situation does not seem to have changed over the last 40 years. Martin (1962) found that of the 18 reasons cited for turning down male applicants for jobs, ‘a history of mental illness came third in the list, ahead of the knowledge that the applicant had a criminal record’. As the largest employer in Europe, the NHS has been exhorted by the Secretary of State for Health to take a lead in increasing access to employment for people with mental health problems (Department of Health, 2000a; House of Commons Health Select Committee, 2000):

A key objective of the Government is to enable all disabled people, including those with mental health problems, to make the most of their abilities at work and in the wider society and, as the largest public sector employer in the country, the NHS should also be making a significant contribution to delivering this agenda. (Department of Health, 2000b)

This statement is reflected in more recent policies (Department of Health, 2002; Department of Health, 2004a; Social Exclusion Unit, 2004; Department for Work and Pensions, 2005), and the role of public services as exemplar employers is identified as one of the five key elements within the commissioning framework for vocational services for people with severe mental health problems (Department of Health, 2006). The employment of people who have personal experience of mental health problems within mental health services can actively improve the quality of service offered in a number of different ways (Perkins et al, 1997, 2000; Perkins, 1998; Perkins and Selbie, 2003; Rinaldi et al, 2004; Seebohm and Grove, 2006; Shepherd et al, 2008). It increases the skill mix available within services, and enables service users to benefit from the experience of others who have faced similar challenges. Seeing people with mental health problems working within mental health services serves to increase both staff and service user expectations of what people with such difficulties can achieve. If people with mental health problems work alongside and on equal terms with those who have not experienced such difficulties, this serves to break down the prejudice and discrimination and the destructive ‘them and us’ attitude that permeates services (Link and Phelan, 2001; Hewstone, 2003).

The South West London User Employment Programme This programme has two elements. 1 A supported employment programme, based on the Individual Placement and Support approach, and adapted to a single employer. This programme is designed to help people to gain and retain employment in positions within the organisation on the same terms and conditions as all other staff. The programme has four distinct areas: . assistance with the recruitment process: information about the requirements of jobs and the support available, help in completing application forms and preparation for interviews . assistance with the transition to work: specialist advice about welfare benefits, identification of workplace mentors, assistance with the

Harnessing the expertise of experience

practicalities of starting work and negotiating particular support and adjustments that may be needed, help with weighing up the advantages and disadvantages of disclosing mental health problems to colleagues . ongoing support to retain employment: help with resolving difficulties that arise at work and problems outside work that might interfere with work performance, assistance with working out how to manage specific symptoms in a work context and help with career development . provision of support, reassurance and guidance to line managers to enable them to build confidence and capacity in working alongside and managing a person who has mental health problems. 2 A Charter for the Employment of People who have Experienced Mental Health Problems that is designed to decrease employment discrimination throughout the organisation and recognise the important contribution that people who have personal experience of mental health problems can make. This charter recognises that prospective employees may be subject to discrimination in recruitment and selection procedures as a consequence of mental health problems: . personal experience of mental health problems is identified as desirable on all person specifications for jobs in the trust . advertisements encourage applications from people with mental health problems: ‘The Trust welcomes applications from those who are underrepresented in the workforce. This includes people from minority ethnic groups and people with mental health problems’ . existing confidential equal opportunities monitoring of recruitment in terms of gender, ethnicity and disability was extended to include monitoring of mental health problems. The User Employment Programme is integrated within the human resources department and includes liaison with occupational health services, but is managed by the trust’s vocational services. This programme has been described in more detail elsewhere (Perkins et al, 1997; Rinaldi et al, 2004). The purpose of the present paper is to describe the employment outcomes that were achieved during the 12-year period between January 1995 and 2007.

Data collection Within the Supported Employment Programme, the Employment Specialists who provide employees with support collect basic demographic, clinical and

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employment data. This includes data on age, gender, ethnicity, diagnosis, post details and outcomes, including career progression. In order to monitor the Charter for the Employment of People who have Experienced Mental Health Problems, the confidential equal opportunities monitoring section of all application forms has been modified to include personal experience of mental health problems. In order to ensure that the information they contain is confidential, these monitoring sheets are removed prior to the distribution of application forms to recruiting managers, and they are collated within the human resources department.

Results Supported Employment Programme Between January 1995 and January 2007, a total of 142 people with mental health problems were provided with support in 163 positions in the trust. Of these, 126 people held a single job within the organisation, 12 people held two jobs, 3 people held three jobs and one person held four different jobs during this 12-year period. On average, these recruits had been unemployed for over 2 years before taking up their posts, and although the largest proportion reported a primary diagnosis of depression, 44% had a diagnosis of some form of psychosis (27% with schizophrenia and 17% with bipolar disorder) (see Table 1). In addition, 80% had experienced at least one psychiatric inpatient admission. Figure 1 shows that two-thirds of supported employees (94 individuals) were employed in clinical positions in both inpatient and community settings, and 18 of these individuals (nearly 20%) were recruited to posts that required clinical qualifications (12 nurses, three occupational therapists, one psychiatrist, one psychologist and one social worker). In total, 27% were employed in administrative or managerial positions, including reception, secretarial, data entry and project management posts. Only a small number were employed within support services such as catering, gardening and portering. The majority of individuals were supported in lower-grade positions. However, it should be noted that 18% were recruited to posts in Agenda for Change (Department of Health, 2004b) Bands 5 to 7, which require at least graduate-level qualifications. During the period in which they were receiving support, 15 supported employees were promoted, as indicated by an increase in a Band, resulting in 22% of supported employees occupying positions in Bands 5 to 7 by January 2006 (see Figure 2).

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Table 1 Demographic and diagnostic characteristics of the 142 supported employees Mean age at appointment (years) (s.d.)

38.1 (8.4)

Mean duration of unemployment on recruitment (months) (s.d.)

27 (59.7)

Gender

Male Female

36% 64%

Ethnicity

White Asian/Asian British Black/Black British

72% 8%

Depression Schizophrenia Bipolar disorder Personality disorder Eating disorder Other

41% 27% 17%

Diagnosis

20%

longer required support to sustain their employment (26% were continuing to work within the trust, 14% had moved on to jobs outside the organisation, and four people had commenced professional training in nursing or clinical psychology) (see Figure 3). There was a significant association between duration of unemployment prior to recruitment and diagnosis (F = 3.37, P < 0.05). Whereas individuals with a diagnosis of depression had been unemployed for a mean period of 13.9 months, those with a diagnosis of bipolar disorder had been unemployed for a mean period of 29.6 months, and those with a diagnosis of schizophrenia had been unemployed for a mean period of 52.8 months. As might be anticipated, this suggests that individuals with psychotic diagnoses, in particular schizophrenia, experience a higher level of employment discrimination. However, it is noteworthy that there was no significant association between diagnosis and any of the following: . .

4%

.

4% .

8% .

The mean time period for which people received support in their employment within the trust was 18 months, although it should be noted that there was very wide variation between individuals, ranging from 1 month to 98 months. On 1 January 2007 the majority of the 142 supported employees (86%) were continuing in employment or professional training. Of these, 42% continued to work within the trust with support, but 43% (57 individuals) no

.

length of time for which individuals received support in employment (F = 1.8, P = 0.15) duration of employment (F = 0.7, P = 0.56) type of job in which the person was supported (clinical, administrative or support services) ((2 = 7.2, P = 0.30) grade of job to which the person was recruited (2 = 22.3, P = 0.10) grade of job in which person was supported on 1 January 2007 (2 = 21.4, P = 0.12) outcomes of support ((2 = 18.9, P = 0.22): 27% (n = 15) of those with a diagnosis of depression and 31% (n = 11) of those with a diagnosis of schizophrenia continued to work in the trust with support. while 44% (n = 24) of those with a diagnosis of depression and 49% (n = 17) of those with a diagnosis of schizophrenia continued to work in the trust without support.

Figure 1 Type of job in which people with mental health problems were supported (n =142).


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Figure 2 Grade of job in which people with mental health problems were supported (n = 142).

Figure 3 Employment status on 1 January 2007 (n = 142).

This suggests that, despite their longer period of unemployment, individuals with diagnoses of schizophrenia could be equally successful in their employment within the organisation.

The Charter for the Employment of People who have Experienced Mental Health Problems Confidential equal opportunities monitoring data showed that, in every year between 1999 and 2006, at least 15% of recruits to the organisation had experienced mental health problems themselves (23% in 2007). A more detailed analysis of the data for 2007 showed that overall a total of 327 people were recruited by the trust. Of these, 101 individuals were recruited to posts in lower-grade positions in Bands 1 to 4, 171 were recruited to posts in Bands 5 to 7, and 54 were recruited to posts in Bands 8 or 9. Confidential equal opportunities monitoring data for these appointments

showed that 90% of applicants stated whether or not they had experienced mental health problems. Figure 4 shows that, for the 327 positions that were advertised, 23% of applicants said that they had experienced mental health problems themselves. It is encouraging to note that, in line with the organisation’s commitment to viewing personal experience of mental health problems as desirable, 21% of those who were short-listed and 23% of those who were actually recruited had themselves experienced mental health problems. It is sometimes suggested that people with mental health problems are recruited only to lower-grade ‘entry-level’ positions. In order to explore this possibility, the proportion of people recruited to different levels of jobs who said that they had experienced mental health problems was examined. Figure 5 shows that, contrary to expectations, a higher proportion of people who had been recruited to more senior positions had experienced mental health problems.

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Figure 4 Confidential equal opportunities monitoring data for the period 1 January 2007 to 31 December 2007: proportion of applicants and recruits who stated that they had personal experience of mental health problems (n = 327).

Figure 5 Confidential equal opportunities monitoring data for the period 1 January 2007 to 31 December 2007: proportion of people recruited to different grades who had personal experience of mental health problems (Bands 1-4, n = 101; Bands 5-7, n = 171; Band 8 and 9: n = 54).

Discussion The data collected on the outcomes of the South West London and St George’s Mental Health NHS Trust User Employment Programme over the 12 years of its operation strongly suggest that people who have experienced mental health problems can work effectively in ordinary positions within mental health services under the same terms and conditions as any other employees. We have found that some individuals with more serious mental health problems may require additional support in order to gain and sustain employment. This can be divided into two elements, namely an initial critical period of support followed by regular assessment of adjustments or extra assistance for a short period of time with the proviso that ongoing support is available if it should be needed. With this assistance, 86% of individuals were able to sustain employment within or outside the organisation, or to progress to further professional training. Although those with a diagnosis of schizophrenia had

been unemployed for significantly longer periods at the time of recruitment, there were no significant associations between diagnosis and success of employment within the organisation, as 71% of those with a diagnosis of depression and 80% of those with a diagnosis of schizophrenia continued to work within the organisation with or without support. In a previous analysis (Perkins et al, 2000) it was found that employees with mental health problems who were provided with such support took less sick leave than did other staff. The majority of supported employees occupied more junior positions. However, 15 individuals were supported in nursing, occupational therapy, psychiatry, psychology or social work positions that required professional qualifications. In addition, confidential equal opportunities monitoring data that had been collected in accordance with the Charter for the Employment of People who have Experienced Mental Health Problems clearly indicated that people with mental health problems were not confined to the lower echelons of the organisation.


Our data show that many people who experience mental health problems do not require special support from their employer, and that they get the assistance they need from other individuals and services. All that they require is a willingness on the part of the employer to consider their application on its merits, rather than dismissing it out of hand because of their history of mental health problems. It was this that the development and implementation of the Charter for the Employment of People who have Experienced Mental Health Problems was designed to achieve, and the data collected clearly suggest that it has been successful. In overall terms, 23% of the 327 people recruited by the organisation in 2007 had personal experience of mental health problems, and this proportion rose with increasing grade of post. Whereas only 21% of those recruited to lower-grade positions (Bands 1 to 4) had experienced mental health problems, 31% of those recruited to the highest grades (Bands 8 and 9) had experienced such difficulties. Equal opportunities monitoring data also suggest that the intention to view personal experience of mental health problems as positively desirable was realised in practice. Whereas 19% of applicants had personal experience of mental health problems, 23% of those actually recruited reported experiencing such difficulties. The grand intentions of a charter can only be realised if they are translated into behavioural changes by line managers who actually deliver the change. This has been achieved by supporting line managers to build their confidence and capacity in managing and working alongside people who have mental health problems. The development of disability rights legislation and growing concern about the number of people claiming incapacity benefit because of mental health problems have resulted in the focusing of increased attention on ways in which people with such difficulties can be assisted to gain and maintain employment. In the past it has too often been the case that the potential benefits of anti-discrimination legislation and initiatives to help disabled people to enter the labour market have not been fully realised for individuals with mental health problems. Mental health services can play a major role in rectifying this situation, not only in their role as provider of treatment and support, but also in their role as a major employer. In this context, public bodies are legally required under the Disability Discrimination Act (2005) to produce Disability Equality Schemes and action plans on how they intend to meet their duties and review their progress annually. For many people who have experienced mental health problems, the only barrier to employment is employers’ unwillingness to consider them because of their psychiatric history. Within health and social care

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organisations, an all too common scenario is one in which health and social care professionals and other people working in mental health services with mental health problems experience stigma, prejudice and discrimination in either gaining or retaining employment, or both. This is clearly illustrated in medicine (Pilowski and O’Sullivan, 1989; Wall et al, 1997; Department of Health, 2008; Samuel, 2008), in social work (Stromwell, 2002; Samuel, 2005; Stanley et al, 2007) and in nursing (Caan et al, 2001; Glozier et al, 2006; Joyce et al, 2007), For instance, a formal investigation by the Disability Rights Commission found that in order to become accredited as a nurse, an applicant must comply with the fitness-to-practise criterion. The investigation found these accreditation criteria to be a formidable and unnecessary barrier for people with mental health problems (Disability Rights Commission, 2007). Whilst the trust welcomes applications from people who have personal experience of mental health problems as set out in the Charter for the Employment of People with Mental Health Problems, we believe that some applicants to the organisation will still choose not to disclose their personal experience of mental health problems, due to fear of stigma, prejudice and discrimination. As a result, we suspect that although the rates of applicants reporting mental health problems reported in this study are very encouraging, they are likely to be an underestimate of the total number of staff with personal experience of mental health problems. This study has several limitations. First, there is no comparison group, which means that the study is exploratory in nature. Lack of routine collection of data on the recruitment of people with mental health problems in the NHS and other statutory organisations has made it impossible to benchmark our recruitment experience against that of others, despite the requirement for statutory organisations to produce annual progress reports on how they are meeting their public-sector duty under the Disability Discrimination Act. Employers from others sectors in industry do not disclose equal opportunities data, as this is often considered to be commercially sensitive information. Secondly, within the Charter for the Employment of People who have Experienced Mental Health Problems, applicants are asked whether they have personal experience of mental health problems. It would be inappropriate to ask applicants to state their diagnosis, and this would be part of the confidential occupational health pre-employment screening which is not seen by human resources or the employing manager. As a result, there is no means of assessing whether severity of diagnosis has a general effect on the recruitment and selection of staff within the organisation.

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Conclusion Mental health services have an important role to play as exemplar employers by ensuring that people with mental health problems receive the support and adjustments to which they are entitled, and which they need if they are to access employment. Over the 12 years of its operation, the South West London User Employment Programme has demonstrated one way in which mental health services can lead by example in the employment arena. The combination of support in employment and, more generally, the Charter for the Employment of People who have Experienced Mental Health Problems, has also improved the quality of service that is offered, by enabling the organisation to harness the expertise of personal experience and reduce discrimination by offering a very material challenge to the construction of the mental patient as other and the destructive ‘them and us’ barriers that can result. REFERENCES Angermeyer MC and Schulze B (2001) Reinforcing stereotypes: how the focus on forensic cases in news reporting may influence public attitudes towards the mentally ill. International Journal of Law and Psychiatry 24:469–86. Bacani–Oropilla T, Lippmann S and Tuln E (1991) Patients with mental disorders who work. Southern Medical Journal 84:323–7. Becker DR and Drake RE (1993) A Working Life: the Individual Placement and Support (IPS) Program. Concord, NH: New Hampshire-Dartmouth Psychiatric Research Center. Caan W, Morris L, Brandon D et al (2001) Wounded healers speak out: experiences of nurses with depression. Mental Health Practice 4:20–26. Campbell P (1997) Clocked off. OpenMind 88:11. Chartered Institute of Personnel and Development (2006) Labour Market Outlook: Quarterly Survey Report, Spring 2006. London: Chartered Institute of Personnel and Development. Crisp AH, Gelder MG, Rix S et al (2000) Stigmatisation of people with mental health problems. British Journal of Psychiatry 177:4–7. Department of Health (2000a) Looking Beyond the Labels: widening the employment opportunities for disabled people in the new NHS. London: Department of Health. Department of Health (2000b) The Government’s Response to the Health Committee’s Report into Mental Health Services. London: Department of Health. Department of Health (2002) Mental Health and Employment in the NHS. London: Department of Health. Department of Health (2004a) Choosing Health. London: Department of Health. Department of Health (2004b) Agenda for Change Final Agreement (December 2004). London: Department of Health.

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CONFLICTS OF INTEREST

None. ADDRESS FOR CORRESPONDENCE

Miles Rinaldi, Service Development, South West London and St George’s Mental Health NHS Trust, Springfield University Hospital, 61 Glenburnie Road, London SW17 7DJ, UK. Tel: +44 (0)20 8682 6929; email: [email protected] Received 4 August 2009 Accepted 29 October 2009