Issued: 20 February 2017 by BABCP Board JOINT RESPONSE TO: IMPROVING LIVES GREEN PAPER Green Paper – Improving Lives This is a joint response on behalf of: British Psychological Society (BPS) British Association for Counselling and Psychotherapy (BACP) British Psychoanalytic Council (BPC) British Association for Behavioural and Cognitive Psychotherapies (BABCP) UK Council for Psychotherapy (UKCP) Download: Joint Response to: Work and Health Green Paper [PDF] Work and Health Green Paper Improving lives [PDF] BPS, BACP, BPC, BABCP and UKCP are the UK’s leading professional associations for psychological therapies, representing over 110,000 psychologists, counsellors, psychotherapists, psychoanalysts and psychiatrists who practice psychotherapy and counselling. Supporting people into work: Building work coach capability How do we ensure that Jobcentres can support the provision of the right personal support at the right time for individuals? The Need for Culture Change: We urge the Government to explicitly recognise that any attempts to support the provision of “the right personal support at the right time for individuals” must be underpinned by a significant culture shift within the DWP and JC provision. We note the long overdue recognition in the Green Paper of the inappropriateness of a one-size-fits-all approach. However, the provision of appropriately tailored support to those with varied, complex and substantial barriers to work must be distinct from general JCP provision. The Green Paper provides no clear indication of how the proposed reform will be implemented, supported and reinforced. The Importance of the Quality of Work We urge the Government to consider not only the Jobcentre's role in increasing the rate of employment, but also in ensuring the quality of that employment. The support packages and employment opportunities need to be meaningful and sustainable. Compulsory, short-term quick fixes risk either a deterioration of mental health in previously unaffected individuals, or an exacerbation of existing mental health conditions for already vulnerable individuals, as well as potential longer term unemployment. There is significant evidence that inappropriate and unsupportive employment can be worse for people’s mental health than unemployment. A large-scale study that tracked people over time in Australia found that people in jobs that have some combination of high insecurity, low pay, high demands and complexity, and low employee control can be even more detrimental to mental health than unemployment (Butterworth et al., 2011). Similarly, a British study also concluded that jobs that exhibited such characteristics were no better for people’s mental health than unemployment (McManus et al., 2013). A Korean study also found that those in precarious employment had a higher risk of depression than those who were unemployed (Yoo et al., 2016). Enabling and Supporting Work coaches The recent DWP work with work coaches on increasing their capability and adopting a more “strengths based” as opposed to “problem based” approach is an important development as the role of the work coach is to guide the individual to consider what would assist them in returning to work and to signpost the various options. However, the claimant population is very mixed and the training will need to ensure a sufficient awareness and sensitivity to the needs of a complex range of individuals. We would welcome the opportunity to provide additional expertise to support the DWP work psychologists in the development of any such training and our organisations are well placed to do so from a wide range of practitioner areas (including psychological and psychoanalytic therapy, occupational, counselling, clinical, and health psychology). Role Conflict and Work coaches Nevertheless, we are concerned that there are some inherent difficulties within the current system which impede upon the development of a supportive and constructive relationship between each individual and each work coach. As highlighted in the Select Committee on Work and Pensions report on Job Centre Plus (2016), the current system creates a real tension between the dual roles of the work coach. Between the “supporter/nurturer” and the “policing/punisher” roles, this is a conflict of interest that needs consideration. “… trustful, positive and personalised support is central to the work coach role working effectively, but currently the Department [DWP] has little means of assessing how far this is being delivered” (p.13). The Black Report (2016) also identified the importance of the relationship between the claimant and the work coach, especially in relation to disclosure and discussion of their health conditions and specific needs. Our organisations would also be able to provide expert input on improving the quality of the relationship between the work coach and the client, where the quality of the relationship impacts on the wellbeing of them both. We therefore strongly recommend that any changes the Government makes to the tools and specialist support given to work coaches should be trialled before roll out, and the impact of these changes on mental health and wellbeing should be monitored. The changes should not only be trialled individually, but also as a package, as the impact of changes may be cumulative. What specialist tools or support should be provided to work coaches to help them work with disabled people and people with health conditions? Impact of Job Centre Systems and Requirements on Mental Health We urge the Government to look at how Job Centre systems and requirements may themselves be exacerbating mental health problems. The sheer degree of focus on work - which they want to embed within health systems – runs the risk of a) making individuals with disabilities or mental health conditions feel pressured to work, or b) of making them feel worthless if they do not quickly enter a post. Both these could have a considerable negative impact on mental health and wellbeing. Job centre clients experience an unacceptably high prevalence of mental health conditions. Those who have been unemployed for more than 12 weeks are 4-10 times more likely to experience depression and anxiety than the general working population. 2.3 million people with mental health conditions are on benefits or out of work, and 42% of health-related benefit claims are due to mental health issues, making it the number one reason for claiming health-related benefits. Mental health conditions and disabilities are highly individualised. We are concerned that an inflexible approach may mean the individual needs of people with mental health conditions and disabilities, to seek and secure sustainable, appropriate employment are not met. Mental Health Awareness Increasing understanding and awareness of mental health issues amongst staff must therefore be an essential component of any reform – combined with JCP staff increasing sensitivity to the difficulties experienced by these individuals. This will necessitate both training towards expanded awareness and a lifting of pressure on staff to get ‘results’ by returning a fixed proportion of individuals to work within a set time frame. It is inevitable that some of this pressure influences the relationship between JCP staff and clients. It may be extremely difficult for work coaches to remain patient and positive, informed, encouraging and provide appropriate support when faced with such pressures. For clients with mental health conditions and disabilities, this may potentially heighten their stress and anxiety which can be extremely detrimental for an already vulnerable individual.We are therefore disappointed that the Governments’ response to the Five Year Forward View outlines the introduction of giving providers considerable freedom in how they support claimants in moving to sustainable employment and that this is backed by payment by results – including accelerated payments for getting those hardest to help back into work. We recommend that providers should ensure all advisers and front-line staff, such as work coaches, receptionists, supervisors, etc. have completed mental health and disabilities awareness training. We also recommend that refresher training be completed at least once a year by all relevant staff. We note the recommendation in the Select Committee on Work and Pensions reports on both Job Centre Plus (2016) and of the Disability Employment Gap (2017) on the establishment of the role of senior specialist work coaches with more in-depth knowledge who are better able to refer clients to appropriate health care and occupational health professionals. We suggest that this would potentially be a beneficial development for those requiring specialist interventions and support but should be subject to evaluation. Specialist Supervision and Support for Work Coaches Paid employment can be a useful element of psychological rehabilitation and recovery and tailored services are welcomed. However it is vital that the staff employed to offer such tailored support receive good supervision and that the programmes themselves are meaningful and focussed on psychological wellbeing. Furthermore, it is important staff are provided with effective supervision to support their own psychological needs and the pressures of working in environments which may be emotionally challenging. The Boorman Review (2009) noted in relation to healthcare provision, negative impacts on job performance tend to follow where staff well-being is suffering. From a wealth of occupational psychology and occupational medicine literature it is recognised that high workload and role conflict contributes to poorer psychological health. We urge the Government to ensure that the well-being and work situations of work coaches and of psychologists and psychotherapists already working in the DWP are monitored and regularly reviewed. In addition to scrutinising the work context of work coaches in order to support their effective functioning, the building of resilience may help these front-line staff on a personal level as well as give them insights into key concepts likely to be of benefit for their clients (Kinman and Grant, 2016). The work currently being undertaken by the DWP to increase the resilience of JCP work coaches should be evaluated, and if demonstrably effective, be expanded. The Green Paper specifically proposes ‘a new Health and Work Conversation between an individual and their work coach’ with a focus on using ‘specially designed techniques to help individuals with health conditions to identify their work and health goals, draw out their strengths, make realistic plans and build resilience and motivation’ (p.31). This proposal is supported by ensuring work coaches can access the right specialist advice and support, so they can understand how a complex health condition might affect an individual’s ability to work’ (p.31). This new approach must be underpinned by appropriate specialist advice and be developed in consultation with relevant disabled and mental health organisations. Moreover, as stated previously, we strongly recommend that any changes the Government makes to the tools and specialist support given to work coaches should be trialled before roll out, and the impact of these changes on mental health and wellbeing should be monitored. The changes should not only be trialled individually, but also as a package, as the impact of changes may be cumulative. Chapter 2- Supporting People into Work: What support should we offer to help those “in work” stay in work and progress? Psychological Healthy Workplaces and Statutory Support Psychological health and safety in the workplace is key. The Green Paper fails to acknowledge the importance of meaningful work for all, not just those with disabilities and mental health conditions. We urge the Government to consider the need to prevent or minimise the risks created by the workplace for employees, regardless of their health status or condition. It is therefore vital that efforts to ‘help those in work stay in work’ encompass the preventative strategies reflected in the psychological literature and highlighted in HSE Management Standards and NICE guidance (2009; 2016). That the ‘type of work matters’ for individual health is alluded to in the Green Paper (p.11), however the annual UK cost of mental health problems at work of £26-30bn (Centre for Mental health, 2016; ACAS, 2017) underlines the need to take action with employers and organisations to optimise psychosocial working conditions to make it easier for individuals to stay in work, regardless of their health status. The importance of social factors (such as self-esteem, self-worth, social identity and social comparisons) at work have been well evidenced (Grant & Parker, 2009; Oldham& Hackman, 2010). One meta-analysis of 259 studies involving 219,625 employees showed that social factors at work explained 24% of the variance in intentions to leave a job (Humphrey et al, 2007). This highlights that such factors in relation to the work environments and accompanying work outcomes experienced by able and disabled individuals must be considered as part of any recommendations for employers and organisations and the provision of in-work support. We recommend the development of statutory support for creating, maintaining and enabling psychologically healthy workplaces in conjunction with employee and employer representatives. The Government should consider the adoption and maintenance of national standards, such as those recognised in Canada as signifying a Psychologically Safe Workplace. The Government may, however, also need to consider the need for incentives for employers to adopt such standards. Alternatively, perhaps the time has come for legal requirements for psychological health and safety at work, given the huge costs to the UK in terms of losses to individuals and organisations. Meaningful Work Moreover, we urge the Government to support employers to provide meaningful work opportunities for people with mental health conditions, especially part-time and flexible positions, to help overcome stigma and discrimination in the workplace. The recently announced review of mental health in the workplace is to be welcomed and the Government should ensure that this incorporates consideration of the framework, standards, guidance and resources to assist employers in designing and maintaining a psychologically healthy workplace. Our members would be well placed to lead on this work, as experts in not only individual level, but also organisational and population level interventions alongside other occupational health specialists. In-Work Progression We are also concerned about the effectiveness and potential negative impacts of “in work progression” which broadens the reach of conditionality to those who would previously have been working independently, without any intervention. In-work claimants are required to seek more hours of employment, better pay and/or additional jobs to satisfy the conditionality requirements to receive Universal Credit (UC). Firstly, the extension of conditionality to people in work may have profound psychological consequences. The threat of financial penalty if more hours or higher pay are not secured will likely add to the stress, and indeed, the financial hardship that many individuals face – with consequences for themselves, their families and the local mental health services. Secondly, one of the underpinning intentions of the introduction of Universal Credit was to ensure that individuals are “always better off in work”. We are concerned that the conditionality associated with UC means that this is often not the case. In practice, it requires the individual to look for multiple jobs or increased hours and pay from current employers; JCP appointments must also be attended to avoid sanctions for non-attendance. We are concerned that there is a significant mismatch between the intention of conditionality and its application to in-work claimants. It is counterproductive and introduces new disincentives to work. It causes severely detrimental financial, material, emotional and health impacts of those subjected to it (Wright et al, 2016). We therefore urge the Government to suspend the “in-work progression” programme subject to an independent review of its consequences on material deprivation and its impact on mental health and wellbeing, for not only those with pre-existing mental health conditions, but also across the population in receipt of “in-work” benefits. What does the evidence tell us about the right type of employment support for people with mental health conditions? The right kinds of employment support must be underpinned by a) a system that is designed from end to end to provide support for individual’s needs, at the right time and in the right way; b) a method of determining those needs which elicits accurate, detailed outcomes tailored to each individual, c) is implemented in a way that continues to support and encourage rather than sets inappropriate and unachievable requirements under threat of sanctions and d) that there is appropriate monitoring and measurement of the outcomes of this support (whether that be employment, unpaid work, or appropriate health and social care). Culture Change: As stated at the beginning of this response, we urge the Government to explicitly recognise that any attempts to support the provision of “the right personal support at the right time for individuals” must be underpinned by a significant culture shift within the DWP and JC provision. The focus should shift to “making work more attractive rather than making unemployment less attractive”. Movement is also needed away from the implicit assumption of the current system and culture that “there is something wrong with unemployed people” to understanding that the support mechanisms must be individualised and tailored to their biological, psychological and social needs. Needs Assessment: The Government’s intention to move to a system of individualised, tailored support is a positive move, but now needs to be underpinned by an appropriate method for determining those needs and what level of financial support is needed to ensure the individual is supported whilst they are unable to work (no matter how short or long term that is). In June 2015, The BPS published its Call to Action and Briefing Paper on Work Capability Assessment Reform. This highlights the flaws in the current assessment and the detrimental consequences arising from this erroneous process. We urge the Government to reform its approach and the assessment process. We also strongly recommends that this be developed utilising suitable psychological expertise as well as service users, and be subject to regular, independent and systematic evaluation. We remain concerned that without an end to end redesign of the system from its assessment process to its outcomes, any attempts at culture change will be meaningless. The WCA assessment and resulting categorisation of individuals into either “fit for work”, “work-related activity” or “support” groups, do not allow for sensitive and objective discrimination between individuals with different levels of functional impairment, whether they are physical, mental, cognitive or intellectual. This is producing inappropriate outcomes. Such outcomes range from those with serious physical, mental, cognitive and intellectual disabilities being placed in the “fit for work” group or “work-related activity” group, or those with transient, short-term, acute mental health conditions being placed in the “support group” category. That the Government has now recognised that these binary outcomes are insufficient and inappropriate is an important development but it now needs to commit to addressing the fundamental flaws within the WCA. We are extremely concerned that the WCA was not developed with a reference standard and with no testing of reliability or validity or involvement from expert health and social care professionals. We understand that at no point has the WCA been subjected to systematic evaluation and review of its validity and effectiveness. We do not believe that the WCA assesses work fairly or effectively. Determining ‘fitness for work’ for people with mental health conditions and disabilities is not only difficult, but it may also have adverse consequences on an individual’s understanding of themselves, their attitudes, behaviour and psychological wellbeing. Ultimately, any process designed to support those in need must uphold or improve the psychological wellbeing of those individuals. Moreover, a significant body of published psychological literature highlights that inappropriately labelling individuals as ‘unfit for work’ or “fit for work” can have significant and far reaching consequences on psychological wellbeing, impacting on self-esteem, self-image, self-belief and self-worth (Steele, 1997); as well as the ability (Rydell et al., 2009) or motivation of the individual to engage in the process (and specifically with the source of the perceived threat – Major et al., 1998). By focusing on “fitness for work” or limited capacity for work, the system has the potential for detrimental impacts on the beliefs of many potentially employable people, as well as those who are seriously unwell. It is therefore important that the Government understands the importance of these social aspects of work for those with health conditions and disabilities. The concept of social support at work is recognised as an important element for individual well-being, and in the context of the Green Paper’s theme of changing attitudes towards disability this plays a vital part too. The Government has missed an opportunity to effectively use psychological theory and practice within the benefits system, which has left it open to results that lack validity, efficacy, fairness and compassion for people’s mental health and wellbeing. We urge the Government to ensure that future reform of the JCP, the WCA and the commissioning of the Work and Health programme takes steps to correct that. Sanctions and Conditionality: In January 2017, we called for the suspension of the use of sanctions outlining that whilst the sanctions process is undermining mental health and wellbeing – there is no clear evidence of pay off in terms of increased employment. International evidence indicates that although benefits sanctions substantially raise exits from benefits and may increase short term employment; there are unfavourable longer term outcomes for earnings, job quality and employment retention. Moreover, whilst the utility of the sanctions process rests on the assumption that job centre claimants are insufficiently motivated to seek work; reported data estimates 86-90% of people with mental health conditions that are not in employment want to work. People with specific vulnerabilities and individuals with multiple and complex needs have been disproportionality affected by the increased use of welfare conditionality. This has had a range of unintended consequences including disengagement from the welfare system, destitution and hardship, displacing rather than resolving issues such as long term worklessness, substance misuse and negative impact on children. Research from the Centre for Welfare Conditionality at the University of York highlights that the link between the continuation of welfare payments to mandatory behavioural requirements under the threat of sanctions has resulted in widespread anxiety and feelings of disempowerment. The researchers conclude that there is limited evidence of welfare conditionality bringing about positive behaviour change. In its report Benefit Sanctions (2016), the National Audit Office concludes that “…the Department has limited evidence of how people respond to the possibility of receiving a sanction, or how large this deterrent effect is in practice” (p.7). Moreover, the Department has not used its own data to evaluate it or supported wider work, such as that by the Centre for Welfare Conditionality at York. We reiterate our call on the Government to address these concerns and suspend the use of sanctions subject to the outcomes of an independent review of the links between the sanctions regime and the mental health and wellbeing of individuals. We also encourage the Government to consider the promotion of the use of incentives for individuals rather than punitive measures to encourage job uptake. We could provide both academic and practitioner psychological literature which could make a major contribution to informing evidence-based policy development in this area. The Government should also play close attention to the trials of “citizen’s income” (also known as basic income) around the world, which if demonstrated to be effective may potentially provide a template for a benefits system with a clearer incentive structure to work without the psychologically and materially damaging elements of conditionality and sanctions. Work as a Health Outcome: Work is not a health outcome for all. The commitment to “work as a health outcome” has the potential to underestimate the disabling aspect of unemployment on individuals and risks ignoring the impact of wider social, community and economic factors which contribute to an individual not being in work. Large scale meta-analyses show that unemployment causes psychological distress and the associated risk of mental health problems increases continuously over the first nine months of unemployment (Paul and Moser, 2009). In such cases work is not a health outcome but an associated cause of ill health. We are concerned that the commitment to “work as a health outcome” has been made without any clear acknowledgement of the importance of ensuring that employment is appropriate, sustainable, provides essential tailored support and that appropriate monitoring of continued improved mental health will be put in place for individuals with mental health conditions, not just those identified as having “severe mental illness”. Employment as a “health outcome” is not straightforward in the case of people with mental health conditions and disabilities. Without this acknowledgement, there is a real risk of jeopardising the recovery of those with less severe conditions by placing them in unsuitable, unsupported employment, which may in turn, result in or lead to a worsening of symptoms and an inability to work. In efforts to ‘place’ individuals in jobs and support their maintenance at work, we urge the Government to ensure due consideration firstly be given to the potential for unhelpful placement. This results from placing individuals in jobs which are poorly designed and as a consequence contribute to or directly result in detriment to the individual’s psychological health. Large-scale research shows that the prevalence of common mental health disorders is similar for unemployed people and those engaged in work characterised by poorly designed psychosocial job conditions, i.e. low control, high demands, insecurity and low job esteem (Butterworth et al, 2013). This combination of factors is not unusual in short-term employment. This places an emphasis on very careful consideration of suitability of employment prior to placement and also where placement is considered suitable, that work coaches are able to monitor concerns as they arise and act accordingly. This is likely to require additional resources to sustain over more than one Health and Work Conversation (p.26) but is vital to avoid worse case scenarios. We understand that the DWP/DH is currently unpicking this recommendation to consider meaningful activity as a health outcome – whether this be paid employment, unpaid/voluntary work, or basic functioning. We recommend that this is further developed by DWP/DH/NHSE as well as the explicit recognition that for some individuals their employment journey with the JC may not end in paid employment. There also needs to be serious consideration of what would constitute appropriate measurements of employment as a health outcome. We note that the Green Paper outlines the Government’s commitment for the DWP/DH to work with NHS England on “developing a basket of work and health indicators to support improved health and work outcomes”. We urge the Government to ensure expert input in this development work. The BPS and its Psychological Testing Centre provide advice on existing tests and their use including a wide range of occupational and health-related measures, as well as on links with accredited test users. Consideration should be given to drawing on this considerable expertise and utilising established and reputable assessments. For example within Occupational and Health Psychology measures of well-being and work environments have the advantage of being standardised, validated, widely used and provide norms for comparison, e.g. ASSET (RobertsonCooper). We emphasise that, in addition to the need for a flexible approach to employment, it is important for work coaches to understand the importance of social aspects of work for those with health conditions and disabilities. More specifically this should include the role of self-esteem (linked to self-worth), social identity and social comparisons (underpinning perceptions of group membership and fairness) and social learning theory (manifested in organisational culture) in helping to understand how the individual sees himself/herself in relation to work and the workplace and how colleagues within the workplace respond. The concept of social support at work is recognised as an important element for individual well-being and in the context of the Green Paper’s theme of changing attitudes towards disability, this plays a vital part too. As outlined previously, if the Government wants to improve people’s mental health and wellbeing it needs to consider not only the Jobcentre's role in increasing the rate of employment, but also in ensuring the quality of that employment. We fully accept that an individual’s health goals might include work, but this needs to come from that individual and not as a one-size-fits-all policy. If employment is to improve mental health it must be entered into without coercion and be of appropriate quality. Furthermore, for individuals with identified mental health conditions, it must be accompanied with tailored support and appropriate monitoring of continued improved mental health. Improving Access to Employment Support: Should we offer targeted health and employment support to individuals in the Support Group and UC equivalent where appropriate? Until the concerns regarding the assessment process that are outlined above are addressed, we have reservations about the wide effectiveness of any type of support that may be provided and are concerned about the consequences of inappropriate allocations of some claimants to the Support Group. This is particularly the case for young people with mental health conditions. For young people, the percentage of support group placements has increased most significantly due to “a depressive episode” or “other anxiety disorder”. In 2013, mental health conditions accounted for just under 50% of all young people placed in the support group. We are concerned that the current system of assessment is not sensitive or responsive enough to recognise that in some instances individuals initially assessed as falling into this category , may have “acute and generally self-limiting periods of illness from which they are expected to recover in the near future” (Litchfield Review, 2015, p.53). Placing such individuals in the support group may result in greater negative long-term consequences rather than providing appropriate short-term support (as outlined previously - such as the impact of labelling as “unfit for work” on self-esteem, self-worth etc. and the lack of access to positive, meaningful activities and engagement). We are particularly concerned however about the suggestion that conditionality may be extended to apply to the Support Group. As outlined earlier in this response, the effectiveness of conditionality in producing positive behavioural intentions is not supported by the evidence and more often is counterproductive and harmful to psychological wellbeing. In accordance with Select Committee on Work and Pensions (2017), we urge the Government to ensure that any steps to engage the Support Group are introduced on a voluntary basis and are led by the needs of individual claimants. How can we best maintain contact with people in the Support Group to make sure that no-one is written off? Co-location within health settings could be trialled as a means of maintaining such contact. However, it is important to acknowledge that being asked about work whilst seeking health support may exacerbate an already vulnerable individual’s condition, be detrimental to their trust in their HCP and puts a huge load on already pressured health services. Privacy and control of access to confidential clinical records are other important issues that require careful consideration. We urge the Government to ensure that any proposals are developed in consultation with relevant professional bodies and service users and fully trialled and evaluated prior to national roll out. Chapter 3- Assessments for Benefits for people with health conditions: Should the assessment for the financial support an individual receives from the system be separate from the discussions a claimant has about employment or health support? As outlined above, we strongly recommend that the methods of assessment under the benefits system require an end to end redesign and not just the separation of the financial and employment and health support components. Nevertheless, this may be a way in which the concerns regarding the conflict of interest between the dual roles of the work coach (as nurturer/supporter and policing/punisher) could be directly addressed. We recommend that this separation of finance and employment and health support should be considered further under a fundamental redesign of the current system. How can we ensure that each claimant is matched to a personalised and tailored employment-related support offer? As outlined above, we urge the Government to reform the WCA so that needs not capability are accurately and fairly assessed. The Government also needs to ensure that work coaches are appropriately trained and supported to work with claimants with a range of complex conditions. Our organisations are well placed to provide the expertise of its members to advise and assist in the necessary development of a revised form of assessment and the training required. Whilst the trialling of the Work and Health conversations is an important step towards developing individualised, tailored support, we are ultimately concerned that the Green Paper is focused on the quick fix and not the long-term resolution of a fundamentally flawed system. How might we share evidence between assessments, including between ESA/UC and PIP to help the DWP benefit decision makers and reduce burdens on claimants? We note that this would be dependent on consistency between assessments and how appropriate health information is obtained and recorded. As Capita is currently considering how best to reflect mental health conditions in the PIP assessments, we urge the Government to liaise with Capita to ensure that it is appropriate, compassionate, fair and compatible with the DWP’s own thinking. Building on our plans to exempt people with the most severe health conditions and disabilities from re-assessment, how can we further improve the process for assessing financial support for this group? As outlined above, we strongly recommend that the methods of assessment under the benefits system require an end to end redesign and not just the separation of the financial and employment and health support components. Nevertheless, this may be a way in which the concerns regarding the conflict of interest between the dual roles of the work coach (as nurturer/supporter and policing/punisher) could be directly addressed. We recommend that this separation of finance and employment and health support should be considered further under a fundamental redesign of the current system. However, we recommend that training on the impact of these long term conditions on mental, neurological and cognitive conditions and the needs of the individual is provided for specialist work coaches (including “early on-set” conditions such as Dementia). We also recommend that any assessments be based on detailed and accurate specialist reports (from ALL relevant health and social care professionals) on the individual’s condition, specific needs and their prognosis. Chapter 5 - Supporting Employment through health and high quality care for all: Improving discussions about fitness to work and sickness certification How can we bring about better work-focussed conversations between an individual, healthcare professional, employer, and JCP work coach, which focus on what work an individual can do, particularly during the early stages of an illness/developing condition? Whilst the development of the Work and Health conversations potentially introduces a more personalised element to work and health support, we urge the Government to address the wider concerns raised throughout this response. Culture change Suspend the use of conditionality and sanctions pending the outcomes of an independent review of their impact on mental health and wellbeing, material deprivation and efficacy in terms of boosting levels of meaningful employment. Appropriate specialist training for the work coach and involvement of HCPs and OHS with the appropriate expertise. We also emphasise that the multidisciplinary approach to supporting the individual is vital and understanding the individual’s condition is important for more successful outcomes. As mentioned previously the importance of social aspects of work play a key part in psychological well-being and research has consistently shown the significant contribution to the mental health of employees made by their relationship with the line manager as well as line managers’ behaviour (NICE, 2015). We suggest that work coaches should be in a position to share NICE guidelines about the role of managers with employers – particularly those who are unaware of them - in improving and maintaining the mental health of employees. This carries potential benefits for both new and existing employees and ultimately the functioning of the organisation. Where the employer and manager are different individuals, steps should be taken to involve the line manager in these discussions as appropriate. Are doctors best place to provide work and health information, make a judgement on fitness for work and provide sickness certification? If not, what other healthcare professionals do you think should play a role in this process to ensure that individuals who are sick understand the positive role that work can play in their recovery and that the right level of information is provided? We are concerned that the current system can operate under an overly medicalised model, sometimes relying too heavily on the input of General Medical Practitioners when other practitioners may also be leading key elements of care and support. It may be the individual’s psychologist, counsellor, psychotherapist, consultant, allied healthcare professional or social worker that is best placed to provide specialist input in relation to their physical, mental, neurological and cognitive functioning. We do note, however, the development of mental health training for GPs and the work of HEE, NHSE and RCGP on improving and extending the current training provision. Our members are well placed to contribute their expertise in the design and the delivery of such training. Chapter 5 - Mental Health and musculoskeletal services: How should access to services, assessment, treatment and employment support change for people with mental health or musculoskeletal conditions so that their health and employment needs are met in the best possible way? The Importance of the Workplace We are concerned that within the Green Paper, mental health provision is currently focused on the individual without obvious reference to their workplace (p. 69), whereas musculoskeletal problems are clearly considered in relation to the work context (p. 70). This creates the potential for an erroneous assumption that psychological well-being is routinely generalised in its influences and this risks underestimating the role of unhealthy working practices and therefore also of interventions to support individuals experiencing an episode of psychological ill health or condition. Whilst it can be the case that triggers for an episode of poor psychological health may be outside work, this should not be presumed and additionally there should be understanding that work-related factors can exacerbate individuals’ experience of ill health. We recommend that Occupational Psychologists are involved in working alongside Occupational Health departments (where these exist or in the absence of these) to help inform understanding of psychosocial aspects of the workplace and thereby facilitate assessment of these aspects and advise as appropriate in relation to ameliorating the impact of workplace factors on mental health conditions. This can be done in conjunction with employers and line managers as appropriate. Care Pathways and Cross-Agency Co-ordination When a JCP client accesses mental health support, such as psychological therapy, methods of joint working should be explored between the employment and health and care services to ensure the individual’s mental and physical health needs are met and adequate ongoing support is in place when they return to work. Any proposals, however, must keep the privacy of the individual in mind. Moreover, better coordination between the JCP and NHS services could of course help to improve awareness and understanding of mental health problems and chronic health conditions and how these impact on a person’s ability to work. Therapy delivery agencies within the NHS such as IAPT can also have a useful advisory and educational role for JCP work coach (i.e. assisting JCP staff in identifying self-help materials etc. to help their clients back to work). This requires significantly increased and improved joint agency working. However, as outlined in the Select Committee on Work and Pensions Report on Job Centre Plus (2016), there is concern that the JCP has limited experience of doing this. Importance of Informed Voluntary Choice We are concerned that when work coaches are considering making a referral of a claimant for psychological intervention or treatment for individuals, it is essential to ensure that this is understood to be voluntary and that there are a range of appropriate options to consider. We are strongly committed to the importance of ensuring a choice of interventions and that the means of delivery must be tailored to the individual as some interventions are not appropriate or effective for all. Inappropriate interventions can have adverse consequences on an individual’s understanding of themselves, their attitudes, behaviour and psychological wellbeing. Ultimately, any process designed to support those in need must uphold or improve the psychological wellbeing of those individuals. Genuine choice between these options means providing high quality information about what an intervention consists of, how it might benefit the individual, together with high quality consultations or assessments. The system must enable and engage the client to understand how the chosen approach will support and assist them. We recommend that the trials conducted under the Work and Health Unit consider the importance of the type of intervention beyond just CBT and IAPT. Chapter 5 - Transforming the landscape of work and health support: How can occupational health and related provision be organised so that it is accessible and tailored for all? How is this best delivered? We emphasise the role of psychologists (occupational, clinical, counselling and health in particular) and psychological therapists in providing occupational health support at an individual, population or organisational level to ensure that it is appropriately tailored and accessible. Chapter 5 - Creating the right environment to join up work and health: How can we best encourage innovation, promoting models of joint working such as co-location to improve health and work outcomes? We encourage the Government to commit to the continuation of investment in the Innovations Fund for the DWP to enable more RCTs followed by full evaluations incorporating the user’s perspective. However, whilst we note the increased use of trials and feasibility studies by the Joint Work and Health Team, some of these have, so far, only been subject to light-touch review. All trials should be rigorous, informed and subject to an in-depth, independent evaluation. References ACAS. (2017). Mental health. Available at: http://www.acas.org.uk/index.aspx?articleid=1900 British Psychological Society. (2016). Work capability assessment reform: Call to action. Available at www.bps.org.uk Boorman, S. (2009). NHS health and well-being review. 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