Poor mental health care in the workplace can create enormous costs for employers. But as Mark Armour explains, companies that provide employees with cognitive behavioural therapy by telephone can help reduce the number o incidences of mental health-related issues and associated costs.
In January 2014, Deputy Prime Minister Nick Clegg re-opened the debate about the state of mental health care in the NHS and across the UK. He launched a strategy document, Closing the Gap in which he outlined the current challenges facing those with mental health illnesses, including the stigma that still exists in many circles and the lack of joined-up thinking and practice, which can be observed in many parts of the NHS.
With one in four of us likely to experience a mental health condition at some point during our lives, the responses that employers make to their workforce’s changing mental health needs and how these can be effectively responded to and addressed, is something that all managers need to consider.
The Organisation for Economic Co-operation and Development (OECD) 2014 report Mental Health and Work: United Kingdom states that each year, mental ill-health costs the UK economy an estimated £70bn, equivalent to 4.5 per cent of GDP, through lost productivity, social benefits and health care.
Two key directions in the report were identified. Firstly, there should be policies that create early intervention at different stages of life, and secondly, there should be moves to integrate health and employment, with several core priorities highlighted, including “workplaces to protect and promote mental health in order to prevent illness and reduced productivity arising in the workplace and labour market exit of those still employed”.
The report further states that common mental health problems are widespread in the workplace and notes that poor mental health at work creates enormous costs for employers through absence and a fall in productivity. It concludes that resolving mental health problems should be a top priority, with employers in the best position to do so.
There is an estimated cost of £26bn a year in costs to employers, covering sickness absence, staff replacement and presenteeism, resulting in loss of productivity, and a further £15bn a year in costs to UK businesses whose employees remain at work with a mental health condition without the support they need. According to the Boardroom Briefing 2012, the proportion of surveyed employees reporting a rise in mental health conditions such as anxiety and depression has been steadily increasing from 21 per cent in 2009 to 44 per cent.
“The biggest challenges for an employer when dealing with an employee who is off with stress, anxiety or depression or other mental health issues is how to approach them, ensure they have appropriate support and manage an effective return to work,”€ﾨsays Clare Price, head of psychological therapies service at RehabWorks, a health and wellbeing service provider that works with blue chip and government organisations to provide a range of occupational health services for employees.
“From our perspective, one of the major barriers to maintaining people in work or getting them back to work can be GPs and other professionals who send them home and continue to sign them off sick,” says Price.
“This can lead to people just festering, being alone with their thoughts and feelings and becoming more anxious about returning to work. Equally, line and senior managers don’t know how to keep lines of communication open with their absent employee; they’re often worried they might make things worse and will back off€ﾨand leave the person who is signed off with minimum contact or interaction from the workplace.”
Price says that the majority of people she sees genuinely want to return to the structure that work provides, which means that work needs to be seen as part of their recovery. The National Institute of Clinical Excellence recommends cognitive behavioural therapy (CBT) as being at least as effective as medication in the treatment of common mental health conditions.
CBT is used as a talking therapy to help people experiencing a wide range of mental health difficulties, continues Price.
“How people think can affect how they feel and how they behave,” she says. “In its simplest form, this is the basis of CBT. During times of mental distress, people think differently about themselves and what happens to them. Thoughts can become at times extreme and unhelpful. This can worsen how a person feels. They may then behave in a way that can prolong their distress.”
The role of a CBT therapist is to help each person identify and change extreme thinking and unhelpful behaviour. In doing this, the result is often a major improvement in how a person feels and lives their life.
“Within a CBT framework, activity is definitely part of what helps a person to move towards recovery,” she says. “When people aren’t active, it doesn’t help them at all. CBT supports someone to stop avoiding and, in fact, face the things that may be maintaining their symptoms.”
Price adds that CBT can help people develop coping strategies to help them move forward and return to being a productive and effective member of the team. “Sitting at home ruminating doesn’t do any of that,” she points out.
Within a corporate environment, she says, businesses do need further education, both at board level and within the HR and health, safety, environmental and quality (HSEQ) function. Training for line managers is essential and should include resilience and stress management training, ideally delivered alongside treatment services for employees who are experiencing symptoms which are only likely to be resolved with intervention.
Another challenge Price identifies is that many businesses, large and small, don’t record absence in a meaningful and consistent manner. This makes it difficult to implement appropriate management strategies and evaluate the potential cost/benefit of prevention and treatment services to their business. The true cost is almost never recorded because people don’t phone in saying they’re anxious, stressed or depressed. They phone in with a cold or a stomach bug because those illnesses are more socially acceptable.
The recent Department of Work and Pensions (DWP) report Telephonic support to facilitate return to work: what works, how, and when? (RR853), released on 6 December 2013, echoes the value of CBT delivered in the workplace and in fact cites among others, RehabWorks’ approach to delivering CBT to client employees by telephone.
Price comments: “The DWP report validates what we demonstrate every day within our Psychological Therapy Service through continual audit€ﾨand the compilation€ﾨof practice-based€ﾨevidence.”
She agrees with€ﾨthe summary that€ﾨtelephonic approaches€ﾨcan be effective in€ﾨreducing the number of incidences of mental health-related issues and associated costs within the workplace and adds, “employers and employees alike benefit when work and work participation are at the heart of their service provider’s strategy”.
Service providers need to design services that show fidelity€ﾨto the evidence base and are responsive to the needs of those accessing them, Price goes on to say. They should also be delivered by appropriately-qualified professionals.
“There is a misperception that quality mental health services, which can impact on return to work, can be delivered without those basic components. If that happens, everyone loses as outcomes and levels of satisfaction are compromised and cost benefits and cost effectiveness are compromised,” continues Price.
“It is phenomenal that the DWP-commissioned review of the evidence proved the utility of telephone-based assessment and treatment services for common mental health conditions. The only way that healthcare can move forward is by innovation and contributing to the evidence for the future.”
Telephone services serve employees extremely well, they are accessible and acceptable especially as our affinity with technology continues to grow €ﾓ it has been estimated that the number of mobile phones will exceed the world population in 2014.
For many, particularly men, they are needlessly embarrassed€ﾨto be signed off work with depression and the thought of having€ﾨto attend CBT sessions face-to-face feels like another burden, something that can be another source of anxiety. Because CBT is€ﾨa collaborative therapy, it is necessary to have the full commitment and participation of the person.
A CBT therapist’s role is not to take sides, rather it is to provide a ladder and encourage the person to put a foot on the bottom rung and gradually climb out of the place they find themselves in.
They will consider the person’s symptoms and resources and work with the patient to enable them to return to, or function more effectively in, their identified role.
There can be an intricate balance between the person€ﾨand the employer or insurer. Good lessons can be learned through supervision, collaboration, partnerships and a shared understanding. RehabWorks’ clinicians take an open and honest approach with everyone involved.
“We do disclose functional information to employers. In other words, we talk about process rather than confidential information,” Price says. “This means the individual welcomes the validation we provide for them and we can encourage a staged return to work or reduced workload, or both if it is likely to assist and maintain the person at work in the longer term. We encourage people to talk with their line manager and we do too, which helps to stop things getting lost in translation.
“Beyond the work context, an NHS CBT practitioner would not have this direct contact with the workplace. A dedicated workplace service for employees delivers a much more value-driven service for both parties and does result in a speedy and effective return to work.”
In terms of benefits to employers, this can be separated into three distinct areas.
Firstly, introducing wellbeing services helps perpetuate an informal education programme on the management of mental health across the business through targeted and focused feedback. It can seem as if it is learned by line managers through a process of osmosis and this begins to permeate into wider management practice, which begins to challenge organisational cultures at ground level. The line managers throughout the business feel their own confidence improve as they learn to manage employee mental health in the future while support systems are set up to implement new suggestions or actions, which reassures managers that they are in fact doing the right thing for their employees. This area can sometimes be seen as less tangible, but is no less important.
Secondly, there are clearly tangible cost management benefits to businesses that seek to manage employee wellbeing in a proactive, targeted manner. The cost savings to the organisation brought about through early access to evidence-based services pay for themselves and, in the long term, this reduces absence costs to business.
Furthermore, employees become more resilient, either through resilience training or as a result of the CBT and are then less likely to be absent for as long, if at all. Those that return to work from a period of absence do so more quickly than otherwise, and are consequently more productive. Staff are also supported to make not just a return to work, but a sustainable return to work. Employees generally deliver an enhanced performance through positive wellbeing and a business committed financially to improving its employees’ health and wellbeing will enjoy an overall reduction in sickness absence and staff turnover.
Finally, the organisation will benefit from an improved corporate and brand image. Investing in employees supports objectives of corporate responsibility and shared accountability. It underpins goals of inclusion within the workforce, and raises a business’s external perception as a caring employer that doesn’t merely give lip service to investing in its people. This should closely align with its strategic objectives, support skilled and experienced employee retention and achieve improved overall productivity for the entire business.
One major utilities client appointed RehabWorks to run a pilot scheme focused on mental health rehabilitation following successful implementation of its physiotherapy services. The pilot was available to employees who were both at work and off work and the pilot was evaluated in June 2013.
The cost benefit analysis showed that the employer invested £20,000 in those employees who were off work and a further £25,000 for those participating employees who were at work. Cost savings were calculated using MDGuidelines, a respected and internationally-adopted US database that is widely used by the insurance and other industries to calculate how sickness absence financially impacts the workplace. This took into account the cost of days saved from earlier returns to work and days saved by preventing absence. Direct costs only were calculated and other associated costs, such as replacement staff, were not evaluated. In total, the blue chip utility provider invested £45,000 and found a saving of £403,000, creating a return on investment of 9:1 or 900 per cent.
The OECD report cites an example of good practice in€ﾨUK companies like British Telecom for taking a three-tiered approach to good mental health practice in its business. Another RehabWorks client, the CBT service was launched and used by more than 200 people, with satisfaction rates reported as being very high. There has been a 30 per cent reduction in mental health-related sickness absences and a return to work rate of 75 per cent for people absent for more than six months.
Mark Armour is the clinical director and chair of the Clinical Governance Panel
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