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Mental Health and Social Inclusion

Severe mental illness & employment: cost-benefit analysis and dynamics of decision
making David Booth Simon Francis Neil Mcivor Patrick Hinson Benjamin Barton
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David Booth Simon Francis Neil Mcivor Patrick Hinson Benjamin Barton , (2014),"Severe mental illness & employment:
cost-benefit analysis and dynamics of decision making", Mental Health and Social Inclusion, Vol. 18 Iss 4 pp. 215 - 223
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Severe mental illness &
employment: cost-benefit analysis
and dynamics of decision making
David Booth, Simon Francis, Neil Mcivor, Patrick Hinson and Benjamin Barton

David Booth is a Chartered Abstract


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Occupational Psychologist, Purpose – The purpose of this paper is to explore the economic benefits of Individual Placement with
Simon Francis is a Senior Support programmes commissioned by NHS North in the North West and Yorkshire and Humber
Policy Advisor and Neil Mcivor regions. Design/methodology/approach – A literature review was conducted and data collected from
is a Chief Statistician, all are supported employment programmes in four localities. An econometric analysis was performed to
based at Department for Work evaluate likely savings for local commissioners and return on investment for the Treasury.
and Pensions, Sheffield, UK. Findings – Integration of employment support within mental health services is central to success.
Patrick Hinson and Benjamin Econometric analysis showed that local commissioners could save £1,400 per additional job outcome
by commissioning evidence-based interventions and there is a positive return on investment to the
Barton are Researcher, based
Treasury for every £1 spent there is a return to the Treasury of £1.04.
at Sheffield, UK.
Originality/value – This paper demonstrates the economic and social value of evidence-based
supported employment for people with severe mental illness. The economic data generated could be
helpful in encouraging investment in effective employment support in other areas. The work, views
and perspectives contained in this paper are those of the authors. It does not necessarily reflect the
views of the organisations for whom the authors work.
Keywords Social exclusion, Employment, Cost-benefit analysis, Economic and social
costs, Individual placement and support, Severe mental health problems
Paper type Research paper

Background to the study


This research was commissioned by NHS North to investigate the potential broad-based
economic benefits accrued from their investment in mental health and employment, and
also to understand the dynamics of local decision making. Most of the projects studied,
which were based on the Individual Placement and Support model, took place in the North
West and Yorkshire and the Humber regions and ran for two years.

This study offers insight into local decision making and will highlight the broad economic
and social benefits of employment for people with severe mental illness, with a primary
focus on health, using data captured from four localities. The intention is that the
economic arguments outlined in this paper will be helpful in encouraging investment
towards positive and recovery-focused interventions.

Around £2 m was invested, covering around 20 individual projects, ranging from direct
The work, views and
perspectives contained in this employment services to capacity building and developmental projects such as training
paper are those of the authors. It packages and web-based support. The primary driver for this investment was the now
does not necessarily reflect the
views of the organisations for defunct Public Service Agreement 16 (PSA16) on socially excluded adults (PSA Delivery
whom the authors work. Agreement 16, 2007).

DOI 10.1108/MHSI-08-2014-0025 VOL. 18 NO. 4 2014, pp. 215-223, C Emerald Group Publishing Limited, ISSN 2042-8308 j MENTAL HEALTH AND SOCIAL INCLUSION j PAGE 215
Poor mental health brings with it a significant cost, estimated to be around £105 bn (Sainsbury
Centre for Mental Health, 2010). This figure is for all mental illness, people with severe and
enduring mental illness constitute only a small fraction of the overall number. It is reasonable to
assume, however, that a disproportionately high element of this cost is taken up by people with
severe and enduring mental illness, as treatment and other costs are much higher for this group
and they tend to draw on services for prolonged periods of time.

Context
Employment rates
Research continues to highlight the poor labour market position of people with mental health
needs; the mental health group constitute the highest proportion of people on disability benefits;
they have amongst the lowest employment rates; and have difficulty in retaining jobs when
mental health problems occur. In an economic downturn they have a lower re-entry rate into the
labour market than other disadvantaged groups (Booth et al., 2007).

The employment rate for people with severe mental illness is significantly lower than both
the general population and disabled people generally, including those with common mental
health conditions. This, despite the high proportion of people with severe mental illness
who say that they want to work (Grove, 1999). For the general population, a will to work is
a strong determinant of the likelihood of securing employment, which unfortunately does
not apply to people with severe mental illness creating a disconnect between people’s
employment ambitions and subsequent outcomes (Figure 1).
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Cost

Whilst there have been several attempts to quantify the likely cost-benefit of mental health
and employment, the evidence is not strong. Kirklees Local Authority, working with the
New Economics Foundation, have undertaken some economic modelling on prospective
savings to health, comparing traditional methods of treatment against a more innovative
and recovery focused approach. The recovery focused journey assumes a job at just
below the minimum wage, (experience suggests that this is not always the case, and often
people earn more than this), and a reduction in secondary service usage over time. In
Kirklees, the immediate savings to the state are around £35 k per person over two years.

Figure 1 Relative employment rates for people with mental health conditions, those with
disability and the general population

100.00%
90.00%
80.00%
70.60%
70.00%
60.00%
50.00% 46.20%

40.00%

30.00%

20.00% 8.40% 15.00%

10.00%

0.00%
Those receiving People with any People with any Whole economy
secondary mental mental illness disability working age
health services on the employment rate
Care Programme
Approach

Sources: Routine quarterly Mental Health Minimum Dataset (MHMDS) reports:


NHS Information Centre, (2012), and Labour Force Survey, (2012)

PAGE 216 j MENTAL HEALTH AND SOCIAL INCLUSION j VOL. 18 NO. 4 2014
The association between poor mental health and poverty

Whilst mental illness does not discriminate, anyone can become mentally ill, its incidence
does show patterns There is a strong association between poor mental health and poverty.
The graph below shows that there is a significant correlation between low income and
severe mental illness (Figure 2).

Individual placement and support (IPS)


Most of the evidence about what works suggests that the IPS approach is the most
effective way to help individuals with severe mental illness gain competitive employment.
A multi-site European trial found that individual placement and support clients had fewer, shorter
hospital stays than clients in traditional services (Bond et al., 2008), which contributed to significant
savings of in-patient costs over an 18-month period. These findings were recently corroborated by a
US study which found that mental health service costs over a ten-year period were 50 per cent lower
for people supported into regular employment than among other groups (Drake, 2008).

There is some evidence that the effectiveness of IPS can be improved still further by
coupling it with a cognitive training programme (McGurk et al., 2005). Over a two- to three-
year period participants who had cognitive behavioural therapy along with supported
employment were more likely to work more hours and more weeks than those in the
programme that offered only supported employment. Clients also had significantly greater
cognitive function and fewer depressive incidents than their counterparts. This suggests
that there may be obvious benefits in the UK of pairing Increasing Access to Psychological
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Therapy services with evidence-based supported employment programmes.

Methodology
The first stage of this research was to conduct a literature review, using over a 100 relevant
publications on employment support for people, with severe mental illness. This included an
examination of previous approaches to the economic cost-benefit analysis which frame this
study. The documents were drawn from a broad range of sources including government
departments, randomised controlled trials, meta-analyses, charities with a focus on mental
health and employment, and a variety of journal articles. The results were used in three ways:
1. to inform the development of the questions for site visits;
2. to generate ideas and inform thinking for building the cost-benefit model; and

3. to check assumptions in the research findings in order to test whether our outcomes
were broadly comparable with results from previous studies.

Figure 2

Prevalence of Psychotic Disorder in the past year


(age-standardised) by equivalised household income
1
0.9
0.8
Per cent

0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
Highest Second Third Fourth Highest
Equivalised Household Income
Source: Dorling (2009)

VOL. 18 NO. 4 2014 j MENTAL HEALTH AND SOCIAL INCLUSION j PAGE 217
As part of this the team set up an intercontinental discussion with experts from the USA
and Canada, to share thinking on the overall approach and to make best use of their
knowledge and expertise.

This was followed by a data trawl to see what information was available. National and local
databases were utilised to evaluate the results and to cross-check the analysis.

The next stage was to further our understanding of the dynamics of local decision making
and to get a practical feel for local delivery. This was done through qualitative interviews
with key staff members representing four sites, two in the North West region and two in
Yorkshire and the Humber region. This information, along with service and performance
data helped to inform the cost-benefit model and the overall analysis, thus ensuring that
the evidence presented was meaningful.
The findings were then checked by peers to quality assure the methodology and outcomes
to give the piece critical validity and credibility.

Findings – the site visits


Researchers visited and collected data from several sites across the north of England to gather
data in order to perform a real time cost-benefit analysis of services. Whilst the primary driver for
this report was a better understanding of the economic rationale for investment, researchers
also gained insight into the dynamics of local decision making, including commissioning. All sites
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were only working with those people in the secondary mental health system and on the Care
Programme Approach, arguably one of the hardest groups to place into employment.

All of the sites stressed the importance of local integration and connectivity between health and
employment services, and most were funded with an expectation that they would use the IPS
approach. Closer integration of employment with health means that the employment, and thus
recovery becomes embedded within the care and action planning process.

Employment and Support Allowance (ESA) and Workplace Capability Assessments (WCA)
are seen as major issues for services as customers are generally concerned about future
welfare provision. This would appear to have impacted on progress to work for some
individuals. This is further hampered by a disconnect between primary and secondary
services (clients being ineligible for IPS services in primary care), and an overall lack of
awareness from primary care services, resulting in a lack of referrals.

Although anecdotal, managers felt that service users gained wider benefits from using the
services such as needing less medication; fewer accident and emergency visits and fewer
visits to a clinician. Service user satisfaction surveys appear to confirm this.
People in secondary mental health services appear to be struggling with alternatives like work
choice (many clients being deemed unsuitable) and the work programme where the service may
not be geared up to adequately serve the needs of those with severe mental illness.

When asked the question what would encourage increased investment in employment, it
was suggested that “were they to start from the beginning, there would probably need to
be fewer doctors and nurses, as fewer patients would need formal treatment. Unfortunately
throughout the country investment almost always goes into front line services, rather than
in preventive interventions”.

The site visits enabled the researchers to gain an insight into local decision making and
how this translated into operational delivery.

There was much agreement between the sites about potential success factors with full
integration with local mental health services achieving being a major critical success factor.
The role of local targets linked to reducing health and social inequalities through
employment also figured highly.

Additional support given to help employers was mentioned by two services as contributing
to their success in employer engagement. By considering and responding to employers’

PAGE 218 j MENTAL HEALTH AND SOCIAL INCLUSION j VOL. 18 NO. 4 2014
difficulties, such as health and safety and human resources, particularly among SMEs, the
service can reap benefits for their clients. It enables the service to develop a mutually
beneficial relationship with employers that can be used to benefit customers in the longer
term.

Findings – the cost-benefit analysis


The main purposes of the cost-benefit analysis are twofold; first, to consider the local effects on
the reduction in service use, compared to the cost of investment in employment; and second to
look at the potential benefits to the exchequer from effective evidence-based interventions. This
“fiscal” benefit comprises benefit savings including unemployment, housing and council tax
benefit and increased direct and indirect tax revenues.

Data from these site visits ranged in quality, from high-level management information, to
detailed individual level anonymised data, which included wages and hours worked for
each individual in employment.

A total of 262 people were referred to these services in 2010/2011, 79 of which secured
paid employment during that time. Seven of these found employment of four hours or less,
16 were employed for between five and 16 hours, the remaining 56 for 16 hours or more.

Analysis was conducted using each of these groups. Employment of 16 hours or more is
important for fiscal and economic calculations, as this is generally the point where benefits
stop and tax credits start being received. However, in calculating the local benefit, which is
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primarily concerned with reduced service provision, any job can be seen to be important.
This research did not find any evidence that a one hour a week job reduces symptoms and
service need, however, it is generally accepted that work is good for people with severe
mental health conditions.

Additionality

Not every job outcome of a back to work programme can be claimed as being a direct
result of that programme. Some outcomes would have occurred despite the programme.
These naturally occurring outcomes are referred to as deadweight. It is vital in any serious
cost-benefit analysis to only consider those outcomes that occur because of the
programme, that is, the additional jobs (additionality) the programme delivers.
The Labour Force Survey is the source most commonly used for determining employment rates.
This survey is a self-declaration survey, where being in employment is defined as completing at
least one hour of paid work during the week before the interview. Owing to the relatively small
sample sizes for specific self declared disability, it is only possible to give a range of between 12
and 18 per cent for the employment rate for those suffering from “Mental illness, phobia, panics
and other nervous disorders”. Arguably this is also an over estimation of the client groups
covered by the CPA including the client group studied as part of this research.

The NHS Information Centre (NHSIC) publish National Statistics from their Mental Health
Minimum Data Set (NHS Information Centre, 2012), which now also includes employment
rates, and suggests that the rate for the client group we are most interested in for this
research is around 8 per cent.
For the purposes of this analysis the NHS IC is the figure used. The additionality factor is
therefore calculated as follows:

Additionality factor ¼ ððNj NrÞ EÞ ðNj NrÞ

where Nj is the number of jobs, Nr is the number of referrals and E is the natural employment rate.

Therefore:

ðNj NrÞ ¼ 79 262


¼ 0:3ð30%Þ

VOL. 18 NO. 4 2014 j MENTAL HEALTH AND SOCIAL INCLUSION j PAGE 219
So Additionality factor ¼ ð0:3 0:08Þ 0:3
¼ 0:73ð73%Þ

This tells us that 58 of the 79 jobs achieved (73 per cent), are as a direct result of this intervention.

McCrone and Dhanasiri (McCrone et al., 2008) estimated the average service unit costs
(in 2007/2008) for various mental health conditions. By using uprating factors (HM
Treasury, 2011-2012) supplied by HM Treasury these can be shown as 20,012 prices.

Impact on service use

Highly significant reductions in service use have been associated with steady employment.
(Bush et al., 2009) suggest that over a ten-year period, service use costs reduced
significantly for both those with steady work (individuals whose work hours increased
rapidly and then stabilized) and minimal or no work. However, the steady work group
reduced significantly more than the other groups. Bush et al. (2009) suggested that the
annual costs for outpatient services and institutionalised days were more than twice for the
minimum work group than the steady state group over ten years (Bush et al., 2009).

Data from the King’s Fund (2012) was used to estimate the average service cost per
person for a range of mental health conditions. These data, at 2007-2008 prices, were
uprated to 2011-2012 prices using GDP deflators consistent with the Autumn Statement,
29 November 2011 (Table I).
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Using a similar demography as the case studies we have looked at, the individual service
costs (in 2011-2012 prices) is estimated to be around £3,800.

The reduction in treatment is hard to quantify, but anecdotal evidence would suggest that
around 25 per cent service use reduction can be obtained for those with schizophrenic,
bipolar or personality disorders, and around 50 per cent reduction in services for the other
conditions in this client group.
Using McCrone et al.’s (2008) data we can estimate the savings to primary provision in these four
case studies of around £1,350 for each individual placed into at least one hour of employment. Indeed
these savings may increase over time as sustained employment decreases further the ongoing
service provision required. This is comparable to the potential savings of ££1,290 suggested in the
analysis of Kent Supported Employment (KSE) (Kilsby & Beyer, 2010).

In order to calculate the cost effectiveness of this provision over other types of provision it
is best to look at the costs of getting one individual into work. The four interventions
investigated cost a total of around £350,000, and obtained 79 jobs at a cost per job of
around £5,670 (£6,250 for 5 þ hour jobs and £8,030 for 16 þ hour jobs); and a unit cost
(cost per referral) of around £1,700.
Comparable costs are shown in Table II.
The only directly comparable cost here is the KSE, which looked at a similar client base.

Table I
2007-2008 average
annual
service cost per 2008-2009 2009-2010 2010-2011 2011-2012
person (£) (£) (£) (£) (£)

Depression 2,085 2,148 2,186 2,245 2,304


Anxiety disorders 1,104 1,124 1,154 1,184 1,184
Schizophrenic disorders 10,687 10,976 11,262 11,262 11,262
Bipolar 1,424 1,461 1,461 1,461 1,461
Eating disorders 137 137 137 137 137
Personality disorders 286 286 286 286 286

PAGE 220 j MENTAL HEALTH AND SOCIAL INCLUSION j VOL. 18 NO. 4 2014
Table II
Provision Cost per job (£)

Residential training colleges 78,000


Remploy sheltered employment 25,000
Kent supported employment 15,818
Remploy employment services 3,400
Access to work 2,900

Note: Unit costs in the above table are for 2009/2010 costs per job of DWP’s work choice programme are
not available
Sources: Sayce (2011) – “Getting in, staying in and getting on”

Fiscal and economic benefits


The fiscal and economic benefits arising from these services have been analysed.

This “fiscal” benefit is comprised of benefit savings including unemployment, housing and
council tax benefit, and increased direct and indirect tax revenues.

Gross wages for those entering employment ranged from minimum wage, around £230 for
someone working a 38-h week, to a notable instance of £20 per hour, although this was for
only a few hours per week. Gross weekly wages ranged from just £28 per week to £420.
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Clients referred to these programmes ranged from being on a variety of benefits (ESA,
JSA, Income Support) to not being on benefits at all. Detailed analysis of these pre
employment incomes suggest that the average annual benefit cost, including Housing and
Council Tax credit, was around £9,445.

In order to assess the additional costs and benefits in terms of increased tax and reduced
benefit payments, demographic breakdowns were used to assume benefit levels, including
Housing and Council Tax Benefit. Changes to the rules regarding Housing Benefit and the
introduction of local area housing allowances necessitated using local area calculators for
the areas covered by this study (Tonbridge and Malling).
The gross fiscal benefit for each additional job is calculated by summing individual’s tax and
National Insurance credits, employers National Insurance, any additional working or child tax
credit, savings from benefits payment and the net increase in indirect taxation created by a
greater disposable income. Most extra money for those on low incomes is spent on items which
in themselves generate tax income for the exchequer. This is then netted off against the costs of
provision, and the savings to healthcare resulting from increased employment.

If we only consider those jobs of 16 hours or over, whereby individuals lose most benefits
and are entitled to tax credits, the total net fiscal benefit was around £3,030 per additional
job and a spend to save ratio of 1.04.

The spend to save ratio is calculated by dividing the gross fiscal benefit cost of the
programme and gives an indication of value for money to the treasury.

This means that for every £1 spend on these programmes, the exchequer receives £1.04
as a result of increased tax and reduced benefit payments.

Conclusion
This paper presents both an economic and social argument for the continued and increased
funding of evidence-based employment provision for people with severe mental illness.

The evidence for the beneficial health effects of employment is very strong and is at the
forefront of successive government’s back-to-work and welfare-to-work message
campaigns. Conversely there is indisputable evidence that unemployment is generally bad
for health.

VOL. 18 NO. 4 2014 j MENTAL HEALTH AND SOCIAL INCLUSION j PAGE 221
The picture for those people with severe mental illness is more complex in that all the negative
effects of unemployment and the general health benefits of employment apply. Employment can
also be instrumental in reducing reliance on statutory health and social care services. However,
despite many people with severe mental illness wanting work, and the government’s efforts to
improve outcomes, the employment rate for this group remains pitifully low.

Unless there is a significant change, this already disenfranchised group will continue to
struggle to gain a meaningful stake in society by being full, active and valued members.
There is also a strong likelihood of future and ongoing negative effects on families and
children. Whilst employment is not the only way to increase social inclusion, it is an
important one, not least because of the high social value placed on work.

Local investment decisions are sometimes made without reference to evidence-based


argument, and against a backdrop of limited budgets and competing local priorities. Local
leadership and influence makes a difference to whether ideas take hold and it is interesting
that two of the programmes studied that have secured additional funding have been
running the longest. Perhaps then local decision making is driven by the fact that these
services have become mainstream within local health service funding.

One of the other services studied is also hopeful of securing at least additional short-term
funding and this again would appear to be because there is a strong local impetus to
improve the employment of people with severe mental illness, in spite of the demise of the
original driver (PSA 16). The exploitation of major, national drivers, then, can stimulate
local service developments in this area given the will and interest of local decision makers.
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This is likely to be key for wider-scale adoption of programmes like these.


A key success would seem to be the level of integration of employment within local mental health
services. This promotes the inclusion of employment more tightly with care plans, leading to a more
effective service and better experience for the customer. In one service integration was made easier
by an existing good track record of the service in providing other services to the local mental health.
The lesson here suggests that parachuting a brand new service provider into a locality with short-term
funding is probably less effective. Relationships, including trust, are harder to develop and penetrating
the local mental health system is more difficult. By the time any real progress and cooperation is made
much of the project run-time is gone. The current approach to funding is, therefore, probably
hindering, more than helping the development, of effective services and is certainly affecting the ability
to collect consistent data across a meaningful time span.

The economic analysis in this study has, by necessity, been based on limited live data and therefore
contains many assumptions. It does though present a very positive picture for the individual and their
family, particularly when the benefits gained are broadened to include personal health and social
benefits. For localities, reductions in health and social care reliance can be translated into savings.
According to this study local commissioners could save £1,400 per additional job outcome by
commissioning evidence-based interventions. This could be re-invested according to local priorities.
There also appears to be a positive return on investment for the Treasury. From this study it would
appear that for every £1 spent there is a return to the Treasury of £1.04.

Increased access to evidence-based programmes and interventions as outlined in this and


other studies, represent a possible new future for those facing a lifetime of unemployment
and social isolation, actively demonstrating very encouraging levels of success. Individual
Placement and Support programmes in particular have shown that they can achieve
positive employment outcomes at much higher levels than more traditional approaches.

In summary, in order to make social integration, participation and choice a reality for people with
severe mental illness we need an evidence-based efficient, effective and respectful intervention,
or suite of interventions, that people can use to secure and maintain sustainable employment.

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Corresponding author
Simon Francis can be contacted at: simon.francis@dwp.gsi.gov.uk

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