Qualitative evaluation of a job retention pilot for people with mental health problems

Abstract

The aim of this study was to evaluate a job retention service intended to support GPs in preventing unemployment among patients with mental health problems. Interviews with job retention clients, their employers and case managers were carried out. A group interview with GPs was also conducted. Client-focused interventions were reported to be helpful by clients and GPs and employer-focused interventions were appreciated by both clients and employers. All clients attributed positive outcomes to the service. In conclusion, these preliminary results support the further development and evaluation of job retention services.

INTRODUCTION

Unemployment associated with mental health problems is widespread and increasing.¹ As the clinicians responsible for signing sickness absence certificates in the UK, GPs could play a pivotal part in reversing the slide to long-term unemployment. In Australia job retention services based on a case management model have proved effective in supporting GPs to do so across conditions, including mental ill health.²

In 2002 the UK Department of Health and Department for Work and Pensions funded a pilot service based on the Australian model.³ The service was delivered by a job retention team located within a mental health NHS Trust. Two case managers provided the service, to which GPs in four collaborating practices referred patients. The project was evaluated over its first year of operation.

METHOD

Study samples

All 16 clients with whom the job retention team had worked before April 2003 were invited to interview and 13 agreed to take part. All clients consented to their case manager being interviewed, seven to their employer being contacted and 10 to contact with their GP. Six employers, six GPs and both case managers agreed to interviews (several GPs had more than one client using the job retention team service; a total of seven were invited to participate).

Data collection

Semi-structured interviews explored participants' experiences of the job retention service. Due to constraints on their time, GPs were invited to participate in a group interview.

Analysis

Interviews were recorded and transcribed verbatim. The ‘frameworks’ approach was used to inductively identify key themes within and then across stakeholder groups in relation to the main interview topics.⁴

RESULTS

All study participants agreed that the job retention service was valuable. As one GP commented:

‘I tend to the person's mental health, do sickness certificates and prescribe medication. I can't be an expert on employment law and spend time negotiating with employers.’

Client-focused interventions

The 13 clients commented on how helpful it had been to have someone who was supportive and listened to them. Over and above this supportive counselling, clients described four further types of intervention they had found helpful:

• Vocational counselling aimed at planning their return to work, in some cases to a more appropriate job (13 clients);

• Specific mental health interventions, including anxiety management, confidence building and assertiveness (13 clients);

• Encouraging clients to explain the problems they were experiencing to family members, an intervention reported to increase family support (4 clients);

• Ongoing support once the client had returned to work (11 clients).

Employer-focused interventions

Ten clients reported that their case manager had been an advocate for them with their employer and many highlighted this as the most helpful intervention. In addition, clients described two further helpful employer-focused interventions:

• Assistance with legal issues arising from work situations (3 clients);

• Negotiation of adjustments to facilitate return to work (6 clients).

Employers also reported that it was helpful to have someone negotiate adjustments and return to work plans. They also valued information and support in relation to managing employees with mental health problems and access to an objective perspective. Across all their clients' employers, however, the job retention team case managers experienced a range of reactions. While some were supportive, others were resistant to intervention. In these circumstances the case managers had to take a more assertive stance, including highlighting legal obligations.

Reported outcomes

Seven clients retained employment in their original organisation. All seven thought they would either have lost their job without the job retention team's involvement, or would have had a delayed return to work and further sickness absence. Four clients obtained new jobs that they thought more appropriate, while two were still looking for work when interviewed. These six clients thought their mental health would have deteriorated without the support provided.

How this fits in

Unemployment associated with mental ill health is widespread and increasing. In Australia, job retention services based on a case management model have proved effective in supporting GPs to prevent the slide into unemployment and criteria associated with effective services have been established. Job retention services based on the Australian model hold promise for preventing unemployment due to mental ill health in the UK, although further evaluation is required to establish effectiveness. Further criteria for effectiveness may include family support and a neutral stance where employers are supportive.

DISCUSSION

Larger scale evaluation is required to establish the effectiveness of job retention services, but comparison with the international literature does provide support for the present promising results. A literature review (K Thomas, J Secker and B Grove, unpublished data, 2002) identified seven criteria associated with effective job retention services, all of which were met by the job retention team:

• Vocational counselling;

• Mental health counselling;

• A primary allegiance to the client;

• Advocacy for the client in the workplace;

• Facilitating communication between employee and employer;

• Providing information, advice and training for employers;

• Ongoing support.

Additionally, this study suggests that family support can be important and that while a primary allegiance to the client may be called for where the employer is not willing to engage, where the employer does engage, a neutral stance with support for both parties may be more appropriate.

Funding body

Department of Health and Department for Work and Pensions

Ethics committee

Swindon Research Ethics Committee (SW22/2002) and Bath Local Medical Ethics Committee (BA283)

Competing interests

None