In these unstable times, in parallel to the broader NHS crisis, Britain faces a mental health crisis. Mental illnesses triggered by the fallout from the Covid-19 pandemic, rapidly rising energy costs, inflation, spiralling personal debt and unaffordable housing risk overwhelming health services. It is time to radically change the way front-line public services outside of the NHS are designed so that they can be used to respond to the crisis. This can save money and prevent people from becoming ill.
The wider economic costs of mental illness in England alone have been estimated at £105.2bn each year. Mental ill health is the second-leading cause of disability in the UK. Data from the Office for National Statistics shows that 10 per cent of the UK workforce (2.5 million people) is registered as long-term sick. And 40 per cent of those who find themselves out of work cite their mental health as a key reason. Even before Covid-19, 23 per cent of those receiving Jobseeker’s Allowance (JSA) were suffering from common mental health problems.
Meanwhile, the British economy is driving precarious employment, declining living standards and growing household debt. Millions of workers are finding that one job cannot provide enough to get by, let alone move up the social mobility ladder. Compounding the problem, the sick and mentally unwell do not have the time, personal resources or energy to search for jobs. With budget cuts and austerity measures to come, unemployment, joblessness and poverty will likely rise. We know these have a devastating impact on mental health.
The constant restructuring and dissolution of public institutions such as Public Health England, NHS Digital and NHSX have also had a destabilising effect on the government’s ability to respond to social and economic crises. In a state of flux and insecurity, civil servants and front-line staff are overwhelmed and demoralised. On the ground, services are chronically underfunded and over capacity. The investment required to restore the operational capacity and capability of mental health services after years of neglect is dependent on a stable government and capable ministers committed to change. It critically depends on how much they understand that their existing brief should extend beyond hospitals and clinics.
The NHS has become a “sick service” where you go to get fixed, much like taking your car to a garage when it needs repairs. It is no longer the public health system or institution that prevents people from becoming ill. But as the evidence shows, our health and wellbeing are influenced by social, economic and political circumstances. Despite this, policymakers are yet to fully grasp the preventative approach that can tackle the causes of mental ill health.
The 2022 Health and Care Act and the creation of integrated care systems (ICSs) have begun to address the wider social and economic determinants of health, creating more joined-up policy in tackling health disadvantages and inequalities. The former health secretary Sajid Javid’s mental health and wellbeing plan attempted to create a more holistic approach to preventing mental ill health and suicide among the most vulnerable. However, implementing these changes will require time, and little is said of how to actually do it.
[See also: Well-being at work is key to growing the economy]
Unfortunately, at all levels of government – from the national and regional to the local – health is viewed as being in the hands of clinical services. Given the immediate social and economic challenges the country faces, we need to urgently move beyond this and focus on preventing people from becoming patients in the first place. This means that the NHS, in cooperation with services such as job centres and employment providers to housing associations, need to increasingly operate together. Departments outside of the NHS, such as the Treasury, the Department for Work and Pensions (DWP) and the Department for Business, Energy and Industrial Strategy, need to provide the leadership and guidance. These departments create the social and economic context in which people can find stability and mental health can flourish.
Job centres have barely changed since New Labour reformed the welfare system after its election victory in 1997. The majority are outdated and demoralising places, as many who have to use them will tell you. But this is counterproductive and detrimental to people’s mental health, employment and economic outcomes. There are thousands of people passing through these services on a daily basis, yet little is known about their mental health, or how to collect this data and signpost them for appropriate support.
Job centres are an ideal setting for delivering vital public health and preventive support services. They need to be places of support, stability and rehabilitation, where people receive professional help both with their job search and mental health issues. There are new initiatives linking employment services to improved access to psychological therapies (IAPTs) and pilots of “health model offices” (HMOs). The problem is that, in reality, you have to be nearing a catastrophic mental health episode to be clinically referred to IAPTs, and HMOs are still to be fully tested. Large numbers of people are reporting mental health conditions as a reason for being unable to work. And yet, front-line services such as job centres lack the operational capacity to triage vulnerable people with mental health issues at pace and scale. Integrating early identification of mental health risks into non-health services is vital for prevention.
Part of this new approach requires reframing the role of the job centre “work coach” as an “employability and social support adviser” – professionalised and well paid to reflect the heavy workloads and safeguarding responsibilities they undertake. Luckily, there are existing models for this, including career guidance services for young people and good-quality back-to-work programmes offering counselling-style support delivered by qualified professionals. This holistic approach promotes access to learning and skills as well as work, while seeking to support people with mental health issues, personal needs and domestic constraints – all of which promote social support, stability and employability.
The government faces an enormous challenge in trying to stabilise the economy while offsetting the effects of dramatic economic changes on the most vulnerable. To meet it, a cultural shift is required that involves a more agile, systemic and human-centred approach to policy design and implementation. The Treasury, Department of Health and Social Care, NHS, DWP and job centres in cooperation can prevent thousands of people becoming ill due to a likely surge in unemployment and poverty over the coming years. These policy choices will affect not just the economy, but the health, wellbeing and productivity of the nation for the next ten years and beyond.
With thanks to colleagues from the NHS, JCP, DHSC, and the Office for Health Improvement and Disparities (OHID).
Dr Coutts is supported by the National Institute for Health and Care Research (NIHR) Applied Research Collaboration, East of England (NIHR ARC EoE). The views expressed are those of the author and not those of the NIHR.
[See also: Two thirds of young people say work damages their mental health]
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