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Mental Health

Volume 701: debated on Thursday 15 May 2008

asked Her Majesty’s Government in light of the Sainsbury Centre for Mental Health report on the cost to business of mental ill health at work, what support they are providing to business to deal with mental ill health at work; and what plans they have to ensure that the public sector leads in this area.

The noble Baroness said: The Sainsbury centre report, Mental Health at Work, was what alerted me to these serious issues and led me to table this Question. I need to declare an interest as an adviser to the trustees of the Sainsbury centre, but I also have some experience of this, having been the chair of an NHS trust for four years and having seen several of my employees, numbering in the teens, who confessed to me after I had stepped down that they had been mentally ill during the time they were employed by the trust but had felt nervous about confessing to management that that was the case—and this was in an NHS trust where 25 per cent of its functions were dedicated to mental health services. It is that situation which has made me very concerned about these issues.

The Sainsbury centre report, Developing the Business Case, found that the cost to business of mental ill health at work is £25.9 billion in the UK each year, which is just over £1,000 for every employee in every workplace, and the equivalent of £1.3 billion just in the NHS, because I suspect that my trust was by no means alone. More than half of that cost is the result of lost productivity in people who turn up for work. The term that is used—the noble Lord, Lord Ramsbotham, has already told me that he thinks it is a terrible word—is “presenteeism”. It means being present at work but not being of much use.

It has been calculated that sickness absence costs £8.4 billion a year. Around 40 per cent of all sick days are taken for mental health problems, up to a total of some 70 million working days. Reduced productivity amounts to about £15.1 billion and accounts for 1.5 times as many working days lost as sickness absence, but costs more because presenteeism is relatively more common among higher paid workers; lower paid workers are more likely to take time off sick. Staff turnover costs £2.4 billion a year, which represents the costs inherent in replacing around 200,000 employees who leave their jobs because of mental ill health. This is a really huge issue and it is important to recognise that only 15 per cent of these costs are caused by work-related mental distress. Most mental distress arises for other reasons and from other causes; stress and distress are very different things.

I turn again to the horrible word, presenteeism. Employees may take time off from work because of ill health, or they may turn up for work as usual, sometimes because they feel duty bound, sometimes because they are worried about what people will say if they do not, and sometimes because they do not want to admit that they have a mental illness. However, they function at less than full capacity because they are feeling terrible. It is much more difficult to measure presenteeism than it is to calculate straightforward absence from work, but studies have been carried out in the United States, Australia and Canada. The key finding is that presenteeism is a much more important cause of lost output than sickness absence, with some studies suggesting that it is six times as costly as absenteeism. The Sainsbury centre has taken a rather conservative view of all this because little information is available on what really goes on in the UK. As an estimate, it has chosen to double the cost of absenteeism, but it still means that it is a huge cost. We know perfectly well that mental health matters to every business in Britain. One worker in six experiences depression or anxiety in any one year. If you add in drug and alcohol problems and severe mental illness, this rises to one in five.

We also know that most employers vastly underestimate the importance of mental health. A Shaw Trust survey of senior managers found that half thought that none of their staff would ever have a mental health problem. A report that will come from the Sainsbury Centre for Mental Health and the Employers’ Forum on Disability fairly shortly will show that most employers think that their workplace has less mental ill health than society as a whole. If they all think that, something very strange is going on. This is a wonderful example of denial that tells us a great deal about stigma and the desire to bury the facts.

This is obviously partly about stigma; people are afraid of telling their employers and colleagues if they are distressed. They are much more likely to come into work when they are unwell with a mental illness or from mental distress than if they have a physical health problem. However, the figures are likely to be an underestimate, if anything. Large numbers of people who present to their GPs or to occupational health services with medically unexplained physical symptoms may well have mental health problems that neither they nor their GPs recognise.

The report says that employing people with mental health problems is a good thing, not a bad thing. It is impossible anyway to say that one should not employ them, given the prevalence of the distress. We also know that working is good for people with mental illness. A recent Chartered Institute of Personnel and Development survey of employers found that 61 per cent reported a positive experience of employing people with a history of mental health problems, and that only 15 per cent reported a negative experience, which is probably lower than the normal rate of dissatisfaction with new employees in general.

We also know that having a mental illness does not make a person unemployable. The former Norwegian Prime Minister, Kjell Magne Bondevik, served two successful terms, despite having time off with depression. His openness about suffering from depression during his first term did not stop him winning a second term. We also know that employers can cut the cost of mental ill health through good management of their staff. BT has reduced its mental health sickness rate by a third through its Work Fit programme, which offers support to staff experiencing distress. We also know that a few simple and quite inexpensive measures to reduce stress and support people who become unwell can save thousands of pounds in lost output and precious skills.

We also know what the keys to reducing mental distress at work are. First is the recognition that work is good for health. Evidence is clear that being in work makes people healthier, both physically and mentally, and being out of work reduces life expectancy as severely as smoking and obesity—by about 10 years. Preventing work-related mental distress, such as ensuring that staff do not have unrealistic expectations, tackling bullying at work and so on, makes a huge difference. Giving workers greater control over how they work probably makes the biggest difference of all. Raising awareness of the possibility of mental illness among line managers makes a great difference, as does giving them more knowledge about mental health and helping them to respond confidently and in good time to staff who appear to be distressed. Improving access to help also makes a great difference. That is particularly true of speedy access to psychological therapies, especially to CBT, cognitive behavioural therapy. I very much hope that the Minister will be able to give me lots of good news about that. That makes all the difference between staying at work and going off sick and ultimately losing your job. Providing effective rehabilitation for those who need time off work also helps a lot, but you must maintain regular contact during periods of absence. That is crucial to give the person concerned hope and a clear goal for coming back.

Supporting mental well-being is likely to be different in small businesses than in large ones. Big employers have human resources departments and occupational health services, and can organise staff training and so on. However, small businesses can do their part and it would be really wonderful if the Government could give a bit of lead on that by encouraging small businesses to allow flexible working and encourage them to keep in touch with staff who are off work to help them to return.

We know a great deal. The real problem is that we do not act on it. That is why this report is so important. I really hope that the Government, and the Minister on behalf of the Government, can do something about what goes on in the public sector. The public sector employs millions of people and it has contracts with businesses that employ millions more. Mental ill health among staff costs the NHS over £1 billion, which is equivalent to a quarter of the entire mental health budget for England. I think that the noble Baroness, Lady Meacher, has experienced that as much as I have in the NHS.

It seems to me that public services should be required to demonstrate good practice as employers and in contracts with providers, and that they should be required to support the mental well-being of staff. At the moment, you see them responding less than well when people become unwell. Public services should be doing more to actively seek applications for ordinary jobs at all levels from people who admit to having a mental health problem. I wonder whether the Minister will be able to tell us that the Government will do a little more about that and that they, through the public sector as an employer, will do more to make it possible for people to admit that they have a mental illness, so we have less presenteeism and we can get rid of that horrible word. Can he say whether the Government will ask the public sector to set a lead in its employment practices and contracting practices? That is what has to happen if we want to make a difference to stigma and if we want to reduce the cost of all this.

I thank the noble Baroness, Lady Neuberger, for obtaining this debate and for giving us an opportunity to raise a matter that is of considerable concern to many of us who are looking at different aspects, particularly the public service.

I declare an interest as an adviser to the trustees of the Sainsbury Centre for Mental Health. My advice is slightly differently pitched from that of the noble Baroness, because recently the Sainsbury centre has deliberately focused on two aspects. The first is the mental health of prisoners, and the second is the problems faced by those with mental health problems obtaining work: two areas that have been neglected for too long. Therefore, I was very glad to see this paper, which is in a way a precursor to the work of the problems of people getting work. Unless things are right for staff, nothing will be right for others. I will concentrate on the Prison Service as an example of a public service in which a great deal more could be done.

It is right to say that there probably is no more stressful job in the United Kingdom than being a prison officer. I remember once watching a sex-offender treatment programme and marvelling at the tutors and what they were having to go through when they were role-playing with people who had committed the most awful crimes. They came out of that session literally shaking. One of them said to me that going through that work caused them to think twice when bathing their own children in the evening. That puts tremendous demands on staff; yet there was no proper support mechanism in the Prison Service for looking after those tutors, who were at the leading edge of doing the work of protecting the public on behalf of the community. In a way, the report is a wake-up call to the Prison Service to do a great deal more. We hear quite a lot about absenteeism in the Prison Service, and it varies from prison to prison. The interesting theme to me when inspecting prisons and looking at that was that there was a definite correlation between the management of a prison and absenteeism. It tells you quite a lot that if the management style is not right, people are not going to turn up for work.

There are two workforces in prisons, and prisoners represent a huge mental health problem. There is an Office for National Statistics report that is worth referring to, in addition to those referred to in the Sainsbury centre paper. It was done in October 1998, and it is called Psychiatric Morbidity among Prisoners in England and Wales. It is still the most accurate document available. It shows that 70 per cent of those in prison suffer from some form of identifiable personality disorder. That does not mean that they are certifiable, but that something is affecting their proposal. The reason why that is important and should not be lost sight of in this debate is well contained in a paper that I am very glad has been published today by the CBI, Getting Back on the Straight and Narrow. It proposes a better criminal justice system for all and amounts to a critique of a great deal of what the Government have not been doing. It wants them to do the central work that they say should be done—helping offenders to gain work, which is at the heart of the Government’s recent welfare-to-work programmes helping the hardest-to-reach long-term unemployed, many of whom are ex-offenders.

Unless there are programmes in place to get to the bottom of the mental health problems of those looking for work, you are affecting in many ways the whole of the workforce of the United Kingdom. While it is absolutely right to have the staff right, particularly in prisons, it is worth making certain that the workforce—in this case those seeking work—can be employed. The Sainsbury Centre for Mental Health’s report is extremely timely and the quality of the work that has been done by that centre has struck me ever since I first was in contact with it. I hope that the Minister can tell us that the Government are taking this seriously. This is not only a criticism, it is advice. I particularly like the five “How can savings be delivered?” points—recognition, prevention, awareness training, better access to health and effective rehabilitation—because they can be applied to many other aspects of improving all sorts of things in this country, not least the mental health of our workforce.

I am very grateful to the noble Baroness, Lady Neuberger, for introducing this debate. I probably should, as always in these situations, declare an interest as the chair of a mental health trust in East London and more recently as the chair of a mental health initiative for young people, spearheaded by the Paul Hamlyn Foundation and the Mental Health Foundation—which is relevant to this debate.

Our starting point is of course that mental health is a significant issue for every business in Britain. As the noble Baroness, Lady Neuberger, mentioned, one in six workers will experience depression or anxiety in any year. Yet, as she also mentioned, employers vastly underestimate its importance. Indeed, employers even assume that they do not have anyone at all with a mental health problem. I have to confess that in our trust, although we have encouraged openness on this matter with our staff for some period—certainly since I have been there—we have made slow progress in this area. I will come back to that point later. Such is the stigma of mental illness that, even within a mental health trust, employees will carry on soldiering on and concealing their problems for long periods at considerable cost to the employer in reduced productivity. I am aware that many of our nurses are underperforming quite drastically. If we could get at the mental health issues of those nurses, we may make considerable progress.

Help for employees, and therefore employers, is potentially on the way. That is the good news and I applaud the Government’s commitment to a considerable increase in spending on evidence-based psychological therapies—I emphasise evidence-based—in the most recent Comprehensive Spending Review, building up to £70 million in the third year. However, I also want to draw the Committee’s attention to the significant risk that much of this money may not be spent on these evidence-based therapies. It is important that strategic health authorities, and at the end of the day PCTs, follow the professional guidance issued by the Department of Health to ensure that the money really is used to the best effect. If it is spent on therapies that have been shown to be pretty ineffectual, it would be a terrible waste. Can my noble friend the Minister assure the Committee that his department will do all that it can to ensure that the funds are spent as the Government intend?

Another important point is the relevance of these evidence-based therapies to the achievement of the Government’s target to reduce the number of people claiming incapacity benefit—or is it employment support allowance now? I am sorry I have slightly lost track of the time frame—by 1 million over 10 years. If this is to be achieved, employers need ready access to evidence-based therapies so that employees suffering from severe distress, depression or anxiety can readily be referred for treatment at an early stage. At the same time employers need to change their internal policies so that anyone going off sick is not left alone on the basis that the manager must not interfere, as this would be harassment, and is followed up by the occupational health people—and, in the case of a smaller employer, somebody within the firm—without delay to identify the problem and, where appropriate, to refer him for evidence-based therapy.

The noble Baroness, Lady Neuberger, mentioned the incredible success of BT. It is phenomenal. BT has reduced its mental health sickness absence by a third through its Work Fit programme. Other employers would do extremely well for themselves if they followed BT’s example.

Employment coaches, otherwise known as employment support workers, need to be available to those at risk of losing their jobs due to mental health problems and also to ensure that appropriate support is provided to line managers. It is no good supporting just the employee; you must also support managers. Why should they have any experience of these issues? If all these pieces of the jigsaw can be brought together, the benefits to employers, employees and the taxpayer would be extraordinarily significant. We would see a dramatic fall in the number of benefit claimants.

As regards incapacity benefit or employment support claimants, every general practice needs practitioners of evidence-based therapies. Lots of general practitioners have counsellors of one sort or another, who I am sure are very helpful. You can just shift somebody off to see the counsellor rather than the doctor, and that makes sense, but if you really want these people to cease coming to your practice for a while, or, you hope, indefinitely, you have to have a change of mentality. We have to have people in general practice providing therapies that we know will help to cure the person. We know that about 50 per cent of people suffering from depression can be cured through these evidence-based therapies and will remain well for at least two years—if longer studies were done, I think they would show lengthier cures—and that the success rate for those with anxieties is higher still.

A more challenging area for public sector involvement is that of the secondary mental health services. Here the need is for every community team to have an employment coach with the right skills to work with employers. This probably does not mean OTs but rather people used to working with employers who have advertising or PR skills and are helped to understand mental health issues with which they may be less familiar.

If mental health trusts did this, they would enable people to go through the route of voluntary work within their trust and ultimately perhaps to jobs within it, or indeed elsewhere. Again, this employment support should be linked to the provision of evidence-based therapies. They have to go together. It is no good having one and not the other. In East London we have employment coaches and psychological therapists in all our community teams, but I have to confess that this has happened only within the past 12 months due to a thoroughgoing push from certain people within the trust. Does the Minister know to what extent this is now common practice across all mental health trusts? It is probably unreasonable to ask him that, but it certainly would be very interesting to know because that should be the case.

The Healthcare Commission now has a target for local authorities, through their mental health trusts, to increase the proportion of mental health service users in employment year by year. Although there is no specificity there, the idea that you will be marked “good” only if you increase the proportion each year is pretty promising and a good start. There is good evidence that the initiatives discussed here are the best way to achieve that target.

Again, I recognise that this is somewhat outside the Minister’s remit, but cross-departmental work on these matters will be essential if the target of a 1 million fall in the number of benefit claimants over 10 years is to be achieved. Therefore, what progress has been made with the Department of Health in progressing those agendas?

I had not planned to mention the role of the foundation trust model in all this, but I think I will. Others may be aware that we now have something called a board of governors or a member’s council elected by our community. We also have thousands of members, many of whom are service users of our trust. We have had to think how to involve our membership. Our trust has come up with precisely the solution that we are talking about today—it seems eminently sensible for every other mental health trust to do the same—the members need to be invited and encouraged to become involved in voluntary work and, ultimately, in employment. We are right at the beginning of this; we became a foundation trust only on 1 November; but we feel that there is a lot of interest in this and it may be something that we need to encourage nationally. It could be quite a significant way forward for people in the secondary sector. I realise that large numbers of people are not in the secondary mental health sector, they are in the primary care sector, but we could really make progress through that foundation trust model that, when we started, we had not thought of as a major issue.

My final point is one that I raised during our debates on the Welfare Reform Bill last year. The Minister may guess what I am going to mention. I hope that his heart will not sink to hear me mention the words “linking rules” again, but the issue remains as pressing as ever. For noble Lords unfamiliar with this territory, the aim of the linking rules is to ensure that anyone on incapacity benefit who finds a job and who, within two years loses the job, can restore those benefits, supposedly without delay—unless things have changed since I was involved in those matters.

I am concerned that in such circumstances, someone still needs to complete a form, and there are inquiries to be made, before benefits are restored. Also, housing benefit is considered quite separately. In reality, those procedures can take weeks, perhaps months, especially for people with mental health problems who are likely to have fallen out of a job because of a recurrence of those problems. They will be lying in bed, they will not be picking up the phone, answering letters, making sure that they are filling in forms or getting someone else to do it for them.

When we last debated these issues, the DWP was considering the possibility of aligning the reclaim process for housing benefit with that for employment support allowances. I have not completely given up hope of further improvements to the linking rules themselves for employment support allowances. It may be reasonable to limit those special provisions to people with mental health problems, because if your mind is working all right, you can probably deal with those matters, even if you have to sit in a wheelchair; but if your mind is not helping you at all, the linking rules do not answer the problem. Has the Minister managed to make any progress since last summer with those matters? I look forward in anticipation to his reply.

We must all be grateful both to my noble friend Lady Neuberger for introducing this debate on this very important issue and to the Sainsbury Centre for Mental Health for producing its report and highlighting so graphically the real crisis that we are facing in this country: how issues of mental ill health are costing this country dear. Although the noble Baroness's Question focuses on the cost and the need for support to business, there are the other inevitable costs incurred by the range of agencies to pick up the pieces of fragile or broken lives; the human cost to those who are ill, to other individuals, families and communities; and the urgent need for support for them as well.

One of the real ironies is the extent to which mental illness is the object of so much fear, stigma, ignorance and even cruelty when it is such a common feature of our society, and the evidence shows that it is getting worse. With one in four of us experiencing mental ill health at some point in our lives, there will be very few individuals anywhere who do not know directly of someone who has been mentally ill. I declare an interest here. I have a wonderful son who is now 37. He has had severe manic depression since he was 15, a fact which has had a huge impact on all who have had the good luck to know him. Indeed, it has inevitably involved times of great distress, anxiety and, indeed, fear for us all, and which in his case has meant that long-term real employment has not been possible. We are a society that fears any deviation from what is normal, particularly when mental illness and other disabilities significantly affect and damage the normal, strong or successful in our communities. I believe that we are getting it badly wrong, both materially and morally, where the mentally ill are concerned. The Sainsbury report not only points out graphically the costs of our failure, but also, very usefully, how to begin to deal with the problem.

My noble friend Lady Neuberger has already gone through the detail of the report, and I hope noble Lords will forgive me if I repeat some of it. The cost to business alone of mental illness is vast. The figure of £26 billion annually is hard to get our heads around, unless we think of it as over £1,000 for every single employee, everywhere, each year. Of these employees, the report tells us, at any time one in six will be experiencing a neurotic disorder such as depression, anxiety or stress-related problems. That is different from the group of people who, like my son, suffer from long-term severe mental disorders. The former group is by far the larger and represents the chief concern in the report because people in that group are more able to work and their illness is less likely to be permanent.

We have discussed that ghastly word, presenteeism, which along with absenteeism and high staff turnover, are the main costs. Presenteeism suggests a sort of ghostly figure drifting around the workplace, and I am sure it should not be difficult to find a better word. Being present but unable to work properly is a reflection of the fear felt by the employee of being mentally ill or being found out because of the stigma the illness generates, and the stigma itself is rooted in fear. Furthermore, most employers hugely underestimate the prevalence of mental illness in their workforce, partly because they are simply unaware of it and partly because, I suspect, they do not want to recognise it. That is fear once again. Yet we all know that work is good for business, good for individual self-confidence and self-esteem, good for health, and of course, as the husband of the noble Baroness, Lady Meacher, knows, good for happiness.

Apart from the stark detailed calculations of the cost of mental illness, we see that appropriate, constructive and effective ways of dealing with mental ill health at work is not rocket science and can save thousands in pounds and people. It is crucially to do with the attitude towards staff of managers, which should be free of prejudice. Managers who are properly informed about the nature of mental illness and trained accordingly are able to facilitate early recognition and swift access to appropriate help. As we know, most fear and prejudice is rooted in ignorance. Much stress can be mitigated by having realistic expectations of staff, dealing effectively with bullying in the workplace and giving people more say over how they work—all of which amount to strategies that lead to a positive working environment. Training is important, so that a manager can feel confident about dealing with someone who is showing signs of mental illness that could otherwise be quite threatening. Knowing where to go for the appropriate help is essential. In this way, appropriate and effective interventions, such as CBT—although sometimes I think that can be exaggerated—can prevent the loss of a job or facilitate an early return to work.

Proper support to stay in or return to work can be crucial. It all seems quite obvious, but it is still sadly lacking and is a real challenge to the Government. My experience over the past few years is that it is not the Government who are leading the way here, but the voluntary sector and the world of social enterprise, with the growing and very exciting development of social firms. They are businesses with a moral compass, where not only do the usual criteria apply for any successful business—such as a proper business plan, a healthy profit at the end of the year, top-class service to the customer and a budget showing future growth—but there is an overarching rationale of meeting a particular social need in the people whom it employs and in the service that it gives.

Social firms are by no means exclusive to the mental health field, but they employ, among many others, people with severe and/or enduring mental health problems. They provide a supportive working environment that recognises and responds to the needs of individuals and, where appropriate, challenging environments where people can carry out real work in real businesses. That may be a stage in recovery in the sometimes long journey to sustained, meaningful employment, or perhaps a place where the individual can be sustained and supported over many years.

I declare a second interest, as my daughter is a beneficiary of just such a firm in Scotland, which I commend to the Committee. It is called Forth Sector, and it is based in Edinburgh. It runs a group of small businesses, including a small guest house where the trainees all have mental health issues of some kind. It is a delightful place, where the highest standards apply, the service is excellent and the occupancy rate is high. I cannot sing its praises highly enough.

The Freud report in 2007 suggested that the true cost to the state of a person on incapacity benefit was around £64,000 a year. The cost of sustaining a person in one of Forth Sector’s social firms is a 10th of that, without including a calculation of the personal, family and social capital that such a placement creates. By trading as they do, not only do social firms provide real work experience, but they effectively substitute for and subsidise the state provision of care. I suggest that the Government take a sustained and real interest in the support and development of this approach and of the work of social firms.

Finally, I quote the example of the National Schizophrenia Fellowship in Scotland, of which I am a patron. It has been supporting people with a range of mental illnesses for years in a variety of areas, including employment. Sometimes clients start by volunteering with a large organisation, such as the National Trust for Scotland, with which there is a long-standing relationship, and sometimes with small businesses. In this and many other ways, its work is invaluable to many people and their families. Typically, it may intervene when a person has become ill and before too long has perhaps lost his home and job, while the employer was simply not aware of illness or the reality of the situation. The outcome of the intervention is a negotiation with the employer and a return to work, home and stability. That is immeasurable. Without NSF, such a person is to be found on the state’s very expensive scrapheap. Its work with young people may involve starting with volunteering, often working alongside them, to experience the working environment, before graduating to real work. That is something that the Government should be encouraging and developing.

The marvellous work of such social firms and voluntary organisations is the beacon in what is still a dark world for so many of the mentally ill. Of course the noble Baroness, Lady Neuberger, is right to challenge the Government to follow their lead, which is now so overdue and so pressing. I sincerely hope that they will take this latest report from the Sainsbury Centre very seriously, for literally none of us can afford to ignore its message any longer.

I, too, would like to thank the noble Baroness, Lady Neuberger, for initiating this important debate. At the outset I would like to contrast West Africa with this country in several respects. My clinical practice is in West Africa for several months every year with a charity known as Mercy Ships. Many of the patients that my wife and I operate on have been rejected by their fellow countrymen because they are assumed to have some sort of curse. This leads to throwing stones at children with hare lips, cataracts, squints and many other conditions. Women who have been rendered incontinent through disasters in childbirth are completely ostracised by society.

Before we adopt too critical an attitude to such behaviour in Africa, it is worth remembering that in this country the all too common attitude towards those with mental ill health can be very strange, to say the least. Even highly intelligent, educated people will use terms like “nutty”, “barmy” and “bananas” to describe those who are mentally ill. The same people would never dream of using such language to describe those with heart failure, pneumonia or cancer. Some have tried to explain this inappropriate behaviour in terms of fear or ignorance of mental illness, or that it acts as a kind of protective carapace. The strange thing is that doctors have also used these derogatory terms, but what is even more surprising is that psychiatrists have done the same. A medical student spent an hour carefully assessing a patient in a psychiatric outpatient clinic and then presented the case history to a distinguished psychiatrist, who started laughing. “What’s the joke?” asked the student. “The joke is that he is a psychopath”, was the reply. “Yes, I know that he is a psychopath”, said the student, “but what is the joke?”. “The joke is that there is nothing we can do for him”. The student thought that the consultant’s response constituted what psychiatrists call incongruity of affect, which is a well known symptom of schizophrenia. That was a few years ago, and hopefully things are improving.

These things are always difficult to judge, but my impression is that there is now less prejudice and ignorance about mental illness, but unfortunately, as has been mentioned already, recent surveys suggest that tolerance towards those with mental health problems is now lower than it was in 1994, which is very discouraging. A survey of members of the Depression Alliance showed that 79 per cent of them were fearful that revealing their condition at work would be damaging. That is a sad state when one bears in mind how common mental illness is in the population as a whole. As the noble Baroness said, one in four in the nation will suffer from mental ill health during their lifetime and at any time one in six workers will be experiencing anxiety, depression or problems related to stress.

Mental ill health is normal in every workplace. We have heard the figures about how much it costs, so I will not repeat them. We have heard the term “presenteeism”, which I do not like at all. I would prefer to use the Latin phrase, labore sed aeger, which means labouring but ill. The Latin word “aeger” covers mental as well as physical ill health. The phrase could be abbreviated to LSA, and would certainly be better than presenteeism.

The figures we have heard are probably underestimates because many people present with medically unexplained physical symptoms that are due to mental health problems. These are not recognised by patients themselves or by their doctors. Indeed, these symptoms can be difficult to diagnose. To make matters worse and even more complex, a patient’s symptoms may be due to mental health problems and concomitant physical disease. It is important to state the obvious that, as has already been said, mental illness does not make a person unemployable. There have been many recent examples of this: one in the form of the Norwegian Prime Minister, Kjell Magne Bondevik. My Norwegian friends in Norway said that people were amazed when he admitted publicly his illness and then took six months off, but his openness was so impressive that he was elected for a second term. Such openness is a great inspiration for those with the same condition.

Mental ill health can be cut by the good management of staff, and there are several excellent examples. BT, as has been mentioned, has reduced its mental health sickness absences by one-third through its Work Fit programme. There is also good evidence that being in work keeps people healthier, both physically and mentally. Unemployment reduces life expectancy by 10 years, as the noble Baroness, Lady Neuberger, pointed out.

Work-related mental stress can be reduced by creating more pleasant working conditions, giving staff more say over how they work, and dealing with bullying. I remember some years ago in a hospital how some secretaries got very angry with the way they were being bullied and mistreated by people who should have known better. I suggested to them that the next time it happened they should just look the guy in the eye and think to themselves, “Poor chap, he’s not having enough roughage in his diet”. The only problem with this was that it would make the secretaries smile, which sometimes inflamed the situation even more.

Managers should be, and are being, trained in how to deal quickly and effectively with these problems and how to get people to take up psychiatric therapies and effective rehabilitation. On the subject of rehabilitation, it is helpful if managers keep in contact with people when they are off sick and help them to return to work earlier.

There is no doubt that this is a very neglected subject due to the lack of public awareness, the persistent stigma of mental illness and a lack of training among management. Much needs to be done. The Department of Health’s commissioning of the Sainsbury Centre for Mental Health to tackle stigma and discrimination around mental illness is a welcome development, and I look forward to hearing what more the Minister is going to do.

I start by expressing my gratitude to the noble Baroness, Lady Neuberger, for calling this debate today and to all noble Lords for devoting their time to this very important issue. I fear that 12 minutes is too short to do full justice to the weight of noble Lords’ contributions, but I shall try. I am also indebted to the Sainsbury Centre for Mental Health for its policy paper on developing the business case and for all its ongoing work on the mental health agenda, particularly in its links with employment.

The Government are committed to ensuring that 2008 marks a step change in the way we approach the health of the working age population and in particular support for people with mental health conditions. It is central to our aspiration of achieving an 80 per cent employment rate that we improve the health of our working age population, reduce sickness absence and drive down the number of people falling out of work and on to welfare benefits. This success will mean healthier and more productive employees and a stronger economy.

We recognise the changing dynamic of British business and the corresponding shift in the nature of ill health and sickness absence for working age people. Mental ill health is now the greatest single cause of sickness absence. As the noble Baroness, Lady Neuberger, explained, the Sainsbury Centre for Mental Health estimates that it accounts for 40 per cent of all sickness absence—some 70 million days a year. The impact on business is more than £25 billion a year, including £15 billion from—I hesitate to say—presenteeism, with employees staying in work but performing below par.

Mental health conditions are also the single biggest cause of people claiming incapacity benefit—a higher figure than the number of people claiming jobseeker’s allowance. Dame Carol Black’s recent review of the health of Britain’s working age population rightly drew attention to the challenges. An accompanying report from the Royal College of Psychiatrists highlighted that mental health problems cost the British economy more than £40 billion each year.

The evidence is clear that work is generally good for health, and that is true for mental health as well as physical health. The Government have made considerable progress in working to address those challenges—as the noble Baroness, Lady Linklater, said, it is not rocket science—but we must go further. We must help all employers to manage mental health conditions at work by tackling the stigma associated with mental ill health; and wherever possible prevent such conditions developing in the first place. The noble Lord, Lord McColl, graphically challenged us on some prevailing attitudes and on the prejudices which, sadly, still persist. We must further improve the access to mental health support services for those who develop conditions, helping people to stay in work or to return to work as quickly as possible.

We have been looking at ways to improve the support that is available to employers, both to ensure that they understand what they can do to prevent mental ill health being caused by work and to help them manage staff with mental health conditions, whatever the cause. The Health and Safety Executive developed its excellent management standards for identifying and managing the risks so that work-related stress can be prevented. The HSE is also supporting employers by developing improved information and guidance through its website.

As part of Dame Carol Black’s review, PricewaterhouseCoopers considered the economic case for business investment in wellness. The evidence from 50 employer case studies suggests that the initial programme costs can quickly be translated into financial benefits. PwC is now working on developing a toolkit that will allow employers to quantify the financial benefits of their wellness interventions. We intend to pilot this toolkit in the summer, and we will encourage employers in both the public and private sectors to take part in this pilot and to use the toolkit to move towards reporting on health and well-being in the boardroom.

We have also been looking at destigmatising mental health conditions in the workplace. The Department of Health, in partnership with Shift, has taken forward the successful “Action on Stigma” campaign, which tackles the stigma and discrimination that people with mental health conditions too often face. The early focus has been on the public sector audience, addressing our wish that government—central government departments, executive agencies and NHS trusts—should be an exemplar, as it is absolutely right that they should, but increasingly Shift has been invited to engage with blue chip companies to support business in tackling discrimination and promoting healthy workplaces.

We need to go further in improving the support for those with mental health conditions to help them stay in work or to return to work quickly. Since 1997, the Government have made a record investment in mental health services. Real terms investment in adult mental health services has increased by nearly a third in the past five years alone. We now have over 60 per cent more consultant psychiatrists, 70 per cent more clinical psychologists and at least 20 per cent more mental health nurses than in 1997.

As the noble Baroness, Lady Meacher, said, last October we announced a significant investment to deliver the Improving Access to Psychological Therapies programme, rising to £173 million in the third year. That will enable the training of more than 3,000 extra therapists to deliver psychological interventions for up to 900,000 more people over those three years. My department is working closely with the Department of Health on this, and we will make sure that it links with our Pathways to Work programme, which is now available across the country. We are providing funding to test private and voluntary sector delivery of employment support within the IAPT programme itself. Employment advisers will help individual customers to remain in, or quickly return to, work, or find jobs that are more suitable for them. As the noble Baroness, Lady Meacher, said, we need to go further in improving the integration of health and employment programmes to ensure that those out of work with mental health conditions have the best possible support to consider a return to work and that employers have the appropriate information and support to make the necessary adjustments that can make a return to work possible.

Yesterday’s survey from the CBI illustrated the considerable employer support for the introduction of what Dame Carol Black described as “fit notes”. We have been working with a wide range of stakeholders to create a revised medical certificate that is more positive and supports GPs in providing the best possible advice to their patients. More helpful fitness-for-work advice can also help employers to facilitate an earlier return to work, by switching the focus from what people cannot do to what they can do. We are doing so in replacing incapacity benefit with the employment and support allowance. The Department of Health has already agreed to pilot a fit for work service, as recommended by Dame Carol. The DWP has set up a vocational rehabilitation task force to determine what incentives and disincentives currently exist and how we might better encourage employers to provide such services.

The CBI survey also highlighted the significant challenge that is still facing the public sector in tacking sickness absence. All government departments now report their sickness absence to the Cabinet Office on a quarterly basis, and we are committed to reducing current levels by promoting good health and well-being and by addressing the causes of long-term sickness absence. Good line management and a renewed focus on improving support for those with mental health conditions will be a critical part of that. As several noble Lords have commented, it is absolutely right that the Government take the lead in this area. There are examples of good sickness management practice in some government departments, as well as examples of not so good practice in others, and we have heard some of those this afternoon.

To reflect the importance of mental health support for the future health of Britain’s working age population, we have asked Dame Carol Black to support us in producing, for the first time, a co-ordinated, cross-government strategy for mental health and employment. It will build on our current work to address and meet the challenges faced by people with mental health problems, helping to improve their employment chances. Providing improved support to employers, linking mental health and employment programmes, tackling stigma and discrimination and the other issues mentioned today will all be considered as we develop this strategy. Dame Carol has agreed to take the lead on that work, supported by a group of eminent experts from the business, medical and academic worlds, including my noble friend Lord Layard.

The Government are committed to the challenge of reducing the impact of mental health issues on business, reducing sickness absence and improving more generally the health of the working age population. The noble Lord, Lord Ramsbotham, referred to the five identified components of an effective work-based programme in the Sainsbury centre report. Across government, work is under way on each of those components. The recognition by employers that work is, on the whole, good for mental and physical health lies at the heart of our health, work and well-being programme. The HSE’s stress management standards address issues of prevention, Shift’s action on stigma, awareness training and improving access to psychological therapies for increased help. The vocational rehabilitation task force helps the focus on effective rehabilitation. There is still much to do, and now is the time to make extra progress. In the words of the noble Baroness, Lady Neuberger, the word “now” means that it is time to do it.

In the remaining time, I will pick up on the specific questions that were asked. My noble friend Lady Meacher asked about the linking rules again. I will write more fully on that. I am afraid that we are not yet in agreement with her on the issue of not having to have a claim in the system to access that. We are looking at making sure that the claim process and the reclaim process can be as smooth and effective as possible.

On the mental health of the prison population, there has been extra investment each year in mental health in-reach services and additional funding over three years for support in training for prison officers and staff on mental health. The figure is £600,000; the noble Lord may think that it should be more than that, but we are seeking to focus on that.

The noble Baroness, Lady Meacher, asked what we are doing to encourage employment support workers within psychological therapy services. I touched on that a little, but the IAPT programme is working with the NHS to encourage the provision of employment support workers in IAPT services. The programme is rolling out at present and the first services will come on stream in September 2008. The DWP is also testing the provision of employment support workers in psychological therapy teams.

I hope that noble Lords will acknowledge that that is some real progress with real opportunities in future on a range of matters on which we now have a real focus. I again thank the noble Baroness for raising this important issue and all noble Lords who have contributed.

That completes the business before the Grand Committee this afternoon. The Committee stands adjourned.

The Committee adjourned at 5 pm.