Introduction

I am writing this proposal for a framework of employment and training projects across Berkshire from the perspective of a user of mental health services in Bracknell. Part of the origin of its production has been my concern about an alternative model (based upon 'real jobs' across disabilities) which I feel, and others I consulted with, was inadequate and inappropriate. I also have the perception (which may be quite ungrounded) that there are a number of different projects doing different things but little coordination and synergy between them.

Writing from the perspective of a user means that I have the advantages of considerable ignorance about funding and a naive optimism about what may be possible with regard to benefits. Ignorance and naivety may seem strange advantages, but they mean that my dream for an employment scheme is not permanently disturbed by the hard bumps of reality. Part of my hope is that if others can share this dream we might together be able to change the reality which stands in its way. To put this in a more technical sense, I am arguing for a needs-based approach, rather than one based upon available funding, extension of existing services, the limitations imposed by the benefits system, or other provider-based approaches.

I know from my own personal experience the importance of some sort of work in maintaining my own mental health. I am also personally aware of some of the things that get in the way of me working and moving from welfare to work. Other mental health service users' experience will, of course, be unique to them. But themes of anxiety about not knowing what sort of work I am capable of, trying work and failing, losing benefits, filling in numerous forms, needing to get 'permission' from the psychiatrist are just as real, and high, hurdles as the stigma of mental health problems in 'the outside world'. Probably many of us with mental health problems wanting to return to work need a ladder which we can use to gradually ascend (and quite possibly sometimes have to gently descend). Unfortunately it often feels as though the ladder has been chopped up to make hurdles which we have to get over.

To not have the support needed to return to some sort of work means that many of us are permanently impoverished; not only financially, but in our opportunities for social contact, structure for our day, in our self-esteem. All work and no play may make Jack a dull boy. No work, and no prospect of work, not only makes Jack a poor boy but contributes to him continuing to be an ill boy. (The same applies to Jill as Jack).

My hope is that some of the ideas in this proposal may be useful to those responsible for making provision in this area. Although what I am proposing is a fairly comprehensive scheme, this is not a 'bid' to actually run such a scheme. I hope that as well as the scheme (which may be thought to be impracticable or undesirable for reasons beyond my knowledge) it is a collection of values and ideas, some of which I hope might be useful in considering other projects and frameworks.

Key Desirable Features of Employment Projects and Training
(From the perspective of the service user)

1. Flexibility:

People who have experienced serious mental health problems, which have meant that they have never worked or have lost their jobs because of their illness, are a very diverse group who may have:

• a very wide range of qualifications (from none to people with higher degrees
• varying prior experiences of work (from none to many years)
• differing present capabilities for work (from none (really?) to full-time employment in a stressful environment)
• differing degrees of 'readiness for work' eg confidence to receive and give instructions in the workplace, basic timekeeping skills
• differing degrees of confidence in their ability to work
• differing degrees of desire to work
• differing degrees of 'illness' at different times.

Employment/training projects attempting to meet the needs of this very diverse group must be very flexible. This flexibility is partly provided by the service giving access to:

2. A full range of employment services.

Ideally this should include:

• support to people with mental health problems still in employment to try to help them hang on to their jobs (this support might, with the permission of the client, include providing advice to the employer)
• helping clients to:

• recognise their strengths and weaknesses
• draw up realistic plans for their medium and long term future based upon well-informed information about their present and likely future mental health as well as other considerations. Broadly speaking clients should be encouraged to aspire to the level of employment which they had attained prior to becoming ill, or recognise what is a new appropriate level given the severity and enduring quality of their illness.
• identify areas in which they would like to work

• providing information to clients on the opportunities open to them. These opportunities may be:

• Training. This may be specially designed for people with mental health problems or general public training. It may be on general job skills or to develop specific skills.
• Voluntary work in the community. The employment service should have a access to a wide range of opportunities for voluntary work of differing types with different levels of commitment required.
• Work in one of a number of employment projects which are part of this employment framework. This work might be voluntary, work allowing the client to receive therapeutic earnings or paid employment, part-time or full-time.
• Work in a job in the local community. Such work again may be full or part-time. It may be supported by the project in various ways (eg by a 'mentor') or the client may feel they do not need any further support.

• Helping clients to plan their next step. This might include introducing the client to other clients who had previously explored that option or allowing the client to have a short trial period with options that interested them.
• If necessary helping the client to make the necessary practical arrangements to implement this plan (eg solving transport problems)
• supporting the client during this work/training experience. If this turns out to be long term employment, then long term support may be necessary.
• Helping the client to move forward to the next step. Or if this experience has proven to be too much, or the client's mental health has deteriorated, it may be necessary to take a backward step.
  

3. Recognition of the specific employment needs of people with mental health problems. Any good employment scheme for people with mental health problems must be designed around this group's specific needs. These would obviously vary from individual to individual, but the sorts of needs might include:

• inappropriate (normally too high but also sometimes too low) levels of stress may result in the person becoming more unwell. This may be particularly relevant in training where methods of assessment may produce stress, or in work situations where the work level is largely dictated by external considerations.
  
• considerable variability in the person's capabilities over a periods of time. This may, for example, result in high levels of absenteeism or 'unreliability'
  
• individuals may have specific needs which may seem unreasonable to those not knowing the background. For example some clients may feel very anxious about being parts of large groups or being given sole responsibility for areas of work.
  
• for many individuals there may be a single episode of a mental health problem, for others there may be repeated incidents. In both cases appropriate long term support may help to keep the person 'well' and in employment.
  

That part of an employment scheme which is responsible for the placement and support of clients needs to have mental health expertise.

4. Offer choice to users.
At one level this is the choice between using an employment service rather than a day centre or day hospital as a way of getting through the day. But also within the scheme itself there needs to be choice offered to the users about their area of work and their times of working etc (recognising that users, like other members of society, have both interests and restrictions from other aspects of their lives)

5. Provide additional income to users.
Most people who work expect some financial reward for their labours. Mental health service users are no different. There are at least two potential obstacles to this happening:

• the benefits system which limits the amount which a person can receive whilst on benefits, and sets conditions which must be satisfied before a person can receive anything (or even do voluntary work)
  
• the work that a person does, or rather, the 'business' in which they work, must be sufficiently profitable to be able to pay the workers
  

6. Remove the 'benefit hurdles' of needing 'permission' to work and all the delays, examinations and potential humiliations each time there is any change in work

7. Security of income, meaning that if a person attempts paid work and is unable to continue for health reasons then they will be guaranteed an immediate return to their previous benefits.

8. To be treated in the appropriate role for example employee or student in employment projects or training, rather than 'client' which effectively creates an 'us and them' between staff and users.(Eg if a member of staff goes out for a drink with a service user - or perhaps even goes home with him later- it is a matter of workplace gossip not disciplinary action.)

9. Clients should not be exploited to provide labour for an organisation where some staff are receiving high salaries and they are only being offered low wages.

10. Offering opportunity for work is part of being socially inclusive. The consequences of this include:

• users should have as greater opportunity to be part of 'mainstream' employment as they feel able and wish
  
• employment and training opportunities should not have policies which exclude people who suffer from social exclusion (eg people from ethnic minorities, people with learning or physical disabilities)a
  

11. Recognise that the experience of having suffered from mental health problems is a useful qualification in working with others who are suffering from mental health problems. Hence service users should be encouraged to use their experience in supporting others in moving towards employment or in other aspects of care in the mental health arena (eg advocacy, nursing auxiliaries, training as mental health care professionals)

12. Users should not be limited by the location (both physical and by unitary authority) in their choice of activity. Obviously there will be limits on this based upon what are reasonable travelling times/costs. However, it would be highly regrettable if, for example, a user wanted to work in a particular craft which was happening in the neighbouring authority, but was unable to do so because their authority was not responsible/paying for that project.

The Delivery

If it is agreed that the above features are recognised as being desirable, how might they be delivered' The demands for flexibility, a wide range of employment options and choice for users of such a service, suggest that it would be very difficult to provide such a service in a single Unitary Authority. Similarly the demands of overcoming the 'benefit hurdles' and providing security of income would require negotiation with agencies responsible for the payment of benefits. Such negotiations, I would suggest, are more likely to be fruitful if they can be conducted with senior representatives on both sides. This suggests that this should also be done at a level higher than that of an agency from a single Unitary Authority.

On the other hand, some things will be much more effectively done at a more local level. This would apply particularly to building links with local employers (for both voluntary and paid work) and training organisations. Given the fact that many people with mental health problems are living in chronic poverty, transport can be difficult and can discourage people from accessing services or working in areas other than those easily accessible to them. This suggests that people's access to the service should be local and that it may be necessary to provide transport services for people to access work/training not in their immediate vicinity.

These considerations lead me to suggest that the following components are required:

13. A County-wide body. This would have the following responsibilities:

• Negotiation with benefit agencies to agree the necessary changes in the treatment of people with mental health problems (see below)
  
• Employ and manage the 'Employment Support Workers' in each Unitary Authority
  
• Do the necessary fundraising (both in negotiation with the statuary authorities and other grant making bodies eg National Lottery Charities Board)
  
• Provide expertise in the setting up of Small Employment Projects.
  
• Provide 'small business advice' to the individual Small Employment Projects. This might include both
  
  • General business advice (comparable to what might be provided by a small business adviser in a bank, indeed such a person may be ideal in doing this)
    
  • Business specific advice. For example, it might be the case that there may be a number of horticultural projects. One central horticultural advisor may mean that each business could effectively be run by a 'foreman' on a daily basis with the business decisions being taken centrally.
    

• Encourage synergy between different employment projects and training. For example, there may be a number of projects making some product for retail sale (eg crafts, nurseries). Rather than each project having to have retail facilities, there could be small number of retail outlets which would be supplied by these projects. This would also increase the range of job opportunities available to people.
  
• Identify areas of poor provision (eg geographic areas poorly served, types of work that are popular but often not available) and plan to provide.
  
• Be responsible for providing the necessary infrastructure for the scheme to work. This would almost certainly include transport (particularly users to projects, but also eg goods to shops). This would again be a possible source of employment (voluntary or paid) to some clients.
  

14. In each Unitary Authority there would be:

• Employment Support Workers. These would be individuals with expertise in mental health and employment. Their roles would be:
  
  • To have delegated authority from the medical staff in liaising with benefit agencies. This would mean that users could be referred to the service with an agreed level of hours and types of work by the referring doctor. This would be recognised by the benefit agencies and the user would be allowed to do any form of work within this boundary. The Employment Support Worker would be responsible for ensuring that these limits were not exceeded. They would also be responsible for liaising with the psychiatrist / GP if they believed that these conditions needed to be varied.
    
  • To provide, either by themselves or by using the services of others, the tasks of
    

• helping users to identify and explore the area of work in which they wish to work (in a voluntary or paid capacity) or train
  
• overcoming practical obstacles to this work/training taking place
  
• providing support
  
• helping the user to move forward as they are able to do so (eg working longer hours, taking more responsibility)
  

• To manage the 'guaranteed benefit' system (see below). This would involve:
  

• recording the benefits a person is receiving prior to any paid employment
  
• ensuring an immediate return to these benefits if they cease this paid employment because of ill health.
  

• To provide a first-line of support to the managers/trainers in the event of problems which may be the result of the users mental health problems (eg absenteeism)
  
• To have an accurate and up-to-date knowledge of opportunities for training and work (voluntary and paid) to be able to advise users.
  

The number of Employment Support Workers in each Unitary Authority would be dependent upon the demand for this service. Initially it would be possible for this to be a part-time post, or a full-time post shared with other Authorities.

• Local Business Liaison Officers. These would be people (possibly having taken early retirement) with good local contacts with the businesses in their area. They would be attempting to build good links with businesses to achieve the following:
  

• Encouraging each business to examine their employment and support of people with mental health problems
  
• Identifying possible voluntary/paid placements/posts
  
• Encouraging each business to support the scheme. This might be through such things as:
  

• providing expertise/personnel
  
• using the services of one or more of the Small Employment Projects
  
• encouraging their staff to buy products (eg ten companies with a thousand staff each receiving an annual £25 Christmas voucher to be spent on products produced in the Small Employment Projects would give them an annual guaranteed income of £250,000)
  
• Sponsoring an individual Small Employment Project (eg by providing the capital for purchasing and equipping a glasshouse for a nursery)
  

15. Throughout the county there would need to be a number of Small Employment Projects. These should be small businesses which are labour intensive, some of which does not have to be very skilled labour. Crafts, horticulture (both nurseries and landscape/maintenance) and some forms of catering are likely candidates. I do not know enough about the pros and cons of the different legal statuses of charities, not-for-profit businesses. What is required is the ability to get grants, not pay tax etc. The county-wide body would be responsible for setting up new Projects, or there could be local initiatives. Such businesses should be:

• Managed by people with expertise in that area of business, rather than having mental health expertise. It might be found to be useful to give the managers some sort of mental health awareness training to help them understand the problems that some users may experience. Such training might be done by users who have discovered for themselves the ways in which their mental health problems affect their work. Primarily, however, the business managers should be concerned with running a business that happens to have many workers with mental health problems.
  
• Expect users to behave as employees. This would mean agreeing their hours, remuneration (if any), length of 'contract'. Part of the managers function would be to record the user's attendance and productivity so that this information could be used by the user in seeking employment elsewhere. Where 'employees' were having problems in fulfilling this agreement, the first point of call for support or adjustment would be the Employment Support Worker for that person.
  
• Financially viable, as far as this is possible within the demands of providing opportunities for employment, for many people on a part-time basis. This financial viability should be made more possible by:
  
  • The managers of the projects (or personnel employed centrally) having the necessary knowledge of their business and market to run profitable businesses
    
  • Use of good small business practice, provided by the 'small business advisor' employed centrally
    
  • Paying the project managers at the going rate for the business sector rather than the (I suspect normally higher) rate for people in one of the 'caring professions'
    
  • Access to capital and markets generated by the Local Business Liaison Advisors
  • As far as possible treating the employment scheme users as 'employees' rather than people with mental health problems. This would mean giving them the necessary training to work as productively as possible and encouraging the maximum possible productivity from each of them (rather than adopting an attitude of low expectations of their capabilities and failing to provide the necessary training to work productively)
    
    

It is worth noting that it may be desirable to share some of these Small Employment Projects (and possibly the Local Business Liaison Officers) with services for people with learning disabilities (and physical disabilities'). Please note that this is not a return to BREAD. This scheme recognises that for many people 'real jobs' may be the end product of a long climb of shorter steps, not the only option. Nor does this scheme ignore the special employment needs of people with mental health problems. The placement and support of people would be done by people with mental health expertise. It is the employment projects which might be shared with people from different disability groups.

16. Multi-agency participation is required

17. Organic growth needs to be planned in

18. Subsidiarity (the principle that a central authority should have a subsidiary function, performing only those tasks which cannot be performed effectively at a more immediate or local level)

19. Provide Employment opportunities for people within the scheme

20. Offer appropriate long term support (where appropriate by other users)

21. The scheme should be needs led

A Guaranteed Benefit Scheme?

What is required'

• People with chronic mental health problems, unless they have some means of support other than benefits, are unlikely to have any savings. Hence any loss of earnings not immediately replaced by benefits is likely to lead to a serious 'cash flow' problem. Fear of the destitution that delay in payment of their benefits can bring about creates a strong disincentive for people to take on any paid employment which reduces their benefits if they think there is a real possibility that they may lose that paid employment.
  
• A second disincentive to taking on paid employment (even that which is only for therapeutic earnings) is the fact that this change in their circumstances affects their eligibility for means tested benefits such as Housing Benefit and Council Tax Benefit. This means that there are forms to complete or letters to write. This bureaucratic exercise, which may not seem significant to people who have not been caught up in a system which endlessly asks for proof and threatens to discontinue benefits unless it is provided, is another good reason why many people may feel that paid employment 'played by the book' is not worth attempting when there is always the possibility (or probability) that they will in the near future become too ill again to continue to work.
  
• A third concern is that some benefits (eg Incapacity Benefit) are paid at a higher rate when a person has been claiming it for some time. If a person tried to return to work, was not successful in the medium term, do they return to their previous higher level of longer term benefit or the lower level' Is there a cut off point (eg if you work for more than three months) which affects which level you return to if you are unable to maintain your paid employment'
  Issues such as these three mean that there are high hurdles to overcome in taking up paid employment when there is a real risk of becoming ill again, being unable to sustain the paid employment, and becoming dependent upon benefits.
  
  

There are at least two ways in which an employment scheme might attempt to address these concerns:

21. A gradual progression of employment steps for a person through, for example, voluntary work, work with therapeutic earnings into part-time paid work. This means that they need not put any benefit at risk until they are confident that they are likely to be able to work at that level without becoming ill again. Whilst this approach of gradual progress would be an essential part of the scheme that I am suggesting, it would not be right that a person's progression should be governed by their fears about their benefits. The rate at which a person takes up work or returns to work, should be governed by what is promoting their own mental health, not their fears about benefits.

22. A Guaranteed Benefit Scheme is a scheme which guarantees to users of the employment scheme that those who attempt to return to paid employment but have a setback which means that they are no longer able to work and are dependent upon benefits, will not result in them:

• Risking being without benefits during the process of the recalculation following their loss of earned income
  
• Becoming responsible for the completion of forms and providing proofs for benefit providers
  
• Losing benefit, thus ending up receiving less than they had done prior to their attempt to take up paid employment.
  

Obviously there would need to be some time limit on such a scheme. Somebody who had successfully maintained a job for many months or years and then had another episode of their mental illness could not expect to return to the benefit status they had reached when they first took up the job.

How might this Guaranteed Benefit Scheme be delivered?

• Agreement with Benefits Agency and Unitary Authorities (eg for Housing Benefit, Council Tax Benefit) that they can deliver. These other parties may agree to act in this way if they recognise the contribution this employment scheme would make to social inclusion and welfare to work.
  
• Alternatively the Benefits Agency and Unitary Authorities may be willing to take on the extra work involved if the employment scheme agreed to pay them for the additional costs they would incur in providing this service.
  
• Scheme provides loan to user, repaid when they get their benefits back (repaid directly by Benefit Agency or how guarantee from user?