Intended for healthcare professionals


Work and mental health in the UK

BMJ 2014; 348 doi: (Published 21 March 2014) Cite this as: BMJ 2014;348:g2256
  1. Max Henderson, senior lecturer in epidemiological and occupational psychiatry1,
  2. Ira Madan, consultant in occupational medicine2,
  3. Matthew Hotopf, professor of general hospital psychiatry1
  1. 1Kings College London, Institute of Psychiatry, Weston Education Centre, London SE5 9RJ, UK
  2. 2Guy’s and St Thomas’ NHS Foundation Trust, London, UK
  1. max.j.henderson{at}

A case of could do better

Psychiatric disorders are the most important cause of absence due to sickness and receipt of health related benefits in the United Kingdom.1 Recipients stay on benefits longer and have worse employment outcomes than those with physical disorders.2 An alarming employment gap now exists—the rate of employment in people with common mental disorders is half that of people without a psychiatric disorder, and this figure is a quarter in those with more “severe” illnesses, such as schizophrenia.2

In 2012 the Organisation for Economic Cooperation and Development (OECD) published Sick on the Job, a substantial and important review of the challenge posed by psychiatric disorders across its member states.3 A series of reports on how individual member countries are meeting these challenges has followed. The UK report on mental health and work, published in February 2014,2 draws on data provided by the Department for Work and Pensions, the psychiatric morbidity survey, the OECD’s Eurostat labour market programme database, and Eurobarometer. It estimates that psychiatric disorders cost the UK economy £70bn (€83.8bn; $115.9bn; 4.5% gross domestic product) a year. Although the UK is more aware of the impact of psychiatric disorders on employment than most OECD countries, much remains to be done in terms of delivery.

The OECD made several recommendations. These included intervening early to prevent “sickness” becoming a “permanent disability,” improving the integration of health and employment services, and further expanding Improving Access to Psychological Treatment (IAPT) services. Although reasonable, these suggestions underestimate the seriousness of the report’s findings, and will probably not substantially change the psychiatric disorder and work landscape.

Employers have a key role to play. Conflicts with managers are the most common reasons for patients under Improving Access to Psychological Treatment services to see an employment adviser.2 Although absent from some reports,4 evidence suggests that poor working environments are associated with worse mental health and absence owing to sickness.5 A focus on creating workplaces that are good for mental health would probably be a more effective strategy than carrying out “stress audits,” which are often superficial and arbitrary, and may be counterproductive. However, the recently announced Health and Work Service, rightly praised by the report, is a genuine opportunity for employers to engage with this problem.

The work programme, whereby private and third sector providers are paid to get long term unemployed people back to work, has been disappointing.6 The OECD suggests that better aligned incentives could produce better results for those with psychiatric disorders, although its architect is on record as saying that providers may decide that getting people with psychiatric disorders back to work is not cost effective.7

Some elements of the health response to the problem of psychiatric disorders and work were missing. Occupational medicine, which is ideally placed to advise employers, employees, and medical colleagues, is under-resourced in the UK compared with other European countries. This is symptomatic of a wider failure of health services to engage with employment problems, from the minimal teaching of employment matters to undergraduate medical students, to the reluctance of the National Institute for Health Research to accept occupational outcomes as relevant to health.

Compared with other OECD countries, more patients with psychiatric disorders in the UK access primary care, but many fewer receive specialist care.2 There is a widespread under-recognition of the effects, often multiplicative, of physical and mental comorbidity on long term absence for sickness.8 Structural problems, most notably the focus on “severe” or “serious” mental illness, result in secondary psychiatric services failing to provide general practitioners, occupational health practitioners, and other colleagues with appropriate support. The binary distinction between “common mental disorders” and “serious mental illness” is no longer sustainable. If a person has a psychiatric disorder that has taken, or is about to take, him or her out of the labour market, this should be “serious” enough to prompt specialist care if requested by the GP.

For too long secondary mental health services have focused on the risks of rare, and therefore unpredictable, events (suicide and violence) as a means of rationing care. This is stigmatising and ultimately futile.9 Not being able to work because of a psychiatric disorder is a more common and arguably a more predictable outcome that affects the individual and the wider economy. Functional impairment, not labels, must determine whether patients move across the interface between primary and secondary care.

The OECD report rightly praises the UK for the progress in the policy area of work and health. “Good work is good for your health” is now widely accepted.10 Nonetheless, the extent to which disadvantage clusters in society needs to be more widely recognised; people with a psychiatric disorder who are out of work may also be less well educated, with the least economic resources.11 Those most in need of support remain the least likely to receive it. The idea that such people are shirkers who just need motivating is as simplistic as telling obese people to eat less and will fail similarly.

Carol Black’s landmark report in 2008 was the launch pad for the recent improvements highlighted in the OECD report.12 One of her key proposals, the creation of a centre for work and health responsible for driving a research agenda and drawing together research policy and practice, was not implemented. Its time has now come. The NHS outcomes framework, for both long term conditions and “severe” mental illness, includes an employment measure. Major research funders must follow suit. Although the OECD report identifies pockets of excellence in the UK, sustained improvement in the employment outcomes of those with psychiatric disorders is urgently needed. However, this can be achieved only by joining up research policy and practice.


Cite this as: BMJ 2014;348:g2256


  • Competing interests: We have read and understood the BMJ Group policy on declaration of interests and declare the following interests: MH is seconded part time to the Practitioner Health Programme, an NHS service for doctors and dentists in London with psychiatric disorders or addiction problems. This service was highlighted as an example of good practice in the OECD report. IM and MH have no competing interests.

  • Provenance and peer review: Commissioned; not externally peer reviewed.


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