Thriving at-work-stevenson-farmer-review

Thriving at work
The Stevenson / Farmer review
of mental health and employers
October 2017

Dear Prime Minister,
On January 9th you asked us to undertake an
independent review into how employers can
better support the mental health of all people
currently in employment including those with
mental health problems or poor well-being to
remain in and thrive through work.
This has turned out to be a very timely brief.
Our work has revealed that the UK is facing a
mental health challenge at work that is much
larger than we had thought. Not only is there a
big human cost of poor mental health at work,
there are also knock on impacts for society,
the economy and Government. Employers are
losing billions of pounds because employers are
less productive, less effective, or off sick.
Happily our research has found green shoots
of good practice. Using good practice and
evidence where it exists, this review sets out
a number of mental health core standards
that can be adopted across all workplaces
at little or no cost. We strongly recommend
that change be encouraged by increasing
employer transparency – not only internally
to their employees, but also across industries
and through the public domain. You will see
in the report that we very much hope you
will lead the way in committing the public
sector to implement these measures, and use
Government policy to encourage and support
employers more effectively.
Our vision – which is in our view wholly
realistic – is that in ten years’ time the
following changes will have happened:
• Employees in all types of employment
will have “good work”, which contributes
positively to their mental health, our society
and our economy.
• Every one of us will have the knowledge,
tools and confidence, to understand and
look after our own mental health and the
mental health of those around us;
• All organisations, whatever their size, will be:
·· equipped with the awareness and tools
to not only address but prevent mental ill-
health caused or worsened by work;
·· equipped to support individuals with
a mental health condition to thrive,
from recruitment and throughout the
organisation;
·· aware of how to get access to timely help
to reduce sickness absence caused by
mental ill health;
• We dramatically reduce the proportion
of people with a long term mental health
condition who leave employment each year
and ensure that all, who can, benefit from
the positive impacts of good work.
The UK could and should be one of the leading
nations in relation to mental health. If the
UK prioritises mental health at work, we can
become global leaders in reducing stigma,
improving the mental health of the population
and support for those who need it, and in the
process improve the UK’s productivity.
We very much hope that Government is able to
implement our recommendations, measure the
results and make a long-term commitment to
improving mental health at work.
Yours sincerely

Thriving at Work: The Independent Review of Mental Health and Employers4
Executive summary
The Prime Minister announced on 9 January 2017 that she
was asking us to carry out an independent review into how
employers can better support all individuals currently in
employment including those with mental ill health or poor
well-being to remain in and thrive through work.
“ Many employers are already creating healthy, inclusive
workplaces, but more needs to be done so that
employers provide the support needed for employees
with mental health conditions.
”Prime Minister Theresa May, January 2017

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Executive summary
This study has led us to conclude that
underneath the stigma that surrounds mental
health and prevents open discussion on the
subject, the UK faces a significant mental
health challenge at work.
• While there are more people at work with
mental health conditions than ever before,
300,000 people with a long term mental
health problem lose their jobs each
year1
, and at a much higher rate than those
with physical health conditions.
• Behind this, our analysis shows that around
15% of people at work2
have symptoms
of an existing mental health condition.
The human cost is huge, with poor mental
health having an impact on the lives of many
individuals and those around them. This
manifests itself in a variety of ways both at work
and at home, and impacts a person’s ability to
manage other elements of their personal life.
Then there is the ultimate human cost of loss
of life through suicide. We know that rates of
poor mental health and suicide are higher for
employees in certain industries.
With the help of an independent study on the
cost to employers commissioned from Deloitte,
we have also found:
• There is a large annual cost to employers
of between £33 billion and £42 billion3
(with over half of the cost coming from
presenteeism – when individuals are less
productive due to poor mental health in
work) with additional costs from sickness
absence and staff turnover.
• The cost of poor mental health to
Government is between £24 billion
and £27 billion4
. This includes costs in
providing benefits, falls in tax revenue and
costs to the NHS.
• The cost of poor mental health to the
economy as a whole is more than both of
those together from lost output, at between
£74 billion and £99 billion per year5
.
At a time when there is a national focus on
productivity the inescapable conclusion is
that it is massively in the interest of both
employers and Government to prioritise
and invest far more in improving mental
health. The UK can ill-afford the productivity
cost of this poor mental health.
It could be argued that these costs are
the “normal” cost of being alive and doing
business. Our work suggests strongly that this
is not the case.
• Deloitte’s analysis of the case studies
where investments have been made
in improving mental health show
a consistently positive return on
investment… a finding which is bolstered
by a number of academic meta-studies
which demonstrate the benefits of
good work for mental health6
and key
workplace enablers. As this review is going
to press, the Lancet has also published
findings from a study in the Australian Fire
Service which found that a manager mental
health training programme could lead to
a significant reduction in work-related
sickness absence, with an associated return
on investment of £9.98 for each pound
spent on such training.
• This is borne out by our own
conversations with over 200
organisations which have uncovered a
number of successful investments, activities
and approaches in improving the mental
health of employees.
Our approach and vision
We start from the position that the correct
way to view mental health is that we all
have it and we fluctuate between thriving,
struggling and being ill and possibly
off work. People with poor mental health
including common mental health problems
and severe mental illness can be in any of
these groups. An individual can have a serious
mental health problem but – with the right
support – can still be thriving at work.

We need to move to a society where all of
us become more aware of our own mental
health, other people’s mental health
and how to cope with our own and other
people’s mental health when it fluctuates.
It is all our responsibilities to make this
change. However in line with the brief we
have been given by the Prime Minister,
employers are perhaps able to have the
greatest impact and scope to make an
impact and are the focus of this review. To
quote Sir Simon Wessely, past President of The
Royal College of Psychiatrists, “You own it!”,
meaning that employers can create a positive
and supportive workplace culture themselves,
free from stigma.
Our vision is that in ten years’ time the
following changes will have happened:
• Employees in all types of employment have
good work, which contributes positively to
their mental health, our society and our
economy.
• Every one of us will have the knowledge,
tools and confidence, to understand and
look after our own mental health and the
mental health of those around us.
• All organisations, whatever their size, will be:
·· equipped with the awareness and tools
to not only address but prevent mental ill-
health caused or worsened by work;
·· equipped to support individuals with
a mental health condition to thrive
from recruitment, and throughout the
organisation;
·· aware of how to get access to timely help
to reduce sickness absence caused by
mental ill health;
• All of these measures result in dramatically
reducing the proportion of people with a
long term mental health condition who leave
employment each year and ensure that all
who can, benefit from the positive impacts of
good work.
As we outline in the review, we believe that the
number of people leaving work with mental
health problems could be reduced by 100,000
to bring the number in line with physical
health conditions in the first instance.
How can this vision be achieved?
To achieve this, the report sets out what we
describe as “mental health core standards”
– a framework for a set of actions which
we believe all organisations in the country
are capable of implementing quickly. These
mental health core standards are as follows:
• Produce, implement and communicate a
mental health at work plan;
• Develop mental health awareness among
employees;
• Encourage open conversations about
mental health and the support available
when employees are struggling;
• Provide employees with good working
conditions and ensure they have a healthy
work life balance and opportunities for
development;
• Promote effective people management
through line managers and supervisors;
• Routinely monitor employee mental health
and wellbeing.
These mental health core standards are drawn
from best practice and, as far as possible,
are evidence based, albeit we feel there is a
pressing need for more evidence. In Annex A
the reader will find guidance, suggestions, and
tools to help with implementing the standards.
The report also outlines a series of more
ambitious ‘enhanced’ standards for
employers who can and should do more
to lead the way, building on the mental
health core standards these are as follows:
• Increase transparency and accountability
through internal and external reporting
• Demonstrate accountability
• Improve the disclosure process
• Ensure provision of tailored in-house
mental health support and signposting to
clinical help

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Three other factors will help the implementation
of these “mental health core and enhanced
standards”.
1. Increasing employer transparency
presents the biggest opportunity to
encourage a greater breadth and depth
of employer action on mental health, and
strong leadership is vital to ensuring this
change is felt throughout organisations.
Employer action on mental health is
intrinsically measurable. Increased
transparency will go a long way to
generating a culture of measurement
and will enable the development of
voluntary ranking schemes to help drive
accountability and further improvement.
2. While we believe that it is clearly in
the interests of all businesses and
organisations to implement these mental
health core and enhanced standards, we
are calling on trade unions, industry
groups, professional and regulatory
bodies to help with the implementation
of these standards.
3. Digital tools and products are an
enabler of change and there is a
significant opportunity for low cost,
scalable interventions in workplaces.
We are witnessing an explosion of such
technology and it is vital that there is a
firm evidence base that is accessible for
employers and employees.
The role of the public sector
The public sector, which employs 5.4
million people7
, has a huge opportunity
to lead the way. We believe the public
sector is ideally placed to implement our
recommendations, innovate and build the
evidence base.
It is beyond the scope of this report to cover
what is needed in the entire public sector.
We acknowledge that we do not have all the
answers and further innovation and work to
build the evidence base is needed. Within the
public sector, we have spoken to a number
of leaders who are already developing good
practice, and have proposed specific areas of
focus for the three largest public employers:
the National Health Service, Education and
the Civil Service.
We also draw attention to the need for
particular focus to be given to areas of the
public sector at highest risk of stress and
trauma, and the need to establish clear
accountability for supporting their mental
health.
The role of Government
The report sets out a series of areas where
Government can use its influence and its
purchasing and legislative power to encourage
faster change:
• Government can do more to make it
simple for employers, through support
and online information platform and
joining up existing provision aimed at
employees and employers.
• Government should consider exploring
further the role of incentives and public
procurement to drive implementation of
the mental health core standards.
• We also suggest Government sets clearer
expectations of employers through
legislation, and makes Statutory Sick
Pay more flexible to better support people
with mental health problems to make
voluntary phased returns to work where
appropriate.
• There is a significant role for the NHS
to support workplace mental health by
ensuring support is accessible, high
quality and fits around work.
• Government does more to prevent and
end employer practices which contravene
employment and equalities legislation.

Delivery and implementation
We very much hope that the Prime Minister
and her colleagues will embrace this report
and implement it publicly.
It is clearly important this is done in a
way that creates a self-sustaining and
measurable change process which survives
future elections changes in personnel and
is visible for future generations.
To that end, we recommend that all
Permanent Secretaries Chief Executives
and equivalent senior leaders across
the public sector, have a performance
objective relating to ensuring the
mental wellbeing of all employees, and
accountability for adopting the ‘mental
health core and enhanced standards’. We
outline in the review how progress can be
measured.
We also suggest that so as to achieve
leadership across the private, public and
voluntary sectors, the Prime Minister sets up a
new Mental Health and Employer Leadership
Council. We are glad to report that there will be
many willing volunteers to serve on it.
Implementing the mental health core standards
will be easier for workplaces that have scale
and existing structures. Small and medium
enterprises and the self-employed present
different challenges. The implementation of the
mental health core standards among these
groups will be greatly helped by:
• Joined up efforts from organisations who
already work with small and medium
enterprises and the self-employed
(for example, as this goes to press we
understand that one of the major banking
groups may be prepared to help implement
them among their SME customers).
• Utilising local organisations and networks
who are particularly important for reaching
these groups. We very much support
and encourage innovation including, for
example, the work in areas including the
West Midlands.
Local trials and nationwide research should
be fully utilised and joined up to build the
evidence base of what works.
On the following pages, we summarise our key
recommendations.
Our recommendations for
employers
1. We recommend that all employers,
regardless of workplace type, industry
or size adopt the mental health core
standards. This will ensure ‘breadth’ of
change across the UK workforce and lay
the foundations for going further, and can
be delivered proportionally depending on
the size and type of business. The mental
health core standards should provide a
framework for workplace mental health
and we have designed them in a way that
they can be tailored to suit a variety of
workplaces and be implemented by even
the smallest employers. We believe all
employers can and should:
1. Produce, implement and
communicate a mental health at
work plan
2. Develop mental health awareness
among employees
3. Encourage open conversations
about mental health and the
support available when employees
are struggling
4. Provide your employees with good
working conditions
5. Promote effective people
management
6. Routinely monitor employee mental
health and wellbeing.
2. We recommend that all public sector
employers and the 3,500 private
sector companies with more than 500
employees, deliver the following mental
health enhanced standards which will
reach 46% of employees:

9
1. Increase transparency and
accountability through internal and
external reporting.
2. Demonstrate accountability
3. Improve the disclosure process
4. Ensure provision of tailored
in-house mental health support
and signposting to clinical help
The importance of transparency
and leadership
3. We recommend that Government
considers amending legislation and
guidance , for example the Companies
Act, to encourage employers to report on
workplace mental health on their website
or other channels
4. We welcome the adoption of workplace
mental health indicators in employer
rating initiatives.
External support for employers
and the role of regulators
5. We recommend that industry groups
provide guidance and support to enable
employers to implement the mental health
core standards, and take steps to support
increased employer transparency and
accountability on workplace mental health.
6. We recommend that professional
bodies with responsibility for training or
accrediting professional qualifications
should include workplace mental
health in their training programmes and
assessments.
7. We would welcome industry efforts to
support employers to be able to better
understand and compare Employment
Assistance Programmes and Occupational
Health services by developing standards,
and by developing online comparison
tools.
8. We recommend that insurers explore how
they could support and reward employers,
in particular SMEs, who adopt preventative
policies and provide mental health
support to their employees.
9. We recommend that workplace regulators
use the most suitable regulatory
approaches available to them to
encourage the take up of the mental
health core standards amongst employers.
10. We recommend that the Equality and
Human Rights Commission considers
taking a more proactive role in monitoring
and taking enforcement action against
employers that discriminate against
individuals on the grounds of mental
health.
11. We recommend that the Health and
Safety Executive revise its guidance to
raise employer awareness of their duty to
assess and manage work-related mental
ill-health.
12. We recommend that the Health and Safety
Executive builds on its risk assessment
guidance and Management Standards
approach by highlighting how these
actions will help employers deliver key
parts of the mental health core standards.
13. We recommend that Local Authorities
adopt the same recommendations as the
Health and Safety Executive throughout its
guidance and practices, and ensure join
up between its public health and health
and safety enforcement roles.
Our recommendations for the
public sector
14. We recommend that all public sector
workforces should implement the mental
health core and enhanced standards.
15. We recommend that public sector regulatory
bodies who are regularly in contact with
public sector employees include the
employer’s approach to employee mental
health in their assessments.

16. We recommend that all Permanent
Secretaries, Chief Executives and
equivalent senior leaders across the public
sector, have a performance objective
to support the mental wellbeing of all
employees, through the implementation of
the core and enhanced standards.
17. We recommend that NHS England
continues to develop its current offer on
mental health in the Healthy Workforce
Programme and other on-going initiatives,
and look to ensure that every NHS Trust
arms NHS employees with basic tools for
prevention and self-care.
18. We recommend that the Department for
Education implement the commitments
in the published workload action plan
and consider how teacher mental health
can be incorporated into school mental
health strategies, including the upcoming
Children and Young People’s Mental
Health Green Paper.
19. We recommend that, in addition to its
existing initiatives to train senior leaders
and coaches in mental wellness, the Civil
Service reviews and enhances mental
health training for all grades and ensures
all Departments have a planned approach
to ensuring employees have received
training appropriate for their role.
20. We recommend that public sector employers
should identify employees at higher risk of
stress or trauma and produce a national
framework which coordinates support for
these employees and establishes clear
accountability for their mental health.
Our recommendations for
Government
21. We recommend the formation of a
mental health online information portal,
co-produced by the voluntary, public and
private sector, to promote best practice
and enable employers of all sizes to
implement the mental health core and
enhanced standards.
22. We recommend that Government aligns
the fragmented occupational health
and practical support available currently
from Access to Work, the Fit for Work
Service and other NHS services to create
an integrated in-work support service to
better support the needs of those with
mental illness, and other physical health
conditions and disabilities.
23. We recommend Government protects
and promotes the current tax relief for
employers to invest in the mental health of
their employees.
24. We recommend Government explores
the potential to incentivise employers,
especially SMEs, to implement the mental
health core standards, including building
on evidence from the West Midlands
‘wellbeing premium’ trial.
25. We recommend that public bodies
encourage their suppliers to implement
the mental health core standards.
26. We recommend that the Government
consider legislative change to enhance
protections for employees with mental
health conditions, particularly fluctuating
mental health conditions and clarify the
role of employers in providing reasonable
adjustments.
27. We recommend that Government examine
what more it can do to require employer
compliance with existing equalities and
employment laws.
28. We recommend that Government develops
a new flexible model for Statutory Sick
Pay to better support those with a mental
health condition, where willing and able,
to return to work on a voluntary phased
return and receive wages and SSP on a
pro-rata basis.
29. In England, the NHS and Government
should fully implement the Five Year
Forward View for Mental Health, and the
Scottish Government, Welsh Government

11
and Northern Ireland Assembly should
consider how best to prioritise mental
health in line with local needs.
30. We recommend that the Government
and NHS bodies enable and encourage
IAPT and other mental health services to
provide quick and convenient access to
care to fit around employment.
31. We recommend that NHS bodies should
provide clear ratings for apps and other
digital platforms which provide mental
health support.
32. We recommend that the responsibility
for completing fit notes is extended
to mental health professionals and
Government considers how to further
improve communication between health
professionals, employees and employers
where appropriate.
33. We recommend that Government and the
NHS work to improve patient access to
their personal health record, empowering
employees to share their data and
information with their employer when they
wish to do so, where it can be done safely
and securely, to support people to thrive
in work.
Implementation and delivery
34. We recommend that Government invites
leaders from a variety of organisations to
join a Leadership Council to maintain the
momentum built by this review.
and other organisations should focus
information, support and funding
to support small and medium sized
core standards, and ensure the impact of
this is evaluated.
36. We recommend that online platforms
with large reach amongst self-employed
workers link up with NHS-approved health
and wellbeing support to provide mental
health support and advice which can be
accessed by those working through their
technology.
37. We recommend that the relevant
Government Departments explore ways
of supporting and encouraging local
networks, particularly through City Regions
and combined authorities, to develop
integrated approaches to improving
workplace mental health.
38. Given the clear links between mental
health and productivity, we invite ‘Be
the business’ and similar initiatives to
incorporate employee mental health in
their tools and information.
streamlines research and activity relating to
workplace mental health to drive evidence-
building and innovation, putting it at the
heart of the 10 year research strategy.
40. We recommend that Government funded
mental health campaigns include
information and support for improving
workplace mental health, and that where
possible their impact is evaluated.
Throughout the review there are a
number of other areas outside of these
recommendations where we are calling
for action or further progress to be
made in order to achieve our vision for
ten years’ time. This is particularly the
case in Chapter 6: The Importance of
Transparency and Leadership, and
Chapter 9: Implementation and Delivery.

Chapter 1: Introductions and Definitions...............................................................14
Chapter 2: The Facts.................................................................................................. 18
Chapter 3: The Costs.................................................................................................22
Chapter 4: The Green Shoots: Grounds for Optimism........................................26
Chapter 5: Our Recommendations for Employers...............................................28
Chapter 6: The Importance of Transparency and Leadership...........................36
Chapter 7: External Support for Employers and the Role of Regulators.........40
Chapter 8: Our Recommendations for the Public Sector...................................44
Chapter 9: Our Recommendations for Government...........................................48
Chapter 10: Implementation and Delivery............................................................54
“ Employers have a huge positive role to play in improving the
nations mental health and it also makes perfect business
sense to keep our colleagues as mentally fit and productive
as possible. I particularly welcome the fact that the review
suggests practical steps that large and small businesses can
take to start moving forward on this vital topic.
”Sir Ian Cheshire, Heads Together
Contents

1. Introductions and
definitions
Our work has consisted of the following:
• We have drawn on the expertise of our Leadership Panel
and Expert Advisory Group, to whom we are grateful for
their insights and support throughout this review.
• We have held a series of meetings and workshops with
individuals with lived experience of workplace mental
health issues, who have shared with us their personal
experiences – good and bad – and to whom we are
extremely grateful for doing so.
• We have also consultedwith over 200 employers and
stakeholdersfrom acrossthevoluntary, publicandprivate
sector.We have also testedour findingswith regulators,
professionalbodies, health providersandtrade unions.We
are gratefulto these employersfor their insightandfeedback.
• We have worked with Deloitte, who have produced an
estimate of the total costs to business of mental ill health
and poor wellbeing and the evidence for, and return on
investment of, a range of interventions employers can
make in order to demonstrate the business case for
investment. Deloitte also supported the review by
collecting examples of good practice internationally.
• Finally, we have had the privilege of working with an
outstanding team of Civil Servants.

15
Introductions
As a result of decades of ignoring the problem,
general understanding of mental health is
limited. It is especially important therefore to
be crystal clear about definitions.
First, mental health itself. By mental health
we do not mean “mental ill health”. We mean
the mental health we all have, just as we
all have physical health. The World Health
Organisation defines good mental health as
“A state of wellbeing in which every individual
realises his or her own potential, can cope
with the normal stresses of life, can work
productively and fruitfully and is able to make
a contribution to her or his community.”
This provokes the question as to what we mean
by poor mental health. In this review we
consider the full spectrum of poor mental health,
from common mental health problems to more
severe mental illnesses. One in four people in
England have been diagnosed with a mental
health condition in their lifetime. In 2014, one
in six adults in England met the criteria for a
common mental disorder in the past week. Of
these, around half have more severe symptoms8
.
The prevalence of common mental health
problems appears to have increased slightly
over the last two decades9
, with the biggest
rises in anxiety and depression, particularly
among younger women and older men. Many
individuals do not get diagnosed and of
those who have a diagnosed mental health
condition, some choose not to disclose it
because of the perceived stigma or fear of
potential consequences.
The scale of poor mental health in the
population is significant, but it is very
often preventable and recovery is possible
for many people.
“Everyone is somewhere on the
mental health spectrum, so this is
a business productivity issue which
should be dealt with alongside other
health and safety considerations.
Creating a positive environment for
mental health demonstrably costs
less than failing to do so.
”Nigel Carrington, University of the Arts London
Some key points of definition
And then there is the question of what we
mean by “mental health at work”. In this
Review we consider any mental health
problems at work caused not just by work,
but any mental health problems which are
brought to, and experienced at, work. Most
adults spend a significant proportion of their
waking hours at work, so it is inevitably a
setting where problems are often experienced.
Employment can also have both a positive
and negative impact on an individual’s mental
health.
The nature of work is changing and all
workplaces are not the same. We have
tried to ensure that our recommendations can
be adopted regardless of the size or type of
workplace. However, as the workplace and the
workforce changes, so there is the need to do
analysis to keep abreast of the implications of
those changes, especially among small and
medium-sized enterprises, the self-employed
and those working in the gig economy.
In this context we should make clear that our
review has been underpinned by the well-
established academic evidence-base that good
work is good for mental health10
, and we have
considered the findings of the recent Taylor
Review of Modern Working Practices in
reaching our conclusions.

Good work consists of autonomy, fair pay,
work life balance and opportunities for
progression, and the absence of bullying and
harassment. Good work can help prevent new
mental health problems and support those
with existing conditions to get on in work and
thrive. We want all employers and employees
to understand the benefits of good work,
including those with mental health problems
who may be off sick or out of work.
Finally, we should make plain our approach to
analysing mental health at work. Our approach
is to think of three phases that most of us go
through at different points and between which
we fluctuate during our lives. First, people who
are at any point in time are thriving, second,
people who are struggling and third, people
who are ill and possibly off work. People
with poor mental health including common
mental health problems and severe mental
illness can be in any of these groups. An
individual can have a serious mental health
problem but – with the right support – can still
be thriving at work.
At any one time many employees will be thriving, but with frequent movement between
thriving, struggling and those who are ill, and possibly off work.
Figure 1: Three phases people experience in work
Thriving
in work
Struggling
in work
Ill,
possibly
off work

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There are two other important points of definition.
First, some individuals have mental health
problems which have impacts that, in turn,
prevent them from working. Whilst this is a vital
group for improved support, we were asked
to focus on those who are currently in work,
including self-employment, for this review.
Second, it is important to acknowledge that
for many people their mental health condition
is not their only health problem. 71% of long
term mental health conditions are present
alongside other long term health conditions.
One in four individuals with a long term
mental health condition have 4 or more
other long term health conditions, including
musculoskeletal conditions, heart problems
and chest or breathing problems11
. Research
has found that those with long term physical
health conditions are two to three times more
likely to experience poor mental health than
the general population12
.
Whilst this review is focussed on workplace
mental health, we should consider mental
health alongside how employers can support
employees with physical illnesses and
disabilities and improve our understanding of
how to support people with comorbidities to
thrive in work.
“ I was diagnosed with Generalised
Anxiety Disorder with a depressive
episode, and whilst off work unwell
it was really important to me that
my manager kept in contact and
gave me updates on what was going
on at work as well as listened to
me tell him how I was feeling in a
caring and non-judgemental way.
When I returned to work he agreed
regular “check ins” to hear how I
was settling back into work and if
any adjustments were required. This
helped build back my confidence
in getting back to working
efficiently.
”Steve Loft, formerly Transport for London

2. The facts
More people are in work with a mental health condition than
ever before, but many individuals with mental health
problems are struggling emotionally, off sick, less
productive, or leaving employment. 300,000 people with a
long term mental health condition leave employment every
year, equivalent of the whole population of Newcastle or
Belfast.
“ Presenteeism is particularly common in organisations
where a culture of long working hours is the norm and
where operational demands take precedence over
employee wellbeing. Also, in periods of job insecurity,
people may be more likely to go into work when they
are ill, rather than take a day off sick, for fear their
commitment to their job will be doubted. It is this
culture and these fears that need to be addressed in
order to reduce presenteeism at work.
”RachelSuff, Chartered Institute of Personnel and Development

19
The facts
We have been keen to introduce discipline
into the analysis of the extent of mental health
problems at work in an area where there is a
lot of sweeping generalisation and anecdote.
To this end with the help of the Government
Economic Service we have conducted rigorous
analysis on existing figures.
There is some good news. We know
that individuals with a mental health
condition can find it harder to find
employment, but there are 1.5 million
individuals in the UK with a diagnosed
long-term mental health condition in
work and the rate of employment has
increased13
.
However, the bad news is that there are
still major challenges around mental health
at work:
• Around 15% of those in work in England
have symptoms of a mental health
problem14
.
• Individuals with long-term mental health
conditions are still far less likely to be
in work than those without any health
conditions, or those with a physical
health condition15
.
• Those with psychotic conditions are less
likely to be in work than with common
conditions such as anxiety or depression16
.
• Furthermore, our analysis has shown that
those with a long-term mental health
condition lose their jobs every year at
around double the rate of those without
a mental health condition and at a much
higher rate than those with a physical
health condition.
• Finally it is perhaps most shocking that
this equates to 300,000 people with
a long-term mental health condition
losing their jobs every year. This is the
equivalent of the whole population of
Newcastle or Belfast.
Around 3%of
employed people with
no LTMHCs
lose their jobs after
one quarter
This increases to
4%looking at those with
constant long
term physical
conditions
And increases
further to
6%looking at
those with
constant
LTMHCs
300,000people leaving work
each year
This chart shows the chance of an individual who
is in work losing their job in the next quarter.
It is significantly higher for those with a long
term mental health condition than a physical
health condition or no long-term mental health
(LTMHC). Annex C provides more details
Figure 2: Percentage of people leaving employment with no long-term mental health
condition, a physical health condition and long-term mental health condition, per quarter.
Please see Annex C for further information.

For employers, there are a number of ways in
which which poor mental health can display
itself. These are:
• Sickness absence: Mental health is one
of the greatest causes of sickness absence
in the UK. While the overall rate of sickness
absence has fallen by 15%-20% since 2009,
absence due to mental health reasons in
this period has actually risen by around
5%17
. People with a mental health condition
are also three times more likely to have a
long term period of sickness18
.
• Presenteeism: Presenteeism is defined
as showing up to work when one is ill,
resulting in a loss of productivity and
sometimes making an individual’s condition
worse. Whilst the percentage of days off
due to any type of illness is around 25%
lower than a decade ago, various studies
suggest that presenteeism is increasing
year on year.
• Limiting progression: Across all
businesses, there are still few managers,
directors and senior officials declaring
a long term mental health condition.
Employees tend to perceive that having
a mental health condition could hamper
their progression: 35% of people think
they would be less likely to get promoted
if they had depression19
, resulting in a
loss of diversity and skills throughout
organisations.
• Impact on wider workforce: people not
being supported with their mental
health by their employers can have a
knock on effect on other members of
teams/organisations if problems are
left un-managed e.g. if someone isn’t
supported with the right adjustments to
stay in work, they may need to take time
off, meaning other team members have
increased workload. There are also turnover
costs from the recruitment and training new
employees when someone is off sick from
work or leaves the organisation.
• Impact on employee turnover: An employee
may leave their employer if they feel
unable to continue at that organisation due
to poor mental health or the impact of work
on mental wellbeing. There will be costs to
the employer of finding a new employee
and making them fully effective.
Together, this accounts to a significant loss of
productivity and human and economic costs.

3. The costs
The human costs of mental illness are clearly significant, and
mental health problems caused or exacerbated by work can
have knock-on impacts across an individual’s home life, even
where they appear to be coping at work. The economic costs
to employers, directly to Government and to the economy as
a whole are also far greater than we had anticipated.
“ While I was at work my mental health was constantly
used against me, I feel that telling my department was
the worst decision I made…if I complained about one of
my classes or my workload I was immediately told my
mental health was the problem. Whereas everyone else
in the department was allowed to complain about this….
my mental health gave everyone a get-out clause.
”Michelle Cush, Teacher

23
The costs
The human costs
We know that poor mental health has a
huge impact on an individual’s life and
those around them. Impacts can range from
lack of sleep or panic attacks; difficulty in
concentrating; and low confidence. This can
lead to a downwards spiral, as an individual
may withdraw from social situations and lose
their support networks and structures at a time
when they need them most.
The knock-on impact on family life and friends
is also important here, with many people
‘holding it together’ at work, but then not being
themselves at home. Poor mental health also
means that individuals can find themselves
less able to cope with elements of their
personal lives such as relationship breakdown,
problem finance and housing worries.
The ultimate human cost is loss of life through
suicide. We know that rates of poor mental
health and suicide are higher for employees
in certain industries though clearly there are
a number of factors which contribute to such
trends. For example, suicide rates among men
working in construction and decorating are
more than 35% more likely to take their own
lives, and female nurses are 24% more likely
to commit suicide than the national average
for women20
.
“ Pressures vary significantly
across different industries. In the
predominately male construction
industry, rates of suicide are
particularly high, specific pressures
include physically hard work, cold
and harsh working environments,
low pay, long hours, time pressures,
job-insecurity and a ‘macho’ culture.
All of these things along with
significant periods away from home
can lead to feelings of isolation,
loneliness and poor mental
health.
”Shaun Atkins, Willmott Dixon Construction
“ I know from first-hand experience
what it can be like to suffer from
depression and heightened anxiety
and be afraid to speak out at work
for fear of what others might think.
This led in my case to having a
complete breakdown, being off
sick for 3 months and being in a
psychiatric hospital for three weeks.
I now know if I had got help earlier
much of what I suffered could have
been avoided. My experience even
back then was that people at work
were much more supportive than I
expected after the crisis. Thankfully
at Deloitte we have taken some
really great steps over the last
10 years to get training in mental
health awareness and prevention
firmly on the agenda.
”John Binns MBE, City Mental Health Alliance

Cost to Employers
Since 2003, the Centre for Mental Health has produced various analyses on the economic and
social costs of mental health problems.
Deloitte have produced new analysis that not only considers the costs to employers of
presenteeism, absenteeism and staff turnover due to mental health problems and for the first
time this has also been broken down by industry. This analysis has been published separately
and can be found at www.deloitte.co.uk/MentalHealthReview
Figure 3: Poor mental health costs employers between £33 billion and £42 billion a year21
.
Finance, insurance
and real estate
£2,017
£2,564
£1,473
£1,998
£1,313
£1,439
£1,172
£1,531
£841
£1,421
£777
£989
£497
£932
Average cost per employee: £1,119 – £1,481
Figure 4: Private Sector mental ill health costs per employee
Professional services
Transport, distribution
and storage
Other private services
Information and
communication
Retail and wholesale
Hotels, catering
and leisure
Low estimate
High estimate
This is made up of:
Absenteeism
cost:
£8bn
Presenteeism
cost:
£17bn to
£26bn
Staff turnover:
£8bn
Total cost:
£33bn to
£42bn
This amounts to a cost per employee of between £1,205 and £1,560 per year. This cost is
for all employees, not just those who are ill.
These figures are higher than previous estimates but in line with other analysis, including from
the Centre for Mental Health. We acknowledge that some of these costs will always exist and
we acknowledge there is some uncertainty about the costs of presenteeism. However, even if
we applied more conservative assumptions in particular to the calculation of presenteeism, the
figures that emerge for the cost to employers are huge.

25
The Deloitte report also looked at variation between sectors for the first time and found the cost
per employee varies significantly between sectors. Figure 4 shows their estimates of the cost
per employee in each sector for the low and high cost scenario. Industries such as finance and
insurance have a much higher cost per individual per year (over £2,000 per employee per year)
than the retail or leisure sectors (£500 to £1,000 per employee per year).
There are also higher costs per employee in the public sector (£1,551-£1,878 per year) than in
the private sector as a whole (£1,119-£1,481 per year) so we will give additional focus to this
workforce in chapter 7.
Deloitte also estimate a cost of around £1 billion per year of sickness absence to the self-
employed. This presents unique challenges and we will consider self-employed later in this review.
Costs to Government
Figure 5: Cost of poor mental health to UK Government
Poor mental health at work costs Government between £24 billion and £27 billion per year22
.
Benefits:
£10bn
Lost tax/
National
Insurance revenue:
£11bn to
£14bn
NHS costs:
£3bn
Total cost:
£24bn to
£27bn
The direct cost to Government is constituted of the cost of benefits paid to individuals who are out
of work for mental health reasons, tax and national insurance foregone and additional cost to the NHS.
The NHS costs are based on an estimate of mental health service usage among working age people
out of work with mental health conditions.
Costs to the UK Economy
Figure 6: Cost of poor mental health to the UK economy
Poor mental health at work costs the UK economy between £74 billion and £99 billion per year23
.
Lost output:
£37bn to
£52bn
Costs to
employers/self
employed:
£33bn to
£43bn
NHS costs:
£3bn
Total cost:
£74bn to
£99bn
The wider cost to the economy is an estimate of the extra output (goods and services) that
could be created if there wasn’t any working-age mental ill health, which prevented people from
working or reduced their productivity in work. Here, we have also included the self-employed
in the cost to employers. In addition it also includes a potential saving to the NHS as a result of
reduced service usage because of improved mental health.
The cost to Government of welfare benefits and foregone tax revenue are not included in this estimate
as this represents a transfer of money between different groups in society rather than a loss in output.

4. Green shoots:
grounds for optimism
It could be argued that the substantial human and financial
costs outlined in the previous chapter are the natural order
of things. In the same way that we all have physical health
that fluctuates, we all have mental health that does the
same. Just as in any year a significant percentage of the
workforce will develop flu or other illnesses, a certain level
of people experiencing poor mental health is inevitable.
However, we are glad to report there are a number of reasons
for believing that we can prevent more people from
struggling with poor mental health at work; and reduce the
impact of mental health problems on someone’s ability to
thrive in work.
“ I’ve been fortunate to have had very good experiences
with three different employers regarding my bipolar
disorder. These include two major city law firms and a
local authority. In every case they dealt with me in a
professional, supportive and careful way. I really could
not fault them.
”Michelle Passfield, Marketing Professional
and Mental Health Advocate

27
Grounds for optimism
In recent years, there has been a growing
emergence of work on workplace mental
health, led by Business in the Community, the
City Mental Health Alliance, Time to Change,
Mental Health First Aid and Mind, amongst
others.
Throughout this review we have observed
increasing signs of good and successful
practices emerging among the employers
we have talked to. There are a growing
number of companies large and small, who
are demonstrating a tangible commitment to
employee mental health, often championing
their own policies and programmes, whilst
engaging with industry and voluntary sector
led benchmarking.
Deloitte conducted a systematic review of
literature on the returns from investing in
Mental Health in the workplace resulting in
the inclusion of 23 high quality examples
where investments were made in trying to
improve mental health and where there was
enough information to evaluate the impact.
The return on investment of workplace mental
health interventions is overwhelmingly
positive. The average return per £1 spent was
£4.20 (with a range of between 40p and £9),
and this has been supported by international
academic literature in the form of meta-
studies24
.
As this review is going to press, the Lancet
has also published findings from a study in
the Australian Fire Service which found that a
manager mental health training programme
could lead to a significant reduction in work-
related sickness absence, with an associated
return on investment of £9.98 for each pound
spent on such training.
The scale of the opportunity
If employers and Government work together
to reduce the number of people who leave
work with mental health problems to even
the same rate as those with a physical health
condition, this will prevent around 100,000
with a long term mental health condition
leaving employment each year. This is
entirely measureable and achievable, and will
be a key way of determining success.
Other measures include identifying positive
changes in the mental health of the UK
population over time and measuring effective
implementation of our mental health core
standards throughout workplaces.
We understand that there will be challenges
ahead, but we think there is a real
opportunity here to become global leaders in
“I have really valued being supported
through having sessions of
Resilience Training. This has proved
invaluable and has helped to
address the potential work-related
contributing factors that can lead
to a bipolar episode, such as being
overly sensitive when things ‘go
wrong’, feeling I have to work even
harder to make up for lost time,
self-stigmatisation, and feelings
of insecurity about the potential
effects on my job security as a result
of my mental health problems.
”Ian Callaghan, Rethink Mental Illness

5. Our recommendations
for employers
Employers have told us they face a number of obstacles
when trying to do more on mental health. Our review
establishes a set of mental health “core standards” which
we believe all organisations in the country should be
capable of implementing – whether they are small, large,
private, voluntary or public sector. We then outline a series
of more ambitious mental health enhanced standards for
employers who can and should do more to lead the way.
“ I experienced depression and anxiety during a period
of sick leave following a second requirement for major
spinal surgery. The surgery, although lengthy and with its
risk wasn’t the concern I had, it was the fact that I wasn’t
going to be at work and wasn’t sure how I would / could
cope with that. I was able to be open and honest with
my HR team and senior manager, discussing that I was
feeling in a ‘dark place’ and getting anxious about being
away for so long – my recovery time was anticipated at
12-16 weeks, which filled me with dread! In a short time
frame, I was able to positively discuss what returning to
work looked like for me – which with the agreement and
support of the service allowed me to reduce my anxiety
and allow me to have a more realistic and positive outlook
for both physical and mental health recovery. My return to
the service was 6 weeks on reduced hours / days.
”Jules Lockett, London Ambulance Service

29
Many employers know they are missing
opportunities to intervene early when
employees are struggling, as the stigma
of disclosing a mental health condition
is still a significant barrier to employees
seeking support.
Only 11%
of employees
discussed a recent
mental health problem
with their line manager,
and half of employees
say they would not
discuss mental health
with their line manager25
.
“ Mental health is still the elephant
in the room in most workplaces
– employees are reluctant to
raise the subject for fear of
discrimination, while managers
often shy away from the subject
for fear of making matters worse
or provoking legal consequences.
This culture of silence means that
opportunities to support someone
in the workplace are being missed,
resulting in staff being off sick
or falling out of the workplace
altogether.
”Emma Mamo, Mind
A significant number of employers are
not currently very transparent about the
mental health and wellbeing of their
employees, and not many ensure that
there is adequate accountability at a
senior leadership level.
Only 11%
of the Top 100
companies inGreat
Britain have disclosed
information about their
initiatives to support
their employees’
mental health in their
annual reports26
.
“ The need to address employee
mental health is increasingly
recognised in boardrooms, but
there is more to do to ensure
widespread and consistent
reporting. We know that investors
are demanding a clearer and more
consistent way to understand how
organisations are managing their
most important asset – people.
”Louise Aston, Wellbeing Director, Business
in the Community
Throughout the review, we have spoken to employees, line managers and
employers about their role in supporting better workplace health and
some of the challenges they face. We will start with summarising the key
conclusions from this work.
Our key findings from these discussions are:

Many employers have a general
lack of awareness of how to promote
good mental health for all, support
someone with a mental health
condition and where to start looking
for external support.
Overall, around
4 in 10
organisations (39%)
have policies or
systems in place to
support employees
with common mental
health27
.
“ So why is mental health at
work still far from being widely
accepted and understood? Take
this example from our helpline,
where one employer said of
a member of their staff: “She
hasn’t got a disability as such, it’s
just the mental health issues”.
Irrespective of the diagnosis or
correct definitions, perhaps the
word “just” is the worst part of
that sentence.
”Adrian Wakeling, Advisory Conciliation
Arbitration Service
Employers want to do the right thing but line managers lack the training,
skills or confidence required to effectively support others at a very basic level.
Only 24%
of managers have received some form
of training on mental health at work28
.
“ We need to de-medicalize discussion around mental health because the most
important factors are the preventative role of line managers and good people
management.
”Rachel Lewis, Affinity Health at Work, Kingston Business School
All of this leads to our key recommendation.
Most employers are not regularly
monitoring and assessing the mental
health of their employees, either
through organisation-wide employee
surveys or ensuring all staff have regular
conversations with a line manager or
supervisor to check-in.
8 in 10
employers report no
cases of employees
disclosing a mental
health condition29
.
“ Measuring well-being is beneficial
in two broad ways. Firstly, the
boards of companies can use
the information from surveys
to establish well-being leads
and strategies, targeting those
areas of staff well-being and
engagement most in need.
Secondly, for individual
employees…feedback allows
individuals to take positive action
to improve their own health and
well-being, driving up employee
well-being as a whole.
”Christian van Stolk, RAND

31
Aviva has well-being strategy which
incorporates health checks, nutritional
advice, a wellbeing app, mental health
support and income protection provided
free to all staff. They have appointed
a senior executive as mental health
champion and heavily promoted to
employees the benefits of opening up
and seeking support. Line managers
are being provided with training to help
facilitate this.
“ If the review generates an appetite
for agreed standards of employment
practice, shared across the wide
range of stakeholders, that will be
a significant step.
”Dame Carol Black
Introducing the mental health
standards for employers
In light of the feedback received from a wide
variety of employers, we feel confident in
concluding that an increasing number of
employers want to improve the mental health
of their workplace but need help in doing so.
Therefore, we have devised a common sense
package of standards that we believe any
employer in the UK could implement.
The mental health standards are built
on a range of existing good practice and
evidence, where it is available. We have
reviewed a wide range of academic literature,
guides and toolkits from organisations such
as What Works Centre for Wellbeing, Mind,
CIPD, NICE and Business in the Community.
We have also considered conclusions from
previous government reviews and data
from a range of surveys which Government
and other organisations have undertaken.
Deloitte’s review of international evidence30
and return on investment analysis has also
informed this work.
Support for every
employee, including
those who may be
thriving with a long term
mental health condition
Support for all employees to thrive
Targeted support for those
who are struggling
Tailored support for
those who are ill
and possibly
off work
Support for some
individuals who need
support from their
employer
Figure 7: Employers can provide support for all employees to thrive, and more targeted and
tailored support for those who may need it

core standards
We believe all employers can and should:
communicate a mental health at
work plan that promotes good mental
health of all employees and outlines
the support available for those who
may need it.
2. Develop mental health awareness
among employees by making
information, tools and support
accessible.
3. Encourage open conversations
about mental health and the support
available when employees are
struggling, during the recruitment
process and at regular intervals
throughout employment, offer
appropriate workplace adjustments to
employees who require them.
4. Provide employees with good
working conditions and ensure they
have a healthy work life balance and
opportunities for development.
management to ensure all employees
have a regular conversation about their
health and well-being with their line
manager, supervisor or organisational
leader and train and support line
managers and supervisors in effective
management practices.
6. Routinely monitor employee
mental health and wellbeing by
understanding available data, talking
to employees, and understanding risk
factors.
enhanced standards
Our long term ambition is that many
employers can and will go beyond our mental
health core standards outlined above. We
therefore recommend that public sector
employers and the 3,500 private sector
companies with more than 500 employees,
deliver the following mental health enhanced
standards. Together, this will ensure the core
and enhanced standards reach around 46%
of the working population32
who work in
these organisations.
We suggest these employers can and should:
1. Increase transparency and
accountability through internal
and external reporting, to include a
leadership commitment and outline of the
organisation’s approach to mental health.
(We will discuss this further in chapter 5.)
2. Demonstrate accountability by
nominating a health and wellbeing lead
at Board or Senior Leadership level, with
clear reporting duties and responsibilities
3. Improve the disclosure process to
encourage openness during recruitment
and throughout, ensuring employees
are aware of why the information is
needed and make sure the right support
is in place to facilitate a good employer
response following disclosure
4. Ensure provision of tailored
in-house mental health support and
signposting to clinical help, including
digital support, employer-purchased
Occupational Health or Employee
Assistance Programmes, or NHS services,
amongst other sources of support.
Larger employers also have significant
influence through their supply chains,
customers and contractors, and can use this
influence to encourage and support smaller
core standards, as well as sharing resources
and knowledge.
Many smaller employers will also aspire to, or
be able to implement, the enhanced standards.

33
South Liverpool Homes Housing
Association has involved all staff in
creating their mental health and well-
being policy, which has now been built
into the overall business approach
and vision. Colleagues are offered the
opportunity to meet with a life coach
individually and are offered advice on
helping to adopt a healthier attitude to
life and work. Their package includes
mentoring opportunities, a monthly focus
on wellbeing which is integral to their
people management approach – the first
question that is asked at monthly one to
ones is and “How is your wellbeing?”
“ Talking about mental health at
work can be hard. Sometimes it’s
easier to start the conversation by
focusing on the practical factors
that affect our mental health, rather
than mental health itself. A quarter
of employees are in a difficult
financial situation, with debt and
a lack of savings meaning a simple
unexpected cost, like a broken
down car, can cause real distress.
Offering support or providing access
to specialist help with issues like
debt or money worries can have a
huge impact on mental health –
without necessarily having the
same stigma attached.
”Money and Mental Health Policy Institute
The Global Workforce Happiness
Index31
is an annual study of workplace
wellbeing. In 2016, Denmark, Norway,
Sweden and Finland all scored in the top
ten countries and there is a lot we can
learn from this study:
• Work-life balance is an absolute
priority and employers have strategies
in place to ensure their people are
achieving this. The average working
week in Denmark, across industries
and job roles, is 37 hours and overtime
is actively discouraged.
• Employees are often elected to sit on
a workplace wellbeing panel and play
a vital role in promoting everything
from healthy lifestyle habits and work-
life balance, to improved nutrition and
exercise.
• Employees in Nordic countries report
feeling a sense of autonomy in their
work, something that has long been
associated with high job satisfaction.
Canada provides a structured framework
for workplace mental health. Their
framework, called ‘the Standard’ provides
a comprehensive framework to help
organisations of all types improve their
workplace mental health offer to provide
the best return on investment. The
Mental Health Commission of Canada has
developed a variety of resources to help
organisations implement the Standard.
Further details about what the mental
health core and enhanced standards
involve, along with links to helpful
organisations and resources, can be
found at Annex A.

The mental health standards
can be applied across very
different workforces
We firmly believe these mental health
standards are doable for all employers
and the self-employed, and we will discuss
communication channels and additional
support in Chapter 10.
Some organisations with fewer than 500
employees will also want to go further and
implement, or aspire to implement, the mental
health enhanced standards too.
We acknowledge that workforces are
incredibly diverse. It is vital that employers
tailor the mental health core and enhanced
standards to fit their organisational cultures
and practices, and to meet employees’ needs.
Employers may wish to build the mental
health core standards into a broader offer
to employees to attract or retain employees,
improve engagement or boost productivity
– de-medicalising their mental health offer
to ensure it is embedded throughout the
organisation’s structures and processes.
We also know that the nature of work is
changing, with more people working remotely
and more flexibly than ever before. It is vital
that employers consider their full range of
employees when implementing the mental
health core standards, including those working
part-time or on shift patterns, or those with
additional needs or at a higher risk of stress or
trauma. We are also aware that in some roles
where developed vetting is required, having a
mental health illness can preclude individuals
from gaining work – this must be in minimal
circumstances where based on legal or
regulatory requirements, and reasons should
be made clear to employees.
Most of the mental health core and enhanced
standards can be implemented at little or no
cost, but employers may choose to invest in
interventions to support and build on these
mental health core standards.
“ There’s a clear link between
relationship satisfaction and job
performance, with 25 per cent of
employees surveyed telling Relate
that stress at home adversely affects
them at work. With one-in-five UK
adults in a distressed relationship,
the impact on productivity is likely
to be significant. Not everyone will
deal with relationship distress such
as bereavement or divorce in the
same way – for some, work might
prove a welcome distraction. Others
may find it difficult to concentrate.
However, people are inclined to
cope, knowing that someone is
there to talk to if it all gets too much
can make a big difference.
It’s good to see employers doing
more to invest in the wellbeing of
their staff by offering individual
counselling as part of Employee
Assistance Programmes (EAPs)
but we’re calling on calling on
employers to make relationship
counselling available to employees
and their partners as part of
EAPs. Of course, the quality of
our relationships at home is also
influenced by stress at work, so
offering flexible working and not
expecting employees to work
unreasonably long hours will also
make a big difference.
”Chris Sherwood, Relate

35
The mental health standards
can and should support all
employees and managers
Much of ‘what works’ to support all
employees to thrive can be effectively applied
to individuals with serious illnesses. If
appropriate measures are put in place from
day one, and there is culture and environment
where both employee and employer can be
open to discussing potential challenges and
options, this can reduce fears for both the
employee and employer.
We have spoken to employers who shared
concerns that employees might feign mental
health problems as an excuse for poor
attendance or low productivity. We believe
that this can be addressed through ensuring
that line managers are well trained to have
practical and engaging conversations with
employees, and create a culture where working
with a mental health problem is supported.
Our hope is that he mental health core
standards will encourage awareness and
training amongst those who might find it
difficult, but also put in place wider structures
and processes which encourage managers to
develop skills and understanding of mental
health whilst providing alternatives sources of
support for employees.
Employers should also recognise that their role
goes beyond what happens in the workplace as
technology and other factors increasingly blur
the line between work and home life. Flexible
working can benefit all employees, including
those with caring responsibilities. Employers
can also play a more significant role in
supporting employees through major life events
which may include bereavement, problem debt,
and relationship breakdown, which can cause
or exacerbate mental health conditions.

6. The importance of
transparency and
leadership
We believe increasing employer transparency presents the
biggest opportunity to encourage a greater breadth and
depth of employer action on mental health, and strong
leadership is vital to ensuring this change is felt throughout
organisations. Throughout this review, we have heard from
employers where change has been driven by organisational
leaders opening up about their own experiences or those of
family or friends. We have heard from a number of
inspirational leaders, including Sue Owen at the Department
of Digital, Culture, Media and Sport, who by sharing her own
problems with mental health was able to encourage
employees to be open about their own experiences.
Nigel Wilson, Chief Executive of Legal & General, has also
shown impressive leadership of the Not a Red Card Offence
campaign which aims to reduce the stigma of mental health
problems throughout the organisation. We need to
encourage this leadership throughout different workplaces.
“ In my experience there is a strong correlation between
the authenticity of an organisation’s support and
commitment and the willingness of staff to speak up.
This is governed by how supported individuals feel
and how visible, active and credible their most senior
leaders are on this front.
”Jeremy Heywood, Cabinet Secretary

37
Internal Transparency
Employers can improve internal transparency
by adopting our mental health “core
standards”, in discussion with their employees.
It is vital that employees can help steer
initiatives to ensure that the mental health
core standards are adopted in a way that
meets the particular interests and needs in
that organisation.
Employers can also be transparent internally
about the impact of any initiatives or support.
Employers can measure employee mental
health and well-being through surveys and
mood trackers. Organisations can report
on findings internally in order to encourage
discussion throughout the organisation and
increase accountability of the organisation to
employees for delivering against the mental
health core or enhanced standards.
“ In many sports a Red Card is the
ultimate punishment for bad or
inappropriate behaviour. We’re
using its symbolism to help lift the
mental health taboo and encourage
more conversations in the workplace
about mental health. It’s OK to have
a mental health problem, just like
it’s OK to have a physical health
problem. We talk about physical
health so why don’t we talk about
mental health?
”Not a Red Card Offence campaign, Legal and
General
“ At Thames Water the Board of
Directors are accountable for staff
wellbeing. Its Executive Team review
company absence figures and trends
and for all work related illness cases
an Executive review is undertaken
triggering conversations with
local managers about each case.
Occupational Health are brought
in to find the cause of illness and
to learn from every individual
case what the issues are, crafting
solutions to support each individual
and promote any wider business
learning.
”Thames Water

External transparency
We believe greater public transparency will
create a sense of competition between
employers, promoting success and driving and
maintaining cultural change. Yet according to
data gathered by Business in the Community,
only 11% of the Top 100 companies in Great
Britain have disclosed information about their
initiatives to support their employees’ mental
health in their annual reports34
. This needs to
change.
First, employers can signal commitment to
mental health through publicly committing
to delivering the mental health core and
enhanced standards to protect and improve
the mental health of their employees.
All employers can also publicly commit
to mental health by signing a pledge, or
publishing a statement or plan. Thousands of
employers have worked with Time to Change
and Mindful Employer over the last 15 years.
There are already various platforms in place
to encourage public sector organisations to
signal commitment on mental health, and
private sector organisations are encouraged
to commit to various social, ethical or
environmental priorities through legislation
and guidance. In chapter 4, we recommended
public sector employers and the 3,500
private sector companies with more than 500
employees report externally on their work
to improve workplace mental health. We
recommend that the Government considers
amending legislation and guidance,
including the Companies Act, to encourage
employers to report on workplace mental
health on their website or other channels.
Employer action on mental health is
intrinsically measurable. Employers can
track a number of measurements including
sickness absence; staff survey results; take
up of Employee Assistance Programmes or
Occupational Health Services; and disclosure
rates. On certain measures, we would expect
numbers to rise initially as people become
more confident in discussing their mental
health and aware of the support on offer to
them.
Increased transparency will go a long way
to generating a culture of measurement and
will enable the development of voluntary
ranking schemes to help drive accountability
and further improvement. We welcome the
adoption of workplace mental health
indicators in employer rating initiatives.
As employers implement the mental health
core and enhanced standards, bench-marking
exercises provide an opportunity to test the
impact and effectiveness of their support and
highlight areas of opportunity to do more.
Benchmarking programmes exist to evaluate
employer performance on mental health
through key wellbeing performance indicators,
employee surveys and external assessment.
Top performers are publicaly recognised
and their good practice promoted to other
employers. Two examples of benchmarking
include:
• Mind’s ‘Workplace Wellbeing Index’35
,
which uses an employer and staff survey
to assess an employer’s current policy
and practice. The higher tiers of this
assessment include staff interviews
carried out by a Mind consultant to gather
qualitative feedback to be integrated into a
comprehensive report.
• Vitality’s ‘Britain’s Healthiest
Workplace’36
which requires employees to
fill in an online survey about their general
health, lifestyle behaviours, mental health
status and their work environment. High
performing organisations receive awards.

39
“ Where mental health and wellbeing
sits is less relevant than whether
or not it reports to or has exposure
to the Chief Executive & Board of
Directors. In high risk industries,
injury and safety are a Board
and instead of, it should be the
same for health and illness. It is
a multidisciplinary matter that
should be owned by the whole
organisation, be reflective in
People Management Policies and
be at the forefront of business
decision making.
”Karl Simmons, Head of Health, Safety, Security &
Wellbeing, Thames Water
“The biggest problem is the absence
of reliable data or an accepted
common definition of mental
health. This makes it difficult
for businesses to assess the
workplace mental health,
understand their responsibilities
and benchmark the level of support
they should put in place.
”Nigel Carrington, University of the Arts London.
Since 2014, RBS has taken a holistic
Bankwide approach to wellbeing focusing
on mental, physical and social wellbeing.
The Banks initiatives have gained traction
across the organisation, leading to an 8%
increase in their wellbeing index (part of
the annual employee survey) in 2015, with
the score having been maintained in 2016
and a further increase of 4% in September
2017. They have seen a significant
increase in the number of employees
accessing support such as their Employee
Assistance Programme (EAP), mindfulness
toolkits and health checks.

7. External support for
employers and the role
of regulators
Employers do not need to carry all the burden, we are also
calling on industry groups - trade unions, professional
bodies and accrediting organisations to help implement the
mental health core and enhanced standards. We also
recommend that regulators, including the Health and Safety
Executive and Local Authorities, develop their approach to
mental health.
“ Practical solutions are often best derived through
engagement between employers and employees or their
representatives. Mutually agreed solutions offer greater
chance of buy in and sustainability.
”Sir Brendan Barber, Chair of ACAS

41
Industry groups and trade
unions
Many employees are members of trade
unions or professional bodies. Trade Unions
have a significant interest in supporting the
mental health of their employees, and many
Trade Unions are developing their offer on
mental health. Likewise, we have heard from
professional bodies who are providing tools
and information on mental health to their
members. We welcome this engagement
and would encourage trade unions and
professional bodies to support implementation
of the mental health core and enhanced
standards, and help to join up information and
support for their members.
Industry groups also have a crucial role to play
to help facilitate the adoption of our mental
health core standards amongst employers.
Many of these organisations are already starting
to champion change and disseminate good
practise on mental health, such as the Institute
of Directors, Federation of Small Businesses
and EEF: The Manufacturer’s Organisation.
We recommend that industry groups
provide guidance and support to enable
core standards, and take steps to support
increased employer transparency and
accountability on workplace mental health.
Professional bodies and
accrediting organisations
Many employees are required to register and
maintain professional accreditations, and
professional bodies that register or accredit
qualifications promote the mental health and
wellbeing of their members. There are 3,500
such organisations, ranging from the Royal
Medical Colleges to the Association of Plumbing
and Heating Contractors to the Federation of
Master Builders. Some of these organisations
will directly award or accredit qualifications
that are required to practice in a certain field,
such as the Association of Chartered Certified
Accountants . Training bodies, including
City and Guilds and Business Schools, also
have incredible opportunities to include
mental health awareness and training in their
courses. We recommend that professional
bodies with responsibility for training or
accrediting professional qualifications
include workplace mental health in training
programmes and assessments.
Mates in Mind is an initiative
established in 2016 in support of the
construction industry’s desire to improve
the mental wellbeing of its workforce.
Supported by the British Safety Council
and the Health in Construction Leadership
Group, it delivers tailored, targeted
training programmes which encourages
workers to be aware of their own and their
colleagues’ mental health.
This initiative is working collaboratively
through supply chains to support SMEs
and aims to reach 100,000 workers in its
first year.
Occupational Health Providers,
Employee Assistance
Programmes and Insurance
Employers can buy in products and services to
support the mental health of their employees,
whether they are in work or off sick. Products
include Employee Assistance Programmes and
Occupational Health provision. These products
and services can be effective if properly utilised,
but many employees have told us that they are
unclear about what is on offer for mental health
from such providers. There also seems to be
significant variation in the quality of services
and the evidence base for support, leading to
some scepticism amongst employers.
There is also a role for providers of these
products and services in helping to deliver the
mental health core and enhanced standards. We
have heard from some SMEs that they struggle to
access such provision due to the costs involved
or they do not know what to buy to best support
their employees. We would welcome industry
efforts to support employers to be able to

better understand and compare Employment
Assistance Programmes and Occupational
Health services by developing standards,
and by developing online comparison tools.
Employers are able to buy insurance
products to help support the mental health
of their employees, including private medical
insurance, health cash plans and Group Income
Protection. Many insurance products provide
early support for mental health conditions for
individuals who are still working and those
who are off sick to help them recover and
return to work. They also often qualify for
corporation tax relief, providing a financial
incentive for employers to procure the policies.
If employers prioritise the mental health of their
employees, this should reduce the risks for
insurers. Insurers discount premiums based on
safety measures or other efforts, such as burglar
alarms which can reduce home insurance
premiums. We recommend that insurers
explore how they could support and reward
employers, in particular SMEs, who adopt
preventative policies and provide mental
health support to their employees.
Workplace regulators
Regulators have an important role to play in
encouraging employers to effectively implement
the mental health core and enhanced
standards. There are over 70 regulators in the
UK which either directly regulate a workforce,
such as the Nursing and Midwifery Council, or
regulate sectors which employ a large number
of people such as the Financial Conduct
Authority. These regulators can and should be
doing more to drive up employer standards on
workforce mental health. We recommend that
workplace regulators use the most suitable
regulatory approaches available to them to
encourage the take up of the mental health
core standards amongst employers.
Public sector regulators will also help the
Government lead the charge in transforming
standards of mental health and wellbeing in
the public sector workforce. We will go on to
describe this further in Chapter 6.
The Health and Safety Executive
and Local Authorities
“ In many workplaces, safety is
managed as a separate process,
largely disconnected from the
business imperatives of production
and profit. However, health and
safety is not a process in its own
right but an outcome of business
decisions, strategy, culture and
performance.
”Mathew Nelson, Ernst and Young
The Health and Safety Executive is the
national regulator in England, Scotland and
Wales for work-related health and safety. The
‘Management of Health and Safety at Work
Regulations 1999’, require all employers to
conduct a risk assessment to identify and
capture any hazards in their workplace,
including risks to physical and mental health
and safety.
However, we have found that too often
employers only focus on the risks to physical
health and safety in the workplace. This
should not be the case, and there is no such
limitation in the Health and Safety at Work
Act. Employers should risk assess and manage
work-related mental ill-health in the same
way as they would for work-related physical
ill-health. We recommend that the Health
and Safety Executive revise its guidance to
raise employer awareness of their duty to
assess and manage work-related mental
ill-health.
HSE has developed the ‘Management
Standards’ for work related stress which cover
six key areas that, if not properly managed, can
be the primary sources of stress at work. Whilst
this is a first step, this can encourage employers
to take a narrow approach to workplace mental
health. Employees with mental health problems
can present or face particular risks in the
workplace, whether or not their condition was
caused by or brought to work.
HSE’s guidance could provide a more holistic

43
approach that helps support employers to
protect and enhance the mental health of their
workforce. We recommend that the Health
and Safety Executive builds on its risk
assessment guidance and Management
Standards approach by highlighting
how these actions will help employers
deliver key parts of the mental health core
standards.
When an employer has a high rate of safety
incidents, this can trigger inspections. HSE
inspectors will visit organisations to examine
the arrangements in place for assessing and
controlling risks from work-related pressures
or other health and safety at work issues.
The Health and Safety Executive should
increase the focus on workplace mental
health and safety during its inspections.
Whilst regulation of comparatively higher risk
workplaces is the responsibility of HSE, lower
risk activities and premises are regulated
by Local Authorities or the relevant sector
regulator. HSE and Local Authority inspectors
have the same regulatory powers and are
governed by the same guidance. Local
Authorities can also undertake a whole range
of interventions such as awareness raising
and advice visits and may also undertake
initiatives as part of their wider responsibilities
to promote public health. We recommend
that Local Authorities adopt the same
recommendations as the Health and Safety
Executive throughout its guidance and
practices, and ensure join up between
its public health and health and safety
enforcement roles.
Germany’s ‘Psyche’ Work Programme
is a nationally-led programme, in
partnership with insurance companies
to reduce work related mental ill-health.
This programme will aim to ensure that
6000 labour inspectors are qualified in
psychological stress and strain at work
and can conduct reviews of workplace
mental health. These reviews will consider
factors including how an employer
assesses the mental health of their
employees and the risk of facing trauma.

8. Our recommendations for
the public sector
We will set out opportunities for the public sector to lead the
way to implement our recommendations, innovate and build
the evidence base. Within the public sector, we have
proposed specific areas of focus for the 3 largest public
employers: the NHS, Education and the Civil Service.
Particular focus must be given to areas of the public sector at
highest risk of stress and trauma, and establish clear
accountability for protecting their mental health and we hope
that the mental health core and enhanced standards can be
effectively implemented to benefit all public sector
employees.

45
Delivering the mental health
core and enhanced standards
The Prime Minister asked us to make
recommendations on how to improve
mental health at work. The obvious place
for the Prime Minister to start, is of course,
the entirety of the public sector.
The public sector has the potential to have a
very powerful impact, since it employs 17% of
those in work, equating to 5.4 million people
in the UK37
. The public sector is very diverse
and there is significant variation in the type of
jobs people are doing.
Sickness absence rates are higher in the public
sector compared with the private sector[i].
Deloitte’s analysis estimates that the cost per
employee of mental ill health is higher in the
public sector (£1,551-£1,878 per year) than the
private sector (£1,119-£1,481 per year). Within
the health sector these costs are even higher,
potentially more than £2,000 per employee
per year.
Figure 8: Cost of poor mental health in the public sector
Health
£2,029
£2,174
£1,697
£1,817
£1,676
£1,795
£1,485
£1,590
Education
Other public services
Public administration,
defence, social security
Low estimate
High estimate
Public Sector mental health costs per employer
Average cost per employee:
£1,551 – £1,877
In total, poor workplace mental health costs
public sector employers between £8 and £10
billion per year.
We recommend that all public sector
workforces should implement the mental
health core and enhanced standards.
The standards will need to be tailored to
fit organisational cultures and practices, as
well as employee needs. Implementation will
require prioritisation and leadership across the
public sector and can be encouraged through
increased internal and external transparency.
Many changes can be made at little or no
cost, but small amounts of investment may be
required to accelerate this change across the
public sector.
We suggest that three other changes could be
made to ensure smooth implementation:

We recommend that all Permanent
Secretaries, Chief Executives and equivalent
senior leaders across the public sector,
have a performance objective to support
the mental wellbeing of all employees,
through the implementation of the core
and enhanced standards. Performance
reviews can consider a range of measurements,
which may include sickness absence; staff
survey results; take up of Employee Assistance
Programmes or Occupational Health Services;
and disclosure rates.
Commitments should be reflected in
Single Departmental Plans and similar
assurance processes to hold Public Sector
Employers to account for delivering
standards. At present many public sector
regulators consider the mental health of
service users but not employees. We believe
the mental health of employees should be
considered by public sector regulators. This
should be done a way which encourages
honest feedback from employees, without
fear of this impacting assessment scores or
ratings on service delivery. We recommend
that public sector regulatory bodies,
who are regularly in contact with public
sector employees, include the employer’s
approach to employee mental health in
their assessments.
The Environment Agency’s ‘Healthy
Minds programme’ aims to create a
positive, safe environment, helping
staff break down any barriers and talk
without fear of stigma; by providing tools,
techniques and information on how
to spot emotional distress and access
appropriate support.
Leadership in the three largest
areas of the public sector
Through the study of public sector practice
through this review, we have identified
significant variation in practice across
different workforces. We have made specific
observations and recommendations regarding
the three largest areas of the public sector,
choosing to focus our energies on these
areas whilst of course acknowledging that all
public sector staff need to be appropriately
supported to thrive at work.
The three largest areas of the public sector38
are:
• NHS – employing 1.62 million people
• Education – employing 1.52 million people
• Civil Service – employing 420,000 people
There is a range of good practice being
developed in these workforces and we
invite employers in these areas to continue
to develop and innovate, and share their
evidence with other public sector employers.
2016 NHS Staff Survey found that 37% of NHS
employees had experienced work related
stress39
and this has remained constant over
the last few years. NHS England is introducing
their Healthy Workplace programme that has
the overall objective to improve the health
and wellbeing of NHS employees, including
through stress audits and improving access to
counselling. NHS Employers has also produced
an Emotional Wellbeing Toolkit which provides
resources on developing a mentally healthy
workforce. Health Education England also
recently published ‘Stepping forward to
2020/21’ which committed to set an exemplar
in creating a mentally healthy workplace
and increasing board-level accountability for
workplace mental health. We recommend
that NHS England replace with continues to
develop its current offer on mental health
in the Healthy Workforce Programme and
other on-going initiatives, and look to
ensure that every NHS Trust arms all NHS
employees with basic tools for prevention
and self-care.
In the ‘Education and Support Partnership’s
latest Health Survey, 75% of people working
in education staff reporting suffering from
stress in the last 2 years40
.Lack of flexibility
and unacceptable workloads have been
identified by teachers and teaching unions as
significant factors for poor mental health in

47
the profession, as have constantly changing
processes, and continuous pressure to improve
performance. We have found that the majority
of support for governors and teachers is
available through the various teachers unions
and the voluntary sector. The Department for
Education recently published its action plan
to reduce teacher workload and Ofsted also
have a role to play in taking account of the
mental health of teachers in its inspections
and processes. We recommend that the
Department for Education implement the
commitments in the published workload
action plan and consider how teacher
mental health can be incorporated into
school mental health strategies, including
the upcoming Children and Young People’s
Mental Health Green Paper.
The approach in the Civil Service is supported by
the ‘Five Strategic Priorities for Health and Well-
being (2017-2020)’ to which every department
within the Civil Service has signed up to.
There is a core offer to all civil servants which
includes access to support through Employee
Assistance Programmes, Occupational Health,
counselling and talking therapies. However,
there is variation in terms of how widely and
effectively this offer is promoted across the Civil
Service. We recommend that, in addition to
its existing initiatives to train senior leaders
and coaches in mental wellbeing, the Civil
Service reviews and enhances mental
health training for all grades and ensures all
Departments have a planned approach to
ensuring employees have received training
appropriate for their role.
There are other significant areas of the public
sector workforce, including in the Devolved
Administrations and Local Government, who
are developing offers to support the mental
health of their employees. We welcome this
leadership and invite public sector employers
to work together to build and share good
practice and evidence of what works.
Employees at Ark Conway Academy
have time set aside for wellbeing and
the culture encourages staff to discuss
mental health openly, including during
dedicated weekly staff meetings where
staff can discuss how they are feeling
and the strategies they are taking to
sustain a positive wellbeing. Staff also
receive peer to peer support, regular
check-ins, have access to an Employee
Assistance Programme and effective
and compassionate people management
processes.
Areas of the public sector at
higher risk of stress or trauma
We know that some public sector roles, such
as those in the Armed Forces, emergency
services, social workers and prison officers
carry a significant degree risk of developing
or exacerbating mental health problems. For
example, a survey in 2015 of members of the
Prison Officer Association41
found that 49.9% of
individuals felt stressed from work. Employees in
these roles require more targeted help and clear
accountability from responsible departments,
and we support work including the Police Welfare
Fund which is investing in support for employees
which may be at higher risk of mental health
problems. We recommend that public sector
employers should identify employees at
higher risk of stress or trauma and produce
a national framework which coordinates
support for these employees and establishes
clear accountability for their mental health.

9. Our recommendations for
government
We have a significant opportunity to become a global leader
in improving the mental health of our population and
Government has a vital role to play in encouraging and
facilitating change. Government should consider doing more
to make this simple for employers, through an online
information platform and joining up existing support aimed
at employees and employers.
Government should look at incentivising employers to
prioritise workplace mental health, including using
Government procurement to encourage take up of the
mental health core and enhanced standards. Legislative
changes should be considered to enhance protections for
people with mental health problems in employment, and to
make Statutory Sick Pay more flexible. Finally, we recognise
the crucial role of the NHS in supporting people and it is vital
that Government and NHS bodies continue their work to put
mental health on a par with physical health.

49
Streamlining information and
financial support
Employers are able to access a wealth of
information from Government, private providers
and the voluntary sector on workplace mental
health. However, employers have told us this is
fragmented and confusing, and often they do
not know where to start or who to trust. From
Government alone, online advice and support
tools are available from NHS and public health
organisations in each nation (including Public
Health England, Northern Ireland’s Public
Health Agency, Public Health Wales and
Health Protection Scotland); work and health
organisations (including the Scottish Centre for
Healthy Working Lives and the Joint Work and
Health Unit)l; Business in the Community; the
Health and Safety Executive, and programmes
part-funded by Government including Time
to Change and the What Works Centre for
Wellbeing. We recommend the formation of a
mental health online information platform,
co-produced by the voluntary, public and
private sector, to promote best practice and
enable employers of all sizes to implement
standards.
Government offers support to employees
and employers to help employees remain
in work and return to work after a period of
sickness absence. These include the Access
to Work Scheme, Fit for Work Service (which
both operate in some form across England,
Scotland and Wales), and locally led support
available through IAPT services, amongst
others. However, we found that the mental
health offer from these support programmes to
be disjointed and not well utilised, particularly
by SMEs. We recommend that Government
aligns the fragmented occupational health
and practical support available currently
from Access to Work, the Fit for Work
Service and other NHS services to create
an integrated in-work support service to
better support the needs of those with
mental illness, and other physical health
conditions and disabilities, and other
physical health conditions and disabilities.
Australia’s Mentally Healthy
Workplace Alliance brings together
a large number of stakeholders and
provides a significant resources and
advice for employees, line managers,
employers and employer organisations.
This has enabled employers to implement
a number of workplace interventions,
examples of which include providing
access to a company doctor and an
Employee Assistance Programme and
a range of mental health training for all
staff. There is also specific guidance and
advice to help small business to create a
mentally healthy workplace.
Incentivising employers
All employers can and should adopt the
mental health core standards in order to
protect and improve the mental health of all
employees. However, even with the sound
business case for prioritising workplace mental
health and access to support, some employers
may need further encouragement.
The tax system already encourages employers
to invest in employee mental health, through
exemptions or reductions for training and
other provision. Yet awareness of these
exemptions are poor and take up is low.
We recommend Government protects
and promotes the current tax relief for
employers to invest in the mental health of
their employees.
The review has found that workplace initiatives
can have wider benefits to Government
and society. We have also heard that small
employers may respond to financial incentives
though further evidence would be required
to support such a change. We recommend
Government explores the potential to
incentivise employers, especially SMEs,
to implement the mental health core
standards, including building on evidence
from the West Midlands ‘wellbeing
premium’ trial.

Some people will ask why we have not
suggested going further on incentivising
employers to prioritise workplace mental
health during this review. There are two main
reasons: we believe the business case is
strong enough for many employers who want
to do more to support the mental health of
their employees, but just do not know where
to start. It is also our belief that the core and
enhanced standards will provide the basis
for new measurement and transparency
initiatives, which in turn will help to develop
the evidence base for what is most effective.
We welcome further consideration of financial
or other incentives in the future, and adopting
our standards could form one part of the
employer requirements.
Public procurement
Public sector procurement was worth £277
billion of UK central government spend in
2016/1742
, and £45 billion of local government
spend in England in 201443
. There is already a
precedent for ethical and social priorities to be
included in public sector procurement models,
including the purchase of environmentally
sustainable products and encouraging the
recruitment of disabled people. We believe
this purchasing power should be used to
positively influence the behaviour of suppliers
and their supply chain to support and improve
The Crown Commercial Service is responsible
for the legal framework for public sector
procurement and can encourage public
bodies to disseminate good practice through
their supply chains and hold organisations to
account through contracts. We recommend
that public bodies encourage their
suppliers to implement the mental health
core standards.
The role of legislation
Too many people experience discrimination on
the grounds of mental health in the workplace,
and employers often go unpunished for not
taking appropriate action.
Government should look to set clearer
expectations of employers, who tell us they
often do not feel clear on their minimum legal
and regulatory responsibilities when it comes
to mental health, nor confident in fulfilling
these responsibilities. This should start with
clarifying the legal provisions through the
Equality Act 2010 (the relevant equalities
legislation in England, Scotland and Wales).
This legislaton does not provide sufficient
protections for individuals with fluctuating
mental health conditions, and does not give
employers clear accountability for providing
reasonable adjustments. We recommend that
Government consider legislative change
to enhance protections for employees
with mental health conditions, particularly
fluctuating mental health conditions and
clarify the role of employers in providing
reasonable adjustments.
The rate of workplace discrimination on the
grounds of mental ill-health is significant,
and some employers are not doing enough
to end discriminatory practices. The Equality
and Human Rights Commission monitors
and enforces equality legislation in England
Scotland and Wales, and can take enforcement
action in respect to workplace mental health
discrimination. We recommend that the
Equality and Human Rights Commission
considers taking a more proactive role in
monitoring and taking enforcement action
against employers that discriminate against
individuals on the grounds of mental health.

51
Unfortunately there will still be employers
who will deliberately choose not to fulfil their
duties under equality and employment law. As
it stands it is too easy for employers to escape
punishment, with the enforcement powers of
the Equality and Human Rights Commission or
the threat of an employment tribunal often not
a strong enough deterrent. We recommend
that Government examines what more it
can do to require employer compliance with
existing equality and employment laws.
Current Statutory Sick Pay arrangements don’t
respond to the reality of returning to work
after a period of absence due to mental health
problems. Many people returning to work find
it easier to manage the transition through a
phased return – working reduced hours or
fewer days for a period of time. International
evidence suggests that a more flexible
approach to sick pay can have a positive
effect, and evidence from Finland shows
that promoting partial returns to work has
proved successful in reducing the time before
an employee returns to their normal duties.
Alongside retaining the current Statutory Sick
Pay system for people who are unable to work,
we recommend that Government develops
a new flexible model for Statutory Sick
Pay to better support those with a mental
health condition, where willing and able,
to return to work on a voluntary phased
return and receive wages and SSP on a pro-
rata basis.
The role of the NHS
Only three quarters of people with mental
health problems receive any support44
. Among
those who do receive care, too few have
access to the full range of evidence based
interventions. Government and NHS bodies
need to continue their work to put mental
health on a par with physical health. Mental
health problems will always exist and we
still need improvement in the access to, and
quality of, clinical care available through the
NHS.
There is a large variation in access and
waiting times for NHS mental health services,
particularly those requiring treatment for
severe conditions. The longer it takes for
people to access the treatment they need
the longer they may be ‘struggling’ in work,
or be off work. We know that across the UK,
plans such as Together for Mental Health in
Wales, are being implemented to ensure that
people can access the support they need. In
England, the NHS and Government should
fully implement the Five Year Forward
View for Mental Health, and the Scottish
Government, Welsh Government and
Northern Ireland Assembly should consider
how best to prioritise mental health in line
with local needs, and their specific mental
health plans. There has been a significant
expansion in access to psychological therapies
following the introduction of the national
Improving Access to Psychological Therapies
(IAPT) programme in England, and we support
the expansion of employment support
supervisors in IAPT services. However, there
is a significant variation in waiting times to
access IAPT45
services and individuals cannot
always access services near their place of
work, meaning they may need to take time off
work to access the treatment they need. We
recommend that the Government and NHS
bodies enable and encourage IAPT and
other mental health services to provide
quick and convenient access to care to fit
around employment.

Individuals need clearer advice on using
appropriate digital support, which has the
potential to provide low cost, scalable support
for employees. We have found that individuals
and employers do not have a clear idea of
whether available technology is effective, and
some individuals are using digital support
that does not have strong clinical evidence.
We recommend that NHS bodies should
provide clear ratings for apps and other
digital platforms which provide mental
health support.
The ‘fit note’ system needs improvement to
provide patients with the support they need to
get back to work, and we welcome the current
review of the fit note. There is limited evidence
that the current ‘fit note’ process is effectively
encouraging GPs and patients to discuss work
and health. Currently only GPs and hospital
doctors can sign a fit note, and many feel that
they are often not best equipped to provide
employment advice for people with a mental
health condition and many are concerned
about the implications of ticking ‘may be fit
for work’ when support might not be available
to the individual. We recommend that the
responsibility for completing fit notes is
extended to mental health professionals
and Government considers how to further
improve communication between health
professionals, employees and employers
where appropriate.
Patients should have more ownership over
their medical records. Accessible summary
medical records could empower employees
to request reasonable adjustments from their
employer, or enable employees to share
this information where appropriate and it
would benefit them. We recommend that
Government and the NHS work to improve
patient access to their personal health
record, empowering employees to share
their data and information with their
employer when they wish to do so, where
it can be done safely and securely, to
support people to thrive in work.

10. Implementation and
delivery
Achieving change will not be easy. We believe a 10 year plan
is required to achieve the levels of cultural change required
amongst employers and throughout organisations, but this
underpinned by urgent action required in the next 2 to 3
years. We need joined-up efforts from organisations who
already communicate with SMEs and the self-employed to
support the delivery of the mental health core standards and
ensure information has the largest reach possible.
Local organisations and networks are particularly important
for reaching these groups, and we support innovation in
areas including the West Midlands. Local trials and
nationwide research needs to be fully utilised and joined up
to build the evidence base of what works. Ultimately,
workplace mental health is one part of a wider programme of
mental health awareness and culture change across
communities and we hope that employers can help to deliver
this change.

55
Leading the change
We have already suggested many key steps to
achieving the change.
To drive and maintain this support, we
recommend that Government invites
leaders from a variety of organisations to
join a Leadership Council to maintain the
momentum built by this review.
Second, the Government should lead
this change in the public sector to reach
a significant proportion of the working
population and develop and demonstrate good
practice for other employers to learn from.
Third, this is embedded by ensuring that
the senior management in the public sector
have their employees’ mental health and
wellbeing as one of the criteria by which their
performance review is assessed and linked to
the regular delivery of measurable results so
as to ensure that there is real meaning behind
the assessment.
Fourth, these commitments are further
enforced by being reflected in the Single
Departmental Plans of Whitehall Departments.
We hope that Government’s response to this
review is coordinated by the Joint Work and
Health Unit, properly coordinating with the
devolved administrations and other relevant
Government Departments.
Throughout the review we have tried to make
the recommendations implementable on
a UK-wide basis. However, there are some
differences in policy approach and organisations
responsible for delivering certain measures. This
is particularly the case in Northern Ireland, where
they have their own Health and Safety Executive
and separate equalities legislation, for example.
It is vital that the Devolved Administrations are
engaged and consider how to take forward the
recommendations in this review.
In this final chapter we cover a number of the
more difficult areas that will be faced in the
implementation in particular the challenges
dealing with SMEs and the self-employed.
Build public and employer
awareness for culture change
Workplace mental health needs to be an
important part of the wider transformation
of how society approaches mental health,
empowering individuals as employees to
require transparency of their employers, and
understand how to support themselves and
others. Existing public education campaigns
including Time to Change, and the ambition
to train 1 million members of the public
in mental health awareness and skills will
help, but we should utilise workplaces as
conduits for such campaigns and ensure
tools and materials are relevant for work
related risks and support. We recommend
that Government funded mental health
campaigns include information and
support for improving workplace mental
health, and that where possible their
impact is evaluated.
Ensure the mental health core
standards reach everyone
We expect adaption to suit workplaces but
we have identified two particular areas of
focus for implementing and spreading the
mental health core standards:
The SME challenge: 60% of employees in
the private sector work for small and medium
sized employers (organisations employing less
than 250 employees) and SMEs account for
99% of UK businesses. However, lack of time
and resources mean they are not all able to
offer as much support for employees and tend
to be very reactive. Only 1 in 10 SMEs46
offer
occupational health support compared to
8 in 10 large organisations, they are less
likely to have mental health policies in
place47
and are less likely to utilise existing
government support programmes such as
Access to Work and Fit for Work. This is in part
due to simple misunderstanding that many
of the ways to promote good mental health
at work do not require significant financial
resources. It is worth also noting that in many

ways SME cultures can be more conducive
to good mental health as a result of closer
relationships, and individuals understanding
the part they play in the business.
It is therefore vital that the mental health core
standards and support available are promoted
to SMEs through the various channels we
discuss in earlier chapters; incentives,
regulators, professional bodies, trade unions
and large companies using their supply chains
to help share resources and influence the
behaviour of smaller companies. We also
need to utilise the numerous touch points that
already exist, such as embedding the mental
health core standards online when businesses
register with Companies House, or engage
with HMRC. Banks or providers of employer’s
liability insurance can also have influence here.
We recommend that Government and other
organisations should focus information,
support and funding to support small and
medium sized employers to implement the
mental health core standards, and ensure
the impact of this is evaluated.
The self-employed
There are 4.8 million self-employed workers
in the UK48
, and growing, many of whom
operate through online businesses or within
the GIG economy. This group has a higher
risk of mental health problems due to the
nature of their work, which can be isolated
and less stable. Deloitte analysis suggests
that sickness absence due to mental health
reasons results in a £1 billion annual cost
for the self-employed. There are many
organisations that do not directly employ
individuals but could use existing channels
to convey information to a large proportion
of the self-employed population. Public
awareness campaigns as mentioned above
will also go a huge way to reach those who
won’t receive support from an employer.
There are an increasing number of high
quality digital health apps available to help
people manage their physical and mental
health. Companies including Silver Cloud,
Big White Wall and Babylon Health provide
health services via digital apps which provide
a combination of GP consultations, online
Cognitive Behavioural Therapy, mental health
self-care toolkits and advice as well as access
to support networks. The advantages of these
technologies is that they can engage with a
much higher volume of users than face-to-
face treatments, they are accessible anyplace,
anytime and are available on all kind of
platforms e.g. phones, personal computers
and treatment can be adapted and tailored to
the needs of the user. We recommend that
online platforms with large reach amongst
self-employed workers link up with NHS-
approved health and wellbeing support to
provide mental health support and advice
which can be accessed by those working
through their technology.
Local networks are particularly important
to SMEs and the self-employed, who will
often use Local Enterprise Partnerships and
similar networks as an important source of
information and advice. We recommend that
the relevant Government Departments
explore ways of supporting and
encouraging local networks, particularly
through City Regions and combined
authorities, to develop integrated
approaches to improving workplace mental
health.
A number of organisations are already working
to improve information and support regarding
mental health for SMEs. Alongside Public
Health England and others, the Federation of
Small Businesses has developed ‘Wellbeing
in Small Business: a short guide’, and The
Institute of Directors has also launched an
online portal of information for SMEs. We
encourage more join-up of central points
of information to SMEs to ensure clear
messaging that reaches a broad range of
SMEs.

57
Building the evidence base
We have worked with Deloitte to provide
examples of return on investment for mental
health interventions. However, in many
areas there is not a comprehensive evidence
base of what specific interventions work
to improve mental health and wellbeing in
the workplace. To drive forward change and
achieve our vision, we need to have a better
understanding of what interventions
work. This will involve better adoption
of interventions by employers and clear
reporting on what does and does not work.
There is some excellent work going on across
the country in locally devolved areas, where
various initiatives are being trialled. The
West Midlands is one example of this, where
their mental health commission is trialling
a ‘Wellbeing Premium’ with the support of
central Government. This is a tax incentive
that rewards employers demonstrating their
commitment to mental health and wellbeing.
Working with over 100 companies it hopes
to establish whether a financial incentive,
accompanied by an employer action plan,
reduces staff sickness absence, improves
productivity and prevents people leaving work
due to mental ill health. Government should
support the evaluation of such trials and
help local areas to share their findings
with other areas.
Government funded research on workplace
mental health is fragmented between
Departments and various programmes,
and needs to better joined-up to improve
effectiveness. We support the Department of
Health’s 10 year research strategy on mental
health, which Government should ensure
has workplace element. We recommend
that Government streamlines research
and activity relating to workplace mental
health to drive evidence-building and
innovation, putting it at the heart of the
10 year research strategy.
Monitoring and measuring
impact of delivery
We believe our recommendations are
ambitious but achievable. Expecting all
core and extended standards would create
a significant change to how mental health is
viewed across the UK and support the mental
health of employees. People will rightly want
to know what progress is being made and
we would encourage regular monitoring of
employer take up of the standards, potentially
through the annual Employer Engagement
Survey. Implementation will also require
measurement of the impact on employee
mental health and other factors, including
whether there is a reduction in the number
of people leaving employment due to mental
health problems through the Labour Force
Survey.
As we have stated throughout the Review,
increased transparency will go a long way to
generating a culture of measurement and will
enable the development of voluntary ranking
schemes to help drive accountability and
further improvement.
Over the past year Sir Charlie Mayfield has
been working with a group of senior business
leaders to understand the UK’s productivity
performance, and what can be done to
improve it. “Be the business” is a portal which
provides: practical business-developed tools
and products, case study examples, articles,
reports, videos and podcasts. They are also
working to provide a set of measurements for
businesses to determine how productive their
business is. Given the clear links between
mental health and productivity, we invite
‘Be the business’ and similar initiatives to
consider incorporating employee mental
health in their measurement tools and
information.

Conclusion
Workplace mental health should now be
a priority for organisations across the UK.
We need the right leadership amongst
employers in the public, private and
voluntary sectors, and a mandate from
policy-makers to deliver the mental health
core and enhanced standards. Together we
can support all employees, including those
with mental health problems, to thrive in
work.
“ Employees will respond negatively
to wellbeing initiatives if they
believe they are merely being
implemented to get them to work
harder. This is why harnessing the
right culture in the workplace is
important. So it is an environment
where employee wellbeing can
flourish. Leadership is key to
developing this culture and its
success relies upon buy-in and
cooperation of all leaders from
the board level down.
”Professor Sir Cary Cooper, CBE, Professor of
Organizational Psychology and Health,
Manchester Business School

Acknowledgements

61
Acknowledgments
We would like to thank the members of our Leaders Panel, Lived Experience Panel and Expert
Advisory Group, whose advice and guidance has been invaluable in helping us draw together and
test the recommendations for this review. We would like to particularly thank Matthew Shaw, Sue
Owen, Jeremy Heywood, Cary Cooper, Christian van Stolk, Nancy Hey, Rachel Suff, David Halpern,
Victoria Fussey and Karl Simons.
We have also consulted with over 200 employers, academics, think tanks and individuals. This
has been through a combination of face to face conversations and focus groups, larger themed
workshops and an online survey. We would particularly like to thank those who have shared their
personal experiences of living and working with a mental health problem, including those who
took the time to attend our workshop arranged by Rethink Mental Illness, and all those who came
to our launch event at Number 10.
We would specifically like to thank our three panels who we appointed at the start of this review
and have acted as a sounding board for us:
Our Leaders Panel: a group of senior leaders across the public, private and voluntary sectors,
who have acted as a support and guide to the Review, particularly around implementation.
Moya Green Royal Mail
David Sproul Deloitte
Robert Peston ITV
Nigel Wilson Legal & General
Sally Boyle Goldman Sachs
Gaenor Bagley Price WaterHouse Coopers
Brian Heyworth HSBC
Susan Bright Hogan Lovells
Sir Ian Cheshire Heads Together
Sue Owen Department for Digital, Culture, Media and Sport
Sir Brendan Barber Advisory, Conciliation and Arbitration Service (ACAS)
Our Lived Experience Panel: a group of people are working to improve prevention or support in
their own organisations or have personal experiences of mental health and workplace issues.
Adam Spreadbury Bank of England
John Binns MBE City Mental Health Alliance
Pete Rogers KPMG
Sue Baker Time to Change

Our Expert Advisory Group: a group of individuals who have contributed evidence, examples of
good practice and practical advice to the Review.
Andy Bell Centre for Mental Health
Dr. Max Henderson Leeds & York Partnership NHSFT
Steve Bevan Institute of Employment Studies
Karen Steadman Work Foundation
Dame Carol Black Adviser to PHE and NHSE on Health and Work
Rachel Suff Chartered Institute of Professional Development
Prof. Sir Simon Wesseley Royal College of Psychiatry
David Haslam National Institute for Health and Care Excellence
Paul Litchfield British Telecom
Paddy Watt BUPA
Nigel Jones City Mental Health Alliance
Beth Robotham BUPA
Gregor Henderson Public Health England
Louise Aston Business in the Community
Matthew Shaw BBC
Poppy Jaman Mental Health First Aid England
Polly Mackenzie Money and Mental Health
Mark Winstanley Rethink Mental Illness
We would like to extend our special thanks to the team from Deloitte who created an excellent
piece of work which provides significant supporting analysis that there is a quantifiable business
case for creating workplaces that enable all employees to thrive at work.
Finally, we would like to thank our dedicated team of Civil Servants, under the leadership of
Clare McAvinchey, who has been instrumental to this review. We are very grateful to Charlotte
Kume-Holland for her insight throughout, and to all of our team who have each gone beyond
the call of duty: Elenor Styles on stakeholder engagement; James Silcox for helping to land key
recommendations; Leo Warren, Charles Aldridge; and our Analytical team Chris Sutton, Rosina
Citrone and Caroline Floyd. The team have also been supported by Madeleine McGivern of Mind
who deserves real credit for her input.

63
Endnotes
1 See Annex C for more detail
2 NHS Digital. Adult Psychiatric Morbidity Survey
2014; 2016
3 Deloitte report www.deloitte.co.uk/
MentalHealthReview
6 (Waddell and Burton 2006) and the Marmot
Review – ‘Fair Society, Healthy Lives’(2010)
7 Office for National Statistics. UK Labour
Market: September 2017; 2017
2014; 2016
2014; 2016
10 (Waddell and Burton 2006) and the Marmot
Review – ‘Fair Society, Healthy Lives’(2010)
11 Office for National Statistics. Labour Force
Survey, Q2 2016; 2017
12 Depression in Adults with a Chronic Physical
Health Problem: Treatment and management,
nIcE clinical Guideline 91; 2009
Survey, Q2 2017-April-June 17.
2014; 2016
Survey, Q2 2017-April-June 17
2014.
17 Office for National Statistics. ONS Sickness
Absence in the Labour Market: 2016; 2017.
18 Department for Work and Pensions. Work,
health and disability green paper: data pack;
2016.
19 Department for Transport. British Social
Attitudes Survey 2015; 2017.
20 Office for National Statistics. suicide by
occupation, England: 2011 to 2015; 2017.
21 Costs are rounded to the nearest £billion and
may not sum due to rounding. More detail on
the methodology is available in the Deloitte
publication (add link )
22 Costs are rounded to the nearest £ billion and
may not sum due to rounding. More detail on
the methodology is presented in Annex C
23 Costs are rounded to the nearest £ billion and
may not sum due to rounding. More detail on the
methodology is presented in Annex C
24 ‘Mental Health Interventions in the Workplace
and Work Outcomes: A Best Evidence Synthesis
of Systematic Evidence’ Wagner et al Jan 2016
25 ‘Business in the Community. Mental Health at
Work Report 2017; 2017
26 Business in the Community. FTSE 100 public
reporting: employee engagement and
wellbeing
27 Department for Work and Pensions. DWP
Employer Experience Survey 2015 to 2016;
2017.
28 Business in the Community. Mental Health at
Work Report 2017; 2017
29 Department for Work and Pensions DWP
Employer Experience Survey 2015 to 2016; 2017.
30 See Section 3 of Deloitte report.
31 Universum. Global Workforce Happiness Index
2015 to 2016.
32 Department for Business, Energy and
Industrial Strategy. Business Population
Estimates 2016; 2016.
33 See Section 2 of the Deloitte report
34 Business in the Community. FTSE 100 public
reporting: employee engagement and
wellbeing. May 2014.
35 MIND. Workplace Wellbeing Index.
36 Vitality. Britain’s Healthiest Workplace.
37 Office for National Statistics. UK Labour
Market: September 2017; 2017
(i) Office for National Statistics. ONS Sickness
Absence in the Labour Market: 2016; 2017.
Figures
Figure 1: Three phases people experience in work
Figure 2: Percentage of people falling out of
work with no long-term mental health condition,
a physical health condition and long-term mental
health condition per quarter
Figure 3: Cost of poor mental health to employers
Figure 4: Private Sector mental ill health costs per
employee
Figure 5: Cost of poor mental health to
Government
Figure 6: Cost of poor mental health to the
economy
Figure 7: Forms of support employers can offer
Figure 8: Cost of poor mental health across the
public sector

38 Office for National Statistics. Public Sector
employment 2017; 2017.
39 NHS. Staff Survey 2016 Detailed Spreadsheets.
40 Education Support Partnership. How to handle
stress.
41 The Professional Trade Unions for Prison,
Correctional and Secure Psychiatric Workers.
POA members work-related stress and
wellbeing survey 2015; 2015.
42 HM Treasury. Public Spending Statistics July
2017.
43 House of Commons. Local Government
Procurement 2013 to 2014; 2014.
44 Mental Health Foundation. Fundamental Facts
About Mental Health 2015.
45 NHS Digital. Psychological Therapies: Annual
Report on the use of IAPT services 2015/16 –
re-issue; 2017.
46 Department for Work and Pensions. Health
and well-being at work: a survey of employees:
2011; 2015.
47 Department for Work and Pensions. DWP
Employer Experience Survey 2015 to 2016; 2017.
48 Office for National Statistics. UK Labour Market:
September 2017; 2017

Annexes

67
Annex A:
Further information and support for employers
We have recommended that all employers, regardless of workplace type, industry or size adopt
a set of mental health core standards. For employers who can and should go further, we have
presented some mental health enhanced standards.
We know that some employers will find our mental health standards easier to adopt than others,
and the standards will need to be adapted differently to suit organisations and meet particular
employee needs. For example, producing a mental health at work plan does not need to be
burdensome and for small employers this could be an informal meeting to discuss their approach
and reflect on resources available rather than a formal document.
For all employers, our hope is that they provide a framework to structure an approach, and will
support employers who currently do not know where to start. We have therefore provided:
• A more detailed explanation of each of the mental health core and enhanced standards.
• A collation of links to information, advice, training and practical resources which can support
employers to help implement the mental health core standards. This list is not exhaustive and
we are aware of lots of other good sources of support that employers and employees can access.
• A guide to support employers to offer workplace adjustments for employees who need them
(see Annex B).
Mental health core standards
What should I do? How could I do this?
communicate a mental
health at work plan that
encourages and promotes
good mental health of
all staff and an open
organisational culture.
An organisation’s mental health plan should outline the
approach to improving and protecting the mental health of
all employees, including any awareness activities or training,
and the support available to employees who need it. The plan
can be developed collaboratively with employees, through
an informal discussion for small and micro employers, but
to include mental health champions or other leads in larger
organisations.
The plan could include how employers are improving the
physical environment to improve employee mental health, or
how the organisation encourages and supports employees to
engage in physical activity, staff networks or social action.
The workplace mental health plan could also be linked to other
plans in an organisation, including strategies to improve staff
engagement, corporate social responsibility plans, supportive
and proactive sickness absence policies, and improving the
physical workplace environment.

2. Develop mental health
awareness among
employees by making
information, tools and
support accessible.
We know that employee awareness of mental health, including
for line managers and supervisors, will encourage individuals
to care for themselves and help them to provide support to
others.
There are many sources of information available from
Government, voluntary sector organisations and other bodies
(some are included in the next section), many of which include
free to use materials that employers can share within their
organisation.
Employers may also wish to appoint employee champions
to share their experiences of mental health problems or
other challenges through peer support and mentoring, and
provide training courses or other tools for employees to use to
further develop their knowledge and skills.
3. Encourage open
conversations about
mental health and
the support available
when employees are
struggling, during the
recruitment process
and at regular intervals
throughout employment,
with appropriate workplace
adjustments offered to
employees who require
them.
Mental health should be discussed openly with employees
wherever possible and appropriate. This is not just about
discussing mental health problems, but about creating an
environment in which employees feel able to talk openly.
Engaging with external campaigns to address stigma are a
good first step, and encouraging staff networks and groups
of individuals with similar interests and experiences can also
encourage openness. Where someone is struggling or is absent
from work for any reason, conversations about workplace
adjustments or returning to work should include mental health.
Tools are available to encourage and support ongoing
conversations, including ‘Wellness Action Plans’ which can be
kept up to date by employees (more information available at
www.mind.org.uk/workplace/mental-health-at-work/taking-
care-of-your-staff/employer-resources/wellness-action-plan-
download/).

69
4. Provide your employees
with good working
conditions and ensure they
have a healthy work life
balance and opportunities
for development.
Creating good working conditions for employees can help to
prevent new mental health problems and support those with
existing conditions to get on in work and thrive. Good work and
jobs consists of components such as fair pay, job security, good
working conditions, education and training, staff consultation
and representation. The What Works Centre for Wellbeing have
produced evidenced guides on characteristics of a good job
and team working, where we know that control, autonomy and
social networks are crucial for a positive experience at work.
management to ensure all
employees have a regular
conversation about their
health and well-being
with their line manager,
supervisor or organisational
leader and train and
support line managers
in effective management
practices.
We know that effective people management at all levels is
crucial for supporting the mental health of all employees.
It is vital that managers, supervisors or someone else have
regular conversations with their employees so that employees
have an opportunity to raise any issues. Giving and receiving
feedback, as part of wider positive management processes, can
help to identify problems early. Managers and supervisors can
receive training and support to be confident in spotting signs
of distress, ensuring they’re own behaviours are positive and
dealing with problems as early as possible.
Employers should look for training which provides practical
examples, and is tailored to the specific practices of their
organisation. Resilience, stress management training and
line manager communication training have been shown
to be particularly effective. A recent study published in the
Lancet has shown face to face training comprising of specific
components has had a particularly strong return on investment.
The research can be found at: http://www.thelancet.com/pdfs/
journals/lanpsy/PIIS2215-0366(17)30405-4.pdf.
6. Routinely monitor
employee mental
health and wellbeing by
understanding available
data, talking to employees,
and understanding risk
factors.
An approach to measuring staff wellbeing will vary depending
on employer size. The majority of employers will hold basic
information about their employees, including sickness absence
data, which can be used to spot problems and focus any
support. Employers can also use staff surveys, mood trackers
and other tools to improve communication with their employees
and better understand risks to employee mental health.

Mental health enhanced standards
1. Increase transparency
and accountability
through internal and
external reporting,
to include a leadership
commitment and outline of
the organisation’s progress
on mental health
In additional to communicating the mental health and
wellbeing plan in the mental health core standards, this is
about reporting more formally both internally and externally.
Internally employers should consider producing an annual
report on mental health, potentially within a report on
wider employee health and wellbeing, to be shared with all
employees. This can include; a statement from the individual
accountable for the plan, priorities for the next period, relevant
data such as staff survey or mood tracker results, sickness
absence data, engagement in mental health activities or take
up of support, or mental health disclosure rates within the
organisation. Employers should seek opportunities for staff
feedback on this report.
Externally employers may wish to share information with board
members or publicaly through their websites or annual reports.
2. Demonstrate
accountability by
nominating a health and
wellbeing lead at Board or
Senior Leadership level,
with clear reporting duties
and responsibilities
Board level reporting ensures that mental health is prioritised
and taken seriously. This could be part of the Human Resources
or Health and Safety functions in larger organisations. It is
important that this lead has clear accountability for protecting
and support mental health of employees throughout the
organisation, and looking for opportunities to increase
collaboration.
3. Improve the disclosure
process to encourage
openness during
recruitment, ensuring
employees are aware of
why information is required
and make sure the right
support is in place to
facilitate a good employer
response following
disclosure.
Any processes designed to encourage employees to discuss
mental health or disclose any mental health problems need to
be clear and fair to avoid discouraging employees from being
open. For example, employers should explain on any forms
why individuals are being asked to share information about
any mental health problems and what will happen with that
information.
4. Ensure provision of
tailored in-house mental
health support and
signposting to clinical help,
including digital support,
employer-purchased
Occupational Health or
Employee Assistance
Programmes, or NHS
services, amongst other
sources of support.
We know that there will always be some employees who
are struggling, and may need clinical help or other practical
support. Employers can provide support in house or buy
in additional support for their employees, including access
to Cognitive Behavioural Therapy (including through digital
platforms), Occupational Health, counselling or through
Employee Assistance Programmes and other tailored mental
health and well-being support. Some employers are extending
such support to organisations in their supply chain, particularly
for smaller employers, to help them improve the mental health
of their employees.

71
Information, advice and training
All employers can share information about how
to protect and maintain mental health with their
employees; signposting to tools and support;
and offering training. This information can be
made available through digital channels; during
employee events; and as part of employee
training to ensure it is practical and tailored
to the employee’s role and responsibilities.
Mental health champions, individuals with
lived experience of poor mental health and
other leads in the organisation can also help by
providing awareness and training sessions.
For information, advice and tools for creating
a workplace mental health plan and increasing
employee awareness of mental health, the
following sources of information are available:
• The Business in the Community Mental
Health Toolkit is a helpful guide to follow for
formulating a plan and has many links to
useful resources and case studies of good
practice https://wellbeing.bitc.org.uk/sites/
default/files/mental_health_toolkit_for_
employers_-_small.pdf
• Mental Health First Aid England has
produced a ‘Workplace Wellbeing Toolkit’
https://mhfaengland.org/mhfa-centre/
campaigns/wmhd17/
• The What Works Centre for Wellbeing
provides evidence based guidance on a
range of mental health and workplace
issues. (https://www.whatworkswellbeing.
org/product/why-invest-in-employee-
wellbeing/) characteristics of a good job,
improving job quality and team working
• The Institute of Directors has produced a
mental health hub of advice, best practice
and resources to help small and medium-
sized businesses develop their approach to
mental health https://www.iod.com/news-
campaigns/mental-health
• Healthy Working Wales provide face-to-
face, telephone, online and one-to-one
support around health and safety, sickness
absence and workplace approach to
managing health and wellbeing.
www.healthyworkingwales.wales.nhs.uk/
about-hww
For practical and downloadable guides to
promote mental health awareness in an
organisation:
• Time to Change England and Wales have
produced guidance and a range of free
resources on how to create a workplace
mental health plan and other ideas for
workplaces. (In England https://www.time-
to-change.org.uk/ and Wales http://www.
timetochangewales.org.uk/en/)
• Mind offers a range of information for
employers and employees, and related
training courses and consultancy. https://
www.mind.org.uk/workplace/mental-
health-at-work/
• Rethink Mental Illness has published a
range of mental health factsheets. https://
www.rethink.org/news-views/2016/1/8-
ways-to-start-your-conversation
• NHS England has published the ‘Five ways
to Wellbeing’ to improve public awareness
of how to look after mental health. http://
www.nhs.uk/Conditions/stress-anxiety-
depression/Pages/improve-mental-
wellbeing.aspx
• ACAS also provide a range of guidance
http://www.acas.org.uk/index.
aspx?articleid=1900
• The Federation for Small Businesses has
produced an online portal of guidance
specifically for small businesses and the
self employed https://www.fsb.org.uk/
standing-up-for-you/our-campaigns/
wellbeing-hub/wellbeing-in-small-business-
hub

Training and guidance for general awareness:
• Mind offer a range of training courses
https://www.mind.org.uk/workplace/
training-consultancy/upcoming-courses/
mental-health-awareness/?ctaId=/
workplace/training-consultancy/courses-
for-anyone/courses-for-anyone/mha-
training/
• Business in the Community has published
a range of toolkits to help employers
communicate about mental health and
implement effective training courses.
https://wellbeing.bitc.org.uk/all-resources/
toolkits
• Mental Health First Aid England provide
various online free resources and workplace
training courses https://mhfaengland.org/
organisations/workplace/
• Time to change offer training and guidance
for mental health awareness https://www.
time-to-change.org.uk/resources
There are many other external campaigns
working to tackle stigma which are worth
connecting to and promoting such as: Time to
Change England and Wales, Heads Together
- https://www.headstogether.org.uk/, See
Me Scotland - https://www.seemescotland.
org/ and Inspire Wellbeing - https://www.
inspirewellbeing.org/ for Northern Ireland
Training and guidance for line managers,
supervisors and leaders:
• The Chartered Institute for Personnel and
Development (CIPD) offer various modules
and guides in line manager training such
as how to have difficult conversations and
compassionate leadership https://www.
cipd.co.uk/knowledge/culture/well-being/
mental-health-factsheet

• Mind and CIPD have produced ‘Managing
and supporting mental health at work’ a
guide for employers to help them manage
employees’ mental health positively and
sensitively https://www.mind.org.uk/
media/44253/Managing_and_supporting_
MH_at_work.pdf
• Mental Health First Aid provide a line
manager resource to support employees
experiencing mental health issues and
create a mentally healthy workplace
• ACAS run practical training courses
for managers, supervisors and HR
professionals http://www.acas.org.uk/index.
aspx?articleid=2002
Local Advice and Support
In some instances, local advice and support
may be more suitable for employers to engage
with. There is a range of local Minds across
England and Wales https://www.mind.org.uk/
information-support/local-minds/. There are
also local movements such as Thrive London
which can provide links to local services.

73
Mental health problems can be
experienced very differently by different
people and as a result individuals
themselves are best placed to identify
what their needs are. Any workplace
adjustments should be decided in
consultation with the individual concerned.
Some people may not know what might be
helpful to them so exploring their options in a
safe, constructive and supportive environment
is recommended. It’s also a good idea to set
a trial period after which the employer and
employee can review together how effective
the adjustment has been, and whether any
other changes are needed. Employers should
be creative and flexible in considering and
applying different workplace adjustments.
Under the Equality Act, disability, which
includes mental health, is a ‘protected
characteristic’. Workplace adjustments
themselves do not address the specific mental
health problem, but are designed to address
the disadvantage that the mental health
problem might cause for a person in their
role or the wider workplace. The following
suggestions are not designed to be exhaustive
but provides ideas to help guide these
conversations
Changes to how employees perform their
role:
• Flexible hours or change to start or finish
times. Change of workspace e.g. quieter,
more or fewer people around, dividing
screens
• Working from home at certain times or on
certain days in a given period
• Changes to break times
• Provision of quiet rooms
• Light-box or seat with more natural light
• Agreement to give an employee time off
for appointments related to their mental
health, such as therapy and counselling
Changes to the role itself (temporary or
permanent)
• Temporarily changing duties, for example
changing the balance of desk work and
customer facing work, reducing caseloads,
changing shift patterns
• Reallocation of some tasks or amendments
to the employee’s job description or duties
• Redeployment to a more suitable role
Annex B:
Making workplace adjustments for employees with
mental health problems

Extra support
• Increased supervision or support from
manager, buddy or mentor. Extra help with
managing and negotiating workload
• Debriefing sessions after difficult calls,
customers or tasks
• Mediation can help if there are difficulties
between colleagues
• Access to a mental health support group or
disability network group
• Identifying a ‘safe space’ in the workplace
where the person can have some time out
or access support
• Provision of information to promote self-
care
• Encourage employees to work on building
up their resilience and doing things that
support good mental health such as
exercise, meditation or eating healthily
• Provide regular opportunities to discuss,
review and reflect on people’s positive
achievements – this can help people to
build up positive self-esteem and develop
skills to manage better their triggers for
poor mental health.
Government support for Employers
Access to Work (available in England, Wales
and Scotland) is a publicly funded employment
support programme that aims to help more
disabled people start or stay in work. It can
provide practical and financial support if you
have a disability or long term physical or
mental health condition. Support can include
referral to the Mental Health Support
Service.
All employers across England and Wales can
refer employees who have been off work for
four weeks or more for a free occupational
health assessment, as part of the Fit for Work
Service. The occupational health professional
will identify obstacles preventing the employee
from returning to work. A Return to Work Plan
will be agreed providing recommendations
tailored to the employee’s needs, which can
replace the need for a fit note.

75
Annex C:
Analytical evidence and Methodology
The Economic Cost of Working Age Mental Ill Health
This review has looked to estimate the total cost of working age mental ill-health to employers,
the whole economy and to the Government.
Deloitte have produced an estimate for the cost to employers and have published the details of
their methodology which can be found here: www.deloitte.co.uk/MentalHealthReview
Government analysts have produced an estimate of the costs to the wider economy and the costs
to Government below. The assumptions made for each component are detailed below.
Cost Element Methodology Estimate (to
nearest 0.1 bn)
Economic Cost Lost output due to
worklessness
This has been estimated by applying the
proportion of Employment and Support Allowance
claims with mental health as the primary condition
(49%) to the estimate of lost output in the Work,
Health and Disability Green Paper.
37.0-52.4 bn
Lost output from
those in work
This has been assumed to be the same as the cost
to employers and the self-employed in the Deloitte
report.
£33.4-£43.0 bn
NHS Cost The 2014 Adult Psychiatric Morbidity Survey for
England shows that out of work people with mental
health conditions are more likely to be in receipt
of treatment than those in work. We estimate that
the NHS spends an estimated £3.3bn a year in
treatment costs caused by mental health conditions
affecting working age people’s ability to work – this
is equivalent to about 60% of total mental health
service spend for working age people.
£3.3m:
Total £73.7-98.7 bn
Cost to
Government
Welfare Benefits This has been estimated by applying the
proportion of ESA claims with mental health as
the primary condition (49%) to the estimate of
the cost of welfare benefits in the Work, Health
and Disability Green Paper, which covered ESA
and an estimate of the proportion of other
benefit expenditure (for instance Housing Benefit)
attributable to incapacity to work.
£9.6 bn:
NHS Cost As above £3.3bn
Lost Tax/National
Insurance revenue
Individuals out of work or off work on sickness
absence due to mental ill health will be paying less
tax and national insurance than if they had been
in work. This has been estimated by applying the
same flowback rate (23.5%) as in the Work, Health
and Disability Green Paper to the combined lost
output from worklessness (£36-£51bn) and those
in work on sickness absence (£8.7bn of the cost to
employers/self-employed).
£10.8-14.4 bn:
Total £23.7-£27.3 bn

These assumptions are consistent with those
set out in the estimate of ill health amongst
the working-age population in the technical
Annex to accompany the Government’s Work,
Health and Disability Green Paper ‘Improving
Lives (October 2016)’1
and have been adjusted
from an estimate of Great Britain to the United
Kingdom based on ONS population estimates.
This is with the exception of those made for
the cost to employers which are consistent
with those made by Deloitte in their analysis.
Further detail on that methodology is available
in the Deloitte report.
Flows in and out of employment
for people with mental health
conditions
This new analysis looks at the rate at which
people move in and out of work) for people
with a long term mental health condition
(LTMHC) and compares those with an
equivalent long-term physical health condition
(LTPC) and those with no long-termi
MH
conditions.ii
Data
The two-wave longitudinal Labour Force Survey
(LFS) has been used to conduct this analysis.
Each individual in the data is measured at two
snapshot interviews, one quarter apart. The
data does not capture any movements before
or after this quarterly period, or any short-term
moves that may have been reversed between
the two snapshot interviews. It should however
give a broad measure of the degree of ‘churn’
for different groups.
Due to sample rotation and non-response,
the sample sizes of the two-wave longitudinal
datasets are smaller than the regular Labour
Force Survey. To generate more robust
sample sizes, and to average out any seasonal
variations, four quarterly cohorts of data (Q2
2016-Q2 2017) have been combined. However,
each individual is only measured for a single
quarter-on-quarter period within that time.
As this analysis is based on longitudinal survey
data, the precision and accuracy of these
estimates can be affected by response errors,
sampling errors and attrition bias. This analysis
should be seen as experimental and designed
to give a broad order of magnitude.
Methodology
Individuals aged between 16 & 64 in both
quarters were selected and their health
condition and employment status in both of
the quarters were recorded.iii
For the purpose of this analysis we are only
considering those that report the same health
condition in both quarters. This eliminates
those individuals that may not self-identify
as having a LTMHC all the time, some of
whom may be subject to reporting errors (see
Caveats).
The following table looks at the flows in and
out of work for both of these groups between
the first and second quarter. The number of
movers can then be taken as a proportion
of the stock of employed people with the
consistently-reported health condition in the
first quarter, to obtain the proportion who lose
their job each quarter. The 6% per quarter who
lose their job each quarter is approximately
300,000 instances (to nearest 50,000) per
year. If it were the same rate as those with
a physical health condition it would be
approximately 100,000 lower per year (to the
nearest 50,000).
1 https://www.gov.uk/government/statistics/work-health-and-disability-green-paper-data-pack

77
Table 1: Flows in and out of work per quarter by health status
(table in 100,000s)
average per quarter
Status in the first
quarter
Status in the second quarter % falling out of
work per quarter
In employment Out of work
Long term mental health
condition in both quarters
In employment 12.0 0.7 5.7%
Out of work 0.7 18.7
No long term mental health
In employment 279. 2 7.5 2.6%
Long term physical health
In employment 50.0 1.8 3.5%

Caveats
There are factors which suggest our estimate
of the 300,000 individuals losing their jobs
each year may be too high, but also that it may
be too low.
Firstly, there are two factors which suggest our
estimate may be too high.
Double Counting
It is possible that an individual that was in
work in the first quarter may have lost their
job in the second quarter, may then have
found another job in the 3rd quarter and
subsequently lost it in the 4th or 5th quarter
of this analysis. Therefore, with the estimate of
300,000 individuals per year losing their jobs
there may be some individuals, who frequently
move into and out of work, counted twice.
Attrition bias
One of the main issues with using longitudinal
data is the issue that attrition can cause;
attrition being the drop-out of individuals
from one quarterly survey interview to the
next. This can cause attrition bias – if people
who were interviewed in both waves are not
representative of the wider population.
It is not possible to fully quantify attrition bias
however, based on table 1, the employment
rate of people reporting LTMHCs is 42.5%
in the first quarter and 42.5% in the second
quarter – a change of less than of 0.1%pts
over the average quarter.
Over the same period (Q2 2016-Q2 2017), the
regular ‘snapshot’ LFS (which is unaffected by
attrition bias) suggests that the employment
rate for this group increased by an average of
0.96 percentage points a quarter.
The difference between these two estimates
gives an indication of the scale of any attrition
bias. In other words, if the data suggests that
around 5.7% of people in employment who
consistently report a MH condition move
out of work each quarter, without attrition
bias the estimate could be less than 5%.
We cannot measure if the 0.96 percentage
point difference is due to more people
joining work or fewer leaving, than estimated
here. However, if half of this difference was
due to reduced outflows, this would have a
dampening effect on the 5.7%, bringing it
closer to 5.2%.
The employment rate for those with no
reported LTMHC had a percentage change
of 0.66 percentage point over the average
quarter. The ‘snapshot’ LFS differences
over this time was 0.15 percentage points,
suggesting minimal attrition bias for those
with no LTMHC
However, there are also two factors which
would suggest our estimate is too low.

79
Constant health condition
We have only included individuals who self-
identified with the same health status in the
two consecutive quarters. By doing this, we
have excluded 25% of individuals who have
had a LTMHC at any time. People can change
their reported health status due to changes in
their health condition and how it affects their
activities. However, reporting can also change
purely due to the respondents’ own perceptions
(which in turn can be linked to employment
changes), or inconsistent reporting – especially
if the answers in one of the quarters were given
by a ‘proxy respondent’ (another member of
the same household) on their behalf. For the
reasons outlined above, there is uncertainty
around the movements of those who change
their reported MH status. However, including
these in the LTMHC group still leads to an
estimate of around 6% leaving employment,
suggesting that results on the proportion who
flow out of work are not particularly sensitive to
this aspect of the methodology.
However, this also means that we do not include
these individuals with fluctuating conditions in
the calculation of the 300,000 who lose their
jobs. Whilst we do not know whether they had
a long term mental health condition when they
lost their job this will lead to an under-estimate
of the numbers.
Increase in the number in work
Over the past year the number of individuals
reporting a long-term mental health condition
who are in work has increased by around
200,000 due to a higher employment rate.
Therefore, we would expect that the number
who would flow out of work in the next 12
months would increase, if the percentage flow
remained constant, compared to this estimate.
When assessing the numbers losing their jobs
each year, these two factors provide an off-
setting effect to the potential attrition bias and
double counting described above.
Summary
In summary, taking all the caveats into
account, we can still draw the conclusion that:
• Those with a consistently reported LTMHC
are around twice likely to flow out of work
than those without and significantly higher
than those with an equivalent physical
health condition
• This equates to up to around 6% per
quarter with a LTMHC falling out of work
each quarter which equates to around
300,000 instances per year.

Additional Tables
Table A1 – Time Series of the employment rate of those with a long term health mental
condition and the number in work
People with a long term mental health condition
Year Employment rate Employment Total
2017 44% 1.5m 3.4m
2016 40% 1.3m 3.3m
2015 37% 1.2m 3.1m
2014 36% 1.0m 2.9m
2013 32% 0.9m 2.6m
2012 29% 0.7m 2.4m
2011 26% 0.6m 2.3m
2010 27% 0.6m 2.2m
2009 25% 0.5m 1.8m
2008 24% 0.4m 1.8m
2007 23% 0.4m 1.7m
Note: Percentages rounded to the nearest 1 percent. Numbers rounded to the nearest 100,000
Source: Labour Force Survey Q2 (April-June)
Table A2 – Current employment rates by long term health condition
Employment rate In employment
None 80% 23.4m
Mental Health 44% 1.5m
Physical Health 62% 6.0m
Percentages rounded to the nearest 1 percent. Numbers rounded to the nearest 100,000
Source Labour Force Survey Q2 (April-June) 2017
Endnotes
i This category might include people with
short-term MH conditions however these
people aren’t identified by the LFS.
ii See footnote i.
iii Those that had missing data on the health
condition question have been excluded
from this analysis. This excludes a group of
only 1.4%.

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