Mental Health and Social Exclusion
Social Exclusion Unit Consultation Document
A commentary and response from NIACE
Published: July 2003
Introduction
This document is both the response of the National Institute of Adult Continuing Education to the consultation document ‘Mental Health and Social Exclusion’ published in May 2003 and a commentary on the paper for our members and stakeholders, with comments on the impact on adult learners with mental health needs. In addition, it responds to five questions included in the consultation document, on which NIACE has specific concerns. These are included at the end of this document.
Consultation on Mental Health and Social Exclusion
The Social Exclusion Unit is investigating how to reduce social exclusion among adults with mental health needs. It will consider how to improve rates of employment, through support in retraining and taking up work. It will also consider how to promote social participation and access to a broad spectrum of services in the community. The Unit will then deliver recommendations designed to bring about improvements in services, support and employment opportunities.
The Social Exclusion Unit Project
The work was announced in March 2003 and will address two key questions:
1. What more can be done to enable more adults with mental health problems to enter and, crucially, to retain work?
2. What more can be done to ensure that adults with mental health problems have the same opportunities for social participation and access to services as the general population?
Responses to this consultation must be with the Social Exclusion Unit by 5th September. It will report to ministers by early 2004. A full report with an implementation action plan will be published by Spring 2004.
| NIACE welcomes the Social Exclusion Unit’s investigation of mental
health and social exclusion. We welcome the fact that it addresses the two
key questions of employment and social participation. However, we would like
to stress the role of learning in enabling access to employment and,
at times, in helping to retain employment. Equally we note the role
that adult learning has in promoting and enabling social participation
and access to services. We are disappointed that little mention is given
to the important role of lifelong learning in determining individuals’
chances in life, in the development of skills and in the impact on
self-esteem and self-efficacy1, particularly at a
time of recovery from mental health problems. We hope that the Social
Exclusion Unit will take on board these concerns. 1 The Skills Strategy White Paper ‘21st Century Skills - Realising Our Potential: Individuals, Employers, Nation’ was published by The Stationery Office, July 2003. Available online at www.dfes.gov.uk/skillsstrategy |
Background
The report sets in context the nature and prevalence of mental health difficulties noting that they are widely misunderstood. It states that the nature and impact of mental health difficulties varies from individual to individual and often co-exist with other problems such as substance misuse, homelessness, poor physical health and learning difficulty.
The report identifies a range of risk factors that influence the development of mental health difficulties. These include socio-economic disadvantage, homelessness, neighbourhood violence and crime, unemployment, poor education attainment, being a member of a minority group and being a lone and/or teenage parent.
Mental health difficulties can have a negative effect on employability, housing, income and opportunities to access services and social networks, leading to severe deprivation and social isolation.
| We agree that a range of risk factors contribute to the development of mental health difficulties. However, these are not unconnected but inter-relate in complex ways that the document does not always acknowledge. For example, poor educational attainment is likely to lead to poorly paid employment and increase the chances of unemployment thereby creating socio-economic disadvantage and poverty. Socio-economic disadvantage is a risk factor in poor educational attainment among children and can be a barrier to participation in lifelong learning as an adult. Education and training are, however, recognised by government as a route out of poverty and can have an important and positive impact on the risk factors that contribute to social exclusion. |
Gathering Evidence
In addition to the consultation exercise the project has collected evidence in other ways. The project wishes to explore the cost benefits of delivering individual services or initiatives. Information is requested about:
 | current costs to public, voluntary and community services of mental health difficulties; |
| the costs of preventative or rehabilitative interventions - at both the local, individual level and at a national level; and |
| the cost of any unsuccessful interventions or the long-term costs of failure to provide appropriate services or support. |
| While the cost of services is important, so are the savings made from
encouraging participation in one form of support over another. For example,
does attendance at a local adult education class create savings by reducing
attendance at a day centre? Does successful participation in adult learning
give an individual the skills and confidence to access services, provide
opportunities for social interaction and/ or create greater feelings of
well-being and therefore necessitate less dependence on health and social
services? Does addressing poor literacy skills create savings by enabling an
individual to access and manage their own healthcare more effectively? NIACE
believes that the SEU can - and must - take an holistic view that transcends
departmental and other organisational silos.
NIACE draws the attention of the SEU to the Wider Benefits of Learning Research Centre (www.learningbenefits.net), which is researching the impact of education on depression and other health and well-being indicators. The Centre’s evidence was cited in the Skills Strategy. This research provides robust evidence to suggest that participation in learning has a significant impact on the likelihood of depression, particularly among adult women. Earlier research has shown the link between poor literacy skills and the incidences of depression - being five times higher in women with poor literacy skills than in those with good literacy skills2. Literacy and numeracy skills are also linked to ability to access and understand health services and information as well as financial services. Therefore addressing the learning needs of adults has cost implications but is likely to have significant cost savings alongside benefits to individual’s quality of life and independence. 2 Bynner, J., Parsons, S. and Basic Skills Agency (1997). It Doesn’t Get Any Better: The Impact of Poor Basic Skills on the lives of 37-year-olds. The Basic Skills Agency |
The project wants to identify and build on ‘what works’ in tackling particular problems. Information is requested on projects or services that are effective in supporting people with mental health difficulties in work or in promoting social participation, either in the UK or overseas.
There is an intention to undertake intensive fieldwork in four local areas across England. This will give the SEU a better understanding of development at local level and the challenges to effective delivery.
The Consultation Exercise
Information gathered through the consultation exercise forms a key part of the project’s evidence base.
The consultation has been sent to health and social care bodies, professional organisations, voluntary bodies, local authorities and organisations providing housing, employment and benefit support. Copies can be obtained at www.socialexclusionunit.gov.uk by phoning 0207 944 5713. It is also available in alternative formats and languages.
Details of consultation events for people using mental health services, as well as practitioners and service managers can be found at www.socialexclusionunit.gov.uk
| NIACE applauds the Social Exclusion Unit’s wish to consult a wide range
of stakeholders. We hope this will include those outside of the ‘mental
health world’ and that recognition will be given to the important role, and
the expertise of non-mental health services such as those involved with
post-16 education, arts, leisure and culture and neighbourhood renewal. We
hope the SEU will gather information about the wide range of approaches used
to enable people with mental health needs to increase their social capital
and increase their potential for greater social inclusion.
We urge all adult learning providers, voluntary and community groups and providers of other services to respond to this consultation document and to the Social Exclusion Unit’s request for information. |
Scoping Exercise
Mental health problems are both a consequence and a cause of social exclusion. There is high prevalence of poor mental health among socially excluded groups and this can act as a major barrier to successful reintegration into society for excluded groups.
Information relating to the inequalities in key social outcomes for adults with serious mental health problems, compared to adults in the general population is given. For example, there appears to be almost twice the number of people with qualifications above GCSE without probable psychosis than those with it.
| This figure indicates a generally low rate of educational attainment
among adults with severe mental health difficulties. However, there is also
a probable low rate of educational attainment among those with general
mental health difficulties which points to the link between level of
education and other risk factors that contribute to social exclusion.
Further research would be helpful. We know that there is also a low level of
participation in learning among those with a negative experience of initial
schooling and/or low levels of educational attainment, creating an
inequality in access to adult learning opportunities3. We also know that
there are low levels of participation in learning among adults with mental
health needs. Yet participation in learning and education has a positive
impact on the factors that contribute to social exclusion and can help to
break the cycle of social exclusion. Inequality in access to adult learning
cannot be tolerated. Many people with mental health needs4 are highly
educated and highly qualified. Returning to learning for this group of
learners still has positive benefits for personal development, regaining of
lost skills and confidence in ability, pleasure and satisfaction in
achievement, re-training and change in career direction.
3 Sargant, N. (2000). The Learning Divide Revisited. NIACE 4 FEFC Committee on Students with Learning Difficulties and/or Disabilities and Tomlinson, John (1996). Inclusive Learning report of the Learning Difficulties and/or Disabilities Committee (Tomlinson Report). London, HMSO |
Evidence is also given of the low rate of employment among people with mental health difficulties.
Participation in learning influences access to employment.
|
The SEU report notes that adults with mental health difficulties are less likely to:
| access everyday goods and basic services such as health and banking services; |
| take part in leisure, arts and community activities; |
| be living in appropriate or private housing; or |
| have strong family networks. |
Social participation can affect an individual’s quality of life and contribute to the mental health and well-being of individuals and their families.
| NIACE’s research on the impact of learning on health shows there is a
strong relationship between increased feelings of positive health and
well-being and participation in learning.
5Participation can improve confidence and self-esteem,
increase activity, provide structure and purpose to the day, enhance the
development of new friendships and social networks, as well as the gaining
of new skills and qualifications.
NIACE has also developed work on financial literacy for older people and families and this shows that people need more than just information. They require appropriate learning about finance so that they can develop the confidence and skills to access and critically assess the services on offer. Similar research would also suggest that individuals also need the same support in health literacy in order to access health services and information6. Evidence from the Wider Benefits of Learning Research Centre suggests that learning and education impacts on health through a series of mediators, such as:
These benefits impact across the general population but can be extrapolated to show that participation in lifelong learning can have benefits for adults with mental health needs8. 5 Aldridge, F. and Lavender, P. (1999). The Impact of Learning on Health, NIACE. James, K. (2001). Evaluation Report of ‘Prescriptions for Learning’ Nottingham, NIACE, unpublished. James, K. (2002). Evaluation Report of ‘Prescriptions for Learning’ Restormel Primary Care Group and St Austell College, NIACE, unpublished. James, K and Aylward, N. (2002). 2nd Evaluation Report of ‘Prescriptions for Learning’ Nottingham, NIACE unpublished. 6 Durbin, D. and Summer, S. (2001). Literacy Links to Health. A basic skills approach to tackling health equalities, CEDC. 7 Hammond, C. (2002). Learning to be healthy. The Wider Benefits of Learning Papers No3, Institute of Education. 8 Werteimer, A. (1997). Images of Possibility - Creating Learning Opportunities for Adults with Mental Health Difficulties. NIACE |
The SEU report states that adults with mental health difficulties are likely to face barriers preventing them from working or participating in their communities. These barriers include discriminatory practice and stigma, perceived difficulties in moving from being on benefits to paid employment, lack of skills, resources and networks to secure and retain employment, poorly co-ordinated support and lack of money to access services.
| Adults with mental health difficulties face barriers to participating in
learning, and a recent survey conducted by NIACE and NIMHE (National
Institute of Mental Health in England) has shown that while the amount of
provision has increased in recent years there are still gaps in provision in
some areas9. NIACE is working to promote access to learning for adults with
mental health difficulties. However, there are examples of learning
providers who actively encourage participation in learning for adults with
mental health needs and NIACE urges all such providers to respond to the
consultation document with examples of positive practice. Equally, there are
still difficulties for some providers in setting up provision and it is as
important that these providers respond to the Social Exclusion Unit with
information about barriers to setting up responsive and appropriate
provision for adults with mental health needs.
9 James, K. (2003). Access to Adult Education for People with Mental Health Needs. Report of a National Postal Survey of Colleges of Further Education and Local Authority Adult Education Services, NIACE and NIMHE, unpublished. |
The SEU The SEU report highlights a number of important Government programmes relevant to this project:
| the National Service Framework for Mental Health, the Mental Health Bill and Joint Investment Plans; |
| the New Deal for Disabled People; |
| the Disability Discrimination Act; |
| the Supporting People programme; and |
| measures to tackle financial exclusion including the introduction of universal banking services. |
The Social Exclusion Unit project builds on work already underway across Government and considers what more can be done to reduce social exclusion among adults with mental health difficulties.
| NIACE believes that programmes and initiatives to widen participation in learning among those who do not traditionally access learning, including those with mental health needs, are relevant to the project as well. We hope that the Social Exclusion Unit will liase with the Department for Education and Skills and the Learning and Skills Council. |
The SEU project will focus in particular on individual experience and will aim to address the particular problems faced by adults with multiple needs, such as drug and alcohol problems or learning difficulties. It recognises that different solutions are needed for different personal circumstances and that work, through appropriate for many, is not appropriate for all.
| NIACE welcomes the emphasis on individual needs and urges providers that have developed inclusive provision addressing the needs of adults with multiple needs to respond to the consultation document. Inclusive learning provision recognises that each learner has individual needs and seeks to address the learning needs of all learners rather than responding to the label attached to the learner. Simply providing training and learning opportunities is not enough to encourage and motivate learners to access learning and NIACE recognises that sensitive and empathic guidance is needed as a first step into learning for many adults, particularly those with mental health needs. Guidance allows for individual needs, preferences and ambitions to be identified and for individual learning plans to be devised. Time invested in this process enables adults to successfully access appropriate learning. |
The SEU consultation document anticipates a need to consider the following key problems:
| stigma and discrimination towards adults with mental health difficulties; |
| access to appropriate education, training and employment; |
| the accessibility and adequacy of key services - health, housing, finance, arts and leisure; |
| how services can be linked better to provide a sustained pathway of care and support designed around the needs of individuals; and |
| the role of social networks and local communities. |
The project will include:
| a public consultation exercise; |
| involvement of adults with mental health difficulties; |
| a number of local area studies to improve our understanding of how services are delivered on the ground; |
| a review of the available research evidence and new research to fill any important gaps identified; |
| group discussions with key stakeholders to test the emerging analysis and recommendations; and |
| learning from the experience of other countries. |
Questionnaire
The Social Exclusion Unit poses a number of questions. The following is a response from NIACE to several of these.
1. Mental Health and Social Exclusion
Q1 How does mental ill health cause and sustain social exclusion?
Mental ill-health causes and sustains social exclusion through a number of ways:
| Stigma and discrimination against mental health exists. NIACE supports initiatives that promote positive mental health and mental health awareness and thinks that non-mental health organisations can facilitate it. A strengthening and reinforcing of the importance of the National Service Framework Standard One to mental health services and education providers would be useful. |
| Mental health difficulties erode confidence and self-esteem which can act as a barrier to individuals accessing services and facilities and making the most of life’s opportunities. This compounds social exclusion. NIACE would like to see more support and recognition of the impact that low self-esteem has on social exclusion. |
However, it is also important to ask how social exclusion causes and sustains mental ill-health. We know that unemployment, poverty, poor housing, violence, crime and fear of crime are among many factors that negatively affect individual well-being and are triggers for long-term stress. Support needs to be given to empower and enable
individuals and communities to have the confidence and skills to tackle these problems. Policies need to ensure that adequate legislation, funding and resources are available to individuals and communities to make positive changes.
2. Employment
Q3 Do you think
people with mental health problems want, and feel able, to work?
Why/Why not?
NIACE believes that most people want to work but often feel unable to do so for a variety of contradictory reasons:
| they may never have worked before and/or lack the skills or qualifications to gain meaningful employment; |
| their previous employment may have been a source of stress and the cause of mental ill-health and they feel uncertain about what else to do and how to affect a career change; |
| they may have gaps in their employment history which they do not know how to disclose or deal with; |
| they may be fearful about only being able to secure low paid employment and coupled about doubts in being able to cope make the risk to benefits seem to high; |
| they may fear work may result in them becoming ill again; |
| they may fear that getting a job will be interpreted as being a sign that they are well and therefore without need for other support; and |
| they may lack the job search skills, networks and resources. |
Q4 What are the main barriers to employment for adults with mental health problems?
Many of the barriers to work may be internal barriers such as those listed above. However there are undoubtedly other barriers to employment for people with mental health needs. These may include:
| stigma and discrimination against mental health difficulties; |
| lack of appropriate or sensitive services to support access to employment; |
| perceived or real financial difficulties associated with moving off benefits and into employment; |
| the barriers experienced by the general population such as difficulties in obtaining affordable childcare; and |
| discrimination due to age, race or gender as well as discrimination due to mental health. |
Q8 How much emphasis do local services place on helping people with mental health services problems find and keep work?
This depends on the type of service. In adult and further education, where courses are set up to help adults with mental health difficulties find work, the funding for such courses is dependent on the learner completing the course and gaining accreditation rather than in securing employment. There is no funding to allow the tutor development time to build links with local employers and no funding to allow tutors to support individuals to keep employment. Where local training for work providers secure funding to support people into employment this only fund the securing of employment but not to retain employment should an individual start to experience problems.
Q9 How does the welfare benefits system, including the operation of housing benefit, affect people with mental health problems who want to resume work?
People with mental health problems need to have protected benefits while making the transition to work, to work-based learning and other learning opportunities that might otherwise jeopardise their benefits and inhibit their development and progression.
Q10 What could the government do differently to enable more people with mental health problems to work?
NIACE would support initiatives that acknowledge the different pathways that individuals may need to take to find appropriate employment. We would also support initiatives that recognise the differentiated support needs of individuals with mental health difficulties.
Social Participation
Q11 Which community-based services, civic and recreational activities are the most important to people with mental health problems? Please give details of any examples of good practice.
Adults with mental health difficulties are not a heterogenous group and as such have a need to be able to access the same variety of community-based services, civic and recreational activities as does the general population. We need to recognise the individual preferences as well the cultural, gender and age related needs of adults who want to access a range of services. People may take different routes to social inclusion and need a variety of means of support to help them get there.
NIACE also thinks it important to recognise that a level of confidence and skill is often required to access some services and these learning needs should be met sensitively and in a variety of ways. NIACE knows that some adult and community learning projects have supported learners to access community resources and services e.g. banking services, healthcare services, local tourist and historical attractions, cultural venues etc, and hope that providers of such learning respond to the consultation document.
Q12 How easy is it for people with mental health problems to access these services? Why/Why not?
This depends on the nature of the service being accessed and the nature of the mental health difficulty experienced by the individual. Barriers do exist for many individuals such as:
| stigma and discrimination; |
| lack of confidence and self-esteem on the part of the individual; |
| lack of awareness of rights and what to expect; and |
| financial restrictions. |
We know that access to learning opportunities are variable in adult and further education. A recent survey 10 conducted by NIACE and NIMHE has revealed that while there are areas where there is adequate learning provision for adults experiencing mental health difficulties, there are still gaps in provision in some areas.
10 (NIACE/NIMHE Partnership Project (2003). Access to Adult Education for People with Mental Health Needs. Report of a National Postal Survey of Colleges of Further Education and Local Authority Adult Education Services. NIACE, Unpublished. )
Q13 How could access to services, civic and recreational activities be improved for people with mental health problems?
| Access to services and activities for people with mental health difficulties could be improved in three ways: |
| by working with services to ensure that they are accessible and inclusive. Services need support to ensure that they understand what the psychological and emotional equivalent of a ramp is; |
| by working with adults with mental health needs to improve skills and confidence to access services; and |
| by raising awareness of mental health services of the importance of social inclusion and access to services on the grounds of equity and for recovery. |
Q14 How important are families and friends in supporting people with mental health difficulties?
Family and friends are often unpaid carers of people with mental health problems. This can leave them socially isolated and on benefit/low income which in turn makes them vulnerable to poor mental health. They also require support to access facilities and resources, including learning opportunities and to seek fulfilment through such activities.
Strengthening Delivery and Measuring Results
Q17 What gaps would you identify in current service provision?
Difficulties are often experienced in setting up partnerships between learning organisations and health and social care providers for a variety of reasons. Time and resources to set up partnerships would provide more holistic, joined up and socially inclusive services.
Q18 Are there examples of good practice in service provision by the voluntary/community sector which could be disseminated more widely?
There are numerous examples of good practice in adult and community learning provision in supporting people with mental health difficulties to access different learning opportunities, in a range of environments and on a variety of subjects. Evidence of this provision is available from the NIACE/NIMHE survey and through other databases held at NIACE. Dissemination is through conferences, publications and through Adult Learners week.
Q20 What would be the best way to measure progress in reducing social exclusion for adults with mental health problems?
Measures already exist, such as the widening participation uplift in community and further education, that indicate how many non-traditional learners access learning opportunities. Perhaps the need is to promote the importance of these indicators and to highlight the needs of people with mental health need among those groups to be attracted into learning.
Further Details
If you would like further details or information about this response please contact:
Kathryn James
Development Officer - Learning and Health
NIACE
21 De Montfort Street
Leicester
LE1 7GE
kathryn.james@niace.org.uk
0116 2044281
