Building Back Resilience: an integrated approach in the aftermath of an Anti-Social Virus.

Summary: Jeremy Heywood left a legacy of an innovative, locally-led programme (Greater Manchester’s Working Well pilot) that demonstrated it could improve resilience even in challenging circumstances, where other programmes had failed. Building Back Resilience proposes to take the learning from this work and apply it to the challenge of the impact on unemployment and mental health in the aftermath of the pandemic. It will introduce and test two additional innovative features: a diversion scheme away from sanctions and focused on life-skills and new vocational skills acquisition for those at risk of dropping out of employment, education and training as a result of depression; a new remote multi-disciplinary support team, with keyworkers drawn from experts-by-experience at its heart, to take the place of the face-to-face teams of talking therapists and keyworkers previously. Policy Background: Jeremy Heywood provided the kind of open-minded, pragmatic leadership that was always willing to reconsider existing policies in the light of the changing facts – in the words of another great leader: “However beautiful the strategy, you should occasionally look at the results” (Winston Churchill). No sooner had we agreed with the Treasury, in 2007, for an investment of £300M in the new IAPT programme to roll-out talking therapies on the NHS, than we were faced with the financial crash in 2008. It is recognised that IAPT has gone on to be a world-leading exemplar for implementing access to evidence-based therapies. But as well as the promise to scale up access (IAPT was set to achieve a target of 1.5M adults per year, prior to the pandemic), which it has delivered, when Lord Layard and myself agreed the business case with Jeremy Heywood and the Treasury mandarins there were two further promises that we made: 1. To reduce the burden of depression as a common mental illness and 2. To support people with depression who were also unemployed to return to work, to achieve cost-savings on welfare benefits, as well as improve population wellbeing. After the financial crash in 2008, IAPT was unable to achieve either of these other 2 promises. Under the Coalition government, during a period of austerity, we saw rates of suicide increase; rates of self-harm, depression and anxiety also increased; rates of disability and long-term unemployment attributed to depression increased, along with steep increases in rates of prescribing antidepressants (from 35M in 2008 to 70M in 2018, notwithstanding the success of IAPT on reducing waiting times for talking therapy, and the fact NICE guidance in 2009 had not recommended antidepressants as the first line treatment for most cases of mild-to-moderate depression). Government policies had been designed to be evidence-based and faithfully implemented. But on the health side (IAPT) and welfare side (Universal credit and the Work Programme) their results were both showing up as increased harms. Building Back Resilience: an integrated approach Heywood was persuaded that what he called ‘a market failure’ was responsible. IAPT services were not prioritising the employment support needs for these patient groups because that was ‘not our responsibility’ (“we are mental health professionals, not job coaches”). The Work Programme providers, who were contracted under a Payment-By-Results programme, were not prioritising the mental health needs for these client groups because that was ‘the responsibility of the NHS’ (“why should we waste our money on offering access to private therapy when the NHS says it is already offering this for free?”). RAND Europe were jointly commissioned by the Ministers (Lord Freud at DWP; Sir Norman Lamb at DoH) to report on a more integrated model that could overcome these problems. Out of this a series of pilots were set up by the Joint Work and Health Unit and, in Greater Manchester, given the opportunity of a newly devolved agreement, an investment of £10M was match-funded by the Cabinet Office and European Social Fund for a Working Well pilot. The results of the 3-year Working Well pilot in Greater Manchester were impressive: over 20% of clients returned to sustained employment (4-5 times better results than elsewhere). Building Back Resilience: adapting to changed circumstances The cost-benefit aspect of Greater Manchester’s Working Well design was based on an ambitious target for 20% of clients returning to sustained employment (over 12 months). In the areas of the country that are most impacted economically, and in certain employment sectors, a more innovative cost-benefit model will need to be built. We will draw on work done by the What Works Centre for Wellbeing, bring in expertise from the British Business Bank and elsewhere, and use this to construct and adapt a new cost-benefit model based on local, social resilience returns for investment. In addition to the independent quantitative evaluation of Working Well, we undertook a qualitative evaluation, led by a joint LSE and Durham University team, funded through a European Research Fund project – Knowledge for Use. From this we learned more about the untapped knowledge and potential for greater use of non-professional, expert-by-experience skills and expertise. There are challenges to enable effective teamworking when multi-disciplinary teams include different professional backgrounds working alongside non-professionals. The changed circumstances of the pandemic, however, offer an opportunity for greater collaborative working via remote platforms (e.g. MS Teams, Zoom etc), as well as greater flexibility in working with clients remotely likewise. Key to this are good attachments and building trust with clients over time which, in turn, needs good support also for teams. It is precisely the kinds of interpersonal relationships that Building Back Resilience will aim to improve, through what we refer to as conditions for building epistemic trust, where the consequences of the pandemic have wreaked additional collateral damage. Hence, we believe, that the urgent crisis for mental health that we face also presents an opportunity. Building Back Resilience combines learning from previous evidence-based policies with adapting to a changed situation by offering a new solution with realistic promise of success.

 

 

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