This piece originally appeared on LSE Blogs, and has been republished here with permission to its author, Elizabeth Cotton.
The government will soon be placing job coaches in GP surgeries in Islington as part of a pilot to “coach” the unemployed into work. What is the aim of this process, how will its results going to be evaluated, and who will deliver it? Here, Elizabeth Cotton explains that the devil is in the detail and raises the questions we should be asking so that people who are vulnerable are not put in an even more precarious position.
In the mayhem of disability welfare cuts, important details about the politics of health can easily get missed. The recent crisis is not just about cuts in public services, but also about the growing policy link between health and work. Over the last year the government has announced the creation of the Joint Health and Work Unit and the Health and Work Service, both with a clear remit to cut benefits and get people into work. Given that mental health is the number one cause for long-term sickness absence in the UK, a key aspect of this policy is to provide mental health services that get people back into work.
One such attempt to provide mental health services for people on benefits includes a heavily resisted pilot to put therapists into job centres. And so recently the government announced another health and work pilot programme to put Job Coaches in GP surgeries in Islington. This initiative comes after years of independent reviews into disability assessments, attempts to put mental health services into job centres, and complaints and evidence against the way in which fitness for work is assessed in the UK. A toxic combination of scripted assessments that don’t take mental illness seriously, quotas for sanctions, and the contracting out of the state’s responsibility to protect vulnerable people.
The proposal to put job coaches into doctor’s surgeries would be funny if you weren’t talking about actual human beings, including those who become the coaches. The people that provide these new mental health services are, if the experience of the largest NHS programme Increased Access to Psychological Therapies (IAPT) is anything to go by, themselves vulnerable. This includes an employment relationship with low pay, low training and clinical supervision and at best a situation of ambiguous clinical responsibility raising a question whether new job coaches will be able to contain their clients’ and their own states of mind. So here are some questions that the good people of Islington could ask their democratically elected leadership:
First, given that people who are out of work and need to see their GP about it are likely to be feeling pretty vulnerable, how is the government going to make sure they are treated with the respect, kindness and get the clinical help they actually need? People can easily be bullied and often blame themselves for their situation. The risk of suicide is real and any system of ‘coaching’ has to include proper safeguards in the scenario that someone turns up to talk to a job coach and breaks down.
Second, if a private contractor gets this gig to provide job coaches, how are they going to be managed? As the Mental Health Taskforce report states very clearly, there’s virtually no monitoring of private providers in mental health at primary care level. It is estimated by the Centre for Health and the Public Interest that 50 per cent of private contractors don’t provide services that follow the guidelines provided by the National Institute for Health and Care Excellence, many of them providing non-clinical services under the title of ‘wellbeing’ or ‘resilience’. Very soon the Commissioning Support Units that administer funds for services within Clinical Commissioning Groups are themselves going to be privatised. So in the likely event that big contractors move in to provide these services we can no longer ignore the impact this will have on people who sign up. And third, who is actually going to manage this pilot programme so it doesn’t turn into another cynical attempt to pathologise people who are unemployed?
Given that these pilots have already been agreed, the best case scenario is that someone in Islington ensures the process is transparent and set up in such a way that we might all learn something. This will require some very close scrutiny of the contract and realistic statements about:
- the primary aim of this initiative
- how are the targets set and do they test the validity of the intervention?
- is this therapy or not?
- who holds clinical liability for the people who take up this service?
- what measurements are going to be used to evaluate these pilots?
- who is going to do the dog work of setting up this pilot so that it is open, honest and shows actual results?
Lastly, how are they going to make sure that the job coaches aren’t as vulnerable as their clients? Not wishing to blind you with Industrial Relations science but there’s a high chance these are going to be bad jobs. We do not have a good experience of the young people working within the NHS’s mental health services. To make sure we don’t repeat this attack on decent work, we need clarity on what training and support they will receive, what contracts they will have and how they will be supervised. We also need absolute transparency on their targets, learning the lessons of the WCA and Maximus whistleblowers; if you base this new job coach service on impossible targets of getting people with mental health problems back into work and then make it impossible for coaches to raise their concerns about how vulnerable people are treated, part of their duty of care, then we end up with a culture of bullying and fear, one of the most shameful aspects of today’s health services. If the job is to cut benefit claimants by 20 per cent let’s be clear about that from the onset so that we can protect the coaches and their clients right from the onset.
In the current anti-welfare environment putting job coaches into GP surgeries is a service that can easily be used to bully already vulnerable people into giving up their rights to be cared for. The professional bodies who are at the negotiating table with the DWP need to understand both the politics and broader public interest issues at play. This means critically and diligently negotiating over what mental health services are delivered, to whom, by whom and under what conditions. We need our politicians and our clinicians to protect the principles which underpin public services by looking out for the devil in the details.
Elizabeth Cotton is a Senior Lecturer at Middlesex University Business School. Her academic background is in political philosophy and current writing includes precarious work and employment relations, activism and mental health at work. She is working on her new book, Surviving Work: How to Manage Working in Health and Social Care (Gower 2016).
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