Economic inactivity in Scotland: supporting those with longer-term health conditions and disabilities to remain economically active

Key Findings

Overarching points

The evidence base around supporting those with longer-term health conditions and disabilities was clear in promoting early intervention. The earlier an employer is able to start addressing arising concerns and put in place relevant support the better – the earlier employees feel supported the less likely a situation is to deteriorate and the more likely open communication and trust can be maintained. This can simply mean having good conversations with a manager, as well as starting more formal support processes. A proactive approach from employers when a staff member’s situation changes is ideal.

This kind of approach does require positive, open, and trusting relationships between managers and their employees, as it will often require disclosure from staff of their health circumstances. The evidence base was clear that this kind of communication was key to supporting staff with chronic conditions and disabilities. For some of those with lived experience of longer-term ill health and disabilities, they found that the right manager could mean no further action was needed to support them to stay in work.^[28] There was consensus that managers are central to improving the experiences of their staff, but that there was also a lack of training for managers in having good conversations about sickness at work, including longer-term ill-health and disabilities.^[29] There is an important role here for employers in encouraging these kinds of conversations and supporting managers to feel confident in holding these conversations through formal and informal resources, training, and peer support. There is also an economic case for this kind of intervention. Though the evidence is from Australia, a manager mental health training scheme in the Australian Fire Service was found to lead to a significant reduction in sickness absence, with an associated return on investment of £9.98 for each pound spent on the training.^[30]

When managers were asked about good communication between themselves and their staff, there were good practice examples within the literature of encouraging as much disclosure as necessary to put in place adequate support, but that full disclosure of health circumstances should not be required to receive relevant support. For example, one participant in ‘The Great Big Workplace Adjustments Survey 2023’ said:

‘I don’t need to know what an employee’s condition is. I need to know what they’re finding difficult at work. Employees need to feel safe to disclose what they’re finding hard, so a good working relationship and psychological safety is essential.’^[31]

The use of health passports^[32] could also be encouraged across employers – however, the evidence base was not unanimous in supporting this kind of scheme, with some users feeling it demanded too much disclosure and meant very personal data was held by various individuals in a way they could not control (e.g. sitting within email inboxes), that it could be too upsetting to complete, or that managers did not read and action what was held in the passports.^[33] Passports could therefore be encouraged as one tool among many, used as a matter of choice by employees, and backed up by robust HR processes.

Much of the literature that had engaged directly with those with lived experience of chronic conditions and disabilities, described their frustration with the lack of understanding of their condition(s). This meant that appropriate understanding of the impact on their work and the support needed was missing. Suggestions in the literature for this, were greater access to good quality occupational health (OH) services (more discussion of OH services can be found in the ‘In-work support’ section below), as well as centrally created (i.e. by relevant health and/or third sector organisations) toolkits that could be accessed by employers, providing drop down menus to select relevant conditions, potential impacts on individuals, and required support – there was an example of such a toolkit for epilepsy.^[34] These solutions require resource and relevant expertise, but could be a means of helping employers to better understand their employees’ needs, and encouraging them to authorise and tailor adjustments and support. The Access to Work scheme is also intended to support employers’ understanding of physical and mental health.^[35]

This tailoring of support was a concern for those with lived experience. It was important for the individuals taking part in research to be seen in the round: they may be an older worker and have specific support needs around, for example, training and/or they may have caring responsibilities that impact on the hours they can work, as well as the impacts of their condition. Much of this discussion falls under what it means to have ‘good’ work and will be returned to below. The Public Policy Institute for Wales noted that, to ensure tailoring of support and the ability to tackle an individual’s needs and concerns from all angles, there are opportunities for greater joined up working across organisations, e.g. the NHS, third sector, DWP/Job Seekers, and allied health professionals, such as Occupational Health.^[36] Working together could provide more holistic and tailored solutions for individuals to ensure they stay in work.

Though much of the above around workplace culture, communication, and timely intervention falls to employers, there is a role for government and other public sector bodies in engaging with employers around these issues.^[37] Building links and relationships across sectors, as well as sharing information and best practice examples, can support the development of better policies and processes. These should then provide employees with longer-term conditions and disabilities meaningful and genuine change in the workplace.

Workplace adjustments

Workplace adjustments were highlighted by the literature as essential to ensuring those with long-term ill health and disabilities remain in work.^[38] SCOPE found that workplace adjustments were one of the four main concerns to be addressed for those with disabilities when thinking about how to retain staff (also including, inflexible work contracts/working conditions, issues with sick pay and return to work, and negative attitudes and discrimination, which will all be discussed below).^[39] With the right support in place to enable work, not only were the difficulties that might arise in the workplace from the primary condition alleviated, but potential secondary issues, such as stress, which could emerge from negotiating a complex system, were also avoided.^[40]

When making workplace adjustments, they should be thought of in the widest possible sense. This may include specialist equipment, but can also involve flexible working options, breaks within the day, reduced hours, flexible and compassionate absence management, time off for medical appointments, and sick or special leave that takes into account the person’s health (and the potentially fluctuating nature of this).^[41] There was some evidence that flexible working options were not considered as part of workplace adjustments in the same way equipment was – however, flexible working was highlighted as having the potential to make the biggest difference to some disabled staff.^[42] The pandemic has brought about a range of changes in the rights workers have around flexible working requests, but there may be more than can be done by government, employers, and others to raise awareness of these rights and the ways in which flexible working can be used to support staff who may otherwise be at risk of leaving employment due to ill health.

The evidence base makes it clear that workplace adjustments are not consistently delivered to staff. In some sectors and organisations it took years to implement them, and in some businesses and organisations they simply never materialised or were refused. The reasons for this included processing delays to the request, poorly embedded systems for requesting adjustments, ignorance around the importance of the adjustment to the employee, cost, and discrimination.^[43] The impact on staff was highly negative and in some cases directly led to them leaving the workplace and/or developing further conditions (e.g. mental health conditions related to stress).^[44] There is an opportunity here for relevant groups and authorities to raise awareness around the rights workers have to workplace adjustments and the importance of delivering them in a timely manner.

Several sources noted the importance of the UK government’s Access to Work scheme^[45] (which is also open to Scottish employers/employees), which, after a successful application (which includes an assessment of need), will pay for some of the cost of workplace adjustments to support businesses.^[46] The scheme has been deemed successful by the Joseph Rowntree Foundation, but it was noted that it did need some reform and better funding to support more workers with disabilities.^[47] The wider literature suggested reforms to the scheme, including raising awareness among the targeted populations; reducing delays for assessments; changing the cost cap, which was found to exclude around a quarter of disabled people^[48]; providing better training for assessors on conditions; and exploring ways to make employers more receptive to the findings of assessments – in some cases disabled participants taking part in research had been denied the adjustments recommended even after going through the full Access to Work application process.^[49]

Workplace adjustments should also not been seen as a one-off intervention.^[50] Instead they should be linked to good conversations between managers and their staff, health passports (where they exist) and work to better understand conditions and tailor support. Essentially there should be regular and consistent review points and it should be expected that changes to the adjustments may need to be made as health needs change. Without this the positive impact of workplace adjustments will not be maintained.

The role of discrimination

The lived experience of those with disabilities reveals that cultures of discrimination exist within the workplace and beyond. Two quotes from SCOPE research into attitudes towards disabled people illustrate this^[51]:

‘I parked in the disabled spot. I have a blue badge myself. Please don’t think I don’t, I do. They were like, ‘Hold on a minute, you’re not disabled.’ I said, ‘I am, that’s my name written on the badge.’ They were, like, ‘No, you’re not allowed, you don’t look it.’ You’re sitting there thinking, do I really need to look disabled? What does looking disabled mean to you?’

‘Sometimes people make jokes… and sometimes those jokes can be about something that actually is what’s directly affecting you... I can’t challenge them [like other people] and I just find I go within myself, lose more confidence, and back off from people. And then it’s difficult then to turn it all around, and start again, and trust people.’

These attitudes are a part of hindering or actively preventing workplace adjustments from being finalised and provided. Some staff were accused of being ‘entitled’ by making these requests, which are their right within the law.^[52]

More widely, discrimination was felt to play a role in whether the organisation wished to support its disabled and chronically unwell staff in the first place. Workplace discussions often focus on what staff can’t do, rather than what they can, and a sense of disabled or chronically unwell staff as a ‘burden’. Some reports that included lived experience revealed highly discriminatory comments being made to individuals, which were often combined with age discrimination for older workers, and/or gendered or racialised discrimination.^[53]

These attitudes need to be challenged by employers and within teams. Workplace cultures should actively promote the need for genuine diversity and inclusion. However, there is also a role for government and wider society, as such discrimination will go beyond the workplace. There is a potential to tackle such viewpoints with ongoing communications campaigns, as well as to create and provide resources that businesses and employers can use as part of awareness raising and training for staff.

In-work support

Much of the above discussion hinges on what support is provided to workers while they are still in work and the quality of that provision. Significantly, there are financial constraints to the in-work support offered to employees, with UK Government research finding SMEs the most likely not to provide any support beyond basic health and safety advice, due to cost and poorly developed infrastructure.^[54] This suggests that centralised provision of in-work support could be best targeted at SMEs.

For any programme of in-work support, having expert support that understands the difficulties harder to reach or more disadvantaged groups may face, is important.^[55] This links to the discussion above, that workers wanted to see greater understanding of their condition(s) but also of them as a person in the round. Understanding of their wider circumstances, as well as the potential barriers they might face to work due to their health and beyond was important to making them feel heard and valued. In response to this, the literature recommended that all businesses invest in good occupational health services (OH) – again, SMEs are currently less likely to have these given their smaller size and their employees can be left without good support.^[56] Informed, quality OH services could have a highly positive impact for staff, and could support staff who might face difficult conversations with managers and employers when requesting workplace adjustments.

This is not to say the literature was wholeheartedly supportive of OH – some disabled people spoke of having traumatic interactions with OH when the service did not understand their condition or was unsupportive.^[57] The provision must be quality, tailored, and aware of the complexities of long-term conditions and disabilities. To ensure this is the case, good quality (ongoing) training for occupational health professionals is required. However, an All-Party Parliamentary Group report on the occupational health service finds that occupational health as a sector is declining, so the pool of relevant professionals is becoming smaller and more thinly spread.^[58] This presents risks to the support available for employees in the future, and to the quality of provision already in place. There may be a role for a wider range of allied health professionals here in supporting those with chronic conditions and disabilities and reducing health inequalities.^[59]

The literature search found a range of evaluations of in-work support programmes that have been designed to support those with longer-term ill health and/or disabilities to remain in work, including evaluations of programmes supported by both Scottish and Welsh governments.

‘In-Work Support’ was trialled by the Welsh Government, with the evaluation published in 2019.^[60] This scheme provided support for private and third sector workers (public sector employees were considered more likely to have access to occupational health). Participants were either employed or self-employed. It was designed to support 4,232 participants with a ‘work-limiting condition or disability’:

‘Participants were expected to fall into one of two categories: ‘absentees’ and ‘presentees’. Absentees were defined as participants who had reached or were expected to reach four weeks of sickness absence [whilst] presentees were defined as those who were at risk of long-term sickness absence.’

The scheme had several aims:

• allow multiple referral routes for participants to access the service;
• provide early or rapid intervention;
• deliver work-focused health therapies;
• offer flexible and personalised provision according to the needs of participants and informed by a biopsychosocial assessment
• offer a voluntary service for participants who wanted to return or remain in work.

There were positive outcomes for both health and employment for the majority of participants. Participants reported increased mobility, reduced pain, reduction in anxiety, better ability to cope with their condition and/or greater acceptance of it, feeling more in control of their condition, better sleep, improved confidence, improved wellbeing, and better understanding of their condition and needs. Better education about their condition and managing it also meant better understanding of what was possible at work and what might need to be amended to support their health e.g. less lifting and carrying. The techniques, exercises, and support offered had ensured that some clients had not had to take sick leave and/or had been able to remain in work when this had felt difficult.

There were a range of other positive work outcomes: being able to work pain free; take on full duties rather than reduced duties; better concentration at work, so able to perform better; less time off due to ill health; able to work for longer, so increased productivity; able to work more efficiently; and take on new projects and challenges (including enrolling in university for further training and career progression).

This was not the case for all participants though – some felt the programme had been marginal in helping them. It was only where take-up was good and access to sessions was consistent that things were positive. Despite the aim of flexible and personalised provision, this had not been the case in every area of the pilot, with some participants only able to access one service, which had been a hinderance to their improvement – for example, they needed physiotherapy but also counselling, and it was only possible to access one or the other. Different approaches were used at different sites, with relative pros and cons, including the above. If similar schemes were to be implemented in future these differences would need to be studied in more detail to ensure the best possible outcome.

In 2018 the evaluation of the ‘Working Health Services Scotland’ scheme was published.^[61] Its findings were highly positive, showing ‘significant improvements from entry to discharge in health and functional ability’.^[62] The majority of cases were found to have health benefits and both 3 and 6 month follow-ups found sustained improvements, with clients in work and working normal hours. A important part of the work was highlighted by the evaluation, which was finding co-morbidities, and factoring them into the support and treatment process. These may not always be recognised in routine care, though will impact the health and work outcomes of individuals. The evaluation stressed the need for early intervention. It also found that older workers were more likely to have longer periods of sickness absence (though fewer individual periods of absence) and stated that this ‘indicates the need for improved OH and routine care for older workers’.^[63]

The Scottish Government undertook a pilot of ‘Health and Work Support’ (HWS), with a related evaluation, published in 2022^[64]: this scheme provided specialist in-work support from a case manager and for a specific condition and created a single-access gateway to the service. There was positive feedback on the full process from the majority of clients, from referral to staff support, and the single-access gateway achieved a positive upturn in use of the service. Absence from work fell and people were less worried about losing their job. Overall, people felt their health had improved. However, those with more complex needs were less positive and did not feel the pilot had benefitted them, particularly where mental health was a concern. Also, the evaluation pointed out that work coaches cannot instigate health interventions and other professionals may need to be engaged/there are other barriers to be overcome for some clients that the HWS programme cannot manage alone. It did help employers to see the scale of some of the issues being faced by their staff and the need for early intervention.

Overall these kinds of programmes appear to have positive outcomes for clients and support individuals to stay in work. There are nuances in delivery and scope that may need to be bottomed out to ensure the best possible approach is followed, but the benefits of similar schemes have been evidenced.

In November 2023, the UK Government announced its ‘Back to Work’ plan: a new package of measures to ‘help up to 1,100,000 people with long-term health conditions, disabilities or long term unemployment to look for and stay in work’.^[65] Alongside a range of social security changes, four health and employment interventions were also announced. These were^[66]: (i) boosting the NHS Talking Therapies scheme to increase access to this service which provides evidence based psychological therapies including Cognitive Behavioural Therapy (CBT), for treatment of mild and moderate mental health conditions such as depression and anxiety disorders; (ii) providing Individual Placement Support (IPS) to an additional 100,000 people with severe mental illness to find and stay in employment (more on IPS below); boost Universal Support in England and Wales – matching 100,000 people per year with existing vacancies and supporting them in their new role. Participants access up to 12 months of personalised ‘place and train’ support. The individual will be supported by a dedicated keyworker who will help the participant find and keep a job, with up to £4,000 of funding available to provide each participant with training, help to manage health conditions or help for employers to make necessary accommodations to the person’s needs; and (iv) formally launching WorkWell – launched to Integrated Care Systems across England and will help support people at risk of falling into long-term unemployment due to sickness or disability, through integrated work and health support. Integrated Care Systems across England will be supported to develop a localised work and health strategy, and then services will be provided in approximately 15 pilot areas.

These are all important interventions to support those with longer-term health conditions and disabilities to stay in (or find) work. IPS is a particular intervention for those with mental health concerns, and has mainly been used for those with severe conditions, though trials for mild and moderate conditions have been undertaken with some success. The UK Government describes IPS as

‘an employment support programme integrated in community mental health services. IPS employment specialists: work with people accessing the service to find them employment that matches their aims, interests and skills, and offer continued support once they are in post; integrate with the mental health team to support the individual with any issues that affect their work and recovery; build relationships with employers to negotiate job opportunities.’^[67]

The Department for Work and Pensions trialled this kind of support (i.e. IPS) via a randomised control trial for those with mild to moderate mental health conditions with some success. The Health-led Employment Trials Evaluation of this service, published a 12 month outcomes synthesis in August 2022^[68], which found clients were generally very positive about the support they received. Two sites were used to implement the trial and differences in delivery emerged that did produce some different outcomes, including the caseload of advisors and their expertise. There were also differing impacts for those in work but struggling and those out of work. However, progress was made on all intended outcomes for the treatment group in the trial: job search capability, use of health services, and self-confidence. In terms of the value for money of the scheme, health outcomes produced a stronger return to society and the exchequer than employment outcomes, which also differed by site and cohort. For every £1 invested in the IPS services there was a return of between £0.01 and £2.32 depending on the site/cohort. Though the economic case is variable in this trial, other evidence on IPS schemes suggests there is a strong economic case to introducing them, and that current evidence may be conservative.^[69]

Absence policies and return to work

If staff do need to take sick leave, there are still a range of things employers can do to make this as positive an experience as possible and to ensure employees feels supported. Firstly, absence policies need to be more flexible and compassionate.^[70] Individuals with long-term ill health or disabilities may frequently trigger attendance monitoring thresholds and be subject to related processes, including disciplinary processes. These add unnecessary stress in what should be a predictable circumstance (i.e. that an individual may be off work for extended periods of time or frequent shorter periods). Employer/HR absence policies should be able to work with individuals and their managers to be more tailored and supportive, and to take into account known health issues, including fluctuating health.

Beyond this, staff who did have to take time off because of their illness often faced poorly considered phased returns to work or were not offered phased returns at all. Respondents in empirical research felt that phased return (working shorter hours or fewer days initially, and rebuilding to their previous capacity over time) would have helped them to get back into work in a more sustainable way.^[71] Pre-return to work support is vital: engaging with employees and preparing for their return before it occurs, including engaging with relevant support services (e.g. HR, OH).^[72]

The Joseph Rowntree Foundation suggests a ‘right to return’ period where employers must keep a job open to those on longer-term sick or with a disability to keep those already in work in their employment.^[73] In Germany, employers are required to offer their staff who have been off work for more than six weeks a ‘reintegration’ discussion and plan.^[74] This is intended to identify work-related barriers to returning, find solutions, and set out a return to work plan.^[75] This, alongside a wide-range of government resources and support (particularly for smaller businesses) has been widely accepted in Germany as a positive for retaining workers.^[76]

Benefits and sick pay

Benefits and sick pay are frequently mentioned in the literature as levers by which to support staff with longer-term health conditions and disabilities to stay in work. It should be noted that many of the recommendations, across the literature, on Statutory Sick Pay were suggested by the UK Government in a 2019 consultation – these have not necessarily been implemented but show a recognition that a more modern approach to sick pay is required.^[77]

Much of the evidence base around social security and sick pay argues that the payments provided are not enough and that they help to keep people in poverty and outside of work. For example, the Joseph Rowntree Foundation argues that the social security system must cover the essentials of life to relieve the worst of the cost of living crisis and support families away from poverty.^[78] A report by the All-Party Parliamentary Group on Poverty found that the low level of benefits encourages ‘impossible decisions’ for disabled people, including deciding between paying^[79] for the medications and treatments they need and not being able to feed their families, or choosing to feed their families and resign themselves to weeks of pain.^[80] These kinds of real world examples show the difficulties faced by those with chronic conditions, where work may become difficult to continue without the correct support.

Statutory Sick Pay (SSP) is lower in the UK than across the majority of the EU^[81]. This low level of SSP has been found to be inadequate for many disabled people to live on and recover from ill-health while on sick leave.^[82] Those who are economically inactive because of long-term ill-health and disability are more likely to have lower incomes and be less economically resilient than those economically inactive for other reasons.^[83] There is therefore a greater risk of falling into poverty for this group. An Action for Children report, recommends that SSP should be increased to support people to remain out of poverty and to stay well while on sick leave: this should encourage them to return to work and reduce the risk of increasing ill health^[84]. Furthermore, for those earning the least, SSP is not available: SSP is only paid to those earning on average at least £123 a week, meaning the most vulnerable and deprived are not supported at all should they require time off from work for health reasons, increasing inequalities.^[85]

The other aspect of SSP that the evidence base was concerned about was the lack of flexibility in the system and the time limits that are in place. Currently SSP cannot be paid in combination with earnings, which means SSP cannot be used in conjunction with a phased return to work.^[86] Though working fewer hours as a phased return (or as a continuing changed working pattern) may support those with chronic conditions to remain in work longer-term after a period of illness, the system currently does not support this, meaning individuals may have to return to work before they are ready – risking further illness and/or lack of productivity in the workplace – or make the decision to leave work to focus on their health.^[87] SSP can also be paid only after four days of consecutive sick leave and only up to 28 weeks. This may not be helpful for those with fluctuating ill health, who may require sick pay over a much longer period or for many more shorter bouts over the year.^[88] This again risks an early return to work or an individual falling out of work because they breach the 28 week threshold and cannot work.

The Chartered Institute for Personnel and Development (CIPD) has made several recommendations around SSP, based on the 2019 consultation from the UK Government and the wider evidence base^[89]. These recommendations include reviewing and reforming SSP; extending SSP to those on the lowest incomes; raising SSP to be closer to the Minimum Wage or National Living Wage; and consulting on wider reform of SSP. They also recommend strengthening employer compliance with and state enforcement of SSP; exploring the possibilities available of the insurance sector better protecting incomes; and looking at ways of protecting income for the self-employed while unwell. Employers are also recommended to look at how they can develop an effective occupational sick scheme and implement a financial wellbeing strategy, which takes into account any health and wellbeing frameworks and is tailored to staff diversity and needs. A summary of these recommendations can be found here: What should an effective sick pay system look like? Policy recommendations | CIPD.

Ultimately, better employment protection had been found to increase employment retention and minimise the inequalities between those with lower education and poorer health and those with higher education and better health.^[90] Where there is a stronger ‘safety net’ for people, there is reduced health inequality.^[91] Policies that support workers and protect them within work are therefore more likely to encourage longer-term participation in the workforce and a more sustainable economy.

Mental health

As noted above, there has been a rapid rise in mental health conditions.^[92] Looking at the Scottish Surveys Core Questions (2022, latest data)^[93], the mental wellbeing scores^[94] for those inactive are lower than those in employment (23.5 and 24.1 respectively), with those unemployed scoring the lowest of all at 22.7.^[95] The mental wellbeing score of those with a limiting long-term physical or mental health condition is even lower, at 21.9.^[96] As the prevalence of mental health conditions increases across the population, the imperative to act to support those with these conditions also increases, including within the workplace.

In a 2017 publication, ‘Thriving at Work’, Stevenson and Farmer recommended that every employer take forward a set of ‘mental health core standards’ to create an open workplace culture around mental health, and robust work policies and processes to support staff.^[97] These are:

• 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.

They developed these ‘core standards’ from a range of evidence and best practice examples. They also encourage employers to go further where possible and produce internal and external reports on their monitoring of mental health in their organisation and response to it – as way of increasing transparency and accountability – improve their disclosure processes when a member of staff does want to discuss a mental health concern, and in-house, tailored mental health support for staff, as well as signposting to external clinical help.^[98] Stevenson and Farmer also recommend the use of digital tools and solutions by employers to support staff, as a low cost means of providing a wide range of ‘scalable interventions’.^[99] Though these core standards were adopted by some organisations at the time, a return to them and refresh may be necessary to address current concerns around mental health.

Furthermore, the ‘Thriving at Work’ report suggests that government has a role in joining up existing networks and provision, using public procurement to drive the mental health core standards, setting clear expectations of employers via legislation, improving Statutory Sick Pay, and encouraging the NHS, in particular, to provide support that is high quality, accessible, and fits around work, to complement workplace support.^[100] Overall this report provides a range of recommendations for employers, the government, and the public sector more widely. Many of these are covered within this report, but the full list can be found here: Thriving at Work: the Stevenson/Farmer review on mental health and employers (publishing.service.gov.uk)

Mental health concerns are an increasing issue for younger people: a recent Resolution Foundation report states that, in 2021-2022, 34% of 18-24 year olds in the UK report having a ‘common mental health disorder’ (CMD) such as depression, anxiety, or bipolar disorder; in 2000, that figure was 24%.^[101] Action for Children also report that ‘two thirds of young people who are economically inactive also have a common mental health disorder, compared to 40% of those who are unemployed and 22% of those who are in employment’.^[102]

Young women, the Resolution Foundation finds, are one and a half times more likely than young men to report having a CMD.^[103] The report goes on to state that

‘young people with mental health problems are more likely to be out of work than their healthy peers: between 2018-2022, one-in-five (21 per cent) 18-24-year-olds with mental health problems were workless, compared to 13 per cent of those without.’

However, it also finds that, despite the fact more young women report having a mental health concern, comparable numbers of young men and young women are economically inactive due to their health. The authors suggest this means younger women with mental health concerns cite being out of the labour market for a range of reasons, while younger men with mental health concerns are more likely to cite ill health as the main reason for being economically inactive.

Depression, anxiety, and stress are common and significant concerns for mental health. Workplace interventions that provide training to better understand the potential risks to mental health for workers of these kinds of conditions, and therefore create greater understanding, were found to be highly cost effective.^[104] As was the provision of personalised exercise plans by relevant professionals.^[105] The Resolution Foundation recommends catering and retail employers become aware of mental health concerns and needs as a particular priority, given they frequently employ younger people.^[106] Employers may be able to take forward these kinds of training programmes for the health and wellbeing of their staff, with some upfront investment.

Deloitte undertook some analysis into the case for investment in mental health support at work, and found that, on average, for every £1 invested employers obtained £5 in return.^[107] However, they accepted that there was a wide spread of returns in their study and the best return was found in interventions that:

• Offer a large‑scale culture change, or organisation‑wide initiatives supporting large numbers of employees;
• Are focused on prevention or designed to build employee resilience;
• Use technology or diagnostics to tailor support for those most at risk.

They recommended developing mental health support plans for the organisation and co-producing these with employees with lived experience. These should be a priority for the organisation, with senior leadership buy-in and promotion. They should also be monitored, audited, and asked about regularly in, for example, staff surveys. The plans should:

‘include clear objectives shaped around organisational vision, plans on how wellbeing will be promoted amongst staff, plans for tackling causes of mental health problems, aims for supporting staff experiencing poor mental health, and signposting to resources. The plan should be easily accessible to all staff.’

There should also be a focus on creating a positive working environment, reducing stress and overburden, ending lone working, reducing poor managerial practice, and support at all stages of recruitment, as well as when off sick and when returning to work. There should be good physical environments. The paper recommended creating an open culture around mental health and having two-way conversations, providing information and support to employees. If support is given to those with mental health issues, it should be ongoing. There should be tools and support for staff, but also training and confidence building so people – most especially managers – have the capability to discuss and support those with mental health concerns. There should also be more transparency around what the organisation is doing to better understand mental health and support its employees.

Similar suggestions can be found in other literature, and many of the suggestions for mental health are the same (or very similar) to suggestions for supporting those with physical health conditions. For example, an article in the Scandinavian Journal of Work, Environment, and Health recommended that a range of supports should be put in place to keep those with common mental health problems in work. These include an open organisational culture, positive and trustful relationships with one’s manager, social support at work from colleagues, timely support, independent professional support, manageable workload, control over job, adjustments at work, and more personal and social factors, such as positive coping styles and support from family and friends.^[108]

Skills, training, and socio-economic disadvantage

Those who are economically inactive due to ill-health have disproportionately high poverty rates and limited financial resilience: the Joseph Rowntree Foundation found the poverty rate for those who are economically inactive due to ill-health to be 38%, almost twice the rate for all working-age adults (20%) and nearly three times the poverty rate of those in work with ill health (11%).^[109] This shows the very real financial significance of supporting those with ill-health and disabilities to stay in work – and thereby supporting their health and wellbeing.

Workers with low educational attainment and low skills are more likely to report having a chronic condition that limits their abilities; they are also more likely to report not being provided with workplace adjustments.^[110] Those who have workplace adjustments (across demographics) are more likely to report better job quality than those without. They are also more likely to report better career progress than their counterparts who are not provided with appropriate adjustments. These workers also report less work intensity, better work-life balance, and lower stress levels, which also all contribute to better performance and sustainability of work.^[111] These findings suggest there are inequalities in who is experiencing ill-health, but also who is being better supported by their employer. As Stevenson and Farmer stress, there is a role for government here in ensuring employers do not ‘contravene employment and equalities legislation’.^[112]

Training and retraining are suggested as support solutions for those with longer-term ill health and disability. This focus on skills and training can begin from an early age, particularly given the concerns of long-term scarring for younger people out of work for long periods of time. When looking at inequality for young people in England in post-16 education and other training and occupational pathways, Field points to the fact that there are limited options for those who do not wish to go into higher education.^[113] However, Field also finds that, to reduce inequalities across the lifecourse, strengthening options other than higher education is key e.g. quality skills and training programmes, apprenticeships, and highly-valued technical education. This may be particularly significant for younger people experiencing ill health who may not feel higher education is the correct pathway for them.

The ONS found that around a quarter of older adults (26%) who had left the workforce since the Covid-19 pandemic feel they do not have the right skills to get a new job.^[114] To counteract this, and harness the health protection factor of good work, recommendations are to give older workers a right to a mid-life career and skills review, access to retraining where necessary, and to ensure in-work support is tailored to their circumstances.^[115]

Once in the workplace, investment in ongoing skills training (and where appropriate retraining) can support the closing of the skills gap for those with longer-term ill-health and disability. SCOPE recommends the creation of a fund to support such skills training, but also to trial and test innovative approaches to in-work and other support.^[116] In their report they set out the programme they see as possible for a national-led fund to support skills, training, and innovate approaches to employee retention – they argue that, if their approach is followed at UK Government level, the employer landscape for disability retention ‘[could be transformed] within a decade.’^[117]

Key target groups for in-work support and skills (re)training should be those with lower skills from more socio-economically deprived backgrounds who are in ill health or have a disability – whatever their age. This should ensure better retention of these workers on the basis of their skillset.

Practical considerations: transport and childcare

There are important practical considerations to retaining a workforce facing chronic conditions and disabilities. Though many of these recommendations will also apply to the wider workforce, their importance can be amplified by those experiencing ill-health. This section will focus on transport and childcare.

Transport has a range of health impacts, both positive and negative, direct and indirect. An important consideration for workforce retention is the access transport allows to employment opportunities. As a recent Public Health Scotland report on transport and health sets out, transport must be accessible, affordable, available, reliable, and safe.^[118] Without these things in place, a lack of good quality transport can limit access to job interviews, employment, training opportunities, and nursery and school education – which can in turn have an impact on a parent’s ability to work. This in turn impacts the health, wellbeing, and financial aspects of not being in work.

Those with lower incomes are most likely to require public transport, as are older people and those with a disability.^[119] Given the crossover between these groups and those who are economically inactive due to a health condition there is a strong argument for ensuring transport meets the standards set out in the Public Health Scotland report to support access to work. The report also notes the importance of good transport for accessing health and social care, which has a wider impact on the health of workers.^[120]

Examining the evidence about job prospects, transport, and accessibility: being closer to a city helps with job prospects across economic inactivity categories^[121]. This is about literal access to work, the opportunities, and improved transport links this allows. This highlights the inequalities that exist between those in urban and rural environments, which will be exacerbated for those with existing health conditions and disabilities.

There are also important considerations around childcare. Childcare costs are high across the UK, and are some of the highest in the OECD.^[122] The cost of childcare can be a barrier to work, particularly for those on low incomes. As an Action for Children report notes:

‘The average price of a part-time childcare place (25 hours a week) for a child aged under two in a nursery is £148.63 [per week] across Great Britain, or £7,729 a year. For parents of three- or four-year-olds in full-time work – for whom support is most generous – the typical weekly cost of a nursery place in England reached £117.60 this year.’^[123]

These costs are high for many parents, but for those with lower incomes (particularly single parents) such costs may create a situation where a decision has to be made whether to continue to work or not – and this may mean children with chronically unwell parents lose out on quality childcare that can support their longer-term outcomes, increasing inequalities.^[124] Where parents are already struggling to work due to ill-health, high childcare costs may act as a push factor to leave the workforce, while good quality, accessible, and affordable childcare can support parents to remain in work.^[125] Benefits are also important here: parents are usually only supported with childcare benefits when in work – they cannot access education and training and remain on relevant benefits.^[126] This may put those with longer-term conditions at a disadvantage when looking to retrain or upskill, which was mentioned as an important support solution by the evidence and is discussed in a previous section of this report. Supporting all parents to access and sustain work is a current Scottish Government priority: Executive Summary - Best Start, Bright Futures: tackling child poverty delivery plan 2022 to 2026 - gov.scot (www.gov.scot).

This evidence shows that accessing work can be about the practicalities, as well as wider concerns. Having these basics right for everyone can also support those with longer-term ill health and disabilities.

Job security

Disabled workers are more likely than non-disabled workers to be in insecure work at all levels of employment: the Work Foundation (a think tank sitting within Lancaster University) found that disabled workers are 1.5 times more likely than non-disabled workers to be in insecure work.^[127] The Work Foundation summarises the current situation for disabled workers:

‘Disabled people are over-represented in lower paid, more precarious work and are more likely to work part-time than non-disabled workers. For some, a shorter working week will be a personal choice which helps to manage a long-term health condition or caring responsibilities.

However, our analysis found that disabled workers are also more likely than non-disabled workers to be underemployed or in involuntary temporary work which means they would prefer to work more hours or to be on a permanent contract.

Disabled workers are also less likely to be with the same employer for more than two years, which means they might miss out on key rights and protections, such as access to redundancy pay. This could reflect societal barriers to accessing secure jobs and underscores the need to raise the floor of working standards across the UK.’^[128]

This ‘disabled gap’ in insecure work was worse for women, minority ethnic communities, and those with autism and mental health conditions.^[129]

Although some evidence finds that workers – particularly younger workers – can value the flexibility of less secure work^[130] there is a greater weight of evidence that insecure work takes a toll on workers. The Work Foundation recommends increasing opportunities for flexibility at work for all workers, but particularly improving job security for disabled workers, reforming the Personal Independence Payment (their report is focused on the UK and Scotland’s disability benefits are not discussed), enforcement of labour market regulations, and reforming statutory sick pay.^[131] Other sources suggest the need to prioritise skills training, which links to other recommendations in this report.^[132]

There is evidence that the impact of job insecurity can be as negative to health as actual unemployment.^[133] This will therefore disproportionately impact those with disabilities and chronic conditions who, as discussed throughout this report, are already at greater risk of leaving the labour market, of being in lower paid occupations, and having less resilience to financial shocks than those who are not disabled or chronically unwell. To combat this impact, giving employees as much control over their job as possible is important, such as encouraging employee participation in decision-making.^[134] Good communication across the organisation can also help, while ensuring good social support (e.g. peer support, peer groups) can improve psychological wellbeing.^[135] However, this point around job security makes clear that there are a wide range of structural issues to be tackled to support the health and wellbeing of those with longer-term ill-health and disability to stay in work.