We will sadly never know whether, or to what extent, access to cognitive behavioural therapy (CBT) or some other form of mental health or psychiatric support would have helped David Charlesworth from Harrogate.
But the inquest in February into the death of the teacher, who set himself on fire in the car park of his school after becoming depressed about exam results, did highlight the importance of support being offered fast and proactively, with his GP chasing his local NHS trust in vain on four separate occasions to carry out an assessment for referral to such “talking therapies”.
Such a tragic outcome may be, thankfully, as rare as it is extreme but the issue of mental ill-health nevertheless remains a very real one for employers and is, if anything, becoming increasingly pressing.
The Chartered Institute of Personnel and Development’s annual absence survey, carried out in conjunction with Simplyhealth and published last October, calculated that, for the first time, stress had now overtaken musculoskeletal disorders (such as bad backs) as the most common cause of long-term sickness for both manual and non-manual workers.
And in recent weeks, an analysis of government sickness benefits claimant data by insurer Legal & General calculated that more than 260,000 people are claiming sickness benefits because of mental and behavioural disorders while research by academics from the universities of Nottingham and Ulster concluded that stress-related absence from work tends to rise by a quarter during times of austerity.
On top of this there have been calls for the government to appoint a Cabinet-level “Minister for Mental Health”.
A balancing act
The challenge for both insurers and employers is how to square the circle between recognising mental ill-health is a growing problem that needs to be addressed if productive and healthy workforces are to be maintained (the relatively easy bit), but how to do so without completely breaking the bank (much harder).
One of the problems is that mental ill-health benefits, especially psychiatric benefits, have, rightly or wrongly, traditionally been seen as something of an expensive “nice to have” rather than a “must have” when it comes to budgeting for cover, particularly private medical insurance cover.
“The focus has been more on the physical side of things and, yes, a lot of employers and brokers have cut back on psychiatric benefits,” concedes Eugene Farrell, key accounts director at PMI provider AXA PPP healthcare and international director of the Employee Assistance Professionals Association. “But that is changing; it is now massively coming into the consciousness of employers. If you are not covering terribly well the biggest cause of absence in your workforce then you have a problem.”
“There has been a tendency for psychiatric benefits to be seen as an easy option in terms of reducing costs,” agrees Kirsty Jagielko, head of product management at Cigna, another insurer. “Employers have been saying ‘do we really need that cover, what is the benefit to us?’. A lot of the time, of course, these conditions are hidden. It is much easier to see the benefit from, say, fixing a hip.”
Within this, another complication has traditionally been where to draw the line between chronic and recurrent.
“Chronic versus recurrent can be very hard to pin down when it comes to mental health. When something becomes chronic you can normally exclude it from the medical plan. But it is not like cancer where you have the pathology to refer to,” argues Jagielko.
The employee benefit consultant’s view
“What we have also seen over the past 10 years is the number of days benefit for inpatient treatment reducing from what used to be the standard of 90 days to 45 and then 28,” suggests Sandra Hall, senior consultant at Lorica Employee Benefits. “There will be cases, of course, where companies have looked at the benefit they are providing and perhaps dropped days benefit because of liability issues or wanting to protect themselves. But that is not the main reason why we have seen levels reduce.
“It is more about access to treatment changing. Insurers are now looking at different pathways to facilitate quicker, easier access to, say, talking therapies. If an employer has a good occupational health service, or access to a good GP, it could be that the insurer will accept them as the initial referrer, perhaps to a network of CBT or psychotherapists.”
More widely, we are already seeing insurers wrapping enhanced mental health benefits into their offers. Cigna, for example, in February enhanced its psychiatric benefit to offer a full refund on outpatient psychiatric care, and up to £15,000 for inpatient and day case treatment; it also provides access to online CBT therapy for less severe cases. Back in 2010, too, cash plan provider Westfield Health moved to include CBT as a core benefit within its corporate plans, in a move it argued was a first for the industry.
“Psychiatry and psychological treatments are coming of age now,” AXA PPP’s Farrell says. “There is a cost advantage, of course, in trying to avoid inpatient psychiatric care, so I think insurers will be inevitably leading the way. Others will follow and employers will start to ask questions about what they can expect and how it can work for them. It will be about blending it all together.”
Employee assistance programmes (EAPs), structured telephone counselling, face-to-face counselling and CBT are all now becoming an additional “duty of care” priority for employers, suggests Matthew Judge, director at Jelf Employee Benefits, though employers do need to be careful not to see them as a panacea.
“It is not the solution for everything, of course, but it can add value for stress-related problems,” he explains. “Cash plans that offer a therapist benefit are probably not going to exhaustive, but they may give you a start.”
James Hall, head of health and risk at employee benefits firm Vebnet Services, equally sounds a cautionary note about relying too heavily on EAPs. While EAPs can be very useful in tackling mental health issues, their value can sometimes be undermined by elements of the service often being available as free-of-charge add-ons with other employee benefits, such as group income protection.
“As a result they are often not the priority and not communicated as effectively, and can be under-utilised,” Vebnet’s Hall says. Also, employees do not always seek the services of an EAP for advice on preventing issues, such as stress or depression, until after the issues become apparent. Generally it is only then when they will seek support.
“More extensive health screens could see GPs exploring a person’s mental health, identifying how much sleep they get or how stressed they are at work, but this is not always enough to really gauge the mental state of an employee.
“So, while we are seeing more and more employers looking to introduce basic health screens to help identify potential physical impairments, employers and the health insurance industry could go one step further and offer the same dedicated basic screens for mental health.”
Finally, a key factor in this evolving picture is, of course, the sort of back-up the NHS can offer employers, or will be able to offer in the future. At one level, mental ill-health has become much more of a priority in recent years in terms of state provision.
The National Institute for Health and Clinical Excellence (NICE) has issued clinical best practice on the treatment of depression in adults and the government in February last year published a substantive new mental health strategy No Health Without Mental Health.
On top of this there has been the rolling out of the Improving Access to Psychological Therapies programme, which has been establishing a network of treatment centres for people with mild anxiety and depression. The government’s Fit for Work service, not to mention the recent reviews of workplace health and absence carried out by Dame Carol Black, the national director for health and work, and David Frost, former director general of the British Chambers of Commerce, have also put tackling mental as well as physical ill-health centre stage.
But with the NHS in flux as the government pushes through its controversial health reforms, employers may not be able to rely on it to be supporting employees with mental ill-health and may therefore need to continue to work closely with insurers to come up with affordable solutions.
As Jelf’s Judge points out: “A lot of people will be waiting to see what happens in regards to the NHS reforms. Corporate UK may be forced to take on a greater burden of this risk.”
Similarly, Lara Rendell, marketing manager at cash plan provider Health Shield, argues that, as stigma about owning up to mental ill-health and frailty gradually lifts – and you need to look no further than the highly publicised stress-related absence of Lloyds Banking Group Antonia Horta-Osorio to get a sense of how attitudes are changing – employers increasingly are now seeing value in putting in place provision such as EAPs, alongside wider health and wellbeing programmes.
“As we see the NHS changing, we may start to see more cash plans starting to adapt their offer in line with what people really feel they need,” she predicts.
Whatever future models emerge, there will need to be structured, consistent approach from both employers and insurers, with Dr Doug Wright, head of clinical development at Aviva UK Health, suggesting the norm is likely to be a mix of early identification, access to talking therapies and then structured elements coming through PMI. There will probably be more use of CBT through group protection insurance as well as PMI, he also asserts.
“I do not think stress in the workplace is going away,” agrees Howard Hughes, head of business marketing at Simplyhealth, the insurer. “I do think people are looking for help and, as an industry, we have a part to play in that. If employers are using intermediaries and they have policies that include psychiatric benefit within them we do need to be engaging with them and saying are you sure you want this? Too often they can be working to an old-fashioned model that might be expensive or ineffective.”