IAPT Employment Support Services in London

IAPT Employment Support Services in London Assessment of the Economic Impact How a dedicated employment support service can generate 2.79 in benefits for every 1 spent, add value to psychological services and improve the quality of outcomes for people affected by common mental health problems. Page 1 of 18

Service summary In 2010, Working for Wellness championed the roll-out of integrated clinical and employment support services as part of London s Improving Access to Psychological Therapies (IAPT) programme. Embedding employment support and advice in health care services for individuals experiencing mental health problems is viewed as a key element in the recovery process. Whilst health interventions alone can make a contribution to beneficial employment outcomes, there is now a growing body of evidence that indicates targeted health and work related support achieves greater impact. This is true for reducing the incidence of job loss and for promoting people s 1 return to work. The purpose of the service is to offer a range of individually tailored, practical and motivational support and advice to people affected by mild to moderate mental health issues in order to support them into employment or to retain their current employment. The service is designed to compliment the therapeutic treatments individuals are receiving as part of the IAPT programme. Impact summary In 2010, 865 people entered the 5 Working for Wellness Employment Support Services included in this study. Of these: 260 people were supported to retain their employment; 95 people were supported to move into work; 41 people were supported to move into education and training having been previously unemployed. It has only been possible to claim outcomes for those people who have exited the service. It is expected that other benefits accrue for people who remain in contact with the service. The data suggests that every 1 spent by the state on IAPT employment services generates 2.79 of benefits, of which 0.84 benefits the individual and 1.95 benefits the state. Page 2 of 18

Background The positive link between employment and mental health is firmly established 1. Research demonstrates that work is good for people and being unemployed is damaging to physical and mental health 2. The proportion of unemployed people in need of psychological treatment is more than double that of those who are employed 3. There is also a strong correlation between unemployment and higher mortality, higher medical consultation, higher healthcare consumption and higher hospital admission rates 4 5. After an individual has been absent from work for six months, there is only a 50% likelihood of the employee returning to work; this falls to 25% after a 12-month absence and after 2 years it is virtually nil 6. Experts have used this evidence to demonstrate that significant economic and wider societal cost savings can be achieved through targeted interventions. Recent estimates suggest that the cost of mental health problems in England increased from 77.4 billion in 2002/03 to 105.2 billion in 2009/10 in terms of health and social care costs; output losses in the economy; and an imputed monetary valuation of the human cost of mental illness 7. The London School of Economics calculated that the total loss of output due to depression and chronic anxiety is some 12 billion a year 1% of our total national income. Of this the cost to the taxpayer is some 7 billion including incapacity benefits and lost tax receipts 8. By articulating the links between mental illness and deprivation and the economic costs of untreated illness, the Depression Report in 2006 helped to secure a three-year Government commitment of 173 million in 2008/09 to deliver the Improving Access to Psychological Therapy (IAPT) programme 9. Central to IAPT is the recruitment and training of a therapist workforce to new services delivering NICE compliant cognitive behavioural therapy and other treatments for anxiety and depression within primary care. Against the backdrop of the economic downturn, Working for Wellness has led the development of integrated psychological therapy and employment support pathways which are available in 15 of London s 31 PCTs. In 2009 Working for Wellness championed an investment fund of almost 4.5million 10 to offer all London PCTs the opportunity to bid for additional resources. A total of 27 PCTs were successful in their application with most investment directed towards the 15 IAPT services that were already live. Unique to London, Working for Wellness approach is to support commissioners with the service design and development of local delivery models that feature appropriate provision for job retention and back to work support. The Coalition Government has made clear that mental health and employment is a priority. The new national mental health strategy No Health without Mental Health published in February 2011 and the NHS Outcomes Framework for 2011/12 both emphasise the importance of 1 3 Paul, K., & Moser, K. (2009). Unemployment impairs mental health: Meta-analyses. Journal of Vocational Behaviour, 264-282. 4 Waddell, G., & Burton, K. (2006). Is Work Good for your Health and Wellbeing. Norwich: TSO. 5 Yuen, P., & Balarajan, R. (1989). Unemployment and patterns of consultation with the general practitioner. British Medical Journal, 1212-1214. 6 7 Health Work and Wellbeing. (2009). Working our way to better health. Norwich: TSO. 2 Waddell, G., & Burton, K. (2006). Is Work Good for your Health and Wellbeing. Norwich: TSO. British Society of Rehabilitation Medicine. (2001). Vocational rehabilitation: the way forward. London: BSRM. Centre for Mental Health. (2010). The economic and social costs of mental health problems in 2009/10. London: Centre for Mental Health. 8 London School of Economics. (2006). The Depression Report: A New Deal for Depression and Anxiety Disorders. The Centre for Economic Performance's Mental Health Policy Group. London: LSE. 9 Department of Health. (2008). Improving Access to Psychological Therapies Implementation Plan: National guidelines for regional delivery. London: DH. 10 A total of 4,401,720 was allocated in 2009/10. The London investment fund comprised 2,465,000 joint Commissioning Support for London and Department of Health funding, which was matched by 1,936,720 from PCTs and other Local Strategic Partner agencies. Page 3 of 18

employment for people with mental illness. Accompanying the national mental health strategy is the supporting document Talking Therapies: a four year plan. This paper builds on the Government s Comprehensive Spending Review announcement to continue to fund the IAPT programme under its new name Talking Therapies and complete its intended seven year rollout through a 400million allocation up until March 2015. The expansion of the programme aims to achieve full geographical coverage as well as to extend provision to meet a range of needs. Employment support is also recognised as a vital part of the service model and there is an expectation that PCTs will fund this work out of baseline budgets to build on their achievements to date. Page 4 of 18

The Service Project aims and purpose As discussed, the Working for Wellness Employment Support Service was introduced as part of London s Improving Access to Psychological Therapies (IAPT) programme. Embedding employment support and advice in health care services for individuals experiencing mental health problems is viewed as a key element in the recovery process. Whilst health interventions alone can make a contribution to beneficial employment outcomes, there is now a growing body of evidence that indicates integrated health and work related support achieves a greater impact. This is true for reducing the incidence of job loss and for promoting people s return to work 11. The purpose of the service is to offer a range of individually tailored, practical and motivational support and advice to people affected by mild to moderate mental health issues in order to either get them into employment or to retain their current employment. The service is designed to compliment the therapy individuals are receiving as part of the IAPT programme. Sites included in this evaluation Five IAPT sites in London offering an Employment Support Service have been included in this economic evaluation. Each site has a slightly different service model as described in Table 1 below. Table 1: Service information for sites included in this evaluation Location Service model Staffing Tower Hamlets The Employment Support Service is not co-located with the IAPT Service and the staff have different employers. Clinical staff are employed by Tower Hamlets Community Health Service and the Employment Support Workers are employed by a voluntary sector organisation called the Working Well Trust. The Employment Support Service is located in a premises owned by the Working Well Trust in Whitechapel, Tower Hamlets. 1 x full-time Senior Employment Advisor 2 x full time Employment Advisors 2 hours support per month from a more experienced employment retention worker from within the Working Well Trust Southwark The Vocational Service (Southwark s Employment Support Service) is colocated with the IAPT Service and the staff have the same employer. Both Clinical and Vocational Service staff are employed by the South London and Maudsley NHS Foundation Trust. The IAPT service operates an outreach style of service in different localities - 2 in the south of the borough and 2 in the north of the borough and a vocational specialist works with the IAPT team in each locality. 1 x 0.5 FTE Team Leader 1 x full- time Lead Vocational Specialist (12 months) 3 x full-time Vocational Specialist (12 months) 1 x full-time Vocational Specialist (7 months) 1x 0.3 FTE Administrator (12 months) Lambeth The Employment Support Service is colocated with the IAPT Service although the staff have different employers. Clinical staff are employed by Lambeth 1 x full-time senior employment advisor 1 x full-time employment support coordinator 11 Lelliott P, Boardman J, Harvey S, Henderson M, Knapp M, Tulloch S (2008). Mental Health and Work. A report for the National Director for Work and Health. London: Royal College of Psychiatrists. Page 5 of 18

PCT and the Employment Support Workers are employed by a voluntary sector organisation called Status Employment. The service operates in three locations across the borough: a community centre in Brixton, a GP surgery in Streatham and St. Thomas hospital in the north of the borough. 2 x full-time employment advisors Islington The Employment Support Service is not co-located with the IAPT Service and the staff have different employers. Clinical staff are employed by NHS Islington and the Employment Support Workers are employed by a voluntary sector organisation called Mind Islington. The IAPT service in Islington is run on a geographical basis in North, South and Central Islington. Although the Employment support service is not colocated it is based next door to the North and Central Islington IAPT teams. 3 x full-time job retention workers 1 x full-time employment support advisor Hackney The Employment Support Service is colocated with the IAPT Service although the staff have different employers. Clinical staff are employed by City and Hackney PCT and the Employment Support Workers are employed by a voluntary sector organisation called City and Hackney Mind. The service is colocated at St Leonards Community Hospital, Hackney. 2 x full-time employment support advisors Services offered and intended outcomes The IAPT Employment Support Service offers a comprehensive package of interventions, according to an individual s needs, to help people to gain or regain work or to retain their current employment. Key interventions offered to help people to gain or regain employment include: Basic advice and career guidance; Post-placement in-work support to maximise job retention; Vocational information and advice, including CV writing, job search and interviewing skills; Individual support for motivation, confidence building and assertiveness skills; Signposting to Job Centre Plus (JCP) support; Access to expert advice, benefits counselling and debt counselling. Key interventions offered to help people to retain employment include: Management of employment and employer-related issues; Individual support for motivation, confidence building and assertiveness skills; Adjustments in the work place to help maintain attendance at work; Help to return to work after sick leave; Access to occupational health support; Careers guidance; Help to look for more suitable jobs whilst still employed; Sign-posting to legal advice and legal aid. Page 6 of 18

A more detailed overview of the services provided (outputs and activities) is illustrated in Appendix A. The outcomes the Employment Service is seeking to achieve are also outlined in Appendix A. Delivery volume: referrals and patients/clients Overall in 2010 across all five IAPT sites, 1319 individuals were referred for employment support. All referrals came from IAPT clinical teams. As outlined in table 2 below of the 1319 individuals who were referred, 865 actually entered the Employment Support Service. Table 2: Breakdown of referrals and numbers actually entering the service across the five sites Location No. of referrals No. actually entering the service Tower Hamlets 211 130 Southwark 351 212 Lambeth 250 177 Islington 265 170 Hackney 242 176 Methods of delivery Each individual who enters the Employment Support Service after referral is given an initial assessment to understand their specific employment needs. One of the advisors then works with the individual to develop an action plan of work-focused solutions which will be a combination of the interventions described above. The advisor then works with individuals on a one to one basis to offer a range of practical and motivational support and advice. Page 7 of 18

Impact Evidence Standardised IAPT Employment Data collected locally indicate that the Employment Support Service is delivering a range of outcomes for the state, employers and for people affected by common mental health problems. These can be grouped as per Appendix A. Employment Outcomes As shown in Table 3 (over), of the 865 people who entered the employment support service across the five sites: 260 people were supported to retain their employment; 95 people were supported to move into work; 41 people were supported to move into education and training having been previously unemployed. Table 3: Employment outcomes achieved across the five sites Entered employment (previously unemployed and claiming JSA or income support) Entered employment (previously unemployed and claiming IB) Entered employment (previously claiming sick pay) Entered employment (previously unemployed and claiming no benefits or not known) Entered employment (previously a full-time student) Entered education or training (previously unemployed) Supported to stay in work (either full-time or parttime) Became unemployed having been employed either full or part time Tower Hamlets Southwark Lambeth Islington Hackney Total 6 14 3 1 13 37 3 0 1 0 3 7 3 9 5 10 8 35 0 6 6 0 0 12 0 1 3 0 0 4 4 28 1 0 8 41 26 93 68 30 43 260 3 9 11 3 3 29 Page 8 of 18

Economic Model and Cost Calculation Economic model The economic evaluation approach adopts a top down perspective that takes into account the total budget for an Employment Support Service and outcomes for all individuals seen over one year. The operational budgets of each service were used to calculate costs. were claimed only for individuals who exited the service during the 12 month period. A number of financial components were used to value three types of outcome. Individuals who gained employment Income for the individual; 12 Tax and national insurance to the state; 13 Reduction in welfare benefit costs to the state. 14 Individuals who retained their employment Avoidance of welfare benefit costs to the state. 15 Individuals who lost (failed to retain) their employment 16 Income lost to the individual; Tax and national insurance lost to the state; Welfare benefit costs to the state. The cost model assumes that the benefits or outcomes that individuals achieve will last for at least 12 months. This is a conservative estimate. The model therefore includes a further calculation that assumes the outcomes will last for up to 24 months. This is a more optimistic upper limit for which there is less certainty. However, it is not unusual for economic calculations of this type to use such upper limits e.g. DWPs 2008 analysis of Pathways to Work for incapacity benefit claimants, which reported outcomes with a confidence interval of 70 to 150 weeks 17. Twenty four month results need to be treated with some caution. However, given this evaluation applies monetary values to outcomes achieved only by people who exited the service, the use of a 24 month interval may still generate a conservative overall estimate of any return on investment. The cost model therefore provides a confidence interval for results based on 12 and 24 month time periods across which the outcomes are predicted to continue. The study also reports the mid point, or 18 month figure, which provides a balanced estimate that is in line with the Coalition Government s move toward achieving longer term, sustainable outcomes. Approximately 30% of benefits accrue to the individual and 70% to the state. The cost model therefore reports an overall return on investment dividend as well as describing in monetary terms what proportion benefits the individual and what proportion benefits the state. Working for Wellness data indicates that employment support input results in approximately 2.2 more people returning to work than would have done with clinical input only. This means that 45% of the benefit achieved for people returning to work would have accrued anyway with clinical input only. The model subtracts this proportion from the monetised benefits attributed to this group of individuals. 12 ONS lower quartile median London salary 14,742 13 Based on lower quartile median London salary 14 Anchored to individual SSP, IB or JSA costs see Table 3 15 Anchored to SSP for all 16 calculated and subtracted from the benefit total. 17 Dorset R. (2008) Pathways to Work for new and repeat incapacity benefits claimants: Evaluation synthesis report No. 525. London: HMSO Page 9 of 18

Cost calculation Table 4, Appendix B, provides indicative figures for the costs and benefits to both the state and those individuals using the service based on 2010 data. This does not include the nonmonetisable, categorical benefits summarised in Appendix A. Monetising costs and benefits at the highest-level shows: an annual service cost across the five sites of 745,117 in 2010 the benefits accrued as a result of the employment support service reducing both the actual and potential number of people out of work at a number of intervals over a 24 month period as follows: 12 months 18 months 24 months accrued by service users in terms of the income gained by returning to work (this figure takes account of those who would have returned to work without support and those who moved from being employed to unemployed whilst being supported) accrued by the state including the tax and national insurance gained from those returning to work and the income saved by a reduction in those actually or potentially claiming social security benefits (this figure takes account of those who would have returned to work without support and those who moved from being employed to unemployed whilst being supported) 342,752 514,128 685,503 1,160,505 1,568,189 2,212,102 Total monetary benefits accrued 1,503,257 2,082,317 2,897,605 1. Possible return on investment dividend Applying a ROI calculation to the high-level data (total service costs) and total money accrued by the reduction in the actual and potential number of people out of work we see that: After 12 months After 18 months After 24 months Every 1 spent by the state on IAPT employment services generates 2.02 of benefits, of which 0.61 benefits the individual and 1.41 benefits the state Every 1 spent by the state on IAPT employment services generates 2.79 of benefits, of which 0.84 benefits the individual and 1.95 benefits the state Every 1 spent by the state on IAPT employment services generates 3.89 of benefits, of which 1.17 benefits the individual and 2.72 benefits the state As discussed above we have only claimed outcomes for those people who have exited the service. We would expect these returns to improve as more people exit the service. For example, a proportion of service users may exit the service with positive outcomes between years 1 and 2 for which their first year of contact with the employment service would have been a necessary foundation. This type of benefit is not monetised in the calculations. Page 10 of 18

2. Additional indirect benefits Monetary values could be assigned to some other benefits that will gradually increase the return on investment dividend. For example, evidence indicates that by improving people s employment status and their health and well-being there is a corresponding reduction in their use of health services. This is an important wider benefit that warrants closer scrutiny. For example, the average consultation rate per person of working age per year is 4.49, where as the average rate for a patient with depression is twice that at 8.89 GP consultations 18 19. It is reasonable to deduce that employment support would reduce participants use of their GP to average levels. If we apply an average consultation rate to these efficiency savings the return on investment increases further: Applying a ROI calculation to the high-level data (total service costs) and total money saved by the reduction in the actual and potential number of people out of work and the reduction in the use of health services we see that: After 12 months After 18 months After 24 months Every 1 spent by the state on IAPT employment services generates 2.08 of benefits for both the state and individuals Every 1 spent by the state on IAPT employment services generates 2.87 of benefits for both the state and individuals Every 1 spent by the state on IAPT employment services generates 3.99 of benefits for both the state and individuals Other benefits were also realised for which it has not been possible to assign monetary values. For example, council tax and housing benefit are adjusted as individuals regain or lose employment. The benefit status of individuals included in this analysis in these respects was not known. However, if included in the calculation these adjustments would be expected to further increase any return on investment. In a similar vein, prescription use and costs would likely change as employment brings health and well being benefits to people with mental health problems. These anticipated cost reductions are not included in the calculation. It is also important to note that a large proportion of users across the five sites are referred to other services including: Citizen s Advice Bureau (i.e. for in-depth benefits advice, debt counselling etc.) The local legal advice and legal aid service Dress for Success (a charity that provides clothing to women for interviews) Physiotherapy project (funded to provide physiotherapy to those who have a physical condition that is impacting on their ability to work) Skills for Life (NHS funded employment support project for those who speak English as a second language) However it is not possible to include any costs or benefits associated with these services as no data were available to indicate whether people received the services they were referred to and for how long. It is important to remember that the services levered in would be provided even in the absence of the IAPT employment service and the costs would generally be out weighed, over time, by the benefits to an individual of regaining or retaining their employment. Potential costs incurred in the absence of the service In the absence of a dedicated employment support service as part of the IAPT service there are a number of other employment initiatives that people could be referred to. However, these alternative initiatives are often not suitable for IAPT clients for a number of reasons: 18 NHS Information Centre for Health and Social Care. (2009). Trends in Consultation Rates in General Practice 1995-2008: Analysis of Q Research (r) database. NHS Information Centre. 19 Thomas, C. & Morris S. (2003). Cost of depression among adults in England 2000. The British Journal of Psychiatry, 183, 514-519 Page 11 of 18

Alternative employment initiatives are generally only available to people who are claiming a social security benefit. The IAPT employment service is available to those who are not claiming any benefits. The majority of alternative employment initiatives are not specifically tailored to those with mild to moderate mental health problems. Alternative employment initiatives do not generally offer support to people to retain their current employment. People with severe and enduring mental health problems can generally access retention support but there is a definite gap in retention support for those with mild to moderate mental health problems like anxiety and depression, which have significantly higher prevalence rates. Page 12 of 18

Appendix A: Pathways to outcomes for IAPT Employment Support Service INPUTS (routes in) Referral from the Improving Access to Psychological Therapies (IAPT) service Package of support Employment at risk or Unemployed Initial Assessment (Employment needs) Not eligible Signposting to other services E.g. debt counselling OUTPUTS (activities) Information and advice services Info about corporate and individual legal rights, responsibilities and representation Dissemination of materials. Provision of info about: and JCP services, labour market, local employers and their recruitment practices, workplace solutions and provision for people with MH conditions. Signposting to other relevant support, including info about vacancies and training. Careers guidance: helping clients think about employment options, barriers to employment and potential aspirations. Suggestions about non-employment activities. Motivational support services Helping clients to realise their strengths through vocational support. Education and training on physical and mental coping strategies for work and everyday activities. Help with developing strategies to communicate and negotiate with employers. Practical support Support (including advocacy) with job searching, applications and preparing CV. Helping clients to negotiate with employers and with job redesign/adjustments/ phased return to work Arranging places on suitable training courses. Providing opportunities to practice interview skills. Support to trade union representatives. Practical help to overcome barriers e.g. help with sorting out paying bills, getting spectacles, talking to GP, managing anxiety. Liaising with partners Gain info, advice and services for clients by liaising with: JCP, benefits advisors, training providers, and health services. Work in partnership with IAPT practitioners who are providing low/high intensity interventions (sharing case information). Other: Promote awareness of the Employment Support service in the local community. Service development. Mapping local labour market provision for people with MH issues Support to employers. Tracking the progress of clients Development of Action Plan with work-focused solutions Ongoing case management Track progress (for those that move into/return to/remain in work) Page 13 of 18

Outcomes (why doing it) Employment outcomes Economic outcomes Health and well-being outcomes Wider outcomes Prevention of dropout from the workforce due to mental health problems (job retention) Recruitment of individuals who face barriers to employment due to mental health problems (access to employment) People return to work from sickness absence People move off benefits and into employment People with mental health problems exchange to more suitable job roles London achieves its regional employment commitments Moving people closer to the labour market through volunteering, learning and skills development Reduced use of health services (both mental and wider health services) Reduced use of state benefits Reduced number of people on employer sick pay Increased working population by enabling people with mental health problems to remain at work, gain work, or increase their employed hours Reduction in the number of days sickness absence taken Reduced cost to individual of being unemployed Increased tax and national insurance contributions Improved mental wellbeing of service users Improved quality of life for service users Improved or increased social contact for service users Increased self confidence and motivation for service users Reduced risk of long-term incapacity Reduced poverty (including child poverty) Improvement in work and social adjustment scores (WS&S) Prevent deterioration of mental health due to unemployment Improved social inclusion of people with mental health difficulties An embedded employment focus as a core component of IAPT services Skills development for high and low intensity IAPT practitioners in recognising and responding to employment related issues Freeing up clinician time Evidence that a collaborative care model (i.e. between a therapeutic service and employment support service) works Appendix B: Economic Evidence Table 4: Available cost and benefit data for all five sites, 2010 Cost/benefit type Measure/s Total Direct costs 1. Fixed operational budget Value in Tower Hamlets = 129,588 Southwark = 185,856 Lambeth = 150,000 Islington = 194,673 Hackney = 85,000 745,117 Direct benefits 2. Number of people regaining employment, returning to work or entering education or training following completion of the intervention (Working for Wellness data indicates that employment support input results in 2.2 more people returning to work than would have done with clinical input only. The number of people who would have returned to work without employment support has been taken into account when calculating the overall benefits accrued) Cost/benefit type Measure/s Confidence interval Income gained by Number of individual returning people x Total 95 x 14,742 20 1,400,490 20 Office for National Statistics, 2010 Annual Survey of Hours and Earnings, available at : http://www.statistics.gov.uk Page 14 of 18

to work Income gained by the state in income tax and national insurance from those returning to work Reduction in the number of people receiving welfare benefits Lower quartile median London salary (net per annum) Number of people x tax and national insurance from lower quartile median London salary (per annum) Number of people x cost of social security benefits per person 12 months 18 months 24 months 12 months 18 months 24 months 12 months 95 x 22,113 2,100,735 95 x 29, 484 2,800,980 95 x 5,480 520,600 95 x 8,220 780, 900 95 x 10,960 37 people x 3,354 (Based on Job seekers allowance 64.50 x 52 weeks) 7 people x 3,585 (Based on Incapacity Benefit (lower rate) 68.95 x 52 weeks) 35 people x 3,754 (Based on Statutory sick pay 79.15 x 28 weeks and Job seekers allowance 64.50 x 24 weeks) 1,041,200 280,583 18 months 24 months 37 people x 5,031 (Based on Job seekers allowance 64.50 x 78 weeks) 7 people x 5,378 (Based on Incapacity Benefit (lower rate) 68.95 x 78 weeks) 35 people x 5,441 (Based on Statutory sick pay 79.15 x 28 weeks and Job seekers allowance 64.50 x 50 weeks ) 37 people x 6,708 (Based on Job seekers allowance 64.50 x 104 weeks) 7 people x 7,170 (Based on Incapacity Benefit (lower rate) 68.95 x 104 weeks) 35 people x 7,118 (Based on Statutory 414,228 547,516 Page 15 of 18

sick pay 79.15 x 28 weeks and Job seekers allowance 64.50 x 76 weeks ) 3. Number of people retaining employment following completion of the intervention Savings made by the state of people not claiming social security benefits Number of people x cost of social security benefits per person 12 months 260 people x 3,754 (Based on Statutory sick pay 79.15 x 28 weeks and Job seekers allowance 64.50 x 24 weeks) 976,040 18 months 260 people x 5,441 (Based on Statutory sick pay 79.15 x 28 weeks and Job seekers allowance 64.50 x 50 weeks ) 1,414,660 24 months 260 people x 7,118 (Based on Statutory sick pay 79.15 x 28 weeks and Job seekers allowance 64.50 x 76 weeks) 1,850,680 Page 16 of 18

Indirect costs 4. Number of people not retaining employment following completion of the intervention Income lost by individual not retaining employment Income lost by the state in income tax and national insurance from those not retaining employment Cost to the state of people claiming social security benefits Indirect benefits Number of people x lower quartile median London salary (net per annum) Number of people x tax and national insurance from median London salary (per annum) Number of people x annual cost of social security benefits per person 12 months 18 months 24 months 12 months 18 months 24 months 12 months 18 months 24 months 29 x 14,742 21 427,518 29 x 22,113 641,277 29 x 29,484 855,036 29 x 5,480 158,920 29 x 8,220 238,380 29 x 10,960 317,840 29 people x 3,354 (Based on Job seekers allowance 64.50 x 52 weeks) 29 people x 5,031 (Based on Job seekers allowance 64.50 x 78 weeks) 29 people x 6,708 (Based on Job seekers allowance 64.50 x 104 weeks) 97,266 145,899 194,532 Reduced use of health services Number of people with a positive employment outcome x average cost of reduced GP consultations 12 months 18 months 396 people x 99.27 (Based on a reduction in GP consultations from 8.98 to 4.49 per year at a cost of 22.11 per consultation 22 ) 396 people x 148.91 (Based on a reduction in GP consultations from 8.98 to 4.49 per year at a cost of 22.11 per consultation 23 ) 39,311 58,968 21 Office for National Statistics, 2010 Annual Survey of Hours and Earnings, available at : http://www.statistics.gov.uk 22 NHS Information Centre for Health and Social Care. (2009). Trends in Consultation Rates in General Practice 1995-2008: Analysis of Q Research (r) database. NHS Information Centre. 23 NHS Information Centre for Health and Social Care. (2009). Trends in Consultation Rates in General Practice 1995-2008: Analysis of Q Research (r) database. NHS Information Centre. Page 17 of 18

24 months 396 people x 198.54 (Based on a reduction in GP consultations from 8.98 to 4.49 per year at a cost of 22.11 per consultation 24 ) 78,622 24 NHS Information Centre for Health and Social Care. (2009). Trends in Consultation Rates in General Practice 1995-2008: Analysis of Q Research (r) database. NHS Information Centre. Page 18 of 18