Fit for Purpose
Transforming employment support for disabled people and those with health conditions
Ann Purvis
Sarah Foster
Lorraine Lanceley
Tony Wilson
July 2014
This report has been quality assured by: Name: Tony Wilson Position: Policy Director Date: 2 July 2014
Tony Wilson Centre for Economic and Social Inclusion Third Floor 89 Albert Embankment London SE1 7TP Tel: 020 7840 8346 Email: [email protected]
Contents
Acknowledgements ...... 4 Executive Summary ...... 5 1 Introduction ...... 14 Context ...... 14 The ‘Fit for Purpose’ project ...... 19 2 The landscape of support ...... 21 The current framework ...... 21 Local provision ...... 29 Conclusion ...... 30 3 What works (and for whom)? ...... 31 Introduction ...... 31 The effectiveness of different types of support ...... 32 What works for specific groups? ...... 43 Cross-cutting themes ...... 52 Conclusion ...... 58 4 Commissioning support ...... 59 Payment by Results ...... 59 Individual budgets ...... 62 Local and joint commissioning ...... 64 Evidence based commissioning ...... 69 Conclusion ...... 70 5 Recommendations ...... 71 The framework for future employment support ...... 71 The management of future programmes ...... 80 Workforce development ...... 85 Conclusions ...... 87
Fit for Purpose: Transforming employment support
Acknowledgements
This project would not have been possible without the financial support of a number of organisations. We would like to extend our thanks, both for this support and for their time in attending workshops, shaping the direction of the work and discussing and commenting on findings and recommendations. Many also gave their time to be interviewed for case studies, for which we are grateful.
A4e Avanta ESG i2i Ingeus Interserve intraining Kennedy Scott learndirect Maximus Prospects Randstad Reed RNIB Seetec Serco Shaw Trust CDG St Loye's Foundation The Salvation Army Wheatsheaf Trust Work Solutions Working Links
We would also like to thank BASE, Remploy and PublicCo for the time and expert input that they have contributed throughout this project.
Particular thanks go to the participants of our focus groups for their time and views on the emerging recommendations – as well as to Shaw Trust CDG, St Loye’s Foundation, The Salvation Army, and the Central and the North West London NHS Foundation Trust for arranging and hosting these groups.
Finally, many thanks to Inclusion colleagues – past and present – for their contributions to this work and report, including Paul Bivand, Tim Riley, Malen Davies, Callum Miller and Lauren Bennett.
4 Fit for Purpose: Transforming employment support
Executive Summary
Disabled people and those with health conditions are far less likely to be in work, less likely to find work and spend longer out of work than the population as a whole. Despite more than a decade of near-constant reforms to disability benefits and to employment support, these gaps did not narrow by much during the boom years, and progress may have stalled more recently.
Fewer than half of all disabled people are in work and we estimate that just one in ten of those not in work are being supported through either the Work Programme or Work Choice. Almost all of these are in the Work Programme, with only limited funding available to provide intensive or specialist support.
This project sets out how the employment support system can be transformed to create a system that offers employment opportunity for all – with the right support to prepare for and take up work. It sets out twenty case studies of current good practice, and has been ‘crowd funded’ by twenty-two organisations that work with and support disabled people and those with health conditions.
The landscape of support
The current system of support for disabled people and those with health conditions is complicated and complex.
Jobcentre Plus provides limited specialist support and more extensive support to jobseekers (many of whom may be disabled). However, concerns have been raised around resource levels and specialism.
The Work Programme supports disadvantaged jobseekers and many claimants of ESA – however disabled people are less likely to find work than participants without an impairment and may also be less likely to receive appropriate support (driven in part by very low funding).
Work Choice provides more specialist support to those with complex needs – supporting around 20,000 people a year, many of them on JSA and with pre-work support limited to six to twelve months1.
1 There is an option to extend the pre-work support module of Work Choice from six months to one year, although the evaluation of Work Choice (Purvis et al (2013) Op. cit.) found little evidence of this being used in practice.
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Access to Work provides employers and individuals with funding to meet the extra costs of employing a disabled person – but awareness and uptake is often low.
Finally, a range of local and national provision supports disabled people with specific (and often severe) needs – in particular through local ‘Supported Employment’ and national residential training. However budgets for the former are devolved and not ring-fenced, and for the latter have been reduced and remain under threat.
What works (and for whom)?
This complex landscape only partly reflects the evidence on what works. This evidence is far from complete, but points to a number of effective service models and common themes.
Different types of support
There is unequivocal evidence that Supported Employment, when implemented effectively, can lead to significant positive impacts on employment. This ‘place, train, sustain’ model is built around holistic engagement of the participant and those around them, effective profiling, job matching and then extensive support in work. However, Supported Employment when implemented fully is relatively expensive and needs to be effectively targeted.
Personalisation of service delivery appears to be key, and in particular having adequate time to spend with participants and the opportunity to tailor services.
Effective employer engagement includes both in-work support to employers and employees, alongside wider engagement to source and secure job opportunities – the so-called ‘individual’ and ‘employment agency’ approaches.
There is no clear evidence that financial incentives – to individuals or employers – have had positive impacts in UK programmes, although there is a wide literature on the use of incentives for other groups and they remain a key pillar or support in many countries.
Well-designed ‘intermediate labour market’ models (ILMs) – which create temporary employment with structured support to move into unsubsidised work – can have lasting positive impacts. However these are relatively expensive, and ‘supported business’ models have been criticised for increasing segregation in the labour market. We believe that there are clear opportunities to develop models that build on the strengths of ILMs and supported businesses.
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What works for specific groups?
There is some evidence on models that appear to be particularly effective for those with specific impairments or barriers to work.
There has been extensive work on mental health and employment in recent years. This points to the importance of early engagement, co-operation with health and employment services, integration of psychological therapies and tailored support (including small adviser caseloads). Individual Placement and Support (IPS), a form of Supported Employment, combines these elements and has delivered impressive results. There is also robust evidence that peer-led group work can be effective in improving wellbeing and employment.
Recent work on sensory impairment points to the importance of specialist adviser support; supporting computer skills including use of assistive technology; independent travel; and effective employer engagement.
Musculoskeletal conditions are among the most common reasons for absence from work. There is some evidence that a multidisciplinary approach (involving, for example, workplace-focused interventions, cognitive behavioural therapy and social support) is effective.
Moving from education into work is harder for disabled people. Specialist job coaches and Supported Employment services appear to be successful for young people with learning difficulties and/or disabilities; other key aspects of support include effective working relationships, mentoring and links with employers.
Across all of this, there are common themes that appear key to delivering effective support: the timing of interventions, assessment and segmentation, partnership working, workforce development and quality management.
Commissioning support
The use of ‘Payment By Results’ (PBR) models has delivered real benefits in ensuring that commissioners and providers are focused on outcomes. However, PBR can present particular challenges for supporting those facing the most significant barriers to work – so-called ‘creaming and parking’ – while the interim report of this project demonstrates that very high gearing towards outcome payments has led in the Work Programme to systemic under-funding by Government.
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Individual Budgets have been tested in recent years, although with mixed results. Service users often report difficulties (and stress) in managing them and there have been difficulties around implementation and take-up.
Joining up commissioning is critically important, given the diversity of support across welfare to work, health, education and social care. There is limited evidence of jointly commissioned services, but a growing commitment at strategic levels and good examples of effective provision of employment support within health settings (including co-location and joint working).
Recommendations
The design of future employment support
1. Future employment support for disabled people and those with health conditions should be built around three levels:
‘Into work’ support – for those closest to returning to work, with some specialist support
Health and disability employment support – for those needing more intensive and joined up support to secure employment
Supported Employment and rehabilitation – for those with the most significant support needs
‘Into work’ support would support those who have health- or disability-related needs but are closer to work and could (re)enter employment with the right support. This would include many of those on Employment and Support Allowance (ESA) following Statutory Sick Pay, as well as those found ‘fit for work’. Support would be adviser-led, with small caseloads, and focused on job- placement and condition management – with signposting or referral to more specialist services.
Health and disability employment support would support those whose health conditions and impairments have a more significant impact on their ability to find work, who may have been out of work for some time or never worked, and who would often need additional support in work. This would integrate employment, health, disability and wider support, would be led by specialist advisers, and would be built on Supported Employment principles: small caseloads, a holistic approach, and an emphasis on effective employer engagement and job brokerage.
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Supported Employment and rehabilitation would support those with more significant impairments – including learning disabilities, severe autism and severe mental illness – who are unlikely to have their needs met through the two levels of support described above. We propose additional and separate support for these groups – in particular Supported Employment and residential training.
2. Review the operation of Access to Work to improve utilisation and ensure that it fully integrates into a coherent and simplified system of DWP employment support
This review should aim to ensure Access to Work fully aligns with other aspects of the DWP disability employment support offer – resulting in a more coherent, comprehensive and simplified system of support.
3. Access to, and funding for, employment support for disabled people and those with health conditions should be significantly increased
Recent work by the IPPR sets out that well-designed future disability employment support could reasonably expect to draw on £400-800 million of funding from central government, local government and health services. This could support between 200 and 400 thousand people each year. We support this ambition.
4. Access to each of the three levels of support should be underpinned by a common, robust assessment process – joined up with other assessments, and with decisions reviewed after three months
This process should be based on needs rather than benefit type and should be common across all levels of support. In line with the Government’s proposed Gateway, the process should be applied at the right time and be capable of being applied by local partners and organisations working with disabled people.
5. Individuals should be able to access employment support on a voluntary basis, but the assessment process should include the scope to require individuals to participate where that is appropriate and in line with their conditionality rules
Those that volunteer for employment support should in principle be able to receive it. At the same time, we would expect that many of those referred, particularly for ‘Into work’ support, will be Jobseeker’s Allowance (JSA) claimants or ESA claimants in the Work Related Activity Group. Well designed, specialist
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employment support should take the place of their requirements to look or prepare for work.
6. Participants should normally be able to receive pre-employment support in any one level for up to two years
Individuals should be able to stay in support for up to two years, with in-built reviews so that participation can be ended earlier than this where appropriate.
7. Government and service providers should review their approach to employer engagement, with a focus on: simplifying employer access; co-ordinating work to improve awareness and education; and building sector-led approaches
Employers encounter a fragmented system with often overlapping programmes but also clear gaps in support that meets their needs. There are good examples from Government and the employability sector in developing more co-ordinated approaches. These should be built upon to ensure that employers have a clear and simple route in, that there are co-ordinated efforts to raise awareness, and that sector bodies including trade associations are engaged effectively.
The proposed new framework of support is illustrated below.
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The commissioning and delivery of support
8. Local and national commissioners should work together to ensure that the three levels of support are in place – within a clear national framework but with approaches to devolution, joint commissioning, pooling or alignment that are appropriate to local areas
We propose a clear national framework for employment support, with provision then commissioned in the most appropriate ways within that. This national framework should include:
That support will be available to meet the three levels set out above
That access will be underpinned by the common assessment approach
That there will be national (GB) coverage – perhaps aligning with LEP boundaries or groups of local authorities, but that support may be commissioned within smaller geographies where appropriate
That clear local governance will support service providers to join up – in particular health, skills and other employment support
Within this, we recommend that central and local government, and their partners, work together to agree the most appropriate ways to commission support locally.
9. Jobcentre Plus and local Health and Wellbeing Boards (HWBs) should work together to develop protocols on joint working, including information sharing
Senior level buy-in is critical in driving effective local partnerships. Developing strong links between HWBs and Jobcentre Plus should underpin efforts to improve partnership working more generally, and in particular how information is shared on local priorities, needs, funding and provision.
10. Funding models for all three levels of support should include ‘payment by results’, but with clear safeguards to minimise risks of vicious circles, creaming and parking
Payment By Results should continue to play a role, but future provision should retain ‘service fees’ that ensure that providers can meet the upfront and delivery costs of programme provision – and so that unintended risks around vicious circles, creaming and parking can be reduced.
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11. There should be a common quality framework across all provision, based on self-assessment, external inspection, service user input and continuous improvement
This framework would cover all three levels of support. It need not reintroduce fully independent inspection, but should be based on rigorous self-assessment alongside periodic external inspection and assessment.
12. A ‘What Works Unit’ should be established with a remit to collect, review and disseminate best practices; facilitate knowledge exchange between providers; and encourage innovation in service design and delivery
The unit would support commissioners and delivery organisations to build capacity and capability, measure impact, learn what is working, share practices and drive up performance and quality.
Workforce development
13. Jobcentre Plus and the wider employment services industry (through ERSA and Institute of Employability Professionals) should work together to ensure that all advisers have training in identifying health and disability needs and providing initial support and signposting
This will ensure that advisers have the right training to identify needs, and confidence in how to support and direct those who need more specialist support.
14. The Institute of Employability Professionals (IEP) should work with organisations including the British Association of Supported Employment (BASE) to develop industry-wide, best practice training for specialist disability employment advisers
The IEP exists to professionalise the industry and drive up standards, and would be the obvious organisation to lead on developing or distributing a range of materials to the sector.
15. Jobcentre Plus and employment services providers should commit to ensuring that all advisers leading on employment support for disabled people and those with health conditions will have been trained in line with industry benchmarks, or be on the journey to receiving that training
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Conclusions
This report draws on input from service users, service providers, those that work with disabled people and a range of national and international evidence. They show that there is a long way to go in tackling the entrenched gaps in opportunity for disabled people and those with health conditions – but that there are good practices, here and abroad, that can be built upon. The proposals presented here would have the scope to radically reform support for these groups and to strike a new balance between health and employment services and between national and local government.
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1 Introduction
Context
1.1 Nearly eight million adults of working age are disabled or have a work- limiting health condition.2 Nearly five million people report that this limits their daily activities to some extent, while 1.6 million classify their health as ‘bad’ or ‘very bad’.3
1.2 Those whose activities are affected by a health problem or disability are far more likely to be over 50 than under, to be in lower socio-economic groups, to live in deprived areas, and to be out of work or to have never worked.
1.3 Overall, half of all disabled people are out of work, compared with one quarter of those who are not disabled. This wide difference in the likelihood of being in work narrowed markedly throughout the 2000s, and continued to narrow slowly through the recession. However most recent data suggests that progress may have stalled, as Figure 1.1 shows.
Figure 1.1: Employment rate ‘gap’ between disabled people and the overall employment rate, 1998-2013
Source: Labour Force Survey and Inclusion calculations
2 Source: Labour Force Survey 3 Source: Census 2011
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1.4 Four million people who are out of work are disabled or have a long-term health condition. Disabled people are twice as likely as non-disabled people to be out of work, and the likelihood of being out of work increases with the extent to which disability or ill health limits an individual’s day-to-day activities. This is shown in Figure 1.2 below.
Figure 1.2: Economic status of disabled people and those with long-term health conditions
Source: Census 2011 and Inclusion analysis
1.5 This also illustrates the extent to which those who are out of work are ‘economically inactive’ – meaning they are not looking for work or available for work – rather than unemployed. 44 per cent of disabled people are economically inactive, compared with 17 per cent of those who are not disabled. And of those who are unemployed, disabled people are more likely to have been so for long periods, and in particular much more likely to have been unemployed for five years or more – as Figure 1.3 below shows.
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Figure 1.3: Duration of unemployment for the disabled and non- disabled population (proportion of total unemployed population)
Less than 3 months 3 months but less than 6 months 6 months but less than 12 months 1 year but less than 2 years 2 years but less than 3 years 3 years but less than 4 years 4 years but less than 5 years 5 years or more
DDA and/or work- limited disabled people
Non-disabled people
0% 20% 40% 60% 80% 100%
Source: Labour Force Survey and Inclusion analysis
1.6 Perhaps most concerning of all, recent research by Inclusion for the TUC4 has found that disabled people are far less likely to move into work than the non-disabled, and are even less likely to do so if they are ‘economically inactive’. Figure 1.4 illustrates this, showing the probability of an individual who is unemployed or inactive moving into work from one quarter to the next.
4 Wilson, T. and Bivand, P. (2014) Equitable Full Employment: Delivering a jobs recovery for all, TUC Touchstone Extras
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Figure 1.4: Hiring rates by economic inactivity and disability status of the workless population
Source: Labour Force Survey and Inclusion analysis
1.7 The differences here are stark. The hiring rate for unemployed disabled people is 8 percentage points below that for their non-disabled peers. And while around one in six unemployed disabled people move into work each quarter, just one in fifty disabled people who are ‘economically inactive’ do so. Chances of finding work have fallen since the recession and not regained the ground lost.
The benefits system
1.8 Many disabled people and those with health conditions who are out of work also receive benefits due to their disability or ill-health. In total there are 2.4 million claimants of Employment and Support Allowance (ESA) or incapacity benefits – more than half of all working age claimants. Many of these have been claiming for a very long time – with ESA claimants accounting for only 3 per cent of short-term benefit claims (when you exclude Incapacity Benefit (IB) claimants who have recently been reassessed) and more than half of claimants out of work for five years or more5.
1.9 Numbers claiming ESA and IB grew strongly through the 1980s and 1990s and have remained high ever since – even at a time of falling claimant unemployment and a growing economy, as Figure 1.5 shows.
5 Source: DWP statistics
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Figure 1.5: Claimants of key ‘out-of-work’ benefits
Source: Labour Force Survey and Inclusion analysis
1.10 A growing proportion of JSA claimants are also likely to be disabled or have health conditions, as a result of the tighter Work Capability Assessment (WCA) for claiming ESA. Since ESA was introduced in 2008, 3.2 million claimants have completed the WCA (including those claimants of predecessor benefits reassessed under the new regime), with 1.2 million of these being found ‘fit for work’6. Many of these will instead have gone on to claim JSA.
1.11 Alongside this, there are two million working age claimants of Disability Living Allowance7, which provides financial support to help meet the additional costs of living (mobility and caring) for disabled people. It is estimated that nine out of ten of these claimants are out of work8, while half also claim ESA or incapacity benefits.
1.12 Government research has found that most disabled benefit claimants want to work (56 per cent) and believe that having a job would make them better off financially. However, a far smaller proportion thinks that
6 Source: ‘ESA: outcomes of Work Capability Assessments June 2014’, Department for Work and Pensions 7 Source: DWP statistics 8 Berthoud, R. (2006) The employment rates of disabled people; DWP Research Report No 298
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they are currently able to work (15 per cent), and just one in four believe that having a job would be good for their health.9
Employment support
1.13 Given the position set out above – of wide employment inequality, poorer outcomes for many disabled people, and a growing share of those on benefits claiming due to ill health or disability (and many claiming for long periods), successive governments have prioritised employment support for disabled people. However, this support has often not lived up to expectations and has tended only to support a small fraction of those who are out of work and disadvantaged.
1.14 Just 20,000 disabled people per year access Work Choice – the Government’s specialist disability employment programme – with about ten times as many disabled people or those with health conditions joining the Government’s Work Programme (between 170,000 and 200,000 per year). In total, of the 3.6 million people who are out of work and have a work-limiting disability, we estimate that just one in ten are receiving support through either of these programmes.10 And within the Work Programme, disabled people are far less likely to secure employment, and overall funding per participant has fallen to just £550 for ESA claimants against an original expectation of £1,170.11
1.15 Tackling the gap in employment opportunity, and supporting more households to move off benefits and into work, requires radical action to reform our employment services for these groups.
The ‘Fit for Purpose’ project
1.16 This project has been ‘crowd funded’ by twenty-two organisations that work with and support disabled people and those with health conditions, with a further five organisations providing ‘in kind’ support. The project sets out how employment services can be reformed, based on our assessment of provision in the UK and internationally. It has included:
9 DWP (2013) A survey of disabled working-age benefit claimants, In House Research Report No.16. 10 Source: DWP Work Choice and Work Programme Statistics. 373,000 claimants starting the Work Programme in the two years to March 2014 were either claimants of IB/ ESA or were JSA claimants identified as being disabled. 10,000 claimants started Work Choice in the six months to March 2014. 11 Riley, T., Bivand, P. and Wilson, T. (2014) Making the Work Programme work for ESA claimants; Centre for Economic and Social Inclusion
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An extensive data and literature review, looking at the landscape of support for disabled people and those with health conditions, what has been tried before, and what works for whom;
Interviews with organisations delivering services, to identify examples of current and/ or innovative service delivery – with twenty case studies presented in this report;
Four focus groups with participants in employment support, to discuss their experiences and to review the emerging findings from this project; and
Detailed analysis of Work Programme performance and financial information, which informed our interim report on Work Programme funding models, published in April 2014.12
Report structure
1.17 Chapter 2 describes the current and recent landscape of employment support for disabled people and those with health conditions, exploring both mainstream and specialist support with a primary focus on provision funded by DWP.
1.18 In Chapter 3 we then describe ‘what works’ in supporting disabled people and those with health conditions both to find and maintain employment. We also set out the evidence on what works for particular groups, such as those with mental health conditions, alongside case studies of more recent practices and innovations.
1.19 Chapter 4 reflects on lessons on how support is designed and commissioned – including the use of ‘payment by results’, personal budgets, and how organisations work together in partnership.
1.20 Finally, in Chapter 5 we set out practical recommendations to ensure that the future of employment support for disabled people and those with health conditions is fit for purpose.
12 Riley, T., Bivand, P. and Wilson, T. (2014) Op. cit.
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2 The landscape of support
2.1 Until recently, labour market policy in most countries offered very little support for disabled people and those with health conditions, particularly those on disability benefits. And while this had started to change by the end of the last decade, work by the OECD13 concluded that in the UK and many other developed economies, these shifts had not yet fed through into better outcomes and higher employment for disabled people.
2.2 Here in the UK, the Government has likewise acknowledged14 the need to do more to develop effective employment support for disabled people and those with health conditions. This chapter sets out the current system of support.
The current framework
2.3 As set out in Chapter 1, most disabled people who are not in employment do not receive structured support to prepare for work. Eligibility for employment programmes is generally based on benefit rules and then individual or adviser discretion. Most of those who have a work-limiting disability or health condition, and claim an ‘out of work’ benefit (Employment and Support Allowance (ESA), Jobseeker’s Allowance (JSA) and Income Support (IS)), are eligible to access support. However very few choose to take it up.
2.4 There are three broad strands of support nationally, through the Department for Work and Pensions: Jobcentre Plus support, the Work Programme and Work Choice. These are set out in more detail below.
Jobcentre Plus support
2.5 Jobcentre Plus delivers back-to-work support to benefit claimants across all working-age benefits, which includes three key elements:
A core regime of mandatory interventions which vary depending on benefit and circumstances;
13 OECD (2010) Sickness, disability and work: breaking the barriers. A synthesis of findings across OECD countries, OECD 14 DWP (2013) The disability and health employment strategy: the discussion so far
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Flexible adviser support; and
A flexible menu of support options.
2.6 If an adviser, or other frontline staff member, feels that a claimant needs more specialist support due to a health condition or disability, they can refer them to a specialist Disability Employment Adviser (DEA). However a recent Work and Pensions Select Committee report15 indicates access to this specialist support is limited – with an estimated ratio of one specialist DEA to more than 600 ESA WRAG claimants (compared to Jobseeker’s Allowance caseloads of around 140 claimants per adviser).
2.7 The most recent evaluation of the Jobcentre Plus Offer16 also found that some JSA claimants with health conditions (particularly a mental health condition) and ESA claimants do not always discuss or receive the level of support they require. It recommended strengthening adviser support to help meet the needs of ESA claimants to ensure they are referred to appropriate support to help them into employment.
The Work Programme
2.8 The Work Programme aims to offer tailored support to claimants who are long-term unemployed or have other significant disadvantages in the labour market. Claimants are referred to the Work Programme at different points depending on the benefit they are claiming and their individual circumstances. Once on the programme, participants are required to remain for two years, and providers are paid according to the results that they achieve (with discretion in how they design and deliver support).
2.9 Four-fifths of those who have joined the Work Programme since it began in June 2011 are on Jobseeker’s Allowance (1.26 million claimants in total). These are typically claimants who have been unemployed for more than nine months and are required to participate, but also includes claimants who have volunteered for early support (including due to a health condition or disability). A quarter of JSA claimants who have joined the Work Programme are disabled.
15 Work and Pensions Select Committee (2014) The role of Jobcentre Plus in the reformed welfare system 16 Coulter, A., et al (2013) The Jobcentre Plus Offer: Final evaluation , DWP research report 852
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2.10 One fifth of those who have joined (260,000) are claimants of Employment and Support Allowance or incapacity benefits, who by definition will have work-limiting health condition. Most of these are claimants who are required to attend after their Work Capability Assessment (WCA) as they are assessed as being likely to be capable of returning to work within twelve months. In addition, any ESA or incapacity benefit claimant can volunteer for the Work Programme but just 110,000 claimants have done so – around one in twenty of all of those that are not required to participate.
2.11 Looking across the programme as a whole, then, those who have joined the Work Programme who are disabled or have a work-limiting health condition are more likely to be JSA claimants, and much more likely to be those that have been required to take part in the programme. This is shown in Figure 2.1 below.
Figure 2.1 – Cumulative Work Programme participants who are disabled and/ or claim ESA/ IB by referral type (thousands)
Source: DWP statistics and Inclusion analysis
2.12 The latest analysis of the Work Programme shows that disabled people and those with health conditions are less likely to leave benefits and enter employment than participants without an impairment, and less likely than any other identified disadvantaged group. Figure 2.2 below sets this out. Meanwhile, programme evaluations suggest that these groups may also be less likely to receive appropriate support17 - with more ‘job-ready’
17 Newton, B., et al (2012) Work Programme evaluation: Findings from the first phase of qualitative research on programme delivery, DWP research report 821
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participants being prioritised for support ahead of those with more complex or substantial barriers.
Figure 2.2 Proportion of Work Programme referrals that achieve a job outcome
Source: DWP statistics and Inclusion analysis
2.13 The interim report of this project18 demonstrates that performance against job outcomes for those on ESA is far below the levels expected by the Department when the programme was commissioned. The interim report concludes that a range of factors may explain this – including targets being set too high, a weaker than expected economy, referrals of claimants further from work, and provider performance.
2.14 In some respects, this is nothing new: previous programmes for jobseekers, such as the Flexible New Deal (FND), have also typically delivered lower employment outcomes for disabled than for non-disabled participants19. Similarly the specialist programme for those with health conditions that the Work Programme replaced (Pathways to Work) also under-performed. Its evaluation concluded that it had had no significant employment impact20, with the programme being judged poor value for money by the National Audit Office21. More positive impacts22 were found
18 Riley, T., Bivand, P. and Wilson, T. (2014) Op. cit. 19 Hill, D., et al (2007) What works at work? Review of evidence assessing the effectiveness of workplace interventions to prevent and manage common health problems. HMSO. 20 Bewley H, et al (2009) The impact of Pathways to Work on work, earnings and self- reported health in the April 2006 expansion areas. DWP research report 601 21 National Audit Office (2010) Support to Incapacity Benefit claimants through Pathways to Work.
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in the New Deal for Disabled People (NDDP) although overall the programme was only taken up by a very small number of people.
2.15 In November 2013 DWP announced a series of pilots within the Work Programme aiming to test approaches to developing work with the ESA claimant group23. The pilots will compare three approaches:
Regular appointments with healthcare professionals
Enhanced support from Jobcentre Plus
Enhanced support from Work Programme providers
2.16 Participants will be selected on a random basis and the pilots are due to run until August 2016. An overview of one pilot is set out below.
Case study: Work Programme PG7 pilot, Intraining
Intraining have secured funding to deliver a pilot for Work Programme participants in ‘Payment Group 7’ (ESA volunteers who had previously claimed incapacity benefits).
Advisers use a self-assessment tool that helps participants to address what health issues they have and how they can live with them. It is based around the social model of disability, rather than the medical model. This means that the main emphasis is on what impact their health condition has on their lives and what they can do about this in the long-term, rather than how they can recover from their health condition. It is completed on paper over a period of time and focuses on factors including claimants’ daily activity and their sense of well-being.
It attempts to get participants to stop defining themselves by their disability, which they see as the biggest barrier, and to instead start to think about how their life can be different and what can be changed to successfully deliver this.
Work Choice
2.17 The final strand of support for those out of work is Work Choice – the Government’s specialist disability employment programme. This was
22 Orr, L., et al Long-term impacts of the New Deal for Disabled People DWP Research Report 432 23 https://www.gov.uk/government/news/pilot-schemes-to-help-people-on-sickness- benefits-back-to-work
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introduced in October 2010, replacing two previous specialist programmes (WORKSTEP and Work Preparation). It is aimed at people who:
Have complex work-related support needs that cannot be met by Jobcentre Plus and the Work Programme;
Have requirements in work which cannot be immediately overcome through reasonable adjustments or Access to Work support (see below); and
Can aspire to work for a minimum of 16 hours per week.
2.18 Work Choice is a voluntary programme. It was designed using a ‘modular’ approach to move participants along a clear path from supported to unsupported employment. Specialist advisers work with individuals to assess their needs and to develop an action plan based on a range of support tailored to the needs of the individual. Once participants move into work they are offered short to medium in-work support for up to two years or, for those with more complex needs, longer term in-work support.
2.19 Whilst there were initial concerns related to the performance of the Work Choice programme, there have been recent improvements. Looking at those who joined the programme in the first half of 2013 (9,390 participants), nearly half had obtained a ‘job outcome’ by the end of that year (4,310)24.
2.20 In the DWP Work Choice evaluation25, carried out by Inclusion, participants reported positive impacts of the programme on their ability to gain employment and remain in work. Many elements of delivery that providers identified as contributing to good performance align with the ‘Supported Employment’ model, which is discussed further in Chapter 3.
2.21 Just over one third of those who have participated in Work Choice (32,950 individuals) were claimants of ESA/ incapacity benefits or Disability Living Allowance, or both. However this means that nearly two thirds of those who have taken part were not claiming a benefit due to disability or ill health. Of these, around three quarters were claimants of JSA (26,250) while one quarter was not benefit claimants (9,870). These low numbers of ESA participants are in turn in part due to the fact that
24 Source: DWP Work Choice official statistics, February 2014 25 Purvis, A et al (2013) Evaluation of the Work Choice Specialist Disability Employment Programme, DWP Research Report 846
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many ESA claimants are mandated to the Work Programme – whether it is appropriate for their needs or not.
Access to Work
2.22 In addition to the three broad strands of support set out above, Access to Work provides funding and support to disabled people and their employers on meeting the extra costs that may arise because of an individual’s impairment. This can include the cost of specially adapted equipment, support workers, interpreters and travel to work. Access to Work is administered by advisers and staff based in Jobcentre Plus offices. Since December 2011, Access to Work has also offered a mental health support service, delivered by Remploy Employment Services.
2.23 The 2009 evaluation of Access to Work26 reported that clients and employers were happy with the amount and quality of support overall. They also reported a number of positive impacts including reduced levels of sickness and absenteeism, increased well-being and productivity, and improved staff retention.
2.24 Access to Work supports over 30,000 disabled people and people with health conditions every year27. However the evaluation reported that there was no systematic way of informing clients of its availability, and that there was low awareness amongst employers and Jobcentre Plus staff. The Sayce Review28 described Access to Work as the Government’s ‘best kept secret’ and DWP have acknowledged that many employers are still unaware of the programme, particularly in small and medium enterprises.
2.25 In addition to poor levels of awareness, some agencies have reported a number of concerns following the introduction of the new application process via centralised call centres. Whilst there are currently a number of proposals to improve awareness, accessibility and uptake of the programme currently under consideration by DWP29, the Work and
26 Dewson, S., et al (2009) Evaluation of Access to Work , DWP Research Report 619 27 DWP (2013) Access to Work: Official Statistics. 28 Sayce L. (2011) Getting in, staying in and getting on: disability employment support fit for the future. DWP 29 DWP (2013) The disability and health employment strategy: the discussion so far
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Pensions Committee have also launched an inquiry to consider the effectiveness of the programme.30
Residential Training
2.26 The Department for Work and Pensions also currently offers Residential Training through nine contracted providers who offer specialist disability employment training provision to disabled people and people with health conditions who have the most significant barriers to work. A 2007 DWP evaluation of Residential Training provision31 reported that that quality of training was high, although this did not appear to be geared towards securing employment outcomes. There was also an indication that there was a limited focus on job placements or jobsearch activities.
2.27 In recent years, funding for Residential Training has been around £12-14 million per year. 1,224 people were supported through Residential Training between April 2012 and December 2014, with over one third (464) achieving job outcomes.32 Overall, costs per participant are around £17,000 – driven in part by the requirement to offer full board for up to a year to all participants, and by the intensive nature of the support (31-37 hours per week of structured support, and specialist sensory impairment training where appropriate).
2.28 The 2011 Sayce review33 recommended that DWP should discontinue direct funding for Residential Training, although a subsequent Independent Advisory Panel review reported in 201334 evidence of direct benefits of the holistic and intense nature of this provision. This report strongly suggested that there is a case for Residential Training and made a number of recommendations to DWP including that they work with Residential Training providers to integrate this provision with other specialist disability employment support.
Health and Work
2.29 Although the main focus of this report is support for individuals to prepare for and take up work, it is important to note that around 300,000 people
30 http://www.parliament.uk/business/committees/committees-a-z/commons- select/work-and-pensions-committee/news/access-to-work-launch/ 31 Griffiths, R., et al (2007) Evaluation of Residential Training Provision, DWP research report 448 32 Source: DWP performance management statistics 33 Sayce L. (2011) Op cit 34 Residential Training Provision - Independent Advisory Panel report (2013) DWP
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per year fall out of work and into the welfare system because of health- related issues.35 The 2011 Health at Work review examined the impact of sickness absence and the effectiveness of the current system.36 In January 2013, the Government published its response37, which included plans to establish a health and work assessment and advisory service to help individuals with a health condition to stay in or return to work.
2.30 This Health and Work Service will provide an occupational health assessment and general health and work advice to employees, employers and General Practitioners (GPs). The service, which is due to start in late 2014 has two elements:
Assessment: Once the employee has reached, or is expected to reach, four weeks of sickness absence they will normally be referred by their GP for an assessment by an occupational health professional, who will look at all the issues preventing the employee from returning to work.
Advice: Employers, employees and GPs will be able to access advice via a phone line and website.
2.31 In addition to this, the current Work Choice programme also includes support for individuals in employment who becomes disabled, or whose existing disability worsens, to retain their job.
Local provision
2.32 In addition to central government (DWP) provision, there is a range of support commissioned and delivered locally through health, education and social care. This support is funded by local and central government and the charitable sector. However, the full nature and extent of this support cannot be quantified (despite the efforts of researchers38), so it is far from clear what provision is available in different areas, and for whom.
35 DWP (2013), Fitness for work: the Government response to ‘Health at work – an independent review of sickness absence 36 Black, C. and Frost, D. (2011), Health at Work: An Independent Review of Sickness Absence 37 DWP (2013), Fitness for work: the Government response to ‘Health at work – an independent review of sickness absence 38 Wilkins, A., Love, B., Greig, R. and Bowers, H. (2012) Economic Evidence Around Employment Support, National Development Team for Inclusion / School for Social Care Research, National Institute for Health Research
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2.33 Local Authorities in particular have historically been closely involved in the provision of employment support for disabled people39. There is evidence of a reduction in direct service provision in this area40 with some indications that the overall spend on support has declined41. However the performance frameworks for adult social care and public health include targets aiming to support a reduction in the gap in the employment rate between those with a long-term health conditions, mental health conditions or a Learning Disability and the overall employment rate, so the commissioning of relevant services remains a focus.
2.34 One of the most common areas of NHS commissioned and/ or delivered employment support is for people with mental health conditions. For example the ‘Individual Placement and Support’ approach, which helps people with severe and enduring mental health conditions to move into and maintain employment, is discussed further in Chapter 3.
Conclusion
2.35 There is a complicated landscape of employment support for disabled people and those with health conditions. While there have been extensive efforts to extend coverage and support since the late 2000s, we estimate that just one in ten disabled people who are out of work are in structured support and often have poor outcomes than non-disabled peers. Spending on Access to Work is flat, despite efforts to increase coverage, while funding for more specialist Residential Training is falling. Additional local provision can play a key role, but there is no systematic evidence on what support is available where – with some evidence that the availability of provision may be declining.
2.36 However, the increased focus in public health and social care, and piloting of new support through mainstream programmes, suggests that there may be opportunities to extend access and support.
39 Purvis, A et al (2013) Op cit 40 Purvis, A et al (2013) Op cit 41 Greig, R., and Eley, A., (2012) The Cost Effectiveness of Employment Support for People with Disabilities Early Findings , National Development Team for Inclusion
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3 What works (and for whom)?
Introduction
3.1 This chapter sets out the evidence on ‘what works’ in supporting disabled people and those with health conditions to find and maintain employment. In particular it draws on recent reviews of both UK42 and international43 evidence along with reports produced subsequent to these two key reviews. The evidence is divided into three sections:
Evidence on the effectiveness of different types of support – looking in particular at ‘Supported Employment’ models, personalised services, employer engagement, financial incentives, ‘Intermediate Labour Markets’ and emerging evidence on telephone and online services
What works for whom – focusing on mental health, young people’s transitions to employment, sensory impairment and musculoskeletal conditions
Cross-cutting themes that are important in delivering effective support – covering the timing of interventions, the assessment of support needs, partnership working, workforce development and quality management
3.2 Throughout, we also include case studies of current and/ or innovative service delivery, drawn from interviews with those delivering services and from partners involved in the project.
3.3 As a number of previous reviews44 have noted, there are constraints in terms of clearly identifying what works. These constraints include a lack of consistency in the definitions used to categorise participants, support models or methods of service delivery and programme outcomes45. There is also a lack of robust assessments of the additional impact of
42 Shaw Trust, (2013) Making Work a Real Choice: Where next for specialist disability employment support? 43 Coleman, N. et al (2013) What works for whom in helping disabled people into work? DWP Working Paper 120 44 For example: Shaw Trust (2013) Op. cit.; and Dibden, P et al, (2012) Quantifying effectiveness of interventions for People with common health conditions in enabling them to stay in or return to work: A rapid evidence assessment DWP research report 812 45 Wilkins, A., Love, B., Greig, R. and Bowers, H. (2012) Op. cit.
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programmes, and on the costs and benefits of interventions46. This has, in part, been linked to the fragmentation of support across multiple agencies and programmes and which makes it difficult to plan, design and evaluate interventions47. The most recent (2013) DWP working paper on ‘what works’48 reiterated that ‘good evaluation evidence is scarce’.
The effectiveness of different types of support
Supported employment
3.4 Notwithstanding these overarching limitations to the evidence on effective employment support for disabled people and those with health conditions, there is a strong body of international evidence related to Supported Employment49. In 2010 the OECD50 concluded that the evidence on the effectiveness of this approach was ‘unequivocal’, and a number of subsequent studies have reached similar conclusions51.
3.5 Supported Employment was originally developed with the United States (US) to support people with learning disabilities enter and maintain employment. Within the European context the European Union for Supported Employment (EUSE) has developed a best practice model of Supported Employment which is supported by quality standards and a number of ‘how to’ guides and toolkits52. This model, which is also endorsed by the British Association for Supported Employment (BASE), offers a framework which has previously been used by Government to define and agree standards for Supported Employment in England. The Valuing Employment Now (VEN) policy paper on Supported Employment53 described the key stages of Supported Employment which are outlined below:
Participant engagement - The Supported Employment model recognises the importance of raising the employment related
46 Dibden, P et al, (2012) Op cit 47 Wittenburg, D et al, (2013) The disability system and programs to promote employment for people with disabilities, IZA Journal of Labor Policy 48 Coleman, N et al (2013) Op. cit. 49 Also known as the ‘place, train and maintain’ model or job coaching 50 OECD (2010) Op cit 51 See for example Coleman et al (2013) Op. Cit; and Wittenburg, D et al (2013) Op. cit. 52 EUSE http://www.euse.org/process 53 HM Government (2010) Valuing Employment Now: Job Coaching or Supported Employment- Approach and Progress in Developing Standards. HM Government.
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expectations of disabled people, their families, and relevant education, health and social care professionals.
Vocational profiling - Supported Employment should include a mechanism for the identification of the aspirations, learning needs, skills, and job preferences of the participant. This vocational profile then informs job searching to ensure a high quality job match is obtained.
Job matching - The accuracy of job matching should ensure the long- term suitability of employment. Once an employer’s commitment to offering work is secured, a job analysis is usually undertaken. This may suggest ways of carving together parts of job descriptions that suit a participant’s talents and are cost effective for the employer.
Employer engagement - is seen as a key element, where employers are partners with whom the provider has an ongoing relationship. It can help to overcome traditional recruitment barriers through the use of working interviews and recognises that most people learn skills better in situ adopting a ‘place and train’ approach.
In-work support - vocational profiling and job analysis should ensure that in-work support is individually tailored. Where appropriate this support may include specialist elements such as systematic instruction54, alongside the development of natural supports within the workplace. Providers should also ensure that goals are agreed and progress recorded, that ongoing training takes place and offer out-of- work support if needed.
3.6 The diagram below, produced by BASE55, illustrates how these elements come together to support both employees and employers.
54 Systematic instruction is a particular method of job coaching that supports disabled people in the workplace, and is felt to be a particularly useful approach for those with a learning disability. 55 http://base-uk.org/information-commissioners/what-supported-employment
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Figure 3.1 – the Supported Employment model
Source: BASE
3.7 Core elements of Supported Employment are also found in related models of employment support developed to focus on supporting particular groups of disabled people. For example the Individual Placement and Support (IPS) model, which has been found to be successful for supporting people with mental health conditions into work56 and some
56 Sainsbury Centre for Mental Health (2009) Doing what works, Individual placement and support into employment. Briefing 37.
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supported internships57, which support young people with a learning disability in their transition from education into employment. Further discussion of IPS and supported internships is offered below.
Personalised support
3.8 The DWP review of evidence from the evaluations of their programmes58 noted the heterogeneous nature of disability and the wide range of issues that people face in entering and retaining work. Thus the personalisation of service delivery, so that it meets the specific needs of individuals, is crucial. In particular, ensuring that staff have adequate time to spend with participants and the opportunity to tailor services to meet individual need are seen as key factors in moving disabled people towards work.
3.9 Another DWP review of lessons from the US59 also reported that initiatives that had the largest positive impacts on employment for this group generally offered more intensive and personalised services. More recent evidence on employment focused interventions within the US disability system60 has also noted that interventions with a broad focus do not work as well as those where support is individually customised.
3.10 The importance of personalised support, and of advisers that understand an individuals’ barriers and their needs, also came across strongly in our focus groups with service users. As one participant put it, describing the characteristics of effective support:
“Somebody recognised what the problem was, and how to get you from where you were, with depression, slow steps to get you where you wanted to be, back to work. And it was ok to have that condition, and you could work with it to get where you wanted to go. Most of the places it’s not even recognised. So you weren’t having to pretend... I felt that I had some hope.” (Participant with mental health condition)
3.11 Likewise, the focus groups reinforced the importance of staff having the time and space to listen and get to know each individual. It was felt that, where advisers spent longer time discussing barriers including health
57 Purvis, A., Small, L., Lowrey, J., Whitehurst, D. and Davies, M. (2012) Project SEARCH Evaluation: Final Report. Office for Disability Issues. 58 Hasluck, C. and Green, A. (2007) What works for whom? A review of evidence and meta-analysis for the Department for Work and Pensions. Department for Work and Pensions Research Report No. 407. 59 Rangarajan, A, et al, (2008) Programmes to Promote employment for disabled people: Lessons from the United States, Department for Work and Pensions Research Report 548 60 Wittenburg, D et al (2013) Op. cit.
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conditions, they gained a better understanding of needs and were able to better personalise support.
“They didn’t say a lot, they allowed me to speak and that communicated to them about my situation... I felt that was quite supportive, it wasn’t rushed. They listened.” (Participant recovering from major surgery)
Case study: Want to Work, ESF/ Jobcentre Plus
Want to Work offers employment support to inactive people in Wales. It is a voluntary programme financed by the European Social Fund and run by Jobcentre Plus, and has some overlaps with the ‘voluntary’ access groups in the Work Programme.
Despite the programme being targeted at those with significant challenges in the most disadvantaged wards in Wales, Inclusion’s evaluation found that the programme got 49 per cent of participants into work, with 80 per cent staying in work for more than 10 months.
A central factor in the programme’s success, according to both participants and staff, was the customer-focused advice and guidance that delivered holistic support to tackle all of the barriers that kept participants out of work. Focus was placed on building trust and confidence instead of on the job search.
When possible, it embedded its services within communities and made efforts to link up with health services, to support those that did not normally interact with employment services and who were furthest away from work. This enabled advisers to develop knowledge of, and relationships with, other services on offer so that they could refer individuals accordingly: likewise the other services found this partnership beneficial for their service users.
Employer engagement
3.12 Working with employers should include both ‘in-work’ support to individual employers to build their capacity to support disabled employees, and wider engagement with employers and local labour markets to source and secure job opportunities.
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3.13 The WORKSTEP Evaluation61 described two approaches to employer engagement:
The individual approach, which placed more of a focus on the individual requirements, capabilities and aspirations of the programme participants to ensure a good job match (in line with the Supported Employment model); and
The employment agency approach – with more of a focus on developing relationships with larger employers (in some cases via service level agreements) and adopting an agency approach to filling their employment needs.
3.14 There are benefits and limitations to both of these models. The individual approach is likely to be more resource intensive for the provider, but also more likely to yield sustained outcomes. The agency approach is dependent on the engagement of larger employers and may not deliver as close a job match, but it does increase the number of vacancies that can be offered to participants. The Work Choice evaluation62 therefore recommended that providers should consider the use of both approaches to employer engagement, as appropriate for participant needs and local labour markets.
Case study: Access Ability
Access Ability is a web portal that represents collaboration between the leading providers of Work Choice and Access to Work. The initiative is concerned with reaching the maximum number of employer organisations – the majority of whom have not yet considered employing disabled people – with a ‘Responsible Employment’ message.
It was developed in response to consistent complaints from UK employers about the complexity faced when hiring those with a disability. It is designed to provide a practical and accessible ‘single point of contact’ – allowing any employer organisation anywhere in Britain to find expert, local assistance to recruit a disabled person with one click: “the right support, from the right people, right on your doorstep”.
61 Purvis A, Lowrey J and Dobbs L. (2006) WORKSTEP evaluation case studies: Exploring the design, delivery and performance of the WORKSTEP Programme, Department for Work and Pensions Research Report No 348. 62 Purvis A., et al (2013) Op. cit.
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The primary site functionality – its address/ postcode search and mapping of local Work Choice and Access to Work providers – is complemented by an extensive information repository. The site has therefore been able to play an important role in the delivery of the Government’s ‘Disability Confident’ employer campaign as well as in other areas of Government employment service delivery.
It also manages much of its communications output in line with sector ‘verticals’, and specifically through employer organisations and associations within these sectors (which already have communications channels in place and have the authority to command attention). This makes for an innovative, low-cost, high impact communications model that is scalable across all sectors of industry.
This web portal can be found at http://accessability.info/
3.15 The role of employers is a key theme in the DWP development of a new disability and health employment strategy63. This paper identifies employers as key partners in terms of the improving the recruitment, retention and progression of disabled people and those with health conditions. Whilst it reports some examples of good practice in these areas it acknowledges that there is more that Government can do to help employers build their knowledge and confidence recruit, retain and support this group. The Government’s ‘Disability Confident’ campaign aims to achieve this, by increasing understanding among employers and widening opportunities for disabled people.
Financial incentives
3.16 Many countries, including Britain, have a history of giving financial support to employers to encourage the employment of disabled people. The terms ‘incentive’ or ‘subsidy’ have been used interchangeably, although here incentive is used to describe a short-term encouragement to employ someone and address any initial needs. Subsidy here describes the (older) model of compensating an employer on an ongoing basis for employing a disabled person who is potentially regarded as less productive than other employees. In Britain there has been a move away from the use of long-term financial subsidies, as they can become a barrier to progression to open employment64. In many European
63 DWP (2013) The disability and health employment strategy: the discussion so far 64 Purvis A., et al (2006) Op. cit.
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countries, however, these still form a proportion of spending on active labour market programmes for disabled people65. For example Poland and Denmark have both provided permanent subsidies, although progression to unsubsidised employment is low.
3.17 An exploration of financial support to employers within Work Choice did not appear to offer any clear evidence on the effectiveness of this approach. Many providers reported a move away from their use, in particular the longer-term subsidies. Some providers did report some benefit from using short-term incentives, although this was not universal. Findings from the related review of the Work Choice wage incentive for young people were also mixed.
3.18 More generally, there is extensive evidence66 that financial support to employers can enhance employment prospects, but tends to have relatively high deadweight costs (paying for employment that would have happened anyway) and substitution and displacement effects (improving prospects for some workers at the expense of others).
3.19 There are a number of examples of financial incentives being used to support individuals, to support the transition to work and to create a stronger incentive to seek or prepare for work. The recent DWP review of evidence67 examined in particular Tax Credits in the UK; In Work Payments in Denmark and the Netherlands (which top up wages to the level they would be without reduced earnings capacity); and the Resting Disability Pension (RDP) in Sweden. However, the available evidence was considered ‘patchy’, making it difficult to establish a clear view on the impact of financial incentives to individuals and what works best.
Intermediate Labour Market models
3.20 In an independent report for DWP68 Professor Paul Gregg noted that the Intermediate Labour Market (ILM) model can be particularly useful as a means of tackling barriers to employment faced by those furthest from the labour market. His report went on to recommend that providers
65 European Commission (2011) Supported Employment for people with disabilities in the EU and EFTA-EEA: good practices and recommendations in support of a flexicurity approach. European Commission Study Report 66 See for example Martin J and Grubb D. (2001) What works for whom: a review of OECD countries’ experiences with active labour market policies. Institute for Evaluation of Labour Market and Education Policy Working Paper 2001:14 67 Coleman, N. et al (2013) Op. cit. 68 Gregg P. (2008) Realising Potential: A Vision for Personalised Conditionality and Support. Department for Work and Pensions.
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should be encouraged to provide this model as an option for support. A subsequent impact assessment of the Future Jobs Fund69 demonstrated that a carefully-designed ILM programme can have significant and lasting impacts on the employment prospects of young people. This found that the FJF had a significant and long-lasting positive impact on participants’ chances of being both off benefits and in unsubsidised employment.
3.21 The development of ILM models has also been noted within some workplaces that have been set up specifically to offer employment to disabled people (known as supported businesses). Whilst in some EU and OECD countries there have been moves away from supported business provision towards jobs in the open labour market70, some European countries, such as Germany, Finland and Italy, there have been moves to expand this approach71, suggesting that some support for this approach remains at an international level.
3.22 In Britain the supported business model has been criticised on the grounds of creating a segregated environment for the employment of disabled people and low levels of progression to open employment72. Research on the WORKSTEP programme73, however, noted a number of positive attributes related to the supported business model, such as high levels of satisfaction reported by their supported employees. This research, along with evidence from the Work Choice Evaluation74 also reported an increasing use of short-term contracts within supported businesses as part of developing an ILM model. This model offered the experience of real work coupled with additional support to help participants move into external employment (usually a supported job with the longer-term goal of open employment).
3.23 The Work Choice Evaluation also found positive evidence of the benefits of integrating existing supported businesses with wider programme delivery via an ILM approach. This included developments of ILMs with host employers.
69DWP (2012) Impacts and Costs and Benefits of the Future Jobs Fund 70 OECD (2010) Op cit 71 Greve B. (2009) The Labour Market Situation of Disabled People in European Countries and Implementation of Employment Policies: A summary of evidence from country reports and research studies. Report prepared for the Academic Network of European Disability experts (ANED) Report 72 Sayce (2011) Op. cit. 73 Purvis et al (2006) Op. cit. 74 Purvis et al (2013) Op. cit.
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Case study: Work Programme PG7 Pilot ILM model, Work Solutions Work Solutions are a Work Programme sub-contractor in the North West. They are piloting a Payment Group 7 (PG7) ILM Model, in which employer engagement officers work with claimants to find them 16 hours of work per week for 13 weeks. In agreement with the employer, they pay the participant’s wages in this period, and once the ILM funding has finished they work with the employer and participant to try and get the contract extended. The success of the ILM model with other groups prior to the Work Programme led to it being established as a pilot for Work Programme participants (with 65 to 70 per cent of lone parents and disabled people maintaining work once funding ended). Thus it was decided that the large up-front costs were justified, as there was evidence that it was likely to be profitable and lead to successful outcomes in the long-term. Telephone and online services
3.24 Recent DWP research75 found robust evidence that assessment of needs by telephone can compare favourably to face-to-face methods, and that even case management by telephone can be an effective way to support people with common health problems through care pathways, monitor progress and facilitate return to work.
3.25 Effective approaches to the provision of telephonic support were found to include the identification of obstacles to work participation, the development of return-to-work plans, the provision of work-focused information and the coordination of ‘key players’. An important caveat to these findings was the need for services to be well designed and implemented, and staffed by professionals who have appropriate training and support.
3.26 Following this, a recent study on Psychological Wellbeing and Work76 commissioned by the Department of Health and DWP has proposed piloting four potentially complementary employment support options including telephonic and on line support. It recommends that Jobcentre Plus Districts procure third party telephone-based psychological and
75 Burton et al (2013) Telephonic support to facilitate return to work: what works, how, and when? DWP Research Report 853 76 van Stolk et al (2014) Psychological Wellbeing and Work Improving Service Provision and Outcomes, Department for Work and Pensions/ Department of Health
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employment-related support, to be offered to JSA or ESA claimants before they enter the Work Programme. For online support, the report proposes building on tested eHealth models of online mental health assessment and Cognitive Behavioural Therapy (CBT), with an additional vocational element.
Case Study: SHINE, Greater Manchester Public Health Network
SHINE is an intervention that ran in Bolton in 2011 and demonstrated an innovative use of technology to engage with a client group with alcohol dependency.
It involved using an everyday text messaging service to monitor client’s progress. Each individual who had opted in to the service would get a message at a time that suited them asking how they were. Their replies were then tracked by software, and they would get another message based on their response. If it was extremely negative, their key worker would be notified and could then call them to intervene at a critical point. If not they would be congratulated or encouraged to keep going with a personalised message.
This easy and not intimidating contact worked well, especially as clients were nervous about speaking on the phone and reluctant about engaging with health services. It was also found to be cost-effective as it freed up key workers time and allowed performance managers to better balance caseloads.
It has since been adopted for people on Working Well in Greater Manchester and has been piloted with primary drug using clients in Darlington and Bradford.
Use of behavioural insights and techniques
3.27 Finally, there is evidence of growing use of ‘motivational interviewing’ and other techniques that draw on behavioural economics, including the ‘Stages of Change’ model. All of these approaches have been applied in a wide range of settings, not just in relation to welfare to work. As they are fairly new there is limited evidence on their effectiveness in supporting disabled people and those with health conditions.
Case study: Motivational workshops, Randstad
Randstad provide pre-employment motivational workshops for disabled people and those with a health conditions on the Work Programme.
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Participants are ESA claimants, many of whom also suffer from depression or anxiety, who have been moved onto JSA and are now having to look for work. Providing this specific support, alongside the work of the Work Programme adviser, they are able to achieve a higher than average success rate for these people.
The workshops are two hour sessions, with three follow-up telephone calls. Workshops may have up to 15 participants. The purpose of the workshop is to engage with people and help them set realistic goals to get closer to, and into, work. The workshops provide helpful ideas and tips on how they can look for work. The follow-up coaching calls are to see how they are doing, assess if they have reached the three goals they set during the workshop and to offer support and sign posting.
Randstad believe a key factor in the success of the workshops is the specialist trainers. The trainers have had personal experience of disability which resulted in them being out of work for a period of time and this has a very positive impact on participants too. Furthermore it means the trainers are empathetic to the course participants. They understand that just attending the course can be a huge step for people who feel that their barriers are preventing them from a successful return to work.
What works for specific groups?
3.28 There is some evidence that different forms of interventions can be particularly effective for some groups, or more effective for these than for others. These differences illustrate the fact that disabled people are a diverse group with diverse needs. We have presented below the evidence on what works across four key groups: those with mental health conditions; sensory impairment; musculoskeletal conditions; and finally for young people making the transition into employment. In all cases, this evidence reinforces many of the key points on what works more generally – and in particular the need for personalised and tailored services, effective employer engagement, and a holistic approach.
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Mental health
3.29 Recent research by the OECD, on mental health and work in the UK77, identifies a number of key ingredients in supporting people with mental health conditions who are out of work:
Addressing issues in the early stages of unemployment
Systematic, timely and accurate identification of mental health problems for jobseekers on all benefits – through robust profiling tools and ensuring that advisers have the right skills
Strong co-operation between employment and health services, either through referrals or service integration
Reduced caseloads for staff doing targeted work with those with mental health conditions.
Tailored services for clients with mild and moderate mental health problems including more use of specialist mental health subcontractors
Case study: Psychologically trained caseworkers
In Denmark, the use of psychologically trained caseworkers has resulted in improvements in job placement outcomes for people with common mental health conditions. Jobseekers have weekly 1:1 meetings with the specialist caseworkers focused on training and employment. These meetings involve discussion about returning to work, psychological counselling and the provision of help to access mental health treatment.78
Psychological therapies such as cognitive behavioural therapy (CBT)
Greater in-work follow up and support, including greater use of Access to Work
A strong relationship with employers to address the stigma related to mental health problems
Following the principles of Individual Placement and Support (IPS).
77 OECD (2014) Mental Health and Work: United Kingdom 78 OECD (2013) Mental Health and Work: Denmark
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Case study: Individual Placement and Support (IPS)
The IPS model is an approach which helps people with severe and enduring mental health conditions to move into and maintain employment. The IPS model was developed in the US in the 1990s, and, in the UK, IPS is primarily offered via mental health rather than employment, provision. IPS is a variant of the Supported Employment model and the key principles of IPS are:
A goal of competitive employment
Everyone with severe mental health problems is eligible
Individualised and rapid job search
Co-location and joint working between employment and clinical specialists
Support is time unlimited
Employers are approached based on the client’s preferences
3.30 There is a substantial evidence base supporting the efficacy of the IPS model79. However, the model needs to be implemented well in order to be effective. A randomised controlled trial of IPS in the UK80 found no evidence at a one-year follow up that IPS was of significant benefit for achieving competitive employment as compared to standard vocational services. A possible explanation was that the IPS programme in this trial was not integrated with community mental health services.
3.31 There is also robust evidence that well designed, peer led group work can be effective both in improving wellbeing and employment prospects – from the ‘JOBSII’ model in the US.
Case study: JOBSII
JOBSII is a peer-led group intervention programme with the dual goals of facilitating jobseekers to return to work and preventing negative mental health consequences of unemployment. JOBSII is based on theories of active learning process, social modelling, gradual exposure to acquiring
79 Bond GR, Drake RE, Becker DR, et al. (2008) ‘An update on randomised controlled trails of evidence-based supported employment.’ Psychiatric Rehabilitation Journal, 31 80 Howard et al. (2010) ‘Supported Employment: Randomised Controlled Trial.’ The British Journal of Psychiatry, Vol. 196, 404–411.
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skills and practice through role playing. It aims to increase jobseekers’ sense of job search self-efficacy and improve their ability to deal with setbacks during the job search process. The group sessions are intensive: lasting around four hours a day, four days a week, over six weeks. There is evidence to suggest that JOBSII has a significant effect on re-employment and decreasing psychological distress81.
3.32 Both JOBSII and IPS were recommended in the recent study on mental health and employment commissioned jointly by the Department for Work and Pensions and the Department of Health82 (alongside the online and telephonic support services described in paragraphs 3.24 to 3.26).
Case study: Workwell – Business in the Community Business in the Community (BITC) is a business led organisation. One of their programmes is Workwell, a coalition of businesses committed to improving levels of understanding of the role of workplace wellness. Recently, Workwell has focused on mental health in the workplace and has released a paper, Mental Health - we're ready to talk.83 This is an employer-led initiative that aims to break taboos about discussing mental health in the workplace, based on the idea that there is a clear business case for employers to help maintain the mental health of their workforce. The BITC approach aims to encourage employers to discuss this issue and to put in place processes to support staff. The campaign is led by the BITC Workwell Mental Health Champions group, a group of large employers such as BT and Santander. Employers are encouraged through the campaign to make the Time for Change Pledge: a public statement that their organisation wants to tackle mental health stigma and discrimination. Sensory impairment
3.33 As part of a recent three year action-based research project, RNIB and the University of Birmingham looked at what works for blind and partially
81 Audhoe, S. S., Hoving, J. L., Sluiter, J. K. and Frings-Dresen, M. H. (2009) ‘Vocational interventions for unemployed: Effects on work participation and mental distress. A systematic review.’ Journal of Occupational Rehabilitation, 20(1), 1–13; Vinokur, A. D., Price, R. H. and Schul, Y. (1995) ‘Impact of the JOBS intervention on unemployed workers varying in risk for depression.’ American Journal of Community Psychology, Vol. 23 No. 1, 39–74. 82 van Stolk C, Hofman J, Hafner M and Janta B (2014) Psychological Wellbeing and Work: Improving Service Provision and Outcomes. Department for Work & Pensions and Department of Health Policy Paper 83 http://www.bitc.org.uk/programmes/workwell/mental-health-were-ready-talk
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sighted jobseekers in terms of assessment and employment support interventions84.
Case study: A specialist assessment toolkit, RNIB
Most employment services for blind and partially sighted people are delivered by non-specialist organisations. These organisations often lack sufficient knowledge about the particular needs of blind and partially sighted jobseekers, and are therefore unable to deliver the specialist support required.
RNIB group of charities worked closely with blind and partially sighted people, the University of Birmingham and employment professionals to develop a comprehensive employment assessment toolkit, which takes account of the specific needs of blind and partially sighted job seekers.
The toolkit was developed because there was nothing in place to assess distance from the labour market and to segment blind and partially sighted people into groups and level of support needs. While it includes the assessment of proximity to the labour market and job aspirations, it places sight loss at the heart of this tool.
Over 100 people were consulted over three years of development including service users and delivery staff making this a robust toolkit. The tool was developed through a mix of practical knowledge and gap in the market alongside academic research which validated the model.
The toolkit enables employment advisers who work with blind and partially sighted people to gain a clear understanding of their clients’ employment aspirations and to design appropriate interventions to help them on their path to employment.
The toolkit can be found here www.rnib.org.uk/assessmenttoolkit and can be used by any employment provider working in the welfare to work industry that supports blind and partially sighted people.
3.34 The research85 found that blind and partially sighted people who are furthest from the labour market benefit from intensive support and specialist interventions in relation to:
84 Saunders A, Douglas G and Lynch P. (2013) Tackling unemployment for blind and partially sighted people. RNIB Research report 85 Saunders A, Douglas G and Lynch P. (2013) Op. cit.
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Developing computer skills, including use of assistive technology
Developing the confidence and ability to travel independently on public transport
Disability disclosure and communicating their needs and workplace adjustment requirements
Making the most of any residual vision
3.35 These specialist interventions can be delivered either as targeted interventions or as part of a standard pre-employment programme specially designed for blind and partially sighted people.
Case study: Specialist pre-employment programme
One of the innovative support strategies RNIB have been trialling is a pre- employment programme designed for small groups of blind or partially sighted jobseekers. RNIB has just completed a major revision to the pre- employment programme trainer’s toolkit, which can be found here: www.rnib.org.uk/preemployment
3.36 In addition to the specialist interventions highlighted above, the research found that blind and partially sighted people also benefit from interventions which are not disability specific such as:
Developing job search skills
Attending training/college programmes
Gaining work experience, especially where this is linked to meaningful practice and the development of other skills such as mobility, IT and confidently discussing their sight loss with work colleagues
Access to wider support services such as independent living training, self-care support and benefit advice
3.37 Finally, evidence suggests that the majority of employers have a negative attitude to employing a blind or partially sighted person. Therefore it is also critical to develop links with employers to generate opportunities and appropriate support; and to increase awareness amongst employers and
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jobseekers of positive role models (i.e. blind and partially sighted workers achieving successful outcomes)86.
3.38 In relation to hearing loss, some specific recommendations for improving the effectiveness of employment services for this group from the RNID87 include:
Specialist deaf awareness training for all employment advisers
Providing the opportunity for every deaf client to see an employment adviser with appropriate communication skills/support
Ensuring appropriate alternatives to telephone contact are readily available
More awareness and promotion of the Access to Work scheme to both employers and potential employees
3.39 Research also suggests that there are specific lessons on supporting those with hearing or sight loss to stay in work88, specifically by:
Providing people with sensory impairment with appropriate vocational rehabilitation support
Increasing awareness within occupational health and human resource teams of possible adjustments that can be made and specialist retention services, including Access to Work
Encouraging employers to provide training to staff on disability awareness, including understanding the impact of sight and hearing loss on an individual, the importance of adjustments, and the legal rights of disabled people
Helping employers to understand the business case for job retention
Musculoskeletal conditions
3.40 A 2012 rapid evidence assessment conducted for DWP89 examined evidence on the effectiveness of interventions for people with common
86 Saunders A, Douglas G and Lynch P. (2013) Op. cit. 87 RNID (2007) Opportunity Blocked. RNID Research Report 88 RNIB (2013) Evidence-based review: People of Working Age. RNIB Evidence Review; and Matthews, L. (2011) Unlimited Potential? A research report into hearing loss in the workplace. Action on Hearing Loss Research Report
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health conditions, including musculoskeletal conditions, in enabling them to stay in or return to work.
3.41 Non-specific low back pain is one of the most common, and most costly, causes of absence from work. The evidence review found that the majority of studies conducted in the area of musculoskeletal conditions that included measurement of employment outcomes were focused on low back pain. There is some evidence that a multidisciplinary approach (involving, for example, workplace-focused interventions, cognitive behavioural therapy and social support) is effective.
3.42 Coordination also appears to be important, with studies finding that interventions that involve employees, health practitioners and employers working together to implement work modifications were more consistently effective than other interventions. Lessons on joining up commissioning are set out in Chapter 4.
Young people’s transitions to employment
3.43 Finally, there is clear evidence that young disabled people are particularly disadvantaged and suffer from poorer transitions from education to work90. In our view it is therefore a priority to support young disabled people to find and keep work. We set out below the evidence on what works.
3.44 A 2010 Ofsted91 review identified that initiatives involving job coaches and Supported Employment services were successful in helping young people with learning difficulties and/or disabilities to access work, and also had a significant positive impact on their aspirations.
3.45 A 2012 research study which analysed 44 case studies of good practice across 11 EU countries92 identified a number of further elements of good practice, which included:
89 Dibben P, Wood G, Nicolson R and O’Hara R. (2012) Quantifying effectiveness of interventions for People with common health conditions in enabling them to stay in or return to work: A rapid evidence assessment. Department for Work and Pensions Research Report 812 90 DWP (2013), Fulfilling Potential: Building a deeper understanding of disability in the UK today 91 Ofsted (2010) The special educational needs and disability review: A statement is not enough. 92 McAnaney D, Wynne R, DeVos E, Reijenga F, Delfosse C and Spooren J. (2012) Active inclusion of young people with disabilities or health problems. Eurofound Report
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Good working relationships between all those involved in supporting young people into work
The use of mentoring
Close links with employers, including to identify local labour demand and then providing targeted training and support
Case Study: Supported internships
Supported internships were one of a number of initiatives proposed in the 2011 Special Educational Needs Green Paper93.
Following the Project SEARCH supported internship demonstration projects94, in autumn 2012 a supported internship trial began at fifteen Further Education (FE) colleges in England. These supported internships provided a structured study programme for 16 to 24 year olds with a learning difficulty assessment.
The evaluation of the trial95 identified a number of key success factors for supported internships:
The need to be distinctive from other forms of college provision, with a clear focus on achieving sustainable employment
Job coaches with broad skill sets
Interns that want to work and that have families supportive of this
Personalised, tapered support, with further support available post- programme as needed
On-going partnerships between employers, interns, college staff, and where appropriate, parents and carers
Achieving an appropriate realistic job match for an intern
College-based learning that is personalised, clearly linked to the workplace and a source of peer group support
93 DWP (2011) Support and Aspiration: a new approach to special educational needs and disability. Green Paper 94 Purvis, A., et al (2012) Op. cit. 95 CooperGibson Research and Disability Rights UK (2013) Supported internship trial for 16 to 24 year old learners with learning difficulties and/or disabilities: An evaluation. Department for Education Research Report
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A focus from the outset on how to secure employment by the end of the internship, especially for those who are not offered paid work by their internship employer
Case study: Group Supported Internships, Remploy
Remploy have developed a supported internship approach for individuals with severe disabilities, which aims to pool funding from a range of sources and reduce unit costs by providing group internships with large employers.
These internships are targeted at young people under 24 who typically have a learning disability, autism or behavioural problems. They are usually at FE colleges, and the supported internship forms their final year.
Remploy have targeted large employers and placed 10 to 12 young people with them, staggering starting dates. This drives down costs and means that one support worker can be available to support more participants and is present if there is an urgent need.
There is an estimated unit cost of £6,500 per participant (met by the SFA, the participant’s FE college and LEA’s), and around 60 to 70 per cent of participants get into work at the end of the programme; a considerable success considering that the employment rate for this group is around 10 per cent.
Cross-cutting themes
3.46 We have also identified five cross-cutting themes that are key to the successful delivery of employment support for disabled people and those with health conditions: the timing of interventions; assessment and segmentation; partnership working; workforce development and quality management. These are explored below.
The timing of interventions
3.47 The Government identifies96 that getting the right support at the right time is particularly important for disabled people and those with health conditions. It reiterates that the longer an individual is out of work, the
96 DWP (2013) The disability and health employment strategy: the discussion so far
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more likely they are to remain out of work for long or even indefinite periods. Early or timely intervention is also important where individuals develop an impairment in work, to prevent loss of employment97.
3.48 Timely intervention can also mean providing employment support at the point where any health condition has been stabilised. For example for those with fluctuating mental health problems, delivering employment support at the point where the condition is being effectively managed is likely to have more impact than delivering the same support alongside condition management.
Assessment and segmentation
3.49 Delivering early intervention also critically depends on effective assessment of need and then referral to support. As the Government acknowledges98, assessment based on benefit or health condition alone does not give an adequate indication of support needs.
3.50 The Work Choice Evaluation99 and evaluation of the ‘Jobcentre Plus offer’100 noted difficulties with the identification of claimant support needs within Jobcentre Plus. This can result in support not being appropriate, and effectively block access to specialist support – for example for some claimants referred directly to the Work Programme following the outcome of a Work Capability Assessment (WCA).
3.51 The DWP strategy paper acknowledges that, as reported within the Work Choice Evaluation, the Statutory Referral Organisation (SRO) referral route onto the Work Choice programme is also not working well. It therefore goes on to outline proposals for a new ‘Gateway’ to employment services for disabled people and people with health conditions.
3.52 The approach for this new Gateway is described as ‘a timely and light touch way of identifying the right type of support for each individual, focusing on each person’s strengths and employment support needs, rather than their health condition, impairment or the type of benefit they receive.’ The assessment process is described as potentially involving two stages, based on a first step filtering, followed by a more in-depth engagement with an adviser where appropriate.
97 Coleman, N et al (2013) Op. cit. 98 DWP (2013) The disability and health employment strategy: the discussion so far 99 Purvis, A., et al (2013) Op. cit. 100 Coulter, A., et al (2013) Op. cit.
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3.53 The Work and Pensions Select Committee has recommended101 a more thorough and systematic assessment of claimants' needs, similar to the Jobseeker Classification Instrument (JSCI) used in the Australian welfare system. DWP have already carried out some research exploring the development of such a ‘segmentation’ tool102, although even the best- performing model could only predict 59 per cent of data variation.
3.54 In our view, there are two key issues in the development and implementation of any new assessment processes:
First, to ensure that they are appropriately aligned with each other and the WCA, to ensure consistency of outcome; and
Secondly, that relevant information is shared between the assessor and the service provider that an individual is then referred on to. A number of programme evaluations have reported difficulties related to the inadequacies of referral information103.
Case study: Systematic assessment
In Belgium, the public employment service addresses health problems routinely and jobseekers are systematically assessed for mental health problems. Those found to have more severe barriers are sent for a diagnosis to an in-house psychologist or to an external specialist in in- depth multidisciplinary screening.104
Partnership working
3.55 Partnership working, and joining up services between employment, health, social care and other services, underpins many of the examples of ‘what works’ set out in this chapter. The importance of joining up services came across particularly strongly in focus groups conducted with service users. In general, the more linked up different forms of support could be, the better.
“I think it’d give both sides a better understanding of our needs, and might help these people at [the employment provider] get a better handle
101 Work and Pensions Select Committee (2014) The role of Jobcentre Plus in the reformed welfare system 102 DWP (2013) Predicting likelihood of long-term unemployment: the development of a UK jobseekers' classification instrument, Working Paper No. 116 103 For example Newton, B., et al (2012) Op. cit. 104 OECD (2013) Mental Health and Work: Belgium
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of what my mental health conditions are.” (Participant with a mental health condition)
“I think the more they co-operate the better – I can’t see a downside to it to be honest.” (Participant with a mental health condition)
3.56 One focus group was conducted with users of NHS services, whose experiences demonstrated that linked working was already being delivered to some extent – with employment-related support delivered within mental health services. There was general support for this way of working services, with the service user at the centre of all of the support being delivered.
“I like the way that the employment specialists are included in the medical team, the care co-ordinators, the psychiatrists, so no matter what information you give it all gets fed back and then there’s a plan made. I know for a fact that if I don’t feel very well, if I mention it to my employment specialist, I know for a fact that I’m going to get a phone call from my care co-ordinator to ask I need to go and see them.” (Participant with a mental health condition)
Workforce development
3.57 The importance of adviser attributes, in terms of their skills, commitment and enthusiasm, has been identified in a range of studies105. A 2010 report by Inclusion106 highlighted that, even though high levels of satisfaction were associated with job roles, there was evidence of churn within the workforce, with salary and progression outlined as areas of weakness but with staff showing a strong interest in training and professional development. The report recommended clear development pathways, transferable skills and an overarching professional membership body for the sector.
Case study: The Institute of Employability Professionals (IEP)
The Institute of Employability Professionals (IEP) was launched in 2012. It is a membership body for those working across the employment related services (ERS) sector. The IEP is setting professional standards for the employability sector and overseeing the implementation and adaptation of
105 See for example Hasluck C and Green A. (2007) Op. cit. 106 Crawford, E. and Parry, F. (2010) Professionalising the welfare to work industry: developing a framework for action. Centre for Economic and Social Inclusion
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the ERS framework of qualifications. This is expected to lead to the creation of National Occupational Standards and possibly practitioner licensing and a National Skills Academy. By September 2013, the IEP had nearly 4,000 members, engaged 18 prime contractors and approved 60 new qualification units.
3.58 In their submission to the Government Review of Disability Employment Strategy, BASE advocate107 more support for provider development, including the need for ongoing workforce development. The BASE submission notes the highly skilled nature of the adviser role within this area of service provision and the evidence on what works highlights the key role adviser staff play in successful service delivery. The BASE paper reports on current developments such as National Occupational Standards for Supported Employment and the Level 3 certificate in Supported Employment. It recommends that all providers (including Jobcentre Plus) must ensure their staff are appropriately trained to support those with complex needs.
3.59 The importance of skilled advisers was also emphasised by participants in our focus groups. They did not expect advisers to be medically trained, but emphasised the need for a good understanding and appreciation of health conditions. Mental health conditions in particular were singled out. Many described the importance of advisers with experience in working with a range of health conditions, and perhaps who had themselves experienced mental health issues. As one participant put it:
“She’s got a lot of experience and training, she’s got a lot of understanding, she’s got a lot of contacts and numbers, and she has that professionalism. That was very helpful, because you could talk about mental health conditions and physical health and she’s got experience of it and she understands it.” (Participant with mental health condition)
3.60 Hasluck and Green108 also cited the importance of continuity in adviser relationships with participants, particularly at times of transition. This was also emphasised in the Work Choice Evaluation109 and the evaluation of
107 BASE (2013) Submission to the Government Review of Disability Employment. British Association for Supported Employment Response Paper 108 Hasluck, C. and Green, A. (2007) Op. cit. 109 Purvis et al (2013) Op. cit.
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WORKSTEP110, which also attributed the positive outcomes for many participants to the commitment of advisers.
Case study: Training of advisers, Remploy
Over the last 18 months, Remploy has overhauled staff training in order to improve the service it offers those with health conditions and disabilities, and to help more into work.
They have invested in specialist disability training to improve performance by: changing the beliefs and attitudes of advisers; persuading them that they can support those with disabilities into work; providing advisers with the specialist knowledge and ensuring that they have access to tools to help them deal with different situations.
All staff receives basic level training to get a baseline knowledge about disabilities. All staff that work with disabled people receive intermediate training, to get more detailed knowledge so they can support them back into work. The IEP Level 3 ERS qualifications will be provided over the next few years, and Remploy have worked with EDI to refine each unit with additional criteria about disabilities. Furthermore, a small number within the organisation receive specialist training, such as how to support those with dyslexia, while 29 ‘how-to’ guides have been developed with practical advice for employers and staff.
Quality management
3.61 The DWP evaluation of Work Choice found that, in general, the mechanisms used to manage performance appeared to focus primarily on monitoring and managing outcomes rather than developing service quality. A lack of external quality inspection was felt to have compounded this issue.
3.62 Evidence from the evaluation of the predecessor to Work Choice, WORKSTEP111, noted the positive influence that an external inspection process had in developing the quality of provision. Such inspection processes linked to a quality framework also forms a core element of contracted employment services in some other countries such as
110 Purvis et al (2006) Op. cit. 111 Purvis et al (2006) Op. cit.
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Australia112 and in Northern Ireland113. The Work Choice Evaluation therefore recommended development of a quality framework for specialist disability employment services, along with the reintroduction of external inspection. This was supported by BASE in their submission to the Government Review of Disability Employment Strategy114.
3.63 The importance of developing service quality was also acknowledged by Shaw Trust, in their report on the development of a future disability employment programme115. They note that in order to ensure support delivered is consistently of the highest standard, an independent quality evaluation, using feedback from participants and employers should be undertaken at regular intervals.
Conclusion
3.64 While there are limitations in the evidence around what works, this chapter sets out that there is nonetheless extensive research – and numerous case studies – that can point us in the right direction. There are a relatively small number of well-evidenced models, but a broad range of evidence that emphasises the importance of personalised support, small adviser caseloads, holistic services (that go beyond just condition management and employment advice), and a different approach to employer engagement. Ensuring that needs are fully understood, and support is well-timed, are also key.
3.65 These principles, and many of the specific models and approaches covered in this Chapter, should underpin future employment support.
112 In Australia all disability employment services must meet the requirements of the independently assessed quality assurance system to receive funding. 113 Through the Northern Ireland Education and Training Inspectorate 114 BASE (2013) Submission to the Government Review of Disability Employment. British Association for Supported Employment Response Paper 115 Shaw Trust (2013) Op. cit.
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4 Commissioning support
4.1 There is growing evidence that how programmes are commissioned can have a bearing on the effectiveness of support for disabled people and those with health conditions. In particular, the use of ‘Payment by Results’ models, personal budgets, and locally-based and joint commissioning models all have important lessons for the future of employment support. These areas are explored below.
Payment by Results
4.2 Outcome based payment structures, or Payment by Results (PBR) models in employment support were first developed in the USA and subsequently adopted in a number of countries including the UK. Such systems incentivise providers to achieve entry into sustained employment, rather than payments being simply based on the number of participants starting a programme. There have been real benefits from these contracting systems – in terms of ensuring that commissioners and providers are focused on outcomes, that spending is geared towards achieving results, and finances are closely managed. However the PBR model can present a particular challenge for the delivery of support to those facing the most significant barriers to the labour market116. This is related to concerns about ‘creaming’ and ‘parking’ behaviour on the part of providers, whereby effort and resources are focused on those participants for whom employment outcomes can be achieved most quickly and/ or cheaply.
4.3 The Work Choice programme has retained significant levels of service fees (70 per cent of a provider’s contract price, paid monthly) alongside outcome payments for short and sustained job outcomes. The evaluation117 reported that this balance between service fees and outcome-based funding was welcomed by providers. The service fee element was felt to allow for investment (which was felt to be particularly important given the support needs of participants) and to facilitate the participation of some smaller specialist providers in the programme. It also appeared to reduce any perverse incentive to ‘park’ participants unlikely to achieve an employment outcome. The research therefore
116 Finn, D (2011)Job Services Australia: design and implementation lessons for the British context, DWP Research Report 752 117 Purvis et al (2013) Op. cit.
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recommended that future funding models for specialist support should recognise the role of service fees within the funding model.
4.4 However, it is important to note that concerns were nonetheless raised in the Work Choice evaluation that the ‘prime provider’ model used to commission the programme had led to some specialist providers (and local authorities) exiting the market, and others only being utilised on a very limited basis. This was likely to have a negative impact on specialist service delivery and on the diversity of provision in the future (particularly for those with specialist needs).
4.5 Within mainstream employment programmes, differential payment models have been developed in an attempt to address concerns regarding ‘creaming’ and ‘parking’. Under these models, providers are paid at different rates for outcomes achieved by different target groups (with outcomes for the harder-to-help groups being paid at higher rates than those for groups closer to the labour market)118. For example in the Work Programme, there are nine ‘payment groups’ primarily based on an individual’s benefit type. Providers are paid at different rates for outcomes achieved by these nine groups, with outcomes for ‘harder-to-help’ groups being paid at higher rates than those for groups deemed to be closer to the labour market.
4.6 There is, however, concern that this differential payment model is not working effectively, with the first report of the DWP Work Programme evaluation119 noting that those furthest from work have infrequent access to specialist provision and see support reduce over time.
“Providers routinely classify participants according to their assessed distance from work, and provide more intensive support (at least as measured by the frequency of contact with advisers, for example) to those who are the most ‘job-ready’. Those assessed as hardest-to-help are in many cases left with infrequent routine contact with advisers, and often with little or no likelihood of referral to specialist (and possibly costly) support, which might help address their specific barriers to work.”
4.7 The interim report of this project120 sets out starkly the limitations of the PBR model in the Work Programme. As a consequence of outcomes
118 Finn, D (2009) Differential Pricing in Contracted Out Employment Programmes: Review of International Evidence, DWP Research Report 564 119 Newton, B et al (2012) Op. cit. 120 Wilson, T. and Riley, T (2014) Op. cit.
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being below expectations, DWP funding per ESA participant is significantly lower than DWP intended, and will fall to just £550 per person for those now joining the programme. That report proposes a revised payment model in order to ensure that payment levels for ESA claimants are in line with original plans. This model would maintain some level of attachment payments, introduce job entry payments as well as job outcome payments, and compress the time period in which sustainment payments are made. Our proposals are set out in Table 4.1 below.
Table 4.1 – Proposed Work Programme payment model for ESA claimants
PG5 - ESA PG6 - ESA PG7 - ESA Volunteer Flow ex-IB Attachment payment £350 £350 £350 Job entry payment £600 £900 £1,250 Job outcome payment £1,150 £1,400 £4,000 (three months in work) Maximum job sustainment £2,300 £4,700 £9,620 payment* Cost per attachment £1,018 £1,181 £1,413 * Same overall levels as current model, but paid over 9 months after job outcome payment.
4.8 Other approaches proposed to adjust the Work Programme funding model include the introduction of payments for outcomes other than employment such as ‘progression measures’121, an approach that is currently used within the DWP ESF Families programme.
4.9 International research into the use of differential pricing122 has explored other proposals such as a ‘target accelerator’, with a sequence of differential fees for each segment of a specific claimant population, although this model is currently untested. In the Australian system the use of the Jobseeker Classification Instrument (JSCI) and a differential pricing system have been relatively effective at targeting support towards highly disadvantaged job seekers. However there has also been some strengthening of financial incentives, with specific funds for employment barrier reduction, greater scrutiny of ‘parking’ and frequent adjustments to the JSCI and the performance management Star Rating system. The
121 Inspire to Independence (2013) How to improve on The Work Programme 122 Finn D. (2011) Op. cit.
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key source of additional funding in Australia is the Employment Pathways Fund, which is described below.
Case study: Employment Pathways Fund, Australia
The Employment Pathways Fund (EPF) is a flexible pool of funding that can be drawn down by employment services providers to support jobseekers or groups of jobseekers. The fund allocates a notional ‘credit’ for each jobseeker, with the level of the credit linked to the level of labour market disadvantage. Providers can then claim reimbursement against these credits for eligible expenditure. They cannot draw down funding to cover administrative costs or overheads.
Credits range from A$11 for those closest to work to A$1,100 for the most disadvantaged.
The evaluation of the EPF123 found that three quarters of the most disadvantaged jobseekers receive support through the fund – typically, training support, wage subsidies, adviser support or other professional services (including health services) – and concluded that the fund was generally well targeted towards those with greater disadvantages.
However the evaluation also found significant underspends for ‘Stream 4’ jobseekers, which covers those with the most significant barriers – including many disabled people and those with mental health conditions.
4.10 In practical terms, any future changes to the current differential payment model will need to be easy to administer, both in terms of the capacity to apply and assess eligibility and to manage performance and financial accounting. Increasing the targeting capacity of the assessment and pricing model while retaining simplicity remains a significant challenge.
Individual budgets
4.11 An alternative to the current PBR models is the use of individual (personal) budgets. This approach was proposed within the Sayce Review124 of DWP specialist disability employment support and more recently within a Disability Rights UK (DRUK) report125. The DRUK report offers findings from an on-line survey of disabled people that indicated
123 DEEWR (2012) Employment Pathways Fund evaluation, Australian Government 124 Sayce, L (2011) Op. cit. 125 DRUK (2013) Taking Control of Employment Support
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that many respondents would like to decide how the money for their employment support is spent. It goes on propose that disabled people should be given the opportunity to choose how to spend the budget for their employment support via individual budgets.
4.12 Research commissioned by Shaw Trust126, which included focus groups with their customers, offered a different view, with most participants hesitant about the concept of individual budgets. Concerns were expressed that individual budgets would be ‘complicated’ and ‘stressful’ and would result in employment support becoming more difficult to access. The DWP Fulfilling Potential report127 also noted that many disabled people experience difficulties managing an individual budget.
4.13 Similar concerns were raised by focus groups conducted for this project. Most participants felt that even if information was provided, having a personal budget would just be another thing to have to think about. Many did not want to have to make any more decisions, and were happy to trust the professionals to refer them to the right provision for them.
“In my state of health I’d find that too challenging.” (Participant with a mental health condition)
4.14 Some also questioned what would happen if they chose a provider and they turned out not to be suitable; whether there would be a way to change provider or get the money back? Others highlighted that some people may not need as much funding as other people and so questioned how the level of funding would be appropriately decided if it was allocated at individual level.
4.15 The use of individual budgets to commission employment support has been subject to some evaluation and, to date, there is little evidence to support their use. A pilot on provision of employment support and Access to Work alongside Individual Budgets128 reported implementation difficulties and very low uptake. The early evaluation of the Right to Control Trailblazers129, which include Work Choice and Access to Work budgets, described similar difficulties. Despite subsequent progress in
126 Shaw Trust (2013) Op. cit. 127 DWP (2013) Fulfilling Potential: Building a deeper understanding of disability in the UK today 128 Aston, J. (2009) Evaluation of Access to Work: Individual Budget Pilot Strand, Department for Work and Pensions Research Report No. 620 129 Tu, T et al (2012) Right to Control Trailblazers Process Evaluation Wave One, Office for Disability Issues.
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delivering Right to Control, the final evaluation report130 found no evidence of the Right to Control having a measurable impact on experiences of accessing services or on day-to-day lives.
4.16 The evaluation of Job First131, a Department of Health project which aimed to test out the use of Personal Budgets combined with non-social care funding streams for people with learning disabilities, also found little evidence that this approach was effective. It did, however, recommend joint funding of Supported Employment for this group, along with a need for central and local government responsibility for providing and funding these services to be clarified.
4.17 Overall, therefore, whilst there is considerable evidence to support the need for the delivery of personalised services, there is currently a lack of evidence to support the use of individual budgets as an effective route for the commissioning of employment support.132
Local and joint commissioning
4.18 As noted in Chapter 2, employment support for disabled people and those with health conditions is currently being provided across welfare to work, health, education and social care133. However, there is little evidence of jointly commissioned services – despite at a strategic level an increasing commitment to develop this approach. For example there is improved alignment between the relevant aspects of Adult Social Care Outcomes Frameworks (ASCOF) and the Public Health Outcomes Frameworks (PHOF), reflecting the joint contribution of health and social care to improving outcomes. The 2013/14 ASCOF, NHS Outcomes Framework and the PHOF include shared measures aiming to support a reduction in the gap in the employment rate between those with long-term health conditions, mental health conditions or a Learning Disability and the overall employment rate.
130 Tu, T et al (2013) Evaluation of the Right to Control Trailblazers Synthesis Report. Office for Disability Issues 131 Stevens, M. and Harris, J. (2013) Jobs First Evaluation: Final Report, Social Care Workforce Research Unit Kings College London 132 Looking ahead, the Greater Manchester (GM) Youth Contract Extension is piloting the use of personal budgets for young unemployed people. This should provide further and more current evidence on the effectiveness of personal budgets, albeit for a different client group. 133 Wilkins, A., Love, B., Greig, R. and Bowers, H. (2012) Op. cit.
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4.19 There are a number of benefits reported by initiatives adopting a locally based partnership approach to providing this type of support, such as the European Commission funded Help to Work Plus project in Bolsover and Chesterfield134.
Help to Work Plus offered employment related support to disabled people and those with health conditions. It was funded by Partnerships between Employment Services (PARES), a European Commission initiative which aims to bring together all types of employment services with the aim of stimulating and improving the co-operation between them.
The need for a local focus was a consensus observation of the PARES Strategic Dialogue135, which offered recommendations on local and regional partnerships to employment services. Help to Work Plus partners articulated a wide range of strengths of their partnership approach, including the importance of this locality focus. They reported that a local partnership facilitated an understanding of local needs and could potentially support the development of services to meet those needs.
The PARES Strategic Dialogue also noted that the primary justification for establishing partnerships was the recognition that no one organisation has the competences to deliver the entire package of support needed by some client groups. Help to Work Plus partners reported that many of their clients have a wide range of complex needs that one organisation was unlikely to be able to address. The partnership approach facilitated client access to a wide range of services that more traditional delivery models may not be able to provide.
The Help to Work Plus partnership approach was also reported to have improved service delivery within and between individual organisations. For example, there were reports that partnership working had facilitated the sharing of knowledge and techniques for supporting clients into work. In addition to this type of service development, it was reported that the work of the project had facilitated the identification of potential gaps in service provision. The identification of such gaps is potentially the first step in the process to address unmet need, and one of the local authority partners reported that analysis undertaken by the partnership had offered some clarity around where they should focus employment support.
134 Inclusion (2013) Evaluation of Help to Work Plus 135 European Commission (2012) PARES Strategic Dialogue 2012 Local and Regional partnerships: Recommendations to employment services
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4.20 There are also examples of where the provision of employment related support within NHS settings has been found to be effective. For example, the placement of employment support workers within mental health teams as part of IPS service delivery, and within GP surgeries as part of the ‘Getting London Working’ programme. The evaluation of a project which saw advisers from Tomorrow’s People located in GP surgeries was presented as part of their recent report on how to help people overcome health issues and enter employment136. This identified the cost per job achieved by the project as significantly better than comparable models, and also reported substantive reductions in appointments with GPs, counselling sessions and prescriptions costs.
4.21 Many of the specific models of good practice discussed in Chapter 3 on ‘what works’ for specific groups also indicate the need for a co-ordinated approach between health and employment services. For example, the IPS model requires co-location and joint working between employment and clinical specialists, while evidence on musculoskeletal conditions indicates the effectiveness of multidisciplinary approaches.
4.22 A number of disability related organisations have therefore advocated the need to consider local commissioning approaches via collaborative partnerships including social care, health and education agencies137. Such approaches would fit with the Government commitment to devolving and localising control of public services. Whilst the evidence base on these approaches to commissioning employment support is limited, lessons can potentially be drawn from the development of Community Budgets – where public services are given more freedom to work together to join up services, reduce duplication and improve outcomes.
4.23 Some of the lessons from the development of Community Budgets on joining up design, commissioning and delivery of services that have been identified so far were presented in research by Inclusion last year138. This outlined the following key success factors:
Being locally driven;
Having an end to end approach;
136 Tomorrow’s People (2013) Doing Well, Working Well 137 Trotter, R (2013) Work in progress: Rethinking employment support for disabled people Disability Charities Consortium BASE (2013) Submission to Government Review of Disability Employment Support 138 Inclusion (2013) Community Works: Putting work, skills and enterprise at the heart of Community Budgets
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Taking a pragmatic approach to financial control and investment;
Sharing data and information effectively; and
Central government facilitation and support.
4.24 Another initiative that has sought to develop a better understanding of what is needed for effective working relationships between Jobcentre Plus and NHS services was work commissioned by the London Health Inequalities Network139. The study explored current working relationships between Jobcentre Plus and the NHS in two London Boroughs. It made a number of recommendations on improvements to joint working between the two services and these included:
The need for cultural change within the two organisations, including an improved understanding of employment as a key determinant of health
The development of a better understanding of how each other works
The need for more joint case work and potentially shared services
4.25 It also made recommendations for Local Authorities and Public Health professionals on the needs for clear client pathways and on their role in the facilitation of joint working.
Case study: Working Well, Greater Manchester
Working Well is an employment programme in Greater Manchester for Work Programme leavers claiming ESA. It is expected to support 5,000 claimants, with mandatory referrals coming from Jobcentre Plus over the next two years.
Two providers (commissioned locally by Greater Manchester Combined Authority) have been appointed to deliver a key worker service, rather than a more traditional employment adviser service. They have two years to work with each participant, and will also provide up to a year of in- work support, to help sustain employment.
139http://stats.cesi.org.uk/events_presentations/SEMINARSERIES/Tacklinghealth/Andrew _Attfield.pdf
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As well as providing employment support, the key worker helps the participant to tackle the wider barriers preventing them from working. Interventions are sequenced to ensure these barriers are addressed in the correct order, and local authorities across Greater Manchester have developed a Local Integration Plan that helps key workers navigate the different services on offer.
Getting senior level buy-in from different partners early on ensured that stakeholders could influence the development of the programme and enabled close partnership working.
While the budget for the programme itself is around £8.5m, it is expected that the funds focused on supporting this cohort will reach around £20m, as key workers access and refer service users to a wide range of additional support delivered by local partners
4.26 Joining up funding is a key challenge to the development of a more integrated approach to service provision. A number of initiatives that have sought to use a ‘braided’ approach to funding support such as Project SEARCH140, Jobs First141 and Right to Control142 have found the approach to be very complex to implement and difficult to sustain. The provision of employment support services to patients carried out in GP surgeries by Tomorrow’s People143 has also significantly reduced due to the complexity and constraints of funding arrangements. This suggests that further development of such approaches is required to achieve a sustainable and effective model of locally based joint commissioning.
Case study: Central and North West London NHS Foundation Trust (CNWL)
CNWL is recognised as a Centre for Mental Health national ‘Centre of Excellence’ for its vocational services. These comprise the User Employment Programme (helping people access paid jobs and time limited placements within CNWL) and the delivery of an Individual Placement and Support (IPS) model across the organisation. This involves integrating Employment Specialists (ES) into mental health and addiction treatment teams to help those teams become more effective at supporting people to access paid employment. ES posts are funded in a
140 Purvis, A., Small, L., Lowrey, J., Whitehurst, D. and Davies, M. (2012) Op. cit. 141 Stevens, M. and Harris, J. (2013) Op. cit. 142 Tu, T et al (2012) Op. cit. 143 Tomorrow’s People (2013) Op. cit.
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variety of ways including through the NHS, local authorities, ESF, the Lottery and co-location of external employment agencies such as Jobcentre Plus staff.
The IPS team have partnership agreements with a range of providers of employment support which offers a number of benefits. For example, it facilitates the maintenance of on-going contact with referred individuals so the team can be alerted of any difficulties before someone fully relapses. In some cases the agreements also provide access to vacancies before other organisations. The team also work with individuals (and their advisers) on the Work Programme through such agreements. Such partnerships are reported to reduce individual anxiety about job participation and to ensure the focus continues to be placed on them and their needs.
Another important part of their work involves working with Jobcentre Plus and Disability Employment Advisers to ensure that people with mental health problems are not excluded. A key part of the model is building relationships with local employers to access the hidden labour market, given that some people accessing the service have been unemployed for long periods and find it difficult to compete through traditional job seeking approaches.
Evidence based commissioning
4.27 While the evidence on what we know about effective service delivery noted gaps, it also highlighted approaches where there is a strong body of evidence – such as Supported Employment. In order to ensure the most effective models of support are implemented, providers should apply this knowledge to their delivery and commissioners should use the evidence to inform their commissioning decisions. Recent research carried out by the National Development Team for inclusion (NDTi) into the commissioning and delivery of employment support for disabled people144 suggests that this is often not happening in practice.
4.28 The NDTi reviewed the evidence on the cost-effectiveness of different service models and commissioning approaches. It found that commissioners and providers have little systematic data or knowledge about how best to target funding to generate positive job outcomes (i.e.
144 NDTi (2014) The Cost Effectiveness of Employment Support for People with Disabilities Final Detailed Research Report
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jobs gained or jobs retained). For example it reported that only around one third of current employment-related spend within the NHS and local authorities is being committed to the evidence-based models of IPS (in mental health services) and Supported Employment (in learning disability services). It also reported that there is little or no evidence to support other service models currently being used by these commissioners.
4.29 The NDTi study reported significant variability in the cost of employment support services and found that costs per job outcome could not be explained by factors such as complexity of people’s disability or size of service delivering support. The study therefore concluded that variable cost and outcomes was primarily explained by the service model being used and a range of organisational/strategic actions, such as prioritising employment outcomes. It concluded that existing investment in employment support could be used to deliver much higher numbers of new or retained jobs at significantly lower average costs than is presently being achieved by adopting evidence-based models.
Conclusion
4.30 There has been a diversity of approaches to commissioning services for disabled people. At a national level, recent years has seen a strong shift towards larger and longer contracts with increasing use of outcome-based payment models. Locally, there appears to have been a diversity of approaches and often wide variations in the sorts of provision being commissioned. Given the breadth of activity, it is perhaps surprising that there has been so little joint commissioning of support, or even close co- ordination of services.
4.31 Overcoming barriers that prevent co-ordination and joint commissioning – and particularly barriers around aligning funding, objectives and timescales – will be key in the future design of employment support. It will also be imperative to build on the evidence of what has worked well, and less well, in designing and delivering services.
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5 Recommendations
5.1 Chapters 1 to 4 have set out the scale of the challenge in tackling the gap in opportunities for disabled people and those with health conditions; how current provision measures up; and the evidence on what works in both the design and commissioning of employment support. In our view, there is a clear and pressing case for radical reform of the current system of support – both to radically extend access for disabled people and those with health conditions who are out of work, and to create a framework that better reflects the needs and aspirations of those service users.
5.2 We set out below our recommendations for reforms to achieve these objectives. We do so in three broad themes:
The framework of support – ensuring that support is available and appropriately targeted
The management of future programmes – ensuring that support is then effective in improving employment and wellbeing
Workforce development – ensuring that all advisers that work with disabled people and those with health conditions have the skills and capabilities that they need.
The framework for future employment support
1. Future employment support for disabled people and those with health conditions should be built around three levels:
‘Into work’ support – for those closest to returning to work, with some specialist support
Health and disability employment support – for those needing more intensive and joined up support to secure employment
Supported Employment and rehabilitation – for those with the most significant support needs
5.3 As set out in Chapter 2, the current system of employment support comprises the Work Programme for some, the specialist Work Choice programme for far fewer, and then a patchwork of locally commissioned
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programmes and nationally funded provision (like Residential Training) for those with the most significant needs.
5.4 This system lacks coherence and creates risks of some people receiving support that isn’t right for them, or more often no support at all: there is evidence from the Work Choice evaluation, in particular, that many of those who could benefit from more specialist support are not able to because they have already been mandated to join the Work Programme; while those on Work Choice with more extensive needs can see their support end after six months on the programme.145
5.5 Our research – both the evidence on what works and research with disabled people – emphasises the importance of ensuring that support is personalised and recognises the diversity of needs amongst disabled people and those with health conditions. The framework of employment support must also reflect this. We propose three broad levels of support, to ensure that provision is appropriately targeted and that needs can be met.
‘Into work’ support: This level would support those who have health, or disability, related needs but are relatively closer to work and could (re)enter employment with the right support. This would include, broadly, many of those on ESA following Statutory Sick Pay, as well as those who have been found ‘fit for work’. Many of these people are currently on the Work Programme but, as Chapter 2 sets out, achieve poorer outcomes than non-disabled people. ‘Into work’ support would be adviser-led, with small caseloads, and focused on job-placement and condition management with signposting or referral to more specialist services.
Health and disability employment support: This level would support those with health conditions and impairments that have a more significant impact on their ability to find work, who may have been out of work for some time or never worked, and who would often need additional support in work – but who could nonetheless enter work with the right combination of support, and ultimately work independently. Many of these people are currently on the Work Programme, Work Choice or neither – indeed they likely account for a large part of the gap in employment between disabled and non-disabled people. This level would
145 There is an option to extend the pre-work support module of Work Choice from six months to one year, although the evaluation of Work Choice (Purvis et al (2013) Op. cit.) found little evidence of this being used in practice.
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integrate employment, health, disability and wider support, would be led by specialist advisers, and would be built on Supported Employment principles: small caseloads, a holistic approach, and an emphasis on effective employer engagement and job brokerage to place and then maintain participants in work.
Supported Employment and rehabilitation: Those with more significant impairments – including those with learning disabilities, severe autism and severe mental illness – are unlikely to have their needs met through the two levels of support described above. We propose that, as now, there is additional and separate support for these groups – in particular Supported Employment, which has been evidenced to have a sustained positive impact where it is properly implemented, variants of this, like supported internships for young disabled people, and residential training.
5.6 In addition to these three levels of support, our assumption is that there will continue to be mainstream back-to-work support for those who are long-term unemployed or otherwise disadvantaged jobseekers. As now, we would also expect that some of those referred into mainstream support would have mild to moderate health conditions or disabilities that are not in themselves significant barriers to employment. The levels described above, then, would be in addition to this mainstream support.
2. Review the operation of Access to Work to improve utilisation and ensure that it fully integrates into a coherent and simplified system of employment support
5.7 As discussed in Chapter 2, there are a number of proposals related to improving the awareness, accessibility and uptake of Access to Work currently under consideration within the development of the DWP disability and health employment strategy. Development of these areas should prove beneficial within the current system although we also believe there is a need to review the strategic fit and operation of Access to Work alongside other elements of DWP specialist support. This review should aim to ensure Access to Work fully aligns with other aspects of the DWP disability employment support offer, resulting in a more coherent, comprehensive and simplified system of support.
3. Access to, and funding for, employment support for disabled people and those with health conditions should be significantly increased
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5.8 On average 120,000 people a year have been referred either to Work Choice or as an ESA or ex-Incapacity Benefit claimant to the Work Programme. Given the scale of the challenge set out in Chapter 2, we argue that access to support should be significantly extended in future employment programmes.
5.9 Recent work by the IPPR146 sets out that well-designed future disability employment support could reasonably expect to draw on £400-800 million of funding from central government, local government and health services. This in part is based on the findings from the interim report of this project, which demonstrated that central government is spending £380 million less than intended through the Work Programme. The IPPR argue that this funding could support between 200 and 400 thousand people each year. We would support this ambition, and the view that this funding could be realised through a combination of planned expenditure by DWP on support for these groups, alignment of local health funding, and allocations from the European Social Fund.
5.10 The three level model described above should lead to substantially more people accessing support, at all levels. In particular, we would expect that the ‘Health and disability employment support’ level would be significantly larger than Work Choice, which supports fewer than 20,000 people per year.
4. Access to each of the three levels of support should be underpinned by a common, robust assessment process – joined up with other assessments, and with decisions reviewed after three months
5.11 As Chapter 2 sets out, the rules that govern access to current employment support are not fit for purpose – and, to address this, the Government is proposing a light-touch Gateway to initially identify individuals’ employment support needs. Those requiring ‘co-ordinated support’ will be referred on for a more detailed assessment. We believe that that more detailed assessment should in turn be used to identify which of the three levels of support set out above is most appropriate for that individual. This assessment process should be based on needs rather than benefit type and should be a common process across all levels of support. In line with the Government’s proposed Gateway, the
146 Lawton, K., Cooke, G. and Pierce, N. (2014) The condition of Britain: Strategies for social renewal; Institute of Public Policy research
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assessment process should also be applied at the right time (usually, as soon as is possible – but it could also follow from a regular meeting with an adviser or support worker where individuals are ready to engage with employment support) and should also be capable of being applied by local partners and organisations working with disabled people.
5.12 There are a number of assessment tools available that could provide a basis for developing this model, including toolkits for those with specific needs like the benchmarked RNIB Employment Assessment Toolkit. In addition the Department is testing assessment tools that can be used to target access to different forms of adviser and employment support. It will be imperative that any proposed tool is thoroughly tested and kept under continual review. In addition, as we set out in Chapter 3, the assessment process must be aligned with other appropriate assessments including the WCA and assessment for PIP; and relevant information should be shared between the assessor and the subsequent service provider – so that support needs are understood and burdens on individuals reduced.
5.13 Assessment should not just be seen as a one off event. In-depth assessment can only occur over a period of time, particularly where there are multiple barriers, so any future assessment system should include an in-built review – with the ability for individuals to move between levels of employment support where circumstances change or new information becomes available.
5. Individuals should be able to access employment support on a voluntary basis, but the assessment process should include the scope to require individuals to participate where that is appropriate and in line with their conditionality rules
5.14 We believe that individuals that volunteer for employment support should in principle be able to receive it. The act of volunteering is itself a strong indicator that individuals are motivated to prepare for work and would likely benefit from additional support. And by expanding the support available, as we propose, more individuals should be able to access provision that better meets their needs.
5.15 At the same time, we would expect that many of those that are referred for support, particularly the ‘Into work’ support, will be JSA claimants or ESA claimants in the Work Related Activity Group (WRAG(. Both JSA and ESA WRAG claimants are currently required to participate in employment support as part of the conditions of continuing to receive benefit. This
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can include, in particular, participation in regular interviews with advisers, or participation in the Work Programme. Well designed, specialist employment support should be able to take the place of these requirements and it follows that in those cases it will often be appropriate to require individuals to participate in that support rather than to be supported through Jobcentre Plus directly.
6. Participants should normally be able to receive pre-employment support in any one level for up to two years
5.16 The Evaluation of Work Choice identified that the short duration of the pre-employment module of the programme (usually six months147) has reduced the scope to support those with more complex needs. On the other hand, the Work Programme has a fixed period of two years of support (and potentially longer where participants find work). While this allows substantially more time to work with those further from work, it may also put off some of those groups from volunteering – as it is by definition a long-term commitment.
5.17 The focus groups conducted with service users as part of this project found that many disabled people and those with health conditions felt that they needed pre-employment support to be available for at least two years, if not longer.
5.18 In our view, individuals should be able to participate in a specific programme of pre-employment support for up to two years. However there should also be in-built reviews where participation can be ended earlier than this – either where a participant is ending support entirely, or is moving into more appropriate provision.
7. Government and service providers should review their approach to employer engagement, with a focus on: simplifying employer access; co-ordinating work to improve awareness and education; and building sector-led approaches
5.19 As set out in Chapter 3, different strategies are often needed for promoting employment of disabled people and those with health conditions. The evidence suggests the need for a combination of the traditional ‘recruitment agency’ model and more individual-focused
147 There is an option to extend the pre-work support module of Work Choice from six months to one year, although the evaluation of Work Choice (Purvis et al (2013) Op. cit.) found little evidence of this being used in practice.
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support. Often this means addressing specific concerns around work- place adjustments, managing absence, in-work support and potential costs, as well as selling the often less immediate benefits of a diverse and inclusive workforce. However, the delivery of services for employers is fragmented across multiple programmes, and there are distinct challenges in engaging large numbers of employers in supporting these groups.
5.20 The Government acknowledges this to some extent in the review of its disability employment strategy. We consider that there are three priorities for reviewing the system of employer engagement:
First, simplifying employer access. On the one hand the current system leads to duplication and complexity – as employers seeking to support disabled people and those with health conditions do not have a clear single point of contact; while on the other it leads to risks of gaps – as many organisations struggle to directly reach employers (due to their scale or their position within supply chains). A far simpler system would be based around clear points of contact, common approaches to engagement, and as far as possible a single ‘front end’ for employers. There may be lessons here from the Work Programme in London, where the six prime providers have sought to manage key employer relationships in this way. A simpler system for employers should also include an improved online presence and online portal registration for Access to Work.
Secondly, raising awareness and education must play a central role. There are strong arguments for Government co-ordinating activity and playing a stronger communications role; and equally strong arguments for service providers – including, critically, Work Programme providers – to then drive up awareness and education through the employers that they work with. The Government’s Disability Confident campaign, and the industry ‘Access Ability’ initiative (described in Chapter 3) both provide models to build on. These efforts should be aligned and extended to bring in more organisations and common guidance, products and services to support employers.
Thirdly, we would propose focusing on building sector-led approaches and partnerships to ensure that services have maximum reach and are focused on employer needs. Again Access Ability provides some pointers in this, with its focus on engaging industry ‘verticals’ like employer bodies and trade associations. Focusing on sector bodies should also help to ensure that there is a balance between reaching out to small and medium employers, as Disability Confident intends to do,
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and not losing sight of the importance of large employers (which employ as many people within 6,000 organisations as are employed within 4 million small companies; and can themselves be enlisted as visible and influential advocates).
5.21 Drawing these recommendations together, our proposed framework of employment support comprises the four elements set out below – identification; assessment and segmentation; three levels of support; and review.
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Figure 6.1 Fit for Purpose: A new framework for employment support
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The management of future programmes
8. Local and national commissioners should work together to ensure that the three levels of support are in place – within a clear national framework but with approaches to devolution, joint commissioning, pooling or alignment that are appropriate to local areas
5.22 Chapter 4 sets out both the critical importance of joining up provision locally, but also the real need for greater local capacity and capability to commission effective employment programmes. There are a number of areas of real expertise in commissioning often quite specialist support, but many more areas where that capability does not exist.
5.23 We are agnostic on who commissions services – as long as those services are evidence-based, well-designed, appropriately funded, well managed and effectively joined-up. In principle local areas should be best placed to do most or all of these things – but in practice, at least currently, much expertise in design, commissioning and management sits centrally. We do not therefore propose a single commissioning model (for example that everything is commissioned by local government or central government). Rather, we propose that there is a clear national framework and that provision is then commissioned in the most appropriate ways within that.
5.24 This national framework should include:
That employment support will be available to meet the three levels set out above
That access to support will be underpinned by the common assessment approach set out above
That provision will be organised within geographical areas that give national (GB) coverage – perhaps aligning with LEP boundaries or groups of local authorities – but that provision may be commissioned within smaller geographies where this is appropriate (for example, local Supported Employment programmes)
That there will be local governance in place to support service providers to join up with locally available provision – in particular health, skills and other employment support
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5.25 This national framework is important in particular for service users and for employers – to ensure that there is a clear and single system of support, even if the design and commissioning approach will vary between areas.
5.26 Within this, we would recommend that central and local government, and their partners, work together to agree the most appropriate ways to commission support within geographical areas. In some cases, local areas will take the lead in commissioning – with DWP pooling or transferring its funding and local commissioners rolling in local funds. In others, DWP will take the lead, with local partners commissioning complementary services and working to align support locally. In still others, there may be models of co-commissioning or pooled budgets.
5.27 We would also expect that local commissioning would have a stronger role in the third level of provision (Supported Employment and rehabilitation) where there is currently only limited national provision. This should not, however, preclude national organisations from delivering these support services where they can meet specialist needs or have local presence.
5.28 It follows from this proposal that the three ‘levels’ of support set out above need not necessarily be three different, separately-commissioned programmes. Local commissioners may for example decide to combine levels one and two within a single programme, or indeed to commission level one support as an integral part of their mainstream programme for the long-term unemployed. Critically, however, we propose that these decisions are driven locally – within a clear framework that there will be appropriate provision that maps against all three levels.
9. Jobcentre Plus and local Health and Wellbeing Boards should work together to develop protocols on joint working, including information sharing
5.29 Making a real impact on employment of disabled people and those with health conditions depends critically on improving partnership working between the health and employment sectors. This goes beyond just the commissioning of employment programmes. For example as Chapter 4 set out, there have been a number of effective models of co-located health and employment advisers, while models like Individual Placement and Support and support for those with musculoskeletal conditions appear to depend on effective multidisciplinary approaches. The importance of joint working was also emphasised by service users themselves, in the focus groups conducted for this research.
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5.30 Welfare reforms create a further pressure to work together – with health professionals increasingly likely to be encountering patients in financial hardship and with concerns about their benefit status, especially concerning disability assessments and requirements to look for work.148
5.31 Senior level buy-in appears to be critical in driving effective local partnerships: operational staff within sectors find it harder to engage without the clear impetus from the top. We therefore propose a systematic effort to agree protocols on joint working between local Health and Wellbeing Boards and Jobcentre Plus (as the representative of the Department for Work and Pensions). Health and Wellbeing Boards sit within local authorities and bring together key health, local government and other stakeholders (not usually including DWP/ Jobcentre Plus). They do not directly commission, but work to co-ordinate public health provision in local areas including by working with Clinical Commissioning Groups.
5.32 Developing strong links between Health and Wellbeing Boards and Jobcentre Plus should underpin efforts to improve partnership working more generally and in particular to improve how information is shared on local priorities, provision, funding decisions and so on.
10. Funding models for all three levels of support should include ‘payment by results’, but with clear safeguards to minimise risks of vicious circles, creaming and parking
5.33 This report and our interim report set out clearly some of the challenges and limitations of Payment by Results. In principle, PBR models should sharpen incentives to achieve outcomes – specifically employment outcomes – and reduce financial risks on the taxpayer from poor performance. However in practice, if programme performance turns out lower than anticipated then this can lead to permanently lower funding available for support, in turn reducing performance; and an over-focus on employment outcomes can lead to risks that those furthest from work become further marginalised. Both of these appear to be playing out, to a greater or lesser extent, in the Work Programme.
5.34 PBR models also increase the upfront investment costs for providers, which can in turn squeeze out those who are less able to finance risk –
148 Finn and Goodship (2014) Take-up of benefits and poverty: an evidence and policy review, publication forthcoming
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regardless of their effectiveness in delivering results. Other outcome- based models like Social Impact Bonds seek to address this by clearly separating financial risk from delivery risk (with delivery organisations paid for services, but the funders only paid for results), but these are relatively untested and often come with similarly high borrowing costs (far higher than any government would face).
5.35 PBR should continue to play a role, through payments for employment and sustained employment, but future provision should retain ‘service fees’ that ensure that providers can meet the upfront and delivery costs of programme provision, and so that unintended risks around vicious circles, creaming and parking can be reduced. The precise balance between service and outcome fees will depend on the nature or provision and potentially local circumstances (where support is commissioned locally) but we would envisage that service payments would normally comprise the majority of a providers’ income, and a greater proportion where support is relatively more expensive. One option would be to allocate additional notional funding to meet the needs of the most disadvantaged, that providers can draw down for specific expenditure – along the lines of the Australian Employment Pathways Fund.
5.36 Linked to this, we would also recommend that contracts include ‘trigger points’ to review performance and funding where there appears to be systemic (programme wide) under-performance (as there has been with ESA groups in the Work Programme, but with no adjustment of funding).
11. There should be a common quality framework across all provision, based on self-assessment, external inspection, service user input and continuous improvement
5.37 Ensuring that all participants receive high-quality support is important because, in many cases, individuals will not achieve employment during their time on provision. The benefits for most participants will be in building their confidence and motivation, preparing for work, addressing their barriers and ultimately moving closer to employment – in other words, receiving a quality service.
5.38 Previously, quality was managed through Ofsted – with a regular process of self-assessment and then independent inspection. This process was not universally popular with providers, but did appear to improve over time. The evaluation of WORKSTEP in particular noted the positive influence that external inspection had in improving the quality of
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provision. This system was ended in 2011, but continues in Northern Ireland through their Education and Training Inspectorate.
5.39 The benefits of reintroducing independent quality evaluation have been endorsed by a number of disability-focused organisations including BASE and Shaw Trust. We support the development of a clear quality framework that can cover all three levels of support. This framework need not reintroduce Ofsted or fully-independent inspection, and care should be taken to ensure that this does not introduce new burdens and is complementary to other activity like the Merlin Standard on supply chain management. However it should nonetheless be based on rigorous self-assessment alongside periodic external inspection and assessment. In particular, quality management should be focused on understanding the perspective of service users. The use of satisfaction surveys, as have been used in Australian provision, could be one means of achieving this.
12. A ‘What Works Unit’ should be established with a remit to collect, review and disseminate best practices; facilitate knowledge exchange between providers; and encourage innovation in service design and delivery
5.40 This research, and previous work by NDTi, has illustrated that there is both a wealth of examples of innovative practices in supporting disabled people and those with health conditions, but also a dearth of high quality evidence on what is working, and often even of data on what is being delivered where.
5.41 ‘What Works Centres’ have been established in a number of areas to try to pull together robust evidence for policy makers and delivery organisations working in different fields. We propose a lighter touch unit, that would support the range of commissioners and delivery organisations that would need to be working effectively together in order to deliver the proposals set out here. In particular the Unit would have a key role in supporting local partnerships to build their commissioning and oversight capacity, and in supporting organisations in driving up quality management. Its functions should include:
Systematically gathering and collating information on what is being delivered and tested in different areas, so that organisations and commissioners can learn from each other
Supporting organisations to improve how they assess the impact of what they are doing
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Carrying out ‘thematic reviews’ of different models of support and what works for different groups – in particular to extend our understanding of ‘what works’ beyond the relatively small number of very well- evaluated programmes like Individual Placement and Support
Facilitating discussion and sharing between organisations and commissioners – including through events, action learning and virtual networks
Encouraging innovation – for example by (part-)funding pilots of new models of support, or running an ‘innovation fund’ that organisations can bid to
Disseminating learning to wider practitioners – including those delivering mainstream employment programmes, but who may nonetheless be supporting people with mild or moderate illnesses or disability
5.42 The Unit would likely be a relatively small team and would need to prioritise between these areas of focus. Nonetheless we believe that it could make a real impact with a team of 4-8 people, drawn from operational policy, delivery and research backgrounds.
Workforce development
13. Jobcentre Plus and the wider employment services industry (through ERSA and IEP) should work together to ensure that all advisers have training in identifying health and disability needs and providing initial support and signposting
5.43 As already noted, we would expect that many of those with mild or moderate health conditions or disability will be receiving support through ‘mainstream’ employment programmes or through Jobcentre Plus. Others still may have undisclosed health needs or hidden disability. Therefore all frontline advisers will need to play a key role in identifying needs, supporting those that do not enter specialist support, and referring individuals on for assessment where that is appropriate.
5.44 We propose that training should be available to help advisers to identify and understand the different barriers to entering work resulting from different conditions. Ensuring that all advisers receive appropriate training to have confidence that they know how to support these individuals, and what adjustments they and employers might need to
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take, would help drive up service quality. This training could build on initiatives such as the Working for Wellbeing mental health toolkits currently being rolled out in Jobcentre Plus and amongst Work Programme providers, which aim to help employment advisers spot when mental health wellbeing support can help a jobseeker achieve their employment goal.
14. The Institute of Employability Professionals should work with organisations including the British Association of Supported Employment to develop industry-wide, best practice training for specialist disability employment advisers
5.45 As highlighted in Chapter 3, the key role of adviser staff, and the importance of ensuring that staff have the right capabilities and resources, came across strongly in both the literature on ‘what works’ and the focus groups with service users.
5.46 It would not be efficient for providers individually to develop their own tools for more specialist training, nor would it support wider moves towards industry standards through the Institute of Employability Professionals. The Institute exists to professionalise the industry and drive up standards, and would be the obvious organisation to lead on developing or distributing a range of materials to the sector. This would need to draw on the existing good practice evidenced by the BASE adviser professionalisation work. It may also encompass approaches exemplified by Randstad’s package of health specific e–learning modules. Modules include: General Disability Support, Mental Health awareness and Specific Learning Difficulties.
15. Jobcentre Plus and employment services providers should commit to ensuring that all advisers leading on employment support for disabled people and those with health conditions will have been trained in line with industry benchmarks, or be on the journey to receiving that training
5.47 Building on Recommendation 13, we consider that both the industry and Jobcentre Plus, including those delivering Access to Work, should commit to ensuring that those advisers that lead on specialist support (either as Disability Employment Advisers or as caseworkers within disability employment programmes) have had training that is in line with industry standards (including, for example, National Occupational Standards) for supporting disabled people, or are receiving that training or due to start receiving it.
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Conclusion
5.48 These proposals draw on input from service users, service providers, those that work with disabled people, and a range of national and international evidence. They show that there is a long way to go in tackling the entrenched gaps in opportunity for disabled people and those with health conditions – but that there are extensive good practices, here and abroad, that can be built on.
5.49 The proposals presented here would have the scope to radically reform support for these groups and to strike a new balance between health and employment services and between national and local government.
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