Transitional employment services - phase 2: evaluation

Appendix 3: 'Non-user' experience and attitudes to health and employment (cont.)

Participant perspectives on health and work

Attitudes to work

All participants were interested in work. Whatever their current situation, they were keen to secure employment sometime in the future and 'get on'. Most had had some experience of work in the past three years, although a number of younger participants had not yet been able to secure any kind of employment.

However, they were generally aware that, given their medical histories, certain types of job and certain types of employer would not help them manage their health condition over time. Many reported past experiences of taking jobs that might not suit their circumstances and these ending badly. This meant that they were reluctant to engage in any process (whatever the timetable) if they did not feel ready for work and that they would not be able to say 'no' to potential job opportunities that they did not wish to pursue.

Key to understanding this point of view is that many, particularly those who had had longer experience of living with their condition, reported that when employment fails because of a worsening health situation, they did not simply return to the pre-employment position but most often felt much worse. There is an implicit assumption that following an employability pathway is a linear process where clients progress from stage to stage

"Many people assume you will start to get better once you get treatment and counselling, in practice, it gets worse as the sessions brings out all the stuff you have buried. You do get better, but you have a lot to get through first and little things can knock you right back" [Male 35-50]

One participant had taken a job in a call centre after their last involvement with Jobcentre Plus while they were still on Jobseekers Allowance but was experiencing panic attacks and other trauma due to pressure at work and home.

Another had taken a job with a major company who had a full counselling and support service available for their employees but they found that even this level of support was still not sufficient to help them sustain and they did not stay in work beyond a week.

Another realised that things might not be going as well as they thought:

"I thought I was doing OK until the chef asked me if everything was alright. I said I was fine but he said 'you are shaking uncontrollably'. I hadn't noticed and I realised I needed to stop and get some help." Male [25-34]

Engagement with support services

Participants in all four events were asked to explain how and why they had decided to engage with the support services offered by the two community organisations. Their responses reveal a complex picture of the range of support available and how these services can both succeed and fail to interact depending on which advisor the person sees.

Participants liked the community organisations' offer – there is no pressure put on them and they are not made to feel guilty if the process stalls or regresses as this is seen as natural part of the recovery process. Advisors make it clear from the outset that they are not working to targets or a timetable. In some cases the advisors had experienced similar issues themselves and so they engage, listen and do not judge. So many other elements of support in the NHS and especially in JCP is stressed – all frontline staff are working to their targets and participants pick up on the tension this causes. They feel responsible, often agree to take on too much to be helpful to their advisor and when this leads to health problems they feel worse because they have failed.

Most respondents felt that they had come to the community organisations because they felt that they understood their needs:

"They were the first people who gave me the time and listened" [Female, 18-24]

"I was referred by my work coach at JCP. They could see I was not fit for work and said that [community organisation] will understand and have the specialists to talk to me." [Male, 18-24]

"My community practice nurse [community mental health team] sent me along [Female, 25-34]

"Friends told me they were good and there was no pressure" [Female 18-24]

More generally, a range of referral routes were identified – some Jobcentre offices, Community Mental Health teams, Local Authority housing departments and social housing organisations, veterans networks and specialist residential homes. In Glasgow, Community Mental Health funds part of the services offered by the community organisation and so there was closer inter-working between support offered to clients. Elsewhere referrals of this nature occurred but were less frequent.

From the discussions with participants it is clear that the 'system' is much more ad hoc and a great deal depends on the individual General practitioner's, work coach's or other advisor's attitude and knowledge of local services. Luck in meeting the right person at the right time appears to be a significant element in the process. Many participants relayed stories of meeting a CPN, GP, work coach or other advisor who took more time to listen to them and helped make a difference to their referral.

Young people in particular felt that all services were difficult to engage. For them having a more understanding service would involve:

• Someone who can take their time to listen
• Give them time and space to explain their feelings even where they themselves do not know what is 'wrong' with them and no matter how "odd" these may seem
• More time to develop in employment and learn what is expected of them and how to do well.

Part of the frustration of participants was that they want to feel better and progress and this should be possible if they are offered help in the right way.

One local Jobcentre had appointed a young person's work coach which had greatly improved referrals to the community project and relations with JCP services – "Helpful and friendly individuals working in a challenging system". Others had generally positive reputations but some locations elicited more mixed views where "it depends on who you speak to".

Other participants felt that at all levels the system is stressed and professionals do not have the time to fully understand their needs:

"I've learnt that I'm not good with stressful situations but that's all you see at the GPs and at the Jobcentre. These people are all stressed-out with no time and under pressure from their targets. It's better to stay away from that" [Female, 25-34]

Getting help and support with their health condition

Participants revealed that they had a wide range of mental health issues from a general sense of 'not feeling right', anxiety, depression to other conditions such as schizophrenia etc. Whatever their age, background or condition all participants highlighted the difficulty in getting specialist support. Many believed that NHS services were simply not geared up to diagnose their problems, particularly as all parts of the service were very busy:

"They are good with the broken bones, but it's not like they can scan your head and say right you have depression or whatever. We need more time than they can give". [Male 50-65]

A crucial issue for all participants was to obtain a diagnosis. This had been more challenging than might be expected for all participants and many reported a degree of luck in them engaging with the support that started their recovery. The lack of a diagnosis can be very debilitating, but even where participants had progressed into support and were receiving help, the wait times and other issues in time-limited support mean that they can have very limited ability to plan.

In general their time at school was not positive and had been the place where their mental health issues had started to occur. A minority had achieved some qualifications but many had none. Many were Christmas leavers and one young person who was taking a number of Standard Grades was told to drop their subjects in order to undertake vocational and employability support in final year and leave at Christmas. They feel this cut away their future opportunities when they may have got some qualifications.

After school the perception was that the medical services available were overworked and ill-prepared to recognise symptoms and provide necessary support. Many commented on the issues such as lengthy waiting time, brief appointments, unsympathetic GPs, opaque communication processes and sometimes unhelpful outcomes not addressing their concerns. Referral to psychological services (Community Mental Health Teams - CMHT) was the best that they could expect but this was by no means automatic. All participants felt that peer support was really helpful to get through this process. Most felt that group work was too much when they first engaged with the service but as they start to recover peer support is very helpful to progress further.

Veterans reported that it could take some time for them to overcome the culture of the Forces not to speak about mental health issues. There was a strong preference for engaging with veteran networks and support organisations who could understand many of the issues facing individuals. It is, however, important to note that the issues facing this group of participants should not be reduced down to 'just' Post-traumatic Stress Disorder (PTSD). Many had spent most of their adult lives in the forces where food, housing and many other aspects of day-to-day life had been provided. Stepping out into civilian life meant that many of them had to deal with these issues for the first time.

Many have spent many years trying to manage their condition themselves and speak of a sense of insecurity as they are never sure what might trigger a bought of depression, anxiety or even panic attacks. Meeting new people and in unfamiliar circumstances did remain a challenge for some and would affect their ability to engage with any service.

An important point here, made by many participants, was that they would not have engaged in any support service when they had health issues at their worst. As a group they felt that they were 'in recovery' and feeling much better about their health than when they first sought help. A number made the point that when they finally accessed support, this often led to a deterioration in their mental health before support and treatment helps recovery. So other support needs to be timed carefully in order to build on the recovery phase.

Accessing employment

All participants would like to get a job in the future, especially in a job or career that they are interested in, is where they want to be. However, some will not be ready to engage with support to get back to work. Looking for work when they don't feel settled or happy is likely to have less successful outcome:

"You need a lot of strength to apply for jobs, you get knocked back so often it takes it out of you even if you are feeling good to start with." [Female 18-24]

Many would prefer a job that interests them but they are also aware that jobs are very difficult to come by – most require previous experience and so for young people not long out of education often with limited qualifications, struggle to overcome this 'catch-22'. Some had been in employment but this had not sustained.

Those interviewed felt there were very few opportunities where young people can learn appropriate work behaviours. Work experience is available on some services (including the Employability qualification) but these are short duration and are limited in number. Young people with more qualifications were reported to have a better chance of securing the available places.

Interactions with the local JCP offices was generally not seen as positive. Not having any say in what type of work you might consider was the biggest drawback but benefit sanctions and how these were applied were high on the list too. Few of those interviewed felt that they had an understanding work coach (WC), although a small minority felt that they had been lucky and were with WCs who understood what they were wanting to do and tried to make this happen by not pushing them towards just any vacancy.

Community projects were better as they worked with individual aspirations and towards the sort of work participants were interested in doing – or at the very least would help you find other types of work that were similar.

A number of young participants spoke of the pressure they face from families to take options that preserve their access to child benefit for example. Not being paid does not help as they need to be able to contribute to household costs. This can be made much more difficult if they are not getting on with family members at home and need to find accommodation for themselves.

Apprenticeships are highly regarded by most as they can be a route to a career and skills/qualifications. Many young participants had not got on well at school and the opportunity to learn by doing rather than by classroom teaching and exams was seen as a major opportunity. However, some young people had qualifications but many had none. A significant proportion of young people had been Christmas leavers and asked to drop out of formal qualifications to take up work experience and vocational activity in final year.

Apprenticeships were considered to be as scarce as full time job opportunities in some locations (rural and semi-rural areas) and were also seen as being highly competitive and so not offering many young participants from these groups a viable route into work.

Among younger participants a number felt that they should seek to get the qualifications that they did not secure while at school. Attendance at college produced mixed opinions – some felt it was a good option and it was possible to participate without losing benefits. Others felt that they would lose housing benefit and come under pressure to continue with job search activity from JCP (UC requires evidence of 35 hours job search, although volunteering activity can reduce this). Securing a place on a chosen course was not straightforward for all and some were awaiting confirmation of their places on courses.

Another factor that was frequently mentioned as a potential barrier to employment was housing. There was a number of issues here:

• The cost of private rented sector accommodation was seen as being beyond most of those attending, even when working.
• Some veterans were currently living in specialist veterans' accommodation and had been told that if they were to enter employment the weekly rent would increase to £458.
• The majority of young people were living at home with their parents but this was often a source of tension and issues. Few felt that they had any option but to stay home in their present circumstances and this would not change if they did enter work.
• Moreover, few private landlords will consider young people as tenants, especially single males.

Peer support was very important to participants in all groups. In some cases, participants felt that group work would not be appropriate as it could take some time to overcome their issues before they felt strong enough to be members of a group. As they move closer to seeking work, this is really important to help build confidence and receive the encouragement of others. Veterans in particular, felt that peer group work was essential and helped because of their shared background and experiences. For many, the key element of support was information and advice on what services and support were available to them and, vitally, which individual advisors they had found helpful and understanding.

Employment experience

Around 40% of the participants had been in employment in the past 3 years. Employment rates were lower among younger participants. Jobs were characterised as being typically temporary or made so by employers cutting short their contracts. One person worked for 5 weeks and felt that they were getting on well, only to be called in and told that they were no longer wanted. It's not unusual not to get any explanation – whether it is something that they did themselves or simply a lack of work.

Young people were often working for the minimum wage which was seen as very low, meaning that if they were successful in getting employment it can be difficult to get by. If you are living independently then getting a job is really hard to justify the additional cost of rent etc.

The precariousness of the job market meant that securing a job for almost all participants did not mean that you could relax:

"I had a job at [online retailer warehouse]. It was full-time and you think great, this is ok but after the Christmas rush is over you get laid off. Yes, they will pick you back up in 6-8 weeks but what are you meant to do in the meantime. Nothing is steady anymore." [Male 50-65]

Older participants reported a mix of experience and there were clear differences in the availability of work between Glasgow and Edinburgh and the other locations. More young people elsewhere felt that employers were able to pick and choose and they did not have the experience or qualifications to succeed. This meant that many were interested in undertaking work experience and looking for supported employment opportunities to help break this cycle. Community Jobs Scotland had been used by the community organisations in the past to allow them to take their work experience further. These are much more limited now.