Health and work support pilot: final evaluation

Summary of Qualitative Findings

Longitudinal interviews with clients

The first wave of interviews Rocket Science conducted with clients as part of the longitudinal client interviews included 43 interviewees (23 from Fife and 20 from Dundee). This section provides a summary of findings which is set out as follows:

• Referral process – including how interviewees had learned about the HWS pilot and how they found the referral process
• Quality of the service – including views on the quality and ease of the process and quality of the support interviewees received
• Impact on daily life and employment – including how the support received form HWS pilot had impacted interviewees quality of life, relationships and employment.

This section is also supported by evidence from client journey case studies which can be found in Appendix 3 of this report.

Referral process

• Interviewees learned about the HWS pilot through a number of routes. In both areas, the majority of interviewees learned about the service through their GP. However, others heard about the service through a radio advert, from a physiotherapist that they were accessing privately. A small number had been told about it by their Jobcentre advisor.
• The main reasons for being told about the HWS pilot were long waiting times to access NHS services or the possibility of accessing a free service instead of a paid one.
• All interviewees had not previously heard of the HWS pilot. Interviewees explained that if they had not been told about the service by their GP, physiotherapist, Jobcentre advisor, or had heard it through the radio, they would have not known about the service; they felt it was not widely publicised.
• The majority of interviewees had self-referred themselves to the HWS pilot. Interviewees explained that after being told about the HWS pilot, they were given a leaflet that explained how they could self-refer to the pilot.

Quality of the process

• Interviewees felt that the process to access the HWS pilot was effective and efficient. In both pilot areas, interviewees generally felt that the process to access the HWS service was easy and quick and agreed that the waiting time, both to get a call back from the case manager and to access clinical support, had been very short. On average, interviewees received a call back from case managers the next working day after calling the helpline and accessed clinical support within two weeks.
• In both areas, interviewees found the initial assessment straightforward and adequate. All interviewees felt that the initial assessment they completed with their case manager was thorough and adequate to refer them on to the type of support and service they needed.
• The majority of interviewees felt that they had accessed the right level of support. Interviewees generally felt that the support they received was adequate to their needs and that approach worked for people with similar conditions as theirs.

Quality of support

• Access to mental health support varied between pilot areas. In Fife, interviewees experiencing mental health issues only accessed support from their case manager and were not referred on to a specialist clinician, except for one person who accessed counselling. Instead, many people were provided with self-help literature and support from the case manager who, in Fife were often trained professionals in mental health support. In Dundee, the majority of interviewees were referred to and accessed counselling from a clinician.
• Satisfaction with length of support varied according to the type of support accessed. Across pilot areas, clients who accessed physiotherapy felt that the support was the right length and the right frequency, while those who accessed counselling tended to feel that the sessions had been few and far between.
• Interviewees who accessed mental health support had more frequent contact with their case manager. Across pilot areas, interviewees who accessed physiotherapy tended to have a more formal relationship with their case manager and less contact (often just initial assessment and final review). Those who accessed mental health support instead, tended to have more frequent and informal contact with their case managers and, in some cases, received emotional support from them.
• Interviewees felt that staff were friendly and treated them with respect. Across pilot areas, interviewees generally reported feeling treated with respect and dignity by staff and that communication was good and straightforward.
• The element of support that was identified as most useful by clients varied between interviewees who had accessed physiotherapy and those who accessed mental health support. Generally, interviewees who accessed physiotherapy said that the clinical support was the most useful element of the support they received. Those who accessed counselling felt that the regular support from their case manager was the most useful element.

Impact on daily life and employment

• Clients accessing physiotherapy were able to identify tangible benefits from this support. In both pilot areas, interviewees who accessed physiotherapy seemed to have received more tangible benefits and could explain how the service had helped them with their daily life and employment (e.g., pain management, re-entering work).
• Not all clients accessing mental health support were able to identify tangible benefits from this support. A smaller number of those who accessed mental health support were able to articulate the benefits they had received (e.g., management of stress and anxiety). Interviewees who received this support felt their needs were perhaps too complex for the HWS pilot to respond to effectively.
• The support received from HWS pilot helped most interviewees back to or into work. In both pilot areas, the support helped some interviewees re-enter or gain employment and better manage their daily life. However this was not the case for interviewees who had more complex needs and conditions.

Staff and Stakeholder engagement

This section provides a summary of the findings from fieldwork with the following groups:

• Referrers, including healthcare and Jobcentre staff, and employers
• Employers as clients of the service
• Delivery Staff
• Stakeholders

An online survey was developed for a range of referral agencies to gain an understanding of the awareness and expectations of the pilot. In total 53 healthcare and Jobcentre referrers and 9 employers answered the survey.

A summary of the findings is set out below.

Referrers

• Most referrers had a good understanding of the pilot and understood what the pilot was trying to achieve. They felt that they had enough information to be able to explain what the pilot could offer, and how it could benefit the clients, because it had been well explained by the HWS pilot team before it was implemented.
• Most referrers found the referral pathways to be effective. The majority of referrers felt that referral pathways were clear and easy to navigate, particularly Jobcentre Plus staff. All JCP staff interviewed believed that an online referral portal which was developed for their use was useful and provided an easy way for them to refer clients. They felt that it offered a clear single point of access and that the online system was quick and easy to use.
• Despite initial interest, many clients disengaged from the service. Referrers who were interviewed noted that, even though clients initially expressed interest in person, many disengaged before they had been fully enrolled onto the service. On further analysis by pilot staff, they identified that, out of every 10 clients who were told about the pilot by Jobcentre work coaches, only 1 client self-referred on to the pilot. To combat this drop-off rate, an online referral option was made available to Jobcentre work coaches. However, as a result of the time required to get this live, and the onset of the Covid-19 pandemic, the potential of this new referral route was not fully realised.
• Referrers felt that the support provided by the pilot was unique in the service landscape. All staff interviewed believed that, while there was a range of other services that offered health support and work support separately, none took the integrated approach that was adopted by the pilot. They felt the integrated approach filled an essential gap because of the inter-relatedness of issues around health and work.

Employers

Rocket Science interviewed eight employers across Fife representing businesses of different sizes between December 2019 and January 2020. Unfortunately, we were unable to access employers from Dundee for this fieldwork, therefore this section provides a summary of interviews with Fife employers who were all actively engaging with the service when interviewed.

Summary of key findings

• Most employers engaged with the pilot because they understood the importance of providing support for health conditions in the workplace.
• All employers felt that the 'Health and Work Support Pilot' brand was not well recognised among local employers or employees whereas the pre-existing 'Healthy Working Lives' brand was well known.
• Employees were accessing mental health support from the pilot, but a range of other support was also accessed, including physiotherapy, identifying accessibility equipment to stay in work, health and safety advice, sessions on alcohol awareness and suicide awareness, and anxiety management workshops.
• Several employers believed that different types of support should be available to cater for a broader range of health conditions and should be tailored to the needs of each individual.
• All employers felt that it was easy to access support from the pilot, but some were less satisfied with how long it took for employees to receive a response from the service.
• Most employers were not aware that they could make the referral on behalf of the employee.
• Most employers felt that the pilot service had been sufficiently beneficial that they would recommend the service to other employers in the area.
• Overall, employers felt that the pilot had provided the help that they needed to provide support to employees with health conditions. Employers provided positive feedback and felt that the pilot had met the needs of their employees. The easy access to support and resources from the team was felt to be a benefit, and this had helped them to retain their employees.

Stakeholders

Stakeholders, including staff from the Scottish Government as well as local delivery partners, were interviewed between November 2021 and January 2022. This meant that it was possible to capture both their views on the design and impact of the HWS pilot, the implications for the design features of a health and work support service and their reflections on what this meant as the No One Left Behind Approach is developed and rolled out.

Feedback on HWS pilot design. There needs to be a recognition of the different skills required to tackle health related employment issues. Stakeholders acknowledged that many clients still have anxieties and fears of engaging with Jobcentres. It is felt that delivery within a clinical setting and from a trusted brand is the right approach for delivering a health and work service. However, this service needs to be focused on both health and work, so should bring together the right people and services together in an integrated and coordinated way.

"Work coaches can't provide health interventions […] but equally, clinically trained health professionals can't provide employment support."

Evidence from the HWS pilot indicates, that even when work coaches identify a health need and suggest that the client contacts a medical professional, this does not always happen. Work coaches are not able to provide health interventions and need a mechanism and/or support to ensure eligible clients are able to access the support they need. Health and work must be addressed simultaneously.

"[The] pilot approach worked better than JCP trying to provide health interventions. They are not health practitioners and can only suggest people contact their GPs. But in the pilot they have access to resources, and quickly."

However, it is important to note that it is not only health and work which should be addressed simultaneously, but also any other barriers and challenges that an individual is facing to ensure that they are able to continue to maintain and sustain their employment.

"We need specific support from people who are social workers, health practitioners, we can't do it [by ourselves]. We get ourselves in a mess trying to do things we aren't qualified for."

Spending time building partnerships with key groups within the model and aligning values, expectations and priorities is important. Being involved at the design phase gives all partners a sense of ownership and buy-in which will increase the chance of success of the programme.

• This should include time spent on developing more robust data sharing arrangements. These would focus on the client and their journey and mean that clients would not have to disclose information about their condition and situation to different people and services as they made progress.
• Understanding the different cultures and operating practices across the partnership in order to understand challenges and barriers to effective delivery of the service and identify ways in which these can be overcome.

Designing a service that puts the service user at the centre. Although the pilot did create a single point of access, from the point of access to receiving a clinical intervention, it was felt to be "clunky" by a number of stakeholders. There is a need to fully understand the journey through a service for clients to understand what it is like from their perspective – identifying barriers to participation and potential drop out points before a service goes live

"[Clients face] various hurdles, lengthy conversations. The ethos [of the pilot] was meant to be "no dead ends", but people were reaching dead ends – being turned away, given the wrong information."

Including people with lived experience in the design phase should be considered if a service wants to be person centred. For example, the journey through the service can be mapped out with clients to understand what works well and less well in recruiting and engaging clients, and identifying barriers to continued engagement.

Feedback from the HWS pilot suggests:

• Having a service that extends beyond 9 to 5 would help those in employment to engage with the service.
• There should be flexibility in how clients can contact the service and receive support (i.e., remotely, in person)
• The process of referral and handover needs to be refined – client progression is often not a linear journey for clients, especially those who have mental health problems.

For several stakeholders, the most important feature of a health and work service is for it to be holistic, considering health and work together, and alongside other barriers which may present themselves (which may be clinical, work, home, poverty, financial, food). Helping people overcome barriers to work needs be considered in the round, with different services working together to support individuals. The Scottish Government is moving towards an "every contact counts approach" to ensure that the current issues we face in terms of an ageing workforce, profile of the workforce, people working longer with health conditions, will be addressed in order to retain the working population.

"I would say this has to be the approach if we are serious about addressing health inequalities - need to look at this in the round."

Finally, the biopsychosocial model of disability^[7] was mentioned as an appropriate approach for a support service which helps people find work. This uses approach focuses on what clients can do rather than was they can't do. Some of the medical professionals who were involved in the HWS pilot were starting to refer to this model, but it was not clear if this was fully implemented.

Employability and Health Landscape – post Covid

The stakeholders consulted acknowledge that there is a growing awareness of the increasing scale of health issues which affect employment and strengthening recognition of the need to respond with a holistic service offer. They are starting to see that health and work support must be more closely aligned, and they recognise that the pandemic may have accelerated the need for this.

Some stakeholders, although they understood the reasoning for the early closure of the pilot, felt that the closure of the HWS pilot was premature, as the pandemic has highlighted the scale of health problems, especially in terms of its impact on mental health. Several stakeholders felt that this has resulted in a gap in provision. However, it was recognised that the landscape has also become more complex since the pandemic. Emergency funding has resulted in the introduction of a number of small, local services. These are seen as being hard to navigate, even by well-informed professionals.

Although existing resource in this policy area is primarily targeted at those out of work there was recognition that it would be valuable to sustain the early intervention approach pioneered by the HWS pilot focused on supporting those in-work, especially with the emergence and impact of 'long Covid'. There are differing views about what this service could look like and how it could be delivered through the No One Left Behind (NOLB) approach, but there is a recognition of the need to help people with a health condition to remain in work if possible.

Two stakeholders talked about the early intervention and preventative approach of the pilot. Although this evaluation has identified tangible benefits from this approach, it was clear that stakeholders and funders are still trying to understand the concept of preventative spend and move away from employment / disability employment rates, and traditional work-related outcomes.

There was some agreement that the landscape of work has changed since the pandemic, but that the full impact is still being realised. Although many sectors and businesses were affected by the pandemic, many other sectors were able to continue operating with staff working from home. This created a different way of working and has changed expectations around being in offices, but could result in different requirements for a health and work service - such as how employers can support staff remotely, and understanding what the current and emerging needs are (e.g. mental health, but also the potential for a rise in musculoskeletal conditions as people may be more sedentary).

Stakeholders are reporting on and acknowledging the increasing scale and need around mental health in particular. In the wake of the Covid-19 pandemic, there is growing concern about the rising numbers of those who are withdrawing from the labour market and becoming economically inactive.

Some stakeholders expressed concerns about the apparent focus on client numbers rather than service quality, and how this may have got in the way of experimentation, innovation and service refinement. They felt the focus on target numbers had meant in practice that delivery staff worried about achieving the numerical targets rather than feeling able to think about how to improve outcomes. This issue was recognised by the Scottish Government who took steps to ensure that staff felt confident about taking forward a stronger focus on innovation rather than client volume, and the focus on the pilot shifted to the learning and knowledge sharing that this service could generate, rather than a purely numbers focus.

There was also a recognition that a pilot project of this scale and significance needed 'time to bed in', both in terms of the set-up phase and the running of the service after set up.

However, there is a feeling from some stakeholders that there is an element of pilot fatigue in Scotland. The view is that pilots do not work strategically unless they have a long-term vision, and sustainable funding over a longer period of time. Developing an "early adopter approach" where appropriate and taking lessons learned from other programmes to inform delivery is seen as a way of overcoming the shortcomings of pilot programmes.