Fair Start Scotland - individual placement and support review: findings

Executive Summary

The primary aim of this review was to consider the most appropriate approach to delivery of Individual Placement and Support (IPS) in Scotland going forward. IPS is a person-centred, face-to-face model, designed to support clients who are in contact with clinical mental health teams into employment. It focusses on integrating employment support alongside health treatment; providing rapid, personalised job search; tailoring employer engagement to individual aspirations; and offering extended in-work support.

IPS is a well-defined variant of the broader category of supported employment interventions, sometimes called "place, train, and retain" in contrast to traditional "train and place" approaches. Traditional models tend to focus on preparing for work, which may include long periods spent in volunteering, training, or sheltered employment. By contrast, supported employment approaches focus on rapid vocational profiling (identifying skills, experience, aspirations, and required work adjustments), job search and brokerage, and then in-work support for both employer and service user.

Multiple systematic evidence reviews have found that supported employment, specifically the IPS model, is significantly more effective at supporting people with severe mental illness into competitive employment than traditional approaches.^[1],[2] The IPS fidelity scale defines the critical elements of IPS in order to differentiate between programs that have fully implemented the model and those that have not. As demonstrated through research, high-fidelity programs are expected to have greater effectiveness than low-fidelity programs^[3].

The principles of IPS have more recently been applied to support clients with a wide range of barriers to employment, including drug and alcohol substance misuse, learning disabilities, autism, spinal injuries, veterans suffering PTSD, a range of other chronic health issues and disabilities, and other barriers such as contact with the criminal justice system.^[4]

In Scotland, the Scottish Government has incorporated IPS delivery within the Fair Start Scotland (FSS) programme since its launch in 2018. Under FSS contracts, all providers are expected to make available and offer IPS to clients who may benefit from the service.

Through this review, we explored how effectively Individual Placement and Support (IPS) is being delivered in Scotland today through Fair Start Scotland (FSS) and what might need to change to improve delivery. We also compared the delivery of IPS within FSS to other models of successful IPS delivery elsewhere.

We applied a four-step methodology to deliver this:

1. System mapping and evidence review

2. Stakeholder interviews and analysis

3. IPS fidelity reviews with the FSS Providers

4. Report write-up, presentations, and provider follow-up

This report shares our findings based on 21 semi-structured interviews with prime providers delivering employment support through Fair Start Scotland (FSS), providers delivering outside FSS, and policy and implementation leads; an analysis of FSS performance data; and IPS Fidelity and readiness reviews with all FSS contract lots. A full list of the IPS Fidelity and readiness reviews completed is provided in Annex A. A list of the interviews conducted is provided in Annex B.

The decision to include an IPS element within Scotland's mainstream disability employment programme, Fair Start Scotland, was a clear demonstration of the commitment by Scottish Ministers to evidence-based practice to best support people with severe and enduring mental illness.

On an international level, Scotland is pioneering the use of IPS within a mainstream employability programme. However, while IPS has been proven to work, it is a different approach that requires new ways of working by both commissioners and providers of services. Our review has identified implementation challenges faced by Fair Start Scotland providers in delivering high-fidelity IPS, akin to those experienced in other countries when the model was first introduced.

Although the scope for significant change within the existing FSS contracts is limited, we have identified opportunities to build on the commitment to IPS delivery in both current and future employability services. There are also other opportunities to expand access to IPS to support a wider cohort of people with health conditions into work. We hope that the findings and recommendations within this report offer a way forward to maximise these opportunities.

Our findings were:

1. Scotland is pioneering the use of IPS within a mainstream employment contract internationally.

a. The decision to include an IPS element within Scotland's mainstream disability employment programme, Fair Start Scotland, is a clear demonstration of the commitment by Scottish Ministers to evidence-based practice;

b. The FSS experience so far highlights some of the challenges of commissioning IPS as part of mainstream provision;

c. However, there is a commitment from providers and policy makers to build on this work and continue to improve IPS delivery going forward.

2. Although IPS delivery is required as part of Fair Start Scotland, very few participants so far have received an IPS service

a. 6 of 9 FSS lots are currently not offering IPS; those that are have very small services. There are 4 dedicated IPS Employment Specialists in total across all FSS providers^[5];

b. A very small percentage (<2%) of FSS participants have received an IPS service^[6];

c. There are no contractual targets for IPS volumes.

3. Within Fair Start Scotland IPS delivery has not yet attained good fidelity

a. IPS Fidelity and readiness reviews highlighted gaps between current delivery and Fidelity to the IPS model;

b. Key issues are lack of integration and joint working with clinical mental health teams, subsequent lack of engagement with the Severe and Enduring Mental Illness (SMI) cohort, limited individualised employer engagement or in work support;

c. However, there is willingness from the current FSS providers to engage and learn more about IPS, as well as a range of good supported employment practices that map across to IPS.

4. Outside of FSS there are examples in Scotland of small scale, high-fidelity IPS provision delivered which provide learnings around how the quality of IPS provision within FSS could be improved

a. For example, the Fife Employment Access Trust (FEAT) service; and the Glasgow Mental Health and Social Care commissioned IPS service, delivered by the Scottish Association for Mental Health (SAMH);

b. These services are largely funded by Local Authorities, Foundations and a degree of Health Board funding;

c. Key success factors in these services include the availability of block or low-risk funding that supports work with the most vulnerable, buy-in from and integration with the local health system, and the presence of local champions of IPS and relevant governance groups.

5. Examples from other countries demonstrate the importance of health system involvement in the commissioning of IPS services for people with Severe and Enduring Mental Illness (SMI)

a. Health system involvement is essential to build buy-in from mental health teams, enable effective integration, support referral flow, and support the model of "shared care";

b. In England, a scale-up of IPS support for clients with SMI from 10,000 to 115,000 clients per year is being driven by the NHS in England both through policy commitments and transformation funding;

c. In Ireland, the Health Service Executive initially partnered with a European social organisation, Genio, to develop IPS services across mental health teams;

d. IPS is recommended by the National Institute for Health and Care Excellence for adults with psychosis and schizophrenia.^[7] It should, therefore, be considered a core part of evidence-based practice in mental health services.

6. There is growing evidence that IPS can be effective for people with additional barriers to work who are not in contact with mental health services

a. Emerging research shows that IPS delivers comparable employment outcomes for groups other than people with severe mental illness;

b. For example, delivery of IPS for clients with substance misuse issues in England is supporting upwards of 26% of clients into work^[8];

c. Large-scale trials are under way in England to test IPS with referrals from a range of primary and community health and other services.

Our recommendations:

1. In future, IPS for people with severe mental illness should be commissioned outside of FSS through a partnership between health and employability commissioners

a. To achieve the Scottish Government target of halving the disability employment gap, employment needs to be considered as a health outcome and / or Local Delivery Plan (LDP) Standard;

b. International benchmarks suggest that 100 Employment Specialists would be required to reach 25% of the eligible population in Scotland each year;

c. The increase in provision should be phased over 5 years. Implementation support will be crucial to high fidelity delivery;

d. It will be important to build on the examples of good quality local IPS services that work closely with local health boards; piloting an expansion of provision in these areas is a recommended route forward.

2. Existing IPS delivery within FSS could be improved through capacity building support and future contractual changes

a. Providers should develop their IPS capacity and capability, including partnership working with clinical teams, service adherence to IPS fidelity principles, staff understanding of the model through standardised training and quality assurance and supervision processes that promote IPS practice;

b. Achieving high-quality IPS delivery in future contracts will likely require specific targets for IPS access and numbers of Employment Specialists, greater percentage of block funding and a more developed service specification;

c. A suggested service model could be 2 IPS Employment Specialists and a part time team leader in each lot. With good clinical integration and referral pathways, this could allow 900 FSS clients per year to receive an IPS service^[9].

3. IPS provision within FSS should be expanded further to all clients with complex health and disability-related barriers to work. This would make Scotland a pioneer in demonstrating how to achieve outstanding outcomes within mainstream employment support

a. Scotland is the first nation in the UK to include IPS within mainstream disability employment provision. It benefits from a set of committed and engaged providers and policymakers;

b. IPS is the best evidenced intervention to support those furthest from the labour market into work;

c. Delivering effective IPS will be even more critical in the context of the current Scottish labour market.

NOTE: this project was completed virtually due to the impact of covid-19 over the duration of 2020.