Fair Start Scotland - individual placement and support review: findings

Introduction

The Context for IPS Delivery in Scotland

Through this review, we have been exploring 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 support more effective delivery. The aim has been to consider the most appropriate approach to delivery of IPS in Scotland going forward.

Over the past five years, IPS has become an increasingly important part of the employment support landscape for people with mental health issues in Scotland. The Scottish Government has incorporated an IPS strand 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 with severe and enduring mental illness to help them find sustainable, competitive jobs^[10].

Outside of FSS, there are small scale examples of high fidelity IPS services operating. In Scotland, there was a small amount of IPS implemented from 2010-2015, following the publication of "Realising Potential" which encouraged Allied Health Professionals (AHPs) to explore the use of IPS as a vocational rehabilitation tool. Scottish Government, Local Health Boards and AHPs came together to discuss how to establish IPS services across Scotland. Allied Health Professionals played a key role in delivering education programmes across Health Boards and around 4 Health Boards decided to establish IPS services.

Specific Scottish Government policy objectives with regards to employment support include:

• To halve the disability employment gap (Fairer Scotland for Disabled People: Employment Action Plan 2018);
• To create a vision of joined-up, flexible and responsive employability support in Scotland (No One Left Behind: Next steps for employability support 2018);
• Support a minimum of 38,000 people who want help to find and stay in work through Fair Start Scotland^[11];
• To explore innovative ways of connecting mental health, disability, and employment support in Scotland (Mental Health Strategy, 2017).

Finally, the Scottish Government have a values lead approach to public services, aiming that all services should treat people with dignity and respect^[12].

Employability Policy in Scotland

1 March 2016

Review and consultation of employability support in Scotland

In 2015, the Scottish Government undertook a public consultation to develop a new approach to delivering employment support services. Responses to the consultation were used to develop the new employability services when power for design and implementation was devolved to Scotland in 2017.

The responses to the consultation made it clear that individuals wanted more control over their journey into work; more input into service design and delivery; that services should focus on individual needs and be voluntary to engage with.

2 December 2016

Publication of Fairer Scotland for Disabled People

The Scottish Government published a 5-year delivery plan to tackle inequalities, improve rights and create a fairer Scotland for disabled people. There are 5 key ambitions within the document; including protecting rights, creating accessible places and securing "decent incomes and fairer working lives" for disabled people. With regards to employment, the plan focusses on ensuring that disabled people are supported to live and work in a place and in a way they choose and are "able to participate fully in education and paid employment enabling their talent and abilities to enrich Scotland".

The plan commits to:

• reduce barriers to employment for disabled people and seek to reduce by at least half, the employment gap between disabled people and the rest of the working age population.
• It also commits to develop a plan with a more detailed timeline for fulfilling this goal (the action plan was published in December 2018).
• bring in a devolved programme (which becomes Fair Start Scotland) to take a voluntary and person lead approach to supporting people with disabilities into employment.

a March 2017

Publication of NHS Scotland 10 Year Mental Health Strategy

This strategy contains two commitments around Employment:

• Work with employers on how they can act to protect and improve mental health, and support employees experiencing poor mental health.
• Explore innovative ways of connecting mental health, disability, and employment support in Scotland.

The two year-on review of this document points towards the "Fairer Scotland for Disabled People: Employment Action Plan" (see below) as the policy document containing the steps being taken to coordinate and align employability and health pathways. This includes undertaking a review of how IPS is delivered within Scotland.

4 March 2018

No One Left Behind: Next steps for employability support

No One Left Behind plans to create a more straightforward and person-centred employability system in Scotland. In particular, the policy has the following objectives:

• A system that provides flexible and person-centred support;
• is more straightforward for people to navigate;
• is better integrated and aligned with other services, in particular, although not exclusively, with health provision;
• provides pathways into sustainable and fair work;
• is driven by evidence, including data and the experience of users; and
• that supports more people – particularly those facing multiple barriers – to move into the right job, at the right time.

Specific health and work priorities outlined by the plan include:

• partnering with Health and Social Care Partnerships and DWP to pilot Health and Work Gateway in Fife and Dundee (with funding from the Work and Health Unit). This aims to provide early support to people with a health condition (including mental health conditions) or a disability and help them to either sustain or return to work. It also aims to join up existing employment support, including with Fair Start Scotland, and provide a single route or referral.
• test and pilot tools to identify at an earlier stage people who are at the greatest risk of falling out of work and into long term unemployment due to ill health or disability, and support them before this happens.
• align a national MSK Advice and Triage Service (MATS) with employability services to help people with MSK conditions find and sustain work.
• publish a refreshed drug and alcohol plan including a focus on how to better align this with employability support.

7 December 2018

No One Left Behind: Review of Employability Services

A review was conducted of current service provision and steps needed to fulfil the vision for employability services outlined in "No one left behind".

Some of the challenges and areas for priority identified include:

• flexibility of provision and sustainable funding should be able to reflect the varied needs of users and their different rates of progress towards work;
• the Scottish Government to enable more joined-up approach to funding employability services, for example, by acting as an enabler for the delivery of regionally aligned services;
• the role of Third Sector provision was viewed as vital for the success of the employability system;
• the needs of rural employability services. There are fewer services available when compared to cities, as well as a reliance on smaller charities and locally based social enterprises;
• better integration of the employability system with other services, including mapping the impact on eligibility for different services, with wider support including health and housing services;
• a national approach to measurement and outcomes which would improve data quality and consistency;
• challenges around the availability, quality and the limited opportunity to share data across the employability system.
• disparity in how support was commissioned and delivered. In some areas staff are recruited to deliver services directly while in other areas, provision is purchased from the third sector;
• differences in the approaches to administration of the various employability programmes currently available in terms of eligibility criteria, evidence required and performance requirements;

7 December 2018

Fairer Scotland for Disabled People: Employment Action Plan

This plan outlines the next steps the Scottish government, with employers and other partners, will take to meet the ambition to halve the disability employment gap. It also sets out the timescales for doing so. In this document, the government committed to reviewing the delivery and quality of Individual Placement and Support (IPS) in Fair Start Scotland to ensure that participants are receiving the right support to enter work.

IPS Within Fair Start Scotland^[13]:

Fair Start Scotland aims to support a minimum of 38,000 people^[14] who want help to find and stay in work, and for whom work is a reasonable objective. It is delivered across nine geographical areas intended to align with specific local labour markets, whilst ensuring a consistent national standard of service delivery. Fair Start Scotland builds on the Scottish Government's values and principles of public services which are delivered with dignity and respect to individuals. It launched in April 2018 and has been extended to be delivered until March 2023.

It is a voluntary programme aiming to support those with additional barriers or long-term unemployment into work. Clients cannot be sanctioned for non-attendance, failure to engage or if they leave the programme early. However, normal conditionality and work-related activity requirements still apply.

Clients can be offered up to 12 months of pre-employment support and up to 18 months of in work support depending on their level of need.

To be eligible to join FSS, participants must:

• be aged over 18 and in receipt of a working age benefit or be aged 16 or 17 years old if they are:
  • disabled as defined in the Equality Act 2010
  • in receipt of Employment and Support Allowance
  • in receipt of Universal Credit and are in the Work Focused Interview regime, Work Preparation regime or No Work Related Requirements regime (if they particularly want to participate)
• not be in paid work of any kind at the point of referral
• have the right to work in UK (non-benefit customer)
• have the right to live in the UK and be resident in Scotland
• must not have been on SG Work First Scotland, SG Work Able Scotland, DWP Work Choice or Work Programme within 13 weeks of referral to FSS.

and be either:

• long term unemployed (in receipt of a working age benefit and unemployed for 2 years without a break and have reached the 2-year stage on or after 13 March 2018)
• in one of the prescribed disadvantaged groups who need extra tailored support to find employment:
  • Disabled people, as defined by the Equality Act 2010;
  • Lone parents
  • Current and ex-offenders (someone who has completed a custodial sentence or a community sentence)
  • Care experienced young people
  • Refugees with leave to remain and entitlement to claim benefit
  • Black Asian minority ethnic
  • Resident in the 15% most deprived Scottish Index of Multiple Deprivation (SIMD)
  • Unemployed but with a health condition which is a barrier to employment.

Clients with certain barriers to work are eligible from day 1 of becoming unemployed (otherwise after 6 months of unemployment):

• Disabled people;
• Lone parents in the Work Focused Interview regime or the Work Preparation regime;
• Health issue placed in the Work Focused Interview regime or Work Preparation regime;

We understand that this has been recently extended to include care leavers, those with significant health conditions and Black, Asian and minority ethnic clients, are eligible for support from day 1 of becoming unemployed^[15].

There were initial concerns from JCP staff about the eligibility criteria being complex and hard to understand, however these seem to have improved as the programme has embedded^[16].

Specialist help is available to disabled people who require that support. This may include Supported Employment delivered in line with the Scottish Government's Supported Employment Framework (through Procurement), or Individual Placement and Support (IPS), for people with severe and enduring mental health conditions. This is a variant form of IPS as it is not time unlimited.

Figure 2. IPS Services in Scotland

Fair Start Scotland Region	NHS Scotland Region	FSS Provider	# IPS Workers through FSS	Other IPS Provider
1: Glasgow	Glasgow	PeoplePlus	0	SAMH
2: Lanarkshire	Lanarkshire	Remploy	1	SAMH (North Lanarkshire)
3: Tayside	Tayside	Remploy	2	ENABLE Works Dundee
4: Forth Valley	Forth Valley	Falkirk Council	1	SAMH (Falkirk)
5: East	Borders	Start Scotland (FedCap)	0	n/a
	Fife		0	Fife IPS (FEAT)
	Lothian		0	NHS Lothian IPS Service
6: Southwest	Ayrshire and Arran	Start Scotland (FedCap)	0	SAMH (North Ayrshire)
	Dumfries and Galloway		0	n/a
7: Northeast	Grampian	Momentum Scotland	0	n/a
8: Highlands and Islands	Shetland	PeoplePlus	0	n/a
	Western Isles			n/a
	Highland			n/a
	Orkney			n/a
9: West	West Glasgow	The Wise Group	0	SAMH (Inverclyde, Dunbartonshire)

The Evidence Base for Individual Placement and Support (IPS)

IPS is a person-centred, face-to-face model, defined by eight principles (see below). These focus 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.^[17],[18] A lack of effective supported employment services has been cited as one of the key barriers for people with mental health problems to find work.^[19] This evidence base includes:

• A review of 15 Randomised Control Trials (RCTs), of which six were from outside the US, showed a 36 percentage point improvement in competitive employment outcomes for participants receiving IPS versus traditional interventions (58.9% achieving a job outcome with IPS versus 23.2% for the control group, averaging across studies). The differential was 30 percentage points for the non-US studies^[20];
• A more recent review of 19 Randomised Control Trials (RCTs), of which ten were from outside North America, found IPS to be more effective than traditional vocational rehabilitation "regardless of prevailing cultural or economic conditions"^[21];
• Another review of 14 RCTs found evidence that IPS increased the levels of employment, length of job sustainment, and reduced the time taken to get a job^[22];
• A six-country European trial of IPS found that participants receiving IPS had higher rates of job outcomes (54.5% versus 27.6% for traditional support); worked more hours; and remained in work for longer. It also found an 11 percentage point reduction in hospitalisation rates for people receiving IPS and a four point reduction in time spent in hospital.^[23]
• IPS has also been successfully applied to support people with first episode psychosis into employment or, if more appropriate, education.^[24],[25]

IPS has recently been piloted for people exiting prison. A US-based Randomised Control Trial for people with severe mental illness and justice involvement showed that IPS supported significantly more people into employment than those receiving alternative support (31% in work vs 7%). There was no significant impact on justice involvement during the follow-up period.^[26]

In the UK, a pilot run by the Centre for Mental Health from 2013-16 in eight West Midlands prisons supported 39% of those who engaged into paid work (21 out of 54). 128 people were referred, although a significant number were inappropriate referrals (did not want to work, did not realise what the service was about).^[27]

The Impact of Rurality on IPS Outcomes

Research shows that IPS services delivered in rural settings achieve comparable outcomes to IPS services in non-rural areas. There are implementation complexities within rural areas but also potential advantages to delivering employment services in these communities^[28].

Barriers identified internationally to implementing IPS in rural areas include:

• Rural areas require travelling long distances for face-to-face services
• Rural areas may be poorer or have lower employment rates than non-rural areas
• Rural areas may have lower numbers of NHS staff
• Local knowledge and familiarity is required

However there are also advantages of working in rural locations:

• Small mental health teams can achieve better integration as staff know each other
• Many employment specialists have strong relationships with local employers
• It is sometimes easier for small agencies to make changes while implementing IPS.

Research in the USA found that there was no significant difference in the employment rate achieved by urban (36%) and rural (37%) IPS services^[29].

An estimated 17% of Scotland's population live in rural areas^[30]. It is therefore important to consider whether IPS can achieve good outcomes for these populations. IPS services should be well placed to achieve strong outcomes in rural Scotland. Firstly, COVID-19 has shown that IPS services can be delivered remotely, which may help to ease travel constraints. Additionally, rural areas in Scotland do not experience worse employment rates or greater levels of poverty than urban regions. In fact, in Scotland, the percentage of the population that are income deprived is lower in rural areas that the rest of the country^[31]. Finally, employment rates are higher for all age groups in rural areas than in the rest of Scotland^[32].