Fair Start Scotland - individual placement and support review: findings

Approach

The aim of this review has been to consider the most appropriate approach to delivery of IPS in Scotland going forward. 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. We also provide our opinion on:

• the extent to which IPS delivery through FSS is meeting Scottish Government policy objectives of reducing the disability employment gap and supporting individuals with health needs into work.
• lessons for IPS delivery in FSS from other models of IPS being delivered elsewhere, including in Scotland, England and internationally.
• our assessment of the training and workforce development needs of IPS service providers in Scotland.

IPS is an intervention originally designed to work with clients who are in contact with clinical mental health teams, typically with severe and enduring mental health issues. It works by tightly integrating employment specialists into the clinical teams so that employment support is provided as a core part of mental health treatment and recovery planning.

However, the principles of IPS have since 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. The FSS model of delivery is more aligned to supporting these wider groups. We have taken this into account in the provider fidelity reviews and in our overall findings.

We have applied a four-step methodology in this review:

1. System mapping and evidence review

We have reviewed policy documents and the context through which IPS support is commissioned through Fair Start Scotland. We have also compared this with the international experience, drawing particularly on learnings from IPS implementation in England. This included an assessment of how health and work policy developed in England to embed employment as a health outcome.

Our background report highlighted the following points:

• In Scotland, IPS delivery is largely situated within Disability and Employability Policy. It is under these policy areas that Fair Start Scotland is implemented, with limited involvement from the health and social care system in commissioning or delivering employability services.
• A key feature of the IPS landscape in England is that the NHS has taken responsibility for the roll-out of IPS in mental health teams, targeted at people with severe mental illness (SMI), while the Department for Work and Pensions (DWP) is building the evidence base for deploying IPS for other groups.
• This balance between scale-up in mental health teams and trialling for other groups matches the evidence base – while IPS has been extensively tested for people with SMI and is recommended by NICE as part of treatment and recovery for adults with schizophrenia and other psychoses^[33], the evidence base is less developed for the effectiveness of IPS for other groups.
• The adoption of IPS by the NHS in England as core part of mental health treatment also reflects a more fundamental recognition of the role that employment can play in recovery from mental illness. It is, therefore, seen as a health intervention first, even though the first principle of IPS is to support people to achieve competitive, paid job outcomes.
• IPS is undergoing a phase of rapid growth in both Scotland and England however different approaches have been taken with regards to how this scale up is delivered. In England, the NHS is playing more of a leading role in scaling up IPS for clients with severe mental illness, with DWP taking a lead in trialling innovative approaches working with different client groups or in alternative settings. In Scotland, IPS provision is being delivered as part of an integrated and broader set of employability services that draw on the values of dignity and respect through Fair Start Scotland.
• These different approaches present a strong opportunity for mutual learning.

2. Stakeholder interviews and analysis

We delivered semi-structured interviews with:

• every Fair Start Scotland provider;
• providers delivering IPS in Scotland outside of FSS;
• policy and health system leaders.

Details of the interviews carried out are detailed in Annex B. These interviews have focussed on the current policy landscape, delivery of IPS within and outside of FSS within Scotland, strengths, challenges and opportunities. We have also sought to understand how contracts are currently structured and performance managed. As part of this process we have also spoken with Scottish Government staff working on data analysis for the FSS contract. We have analysed data on the number of IPS services operating across Scotland and outcomes being achieved. Where publicly available, key findings from this data analysis are included within this report.

Separately, we have used international benchmarks and data available from Scottish Government to explore the potential size and need for IPS services in secondary mental health care in Scotland and associated cost.

3. IPS Fidelity reviews

To understand the quality of IPS provision, we have undertaken fidelity reviews or guided self-assessments (also referred to as readiness reviews) with every Fair Start Scotland provider.

The interviews with providers highlighted that only 3 out of 9 providers currently have any IPS provision. In FSS lots with low or no IPS uptake, we used guided self-assessment methodology for the prime contracting organisation. This draws on the Dartmouth "Agency Readiness for IPS Checklist" and:

• Engages IPS delivery staff, clinical teams and clients
• Maps current supported employment delivery against the evidence-based 25-point IPS Fidelity Scale
• Highlights practical steps the service and clinical team can take to become "IPS-ready"

The rationale for providing a readiness review rather than full fidelity review in these circumstances is that it can focus on practical steps that the Prime Organisation could take to start to deliver IPS, rather than potentially demoralising and confusing multiple supported employment service providers in each lot who are not currently delivering IPS with a low IPS fidelity score.

We have mapped below the various providers, their current delivery of IPS and noted which Prime Organisations received a desk based guided self-assessment and which lots received a formal IPS compliance fidelity review.

Full details of the reviews and our methodology are detailed in Annex A.

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

This final report contains:

• further reflections based on conversations with the Steering Group;
• our assessment of an indicative cost to deliver IPS to clients with SMI in Scotland;
• recommendations for how this could be delivered;
• fidelity review and self-assessment scores from each FSS provider;
• our assessment of the current Scottish labour market and how this will impact on IPS delivery.