Fair Start Scotland - individual placement and support review: findings

Findings

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

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

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. However, the FSS experience so far highlights some of the challenges of commissioning IPS as part of mainstream provision.

Under FSS contracts, all providers are expected to make available and offer IPS to clients who may benefit from the service. However, data received from FSS shows that there is very limited IPS being delivered.

• IPS is currently only being provided by 3 FSS lot providers.
• The 3 lots that are delivering IPS have small services: the largest service has 2 Employment Specialists, with 4 in total across all FSS providers.
• A very small percentage (<2%) of FSS participants have received an IPS service^[34];

Figure 6: IPS Delivery by FSS Providers

First Start Scotland Region	FSS Provider	IPS Delivery?
1: Glasgow	PeoplePlus	X
2: Lanarkshire	Remploy	√
3: Tayside	Remploy	√
4: Forth Valley	Falkirk Council	√
5: East	FedCap (Start Scotland)	X
6: Southwest	FedCap (Start Scotland)	X
7: Northeast	FedCap (Momentum Scotland)	X
8: Highlands and Islands	PeoplePlus	X
9: West	The Wise Group	X

Clients with severe and enduring mental health needs (SMI) are unlikely to access FSS through current referral routes.

We do not have data on the specific mental health conditions of clients within Fair Start Scotland. However, conversations with providers have indicated that where clients do have mental health conditions, these are generally not severe and enduring conditions (such as schizophrenia, psychosis, bipolar disorder and severe depression). There are a number of reasons for this:

• Clients with the most severe and enduring mental health needs will often not be subject to benefits conditionality and are therefore unlikely to access Jobcentre Plus support. We estimated that over 50% of IPS clients in England are in the ESA Support Group and therefore are not required to seek work^[35].
• Although FSS providers are able to and are expected to take referrals from outside the job centre, there is significant variation between referral sources by lot. In lots where the majority of clients are referred through the job centre, it is unlikely therefore that these clients will have severe and enduring mental health needs. We explain in more detail challenges with integration with clinical teams below.

Secondly, there are no contractual targets for IPS volumes.

Providers do not have targets or detailed specifications around the number of IPS-trained Employment Specialists they are expected to have or the number of IPS referrals that are expected. In England, IPS Grow has developed a standardised set of recommended KPIs for IPS services that include both referrals, job starts and job sustainments per employment specialist.^[36]

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

1. IPS Fidelity and readiness reviews conducted highlighted gaps between current delivery and fidelity to the IPS model;

2. 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 and individualised in work support;

3. However, there is a 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.

The IPS Fidelity Scale is a well-evidenced tool to measure adherence of services to the IPS model to support people with severe and enduring mental illness. Evidence indicates that a higher score on the Fidelity Scale is associated with higher rates of competitive job outcomes.

IPS relies on zero exclusion

When an IPS employment service is integrated into a mental health clinical team, ideally 90% of all the referrals come from that team. Establishing whether an individual wants to work should be the only requirement of the referring clinicians.

Under the current FSS payment-by-results model, providers are only paid for a job outcome when the client works for 16 hours or more a week. For a person considering returning to work after a long period of time or indeed beginning their first employment journey, there is often a requirement to start working a small number of hours and build this up over time. Providers describe flexible ways in which they would try to support individuals who may have an employment goal of less than 16 hours. However, for an IPS service to be successful it is important that all people are eligible for support regardless of how many hours they may work. Paying for job starts, regardless of the number of hours worked, would give providers more financial certainty in investing time and support for clients who may want to start with less hours per week.

IPS requires integration with mental health services

Integration of employment services and mental health treatment provision is a key element of high-fidelity IPS. Integration is vital because it ensures that those people furthest from the job market are considered for referral and provided employment support. This is often referred to as "programme reach". In an IPS service you would expect to see at least a quarter of participants with a diagnosis of psychosis. People who experience a psychosis or psychotic illness have one of the lowest employment rates of any group. They often also have other factors that can complicate their employment search, such as criminal convictions, comorbidities such as physical health issues and / or drug and alcohol addictions.

Currently FSS providers receive few referrals to the programme of people who face these barriers to employment. This is typical for an employment service that is not connected to clinical mental health teams. FSS providers are required to take referrals from the community and outside of the Job Centre. FSS staff therefore currently work with clients from multiple referral sources. However close integration requires the Employment Specialist to be embedded within only 1 or 2 clinical teams. The act of integration with a clinical team improves relationships and trust between providers and clinical staff and allows better joint working, which in turn increases referrals for those traditionally considered harder to reach.

IPS relies on each employment specialist to provide end-to-end support

Many of the providers highlight they have a variety of staff offering different support to clients referred. For example, some providers have engagement consultants (ECs) who welcome potential new referrals to their organisation. If the person wishes to continue with employment support, they are then allocated a personal advisor (PA). In addition to this there can be an employment services team which develops relationships with local employers and explores where potential job vacancies may arise. We understand that FSS providers are expected to have Employment Specialists with small caseloads offering all phases of employment support. Our fidelity reviews have identified that many of the employment team carry caseloads of 40-60 at a time.

Research evidence has confirmed that the best IPS delivery approach for people with severe and enduring mental health issues is to ensure that each member of the IPS employment team completes all phases of employment support with an individual. This is evidenced to improve engagement, reduce programme attrition and enables a better job match between employer and employee. The service user often needs intense in-work supports. If this is provided by the same employment team member who engaged with the employer to create a successful job outcome, there is typically a stronger ongoing relationship with both the employer and the new employee. Caseloads for this main employment specialist need to sit around 20 for them to deliver all aspects of the programme.

High quality Employment Specialists and Training Needs

Employment Specialist Skills

Some IPS services in Scotland have identified a preference for Employment Specialists having clinical qualifications or being Occupational Therapists. They have identified this as being an important factor in building trust and buy in with other clinical team members. Other services have employed Employment Specialists from a range of backgrounds.

The IPS Competency Framework developed by the United Kingdom Royal College of Psychiatrists suggests that the skills and values of an Employment Specialist are the determining factor in their success, rather than clinical experience^[37].

International research consistently highlights that the ideal Employment Specialists possesses competencies in six main domains: time management, advocacy with employers, building trusting partnerships with consumers, working as part of a team, face-to-face communication, and networking^[38],[39].

These competencies are best exemplified when the ES spends extensive time in the community and has high levels of frequency of contact with clients.

Furthermore, evidence would suggest that these competencies are best developed by supervisor field mentoring and support^[40].

Training

There is no standard training programme provided to FSS providers by Scottish Government and the responsibility for sourcing and delivering appropriate training rests with the providers themselves. The quality of training provided to staff delivering IPS in Scotland through FSS varies across providers. We understand that some staff have received a short, half day training course on delivering IPS and other interventions. Other services have sent staff on multi-day training courses run by the Centre for Mental Health, or national IPS experts.

Few staff have received field mentoring although there are pockets of this practice within Fair Start Scotland providers. There is also an emphasis in Scotland on Employment Specialists undertaking NIDMAR qualifications. This is a Scottish Government initiative which is offered to FSS Providers to build their understanding and capacity. International experience suggests that specific IPS training is important.

However, in addition to training courses, employment specialists require specialist supervision as they learn the role and for ongoing development. Evidence has shown that trust must be built between an employment specialist and their supervisor in order to best realise the coaching aspect of supervision and field mentoring.^[41] Consistent field mentoring helps embed and build ES competencies and also a team culture around persistence, hardiness, initiative and team orientation.^[42]

Regular team and individual case reviews by the IPS Supervisor with a focus on the ES promoting hope for the client vocational future and empowerment in relation to client vocational abilities are critical for ES development and in turn good employment outcomes for clients.^[43]

There are international training courses and standards around Employment Specialist skills and training which could be incorporated into future IPS provision in Scotland (see recommendations).

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.

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^[44]. 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. Two examples of services that emerged from these partnerships and continue to deliver high quality IPS services are outlined below:

1. Glasgow: Scottish Association for Mental Health (SAMH) service

SAMH have been delivering an IPS service since a pilot in 2012. A review of the service by Deloitte showed that the service supported 33% of clients into work (41 of 126 individuals in 2016) and has reported an ROI of 107% (a saving of £1,436 per user)^[45].

2. Fife: Fife Employment Access Trust (FEAT) service

This service similarly started following the publication of Realising Potential and work undertaken by AHPs in the area to raise the profile and secure funding for IPS from the local authority and local health board. The IPS service has received multiple fidelity reviews and the outcomes of these reviews have increased from fair to good as the service has embedded.

Interviews have identified the following key elements to successful service delivery^[46]:

• availability of lower-risk funding
• buy-in from health system. For example, in Fife, there was a long-term employability opportunity forum locally which had NHS representation.
• strong integration with local health teams
• leaders who believed in and championed IPS
• local steering group meetings
• strong team and IPS managers
• an emerging IPS network where SAMH, Enable and Fife IPS meet and share learnings across the country

Even these services have identified challenges to sustained delivery, including:

• a strong dependence on local champions pulling together local pots of funding, with the risk that services are small scale and vulnerable to stopping and starting;
• challenges fully integrating with local mental health teams and building referral routes through the NHS.
• a concern that some services call themselves "IPS" to access funding without a focus on high fidelity;
• the need for stronger links between employment boards and NHS boards. The experience of Fife, where there is NHS representation on the local employability board, is atypical across Scotland;

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.^[47] It should, therefore, be considered a core part of evidence-based practice in mental health services.

International examples show the importance of health system involvement in commissioning and scaling high quality IPS services for clients with SMI. In England, the NHS has taken responsibility for the roll-out of IPS in mental health teams, targeted at people with severe mental illness (SMI), while DWP is building the evidence base for deploying IPS for other groups.

The adoption of IPS by the NHS in England as a core part of mental health treatment also reflects a more fundamental recognition of the role that employment can play in recovery from mental illness. This is in line with NICE guidance that IPS is a recommended intervention for adults with psychosis and schizophrenia.^[48] IPS is, therefore, seen as a health intervention first, even though the main outcome is to support people into competitive, paid jobs. In Ireland, IPS is being rolled out to all nine Community Healthcare Organisations and in the national forensic mental health service. The Department of Health has noted that IPS could be scaled up if this initial roll out achieves good results^[49].

Our review has identified that in Scotland there is minimal health system involvement at both a policy level ("top down") in terms of setting targets for health boards to fund and provide IPS services, but also at a delivery level ("bottom up") in terms of delivery teams integrating with clinicians, and mental health specialists putting the recovery agenda^[50] at the front of practice.

"Top down" Health System Involvement

As identified in our background report, the policy landscape under which IPS is delivered in Scotland is driven by the Employability team with minimal Health policy involvement in the current funding and policy development of IPS delivery:

• Policy: the Mental Health Strategy contains two commitments around employment, but points towards "A Fairer Scotland for Disabled People" as the policy leading on coordinating and aligning employability and health pathways for those with mental health conditions. The Mental Health Strategy notes the intention to work with employers to act to protect and improve mental health. NHS Scotland is taking steps, as Scotland's largest employer, to support employability for individuals within its own workforce. It also wants to better connect mental health, disability and employment support. However, it points towards Employability Policy and the "Fairer Scotland for Disabled People: Employment Action Plan" as the policy document containing the steps being taken to coordinate and align employability and health pathways.
• Funding: there is currently minimal NHS Scotland or local health board funding being made available for IPS services across Scotland. FSS services receive no funding from the health system. Some IPS services that are being delivered outside of FSS have managed to some access local health board funding and/or a combination of Big Lottery and EU funding. However this is reliant on particular commissioners or local staff who are interested in the model. Some services have been delivered and then stopped because of short term funding. Where funding has been accessed, it has generally been small scale, making it challenging to employ a large enough team to deliver a robust IPS service^[51].

There is also some concern from providers that commissioners may be delivering IPS "style" services which are not high fidelity and may dilute some of the core IPS principles. As a result, these have not achieved as strong outcomes as a high fidelity IPS service might do.

"Bottom up" Health System Involvement

Interviews with services and with the Allied Health Professionals network have identified a need for practical measures to support IPS staff to deliver services within the NHS as well as a greater focus on the recovery agenda for clinicians.

• Practical: Services noted that it can be difficult to gain access to NHS teams. For example, honorary contacts and access to equipment is challenging.
• Cultural: Interviewees noted that the recovery agenda is not yet at the forefront of clinical practice everywhere. IPS services play a key role in challenging assumptions clinicians may have about their clients, their conditions and their ability to work. Once integrated, Employment Specialists can share recovery stories and build hope in clinical teams. However, even where IPS services are fully integrated in Scotland currently, it can be hard to access referrals from practitioners^[52].

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, IPS provided for clients with substance misuse issues in England is helping upwards of 26% of clients into work^[53];

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.

IPS was originally designed to work with clients with severe and enduring mental health needs. However, the principles and characteristics that underpin the success of IPS (low caseloads, person-centred support, effective job matching, proactive employer engagement, integrated work and health support packages) – should all be translatable to wider cohorts^[54].

There is growing evidence and experience for IPS principles being effectively deployed to different cohorts beyond those with severe mental illness and in different settings (outside of secondary mental health services). This includes:

i. Nine international Randomised Control Trials of IPS for populations other than those with severe mental illness. A meta-analysis showed that eight of the nine trials found IPS achieved higher paid work outcomes than alternatives. These studies targeted people with drug and alcohol addictions, people with common mental health problems, and people with musculoskeletal or neurological disorders^[55].

ii. Health-led Trials: A large-scale two-site trial is being evaluated in England testing IPS for people with a range of health and disability-related barriers referred from health, care and other settings. These were funded by DWP and NHS England and commissioned and delivered via two Combined Authorities in the West Midlands and Sheffield City Region;

iii. Supported Employment Proof of Concept: Supported employment for people with a learning disability, autism, or mental health issue. Funded via DWP outcomes payments in addition to local funding. Commissioned and delivered by Local Authorities;

iv. Reducing unemployment rates of people with drug and alcohol dependency: Public Health England are currently trialling an IPS service for clients with substance misuse issues across seven sites. Mental Health and Employment Partnership has also commissioned an IPS service across eight boroughs of West London. This service has been running since January 2019 and has supported upwards of 26% of clients into work;

v. Prison leavers: A small pilot project by the Centre for Mental Health in eight West Midlands prisons from 2013-16 supported 39% of its participants into work with IPS (21 people out of 54 who engaged)^[56]. This backed up the findings of a US-based Randomised Control Trial of IPS for people with criminal justice involvement, in which 31% of those receiving IPS found work compared to 7% receiving alternative support^[57];

vi. Disadvantaged young people: A recent report by IES highlighted the potential to trial IPS for younger people with additional needs^[58].

vii. Veterans: An IPS service for clients with veterans was piloted in Lothian between February 2016 and January 2017. By month nine of the pilot, the service had supported 54% of the active IPS caseload into paid employment^[59].

In most of these trials, the IPS Fidelity Scale was used to measure service performance even where there was no possibility or intention of integrating employment specialists into mental health teams. Instead of modifying the scale, it is helpful to apply flexibility around how certain elements are interpreted to capture the spirit of the eight core principles of IPS in different contexts.

This emerging evidence base suggests that IPS could be delivered effectively as part of a programme such as FSS to meet the needs of a wide range of people with additional barriers to employment. The benefits of IPS can still apply even if employment specialists cannot be integrated into mental health teams and the cohort is widened beyond those with severe mental illness.

7. However, the FSS experience so far highlights some of the challenges of commissioning IPS as part of mainstream provision

Conversations with FSS providers, sub-contractors and programme management staff have identified three main categories of challenge with the current contracting structure:

1. Service specification

The FSS contract has relatively high-level references to IPS, including a summary of the eight principles and a requirement that employment specialists have training and experience working with people with mental health conditions. There are contractual targets based on provider bids around the proportion of outcomes that should be achieved for all clients, but there are no targets for IPS delivery specifically. There are also no minimum requirements for the number of IPS Employment Specialists provided. Given the lack of experienced IPS providers in Scotland and the up-front investment required in training and developing employment specialists, there would be value in a more detailed specification of the service and outcomes required for IPS delivery.

2. Funding model

70% of the contract value is funded on payment-by-results (PbR) based on sustained job outcomes. Therefore, providers' perceptions were that the PbR element was very significant for their income. This makes providers hesitant to make significant up-front investments in intensive support services, such as IPS, if they are reliant on long-term outcomes payments to recoup them. Specific challenges with the funding model included:

• IPS benchmarks suggest around 50% of clients enter into part time work initially (under 16 hours per week). Although FSS contracts recognise the value in helping clients to start in a part-time job, payments are only made for job outcomes once the client works over 16 hours per week;
• For some providers, the 52-week sustainment outcomes are paid at the highest rate of all the outcomes. However, job sustainment rates are currently lower than forecast, causing a drop in their income. It should be noted that providers were able to set their own payments across each of the job sustainment periods so there is variation among providers. Some providers noted that it is difficult to evidence long term outcomes as clients choose to move on from the service once they are working independently.
• There is concern that the targets used to set the PbR rates will no longer be realistic in a COVID-19 economic environment. For the year April 2020 – March 2021, FSS providers are being paid on a Cost-Plus basis, to cover all operating costs and provide more financial certainty while outcomes may be impacted due to COVID-19.

3. Performance management process

Some providers noted concern with the KDI system of targets, as service credit deductions are made to outcomes funding if these are not met. There are 19 contractual KDIs which are used to monitor providers, define how to supply services and within what time frame different steps should be taken. There are many mitigations in place – for example, providers are only fined for cases that are reviewed and fail to meet standards and mitigations are allowed if case notes explain why the KDI was missed. However, conversations with some providers suggests that the fear of punitive KDI deductions may disincentivise services from working with the most vulnerable clients where KDIs may be challenging to meet.

Provider Capacity Building

Interviews and reviews with providers have identified that all providers have a well-established, well led employment team. Their ways of working map well to IPS delivery in principle. This includes weekly employment team meetings, peer support sessions, providing coverage for other people's caseloads, sharing potential job leads with each other and working through strategies that can be used with hard to place individuals.

However, our experience shows that shifting a delivery model to IPS requires Provider (and the local Mental Health) senior management commitment and focus with a clear change plan for a shift in systems, processes, skills, and culture. There is often a bigger gap between IPS and non-IPS delivery than providers expect. This means that, even where providers understand the IPS principles and have tried to apply them at a high level, an independent fidelity review will often produce relatively low scores. This is what we have found in our reviews of FSS providers, with only 1 lot delivering IPS at fair fidelity (see Annex A).

As part of our fidelity reviews, guided self-assessments and interviews, we have provided all providers with coaching on the IPS model. We have also followed up with each provider individually to share the full fidelity report and to clarify any issues of understanding around the model.

For a provider to develop IPS capability as an addition to their business as usual approach, we would recommend they create a separate team with an implementation or delivery manager. They need to engage and build collaborative working with the local Mental Health Services. There is a wealth of free resources available online, including an e-learning programme for employment specialists, that can support this transition. Some providers may also need additional technical assistance (see recommendation section below).