Doing Well, Working Well

1 Doing Well, Working Well, June 2013

DOING WELL,

WORKING WELL

How can we help people to overcome

health issues and enter employment?

September 2013


CONTENTS INTRODUCTION................................................................................................................................. 3

Aims and objectives ....................................................................................................... 3 Methodology ................................................................................................................... 3

SUMMARY FINDINGS ......................................................................................................................... 5 1. HEALTH, WELL-BEING AND EMPLOYMENT ............................................................. 6

Work has health and wellbeing benefits ................................................................... 6 Specific needs .................................................................................................................. 6 A significant policy challenge ....................................................................................... 7

2. LEARNING FROM EXPERIENCE ............................................................................................... 11

Results ............................................................................................................................ 11 Camden experiences................................................................................................... 13

3. CURRENT HEALTH PROJECT ................................................................................................... 14

Target group ................................................................................................................. 14 Activity ........................................................................................................................... 15 Staff ................................................................................................................................. 16 Outcomes ...................................................................................................................... 17

4. RECOMMENDATIONS ................................................................................................................ 18 USER JOURNEY .................................................................................................................................. 22


INTRODUCTION Health problems present a serious barrier to those seeking employment. Conversely, periods of unemployment have a strong negative effect on health and wellbeing. This link is consistent across academic research and in Tomorrow’s People’s experience of helping people into work since 1984.

This report’s purpose is to analyse the most effective way to help those facing health issues to find and keep a job.

It is the first time Tomorrow’s People has drawn together existing research, the experience of our past health-focussed programmes, our current project to address health and wellbeing issues, and our participants’ experiences. This enables us to gain the clearest possible idea of what is necessary for future interventions in this area.

Praxis, the research and innovation unit of Tomorrow’s People, has compiled this report to inform the charity’s project development.

Aims and objectives The over-arching aim of this report is to inform a programme of work to help those with health and wellbeing issues to enter employment, education or training. Our objectives are to establish the key elements of such a programme: the beneficiaries to target, the partners to work with, the job specifications for any staff involved, the outcomes to achieve and the specific activity to take place.

Methodology We decided that the best way to achieve these objectives was to ask people from a range of different backgrounds to share ideas and knowledge about what works, what’s needed and what can be done to help. Our aim was to speak with policy experts, local authority representatives, health professionals, major employers, delivery staff, end users and service designers, to understand the issues and to work together to deliver the best possible response.

As a result, the focal point of this research was a two-day ‘innovation forum’ held at the James Wigg Practice, Camden in March 2013 (pictured left).


A short literature review preceded this forum. The general link between health and employment being well established, the aim of the literature review was to understand the nature of the causal links between health issues and unemployment; to identify the greatest needs; and to begin to understand the context for work in a specific locality. This guided the specific questions put to the forum, which were:

• What is the link between health and unemployment?

• How can those with mental health issues find the support needed to enter employment?

• How could employers accommodate health concerns in their recruitment process?

• How can a new service compliment and connect with existing services in Camden?

In three sessions, the forum focused on the national research and policy context, the situation local to the James Wigg Practice as an example of a potential project location, and the design of a delivery model. DAY ONE DAY TWO

The forum spoke with staff and former service users about the Camden project specifically. However, we felt it appropriate to update this knowledge with a current project visit and interviews. This involved a visit to Knowsley, where we met service users and staff members who work on ‘Knowsley Positive Progress’, an intervention programme that involves GP surgery-based outreach. In the following four sections this report outlines the research and policy context for work to address health and unemployment, and reflects the conclusions of our literature review and the first session of the forum. It analyses our past projects co-sited with GP surgeries. This is based on our internal review of Tomorrow’s People’s work and on discussions with stakeholders, staff and service users at the forum. We also assess a new Tomorrow’s People project based in Knowsley, which works to help those with health problems but is not centred on GP surgeries or health centres. It discusses the structure and distinctive features of this project, and its experience so far. Finally, we make our recommendations for any future health and unemployment work, based on the understanding gained from the preceding three sections. This includes our user journey that visualises the support mechanism and process of engagement with programme participants.

The national policy context

Gauging existing local

services

Designing a model

for delivery


SUMMARY FINDINGS

1. The voluntary sector is well placed to offer a trusted service that is distinct from statutory welfare provision, more personal than a clinical treatment, and independent of policy reforms. This form of support is replicable across different communities and is situated in locations that participants are familiar with and undaunted by.

2. The service must act as bridge between the worlds of health professionals and social welfare. Doctors and community psychiatric nurses cannot be expected to target employment outcomes or understand the health implications of every welfare reform. A new service should actively share knowledge between employability support and health professionals.

3. An active conversation between an advisor and service user leads to real improvements for patients. If employment is to be an outcome, an advisor needs to act as a coach rather than a counsellor, developing a purposeful and constructive dialogue.

4. Group work helps users to progress. A move from individual advice to peer support networks must be an option as users build their confidence and motivation.

5. Employment is not the sole outcome that marks success in this type of initiative. A programme must recognise a range of outcomes for those who are not ready to work, but who are helped to want to work.

6. Employers are not health experts, but they can be informed about what they can do to support job retention and to recruit those with health issues. Small employers in particular need to be engaged.

7. An integrated service is needed to link users to a range of existing specialist services. A “one-stop shop” is the wrong approach; what users need is a personal relationship with a single contact who can signpost other services through ongoing support with a personal advisor.


1. HEALTH, WELL-BEING AND

EMPLOYMENT

Work has health and wellbeing benefits

It is clear that a move from unemployment into work has benefits for health and wellbeing. The Department of Work and Pensions’ 2006 literature review, “Is work good for your health and wellbeing?” established that work was directly beneficial to health, even after taking into consideration other factors.1

A transition out of employment to unemployment or inactivity leads to psychological distress. Conversely, any transition from worklessness into an activity, whether employment or volunteering, has a positive impact on psychological health and wellbeing.2 However, a prolonged period of insecure employment is as harmful as unemployment: the risk of poor psychological wellbeing is increased by 70% in either case.3 It is secure, paid employment that offers the real boost to wellbeing. Tomorrow’s People’s research on early intervention pointed to the long-term “scarring effect” of youth unemployment.4 We now see that these effects include health outcomes: the London Health Commission found that non-participation of young people in education, employment or training between the ages of 16 and 19 is a major predictor of later unemployment, depression, and poor mental health.5 The effects are seen in all age groups. Among those aged over 50, even a short period of unemployment increases the risk of a heart attack as much as smoking.6

Specific needs

To develop the best approach to improving health and employment, it is important to understand individual issues. Physical conditions present a serious challenge to significant numbers of people who wish to enter or re-enter the labour market. Certain aspects of work can add to the risk of musculoskeletal symptoms (such as back pain). Yet this is a common experience and need not present a lasting barrier to employment. Activity-based rehabilitation and early return to work (or remaining at work) are therapeutic and beneficial to the health and wellbeing of most workers with these conditions.7


There are 560,000 people with cancer in the workforce. 63,000 of these want to work, but are held back by the barriers to employees and employers.8 Employer support, such as transitional work arrangements and improving communication between health care and the workplace, can facilitate early and sustained return to work for those with physical conditions.9 Mental illness and wellbeing are of particular concern for any intervention. Mental health problems are prevalent among the working-age population regardless of employment status: one in three of the working age population experiences mental illness or its symptoms at some point.10 To those out of work, it is an even greater concern: unemployment is linked to overall mental health, mixed symptoms, depression, anxiety, psychosomatic symptoms, reduced subjective wellbeing and reduced self-esteem.11 The effect of unemployment on wellbeing varies by area. Perhaps surprisingly, it is a more distressing experience for those in areas of high employment.12 This is possibly because of the increased loss of status for those whose social groups include many people in employment. Turning to more serious mental health conditions, there is evidence that when unemployment develops into serious long-term social exclusion, there is an increased risk of schizophrenia.13 Conversely, people with schizophrenia in paid employment are over five times more likely to achieve functional remission than those who are unemployed or in unpaid employment. Some of those with schizophrenia could enter employment with correct support. Yet 70% have experienced discrimination, and there are indications that employment is often not considered as an outcome by clinicians.14

The relationship between mental health and unemployment is understood to be highly complex, with many interacting factors affecting the risk of various health and employment outcomes.15 A programme of work will need to take an approach that begins to address both problems, and appears unlikely to succeed in solving health or employment needs in isolation from each other.

A significant policy challenge

As might be expected, the interaction between health problems and employment status presents a serious policy challenge. That it has a significant impact on government spending can be in no doubt:

• There are 1.27 million people on Employment and Support Allowance (ESA). As the replacement for Incapacity Benefit, ESA is given to those who need extra support to enter employment and those whose health issues mean they are unable to work.16

• The total spend on ESA or Incapacity Benefit was forecast to be £9.3 billion for 2012/13.17


• 300,000 a year go from work to welfare because of health-related issues.18

• The estimated annual cost of sickness absence and health-related worklessness is over £100 billion.19 It has not been established how much of this could be recovered.

A detailed analysis of the issue is contained within Dame Carol Black’s 2008 health review, ‘Working for a healthier tomorrow’.20 It further outlined the scale of the problem as a policy challenge and found that employment helps many people to recover from ill health by providing structure, social interaction and a sense of purpose to an individual's life. Among other things, the Black review recommended a switch from sick notes to “fit notes” to focus on what people can do.

Following the Black review, 11 Fit For Work Service pilots were established. The programme aims to provide personalised support for those who are in the early stages of sickness absence or ill-health. The Department of Work and Pensions’ (DWP) first evaluation of the pilot found that most service users were in work and trying to avoid a period of absence.21 Users had multiple needs, including health problems, personal difficulties and poor relationships with employers. However, the programme had difficulty in engaging with small employers, and more importantly, does not target those furthest from the labour market, who have experienced health problems in the long term. For this group, state provision has been a more mixed picture. In 2008 Work Capability Assessments were introduced to assess whether those on health-related benefits are able to enter work. In the period between March 2011 and March 2014, all those on incapacity benefit, income support, or severe disability allowance will be asked to take part in Work Capability Assessment. By August 2012, 742,000 claimants had undergone the assessment.22 Government-commissioned reviews of WCA have called for greater empathy and communication with clients, and less mechanisation in the process.23 This, along with the negative public perception of the assessments, indicates that helping those with health issues into employment cannot be a task for Government alone.24 There is an important role for voluntary sector organisations in providing support outside of the WCA process.

Understanding wellbeing

Accepting the benefits that work can have on wellbeing, we sought to understand the concept better. The frequent use of the term in public discourse often mixes the achievement of wellbeing with its definition. For example, the premise that being in work improves wellbeing supports the idea that financial independence, raised self-esteem, improved social capital and access to networks all lend themselves to the definition of the concept.


While we don’t doubt the benefits that being in work brings, we were also interested in the way that improved wellbeing could be enhanced in order to improve an individual’s progression into work, as well as their subsequent capacity to sustain work.

When working with the participants of our programmes, Tomorrow’s People advisers encounter a range of social and economic barriers to work. These collective experiences are recognisable in The State of Happiness conducted by the The Young Foundation.25 The key measurement criteria they delineate offer a useful framework for our work. Both their ‘domain-based’ and ‘targeted’ approaches to wellbeing measurement offer a codified starting point for our advisers in their attempt to tackle barriers that people may face.

More targeted wellbeing support is given greater attention in the same organisation’s later Who is Going to Employ Me? report, where improved resilience is examined in relation to routes into employment. These findings promote interventions that align to activity that Tomorrow’s People has put into practice for several years:

• Strategies to enhance self-esteem / resilience

• Participation in community based activity

• Development of skills / employment support.

Individual Placement and Support

The evidence shows that employment is beneficial for health and well-being. Internationally, there is one well-evidenced way to help those with mental illness into paid work: the Individual Placement and Support (IPS) method, developed and examined by Dartmouth College in the US. It includes the following elements:26

1. It aims to get people into competitive employment 2. It is open to all those who want to work 3. It tries to find jobs consistent with people's preferences 4. It works quickly 5. It brings employment specialists into clinical teams 6. Employment specialists develop relationships with employers based

upon a person's work preferences 7. It provides time unlimited, individualised support for the person and

their employer 8. Benefits counseling is included.

The Young

Foundation’s

‘domain

approach’ to

wellbeing:


Taken as a whole, this set of principles for the IPS method has been found to be an effective way to maintain or increase health improvements, while supporting individuals to enter employment.27 However, on the individual points of (5) how to integrate employment professionals into clinical teams, (7) how to time-limit support and (8) whether to offer benefits counseling the evidence is less clear.28 In these important areas, the debate should continue.

Studies into IPS provide extensive evidence of the fact that helping people into work can lead to outcomes across the areas of health, well-being and employment. However, given that elements of the model remain unproven and that IPS has been developed and studied solely from a psychiatric perspective, we propose to turn now to Tomorrow’s People’s experience to gain a more informed idea of the optimum approach to take with our service users.


2. LEARNING FROM EXPERIENCE

Tomorrow’s People began work with GPs in 2001, as one element of “Getting London Working”, a DWP-funded programme. The projects carried out in GP surgeries proved so successful that Tomorrow’s People continued a partnership in Camden, with James Wigg Practice and other surgeries. This project saw Tomorrow’s People advisors located within GP surgeries and health centres, accepting referrals from GPs. Service users were patients who faced health issues and were not

in employment. The Tomorrow’s People service was distinct from health provision and to Department of Work Pensions activity. It provided ongoing one-to-one support, information advice and guidance to users. It helped them first to build their confidence and then to enter employment, education or training.

Results

A 2005 evaluation of work in the James Wigg Practice (JWP) found that:

• Tomorrow’s People’s advisor spent on average 22 hours with each user;

• There was a £3,694 saving per participant, in terms of benefits saved and additional tax receipts generated.

• The cost per job achieved by the programme was £2,385, significantly better than comparable models;

• There were substantive reductions in appointments with GPs, counseling sessions and prescription costs.

Dr Roy MacGregor championed GP surgeries-based employability support at the James Wigg Practice for over 10

years


Wider reception

The programme went on to receive extensive media coverage.

“At the James Wigg Practice in Kentish Town, north London, a novel new approach to the issue is under way, and it looks as if it is succeeding where others have failed.” Guardian, 14th July, 2004

“[Tomorrow’s People adviser] Farouk Noor need only act in his clients’ best interests. Why not a Farouk Noor on hand in every surgery? Here is an example of charity can innovate and the voluntary sector can provide an excellent service, but to make it available to all who might benefit, state financial support is vital.” Polly Toynbee and David Walker, Unjust Rewards, 2008

“Dr Roy Macgregor’s practice had been hailed in Parliament as a Government pilot to introduce job consultants in practices. In fact, the scheme has nothing to do with the Government. Dr Macgregor initiated it three years ago at his Kentish Town practice with employment charity Tomorrow’s People.” Doctor, 8th February, 2005

Trade publications including Practice Management, Third Sector, Working Brief, and New Start carried reports on the programme. Coverage highlighted the advantages to health professionals of savings in appointment reductions, counselling time and pharmaceutical costs. The programme soon had a waiting list of 400 GPs who had expressed an interest in having a Tomorrow’s People advisor located on their sites. In addition, Tomorrow’s People received inquiries from other organisations, including Primary Care Trusts, local authorities, the Department of Health, Strategic Health Authorities and a number of smaller local organisations. By the end of 2009, Tomorrow’s People advisors worked in 44 surgeries and medical centres, in contact with 235 GPs, representing 250,000 patients. This work was based in London (in the Boroughs of Camden, Islington and Tower Hamlets), Knowsley, and Bristol. From 2010 onwards, the number and range of sources of funding for this programme (with 83 separate contracts funding by a mixture of Regional Development Authorities, Local Authority and central government funds) and the unfavourable economic climate meant that the programme became impossible to sustain.

“Whitehall is so impressed it plans to set up a pilot scheme in imitation. But officials will face the conundrum government always encounters: transferring the principles from the voluntary to the public sector without destroying the flexibility that makes it work.” Financial Times, 20th January, 2005


Work continued in Camden & Islington until 2011 and now continues in Knowsley in a different format, detailed in the next section.

Camden experiences

The James Wigg Practice in Camden, with 15,481 patients and 16 GPs, was the largest practice involved; indeed, it is among the largest practices in the country. Its extensive involvement with the project, together with its size, makes it a sensible focal point for understanding the past programme’s success factors.

The project reached an especially disadvantaged user group: 85% were long-term unemployed. Simultaneously, there was a much broader mixture of social backgrounds than in the group Jobcentre Plus reaches. Some 75% were self-referred. The outcomes for these users reflected national success: 36% secured employment, and after 12 months, 80% were still in employment. JWP saw 70% fewer referrals to counseling. After the withdrawal of funding, regular patients at the surgery who had benefitted from Tomorrow’s People support self-organised to request the return of the project. Having been supported individually in the past, this was the first point at which the service users acted as a group.

Our forum identified a number of distinguishing problems that persist in the Camden area:

• Isolation is an increasing problem. Some organisations are meeting service users who cannot even name a next of kin.

• Camden has high levels of inequality. It has the second worst health inequality in London. The council’s new Equality Taskforce will look at the issue.

• Early intervention approaches are under pressure during the recession, as resources move instead towards crisis response. The council’s prevention budget has been cut from £7m to £3.5m.

• Camden Council’s key priorities are work with complex families and building healthy lives. With regard to unemployment, the council is most concerned about the levels of maternal unemployment and BME unemployment.

Camden’s particular set of problems offers an example of one set of local needs which future work must meet. The next section discusses the experience of Knowsley, Merseyside, where 24 surgeries worked with Tomorrow’s People in 2009 and where a new project was launched last year. Analysing the work done in this context helps to draw out the key features of any effective new programme.


3. CURRENT HEALTH PROJECT

Tomorrow’s People currently delivers Knowsley Positive Progress (KPP) in the borough of Knowsley, Merseyside. The project started in October 2012 and employs two staff.

The model was developed based on lessons learned from a project based in GP surgeries and other community venues in Knowsley between May 2006 and December 2010. This GP-

centred project worked with 40 GP surgeries, engaged with 850 people and helped over 50% to achieve an employment, training or volunteering outcome.

Feedback showed that beneficiaries appreciated the one-to-one support that was provided and were more willing to engage with Tomorrow’s People as a dependable intermediary because they understood that it was separate from mainstream or statutory provision. Users appreciated the community-based outreach environment of the service delivery, as it was flexible, accessible in a known and familiar location that offers discretion and met their varying needs.

Funded by Big Lottery Fund to run until 2016, KPP’s most significant difference from previous health projects is that GP surgeries are not the main location for reaching users.

Target group

KPP sets out to work with anyone who (1) has a health problem and (2) seeks a volunteering, training, education or employment outcome. Given the second condition, the project works best with those with some motivation or need to change their situation, even if they are far from the labour market or have no specific plans in mind. It has not proved suitable for those who have no desire to engage or plan their options.

Knowsley is the fifth most deprived Borough in England with around 50% of residents living in some of the most deprived neighbourhoods in the country.29 Around 12,000 people in Knowsley receive health-related benefits, of whom 4,000 receive no support from the work programme.30 Those whose health issues require specialist support and would normally be expected to receive Employment and Support Allowance, but KPP works with many people on Jobseekers’ Allowance who are referred by Jobcentre Plus. These people have needs that are unmet within the current statutory framework.


Activity

“Other providers deliver qualifications but no support to get into work.

TP adviser discussed options with me and helped me map out a sensible

way forward. Voluntary work was an important part of that.”

Knowsley service user

At the project’s outset, a four-stage user journey was designed.

1. Users receive an initial assessment, agreed Action Plan; one-to-one

Information, Advice and Guidance; and support in employability skills and job search (including CV production).

2. Users receive soft skills development support including confidence, motivation and positive attitudes. For those furthest from the labour market, the first step is usually to get them on a specialist training or confidence course which will involve practical activities. This has to precede entry into the labour market.

3. Users are signposted to additional support including support to overcome barriers, training, accessing voluntary work and work experience.

4. Advisors maintain contact once an outcome is secured and offer in-work aftercare to sustain employment.

The first two stages of work are the most substantive. During this period, users are given tasks akin to the ‘homework’ that was an important part of the James Wigg Practice model. These give users a way to track their progress and have a sense of achievement. Tasks include:

• CV work

• Application forms

• Internet tasks and research

• Job search

• Understanding child care options

• Open Learning

• Financial management

• Discussing specific issues with JCP

• Making progress in their personal relationships.

Referrals come from a range of sources. Though all users experience health issues, most of the referring organisations are not health-specific:

• Jobcentre Plus

• Knowsley Housing Trust

• Alcohol Service Knowsley (an NHS service)

• Two GP surgeries

• Two hostels

• A community centre

A good relationship with Jobcentre Plus advisors is key to securing significant numbers of referrals from this source. One KPP advisor spends a morning each week in Huyton Jobcentre registering new users. This centre is considered above average in the relationship it has with claimants and with voluntary sector organisations.


In contrast to previous Tomorrow’s People projects, GP surgeries have not been the principal source of referrals for KPP. The project’s relationship with the surgeries is growing and it plans to extend its referral network to five practices in total. However, a high level of staff turnover in the practices has hampered efforts to make GPs aware of KPP’s work. It is felt that relationships with reception and support staff may prove to be more important than those with individual doctors.

The referral picture, then, is the reverse of what might be expected in other areas where relationships with GP surgeries prove easier to cultivate than those with Jobcentre Plus. KPP’s experience shows that any health project model must identify its target users, and then determine referral routes according to local circumstances.

“Clients coming through drug and alcohol team referrals are not job ready. From there it’s about change, it’s about confidence, it’s about motivation.” Tomorrow’s People advisor in Knowsley

KPP advisors have felt that a move toward group work and building peer networks would be helpful to users - a conclusion they reached during the course of their work to support beneficiaries. Staff decided to run a women’s job search fair and a confidence course for women. This is to enable participants to form their own networks, learn about each other’s needs and plans, and support each other’s job search. Advisors have fixed office space but work throughout the borough of Knowsley. They regularly use locations such as hostels and the Jobcentre as bases, but are also able to meet users in a neutral space where they feel more comfortable, such as cafés.

Staff

The two staff are both called Personal Advisors. It was felt that this job title conveyed the active coaching role they played, without limiting them to employment advice as the title Job Advisor does.

Their relationship with users is similar to that discussed in Camden. Their role gives them more room to build a long-term relationship than Jobcentre Plus staff might be expected to have. They have an informal and personable approach, within the framework of regular meetings and setting goals against an action plan. They see their role as very different to that of a counsellor, with an open two-way conversation essential to their work.

“For me, the informal way it worked was the important point. It gave me the impetus to start. Some people sit behind a desk, but it was the fact that we could sit and talk to each other.” Knowsley service user


“JCP weren’t encouraging me to back to work as I am a carer. The first appointment with Nikki was completely different, she looked at what qualities I had to offer and encouraged me to think about myself.”

Knowsley service user

One staff member’s background was in working with Jobcentre Plus on the New Deal for Disabled People, the other in working on Tomorrow’s People previously Knowsley GP-based work. As such, the advisors had extensive experience of working with unemployed people with complex needs.

Outcomes

Knowsley Positive Progress tracks a range of outcomes for users, listed below.

• The fundamental outcome is the number of people experiencing general improvements in motivation, confidence, skills and qualities required to enable them to move into the labour market (moving closer to ''job readiness'').

• Number of people finding work, assessing their financial situation or personal well being as ‘improved’

• Number of people moving off benefit and into employment

• Number of people finding work and sustaining employment for 6 months assessing their health or self esteem as ‘improved’

• Number of people finding work and sustaining employment for 6 months re-assessing their financial situation or personal well being as ‘improved’

• Number of people moving off benefit and into employment and sustaining employment for at least 6 months

• Number of people accessing training or further education opportunities

• Number of people accessing volunteering opportunities

• Number of people showing positive attitudes to volunteering, training or further education evidenced by accessing volunteering, training or education

While employment is a key outcome for KPP, its most substantial target is to get over 300 people into volunteering, training or further education. Advisors recognise these routes out of unemployment as the most important first step for those furthest from the labour market. Volunteering was also specified as an important outcome by past service users at the James Wigg Practice.

Six months on from its launch, Knowsley Positive Progress has far exceeded its targets for helping people into education, volunteering or training. Employment outcomes have been on track or slightly below target in this initial period. This underlines the wisdom of an approach that helps users to become work-ready, rather than aiming for an immediate employment outcome. Work-readiness can here be seen to include ‘soft’ outcomes such as confidence and motivation, and the hard outcomes of entry into education, training or volunteering.


4. RECOMMENDATIONS

These recommendations represent the conclusions of our discussions at the expert forum, our literature review and our extensive experience of running health-related interventions. They are designed primarily to inform future work by Tomorrow’s People but should inform the work of

other voluntary sector organizations, policy makers and health professionals.

A service must be trusted by its users

• The success of the previous service was the trust that came from being based in the GP surgery. The familiar setting helps to engage people on their own terms, in a situation they feel comfortable with. The advisor needs to facilitate an active conversation

• The approach should be an active discussion rather than an opportunity to have someone ‘listen to your problems’. The advisor should be able to be an active coach / challenger as well as a good listener.

• The advisor’s personality is central to maintaining a non-judgemental, approachable service.

• The advisor can make the project an engaging experience for the user by continuing the current practice of using an action plan to track progress and to mark the achievement of specific tasks and goals. Past service users rated “homework” style tasks as important steps in building confidence. A civic or community body can make a unique contribution to health and wellbeing

• Many of our contributors thought the project’s advantage was to be a source of stability and wellbeing set apart from statutory services.

• It is suggested that this role was once fulfilled by the church, and that with the decline of religion a need has grown.

• Tomorrow’s People, as a voluntary organisation set apart from health professionals and the DWP, can go some way towards meeting this demand. A new service needs to take a scientific, co-ordinated approach

• A multitude of existing services aims to reach the users any health-based employment programme would target. It is essential that no duplication takes place and that existing services are utilized effectively.


• To prevent duplication, each agency needs to be devoted to a specific task within the network of services.

• The previous project, though it achieved consistent success for service users, faltered because of the range of funders and contracts with which it operated. Designing a clearer, more evidence-based programme will go some way to mitigating this risk. Services should be integrated, but with a single relationship for the user

• Our previous work could have been better integrated with services offered by clinical professionals. This would mean that an employment advisor doesn’t have to take care of every problem and shouldn’t try to be a “one-stop shop”. They could instead act as a single point of access, to identify other relevant services. A user can build a relationship with one worker much more easily than with an entire network of services. Yet people must not divert all their needs to one person.

• Our Maidstone project has a “drop-in job shop.” Its great advantage is in being a light-touch, open service.

• Camden Council is increasing co-location of services. This forces services to ensure they are working together and each doing distinctive things. Those with mental health issues are a particularly important group

• People are coming to GPs with anxiety symptoms much more than they used to. Dr Roy MacGregor identifies this as the most significant change in patient behaviour in the past generation.

• Those with moderate mental health issues responded much better to the Tomorrow’s People service than to anything current DWP-led provision.

• Therapies by professionals look at what’s behind certain issues. Practical advisors can be important in dealing with the consequences of these issues and signposting to clinical therapies where necessary.

• We need to account for those who are too far from work-readiness to enter employment in the near future. To take Camden as an example, an estimated 15% of those using the current Mental Health Working service will not be able to get into work. GPs need to understand how welfare reform relates to their work

• Welfare reform has a relationship to mental health needs.31 The relationship is not clearly understood by GPs as part of their routine work, but Clinical Commissioning Groups should be concerned to look at the overall relationship between welfare, unemployment and mental health.

• Responsibility for public health has been transferred to local authorities, which presents an opportunity for a local approach to addressing wellbeing, health and employment together.

• Employment is not recognised as an outcome for clinicians to target. Similarly, the Work Programme doesn’t reflect health outcomes for those who need this help. We need to make a better connection between Tomorrow’s People-style work and clinical outcomes.


• A new service could act as an interlocutor between GPs and welfare issues.

• GPs are caught between their role as police officers (preventing people from claiming benefits falsely) and helpers (giving people the certification they need). Group work is a suitable progression from individual support

• The experience of Camden’s patients following the withdrawal of Tomorrow’s People’s service, and the decision by KPP staff to create informal networks among users, indicates the potential for group-based work.

• A progression into group-based work would be a positive step for those who do not benefit from an indefinite period of one-to-one support.

• Tomorrow’s People’s youth programmes could be a progression route for young people who have overcome some of their health issues. Working It Out works with groups of fourteen young people for ten weeks; its locations include three London boroughs and Merseyside. Employment is the ultimate objective, but not the immediate goal.

• Though employment has been shown to improve health significantly, it is not always feasible or sensible as an initial outcome. Past and current work has taken this into account.

• Recommended outcomes to target include:

• Confidence

• Motivation

• Volunteering

• Education

• Training

• Employment

• Employment sustained for six months

• Health and active living

• Integration with the community

• Job retention and unemployment are separate issues requiring different approaches. For cancer sufferers, job retention is the main issue. For those with mental health problems, gaining access to the labour market is a problem.

• GPs currently target outcomes such as blood pressure and cholesterol. To move to looking at employment outcomes would be a huge step. They would be resistant to changing their role. Thus the easiest approach is to have an employment advisor in their locality or building.

Employers need to be equipped to address health concerns

• We can’t expect employers to be experts, but we can advise them. Employers may understand that they need to look after employees’ health and wellbeing but not know how to go about it or not know how to quantify the benefits to the business. Employers often don’t understand exactly how to recognise depression and anxiety.

• Large employers can work with health issues, but it’s harder for small ones. It shouldn’t be seen as CSR but as business responsibility.


• Individuals need to know their own needs and rights, in order for all this to work. Legislation is currently being drafted to bar discrimination on the grounds of mental illness.

• The market benefit to employers of overcoming health issues needs to be as clearly articulated as possible.

The policy environment is going through a period of change, and there is a role for specialist voluntary sector support

• The Work Programme structure hasn’t proved right for those furthest from the labour market. The time and expertise needed to help people with health issues into employment is not available. 50% of Work Programme clients with disabilities are only on JSA and have no recognised health issues.

• Separately from the Work Programme, 75% of claimants are with Jobcentre Plus. Many of the referrals to KPP are from Jobcentre Plus and have often had no previous specialist support.

• Increasingly, local organisations are finding that contracts go to larger ‘prime’ organisations. Payment by results contracts are hard for smaller bodies to take on by themselves.


USER JOURNEY

Our recommendations are best understood in the context of a new programme design, presented in the user journey below.

1. Patients access support from their GPs via a health centre / surgery, where their physical and mental health is assessed and their capacity to work is determined through consultation with GPs and psychiatric nurses. 2. If appropriate, patients are referred to a Tomorrow's People adviser, based in the centre. Working in consultation with the clinical team the adviser learns about the barriers faced by each individual. A combination of coaching and signposting is used to build a personal plan towards employment for each individual. This plan accounts for a range of

barriers or issues that they face in their life. 3. Participants and advisers work together to identify and address issues that may impact upon their well-being. This may include relationship advice, housing / accommodation support, community integration, financial advice or security / safety concerns. This is done through signposting and guidance. 4. A peer network of programme participants is facilitated to encourage progression and personal development away from the adviser. These groups can run alongside and independently of the proposed programme of work. 5. Tomorrow's People advisers work with participants to identify the right progression route. The aim is to move to employment, but for some it may be that the first step will be in voluntary work, training or further education.


ACKNOWLEDGEMENTS

We would like to thank: All participants in our innovation seminar, especially previous participants who shared personal stories with us The James Wigg Practice for facilitating our seminar and Dr Roy Macgregor for supporting this research

Tomorrow’s People staff and project participants in Knowsley for sharing their experience of Knowsley Positive Progress APS Group for printing this and our other Praxis reports

Report Authors

James Magowan, Director of Strategy

Ronan McDonald, Research & Policy Officer


NOTES 1 “Is work good for your health and well-being?”, Waddell and Burton, DWP, 2006 2 “Employment transitions and mental health: an analysis from the British Household Panel Survey”, Thomas, Benzeval and Stansfeld, Journal of Epidemiology & Community Health, 2005 3 Flint, ES (2012) “Investigating the relationship between labour market status and minor psychiatric morbidity: Longitudinal and spatial analysis of the British Household Panel Survey, 1992-2008.” Doctoral thesis, University College London. 4 “The Early Bird… Preventing Young People From Becoming A Neet Statistic”, Britton, Gregg, Macmillan and Mitchell, 2011 5 “Fair London, Healthy Londoners?”, London Health Commission, 2011 6 “The Cumulative Effect of Unemployment on Risks for Acute Myocardial Infarction”, Dupre, George, Liu and Peterson, Archives of Internal Medicine, 2012 7 “A systematic review describing the prognosis of chronic fatigue system”, Cairns and Hotopf, Occupational Medicine, 2005 8 “Can Work, Will Work”, Oxford Economics Foundation, 2012 9 “Women with fibromyalgia: work and rehabilitation”, Henrikssen, Liedberg and Girdle, Disability and Rehabilitation, 2005 10 “Working our way to better mental health: a framework for action”, Department of Work and Pensions and Department of Health, 2009 11 “Unemployment impairs mental health: Meta-analyses”, Paul and Moser, Journal of Vocational Behaviour, 2009 12 Flint (2012) 13 “Hypothesis: Social defeat is a risk factor for schizophrenia?”, Selton and Cantor-Graae, The British Journal of Psychiatry, 2007 14 “Working with Schizophrenia: Pathways to employment, recovery and inclusion”, Bevan, Gulliford, Steadman, Taskila, Thomas and Moise, The Work Foundation, 2013 15 “The four dimensions: a model for the social aetiology of psychosis”, Shah, Mizrahia and McKenzie, The British Journal of Psychiatry, 2011 16 DWP Statistics for August 2012 17 Freedom of Information Request 774/2013, DWP, 2013 18 “Fitness for work: the Government response to ‘Health at work – an independent review of sickness absence’”, DWP, 2013 19 “Working for a healthier tomorrow”, Dame Carol Black, DWP, 2008 20 “Working for a healthier tomorrow”, Dame Carol Black, DWP, 2008 21 “Evaluation of the Fit For Work Service pilots: first year report”, Hillage et al, DWP, 2012 22 “Employment and Support Allowance: Outcomes of Work Capability Assessments”, DWP, April 2012 23 “Independent Review of the Work Capability Assessment – year 1”, Harrington, DWP, 2010 24 “The Government’s Work Capability Test is Truly Shocking”, Helen Goodman, The Huffington Post, January 2013 25 “The State of Happiness”, Bacon, Brophy, Mguni, Mulgan and Shandro, The Young Foundation, 26 Dartmouth IPS Employment Centre website, last updated January 2012 27 “An update on randomized controlled trials of evidence-based supported employment.” Bond, Gary R.; Drake, Robert E.; Becker, Deborah R.; Psychiatric Rehabilitation Journal; Vol 31 (4), 2008 28 “Supported Employment: Evidence for an Evidence-based Practice”, Gary R. Bond, Psychiatric Rehabilitation Journal; Spring 2004; 27, 4 29 English Indices of Deprivation 2010, Department of Communities and Local Government, 2010 30 DWP figures for Incapacity Benefit and Employment Support Allowance, August 2012 31 “General Statement on Welfare Reform Bill”, Centre for Mental Health, Mind, Rethink, Royal College of Psychiatrists and the Scottish Association for Mental Health, 2011


Tomorrow’s People is a national employment charity. Our mission is to help people get and keep a job. Praxis is the research and innovation unit of Tomorrow’s People.

Doing Well, Working Well

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