Synthesis of Findings and Lessons Learned
Design stage of the pilot
It was seen as important to have had the right strategic people involved in the initial design stages, and in the lead up to the launch date. Those involved in the HWS pilot design had a thorough understanding of the service landscape and the requirements to create a single access point for clients, and this had strengthened the service design and implementation process.
This early buy-in from key stakeholders created a shared vision for the service. This has meant that good relationships between the different delivery partners were developed prior to implementation. This was particularly important given the short 6-month time frame between the award of funding and the launch of the pilot.
However, the design stage could have been improved by including those who would be managing and delivering the service on a day-to-day basis and by including people with lived experience in the design of the service to improve the pathways through the service and on to clinical interventions.
There were challenges with the 6-month lead-in time for the delivery of the service, although there were differing views on whether or not this was enough time to design and implement a service.
The short lead-in time was seen by many of the strategic staff who were involved as creating significant pressures on them. It had knock-on effects through to the implementation stage, resulting in a perceived lack of mutual knowledge between delivery partners, and the need for ongoing changes to refine the design and the way it was implemented.
Ongoing changes and improvements were made to the pilot after the launch in June 2018. These were based on early feedback and conversations with delivery staff. This forms part of the continuous improvement approach which it was important to adopt to ensure that the programme or service was meeting the needs of the target population as well as ensuring a high quality of delivery.
1. It is important to have a well-planned and effective lead in time, to ensure full ownership by all those involved.
2. The full range of stakeholders – including key professionals and all potential referrers, as well as those with lived experience – need to be involved to ensure buy in at the right levels
Referrals and client profile
Although both clients and referrers felt the pilot improved access to health and work support in Fife and Dundee, there were some challenges in generating referrals for the service.
Based on the Memorandum of Understanding between UK Government and Scottish Government, Key Performance Indicators (KPIs) were agreed to monitor the progress of the pilot. The target number of clients to receive support over the 2-year period of the pilot was 6,000. However, between June 2018 and March 2020, only 2,685 clients engaged (45%) with the HWS pilot.
Despite there being an anticipated demand for the service, it did not translate into numbers flowing into the service initially (as described in the Early Implementation Review). There were a number of challenges faced by both delivery teams around generating referrals, and efforts were made across the pilot sites to increase referrals through local advertising and working with employers.
3. Ensure the lead-up time is used to engage with employers, referral partners, and build relationships with partners to maximise awareness and understanding of the service before it goes live.
4. It is hard to assess the exact level of demand in advance of launching a service. Further consideration should also be given to the intensity of support required by sub-sections of the target population in addition to overall numbers.
In terms of the client profile, the pilot initially aimed to have an equal proportion of clients who were in in work, absent from work and unemployed. In reality, the employment status of people accessing the service across both areas were:
- In total, 71% of clients were employed
- A further 13% were self-employed
- Around 16% of clients were unemployed, with approximately 52% of these clients unemployed for less than six months.
This was broadly similar across both locations – a slightly higher proportion of clients in Dundee were self-employed, and a somewhat higher proportion of clients in Fife were unemployed. This reflects the general population, where a slightly higher proportion of individuals aged 16-64 in Fife (65%) are employed compared to Dundee (64%), and a slightly higher proportion in Dundee are self-employed (8.4%) compared to Fife (7.9%).
Overall, around 43% of HWS clients reported that they were living with a disability – 46% in Fife and just under 41% in Dundee. The remaining 9% of clients (around 8% in Dundee and 11% in Fife) stated that they did not know or preferred not to answer. Around 48% of clients reported that they had no condition. However, some stakeholders suggested that many people who accessed the service – and many more who could have benefitted from the service – may not perceive their physical or mental health to be severe enough to constitute a disability, so they are unlikely to self-report a condition.
5. There is a need for care in the terminology used to describe and promote the service to ensure that the full range of people who could benefit are being reached. Making a link to disability may not be helpful as many of those who could benefit may not consider themselves as having a disability.
6. It is helpful to frame approaches using the biopsychosocial model of health.
7. There are a wide range of ways that people who can benefit from this support can be engaged – it requires a full range to ensure an appropriate reach for the service.
The referral process
Overall, referrers felt that the HWS pilot improved the referral process for clients who were eligible for the service in Fife and Dundee. Most referrers felt they had a good understanding of the pilot through engagement with pilot staff, and the routes and process to the service were both clear and effective.
Referrers (including all JCP staff interviewed) felt that the support provided by the pilot was unique in the service landscape. They believed that, while there was a range of other services that offered health support and work support separately, none took the integrated approach that was adopted by the pilot. They felt the integrated approach filled a gap because of the interrelatedness of issues around health and work. However, there were some referrers (mainly GPs) who felt that they did not have the full information they required about the pilot.
One of the main areas for improvement identified was felt to be around disengagement from the service by clients. This was fed back to the Scottish Government and an online referral tool was created for GPs and Jobcentre work coaches to directly refer their customers and patients as opposed to relying on clients self-referring. This did improve referral rates and reduce disengagement, but it took time for it to be developed and integrated.
Although the referral process created a single point of access to the pilot and helped simplify the service landscape, some stakeholders felt that there were too many steps for clients to go through from the first point of contact through to their first clinical intervention. Some clients echoed this view, feeling that they were being 'passed from pillar to post' and had to repeat information on their condition numerous times. In addition, some case managers in local delivery teams found that they did not have enough information on clients through the enrolment questionnaire to help develop their action plans and identify the right support.
In addition, the service operated in a very linear way from the first point of contact, through to the case managers and finally the clinicians. This linear progress does not necessarily match a clients' progression through a service, and more time needs to be spent developing referral networks and pathways that can respond to non-linear progression though a service.
8. People with lived experience should be part of the design of the pathway through the service to ensure that they are at the centre of the service, that it's appropriate, and ensures dignity and respect of the client.
9. For many clients their pathway will not be linear, so it is important to ensure the service is set up around the client journey rather than stages of service delivery
10. Having more open service level agreements and better data sharing options will help as the pathways through the service will appear to be smoother and more supportive for the individual (i.e., not having to repeat their stories multiple times, and ensures that their data follows them through the service).
11. Ensure data collection and systems are fit for purpose and fully designed for the launch date, focused on the right / must have information, proportionate and appropriate.
12. Referral routes should be designed with frontline staff delivering the service and should be tested with referral partners and clients before a service goes live.
All pilot partners agreed that, although changes could be made in the referral process, local delivery teams delivering clinical interventions on the ground were best placed to provide the required support or signpost to local support services in the area. This relies on having the service and local teams integrated into the local service landscape. This takes time and it can be difficult to create momentum and traction for a pilot service.
Stakeholders agreed that having the service delivered within a clinical setting was the right approach, but there needed to be strong networks linking support between health and work, but also with other services such as housing or social work depending on what the client required. While the clinical setting is likely to result in better outcomes for clients, especially with a trusted brand like the NHS, the focus also needs to be on ensuring people are able to maintain employment or get back into employment quickly. For this reason, referrals and partnership with JCP is an important part of the referral process as they provide the main contact for many of these clients.
As part of the initial lead-in time for the service, mapping of the third sector in the local areas should be a priority so that 'move on' and signposting support is readily available for clients should they require additional or ongoing support outwith the 20 weeks pilot intervention period. Building these relationships from referrers through to onward support is crucial.
13. Develop a referral process that reduces the number of drop out points and ensures ease of access for clients. Ensure referral processes are tested with delivery and referral partners before the service goes live.
14. The development of relationships – within and outwith the service – is important to maximise the value of the existing landscape of support and further raise awareness of the service. This landscape will vary from place to place.
Delivery of the service
There is consensus from amongst stakeholders that the pilot was providing a good service and it was clear that everyone, from strategic level to local delivery, was very committed to the pilot.
Although there were a few challenges around the experience for clients, and around roles and responsibilities of the delivery partners, it was felt that this did not affect the outcomes for clients because of the professionalism and experience of the delivery team involved. Beyond the pilot, the local delivery teams had good relationships with the third sector and had a good knowledge of the service landscape. These relationships were further strengthened during the pilot delivery period, and both the knowledge of the service increased, and the knowledge held by the service.
Delivery of the service was sometimes felt to be inefficient and case managers felt they were being pulled in different directions. The way the pilot was intended to operate required delivery teams (i.e., clinically trained staff), in addition to providing a service for clients, to do work they were not trained in or familiar with, such as advertising, marketing, and employer engagement. Because they had clinical experience, case managers often provided advice and support to clients, especially in terms of mental health support, before transferring them to the clinical support provided as part of the pilot. Their role was meant to be facilitating the clients' progression through the service, rather than delivering interventions.
One of the benefits of having clinically trained staff as case managers is that they were able to provide some light-touch support and advice to clients when this was appropriate. For some clients this meant that they got what they needed very quickly, and it took away the need for a further referral. It was recognized however that this role needs to be more clearly defined and adapted.
In terms of delivery, local delivery teams felt that many people accessing the service were presenting with more complex requirements which required more intensive support. This means that either the marketing and awareness raising needs to be clearer about the kind of needs that realistically can be met by this service.
There was clear evidence that this case manager role was one of the most important elements in the success of the pilot. They are able to build a trusting relationship with each client and support and advocate for them throughout their journey. Their introductions to other services / people is important for ensuring continued engagement and successful outcomes. The role is particularly important in terms of managing a client's journey through the service, particularly with mental health as that pathway and journey is seldom linear. It was important to ensure that a client didn't drop out or feel like they have nowhere to go, so having a someone who is able to continue to support them and find alternative support is important in ensuring continued engagement.
15. Staff roles need to be clearly defined and it is important to have people with the right skills and experience in each role. This applies particularly to the case manager role – it helps to have case managers with clinical training, but it is important that this is used to strengthen the early assessment and accuracy of referral rather than be drawn into the provision of support.
16. JCP and GPs have a lot of resources at their fingertips – a lot of information and knowledge about a complex landscape of support – so it is particularly important that they are aware of the service and who it is for, so the right referrals are made first time.
In order to provide commentary on whether or not this particular service delivery approach should be taken forward, more information is needed in terms of the cost effectiveness of the service. Unfortunately, this data was not available at the time of evaluation. While it is clear that this approach provided positive outcomes for clients overall it is unclear whether this approach delivered cost-effective interventions.
Impact of the service for clients
Based on participant survey findings and longitudinal interviews with clients, it is clear that overall the HWS pilot made a positive difference. The benefits that clients reported from accessing the HWS pilot varied depending on the type of support they received. It is important to note that there are nuances and important contextual information that needs to be taken into account in assessing the impact of the pilot on clients.
Clients in both Dundee and Fife generally felt that both the engagement process with the pilot and the quality of support were of high standard. The process was felt by most to be efficient and simple, and support was felt to be person-centred.
Clients in Dundee tended to report greater improvements in their life as a result of accessing the pilot compared with clients in Fife. This was a result of clients in Fife tending to present with more complex conditions, and specifically with a combination of mental and physical health conditions. Additional interacting factors may include challenges related to rurality and different employment and living conditions compared with clients in Dundee.
Clients who received physiotherapy support reported that the pilot had a greater impact on their lives compared with clients who received mental health support. This was due to the more tangible and practical benefits resulting from physiotherapy support compared to mental health support. Clients recognised that this was related to the different nature of physical and mental health issues. They felt that mental health support should last longer and include more clinical support.
Overall levels of satisfaction with the support received through the HWS pilot were found to be very high. Clients were generally very happy with the way the model worked from enrolment through to the clinical support received (all above 90%).
The service did provide the support and advice that clients were seeking, such as access and support to specialists on how to manage or treat a health condition. However, more than half of clients surveyed indicated that they had low awareness of what the service actually offered prior to engaging. Stakeholders felt that this might be one of the reasons the targets for engagement with the service were not met.
Stakeholders felt that, for some clients, not knowing what the service could offer, what was required of them, and what the journey would involve, may have prevented them from self-referring to the service. This was seen in referral rates from JCP and through feedback from GP referrals. Time and resources need to be put to developing relationships with GP's and understanding the ways in which they operate and the pressures they face. For example, Jobcentres have a menu of options to refer people to, but limited information on what each service provides beyond eligibility. They are faced with a very cluttered landscape of support and are time limited, and therefore do not have the time to search for detailed information about one service. This also applies to GPs and resources should be developed which includes the must have information about the pilot to help referrers make the best onward referrals (or suggestions) for the individuals they see.
17. This approach to health and work support was focused on the client and getting quick access to support and clinical interventions which made a difference to client's lives.
18. The clinical focus of a service focusing on health and work may increase willingness to engage and potentially overcomes barriers of engaging with Jobcentres where concerns may exist related to sanctioning and receipt of benefits.
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