Overview
A retrospective look at an innovative approach for clients wishing to make the transition from NHS day service provision to mainstream vocational activity.
Care Setting
Education and Training
Evidence Base for Practice
Introduction
It is increasingly well recognised that work brings physical, mental and financial benefits to individuals, promoting confidence, independence and participation in society (Waddell and Burton 2006). Following the Welfare Reform Act 2007, services such as Pathways to Work (Pathways) were commissioned by the Department of Work and Pensions (DWP) and delivered by Jobcentre Plus from 2007. The aim of Pathways is specifically to support customers on Incapacity Benefit (IB) (Employment Support Allowance (ESA) for new claimants since October 2009) to seek and return to work.
The Black Review (2008) estimated that 5 million people in Great Britain have a common mental health disorder with just under 1 million people having a severe mental health disorder. Due to socio/economic changes and challenges in the 1980s and early 1990s IB claimants trebled and, for each year of the past decade, 200,000 people with a mental health problem have started claiming benefit (Black 2008). . Black (2008) and Perkins et al (2009) estimated that 1.3 million people with a mental health problem receive benefit and a further 1 million are workless but not on benefit. However, despite encouraging results from Pathways, Black (2008) indicated that the impact for individuals with mental health problems has been limited with such people continuing to comprise 40% of IB caseloads.
Given that only 8% of people with severe and enduring mental health problems are in employment falling to 4% for individuals with schizophrenia (Rinaldi and Perkins 2007), there has been increased interest in the Individual Placement Support Model (IPS) developed in North America. IPS focuses on assisting an individual to get a job quickly and supporting the employee and employer as long as required. Success rates of 30% to 60% in North America have been reported. IPS was a key recommendation in the Perkin’s review (Perkins 2009).
However Howard et al (2010) carried out a randomised control trial
Quality assurance/impact of practice
DEMOGRAPHIC DETAIL
A total of 98 clients, 54 male and 44 female, from Dundee’s CMHS with a severe and enduring mental illness were referred for the Moving Forward Course. Their demographic data are summarised in Tables 1 and 2a-d
Table 1 Duration of contact with Community Mental Health Services (CMHS) at referral, start and completion of Moving Forward Course (n = 98)
Duration of contact with AMHS
at referral at start of course at end of course
< 1 year
13 10 8
1 – 2 years
12 8 8
3 – 5 years
15 14 11
6 – 10 years
28 20 14
> 10 years
30 23 14
Table 2a Clients who started Moving Forward Course but withdrew during the course (n = 20)
Highest Educational Achievement Most Recent Education
None 5 25% >1 year 2 10%
Standard Grades 7 35% 1 -2 years 0 0%
Higher Grades 3 15% 3 -5 years 7 35%
NC 1 5% 6–10years 4 20%
HNC 0 0% <10years 7 35%
HND 3 15%
BA/BSc 1 5%
Higher Degree 0 0%
Type of Previous Employment Last Paid Employment
Never Employed 2 10% None 2 10%
Manual Unskilled 13 65% >1 year 1 5%
ManualSemi-skilled 4 20% 1 -2 years 3 15%
Clerical 0 0% 3 -5 ye
Practice Summary
Abstract
From 2004 to 2008 the Dundee Adult Mental Health Occupational Therapy Service led and co-ordinated a multi-agency employability partnership, the Moving Forward Partnership.
This partnership delivered a part-time, eight week course biannually, for clients wishing to make the transition from NHS day service provision to mainstream vocational activity. This is a retrospective audit of nine courses during that time.
Community integration was achieved by 85% of individuals who completed the course. Central to clients’ achieving and sustaining their outcomes was agreement to a post-course action plan and ongoing case management by an Occupational Therapist.
Practice Detail
MOVING FORWARD PARTNERSHIP
The Moving Forward Partnership comprised NHS Tayside Adult Mental Health Occupational Therapy Service (OT), Dundee City Council’s Employment Unit (EU) and Welfare Rights Service (WRS) and Dundee College. OT, EU and WRS were funded through the Scottish Government’s Mental Illness Specific Funding. College used existing resources.
The aim of the Moving Forward Partnership was to provide a service which would:
• promote social inclusion, well being and independence
• promote recovery and support ordinary living including access to employment education and leisure
These aims were met by delivering a bi-annual, part-time course over eight weeks, with individualised follow-up for up to two years.
Clients who met criteria of:
• focusing on their future developments
• successfully engaged in structured activity in recent months
• not currently misusing drugs or alcohol
• having the support of their CMHS key-worker
were referred from the CMHS to the OT who coordinated the project.
Clients were screened using a semi structured interview and a separate tool was
devised to collate demographic data which included housing, benefits, previous
employment and education, duration of contact with and usage of the mental health
service. Consent was obtained at the outset to share relevant information with the
partnership agencies regarding their support needs.
The course was delivered by staff from the partnership organisations who delivered psycho-social education and explored vocational and educational opportunities. OT delivered the psycho-social sessions which comprised anxiety management, goal setting, assertiveness, problem solving and stigma. The EU explored vocational opportunities and development, including information on volunteering, visits to potential placements, identifying transferable skills, writing CVs and discussing and setting up work placements. Sessions on educational opportunities led by colle
Challenges
Case Management
Ross (2007) describes case management as requiring skilled communication, networking, negotiating and the ability to resolve conflict. She highlighted the complexities of the clinical case manager in balancing duty of care towards the client with advancement of the rehabilitation process. The case management model is used in long term conditions with the aim of improving quality of life and outcomes for the client (Ross 2007). Department of Work and Pensions (2009) reviewed case management undertaken by Jobcentre Plus advisers and concluded that formal allocation of a case manager ensures responsibility for case management and reduces duplication.
The OT case managed the 47 (85%) clients who engaged with an action plan post- course. Central to this approach was working in a client centred way to empower recovery by supporting the management of their mental health condition whilst encouraging more personal responsibility and increasing structured activity in more formalised mainstream environments. This underpinned skills for employment. On average, individuals required support for 11.7 months with a range of 3 months to 24 months. Closer links between Dundee College and OT enhanced the clients’ access to mainstream college support and the development of discrete groups in art and computing improved engagement.
Grove et al (2005) indicated approximately 5% and Rinaldi and Perkins (2007) suggested 8% of people with a severe and enduring mental health problem are employed. However, with a case management approach, 18% of the individuals in this project who sustained an outcome achieved employment.
Recovery
The current evidence suggests (IPS) delivers the most effective means of maximising employment for individuals with mental health problems and questions the efficacy of pre-vocational/transitional programmes.(Rinaldi and Perkins 2007). However, Blank & Hayward (2009) commented that a definition of employment should include paid employmen
Additional Comments
CONCLUSION
The Moving Forward Partnership achieved positive outcomes in vocational rehabilitation and community integration for 85% individuals who completed the course. Central to clients’ achieving sustained outcomes was case management and multi-agency working by the OT.
Predictors of outcome for employment were pre-morbid education and previous employment at higher than a level entry job. Sustained volunteering, training or education was regarded as part of the multidimensional recovery journey.