Is there a recipe for delivering quality at scale within health and work settings? Four recommendations for employment services

Having worked with 25 government bodies to help 1,000 people with a range of health conditions into work, we’ve learnt that the service model is only one ingredient to quality at scale. 

In this article we make four recommendations for employment services drawing on our experience of bringing multiple funders together to co-commission employment services around a core set of outcomes.

The employment rate for people with severe mental illness is shockingly low. Just one in 14 people with this type of condition enjoy the financial independence and sense of purpose and fulfilment that comes with paid work. Employment is also one of the best ways to help people recover from mental ill health.

There are many areas of social injustice where a solution is not immediately evident: that is not the case here. There is abundant evidence from around the world that, with the right kind of support, people with serious mental illness can find and sustain work.

This approach, called Individual Placement and Support (IPS), delivers tailored employment support to the individual and works quickly to find them a real paid job. 

In 28 global Randomised Control Trials (RCTs), IPS has supported more than twice the number of people into work than alternative programmes. It benefits from a very clearly defined fidelity scale – a set of principles that research shows deliver the best possible outcomes. IPS is that rare jewel: a well evidenced social programme with clear principles to deliver strong outcomes.  Surely it should be simple to scale up this model to deliver quality…   

Unlocking funding for mental health and employment support at scale

At Social Finance, we work to find scalable solutions to entrenched social problems.  When we started to explore how to improve outcomes in health and work in 2015, we found that there was limited IPS provision in the UK, with small services buffeted by short term funding and limited data on outcomes achieved.

We set up Mental Health and Employment Partnership (MHEP) in 2015 to tackle this.

Over the past five years, we have worked with 25 government bodies to help 1,000 people with a range of health conditions into work.  We’ve learnt that a well evidenced service model isn’t enough. Strong delivery partners and a supportive commissioning environment are crucial to success.

Reflecting on what we’ve learnt, we have four recommendations for employment services to drive quality within the system and within service delivery:

Recommendation 1: Innovative financing models can align funders and grow services

A transformational programme like IPS can easily fall between government silos. Until recently, the NHS expected DWP to fund employment support, while DWP would not pay for employment specialists based in mental health teams.

What we did: The Mental Health and Employment Partnership (MHEP) Social Impact Bond (SIB) was designed to create partnerships between agencies and combine both sources of funding into one pot on a payment-by-results basis. That meant that each funder, whether local or national, health or employment focused, could link their payments to the outcomes they’re most interested in.

How did this work for us?

In 2019, we launched the largest pilot globally of IPS for clients with addictions in eight boroughs of West London. By allowing each commissioner to pay for the outcomes that impact their budget line, we were able to convene 18 different local and national funders.  This led to the launch of a larger and more robust service than would have otherwise been possible. 

Recommendation 2: Continuous learnings need to be shared to influence wider practice

Bringing together multiple funders all paying in a different way can get complicated quickly.

What we did:  The role MHEP plays is to manage that complexity away from stretched council officials and small charitable employment providers. 

How did this work for us?

By specialising in one specific model ‘IPS’ and working with a whole range of different government agencies in different geographic areas, we brought a level of expertise to the table that no one funder would otherwise have available.  

We also built up an evidence base for how the model needs to adapt to the needs of different cohorts, such as those with Learning Disabilities and Drug and Alcohol Addictions.  We now have standardised performance metrics with a rich set of benchmarks that tell us what kind of cost per user and cost per outcome we should be able to expect. These are published for anyone to review as part of a recent evaluation of the model.

Recommendation 3: Strong service leadership is crucial

We know that the IPS employment model works. But as a person centred relational project it is only as good as the people delivering it. This requires strong service leadership; a capable, motivated, trained staff team with low levels of churn; and a supportive environment to generate referrals.

What we did: Once we had services operating on the ground, we quickly found that achieving all of this consistently was going to be harder than we imagined. Some teams lost experienced staff while others struggled with effective leadership. To address this, we brought in a specialist operational adviser with decades of experience managing health and employment services.

Our adviser was able to get under the skin of delivery problems and provide direct coaching, training and support. The IPS model itself can be inspiring for providers and staff because of the opportunities to provide meaningful, intensive, personalised support; and see first-hand the impact that it has on real lives. 

How did this work for us?

High quality services are often provided by small but experienced third sector partners operating under significant financial pressure. Our initial contracts paid providers a meaningful proportion of funding on outcomes, in the expectation that this would incentivise quality delivery. Over time we have learnt that lower risk and block funding gives providers the space needed to innovate and provide tailored support to clients. This, combined with high quality performance management, can improve outcomes. There is now a strong and growing leadership of high quality IPS providers that are committed to the model and delivering high quality support.

Recommendation 4: Strong performance management with a focus on outcomes is needed

Often when local councils or NHS bodies fund services, the contract managers responsible for them are stretched over dozens of projects with almost no time to sort out operational issues. Even getting basic data, like how many people got a job each month, proved tricky. The MHEP programme brought two innovations to tackle this.

What we did: First, we structured the contracts on a payment by results basis, with the upfront service cost paid for with social investment from Big Issue Invest. Over time, that’s amounted to £2 million of flexible capital that we could use to pay for services. When those services achieved job and health outcomes, our investor started getting repaid. By putting outside investors’ money on the line, getting outcomes wasn’t a nice-to-have – it was make-or-break.

Secondly, we built a performance team that was dedicated to tracking outcomes monthly and working with providers and commissioners to resolve issues quickly.  

How did this work for us?

Throughout the first lockdown in 2020 when clients were less able to look for work, all of our services were able to pivot to provide wellbeing support, employment skills and tackle digital exclusion. This focus on outcomes has also supported a quick recovery despite the challenging environment, with MHEP services supporting 312 people into work in 2020.    

What next?

IPS employment support works to help people with health conditions find work in a way that is fundamentally life changing.  Since MHEP’s launch, there has been a revolution in mental health and employment services. 

The NHS in England has made a significant commitment to make IPS employment support a core part of mental health services across the nation.

Over the past five years we have learnt that having a well evidenced social intervention is only one of the ingredients to success.

A supportive system around the service model and the quality of the delivery provider can be the difference between success or failure. So, while there are more people to help, we will keep working to ensure everyone who needs it has access to high quality, health based employment support.

Bex Spencer, Associate Director, Social Finance