Plotting a roadmap for those with complex needs

11. June 2015 Laura Bimpson

Local commissioners across the UK now have an opportunity to look beyond mere compliance with the Care Act, Universal Credit or employment programmes and to generate systemic change to address the issues of complex dependency states PCG’s Jenny Pescod and Cathy Anderson.

This PCG opinion piece was published in The MJ (4 June 2015).

The US recently took a significant step towards fully embracing independence and employment as the primary goal for disabled individuals, making explicit reference in legislation to: ‘opportunities to seek employment and work in competitive and integrated settings, engage in community life, control personal resources and receive service in the community to the same degree as individuals who do not receive support…’

Local commissioners across the UK have an opportunity to look beyond compliance with the Care Act, Children and Families Act, Universal Credit or employment programmes to generate the same ambition for disabled individuals, their families and for systemic change to address complex dependency.

Employment, health and social care strategies are coalescing around the promotion of independence and a person-centred approach to disability and employment.

The Care Act 2014 requires local authorities to provide person-centred planning with a view to individuals becoming and staying independent. Employment is identified as a key outcome, whether for individuals with care needs, or for their carers, and local authorities should take employment into account in support planning and the provision of information, advice and guidance.

The Local Offer, required under the Children and Families Act 2014, must include information on employment services, traineeships and other local support for young people with special educational needs or disabilities to smooth their transition from education into employment.

The draft statutory guidance in support of the Government’s autism strategy adds that in addition to the above, local authorities should consider whether personal budgets can be used to support adults with autism to become work-ready.

Universal Credit, rolled out across England from February 2015, provides a greater push towards employment for those who have been assessed under the Work Capability Assessment, and moved from incapacity benefit on to employment support allowance, as well as challenging some individuals in work to earn more.

Over time, income-related benefits will reduce, decreasing the ‘benefits trap’ experienced by some jobseekers with disabilities, where the incentive to work is outweighed by the cost of losing benefits.

These changes offer local commissioners an opportunity to re-orient their systems towards integrated support to improve employment for people with disabilities, and relieve issues of complex dependency.

Public services are increasingly centred around the person. The view is that this will help the vast majority – those who need only a little help to help themselves to just as much as they need – and those who need more help to have access to services that work around them to ensure complex needs are met as effectively and efficiently as possible.

Person-centred services shift away from state-planned provision of standardised services to targeted and individualised provision for those that need it most.

We know that the primary way for people to escape poverty and increase their standard of living is employment. It allows people to make choices about where they live and what kinds of social activities they engage in; it widens opportunities for relationships and provides status in our lives and in the eyes of others.

People with disabilities are much less likely to be in work than people without. For the period between April and June 2014, the employment rate for disabled people was 47.7%, compared to 79.3% for working age non-disabled people. The unemployment rate was 11.7% compared to 5.6% of those without disabilities and the economic inactivity rate was 46%, compared to only 16% of those without disabilities.

Employment prospects are particularly poor for those with a learning disability or with a mental health disorder. According to the Adult Social Care Outcomes Framework 2015/16 prospects were 6.8% in 2013/14, and had decreased from more than 7% over the previous two years.

The proportion of people in contact with secondary mental health services in paid employment was 7.1% in 2013/14, decreasing from almost 9% in 2011/12 .

Nationally-directed programmes have not proved effective in helping individuals with more complex needs into employment.

Despite a specifically designed payment structure for the Work Programme, recent Department for Work and Pensions (DWP)evidence to the Public Accounts Committee report found that the higher payments for harder-to-help groups ‘had not been effective in preventing contractors from focusing on easier-to-help claimants and parking the harder-to-help clients, often those with a range of disabilities, including mental health challenges’.

The most recent evaluation of Work Choice was found to still have barriers to helping those with the highest support needs.

Employment advisors found it hard to combine the programme’s aim to work with those with the most complex needs with the requirement for eligibility that anyone referred to the programme should be able to work for a minimum of 16 hours a week, following the time-limited, pre-work support period. Referral into the programme and then referral on to a provider relies heavily on the judgment of the disability employment advisor.

Not just the DWP, but the Department of Health, Department for Education, and local authorities also want and need to ensure that people are obtaining employment in order to improve health outcomes, relieve poverty and the knock-on effects on child welfare and domestic violence, while reducing demand for government-funded support.

Recent moves towards locally-led employment and health services, alongside social care and community services, have made the case stronger for local authority direction of integrated, person-centred services.

Finding sustainable employment that lifts individuals and families out of poverty can be particularly challenging for individuals with complex needs whose lives may already be in contact with a number of different public services.

Health and employment services commissioners design programmes to address the needs of their core populations, but individuals with complex needs may not fit traditional programme eligibility requirements and can end up in a cycle of referrals between providers that is not conducive to improving their economic situation.

The Troubled Families programme and Community Budgets funding streams were intended to achieve employment for those with complex needs.

The latest data from the Troubled Families programme shows that so far only 9% of families across the whole programme have had at least one adult achieve continuous employment.

A number of Transformation Challenge Award projects are aiming to address these issues, for example, by creating a single service of employment support for residents with complex needs.

The Working Capital programme has launched across London, aimed at employment and support allowance claimants who have been in the Work Programme for two years without finding a job.

These types of local intervention allow case workers to focus on issues surrounding complex dependency and longterm unemployment where, whether an individual is disabled or not, their chances of getting into work are often hampered by multiple other barriers, including poor mental health.

Local direction of person-centred provision can ensure management and training that help case workers to coach an individual into employment in the context of the local economy, with knowledge of local employment markets and constraints.

Some local initiatives are beginning to pursue the Individual Placement and Support model which has been shown to be effective in securing work for those with severe and enduring mental health problems.

Other innovative examples included membership models, which match up individuals with learning disabilities with potential carers.

All these models involve an element of integrating the service user into a social network. This is more supportive than letting them try to find employment and look after themselves, but more integrated into the community than the traditional supported employment network and so potentially, more resilient.

Funding these programmes across multiple partners can be a particular challenge. In a fragmented, disconnected system, it is challenging to engage in person centred planning. Those with complex needs are best served when processes are agile and flexible. This requires leveraging a variety of publicly- funded services, as well as community partners. Gaps may exist in any single commissioner’s array of services.

Data transfer between delivery organisations in the system is often patchy, limiting the ability to see what services and combination of services could result in the best outcomes for these groups and for the public purse.

There are grant funds available to help kick-start these programmes. Many local areas are looking to the next round of European Structural Investment Funding to potentially secure investment in new ways of working.

Employment and social inclusion is one of the stated five themes for the next round of the strategy to 2020.

Others are looking to fund projects through the Transformation Challenge Fund, which is due for a refresh post-election, or from Social Investment Funds, such as the current Community Investment Fund. But, for more integrated employment programmes to have long-term widespread effect, sustained, cross-discipline funding will be required.

Greater Manchester was already planning expansion of its Working Well pilot programme from summer 2015. The recent addition to the devolution settlement of the £6bn health and social care budget for Greater Manchester could herald the potential to combine health, social care and employment services in commissioning.

Whatever happens post-election, the door has been wedged open for other local commissioners to explore integrated local support which goes beyond compliance with legislative requirements.