lindsay and dutton promoting healthy pathways to employability spa2013

8/13/2019 Lindsay and Dutton Promoting Healthy Pathways to Employability SPA2013

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focused Condition Management Programme (CMP), developed in partnership with

the National Health Service (NHS), in an apparent acknowledgement that many of

those on IBs were disadvantaged in terms of both employability and health

problems/disabilities. The successor to PtW the Work Programme was

introduced by the Conservative-led Coalition government in 2011, and makes no

such explicit commitment to linking employability and health-focused interventions.

The Coalition government has declined to provide early/formative evaluation data on

the performance of the Work Programme, so that it will be some time before we

know the impact of these changes to the welfare-to-work agenda.

It therefore seems timely to reflect on the evidence to date on the potential added

value of health-focused condition management services within the broader welfare-

to-work agenda. To what extent are health-focused interventions likely to be a

necessary component of any successful welfare-to-work programmes targeting the

more than two million people on IBs? What does the evidence say about health and

employability outcomes delivered by condition management services under PtW

and other welfare-to-work programmes? And what lessons can be identified for the

development of the Work Programme and future welfare-to-work initiatives?

This article seeks to address these questions in two main ways: first, by reporting on

a structured evidence review focused mainly on the outcomes delivered by CMP

services within the PtW initiative; and second, by analysing the views of health

professionals involved in the delivery of these CMP services. In the latter case, we

draw on more than 50 in-depth interviews conducted by the authors with NHS

professionals engaged in the delivery of CMPs, which gathered perceptions of the


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benefits of condition management services, but also the limitations of the programme

as developed under PtW. We bring these bodies of evidence together in our

Discussion and Conclusions, before identifying lessons for future welfare-to-work

provision. A key priority for our discussion is to explore the tensions between

dominant assumptions around the appropriateness of Work First approaches to

welfare-to-work, and the evidence that suggests the need for (and potential value of)

more holistic interventions promoting gradual progression in both wellbeing and

employability. First, we begin by providing a brief discussion of the background to the

welfare-to-work agenda targeting people claiming IBs, and describing the evolution

of condition management services under PtW.

Background: employability, health and welfare-to-work

Linking health and employability in welfare-to-work

The Labour government of 1997-2010 viewed its welfare-to-work strategy as being

informed by a Work First approach (DWP, 2006). While policy makers were vague in

how they defined Work First, the social policy literature has identified distinctive

features of this approach as including: prioritising a quick return to work for those on

benefits; encouragement to accept any job irrespective of quality; programme

content that tends to be short-term, with a strong emphasis on job search; and the

use of monitoring and sanctions to enforce compliance (Lindsay et al, 2007).

These characteristics were seen as broadly defining the Labour governments initial

welfare-to-work programmes (Weston, 2012). Policy makers pointed to apparently

encouraging job entry rates reported by the New Deal programmes established


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from 1998 (and their successor programme Flexible New Deal, introduced in 2009),

but revolving door repeat participation whereby the job seekers cycled between

periods of unemployment, short-term jobs and welfare-to-work and continuing

high unemployment in low-demand labour markets led many analysts to question the

impact and value for money of Work First interventions (Lindsay and Houston, 2011).

During the first term of the Labour government, those claiming IBs were largely

untouched by welfare-to-work. The New Deal for Disabled People was introduced

from 1998, but was relatively small in scale and, crucially, was entirely voluntary

(Weston, 2012). With the establishment of Jobcentre Plus in 2002, new claimants of

IBs were required to attend compulsory work-focused interviews, but faced no

additional requirements in terms of work-related activity. Despite these early

measures, there was a sense that people with health problems and disabilities had

been marginalised within a policy agenda dominated by Work First interventions and

funding mechanisms that incentivised assisting the most employable claimants (few

of whom were on IBs) to re-enter employment (Lindsay et al, 2007).

However, the 2000s also saw a shift in the focus of welfare-to-work towards people

on IBs. Policy makers promised a new intervention regime to activate peoples

aspirations to return to work (DWP, 2004 p. 16), acknowledging the need for joined-

up health and employability provision through new programmes, delivered in

partnership with the NHS (DWP, 2006 p. 28). The introduction of PtW was an early,

and crucial, element in a welfare reform agenda that sought to transform the states

relationship with people on IBs.


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From Pathways to Work to Work Programme

The evidence suggests that many of those on long-term IBs are among the most

disadvantaged people in the UK labour market. First, despite policy makers rhetoric

around the danger that large numbers of claimants are cheating the system (DWP,

2010a), there is a substantial evidence base that people on IBs do indeed face

health and disability-related limitations, as well as a range of employability-related

barriers (for reviews of evidence, see Bambra, 2011; Lindsay and Houston, 2011).

Fully addressing these problems arguably requires the dismantling of societal

barriers to equal participation (in line with a social model of understanding disability)

and the transformation of workplaces so that jobs are adaptable to the different

capacities and needs of employees (Barnes, 2000; Patrick, 2011). As Danieli and

Woodhams (2005 p. 103) note if the social model informed the management of

disability in the workplace, monitoring would shift from the individual to the social and

environmental aspects of the organisation. Clearly, recent and current policy

agendas in the UK fail this test, with the focus remaining on barriers seen as being

associated with the individual. However, in lieu of more radically transformative

measures, it is essential that welfare-to-work policies targeting people on IBs at least

seek to address both health-related and employability-related barriers to work.

As noted above, a central element in the 1997-2010 Labour governments response

was the introduction of PtW. PtW was piloted in seven delivery districts from 2003,

before being rolled out across Great Britain by the end of 2008 (employment policy is

devolved in Northern Ireland, but a largely similar programme was developed there).


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All new claimants of IBs (and in some areas those who started claiming during the

two years preceding the introduction of the programme) were initially eligible. PtW

was wound up in 2011, but activating claimants of IBs remains a key priority for

government and provides a central focus for the Work Programme that has replaced

pre-existing employability initiatives, including those targeting people with health

limitations. The content of the overall PtW initiative included:

five compulsory work-focused interviews with advisers working for Jobcentre Plus

or contracted providers;

a one year Return to Work Credit paid at 40 per week for full-time workers

earning below 15,000;

voluntary Choices support options (such as work preparation programmes);

as part of Choices, the Condition Management Programme (CMP)a 6-13

week intervention designed to enable clients to cope with mild/moderate health

conditions (and which provides the focus for findings discussed below).

Accordingly, much of the content of PtW reflected the Work First model of welfare-to-

work that has long-dominated UK policy compulsory work-focused interviews and

short-term, employability-focused services were prominent components of the

programme. However, the inclusion of the CMP option arguably reflected some,

albeit limited, acknowledgement within the then government that the rise in numbers

claiming IB was explained by a combination of problems around individuals

employability andhealth-related barriers (Lindsay and Dutton, 2010).

CMP services delivered a range of interventions including: pain management;

exercise planning; stress management; techniques to improve sleep; relaxation


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therapies; and anxiety management. At the centre of the CMP model was a

commitment to the principles of Cognitive Behavioural Therapy (CBT) techniques as

a means of helping clients to manage health conditions. In the first eighteen districts

where PtW was established, the programme was led by Jobcentre Plus (which

provided basic employability support and referred clients to the CMP and other

provision). In these districts the CMP element of PtW was developed by NHS

organisations, with NHS clinical professionals leading its implementation. However,

as PtW was rolled-out across Britains remaining Jobcentre districts, policy makers

applied a contracted-out programme managed by mainly for-profit Lead Providers.

While Lead Providers were required to include CMPs in their PtW services, in all but

one of these districts NHS organisations were not involved in the delivery of

condition management services (Lindsay and Dutton, 2012).

We will review the evidence on the specific benefits and limitations of NHS-led CMP

services in the next section, but it is first important to recognise that the impacts of

the overall PtW programme can be described as modest. National-level evaluations

found limited additional impact in terms of increasing employment or reducing the

numbers on benefits (NAO, 2010). Regarding the PtW CMP, a striking feature was

the extent to which it was relatively under-used, even in districts where Jobcentre

Plus-NHS partnerships operated. The 'new programmes, delivered in partnership

with the NHS that were supposed to be central to the PtW model (DWP, 2006 p. 28)

in fact tuned out to be fairly marginal to the overall operation of the programme. The

final statistics available for PtW show that of the 1.8 million people starting the

programme up to March 2011, only 123,880 (around 7%) engaged with the CMP

(DWP, 2011). This is not to say that the CMP was marginal within the Choices


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support options of PtW it accounted for more than 40% of Choices starts in

Jobcentre Plus-NHS districts (as noted above, condition management services were

also available in districts where provision was managed by contracted Lead

Providers, but data on participation were never made available).

The Coalition government replaced all existing welfare-to-work provision (including

PtW) with the Work Programme in 2011. The Work Programme and related reforms

represent a decisive shift towards further compulsion and Work First activation.

Despite private providers failure to deliver better results under PtW (NAO , 2010), all

Work Programme services have been outsourced to Prime Contractors in the

private and third sectors. A black box funding mechanism means that there is no

requirement on Prime Contractors to deliver condition management; and given the

current paucity of evaluation data, there is limited information on what services are

available to people with health limitations the model grants providers free rein to

design support that will achieve sustained work targets(Weston, 2012 p. 516).

The Coalition has also built upon and prioritised two welfare reform measures

established by its Labour predecessor: the replacement of existing IBs with the

Employment and Support Allowance (ESA), which will in turn soon be amalgamated

into the Universal Credit; and the restriction of access to benefits by re-assessing all

claimants under a stricter medical Work Capability Assessment (WCA). These

measures have strengthened conditionality, resulting in the vast majority of new IB

claimants having their benefit claim rejected, or being directed to compulsory work-

related activity (although many have successfully appealed against these decisions)

(Patrick, 2011). The Coalitions future welfare-to-work agenda is likely to retain a


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their specific interest in the outcomes, benefits, limitations and lessons of the CMP.

In addition to these articles and reports selected for the main structured literature

review (see Table 1), we also draw on a wider range of supplementary material that

touches on the delivery and impact of PtW.

Interviews with NHS professionals

We are able to add to the evidence from our desk-based research by drawing on our

own fieldwork with NHS professionals involved in the delivery of CMP services.

Semi-structured, qualitative interviews were deployed in order to explore the

experience and practice of NHS professionals involved in PtW CMPs (CMP teams

involved inter-disciplinary working that brought together mental health nurses,

occupational therapists, physiotherapists and other NHS professionals). Most

interviews were conducted in 2008-09, at a time when CMPs in all areas were well-

established. Interviews were conducted with 52 CMP practitioners and managers

involved in the delivery of PtW condition management services across five Jobcentre

Plus districts in England (10 interviews), Scotland (33 interviews) and Wales (9

interviews). The initial focus of the study was the practice of NHS professionals

under PtW in Scotland, reflecting an effort to build on previous work undertaken by

members of the research team. However, additional fieldwork was undertaken in

England and Wales in order to explore how different organisational contexts shaped

NHS professionals experiences (Lindsay and Dutton, 2012). Participants were

selected on the basis of a purposive sampling model, ensuring representation from

NHS staff with different professional backgrounds and levels of experience. All

interviews were undertaken by the authors. Interview data were analysed using QSR

NVivo. Caution is clearly required in considering the views of NHS professionals who


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inevitably felt a degree of ownership over the CMP, but the findings below suggest

that our interviews were effective in drawing out critical reflections on the limitations

of condition management services, as well as their positive outcomes.

Findings (I): evidence review on condition management services

A synthesis of the literature in Table 1 suggests that CMPs delivered important

benefits, especially in terms of helping individuals to cope with on-going health

problems.

INSERT TABLE 1 HERE

Benefits and added value of CMP services

Evaluations suggest that CMPs enjoyed success in relation to their primary objective

to help IB claimants to manage health conditions and disabilities. Ford and

Plowrights (2009) longitudinal data gathered from more than 480 CMP completers

across Britain identified significant positive effects using standardised Hospital

Anxiety and Depression(HADS) measures. They found positive impacts on HADS

anxiety measures, with less strong, but still statistically significant, relationships with

reduced levels of depression. Similarly significant HADS impacts emerged from

Reagon and Vincents (2010) analysis of outcomes among more than 240 CMP

participants. Kellett et als (2011) analysis of outcomes from more than 2 ,000 CMP

completers found significant improvements in psychological wellbeing and reductions

in distress and perceived disability. This major quantitative study provides consistent

evidence of improvement in self-assessed wellbeing among service users reporting


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both mental health and physical problems as their primary conditions (although

outcomes were significantly more positive for the mental health group). However, the

authors are careful to note that a statistically reliable improvement in psychological

wellbeing falls short of clinically significant improvement, given that their study

lacked sufficiently detailed diagnostic data on individuals conditions at the start of

the process and following CMP participation (Kellett et al, 2011 p. 173). The other

large-scale quantitative study included in our review reported more basic self-

assessed health outcomes, but found that CMP participants were much more likely

to state an improvement in their health condition than were a matched-comparison

group on non-participants (Adam et al, 2009 p. 35).

Joyce et als (2010) qualitative research with CMP participants identified additional

positive outcomes in improved health behaviours (specifically, better diet, increased

exercise and improved agility); and Secker et als (2012p. 279) focus groups with 39

completers reported benefits such as giving up smoking; reducing medication; [and]

increased understanding of medication and its use. The studies included in our

review also confirmed that many CMP participants gained a better understanding of,

and were better able to cope with, their health conditions. Kellett et als (2008p. 119)

extensive focus group research found that for many individuals the CMP facilitated a

new enhanced perception of control over their condition , with similar findings

reported by Secker et al (2012) and Warrener et al (2009). These and other studies

included in our review identified other psycho-social benefits for many participants,

including: reduced feelings of isolation and increased social activity; improved self-

confidence and self-esteem; and increased vocational activity and motivation to

return to work when more fully recovered (Barnes and Hudson, 2006; Kellett et al,


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2008; Warrener et al, 2009; Joyce et al, 2010; MCR, 2010; Secker et al, 2012; see

also Corden et al, 2005). Generally positive impacts on health and wellbeing were

also identified by both NHS and Jobcentre Plus staff working with CMP participants

(Barnes and Hudson, 2006).

At a more basic level, the evidence review identifies positive evaluations of the CMP

from many users, who valued the empathy and expertise demonstrated by NHS

professionals (Warrener et al, 2009; see also Corden et al, 2005). Most of the 450

CMP participants responding to Hayllar et als (2010) survey reported positive

experiences (although it should also be noted that a substantial minority one in six

held more negative views). Hayllar et al (2010) found the most positive

experiences among those with medium, changeable health conditions (suggesting

that condition management services were most effective for those with significant,

but not the most severe, conditions).

Many of the studies included in our review acknowledged their own limitations for

example, the absence of control groups, or the weakness of evidence on longer-term

physical health improvements that can be attributed to the CMP. However, there

seems to be a robust evidence base confirming that CMP participants experienced

significant benefits in terms of: psychological wellbeing; coping with and managing

conditions; confidence and social engagement; and (in some cases) other health

behaviours. A number of the qualitative studies reported progress towards (and into)

work for some participants, although job entry was not a primary target for the

programme (Ford and Plowright, 2009; Warrener et al, 2009).


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Limitations and problems of CMP services

While evaluations point to a number of areas where NHS CMPs added value to the

welfare-to-work agenda, there were also lessons in terms of weaknesses in services.

First, it is important to reiterate that those participating in the CMP like all other

PtW Choices options were not significantly more likely to have found work than

other IB claimants within one year (Adam et al, 2009; see also NAO, 2010). The

DWP (2012 p. 13) Lessons Learned report included in our review noted that the

CMP was discontinued as there was not sufficient evidence to show that it offered

value for money in terms of measurable job outcomes, identifying the lesson that

earlier and more invasive activity was required to assess the effectiveness of the

CMP in employment terms.

Yet as Adam et al (2009 p. 37) noted, low levels of job entry were not surprising

since the CMP [was] designed to help those further from the labour market improve

the management of their health, with a longer-term trajectory towards moving into

work.Hayllar et al (2010 p. 84) similarly acknowledged that relatively low job entry

rates were understandable given that the CMP was a health management service

as opposed to a work-focused Choices element. The DWP (2012) claim that the

CMP failed to deliver value for money against job entry criteria that were never linked

to the programme therefore seems disingenuous.

However, more substantial criticisms of CMPs also emerged from our evidence

review. As a short, user-led intervention, the CMP was unable to assist some of the

most vulnerable PtW participants, such as those suffering from a range of complex,


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chronic conditions (Barnes and Hudson, 2006). Indeed, it is important to note that

the major quantitative evaluations included within our review (Ford and Plowright,

2009; Kellett et al, 2011) found significant improvements in wellbeing taking their

samples as a whole, but also no improvement reported by substantial minorities and

deterioration in some cases. These studies noted the need for further research, but

hypothesised that people failing to progress were more likely to have

complex/multiple conditions that the CMP was not designed to address. Warrener et

al (2009) identified less positive evaluations of the CMP among those reporting

physical problems; and those with more severe physical conditions, such as cancer,

clearly found some CMP content of little value (MCR, 2010). The chronic/recurring

nature of health problems also resulted in some clients failing to complete the CMP

or rejecting offers of support in the first place (Warrener et al, 2009).

The core content of the CMP was also problematic for some users. While CBT-

oriented approaches are backed by a solid evidence base, some studies pointed to

problems engaging those who were simply not yet ready to make progress(Barnes

and Hudson, 2006; Hayllar et al, 2010). Other studies reported concerns among

CMP users relating to the format of services, and especially the reliance on group

discussion in some CBT-oriented programmes (Kellett et al, 2008; Warrener et al,

2009). While these studies point to positive feedback from CMP completers who had

initially been worried by group-work, there remains the concern that some people

may have been deterred from participation.

A further limitation identified by the evidence review related to the failure to provide

adequately for in-work support, and to engage employers as active partners in


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facilitating sustained transitions to work. A number of the studies reported service

users concerns that they would be unable to maintain the progress that they had

made under the CMP when exposed to the pressure of work (Warrener et al, 2009;

MCR, 2010; Secker et al, 2012). Finally, in line with the arguments made by Patrick

(2011) and others, our evidence review points to the inherent weaknesses of a

programme that sought to improve the coping strategies of IB claimants, rather than

challenging the multiple socio-economic inequalities that limited opportunity. This

was reflected in discussions of other barriers that undermined the progress of CMP

participants, including: debt problems; scarcity of appropriate jobs; lack of transport;

and caring responsibilities (Barnes and Hudson, 2006; Secker et al, 2012).

Findings (II): interviews with NHS professionals delivering CMP services

Benefits and added value of CMP services NHS professionals views

Interviews with NHS managers and professionals involved in CMPs identified a

familiar range of benefits delivered by these services. All interviewees reported at

least some positive impacts associated with the CMP, with the most commonly

identified benefits being improvements in clients: management and understanding of

stress and symptoms; sense of control; diet and drinking/substance use habits; pain

management; anxiety and depression symptoms (as measured using HADS and

other clinical tools); and reduced dependency on medication. For most NHS

professionals, the CMP delivered its core objective, by assisting clients in managing

their problem more effectively than they did previously (Senior CMP Practitioner,

mental health nursing background, Scotland).


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The coping skills delivered through the CMP helped clients to understand and

manage health limitations more effectively, and could, it was argued, lead to more

general improvements in self-efficacy and confidence. Interviewees consistently

reported evidence that the CMP had improved confidence among participants, with

their progress rooted in the development of new coping skills:

Confidence to be able to deal with their conditions and having more control in

their lives, knowing what to do when they do have setbacks It [the CMP] is

enabling them to feel as though theyve got that skill to do that.

Senior Therapist, occupational therapy background, Wales

NHS managers and professionals did not see the CMP as a Work First activation

programme, and so were rarely concerned with short-term job outcomes. However,

they did understand the CMP as helping participants to make gradual progress

towards work through improved wellbeing.

I think that the CMP helps people towards work. A lot of the coping strategies

that we teach will help people to cope in work but it might take another couple

of months before they are ready for work.

CMP Practitioner, occupational therapy background, Scotland

Interviewees consistently referred to the benefits of a flexible CMP, within which

health professionals had the autonomy to develop a combination of approaches to

assist participants. While CBT-oriented approaches formed the core content, CMP

practitioners felt that they had freedom to shape services to individuals needs


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(although, as reported in the previous section and discussed below, there were also

perceived gaps in services). As we have argued elsewhere, there may be additional

benefits associated with the experience and professionalism brought to these

services by NHS staff (Lindsay and Dutton, 2012) our interviewees spoke of the

value of colleagues skillsin being able to read people(picking up on verbal signs

and body language to detect often undeclared health problems); and of the

importance of having a depth of knowledge that allowed for an understanding of why

as well as just how certain interventions might work (CMP Programme Manager,

mental health nursing background, England). Finally, interviewees pointed to the

trust associated with the NHS brand and especially clients belief that NHS

professionals were solely committed to assisting them towards improved health

as a major strength of the CMP. It was suggested that clients welcomed the NHSs

independence from the Work First agenda associated with other elements of

Jobcentre Pluss welfare-to-work provision.

[The NHS] makes people feel at ease, takes the pressure off. They know we are

not going to force them into work. We explain that for us it is about helping them

manage their health conditions better, with a view to exploring routes into work.

CMP Practitioner, nursing background, Scotland

While such exercises in self-evaluation must be treated with some caution, we have

noted above that the broader evidence base seems to point to generally positive

views of NHS staff among PtW clients. It also seems reasonable to argue that the

inter-disciplinary skills and clinical expertise of NHS professionals were important to

delivering positive outcomes.


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Limitations and problems of CMP services NHS professionals views

Just as the benefits identified in the evidence review were reflected in our interviews

with CMP practitioners, so there were consistencies in the concerns raised around

the limitations of the programme. First, although interviewees were satisfied that

there was a solid evidence base for the CMPs content, there was a shared sense

that services offered too narrow a range of therapeutic interventions, excluding some

PtW clients. Most practitioners thought that CBT-based approaches could be helpful

for many clients, but were clear that such interventions require the individual to be

psychologically ready and seeking change.

The outcomes that have been successful is when an individual has come along

really ready to make some sort of change if people grasp the CBT approach

they seem to just be able to run with it something clicks with them...

Senior CMP Practitioner, nursing background, Scotland

Numerous interviewees called for further investment in counselling services as an

alternative therapy option for those clients unsuited to CBT-oriented approaches.

CMP practitioners working in England sometimes discussed their hope that the

strengthening of services under the NHSs Improving Access to Psycho logical

Therapies programme would allow for more integrated and tailored mental health

provision. Interviewees were also consistently frustrated by problems identifying

appropriate treatment and/or referral options for participants presenting with a range

of more complex health problems, including: ME; chronic fatigue conditions;


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alcohol/substance dependency; and more severe musculo-skeletal problems that

produced significant physical limitations. This again tallies with the findings above.

Finally, and again concurring with our evidence review, interviewees argued that an

additional barrier to progress was the experience of poverty, disadvantage and

chaotic lives among many clients. Interviewees spoke of how progress made by

individuals could be undermined by things outside work and health (CMP Team

Leader, occupational therapy background, Scotland) problems of debt and

housing; the consequences of offending behaviours; and the effects of addiction

problems experienced by clients or family members. Our interviewees acknowledged

the limitations of interventions that can at best help the individual to cope, rather than

addressing the fundamental social and labour market inequalities that explain why

some people with health limitations find themselves trapped on benefits.

Our discussion above is necessarily brief. Elsewhere, we have provided detailed

analyses of the role of NHS professionals within CMPs and the governance regime

facilitating their work (Lindsay and Dutton, 2010, 2012). However, our analysis does

support the key themes of the preceding evidence review. CMP practitioners

described an intervention that delivered positive outcomes benefits apparently

facilitated by the expertise of NHS staff, a relatively flexible delivery model, and the

relationships of trust established with PtW clients. But they also confirmed serious

limitations: the CMP was unable to assist clients presenting more complex

conditions; referral routes to alternative therapy options were often weak; and,

crucially, such self-management interventions left many of the barriers faced by

clients (rooted in social, health and labour market inequalities) untouched.


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Discussion and conclusions

The Coalition government and its successors will be required to continue to act to

address high levels of benefit claiming among people with health problems and

disabilities. The previous Labour governments PtW programme arguably

represented the first serious attempt to activate this client group; and the CMP

marked an unusual if limited departure from the Work First model that had

dominated welfare-to-work policies. The Coalition abolished PtW and retreated from

the programmes limited commitment to providing condition managementservices.

The government has refused to provide detailed information on services being

received by IB claimants under the new Work Programme, but the extension of

black box contracting means that there is no requirement that providers invest in

condition management. Furthermore, early evidence suggests that contracted

providers have demonstrated a variable and limited commitment to resourcing

health-focused services (Ceolta-Smith, 2012). This may explain why the evaluation

data that are available demonstrate poor performance across all contacts, with IB

claimants in particular receiving a poor service from providers (HoC, 2013: 9).

The Coalitions broader welfare reform agenda implies a reassertion of the Work

First ethos, through: the means-testing of ESA beyond a one-year time threshold;

restricting access to benefits through the WCA; and imposing more work-related

activity on claimants. The evidence suggests that these measures are likely to

encounter problems in promoting progression towards work for IB claimants. While

the WCA has restricted access to the new ESA, many of those initially denied


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benefits have successfully appealed (Patrick, 2011). Furthermore, there is little

evidence that people with health limitations who are refused benefits will be

employable in a recession-bound labour market. Accordingly, while the stringent

WCA may mean less people are on IB/ESA in the future, they may not be in

employment either (Lindsay and Houston, 2011 p. 714).

A central finding from the evidence reviewed above is that IB claimants conditions

can be diagnosed, measured and targeted; and therefore that significant

improvements in wellbeing (and in some cases employability) might flow from

services designed to assist in managing these conditions. The discussion above

suggests that there are good practice examples to be drawn from the CMP delivered

by NHS practitioners under PtW (as well as lessons about the limitations about such

interventions). The CMP delivered positive outcomes as captured using well-

established measures of psychological wellbeing, while the qualitative evidence

(albeit based on small samples) suggests that some participants experienced

improvements in relation to social connectedness, healthy behaviours and

understanding/managing conditions. There was also some evidence of positive

effects on employability, but we lack the long-term data to judge the CMPs impact

here, and there was no immediately significant employment effect.

The positive findings that emerge from the research evidence on the CMP are

important. Despite the Coalitions re-prioritisation of Work First, there is a substantial

evidence base to suggest that the health and disability-related limitations reported by

those on IBs are real, and that targeted health interventions will be needed if they

are to be assisted to make transitions to work. Punitive benefit restrictions and Work


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First activation have defined successive governments policy agendas. For Patrick

(2011 p. 275), the current emphasis on compulsion and conditionality to shape

behaviour is both blunt instrument and wrong prescription. The evidence seems to

back this analysis. Learning from what worked under the CMP may provide a good

starting point for the development of future health-focused employability services.

None of the studies included in our evidence review included randomised control

trials (RCTs)seen as the most robust test of health interventions but the weight

of evidence suggests that condition management worked for many participants.

Further investment in the development of similar services with impacts tested

through RCTs and other robust evaluation methodologiesis therefore justified.

It is important to note that the CMP was not a panacea. Our interviews with NHS

professionals confirmed concerns raised by our evidence review, that additional

services may be required to address the needs of those with a range of complex

physical problems and chronic conditions. Crucially, there is also a limit to what

stand-alone condition management services can achieve, given the broader context

of a UK labour market dominated by intensified, low quality jobs at the bottom end,

and where employers rarely adopt a proactive role in supporting people with health

problems/disabilities. A review of the evidence on the limited successes of the CMP,

and the views of the professionals who delivered it, point to the need for more

interventionist strategies that demand workplace adjustments and provide in-work

support for returners who continue to struggle with health/disability-related

limitations. Such an approach would fit within a much-needed, broader recalibration

of how we think about welfare-to-work for sick and disabled people the focus must

shift from the imagined behavioural deficiencies of IB claimants, to the very real


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socio-economic barriers that prevent them from coping with health limitations within

the context of the workplace (Patrick, 2011). As well as the health-focused services

discussed in this article, there is a need for joined-up solutions combining workplace

adjustments, access to transport and peer support (Barnes, 2000). Policy also needs

to move beyond the overloaded concept of incapacity to acknowledge the different

barriers faced by people with a range of disabilities and those seeking to cope with

limiting health conditions (Roulstone and Barnes, 2005).

At the time of writing, there is little sign of the adoption of such a holistic model of

engaging with the IB problem. Yet the evidence suggests that policy will need to

address the health and disability-related, social and workplace barriers faced by IB

claimants if large numbers are to be helped towards work. A renewal of services

helping IB claimants to manage health conditions should be a necessary starting

point for attempts to arrive at more effective, evidence-based policy in this area.


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References

Adam, S., Bozio, A. and Emmerson, C. (2009) Can we estimate the impact of the

Choices package in Pathways to Work? DWP Research Working Paper 60,

Norwich: HMSO.

Bambra, C. (2011) Work, worklessness and the political economy of health, Oxford:

Oxford University Press.

Barnes, C. (2000) A working social model? Disability, work and disability politics in

the 21st century, Critical Social Policy, 20 (3): 44158.

Barnes, H. and Hudson, M. (2006) Pathways to Work: Qualitative research on the

Condition Management Programme, DWP Research Report 346, Norwich:

HMSO.

Ceolta-Smith, J. (2012) Health-related support and the Work Programme: Whats on

the menu?, presented at White Rose Collaboration Seminar on Linking best

practice in clinical and employability-focused research for claimants of disability

benefits, Sheffield, 29 June.

Corden, A., Nice, K. and Sainsbury, R. (2005) Incapacity Benefit reforms pilot:

Findings from a longitudinal panel of clients, DWP Research Report 259,Leeds:

Corporate Document Services.

Danieli, A and Woodhams, C (2005) Disability frameworks and monitoring disability

in local authorities, In A. Roulstone and C. Barnes (eds) Working futures?

Disabled people, policy and social inclusion, Bristol: Policy Press:91-105.

DWP (Department for Work and Pensions) (2004) Building on New Deal: Local

solutions meeting individual needs, London: DWP.


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DWP (2006)A new deal for welfare: Empowering people to work, London: Stationery

Office.

DWP (2010a) 21stcentury welfare, London: Stationery Office.

DWP (2010b) Universal Credit: Welfare that works, London: Stationery Office.

DWP (2011) Jobcentre Plus Pathways to Work: Official Statistics October 2011,

Sheffield: DWP.

DWP (2012) The DWP-funded and NHS-delivered Condition Management

Programme: Lessons Learned, Sheffield: DWP.

Ford, F. and Plowright, C. (2009) Realisticevaluation of the impact and outcomes of

the condition management pilots, Preston: Department of Health/University of

Central Lancashire.

Hayllar, O., Sejersen, T. and Wood, M. (2010) Pathways to Work: The experiences

of new and repeat customers in Jobcentre Plus expansion areas, DWP Research

Report 62,Norwich: HMSO.

HoC (House of Commons Public Accounts Committee) (2013) Department for Work

and Pensions: Work Programme Outcome Statistics,London: Stationery Office.

Joyce, K., Smith, K., Henderson, G., Greig, G. and Bambra, C. (2009) Patient

perspectives of Condition Management Programmes as a route to better health,

well-being and employability, Family Practice, 27 (1): 101-109.

Kellett, S., Bickerstaffe, D., Cooper, S., Dyke, A., Filer, S. and Lomax, V. (2008)

Condition management: A qualitative investigation of the customer experience,

Journal of Occupational Psychology, Employment and Disability, 10 (2): 115-127.

Kellett, S., Bickerstaffe, D., Purdie, F., Dyke, A., Filer, S., Lomax, V. and Tomlinson,

H. (2011) The clinical and occupational effectiveness of condition management


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for Incapacity Benefit recipients, British Journal of Clinical Psychology, 50 (2):

164177.

Lindsay, C. and Dutton, M. (2010) Employability through health? Partnership -based

governance and the delivery of Pathways to Work condition management

services, Policy Studies, 31 (2): 245-264.

Lindsay, C. and Dutton, M. (2012) Promoting healthy routes back to work?

Boundary spanning health professionals in employability programmes in Great

Britain, Social Policy and Administration, 46 (5): 509-525.

Lindsay, C. and Houston, D. (2011) Fit for purpose? Welfare reform and challenges

for health and labour market policy in the UK, Environment and Planning A, 43

(3): 703-721.

Lindsay, C., McQuaid, R. and Dutton, M. (2007) New approaches to employability in

the UK: Combining Human Capital Development and Work First strategies?,

Journal of Social Policy, 34 (4): 539-560.

MCR (Macmillan Cancer Research) (2010) Evaluation of Pathways to Work

programme for people living with cancer, London: MCR.

NAO (National Audit Office) (2010) Support to Incapacity Benefits claimants through

Pathways to Work, London: NAO.

OECD (Organisation for Economic Cooperation and Development) (2010) Sickness,

disability and work: Breaking the barriers, Paris: OECD.

Patrick, R. (2011) The wrong prescription: disabled people and welfare

conditionality, Policy & Politics, 39 (2): 275-280.

Reagon, C. and Vincent, C. (2010) An evaluation of three NHS-led Condition

Management Programmes in Wales, Cardiff: Cardiff University.


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Roulstone, A. and Barnes, C. (eds) (2005) Working futures? Disabled people, policy

and social inclusion, Bristol: Policy Press.

Secker, J., Pittam, G. and Ford, F. (2012) Customer perspectives on the impact of

the Pathways to Work Condition Management Programme on their health, well-

being and vocational activity, Perspectives in Public Health, 132 (6): 277-281.

Warrener, M., Graham, J. and Arthur, S. (2009) A qualitative study of the customer

views and experiences of the Condition Management Programme in Jobcentre

Plus Pathways to Work, DWP Research Report 582, Norwich: HMSO.

Weston, K. (2012) Debating conditionality for disability benefits recipients and

welfare reform: research evidence from Pathways to Work, Local Economy, 27

(5/6): 514-528.


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Table 1 Review of findings on impacts of Pathways to Work NHS condition management programmes

Study (date) Methods/data Outcomes/benefits of

condition management

Limitations/problems of


Lessons for policy and

practice

Adam et al (2009) Quantitative analysis of

DWP benefits data; two-

wave survey of more than

1,000 PtW participants,

compared with matched

comparison sample of

non-Choices

participants.

No significant

employment impacts, but

CMP engaged severely

disadvantaged clients

and was designed to

improve health

managementsurvey

data suggested positive

impacts on self-reported

health.

CMP participants did not

exhibit higher

employment rates than

those who did not

participate in Choices.

Exit rates from IB were

significantly negative

compared to overall

claimant population.

Apparent low

employment impact

probably due to

unobserved

characteristics,

highlighting need for

improved data on the

needs/barriers of clients

so that they can be

matched to appropriate

services.

Barnes and

Hudson (2006)

Qualitative interviews with

37 CMP practitioners, co-

ordinators and managers

in first seven districts.

CMP seen as effective in

assisting participants to

understand/manage

conditions; quality of

interventions appropriate.

Less effective where

clients participated due to

sense of obligation. Poor

fit between CBT-oriented

approaches and needs of

some clients (e.g. those

with language barriers).

Need for range of

therapeutic interventions;

need to consider

accessibility of

materials/approaches.


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DWP (2012) Summarises evidence

from DWP evaluations

and views of staff,

managers and policy

stakeholders on CMP

performance.

Positive social and health

outcomes reported by

multiple studies, although

less effective for people

with physical limitations.

Voluntary participation

valued as building trust.CMPs delivered

innovative partnership-

working between NHS

and Jobcentre Plus.

CMP did not deliver value

for money in relation to

employment outcomes.

Delivery costs relatively

high (although

comparative cost data for

other programmes notprovided). Support and

knowledge of Jobcentre

Plus staff sometimes

lacking.

Need for clearer/earlier

evaluation of CMP-type

interventions. Need for

improved knowledge of

future health-focused

interventions among

Jobcentre Plus staff.

Ford and Plowright

(2009)

Qualitative research with

CMP staff/managers at

seven sites. Baseline and

progression data on

HADS and other health

outcomes for approx. 480

CMP participants.

Significant impacts on

anxiety/depression;

progression towards and

into employment for most

clients.

Negative outcomes for

some more severely

disadvantaged clients.

Work-focused activities

viewed negatively if not

integrated throughout

CMP.

Positive (mental) health

outcomes can be

achieved by CMP-type

interventions. Work-

focused support must be

carefully integrated with

CMP.

Hayllar et al

(2010)

Survey of approx. 8,000

PtW clients, including 450

CMP participants.

Most scored CMP

positively, especially

those whose health was

More negative views

among those with most

severe conditions.

Positive outcomes can be


interventions for those


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improving and with

medium/changeable

conditions.

ready to change; need

for further support for

most disadvantaged.

Joyce et al (2009) Focus groups and

interviews with 25 CMP

participants.

Positive outcomes in

health behaviours, mental

health, self-esteem,

confidence, motivation.

CMP too short for people

with severe barriers;

concerns around

availability of follow-upsupport.

Positive health behaviour

changes can be achieved

by CMP-type

interventions. Need toconsider how best to

integrate CMPs with

mainstream/follow-up

health services.

Kellett et al (2008) Reported sample of ten

focus groups from 50

completed with CMP

participants.

Positive impacts on

managing/understanding

conditions, less isolation;

improved sense of

control, confidence.

CMP considered too

short for some people

with more severe

barriers. Groupwork and

CBT-oriented approaches

not suited to some

clients.

Positive changes in

confidence/social

engagement and


can be achieved by CMP-

type interventions. Need

sufficient flexibility in

delivery to address needs

of different clients/

conditions.


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Kellett et al (2011) Pre- and post-CMP

measures of health and

wellbeing gathered from

2,064 completers.

Positive outcomes in

psychological wellbeing,

reduced distress,

improved sense of control

and self-esteem.

Fewer positive outcomes

reported by those with

physical health

conditions. Unclear if

health improvement fed

through to reduced

benefit-claiming. Unclearif CMP able to address

comorbidity in clients

reporting mental and

physical limitations.

Positive psychological

outcomes can be


interventions. Alternative

therapeutic interventions

required for those with

complex physical/mentalhealth conditions.

Macmillan Cancer

Research (2010)


16 cancer survivors

participating in CMP.

Workshops with MCR

support staff, Jobcentre

and CMP professionals.

Improvements in

confidence, social

interaction, motivation

and vocational activity.

Limited benefits in pain

management/coping with

physical conditions.

Concerns that gains

would be lost due to lack

of in-work support. Too

generic to support people

with cancer-specific

needs.

Need for therapeutic

options addressing

cancer-specific and other

needs associated with

chronic/severe physical

conditions. Need for

greater collaboration

between cancer-specific

organisations, Jobcentre

Plus and CMP providers.


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Training in dealing with

cancer survivors would

improve the confidence of

Jobcentre Plus staff.

Reagon and

Vincent (2010)

Quantitative analysis of

HADS outcomes of 244

CMP participants in threeareas of Wales during

programme and after

twelve months.


CMP participants and

staff/managers.

CMP participants

generally reported

positive views of services.Positive impacts on

managing conditions,

confidence, self-esteem,

pain management, levels

of social interaction.

Concern over need for

follow-up support,

problems re-accessingservices. Groupwork not

suited to some clients.

Concerns over

accessibility of services

for clients in rural

communities.

Positive health and social

outcomes can be

achieved by CMP-typeinterventions. Need to

integrate CMPs more

consistently with follow-

up services. Need to

ensure accessible

services in rural areas.

Secker et al

(2012)

Focus group research

with 39 CMP completers

in seven pilot sites.

Positive impacts on

understanding

medication/condition,

confidence, self-esteem;

improved health

behaviours and

vocational activity.

Clients raised concerns

regarding lack of in-work

support; external

problems (debt, caring

roles) could undermine

progress. Less positive

views among older

clients.

Positive health/social

outcomes can be


interventions. Need for in-

work support. Older

clients may need targeted

assistance.


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Warrener et al

(2009)


purposive sample of 30

CMP participants.

Positive impacts on

quality of life, confidence,

social interaction, anxiety,

condition management.

Lack of pressure to return

to work welcomed.

Positive views ofaccessibility (including

location) of services.

Less positive outcomes

reported by those with

physical limitations.

Perception of some

duplication with existing

NHS services. Variable

completion rates, oftendue to external factors.

Concerns regarding lack

of in-work/follow-up

support.

Credibility and

professionalism of NHS

staff may add value in

future services.

Alternative therapeutic

interventions required

(e.g. pain management).


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