Lindsay and Dutton Promoting Healthy Pathways to Employability SPA2013
Transcript of 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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24
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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Norwich: HMSO.
Bambra, C. (2011) Work, worklessness and the political economy of health, Oxford:
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Barnes, C. (2000) A working social model? Disability, work and disability politics in
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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
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Corden, A., Nice, K. and Sainsbury, R. (2005) Incapacity Benefit reforms pilot:
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Danieli, A and Woodhams, C (2005) Disability frameworks and monitoring disability
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DWP (Department for Work and Pensions) (2004) Building on New Deal: Local
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DWP (2006)A new deal for welfare: Empowering people to work, London: Stationery
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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,
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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):
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programme for people living with cancer, London: MCR.
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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.
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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
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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
condition management
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
achieved by CMP-type
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
condition management
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
achieved by CMP-type
interventions. Alternative
therapeutic interventions
required for those with
complex physical/mentalhealth conditions.
Macmillan Cancer
Research (2010)
Qualitative interviews with
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.
Qualitative interviews with
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
achieved by CMP-type
interventions. Need for in-
work support. Older
clients may need targeted
assistance.
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Warrener et al
(2009)
Qualitative interviews with
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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