UK: IAPT-Employment Adviser pilots - some information & docs

S

Sarah

Senior Member (Voting Rights)
The IAPT-LTC pathway full implementation guidance was recently published (see below) to support national roll-out of 'IAPT-LTC' (which encompasses MUS). As IAPT-employment adviser cross-referral may be of increasing relevance (due to roll out of IAPT-LTC and inclusion of CFS under MUS in the full implementation guidance for IAPT-LTC pathway), I've posted up some background on the pilots on employment advisers in IAPT below. Bolding throughout is mine.

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An employment adviser in IAPT pilot ran from April 2009 to March 2011 in an initial 11 areas in England with subsequent sites in Wales and Scotland:

"..with the aim of testing the added value of providing employment advice as well as psychological therapy to employed IAPT clients to help them remain at work or return to work if on sick leave."

The full pilot evaluation and a 4 page summary report can be found here:

https://www.gov.uk/government/publi...ss-to-psychological-therapies-programme-rr826

From the summary report, on information-sharing with patients' employers:

p.3 "EAs developed action plans with clients to address their needs including confidence building, seeing the situation from a new perspective, advice on employment rights, and CV/ interviewing skills. Some EAs highlighted the necessity, in most instances, of contact with the employer either by the client and/or by the adviser. Clients felt that where this had happened, it had been effective in helping resolve problems."

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A further pilot is currently in place increasing the number of employment advisers embedded in IAPT services to a 1:8 EA to therapist ratio, and in addition to the data specified in the standard data set for IAPT, and technical output specification for IAPT LTC/MUS, additional information is flowed for these pilot sites relating to employment status. This information includes whether the individual is claiming ESA/UC/PIP/jobseekers allowance.

"NHS Digital collects national service data to produce a number of data sets. The Systems and Service Delivery (SSD) team within NHS Digital host the Bureau Service Portal, a facility that allows centralised collection and processing of service data."

https://digital.nhs.uk/data-sets-bureau-service-portal

EA wave 1 sites have been underway from last year with the first data submission window starting 6 October 2017. Target date for recruitment of EAs in wave 2 sites is June 2018.

Direction from the Joint Work and Health Unit, (which is taking the current EA pilot forward) to NHS Digital to:

"..establish and operate an informatics system for the collection and analysis of work data to support patient care and the evaluation of the initiative Employment Advisers in Improving Access to Psychological Therapies (IAPT)."

https://digital.nhs.uk/article/7846/Employment-advisers-in-IAPT-Direction-2017-

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EA in IAPT pilot data set - technical output specification:

[Xlsx] https://digital.nhs.uk/media/36512/...Pilot_Data_Set_Technical_Output_Specification

LTC/MUS IAPT pilot data set - technical output specification:

[Xlxs]
https://digital.nhs.uk/media/36515/...ion/xls/IAPT_Data_Set_LTC_Pilot_Specification

These specifications and documents (including technical output specification) on the v1.5 IAPT standard data set can be found here:

https://digital.nhs.uk/Improving-Access-to-Psychological-Therapies-Data-Set

"Following the commencement of data collection for the new EA and LTC pilots, a single IDB has now been made available which will hold any combination of v1.5, EA and LTC data."

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Report on Employment Adviser IAPT services pilot - Executive Summary, December 2017:

p.6 "In addition to this routine collection, which is mandatory for NHS IAPT services across England, services taking part in the EA pilot will collect additional information at each patient contact7. This extra information includes details about the patient’s employment status and can be used to compare outcomes for patients in work, on a long-term absence, and not in work."

p.6 "These additional items are being collected by the pilot IAPT service providers from approximately 40 per cent of Clinical Commissioning Groups (CCGs) in England. Pilot services have been selected to be a representative sample of IAPT CCGs across England."

p.7 "Initial reporting will focus on key data quality measures to inform users and services of how well the necessary information is recorded and submitted to NHS Digital."

[PDF] https://digital.nhs.uk/media/36814/...er-2017/default/iapt-ea-rep-dec-2017-exec-sum

Reports are available for Nov 2017 and October 2017:

https://digital.nhs.uk/Monthly-Improving-Access-to-Psychological-Therapies-IAPT-reports
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Potentially sensitive information is generated in IAPT appointments, including outcome measures for the Chalder Fatigue Scale and Patient Health Questionnaire 9 for CFS patients who may be referred for MUS (from the full guidance for IAPT-LTC pathway).

https://www.rcpsych.ac.uk/workinpsy...arepathways/improvingaccess.aspx?theme=mobile

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The content of patient consents for EA->IAPT / IAPT->EA referral and data-sharing is unclear. From reading, consents are probably drafted at a regional level.

From 'public service provider' Reed in Partnership's IAPT Toolkit:

http://www.reedinpartnership.co.uk/latest-news/iapt-toolkit?isarchivenews=true

"5. Cross Referrals

"Objective: Establish a clear process for cross-referrals between the IAPT and employment support services.
Method: The thresholds for referral and the referral route agreed at outset of the partnership between IAPT and employment support provider.

"A reliable cross-referral system is an essential element of the close working relationship between the IAPT and the employment service. This requires client consent, especially when sensitive information is sent.

"The employment service will refer participants to IAPT if the referral threshold is met and advisers believe that the service is likely to improve the client’s mental health. IAPT will refer to the employment service if they believe that their mental health will be improved by entering work or training."

Further on information sharing between IAPT and EA fron the Reed Toolkit:

"6. Case conferencing to close the loop between services

" Objective: Ensure that information about patients/participants engaged in both
IAPT and employment support services is shared between both functions to improve holistic support delivered.
Method: Regular contact between Employment Advisers and IAPT clinicians to discuss individual cases.

"During the referral process the service (IAPT or employment) will explain the benefit of case conferencing to the participant. At the first meeting after referral the employment service will seek signed consent from the participant to discuss their case with the IAPT service and the participant will be asked for contact details of their clinician."

Further:

"8. Evaluation and measuring impact

"The Work and Social Adjustment Scale can be used as a distance travelled measure. It is already used by IAPT services and is a useful tool to link with employment services as it is a good indicator of someone’s readiness to adjust to work."

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Further: limited information that a GP surgery in Boston and in Lincoln may refer directly to EAs:

[PDF:] https://www.uea.ac.uk/documents/246...ples.pdf/ec368015-a4fb-4768-8aa0-962acabd41d9
 

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Sarah said:
"A reliable cross-referral system is an essential element of the close working relationship between the IAPT and the employment service. This requires client consent, especially when sensitive information is sent.
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I wonder what, if any, any consequences there might be to refusing consent.

I can see vulnerable people being pushed from both sides here. This is chilling stuff.
 
Invisible Woman said:
I wonder what, if any, any consequences there might be to refusing consent.
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According to the full evaluation of the original EA in IAPT pilot, some EA services accepted referrals other than IAPT service referrals including referrals from employers:

p.16 "As noted above, where referrals were low, EA services often sought to develop their client base beyond the IAPT service to include, for example, self-referrals. They also contacted employers in some instances to make them aware of their services. Some EA services, however, had decided that they would only receive referrals from the IAPT service."

Refusing EA referral by an employer, if the employer insisted, may raise more complex employment law issues.

Participation in the Work and Health Programme is mandatory if a claimant has been out of work and claiming unemployment benefits for 24 months, and may involve support to "manage health problems to reduce their impact on work".

https://www.gov.uk/work-health-programme

It seems reasonable to infer in such cases refusal to accept an IAPT referral may result in benefit sanction.

As with primary care to IAPT referral, IAPT referral to EA requires patient consent. Patient informedness, felt pressure to consent resulting from trickle down of Joint Work and Health Unit targets, how generated information such as outcome measures charted over a course of IAPT are used by EAs, and patient data-sharing oversight is factored are muddy and relatively opaque matters of key concern.

I've encountered some allusions to information governance and patient confidentiality in the EA in IAPT - I'll try to post up later on, might not be today.
 
Appendices to the IAPT Data Handbook: Guidance on recording and monitoring outcomes to support local evidence-based practice v.2.0.1 June 2011:

[PDF] http://webarchive.nationalarchives....o/files/iapt-data-handbook-appendicies-v2.pdf

Appendix G, pp.45-47, contains guidance on information governance for internal, secondary, and external use of data. The appendices and the Data Handbook (separate document) are available from the National Archives. It is not a recent document, but is cited in the June 2016 IAPT Executive Summary. The IAPT manual (awaiting publication) may have further. Bolding throughout is mine.

"External use of data

"Consent cannot be implied for other purposes, such as disclosure to outreach teams, the police, government departments (other than the Department of Health), or the courts, for example. In most cases, service users should be asked for their explicitc consent for information to be shared for non-care purposes.

"In certain circumstances, information can be disclosed without seeking explicit consent, or where consent has been sought but refused. This happens when:
-The disclosure is required or permitted by law – perhaps by court order or under an Act of Parliament. For example, certain confidential information must be disclosed to the Health Protection Agency for monitoring and controlling disease. Disclosures may also be permitted under section 251 of the NHS Act 2006 (formerly section 60 of the Health and Social Care Act 2001)"

Reed in Partnership's 2016 IAPT Toolkit co-produced with Take Time to Talk emphasises the need to obtain explicit consent for cross-referral and written consent for case-conferencing. The Toolkit was designed:

"..for the benefit of delivery staff and managers of both the NHS's IAPT (Improving Access to Psychological Therapies) and employment services providers - helping to support effective joint working with individuals experiencing mental health difficulties."

http://www.reedinpartnership.co.uk/latest-news/iapt-toolkit?isarchivenews=true

Conjecture:

The Health and Social Care (Safety and Quality) Act 2015 (which amends the Health and Social Care Act 2012) creates a duty for health or adult social care commissioners or providers to share information with any other relevant health or adult social care commissioners or provider with whom they communicate about the individual, providing it facilitates care to the individual and is in their best interests. This is subject to the individual objecting or being reasonably considered to be likely to object to the information sharing, and does not override the Data Protection Act 1998 (to be superceded in May 2018 by the General Data Protection Regulation (EU) 2016/679), or common law duty of care or confidence.

s.253 of the Health and Social Care Act 2012 provides:

"(3)In this Chapter—

“ 'adult social care' —

"(a) includes all forms of personal care and other practical assistance provided for individuals who, by reason of age, illness, disability, pregnancy, childbirth, dependence on alcohol or drugs, or any other similar circumstances, are in need of such care or other assistance, but

"(b) does not include anything provided by an establishment or agency for which Her Majesty's Chief Inspector of Education, Children's Services and Skills is the registration authority under section 5 of the Care Standards Act 2000;

" 'health services' means services which must or may be provided as part of the health service in England"

(For ease of reference: s.5 CSA 2000: https://www.legislation.gov.uk/ukpga/2000/14/section/5 )

The 2010 Dilnot Commission on Funding of Care and Support, published 2011 defined social care as follows:

“Social care supports people of all ages with certain physical, cognitive or age-related conditions in carrying out personal care or domestic routines. It helps people to sustain employment in paid or unpaid work, education, learning, leisure and other social support systems. It supports people in building social relationships and participating fully in society.

"Social care is part of a wider care and support system which includes social care, the NHS, the social security system, housing support and public health services."

It seems reasonable to conjecture that IAPT-EA information sharing on an implied consent footing could have an arguable legislative basis in s.251 of the Health and Social (Safety and Quality Act) 2015.

The Information Governance Alliance guidance on disseminating health and social care data can be found here:

https://digital.nhs.uk/information-governance-alliance
 
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Sarah said:
The Health and Social Care (Safety and Quality) Act 2015 (which amends the Health and Social Care Act 2012) creates a duty for health or adult social care commissioners or providers to share information with any other relevant health or adult social care commissioners or provider with whom they communicate about the individual, providing it facilitates care to the individual and is in their best interests. This is subject to the individual objecting or being reasonably considered to be likely to object to the information sharing, and does not override the Data Protection Act 1998 (to be superceded in May 2018 by the General Data Protection Regulation (EU) 2016/679), or common law duty of care or confidence.
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Bolding mine.

The thing that strikes me about this is it sounds so reasonable for someone who hasn't witnessed how easily things are twisted. In the best interests of the patient and they get to be the final arbiter. Like the don't give them benefits or social care, it's for their own good.
 
since social care budgets have been constantly cut who will these social care providers actually be. in England charities have been filling in the huge gaps left by unfeeling government robots following political dogma. I am constantly horrified by how abusive the d.w.p have become.
 
alktipping said:
since social care budgets have been constantly cut who will these social care providers actually be.
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If the question is: what organisations are providers of employment support in the IAPT pilots?

I'm not aware of an exhaustive list of providers for wave one (or proposed providers of wave two) sites. According to the document 'Evaluation of Employment Advisers in the Improving Access to Psychological Therapies programme' published 2013 (link in original post, but for ease of reference see below), the original pilot site employment adviser provider organisations were as per the attached file (see below)
4lbGb


https://www.gov.uk/government/publi...ss-to-psychological-therapies-programme-rr826

From the evaluation:

'The Department for Work and Pensions (DWP) commissioned, via the Department of Health (DH), a number of separate organisations with experience of delivering mental health and/or employment retention services to deliver the Employment Adviser (EA) pilots. The commissioning was undertaken via local health organisations, such as Primary Care Trusts (PCTs), to meet local needs and priorities.'

(PCTs (primary care trusts) were abolished on 31 March 2013 under the Health and Social Care Act 2012, replaced by clinical commissioning groups.)

According to Kevin Jarman, EA in IAPT Lead, (Work and Health Unit) £47.7m is being invested as result of a WHU Spending Review bid to increase the number of employment advisers working in IAPT services to a 1:8 ratio in 40-50% of CCGs, by way of plans to recruit 275 EAs and 75 senior employment advisers. Further investment may apparently be available dependent upon pilot evaluation findings.

From the Spending Review 2015:

'In addition, the government wants to improve links between health services and employment support, recognising timely access to health treatments can help individuals return to work quicker. Over £115 million of funding will be provided for the Joint Work and Health Unit, including at least £40 million for a health and work innovation fund, to pilot new ways to join up across the health and employment systems. To further integrate services and help people back into work, where it has been agreed as part of a devolution deal, local areas will co-design employment support for harder-to-help claimants.'

Around half of the CCGs will be in wave one and half in wave two. (There may be 195 or fewer CCGs currently in existence, depending on merger status.) Target date for commencement of recruitment of EAs in wave 2 sites is June 2018.
 

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Building a business case for employment advice and support

This document is available on the UEA website, but is unattributed and undated (it predates Spring 2011). PCTs were abolished on 31 March 2013 under the Health and Social Care Act 2012, 'replaced' by clinically led CCGs. EAs in IAPT are funded via CCGs.

[PDF] https://www.uea.ac.uk/documents/246...iapt.pdf/b6575f71-f490-4b5e-a88d-64f37357f753

https://www.uea.ac.uk/medicine/depa...e/implementation-plans-background-information

'A Simple Illustrative cost-benefit calculation

'6. The below outlines a simple cost-benefit calculation. It demonstrates how many people an employment adviser would need to maintain in employment to yield enough PCT savings to offset the upfront cost. Figure 1 represents a simple model of the below calculation.

'7. Cost

Cost of Employment Adviser: this is assumed to be £40,000 p.a. which includes oncosts (e.g. pension, employer NIC) plus management and administrative support costs9.

'8. Potential Saving

'9. Estimated cost of an average person who is unemployed and on incapacity benefits to a PCT, expressed in consumption of NHS services: £1,700 - 3,400 p.a. (A). This is based on research which suggests that as people move from employment to unemployment, they incur 50% more in costs to the NHS than employed people.10,11,12

'10. Estimated average cost to a PCT of employed person: £1,100 - 2,300 p.a.13 (B)

'11. Estimated saving to a PCT of keeping one person in employment for one extra year: £600 - 1,100 p.a.14 (C = A - B)

'Potential Return on Investment

'12. For a return on investment to be made for a PCT, each Employment Adviser would need to support an additional 40 – 70 IAPT service users to maintain employment for a year (over and above core IAPT): £40,000/£600 to £40,000/£1,100 = 40-70. If an average Employment Adviser sees 250 people per annum15, this represents between 16 - 28% of their caseload.

'Note: The calculation does not take into account other fiscal impacts – avoidance of loss in tax revenue and avoidance of benefit payments – or wider economic and social benefits of keeping people in work. The other additional fiscal impact from retaining an average person in work is estimated at £9,000 p.a.16 Thus, if an Employment Adviser is successful in retaining an additional 40 -70 people in work, the avoidance of fiscal loss for this group would be around £360,000 - £630,000 per annum.'

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Context of UEA IAPT website material provision:

The University of East Anglia was a first wave IAPT training provider.

UEA offers several IAPT (including postgraduate, undergraduate, access and CPD) courses for aspiring and existing Psychological Wellbeing Practitioners and High Intensity Therapists. The UEA website houses a repository of IAPT training documents, including national curricula, Positive Practice Guides, and Clinician Guides.

https://www.uea.ac.uk/medicine/depa...oural-therapy-training/iapt-and-cbt-resources

Including IAPT timeline:

http://www.tiki-toki.com/timeline/entry/592316/History-of-IAPT/

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University of East Anglia Head of Department of Clinical Psychology (Norwich Medical School), Professor Kenneth Laidlaw, (Professor of Clinical Psychology) is co-author of:

-Improving Access to Psychological Therapies National Curriculum for CBT with Older People. 2nd Edition. (Revised February 2016) Chellingsworth, M., Davies, S and Laidlaw, K. Department of Health.
('All editions are under the aegis of the national IAPT team/NHS England/Department of Health');

-A Clinician’s Guide to: Low Intensity CBT with older people. (2016) Marie Chellingsworth, Naoko Kishita & Ken Laidlaw;

-A Clinician’s Guide to: CBT with older people. (2016) Ken Laidlaw, Naoko Kishita & Marie Chellingsworth.

Professor Laidlaw's 'conceptualization framework for CBT with older people is part of the IAPT curriculum materials for HI IAPT workers.'

Professor Laidlaw interviewing Employment Advisers in IAPT Services Lead (Work and Health Unit), Kevin Jarman (undated):

https://utv.uea.ac.uk/View.aspx?id=...QUDIvfnhrYIl9ONhAmxDoivo&ax=7A~hCvp9ke2jtWGBs
 
imagine private companies getting their hands on taxpayers money and then wonder why those companies create ever greater need for themselves, in the military its called mission creep. there was a programme last year showing how consultancy firms would get a foot hold in local government bodies and then increase their task and of course their payments of time this became a big enough scandal that investigative journalist made a documentary about it. unfortunately I cannot remember whether it was a dispatches programme or some other doc company.
 
alktipping said:
since social care budgets have been constantly cut who will these social care providers actually be. in England charities have been filling in the huge gaps left by unfeeling government robots following political dogma. I am constantly horrified by how abusive the d.w.p have become.
Click to expand...
Indeed. It is a different breed of person. Esther McVey recently addressed Scottish Parliament ( SNP picked up and politicised the "rape clause" in the child tax credits fiasco) and told them that rape victims should be grateful for the " free counselling" the benefit interview would provide..
 
chrisb said:
Is that cost benefit analysis complete? If, by keeping a person in employment, you can take years off their life, consider all the savings on pension and health care costs that cam be made.
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So the cost benefit analysis is only looking at the potential reduction in consumption of NHS services in cost terms that would be achieved by keeping one individual in employment for a year, and how many individuals must be retained in employment to meet the costs of a single employment adviser for one year. The CBA author reaches the figures 40-70 for individuals to be retained in employment for one year. This is to meet the 'assumed' cost of an EA for one year. The assumed positive return before exceeding these figures would seem to be met as follows:

'The calculation does not take into account other fiscal impacts – avoidance of loss in tax revenue and avoidance of benefit payments – or wider economic and social benefits of keeping people in work. The other additional fiscal impact from retaining an average person in work is estimated at £9,000 p.a.[16] Thus, if an Employment Adviser is successful in retaining an additional 40 -70 people in work, the avoidance of fiscal loss for this group would be around £360,000 - £630,000 per annum.'

This is not an endorsement of the veracity of the CBA calculation, particularly in respect of the estimated figure of 50 per cent increase in costs to the NHS as people move from employment to unemployment and the applicability of the studies cited in support of this figure in the CBA and Fujiwara paper from which calculations for figures used are derived.

Edited to beef out quote.
 
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From the IAPT Manual (bolding is mine):

"11.5 Employment support

"There are poorer employment outcomes for people with coexisting mental and physical health problems. There is a high risk of unemployment, absenteeism and poorer performance29. It has been established that the longer people are absent, or out of work, the more likely they are to experience depression and anxiety. Therefore, employment advice, delivered as a core part of an IAPT service, can be integral to the success of that service.

"IAPT staff should work alongside employment and welfare advisers, whenever that is what people need. For this reason IAPT guidelines have always said that each team should include one employment specialist for every eight therapists4 Employment advice, debt counselling and other social assistance should be available within the IAPT service and offered as part of an integrated care plan with close liaison between clinicians and advisers from the point of assessment, through treatment and to discharge.

"Employment advisers in IAPT work directly with individuals who are in employment, as well as people who are out of work on health-related benefits. They provide practical advice and relevant intervention to help individuals retain employment or enter the workplace. There is scope to adapt aspects of service delivery at a local level.

"Employment support coordination aims to ensure IAPT services are sufficiently integrated with relevant employment bodies at a local level. This can include building relationships with Jobcentre Plus, Work Programme and other relevant employment support providers, local chambers of commerce and local employers. Employment support coordination generally operates at a strategic level and does not have a caseload, but can complement and support the work of hands-on employment advice services."
 
Have they ever tried to calculate the effect on depression and anxiety of implied duress in persuading those unfit for employment to return to work?

Admittedly there are difficult issues involved; the problem is in deciding who can be trusted to deal with them reliably.

On another thread about the conference on malingering and illness deception which took place at, if I remember correctly, Woodstock, I noted that the number of delegates from the University of Sheffield exceeded that from even Cardiff. Presumably this is the sort of work which those two "centres of excellence" have been engaged in.

edited typo
 
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Employment Advisors in Improving Access to Psychological Therapies (IAPT) service at Let’s Talk-Wellbeing
Publication date: 10 May 2018

https://www.england.nhs.uk/publicat...herapies-iapt-service-at-lets-talk-wellbeing/

Excerpts:

"Case study summary

"In autumn 2017 talking therapies service Let’s Talk-Wellbeing (LTW) Leicestershire County and Rutland (provided by Nottinghamshire Healthcare NHS Foundation Trust), with the government’s Joint Work and Health Unit, agreed to be part of a pilot to integrate Improving Access to Psychological Therapies (IAPT), healthcare and employment support. Launched in December 2017, LTW Leicestershire County and Rutland’s Employment Advisory Service has created personalised packages of care by working alongside IAPT practitioners – resulting in 100 people being supported to gain or sustain employment in its first three months."

“'The integrated Employment Advisory Service promotes the link between being in work and achieving improved health outcomes. For example, a service user receiving low intensity psychological treatment for depression in the form of National Institute for Health and Care Excellence (NICE)-approved behavioural activation could also be supported with employment support by setting small, realistic employment goals to improve mood and motivation,' [Ajay Maisuria, Senior Employment Advisor at LTW Leicestershire County and Rutland] explains.

“'Our service model has been created to promote ease of referrals from IAPT practitioners, and provide timely, confidential and impartial support for individuals who require additional interventions based on their employment needs. Ultimately, it’s a service which addresses the emotional challenges of continuing in, starting, or resuming work through integrated psychological treatment and employment support,' says Ajay.

"A team of six Employment Advisors cover north-east, west and south-east Leicestershire County and Rutland. Referrals are accepted from IAPT practitioners via an integrated system that ensures a smooth patient care pathway. In developing the service, local partnerships have been formed comprising the Job Centre, local government, voluntary sector, housing, employment and education-based organisations.

"The service model includes following up service users one year after completing psychological treatment to see if their mental health and employment status has been maintained or improved."


"By focusing on employment and mental health, people of all ages and backgrounds can be supported, through the NHS and local partnerships, in accordance with the Five Year Forward View for Mental Health. This commits the NHS to provide employment support to 29,000 extra people with mental health conditions by 2021 and the Employment Advisers in IAPT programme will make a major contribution to that target."


"Nationally, there are approximately 150 new Employment Advisors working in IAPT talking therapy services – this more than doubles the current employment support capacity within IAPT services. Plans are in place to recruit a total of over 300 by January 2019, supported by £39 million of government investment. To ensure employment support is available in all IAPT services across England, the Department of Health and Social Care/Work and Pensions Joint Work and Health Unit is evaluating the impact of the investment with a view to a possible bid for further investment in Employment Advisors in IAPT services."
 
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