A systematic review of evidence on the effectiveness and health impacts of interventions to promote employment rates among people with chronic illness and disability in the UK and Ireland between 2003 and 2023

Background

There is a large and growing proportion of people in the UK with long-term/chronic illnesses and disabilities. Although employment rates of chronically ill and people with disabilities have grown over time, rates of unemployment and economic activity remain relatively high compared to people without chronic illness or disability, particularly for those with multiple health or serious long-term mental health conditions. There is an established body of evidence that gaining and maintaining decent employment brings benefits to individuals and wider society. Closing the disability employment gap by increasing levels of employment for people living with long-term illnesses and disabilities is a high priority for national and local government.

This review systematically located, appraised, and synthesised evidence on the effectiveness of employment interventions for people with long-term health conditions or disabilities in the UK. The review only included evidence from higher methodological quality peer reviewed academic journal articles on evaluations of employment interventions with control/comparison groups conducted in the UK published between 2003 and 2023. This was to maximise the likelihood that findings would be relevant and transferable to the Liverpool City Region and other UK settings, given the potential for social, cultural, economic, employment, and policy differences in other countries and changes over time that may reduce generalisability of evidence.

The review included evidence on the effectiveness of interventions designed to increase employment rates for chronically ill and people with disabilities. For studies assessing employment rates, additional evidence (including from related peer reviewed publications) on physical and mental health impacts of the interventions, and economic outcomes (e.g., cost effectiveness) were also included.

Methods

Searches of five gold standard academic databases were conducted. This was complimented by iterative supplementary searches via advanced Google/Google Scholar, hand searches of expert and organisational websites, and backward and forward citation searches. At least two reviewers independently screened articles for inclusion, before extracting data, and then assessing the methodological quality of the included studies. Results from the studies were synthesised narratively.

Findings

From over 6,000 articles screened, 14 articles based on 11 underlying studies that met the reviews strict inclusion criteria were included (noting different outcomes reported in different articles). Most examined outcomes (employment, and/or health, economic) for people with long-term severe mental health conditions such as schizophrenia or bipolar disorder. All of the studies bar one were conducted in England (mostly London, south east, midlands). Two studies evaluated condition specific vocational interventions for people with long-term musculoskeletal pain, and recovering from stroke. One study in Wales evaluated an intervention for Incapacity Benefit recipients (with a mix of physical and/or mental health conditions).

Eleven articles (based on eight underlying studies) evaluated employment, health, and economic outcomes for people with severe mental health conditions receiving Individualised Personal Support (IPS) or modified versions of IPS interventions delivered through integration of dedicated employment support within Community Mental Health Teams (CMHTs). IPS groups were either compared to control groups receiving traditional vocational support or modified versions of IPS.

IPS is based on eight principles: (i) Getting people into open/competitive employment. (ii) Open to all who want to work irrespective of condition. (iii) It works quickly. (iv) Jobs choices people prefer. (v) Brings employment specialists into clinical teams. (vi) Specialists develop relationships with employers based on persons preferences. (vii) Ongoing individualised support for person and employer. (viii) Benefits counselling is included.

Looking across the studies, there is high methodological quality evidence that the IPS interventions in England were effective at helping people with severe mental health conditions into employment when compared to traditional vocational interventions. There was also some evidence suggesting that modifications in the form of additional bolt on elements such as motivational training may increase the effectiveness of IPS, although more studies are needed. Increases in employment where, however, modest, likely relating the nature and severity of mental illness of the participants and related barriers to employment. There was also evidence, although from just two studies, that dedicated, specific vocational interventions for people with physical health conditions, improved employment outcomes compared to clinical care only. One study also found that an intervention providing support to people with a mix of conditions receiving Incapacity Benefit in Wales increased employment rates. This UK evidence is consistent with the wider body of international evidence which also found that IPS and dedicated vocational interventions for specific health conditions are effective, and that there is a relative paucity of evidence on employment interventions for people with physical conditions and disabilities.

From studies that measured employment outcomes there is some evidence that IPS interventions increase health and wellbeing outcomes, although the findings were equivocal. A single study, which must therefore be viewed with caution, also found that a stroke specific vocational intervention improved job satisfaction. These findings need to be tested and replicated in other studies to inform policy.

There is also limited albeit consistent evidence from four studies that IPS interventions are more cost effective than traditional vocational interventions in comparisons between the costs of IPS and reductions in costs to health services (in-patient, out-patient, primary care, prescriptions etc). One study provides limited evidence that specific vocational intervention for people with musculoskeletal pain may be cost effective and represent a high societal-level return on investment through reductions in work absence.

Discussion

The evidence indicates that IPS is effective at increasing employment rates in the UK context, at least in the short-term (gaining as opposed to sustaining employment in the long-term), for the population group (severely mentally ill) and settings in the studies (employment specialists within CMHTs, in England). It may also be that high fidelity IPS design and delivery (consistent with IPS principles) are needed and that deviations from the principles may reduce effectiveness.

Additional support bolt on elements such as tackling preconceptions of job seekers and clinical staff may increase effectiveness. If correct, this has clear implications for practice in the design and delivery of IPS. IPS also appears to improve health and wellbeing, but more research is needed, including across different occupations and roles. IPS also appears to be more cost effective than traditional vocational interventions, but again more studies, and of wider service and societal outcomes, are desirable. The effectiveness of IPS and other dedicated specialist employment interventions for other conditions/groups (including people with more moderate mental health conditions, learning difficulties, learning disabilities, a wide range of chronic physical illnesses and disabilities, and various combinations of comorbidities and multimorbidities) and in a variety of settings is yet to be established. This should be a particular priority for future studies. Issues relating to the provision of support for different conditions and disabilities, including integration into a variety of clinical teams and settings, need to be investigated if IPS is to be delivered effectively to a wide range of people in other situations. New applications of IPS, both in terms of populations and settings, and modifications to design and delivery, should be carefully monitored and evaluated to address gaps and limitations in the current evidence base and to better inform future interventions and policies.