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Evidence review for preparation for employment
Evidence review H
NICE Guideline, No. 213
National Guideline Alliance (UK).
Preparation for employment
Recommendations supported by this evidence review
This evidence review supports recommendations 1.13.1 – 1.13.11, 1.17.14. Other evidence supporting these recommendations can be found in the evidence reviews on Views and experiences of service providers (evidence report M).
Review question
What are the most effective models of health, social care and education services working together to prepare disabled children and young people with severe complex needs for employment?
Introduction
The review aims to identify the most effective models where health, social care and education services work together to prepare disabled children and young people with severe complex needs for employment.
At the time of scoping and developing the review protocols, documents referred to health, social care and education in accordance with NICE style. When discussing the evidence and making recommendations, these services will be referred to in the order of education, health and social care for consistency with education, health and care plans.
Summary of the protocol
See Table 1 for a summary of the Population, Intervention, Comparison and Outcome (PICO) characteristics of this review.
Table 1
Summary of the protocol (PICO table).
For further details, see the review protocol in appendix A.
Methods and processes
This evidence review was developed using the methods and process described in Developing NICE guidelines: the manual. Methods specific to this review question are described in the review protocol in appendix A and the methods document (Supplement A).
Declarations of interest were recorded according to NICE’s conflicts of interest policy.
Effectiveness evidence
Included studies
Five studies were included for this review; 1 randomised controlled trial (Carter 2009), 1 quasi-RCT (Izzo 2000), and 3 non-randomised studies (McVeigh 2017, Winsor 2007 and Yamatani 2015).
The included studies are summarised in Table 2.
Three studies examined arrangements/links with third sector/community organisations as the intervention (Carter 2009, McVeigh 2017 and Winsor 2007). Of these, 1 study compared a multicomponent intervention package to typical transition education (Carter 2009); 1 study examined a Show-Me-Careers initiative which supported seamless transitions to integrated employment through a Practice Informing Policy-Policy Enabling Practice framework (McVeigh 2017); and 1 study compared a Jobs by 21 Partnership Project to nonparticipants and to no partnership project county clients (Winsor 2007).
One study examined a named responsible practitioner as the intervention (Yamatani 2015), specifically a Career Transition Liaison Project.
One study examined follow on support as the intervention (Izzo 2000), whereby the extension of transition services beyond graduation was compared to transition services ceasing at graduation.
See the literature search strategy in appendix B and study selection flow chart in appendix C.
Excluded studies
Studies not included in this review are listed, and reasons for their exclusion are provided in appendix J.
Summary of studies included in the effectiveness evidence
Summaries of the studies that were included in this review are presented in Table 2.
Table 2
Summary of included studies.
See the full evidence tables in appendix D. No meta-analysis was conducted (and so there are no forest plots in appendix E).
Summary of the effectiveness evidence
Overall, there was evidence of an important benefit of arrangements/links with third sector/community organisations for progress into employment. This included a multicomponent intervention package (when progress into employment was measured by participation in paid or unpaid community based work, paid competitive jobs, unpaid jobs, and those that did not work at any point during the summer, however there was evidence of an important harm when measured by exclusively held sheltered jobs shown by a meaningful reduction in employed participants in the intervention group), a Show-Me-Careers initiative, and a Jobs by 21 Partnership Project (when compared to both students living in counties receiving Partnership Project funds but not participating in the project, and students who lived in counties not receiving Partnership Project funds). There was also evidence of an important benefit, in terms of increased competence, of a named responsible practitioner, specifically a Career Transition Liaison Project which included a full-time career transition liaison and follow-on support including the extension of transition services beyond graduation for independence (when independence was measured by active in social groups, has savings or current account, and has credit cards, but not when measured by registered to vote or married). Further, there was evidence of an important harm when independence was measured by those participants with a driver’s license shown by a meaningful reduction in participants with a license in the intervention group).
Overall, the evidence was very low to low quality due to concerns about risk of bias, indirectness and imprecision. Studies failed to report on any important outcomes including self-efficacy, successful completion of independent travel training (which is individually tailored), and competence in skills relevant to job search and self-promotion in recruitment and selection processes. Studies failed to report on a number of interventions of interest, for example, supported internships and traineeships, local authority independent travel training, NHS learning disability employment program, work experience coordinators, and short breaks/respite care (those which support employment).
See appendix F for full GRADE tables.
Economic evidence
Included studies
A systematic review of the economic literature was conducted but no economic studies were identified which were applicable to this review question.
A single economic search was undertaken for all topics included in the scope of this guideline. See Supplement B for details.
Excluded studies
Economic studies not included in this review are listed, and reasons for their exclusion are provided in appendix J.
Summary of included economic evidence
No economic studies were identified which were applicable to this review question.
Economic model
No economic modelling was undertaken for this review because the committee agreed that other topics were higher priorities for economic evaluation.
Evidence statements
Economic
No economic studies were identified which were applicable to this review question.
The committee’s discussion and interpretation of the evidence
The outcomes that matter most
The outcomes progress into employment, independence and competence were prioritised as critical outcomes by the committee. Employment was prioritised because identifying joint-working practices to support employment was the primary focus of this review. Independence and competence were selected as critical outcomes because they represent benefits of employment which impact on quality of life.
The outcomes self-efficacy, successful completion of independent travel training and competence in skills relevant to job search and self-promotion in recruitment and selection processes were selected as important outcomes. These were important outcomes because they are part of the pathway towards employment, whereas employment itself may be applicable to a narrower population of disabled children and young people with severe complex needs.
The quality of the evidence
The quality of the evidence was assessed with GRADE and was rated as very low to low. Concerns about the risk of bias were “very serious”. The most serious concerns for the RCT and quasi-RCT were bias arising from the randomisation process, deviations from intended interventions, and missing outcome data. The most serious concerns for the non-randomised, interrupted time series studies were biases arising from the intervention independent of other changes, shape of the intervention effect pre-specified, intervention unlikely to affect data collection, knowledge of the allocated interventions adequately prevented during the study, and other risks of bias. The most serious concerns for the non-randomised cohort study were confounding, selection of participants into the study, measurement of outcomes, and selection of the reported result. There were “no serious” concerns about inconsistency. This was because only one study reported each outcome of interest. Concerns about indirectness ranged from “no serious” to “serious” indirectness. For all outcomes rated as “serious”, this was due to an indirect aspect of the PICO (population) in 1 study. Concerns about imprecision ranged from “no serious” to “very serious”. This was due to the 95% confidence intervals crossing boundaries for minimally important differences.
Benefits and harms
There was evidence of an important benefit of arrangements/links with third sector/community organisations (multicomponent intervention package, show-me-careers initiative and jobs by 21 partnership project) in the progress into employment for disabled children and young people with severe complex needs. The evidence was very low and low quality. The committee agreed with the evidence and discussed how important it is that the local authority provide information about employment support in the SEND Local Offer [1.17.14] in order to help disabled children and young people with severe complex needs move into adulthood, as required by the SEND Regulations 2014 and guidance in the SEND Code of Practice (2015). The committee explained how employment might be a daunting prospect for disabled children and young people with severe complex needs but how this can be reduced when local authorities make the process clear and transparent.
The committee discussed the current variation where some localities provided a guided questionnaire that assisted disabled children and young people with severe complex needs and their families in navigating the employment options set out in the SEND Local Offer, whilst others did not. The committee acknowledged that sometimes the information provided was not easily understandable. The committee recommended that education providers ensure that independent Careers Information, Advice and Guidance on employment is provided using the Gatsby benchmarks of Good Career Guidance (as included in statutory guidance from the Department for Education on careers guidance and advice), in order to help young people think about their employment options and make informed decisions about their future [1.13.1].
There was evidence of a benefit in the competence (capability to meet expectations in an identified workplace) of disabled young people with severe complex needs when provided with a named responsible practitioner, specifically a full-time career transition liaison. The evidence was very low quality. Based on their experience, the committee agreed that an essential component of supported internships is the provision of support to the young person by a lead employment practitioner, often called a job coach, with expertise related to employment of young people with disabilities. This lead practitioner provides 1:1 support to the intern, to coach them on the satisfactory level of performance in skills and operations that are required by the work place. Without this support, the committee felt strongly that achieving employment outcomes would be much less likely to be successful. The committee also noted that in order for each young person undertaking a supported internship to have this lead employment practitioner, this would need to be included as a requirement in the service specification for commissioning employment support services and this was reflected in the recommendation. The committee discussed, based on their experience, that the lead employment practitioner function would usually be fulfilled by an individual with the role of job coach. However, the committee discussed that the term job coach is not well understood across health, education and social care and there are other roles that could undertake this function, so they only gave it as an example in the recommendation [1.13.3]. The committee also agreed that young people who had employment as an outcome in their EHC plan, but who were not undertaking a supported internship would also be likely to benefit from the 1:1 support provided by a lead employment practitioner and more likely to achieve their employment outcomes, so they made a weaker recommendation for this to happen [1.13.4].
The committee agreed, based on their experience, that discussions about employment as a future option should begin early so that if this is something the child or young person wishes to explore, preparation can also start early, facilitating achievement of the best possible outcomes as specified in section 8 of the SEND Code of Practice (2015). However they noted that this does not always happen and relayed examples of parents and carers self-researching employment options at the point when the young person is looking to achieve employment, due to a lack of information and preparation provided beforehand. This was supported by qualitative evidence where both service users and providers reported that preparations for adulthood are insufficient, inconsistent and left too late (see evidence report K, sub-theme 17.1). The committee agreed that in line with their understanding of the SEND Code of Practice (2015) discussions should start at the latest when the child is around 13 to 14 years of age, when the year 9 review would take place, but preferably earlier. The committee also agreed that tailored follow-up discussion is needed as the young person may change their career aspirations as they mature [1.13.5].
Based on their experience, the committee discussed the benefits of vocational profiles in helping to understand the needs, skills and aspirations of disabled children and young people with severe complex needs who are considering employment. A number of committee members felt that the term vocational profile was not widely understood, and it was agreed that in practice a lot of those working in education, health and social care do not always use them. Due to the fact that vocational profiles would be particularly useful and beneficial for disabled children and young people with severe complex needs who want to achieve employment, the committee agreed a recommendation was needed to raise awareness of vocational profiles amongst professionals and encourage individuals working in education, health and social care to use them [1.13.6].
The committee discussed the importance of practitioners from all services working together to ensure that employment support holistically matches the needs of the young person. In their experience, if practitioners do not consider what support is needed outside their specific expertise to bridge the gaps between different services, this may create barriers to the young person effectively participating in employment support and sometimes even cause risk to the young person. The committee felt strongly that practitioners should do this so that the onus for providing comprehensive employment support doesn’t fall on the young person and their family or carers [1.13.7]. Identifying any environmental adaptations or equipment that will be needed for the young person to perform in the same way as their peers will be particularly important to prevent inequalities.
No evidence was identified about supported internships, however there was evidence of a benefit of follow-on support (extension of transition services beyond successful completion of the programme) in the independence of disabled young people with severe complex needs. The committee agreed that the components of the follow-on support intervention such as a structured intervention prior to individualised applications (e.g. interview skills) were similar to those produced in supported internship programs in the UK, and felt it appropriate to extrapolate the evidence in order to make recommendations. Although they were not identified by the evidence searches because they did not meet the inclusion criteria, the committee were aware of evaluations of supported internship programmes, designed to help young people with learning disabilities acquire the capabilities needed to gain employment, that have been undertaken by the Department of Education and UK Government. These evaluations concluded that supported internships are effective at helping young people with severe complex needs to obtain employment. Progress into employment is one of the preparation for adulthood outcomes covered by the SEND code of practice. All children and young people with severe complex needs must have a focus on all four preparation for adulthood outcomes in their EHC plan from year 9 onwards. However, without assistance, young people with severe complex needs have a very low likelihood of progressing to employment. The committee felt strongly that supported internships would be an effective way to help young people into employment and therefore recommended that they are made available. [1.13.2]. Supported internships are cited in the SEND Code of Practice (2015) as a way for young people with special educational needs to get direct experience of work and help prepare them for employment.
There was evidence of a benefit of arrangements/links with third sector/community organisations (multicomponent intervention package, show-me-careers initiative and jobs by 21 partnership project) in the progress into employment for children and young people. The evidence was very low and low quality. The committee agreed based on this evidence and their experience that once a young person has completed a supported internship they will still have other hurdles to negotiate to get a job as they will be competing with non-disabled individuals. In the committee’s experience, there is a need for supported internship providers to create links with local employers and encourage them to buy-in to provide or expand the opportunities available to disabled young people with severe and complex needs. Also that mechanisms should be in place whereby links with potential employers were actively pursued. Doing this will support employers to make reasonable adjustments around recruitment [1.13.8].
The committee agreed that as part of supported internships it was important to plan ahead so that the experiences gained from the internship can be used in a meaningful way, such as enabling the young person to enter into paid or volunteer work once the internship ends. Since the young person should still have an EHC plan in place until securing employment, the committee agreed that the planning of next steps should occur prior to ceasing the EHC plan, and be facilitated between the current provider and prospective employer to ensure continuity. They therefore made a recommendation about how to plan support for the young person after the internship ends [1.13.9].
From their experience, the committee discussed the benefit of both support workers and job coaches in supporting the young person during their employment, specifically by acting as a first point of contact, and providing information, advice, and emotional support. The committee agreed that young people and their families are not always aware that this support is available and so made a recommendation for local authorities to signpost to these services in the SEND Local Offer [1.13.10]. It is a requirement of the SEND Regulations 2014 that the SEND Local Offer contains information about all services available in that local area. In addition, the committee discussed the role of workplace buddies, that is a colleague that can act as a friendly face for the young person during their work day. A workplace buddy might support the young person by providing them with information about the structure of the workplace and teams, introducing them to colleagues, showing them around the office and having lunch with them on a daily basis. The committee agreed that the role of a workplace buddy should not be a line manager because the young person has to be able to share their anxieties with their buddy so they can receive effective support before this results in a performance issue. Therefore, someone independent is needed to do this. The committee felt strongly that a colleague assigned to support the disabled young person would enable the employment situation to run smoothly for both parties so recommended that employers are encouraged to train and appoint workplace buddies for disabled young people [1.13.11].
Cost effectiveness and resource use
There was no existing economic evidence in this area.
The committee discussed supported internships and explained that there is funding available from the Education Skills Funding Agency, Department for Work and Pensions and social care adult services for young people to access supported internships. The committee explained that there are multiple providers across the country in response to the UK government policy. The committee explained that recommendations on making supported internships available are more about changing practice to ensure consistent delivery, coordination and improved outcomes, using existed allocated funding and so recommendations would therefore not incur additional resources to services. Similarly, the recommendations about planning after an internship ends would not have additional resource implications because this would happen as part of the support specified in the individuals EHC plan. The committee also noted that, whilst funding already exists for supported internship teams to function, not all areas have them and there is inconsistency in which sector takes responsibility for setting them up. Therefore, the recommendations would require a change in practice but not incur additional resources.
The committee discussed the recommendation on assigning a practitioner to lead on employment support for young people undertaking a supported internship. The committee noted that there are existing trained professionals to do this job. With supported internships, dedicated job coaches would take on this role. However, many people who are not trained are still delivering such employment support. The committee explained that job coaches/adult social care employment support teams/employment officers should exist everywhere; but that services may call them different things. The committee reiterated that it is important that the person leading on employment support is someone who has been trained in employment support. It is essential to have someone trained because of the complexity of this group of young people. It isn’t as simple as helping them write a CV or getting some work experience. There is tailored and bespoke knowledge that is needed to support young people with complex needs into work. And if a practitioner hasn’t been trained and doesn’t have the required skills, for example, in job coaching or some other specific support models, that young person won’t pick up the required skills as quickly, and they won’t be successful in going into or sustaining employment / paid work. Additional people will need to be trained in order to provide this support to young people who are undertaking a supported internship. Further practitioners will need to be trained if local authorities also decide to provide a lead employment practitioner to those young people who have employment as an outcome in their EHC plan. However, because this is an outcome in the EHC plan, funding already exists to enable this training to happen. Therefore there will not be a significant resource implication.
In relation to the recommendation for local authorities to include information about support workers and job coaches in their SEND Local Offer, the committee agreed this was unlikely to have resource implications as it is about information provision. Additionally they noted that funding is already available to provide support workers and job coaches through the Access to Work scheme run by the Department for Work and Pensions so if a young person decides they would like to have this additional support there should not be any cost implications of doing so.
The committee discussed the recommendation about having a vocational profile for young people who are considering employment. Use of vocational profiles will be a change in practice for those services that do not currently use them. However, preparation for adulthood is a key component of the SEND Code of Practice. Vocational profiles are a way to do the work that is already needed to help young people who have employment identified within their preparation for adulthood transition planning. Therefore there are not expected to be significant resource implications of this change in practice.
The committee believed that other recommendations in this area represent current good practice and are not anticipated to result in additional resource use to services.
Recommendations supported by this evidence review
This evidence review supports recommendations 1.13.1 – 1.13.11, 1.17.14. Other evidence supporting these recommendations can be found in the evidence reviews on Views and experiences of service providers (evidence report M).
References – included studies
Carter 2009
Carter, E. W., Trainor, A. A., Ditchman, N., Swedeen, B., Owens, L., Evaluation of a Multicomponent Intervention Package to Increase Summer Work Experiences for Transition-Age Youth With Severe Disabilities, Research and Practice for Persons with Severe Disabilities, 34, 1–12, 2009Izzo 2000
Izzo, Margo Vreeburg, Cartledge, Gwendolyn, Miller, Larry, Growick, Bruce, Rutkowski, Susan. Increasing Employment Earnings: Extended Transition Services that Make a Difference. Career Development for Exceptional Individuals, Volume: 23 issue: 2, page(s): 139–156. Issue published: October 1, 2000McVeigh 2017
McVeigh, T., Reighard, A., Day, A., Willis, D., Reynolds, M., Jenson, R., John, J., Gee, R., Show-Me-Careers: Missouri’s transition to employment collaborative, Journal of Vocational Rehabilitation, 47, 337–350, 2017Winsor 2011
Winsor, Jean E., Butterworth, John, Boone, Jane, Jobs by 21 Partnership Project: Impact of Cross-System Collaboration on Employment Outcomes of Young Adults with Developmental Disabilities, Intellectual and Developmental Disabilities, 49, 274–284, 2011 [PubMed: 21721980]Yamatani 2015
Yamatani, Hide, Teixeira, Samantha, McDonough, Kathleen, Employing people with disabilities: a preliminary assessment of a start-up Initiative, Journal of Human Behavior in the Social Environment, 25, 830–842, 2015Department for Education and Department of Health and Social Care 2015
Department for Education and Department of Health and Social Care. Special educational needs and disability code of practice: 0 to 25 years. Statutory guidance for organisations which work with and support children and young people who have special educational needs or disabilities. Gov.UK website. Updated 30 April 2020. Available at: https://www.gov.uk/government /publications /send-code-of-practice-0-to-25
Effectiveness
Other
Appendices
Appendix A. Review protocol
Review protocol for review question: What are the most effective models of health, social care and education services working together to prepare disabled children and young people with severe complex needs for employment?
Table 3. Review protocol (PDF, 410K)
Appendix B. Literature search strategies
Literature search strategies for review question: What are the most effective models of health, social care and education services working together to prepare disabled children and young people with severe complex needs for employment?
Databases: Medline; Medline EPub Ahead of Print; and Medline In-Process & Other Non-Indexed Citations
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Databases: Embase; and Embase Classic
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Database: Health Management Information Consortium (HMIC)
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Database: Social Policy and Practice
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Database: PsycInfo
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Database: Emcare
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Databases: Cochrane Central Register of Controlled Trials (CCTR); and Cochrane Database of Systematic Reviews (CDSR)
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Database: Database of Abstracts of Reviews of Effects (DARE)
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Database: Health Technology Abstracts (HTA)
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Databases: Applied Social Sciences Index & Abstracts (ASSIA); Social Services Abstracts; Sociological Abstracts; and ERIC (Education Resources Information Centre)
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Database: British Education Index
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Database: CINAHL Plus (Cumulative Index to Nursing and Allied Health Literature)
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Database: Social Sciences Citation Index (SSCI)
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Database: Social Care Online
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Appendix C. Effectiveness evidence study selection
Study selection for: What are the most effective models of health, social care and education services working together to prepare disabled children and young people with severe complex needs for employment?
Figure 1. Study selection flow chart (PDF, 217K)
Appendix D. Effectiveness evidence
Evidence tables for review question: What are the most effective models of health, social care and education services working together to prepare disabled children and young people with severe complex needs for employment?
Table 3. Evidence tables (PDF, 415K)
Appendix E. Forest plots
Forest plots for review question: What are the most effective models of health, social care and education services working together to prepare disabled children and young people with severe complex needs for employment?
No meta-analysis was conducted for this review question and so there are no forest plots.
Appendix F. GRADE tables
GRADE tables for review question: What are the most effective models of health, social care and education services working together to prepare disabled children and young people with severe complex needs for employment?
Table 4. Evidence profile for comparison 1: Multicomponent intervention package versus typical transition (PDF, 373K)
Table 6. Evidence profile for comparison 2: Before and after the Show-Me-Careers initiative (PDF, 337K)
Table 7. Evidence profile for comparison 3: Jobs by 21 Partnership Project versus nonparticipants (PDF, 348K)
Table 9. Evidence profile for comparison 5: Before and after the Career Transition Liaison Project (PDF, 329K)
Appendix G. Economic evidence study selection
Economic evidence study selection for review question: What are the most effective models of health, social care and education services working together to prepare disabled children and young people with severe complex needs for employment?
One global search was undertaken – please see Supplement B for details on study selection.
Appendix H. Economic evidence tables
Economic evidence tables for review question: What are the most effective models of health, social care and education services working together to prepare disabled children and young people with severe complex needs for employment?
No evidence was identified which was applicable to this review question.
Appendix I. Economic model
Economic model for review question: What are the most effective models of health, social care and education services working together to prepare disabled children and young people with severe complex needs for employment?
No economic analysis was conducted for this review question.
Appendix J. Excluded studies
Excluded studies for review question: What are the most effective models of health, social care and education services working together to prepare disabled children and young people with severe complex needs for employment?
Effectiveness evidence
Table 5. Excluded studies and reasons for their exclusion (PDF, 377K)
Appendix K. Research recommendations – full details
Research recommendations for review question: What are the most effective models of health, social care and education services working together to prepare disabled children and young people with severe complex needs for employment?
No research recommendations were made for this review question.
Final version
Evidence reviews
These evidence reviews were developed by the National Guideline Alliance which is a part of the Royal College of Obstetricians and Gynaecologists
Disclaimer: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.
NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn.
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