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

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 | medRxiv /* */ /* */ <!-- <!-- /*! * yepnope1.5.4 * (c) WTFPL, GPLv2 */ (function(a,b,c){function d(a){return"[object Function]"==o.call(a)}function e(a){return"string"==typeof a}function f(){}function g(a){return!a||"loaded"==a||"complete"==a||"uninitialized"==a}function h(){var a=p.shift();q=1,a?a.t?m(function(){("c"==a.t?B.injectCss:B.injectJs)(a.s,0,a.a,a.x,a.e,1)},0):(a(),h()):q=0}function i(a,c,d,e,f,i,j){function k(b){if(!o&&g(l.readyState)&&(u.r=o=1,!q&&h(),l.onload=l.onreadystatechange=null,b)){"img"!=a&&m(function(){t.removeChild(l)},50);for(var d in y[c])y[c].hasOwnProperty(d)&&y[c][d].onload()}}var j=j||B.errorTimeout,l=b.createElement(a),o=0,r=0,u={t:d,s:c,e:f,a:i,x:j};1===y[c]&&(r=1,y[c]=[]),"object"==a?l.data=c:(l.src=c,l.type=a),l.width=l.height="0",l.onerror=l.onload=l.onreadystatechange=function(){k.call(this,r)},p.splice(e,0,u),"img"!=a&&(r||2===y[c]?(t.insertBefore(l,s?null:n),m(k,j)):y[c].push(l))}function j(a,b,c,d,f){return q=0,b=b||"j",e(a)?i("c"==b?v:u,a,b,this.i++,c,d,f):(p.splice(this.i++,0,a),1==p.length&&h()),this}function k(){var a=B;return a.loader={load:j,i:0},a}var l=b.documentElement,m=a.setTimeout,n=b.getElementsByTagName("script")[0],o={}.toString,p=[],q=0,r="MozAppearance"in l.style,s=r&&!!b.createRange().compareNode,t=s?l:n.parentNode,l=a.opera&&"[object Opera]"==o.call(a.opera),l=!!b.attachEvent&&!l,u=r?"object":l?"script":"img",v=l?"script":u,w=Array.isArray||function(a){return"[object Array]"==o.call(a)},x=[],y={},z={timeout:function(a,b){return b.length&&(a.timeout=b[0]),a}},A,B;B=function(a){function b(a){var a=a.split("!"),b=x.length,c=a.pop(),d=a.length,c={url:c,origUrl:c,prefixes:a},e,f,g;for(f=0;f<d;f++)g=a[f].split("="),(e=z[g.shift()])&&(c=e(c,g));for(f=0;f<b;f++)c=x[f](c);return c}function g(a,e,f,g,h){var i=b(a),j=i.autoCallback;i.url.split(".").pop().split("?").shift(),i.bypass||(e&&(e=d(e)?e:e[a]||e[g]||e[a.split("/").pop().split("?")[0]]),i.instead?i.instead(a,e,f,g,h):(y[i.url]?i.noexec=!0:y[i.url]=1,f.load(i.url,i.forceCSS||!i.forceJS&&"css"==i.url.split(".").pop().split("?").shift()?"c":c,i.noexec,i.attrs,i.timeout),(d(e)||d(j))&&f.load(function(){k(),e&&e(i.origUrl,h,g),j&&j(i.origUrl,h,g),y[i.url]=2})))}function h(a,b){function c(a,c){if(a){if(e(a))c||(j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}),g(a,j,b,0,h);else if(Object(a)===a)for(n in m=function(){var b=0,c;for(c in a)a.hasOwnProperty(c)&&b++;return b}(),a)a.hasOwnProperty(n)&&(!c&&!--m&&(d(j)?j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}:j[n]=function(a){return function(){var b=[].slice.call(arguments);a&&a.apply(this,b),l()}}(k[n])),g(a[n],j,b,n,h))}else!c&&l()}var h=!!a.test,i=a.load||a.both,j=a.callback||f,k=j,l=a.complete||f,m,n;c(h?a.yep:a.nope,!!i),i&&c(i)}var i,j,l=this.yepnope.loader;if(e(a))g(a,0,l,0);else if(w(a))for(i=0;i (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0];var j=d.createElement(s);var dl=l!='dataLayer'?'&l='+l:'';j.src='//www.googletagmanager.com/gtm.js?id='+i+dl;j.type='text/javascript';j.async=true;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-P4HH5NV'); Skip to main content Home About Submit ALERTS / RSS Search for this keyword Advanced Search 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 View ORCID Profile Andy Pennington , David Newbold , Yang Yu , John White , View ORCID Profile Ben Barr , View ORCID Profile Philip McHale doi: https://doi.org/10.1101/2024.12.03.24318405 Andy Pennington 1 Department of Public Health, Policy and Systems, Institute of Population Health, University of Liverpool Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Andy Pennington For correspondence: ajpenn{at}liverpool.ac.uk David Newbold 1 Department of Public Health, Policy and Systems, Institute of Population Health, University of Liverpool Find this author on Google Scholar Find this author on PubMed Search for this author on this site Yang Yu 1 Department of Public Health, Policy and Systems, Institute of Population Health, University of Liverpool Find this author on Google Scholar Find this author on PubMed Search for this author on this site John White 2 Liverpool City Region Combined Authority Find this author on Google Scholar Find this author on PubMed Search for this author on this site Ben Barr 1 Department of Public Health, Policy and Systems, Institute of Population Health, University of Liverpool Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Ben Barr Philip McHale 1 Department of Public Health, Policy and Systems, Institute of Population Health, University of Liverpool Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Philip McHale Abstract Full Text Info/History Metrics Data/Code Preview PDF Abstract 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. Background This systematic review builds on a typology of interventions and earlier systematic reviews reported in Whitehead et al., 2009 ; Clayton et al., 2011 ; and Bambra et al., 2005 . Whitehead et al’s. typology outlined macro- (societal, economic, legislative), meso- (organisational) and micro- (individual) level policies and interventions to increase chronically ill and people with disabilities preparedness for, access to, and rates of employment based on international evidence. The review focussed specifically on the UK and Ireland context to identify the most transferable evidence from studies in the same or similar geographical, sociocultural, and policy contexts. The review also focussed specifically on evidence on meso- (organisational) and micro- (individual) level interventions that are aimed at: i. improving the employment environment for individuals, and ii. ‘strengthening’ individuals/improving the ‘employability’ of chronically ill and people with disabilities themselves, shown in A 1 , B, C, D, F, G, and H in Table 1 . View this table: View inline View popup Download powerpoint Table 1. Perceived problems and underlying theories of change ( Whitehead et al., 2009 ). National-level data on employment, unemployment, and economic activity among people with disabilities According to the DWP (2023) , 4.9m people with disabilities were in employment in the UK in 2022 (July to September figures). This was an overall increase of 2m since 2013. The disability employment rate was 52.6% in the same quarter in 2022, compared to 82.5% for people without disabilities. This was a decrease of 0.8% on the year for people with disabilities, and an overall increase of 9.2% percentage points since 2013. The disability unemployment rate was 7.2% in 2022 July to September), compared to 3.2% for people without disabilities. For people with disabilities, this was a decrease of 0.3% on the year, and an overall decrease of 7.3% since 2013. The disability economic inactivity rate (self-reported not in or looking for work) was 43.3% in July to September 2022, compared to 14.8% for people without disabilities. An increase of 1.1% on the year for people with disabilities, and an overall decrease of 6.0% since 2013. The disability employment gap was 29.8% in 2022, an increase of 1.7% on the year and an overall decrease of 4.4% since the same quarter in 2013. In 2022: One-fifth of the working-age population were classed as disabled. Reporting of a long-term health condition or classed as disabled continued to rise, following long-term trends. Reporting of mental health conditions among people classed as disabled continued to rise. The disability employment gap was greater for men, older (aged 50 to 64) people, people with no qualifications, people of White ethnicity, and people living in Northern Ireland, Scotland, Wales, North West, and North East. The disability employment rate was lower for people with a mental health condition, or with five or more health conditions ( DWP, 2023 ). There is a lack of UK data on employment rates for people with severe mental illness (including conditions such as schizophrenia and bipolar disorder). A five-country European study published in 2002 found less than a quarter of people with schizophrenia were in paid employment, with only 5% of participants with schizophrenia in London being students or in open/competitive employment’ ( Knapp et al., 2002 ). Aims of the review Aim one of the review was to synthesise higher methodological quality evidence on the effectiveness of interventions designed to increase levels of employment preparedness or employment rates (the primary outcomes) on chronically ill and people with disabilities. For studies included as assessing employment outcomes (primary outcomes) there were two further aims. Aim two was to synthesise evidence on the physical and mental health impacts on participants (secondary outcomes). Aim three was to synthesise evidence from assessments of the economic outcomes such as cost-effectiveness of the programmes meeting the inclusion criteria of the review. Relationship to Economies for Healthier Lives (EHL) project aims This is one important part of the process of satisfying the broader overarching aims of the EHL project below, particularly aim 4, and contributing to aim 5: Aim 1. Health and wellbeing outcomes are a feature of all Liverpool City Region Combined Authority (LCRCA) economic strategies and labour market programmes. Aim 2. Employment services are integrated with health and a wider social offer and informed by the lived experience of residents. Aim 3. Systems are in place to identify groups with combined employment and health risks and to monitor and evaluate health outcomes of employment services and economic strategy. Aim 4. Labour market programmes are based on the best available evidence for maximising their benefits for good employment and health. Aim 5. Learning is used to inform and change practice across the UK in embedding health and wellbeing within economic policy. Review questions The identification, analysis, and synthesis of evidence in the systematic review was based on the following review questions (RQs): RQ1 - What is the higher methodological quality evidence on the effectiveness of meso and micro-level interventions to promote employment preparedness and rates among people with chronic illness and disability in the UK and Ireland between 2003 and 2023? RQ2 - For studies included as assessing employment outcomes, what is the evidence on the physical and mental health and wellbeing outcomes? RQ3 - For studies included as assessing employment outcomes, what is the evidence on the economic outcomes/cost-effectiveness of the interventions? Methods Guidance underpinning the systematic review approaches The main approaches in the systematic review were based on methodological and reporting guidelines from Centre for Reviews and Dissemination’s guide to undertaking systematic reviews, guidance on the Conduct of Narrative Synthesis in Systematic Reviews, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and PRISMA-Equity Extension (PRISMA-E) checklists and statements ( CRD, 2009 ; Popay et al., 2006 ; Moher et al., 2009 ; Welch et al., 2012 ; Page et al., 2021 ). These were selected as they provide appropriate guidance for conducting and reporting systematic reviews of evidence on interventions addressing complex social determinants of health inequalities. Where appropriate, elements of the other guides, for example, the Cochrane handbooks section on ‘When not to use meta-analysis in a review’ ( Higgins and Green, 2011 – Cochrane Handbook, Part 2, Section 9.1.4), and Petticrew et al’s guidance on the implications of a complexity perspective for systematic reviews ( Petticrew et al., 2019 ), were also drawn upon. Study identification Development of the search strategy and identification of evidence The search strategy was, based on CRD (2009) guidance, multifaceted and was developed iteratively throughout the review. The strategy and interrogation of the evidence was informed by the typology and earlier systematic reviews ( Whitehead et al., 2009 ; Clayton et al., 2011 ; and Bambra et al., 2005 ) which helped in the identification of databases and other sources (including experts, and organisations), sample papers, search terms and syntaxes, and inclusion and exclusion criteria. The inclusion and exclusion criteria for the review are shown in Table 2 . View this table: View inline View popup Table 2. Systematic reviews inclusion and exclusion criteria Data on health outcomes and economic (cost-effectiveness) (secondary outcomes) was only extracted for studies that first met the above inclusion/exclusion criteria. This review was focussed on peer reviewed publications reporting evidence from quantitative studies with control/comparison groups. We only included peer reviewed publications to ensure a reasonable level of methodological and reporting quality. We only included studies with control/comparison groups to ensure higher methodological quality. Qualitative, other interventional studies without control or comparison groups, and observational studies meeting the other review inclusion criteria were, however, coded and set aside for subsequent reviews. Searches Bibliographic database searches and supplementary searches were undertaken. Electronic searches were conducted in five ‘gold standard’ bibliographic database/search engines: OVID MEDLINE and MEDLINE Epub Ahead of Print, In-Process, In-Data-Review & Other Non-Indexed Citations and Daily; Web of Science Social Sciences Citation Index (SSCI); APA PsycInfo (via EBSCOhost); CINAHL Plus (via EBSCOhost); and EconLit (via EBSCOhost). An example of the (MEDLINE) search syntax is in Appendix 1 . Iterative supplementary searches were also conducted, including searches via advanced Google and Google scholar searches (time limited, and with AND, OR Boolean operators), hand searches of expert and organisational websites, several stages of backward citation searches, followed by forward citation searches (in Web of Science) of all included studies in a ‘pearl growing’ exercise over the duration of the review. Deduplication and reporting of search results Results from the database searches were deduplicated in Endnote 20 reference management software in a three-stage process (one automatic stage [based on authors, title, and year of publication], and two manual stages to deduplicate the remaining articles). Results before and after deduplication are reported in a PRISMA flowchart showing the progression of studies through the review (as per PRISMA guidelines) (see Figure 1 In the Results section). Download figure Open in new tab Figure 1. PRISMA flow chart of the progression of studies through the review Study selection/screening Studies were selected for inclusion in two stages: title and abstract screening, and full text screening. The first 20% of titles and abstracts were screened independently by two reviewers in EPPI-reviewer 4 systematic review management software ( Thomas et al., 2010 ). Following a screening ‘calibration’ exercise with the reviewers, the remaining 80% were screened by a single experienced systematic reviewer. Articles and reports deemed potentially eligible for inclusion after title and abstract screening were retrieved and screened independently by two reviewers as full texts. Lists of included studies, and reasons for exclusion of full texts were recorded and reported in accordance with PRISMA guidelines. Any queries and disagreements/differences in the assessments were resolved by discussion, or by recourse to an additional, third reviewer. Data extraction Data from each included study was extracted into pre-designed and piloted forms independently by two reviewers. Any queries and disagreements were resolved by discussion, or by recourse to a third reviewer. Methodological quality assessment Validity/methodological quality of included studies was assessed using a modified version of a tool designed and tested for methodological quality assessments in systematic reviews of effectiveness (from Orton, et al, 2016 ; Modified from Lorenc et al., 2013 ). A copy of the tool can be found in Appendix 2. Methodological quality/validity assessments (QAs) were assessed independently by two reviewers. Any queries and disagreements/differences in the assessments were resolved by discussion, or by recourse to a third reviewer. Data synthesis Results were synthesised narratively based on Popay et al’s., (2006) guidance, who describes narrative synthesis as: ‘an approach to the systematic review and synthesis of findings from multiple studies that relies primarily on the use of words and text to summarise and explain the findings of the synthesis. Whilst narrative synthesis can involve the manipulation of statistical data, the defining characteristic is that it adopts a textual approach to the process of synthesis to “tell the story” of the findings from the included studies.’In line with the guidance, and based on the findings of the methodological quality assessment, higher methodological studies are reported first and in greater detail. The potential for meta-analysis of the included studies findings was explored. It was not appropriate/possible because of high levels of heterogeneity in the studies (by intervention types, outcome measures, and methods of analysis). Results Results of the literature search From an initial 6,483 unique database records and other sources, 14 articles, covering 11 studies that met our inclusion criteria were included. Figure 1 shows the progression of studies through the systematic review process. Information on the reasons for excluding studies at the full text/article screening stage is within Appendix 3. Characteristics of included studies A list of the 14 included studies in contained within Appendix 4 List of articles included in the review. Key characteristics of the included studies are shown in Table 3 and summarised below. View this table: View inline View popup Table 3 Characteristics of included studies. Populations and geographical settings 11 of 14 articles examined employment, health, and/or economic outcomes for people with either early or first onset psychosis or long-term severe mental health conditions. Long-term severe mental health conditions included, for example, schizophrenia and schizophrenia-like disorders, bipolar disorder, or depression with psychotic features (based of International Disease Classification-10 criteria in the Knapp et al., 2013 study, for example). Two articles reported employment and economic outcomes for employment interventions for people with physical conditions (musculoskeletal pain, stroke), and one article examined employment outcomes for Incapacity Benefit recipients with a mix of physical and mental health conditions. All the studies that met our inclusion criteria were set in UK, with none in Ireland despite the coverage of the searches. In the UK, only one study was set in Wales, with none in Scotland or Northern Ireland. For the studies of employment interventions for people with severe mental health problems, most were set in the South-East of England (mostly London) and some in the Midlands. Two studies of interventions for people with chronic physical health conditions or disabilities were both set in the Midlands, and one study covering a sample population group with physical and/or mental health conditions (incapacity benefit recipients) was set in Wales. Interventions and comparisons 1. Employment interventions for people with severe mental health conditions All eight studies (11 articles) on interventions for people with severe mental health conditions were of Individualised Personal Support (IPS) or modified versions of IPS interventions delivered through integration of employment support within Community Mental Health Teams (CMHTs). IPS was originally designed to get people with severe mental health difficulties into employment. It involves intensive, individual support, a rapid job search followed by placement in paid employment, and time-unlimited in-work support for both the employee and the employer. O’Brien et al. (2003) describe the aims and approach of IPS as: “to help patients obtain open employment with a minimal period of pre-vocational training: a “place-train” approach rather than visa (SIC) versa. Once a job or training place has been obtained as much support as possible is given with the aim of retaining the position”. Major et al. (2010) describe the IPS core principles : “The core principles of supported employment (that demarcate it from other forms of vocational intervention) are that services should be embedded in multidisciplinary teams, based on individual preferences with the aim of obtaining early competitive employment, and offer indefinite follow-on support”. Interventions from three studies were classified as ‘standard’ versions of IPS based on the eight principles of IPS. IPS principles Aims to get people into competitive employment. Open to all those who want to work, irrespective of health condition or benefits claim. Jobs consistent with people’s work preferences. Works quickly. Employment specialists integrated into clinical teams. Employment specialists develop relationships with employers based on person’s preferences. Time unlimited, individualised support for the person & their employer. Benefits counselling included. ( Boardman, 2003 ; Dartmouth IPS Supported Employment Centre, 2008 ; Rinaldi et al., 2008 ) Interventions that closely follow the principles are known as ‘high fidelity’ IPS. Six articles from three studies compared IPS to traditional vocational interventions ( Burns et al., 2007 , 2009 ; Heslin et al., 2011 ; Howard et al., 2010 ; Knapp et al., 2013 ; van Veggel et al., 2015 ). Burns et al. 2007 describe a high quality traditional vocational intervention as: “an assessment of the patient’s rehabilitation needs, and the provision of a structured training programme aimed at combating deficits related to illness and training in appropriate work skills (e.g., reintroduction of a daily routine for attending the centre, time management, or information technology skills). The structured programme usually occupied most of the week and was generally at a day centre.” Five included studies were classified as ‘modified’ versions of IPS: Training existing CMHT staff to deliver IPS, compared to IPS delivery through a dedicated, integrated employment specialist (in O’Brien et al. 2003 ). An employment intervention with characteristics of IPS delivered through training of existing CMHT staff, compared to IPS delivery through a dedicated, integrated employment specialist ( Marwaha et al., 2014 ). A form of IPS for first episode psychosis patients with a greater emphasis on education given their typically younger age, compared to usual (clinical) care only ( Major et al., 2010 ). IPS plus motivational interviewing (see box below), compared to IPS only ( Craig et al., 2014 ). IPS Light, a time limited version of IPS, compared to IPS only ( Burns et al., 2015 ). IPS plus motivation interviewing Craig et al., (2014) compared IPS plus motivation interviewing which involved coaching sessions with participants and staff to reduce negative preconceptions of barriers for severely mentally ill gaining employment. Craig et al., 2014 describe the rationale behind the modification to the IPS intervention used in their study: “translation [of IPS] into routine clinical care has often proved difficult, frequently because of the attitudes of key clinicians who discourage a return to work through a fear that the demands of employment might precipitate relapse. We therefore [combined] IPS with training staff in early intervention teams in ‘motivational interviewing’ strategies. These aim to address anxiety about employment ‘through a directive, client centred counselling style . . . helping clients to explore and resolve ambivalence” ( Marwaha et al., 2008 ; Rinaldi et al., 2010 ). 2. Employment interventions for people with physical illnesses or disabilities, or groups of people with physical and/or mental health conditions Only three studies that met our inclusion criteria evaluated interventions for people with physical illnesses or disabilities, or combinations people with physical and/or mental health conditions. Stroke One study investigated the employment impacts of an early stroke specific vocational rehabilitation intervention in comparison with usual best practice clinical care only ( Radford et al., 2020 ). In addition to usual best practice clinical care the intervention group received: Individual assessment. Job analysis. Provision of information. Education, advice, and psychological support. Goal setting. Work site assessment. Liaison with other services (professionals, family, and employer). Return to work preparation and planning meetings to prepare and plan. Return to work preparation and planning meetings included approaches tailored to individual needs (e.g., fatigue management, cognitive rehabilitation). Return to work was monitored and modifications made to ongoing support were made as required. Support was gradually withdrawn over time in-line with need. Musculoskeletal pain One included study evaluated employment outcomes of a specialist vocational advice services on working with musculoskeletal pain in addition to usual clinical care, in comparison to best practice clinical care only ( Wynne-Jones et al., 2018 ). Mixed physical and/or mental health conditions One study investigated the employment outcomes of the Want2Work scheme for Incapacity Benefit recipients in Wales, a community vocational service with vocational and integrated health service advisors, compared to a statistical control group who had not received the service ( Lindley et al., 2015 ). They identify the range of conditions as “cardio, musculoskeletal, respiratory, other, learning, mental health”. Outcomes measured in the studies Employment For employment outcomes we focused on employment rates, either for commencing competitive employment (in open market), or commencing any employment activity (volunteering, or competitive employment) ( Table 5 ). Some of the studies did, however, considered a wider range of related outcomes such as time to commencement of employment, and duration in. Health and wellbeing In addition to employment outcomes, three studies additionally examined impacts on a wide range of health and wellbeing outcomes including rates of psychiatric hospitalisation, and validated measures of symptoms, functioning, needs, anxiety and depression, readmission, social outcomes, and quality of life ( Table 6 ). For brevity we report findings in relating to selected measures here, for example differences between intervention and control group hospital readmissions and time spent in hospital. Economic In addition to employment outcomes, four studies additionally examined economic outcomes ( Heslin et al., 2011 ; Howard et al., 2010 ; Knapp et al., 2013 ; Wynne-Jones et al 2018 ) including cost-benefit (difference between the cost of the intervention and the value of employment achieved, cost-effectiveness, cost-effectiveness acceptability, and differences in public service use/costs ( Table 7 ). In Knapp et al., 2013 , for example, costs we based on the use of health and social care services and medication, compared to benefit in terms of the value (UK gross wage) of days worked. Wynne-Jones estimated the net societal benefit of the intervention compared with best clinical care, including measurements of the costs of prevented work absence and health care. Study designs Study designs of the included studies are shown in Table 3 . In line with our strict inclusion criteria all included studies have control or comparison groups. These are inherently stronger methodological designs than, for example, single time-point cross sectional observational studies. They provided more robust evidence, through an ability to demonstrate temporal relationships (part of the Bradford Hill Criteria for causation: Hill, 1965). Nine of 14 articles report findings from Randomised Control Trial study designs, including two cluster RCTs and one feasibility RCT. RCTs are considered the strongest methodological design in the hierarchy of individual study designs (with only reviews/syntheses in the form of systematic reviews and meta-analyses, and reviews-of reviews being higher). Four studies used forms of observational study designs that relied on before-and-after (also known as pre-post) control groups, or a statistical/synthetic control group, or a sample from an area receiving a traditional vocational intervention as a comparison group in a prospective cohort study design ( Major et al., 2010 ; Lindley et al. 2015 ; Marwaha et al., 2014 ; van Veggel et al., 2015 ). There are, however, differences in the design, implementation, and reporting quality within and across all study designs. Individual articles are therefore systematically appraised and rated for quality in methodological quality assessments (below). Articles with findings on economic outcomes used various approaches that were forms of cost/benefit analysis; the methodological characteristics and strengths of these approaches are not comparable to the methods used in the above epidemiological study designs. Study methodological quality assessment Results of the methodological quality assessment are summarised in Table 4 . View this table: View inline View popup Download powerpoint Table 4 Summary of methodological quality assessment (QA) results - scores and ranking Quality scoring Methodological quality scores are influenced by the methodological strength of the methods used in the studies, and by the quality of reporting. Studies that fail to provide unclear or no information on methods also receive lower scores. Studies were categorised as ‘very high’ quality if the scored above 15 out of 18, ‘high’ if the scored 14 or 15 out of 18, and ‘low’ quality if they scored less than 10. No studies were rated as moderate/medium quality. Study findings Table 5 , Table 6 , and Table 7 provide an overview of the study findings grouped by outcome types (employment, health & wellbeing, economic, respectively). Employment and health/wellbeing outcome tables are ordered by study methodological quality, based on the methodological quality assessment scores/levels, with higher quality studies first. The economic outcome table is not ordered by methodological quality level as no appropriate quality assessment tool was available. The tables also include further information on outcomes, whether there were any significant differences between the intervention and control groups, and if so, if adjustments were made in the analysis to account for differences. View this table: View inline View popup Table 5 Study findings for employment outcomes View this table: View inline View popup Download powerpoint Table 6 Table - Study findings for health and wellbeing outcomes View this table: View inline View popup Download powerpoint Table 7 Table – Study findings for economic outcomes Employment outcomes (RQ1) Twelve UK studies evaluated employment outcomes of interventions ( O’Brien et al. 2003 ; Burns et al., 2007 , 2015 ; Howard et al., 2010 ; Major et al., 2010 ; Heslin et al., 2011 ; Craig et al., 2014 ; Marwaha et al., 2014 ; Lindley et al. 2015 ; van Veggel et al., 2015 ; Wynne-Jones et al 2018 ; Radford et al., 2020 ). Evidence from studies rated as very high methodological quality Two evaluations of IPS intervention were rated as very high methodological quality. In an RCT of an IPS intervention in South London, Howard et al. (2010) found that differences between the IPS intervention group and control group in finding competitive employment were not statistically significant at 1-year follow up (risk ratio 1.35, 95% CI 0.95–1.93, P = 0.15), although the authors report this may have been due to suboptimal implementation of the IPS intervention in the UK context at that time when it was not structurally integrated into community mental health teams (i.e. ‘low fidelity’ rather than ‘high fidelity’ IPS). In a later two-year follow up of the same intervention, Heslin et al. (2011) found that a higher proportion of severely mental ill IPS intervention group members found competitive employment than the control group receiving a traditional vocational intervention, although the proportion finding employment in both groups was modest (22% vs. 11%, p=0.041), and the authors again questioned the delivery/fidelity of the intervention. In a cluster-RCT that compared a modified version of IPS that additionally involved motivational interviewing (IPS+MI) to tackle negative preconceptions of barriers to severely mentally ill people gaining employment among participants and CMHT staff, with IPS only, Craig et al., 2014 , found that the IPS+MI intervention group had significantly higher odds (more than 4x) of being in open/competitive employment at 12 months than the control group receiving IPS only (OR = 4.3, 95% CI: 1.5 to 16.6), and more than twice the odds of being in any type of employment activity (competitive, casual, voluntary) (OR = 2.4, 95% CI: 1.1 to 5.6). Evidence from studies rated high methodological quality Three studies rated as high methodological quality evaluated the effectiveness of IPS, IPS Light (a non-time limited IPS modification), and a modified version of IPS with a greater emphasis on education, compared to control groups. Burns et al. (2007) report the findings of an RCT (the EQOLISE trial) of the employment outcomes of an IPS intervention for people with severe mental illness. The study involved intervention and control groups in six settings across Europe, but we focussed only on the findings for UK/London participants. They found that the percentage of IPS intervention group participants entering competitive employment was 32% higher than the traditional vocational service control group (CI: 7.7 to 56.3). In prospective cohort study of a modified IPS programme for patients with first (diagnosed) episode psychosis in London, with a greater emphasis on education because of the typically younger age of people first diagnosis/treated, Major et al. (2010) found that the modified IPS intervention had more than three times the odds of achieving ‘vocational recovery’ (a broad definition including enrolment with a job search agency, and gaining employment), compared to usual care from the early intervention for psychosis service control group after adjustment for potential confounders (OR = 3.53, CI: 1.25 to 10.00). 36% of the IPS group achieved competitive employment at some stage within the 12-moth follow up, compared with 19% in the control group, and a further 20% were in education (no education data is reported for the control group). In an RCT comparing a modified, time limited, version of IPS (IPS_LITE) with IPS only, Burns et al. (2015) found that rates of employment were equal at 18 months for IPS-LITE and non-time limited IPS (41% versus 46%, respectively). There were no statistically significant differences between the groups for other employment related outcomes ( Table 5 ). The authors conclude that IPS-LITE may be a more cost-effective intervention. Three other studies rated as high methodological quality found that employment interventions for people recovering from stroke, with musculoskeletal pain, and receiving Incapacity Benefit (for a mix of physical and mental health conditions and disabilities) were effective. In a feasibility RCT, Radford et al. (2020) compared employment outcomes for an intervention group of people receiving usual care plus early stroke-specific vocational rehabilitation with a usual care only control group in the Midlands. They found that more than three times the proportion of the intervention group returned to work in 12 months following stroke than the control group (37.5% vs 11.8%), although it is important to note that although the study was a strong and well reported methodological design, and therefore scored highly in the methodological quality assessment, it was only a feasibility RCT and so the numbers of participants were very low, so the results should be viewed with some caution. In a cluster RCT in the West Midlands that compared employment outcomes for an intervention involving usual (best practice) care for people with musculoskeletal pain plus specialist vocational advice services, Wynne-Jones et al 2018 , found that participants in the intervention group had less time off work over 4 months, compared to the usual care only control group (mean 9.3 days off [SD 21.7] vs mean 14.4 days off work [SD 27.7]. In a quasi-experimental (propensity score matching) study of the Want2Work scheme in Wales, Lindley et al. (2015) , found that 30% of the Want2Work scheme intervention group who received community vocational services with vocational and integrated health service advisors gained employment, compared to 19% in the matched statistical control group. Health and wellbeing outcomes (RQ2) Evidence from studies rated as very high methodological quality One study ( Howard et al. 2010 ) rated as very high methodological quality compared an IPS intervention group with traditional vocational services control group and found control group participants that were admitted to hospital spent significantly more time as psychiatric or general in-patients than the IPS intervention group. They estimated the difference in costs for the health services used, with a mean difference in cost of £1522 per participant (saving for IPS compared to control). Difference in use of other individual services (e.g., social care, community mental health nursing) were not significant, but total costs were significantly higher in the control group by £2176 (95% CI £445 to £4168) than in the intervention group. Evidence from studies rated as high methodological quality Burns et al. (2009) report the health and wellbeing-related outcomes of the EQOLISE trial that compared IPS to traditional vocational services (control group) across six European centres (London, Ulm-Gunzburg, Rimini, Zurich, Groningen, and Sophia). While the results on employment outcomes are presented for each centre including London (results reported above), results for health outcomes are aggregated across all six settings. Across all participants, there were no statistically significant differences in clinical and social functioning outcomes. However, when they analysed participants patients that had worked separately, noting that the proportion of the IPS intervention group entering competitive employment was 32% higher, social functioning was significantly higher in the IPS groups, compared with the traditional vocational service groups. IPS participants had Groningen Social Disability Schedule (GSDS) total scores that were 1.61 points higher out of 21. There was no significant difference in the other measures ( Table 5 ). Across all participants (intervention and control groups), those who had worked during the 18-month follow up period had significantly better global functioning for symptoms (GAF-S [0-100] −5.86 [95% CI −8.28 to −3.44) and disability 9GAF-S [0-100] −7.31 [95% CI (−9.68 to −4.94), less negative and general symptoms (PANSS: negative [7-49] 1.85 95% CI 0.802 to 2.90]; general [16-112] 1.77 [95% CI 0.212 to 3.34]), and lower social disability than those who had not worked (GSDS [0.21] 1.75 [95% CI 0.999 to 2.50]). Burns et al. (2015) found no significant differences in health and wellbeing-related outcomes in their study comparing a modified version of IPS - IPS Light (time limited IPS) to standard IPS. Radford et al. (2020) only provide descriptive statistics of proportions of participant who self-reported job satisfaction at follow ups, with no statistical analysis. They found that people recovering from stroke in the intervention group receiving early stroke-specific vocational rehabilitation in addition to usual care had higher levels of job satisfaction at 6 and 12 month follow ups than the comparison group receiving usual care only (13% vs 9% at 6 months, 12% vs 6% at 12 months, respectively). Economic outcomes (RQ3) Four studies evaluated economic outcomes, for example, cost-effectiveness comparisons between interventions and controls. Knapp et al. (2013) found that the aggregated total costs of IPS employment interventions for people with severe mental health conditions across all 6 European sites over 18 months were significantly lower (by approximately one-third) for the IPS groups than the traditional vocational service groups. Costs were statistically significantly lower in 5 of 6 sites, including London. At these 5 sites, IPS was both significantly less costly and more cost-effective on both outcomes measured at 18-months (additional cost per additional 1% of people working at least 1 day; additional cost per additional day worked). The average cost per client of delivering the IPS service over 18 months in London (based on 2003 rates) was £2086, compared to £3,234. They also examined cost-effectiveness acceptability /willingness to pay for an additional 1% of clients/participants working at least 1 day or working for an additional day. They found that IPS would almost certainly to be viewed as more cost-effective than standard vocational services even if the decision maker is not willing to pay anything for additional work. For their cost-benefit analysis they only report data aggregated for all 6 sites. They estimated the difference between the cost of the intervention and the value of employment achieved (days worked, valued at expected wage in the UK for someone moving into employment following welfare benefits support for sickness or disability). They found that the cost of the intervention exceeded the benefit of the employment gained for both the IPS intervention group and the traditional vocational control group (minus £9,440 versus minus £25,151 over 18 months). They found that IPS was a more efficient use of resources compared to traditional vocational services (a net benefit of plus £17,005 in favour of IPS). It is important to note, as acknowledged by the authors, that this was only a partial cost-benefit analysis because they did not attach/include monetary values to any observed improvements in health or quality of life, and there may have been further, wider unobserved benefits. Howard et al. (2010) compared the service use and costs of IPS participants with control group participants receiving traditional vocational services. They found that control group participants who were admitted spent substantially more days in hospital than the IPS intervention group. As a results, costs were significantly higher for the control group by £2176 (95% CI: £445–4168). At the two-year follow up, Heslin et al., compared the IPS and control group service and prescription use and costs. Their analysis showed a cost difference (£2361) in favour of the intervention, but this was not statistically significant (minus £6105 to £1308). They also conducted a cost-effectiveness acceptability analysis and found a 90% likelihood that IPS was the most cost-effective option. Wynne-Jones et al. (2018) calculated the net societal benefit of vocational advice service plus best usual care compared to best usual healthcare care only for people with musculoskeletal pain (financial benefit of reduction in work absence minus any additional costs to health services of delivering the intervention). They found the addition of a vocational advice service to best current primary care for patients led to a net societal benefit of £733 per participant (£748 gain through reduced absence versus £15 loss in additional health care costs). This represented a return on investment (ROI) of £49 for every £1 spent (£733 / £15), although this did not include staff training and monthly mentoring costs. When these additional costs were included, the ROI was equal to £25 for every £1 spent. Based on a ‘conservative’ estimate of 31 million days are lost from work per year for back and neck pain alone in the United Kingdom, they calculated that if the intervention was delivered to all relevant people across the UK there would be an overall societal saving of approximately £500 million per year, requiring an investment of only £10 million. Discussion Employment outcomes Severe mental health conditions Across the studies included in this review there is limited (number of studies), but high methodological quality evidence from studies conducted in the UK (but limited to England) that IPS interventions are effective at helping people with severe mental health conditions into employment when compared to traditional vocational interventions or clinical care only. The additional studies of modifications to IPS also show IPS to be effective at promoting employment. This is consistent with the wider body of international evidence on IPS which includes studies in the United States, Canada, Australia, Hong Kong which also found similar results for IPS interventions for this population group (Knapps et al., 2013; Levack and Fadyl, 2021). Increases in employment gains, however, appear to be modest for people with severe mental illness. This is, however, the case for all vocational interventions (IPS and traditional vocational interventions) for this population group and may relate to the severity of illness and a range of barriers to employment ( Cook, 2006 ). Authors of two studies ( Howard et al., 2010 ; Hesline et al., 2011), and other authors ( van Veggel et al., 2015 ), suggest that the effectiveness of IPS interventions may be influenced by the level of adherence with IPS principles, and that high fidelity IPS interventions are necessary and most effective at getting people with severe mental health conditions into employment. This assertion should be tested in future evaluations. There is also potentially contradictory evidence from a single study that suggests that a time-limited version of IPS (IPS-Light) with support limited to 9-months following placement may be almost as effective as indefinite support, and potentially a more efficient use of resources ( Burns et al., 2015 ). Evidence from single studies must, however, be viewed with caution unless the findings can be replicated in further studies. Two studies of IPS modifications (IPS plus motivational interviewing, and IPS with a greater focus on education for a younger population group) found they increases effectiveness. Again, the findings of these studies would need to be replicated in further evaluations. The evidence in this review indicates that IPS does appear to transport well into the UK context, at least for this population group (severely mentally ill) and setting (employment specialists integrated within CMHTs). It may also be that high fidelity IPS design and delivery are needed. If correct, this has clear implications for practice in the design and delivery of IPS. Two studies 11 years apart that compared the effectiveness of training existing CMHT staff to deliver IPS with delivery by a dedicated (embedded/integrated) vocational specialist, found delivery by a dedicated specialist more effective (O’Brian et al., 2003; Marwaha et al., 2014 ). O’Brian et al., 2003 concluded that a dedicated vocational appears to be essential for successful delivery of IPS. Achieving high fidelity IPS with a wide range of different health conditions or disabilities (various physical chronic illnesses and disabilities, and less severe mental health conditions) in different settings (i.e. not integrated within CMHTs) may be challenging. Potential approaches to IPS design and delivery to different population groups and in different settings, including potential individual and organisational barriers and facilitators, need to be investigated. This also points to a need for high quality monitoring and evaluations of future IPS interventions for different population groups and in different settings. Physical conditions and disability Only three studies that met our inclusion criteria evaluated outcomes from employment interventions for physical health conditions or disabilities, or physical health conditions as part of a combination of physical and mental health conditions. This included specialist employment interventions for people recovering from stroke ( Radford et al., 2020 ) and people with musculoskeletal pain ( Wynne-Jones et al., 2018 ), and an evaluation of the Want2Work scheme in Wales for people with a mix of conditions or disabilities receiving incapacity benefit ( Lindley et al. 2015 ). All three studies found that the interventions led to better vocational outcomes than usual best clinical care only. The studies together provide an indication that specialist employment services for people with physical health conditions may help people into employment. No firm conclusions should, however, be drawn from evidence from single studies on specific populations/conditions unless and until the findings can be replicated. Comparisons between these interventions and IPS interventions should also be considered. It is possible that a mix of intervention types, rather than a ‘one size fits’ all approach may be most appropriate given the range of conditions and needs across the large and wide population of people with limiting long-term conditions and disabilities in the UK, but this needs further investigation. The findings of this review of evaluations in the UK are consistent with the findings of the wider international literature from high-income countries, for example, Levack and Fadyl’s 2021 review-of reviews of international evidence on the employment outcomes of vocational interventions for adults with long-term health conditions or disabilities (noting that reviews-of-reviews sit at the top of the hierarchy of study designs – i.e., represent the methodologically strongest evidence). They included 26 reviews, and, looking across the international evidence base, found ‘ moderate quality evidence that people with moderate to severe mental health conditions who participate in supported employment, particularly individual placement and support, are more likely to gain competitive employment compared with people who receive traditional vocational services .’ Consistent with our findings, they also found limited evidence on the effectiveness of vocational interventions for people with any other health condition. Strengths, gaps, and limitations in the evidence base and the review, and areas for further research Strengths of the review included that it was designed to only include academic peer reviewed publications reporting evidence from quantitative studies with control/comparison groups conducted in the UK. This provided higher methodological quality evidence that also is more likely to be generalisable to the Liverpool City Region and other parts of the UK. Publications that have undergone stringent editorial and peer review processes are more likely to be higher methodological and reporting quality. Studies with control/comparison groups are of inherently stronger methodological designs, as the use of control/comparison groups reduce the potential influence of confounders and helps to account for underlying trends that may have affected the results/outcomes at the same time as the interventions, for example, major economic or social events/changes – a recession, a pandemic, or loss or gain of a major employer in an area (noting there are lots of methodologically weaker observational studies without control groups in the literature). Including UK evidence only increases the likelihood that findings may be transferable to other settings in the UK, including the Liverpool City Region, given greater likelihood of similarities in social, cultural, economic, and employment contexts, including policies and services. Our strict inclusion criteria, however, limited the range and coverage of the evidence in this review, including the types of employment interventions considered. The nature of IPS interventions may make them more suitable for RCT evaluations than other interventions, such as population wide government interventions. This may have led to a predominance of IPS RCT evaluations in the higher methodological quality evidence base. Consideration of a wider range of types of interventions and quality of evidence requires different review questions and inclusion criteria. We have therefore coded and set aside two potential bodies of evidence for subsequent review, all to focus on impacts on employment and other outcomes for people with chronic conditions or disabilities: i. grey literature evaluations of UK and devolved administration government employment interventions for people with chronic illnesses and disabilities; ii. observational evidence on relevant employment interventions. We also searched for, but failed to find, any such studies conducted in Ireland were high quality studies of employment interventions for chronically ill and people with disabilities therefore need to be conducted and reported in appropriate journals. The review located studies on the effectiveness of interventions to achieve employment and other outcomes. Studies of effectiveness, whether an intervention did or did not achieve the outcome, the level or likelihood of success, whether one intervention type was more or less effective than others, are the most common form of published interventional studies. However, they typically provide limited information on how best to design and implement an intervention. Qualitative and mixed-method studies can provide further insight into specifics of how, when, where, by and for whom an intervention should be designed, including the barriers and enablers to successful interventions across different groups. We therefore coded and set aside qualitative articles for subsequent review on what works in employment interventions for people with chronic conditions or disabilities. All the studies received high scores for methodological design (influenced by the quality of the reporting of approaches) which is unsurprising given the strict inclusion criteria of the review. There were, however, some limitations in the methodological quality assessment approach/tool, and across the methods used in the studies. Although the methodological quality assessment of the Howard et al. (2010) and Hesling et al. (2011) SWAN RCT study one- and two-year follow-ups was rated as very high, based on the tools appraisal of study methods and reporting, the authors identified that the intervention itself may have failed to deliver a high-fidelity approach to IPS, potentially reducing the effectiveness of the intervention and effecting the results. The methodological quality assessment tool was not designed/able to identify this potential issue. We were also unable to appropriately assess the methodological quality of the approaches used to evaluate economic outcomes such as cost effectiveness, as no widely validated minimum criteria for methodological quality assessment of health economics studies for use in systematic reviews is currently available ( Higgins and Green, 2011 ). Despite strengths in methodological design and reporting quality, the Radford et al. (2020) study on early stroke-specific vocational rehabilitation was only a feasibility RCT with small number of participants, so the results must be viewed with some caution, particularly as a single study of this intervention and population. This is not apparent in the aggregate methodological quality assessment score, which is another potential limitation of the tool. It is widely acknowledged that methodological quality assessment tools for use in systematic reviews of complex social determinants of health and related interventions require some careful development and improvement. For the IPS RCT study designs, the column total results in Table 4 , used as a rough identification of relative strengths and weaknesses in the specific methods/criteria across the studies, highlight limitations across the studies with blinding (of participants, experimenters, and analysts) and high levels of participant dropout. Both these issues are to be expected as it is difficult to conceal assignments/treatment groups for these types of intervention, including because it is obvious to participants whether they are receiving the intervention or control, and given the severe nature of the conditions for participants. Information on participant selection was also limited, and that recording and/or reporting could easily be improved in future studies and publications. It was a strength to include studies of interventions were RCTs were not practical/possible, and also using routinely collected data across large population groups/areas in studies such as Lindley et al’s (2015) study of the Want2Work scheme for incapacity benefit recipients in Wales. Also of note in recent years are the technological, demographic, environmental, social, and economic changes that have transformed how many people live, work, learn, shop, socialise, and take our leisure. This has changed employment opportunities and conditions for many. New jobs and working practices, for example, self-employment in platform economies, and remote and hybrid working, are likely to have increasing impacts across society that will be differentially distributed across population groups. The current evidence base is yet to consider the wide implications of these changes. The is much theoretical and empirical work to be done on these important changes to the fabric of our society. The positive and negative impacts of changes to the “world of work” across population groups need to be understood, and potential implications to the design, delivery, and outcomes of employment interventions for people with chronic illnesses and disabilities need to be addressed. Conclusion The evidence suggests that IPS interventions, and to some extent condition specific vocational interventions, have the potential to improve employment outcomes for people with chronic illness and disabilities in the Liverpool City Region and other areas of the UK. Question remain, however, about how effective they will be across a range of different conditions and disabilities, settings and situations, and about the impacts of modifications to IPS design on effectiveness. Data Availability All data in this systematic review is available in the original included pubnlications. Appendices Appendix 1 Example of (MEDLINE) search syntax Ovid MEDLINE(R) and Epub Ahead of Print, In-Process, In-Data-Review & Other Non-Indexed Citations and Daily – 2003 to 2023 - ran 16-05-2023 View this table: View inline View popup Download powerpoint Appendix 2 Quality assessment tool for systematic reviews of effectiveness (based on Orton, et al, 2016 ; modified from Lorenc et al., 2013 ) First author: Year: The quality assessment tool contains six questions: Selection bias Study design Confounders Blinding Data collection Withdrawals and dropouts. Each question can get an A (high), B (medium) or C (low) or D (lowest, for study design) quality rating, as per the tool below. The guidelines for the specific questions are as follows Appendix 3 Table of reasons for excluding studies during full text screening View this table: View inline View popup Appendix 4 List of articles included in the review Burns T, Catty J, Becker T, Drake R, Fioritti A, Knapp M, et al. (2007) The effectiveness of supported employment for people with severe mental illness: a randomised controlled trial. Lancet. 29;370(9593):1146-52. Burns T, Catty J, White S, Becker T, Koletsi M, Fioritti A, et al. (2009) The impact of supported employment and working on clinical and social functioning: results of an international study of individual placement and support. Schizophr Bull. 2009 Sep;35(5):949-58. Burns T, Yeeles K, Langford O, Montes M, Burgess J, Anderson C (2015) A randomised controlled trial of time-limited individual placement and support: IPS-LITE trial. British Journal of Psychiatry . 07(4):351-356 Craig T, Shepherd G, Rinaldi M, Smith J, Carr S, Preston F, et al. (2014) Vocational rehabilitation in early psychosis: cluster randomised trial. Br J Psychiatry. 205(2):145-50. Heslin M, Howard L, Leese M, McCrone P, Rice C, Jarrett M, et al. (2011) Randomized controlled trial of supported employment in England: 2 year follow-up of the Supported Work and Needs (SWAN) study. World Psychiatry. 10(2):132-7. Howard L, Heslin M, Leese M, McCrone P, Rice C, Jarrett M, et al. (2010) Supported employment: randomised controlled trial. Br J Psychiatry. 196(5):404-11. Knapp M, Patel A, Curran C, Latimer E, Catty J, Becker T, et al. (2013) Supported employment: cost-effectiveness across six European sites. World Psychiatry. 12(1):60-8. Lindley J, Mcintosh S, Roberts J, Czoski Murray C, Edlin R (2015) Policy evaluation via a statistical control: A non-parametric evaluation of the ‘Want2Work’ active labour market policy. Economic Modelling. 51:635-645. Major BS, Hinton MF, Flint A, Chalmers-Brown A, McLoughlin K, Johnson S. Evidence of the effectiveness of a specialist vocational intervention following first episode psychosis: a naturalistic prospective cohort study. Soc Psychiatry Psychiatr Epidemiol. 2010 Jan;45(1):1-8. Marwaha, Steven, Gilbert, Eleanor and Flanagan, Sarah. (2014) Implementation of an employment intervention in mental health teams : a naturalistic 1-year employment outcome study in people with severe mental illness. Journal of Mental Health. 23(3):135-139. O’Brien A, Price C, Burns T, Perkins R (2003) Improving the vocational status of patients with long-term mental illness: a randomised controlled trial of staff training. Community Ment Health J. 39(4):333-47. Radford K, Grant M, Sinclair E, Kettlewell J, Watkin C (2020) Describing Return to Work after Stroke: A Feasibility Trial of 12-month Outcomes. J Rehabil Med. 52(4):jrm00048. van Veggel R, Waghorn G, Dias S (2015) Implementing evidence-based supported employment in Sussex for people with severe mental illness. The British Journal of Occupational Therapy. 78(5), 286–294. Wynne-Jones G, Artus M, Bishop A, Lawton S, Lewis M, Jowett S, et al. (2018). 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Share 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 Andy Pennington , David Newbold , Yang Yu , John White , Ben Barr , Philip McHale medRxiv 2024.12.03.24318405; doi: https://doi.org/10.1101/2024.12.03.24318405 Share This Article: Copy Citation Tools 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 Andy Pennington , David Newbold , Yang Yu , John White , Ben Barr , Philip McHale medRxiv 2024.12.03.24318405; doi: https://doi.org/10.1101/2024.12.03.24318405 Citation Manager Formats BibTeX Bookends EasyBib EndNote (tagged) EndNote 8 (xml) Medlars Mendeley Papers RefWorks Tagged Ref Manager RIS Zotero Tweet Widget Facebook Like Google Plus One Subject Area Public and Global Health Subject Areas All Articles Addiction Medicine (574) Allergy and Immunology (865) Anesthesia (304) Cardiovascular Medicine (4462) Dentistry and Oral Medicine (445) Dermatology (383) Emergency Medicine (611) Endocrinology (including Diabetes Mellitus and Metabolic Disease) (1517) Epidemiology (15251) Forensic Medicine (31) Gastroenterology (1132) Genetic and Genomic Medicine (6621) Geriatric Medicine (669) Health Economics (1002) Health Informatics (4564) Health Policy (1372) Health Systems and Quality Improvement (1617) Hematology (544) HIV/AIDS (1272) Infectious Diseases (except HIV/AIDS) (15938) Intensive Care and Critical Care Medicine (1107) Medical Education (624) Medical Ethics (147) Nephrology (670) Neurology (6643) Nursing (346) Nutrition (1001) Obstetrics and Gynecology (1149) Occupational and Environmental Health (957) Oncology (3350) Ophthalmology (981) Orthopedics (369) Otolaryngology (421) Pain Medicine (436) Palliative Medicine (130) Pathology (665) Pediatrics (1698) Pharmacology and Therapeutics (694) Primary Care Research (714) Psychiatry and Clinical Psychology (5465) Public and Global Health (9259) Radiology and Imaging (2212) Rehabilitation Medicine and Physical Therapy (1372) Respiratory Medicine (1198) Rheumatology (598) Sexual and Reproductive Health (716) Sports Medicine (533) Surgery (715) Toxicology (100) Transplantation (289) Urology (265) (function(){function c(){var b=a.contentDocument||a.contentWindow.document;if(b){var d=b.createElement('script');d.innerHTML="window.__CF$cv$params={r:'a03c8f6fae7f4193',t:'MTc4MDEzMTc1MA=='};var a=document.createElement('script');a.src='/cdn-cgi/challenge-platform/scripts/jsd/main.js';document.getElementsByTagName('head')[0].appendChild(a);";b.getElementsByTagName('head')[0].appendChild(d)}}if(document.body){var a=document.createElement('iframe');a.height=1;a.width=1;a.style.position='absolute';a.style.top=0;a.style.left=0;a.style.border='none';a.style.visibility='hidden';document.body.appendChild(a);if('loading'!==document.readyState)c();else if(window.addEventListener)document.addEventListener('DOMContentLoaded',c);else{var e=document.onreadystatechange||function(){};document.onreadystatechange=function(b){e(b);'loading'!==document.readyState&&(document.onreadystatechange=e,c())}}}})();