Flexible and personalised? An evaluation of a UK tailored employment support programme for jobseekers with enduring mental health problems and learning difficulties

The employment position of people with enduring mental health issues and learning difficulties (intellectual impairment) is a major policy and moral challenge. The continued exclusion from paid work for those disabled people who are otherwise keen to work is marked in Western Europe even in high per capita welfare states. The paradox here is that disabled people have received policy and programme attention, but arguably programmes have become increasingly ‘corporeal’ and medicalized. Condition management programmes (CMPs) epitomize this approach and focus on getting the sick and disabled body/brain more work-ready ahead of wider supports. By way of contrast this article presents the results of a large-scale evaluation of a non-medicalized approach in the UK which concentrated on careful job matching, intensive support and barrier reduction. It argues that flexible personalized approaches will afford greater employment success than a focus on deficits and welfare dependency reduction.


Introduction and policy context
Research evidence points to the value of paid employment for disabled people with a range of impairments (Black 2008;Roulstone et al. 2003). Mental health and employment research suggests that paid work is a key tool of social reintegration and inclusion as well as boosting their economic stability longer term (Sainsbury et al. 2008). The absence of paid work is linked to deteriorating mental health and social dislocation (Emerson and Hatton 2008;Jahoda 1988). A positive link between mental health, employment and social engagement is clear for those people who can stay in the labour market (Bond et al. 2001). Paid work also provides a clear route to social inclusion for some people with learning difficulties, especially where longer term supports can be fostered in the workplace (Cabinet Office 2005). assumption that people with significant impairments would have to find 'significant living without work' (Tomlinson Report 1943;Warnock Report 1978) has now firmly been challenged. Few question the potential of paid work to enhance the lives of the majority of disabled people where genuine opportunities are available. Employment is increasingly recognized as synonymous with a facet of independent living in influential organisations of disabled people (European Network on Independent Living 1990; National Centre for Independent Living 2008). We know that at age 16 people with physical/mental health impairments have comparable employment expectations to their non-disabled comparators, but that ambitions deplete significantly by age 24 (Burchardt 2005).
The value of paid work for disabled people is made clear in a range of UK policy documents and programmes from 1998 to date, most notably the New Deal for Disabled People, Pathways to Work and Workstep (Department of Social Security 1998;DoH 2007;DWP 2003DWP , 2008HM Government 2010). Policy and programme challenges for those disabled people traditionally furthest from the paid labour market are addressed in government reports on disability and employment (Cabinet Office 2005;DoH 2001) and the now discontinued Workstep programme (DWP 2009;2010a;Purvis, Lowery, and Dobbs 2006). These developments focus on the need to support sick and disabled people into or closer to paid employment. A key plank of disability employment policy since 1997 in the UK has been the shift to commodify (Esping-Anderson 1990) employment support programmes and contract out previously publically run employment support programmes which were viewed as unresponsive to changing provider and commissioning environments (DoH 2007).
Another key development in UK disability employment policy has been the shift towards voluntary Condition Management Programmes (CMPs) (DWP 2006). The Condition Management Programme is a cross-departmental programme aimed to connect sick and disabled people who claim the out-of-work benefit Incapacity Benefit (ICB now Employment & Support Allowance) and covers 'mild to moderate cases' of the three main health conditions cited in ICB claims Á mental ill health, musculo-skeletal disorders and cardio-respiratory conditions. The main aims are: To help ICB customers to better understand and better manage their condition in the work environment; To help ICB customers feel more confident about returning to work; and to To enable customers when in work to feel more confident and expert about negotiating with their employer; To date evidence points to significant differences across departmental cultures in delivering what is a voluntary national agreement between health care and employment providers (DWP 2012). A more thoroughgoing critique of the programme is that it falls back on a rehabilitation model of employment support which focuses on sick and disabled people's deficits whilst barriers to paid work remain very significant (Warren in Roulstone and Barnes 2005) The limited impact of UK disability employment policy Despite a flurry of sustained policy attention and programme change, the employment rate for people with mental health problems was only 20% in 2009 (Labour Force Survey 2009). Emerson and Hatton noted that in 2008 only 8% working age people with learning disabilities were in paid work (Emerson and Hatton 2008). Although the UK public sector has the highest concentration of disabled people in employment (compared to the private and voluntary employment sectors), people with learning difficulties and mental health problems are much less likely to form part of this workforce (Hirst et al. 2004). In general terms, the efficacy of welfare to work policies and programmes is varied, with mainstream approaches using personal advisors or job brokers achieving very limited results. For example, Pathways to Work data suggests of those who started Pathways in 2009, only 15% went on to any form of paid work (Morse 2010). Contractor underperformance is a key factor in the limited impact of these programmes in getting disabled people off incapacity benefits and closer to paid employment (Morse 2010).
A key aspect of contracted-out employment services is arguably their lack of transparency and evaluation, with many programmes going unevaluated. Most programme evaluations are completed in house by the UK Department for Work and Pensions (DWP). This lack of an independent evidence base in employment programme outcomes has serious implications for disability and employment policy (Barnes, Thornton, and Maynard-Campbell 1998). The recent shift to 'payment by results' and tighter contract compliance detailed in the UK coalition government plans for sick and disabled people are too recent to evaluate; however the intractable nature of worklessness amongst disabled people, especially in post-industrial contexts makes this a very tough policy challenge (Garthwaite 2011). Without intensive support (Crowther et al. 2001), and a buoyant labour market, the risk may be that sick and disabled people simply get moved onto mainstream out-of-work benefits (JSA) and their social exclusion be further engrained. The current demonizing of incapacity benefit claimants in the UK media is arguably unlikely to increase employability in the short-term given the likely reception of images of welfare dependency by potential employers (Watson and Philo 2011).
It is important to reflect on what works, particularly for those people traditionally hardest to place in the UK labour market. Evidence points to the value of projects that provide intensive support to disabled people in getting and keeping paid work (Purvis, Lowery, and Dobbs 2006). Effectiveness of work-related projects relate to their ability to enhance employability, skills and work-readiness (Riddell et al. 2010), to get disabled people closer to or ideally placed in a job, to enhanced educational and training inputs (European Working Conditions Observatory 2009), and to 'place and train' and Individual Placement and Support (IPS) approaches (Centre for Mental Health 2009; Perkins, Farmer, and Litchfield 2006).

Managing conditions or managing employment openings?
With Condition Management Programmes some contract holders have been clear about the need to produce confidence gains and improved health through better 'condition management' ahead of employment options. A discursive reading of many contracted provider programmes suggests their primary aim is to ameliorate the effects of a person's impairment or illness and have given little credence to new models of disability that emphasise social and workplace barriers as key considerations in enhancing employment options for disabled people (DWP 2006). This approach could be viewed as akin to a form of corporeal (body-centred) surveillance which in turn may risk blaming individuals for not entering paid work. There is a heightened risk where condition management discourses do not address the nature of work and workplace barriers. Of note the Condition Management Programme is targeted at Incapacity benefit (ICB) or disabled Income Support (IS) claimants. The focus on ICB/IS claimants strongly suggests a focus on those closest to paid work, the greatest revenue savings and high volume claimant populations within ICB/IS. Whilst this does not discount personalized responses to employability, even a cursory glance at the guidance notes for NHS staff adopting condition management approaches does appear to be top-down and at times didactic in tone in emphasizing the need to 'get better' as a solution to the disability employment problem. An inhouse Department for Work and Pensions (DWP) evaluation of Condition Management (CM) (Warrener, Graham, and Arthur 2009) did however point to one-to-one support for people with mental health issues as being more beneficial than reported satisfaction from people with physical impairments.
The degree of mental health challenge was not made clear in this report however and previous research on a range of DWP funded programmes suggests those closest to the labour market are most likely to avail themselves of these schemes (DWP. 2010b). One key problem with assessing the objectivity of CM approaches and other key approaches (largely cognitive behaviour therapy [CBT]) is that evaluations are in house and by organisations close to delivery or funder (DWP, Primary Care Trusts). One presentation of research findings for example, combines a plethora of success data with a prosyletising message about the merits of CBT and condition management. The approach makes no mention of barriers to appropriate paid work or the nature of contemporary workplaces and the impact on mental health (Perkins, Farmer, and Litchfield 2009). These should cause some concerns. In fact if we look at some of the larger studies of condition management their findings are at best ambivalent even when we account for the often biased construction of questions.
For example Bickerstaff and Purdue's study of CM's effectiveness attributed 'changes in employment status' (which one assumes means getting paid work) to be completely attributable to CM in 13% of respondent cases (Bickerstaffe and Purdue 2011). Return to work, three months post-CM, was achieved in 12.5% of respondent cases. The twin influences of marketized employment programmes and medically rooted condition management approaches has then arguably produced a disability employment practice environment which is often inflexible, largely quantitative and which adheres to medical or bio-psychosocial model constructions of disability.
Significant concerns are raised by participants in Condition Management Programmes (CMP) (Joyce et al. 2009) about the inflexible 'funding window' for condition management support as professional support is for a fixed funding period regardless of progress towards employability. The findings also highlight limited intra-organisational cooperation. The latter is presumably made more difficult by the competitive funding environment where market share is hugely important with profit margins for participant being very low. The other criticism was that actual clinical support is not allowable in the CMP. In this sense, condition guidance and awareness are the primary offerings from CMP.
Personalized support therefore, whilst of clear benefit to connecting work-able disabled people with paid work is not in evidence in many mainstream employment programmes and the scope to emulate the personalization in say adult social care in mainstream national employment programmes (See for example Leadbeater. 2004) is very limited in the foreseeable future. What then of a tailored package of support offered in part in response to the perceived inflexibilities of Pathways to Work and Condition Management Approaches? The following presents details of a study of a tailored Department of Health funded employment support programme made up of a number of constituent projects. What ties these together is an overt commitment to provide flexible projects and to target those further from the labour market but who have expressed an interest in paid work or pathways to paid work.

Method
This article is based on a study of an employment programme funded by the UK Department of Health, but outside of condition management approaches (Joyce et al. 2009). The programme was made up of 13 constituent employment projects aimed at getting people with enduring mental health issues and people with 'moderate/severe' learning difficulties, who have been some distance from the labour market, closer to or into paid work in a large region of England. The study used purposive sampling and was concerned to explore how a programme, avowedly premised on service-user preferences, flexibility, acknowledged diversity and intensive job support/matching, fared in practice. The programme acknowledged impairment effects (Thomas 2007), but placed these in the broader context of the evidence on the range of factors that limit access to paid work (Perkins, Farmer, andLitchfield 2009: Riddell et al. 2010;Roulstone et al. 2003).
The study adopted multi-stage and multi-method approaches which included focus groups, questionnaires, interviews, site visits and data triangulation (Robson 2002). The research team devised pictorial research tools alongside more traditional text-based tools to ensure the accessibility of the research for people with learning difficulties and communication difficulties (Nind 2008). Research tools aimed to evince insights on the barriers, achievements and facilitators of employment and employment-related gains were influenced by phenomenological ideas in benchmarking achievements against project staff and service user views. For example, staff and participant's thought that 'employment success' should include not simply paid work, but also steps to paid work and that both were inherently important in absolute terms (Merleau-Ponty 2002). As a consequence of this the research project adopted both paid work and steps to paid work as measures of 'employment success.' With this in mind, a formative focus group approach aided the building of a research method that best comprehended the skills and knowledge gains en route to paid or voluntary employment. These formative meetings identified a range of employmentrelated skills that were useful in getting closer to paid work. These meetings explored the idea and construction of employment success with project leads who in turn liaised with participants to embed their views on employment success and gains into the research tools. Employment gains included, inter alia, skills in handling money, using public transport, personal presentation, confidence. The study adopted nonjudgmental approaches which valued movements towards paid work-however small. In not being part of a 'moral economy' of Pathways or Condition Management type approaches, the study could explore naturalistically project staff and disabled participants' perceptions and experiences en route to finding paid employment. There were no major differences between project staff and service user constructions of employment success and employment-related gains. Questionnaires were devised with project leads and participants to best capture absolute gains in terms of paid or voluntary work and work-related skills. We used Likert scales (scales with more/less likely characteristics) to capture the graded patterns of skills/employment gains during the project's lifetime. The formative focus groups with project staff from the 13 funded Innovation Projects took place in February 2011.
Following this, all 13 project leads were asked to complete a questionnaire with Lickert Scales of summary organization achievements; a two-page narrative of organizational achievements, and evidential data on employment/accommodation gains. At the same time questionnaires were distributed to all programme participants (n 0257). As a number of participants had learning disabilities a pictorial questionnaire was devised that made service user questionnaires accessible to the fullest range of respondents. Some participants had help completing the questionnaires but helpers reported that all who completed the questionnaires understood the questions and discriminated with the answers they gave (i.e. respondents had been clear that they wanted to indicate 'yes' or 'no' for a certain question).
In all, 144 (56% response rate) employment service participant questionnaires were completed and 13 project leads completed questionnaires on the overall employability impact of their project. In addition to the above, site visits were made in May/June 2011 and project leads interviewed using a semi-structured interview schedule. Participants were given an opportunity to meet the research team to discuss their experiences and to illustrate the nature of their activities more fully. This approach helped minimise 'missing cases' as we explained an answer was important for all questions. Overall the average missing response percentage was B10%.
In total 13 project staff were interviewed (face-to-face), and a further three people were interviewed by telephone where for example projects involved joint working arrangements across health and employment services. Thirteen employment site visits were completed. The research took place between January and September 2011 and was funded by the UK Department of Health and the Regional Innovation and Efficiency Partnership (RIEP). In sum there were 13 constituent projects offering innovative employment-related support activities, with a total of 144 service-user participants funded by the Department of Health employment support programme. Common denominators for all projects however were the DoH funding base and the objective of getting people closer to paid employment. The projects varied in size and focus, with between three and 53 participants, with a (mean) average of 20 service user participants. The projects spanned public, private and third sector providers. Community interest companies (CiCs) made up a significant proportion of the providers. Some projects built on current and wider service expertise-for example, a joint secondary mental health and local authority job coaching project built on existing staff infrastructure and an established Individual Placement and Support (IPS) model but took forward innovation by successfully co-locating mental health and job coach expertise for the first time. Similarly another project built its project on to pre-existing expertise in the placement of disabled people into a number of placement opportunities to maximize the fit between service user and future job opportunities.
As a mixed methods study, the data were triangulated to identify congruence and patterns between quantitative and qualitative findings. Quantitative data were checked for consistency between questionnaire data for individual projects and the project lead summative questionnaire responses. In this way we could ensure the validity of overall claims made by project leads about project successes/gains against service user data. The quantitative questionnaire data were analysed and verified by the wider research team for Likert scale frequencies using the latest version of SPSS software and for inferences drawn from missing data. Open qualitative questions were analysed by hand, looking for thematic patterns across different responses. The research team (n 03) independently analysed each others qualitative responses to check reliability of cross-data analyses and inference. During the qualitative research stage the research team was mindful of the key precepts of qualitative epistemologies which establish that in-depth naturalistic and iterative approaches best capture meanings in the social world and that interpretive insights are best placed to connect wider quantitative data with the richness of social phenomenon (Robson 2002).
The structuring of the questionnaires and interviews enabled comparison of projects-whether they enabled participants to get closer to paid work, as well as common barriers and facilitators in movements towards paid work. As the overall research programme was based on a wider range of measures of employment success than those used in much official research, no generalized comparison can be made with other major surveys of employment support as the funding and parameters of success are very different. However the findings do illustrate powerfully the need for flexibility, intensive and wide-ranging forms of support.

Flexible programmes: overall effectiveness and what works in employment support? Findings
The following section provides insights into the key findings of the employment support programme and its constituent projects. It begins by looking at the perceived past weaknesses of employment programmes, the range of available supports, understanding participant diversity, person-centred planning, job diversity-tasters through to real jobs, job matching and the parallel development of education and skills. All quoted material is anonymized and placed in italics.
Key weaknesses of employment support programmes noted by providers previously funded through mainstream sources were, inter alia, their inflexibility, lack of joined-up working, funding by results, lack of nuanced understanding of impairment/effects. In which ways then were the projects innovative in supporting a range of employment-related needs? In total 27 (27/144 or 19%) people with mental health problems and learning difficulties entered paid work during the duration of their project. Twenty-four people entered voluntary work (24/144 or 17% of participants). The research established, inter alia, that the following were all important in creating conducive opportunities en route to or into paid employment: providing a range of supports, understanding participant impairment diversity, person-centred practice, job tasters, real jobs opportunities (where participants were job ready), careful job matching, general skills and educational development. We begin by looking at the range of supports available.

A range of supports
The Bede Project, for example, took its work beyond viewing support as a single unitary concept as the project lead noted: We recognize that disabled people require an array of supports to get closer to paid work [we offer] . . . training, mentorship, job coaching, career development, supervision and appraisal. (Project Lead) In this sense the Bede Project recognized the many facets of support, information advice and signposting that may be required for people some distance from the labour market. Similarly, the Wearhealth project has, from the outset, blended employment placements with classroom-based foundation level insights which include managing your health at work, working in a team, conduct at work, rights and responsibilities. This has proven effective in supporting on-the-job activity and reduces misunderstandings in the workplace context: Understanding what is expected in the workplace, the types of jobs available and what they involve is best experienced firsthand for a true understanding. . . . Areas that were identified as being in need of development in the workplace have been brought into the education sessions to help with understanding and reinforce work-based learning. . . . Mentors are trained to support interns in a way that results in independent working. They receive support to both encourage the intern, and develop their ability, to take ownership and responsibility for their own workload. (Project Lead) Assessment of diverse project participant needs featured in a number of projects: Before starting the course [education, training and work experiences] the organization got a referral form which laid out types of disabilities, contact details of support workers, and other types of support the organization might need to provide for participants. The organization had a range of people moving from supported living to independent living . . . so the needs of participants was varied. (Project Lead)

Understanding participant impairment diversity
One project adopted what might be described as an impairment or disability-focused approach. Although this might be viewed as against the programme focus on abilities in highlighting impairment, the project was drawing down the recognized skills and attributes of its clients by recognizing the positive attributes of autism. Autlife, a project offering real work opportunities for people identifying as on the autistic spectrum, drew on the ability of some of its participants to focus on detail to test software for major organizations and also to offer autism friendly recruitment insights to employers based on systematic policy reviews as one service user notes: Prior to working for Autlife, I was unemployed for two years. Autlife has provided me with a job and a training opportunity in software testing. The software testing qualification will improve my skills and provide me with a new area of potential employment. I am also able to work for an autism-friendly employer. Autlife will provide reasonable adjustments for employees in the workplace to suit their needs. Autism provides me with insights that will produce better tested software . . . and a reengineering of appropriate operational policies, procedures and guidance to ensure they are all autism friendly. (Participant)

Person-centred practice
Five projects adopted person-centred plans or PCPs as the basis of their mapping of service-users interests, abilities and life histories and their links with employment or para-employment opportunities. This is relatively unusual outside of an adult social care environment such as a day centre or in a social care assessment: We use what might be called informal PCPs, nothing too involved, but these allow our job coaches to connect with employers much more precisely-for example assessment . . . language needed to be clear, more mindful, more planned, more direct in a disabilityfriendly way. (Project Lead) Another project emphasized its aims as providing personalized and ongoing support even beyond the lifetime of any given project: Support is one-to-one intensive support, to facilitate people having choice to do their own job search. It is about working with them, assessing skills, to give them the best opportunities . . . we aim to provide longer term support . . . the local authority and JobCentrePlus [a governmental agency for providing employment services] have reputations for starting projects and then stopping. We won't do that. We are committed to the individual, so that even if the employment stops, we will continue to support the individual. (Project Lead) The above make clear that 'one size clearly does not fit all' in any employment programme with mixed service user constituencies. The role of job coaches was explicit in a number of projects. The focusing of targeted assessment and support, both before and in paid employment, was made very clear by both project staff and participants: Having the employment coaches is working very well. They are able to engage with clients and there have been positive reviews from referral agents. Because the project they are engaged on [. . .] has personal budgets of £500 they can break down barriers between health and social care [services]. . . . Employment coaches had worked well because there was 1:1 support, with weekly meetings with the same person. For most clients this had not happened before: having the same person all the way through [the programme]. (Project Lead)

Job tasters through to real job opportunities
Although there is much evidence that a place-and-train approach is best for many disabled jobseekers (Crowther et al. 2001), there was evidence in this study that those disabled people furthest from the labour market and especially those with enduring mental health problems or a label of autism/Asperger's do seem to benefit at times from job tasters and placements. Here the project lead for an autism employment project makes clear the benefits that can accrue: Work or job tasters give a good idea of how people react to work and can identify what they like, what they can do and things they don't like . . . (Project Lead) The innovative nature of some projects was their aim to span a range of provision for service-users. For example, education, work-based training, paid work, voluntary work in combination all featured across most the range of projects: This is a partnership between Clearwater Foundation Health Trust, Westdale Early Mental Health Response Team and Westdale Employment Team . . . it involves embedding a job coach from the Employment Team with the Early Response Team while maintaining the infrastructure and support of the vocational team within the Employment Team. . . . Our job coach is working alongside the clinical team and housing support staff to integrate clinical, housing and vocational support plans . . . (Project Lead) This project, for the first time in the region being studied, had managed service colocation and a shared records approach which afforded matching based on a careful health evaluation and agreement with servicer users as to suitable job and placement opportunities. This project has gone against the grain of broader service thinking as the health project lead stated: Employment is not seen as health's business. It is not high on the Trust's agenda, although the evidence is clear-work has an impact on everybody's outcomes. The predecessor project to this, one using the same principles placed 32 out of 38 users into jobs or voluntary work. These sorts of figures are unheard of in straightforwardly employment-driven projects. To be honest they still have a lot of work to do in the clinical teams, so they can work with their service user's aspirations, so they are moving people on further towards the goal of employment. (Project Lead)

Careful job matching
A key feature of the more successful projects was the careful matching of service-user to opportunities. This principle is beginning to be recognized in impairment specific employment research, but may deserve greater attention in the wider disability and employment literature. The project lead for Wearhealth noted how matching with opportunities afforded a side-stepping of impairment specific approaches: Students with learning disabilities were not screened but they were matched carefully to ensure that the job was right for them . . .

General skills and educational development
Alongside more general issues of innovation the study was concerned with the development of participant skills. This was seen by the project staff as important and to reflect the strong evidence that skills and education are key variables in job acquisition (Burchardt 2005;Riddell et al. 2010). We asked all projects to appraise the extent to which their participants had developed their skill base. The study findings make clear that the majority of projects [10/13] had participants with increased skills. In total 112 of 134 (83%) participants who responded to this question claimed to have increased their skills. This is significant and suggests that skills have been gained across the majority of projects. Participants from the Thinkwork project have been typical of many participants' responses. Thinkwork had used workshops to help identify self-employment options based on previously successful project activity. Workshops helped improve skills in identifying business and self employment opportunities alongside gains in confidence, social networking and reduced work-related anxieties: Since the project started the confidence and social interaction [of participants] has been greater than expected. Individuals have created themselves a new social network. After gaining more confidence individuals have also accessed more skills. (Project Lead) Alongside greater general skills development, we asked a specific question about transport skills gains attributable to the projects. This reflected the perception of many project leads that transport was a key plank of self determined and independent living for disabled people (Barnes 1991;Cabinet Office 2005;Martin, White, and Meltzer 1989). There were larger numbers of people across the range of projects using transport a 'bit more' and 'much more.' Seventy-one participants used transport a 'bit more' and 25 used it 'much more.' This can be compared with 21 participants used transport 'about the same,' one used it 'much less' and one used it 'a bit less.' Using transport was important to participants: Being able to come to work on the Metro [tube system] or other public transport has been much better for our employees, as both found driving very stressful. (Participant) The study findings established that involvement in project activity had led to greater talking and communication more generally amongst their participants, with the majority stating that their participants had communicated/talked more with others because of their project participation.
For one service user who identified as on the autistic spectrum their project experience afforded them greater confidence linked to a stronger sense of purpose in supporting others: I feel very confident when doing tasks that I feel I am able to do competently and that involve making a difference to peoples' lives for what is an issue that I feel strongly about, difficulties and frustrations that people with an ASC experience in obtaining and maintaining employment. That I am working on a project that is making an effort to change this gives me much confidence, where I can use my experience and knowledge for the good of others. [Participant] The question of confidence building also featured in the EmpHealth project that was supporting people with often very challenging mental health issues to gain more confidence about taking steps to employment: We deal with people with major anxieties about going out, let alone doing paid work. But we see ourselves as getting the 'foot in the door,' in the nicest sense. A number of our clients have real aspirations and hope that they can work and it helps if our clients have a work history. But our role is to provide significant one-to-one support in real work contexts, but with a gradual rather than overnight exposure to new opportunities. (Project Lead) The increased perception of opportunities ranged from generally increased awareness of life opportunities in paid work, and as one project lead put it that there is life beyond a person's bedroom [Wearhealth Project] through to more tangible gains around opportunity awareness. Wearhealth also has the explicit goal of making disabled people aware of a range of job roles and working environments: Project Choice gives the opportunity for an intern to experience different job roles in true work environments whilst gaining skills that will help them to obtain and retain employment in the future. [Project Lead] A number of participants across the projects mentioned being better informed about employment options or support options towards paid work as a service user notes: In total, 92% of participants were either much more or a little more aware of paid job opportunities. Whilst 81% were either much more or a little more aware of voluntary work opportunities. Family liaison proved an important aspect of those projects attended by people with learning difficulties where family based decisionmaking and supports were felt to be important. This reflected wider evidence from the literature on diverse employment supports beyond the workplace (Roulstone et al. 2003): They have helped families by accessing permitted employment (earnings) funds . . . also links to . . . People First which gave advocacy and use of friendships [peer support] to help people. (Project Lead) Here, the ability of many projects to go beyond their own organization to draw on advocacy projects known to participants and locate support as part of their wider 'ecological contexts' (Hollomotz 2009) was a feature of a number of projects.

Conclusions
The key findings from this study are that the rate of achievement of paid jobs is much higher in this programme despite the pre-existing distance from the labour market and project diversity. Unlike private or third sector delivered New Deal or Pathways contracts, providers could support disabled people without having to interface with JobCentrePlus and the broader bureaucratic inflexibilities at the heart of the DWP (Stafford et al. 2007) and were able to exercise greater streetlevel project innovation. Recent National Audit Office figures point to very limited impacts of support in the Pathways to Work programme despite spending of 94 million in 2008Á9 to reduce ICB claimancy. Any approaches that increase confidence, support, skills and tangible job placements have therefore to be welcomed. Disentangling project effect is difficult as control group approaches have been largely dismissed in social research. Thus findings have to be treated with some caution Á their generalizability. Of course the response rate, whilst high suggests that 44% of project participants' voices were not heard. However, most participants' views overlapped in attributing their progress into employment or closer to employment as being positively assisted by their project experience. The limitations of project impact were extraneous and included unpromising local labour markets and finite funding for project activity. Key barriers that we discerned were very challenging local labour markets and the finite nature of the funding that might make longer term support more tenable. This points to the need for greater personalization in employment support where recognition of disability, impairment and diversity are key aspects of enabling disability employment support. To date even those DWP programmes that have emphasized tailored support, such as Workstep have erred on the side of financial incentives which arguably weakens a more nuanced approach to disability, impairment and the interaction between individual and workplace (Purvis, Lowery, and Dobbs 2006;Thornton et al. 2004).
The above points to generic and job specific skills being developed by many of the programme participants. In terms of labour economics, clear supply-side enhancements were evident in the wider programme. The constituent projects point to the positive role of intensive support before and during the early stages of paid work. The need to address a range of supports and skill requirements was seen as important as was a plurality of approaches to support-for example in terms of more/ less impairment-focused approaches which might previously have been seen as mutually exclusive in disability employment policy.