Developing employability skills in local communities: supporting the economy, health sector and addressing the social determinants of health

ABSTRACT

Employment is a key determinant of health and is consistent with a range of positive health, social and economic outcomes for individuals and communities. This paper focuses on an innovative skills and employment project undertaken in Leeds, a large metropolitan city in the United Kingdom. It sought to create an employment pathway from the community into hospital-based employment, mirroring theoretical aspects of the health-promoting hospital philosophy, or more broadly a settings approach to health promotion which seeks greater levels of social justice. Using qualitative methodology with key constituents of the programme, the research identified an approach to connecting local communities with paid employment roles in a local hospital. The research focused on the conception, design and delivery of the programme and has shown the elements required to increase the likelihood of success. This includes providing a bespoke support and tailored intervention package for individuals and strong partnership working between delivery partners and strategic groups. While the focus of the research is not on outcomes, there are examples of instances where individuals had gained employment and skills, increases in confidence and evidence of the programme raising aspirations for themselves and others.

KEYWORDS:

• Health promoting settings
• social determinants
• qualitative

Introduction

The links between secure employment and health are well recognised, with consistent reports in the literature of positive outcomes related to a myriad of health and social outcomes (Jonsson et al. 2021; Gevaert et al. 2021). Conversely, unemployment is a psychosocial stressor that has been linked to an increase in physical and mental health problems, low subjective well-being and quality of life (Peláez-Fernández, Rey, and Extremera 2022). Socioeconomic inequalities remain prevalent in the UK and this is particularly damaging to fostering inclusive and cohesive communities (HM Government 2022). These inequalities arise from a plethora of factors, but income and opportunity for developing education and skills in order to gain meaningful employment is a salient issue which if resolved could offer benefits for individuals and ‘levelling up’ wider society (HM Government 2022). In short, employment is a clear social determinant of health for individuals and communities (Public Health England 2015).

This paper focuses on an innovative skills and employment project undertaken in Leeds, a large metropolitan city in the United Kingdom. The aim of the project was to support individuals and communities in one of the most disadvantaged areas of the city, and indeed in the country, to develop skills and competencies that would better enable them to gain employment. Uniquely, the community identified for further support was based in proximity to the local hospital and therefore the focus was to create an employment pathway from the community into hospital-based employment. One of Leeds’ biggest economic strengths is the health and medical sector, meaning this sector is ideally placed to help people into reliable and quality jobs, such as roles in Estates and Facilities (where there are staff shortages (May and Askham 2005)). The underpinning rationale and aim of the project was to grow the local economy, to also ensure that people were able to reach their full potential in the city and to address shortfalls in NHS capacity and staffing.

The work resonates theoretically and conceptually with the notion of a health-promoting hospital, or more broadly a settings approach to health promotion which seeks greater levels of social justice and reductions in inequality and exclusion through tackling the social determinants of health. The modus operandi of a hospital is not generally health or health promotion (Woodall and Cross 2021). Green et al. (2019) have argued that many hospitals must re-orientate if they are to be health-promoting organisations, making a transition from curing disease to promoting health, from a narrow concern with patients to including the wider community and from being inward-looking to being outward-looking. It was apparent how the design of this project was attempting to address some of the underpinning tenets of a health-promoting organisation through engaging actively with the wider community and connecting ‘outwards’ by working in joined-up ways with other local providers in order to maximise health (Dooris 2013).

The project consisted of a partnership between local healthcare providers, local government and a third-sector skills provider to deliver information sessions and innovative employability courses aimed at connecting residents living in the community with job opportunities. A six-week employability programme, delivered in the local area, was developed to ensure those from the community were equipped with the knowledge, skills and behaviours to enable them to apply for entry-level roles in the NHS. The core elements of the programme included NHS delivery elements, including customer service/moving and handling, IT skills, confidence building, support sessions in completing application forms and interview skills. Ultimately, the programme was about ensuring people are better placed to successfully apply for jobs at the local hospital than they were before taking part in the programme. The programme was delivered free of charge to those that took part.

This paper focuses on capturing the learning from this employment-based project. Specifically, it aims to provide insight into the process and experience of the conception, commissioning, and delivery of the project, which could help to inform the development of future place-based services which seek to support communities who have high rates of unemployment.

Methodology

Qualitative methodology sought to access expert opinion on the commissioning, design and implementation of the project alongside the views of participants benefitting directly from the project. The design sought to triangulate both professional and lay views on the project to offer a rounded perspective of the project and how it operated.

Evidence hierarchies recognise the value of professional and expert knowledge to generate information for decision-making purposes (Green et al. 2019). Expert knowledge is defined as ‘substantive information on a particular topic that is not widely known by others’ (Martin et al. 2012, p.30). Expert knowledge can be particularly useful in understanding the process and mechanisms of implementing an intervention and hence used here to understand the project (Petticrew and Roberts 2003). While experts are regarded as proving credible sources of information, the use of experts to inform decision-making processes is contentious and has been challenged (Martin et al. 2012). Clearly, understanding service user perspectives is critical in understanding the project, but this was not the focus of this aspect of the evaluation.

After gaining full ethical approval from Leeds Beckett University, individual semi-structured interviews were used to ascertain the depth of information required to fully appreciate the nuances and complexities of the project. The interviews were conducted during the programme itself and the interview schedule (which was adapted slightly for the interviewees depending on their role) covered a range of topics, including what worked well, what were the difficulties, programme fidelity, programme sustainability and perceived programme outcomes. A sample of experts were drawn up in consultation with key service personnel – this included individuals from the hospital, local government and other partner organisations. This approach followed what Patton (2002) describes as ‘critical case sampling’, where critical cases are selected as they offer particularly important insight or knowledge on the issue being studied. Six key respondents who were strategically and operationally responsible for the programme and who represented the hospital, local government and other partner organisations were identified who were able to discuss the conception, commissioning, delivery and strategic oversight as they had been involved in the project for some time.

Interviews were also undertaken with four individuals from the local community who participated in the project plus three managers at the hospital who had worked directly with community residents from the project – either directly line managing the new employees or being closely involved with their recruitment from an NHS perspective. Given the timing of the research and data gathering (during the pandemic), it was challenging to increase the sample size given priorities in the health service. All data gathering was done via telephone or through digital platforms, such as MS Teams.

All interviews were digitally recorded, and field notes taken at the time of the interview. Critical listening was undertaken on the recorded data and thematic summaries were produced to outline cross-cutting issues and areas which would produce future learning for the project. The analytical process followed guidance outlined by Braun and Clarke (2013) in that after a period of data familiarisation, the data were coded for salient issues relating to the aims of the research, codes combined and organised, and from these, more substantive thematic categories produced. The themes were discussed between the research team and initially shared with the programme steering group to refine further and gain a greater ‘sense-check’ of the data.

Findings

This section presents thematic areas derived from the analysis of the data. Where direct quotations have been used, they have been anonymised to protect confidentiality and preserve anonymity.

Organisational and strategic rationale

The project fulfils a number of important organisational and strategic agendas for the hospital and local government. Analysis from key stakeholders suggests seven core aspects of the project.

First, from a health inequalities perspective, the project operates on an understanding that there are tangible links and associations between employment skills and health. Overwhelming evidence consistently shows positive impacts between employment and health, influencing mental and psychosocial well-being and promoting social mobility:

The reason we did this ultimately was to break that cycle of deprivation

Second, a socially inclusive city, which not only draws upon but enhances and develops the skills and talents of its community to strengthen the local economy, is also a central pillar to the work:

[the project is] a means to support individuals who would struggle to apply directly for entry level jobs.

Third, addressing the workforce capacity requirement within the NHS, through employing local people, is a clear underpinning rationale – this is important given that staffing shortages are found in some areas of the hospital such as Estates and Facilities. Recruiting locally overcomes challenges of poor transport links for anti-social shift patterns because the employees can walk to work. Fourth, given the profile of the hospital as one of the largest employers in the city, there was a clear potential to support local communities into meaningful employment and create sustainable services. Fifth, the diversity of hospital staffing is important and contributes to patient satisfaction and health outcomes – patient centred care operates on a number of levels, but includes patients feeling that their cultural diversity is represented in the people they see working in the organisation. Sixth, the retention of NHS staff through ensuring that the expectations of applicants are consistent with the reality of employment is a key feature of the project. Finally, the project has the potential to raise aspirations in the most deprived neighbourhoods through demonstrating how, despite structural barriers, people in communities can be meaningfully and securely employed and contribute productively to the local health service and economy. The project can demystify the organisation as a potential employer to local people.

Partnership working is essential to the programme

The combination of expertise, insight and strengths of the partners to deliver the project was a key mechanism facilitating success. This expertise included an understanding of delivering adult learning courses, an understanding of local context and intimate knowledge of the NHS and the recruitment pathways. Clear communication and shared understanding of what the project is seeking to achieve ensured that the joint ambitions of all constituents of the partnership were met (i.e. employment of individuals and/or the increased confidence and skills of the local community). Despite each organisation seeing a different ‘angle’ on the project (e.g. workforce sustainability, economic growth, inequality reduction, sustainable city, social determinants of health), there was a clear sense of each organisation working effectively to reach desired outcomes and goals.

Monitoring the partnership and how it operates is an important element to ensure that aspects of the project stay on-track – this crucial aspect was often monitored during regular ‘catch-up’ meetings, but also through a more formalised evaluation (vis-à-vis the research produced here). Several interviewees described examples whereby the project had diverted at times from its original vision and aims and some organisations felt that the agenda could sometimes be dominated by one organisation over another, which is linked to how the programme was funded.

Flexible and tailored support is effective but resource intensive

A critical mechanism of success of the project was the flexible and tailored way in which individuals were supported. All key informants interviewed described the myriad of backgrounds and skills of people who had attended awareness and training events. The levels of digital literacy and English language were consistently highlighted as being areas of difference between individuals in the community. This was a significant barrier in completing application forms for employment, as an example:

It was a really longwinded and difficult process so the support they got from us was vital! … to get an entry level job in the hospital is not an easy feat and these people that are entry level learners couldn’t get through the first bit, they couldn’t get the application completed to the right specification.

There was consensus among interviewees about how a tailored and bespoke package of support for individuals was the most effective way to increase confidence-levels and employability skills. The programme helped people to identify their own competencies and recognise their transferable skills and past experiences, often derived from their home countries or unpaid roles, e.g. housework. People started to recognise that the life they had before the UK was relevant and important. While such interventions were rewarding and seemingly garnered positive results, the resource implication for staff was a challenge and was seen to be a significant barrier in expanding and sustaining the programme. This was demonstrated by one interviewee highlighting how they would personally support individuals who could not attend the group sessions:

Some people couldn’t attend the programme but were really keen so they were offered the one to one support.

Working in a bespoke way also enabled expectations to be managed and disappointments, if people were unsuccessful in employment, to be reframed as learning opportunities. Managing those who are unsuccessful in their journey towards employment was therefore just as important as supporting individuals who eventually did gain paid work.

Funding and resource

The funding and resourcing of the project was considered both a strength and a challenge. The funding for the work was described as a ‘jigsaw’, comprising funding streams from various organisations. This included local funding from the council and the use of resources that the council already provides, as well as European funding:

It was really mix and match to be able to go ‘right that is the design now how do I make sure that everyone gets the funding’ and the funding is actually there for this to take place.

Despite the seeming complexity in the funding for the project, the ability to have diverse funding sources means that the project can cover a wide number of areas (including focusing on geographic community and particular age groups). However, the downside is a seemingly precarious arrangement which may be open to instability should any of the funding arrangements be no longer available. There was a sense that current resourcing may not be sufficient to enable a high-quality service or further expansion or growth.

Formative learning

It was clear from the interviewees that there had been significant learning as a consequence of delivering the project. This encompassed the way awareness events were delivered, training provided, and the importance of ‘word of mouth’ in the community. What was striking, was the way that the constituents of the project have reflected on progress to-date and revised and reconfigured their practice accordingly. This suggests a number of things, but primarily the flexible and agile nature of the project to react to community needs and also the ability to critically reflect and reconsider the approach or strategy taken.

While the purpose of the key informant interviews was to focus more generally on learning and distilling good practice, the inevitable impact of Covid was raised. The pandemic meant that the employability programme could not be delivered and also meant the recruitment process changed drastically and will look different going forward. It also perhaps exacerbated and highlighted digital literacy issues and moreover created challenges that could have been resolved more efficiently and easily through face-to-face contact.

Longitudinal outcomes

It was clear that there was evidence of success as a result of the project. This included individuals moving into various employment roles, such as non-clinical NHS roles:

The positives that have come out of this project are immeasurable.

Those individuals from the community who had secured employment spoke positively about the experiences they had and the support they had received. There were also clear examples of greater financial stability as a result of paid employment – this included sickness payments when unwell. Some of those gaining employment had been well mentored and did want to progress through the organisation but sometimes faced some barriers in promotion and development:

nobody wants to remain in the same position forever.

In addition, while most people spoke very highly about the support provided, it was not commensurate with the challenges and difficulties of working in the NHS. Some people did not feel ready or able to manage the healthcare context or internal politics and dynamics:

People come with the training, but the training is, I wouldn’t say false but it’s not realistic.

I think if I wasn’t a really, really, really tough cookie, I don’t think I’d be working there now, because it’s not about the system or the job that you’re doing, it’s about the people that you’re working with … I can get on with anybody, I’m lovely, I’m happy to help anybody, but really you do face a massive brick wall … and it’s all about not letting new people in.

Regardless of whether the project led to direct employment, there was a clear sense that individuals in contact with the project and information sessions would benefit from the experience, whether that be better digital literacy or improved confidence to seek employment elsewhere:

It was a great benefit to me. It’s changed my life for the better, going through that course and others that I know of, so I think it’s a shame if it wasn’t carried on and built on the progress of people that have come through it.

Those participating in the project did indeed yield positive impacts, but often felt somewhat let down at various points. One participant noted that the project had prepared them for registering for an NHS job and had supported them with preparing their CV and aligning this with the job specification. However, when they went for the NHS assessment, there was an IT test which people felt was poorly equipped to manage. The delivery partners responded that to address this, they implemented changes after the first cohort to address the issue, but IT skills continued to be a barrier for many.

A number of participants spoke about the ability of the project to lift aspirations in the community and to provide a pipeline into paid employment. One participant who gained employment discussed how their experience has inspired their oldest daughter (age 18) to study health and social care and how it had encouraged her to be a paramedic. Moreover, others mentioned the significant impact on people’s lives by employing people in the community. Many in the community had been unemployed for some time, but this programme allowed a viable opportunity to secure employment.

It was not clear what longitudinal outcomes had been captured and there is some work pending on how best to do this. That said, some informants did not always feel that there was a consistent ‘feed-back loop’ which would enable learning to take place and outcomes to be assessed routinely. There were some disagreements in whether longitudinal measures were being captured successfully, but a general agreement that measuring outcomes – using various measures of success, not only employment – should be routinely embedded. This may include the use of health measures, social inclusivity measures and analysis of cost-effectiveness.

Evidence required to strengthen credibility

Linked to the collection of robust data to determine long-term effectiveness of the project was the benefit of demonstrating credibility. There were some initial concerns from some managers within the hospital that applicants from the local community were given preferential treatment or may not always be best placed to work in the organisation. One participant quoted a conversation where an NHS Manager had stated:

Why do we want them? They can’t get a job anywhere else

Such attitudes were in no-way reflective of the wider workforce and moreover, some of the stigma associated with the project may have manifested from previous (historical) initiatives that did not prove successful. By developing a robust evidence-base, however, it was apparent that some of these concerns could be challenged more effectively with rigorous data capture and transparency of outcomes.

Discussion

This paper sought to capture learning from an employment-based project that connected opportunities for individuals within an identified area of deprivation to gather skills and experiences that could better enable them to be employed in their local community. In this case, the local hospital. Specifically, the paper offered insight into the process and experience of the conception, commissioning, and delivery of the project. It is anticipated that such findings could help to inform the development of future place-based services which seek to support communities who have high rates of unemployment.

This current study was not designed to determine long-term outcomes from the programme, but it was clear that longitudinal measures of success were critical to longer-term sustainability. Many individuals had gained employment – one of the core purposes of the project – and this had provided a range of positive outcomes. This is critical both for individuals and the wider health sector, given that there are continued shortages in some non-clinical areas of the NHS such as Estates and Facilities and portering (May and Askham 2005) and the fact that the NHS is carrying around 100,000 staff vacancies (Waters 2022). Notwithstanding whether individuals had gained employment, there was a clear sense that engagement with the process offered additional benefits and support. This could include increases in confidence or reconfiguring aspirations for themselves and others. There were, however, some unanticipated outcomes that may not have been originally envisaged. Some individuals felt underprepared for aspects of employment or for job interviews and assessment and such experiences may have been counter-productive to the overall aims of the project.

The evidence exemplifies the benefits of interconnected settings – in this case between the hospital and local community. The settings approach in health promotion, or healthy settings approach, is premised on the notion that investments in health are made in social systems where health is not their primary remit (Dooris 2007). Throughout recent times, settings have been mentioned as an important vehicle for health promoters. Some have said that the settings approach is one of the most successful and ‘top rated’ strategies to emerge from the Ottawa Charter (Torp, Kokko, and Ringsberg 2014) and arguably this is because the settings approach offers a very practical and tangible way to ‘do’ health promotion (Dixey, Woodall, and Lowcock 2013). In order to tackle wider inequalities in health, there is an assumption that this must be done holistically and focus on wider health determinants that may cut across all aspects of individual and community life. The response to this here is to operate in partnership and interconnected ways to achieve optimal health improvement. The settings approach, as noted, is a popular strategy to tackle underlying issues and when settings operate like ‘Russian dolls’ (Dooris 2006, 5), whereby settings situate within and alongside each other to maximise health gains. In applying theory to the empirical findings in the paper, it is clear that the hospital is operating outside of its traditional boundaries by broadening its outreach to a local community area – indeed, it could be argued that it would be more pragmatic for the hospital to recruit outside of the local area but instead chose to support the nearby health and social economy. Dooris (2007, 2009) has welcomed healthy settings initiatives that ‘connect outwards’ which has been observed in this project. Moreover, it has been proposed that settings should also ‘connect upwards’ to also ensure that broader political, economic and social factors are being addressed through political advocacy:

Connecting upwards: A focus on the importance of settings programmes and initiatives working upwards, using advocacy and mediation to ensure action on the underlying determinants of health that may lie outside of their boundaries or immediate remit.

(Dooris 2007, p. 139)

The paper then shows key mechanisms which enabled the project to be successful. Most saliently, partnership working between strategic and operational partners was vital to establishing and delivering the work. While the strategic rationale for engaging with the project differed for the constituent partners, it was clear that the motivations for involvement and support were complementary and together provided mutual benefits. It is well recognised that a common vision or shared goal is a key element in partnership development (Wildridge et al. 2004) but there are other factors. Hermens, Verkooijen, and Koelen (2019) suggest three key elements of successful partnership – these include personal elements, institutional elements and organisational elements. The institutional elements were particularly apparent in the project partnership. Hermens, Verkooijen, and Koelen (2019) describe how the importance of the societal and political contexts in which partnerships operate is important. Partnership can only be maintained when local and national policies are in favour of the partnership’s work and goals. This was clearly observed in this work whereby the political drivers of workforce capacity requirement within the NHS and the desire for economic growth and reductions in inequalities came together to be a key enabler for the project to gather momentum and support. There were, however, findings which suggested some partnership challenges – such challenges are not unusual in partnership working (Woodall and Cross 2021) and can be commonplace. Partnerships often have a very high failure rate and are very difficult to measure and evaluate (Jones and Barry 2011), so understanding why partnerships fail can be difficult to fully understand. This study suggests that tensions caused by deviation from the original vision and aim of the project can be one element that can derail this work, and where power imbalances occur in funding or delivery, this can also cause potential issues. Close monitoring and evaluation of partnerships between organisations remains critical to sustainability and long-term success.

While a broadly ‘standardised’ intervention was provided for the local community to enable a greater likelihood of employment, it was clear from key stakeholders in the project that such a standardised approach was not going to be effective to address all of the needs of those in the community. The project was identified as providing a more bespoke, tailored approach which addressed individual issues as they arose. This approach was particularly effective at identifying key strengths of individuals and transferring those assets into a workplace context. Indeed, asset-based approaches are a popular intervention strategy in health promotion and seen as a legitimate way of addressing health inequalities by empowering people in more disadvantaged communities to use local resources and increase control over health and its determinants (Cassetti et al. 2020).

Building meaningful relationships and understanding individuals’ motives and needs was also important when managing disappointments for those not, in the immediate term, gaining employment. Taking time to debrief and reflect on the reasons why this may have been the case proved to be beneficial for the individuals concerned and perhaps mitigated negative emotions. Such a tailored and individually suited programme yielded particular benefits, but this did raise some concerns in relation to the sustainability and the intensive resource implications of such a strategy. Closer evaluation will need to explore whether the social return on investment provides longer-term dividends for individuals and the community.

The partnership was agile and flexible to change and to adapt to delivery if things were not working as planned. Such agility to respond quickly to concerns was an important factor in the project’s success and in listening to the local community. The impact of covid-19 perhaps re-emphasised the need to keep communication open and to respond quickly when concerns developed. The process of formative learning, though, also ensured that areas of good practice were captured and replicated where possible. Indeed, the need to pay attention to process and context as well as outcomes is increasingly apparent in health promotion interventions. The answer to the simple question ‘does it work?’ is not enough, and evidence is needed in relation to the process as well as outcomes to enable successful replication and transferability (Green et al. 2019). In relation to outcome measures, it was apparent that more was required to capture the impact of the project. Qualitatively, though, it was clear that the project provided tangible skill and employment benefits, but also raised aspirations within the community. Members of the partnership recognised that outcomes must be captured more effectively in order to demonstrate the success of the work.

Conclusion

Meaningful employment is an important constituent of individual and community well-being and is a key social determinant of health (Marmot et al. 2020). Data show that in some deprived areas, access to employment is a challenge and unemployment is therefore high. The corollary to this is that health outcomes are poorer in these communities and inequalities are exacerbated rather than narrowed. This paper has illustrated an approach to connecting local communities with paid employment roles – in this case, the local hospital. The paper has focused on the conception, design and delivery of the programme and has shown the key constituents needed for success. This includes providing a bespoke support and tailored intervention package for individuals and strong partnership working between delivery partners and strategic groups. While the focus of the paper was not on outcomes per se, there were examples of instances where individuals had gained employment and skills, individuals increasing in confidence and evidence of the programme raising aspirations for themselves and others. Future investigation should seek to identify longitudinal outcomes of such an approach and provide a cost-effectiveness analysis showing not only the positive contribution to the local community but also to reductions in health inequalities.

Disclosure statement

No potential conflict of interest was reported by the author(s).