Title: Strategies to encourage people to return to work.
1Health, Work and Well-being supporting workers
and Occupational Health Physicians
- Strategies to encourage people to return to work.
- Professor Mansel Aylward CB MD FFOM FRCP
- Director, UnumProvident Centre for Psychosocial
- and Disability Research, Cardiff University
-
- Chair, Wales Centre for Health
- AylwardM_at_cardiff.ac.uk
- www.cf.ac.uk/psych/cpdr/index.html
Manchester Medicolegal Course in Occupational
Health 8th February, 2006
2Challenges for Occupational Health Promoting a
Life in Work
- Work and Worklessness
- Illness, Disability and (in)Capacity for Work
- Illness behaviour
- Obstacles to recovery barriers to (return to)
work - Absence the burden on business and society
- Support into Work
3Developing successful strategies some key
elements
- Unbundling Sickness, Disability, Work and Health
- Recognition Sickness and Incapacity are largely
social not medical problems - Moving Medical model to an integrated
bio-psycho-social approach - Shifting Attitudes to health and work (culture
change) - Adapting New concepts for intervention and
rehabilitation - Integrating Getting all stakeholders on side
4Work
- Benefits
- Symptom management
- Recovery and Rehabilitation
- Self-esteem and Confidence
- Social identity and role
- Promoting activities and participation
- Social inclusions and functioning
- Quality of Life
5Worklessness
- Risks and Harm
- Loss of fitness
- Physical and mental determination
- Psychological distress and depression
- Loss of work-related habits
- Increased suicide and mortality
- Social exclusion
- Poverty
6Long-term worklessness is one of the greatest
known risks to public health
- Health Risk smoking 10 packs of cigarettes per
day (Ross 1995) - Suicide in young men gt 6 months out of work is
increased 40 x (Wessely, 2004) - Suicide rate in general increased 6x in
longer-term worklessness (Bartley et al, 2005) - Health risk and life expectancy greater than many
killer diseases (Waddell Aylward, 2005) - Greater risk than most dangerous jobs
(construction/North Sea)
7- Sickness and disability among main threats to
full and happy life - Work incapacity most significant impact on
individual, the family, economy and society.
8Unbundling illness, sickness, disability and
(in)capacity for work
- Disease objective, medically diagnosed,
pathology - Illness subjective feeling of being unwell
- Sickness social status accorded to the ill
person by society - Disability limitation of activities/ restriction
of participation - Impairment demonstrable deviation / loss of
structure of function - Incapacity inability to work associated with
sickness or disability - The terms are not synonymous there is no
linear causal chain.
9Mental Impairment Challenges in Understanding
and Assessment
- The subjective nature symptoms, limitations,
clinical assessment and diagnosis - Self-reported symptoms assuming underlying
psychiatric impairment (tautology) - Mental impairment specifically and solely
abnormalities of mental function demonstrated,
assessed and evaluated by objective observer
(Mendelson 2004)
10Mental Impairment Challenges in Understanding
and Assessment
- Importance of distinguishing mental impairments
from subjective descriptions of symptoms /
limitations - Clinical Guidelines to the Rating of Psychiatric
Impairment (Epstein et al 1998) (Intelligence,
Thinking, Perception, Judgement, Mood, Behaviour)
11Limited Correlations
The need to unbundle Sickness, Disability
Incapacity
Illness
Working
Disability
Economically Inactive
12Prevalence of subjective health complaints in the
last 30 days in Nordic adults (after, Eriksen et
al, 1998)
- Any complaints Substantial complaints
- Men Women Men Women
- Tiredness 46 56 17 26
- Worry 38 39 13 15
- Depressed 22 28 5 10
- Headache 37 51 4 9
- Neck pain 27 41 9 17
- Arm/shoulder pain 28 38 12 17
- Low back pain 32 37 13 16
-
- gt50 reported two or more symptoms
13Three year incidence () of symptoms in general
practice(Total and with organic cause) (Kroenke
Mangelsdorff 1989)
14Edinburgh Neurology Study
15IB Recipients - Diagnoses
Incapacity-related benefit recipients by
diagnosis group, November 2003
16UK Incapacity Benefit
- Severe Medical Conditions lt25
- Common Health Problems
- - Mental health problems 44
- - Musculoskeletal conditions 25
- - Cardio-respiratory conditions 10
17Common health problems
- Subjective health complaints (Ursin 1997)
- symptoms - self-reported
- Unexplained medical symptoms
- (Page Wessley 2003)
- limited objective evidence of disease, damage or
impairment - Regional pain disorders (Hadler 2001)
- defining feature is regional symptoms (low back,
upper limb, neck etc)
18Common health problems
Less severe mental health, musculoskeletal and
cardio-respiratory conditions Limited objective
evidence of disease Largely subjective
complaints Often associated psychosocial issues
19Illness Behaviour What ill people say and do
that express and communicate their feelings of
being unwell
- Not solely dependent on the underlying health
condition (the limited correlation) - People with similar illnesses may or may not be
incapacitated (Nordic adults) - Roles of attitudes and beliefs, emotions and
coping, motivation and effort - The social context and culture
20Long-term incapacity is not inevitable
- High prevalence in normal population
- Most acute episodes settle quickly most people
remain at work or return to work - There is no permanent impairment
- Only about 1 go on to long-term incapacity
- Essentially people with manageable health
problems, given the right opportunities, support
encouragement.
21Why do some people not recover as expected?
- Bio-psycho-social factors may aggravate and
perpetuate disability - They may also act as obstacles to recovery
barriers to return to work
22Traditional Concept of Rehabilitation
- Secondary intervention - after health care -
separate from health care - Address permanent impairment
- Restore function (within limitations)
- Job placement
- Essentially a medical intervention on person
23Limitations of the Biomedical Model for Common
Health Problems
- Limited evidence of objective pathology or
permanent impairment - Limited correlation physical impairment /
- disability / incapacity for work
- Fails to address psychosocial issues
- Treatment ineffective for vocational outcomes
24Biopsychosocial Model
25Strengths of BPS Model
- Provides a framework for disability and
rehabilitation - Places health condition/disability in
personal/social context - Allows for interactions between person and
environment - Addresses personal/psychological issues.
- Applicable to wide range of health problems
26Management of common health problems must address
obstacles to recoveryand barriers to (return
to) work
27Interactions
28General Principles
- Rehabilitation cannot be a second stage after
health care has failed. - Principles of rehabilitation must be integrated
into- clinical management- occupational
management
29Health care for common health problems
Symptomatic relief AND restoration of
function Every health professional who treats
common health problems should be interested in
rehabilitation and occupational outcomes.
30Occupational management
- Common health problems are not a matter for
health care alone. - They are equally a matter of occupational
health
31Timing
32Personal / psychological change
- Individual motivation and effort
- Building capacity
- Shift perceptions, attitudes beliefs
- Change behaviour
- Improve function
33Culture
- The collective attitudes, beliefs and behaviour
that characterise a particular social group over
time
34Whither Health Care?
- The visit to a health professional
- beware iatrogenesis
- what is said can undo what is done
- More and better health care is not the answer
- Health care needs to work to a new integrated
paradigm - work with employer and worker
- use fit notes instead of sick notes!
35- Sickness and incapacity are social rather than
medical problems
36Shifting Attitudes to Health Work
37Health at Work
- The key idea is that work is healthy
- The workplace environment for promoting health
controlling ill health - Anti-discrimination policy
- Health and Safety
- Occupational health / VR
- Absence Management
- A public health issue
38PUBLIC SECTOR ABSENCE
- Comparative surveys average recorded absence in
public sector higher than private sector - Comparing like with like?
- similar operations show no higher absence in
public sector (ie. Call Centres) - public/civil servicebroadly typical of large
private firms. - In all countries absence in health service is
high - Public sector absence same kind of variation as
private sector
39Disaggregating Absence
- More pronounced among junior grades
- Women take more sickness absence than men
- Older men average more sickness absence (? health
related) - Civil Service
- higher SA in front-line services
- related to numbers of junior staff.
- Public Sector Long-term SA rates but lower
self-certified SA
40Ministerial Task Force and Report on Managing
Sickness Absence
- Managing SA is not rocket science
- TF concluded 3 fundamental systems
- 1. Boards and Senior Management
- a principal function
- install strategies
- progress report (efficiency reviews/performance
partnerships) - 2. MIS
- timely data, monitor absence, take action
- HR to ensure procedures adhered to
41TFs Recommendations(fundamental systems)
- 3. HR management systems
- managers to receive training in systems and
skills - case management referral and RTW discussions
- integration of absence and performance management
(a key lesson from successful private sector
practice)
42TF Recommendations
- SHORT TERM ABSENCE
- checks for persistent short term absences
- involving OH for absence above certain number of
days in 12 month period - daily phone calls/unexpected short term sickness
- Monday/Friday checks
- Challenge more than 5 days absence
- Flexibility around special leave work/life
balance
43TF Recommendations
- LONG TERM ABSENCE
- Collate and analyse literature on sickness
causes - job design
- ergonomics
- flexibility to personal/motivational problems
- Explore non-GP OH services
- Intensive study of LTA (less than full pay)
cases - RTW potential
- contract termination
- HSE in partnership with public sector on
ill-health prevention.
44So What? Lessons Learned
- Productivity and Non-attendance (presenteeism,
turnover, low morale) are symptoms of wider
organisational problems. - Treating symptoms and not the underlying causes
wont improve quality of working life or business
performance
45Climate
- Moderated by leadership, culture, work
organisation, openness, communication, etc - Line Managers key the prism through whom
climate is perceived by employees. - Promote Climate where people allowed to be well.
46Keys to health and productivity
- Good data, trend analysis monitoring
- Role clarity (line, HR, Occ Health, employees)
- Differentiate presenteeism, short-term long
term absence - Intervene early/proactive rehabilitation
- Promote the healthy workplace
- Positive job design good line management
47UK Government Pathways to Work Initiative
- Return to Work Payment
- 40-120 per week
- Mandatory Work-Focused Interviews (Case Managers)
- New Condition-Management Programmes
- (focus m/s, Mental Health Cardiorespiratory)
- - helping people to understand and manage their
condition - - using CBT and related interventions
48Principles of Condition Management
- Voluntary option routed through the PA (Case
Managers) - Cognitive/educational interventions common to all
conditions - Evidence based
- Tailored to individual needs biopsychosocial
approach - Case-managed by CMP in close liaison with PA
- Goals owned not imposed.
49Contents of CM Programmes
- Cognitive/Educational interventions
- Understanding and Managing
- Pain management
- Confidence building
- General health advice
- Individual and group sessions
50Pathways to Work pilots
51Pathways to Work pilots
- 6-800 new job entries / month in Pathways areas
- On a national basis, that would be equivalent to
helping 100,000 IB recipients into work each
year.
52Successful Strategies
- Practical Elements of Condition Management
- Address the main health conditions
- Clear work focus, vocational goals, outcome
measures - Address biological, psychosocial and social
components - Address individuals obstacles to RTW
- Increase activity and restore function
- Shift beliefs and behaviour using CBT (talking
therapies) - Working partnership with Personal Advisors
53Condition Management Successful Strategies
- Make sense of your condition
- Overcome stress and anxiety
- Learn to be assertive
- Promote emotional / physical wellbeing
- Living with fatigue
- Living with pain
- 49 patients have primary and further 39
secondary mental illness diagnosis
54GOVERNMENT GREEN PAPERA new deal for Welfare
Empowering people to work
- Aspiration Employment rate 80 working
population - Reduce By 1 million the number on IB
- Numbers leaving work place due to illness
- New Employment and Support Allowance
- Allowing payments to most severely disabled
people - Transforming the PCA (focus on mental health)
- Conditionality Work Related Interviews and
Action Plans
55A new deal for welfare Empowering people to work
- Supporting GPs
- Improving access to good-quality Occupational
Health Support - Facilitate better absence management
- Pathways to Work extending provision across
country by 2008
56The Scientific and Conceptual Basis of Incapacity
Benefits
Gordon Waddell and Mansel Aylward
57The vision - Changing the world
Changing the culture of health, sickness,
disability, incapacity and work.
- General public / society
- Workers
- Health Professionals
- Employers
- Government
- Not just a matter of economics and business
- efficiency it is about health at work
- and fulfilling potential.
58Professor Mansel Aylward CB
Contact Email AylwardM_at_Cardiff.ac.uk
Website http//www.cf.ac.uk/psych/cpdr/index.ht
ml http//www.wch.wales.nhs.uk