Strategies to encourage people to return to work.

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Health, 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
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Challenges 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

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Developing 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

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Work

• 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

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Worklessness

• 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

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Long-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)

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• Sickness and disability among main threats to
  full and happy life
• Work incapacity most significant impact on
  individual, the family, economy and society.

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Unbundling 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.

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Mental 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)

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Mental 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)

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Limited Correlations
The need to unbundle Sickness, Disability
Incapacity
Illness
Working
Disability
Economically Inactive
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Prevalence 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

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Three year incidence () of symptoms in general
practice(Total and with organic cause) (Kroenke
Mangelsdorff 1989)
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Edinburgh Neurology Study
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IB Recipients - Diagnoses
Incapacity-related benefit recipients by
diagnosis group, November 2003

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UK Incapacity Benefit

• Severe Medical Conditions lt25
• Common Health Problems
• - Mental health problems 44
• - Musculoskeletal conditions 25
• - Cardio-respiratory conditions 10

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Common 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)

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Common health problems
Less severe mental health, musculoskeletal and
cardio-respiratory conditions Limited objective
evidence of disease Largely subjective
complaints Often associated psychosocial issues
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Illness 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

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Long-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.

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Why 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

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Traditional 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

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Limitations 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

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Biopsychosocial Model
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Strengths 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

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Management of common health problems must address
obstacles to recoveryand barriers to (return
to) work
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Interactions
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General Principles

• Rehabilitation cannot be a second stage after
  health care has failed.
• Principles of rehabilitation must be integrated
  into- clinical management- occupational
  management

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Health 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.
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Occupational management

• Common health problems are not a matter for
  health care alone.
• They are equally a matter of occupational
  health

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Timing
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Personal / psychological change

• Individual motivation and effort
• Building capacity
• Shift perceptions, attitudes beliefs
• Change behaviour
• Improve function

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Culture

• The collective attitudes, beliefs and behaviour
  that characterise a particular social group over
  time

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Whither 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!

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• Sickness and incapacity are social rather than
  medical problems

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Shifting Attitudes to Health Work
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Health 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

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PUBLIC 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

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Disaggregating 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

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Ministerial 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

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TFs 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)

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TF 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

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TF 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.

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So 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

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Climate

• 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.

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Keys 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

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UK 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

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Principles 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.

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Contents of CM Programmes

• Cognitive/Educational interventions
• Understanding and Managing
• Pain management
• Confidence building
• General health advice
• Individual and group sessions

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Pathways to Work pilots
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Pathways 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.

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Successful 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

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Condition 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

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GOVERNMENT 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

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A 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

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The Scientific and Conceptual Basis of Incapacity
Benefits
Gordon Waddell and Mansel Aylward
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The 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.

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Professor 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