September 2011

Enshrining the ability to work in the new NHS

By Steve Boorman

1. Introduction The Governments response to Working For A Healthier Tomorrow, Dame Carol Blacks 2007 review of the health of Britains working age population, acknowledged that keeping people well and in work had the obvious benefits of protection against financial hardship; promoting a better quality of life; and unlocking peoples potential. It also noted that being out of work can exacerbate physical and mental health problems and increase the chance of social exclusion.i The report at the time estimated the costs of working-age ill-health to be around 100 billion every year a burden shared by employers, communities and the taxpayer. Approximately 150 million working days are lost each year to sickness absence.ii As part of the governments response, The NHS Staff Health and Well-being Review was commissioned two years later. Led by Dr Steve Boorman, it found that improved attendance by NHS staff would release an annual direct cost saving of 555 million funds which would then be available for investment in patient care. The review also highlighted that improved NHS staff health and well-being was associated with better patient outcomes, and improved financial and regulatory performance.iii Earlier this year, the Department of Work and Pensions (DWP) launched a review into absence lead by Dame Carol Black and the British Chambers of Commerces David Frost. Commenting at the time, Minister for Welfare Reform Lord Freud stated: Too many people, through no fault of their own, have fallen on to a life on benefits because of the failures in the sickness absence system. This isnt fair to the taxpayer but most of all it isnt fair to the individual. We all have a stake in reducing sickness absence, but its not clear who is best placed to take responsibility for this change.iv Jointly sponsored by the Department for Work and Pensions and the Department for Business Innovation and Skills, this review is expected to report back later this year. However, there are still questions over how the NHS (and Department of Health) can best support people to stay in or return to work especially given the sweeping reforms being proposed by the Health and Social Care Bill. GP-led consortia (now clinical commissioning groups), health and wellbeing boards, the new outcomes framework, clinical senates, the NHS Commissioning Board how will these bodies address Lord Freuds question on reducing sickness absence? How will they best link up with employers in supporting workplace health or back-to-work services?

2. The role of local authorities and the outcomes framework While aspects of the Health and Social Care Bill faced concerted opposition from some quarters, the proposed Health and Wellbeing Boards seem to have received widespread support. With membership including the Director of Public Health, representatives from GP consortia / clinical commissioning groups, and local councillors, they have the potential to fulfil a crucial coordinating role in terms of promoting joined-up services to keep people fit for work and prevent them from falling through the gaps.

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The Department of Health published a policy statement in July 2011 following the consultation on the Public Health Outcomes Framework. Healthy Lives, Healthy People: Update and way forward reiterated the Governments commitment to a reformed health system where local authorities take new responsibilities for public health to develop holistic solutions to health and wellbeing across a full range of local services (listing employment alongside health, social care, housing, leisure, planning and transport).v Local authorities have an in-depth understanding of the public health and care needs of their populations, but too often they havent had the right systems in place to work with the local NHS to get the best health and wellbeing for their people.vi Health Secretary Andrew Lansley Lansleys comments are all too true. Current approaches suffer from fragmentation, with individuals being advised by a number of different agencies and organisations that are poorly coordinated and lack a consistent focus on improving opportunities for them to remain in or access work. Integration between local GPs, secondary care, back to work services such as Jobcentre Plus or private providers under the Work Programme is vital to ensure people receive the support they need at the right time either to help them stay or return to work if they are ill. Early intervention on issues such as mental health and musculoskeletal disorders (MSDs) has been proven to mitigate against longer-term ill-health which not only benefits the individual but also saves money for employers, reduces government spending on benefits, and boosts the wider economy. As such, a good Joint Strategic Needs Assessment and subsequent Joint Health and Wellbeing Strategy should include employment as a wider determinant of public health to drive partnership working and promote better commissioning. This could potentially build on existing Fit for Work pilot schemes or see them adopted across the country. It was also reassuring to see employment included within the Outcomes Framework published by the Department of Health in December last year. Domain two of the framework, Enhancing quality of life for people with long-term conditions includes employment under improving functional ability in people with long-term conditions, and enhancing quality of life for people with mental illness.vii A recent ComRes survey of MPs, published in Total Politics magazine, also showed that the vast majority (98 per cent) believed that helping people with long-term conditions stay in or return to work, where their health allows, is an outcome that the NHS should work towards achieving.viii At the same time, and especially during a period of budget pressures, there is a real risk that the performance of local authorities will vary considerably without adequate support and guidance from national bodies. Local authorities must ensure there is proper coordination between the NHS and employment services, such as Jobcentre Plus, and make full use of their influence over wider determinants of health to improve outcomes. The Government must develop national guidance to ensure local authorities, including health and wellbeing early implementers, address employment as part of a Joint Strategic Needs Assessment.

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3. Commissioning groups, patient involvement and accountability While NHS organisations already have a duty of care to their own staff, how commissioning groups and local authorities support the health and wellbeing of the wider community is of course equally important. The accountability of the new structures under the Health and Social Care Bill was one issue that has been closely scrutinised, both in the initial consultation period and in the subsequent pause and review by the NHS Future Forum. One example of this was the relationship between Health and Wellbeing Boards and clinical commissioning groups. Many felt that the Boards have the potential to be powerful co-ordinating bodies, with the freedom to develop Health and Wellbeing Strategies that could address issues such as health and work which have always risked falling through the gaps between DH and DWP. However, there were questions as to the extent that commissioning groups would need to act on the Health and Wellbeing Strategies that would be produced. Commissioning groups initially needed only to have regard to the strategies. Would this have been enough to ensure that health and work is adequately addressed in commissioning and service design? The revised Bill may well have addressed this issue, as it would seek to require commissioning groups to consult with the Health and Wellbeing Board on whether the Health and Wellbeing Strategy was being taken into account as part of its commissioning plans. The revised Bill aims to further strength this process, and there is now the expectation this would involve an ongoing dialogue to produce a commissioning plan. The Health and Wellbeing Boards will be expected to also refer their views to the NHS Commissioning Board. This framework has the potential to help deliver real change on the ground in terms of promoting joined-up services to help keep people in, or return them to work. This could then be supported by further guidance around best practice on the development of Health and Wellbeing Strategies which promote employment including that Health and Wellbeing Boards should consult with appropriate specialists, as well as public and occupational health professionals to ensure services are appropriately configured to help support employers, employees and jobseekers at the earliest opportunity. Clinical commissioning groups should have a duty to help support people remain in, or return to work through commissioning decisions and integrated service design. The performance monitoring of clinical commissioning groups should include their success in helping patients back to work under the Outcomes Framework.

4. GPs and employers One of the recommendations of Dame Carol Blacks review was the implementation of a Fit Note, rather than the Sick Note. Rolled-out in April 2010, this aimed to encourage GPs to look at what work a patient might be able to do, rather than simply sign them off as totally unfit to work. Earlier this year, the Department of Work and Pensions (DWP) published the findings of a study into attitudes of GPs to patients health and work.ix It showed that, whilst the majority reported positive impacts of the fit note on the quality of consultations and outcomes for patients, 38 per cent reported it had made no change to their practice.

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There were some variations between countries. For example, 19 per cent of GPs in Wales had received health and work training within the past 12 months compared with 10 per cent of GPs in England. GPs in England reported greater agreement with the statement The fit note has improved the quality of my discussions with patients about return to work than GPs in Wales. There was also evidence that GPs in England were more in agreement that Staying in or returning to work is an important indicator of success in the clinical management of people of working age. Perhaps what is more concerning was the finding that a third of GPs completely disagreed with statements that there are good services locally to which they can refer patients for advice or support about a return to work. Scottish GPs however reported better levels of service provision. At the same time, organisations such as Crohn's and Colitis UK have voiced concern that too few fit notes are making full use of the may be fit for work section, to help tell employers about changes they can make to help people work. Many are also still calling for the adoption of the electronic version of the fit note a proposal which was less readily embraced by GPs which would enable more comprehensive data collection to improve our understanding of the populations health needs and target appropriate interventions. Some have also argued this could help avoid the problem where employers are unable to read GP guidance on workplace adjustment, such as such as on reduced hours or non-manual work. The Government must improve the capacity of local employment services to ensure GPs are fully supported to help patients remain in, or return to work. The Allied Health Professional Assessment of Fitness to Work should be rolled out in 2012/13, following a successful pilot phase.

5. Occupational health and NHS Plus If the Government is looking to improve back to work services, it is crucial that GPs are kept informed and that there is continued backing for the National Education Programme for GPs on health and work, as well as the online and workshop-based GP training sponsored by DWP with and RCGP and the Faculty of Occupational Medicine. At the same time, local Jobcentre Plus services need to ensure they routinely liaise with healthcare professionals, fast-track referral to occupational health services and support employer check-lists to ensure they are prepared to make reasonable adjustments where appropriate. For example, a Work Charterx developed by the Arthritis and Musculoskeletal Alliance (ARMA), and supported by organisations including NHS Employers, the Royal College of Nursing, and the Chartered Society of Physiotherapy, called on employers to: Comply with musculoskeletal Health and Safety Regulations, and relevant best practice, to prevent work-related MSDs, to facilitate early reporting of symptoms, and to promote access to effective treatment; Train managers to help prevent MSDs occurring in the workplace and highlight the importance of intervening early to support job retention as a way of reducing the risk of long-term sick leave; Offer flexible working arrangements to accommodate the fluctuating nature of some MSDs, and the need for time off to attend routine and emergency medical appointments;

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Facilitate contact with appropriate health professionals e.g. physiotherapists or occupational health nurses and therapists once their employee notifies them of their condition in order to develop a work plan and pain management programme (when required) that fully supports participation in work; and Consult and engage with employees and their representatives to develop positive employment practices.

This could of course be adapted for mental health or other fluctuating conditions such as MS. The final report from DWP on Worklessness Co-design, published in June 2011, noted that the Department is committed to encouraging Work Programme providers to work with strategic partners including local authorities to understand the needs of individuals wherever they live and to develop solutions to local problems.xi Given the scale of the proposed Work Programme, this must certainly include local commissioning groups if they are to effectively interface between local authorities and commissioning groups. Again, the proposed Health and Wellbeing Boards could play an important co-ordinating role here. The NHS Health and Wellbeing Improvement Frameworkxii set out a re-alignment of occupational health services to: Provide services to prevent staff becoming ill or injured at work; Actively promote health and wellbeing in the workplace; and Maximise access to and retention of work through timely rehabilitation services.

It argued that all NHS services must work towards quality accreditation standards based on the Faculty of Occupational Medicines SEQOHS (Safe Effective Quality Occupational Health Service) standard, and be ready to do so by March 2012. This would include an additional domain focused on the particular needs of NHS staff. It suggested that consideration should be given to piloting the appointment of occupational health professionals to a number of local public health teams where they could take lead responsibility for advising on occupational health matters. The framework also set out a minimum specification based on six core services: Prevention of ill health caused or exacerbated by work. Timely intervention easy and early treatment for the main causes of sickness absence in the NHS. Rehabilitation to help staff stay at work or return to work after illness. Health assessments for work to help manage attendance, retirement and related matters. Promotion of health and well-being using work as a means to improve health and well-being and using the workplace to promote health. Teaching and training encouraging staff and managers to support staff health and well-being.

Other resources such as the Health at Work advice linexiii and the Workplace Wellbeing Toolxiv, provided with Business Link, are also welcome but, given the need for meeting the challenge of releasing 20 billion of efficiency savings in the NHS by 2014, and the findings of the GP survey above, many would argue that organisations such as NHS Plus could play a greater role in providing outsourced occupational health services to businesses in addition to screening and advice.

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Good quality and well-developed NHS occupational health services should support primary and secondary care through providing advice on improving clinical services that include work as a positive clinical outcome. Working for a Healthier Tomorrow envisioned an expanded role for occupational health within a broader collaborative and multidisciplinary service. It argued that occupational health should be brought into the mainstream of healthcare provision to address a wider remit and embrace closer working with public health, general practice and vocational rehabilitation. The NHS Health and Wellbeing Improvement Framework should be promoted as a model for occupational health services. Jobcentre Plus services need to ensure they routinely liaise with healthcare professionals, fast-track referral to occupational health services and support employer check-lists to ensure reasonable adjustments.

6. Prevention While the Boorman Review recommended that there should be consistent access to early and effective interventions for common musculoskeletal and mental health problems in all NHS Trusts (as they are the major causes of ill-health among NHS staff) prevention is also a key part of the approach to making cost savings. The Review recommended that all NHS Trusts develop and implement strategies for actively improving the health and well-being of their workforce, and particularly for tackling the major health and lifestyle issues that affect their staff and the wider population. It argued that staff health and well-being priorities need to be aligned with the wider public health priorities of increasing exercise this is still true today. Action that could be taken, within the NHS (but also more widely by other employers) might include steps that are currently advocated by initiatives like Change4Lifexv, such as: A healthy choices of food in their restaurants; Ensuring staff have access to smoking cessation clinics; Support to achieve and maintain a healthy weight; Strategies to reduce harmful drinking; and Active travel strategies to encourage and incentivise staff to walk or cycle to work. With the advent of a new raft of bodies responsible for delivering and shaping services (commissioning consortia groups, Local Authorities, local health and well being boards and clinical senates), a co-ordinated approach must be established to ensure prevention doesnt fall through the cracks between bodies. Public Health Directors within Local Authorities will have the lead for public health, so they must be educated on the Boorman Review conclusions.

7. Measuring success One question is exactly how progress against these Outcome Frameworks will be measured on the ground. While employment levels are an indicator in themselves, they will not drill down into the detail of whether best practice is being adopted by local authorities and health

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services, and might not register the levels of sickness absence among people who may be considered employable but are not currently at work. The NHS Health and Wellbeing Improvement Framework, published in July 2011, listed a number of key metrics for local monitoring, such as: Sickness absence percent and incidence; Incidence of ill-health retirement; Staff turnover; Managerial interest in health and well-being; and Adequacy of adjustments at work for long-standing illness/disability.

Is this something which could potentially be rolled-out to employers more widely? The framework recommended that local authorities and the new Health and Wellbeing Boards could act as a locus for workplace health. More specifically for the NHS, the framework also recommended that the Continuous Quality Improvement Network (CQIN) should reward organisations that deliver high levels of health and wellbeing. Could employment be embedded further in the NHS however? Within the NHS, the Boorman Review argued that staff health and well-being should feature in other board assurance and performance management frameworks, with proper monitoring of the implementation of NICE and other relevant guidance. There is an opportunity here for the Care Quality Commission to use its increasingly sophisticated monitoring systems to encourage Trusts to prioritise staff health and wellbeing and good occupational health, given the links to improved patient outcomes as well as organisational productivity and efficiency. National Institute for Health and Clinical Excellence (NICE) guidelines on physical activity and smoking clearly document scope for improvement and there is evidence that these are cost effective to follow. NICE has also published a list of proposed Quality Standardsxvi, but to what extent could these address a persons ability to work? Is there scope for a crosscutting standard that addresses employment as part of health and wellbeing, potentially building on existing guidance on managing long-term or recurring sickness absence and incapacity? More broadly, other initiatives such as Business in The Communitys Well Work framework and The Wellbeing Charter propose metric frameworks to monitor performance, but are yet to be widely adopted. The Care Quality Commission must have responsibility for ensuring Trusts prioritise staff health and wellbeing and good occupational health.

8. Access to appropriate interventions Of course, along with the range of proposed reforms to the NHS structure, this year also saw the Government publish its response to the consultation on value-based pricing.xvii It noted that giving weight to treatments that provided wider societal benefits such as impacts on carers, and allowing patients to return to work was widely supported.

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The Government announced that it was planning a programme of research to determine weightings that accurately reflect the full value of new products to society. Commenting at the time, Health Secretary Andrew Lansley said: It is vital that doctors are able to prescribe medicines that they think will benefit their patients. They must be able to focus on what matters most achieving the best health outcomes for their patient. Even if NICE looks at employment issues, there have often been questions around how national guidance is implemented. For example, a 2009 report by the Arthritis and Musculoskeletal Alliance highlighted poor implementation of the Governments 2006 Musculoskeletal Services Frameworkxviii, while a Kings Fund report on rheumatoid arthritis in 2009 found that patients and professionals perceive an unacceptably wide variation in the level and quality of care currently available. This is despite the fact that a National Audit Office report showed that one third of people with rheumatoid arthritis will have stopped working within two years of symptom onset, and called for earlier intervention to help people maintain their mobility and independence, and decrease work-related disability.xix Organisations such as the Chartered Society of Physiotherapy are among those campaigning for improved access to services, including for people with disabilities or those living in isolated areas. While the HealthWatch scheme could potentially play a role in preventing postcode lotteries, this will also depend on sufficient support and guidance for local groups from the national organisation in how to effectively engage with local authorities and commissioning groups. The Government must ensure local HealthWatch groups are adequately supported to help build a national picture of access to treatment and reduce unacceptable variations.

9. Conclusion In conclusion, this is a crucial time for the health and work debate. A huge amount of progress has been made over the past ten years to show the benefits to patients, employers and society through better integrated care and service provision by improving rehabilitation and access to work. We have a great opportunity to ensure the proposed changes to the NHS enable a muchneeded coordinated approach to health, work and wellbeing involving dialogue between employers, employees, health professionals, local authorities and employment services. At the same time, the Government needs to provide appropriate support and guidance to local bodies to allow them to make the most of this opportunity. With local authorities facing in-year budget cuts, a comprehensive health and wellbeing strategy might be seen as a nice-to-have, rather than something which can save an organisation such as the NHS hundreds of millions of pounds every year. How initiatives such as the forthcoming Sickness Absence Review will work with these reforms remain to be seen, but there is still a huge amount of work to do to make sure that the fantastic progress to date on health and work is not lost within the significant reforms within DH, DWP and across government. This must remain at the forefront of policymaking if we are to start bringing down 100 billion cost of working-age ill-health.

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Further reading
i

NHS Employers, NHS Wellbeing at Work Department of Health, Healthy Staff, Better Care for Patients Occupational Health Service, Standards for Accreditation Charted Society of Physiotherapy, Campaigns NICE, Managing long-term sickness absence and incapacity for work

www.dwp.gov.uk/docs/hwwb-improving-health-and-work-changing-lives.pdf www.dwp.gov.uk/docs/hwwb-working-for-a-healthier-tomorrow.pdf ii www.dwp.gov.uk/newsroom/press-releases/2011/feb-2011/dwp022-11.shtml iii www.nhshealthandwellbeing.org/pdfs/NHS%20Staff%20H&WB%20Review%20Final%20Report%20VFinal%2020-11-09.pdf iv www.dwp.gov.uk/newsroom/press-releases/2011/feb-2011/dwp022-11.shtml v www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_129334.pdf vi healthandcare.dh.gov.uk/1m-to-support-health-and-wellbeing-boards vii www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_123138.pdf viii ComRes Parliamentary Panel Survey (May 2011) ix research.dwp.gov.uk/asd/asd5/rports2011-2012/rrep733.pdf x www.arma.uk.net/pdfs/ARMA%20work%20charter%20FINAL.pdf xi www.dwp.gov.uk/docs/dwp-worklessness-codesign-final-report.pdf xii www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_128814.pdf xiii www.health4work.nhs.uk/ xiv www.businesslink.gov.uk/bdotg/action/detail?itemId=1084516235&type=PIP&furlname=wwt&furlparam=wwt xv www.nhs.uk/change4life/Pages/change-for-life.aspx xvi www.nice.org.uk/media/CCD/A8/NQBQSProposedLibraryTopics.pdf xvii www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_128404.pdf xviii www.arma.uk.net/pdfs/MSF%20Review_FINAL1.pdf xix www.nao.org.uk//idoc.ashx?docId=3884f599-9c81-4976-aa4b-4ebebbf2dba3&version=-1