The Government has published a report assessing several pilot schemes that it launched in 2010 aimed at improving sickness absence management in small and medium-sized enterprises. Nic Paton discusses the key findings.
Lessons learned from the pilot have fed into design of the continuing service (an extension of the pilot to March 2013) to further develop understanding of how to engage.
Will the Fit for Work Service eventually become a nationally rolled out "National Health at Work Service"? Not on the results of the first evaluation of the 11 pilots that have been testing various different models since March 2010.
Even Jim Hillage, the co-author of the Evaluation of the Fit for Work Service pilots: first year report and director of research at the Institute for Employment Studies, is pessimistic that a Fit for Work Service will be "scaleable" in the current economic and financial climate.
"My expectation is that it is unlikely to become a national service. It is probably too expensive and too narrow to fund nationally, so it may also be a question of whether mainstream support can be provided through GPs or some other organisations," he tells Occupational Health magazine.
"I think we are likely to see more work being done with GPs to help encourage them to work more closely with employers to get people back to work more quickly. So that could be a Fit for Work Service, just in another guise."
Hillage adds: "What the pilots have shown is that there is a group of people off work who could be helped back into work if they had access to the right level of support."
The evaluation report, published in March, found that both the volume and profile of those using the service was generally not what was originally expected, with some 6,700 users logged, about 40% less than anticipated. This was despite one pilot, in Leicester, separately reporting its 1,000th referral in March.
However, those who did use the service, both employers and employees, generally found it useful (see box 1). Scepticism and a distrust of the service from GPs remains a significant barrier, the report also found.
OH advice lines report
The evaluation was published alongside an assessment of the free occupational health telephone advice lines for small and medium-sized enterprises (SMEs) piloted by the Government between late 2009 and March 2011. That report, Occupational health advice lines evaluation: final report, revealed high levels of satisfaction, but, again, a lower than expected take-up (see box 2).
Nevertheless, the lessons able to be drawn from both pilots could prove valuable to OH practitioners, argues Dr Sayeed Khan, chief medical adviser to the manufacturers' organisation EEF.
First, on the Fit for Work Service, the take-up sample, in fact, should not be considered too poor in the scheme of things, Khan contends.
"Time and time again with pilots people over-estimate how many clients or sample respondents they are going to get. But I would argue 6,700 is a good base sample and it does seem to be something that has worked well," says Khan.
My expectation is that it is unlikely to become a national service. It is probably too expensive and too narrow to fund nationally."
Institute for Employment Studies
"Another good thing is that it is using the biopsychosocial approach rather than any single model. In terms of illness or people under-performing at work, the actual illness will probably be just one of a number of factors," he adds.
Another positive finding was that two-thirds of the 6,700 users had still been at work (fewer than 30% of users having been the original prime target group of those already off work for between four and 12 weeks) suggesting that early intervention and support were possibly making a difference in terms of keeping people in the workplace, Khan argues.
Concerns for OH
One area of concern, however, was the issue of liaison between the service and OH practitioners.
"I have heard OH people privately complain that what they were saying was being contradicted by the Fit for Work Service. In some cases, Fit for Work [services] do not know a person has already gone to see OH, so there can be an issue of conflict between their own employer service provision and the Fit for Work Service, and that is something that needs to be looked at. Care needs to be taken to ensure there is contact between the Fit for Work Service and the OH service provider," says Khan.
Second, on the occupational health advice lines, the fact that more than 90% of employers found it useful and would recommend it was a "powerful" conclusion, Khan suggests.
"But one thing that was not clear was the qualifications and experience of the call handlers. Are the right people handling the calls? Are they giving the right advice? That does not come out of the report," he says.
"They need to be much cleverer about marketing and raising awareness of the service. Perhaps, for example, they should be talking to banks or accountants, because every small business will have those.
"I think in future it will develop into a premium line type of thing. The other issue with it is that at the moment it is very reactive; it is just responding to problems."
The lack of engagement from GPs with the Fit for Work Service does make it hard to gauge its long-term effectiveness and future, concedes Dr Steve Iley, head of medical services at AXA ICAS.
"But the concept is good, especially around things such as case management and vocational rehabilitation, plus the fact it focuses on the biopsychosocial model.
"What will be nice to see is what happens when it gets a few more people. As a commercial provider, obviously, at one level this could be seen as a threat. But, in reality, I think it will just become another provider in the market.
"In fact, it may even lead to more work for OH because once employers know what OH can do, they may be more encouraged to use it in the future," Iley adds.
Box 1: Key findings of the Fit for Work Service evaluation report
Over the first year, most pilots successfully established a wide-ranging service using a biopsychosocial approach.
The volume and profile of clients were not in line with expectations, with take-up significantly lower than expected.
All services had difficulties securing the volume of referrals expected from GPs and small and medium-sized enterprises, and had little success in pursuing general marketing exercises.
Most clients had multiple needs. The wide-ranging nature of needs provided support for the use of a biopsychosocial case-managed approach.
The evidence suggests that a successful approach to helping sickness absentees back to work includes:
- quick access to a holistic initial assessment;
- ongoing case management to identify latent concerns (often non-medical) and maintain momentum towards a return-to-work goal;
- fast access to physiotherapy or psychotherapy if required;
- facilitating better communication between employee and employer and providing advice for return-to-work options; and
- advice to improve and manage longer-term health conditions.
By the end of March 2011, 6,726 people had taken up the service offered by the pilots, about 40% of the number expected. The main reasons for this were:
- the size of the core client population of long-term sickness absentees may have been over-estimated; and
- difficulties in generating the expected level of referrals from GPs and employers.
Engagement and referrals
In the first year, the most common way of accessing the Fit for Work Service was by self-referral or referral from a GP. A few pilots focused almost exclusively on referrals through GPs, while three had very few direct GP referrals.
Most pilots spent considerable efforts trying to secure referrals from GPs but found it much more difficult than expected to:
- gain access to GPs to explain about the service or interest once access was eventually granted; and
- ensure GPs had a full understanding or sustain interest and ensure that the Fit for Work Service remained a prominent option.
Some large employers with their own occupational health provision reported that they thought the Fit for Work Service was not relevant to them, although others saw its merit of an impartial service offering a wide range of support. A number of case managers said that, in their experience, some employees did not "trust" their occupational health department not to go back to the manager.
Some 62% of those who were supported by the pilot schemes had been discharged by the end of March 2011 and the remainder were either still with the service or were not yet recorded as having left. Just over 10% of those who were initially assessed subsequently failed to engage.
The average length of time people stayed appears to be around four months, although some sickness absentees may have returned to work before they were formally discharged.
Some 74% of absentees who joined one of the pilots in the first year and who were discharged before the end of March 2011 were back at work by the time they left. Around 18% were still off work on sick leave and 8% were unemployed.
Most respondents said that they would not have received the interventions they had without the support of the Fit for Work Service.
Box 2: Occupational health advice lines evaluation: final report
The pilot was successful in targeting SME employers who needed help to manage an employee's health problem in the workplace.
Employers often sought reassurance for the actions they had taken or were about to take, implying that the advice lines service was an important source of confirmation for employers that might be considering a range of options.
The majority of users called with questions about sickness absence, attendance management issues or advice on the fit note. In addition to OH issues, they often presented problems that were multi-faceted, sometimes requiring legal advice.
The service was highly valued by users and appeared to be addressing a genuine desire for professional OH support among SMEs. The overwhelming majority (more than 90%) found it useful and stated they would recommend it to others.
Employers particularly liked the fact that the service provided fast access to professional advice. Users were attracted to the service because it was free, appeared to be a one-stop shop and provided government-sponsored support through the NHS brand.
The volume of calls was below expectation. This was probably an indication of the difficulty in promoting a service to employers that is needed only when the employer faces an employee health problem. For very small businesses, this may happen relatively infrequently, although the impact at that point may be significant. More time is necessary to increase the visibility of the service among SMEs and refine marketing activities to encourage take-up.