Returning long-term sick to work

With the Government keen to cut welfare spending, could this be the time for OH to get involved with its new Work Programme? Nic Paton reports.

Even before the outcome of the Comprehensive Spending Review last month, we knew that the next few years were going to be tough. Since it was elected in May, the coalition Government, with Chancellor George Osborne in the vanguard, has made it clear that the public purse can no longer continue as it is – and in particular that the bill for welfare and benefits can no longer be sustained.

Those on long-term sickness benefits, such as incapacity benefit, severe disablement allowance or (from 2008 when it replaced existing benefits) employment and support allowance (ESA), have been a particular target for Osborne as part of his aim to reduce the UK’s welfare bill by £15 billion. In September, in an interview with the BBC, he singled out those who made it a “lifestyle choice to just sit on out-of-work benefits” as being an important target.

Similarly, work and pensions secretary Iain Duncan Smith has made no secret of his firm belief that the only realistic way to cut the welfare bill will be by ­encouraging long-term incapacity and ESA benefits claimants to receive training to help them return to employment.

The Government has said that, from next year, it will start a full-scale retesting of ­incapacity benefits claimants as well as bringing in a new “Work Programme”, which employment minister Chris Grayling says will “ensure that long-term unemployed people, and others who need it, have tailored support to move them into sustained work”.

For occupational health practitioners, this focus on getting the long-term sick back into work is potentially something of a dilemma. On the one hand, few would argue that if you can work in some shape or form, then being in employment will generally be better for your health, finances and self-esteem than not working. Similarly, the raison d’être of occupational health in many respects is its expertise in case managing and rehabilitating people who are ill or injured in a productive workplace setting, giving it a golden opportunity to place itself at the heart of what could be a major refocusing on how we work and attitudes to health and work.

Employer commitment

On the other hand, in these cash-strapped times, it is not clear if employers are going to be prepared to make the expensive and time-consuming commitment to support workers with challenging health needs into jobs, or even if the jobs will be there for them to come into.

Moreover, for a relatively small profession that has its work cut out handling the existing health, wellbeing and health and safety priorities of an ageing workforce, there is the question of whether or not OH would have the capacity or resources to take on the extra burden of consistently having to manage large cohorts of workers with complex physical or emotional health needs, with all that that might mean for screening, assessment, workplace adjustments, interventions and so on.

Alternative viewpoint

A study published in the British Medical Journal in August argued that there is potentially another way to look at this whole issue, one that might be equally beneficial, or an equal opportunity, for occupational health practitioners.

The study was led by Professor Jill Morrison, professor of general practice at the University of Glasgow’s Division of Community Based Sciences within its Faculty of Medicine. It recommended that, rather than just focusing on getting people off benefits and back to work, it might be more productive to be addressing if, or how, employers, occupational health and GPs can work together better to identify and intervene earlier to support those in work but at risk of falling through the net and on to benefits because of health issues.

People on long-term incapacity benefits because of mental health problems could have been identified by their GPs as early as three years before they stopped working, it concluded.

The paper analysed data from the 1995, 1998 and 2003 Scottish Health Surveys and from the 1991 to 2007 British Household Panel Survey to examine variation in incapacity benefits claims across the country.

It found no significant variation across GP practices in the UK in the rate of patients claiming long-term sick benefit. The varying rates of benefit claims are attributable to population differences and not to GPs issuing sickness certificates inappropriately.

It calculated that the number of people in the UK claiming such long-term sick benefit had increased by more than 300% in the past 30 years, with the annual cost to the UK economy now around £100 billion, much higher than official estimates.

It also found a significant increase in the frequency of GP consultations for patients with mental health problems in the three years prior to them claiming incapacity benefits. Therefore, there could be an argument for focusing more time and effort on identifying patients who are at risk of ending up on long-term benefits and aiming to keep them in work.

Patient identification

GPs could in this context work to target people who could become dependent on benefits up to three years before such an eventuality occurred by identifying patients who had frequent consultations for emotional distress.

Morrison says: “It’s well known that when someone goes on to incapacity benefit or employment and support allowance for a while it is often very, very difficult to get them off it and only a minority do tend to come back. So if there is anything employers, GPs or OH can do to keep somebody in work in the first place, then that is clearly much better than trying to get them back into work ­after the event.

“It is about raising awareness among GPs about the issue and asking them to be alert to the possibility that some patients are vulnerable to being off work and at risk of going off, and then discussing it with them.”

For GPs, mindful of their role as the ­patient’s advocate, there could be a fine line to tread here. Nevertheless, if opportunities arose to generate discussion or have a conversation about a patient’s capacity to maintain their employment, whether simply with the patient, in conjunction with the employer or involving OH if it were available, then they ought to be actively pursued, Morrison recommends.

“If there are adjustments that can be made to the workplace or can be put in that will help someone to stay in work successfully, then that could be something positive.

“OH in this context should be looking to work more closely with GPs as well as with employees before they go off. From what I have seen, OH generally is more likely to get involved only after a patient has had some time off work rather than before.”

Mechanisms

Morrison believes that procedures can be put in place to help potential sufferers earlier: “So it may be about having mechanisms in place whereby someone can go to see OH at an earlier stage, when they are perhaps not fully well but before the point where they are going to have to take time off work. It may be there needs to be encouragement of people to come forward and have discussions if they are having difficulties.”

Occupational health is potentially ideally placed to give itself a central role in this sort of process, agrees Christina Butterworth, vice-president of the Association of Occupational Health Nurse Practitioners and head of health at BG Group (formerly British Gas).

“I would be upset if there were any OH nurses out there not already trying to get people back into work or preventing them going off,” Butterworth says. “To my mind, the biggest sticking points have been GPs and line managers. OH can to an extent influence line managers but GPs are a whole different matter. Generally, we are still not seeing good certificates [fit notes] about people coming back from GPs, they are not often saying what adjustments might be useful.

“But I also think most workplaces are becoming more educated about workplace health and line managers are not so much taking an all-or-nothing, 100% fit or do not come back, approach.”

Butterworth concludes: “There are many severely disabled people already in the workplace where their line managers have made adjustments and support them. GPs need to recognise that ­occupational health is perfectly placed to help with this and need to be using us more.”

Concerns

Karen Talbot, chair of the Commercial ­Occupational Health Providers Association and director of occupational health firm Diverse Health Solutions, is concerned that people might be forced into work that makes them unwell.

“Of course, OH’s ethos needs to be about trying to keep people at work by making reasonable adjustments and so on. But we also need to ensure we are not putting people at risk or asking them to do activities that will simply exacerbate a medical condition,” says Talbot.

She adds: “But I also agree that both employers and OH could be being more proactive and ensure that people do not simply go off sick and then run the risk of getting lost in the system or take months to come back, if they come back at all.

“It is about education because companies do not want to be seen to be bullying or harassing someone who is off sick. Often managers feel they cannot stay in contact with an employee. But there has to be a happy medium where there is communication in both directions.”

“This is something where OH can often help, because of the way it sits in the middle between the employee and the ­employer so it can often be that the employee can contact them.

“The GP can, too, be an important part of the process. In my experience, once you get to have a discussion with a GP they will often be very good and very supportive.”

Nevertheless, most GPs, even with the OH training programmes that the Royal College of General Practitioners has been running, still do not have specialist training in occupational health or feel comfortable with advising on return-to-work issues and workplace adjustments, concedes Morrison.

“So, in many respects, the onus is on the OH department to be making itself more accessible or available, both to GPs and employees. It needs to be somewhere that people can go and discuss their problems,” she says.

Morrison says: “There has to be a two-way communication between GPs and OH. In many respects it is probably more about GPs remembering to discuss work with the patient at an earlier stage rather than expecting them to be able to advise a patient. And, if they are struggling, they should be going to see OH.”

Early intervention

In the US and Europe, traditionally, around 20% of the population incur 80% of the health costs, so the classic approach has been to focus on intervening and supporting that 20%, argues Dr Peter Mills, director at healthcare consultancy Glasslyn Healthcare Solutions.

While this might make sense on ­paper, what tends to happen in reality is that some of those 20% get better and go back to work but others of the 80% fall through the net. “So it is a revolving door. There is a paucity of evidence to suggest that measures to get people back to work who have been on long-term incapacity are going to work,” Mills suggests.

“Employers need to be more proactive about the health of their workforce. In the UK especially there has been a tradition that ‘it is none of our business’ when it comes to people’s lifestyle habits, how much exercise they do or what their health is. But increasingly employers are understanding they do have role to play in helping employees to manage their health.”

Business sense

Mills says this is not just a duty of care issue but makes business sense too. He adds: “So I believe employers need to be being much more proactive.

“A lot of employers, for example, will ­undertake an annual staff satisfaction survey, so why not tag on a health risk ­appraisal. Or might there be a more targeted, cost-effective intervention than private health insurance (PHI), say, or subsidised gym membership?

“It could be a decision to have an employee assistance programme or just use OH to run workshops and programmes on mental health, or just a decision to access OH services.”

Focusing on the “ill but still in work” may not, in itself, be the answer to how the Government reduces the country’s benefits bill. But it could perhaps provide a more socially constructive, economically positive alternative to simply hammering away at those ill and out of work, as well as having the added bonus of getting GPs, OH practitioners and employers to work more closely together and, crucially, pulling in the same direction when it comes to workers’ health.

Repositioning

Occupational health, within this context, could therefore take a much more proactive role in checking, defining and assessing an employee’s role and how they will contribute to the business, but also how the ­organisation will be contributing to and managing that ­employee’s health needs, Mills suggests.

He says: “The days of people chopping their arms off in machines are almost over, thankfully, especially in the UK. But I think occupational health and OH practices have, to a certain extent, struggled to reposition themselves to this new corporate environment and this could be an ideal opportunity to say, ‘We know about working and how health impacts on work and so we need to be thoroughly integrated in this process’.”

While pre-employment health assessments are usually unlawful under the Equality Act before a job offer is made, Mills believes that health assessments could be useful at that stage for OH.

“[Health assessments] could, for example, become a major part of defining what a person’s role and responsibilities and even their job description could be. It is all part of repositioning occupational health for the 21st century,” he adds.

Pilot scheme: In Work Support

Mental health charity Mind has for more than a year now been piloting an In Work Support scheme with Access to Work and the Department for Work and Pensions. It is designed to support employees through a confidential in-work support service.

The service can help employers to develop and evaluate mental-health-related policies and procedures, putting in place tools to support staff and identifying the best products and services for their business, among other activities.

The free pilots were originally available to organisations only within London and the M25 but last year the Government said it intended to extend the scheme, with a view eventually to rolling it out nationally.

“There are a lot of resources that organisations such as ours can provide because it is well known that many managers struggle with how to approach these sorts of conversations and worry about becoming overly intrusive. And there is a lot of stigma still around mental ill health,” says Emma Mamo, Mind policy campaigns manager.

She adds: “GPs have been quite vocal in saying they do not feel that confident with some of these issues. And it is true GPs are already very, very busy and this is just another thing for them to be looking for.

“But we have also had a lot of feedback from employees suggesting that occupational health can, if anything, sometimes act as a barrier to staying in work. They complain they feel that once OH is involved, they are being managed out of the workplace.

“Employers are used to talking about performance management, but they need to realise there may also be a medical capability issue. So they need to be having that conversation with staff.”

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