The national Fit for Work service has been fully operational since September 2015, but awareness of the service among employers and employees remains low. Nic Paton looks at what is being done to increase its use.
The scale of the challenge the new Fit for Work service faces in getting known, recognised and used by GPs and employers is illustrated by a comment in the June bulletin of NHS Health at Work Network by chair Dr Anne de Bono.
She revealed that 30 members of the network were contracted with Health Management Ltd (HML), which is delivering the service in England and Wales for the Government, to provide face-to-face assessments. But up to that moment, they were still awaiting their first assignment.
Fit for Work service resources
With the original contract with HML outlining a goal of 45 NHS OH teams, covering 103 sites, and progress clearly being made towards achieving this, the NHS Health at Work Network is potentially going to be a significant player in helping HML to deliver the new service.
Nevertheless, while the consensus appears to be that there is a huge spring of goodwill towards the service and a desire to see it succeed, there is concern and frustration that, some 10 months on from its formal launch at the end of December last year, we are still discussing the potential rather than the reality of the Fit for Work service.
Progress of Fit for Work to date
Certainly, the service is progressing. The online and telephone advice service has been up and running since December 2014 and the physical roll-out of the assessment service for GPs across England and Wales began on schedule in the spring, first in Sheffield and then more widely (see timeline below).
This GP referral roll-out phase concluded in July and, in September, the service was opened up to include employer referrals. This, it ought to be stressed, is only within England and Wales, as employers in Scotland can already make phone referrals into the service, where it is being run by the Scottish Government.
Fit for Work Service: a timeline
November 2011: Dame Carol Black and David Frost publish an independent review of sickness absence in the UK, including identifying a lack of access to OH advice as one of the obstacles to people returning to work.
January 2013: Government responds to the Black/Frost review, accepting the recommendation for the creation of a new health advisory and assessment service.
March 2013: Chancellor George Osborne announces he will be scrapping the Statutory Sick Pay Percentage Threshold scheme to fund the new service.
December 2013: The Chancellor outlines a £500 tax break for employers investing in health interventions recommended by the new service.
February 2014: Creation of a new “Health and Work Service” is officially unveiled by the Government.
August 2014: Department for Work and Pensions announces that the five-year £170 million contract for running the service in England and Wales has been awarded to OH provider Health Management. The service in Scotland will be run by the Scottish Government on behalf of the UK Government.
November 2014: The Government announces that the new service will now be known as Fit for Work.
December 2014: Syngentis announces an agreement with Health Management whereby 45 NHS OH teams covering 103 sites will provide face-to-face appointments.
December 2014: The Fit for Work website and telephone advice line is launched. Assessment pilots start across Sheffield, with an aim for a national roll-out from spring 2015 onwards.
January 2015: The Government’s £500 healthcare interventions tax break is introduced.
March 2015: The Government announces that cognitive behavioural therapy is to be offered to employees referred to the service by their employer or GP.
March 2015: Roll-out of pilot GP referral and assessment service begins in Sheffield, extending initially to South Yorkshire and Bassetlaw in Nottinghamshire and, in Wales, Betsi Cadwaladr in Clywd and Abertawe Bro Morgannwg, Swansea.
July 2015: The Government announces roll-out of GP referral service has been completed, with the opening of the service to employer referrals expected to begin in the autumn.
But a concern among many within the industry is the low – some would argue non-existent – profile that the service still has with GPs, with employers and with the general public at large.
The original launch in December 2014 was completely without fanfare and, indeed, happened just as most of the country was disappearing off on its Christmas holidays. Since then, publicity and marketing around the service has generally been low level and low key.
As Professor Sayeed Khan, chief medical officer with the manufacturing organisation EEF, puts it: “The main thing is the whole lack of awareness about the service, both among GPs and employers. It really is a well-kept secret still; so I really think the Government needs to think about how it is going to engage with employers, especially SMEs, because that is primarily its target audience.
“If it were down to me, I’d be pushing to use accountancy firms, banks and insurance companies, because those are the sorts of organisations small firms engage with and listen to. As a small business owner, if you get a letter or email from one of those, you’re going to read it,” he adds.
“Basically, we need whoever is doing the awareness strategy within the Department for Work and Pensions (DWP) or Health Management to be looking at those three groups.
“Perhaps they could link with an organisation such as the Association of British Insurers to develop a promotional script or a flyer that could then be sent to small business clients?
“At the moment they are so far behind where they should be in terms of knowledge and awareness. How many employers, for example, understand that they’re going to have to change their policies to take account of the fact a return- to-work plan under the new service will replace the fit note?” he points out.
Marisa Stevenson, professional development director with the Association of Occupational Health Nurse Practitioners (UK), agrees: “It has all gone quiet up here in Scotland too. I was speaking to my own GP two weeks ago, and he had no knowledge of the service at all and had no contact from anyone.”
As does Graham Johnson, a lead nurse at Bupa UK. “The big thing for me is that it is still not that widely known about.
“The objective of the service is, I feel, sound. Encouraging more employers to do more to support the health of their employees is a really welcome step. But it would be very interesting to see what level of referrals it’s had already and what the measured outcomes have been. We should be looking at how the service can have the biggest possible impact, especially in encouraging employers to take action at an earlier stage.”
Some organisations have found it unclear how the service is going to link back to employer-funded or NHS treatments or interventions. “The success of the service will depend on how it interacts with any occupational health services provided by employers. Is someone who needs treatment simply going to be referred back into the NHS and told to go and sit on a waiting list? Or back to their GP or employer? Or given the option of considering a quicker private referral to access treatment, does that potentially create a conflict of interest?” asks Johnson.
Rationale for the slow roll out
“We have had quite a slow roll-out, but that was planned,” emphasises Dr Lucy Goundry, clinical lead for the Fit for Work programme at Health Management, to Occupational Health & Wellbeing. “It was the DWP’s preference, because it gave us more of an opportunity to learn as we went along and to train up our people,” she adds.
How would you change the service?
In June, manufacturing employers’ body the EEF, as part of its 2015 annual absence survey in conjunction with benefits firm Jelf Employee Benefits, made a number of recommendations as to how it felt the Fit for Work service could be extended and improved.
A key idea among them was the suggestion that referral should be made mandatory for any employee who has been off work for more than four weeks.
It called for the service to be resourced with healthcare professionals with knowledge of different industries.
It also argued for the introduction of a mechanism whereby an employer can speak to the service before coordinating with the employee.
And it said that the £500 tax break on return-to-work healthcare interventions did not go far enough. A further system of health tax credits or allowable business expenses needed to be introduced to “incentivise” employers to pay for treatments recommended by the service or an OH provider.
Statutory sick pay should only be paid on condition that an employee cooperated with the service and restrictions should be put on GPs signing off employees for more than four weeks unless the patient had engaged with the service, it added.
“We were also quite restricted in the marketing we could do to GPs during the general election period but we’ve picked that up since. Behavioural change for GPs is a tough battle; but the way to win that battle is to show it is good value,” she continues.
HML is working with the DWP on an employer engagement plan that will swing into action when the wider referral process begins in the autumn, Goundry reveals. While the exact details of this are being kept under wraps, it is likely to include a range of regional roadshows, as well as national and local marketing campaigns.
Since going “live”, referral numbers had “really ramped up”, she argues. “The advice line in particular has been very popular. It has been really good in the areas where it has been launched and publicised. There has also been a considerable ramp-up since we have gone live over the whole country and given GPs the opportunity to refer in.
The service has now recruited some 50 case managers. While the aim is for the service to be an OH nurse/adviser-led service, the case managers include a wide range of other specialists, including general nurses, occupational therapists, physiotherapists and mental health specialists, Goundry explains.
“So it can be that if someone has been referred for a specific reason, for example mental health, we can direct them to an appropriate professional. Eventually we are, of course, looking to have more than 50 case managers, but we are ahead of the curve of where we wanted to be at this point at the moment. We are aiming for more than 350 by this time next year.
“We are also already engaging with occupational health practitioners – at every assessment we ask the question ‘do you have, or have access to, an in-house occupational health service?’ and, if the answer is yes, we recommend they share their return-to-work plan with their OH service.
“Yes, there is a big job to do around training and communications. But so far, things are going to plan and we expect a big ramp up,” she adds.
Areas of concern for employers
Law firm Eversheds has been running training and briefing sessions on the service for employers and others since last autumn and, agrees partner Naeema Choudry, there is at the moment a degree of scepticism and confusion about it.
“We find common questions include, ‘will we need occupational health people anymore?’ and ‘what if the employee does not comply?’,” she points out. “Employers are thinking, ‘if we cannot compel them to go to the service and if we cannot stop their pay if they don’t go, where is that going to get me?’ Then, with GPs, there is often a fear it may result in people coming back to work before they are ready to do so.
“But I do think the service will be of benefit to smaller organisations, especially those that do not have their own occupational health service and do not have much in the way of support mechanisms in place,” she adds.
One common area of concern for employers is the ability, or lack thereof, of the service to deal with difficult or complex cases or with cases of frequent yet intermittent absence.
An employee can only be referred into the service once they have been off for four consecutive weeks or if their GP expects the illness will cause more than four weeks’ sickness absence. Therefore, in cases where an employee is off frequently but only for short periods, the likelihood is the service is going to be unable to help. Gaining and agreeing employee consent for the voluntary referral and how the £500 tax break for interventions will work in practice are other common issues raised, Choudry points out.
“There does have to be training for line managers about the service. Employees are likely to provide the name of their line manager as a point of contact for Fit for Work and, as such, any return-to-work plan will be sent directly to the employee’s line manager as opposed to HR.
“The line manager won’t necessarily know much about the service, what to do with the return-to-work plan or the implications of not following any recommendations contained within it. Equally, if you are covered by a return-to-work plan, you do not need to provide a fit note, but I am not sure many employers know about that,” she advises, echoing Professor Khan.
“It just seems to have gone very, very quiet. For example, I’ve not seen anything about it on the TV. I’ve seen a lot about [public health campaign] Change4Life but there’s been no awareness-raising at all around the Fit for Work service,” Choudry adds.
This lack of awareness is clear when you speak to employers. Lucy Kenyon, communications director at the AOHNP (UK), approached a chief revenue officer she knows at a start-up business, who revealed a fairly deep level of scepticism about the service. He was, as yet, unfamiliar with the service, she pointed out, did not believe that the service would help people to stay in work and felt that there was a danger the referral process would be subjective. The service could end up being used by employers as a tool to help them release people from employment, rather than help people back into work, he worried.
“We have been talking to the DWP about communications – we’re sure to be using things like our magazine and website to communicate about the employer roll-out as and when we have information, including links to any guidance. We’re going to be doing whatever we can to help make it as visible as possible to employers,” says CIPD adviser Ben Willmott.
“But I do think it is going to take a while for employers to become familiar with it; if it is going to reach the majority of employers it is going to need a concerted push. I don’t think it is on most employers’ radars yet, but it’s going to be a gradual process. The referral process from GPs is, I expect, also going to be quite gradual. How it reaches out to the SME market is going to be critical, as visibility and awareness here is going to be crucial of course.
“But let’s not forget how far we’ve already come. Even just having the free advice line is a significant step forward from what we had before. How employers engage with return-to-work plans set out by the Fit for Work service when they have not been involved in those discussions is going to be key, and it will be really interesting to see how that plays out,” he adds.