Fit for Work Service pilots were launched in an attempt to tackle issues with sickness absence management. Occupational health adviser Teresa Harrison takes a look at an example of the scheme and what it has been able to achieve so far.
The Leicestershire Fit for Work Service (FFWS) pilot is one of 11 Fit for Work pilots that evolved following the Government’s response to the Black review in 2008. Other pilots were based in Rhyl, Birmingham, Coventry, Sandwell and Solihull in North Staffordshire, Stoke-on-Trent, eastern and coastal Kent, Margate, Greater Manchester, Kensington and Chelsea, Wakefield and Nottinghamshire, with a separate pilot in Dundee.
The Leicestershire pilot began in March 2010 after it was initially granted a year’s worth of funding. The pilot has now been extended until October 2011 and a further bid has been put forward to secure another two years’ funding.
The aim of the pilots is to improve the health and wellbeing of the working-age population by supporting people with health conditions to stay in work or enter employment. Research undertaken by Waddell and Burton in 2006 showed that work has benefits for an individual’s wellbeing and health, both psychologically and physically. From their study they identified that worklessness leads to poorer health – both physically and mentally – and, therefore, that the benefits of work far outweigh the risks of work. It is also believed there are greater harmful effects of long-term unemployment or prolonged sickness absence.
FFWS pilots were initiated through the Department for Work and Pensions (DWP) and the Department of Health’s response to the Black review, which was commissioned as part of the Government’s health and wellbeing strategy to assess the health of Britain’s working-age population (DWP, Department of Health and Health and Safety Executive, 2005).
The aim of the pilots is to improve the health and wellbeing of the working-age population by supporting people with health conditions to stay in work or enter employment.”
The Black review set out 10 key challenges and recommendations for the DWP and the Department of Health to consider, with the main objectives being: prevention of illness and promotion of health and wellbeing; early intervention for those who develop a health condition; and an improvement in the health of those out of work so that everyone with the potential to work has the support they need to do so.
The Government response to the Black review was set out in the document “Improving health and work: changing lives”, with the aim being to “create a society where the positive links between work and health are recognised by all, where everyone aspires to a healthy and fulfilling working life, where health conditions are not a bar to enjoying the benefits of work”.
The key initiatives from this response were: creating new perspectives on health and work; improving work and workplace environments; and supporting people to work.
Under each of these points there are a number of initiatives to be achieved, for example:
1) Creating new perspectives on health and work:
- The electronic fit note, which is hoped to be launched by the end of 2011.
- The national education programme for GPs, which is aimed at improving GPs’ knowledge and skills when dealing with work-related issues.
2) Improving work and workplace environments:
- A review of the health and wellbeing of the NHS workforce (Boorman review).
- The occupational helpline for smaller businesses.
3) Supporting people to work includes a range of early intervention services, for example:
- Improving access to psychological therapies.
- FFWS pilots.
The DWP states that the outcome of all these initiatives should lead to better health for individuals, families and communities, improved productivity for employers, a reduction of sickness absence in organisations, as well as a reduction in government costs through fewer people claiming benefits and reduced health spending.
Leicestershire Fit for Work Service approach
The Leicestershire project is based on a case-managed approach. The team consists of the project and clinical lead (GP), occupational health adviser, case managers (CMs) and administration support.
The team works in partnership with healthcare providers and local support agencies to access services or therapies to support an individual return to work or deal with issues that are likely to cause absence if not addressed.
This is done by assessing, recognising and assisting in addressing the barriers or obstacles to work, as described by Waddell and Burton in 2004 (see box).
Obstacles to recovery/return to work
The pilot also pays particular attention to the common health problems (mild/moderate mental health, musculoskeletal and cardiorespiratory conditions) that account for two-thirds of long-term sickness/incapacity. Waddell, Burton and Kendall (2007) reviewed why people with these health conditions do not recover as expected. The authors recommended that these health conditions should have high priority – with return to work being the key outcome – and that a vocational rehabilitation approach is needed.
Waddell, Burton and Kendall define vocational rehabilitation as “whatever helps someone with a health problem to stay at, return to and remain in work”.
There are a team of people involved in the FFWS. The project is led by a representative from each of the stakeholders, which include local primary care trusts (PCTs), the NHS, improving access to psychological therapies (IAPT) teams, together with county and district councils. The clinical lead is generally a local GP with an OH qualification and experience.
Each participant is allocated a CM, who may come from a variety of different backgrounds. Generally, they will have been dealing with unemployed people or people with employment issues, so they should be up to date with what is available and how it should be used.
The team is completed by OH advisers who support and advise the CMs, take referrals from the CM and are able to refer clients to a variety of therapies – such as physiotherapy and occupational therapy – as well as the IAPT team and other health professionals. They are also able to undertake workplace assessments and advise on return-to-work plans.
People can access the pilot study services in one of two ways: referral via the GP; or referral via the IAPT team with GP approval.
To meet the criteria, participants must be employed and not looking to claim jobseeker’s allowance or employment support allowance (incapacity benefit). If individuals are referred who do not meet the criteria, FFWS refers them to the appropriate agencies so that they can still be assessed and supported in gaining employment.
When an individual is referred into the service, a CM will be assigned to support them through the whole process.
The CM will assess the client’s situation at the first meeting, paying particular attention to the barriers/obstacles to work. An action plan is drawn up with the client on what intervention(s) (see figure 1) may help the client return to or stay in work.
At this point, the client is given a copy of the action plan and the recommended interventions. This plan is reviewed on a regular basis to assess the effectiveness of the interventions used. Clients are advised that FFWS will remain objective and impartial in matters of disagreement and/or disputes between the client and other third parties.
Examples of the types of intervention that can be used include physical therapies, which can be accessed within two to five days, occupational therapy, workplace liaison, mediation, financial management and occupational health services.
If liaison with HR, managers, GP and other third parties is required as part of the process, consent is always gained prior to contact being made.
Discharge from the service comes when: an outcome has been reached; both parties agree that no further input is needed; or the client volunteers to leave.
A discharge summary is sent to the client’s GP, which is followed up at one- and three-month intervals.
Why GP referrals?
This brings vocational rehabilitation into the primary care field and introduces a multidisciplinary approach to work and health. Where individuals have not got access to occupational health, the GP has an alternative route to refer that is work focused and objective.
The FFWS can access physical therapies speedily; therefore individuals are not waiting for something to happen if they are off sick. Alternatively, individuals can be at work on modified duties while they are receiving treatment.
Research undertaken by Waddell, Burton and Main in 2003 highlighted that a worker who is off work for between four and 12 weeks has a 10% to 40% risk of still being off work after one year.
Waddell, Aylward and Sawney (2002) found that the longer a person is off work with pain, the greater the risk of developing chronic pain and disability, and the less likely they are to ever return to work.
The FFWS can access physical therapies speedily; therefore individuals are not waiting for something to happen if they are off sick.”
By six to 12 months, there is a 90% chance of the individual never returning to any form of work in the foreseeable future. Therefore, if GPs refer their patients to the FFWS after four weeks plus, they are able to help, preventing an individual from falling into this category.
For the FFWS to take ownership of the fit note process, the GP, as the primary carer, needs to be involved and happy with the referral.
It also means that all areas of Leicestershire are able to access the pilot, covering all population groups including hard-to-reach groups such as the self-employed and SMEs.
Why use a case-managed approach for the FFWS?
It is client focused, evidence based and brings together a team that has a range of skills and resources. A case-managed approach is used because it is a collaborative process. It assesses, plans, implements, coordinates, monitors and evaluates the options and services required to meet an individual’s health, social care, educational and employment needs, using communication and available resources to promote quality, cost-effective outcomes (Case Management Society UK, 2010).
Therefore, a case-managed approach allows obstacles/barriers to be separated out so that each one is addressed with the appropriate intervention or support, enabling the person to be rehabilitated back into the workplace earlier or even prevented from going off sick in the first place.
For rehabilitation to be effective it needs to be:
- responsive to users’ needs and wishes;
- purposeful and goal-directed;
- able to involve a number of agencies and disciplines; and
- available when required.
Results after the first year
There have been a number of benefits noted in the Leicestershire FFWS project so far:
- There is an easy referral into the system as GPs can refer clients by phone, letter or fax.
- Musculoskeletal interventions are funded and swiftly accessed within five days.
- GPs are divorced from signing the fit note, therefore they are written objectively as there is no patient-doctor relationship.
- Obstacles/barriers are addressed quicker and misconceptions are dealt with.
- Improved wellbeing of the individual.
- Financial benefits to both the employee and employer.
- Occupational health expertise ensures that the process is always work focused and objective.
- Because the fit note is signed by the FFWS, it allows objectivity and better targeted advice for employers and employees, even if, at times, the client is not in full agreement with the outcome. This is normally the reason why clients discharge themselves from the service.
Areas to address
There have been a number of obstacles and problems identified that need addressing:
- Solicitors have obstructed return to work.
- Better pain management/education is needed to change perceptions of pain/work. There is also a need for improved clinical management of pain.
- Not all GPs refer; if this model is to be adopted in the future, it may need to be incentive led with referral at certain point of absence from four to six weeks.
- It is not conditional on anything. It is voluntary; the client can leave at any point, normally when they do not agree with return to work/liaison, but there may be an ulterior motive such as compensation.
- GPs are signing people off work, when they could be at work, just because they happen to be fed up with their job for whatever reason.
- No room for people to leave work without losing benefits. Individuals will not move on as benefits will be lost and employers will not terminate because of fear of reprisal.
- The available psychological therapies have inconsistent access throughout Leicestershire as only two providers are in place; better liaison is needed.
- There needs to be more effective liaison with occupational health departments so that they understand how the service can best be used by them. For example, accessing physiotherapy, functional assessments and mediation.
Clients who have been part of the service have responded positively. In surveys undertaken, 50% have indicated that the FFWS assisted in a quicker return to work. Some 18% of respondents felt that they had returned to work one to two weeks sooner, while 30% felt that they had returned to work between four to eight weeks earlier than they would have (52% did not indicate a timeframe).
The aim of the Leicestershire FFWS pilot is to move the management of sickness absence from the medical model into vocational rehabilitation based on a biopsychosocial model, as identified in the work of Waddell and Burton, by using the appropriate interventions to address the barriers/obstacles and misconceptions that prevent people from returning to work/staying in work. The work is ongoing and the above areas will be addressed as the project has been extended. It is hoped that it will continue for another two years.
Teresa Harrison is OH adviser Fit For Work Services/OH manager LFRS/Forge Health Ltd and director AOHNP (UK).
Black C (2008). “Working for a healthier tomorrow”. TSO London.
Waddell G, Burton AK (2006). “Is work good for your health and wellbeing?” TSO London.
Department for Work and Pensions, Department of Health and Health and Safety Executive (2005). “Health, work and well-being – caring for our future. A strategy for the health and well-being of working age people”. TSO London.
Department for Work and Pensions and Department of Health (2008). “Improving health and work: changing lives”. TSO London.
Waddell G, Burton AK (2004). “Concepts of rehabilitation for the management of common health problems”. TSO London.
Waddell G, Burton AK, Kendall NAS (2007). “Vocational rehabilitation: what works for whom and when?” TSO London.
Waddell G, Burton AK, Main CJ (2003). “Screening to identify people at risk of long term incapacity for work”. The Royal Society of Medicine Press, London.
Waddell G, Aylward M, Sawney P (2002). “Back pain, incapacity for work and social security benefits: an international review and analysis”. The Royal Society of Medicine Press, London.
A sample version of the statement of fitness for work (or fit note) that a doctor can give to an employee as evidence of whether or not he or she is able to go to work is available on XpertHR.