Swapping sicknotes for payslips” is how the government (or the then work and pensions secretary Alan Johnson to be precise) described its plan back in December 2004 to, from next month [October], pump 220m into pilots to help get the long-term sick back into work.
As a phrase, it’s certainly seductive but what it means in reality for OH professionals is still far from clear.
The key to Johnson’s announcement was a massive expansion of the government’s Pathways to Work pilot scheme.
These pilots, originally 11 in total, were launched in October 2003 to offer people who have been on incapacity benefit (IB) for three years or more access to personal advisers, to NHS rehabilitation, and links with voluntary and private sector advisers.
Claimants and benefits experts in the pilot areas also work closely with local GPs and employers and, critically, there is an incentive of a 40 a week return-to-work credit.
From October, it is intended that the pilots will begin to be extended across a third of the country, with the aim of initially covering 420,000 people and then, by October 2006, some 900,000 people.
As Johnson put it: “Nine out of 10 people expect to work again when they first claim incapacity benefits – we’re helping them meet those aspirations. With a thriving economy, record low unemployment and more than 500,000 job vacancies, everyone should have the chance to work.”
Alongside this, the government plans to overhaul IB itself (see box on page 14), plus its permitted work schemes, where people with health conditions and disabilities are allowed to try out paid work without losing their access to benefits.
The government is particularly keen on such permitted work schemes. Research by the Department for Work and Pensions (DWP), also published last December, suggested that almost a quarter of people on IB who participated in permitted work schemes went on to find jobs.
Those with moderate musculoskeletal difficulties and mental health conditions were the most likely to get back to work through permitted work.
Many of those polled found their health conditions were not the barriers to work they had originally thought, and most reported increased self-confidence, motivation and independence, said the DWP.
Also from October, IB claimants will be required to attend a work-focused interview after eight weeks of their claim, and to complete an action plan “to keep them in touch with work opportunities”.
GPs will also get better training on helping people get back to work, some will be given specialist rehabilitation training and some surgeries will have employment advisers placed within them. Seven pilot sites have reportedly been agreed.
It is this final reform – putting employment advisers into surgeries – that has caught the headlines, raising fears of ‘Big Brother’ within the GP practice.
The British Medical Association, for one, is keeping a wary eye on the idea. It has made it clear that, if employment advisers in GP surgeries become the norm, it will require a huge overhaul of primary care.
Spokeswoman Linda Millington points out that there are many practical problems with the idea, not least of which is the fact that many GP surgeries are too small for what they already do, let alone adding employment advisers into the mix.
“If it wants this to work, the government will have to put a lot of money into GP premises,” she explains. “At the moment, there is a dreadful shortage of investment in GP premises, even just to expand clinical services properly.”
Then there is suspicion about exactly what role such advisers would have within the GP practice. “If they are going to have a policing role, then that is going to go down like a lead balloon. If they are forcing people back into work, that will not go down well either,” says Millington.
“But if it is more constructive, then it might make sense. GPs do not have the time to act as negotiators with employers in getting people back into work. So it depends very much on how it is put into practice and what is the job description of these people,” she adds.
But Debbie Scott, chief executive of Tomorrow’s People, a charity that specialises in helping the long-term unemployed back into work (including placing advisers in GP surgeries), argues there is a clear demand for such services.
“We now have 35 advisers in GP surgeries, hospitals and health centres and a presence in another 19. We have had more than 300 enquiries from GPs across the UK wanting to work with us, representing more than 462,000 patients” she says.
The issue of premises and space can be solved with a little imagination, she argues. “If there is not enough room, we put out a box where people post a form saying they would like to see an adviser and then our outreach team gets in touch with them. We can often meet in places such as libraries or community centres.”
Either way, one thing worrying observers is the sheer lack of anything concrete to go on from the government.
It is clear, for starters, that the Pathways to Work expansion is running behind schedule. DWP spokeswoman Katherine Barlow stresses that until the Green Paper on welfare reform is published in the autumn – probably October – no further decisions are likely to be made on whether or how employment advisers will go into GP surgeries.
But she adds: “Our view has always been that the sooner we get to people, the sooner we get them back into work. It is still very much at the pilot stage and about building up links with GPs. It is still at an early stage.”
Certainly, Tomorrow’s People’s Scott has found that working closely with primary care can make a real difference. At one practice it has been working with over an 18-month period, GP consultations have been reduced by 18%, prescriptions of anti-depressants have gone down by 32% and referrals to counselling have reduced by 83%.
The government is determined to tackle what it calls “this great residual group” of people who are off work because of long-term sickness or incapacity, stresses the DWP’s Barlow.
And it is this determination that should be making OH practitioners sit up and take notice. Whatever the detail, what is clear is that the relationship between GPs and OH professionals is likely to change rapidly if or, more likely when, more and more people who may once have been off long-term start to come back into the workplace.
The long-term implications of all this for OH may not yet have sunk in for most practitioners, mostly because (and quite rightly) the primary focus of OH is the health and well-being of people already in work.
But, as Dr Bill Gunnyeon, former president of the Faculty of Occupational Medicine, pointed out in May, occupational medicine will need to broaden its horizons to address not only the health needs of people at work, but those of the working age population as a whole.
Gunnyeon’s words have particular resonance because he has stood down from the faculty to become chief medical adviser at the DWP – and so will have a central role to play in helping the government to overhaul long-term sickness absence.
Anything that helps people who have been ill to get back into work would be broadly welcomed by OH professionals, argues Dr Barbara Kneale, occupational health and safety adviser at car manufacturer Peugeot Citron in Coventry.
Kneale, who is leading a government-backed pilot looking at alternatives to GP sickness certification, suggests raising awareness among GPs and the population at large that there are alternatives to being signed off sick would be a positive.
“It is a positive thing if it raises awareness about fitness to work issues,” she says.
But the key will be the remit of any advisers within the GPs surgeries, how exactly they operate and their attitude to those who are ill, she stresses.
Initially, as it will be people who are off long-term and not those currently in employment who will be targeted, the impact on OH is likely to be minimal.
But, as time goes on and more people who were once off sick get back to work, there may need to be much closer co-
ordination, she suggests.
“What needs to be clear is what are the communication channels between the different players involved? How, for instance, will GPs and employers liaise, particularly employers that have an OH service?
“It is a good initiative but the role and limits of the advisers will need to be clearly defined,” she adds.
Another potential positive would be in encouraging GPs to be more proactive about looking at the needs of working-age patients who are off sick with long-term conditions, as it is well-recognised that the quicker you get someone well, the more likely it is you will get them back into work, she suggests.
But, adds Scott, if the government is serious about providing this sort of advice and support to people off long-term sick, it cannot stop once they have found a job.
This means there will need to be close involvement both from and with employers – whether or not through OH – to ensure people are able to remain in work, are supported back into their jobs and that the reasons for them falling ill in the first place (particularly if work-related) have been addressed fully.
“We offer aftercare support for a year after they get a job. The sooner we get this type of service expanded, the better,” she says, adding: “There will always be people that cannot work and it is important they also receive the support they need.”
Citing, again, the sample GP practice surveyed by the charity, out of nearly 200 patients on its programme, 87% had gone back into work or education, and 82% were still in employment 12 months on, she says.
“When people are unwell there is often a whole host of reasons. They will need nurturing to get them to believe that they can go back into the workplace. But it is well worth the investment,” Scott stresses.
Go to www.tomorrows-people.co.uk
INCAPACITY BENEFIT: THE FACTS
Currently, workers are entitled to incapacity benefit (IB) if, as the name suggests, they are incapable of working and Statutory Sick Pay has ended, or if they cannot get it for some other reason.
To be eligible, they must have paid National Insurance contributions (although there are ways of getting it even if they have not paid enough), and been incapable of work because of sickness or disability for at least four days in a row, including weekends and public holidays. Alternatively, they must be able to show they have been incapable of work and have been off sick for at least 28 weeks without a break.
The benefit is paid at three different rates: short-term at a lower rate, short-term at a higher rate, and long-term.
Short-term at the lower rate (currently £57.65 a week) is for those people who have not received sick pay and have been sick for at least four days in a row.
Short-term at the higher rate (£68.20 a week) is for if you have been sick for more than 28 weeks and less than 52 weeks. You must also have been getting IB for 28 weeks.
Long-term IB (£76.45) is paid if you have been sick for more than 52 weeks.
However, the government has said that from 2008, IB will be replaced by two new classes of benefits: Rehabilitation Support Allowance for lesser or more manageable conditions, and Disability And Sickness Allowance, for people with severe conditions.
For the first 12 weeks, IB applicants will also be put on a ‘holding’ benefit at jobseeker allowance rates, while a medical assessment is carried out alongside an ’employment and support assessment’.