“If the government is going to get one million people back to work over 10 years, this means 2,000 people a week will have to be assessed for fitness to work. Who is going to see an average of 2,000 people a week, and then process these cases and follow this up?”
There, in the words of Dr Sayeed Khan, is the challenge facing the government in its proposals for reform of incapacity benefit announced in January. Khan, chief medical officer of the EEF, the engineering employers’ group, is just one of the voices asking who is going to do the work to achieve the government’s goal of getting a million incapacitated people off benefit and into work in the next 10 years, and how it will be paid for.
About 2.7 million people are currently on long-term sick leave in the UK, but the challenge does not end there. The Department for Work and Pensions (DWP) is also seeking to boost the numbers of older people in the workforce by one million. The question for OH professionals is what their role will be if these proposals become law.
Will the drive to get the incapacitated back to work open up new work opportunities for OH nurse advisers and OH physicians? For example, what will be the impact on OH professionals of the arrival of previously incapacitated people in the workplace? And above all, what chance do the government’s lofty aims have of succeeding in reality?
The green paper, A new deal for welfare: Empowering people to work, launched in January proposes that from 2008 incapacity benefit (IB) will be replaced with a new Employment Support Allowance, intended to simplify the current system. The DWP says this will be paid to most people as long as they take part in work-related interviews, agree an action plan and take part in some sort of work-related activity.
Anyone who does not comply with these new rules will have their benefits cut in a series of slices, so that it eventually it is reduced to the same level as the Jobseeker’s Allowance. However, those with the most severe disabilities or conditions will be paid the full amount of benefit without conditions, and should receive more money than they do under the present system.
Among the key proposals to support the goal of getting the sick back to work is an extension of the Pathways to Work pilots to cover the whole of the UK by 2008, and plans to put employment advisers into GP practices to help them decide what work people might be well enough to take on.
The joint DWP and Department of Health publication Health, work and well-being – Caring for our future, published in November 2005, sets out the strategy behind the incapacity benefit plans. Some of the proposals, although vague, hint at a role for OH professionals: developing the evidence base for workplace health interventions; giving OH professionals training in managing mental health problems; expanding services to help people return to work; persuading the insurance industry to support employers which invest in rehabilitation services.
For OH nurse advisers, the proposals offer more questions than answers. Kim Boggins, an independent OH nurse specialist and vice-president of the Association of Occupational Health Nurses and Practitioners (AOHNP), stresses that both the intention of the new legislation and how it will be implemented need to be clarified.
“Incapacity benefit should only be used when you can’t get someone back to work, and with the Disability Discrimination Act (DDA) there is far more help available for organisations to employ people even when they have a disability,” she says. “But a lot of employers don’t have OH staff. My question is – how would employers have the tools to implement this? I work with disability employment advisers in job centres, and I know this service is very stretched.
“If additional OH staff were used – to help assess people for incapacity benefit, or keep them at work with modifications to their job, or a change of employment – who would employ them? OH in the NHS is not a free service: it has to be paid for. And NHS nurses in OH don’t have experience of industry,” says Boggins.
GPs are also concerned about what their role will be. Dr Hamish Meldrum, chairman of the BMA’s GPs Committee, says family doctors would be interested to hear details of how proposed ’employment advisers’ might work with GPs and their patients.
“If these people are able to offer helpful and sensitive advice to patients, they may prove a positive addition to the services available in a GP practice,” says Meldrum. “They will only be effective if they are supportive in helping patients to return to work rather than acting as an enforcement arm of the DWP with the sole purpose of getting people off benefit.”
The DWP, if pressed, does indicate where OH professionals are likely to be involved: “OH has a central role to play in ensuring appropriate support is in place so individuals can be rehabilitated into the workplace. They will also need to ensure appropriate adjustments are made, and monitor and support people who have returned to employment, so that they can remain in work once they have returned. The objective is not just to get people back to work, but to make certain such a return is sustained.”
This does not explain how the work will be resourced or paid for, however. Khan says the devil is in the detail. “OH professionals do have a central role in assessing fitness to work – which was ranked their third most important function in a recent survey we carried out with the Health and Safety Executive,” he says. “This is definitely something which requires OH expertise. But there is still a question mark over who is going to do it.”
Not only is the DWP not saying which group of OH staff might be involved in this: NHS, private sector or consultancies, it is not addressing the fact that this will be a recruitment issue. And there are not enough OH advisers to do the work.
The DWP is aware of this skills gap, and is setting up a working group which will look at ‘workforce planning’. This will have representatives from both the public and private sectors, and “relevant professional bodies”. The DWP also talks about “developing appropriate skills in others so that they may undertake relevant tasks”. It is seeking “innovative solutions” from professional bodies.
So far, professional bodies like the EEF and Royal College of GPs are puzzled as to what the solution might be, innovative or otherwise. “The decision about awarding incapacity benefit is made by a lay person in a job centre, not medics or GPs,” says Khan. “It’s not clear how this is going to work, beyond the nice broad headings [in the green paper]. There’s not much opportunity for OH and GPs to collaborate.”
The issue is further complicated by the DWP’s intention to get one million older people back into the workplace. Both groups – the potentially ‘incapacitated’ and the over-60s – will need to be monitored and supported by OH staff. This means OH practitioners will have to learn a whole new set of skills, says Khan.
“OH assessments will be relevant here: for example, most older people should not be doing shift work,” he says. “This is tough on any age group, and certainly tough on anyone in their late 50s or older. This is an area which OH needs to familiarise itself with – we know a fair bit about the DDA, and now we need to familiarise ourselves with the implications of an ageing workforce and flexible working.”
There are also questions about the role of OH in helping people with mental health issues return to work. What role will OH nurses have, for example, in deciding whether employees should undergo counselling or cognitive behavioural therapy?
Mental health charities such as Rethink and Mind are concerned that the new proposals will force people with mental health problems back to work too soon. And even those who are fit to work need sensitive and informed support if they are to stay in employment.
Another issue for OH professionals is the extent to which they will be working with people who are unwilling to return to employment: a potentially damaging move for employers themselves and a potential threat to employees’ trust in OH.
“The good news for OH practitioners is that there will be more demand for people who can assess fitness for work,” says Khan. “The bad news is that people will have to return to work, or their benefit will be cut.” Coercing resentful employees isn’t likely to boost the performance of any organisation, Khan suggests.
“Pathways to Work was voluntary – but this group is at best passive, and may play ball and go to back to work, but at worst may be disruptive and not comply,” he says.
Equally problematic is the proposal that OH staff should be involved in assessing the ‘severity’ of a condition in relation to an individual’s ability to work. “The government needs to look at what people can do, not what their medical condition is,” stresses Khan. “A person who has an ingrowing toenail and wears steel-capped boots to do their job can be in severe pain, and be incapable of working, while a person with cancer in remission may be functionally fine.”
Yet despite all these concerns, OH practitioners believe there is an opportunity for the profession to develop a key role in the reforms, one which is in tune with the way OH practice is developing in the workplace in general. Many OH nurses support the fundamental shift in philosophy away from signing off people from work towards assessing what work they have the capacity to do.
“It’s a question of stopping people being signed off as unfit to work in the first place,” says Boggins. “Why were people put on incapacity benefit at all? They are given the title of being incapable of work, and then being told to ‘prove’ it. Why were they given this label? In reality, they were no longer capable of doing their original job, but they could have done other work. Once someone has been signed off, it’s very difficult to remotivate them.”
If the proposed legislation did mean a new start, with staff given more support instead of being signed off as being ‘incapable’ of working, Boggins sees this as a positive development.
“Keeping people in the workplace and working to rehabilitate people is the way that OH is going in any case, irrespective of this legislation,” she says. “So this would be part of our expanding role. But there are definitely funding implications here – employers are afraid that those who have been on long-term sick leave will be poor attenders, although the opposite is true. They will need encouragement, and financial incentives.”
Health, work and wellbeing – Caring for our future is available at www.dwp.gov.uk/publications/dwp/2005/health_and_wellbeing.pdf
A new deal for welfare: Empowering people to work is available at http://www.dwp.gov.uk/aboutus/welfarereform
INCAPACITY BENEFIT: The changes at a glance
- Employees are currently entitled to incapacity benefit (IB) if they are incapable of working and Statutory Sick Pay (SSP) has ended, or if they cannot get SSP for some other reason.
- The benefit is paid at three different rates: short term at lower rate, short term at higher rate, and long term.
- Short term at the lower rate (currently £57.65 per week) is for people who have not received sick pay and have been off sick for at least four days in a row. Short term at the higher rate (£68.20 per week) is for those who have been unable to work for more than 28 weeks and less than 52 weeks. Long term IB (£76.45 per week) is for those who have been off work for more than 52 weeks.
- From 2008, the government proposes that IB will be replaced by two new classes of benefit: Rehabilitation Support Allowance for lesser or more manageable conditions, and Disability and Sickness Allowance, for people with severe conditions.
- For the first 12 weeks, 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.
How to have your say
OH practitioners can try to influence the final legislation for incapacity benefit reform by making a response to the green paper, A new deal for welfare: Empowering people to work. Feedback related to specific questions is sought from relevant groups, which in this case include the Royal College of Nurses (RCN), Society of Occupational Health Nurses (SOHN), Association of Occupational Health Nurses and Practitioners (AOHNP), Royal College of General Practitioners and mental health charities, among others. There will be another consultation when the white paper with firmer proposals is published, before the bill is passed in Parliament.