Jonathan Shapiro Health, disease Emma Hill and unemployment: Julia Manning The Bermuda Triangle of Society

Supported by a grant from Health, disease and unemployment: The Bermuda Triangle of Society

Jonathan Shapiro Emma Hill Julia Manning

Supported by a grant from Contents

01 About this Publication 3 02 Executive Summary 4 03 Background and Context 6 Medical view 10 Good work versus bad work 12 Occupational health and vocational rehabilitation 13 Summary of Programmes designed to assist in reducing unemployment 14 Broader costs 15 04 Methodology 16 05 Why a Bermuda Triangle? 18 06 Themes 20 Generic Points 20 British attitudes to work 20 Illness and unemployment are not separate issues 21 Other themes 22 Prevention is better than cure, even with long term ill health 22 Occupational Health: whose services are they anyway? 23 Where welfare is concerned, small is beautiful 24 General practice: tinker, tailor, provider, landlord, case manager, or none of the above? 25 The flexible workplace: oxymoron or aspiration 26 Incentivising the return to work 26 07 Summary of key messages 28 The British andWork 28 Prevention is better than cure, even with long term ill health 29 Occupational health: it is broke, so let’s fix it 29 Where welfare is concerned, small is beautiful 30 The role of general practice 30 The flexible workplace: oxymoron or aspiration 30 Incentivising the return to work 31 08 Conclusions 32 09 Footnotes 34 10 Appendices 35 Appendix 1 –Work Outcomes Interview Schedule 35 Appendix 2 – Interviewees 35

11 Bibliography 38 Health, disease and unemployment: The Bermuda Triangle of society 01 About this Publication

The measure of successful NHS treatment is increasingly not a case of whether a process target has been met, but whether that treatment was a success. In other words, what was the final ‘outcome’? Did the patient get better and stay well? Added to this is the crucial question for the working age population – how quickly did they get back to work?

This project looked at whether being at work is or could be considered a clinical ‘outcome’ of successful health treatment. Can keeping people in work or returning them to work find its place as an indicator of a successful health intervention on which professionals or institutions can be measured? We make fourteen recommendations and observations that we believe will be of value to policy makers. The overall challenge is increasing the visibility to frontline professionals and employers of those trapped in the ‘Bermuda Triangle’ of illness, wanting to work and unemployment - rescuing or preventing them from getting lost there in the first place.

We are indebted to Abbott Healthcare who enabled this research to be undertaken, and to all our sponsors for their unrestricted funding on which we depend. As well as driving our on-going work of involving frontline professionals in policy ideas and development, sponsorship enables us to communicate with and involve officials and policymakers in the work that we do. Involvement in the work of 2020health.org is never conditional on being a sponsor.

Julia Manning Chief Executive June 2010

www.2020health.org

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3 Health, disease and unemployment: The Bermuda Triangle of society

The recommendations and observations that came out 02 of the interviews, discussions and analysis were: 01 The first aim of any policy change should ensure Executive that it is in the interests of the individual, the employer, and society at large to align the Summary incentives and close the loop between health, illness, and unemployment.

02 Raising the perception of control is key to Recent reports have made a huge improving productivity, and all the work on contribution to raising the profile of the leadership, engagement, and so on is actually relationship between health and work. They trying to do this. An overt focus on improving this culture would reap rapid and sustainable benefits. have highlighted how important it is that we have a healthy workforce, that health and 03 Getting patients back to productive and wellbeing are intrinsically connected and sustainable work should become a key that intervening early in illness is a key factor objective and outcome indicator for all health to recovery and the return to work, whether services, particularly the NHS. All forms of clinical education need to include this aim from in the same or a different role. their outset, and throughout both undergraduate and continuing training. With the increased calls for the NHS to be held accountable for health ‘outcomes’, the 04 An important aspect of this emphasis must be the aim of this study was to establish whether inclusion in the diagnostic process of the social and psychological aspects of an illness as well as its being at work is or could be considered physical manifestations, and treatment should a clinical ‘outcome’ of successful health be aimed at ameliorating patients’ ability treatment. Could keeping people in work or to return to work as part of returning them returning them to work find its place as an to better health. indicator of a successful health intervention 05 One essential in this regard would be the on which professionals or institutions could strengthening of direct links between the be judged? This report describes how we NHS and the Department of Work and identified the recommendations previously Pensions (DWP) , not damaging the formal links made with a view to delivering improved and relationships that have been established health and wellbeing in the workforce. We between the departments by outsourcing the joint working. then used these recommendations as a basis for interviewing experts in the field as to 06 There needs to be an acceptance on the part of the their awareness of and /or agreement with employer and of wider society that it is normal them. Their responses prompted two for the work environment and job roles to particular themes that were then taken to change as people’s careers progress , even if that entails physical change (seating, instrumentation, the front line, to test them with people etc), and changes to the terms as well as the working in health, welfare and back-to-work conditions of employment. programmes. These were: 07 OH services should be made more widely 01 ‘Occupational health medicine is available, less focused on the needs of the irrelevant to the link between health employer, and more widely based than on Occupational Health (OH)doctors alone. and work.’ This has only been partly addressed by the DH’s advice lines for small and mid-sized 02 ‘How may a return to work be enterprises (SMEs). incentivised, to the benefit of the individual, their employer, and the state?’

4 08 Clearly, whilst there is an economy of scale in This list reflects both that significant progress has already providing services that help people back to work, been made in the understanding of the relationship the clear message from this work is that any between work and health, but also that there are benefits of size are more than offset by their noteworthy challenges ahead in changing the culture. disbenefits in terms of intimidation and lack There was universal agreement that being able to work of involvement. should be considered a health ‘outcome’. The challenge is increasing the visibility to frontline 09 There was consensus concerning the use of GP professionals and employers of those trapped in facilities as a venue for the work and advice the ‘Bermuda Triangle’ of illness, wanting to work required to help the workless get back to work. and unemployment, and rescuing them from there Their local nature and size and relative informality – or preventing them from getting lost there in the are helpful, and they could be populated by staff first place. from private and/or voluntary organisations. The idea of linking the tasks associated with the return to work to specific health care issues at a single venue was also appealing.

10 However, predicting the absence of sickness or a reduction in turnover require a leap of faith, and such faith is often the missing ingredient in introducing some of these changes. This may be one area where legislation concerning the employee benefits mentioned above may be appropriate.

11 It should be possible to introduce some kind of tapering scale as health and workfullness improve, by which welfare payments reduce as ‘real’ income grows without any step changes being triggered in a way that avoids the classic benefits trap.

12 What is required is genuine early intervention, preferably in time to preempt the whole workless phase, particularly when predictable health issues are causing the problem. There needs to be increased awareness of how important appropriate prescribing is in helping people return to work as quickly as possible.

13 It may be that medical support for such interventions could be an extension of the ‘fit note’ idea, using the GP’s imprimatur to validate such discussions, and preempt any punitive reaction by less enlightened employers.

14 With the rising awareness of and interest in work related stress, it may be that increasing the profile of the Health and Safety Executive (HSE) in this area could bring sufficient pressure to bear on employers on its prevention and more effective treatment of stress. Fear of liability and of compensation may be a useful adjunct to the moral high ground.

5 Health, disease and unemployment: The Bermuda Triangle of society

As the demography of the developed world changes, there is a need to reconsider our attitudes to work and 03 unemployment, and to explore the interventions that lead to and maintain sustainable employment. An ageing Background population means a growing incidence of chronic illness will affect those in work as well as those with caring & Context responsibilities. There is overwhelming evidence that long periods away from work is detrimental to patients’ health. The annual cost of absence and the worklessness associated with working-age ill-health is estimated to be over £100 billion. It has been shown that musculoskeletal disease (MSDs) and stress are the most common health reasons for people taking time off of work but there is also clear evidence of how not working is detrimental to health. This review of existing publications explores some of the recommendations that have been made in the past few years, building largely on four major pieces of work:

01 In spring 2008 the Director for Health and Work, Dame Carol Black, published Working for a Healthier Tomorrow , the first review of its kind that examined the health of Britain’s working age population. It was the culmination of a cross- governmental initiative that started in 2005 and saw the formation of the Work, Health and Wellbeing Directorate. The Black report made a number of recommendations, amongst which a number stood out: the adaptation of GP advice, the initiation of pilots for Fit for Work service, 1 a health and wellbeing consultancy service, and more health information about the relationship between health and work.

02 The government’s response to this review, Improving Health and Work: Changing Lives fully accepted Black’s advice, making both a social and economic commitment to the 2.6 million people on incapacity benefits and the 600,000 people who make a new claim each year. Part of this commitment was the intention to transform the medical ‘sick note’, the introduction of mental health co-ordinators in Job Centres, the creation of occupational health advice lines for small and mid-sized enterprises (SMEs) and a National Centre for working age health and wellbeing. 2

03 Acting on the aforementioned government response, Dr Steve Boorman, Chief Medical Adviser to Royal Mail Group, oversaw an NHS review in the autumn of 2009. In its efforts to ‘get its own house in order’ the NHS fully accepted the need to improve the health and wellbeing of its staff. Boorman’s report suggested that improving the health and wellbeing of NHS staff could save over 3.4 million working days annually, the equivalent of 14,900 full time staff. As Europe’s largest employer, the annual cost of staff sickness to

6 the NHS is estimated to be a staggering £555 Key Facts and Figures million. 3 His recommendations include a ‘prevention focused health and wellbeing strategy’ 175 million working days in Britain are lost due with staff health and wellbeing becoming a key • to ill health annually factor in senior management performance assessments. The NHS intends to support early Cost of sickness absence and worklessness in interventions especially in the areas of MSDs and • Britain estimated at £100 billion annually mental illness, in order to facilitate earlier returns to work. This is in line with the NHS constitution’s The World Health Organisation estimates that intention to help keep staff fit and healthy. • by 2020, depression will have become the second However, it should be remembered that there is leading cause of disability in the world 6 a deep inherent cynicism amongst those working in the NHS, so the notion that staff health and 80% of the adult population will suffer with back wellbeing are significant priorities is likely to take • pain at some time in their working lives considerable time and effort to implement effectively. Approximately 6.9 million people of working age 04 The Marmot Review (Spring 2010), commissioned • report themselves as disabled; this equates to 19% by the Government, looked at health inequalities, of the working population and stated six key policy objectives, one of which was to ‘create fair employment and good work for 7.6% of the working age population (2.6 million all’. The review recommended prioritising • people) claim incapacity benefit with 607,000 new employment programmes, ensuring that equality cases annually; 1.5 million of these have been in legislation is upheld, implementing existing receipt of this benefit for more than 5 years 7 guidance on stress management, and generally creating greater security and flexibility One quarter of GP consultations are work related in employment. • 5.4 million people declare a work-limiting Several of the Marmot Review’s policy objectives link • disability, of whom 50% are in employment directly to the ‘world of work’; these include: enabling people to maximise their capabilities and maintain 1.2 million people who worked during 2009 were control of their lives; ensuring healthy standards of living • suffering from an illness (long-standing as well as for everyone; creating healthy and sustainable places and new cases) that they believed was caused or made communities; and strengthening the role and impact of worse by their current or past work; 551 000 of ill health prevention. 4 these were new cases 8

As the Chief Executive of the Royal College of Nursing Around 46% of people with disabilities are commented on the Marmot Review: “As a nation we simply • economically inactive 9 must not tolerate the difference in life expectancy shown in this report, or the many years spent in preventable poor health...of course individuals need to make health choices for themselves, but to tackle this inequality, government, public services and communities need to work together”. 5

The relationship between work and health is multifaceted, and impacts on areas of social justice, generational poverty and health inequalities. There is an archetypal public health issue in trying to get people to stay at work, back to work or into work, and to achieve these aims requires the adoption of new perspectives to create open dialogues between Government, healthcare practitioners, employers and the individual. The traditional bio-medical model of disease is insufficient to explain and to deal with the complexity of the underlying issues, and a new bio-psycho-social model is required to help understand the importance of wider preventative measures such as job design and skills analysis.

7 Health, disease and unemployment: The Bermuda Triangle of society

In 2006 an NHS Musculoskeletal Framework was devised as part of the Government’s strategy for long 03 term conditions, which set out a vision in which people with musculoskeletal conditions could access effective Background clinical advice, assessment, diagnosis and treatment. It was proposed that this would be accomplished through & Context systematically planned and integrated services 13 . As it stands, the key service recommendation of the framework remains woefully unheeded, with the national average for implementation of the proposals at only 16%. 14 Health conditions are not static but can change over time, and the means of managing these also need to be In 2007 the National Rheumatoid Arthritis (RA) Society flexible; a medical model might be appropriate during a surveyed over 700 RA sufferers about their working lives. period of acute ill health, but within a short time Of those people not working, the survey found that psychosocial issues are likely to predominate. After nearly two thirds (64.8%) were not in employment several months, the whole nature of the illness may have because they gave up work early as a result of their RA, changed again, as the impact of prolonged worklessness this included people above and below the statutory takes its toll 10 . Two of the most pervasive reasons for retirement age 1. With 387,000 RA sufferers in the UK, employees absence from work are mental illness and the costs generated by this burden of disease are musculoskeletal disease, and these services need to be expected to exceed £3.8 billion annually. However considered differently in the context of patients, their Rheumatoid Arthritis is just one specific musculoskeletal friends and families, employers, GPs and the wider NHS. problem, and many other people suffer with more generalised conditions like ‘back pain’. Overall Musculoskeletal Diseases (MSDs) are common, may Musculoskeletal Disorders (MSDs) affect over a million be progressive and are a leading cause of disability and people in the UK, accounting for 9.5 million lost sickness absence, affecting twice as many people as stress. working days and a cost to society of over £7 billion in Despite 80% of adults suffering some form of back pain real terms 15 . Apart from the purely economic costs, there at some point in their lives, spending per patient can vary are genuine inequities as people with RA (and MSDs dramatically between parts of the country from £95 per more broadly) miss out on other opportunities through person in Lewisham PCT to £1379 at Western Cheshire their lives. PCT, 11 a variation that is not easily explained. In addition to such obvious healthcare inequalities there are also In 2009 both ARMA (the Arthritis and Musculoskeletal widely varying views about the MSD sufferer’s ability to Alliance) and the National Audit Office evaluated the work, perhaps because MSDs are the most prevalent progress of the Musculoskeletal Framework and cause of work-related ill health and vary enormously in recommended that a national clinical director be their severity, duration, and psychological impact. appointed for musculoskeletal services and that there should be clear lines of accountability for One person’s ‘aches and pains’ will be another’s ‘acute the implementation of the 2006 Musculoskeletal sciatica’ and yet another’s ‘arthritis’. There is often a Framework. They also suggested drawing on the existing strong psychological overlay to MSD symptoms, strategies for other specific conditions (such as cancer) to particularly if they are protracted. create a model that would establish service priorities, delivery models and funding streams 1, and advised that The Work Foundation has analysed the fitness of various PCTs should not commission musculoskeletal services European countries labour force with respect to without first making an accurate assessment of the needs musculoskeletal disorders. One report concludes that up of their population in terms of their quality of services, to 2% of GDP is lost to MSDs and that there is an even life, information, training and development 16 .The UK higher cost in human terms with respect to sufferers’ has yet to succeed in promoting the cost effectiveness of quality of life. 12 early intervention.

8 Mental Illness had a dedicated National Service Framework forum in which to discuss their difficulties. A research (NSF) on Mental Health introduced over ten years ago report for the Department of Work and Pensions (DWP) which promised to deliver mental health promotion and that surveyed line managers’ attitudes found that they support services specifically to meet the needs of the felt that supporting employees with mental health working age population. Since 2001 there has been an problems placed significant demands on their time and increase of £1.7 billion on the expenditure for adult was hard to keep confidential 21 . A report for managers mental health services. This has meant 64% more on stigma claimed that ‘most of the ideas are ordinary consultant psychiatrists, 71% more clinical psychologists good management practice. The way forward is to bring and 21% more mental health nurses than in 1997 17 . In mental wellbeing within the boundaries of ordinary spite of this, mental illness has become the biggest cause working life.’ 22 of sickness absence and of incapacity benefit, with claims for the latter rising 15% proportionately between 1996 The economic costs of mental illness linked to people’s and 2006, so that despite an overall drop in incapacity ability to work have ranged from £789m in Northern benefit claims, mental health claims have increased. Of Ireland, through £2.3 billion in Scotland, to £23.1 the 600,000 new incapacity benefit claims each year, billion for England. These figures include non- 200,000 are related to mental illness sufferers, many of employment (unemployment and economic inactivity), whom feel that they would have the potential to remain sickness absence, unpaid work and premature mortality. in work with the help of their employers and GPs. Around 60% of people who have a common mental illness are working, compared with 70% of people who There are often mental health consequences of do not 23 . Conversely, mental illness sufferers have argued unemployment for other reasons; people who become that the welfare state actively discriminates against unemployed because of a physical health condition are claimants without a physical disability, who are more much more susceptible to mental health problems, and likely to be branded malingerers. 24 indeed, unemployment itself may be considered as a factor that can precipitate mental illness. In 2009, Rachel The benefits of working in a socially inclusive way are Perkins was commissioned by the Department of Work self evident and include the removal of the severe effects and Pensions to undertake a review of mental health and that stigma has on the individual and their family. The employment. In her report she suggested a vision with RCPsych says that to achieve this, there is a need for three central objectives: increasing capacity; providing ‘recognition of the range of interventions that can support and monitoring effectively. To achieve these, the improve both clinical and social outcomes for service report recommended improving ‘welfare to work’ users, and ensuring that these are commissioned’. 25 services, commissioning employment specialists and providing short unpaid ‘internships’ to help patients Rachel Perkins’ DWP review stated that ‘people with familiarise themselves with the world of work 18 . In March mental health conditions remain among the most 2010 the Department of Health published its report New excluded within our society, particularly in the workplace. Horizon: towards a new vision for mental health . It suggested We know that work improves mental health and that looking at the root causes of mental illness was wellbeing and most people with a mental health fundamental to national economic success. 19 condition would like to be in work and pursue a career’. 26

It is reported that one in six workers will experience At the end of 2009 the Department of Health launched stress, depression or anxiety at any one time, with one in its New Horizons programme which built on the 2000 four of the whole population having a diagnosable NSF for Mental Health . This identified multi-agency mental illness some time during their life. The vast commissioning and value for money as central strategies majority of these continue or return to work successfully. to mitigate the societal, individual and economic burden of mental illness. Proposed actions included better work Despite the NSF on Mental Health and the 1995 Disability place support and employment opportunities for people Discrimination Act (DDA), many of those with mental with a mental health problem, and the report identified illness never declare their health problems to their work as an ‘important outcome of the treatment of employers, and the enduring stigma that surrounds mental illness in health settings.’ 27 mental illness still results in employment discrimination. The Royal College of Psychiatrists (RCPsych) has said At the same time, the Government launched the first that the continued stigmatisation of mental illness in the mental health and employment strategy Working our Way work arena means that many potential recruits may be to Better Mental Health: a framework for action. This proposed denied entry into employment as they are seen as a framework which aspired to transform the ways we as unsuitable, even though they meet all the competencies individuals think about mental health and work; and the for the profession 20 . Linked to this point is that those with ways in which employers and public bodies support mental illness who are in employment often find the people with mental health problems. work environment an unsuitable and inappropriate

9 Health, disease and unemployment: The Bermuda Triangle of society 03 Background & Context

The Sainsbury Centre for Mental Health calculated Mental health services and localism some specific statistics which estimated the sickness In December 2009, Health for Work Advicelines absence costs of this kind of illness to employers (jointly delivered by the DWP and the NHS) annually: began operating in England, Scotland and Wales in order to help SMEs support their employees £8.4 billion a year in sickness absence of up to 70 (although this is project not mental health • million lost working days specific). The Mental Health Co-ordinator Network was also launched, which aims to put a £15.1 billion in productivity losses or co-ordinator in every Job Centre Plus district. • ‘presentee-ism’ (when employees come to work This is hoped to help to develop links between in spite of illness) which costs more because it health and employment services locally. is more common among higher-paid staff Tomorrow’s People, a voluntary organisation that £2.4 billion a year to replace the staff who leave helps people back into work has been • their jobs because of mental ill health recognised as an exemplary model. In a report evaluating how worklessness can impact on £8 billion could be saved by British businesses mental health, Tomorrow’s People were able to • if mental health was managed more effectively drive down anti-depressant drug prescription by at work. 28 means of a new referral process they formed with a local GP. Mindful Employer is another An example of these figures being turned into action is initiative, consisting of a charter supported by illustrated by the fact that BT has reported that its mental over 660 employers to think positive about wellbeing strategy has led to a reduction of 30% in mental mental health. This has become a network of health-related sickness absence, and a return to work rate supporting organisation to adopt a good practice of 75% for people absent for more than six months. 29 on mental health. 1

Medical view Employment is recognised as an important component of recovery from illness, both physically and, by dint of its impact on confidence and self management, psychologically. It allows a person to step out of the sick/dependent role and so is central to self esteem and self motivation. However there is some concern that work could become a faddish ‘panacea’, and work as the only acceptable outcome to an episode (be it of illness or unemployment) could add pressure to an individual’s situation by excluding any other possible solutions. 30

Encouraging GPs and others to recognise the part that they play in making work a potential outcome of treatment has been an ongoing challenge. They could be key contributors to achieving a healthier workforce and saving scarce welfare resources, by changing the emphasis of their involvement when presented with a patient absent from work from incapacity to capacity. The ‘statement of fitness for work’ (or ‘fit note’) was

10 introduced in April 2010, and is hoped to save about patients’ use of other specialist services. The £240million or more over ten years. Unlike its conclusions of this pilot study emphasised the need for predecessor sick note, this new form allows GPs to state GPs to increase their awareness of the therapeutic value whether a patient ‘may be fit for some work’. of work and the availability of support for them, although employers had previously argued that GPs do Although the British Medical Association (BMA) not understand the problems that long term sickness welcomed the new move as a more intuitive way of giving absence can cause. patients advice, there were reservations about employers having the awareness and responsibility to act on the To this end, there have been increasing efforts to boost changes. The qualification of GPs to advise on this topic GPs’ awareness of their enhanced role in patient was also mentioned by BMA General Practice Committee employment issues. The Royal College of General Chairman Dr Laurence Buckman, who was reported as Practitioners (RCGP) is running a national education saying that ‘GPs need to be careful they are not drawn into programme (in the form of half day workshops across making comments they are not qualified to make, because, the country) to tackle this knowledge deficit. Their aim unlike Occupational Health doctors, they are rarely in a is to equip up to 4500 GPs with a better understanding position to know the precise details of a patient’s working of how their duty of care extends beyond clinical conditions, neither do they have specialist knowledge of outcomes. By May 2010, roughly 1000 GPs had received workplace hazards’. The idea of ‘fit notes’ was also this training. 34 received critically by Local Medical Committees who thought that they might be open to forgery. 31 Another requirement of the ‘fit note’ is that line managers will need to be equipped to deal with GPs’ Another anxiety in primary care was that an undue focus advice. In order to do this effectively, employers will need on the ‘return to work’ might conflict with the traditional to have access to current information about their role of the GP as patient advocate, and that although employees. 35 However UK society still struggles to grasp the eventual work outcome would be beneficial to that health and wellbeing at work are not just medical patients, patients may not view it as such. GPs are issues, but extend far beyond, to areas such as increasingly aware how job retention or an early return engagement, and self worth, making the information to work can be beneficial to patients, but reforming the needed much greater than mere medical records. To medical statement is clearly only a part of changing this emphasise the point, there seems to be a clear link mindset. Society also needs to review how GPs and the between the perceived effectiveness of management at other health agencies could intervene earlier and in a work and employees’ feelings of wellbeing. The problem different manner in order to encourage self- in engaging companies and their managers is how to management, and prevent the decline into ‘victim’ role deal with the apparent conflict of interests that arises that often goes with illness and unemployment alike. when employees at work are affected by health problems, This will inevitably challenge traditional health thinking especially when they may have arisen from the work to go beyond physical symptoms with its impending environment itself. Clarifying this conflict, and finding catastrophes and over-medicalisation. 32 ways of dealing with it is key to improving health at work and clinical interventions that have work in mind. It may A pilot to assess GPs’ interaction with their patients be that occupational health services could have an around the subject of sick leave was intended 33 to enhanced role in this function. ascertain how GPs understood their remit in this area, the mode of their discussions with patients, and how well connected they were with the appropriate local specialists and organisations. Several issues were identified as barriers to GPs’ involvement in the ‘return to work’ process. Foremost was their perceived need to preserve the trust of the doctor-patient relationship, as they often felt trapped between their patients and the benefits system or the employers (or all three). Other factors that emerged as obstacles included the time needed to do this work properly, the problems of maintaining continuity of care, funding the new system, GPs’ limited occupational health expertise and patients’ lack of knowledge of the system. As far as understanding the other organisations that might have been involved, there were mixed messages about GPs’ knowledge of these, but misunderstanding of the role of the Job Centre Plus system was widespread, as was scepticism

11 Health, disease and unemployment: The Bermuda Triangle of society 03 Background & Context

Good work versus bad work Men’s working health Although there is often an assumption that work during There is an additional benefit in incorporating illness is harmful and rest away from work is therapeutic, health services at the workplace. As National Men’s the converse notion, that work is good and Health week highlighted, men generally visit their unemployment is bad, is simplistic. High quality GPs less often than woman, work for longer hours, employment is important in maintaining employees’ do more overtime, and retire at older ages. More satisfaction and hence their performance, but the equal men than women have symptoms without formal opportunities implied by ‘high quality employment’ also diagnosis, and they are more likely to become help to address any inequalities that arise around access alcohol dependent, abuse drugs and commit to good working opportunities. Good jobs have long had suicide. There are huge disparities between the an association with good quality education, and sexes in areas such as mental illness too, probably education is linked to longevity. 36 more in the reporting of illness than in its incidence. Even without formal research, it makes intuitive Inequalities are also amplified by the fact that employers sense that wellbeing at work is likely to be an give lower priority to job retention for unskilled important contributory factor to this disparity, as employees than for their more highly skilled ones. men are exposed to the lack of job satisfaction, Smaller companies often have less flexibility than large work related stress, and the pressures of long companies to change employees’ roles as their health working hours more than women, even in today’s varies, or to adjunct the skill mix in different roles. SMEs emancipated society. are also less likely to be aware of issues surrounding disability legislation. Thus, the workplace may be considered an excellent setting for public health practice, for men The factors associated with good jobs have been in particular, and this work should include looking categorised as control, security, diversity of work, at gender specific variations of health and rewards, fair procedures and social capital 37 . The Work wellbeing. Royal Mail’s workforce, for example, is Foundation’s 2009 report Good Jobs suggests that most 85% male, and so the company focused on raising employers recognise the value of ‘good jobs’, realising health awareness amongst staff to see if this would that they have much to gain from them in terms of reduce absenteeism. Part of this initiative was to maintaining a more productive, healthier, stable and circulate health pamphlets in a similar format to the committed workforce. One factor that that seems to ‘Haynes’ car maintenance manuals, and work by remain relatively unrecognised is the impact on the London School of Economics showed that productivity and the ‘health’ of the organisation of absence reduced from 7% to 5% as a result. (Men’s sickness absence, presentee-ism and staff replacement. Health Forum, National Men’s Health Week 2008)

Health and safety at work is another area that affects employees’ health and wellbeing, and is still probably underdeveloped (despite the urban myths!). The Health and Safety Executive (HSE) reported that for 2008/9 over 1.2 million employees suffering a health condition felt that this was made worse by work, with over half a million reporting new issues. This meant a total loss of 24.6 million working days due to work related ill health alone. 38

Alongside health and safety and job design it is evident that in repositioning work as a health outcome there needs to be an ability to match skills for a particular job

12 with the aptitudes of the employees. BUPA, for instance, long term rehabilitation. Employers have become published a report on the future opportunities and increasingly aware of the benefits of OH which is challenges for workplace health up to 2030 - a paper that perceived as part of an employer’s duty of care to its analysed how UK demographics, disease trends, and the employees. However, the practicability of this philosophy economy were likely to interact with the nature of depends on the size of the company, the costs of employment. 39 The report anticipated that a knowledge providing such a service, and the local perception of based economy was likely to change job design and that health as a business priority. this would have consequent effects as ‘knowledge workers’ (often required to apply their skills flexibly and Employers look to government promotion to widen be accessible around the clock) often have a poorer sense access to OH services, as well as wishing for reform of of wellbeing and quality of life than other groups with the costly legal processes that accompany compensation more routine in their work. Mismatches of skill sets and claims. Removal of tax disincentives such as the current job requirements will affect workers’ wellbeing. Theresa ‘benefits in kind’ system would also go a long way toward May MP, (writing as the then shadow Secretary of State ensuring that employers invest in their employee’s health. 1 for welfare) emphasised how a skilled workforce would be an essential part of any welfare reforms, and that From the employee perspective, OH has been seen as a in developing these skills, it was vital that nobody got management tool, whereas it is self evident that OH left behind. 40 professionals should be more sensitive to both employee and management concerns. It would be helpful if some In the context of increasing globalisation, companies of the routine health checks were redesigned, and need to focus ever more tightly on communication and focused more on health promotion than pre- the development of organisational ‘emotional employment checks and health surveillance, 1 as access intelligence’. This should include the consideration of to these services is a vital component of any early mental health issues in the work place, and the intervention. Previously it has been suggested that early organisation of clear responsibilities at work, and for the intervention itself should be streamlined with nationally ‘return to work pathway’ for those who have been agreed service standards, taking into consideration that unwell. 41 The key seems to be that a holistic approach is professional expertise is key to reform. The need for vital, and needs to be consciously maintained at all times. better referral systems and greater OH provision has also Line managers are not just extensions of their been highlighted. 1 corporation’s arm, they are the tangible human link to the organisation for all employees. Vocational rehabilitation (VR) has often been seen as separate from the usual OH working but is actually synonymous with many of the overall aims of OH. It is Occupational health and vocational rehabilitation designed to assist in whatever way possible those with “Rehabilitation cannot be a second stage after healthcare has failed” health conditions to return to or remain in work by – Palmer and Fox 2007 taking an individual approach on the return to work, workplace accommodation and early intervention. This Traditionally Occupational Health (OH) departments “process of facilitation” 42 is fundamental to the have been responsible for the health of workers, and for maintenance of mental health. a safe environment, in terms of hazard assessment. The Black Review highlighted the fact that only one in eight Setting up a UK framework for vocational rehabilitation workers currently have access to any form of OH. The was suggested in 2004 by the HSC (now HSE) in its review recommended a greater emphasis on OH, even ‘A strategy for workplace health and safety in Great Britain to extending its reach to people who are not presently in 2010’ but there has been little mention of progress. The employment. This could be part of a new early Government has said that it was not in a position to intervention process. In recent years much OH has been implement a new approach for VR, but that it fully outsourced, and internal OH departments have supports stakeholders who want to do so. increasingly been disbanded. It has yet to be seen how this has affected employee accessibility and satisfaction with services.

The huge challenge to OH is to overcome its historical detachment from mainstream healthcare. Traditional OH departments can do various things, and a number of measures have been recognised as helping to prevent the drift of employees onto long term benefits. These include risk assessment, disease and absence management, health prevention and promotion, and

13 Health, disease and unemployment: The Bermuda Triangle of society

incapacity benefits must attend five further WFIs. The Pathways programme comprises a ‘choices’ package to 03 improve individuals’ work readiness, a £40 return to work credit and a discretionary fund that advisers can Background allocate to increase the chances of clients finding work.

& Context Although the programme was hailed as a success when it was originally piloted in 2003, attempts to expand and replicate the programme in 2006 showed that the Pathways had had no statistically significant impact on Summary of Programmes designed to assist work, earnings or health outcomes. Within the original in reducing unemployment pilot areas however, analysis showed that Pathways In May 2009 the DWP estimated that there were 4.97 increased the proportion of clients who were in paid million out-of-work benefit claimants of working age, of employment 19 months after they made an incapacity whom 2.62m were claimants of Employment and benefit enquiry and reduced the chances of individuals Support Allowance (ESA) and/or Incapacity Benefits reporting day to day health problems. This disparity was (IB). 43 From October 2008, ESA replaced Incapacity explained by possible variations between the studies. 47 Benefit and Income Support paid on the grounds of incapacity. This benefit attempted to cut costs and Presently, Pathways contracts have been assigned to change the culture of long term sick leave, and it multiple organisations, the largest of which is A4e, included a new work capability assessment. Of 292,300 a multinational recruitment and training service. people tested since October 2008, only 89,600 were Questions still remain about the cost-benefit of the assessed as unable to carry out full time work, which left Pathways programme. If calculated conservatively, it has 69% who were considered well enough to work, and been estimated that the net return to the exchequer was hence moved onto the Job Seeker’s Allowance (JSA). 44 £1.51 for every £1 spent on the Pathways programme. However some costs were not incorporated in this The Welfare Reform Act 2009 aimed to reduce benefit analysis (such as administration, tax losses and utilisation dependency and strengthen the benefit contract. Despite of the NHS) and this calls the results into question. 48 public anxiety about benefit fraud, there was more Interagency concerns about the Pathways work remain, concern among policy makers that the degree of as is shown by the fact that over half of PCTs have not conditionality in the benefit system might work in a made links with their local scheme. 49 Furthermore perverse way and actually lead to less support for the Pathways is said to have failed for those with mental people who needed it most. It was felt that getting people health issues and the National Audit Office have said off welfare benefits should not in itself be perceived as that the programme provides poor value for money. 50 the goal. 45 Access to Work is another Government scheme that helps Helping this group depends on a greater understanding employers to make assessments and provides funding for of why people make these particular benefit claims, and alterations to be made to the working environment. This adaptation of national strategies may be required to benefit contributes towards the costs of equipment an allow a ‘fit’ in local areas. Overall there has been a individual may need at work, offers a communicator at decline in the total number of claims, but with a shift job interviews, helps to adapt premises where necessary, from musculoskeletal problems to mental health issues. and can pay for a support worker. It can also pay towards DWP studies have shown that alcoholism and drug the cost of getting to work if an individual cannot use abuse have increased alongside Invalidity Benefit claims public transport. Reportedly between April and due to mental ill health. It has been suggested that other September 2009, this scheme helped 26,540 individuals. 51 associated factors like poor employment history were linked to this trend and should be taken into account when looking at localised groups. 46 Two major programmes were initiated as part of the overarching ‘work for your benefit’ scheme; these were Pathways to Work and Access to Work.

From April 2008, everyone on Incapacity Benefits has been able to access Pathways to Work . Under Pathways, any individual aged between 18 and 60 who claims incapacity benefits must attend an initial work-focused interview (WFI) with an IB personal advisor eight weeks after making their claim. Most people remaining on

14 Broader costs The costs and effects of absence from work have been widely documented, but the costs of presenteeism, poor productivity of replacement labour, and extra management costs often go undetected. The Chartered Institute for Personnel Development (CIPD) and the Confederation of British Industry (CBI) found that very few organisations make rigorous assessments of the costs associated with employee absence, and that when they do they tend to take an ‘accountancy approach’ without mention of impact on productivity and profitability. 52 There are clear gains to be made by improving absence management, but this has yet to be fully grasped by organisations in the UK. In their report the CBI also noted that ‘Annual absence surveys are not rocket science, but a blend of systematic use of absence procedures and improved communication between staff and management, supported by employee wellbeing policies’. 53

This ‘improved communication’ may simply comprise earlier one-to-one follow up procedures after incidents such as sickness absence. Employee wellness programmes have been slow to be taken up as employers have not perceived any impact in improving the health and wellbeing of their workforce. This is expected to change as the focus on corporate social responsibility increases. A study of workplace wellness programmes found promising cost benefits in important areas such as sickness absence, staff turnover and accidents. These programmes were found to be far more successful when they were tailored to employee needs. 54

It has also been suggested that the National Institute for Clinical Excellence (NICE) guidelines on the cost effectiveness of new medical treatments should consider incorporating social and work factors into their calculations as well, so that the broader benefits of new treatments may be recognised. This raises the perpetual public sector issue of whether the department whose budget funds an intervention should also be the one that reaps its rewards. A classic example would be the potential cost shifting when the DWP saves in benefit payments because of expenditure from NHS budget for treatment that accelerated a patient’s return to work. This consideration was addressed and rejected by the Kennedy Review 55 but other reports have found that a more cross cutting approach resonates better with both professionals and the public 56 . Taking this approach to the frontline would mean that those who held local health budgets could start thinking about savings to the entire welfare budget and which clinical treatments have the most impact on ability to work, hence the question about ‘horizontal integration’ posed during this project.

15 Health, disease and unemployment: The Bermuda Triangle of society

This report is built on the foundations of a selective literature review which was based on expert 04 recommendation, selective news streams and self published, publicly available literature from various Methodology organisations. Many of the fact and figures come from programme specific searches from the Department of Health and the Department of Work and Pensions. Other statistics have been drawn from independent studies.

Ideas that emerged from the literature were then drawn together to inform a semi-structured interview schedule designed to combine non-directive questioning with the opportunity to explore specific issues in some depth (see appendix 1).

The second stage of our research was to conduct over 25 expert interviews with senior figures from a number of diverse organisations, including the NHS, voluntary sector, health insurance providers, private healthcare companies, employee service providers and case management organisations. We spoke not only to Chief Executives, but also to local managers and health professionals (full list available appendix 2). In each case, interviews took place either in person or over the telephone, and were set out relatively informally on a semi structured basis that allowed the interviewee to lead or elaborate. Interviewees were assured that their comments would remain unattributed and were encouraged to express their true opinions, even if they were not in keeping with their organisation’s views.

16 From the interviews were synthesised a number of The two themes discussed in each case were drawn from recurring themes which were tested in local communities the findings of the interviews, and were: by carrying out a short series of workshops. In the event three workshops were carried out, in Coventry, 01 ‘Occupational health medicine is irrelevant to the Newcastle and Exeter in the period from December link between health and work’ 2009 to January 2010. These were attended by a diverse range of people including physiotherapists, occupational 02 ‘How may a return to work be incentivised, to therapists, occupational health physicians, health the benefit of the individual, their employer, and industry representatives as well as people providing the state?’ employment services to mental health users and members of professional bodies. These workshops were The findings of the workshops were collated along with designed on a ‘confirm and challenge’ approach, the themes emerging from the interviews, and intended to encourage a number of groups to take part amalgamated into this report. in active discussion on several different topics. Originally, it had been intended to run four discussions in each The project was supported by an external steering group session, but the number of people attending each of the of unpaid experts with whom the process and the workshops made this impractical. Instead the findings of the work were discussed on several occasions; participants in each workshop were divided into two we would like to acknowledge their invaluable help, and groups, each asked to discuss one of two themes. Half thank them for their contributions. way through the session, the members of each group (except one) rotated, the remaining one acting as the designated ‘guardian’ of the theme. They were also responsible for facilitating and reflecting the findings of each discussion to a plenary session at the end of the workshop.

17 Health, disease and unemployment: The Bermuda Triangle of society

The original hypothesis that underpinned this piece of work concerned the specific link between ill health and 05 work, in the knowledge that long term chronic conditions such as muscular skeletal disease and mental Why a Bermuda illness have a dramatic impact on the workforce and its productivity. However, it soon became apparent that the Triangle? linkages are more complex, and that there is a striking relationship between unemployment, ill health and work.

This is quite hard to explain in concrete terms, but it is clear that unemployment causes ill health just as ill health causes unemployment, and that a return to work can (but only if used appropriately) improve the health of both groups. Thus, for example, someone with a chronic condition such as rheumatoid arthritis (RA) or endogenous depression risks losing their job in the current work environment because there is rising unemployment (and so replacing them is easy).

There are no real incentives for an employer to adapt work circumstances to suit the needs of the disabled person, whether in terms of flexible hours (depressed people usually function more effectively in the latter part of the day) or physical changes (such as special taps in washrooms to suit the needs of those with physical frailty). This makes getting such people back to work highly problematic.

The issues get worse if unemployment (for any reason, not just for those with a chronic illness) continues for any protracted period of time, as the chances of the unemployed person getting back to work diminish rapidly and those who have been unemployed for longer than six months (for any reason) have a lesser chance of ever getting back into permanent employment. Studies have shown that although these limits are unclear, the best window of opportunity for a return to work is between one month and six months. 57

The next loop in the downward spiral is that there is a clear link between long term unemployment (for any reason) and the illnesses of low self esteem such as depression. Ever since the rise of the Puritan work ethic, Western societies have used employment as a key indicator of worth, particularly where men are concerned, so that we tend to adjust our assessment of a person’s status according to the work that they do, and we apply that measure to ourselves as well as to others. Put starkly, those who are unemployed are seen (and see themselves) as having less value as people than those in work. This is bad enough, but the phenomenon is more marked amongst those who have been in work and then become unemployed.

They tend quickly to adjust their self esteem downwards, with the rise of self doubt and the loss of confidence that is bound to make their affect worsen, along with their ability to get back into work, and the longer the

18 unemployment goes on, the worse it becomes, both in their own minds, and in the minds of potential employers. In our society, it is this final twist that completes the vicious circle that creates and perpetuates a lacuna of isolation and neglect, a kind of metaphorical Bermuda Triangle.

It may be more helpful to illustrate this dynamic diagrammatically, as shown below:

Unemployment Work

Ill Health

The Bermuda Triangle

There is a certain invisibility to the group caught between the three pillars of work, ill health and unemployment, and it was that isolation and sense of mysterious disappearance that led to the coining of the ‘Bermuda Triangle’ phrase, and most of the themes and messages that came out of the interviews and workshops were aimed at increasing the visibility of those trapped in the triangle, and helping to rescue them from there. The themes are generally arranged in no particular order, although there are one or two generic points to be made first.

19 Health, disease and unemployment: The Bermuda Triangle of society

Generic points 06 British Attitude to work Underpinning the whole of the study, and present in all Themes the discussions that took place as part of it was the premise that ‘work of the right kind is good for you’. The evidence for this has already been cited, and there is a strong common sense element in that statement, and yet it quickly became clear that there was a dissonance between what people said about the subject and what they felt about it. In everyone’s tone of voice there was a wistfulness as they talked about the place of work in their own lives, as if work was a necessary evil, like medicine.

Anecdotally, this seems to be a widely prevalent attitude to work, that might be characterised in the statement ‘I know work is good for me, but if I won the lottery, I’d give it up like a shot and take up something I wanted to do’.

Within that statement lie a couple of truisms: first, there does seem to be a ‘British attitude’ to work, that is different from (and a lot less keen than) say, an American view. The working population in the UK appear to demonstrate a curious paradox; they work longer hours than any other nationality in the developed world, and yet they are the least enthusiastic about what they do. The second truism is that people would rather be doing something that they enjoy, and when people feel obliged to do anything, they tend to resent it.

The key to the paradox lies in the notion of control; if any of us want to do something, we tend to enjoy it more than if we have to do it. Studies show that productivity, sickness rates, staff turnover, even life expectancy all improve when people feel that are in some way in control of their destiny, and worsen when they feel ‘done to’ rather than ‘doing’, and the lower down the employment chain we work, the less sense of control we have 58 . Winning the lottery is a trite way of claiming control, and with it (in fantasy at least) comes the notion of doing something we enjoy, something that we control, rather than something someone else is obliging us to do.

Quite why this should be more prevalent in the British population than elsewhere is a matter of speculation, but there does seem to be a non-conformist streak among us that means that whilst we rarely revolt (look at our French neighbours for comparison), we commonly subvert. We have a natural suspicion of authority that has generally served us well, even if it does mean that while we hate getting up on Monday mornings, we still do.

In practice, the implications of this observation are that the more perception of control employees have, the more effectively they will work. Workers on a manufacturing line become more productive if they are allowed to stop the line when anything is wrong; it gives

20 them a sense of control. Loosening the rules about when wellbeing is being adversely affected by their position) to breaks may be taken does the same, for the same reason. be directly linked into the NHS. The best that the system Professional workers generally devise their own work can do is try to get them a job, or suggest that they refer schedules and activities, and the clear control that this themselves into the medical hierarchy. gives them means that they enjoy their work more. Similarly, self employed people generally enjoy their jobs One essential that overcomes this arbitrary distinction is more than employees. the direct link between the NHS and the Department of Work and Pensions (DWP) whose remit covers the Nested within this idea of control is also the notion of management and welfare of the unemployed. Such ‘ownership’; if a task matters to me personally, then I ‘horizontal integration’ helps to remove bureaucratic will tend to do it better than if I don’t care about it at all. barriers, and should make the holistic care of the This idea will percolate through many of the findings of workless easier to improve. As with many of the this study, in terms both of the ‘input’ (how events administrative processes that seem to get in the way of influence people) and ‘output’ (how people may effective public services (another classic is the artificial influence events). This will show not only in the factors barrier between the NHS and Social Services), the that influence peoples’ perceptions of work, but also in realities of running a large and complex welfare state the most effective ways of changing these perceptions make the simple conjunction of all these services a much and improving their relationship with work. harder task than first appears, but it is a point worth reiterating repeatedly that the welfare state was The conclusion to be drawn from this is that building in established to ‘do the right thing’, and should not let the perception of control (and it is the perception that ‘doing things right’ subsume that aim. However, matters, not the fact) helps increase productivity, reduce ‘outsourcing’ such joint ventures to external agencies staff dissatisfaction, and improve morale. It also helps to (particularly when they are still being developed) risks engender a better sense of ‘ownership’ of a task, broadcasting an entirely different, and less positive something that will be seen to be an important aspect of message. the links between work and health. These generic observations may colour some of the specific comments that were made during the interviews Illness and unemployment are not separate issues and seminars; these have been synthesised into a A key finding that appeared time and again through the summary that attempts to sort a series of disparate work of this study was the fact that the distinction impressions into some form of order, based on the between illness and unemployment seems to be entirely ‘journey’ from work through illness to unemployment, artificial. Thus, although it is self evident that ill health and then back again. is likely to result in some inability to work effectively, the notion of having the ability to work effectively as a suitable target to which NHS services could aspire is entirely missing from the lexicon of the NHS, indeed, our research found that it is often completely absent from the mindset of clinicians. Britain in not focused on rehabilitation, only 1 in 6 people return to work after a major injury compared to 50% in Scandanavia, a point conceded in Black’s review 59 . Thus, when doctors review their patients, their focus in on the amelioration of symptoms, and of the titration of medication, but their review is rarely carried out with the specific aim of getting patients back to work. This is particularly so in hospital settings; in general practice, effective practice is carried out in the context of the so called triple diagnosis, which includes the social and psychological aspects of any illness as well as its physical manifestations, and consultations may well include an assessment of patients’ ability to return to work. But even here, such an outcome seems to be a by-product of getting patients better, not an end in itself.

Similarly, if the problem is approached from the unemployment end, there seem to be very few mechanisms available that allow workless people (whose

21 Health, disease and unemployment: The Bermuda Triangle of society

the most appropriate medication. Whilst ‘early intervention’ was regularly cited, there was little 06 questioning of whether the individual was receiving the best medical treatment for their particular condition. Themes This is a very relevant supposition and omission, especially when the National Institute for Clinical Excellence (NICE) has significantly raised the awareness of medical choices.In many spheres involving the formal ‘professions’, our society has been moving away from an ‘age of deference’, but questioning the correctness of Other themes prescribed medication seems only to occur when there is an adverse side-effect. However, the fact that Prevention is better than cure, medications are becoming increasingly specialised points even with long term ill health to the need for greater awareness that the correct The welfare state as it is currently configured seems to medication shouldn’t be taken for granted. Appropriate take no account of the fact that chronic illness rarely prescribing can result in a more immediate return to comes completely out of the blue; whether one is work and so is a key factor in enabling work to be seen considering rheumatoid arthritis, schizophrenia, as a health outcome. blindness, multiple sclerosis, cancer or chronic obstructive pulmonary disease, these all develop over Generally, when we are ill we tend to deny it for a while, time, and their impact on sufferers’ lives may generally then consider the immediate crisis of treatment and be predicted, even if the pace of their progress may be diagnosis, and only much later consider the long term harder to define. Despite this, it is not part of our culture consequences of our condition. Partly, this is part of our to consider the implications of illness at work except in hope and expectation for health and longevity, but there the most binary of forms: a person can either work, or is also a genuine uncertainty about the path of most they can’t. People suffering from a long term condition LTCs, so that we do not (and indeed, should not) (LTC) seem be obliged to struggle on at work until they consider ourselves as being crippled by arthritis at the have to give up and retire, with all the feelings of failure first twinge of any joint pain. and loss of purpose that are associated with that sense of ‘giving up’. If they are very lucky, they may then be re- It takes time before an acute illness becomes seen as employed on a part time basis, but this is the exception chronic, and so the challenge is to know when that rather than the rule. change occurs (at an emotional level as well as a clinical one), and then intervene as soon as possible after that. There seem to be no general mechanisms whereby those On the part of the employer and of wider society, there who know that they have a LTC can work with their would need to be an acceptance that it was normal for employer to plan for the future, and modify their the work environment and job roles to change as people’s working conditions appropriately; after all, someone with careers progressed, even if that entailed physical change a LTC may well need to live with it for decades, and it is (seating, instrumentation, etc), and changes to the terms clearly a waste for (as well as a drain on) society to lose as well as the conditions of employment. Not only the benefit of that person’s contribution to the work would this be helpful in keeping those with LTC at work, place for all that time, to say nothing of the impact on but it would fit in with the emerging zeitgeist about their own sense of self worth and life satisfaction. deferring retirement; the same attitudinal changes could apply as age and energy (as well as motivation) affected Several interviewees who worked with organisations that people’s work abilities, thus helping to maintain people’s championed the needs of patients with particular presence at work and optimising their effectiveness. diseases made this point, and suggested that early intervention was a key example of prevention being better than cure: if people who knew that they had a LTC could negotiate the appropriate changes to their working conditions, then they would be able to lead a much more positive, contributory life to the benefit of society as a whole as well as to themselves and their families. To do so would take some cultural changes: the most important of these would be the need for those with potential LTCs themselves to consider this far earlier than happens at present. On reflection it was noticeable that the implicit assumption was made by most interviewees that individuals are automatically on

22 Occupational Health: whose services The third strand of poor perception was based on the are they anyway? apparent strong biomedical bias of OH services, that Both the interviews and the seminars exposed significant was seen to favour the physical aspects of disease and issues about the current nature and purpose of disability, rather than including the social and occupational health (OH), as well as offering some psychological aspects too. This probably originates from interesting and practical suggestions as to how these the medical roots of the specialty, and of the general services might be improved. human propensity to prefer those markers that lend themselves to easy measurement over those which There was a general consensus that occupational health (although conceivably important) are based on intuition services are currently unwieldy, archaic, and of limited and empathy. Thus, OH services were seen as being utility. The starting point for these perceptions is that the dominated by doctors whose interests lay in muscular place of occupational health within the health sector ability and biochemical abnormality more than in the ‘scheme of things’ is obscure and poorly understood. issues of affect and emotional disturbance. The NHS itself has an OH service, which applies to staff within the NHS, and is also offered to external In summary (and with a degree of generalisation!), OH companies on a commercial basis. Beyond that, some services were seen as patchy in their availability, partisan employers do provide an OH service (either in house, as in their application, and narrow in the scope of ‘dis- large employers sometimes do, or on a contracted basis ease’ with which they could deal. However, there were from the NHS (as described above) or from commercial several suggestions as to how these perceptions could be OH companies, whilst others (usually SMEs that find the improved in order to allow more appropriate, useful price of such a service too high to be cost effective) models of OH to bloom: these are based on the notions provide none at all. of making OH services more widely available, less focused on the needs of the employer, and more widely The second issue informing this perception is that there based than on doctors alone. For example, the entire is confusion over the role of the OH service; is the professional group of occupational therapists was service there to help the ill person, or to assist the notable in this study by its absence (although we had employer? In other words, who is the client? This some stalwart attendees at the seminars), and there question was almost always posed in an adversarial way would seem to be a niche waiting to be carved out by with the needs of the patient being perceived as them. A new cadre of occupational practitioners was diametrically opposite to those of the employer, and only mentioned in several of the interviews; another group rarely did anyone see them as aligned. not bound by the strictures of a very traditional medical training. In terms of their utility, it may be helpful to Once again, this seems to link to the issue of ‘ownership’; combine the input end of their function (‘what is going in one of the workshops, for example, it was suggested on?’) with the output end (‘what should we do about it?’), that in a small company owned by its workers, it would be and such an approach might also help to establish and in everybody’s interests to minimise sickness, and that the maintain the neutrality of such a service. The ‘OH occupational health needs of the company would be the helpline’ for SMEs, recommended by Carol Black’s same as those of the employees. It was only when the report and introduced as a result by the Department of interests of the employees became separated from those Health, are one step on this route, but most interviewees of the company that the dichotomy arose, and so one way thought that this represented a first step towards a more to obviate the issue is to remove that distinction, by enlightened OH service, rather than an end in itself. increasing the sense of ‘ownership’ amongst employees.

For most interviewees, OH services were largely seen as representing the employer, policing the sickness of the workforce to ensure that people returned to work as quickly as possible, or were helped to leave if return was seen to be uncertain or unduly delayed. Again, this view may partially be explained by the sometimes ambivalent British attitude to work. There was also a sense that ‘he who pays the piper calls the tune’, and that the needs of the employer were bound to take precedence over the needs of the employee.

23 Health, disease and unemployment: The Bermuda Triangle of society

By nurturing these in a relatively risk free way, the agencies are fulfilling a task far larger than merely 06 ‘signposting’ the journey back to employment, or acting as brokers for available employment, which is how the Themes larger, more impersonal agencies such as Job Centre Plus are perceived. They are helping to rebuild the skills and attitudes that are needed for survival and success in the work place.

Clearly, there is an economy of scale in providing Where welfare is concerned, small is beautiful services that help people back to work (particularly those In the struggle to move from worklessness (whether due that are directly funded by the public purse, where thrift to ill health or some other reason) back to full and probity are paramount), but the clear message from employment, an important observation that came out of this work is that any benefit of size is more than offset by all the work of this study was the inverse relationship the dis benefits in terms of intimidation and lack of between the size of a ‘helping’ organisation and its involvement that go with large scale. It may be that the perceived utility. Time and again, interviewees and compromise is to allow the commissioning of such seminar attendees reinforced the daunting nature of services by public agencies through smaller, more nimble dealing with State bureaucracies, and the relative relief private and voluntary organisations that may be held to felt when working with smaller, more focused account on the basis of their results; such an approach organisations that were less formal and more human in would allow probity and efficiency to be served, whilst their scale. Beyond the obvious link between the maintaining the human scale required for effectiveness, bureaucracy associated with size, it is hard to say why and injecting a measure of competition and this was; perhaps the symbolism of size and State act as contestability for good measure too. However, any such a subtle reflection of the link between self esteem and an approach would need to be ‘lubricated’ by simplifying authority. the complex and bureaucratic tendering processes that currently discourage many suitable organisations from Whatever the reason, it became increasingly clear offering their services in the first place. through all the discussions (both with the helping organisations themselves and with the various lobby and expert groups involved) that people seeking assistance to get back to work found it more helpful to deal with small organisations than with large bureaucracies. ‘Job Centre Plus’ in particular was seen as by many as being particularly impersonal and unhelpful, whereas smaller, more directly involved groups such as Tomorrow’s People were seen as offering better advice and seemed to be more in tune with their users’ needs.

This was especially marked when (as was the case with Tomorrow’s People) these agencies made use of clients to help in their running (often on a voluntary, unpaid basis). Such involvement seemed to help to build up clients’ confidence, perhaps because there was less ‘performance anxiety’ when there were no wages or formal obligations involved, and hence get them re-familiarised with the routines and rituals of the workplace: timekeeping, socialisation, formal tasks, and so on. At a more conceptual level, the involvement with a small organisation that was run by people who had themselves been in a similar position of unemployment, promoted a sense of ‘belonging’ and help to engender the sense of ownership (this time of the organisation) that is needed if the responsibility, motivation, and pride that are vital for sustainable and satisfying employment are to be developed.

24 General practice: tinker, tailor, provider, landlord, Taken one step further, is there a role for GPs to take up case manager, or none of the above? such a function more formally, and work as a ‘neutral In the area of general health care, much is written about agent’ in the area of occupational health? the place of primary care in the delivery of services, and many of the policies of the past twenty years have been General practice as venue for case management: finally, predicated on the transfer of activity and responsibility bringing together the idea of care ‘closer to home’, case to primary care in general, and general practice in management, and the notion of ‘small is beautiful, particular. During our work on the ‘Bermuda Triangle interviewees had some interesting views regarding the of society’, the place of general practice was raised in a use of general practice (or other community based number of ways, and these are discussed below: facilities) as the local base for the provision of services and advice. General Practitioner as case manager: the GP has a central place within the NHS as the co-ordinator of care. Interestingly, there was little consensus as to the place of They are the person who ‘holds the ring’ of what is general practice in solving the conundrum of the provided to their patients, and keeping a record so that Bermuda Triangle. Where the issue of case management the overall provision of care is appropriate, co-ordinated, was concerned, whilst most people acknowledged the and contextualised by the GP’s knowledge of their place of GP as the conceptual case manager in a medical patients in terms of their physical, social, and context, there was not much support for the idea of psychological needs (the so-called ‘triple diagnosis’ letting him/her act as case manager in the field of already discussed above). How well could this concept unemployment and the return to work. Some put this be applied to the area of health and unemployment, down to a perceived lack of skills and interest amongst where the complexity of issues is at least as diverse as in GPs, whilst others felt that this approach would be ‘ordinary’ illness, and where the case for continuity and medicalising a social issue in an inappropriate way. someone to act as mentor and guide is at least as strong? Others again liked the notion, but felt that GPs were already overwhelmed with their current tasks without GP as social security fundholder: in the medical field, taking on a new burden. there has been a growing awareness that GPs effectively control hospital activity by dint of their referrals, and A similar logic informed interviewees’ responses to the this has been used as the basis of a number of initiatives idea of GP as fundholder in the field of worklessness; in that linked their clinical control to a financial interest. addition to the perceived lack of interest/expertise/time, By giving these ‘fundholding’ GPs a vested interest in the there was a feeling that there might be political outcome of their actions (inducing the same sense of difficulties in allocating public funds to GPs to disburse ownership that has already been mentioned in a number as they saw fit without enough accountability. Where of different contexts), the theory was that these GPs GPs as OH physicians was concerned, views were more would feel more involved and act more responsibly in mixed; there was a theoretical agreement with the move carrying out their referrals. Where returning patients to away from ‘sick notes’ towards the idea of defining how the world of work is concerned, there is an hypothesis well a person was, but there were mixed views about the that giving GPs a similar vested interest in the outcome specific notion: one positive view expressed was based (of a healthy and sustainable return to work) by giving on the idea of the GP merely defining that the patient them control of the resources to manage that return was fit for ‘some’ work, and letting the employer then might reap the same benefits. decide how best to utilise the patient’s working abilities.

So interviewees were asked their views about GPs being However, interviewees were concerned that if GPs were given (at least some of) the social security budget to allow expected to define the extent of their patient’s fitness, them to spend it more flexibly (say in treatments such as they would have to develop a sense of all the skills physiotherapy, occupational therapy, or even other less required by local employers, a full understanding of conventional approaches) in the attempt to get patients occupational health, and be prepared to accept a degree back to work more quickly. of accountability (including, presumably, legal liability) for their decisions. Once again, there were doubts GP as occupational health physician: part of the expressed about GPs’ inclinations/expertise/time to report produced by Carol Black introduced the notion of carry out this role. One interesting view expressed was the ‘wellness note’, by which GPs signal their patients’ the idea of incorporating some work related targets into ability to return to some measure of work activity. This GPs’ Quality and Outcomes Framework (QOF), whose idea is currently being developed and rolled out, so achievement is linked to their practice income. interviewees were asked their views on the idea of GP as OH diagnostician, deciding who is able to work, and to what level.

25 Health, disease and unemployment: The Bermuda Triangle of society

hours and a variety of permutations of chairs, desks, and equipment, its ability to do even this would depend on its 06 size; a company of 300 employees should be able to offer more flexibility in any of these factors than a company Themes of ten employees. Conversely, it would be hard for a construction company to take on (or retain) labouring staff with conditions such as rheumatoid arthritis, unless those staff were able and willing to be completely retrained in desk jobs that might be totally alien to them.

The area in which there was most consensus concerning Part of the problem is perceptual and commercial; there the role of general practice was in the use of GP facilities is good evidence that supportive companies that treat as a venue for the work and advice required to help the their staff well and are prepared to be flexible have workless get back to work. The local nature of such reduced staff turnover (and hence lower training time facilities means that such services may be provided in and costs), increased productivity, and better longevity. ways suitable for each local community; they are also However, commercial pressures are often perceived as small and informal enough to avoid the sense of being overwhelming, and many companies take a very bureaucracy and disempowerment linked to the short term view of staff welfare. This is particularly so at enormous edifices of the State. Such centres could be the unskilled end of the market, where training, and populated by staff from private and/or voluntary professional judgment may matter less than sheer organisations, or by more traditional providers of advice, muscle, and where recruitment is relatively easy and but the idea of linking the tasks associated with the retention therefore less important. return to work to the specific health issues at a single venue was appealing to most who expressed a view. To make matter worse, in trying to persuade companies to (say) initiate an occupational health function, it is difficult to demonstrate that they would reap benefits The flexible workplace: oxymoron or aspiration because those benefits are measured in absences, and If we continue categorising the findings of the study in negatives are always much harder to prove: predicting a notional chronology, then the next stop after the the absence of sickness or a reduction in turnover support and rehabilitation offered during worklessness require a leap of faith, and such faith is often the missing should be the re-entry to work, and here we come up ingredient in introducing some of these changes. against the fact that the variety of workplaces is almost infinite, making specific responses to bringing people back to work impossible to prescribe. Incentivising the return to work Finally, to close the circle that runs from the occurrence However, there are probably a number of generic of illness through worklessness and back to the principles that one could apply to the manner in which workplace, it is worth noting interviewees’ thoughts on employers respond when their staff are unable to work the incentives (both positive and perverse) that exist to due to ill health, or to the way in which they might aid and abet in the this process. In this, there is a strong respond to applications to work from those who are politicial element, as peoples’ views on welfare payments chronically workless. These might include: vary considerably. Most participants agreed however that those who were workless through no fault of their Be prepared to be flexible in the working own needed support; the challenge was how to wean • conditions (physical and temporal) that you offer them off it without creating unnecessary hardship.

Take a long term view of staff morale and Intrinsic to this puzzle is the eternal welfare conundrum: • wellbeing: loyalty breeds profits make benefits too good, and nobody wants to give them up; make them too poor, and people suffer. This paper is Offer appropriate occupational health support not the place for a detailed answer, but out of the • interviews emerged the notion of some kind of tapering Tailor the tasks to the abilities of your staff, scale, that married a welfare payment that reduced as • and be prepared to modify these ‘real’ income grew without any ‘step changes’ being triggered that would invoke the classic ‘benefits trap’. In reality, of course, the ability of companies to live up to these promises depends on many factors, some Such a taper is clearly meant to be applied at the end of absolute, some relative, and many a matter of opinion the story when ‘they lived happily ever after’. At the and attitude. Thus, whilst an office based agency doing ‘once upon a time’ end, views from the respondents were computer based work might be able to offer flexible fairly consistent that the current interventions happened

26 far too late: companies rarely identified potential health or performance issues in time to deal with them while employees were still working; state run interventions to get people back to work or to stabilize their payments happened only after they had been workless for several months.

What was required was genuine early intervention, preferably in time to preempt the whole workless phase, particularly when it was a predictable health issue that was causing the problem. Thus, rather than waiting until the rheumatoid arthritis had become so bad that one’s usual work had become completely impossible, it would be better to have discussed with one’s employer the possible alternatives, and set them up so that work of some kind could be set up in a sustainable way that maintained continuity of income for the employee, continuity of output for the employer, and one less person on State Welfare. Of course, measures would have to be taken to ensure that employees would not be disadvantaged by their employer for their openness. It may be that medical support for such interventions could be an extension of the ‘fit note’ idea, using the GP’s imprimatur to validate such discussions, and preempt any punitive reaction by less enlightened employers.

The incentives are fairly clear for both the victim and the State; however, as the system currently runs, it requires an enlightened employer to see that the long term advantages of looking after their employees far outweigh the short term costs of keeping them at work at a lower level of productivity whilst their problems are being resolved.

Moreover, it takes a particularly enlightened company to be prepared to accept back into the workplace an employee with limited capacity, who may need physical adaptations as well as concessions in terms of working hours, job role and so on.

One possible lever for change suggested by an interviewee was the HSE (Health and Safety Executive). Until now, most of the HSE’s recommendations have been based on physical changes to make the working environment safer for employees. However, with the rising awareness of and interest in work related stress, it may be that increasing the profile of the HSE in this area could bring sufficient pressure to bear on employers on their prevention and more effective treatment of the condition when it occurs at work. Fear of liability and of compensation, whilst not the most altruistic of drivers, may be a useful adjunct to the beatitudes of the moral high ground.

27 Health, disease and unemployment: The Bermuda Triangle of society

The British and Work It is clear that unemployment causes ill health just as ill 07 health causes unemployment, and that a return to work can (if used appropriately) improve health. Those who are Summary of unemployed are seen (and see themselves) as having less value as people than those in work. This phenomenon is Key Messages more marked amongst those who have been in work and then become unemployed. There are currently no real incentives for employers to adapt work circumstances to suit the needs of the disabled person, which makes getting such people back to work highly problematic.

01 It would therefore seem sensible for the first aim of any policy change to make it in the interests of the individual, the employer, and society at large to align the incentives and close the loop between health, illness, and unemployment.

There is a dissonance in British culture between what people say about the benefits of work and what they feel about it; work is often seen as a necessary evil. This view is more marked the lower the perceptions of control felt by workers; productivity, sickness rates, staff turnover, even life expectancy all worsen when employees feel ‘done to’ rather than ‘doing’, and the lower down the employment chain people work, the less sense of control they have.

02 Raising the perception of control is key to improving productivity, and all the work on leadership, engagement, and so on is actually trying to do this. An overt focus on improving this culture would reap rapid and sustainable benefits.

Given that the distinction between illness and unemployment seems to be artificial, it is self evident that ill health is likely to result in some inability to work effectively.

03 Getting patients back to productive and sustainable work should become a key objective and outcome indicator for all health services, particularly the NHS. All forms of clinical education need to include this aim from their outset, and throughout both undergraduate and continuing training.

04 An important aspect of this emphasis must be the inclusion in the diagnostic process of the social and psychological aspects of an illness as well as its physical manifestations, and treatment should be aimed at ameliorating patients’ ability to return to work as part of returning them to better health.

Conversely, increasing the awareness that unemployment per se adversely affects health would help to overcome the isolation surrounding the workless, and help to preempt the vicious circle of unemployment and chronic illness.

28 05 One essential in this regard would be the the employees are different to those of the company, that strengthening of direct links between the NHS the dichotomy arises, and so one way to obviate the issue and the Department of Work and Pensions (DWP). is to remove that distinction.

Such ‘horizontal integration’ will continue to make the OH services are often seen as policing workforce sickness holistic care of the workless (for whatever reason) easier to ensure that people return to work as quickly as to manage, and would signal the Government’s intentions possible, or are helped to leave if return is seen to be to continue to tie health and work policies more closely unduly delayed. They are seen to have a strong together. Strengthening these links directly would also biomedical bias, that favours the physical aspects of allow those working in either sector to begin to make the disease and disability, rather than including the social interpersonal contacts that are key to the development of and psychological aspects. effective and sustainable relationships. ‘Outsourcing’ such joint ventures to external agencies (particularly when they Overall, OH services are seen as patchy in their are still being developed) risks broadcasting an entirely availability, partisan in their application, and narrow in different, and less positive message. the scope of ‘dis-ease’ with which they currently deal.

07 These perceptions could be improved by making Prevention is better than cure, OH services more widely available, less focused on even with long term ill health the needs of the employer, and more widely based Chronic illness rarely comes completely out of the blue than on OH doctors alone . In terms of their yet our society seems only to consider the implications utility, it would be helpful to combine the input end of illness at work in binary terms: a person can either of their function (‘what is going on?’) with the work, or they can’t. If people who knew that they had a output end (‘what should we do about it?’), and long term condition (LTC) could negotiate much earlier such an approach might also help to establish and the appropriate changes to their working conditions, maintain the neutrality (real and perceived) then they would be able to lead a much more positive, of such a service. contributory life to the benefit of society as a whole as well as to themselves and their families. Early intervention is the LTC version of prevention being better than cure.

06 To do this, there needs to be an acceptance on the part of the employer and of wider society that it is normal for the work environment and job roles to change as people’s careers progressed, even if that entails physical change (seating, instrumentation, etc), and changes to the terms as well as the conditions of employment.

Such a change would also chime with our changing attitudes to retirement; the same attitudinal changes could apply as age and energy (as well as motivation) affected people’s work abilities, thus helping to maintain people’s presence at work and optimising their effectiveness.

Occupational health: it is broke, so let’s fix it Occupational Health (OH) services are currently seen as unwieldy, archaic, and of limited utility. Their position within the health sector is poorly understood, and employers vary in their OH provision. There is confusion about whether OH services are there to help the ill person, or to assist the employer. The needs of the patient are often perceived as opposing those of the employer; rarely are they seen as aligned, and then only when employees have a strong sense of ‘ownership’ of their jobs and their companies. It is when the interests of

29 Health, disease and unemployment: The Bermuda Triangle of society

a new burden. Similar logic underpinned responses to the idea of GP as ‘fundholder’ in the field of 07 worklessness; in addition to the perceived lack of interest and/or expertise and/or time, it was felt that there might Summary of be political difficulties in allocating public funds to GPs to disburse as they saw fit without much visible Key Messages accountability. In principle, there was agreement with the move away from ‘sick notes’ towards the idea of defining how well a person was, but there were mixed views about the specific notion, and its practical Where welfare is concerned, small is beautiful difficulties in terms of skills, and accountability There is an inverse relationship between the size of a (including legal liability). ‘helping’ organisation and its perceived utility. Dealing with State bureaucracies is seen as daunting compared 09 There was more consensus concerning the use with working alongside smaller, more focused of GP facilities as a venue for the work and advice organisations that are less formal and more human in required to help the workless get back to work. their scale. This is especially marked when such agencies Their local nature and size and relative informality make use of clients to help in their running. Involvement are helpful, and they could be populated by staff of this kind seems to help to build up clients’ confidence, from private and/or voluntary organisations. The and get them re-familiarised with the workplace, as well idea of linking the tasks associated with the return as promoting the sense of ‘belonging’ vital if sustainable to work to specific health care issues at a single and satisfying employment are to be developed. venue was also appealing.

Such agencies are fulfilling a task far more significant than merely ‘signposting’ the journey back to The flexible workplace: oxymoron or aspiration employment, or acting as brokers for available In an ideal work/health world, employers should: employment, which is how the larger, more impersonal agencies such as Job Centre Plus are perceived. Be prepared to show flexibility in the working • conditions (physical and temporal) offered 08 Clearly, whilst there is an economy of scale in providing services that help people back to work, Take a long term view of staff morale and the clear message from this work is that any • wellbeing: loyalty breeds profits benefits of size are more than offset by the disbenefits in terms of intimidation and lack of Offer appropriate occupational health support involvement that go with large scale. Allowing the • commissioning of such services by public agencies Tailor work tasks to the abilities of their staff, through smaller, more nimble (yet accountable) • and be prepared to modify these private and voluntary organisations may overcome this apparent conundrum. Whilst there may be practical difficulties in implementing all these aspirations in all companies, it is Such an approach would need to be ‘lubricated’ by clear that companies that treat their staff well and are simplifying the complex and bureaucratic tendering prepared to be flexible have reduced staff turnover, sick processes that currently discourage many suitable leave, and absenteeism. organisations from offering their services in the first place. 10 However, predicting the absence of sickness or a reduction in turnover require a leap of faith, and such faith is often the missing ingredient in The role of general practice introducing some of these changes. This may There was little consensus as to the place of general be one area where legislation concerning practice in solving the mystery of the Bermuda Triangle. the employee benefits mentioned above There was not much support for the idea of letting GPs may be appropriate. act as case managers in the field of unemployment and the return to work, partly because of their perceived lack When the macro economy is struggling, persuading of skills and interest, and partly because their approach Governments to make this same leap of faith may be as might be medicalising a social issue. difficult as doing it with reluctant companies.

Others liked the notion, but felt that GPs were already overwhelmed with their current tasks without taking on

30 Incentivising the return to work 14 One possible lever for change raised by this study is The eternal welfare conundrum (make benefits too good, the Health and Safety Executive (HSE). Currently, and nobody wants to give them up; make them too poor, most HSE recommendations are based on physical and people suffer), has always suffered from its position changes needed to make the working environment trapped between opposing political philosophies. In the safer for employees. However, with the rising current political climate, we may have a rare opportunity awareness of and interest in work related stress, it to allow it to escape and be solved. may be that increasing the profile of the HSE in this area could bring sufficient pressure to bear on 11 It should be possible to introduce some kind of employers on their prevention and more effective tapering scale as health and workfullness improve, treatment of stress. Fear of liability and of by which welfare payments reduce as ‘real’ income compensation may be a useful adjunct to the grows without any ‘step changes’ being triggered in moral high ground. a way that avoids the classic ‘benefits trap’.

At the ‘front’ end of worklessness and ill health, helpful interventions currently happen far too late: companies rarely identify potential health or performance issues in time to deal with them while employees are still working; state run interventions to get people back to work or to stabilize their payments happen only after they have been workless for several months.

12 What is required is genuine early intervention, preferably in time to preempt the whole workless phase, particularly when predictable health issues are causing the problem. There needs to be increased awareness of how important appropriate prescribing is to helping people return to work as quickly as possible.

It would be better at the outset of such a condition to discuss with one’s employer the possible alternatives, and arrange them so that work of some kind could be set up in a sustainable way that maintains continuity of income for the employee, continuity of output for the employer, and one less person on welfare for the State. Of course, measures would have to be taken to ensure that employees would not be disadvantaged by their employer for their openness.

13 It may be that medical support for such interventions could be an extension of the ‘fit note’ idea, using the GP’s imprimatur to validate such discussions, and preempt any punitive reaction by less enlightened employers.

However, in the current system it requires an enlightened employer to see that the long term advantages of looking after employees far outweigh the short term costs of keeping them at work at a lower level of productivity whilst their problems are being resolved, or accepting into the workplace an employee with limited capacity who may need physical adaptations as well as concessions in terms of working hours, job role and so on.

31 Health, disease and unemployment: The Bermuda Triangle of society

This project started by looking at the links between ill health and employment, under the working title of ‘work 08 as a health outcome’. It soon became apparent that the issue was more complex than a simple linear relationship Conclusion between these two, and the concept of the interaction between health, illness and unemployment arose, with a powerful image emerging of the Bermuda Triangle of isolated people invisible to the outside world, and almost impossible to rescue. The paper used a variety of methods to deconstruct some of the issues, and then reconstruct them through a series of interviews and seminars.

The issue is too multifaceted to be able to produce a simple set of recommendations. Dame Carol Black’s Report has suggested a number of specific changes, some of which have been implemented. However, the overall impression taken away from the interviews was that uptake of the Report’s findings had been limited by lack of political interest.

Thus for instance, one of the Black suggestions was the extension of OH services to cover organisations that would not currently be in a position to use them. The mechanism mooted was the introduction of telephone based OH assistance, which should be available to all employers. Whilst the idea is intriguing, and would clearly be useful, the problems with such a scheme lie in its extent. A telephone based service can never be substitute for proper physical examination, and the level of coverage required to make this anything other than a symbolic gesture is probably not feasible in the short term, especially in straitened financial circumstances, without the political clout to make it really fly.

32 On the other hand, an approach that makes use of Even with such a careful developmental approach, issues existing facilities is relatively cheap, and incremental, might still be raised about funding and organisational evolutionary development is usually more easily format; could employers be persuaded to pay for a assimilated into the national (as well the professional) service that was not beholden to them? Would it be psyche than expensive, disruptive (and professionally reasonable to expect such a service to part of the NHS threatening) large scale change. itself? Is there a viable argument to suggest that users of such a service should contribute to its running costs? With this in mind, it may be that we should looking at basing relatively low level OH services in community Funding also raises the issue of the place of the State in settings (such as NHS facilities including community dealing with the Bermuda Triangle. Much of the work clinics and GP surgeries), to be run by a combination of of both this study and its predecessors is predicated on staff who are able between them to cover both the the basis that lifting the fog of confusion that surrounds assessment (‘diagnostic’) and delivery (‘treatment’) ends its murky centre would liberate the capacity and of the service. The use of that metaphor is ironic, and capability of those who were trapped there, thereby perversely highlights that it would be preferable for such improving their situations as well as increasing the stock a model to encompass the medical model without being of society at large. The spending required to achieve this confined to it, so that the other psychosocial factors that should be seen as an investment, not a cost, for in influence the interaction of work, health and illness in a unraveling this knotty problem, not only will the far less linear way than simple ‘diagnosis’ and ‘treatment’ individuals involved benefit, but the first steps will have may be incorporated into the system. been taken to change for the better Society’s paradigm of values where work, health, and illness come together. Such services would need to be seen as neutral agencies, looking after the needs of their attendees rather than those of the employing organisation, and this suggests a place for the private and voluntary sectors, with their small scale and local ownership.

33 Health, disease and unemployment: The Bermuda Triangle of society 09 Footnotes

1 Health, Wellbeing and Work Directorate 2005 32 McGee, Bevan and Quandrello pp 52 2 Department of Health. 7th Dec 2009 33 Mowlam A, Lewis J. 2005 pp 2 3 Boorman Review 2009 Exec Summary pp 2 34 RCGP. National Education Programme for General practitioners. See http://www.rcgp.org.uk/news_and_events/ 4 Marmot review 2010 pp 9-20 courses__events/health_and_work_training.aspx http://www.ucl.ac.uk/gheg/marmotreview/FairSocietyHealthyLives ExecSummary 35 Black C. pp17 5 Rose D. 11th February 2010 36 Marmot Review 2009 pp 3 6 Lichfield P. 2007 pp 3. 37 Constable S et al. 2009 pp 6 7 DWP administrative data 2007 38 HSE. Health and Safety Statistics 2008/9 National Statistics 8 HSE. National Statistics, Health and Safety 2008/9 39 Vaughn-Jones H, Barham L. pp 38 9 Department of Work and Pensions, Vocational Rehabilitation 40 May 2009. pp 4 2004 pp 16 41 Palmer KT, Cox RAF, Brown I. 2007 pp 77 10 Aylward M. 2003, pp 287-299 42 Odonnell M, Reymon J. October 2009 11 ARMA 2007 pp 3 43 DWP 2009 http://research.dwp.gov.uk/asd/stats_summary.asp 12 See www.fitforworkeurope.eu 44 Wallop H. The Daily Telegraph 1st Feb 2010 13 Department of Health, Musculoskeletal services framework 2006 45 SCMH. Briefing 40: Removing Barriers. July 22nd 2009 14 ARMA 2009. pp 3 46 Brown J, Hanlon P, Turok I, Webster D, Arnott J, Macdonald EB. Oct 2008:1-7 15 NAO 2009. pp 5 47 Bewley H, Dorsett R and Salis S. DWP Research Report 16 ARMA 2009. pp 5 601 2008 17 Department of Health, New Horizons 2009 48 Adam et al. DWP Research Summary 498 2008 18 Perkins R, Farmer P and Lichfield P. December 2009 pp 12 49 ARMA Joint Working 2006 19 http://www.direct.gov.uk/en/DisabledPeople/HealthAndSupport/ 50 Black C. pp 17 MentalHealth/DG_179325 51 DWP Access to Work Statistics January 2010 20 Fitch C, Daw R, Balmer N, Gray K and Skipper M. 2008 52 Marsden D, Marcioni S. pp 1 21 Sainsbury et al. Research report no. 513 2008 53 Ibid pp 17 22 SHiFT Line Manager’s Resource 2007 pp 6 54 PricewaterhouseCoopers 2008 pp 7 23 Fitch C, Daw R, Balmer N, Gray K and Skipper M. 2008 pp 11 55 Kennedy I. 2009 24 DWP. 56 Kanovos P, Manning J, Taylor D, Schurer W, Checchi K. 2010 25 RCPsych position statement 2009 pp 7 57 Wadell G, Burton K. 2006 pp 146 26 Perkins R, Farmer P and Lichfield P. December 2009 58 Constable S et al. 2009 pp 6 27 DH New Horizons 2009 pp 36, 42 59 Black C. pp 76 28 SCMH. Briefing 40: Removing Barriers July 2009 60 PricewaterhouseCoopers 2008 pp 7 29 Wilson A. 2007 30 SCMH. Shepard G, Boardman J and Slade M. SCMH 2008 pp 5 31 BMA press release April 20th 2010

34 Health, disease and unemployment: The Bermuda Triangle of society 10 Appendices

Appendix 1 Work Outcomes Interview Schedule Interviewees asked about their name and position and introduced to the project in a preamble that confirmed that participants understood the objective of the review and their willingness to contribute.

Questions 9. What (if anything) do you know about Carol 1. Personal details and role in your organisation Black’s ‘Working for a healthier tomorrow’, (Brief outline of professional role and career path to date, and the Government’s response ‘Improving Job title, role, CV, ambitions) Health and Work: changing lives’? 2. How (if at all) does your organisation’s work (try to get their sense of these: recommendations, opinions on impinge on the ‘world of work’? their relevance, usefulness, etc) (specific work in this area, keeping people at work, returning 10. Given a clean slate, what would you do to make them there, etc) work a health outcome? 3. What do you think is the relationship between (personally and organisationally) health and work? 11. Have you any other thoughts or observations? (personally and organisationally) 12. Closure 4. What are your views on the notion of ‘work as a health outcome’? (re-iterate confidentiality, future progress of project, feedback from process) (irrelevant, exciting, obvious; explore in some detail) 13. Emerging themes and messages 5. Are there any areas of ill health where this is more (in)appropriate? (main issues, plus any other observations (e.g. interview dynamics etc)) (musculoskeletal, mental health, social, disability, illness linked to unemployed etc) Jonathan Shapiro & Julia Manning 6. How could NHS mechanisms be better used to get October 2009 people back to work more quickly, and in a sustainable way? (role of GP, clinical services (e.g. physio), referral process, 1°/2° care interface issues, technological solutions etc) 7. How could non-NHS mechanisms be better used to get people back to work more quickly, and in a sustainable way? (local authority, social security, voluntary/private sector: health insurers, employers, etc) 8. Have you heard of the ‘fit for work’ schemes? (if so, can you describe them? Who should be responsible for their implementation? On what (if anything) is their success contingent?)

35 Health, disease and unemployment: The Bermuda Triangle of society 10 Appendices

Appendix 2 Interviewees

Name Title Organisation

Samantha Peters CE British Society of Rheumatology

Leonie Dawson Professional Advisor Chartered Society of Physiotherapy

Rachel Hunter Clinical Director RehabWorks

Delia Skan HSENI, civil servant Faculty of Occupational Medicine of the Royal College of Physicians

Ann McCraken Chair International Stress Management Association UK

Prof. Alan President Faculty of Public Health Maryon-Davis

Dr Jed Boardman Consultant Clinical Psychiatrist SCMH Royal College of Psychiatrists

Prof. Jonathan Ayres Environmental & Respiratory Medicine University of Birmingham. Professor and Director of the Institute of Occupational and Environmental Medicine

Col. Malcolm Braithwaite Army Professor of Occupational Medicine University of Birmingham. and Honorary Senior Lecturer

Mike Sobanja Chief Officer NHS Alliance

Karen Charman Head of Employment Services NHS Employers

Steve Shrubb Director of the Mental NHS Confederation Health Network

David Colin Thome National Director of Primary Care Department of Health

36 Name Title Organisation

Ros Meek Director Arthritis and Musculoskeletal Alliance

Brian Kaiser CE British Occupational Health Research Foundation

Helen Bunyan Membership Manager National Rheumatoid Arthritis Society

Steve Swan Director of Welfare to Work Tomorrow's People

Prof. Bob Grove Joint Chief Executive SCMH

Paul Corry Director of Public Affairs Rethink

Richard Frost Vocational Services Manager WorkWays

David Hawley Operation Manager Working Links

Andy Jones Medical Director Nuffield Health

Dudley Lusted Head of Corporate AXA PPP Healthcare Healthcare Development

Dr Mike O’Donnell Chief Medical Officer UNUM

Helen Merfield CEO HCML

Bronwen Williams Occupational Therapist UK QBE

Kelly Du Preez Physiotherapist UK QBE

37 Health, disease and unemployment: The Bermuda Triangle of society

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41 Health, disease and unemployment: The Bermuda Triangle of Society Jonathan Shapiro Emma Hill Julia Manning

The measure of successful NHS treatment is increasingly not a case of whether a process target has been met, but whether that treatment was a success. In other words, what was the final ‘outcome’? Did the patient get better and stay well? Added to this is the crucial question for the working age population – how quickly did they get back to work?

This project looked at whether being at work is or could be considered a clinical ‘outcome’ of successful health treatment. Can keeping people in work or returning them to work find its place as an indicator of a successful health intervention on which professionals or institutions can be measured? We make fourteen recommendations and observations that we believe will be of value to policy makers. The overall challenge is increasing the visibility to frontline professionals and employers of those trapped in the ‘Bermuda Triangle’ of illness, wanting to work and unemployment - rescuing or preventing them from getting lost there in the first place.

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