Health and Worklessness Implications for Primary Care

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Health and WorklessnessImplications for Primary
Care

• Dr Linda Harris MRCGP
• Clinical Director (WISMS)
• GP Member of the Wakefield Worklessness LAA
  Strategy Group

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The Worklessness Charter

• We have a professional responsibility to work
  with patients and their employers to ensure an
  individuals long term employment is not
  negatively affected by poor sickness management
• As medical practitioners we have a vital role to
  play in helping society understand the
  circumstances and aspirations of those farthest
  from the labour market?
• Primary care is best placed to understand the
  wide scale impacts of an individuals
  illness.
• Healthcare professionals have a role in
  highlighting to an individual the role of
  employment status in recovery
• Healthcare professionals have a role in offering
  Evidence Based Interventions that support
  recovery and rehabilitation

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What I will be covering in the presentation

• The relationship between worklessness and health
• Develop the case for GPs and employers working
  together to support people in returning and
  maintaining work
• Identify what works?

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The post Wanless world

• Health policy post Wanless places emphasis on
  personal responsibility for ones own health
  Choosing Health
• Shift from passive recipients of healthcare to
  proactive participants in healthcare ( Our health
  Our care Our say)
• Implicit in welfare reform is commitment to
  improving peoples health and well being
• NHS (primary care) is significant player

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• 2.6 m claim Incapacity Benefit (IC)
• 13billion cost of tax payer per year
• 8billion expenditure on mental health services
• 4billion output lost from depression anxiety
  (annually)
• The longer someone is off work the less likely
  they are to return
• If someone is off work for 1 year they could be
  on benefit for up to 8 years
• Once someone has been on IB for 2 years they are
  more likely to die or retire than to ever work
  again

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• Of all people receiving incapacity benefits
  nationally, nearly 40 have mental health
  problems as their main disability and mental
  health problems are a secondary factor for
  another 10 or more (DWP)
• More people with mental health problems claim IB
  than the total number of people on job seekers
• 79 respondents to HCC survey of mental health
  patients not in paid employment, half who wanted
  help had not had any

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Mental health and worklessness

• Work has been shown to have a beneficial effect
  on mental health
• Unemployment has been shown to adversely affect
  mental health
• Psychological symptoms associated with
  unemployment range from depression and anxiety to
  self harm and suicide

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Health and worklessness

• Unemployed people suffer higher levels of
  morbidity than people in work
• Mortality rates ( particularly premature
  mortality) are consistently higher with an
  excess risk of death of 20
• Young men relatively high rates of injury and
  poisoning and suicide
• Unemployed women increased risk of CHD
• Mortality rates of unemployed women mirror those
  of their husbands
• Unemployed people with pre existing chronic ill
  health suffer double disadvantage

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• Children with low level educational attainment
  tend to suffer from poor adult health related
  to limited opportunities and associated material
  deprivation
• Note relationship with physical environment
  graffiti, vandalism, lack of open spaces not
  conducive to mental health with negative impact
  on educational attainment

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• Evidence from US of projects providing support to
  parents through provision of childcare to
  facilitate further education and employment
• Parents more involved in childrens education
• Better employment prospects
• Benefits to children in physical, emotional and
  intellectual development

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• The circumstances, needs capacities and
  motivations of unemployed people are extremely
  diverse
• Certain groups are farther away from the labour
  market than others
• Homelessness, drug and alcohol addiction, mental
  health and physical disability are significant
  obstacles constraining the attainment of full
  employment
• Diversity BME, womens and cultural issues

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Worklessness local context

• The district has the second highest levels of
  worklessness in West Yorkshire,
• approximately five times more people on
  incapacity benefits than on Job Seekers Allowance
• 20,000 Wakefield residents on incapacity benefit,
  as well as smaller numbers on lone parent
  benefits
• High proportion of long term IB claimants the
  highest in W Yorkshire
• In Wakefield district, some 2,500 people with
  severe mental illness are supported by mental
  health services.

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Ill health, worklessness and local deprivation

• 35 of the Districts population live in areas
  designated the most deprived in England (14.3
  national average). The Indices of Deprivation
  2004 show that the District is particularly
  affected by health, employment, income and skills
  deprivation.
• Over 26 of people employed at workplaces
  situated within the District have no
  qualifications, the highest rate in the region
  and well above the 18 national average.
• Over 39 of people living in the District
  (aged16-74) have no qualifications, rising to 77
  in some parts of the District
• Neighbourhoods most affected by industrial
  decline have high level of dependence on
  Incapacity Benefit

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Incapacity benefit reform

• Through the Local Area Agreements
• Binding contractual agreement between local
  authority, Health, Police, Job centre plus
• Harness the various funding streams that come
  down at once from various government departments
• Four areas including economic development and
  enterprise
• Can incorporate an invest to save fund
  comprising savings made against getting people
  off IC

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Incapacity benefit reform (2)

• By reforming the current policing role for GPs in
  relation to IB
• Managing the tension between GP as patient
  advocate and care provider and their role in
  encouraging patients back to work
• By taking the responsibility away from GPs
  altogether and passing it over to an independent
  panel of doctors and PAMs
• By encouraging a more proactive role for GPs
  working with employers and OH in prevention and
  treatment

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Incapacity benefit reform (3)

• Better access to supported employment
  opportunities for people with SMI
• Creative partnerships between mental health
  trusts and local employers
• Giving mental health trusts the budgets to pay
  patients when they are off work and pay a wage
  instead of IB when they are employed
• Any savings returned to the system to support the
  supported employment schemes
• Volunteering schemes to assist mentally ill
  patients increase self esteem, confidence, social
  skills and social networks

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Incapacity benefit reform (4)

• By the NHS leading by example
• Mental health and employment in the NHS guiding
  principles for current and future employment
• By employing a disabilities coordinator whose
  role is to increase the number of individuals
  with disabilities recruited, breaking down
  barriers, raising awareness, encouraging disabled
  people to apply for posts
• Employment charters

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Pathways to work

• Pilot projects support people on IB by offering a
  range of voluntary treatments
• Mainstay of all interventions is conditions
  management in partnership NHS and Job Centre Plus
• Cost benefit analysis of Pathways to Work is
  significant
• Plans to abolish IB and replace with two new
  benefits -
• Disability and sickness allowance
• Rehabilitation support allowance
• Aim - to differentiate between severe conditions
  and those more manageable in the short term

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Conditions management key principles

• Shift in focus away from an individuals problems
  and toward their capabilities
• Inherent in process is an understanding of the
  complex barriers and insecurities that hold some
  people back
• Treat individuals as citizens with rights and
  choices rather than provider targets

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Primary care, and worklessnessfocusing our
efforts

• Individuals with mental health problems such as
  stress or depression, known to primary care,
  whose clinical diagnosis does not currently merit
  therapeutic interventionshttp//www.strategy.gov.u
  k/downloads/files/mh_layard.pdf
• Problematic drug users with significant mental
  health problems receiving clinical intervention
• The long-term unemployed
• Once someone has been on incapacity benefit for
  two years, they are more likely to die or retire
  than they are ever to work again

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number of claimants who are in receipt of IB/SDA
due to a mental condition.
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Managing common and enduring mental health issues

• Whole person vs. health specific approach
• Aligned with long term conditions management e.g.
  diabetes, COPD
• Incorporates well being support
• Approach suitable for common and enduring mental
  health problems - complexity, chronicity,
  multifactorial, treatment resistant e.g.
• Debilitating depression
• Debilitating anxiety and anxiety related
  disorders
• Chronic self harm
• Mild to moderately severe eating disorders
• Chronic stable SMI

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Requires

• Multidisciplinary approach
• Clarity of roles and responsibilities in relation
  to stepped care and case management
• Access to non pharmacological interventions
• Exercise
• Complimentary therapies
• Facilitated self help
• Basic skills in talk therapies esp. CBT and
  MET, solution focussed
• Group work
• Timely referrals for more specialist psychology
  and psychiatry where necessary

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Better outcomes associated with -

• Competent and motivated Primary Healthcare Team
• Rigorous application of mental health assessment
  and outcome monitoring tools
• Integration of well being support
• Safe drinking, smoking cessation, dietary
  factors, exercise, hobbies and recreation, self
  esteem and confidence, drugs awareness

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The GP and Medical Certification

• Sally is a forty year old administrator in the
  health service, a mother of three small children
  you are aware that over the past year they have
  had some financial difficulties and her son has
  recently been diagnosed with ADHD. Her father has
  Alzheimer's disease and she has been absorbing
  caring responsibilities. She has a history of
  recurrent mild to moderate depression for which
  she has had several short courses of SSRIs.
  During todays consultation Sally breaks down I
  just cannot go on, Im constantly crying and Im
  making mistakes at work I want you to put me
  back on those antidepressants they worked last
  time. Can you write me a sick note I need some
  time to sort myself out
• You counsel her in the ten minute consultation,
  prescribe Fluoxetine 20mgs and make arrangements
  to review her in two weeks time

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• Six weeks have now passed. During this time
  Sallys father passed away suddenly and Sallys
  mood has deteriorated. She has been seen
  fortnightly and the most recent sick note you
  offered is for eight weeks
• You receive a letter from her employer asking you
  When will Sally be back at work?

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• When will Sally be back at work?
• How should the GP respond?
• Does the response help the employer?
• Does the response help the employee?
• How could the question be reframed?

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? A more helpful approach

• Here is a copy of Sallys Job description and a
  list of potential modified duties
• When would you expect Sally to be in a position
  to return to work? by the end of 1 month? if
  not why not?
• Is it OK for us to contact you in 2 weeks for a
  short update report. This will assist us in
  operational planning and arranging temporary
  support

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How can GPs help

• By providing a speedy turn around of reports
• challenged by demands on GPs time, Access to
  Medical Records Act etc, involvement of other
  specialists
• By commenting on how the current illness impacts
  on how a person carries out current job
• By offering clearer and detailed diagnosis
• avoid terms such as lethargy, debility and work
  related stress
• Consider putting prognostic information onto
  medical certificates (e.g. expected to be able to
  return to work in 4 weeks time)
• Identifying triggers and discussing strategies to
  prevent recurrence

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The role of Occupational Health

• Should offer a hub of support
• Consistent link between GP, employer, management
  and the patient
• ? OH specialists in GP surgeries
• OH advice should be passed through to line
  managers
• Need for employers to respect medical
  confidentiality
• Need for OH to offer timely advice and maintain
  appropriate levels of contact with the GP

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Role of occupational health (2)

• Assessing physical and mental ability to do the
  job
• Control point to pull all parties together
• Communicating with GPs
• Giving help on lifestyle factors, smoking
  cessation, exercise, alcohol, diet, CBT,
  counselling etc
• Providing open and shared communication ( with
  employee consent)
• Suggesting redeployment or job role amendments
• Supporting employee to manage condition

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Responsibilities of HR

• Advising guiding and supporting management
• Being a mediator, reference point and policy
  guide
• Providing robust policies and employer training
• Offering job specific training
• Identifying welfare officers and employee
  assistance programmes where appropriate
• Referring onto OH
• Planning phased return plans, modified duties and
  flexible working
• Influencing and encouraging an open culture no
  taboo subjects
• Facilitating back to work interviews
• Involving unions and health and safety where
  appropriate

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• Clarity of roles and responsibilities throughout
  the process for employer, all professionals
  involved and employee
• Being personal
• Being timely
• Access to telephone and online help lines
• Becoming a member of the Mindful Employer
• Encouraging managers to take an active interest
  in employees well being
• Invest in people management skills

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GPs and Employer worklessness initiatives

• Developing partnerships between practices and GPs
• joint training and awareness events
• identifying a named GP Employer Champion
• Practices as sources of information and advice on
  self help strategies
• Accurate and chronological documentation
• Minuting of all joint meetings

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Best Practice Communication with GPs

• Standard letters from employers to GPs
• Consent
• Details of job
• What employer has done
• What employer needs to know e.g. date of return,
  level of functional debilities, modified duties
• Lists of what modified duties are available
• Standardised OH referral and assessment forms
• Access to key policies- flexible working, Drug
  and alcohol polices

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Best practice training support and awareness in
primary care

• GPs need information and training on Occupational
  health - roles and functions
• Access to vocational advice for GPs in the
  surgery can reduce length of time off sick and
  improve communication between health
  professionals and employers
• Access to trained mediators
• Access to mental health awareness training for
  employers
• Access to primary care facilitated CBT

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Best practice employer factors

• Employers to enable safe and secure discussions
  about causes issues problems and concerns was
  it possible to avoid/prevent this episode of
  sickness absence/
• Employers to facilitate sharing lessons from
  causal factors of sickness absence
• Identify those individuals who take frequent and
  short periods off work early referral to OH /or
  contact with GP

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Best practice employer factors(2)

• Proactive, sensitive and regular contact with
  person who is off sick
• when can we expect you back at work! vs. how
  can we help?
• Home visits /neutral venues involving line
  managers
• Formal reviews including, GP HR, Managers,
  employee ( plus representation) external support
• Plan phased returns to work work as part of
  recovery

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Changes to medical certificates

• Work in progress between DWP and DH
• Aim - to redesign the certificate so its easy to
  complete and meets the needs of patient and their
  employers
• GPs expert opinions is being fed into the
  consultation
• Stakeholders including BMA, TUC RCGP and CBI

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Content under consideration for the new Med 3

• To include -
• Medical condition and duration
• Functional limitations
• Reasonable adjustments
• Clinical guidance/management
• Timescale for return to work
• Limitations for overcoming them
• Additional support needed/available

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Content under consideration for the new Med 3 (2)

• Modified duties
• Clear dates for suggested return to work
• Cap on duration of sick notes e.g. no more
  than 3 months before a mandatory clinical review
• Doctors remarks should be mandatory
• Ability to transpose from the GP IT systems onto
  forms

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• WORKSHOP SESSION
• Dr Linda Harris

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Why invest in worklessness initiatives

• Individuals and their families benefit from
  return to work in financial emotional and health
  terms
• Evidence shows that for some patients with health
  problems a return to work will contribute to long
  term recovery
• Savings in doctor time leading to cost savings
  within the GP practice
• Society benefits from individuals becoming
  economically independent rather than benefit
  dependent
• Local communities benefit from more people
  actively contributing to local life

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Vocational employment advisors

• Assess clients strengths and weaknesses in
  relation to employment
• Focus on barriers to accessing work
• Navigate access to arts, leisure, sport,
  vocational and day services and supported self
  care
• Work with primary care on condition management
  plan to tackle weaknesses and barriers to
  employment
• Onward referral, review and advocacy

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Other agencies/options

• Experts by experience
• Colleges
• Local Recreation facilities
• Healthy living centres
• Schools and nurseries
• Voluntary organisations
• Substance misuse treatment agencies and
  structured programmes
• EMPLOYERS

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External support

• Third party support is to be encouraged
• www.jobcentreplus.gov.uk
• Access to work funding for specialist equipment
• Counselling, therapists, mediators
• job coaches
• Travel support
• Addaction
• Optima workplace
• PLUSS
• workWAYS
• employee assistance programmes
• Citizens advice/benefits advisors
• PALS

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What works for individuals

• Outreach services that trade in trust, confidence
  and self esteem building
• Through the use of imaginative and creative
  methods that draw people in who may be
  disillusioned and demoralised
• Gateway services that are accessible and have a
  friendly and positive ethos
• High quality independent personal advisors enlist
  commitment and generate more referrals through
  positive word of mouth
• Learning opportunities, volunteering, work
  tasters need to be seen and counted as valuable
  targets and rewarded as stepping stones in
  personal action plans

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Case study a GP worklessness initiative

• Results of independent evaluation of employment
  initiative at James Wigg Practice Sept 01 Dec
  04
• In house vocational employment advisor integrated
  as part of the PHCT attends surgery one day per
  week
• 200 individuals seen
• 61 registered for the full employment advice
  service
• The remainder received ad hoc advice as required

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The practice cohort

• 59 women
• 41 men
• 44 BME
• 85 long term unemployed
• 46 on combination of incapacity benefits
• 26 job seekers allowance
• 28 economically inactive but not claiming
  benefits
• 19 registered disabled/not producing
  certificates
• 48 below NVQ2 at registration

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Outcomes

• Employment
• 8 clients still in receipt of support
• 36 of completers had employment as their last
  recorded outcome
• 80 of these were still in employment at 12
  months
• 55 of completers achieved other outcomes(
  voluntary work/training)

• Health
• 20 reduction in GP consultations
• 74 reduction in referrals to practice
  counsellors
• 19 reduction in anti depressant prescriptions (
  after 18 months registered with their GP)
• 15 reduction in anti depressant prescriptions
  after 12 months being registered with their GP)

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• David, 37 is long term unemployed, an overweight
  smoker, he regularly drinks 10 pints a night at
  the weekend
• He has three children, his partner works part
  time in a call centre
• A sufferer of chronic anxiety and depression he
  has struggled to hold down employment for over 10
  years
• He is currently working as a bus driver
• Two years ago he started to suffer from Menieres
  disease, he has had numerous episodes of sickness
  
• Routine prescribing and specialist treatment has
  failed to impact on his Menieres symptoms
• Recently his depression worsened and he has been
  off sick for almost 8 weeks. He is reviewed
  fortnightly in the surgery for his anti
  depressants and

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• Ive come in for my sick note doctor
• Im no better
• How will you help David move on