Mental health and work in Norway 2013

MENTAL HEALTH AND WORK: NORWAY

OECD conclusions and recommendations

John MartinDirector for Employment, Labour and Social Affairs, OECD

Niklas BaerAuthor of the Country Report on Norway

www.oecd.org/els/disability >Norway

Dissemination Seminar- 05/03/2013 - Oslo

Contents (for John - not to be shown)

1. Mental ill-health is a key social and labour market issue (3-4; John)

2. Reasons for mental ill-health imposing such a high burden (5; John)

3. The Norwegian context – the broader picture (6-7; John)

4. Problems and recommendations in detail (8-20; Niklas)

5. Conclusions (21; John)

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• Strong employment disadvantage of people with mental disorders:

– In Norway as in other OECD countries, the employment rate of people with a mental disorder is between 55 and 70% (depending on the illness severity) - compared to around 85% in healthy people

• Mental health-related disability benefits have increased– Disability benefit claims due to a mental disorder are on the rise in Norway as

in most other OECD countries – in Norway from around 20% of all new claims in 2005 to around 30% in 2011.

• People with mental health problems have more and longer absences

– In the past four weeks, 30-40% of workers with a mental disorder (depending on the illness severity) have been absent from work - compared to around 20% of workers without a mental health problem.

– The average duration of sickness absence is higher in workers with a mental health problem

• The productivity losses of workers not absent from work are large – this should be the main policy focus in future

– 70 to 90% of workers with a mental health problem have had productivity losses due to a health problem – compared to only 25% of workers without a mental health problem

MENTAL ILL-HEALTH IS A KEY SOCIAL AND LABOUR MARKET POLICY ISSUE

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1 in 5 workers, 1 in 2 unemployed and 2 in 5 inactive people have a mental disorder in NorwayPrevalence of severe or moderate mental disorder (in percentage), by labour force status,

latest year available

Source: OECD (2013), Mental Health and Work: Norway, Paris: OECD Publishing. Figure 1.3 page 26.

MENTAL ILL-HEALTH IS A KEY POLICY ISSUE …… because it is a mass phenomenon

– Point-prevalence of mental disorders in the working population is around 20%

– This applies more or less to all countries, regions and age-groups

– The disorder-prevalence has not increased in the past six decades

– This is a very robust result of many epidemiologic studies all over the world applying professional diagnostic interviews

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MENTAL ILL-HEALTH CAUSES A HIGH INDIVIDUAL, SOCIAL AND ECONOMIC BURDEN, BECAUSE …

• … it mostly starts at a very young age and usually shows an enduring course

• … it affects the brain, resulting - even at a mild level - in relevant disabilities

• … it leads to workplace conflicts, work-related fears and avoidant behaviour

• … it is “unvisible” and related to a still very high stigma

– impeding treatment-seeking and disclosure

– impeding identification and supportive behaviour of the work-environment

– impeding governments to make it a high priority issue

• … current policies and support systems are not yet prepared to tackle mental health-related employment challenges effectively 5

• The NAV-reform – all employment measures under one roof

• A «National Strategy on Mental Health and Work» – pioneering and joint work by the Health and Labour Ministeries

• A traditional work-first approach and many support systems

• High expenditures on Health with many GPs and psychiatrists offering treatment

• High expenditures on Education and a strong focus on a healthy environment in schools

• A strong legislation to ensure health-promotion and sick-leave prvention at the workplace

• The «Inclusive Working Life Agreement» which offers a structure for tripartite co-operation

THE NORWEGIAN CONTEXTPotentials of policies, structures and interventions

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• A strong «First work-approach» – but Norway is highest in spending on disability benefits as % of GDP (2.6%)

• A strong focus on healthy work environments – but sick leave is common

• A strong focus on healthy schools – but Norway is very high in school drop-outs

• A strong focus on equality – but mental health-related inequalities in employment are especially high in Norway

• A strong tripartite structure (IWA) – but almost no obligations for employers and employees to avoid sickness absence, or to enforce re-intergation

• Many social and labour policy reforms – but shying away from necessary (financial) measures

THE NORWEGIAN CONTEXT But strong potentials do not prevent exclusion

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SICKNESS ABSENCESSick leave is a trap for people with mental disorders

Mental conditions are frequent among long-term absences and their share is increasing Share of mental health conditions in total sickness beneficiaries, by duration, 1994-2010

Source: OECD (2013), Mental Health and Work: Norway, Paris: OECD Publishing. Figures 2.1, 2.3 pages 36, 39.

Norway has the highest rate of sickness absences by farIncidence of sickness absence of full-time employees in selected OECD countries

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SICKNESS ABSENCES‘Generous’ conditions are a barrier to job-retention

• The longer the absence the stronger the fear-avoidance behaviour in employees with mental health problems

• All actors and regulations support this negative illness-behaviour:

– Due to the very short employer-paid sick-pay period, employers have no incentives to promote return-to-work

– Due to a 100% replacement rate in case of sickness during one year, employees have no incentives to return-to-work quickly

– Line managers, HR managers and working colleagues are not well-equipped to deal with mental disorders in the workplace, and may be relieved when the mentally ill employee is absent

– The unions are on the healthy workers’ side

– GPs perceive sickness certification as very problematic and do not want to endanger the doctor-patient-relationship

Source: OECD (2013), Mental Health and Work: Norway, Paris: OECD Publishing.9

SICKNESS ABSENCESPossible ways forward

Policy recommendations

– Increase the duration of the employer-paid sick-pay period

– Develop financial incentives for employers to retain employees

– Reduce the replacement rate in case of sickness absence

– Expand and specialise the NAV-Employer Support Centers

» Expand early intervention training for line managers

» Make early intervention a priority in the HR training curriculum

» Base long-term sickness certifications on interdisciplinary assessments

» Develop criteria on when no sick leave should be granted

» Develop standard processes for employers, NAV professionals and physicians on how to co-operate in ‘difficult’ cases

Source: OECD (2013), Mental Health and Work: Norway, Paris: OECD Publishing.10

DISABILITY BENEFITSDisability benefits are a one-way road

Norway has very low disability benefit claim rejection ratesShare of rejected benefit claims among total applications, latest year available

Source: OECD (2013), Mental Health and Work: Norway, Paris: OECD Publishing. Figures 3.3, 3.4 pages 63, 64.

Outflow from disability benefits into employment is close to zeroAnnual outflows to employment as a share of the disability benefit caseload, 1999 and 2008

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DISABILITY BENEFITSArtificial health fluctuations caused by exclusion perspective ?

Symptoms typically improve after disability benefit awardVariation in different symptoms before, during and after disability benefit award (Z scores)

OECD (2013), Mental Health and Work: Norway, Paris: OECD Publishing. Figure 3.8 page 76.

Source: Overland S, N Glozier, M Henderson, J G Maeland, M Hotopf, A Mykletun (2008) Health status before, during and after disability benefit award: the Hordaland Health Study (HUSK), Occupational and Environmental Medicine, 65, 769-73.

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DISABILITY BENEFITSWasting existing working-capacity?

The older the disability beneficiaries, the milder the mental disorderShare of different mental disorders in permanent disability benefits, by age, 2010

Source: OECD (2013), Mental Health and Work: Norway, Paris: OECD Publishing. Figures 3.6, 3.7 pages 67, 74.

0

5

10

15

20

25

30

35

40

45

18-24 25-34 35-44 45-54 55-64 65-67

2010 1990

Strong increase in disability benefits for young adults due to a mental disorderShare of permanent disability benefits which are due to a mental disorder, by age, 1990 and 2010

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DISABILITY BENEFITSPossible ways forward

Policy recommendations

– Apply the already existing strict DB-eligibility criteria in practice

» Expand the explicit medical, social and socio-demographic exclusion criteria (age, firm closure or stress-reactions are not disabling per se)

– Retain a work perspective by closing the gates to DB as early as possible when indicated

» Develop a rapid basic decision about DB-reception possibility

» Restrict the access to DB after several years of vocational rehabilitation

– Strengthen treatment requirements for claimants

» Request specialised adequate treatment over a sufficient period before awarding a DB

– Bind the DB-award to an interdisciplinary assessment including a psychiatrist

– Discuss a co-financing of DB costs for employers and municipalities

– Provide ongoing support and reassessment to DB-beneficiaries

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VOCATIONAL REHABILITATIONMuch training instead of workplace interventions

Source: OECD (2013), Mental Health and Work: Norway, Paris: OECD Publishing. Figure 4.2 page 83.

The use of education and training has decreased, but (more effective) wage subsidies are still scarceShares of vocational rehabilitation measures for clients with mental or musculoskeletal

disorders

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VOCATIONAL REHABILITATIONPossible ways forward

Policy recommendations

– Turn the focus from re-integration to early intervention in mental health-related workplace problems

– Develop interdisciplinary teams in the Employer Support Centers to guarantee their competence

– Decrease re-education and long-lasting training programmes in favour of relevant wage subsidies to employers

– Give incentives to municipalities to change from sheltered work facilities to supported employment programmes

– Insert an interdisciplinary assessment and rehabilitation planning into the Qualification Programme for youth without diagnosis

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MENTAL HEALTH CARETreatment potentials are not used due to fragmentation

Very high inpatient re-admission rates …

Source: OECD (2013), Mental Health and Work: Norway, Paris: OECD Publishing. Figures 5.1, 5.2 pages 98, 99.

… despite high rates of GPs and psychiatrists

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MENTAL HEALTH CAREPossible ways forward

Policy recommendations

– Develop a systematic collaboration between NAV offices, GPs and District Psychiatric Centers

– Expand the personnel and responsibilities of the medical services in NAV

– Install vocational rehabilitation professionals from NAV in the District Psychiatric Centers

– Use the strategic position of the District Psychiatric Centers and establish employment issues as a core competence of the centers

– Develop work-related quality indicators for mental health care

– Improve vertical integration of the municipal, regional and centralised mental health care

– Start a research agenda focusing on employment issues in treatment

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EDUCATION AND LABOUR MARKET TRANSITIONNot enough individual follow-up for “new” disorders

Early school-leaving is frequent in Norway partly because of a high drop-out rate from vocational

educationProportion of youth aged 20-24 (i) not in education

and without upper-secondary diploma(early school leavers) and (ii) not employed and

not in education (NEET), 2009

Source: OECD (2013), Mental Health and Work: Norway, Paris: OECD Publishing. Figures 6.2, 6.3 pages 113, 114.

The composition of mental disorders leading to a disability benefit claim among young people has

changedShare of different mental disorders in all recipients

of a disability benefit aged 18-24with a mental disorder, 1990-2010

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EDUCATION AND LABOUR MARKET TRANSITIONPossible ways forward

Policy recommendations

– Ensure a systematic collaboration between the pedagogical and psychological services at school, the school health services and the child psychiatric services

– Increase resources of the school-based health services and integrate more psychiatrists into these services

– Raise awareness of mental health issues in vocational education and train the teachers

– Establish a close contact between NAV offices, health services and vocational education

– Invest more in early intervention, assertive outreach and enduring individual follow-up with vulnerable pupils

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CONCLUSIONS

– Some features of the Norwegian Welfare system – the easy access to longer sickness absences, the open gate to permanent disability benefits and the lack of re-assessments

» lower the efforts to retain the mentally ill at the workplace

» undermine the potential of the rich set of Norwegian measures in education, health and vocational rehabilitation

– The high expenditures in health, education and NAV do not deliver regarding mental health-related exclusion, partly because

» the different services are not well integrated

» mental health care does not feel responsible for work issues

» medical services in NAV do not have enough responsibilities

– Norway should complement its state-of-the-art prevention by an effective early intervention approach targeting at job-retention of workers with mental health problems.

– But make sure that the financial incentives of all actors are aligned with the need for employment integration of workers with mental ill-health

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For more information and OECD publications on the topic:

www.oecd.org/els/disability

Including free access to the Executive Summary and all tables and charts of “Mental Health and Work: Norway”

Niklas Baer (report author), Phone: +41 79 778 28 84

Christopher Prinz (project leader), Phone: +33 6 1503 35 87

THANK YOUR VERY MUCH FOR YOUR ATTENTION !

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