Strategies to encourage people to return to work. Professor Mansel Aylward CB MD FFOM FRCP Director, UnumProvident Centre for Psychosocial and Disability Research, Cardiff University & Chair, Wales Centre for Health [email protected]www.cf.ac.uk/psych/cpdr/index.html Manchester Medicolegal Course in Occupational Health 8 th February, 2006 Health, Work and Well-being: supporting workers and Occupational Health Physicians
Sickness and Incapacity are largely social not medical problems____Moving: Medical model to an integrated bio-psycho-social approach___Bio-psycho-social factors mayaggravate and perpetuate disability___They may also act as obstacles to recovery & barriers to return to work____Sickness and incapacity are social rather than medical problems____Women take more sickness absence than men_____Shift beliefs and behaviour using CBT (talking therapies)____More and better health care is not the answer_____The vision - Changing the world____Professor Mansel Aylward
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Strategies to encourage people to return to work.
Professor Mansel Aylward CB MD FFOM FRCPDirector, UnumProvident Centre for Psychosocial
Manchester Medicolegal Course in Occupational Health 8th February, 2006
Health, Work and Well-being: supporting workers and Occupational Health Physicians
Challenges for Occupational Health: Promoting a Life in Work1. Work and Worklessness
2. Illness, Disability and (in)Capacity for Work
3. Illness behaviour
4. Obstacles to recovery: barriers to (return to) work
5. Absence – the burden on business and society
6. Support into Work
Developing successful strategies: some key elements
• Unbundling: Sickness, Disability, Work and Health
• Recognition: Sickness and Incapacity are largely social not medical problems
• Moving: Medical model to an integrated bio-psycho-social approach
• Shifting: Attitudes to health and work (culture change)• Adapting: New concepts for intervention and
rehabilitation
• Integrating: Getting all stakeholders on side
Work :
• Benefits:
Symptom managementRecovery and RehabilitationSelf-esteem and ConfidenceSocial identity and rolePromoting activities and participationSocial inclusions and functioningQuality of Life
Worklessness:
• Risks and Harm:
Loss of fitness
Physical and mental determination
Psychological distress and depression
Loss of work-related habits
Increased suicide and mortality
Social exclusion
Poverty
Long-term worklessness is one of the greatest known risks to public health
• Health Risk = smoking 10 packs of cigarettes per day (Ross 1995)
• Suicide in young men > 6 months out of work is increased 40 x (Wessely, 2004)
• Suicide rate in general increased 6x in longer-term worklessness (Bartley et al, 2005)
• Health risk and life expectancy greater than many “killer diseases” (Waddell & Aylward, 2005)
• Greater risk than most dangerous jobs (construction/North Sea)
Sickness and disability among main threats to full and happy life;
Work incapacity most significant impact on individual, the family, economy and society.
Unbundling illness, sickness, disability and (in)capacity for work
• Disease: objective, medically diagnosed, pathology• Illness: subjective feeling of being unwell• Sickness: social status accorded to the ill person by
society• Disability: limitation of activities/ restriction of participation• Impairment: demonstrable deviation / loss of structure of
function• Incapacity: inability to work associated with sickness or
disability
**The terms are not synonymous: there is no linear causal chain.
Mental Impairment: Challenges in Understanding and Assessment:
• The subjective nature: symptoms, limitations, clinical assessment and diagnosis
• Mental impairment = specifically and solely abnormalities of mental function demonstrated, assessed and evaluated by objective observer (Mendelson 2004)
Mental Impairment: Challenges in Understanding and Assessment:
• Importance of distinguishing mental impairments from subjective descriptions of symptoms / limitations
• Clinical Guidelines to the Rating of Psychiatric Impairment (Epstein et al 1998) (Intelligence, Thinking, Perception, Judgement, Mood, Behaviour)
The need to ‘unbundle’ Sickness, Disability & Incapacity
Working
Economically Inactive
Illness
Disability
Limited Correlations:
Prevalence of subjective health complaints in the last 30 days in Nordic adults (after, Eriksen et al, 1998)
Any complaints Substantial complaints
Men Women Men Women
Tiredness 46% 56% 17% 26%
Worry 38% 39% 13% 15%
Depressed 22% 28% 5% 10%
Headache 37% 51% 4% 9%
Neck pain 27% 41% 9% 17%
Arm/shoulder pain 28% 38% 12% 17%
Low back pain 32% 37% 13% 16%
>50% reported two or more symptoms
Three year incidence (%) of symptoms in general practice(Total and with organic cause) (Kroenke & Mangelsdorff 1989)
Edinburgh Neurology Study
IB Recipients - Diagnoses
Incapacity-related benefit recipients by diagnosis group, November 2003
UK Incapacity Benefit
• ‘Severe Medical Conditions’ <25%
• ‘Common Health Problems’
- Mental health problems 44%
- Musculoskeletal conditions 25%
- Cardio-respiratory conditions 10%
Common health problems
• ‘Subjective health complaints’ (Ursin 1997)– symptoms - self-reported
• ‘Unexplained medical symptoms’ (Page & Wessley 2003)
– limited objective evidence of disease, damage or impairment
Less severe mental health, musculoskeletal and cardio-respiratory conditions
Limited objective evidence of disease
Largely subjective complaints
Often associated psychosocial issues
Illness Behaviour: What ill people say and do that express and communicate their feelings of being unwell
• Not solely dependent on the underlying health condition (the limited correlation)
• People with similar illnesses may or may not be incapacitated (Nordic adults)
• Roles of attitudes and beliefs, emotions and coping, motivation and effort
• The social context and culture
Long-term incapacity is not inevitable
• High prevalence in normal population
• Most acute episodes settle quickly; most people remain at work or return to work
• There is no permanent impairment
• Only about 1% go on to long-term incapacity
• Essentially people with manageable health problems, given the right opportunities, support & encouragement.
Why do some people not recover as expected?
SOCIAL
PSYCHO-
BIO-
• Bio-psycho-social factors may aggravate and perpetuate disability
• They may also act as obstacles to recovery &barriers to return to work
Traditional Concept of Rehabilitation
• Secondary intervention - after health care - separate from health care
• Address permanent impairment
• Restore function (within limitations)
• Job placement
• Essentially a ‘medical’ intervention on person
Limitations of the Biomedical Model for Common Health Problems
• Limited evidence of objective pathology or permanent impairment
• Limited correlation physical impairment / disability / incapacity for work
• Fails to address psychosocial issues
• Treatment ineffective for vocational outcomes
Biopsychosocial Model
SOCIAL CultureSocial interactions
The sick role
PSYCHO-Illness behaviour
Beliefs, coping strategiesEmotions, distress
BIO- Neurophysiology Physiological dysfunction
(Tissue damage?)
Strengths of BPS Model
• Provides a framework for disability and rehabilitation
• Places health condition/disability in personal/social context
• Allows for interactions between person and environment
• Addresses personal/psychological issues.• Applicable to wide range of health problems
Management of common health problems must address
obstacles to recoveryand barriers to (return to) work
Components of disability
Barriers to RTW Rehabilitation interventions
Health- related Health conditionCapy –v- demands
Clinical management Occupational management
Personal Psychosocial aspects of work
Change perceptions, beliefs, behaviour
Social OrganisationalAttitudinal
Modified workSystems, attitudes
Interactions
• Rehabilitation cannot be a second stage after health care has failed.
• Principles of rehabilitation must be integrated into:- clinical management- occupational management
General Principles
Symptomatic relief AND restoration of function
‘Every health professional who treats common health problems should be interested in rehabilitation and occupational outcomes.’
Health care for common health problems
Occupational management
• Common health problems are not a matter for health care alone.
• They are equally a matter of ‘occupational health’
Timing
Personal / psychological change
• Individual motivation and effort
• Building capacity
• Shift perceptions, attitudes & beliefs
• Change behaviour
• Improve function
Culture
The collective attitudes, beliefs and behaviour that characterise a particular social group over time
Whither Health Care?
• The visit to a health professional– beware iatrogenesis:
• what is said can undo what is done• More and better health care is not the answer• Health care needs to work to a new integrated
paradigm:– work with employer and worker– use fit notes instead of sick notes!
Sickness and incapacity are social rather than medical problems
Shifting Attitudes to Health & Work
Current: Shift to:
Work is a ‘risk’ and (potentially) harmful to physical and mental health.
Work is generally good for physical and mental health
therefore and
Sickness absence/certification ‘protects’ the worker/patient from work
Recognise the risks and harm of long term worklessness
Health at Work:
• The key idea is that work is healthy• The workplace = environment for promoting
health; controlling ill health• Anti-discrimination policy• Health and Safety• Occupational health / VR• Absence Management• A public health issue
PUBLIC SECTOR ABSENCE:
• Comparative surveys: average recorded absence in public sector higher than private sector
• Comparing like with like?– similar operations show no higher absence in
public sector (ie. Call Centres)– public/civil service=broadly typical of large private
firms.– In all countries absence in health service is high– Public sector absence = same kind of variation
as private sector
Disaggregating Absence
• More pronounced among junior grades• Women take more sickness absence than men• Older men average more sickness absence (?
health related)• Civil Service
– higher SA in front-line services– related to numbers of junior staff.
• Public Sector Long-term SA rates but lower self-certified SA
Ministerial Task Force and Report on Managing Sickness Absence
• Managing SA is not “rocket science”• TF concluded 3 fundamental systems
– 1. Boards and Senior Management:• a principal function• install strategies• progress report (efficiency reviews/performance
partnerships)– 2. MIS
• timely data, monitor absence, take action• HR to ensure procedures adhered to
TF’s Recommendations:(fundamental systems)
– 3. HR management systems
• managers to receive training in systems and skills
• case management referral and RTW discussions
• integration of absence and performance management (a key lesson from successful private sector practice)
TF Recommendations:
SHORT TERM ABSENCE
checks for persistent short term absences• involving OH for absence above certain number of
days in 12 month period • daily phone calls/unexpected short term sickness• Monday/Friday checks• Challenge more than 5 days absence• Flexibility around “special leave” – work/life
balance
TF Recommendations:
LONG TERM ABSENCE:
• Collate and analyse literature on sickness causes:– job design– ergonomics– flexibility to personal/motivational problems
• Explore non-GP OH services• Intensive study of LTA (“less than full pay”) cases
– RTW potential– contract termination
• HSE in partnership with public sector on ill-health prevention.
So What? Lessons Learned:
• Productivity and Non-attendance (presenteeism, turnover, low morale) are symptoms of wider organisational problems.
• Treating symptoms and not the underlying causes won’t improve quality of working life or business performance
Climate:
• Moderated by leadership, culture, work organisation, openness, communication, etc
• Line Managers key – the prism through whom climate is perceived by employees.
• Promote Climate where people allowed to be well.
Keys to health and productivity:
– Good data, trend analysis & monitoring
– Role clarity (line, HR, Occ Health, employees)
– Differentiate: presenteeism, short-term & long term absence