Unum Aylward's 'Vision' at Medicolegal Course

Strategies to encourage people to return to work.

Professor Mansel Aylward CB MD FFOM FRCPDirector, UnumProvident Centre for Psychosocial

and Disability Research, Cardiff University

&

Chair, Wales Centre for Health

AylwardM@cardiff.ac.uk

www.cf.ac.uk/psych/cpdr/index.html

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

• Self-reported symptoms assuming underlying psychiatric impairment (tautology)

• 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

• ‘Regional [pain] disorders’ (Hadler 2001)– defining feature is regional symptoms (low back, upper

limb, neck etc)

Common health problems

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

– Intervene early/proactive rehabilitation

– Promote the healthy workplace

– Positive job design & good line management

UK Government “Pathways to Work” Initiative

• Return to Work Payment

£40-120 per week

• Mandatory Work-Focused Interviews (Case Managers)

• New Condition-Management Programmes:

(focus: m/s, Mental Health; Cardiorespiratory)

- helping people to understand and manage their condition

- using CBT and related interventions

Principles of Condition Management:

• Voluntary option routed through the PA (Case Managers)

• Cognitive/educational interventions common to all conditions

• Evidence based• Tailored to individual needs – biopsychosocial

approach• Case-managed by CMP in close liaison with PA

• Goals “owned”; not imposed.

Contents of CM Programmes

• Cognitive/Educational interventions• Understanding and Managing

• Pain management• Confidence building• General health advice• Individual and group sessions

Pathways to Work pilots

Pathways to Work pilots

• 6-800 new job entries / month in Pathways areas

• On a national basis, that would be equivalent to helping 100,000 IB recipients into work each year.

Successful Strategies:

Practical Elements of Condition Management

• Address the main health conditions

• Clear work focus, vocational goals, outcome measures

• Address biological, psychosocial and social components

• Address individual’s obstacles to RTW

• Increase activity and restore function

• Shift beliefs and behaviour using CBT (talking therapies)

• Working partnership with Personal Advisors

Condition Management – Successful Strategies:• Make sense of your condition

• Overcome stress and anxiety

• Learn to be assertive

• Promote emotional / physical wellbeing

• Living with fatigue

• Living with pain

49% patients have primary and further 39% secondary mental illness diagnosis

GOVERNMENT GREEN PAPER:A new deal for Welfare: Empowering people to work

• Aspiration – Employment rate = 80% working population

• Reduce – By 1 million the number on IB

– Numbers leaving work place due to illness

• New – Employment and Support Allowance

Allowing payments to most severely disabled people

• Transforming the PCA (focus on mental health)• Conditionality: Work Related Interviews and Action

Plans

A new deal for welfare: Empowering people to work

• Supporting GPs

• Improving access to good-quality Occupational Health Support

• Facilitate better absence management

• Pathways to Work – extending provision across country by 2008

The Scientific and Conceptual Basis of Incapacity Benefits

Gordon Waddell and Mansel Aylward

The vision - Changing the world

Changing the culture – of health, sickness, disability, incapacity and work.

• General public / society• Workers• Health Professionals• Employers• Government

Not just a matter of economics and business efficiency it is about health at work and fulfilling potential.

Professor Mansel Aylward CB

Contact:

Email: AylwardM@Cardiff.ac.uk

Website: http://www.cf.ac.uk/psych/cpdr/index.html

http://www.wch.wales.nhs.uk