Health at Work: An independent review of sickness absence

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1 COVER Protection and Health Forum London 3 October 2013 Health at Work: An independent review of sickness absence Dame Carol Black Expert Adviser on Health and Work Department of Health, England Principal, Newnham College Cambridge

2 Fit for Purpose CBI and Pfizer Absence and Workplace Health Survey 2013 The finding that average levels of employee absence have hit a record low is highly encouraging. Although the total direct cost of absence has been pushed down to 14bn a year, this is still a major burden when businesses need to be investing for growth and public-sector budgets are under long-term pressure. More substantial savings can be made, over 1.2bn a year, if managers in the public sector can bring absence levels into line with the private sector. We need fresh initiatives to tackle long-term absence, where mental health conditions top the list of causes. The government s introduction of the fit note in April 2010 should have been the catalyst for major changes. Sadly we are still some way from achieving that. Introduction of the electronic fit note gives another opportunity for change. Neil Carberry, CBI Employment and Skills Director

3 Fit for Purpose CBI and Pfizer Absence rates fall to record low Average absence in 2012 was 5.3 days per employee, down from 6.5 in Average annual employee absence has fallen by more than a quarter since the 1980s. There is still a gap of more than 3 days per year between the bestperforming and lowest quartiles of organisations. Absence remains higher among manual employees, but the gap is narrowing. Absence levels climb with organisation size SMEs under 5 days, larger employers nearly 6. Levels remain significantly higher in the public sector than the private.

4 EEF Survey June 2013 The EEF, the manufacturers organisation, is calling for review after survey data showed its members are unhappy about rising absence rates and saw GPs as the second biggest barrier to rehabilitating employees absent sick. In May 2013 a BMA conference decided by a narrow margin that the fit note was a waste of clinical time and confused employers, patients and doctors. The fit note replaced the sick note three years ago, but employers say that after initial improvement in absence levels progress has stalled. Over 5 years the proportion of employees with no sickness absence has gone up from 40% to 51%, but employers say longer-term absence is increasing because of surgery, back pain, stress, mental illness and other problems. The survey showed that only 26% of employers felt that the fit note had resulted in employees returning to work earlier, but 40% had seen no change. Almost half said that there had been no improvement in the advice given by GPs about employees fitness for work. Telegraph Media Group

5 Sickness Absence Lessons I have learnt: Intervene as early as possible with the right intervention delay takes people further away from the labour market and support Vocational Rehabilitation. Do not over-medicalise much of this is psycho-social. Give GPs an appropriate role but get expert Occupational and Health at Work advice. Work with employers. No progress is possible unless there is visible leadership and line managers understand the relationship between good work, good communications, mental wellbeing, engagement and productivity. Train the line managers.

6 Workplace Health, Safety and Well-being: the key players Health professionals (Primary and secondary care) Public Health Professionals Employers (Workplaces, Line managers, Human Resources) Non-governmental bodies and charities Employees (Patients) OH professionals Trade Unions (less than 15% of the global workforce has access) Governments to support, encourage, initiate, and where necessary legislate.

7 Progress on health and work since 2008 Organisations : Examples of action : Governments - Delivering Black Review in England, Wales and Scotland Employers - investment in Health and Wellbeing at work (private and public) - integration of Health, Safety and Wellbeing Healthcare - educational initiatives professionals - work to be an outcome of clinical encounter - fit note not sick note Trade Unions - increasing engagement with the NHS NGO involvement - e.g. MacMillan Cancer, British Heart Foundation Local engagement - health boards, Councils, third sector

8 Variables affecting sickness absence Extra days absence in year for workers with the following characteristics : (SMDs influence absence more than any other variable.) Note these Results based on European Working Conditions Survey 2010 OECD 2011 Mental Health conditions CMDs SMDs Note this

9 The pace of change was not enough hence an Independent Review of Sickness Absence was announced by the Prime Minister on 17 Feb 2011 Co-chairs: Carol Black, then National Director for Health and Work David Frost, former Director-General British Chambers of Commerce. We simply have to get to grips with the sick-note culture that means a short spell of sickness absence can far too easily become a gradual slide to a life of long-term benefit dependency.

10 The journey from work to welfare in the UK Too few drivers in the journey keeping people in work. 28 weeks 39 weeks Work GPs the gateway to benefits Sickness absence SSP/OSP Claim to Employment Support Allowance (ESA) Work Work Capability Capability Assessment Assessment (WCA) ESA benefit and support JSA benefit and support Work Inactivity Too little help here to maintain people in work. Poor and ineffective early intervention SSP = Statutory Sick Pay OSP = Occupational Sick Pay LEAVE WORK Waiting for WCA completion can be nine months. Active support here BUT too late WCA = Work Capability Assessment

11 SA Review: Conclusions of research and evidence-gathering Current system lacks coherence, wastes human/material resources Advocacy by GPs often inappropriate for employees long term health Lack of appropriate interventions at critical stage, at 4 to 6 weeks of absence. Lower skilled, lower paid employees particularly vulnerable. Some employers lack confidence in the medical certificate ( fit note ) and lack knowledge of legal rights and duties. Some people need to change employment to return to work. Late recognition of the never going back syndrome State too slow to get the right support to individuals at the right time. Significant differences between public and private sectors. 2011

12 Recommendations Six major ones Tax relief on Vocational Rehabilitation Independent Assessment Service Public Sector Review of Sick Pay Abolition of Payment Threshold Scheme in SSP Sickness Absence reduction Job Brokering Service Changes to Employment and Support Allowance plus six of lesser importance.

13 Independent Assessment Service The Fit Note is used to verify illness and fitness for work GPs act as the entry into system. The Note has brought about some change, but nowhere near enough. A new Independent Assessment Service will provide an in-depth assessment of an individual s physical and/or mental function This will act as a functional assessment for employers, doctors and employees seeking specialist advice about capacity to return to work.

14 IAS - Referral system Week 4

15 Essential features of the IAS Much more than a telephone triage Not voluntary A fully functional electronic Fit Note is needed.

16 GP Survey 2012: findings 90% agreed that helping patients to stay in or return to work was an important part of their role, 68% agreed that GPs had a responsibility to society to facilitate a return to work. 76% agreed that staying in or returning to work was an important indicator of success in the clinical management of people of working age only 19% agreed that there were good services locally to which they could refer their patients for advice on return to work. only 10% of GPs reported they had received training in health and work within the past 12 months. After Department for Work and Pensions Research Report No 835

17 Tax Relief on VR and medical expenditure Early intervention is key, yet the tax system can discourage employers from investing in medical intervention or Vocational Rehabilitation (classed as benefits in kind) Discouragement is particularly clear in the more marginal cases (lower paid, lower skilled workers, often in SMEs) We propose introducing tax relief on vocational rehabilitation and employers medical expenditure for basic rate taxpayers. In addition we propose retaining tax relief for Employer Assistance Programmes.

18 Conclusions of the Sickness Absence Review The current system lacks coherence and is wasteful of human and material resources We made recommendations to: support employees at work, to stay in work improve the benefits system to offer better advice and support, towards work tackle sickness absence through various interventions throughout the process. The UK Government s response was published in January.

19 Government s Response to Black and Frost Health and Work Assessment and Advisory Service Retention of tax relief on Employee Assistance Programmes Abolition of the Percentage Threshold Scheme, releasing funds to be reinvested in the new HW Assessment and Advisory Service Limited tax relief on interventions recommended by HWAA Service Removal of the requirement on employers to maintain records for SSP. Revision of guidance on the fit note Improving education for healthcare professionals. Using the Employer s Charter to provide better guidance on what employers can do to manage sickness absence Improving sickness absence management in the public sector Commissioning research on sickness absence management and sick pay regimes in different types of organisation.

20 Health and Work Assessment and Advisory Service: Assessment process Assessment At 4 weeks GP referral Telephone/face-to-face assessment Identification of issues and recommendations Work related/ workplace adjustments Health-related Non-work/non-health related Improvement/ resolution Intervention Case management Return to Work

21 Absence management in the public sector The Government agrees that the amount and cost of sickness absence for each public sector employer must be more transparent to the taxpayer. Employers to publish their data and to be accountable for managing the significant amount of public money that this staff cost represents to drive the spread of best practice and highlight those employers where progress is not being made. The Government will work with Education, Health and Local Government employers to secure progress in reducing sickness absence levels in their workforces.

22 The Health and Well-being Improvement Framework. sets out five high-impact changes that NHS organisations can follow to improve staff health and well being and reduce sickness absence: Developing local evidencebased improvement plans With strong visible leadership Supported by improved management capability Better, local high-quality accredited Occupational Health services With all staff encouraged and enabled to take more personal responsibility As an introductory document, the Department of Health s published Health and Well-being Improvement Framework highlights the evidence and detail behind the 5 high impact change pathway: olicyandguidance/dh_128691

23 HWIF 2 : Strong visible leadership Board level involvement will make the difference Where NHS Boards live the values they want to achieve, staff will take those values seriously A named board member responsible for H&WB and reviewing progress every 6 months will drive this agenda forward. Example: York Teaching Hospitals NHS FT Used board engagement to drive progress across the Trust Board visibly involved in events to promote better health and wellbeing, and communicated this to staff. Delivered sickness absence savings of 2.7m yearly, and 72% reduction in long-term absence.

24 HWIF 3 : Improved management capability Line managers know their staff better than anyone. They can promote better Health and Well-being and manage absence effectively. The best providers enable and support managers to follow good practice in building resilience, holding return-to-work interviews, recognising signs of stress, and addressing health in appraisals. Example: South West Yorkshire Partnership NHS FT Showed that staff H&WB is helped by better management, especially during change. Managers now undertake a learning programme to help build team resilience and increase productivity. Achieved big reductions in working long hours, harassment and bullying, with increases in engagement and uptake of opportunities.

25 RCP Health and Work Development Unit Results on line manager training 2010 Does the Trust provide: From 282 Trusts Number % Training for line managers on how to promote and protect employee mental wellbeing If yes is this training mandatory for all line managers? 33/ Training on identifying and responding sensitively to emotional concerns / symptoms of mental problems? If yes is this training mandatory for all line managers? Training on understanding when to refer an employee to OH or other source of help If yes is this training mandatory for all line managers? / /253 31

26 Results 2010: Actions in high-performing Trusts Actions that have been taken by organisations that are progressing well with the NICE guidance include: assigning responsibility for staff H&WB to a committed and influential board lead who establishes a H&WB Group to interpret data, develop a strategy, and drive forward an action plan establishing and communicating the clear link between staff health (including respecting and engaging staff) and the quality of patient care delivered engaging staff and managers through frequent assessment of staff health and well-being needs, and including H&WB in staff recruitment, managers objectives, training, supervision guidance, and appraisals Audit now in progress RCP Health and Work Development Unit

27 NHS Sports and Physical Activity Challenge Launched July 2010 aiming to capitalise on the 2012 Olympic spirit called the Challenge. Consisted of a range of activities designed to maintain and promote a healthy lifestyle and encourage staff to be more physically active. Additional anticipated benefits: better patient care; better role models for patients. National and local components: the local component has an accreditation scheme.

28 NHS Sports and Physical Activity Challenge Outcomes and Benefits organisations taking part At least 17% of NHS Staff have taken part 68 organisations have achieved accreditation Benefits: - increased levels of physical activity among staff - using the Challenge to kick-start or expand a Health and Wellbeing Strategy - better team working - setting an example to patients, partners and the wider community - reduced sickness absence and agency costs.

29 NHS Sports and Physical Activity Challenge Going for Gold: Inspiring Results : Case Studies Gateshead Health NHS Foundation Trust - comprehensive staff H&WB strategy saved 2m over 15 months to March 2012 through reduced sickness absence The Walton Centre (Neurosciences Trust, near Liverpool) - created Work Well the Walton Way partnering local business. Staff sickness absence reduced from 7% to 4% over three years, saving cost and agency spend; staff survey shows improved positive attitude in many key areas. Team Somerset (a combination of several Trusts) - a county-wide Got for It challenge in 2012 led to significant improvements in health and wellbeing, higher levels of activity, weight loss and reduced sickness absence.

30 Fit for Purpose CBI and Pfizer Fit note scheme needs a tonic The launch of the fit note was welcomed by employers, who had high expectations of its impact as a guide for health interventions. Practical experience has not so far lived up to expectations. Only a fifth of employers report that the fit note has helped their rehabilitation policies. Only a fifth say that fit notes contain constructive advice. Only one employer in ten is confident that doctors are sufficiently well trained to use the fit note differently from the old-style sick note. Only 5% are sure that doctors have sufficient workplace understanding. Only 17% believe that the new fit note has changed the culture around rehabilitation and return to work. The recently-relaunched guidance alongside the roll-out of the electronic fit note provide a clear opportunity to revamp the scheme that we cannot afford to squander.

31 The Future? Will the Government s delivery of their response to the Black & Frost independent review of Sickness Absence bring about the necessary change?