Australasian Faculty of Occupational and Environmental Medicine
REALISING THE HEALTH BENEFITS OF WORK A POSITION STATEMENT Professor Sir Mansel Aylward CB Director: Centre for Psychosocial and Disability Research, Cardiff University and Chair: Public Health Wales
Sydney: 18 May, 2010
Auckland: 25 May,2010
Fundamental Precepts: • Main determinants of health and illness depend more upon lifestyle, socio-cultural environment and psychological (personal) factors than they do on biological status and conventional healthcare.1 • Work: most effective means to improve well-being of individuals, their families and their communities.2 • Objective: rigorously tackling an individual’s obstacles to a life in work. 1. Marmot M. Status Syndrome, Bloomsbury, London: 2004 2. Waddell G, Burton K. Is work good for your health and well-being? TSO, London: 2006
Making the distinction: definitions and usage • Disease: objective, medically diagnosed, pathology • Impairment: significant, demonstrable, deviation or loss of structure or function • Illness: subjective feeling of being unwell (internal) • Sickness: social status accorded to the ill person by society (external)
Unbundling: definitions and usage • Disability: limitations of activities and restriction of participation • Incapacity: inability to work or reduced functioning and performance at work associated with sickness or disability.1 • Unbundling: different elements of the human predicament that underlie incapacity: ¾ no linear causal chain ¾ not interchangeable 1. Waddell G, Aylward M. The scientific and Conceptual Basis of Incapacity Benefits. TSO, London: 2005
Symptoms: • Symptoms: subjective bodily or mental sensations that reach awareness and are generally “bothersome” or “of concern” to the person. ¾ clinical representation/manifestation of disease ¾ associated with normal or unaccustomed activities of daily living ¾ unassociated with any identifiable disease 1,2 ¾ ubiquitous and omnipresent 3,4 ¾ limited correlation with illness, disability and (in) capacity for work 5,6 1.
Ursin H: 1997
2.
Deyo RA et al : 1998
3.
Eriksen H et al: 1998
4.
Buck R et al: 2009
5. Waddell,G: 2004 6. Waddel G, Aylward M : 2005
Genesis: In the beginning…….. The Context: •1993: The growth of Social Security1 •1994: The medical assessment for incapacity benefit (The All Work Test)2 - Self assessment, Scrutiny, examination and Adjudication - Functional approach, greater objectivity, descriptors - Best developed and most stringent (OECD,2003)3
1 Department of Social Security (1993) HMSO, London 2 The medical assessment for incapacity benefit (1994) DSS: London 3 Transforming disability into ability. (2003) OECD: Paris
The All Work Test in Practice: Consequences • A plethora of data • Questioning the “medical model” • Psychosocial issues not health conditions dominate obstacles/barriers to return to work (75%) • Lack of large scale engagement with the client group • Commanding role for non-medical interventions
Changing beliefs and attitudes: the evidence base Getting politicians and key policy makers on side:1 • Concepts and evidence 2 • Economic burden of status quo • Barriers magnify and proliferate with duration of incapacity • Very limited focus on “rehabilitation” • The ubiquity of symptoms in everyday working population • Disastrous effects of worklessness on the individual and society • The Bio-psycho-social paradigm 1.
Halliigan P, /Aylward M (2005) The Power of Belief , Oxford University Press, Oxford
2.
Waddell G, Burton AK (2004) Concepts of Rehabilitation TSO, London
Support into Work Policies: •Incapacity Benefit (1995): relative success/expectations unfulfilled •The focus on Disability Assessment 1,2 •DSS expenditure:1.5% on RTW for IB – vs - 27% for Unemployment Benefits •Passive provision of financial benefits •Marginal effects of existing RTW policies and practices •Ignorance of cardinal obstacles to RTW 1 Aylward M, Locascio J (1995) Problems in assessment of psychosomatic conditions in social security benefits and related commercial schemes. J psychosomatic Res,39:755-765 2 Aylward M (2003) Origins, practice and limitations of disability assessment medicine. Illness Deception. Oxford University Press, Oxford
1 Paradoxes • The typical benefit recipient (perception – vs – reality) • The health paradox (improved health – vs – IB trends) • The failure to recover (clinical recovery – vs – poor work outcomes) • Disability Rights – vs – benefit dependency • Patient advocacy – vs – beneficial effects of work • Inequality paradox: economic prosperity – vs – widening socioeconomic gap 1. Waddell G, Aylward M (2005). The scientific and conceptual basis of incapacity benefits. TSO: London
The 1998-1999 Reforms1-3 Work for those who can: security for those who cannot
• Optimal early intervention/management • Encourage work retention • Emphasise abilities • Engender cultural change among health professionals • Support behaviour change, re-education/skilling and rehabilitation (RTW) • Promote radical change in workplace culture
1.
HM Government (1998) New ambitions for our country.Cm3805.HMSO: London
2.
HM Government (1998) A new contract for welfare: principles into practice. CM4101. HMSO: London
3.
HM Government (1999) Welfare Reform and Pensions Act-1999.
Pathways to Work: Helping people into employment (2002).1 A significant step to realise a vision. • Better framework of support and more focused interventions • Focus on the early stages of IB receipt • Improved, tangible financial incentives • Condition Management-jointly with local NHS providers
A fundamental philosophical shift in services provided for sick and disabled people. A social rather than a health care intervention 1. DWP (2002) Pathways to work: helping people into employment. Department for Work and Pensions CM5690. HMSO: London.
Work and health
Possible causal pathways between health, work and well-being
What do we know about being out of work? • Unemployment is bad for you: – Loss of Income¹ – Destructive on self-respect¹ – Risks of ill-health² – The “psychosocial scar” persists³ – Transgenerational effects 4 1. 2. 3. 4.
Winkelmann and Winkelmann 1996 Clark, Georgellis, Samfey 2001 Clark and Oswald 1996 Aylward 2006
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 longerterm 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)
Is Work Good for your Health and Wellbeing? (Waddell & Burton, 2006) YES: • Strong evidence: Work is generally good for physical and mental health and wellbeing • Reverses the adverse health effects of unemployment • Beneficial effects depend on the nature and quality of work and its social context • Jobs should be safe and accommodating • Moving off benefits without entry in to work associated with deterioration in health and wellbeing
Without work all life goes rotten, but when work is soulless, life stifles and dies. Albert Camus
The Consequences Sickness and disability among main threats to full and happy life; Work incapacity most significant impact on individual, the family, economy and society.
Social Contexts that influence Health and the pursuit of a life in Work: • A person’s past social experiences become written into the body’s physiology and pathology1 • Lack of autonomy in life is an enduring negative leading to poor health, worklessness and frustrated well-being • Work is central to well-being and correlates with happiness and health • Class difference in mortality, morbidity and economic inactivity are a consistent feature of the entire human lifespan.2 1. Blane D. In Social Determinants of Health, WHO: 1998 2. Black D. Inequalities in Health, HMSO: 1998
Incapacity Benefit (IB) Recipients – Diagnostic Groups Incapacity-related benefit recipients by diagnosis group, November 2003 Other conditions or condition not specified 14% Musculoskeletal 26%
Diseases of the respiratory system 2% Injury 1% Diseases of the nervous system 3% Cardiovascular 10%
Mental health 44%
UK Incapacity Benefit
• ‘Severe Medical Conditions’
<25%
• ‘Common Health Problems’ - Mental health problems - Musculoskeletal conditions - Cardio-respiratory conditions
44% 25% 10%
The changing proportion of Incapacity Benefit claimants by diagnosis 50 45 40 35 30
Mental health
25
Musculoskeletal
20
Cardio-respiratory
15 10 5 0
1995
2008
National Statistics: www.dssni.gov.uk/incapacity_benefits
Cardiff Health Experiences Survey (CHES): Face-to-Face Interviews [N=1000] GB population: Main Complaint Open Question: LBP Musculoskeletal Mental Health Cardio-respiratory Headache G/I Without any complaint
8.9% 4.6% 7.5% 3.6% 2.9% 2.4% 70.1%
Inventory: 14.6% 7.0% 25.6% 5.9% 9.3% 4.0% 33.6%
______________________________________________________________________________________________________________________________________________________________________
At least one complaint 2 or more complaints
20.6% 8.4%
66.4% 26.3%
Severity of main complaint greater for open question than inventory
Common health problems
Less severe mental health, musculoskeletal and cardio-respiratory conditions Limited objective evidence of disease Largely subjective complaints Often associated psychosocial issues
Common health problems • Common features – High prevalence in working age population – Largely subjective - little or no disease or impairment – Multifactorial causation – work usually only one contributory factor – Most episodes settle rapidly – though often persistent or recurrent – Most people remain at work or return to work quite quickly – Essentially whole people, with what should be manageable health conditions – Long –term incapacity is not inevitable
Common Health Problems: disability and incapacity • High prevalence in general 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 Thus: • Essentially people with manageable health problems given the right support, opportunities & encouragement • Chronicity and long-term incapacity are not inevitable
Why do some people not recover as expected?
SOCIAL PSYCHOBIO-
• Bio-psycho-social factors may aggravate and perpetuate disability • They may also act as obstacles to recovery & barriers to return to work
Corollary : Management of common health problems must address obstacles to recovery. Beliefs play a pivotal role in propagating and perpetuating these illnesses Social factors dominate
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 Personal Advisor • Cognitive/educational interventions common to all conditions • Evidence based • Tailored to individual needs – biopsychosocial approach • Case-managed • Goals “owned”; not imposed.
Condition Management: The Pathway to Success • Modulate expectations, exploit values and build confidence • Recognise and address the social contexts of health, disadvantage and economic inactivity • Promote emotional/physical well-being • Encourage behaviour change • Living with fatigue/pain
Condition Management Programmes: Principal Findings â&#x20AC;˘ Rather than aiming for control of a health
condition, successful outcomes dependent on learning process towards self-management and independence â&#x20AC;˘ New roles for health professionals: support and guidance rather than therapy
Pathways to work: Condition Management Programmes: • Very favourable reception by participants, personal advisers and CMP practitioners • Doubling of claimants entering work • Higher than expected take-up rates • Exceeds threshold for cost-effectiveness • Perceived to have lasting effects
PATHWAYS TO WORK: PILOTS (2003-2004) • 6-800 new job entries each month in existing Pathways areas • Take-up around 5 times that expected from previous RTW interventions • Welfare Reform :extending provision across country by 2010 :reducing by 1 million the number on Incapacity Benefits :employment rate = 80% working age population
Pathways to Work – So Far • Puts the United Kingdom at the forefront in actively engaging with the client group. • Very few,1 if any,2 social security interventions in the world have ever achieved such take-up rates, labour market outcomes and enthusiasm. • Strong potential to reverse the long history of failed international efforts to address successfully long-term incapacity3. 1.
Corden A, Thornton P (2002) Employment programmes for disabled people. Lessons for research evaluations. DWP In-House Report 90, Department for Work and Pensions: London
2.
Aylward M,Sawney P (2007) Support and rehabilitation (restoring fitness for work). In fitness for Work (Edo: Palmer, Cox and Brown), 4th Edition. Oxford University Press: Oxford.
Cardiff Research: Principal negative influences on return to work: • Personal / psychological: Catastrophising (even minor degrees) Low Self-Efficacy Belief that “stress” is causal factor • Social: Lone parents / unstable relationships “Victim” of modern society Rented or social housing • General Affect: Sad or low most of the time Pervasive thoughts about personal illness
Negative Influences: • Occupational:
• Cognitive:
• Economic:
Job dissatisfaction Limited attendance incentives (esp. work colleagues) Attribution of illness to work Minimal health literacy Self-monitoring (symptoms) False beliefs Availability of alternative sources of income / support
Ranking of Obstacles to Work by Principal Category: Rank(%) • Psychological / Cognitive:
38 %
• Occupational:
32 %
• Social:
11 %
• Economic:
9%
• Symptom severity
7%
(esp: pain, fatigue)
• Impaired function
3% 100 %
Positive Influences on RTW: • • • • • •
Moral obligations Respect for Employer Strong health literacy High score on subjective “happiness” Well managed chronic condition Resilience and coping
Workplace Management of Common Health Problems • Good workplace management: preventing persistent and disabling consequences: ¾ Positive health at work strategies ¾ Early detection ¾ Accommodation of temporary functional limitations ¾ Interventions: early return to sustained work
The Messages: • Barriers to recovery and return to (retention in) work are primarily personal, psychological and social rather than health-related “medical” problems • Workplace culture and organisational features dominate • Perceptions lie at the “heart” of the problem
Engaging and Exploiting Stakeholders • Changing Beliefs and Attitudes: – politicians, civil servants, health professionals, employers, etc • Engaging and Empowering: – individuals and communities – autonomy and social integration • Changing Culture: – about health, work, and well-being • Delivering Results: – visible hard outcomes – demonstrable self-efficacy – working partnerships that work
Engaging and Understanding Stakeholders: An Example1 Background: GPs often feel that work and health-related issues extend beyond their role
Aim:
Exploring perceptions and attitudes (focus group setting)
Results:
Role boundaries, responsibilities, negotiation and knowledge “managing worklessness limited to….. health-related issues only” Personal safety impacted on decision-making
1. Cohen D et al, Occupational Medicine: 2009
Primary Care: Focus Group Study Key Points: GPs’ views: • Management of worklessness lay outside their role • Patients on long-term benefits became “lost” within the system • Rehabilitation rarely discussed • Lack of knowledge and confidence
Public Policy Initiatives - Belief Networks • Changing culture about health, illness and work: • Behavioural Change Modules • General Practitioners/Health Care Professionals • Line Managers and Employers • Citizens/health literacy • Websites: “Healthy Working Wales” and “Healthy Working UK” • Virtual Occupational Health resource • Knowledge and confidence • Engagement and communication
Public Policy Initiatives - Belief Networks • Chronic Condition Management
• Empowerment and autonomy • Health literacy • Integrated healthcare systems • Health, Work and Well-being Programme (Carol Black)
Pursuing Excellence and Achieving Success: • Believe that people can radically transform their behaviour and lives with the right kind of impetus and support in an empowering climate • At the heart of culture lies belief: • Beliefs drive behaviour • Dispel the myths • Modify the experience • Embrace the bio- psycho-social paradigm • Shift core false beliefs • Exploit beliefs - networks
The Way Forward • The case for investment and cost-effectiveness • Substantial work outcomes • Building capacity • Effectiveness of different models of intervention • Lack of engagement • More effective mental health interventions • The general economy and job availabilities • Continuing culture change about health and work.
Models of Sickness and Disability
Gordon Waddell and Mansel Aylward
The Power of Belief
Peter Halligan and Mansel Aylward
Professor Sir Mansel Aylward CB
Contact: Email:
AylwardM@Cardiff.ac.uk
Website: http:// www.cf.ac.uk/medic/cpdr