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Health Works: A Review of the Scottish Government's Healthy Working Lives Strategy



"…people are the key input to any business and therefore enhancing links between the promotion of better health and higher productivity will be very important if Scotland's effective supply of labour is to be secured…"
- John Swinney MSP, Cabinet Secretary for Finance and Sustainable Growth

For people of working age there is a continuum that goes from being in work and in good health through to being unemployed as a result of a health condition. There are a large number of health, social, employability and training services available to help and support people, depending on where they are on this continuum.

For most people of working age, ill-health will be short term and the individual will recover with little or no intervention from health services required and will either be able to remain at work or will return within a small number of days.

Employer-provided occupational health services can help those with more complex needs. However, it has been estimated 22 that no more than 15% of employers in Great Britain offer access to in-house occupational health services.

Figure 2. Health and Work Continuum

Figure 2. Health and Work Continuum

More serious conditions may require more complex health interventions and require a longer period of absence from the workplace. Good workplace management practices, such as remaining in contact with the individual and offering graduated return to work, and early access to rehabilitation interventions if required will support an individual while they are off work and will help them to return as quickly as is appropriate.

Health Services - The 'Scottish Offer'

"…the commitment to include work outcomes as part of the patient recovery plan is of particular significance. This change of approach will go a long way to ensuring that as many people as possible enjoy the benefits to long term health and wellbeing that remaining or returning to work can provide."
- Professor Dame Carol Black, National Director for Health and Work

Those people who wish to enter work and do not have a health barrier to employment can access a range of services to help them find work, develop their skills and knowledge, or help to address other issues that may hinder them entering the workplace.

The review of the Healthy Working Lives strategy has identified that for those with a health barrier to entering work, or who are in employment with a health condition that may compromise their ability to continue in work, there is a need to develop a clear 'offer' that sets out what health services should be expected, standards that they should be delivered to, how they can be accessed and the links to wider services such as employability.

Action 6: Scottish Government, COSLA, NHSScotland and Jobcentre Plus in Scotland will work together to develop and embed a clearly defined 'Scottish Offer' for those with health barriers to work - by end 2010

Most people in work will recover from minor ailments, such as colds, flu or sprains, with little or no health service intervention. Others will have more serious medical conditions that require specialist interventions, such as operations or for chronic illnesses such as diabetes or hypertension. Common conditions such as musculoskeletal disorders or mild to moderate mental health conditions can be treated rapidly in the early stages, before they become a risk to continued employment. Evidence suggests that early interventions are required for these cases to prevent long-term sickness absence.

Dame Carol Black, in her review, recommended the development of a rapid intervention 'fit for work service' aimed at providing quick access for those in work to enable a fast return to the workplace. Dame Carol's recommendation was based on a biopsychosocial model (a biopsychosocial model is one that simultaneously considers the biological (disease or condition), the psychological (impact and perceived impact on mental health and wellbeing) and the social (wider determinants that can have a negative impact on health and wellbeing)) using a vocational rehabilitation approach that de-medicalises the patient's condition.

Vocational Rehabilitation

Vocational rehabilitation can be defined as "whatever helps someone with a health problem to stay at, return to and remain in work". In their review, Waddell, Burton and Kendall concluded that there is strong evidence that return to work assists recovery from many health conditions, that healthcare professionals should play a key role in advising and supporting patients in their return to work, and recognise return to work as an important clinical outcome.

The Scottish Government's Delivery framework for adult rehabilitation identifies the importance of vocational rehabilitation and sets out a model for service delivery. Importantly, the rehabilitation framework recognises that rehabilitation cannot be delivered by health services alone and that an integrated approach across services is required. A network of Rehabilitation Coordinators has been appointed jointly between NHS Boards and local authorities.

The model for vocational rehabilitation outlines the support structures that should be available to individuals in workplaces to promote health and wellbeing at work. It identifies a rapid access referral process through which individuals should be able to secure support and specialist advice from a dedicated vocational rehabilitation team consisting of a range of professionals (case manager (any discipline), counsellor, manual handling trainer, occupational health adviser, occupational health physician, occupational therapist, physiotherapist, psychologist) using case management approaches.

The case management approach to working with clients must be more widely adopted. It is important to de-medicalise the client's situation and take a whole person approach, considering wider issues around personal circumstances, housing, money issues, etc.

Action 7: The National Programme Lead for the Delivery Framework for Adult Rehabilitation, together with regional Rehabilitation Co-ordinators will ensure that all NHS vocational rehabilitation services adopt case management approaches

Three vocational rehabilitation service pilots in Dundee, Lothians and the Borders have been established to trial models of integrated service delivery, allowing rapid access to treatment for employees of small and medium sized enterprises who do not have access to in-house occupational health services.

These pilots are being fully evaluated to establish if the approach provides a cost effective way of helping people to recover from ill-health and return to and retain their employment. The learning from the evaluation will inform further development of vocational rehabilitation based services. The objective will be for every NHS Board area to develop access to relevant health services within their existing resources by adopting the good approaches and practices highlighted by the evaluations of the vocational rehabilitation and Fit for Work Service pilots (see below).

Action 8: Evaluation of Vocational Rehabilitation pilots to be completed - autumn 2010

Following Dame Carol's recommendation, the UK Government is providing funding for a series of 'Fit for Work Service' ( FFWS) pilots across Great Britain. One of these is based on the vocational rehabilitation service in Dundee and the Scottish Government is working with a proposal led by Salus, the NHS Lanarkshire based occupational health service, which will deliver a basic, Scotland-wide service accessible by all. These will also be thoroughly evaluated.

These evaluations will provide data that will allow for the development of a set of standards for service access and delivery that would form the basis for a 'Scottish Offer'. This would set out what can be expected by an individual in terms of obtaining access to work retention or return-focussed healthcare services and what and how these services would be delivered.

A feature of the current pilots, and the work done at Salus, is the use of case management. This approach is also advocated in the rehabilitation framework. The standards of service developed for the 'Scottish Offer' needs to identify a role for a key worker who will ensure that the individual is involved and engaged in the support that is offered and that they are supported through the various services that they may need to access.

The Vocational Rehabilitation Association published a set of standards for vocational rehabilitation in 2008 and the Rehabilitation Council published more general standards for rehabilitation in 2009. Work is required to determine if these could be used as the basis for setting standards for delivery of vocational rehabilitation services in NHSScotland. The Scottish Government Health Directorates National Implementation Group of the Delivery Framework for Adult Rehabilitation will provide a forum to consider how standards for vocational rehabilitation can be developed and adopted across NHSScotland.

Action 9: National Implementation Group of the Delivery Framework for Adult Rehabilitation to address adoption of vocational rehabilitation standards for NHS vocational rehabilitation services as part of the 'Scottish Offer' - by autumn 2010


Another development following Dame Carol's report is the introduction of a 'fitnote' to replace the current GP 'sicknote'. DWP has held a consultation on the draft regulations that are required to make the changes to the current medical certification. The changes will introduce an option on the medical form where the GP can recommend that a person can remain in the workplace, but would require some changes to their work while they recover from their condition. This recognises the evidence that, for many people, remaining in work helps to promote faster recovery.

The proposed changes are planned for introduction in April 2010. These will require to be supported by an education programme for GPs as well as awareness-raising with employers and employees. DWP commissioned work to develop a social marketing campaign to raise awareness of the changes with key groups. This will be an opportunity for the Health Works strategy to work with DWP to promote both health and work generally to health professionals and employers, and the vocational rehabilitation and FFWS pilots specifically.

Role of Healthcare Staff

For those out of work, with a health condition that is a barrier to returning to work, access to healthcare to support a return to work may be more challenging.

Individuals who are on incapacity benefits for any length of time may become distant from the services that can help them. Jobcentre Plus Pathways to Work (PtW) programme is available to those entering Incapacity Benefit ( IB) or Employment and Support Allowance ( ESA). PtW can offer a range of support to help people return to work, including help from the Condition Management Programme ( CMP). CMP assists people to manage their condition so that they are able to move towards work. PtW is also available to those who have been on IB/ ESA for some time, but is not mandatory for all groups of claimants. For those who do not engage regularly with employability service providers such as Jobcentre Plus or other services such as health, it becomes difficult to provide advice on the support available.

Many people who have health barriers to work continue to access public services, though not necessarily in the context of employment, for example social services, housing or debt advice services. Such contacts provide an opportunity for staff to establish whether a person is in work or not and to provide advice on how they can access services to support a return to work. Similarly, healthcare staff may be working with a patient in a context that is not directly related to the individual's employment situation.

Staff need to be suitably empowered to ask a few, basic questions and, where appropriate, the patient care plan should aim to have a work-related outcome, such as referral on to an employability service. This should include healthcare staff engaging directly with patients and where advice is being provided such as through NHS 24. Referral processes into these employability services also need to be addressed and improved. Development of closer partnership working between local NHS Boards and Workforce Plus employability partnerships will facilitate this.

The Equally Well test site in Lanarkshire is rolling out key training to frontline staff that may have historically not explored employability needs with clients/patients, e.g. health, housing and social work staff. This has involved development of a training package and expansion of a phoneline service. The approach needs to be developed and rolled out across Scotland.

Action 10: Scottish Government will promote the adoption of good practice and learning from the Lanarkshire employability test site to NHS Boards and local authorities in the rest of Scotland

NHS Education for Scotland ( NES) is developing a programme for the design and delivery of a knowledge service for vocational rehabilitation. NES has established a consortium of key stakeholders from wider health and work interests in vocational rehabilitation to share education and training, and to jointly commission work to fill the gaps in provision across Scotland. An electronic learning network is to be developed to allow sharing of practice and this will link to the employability learning network to facilitate links across the health and employability agendas. A jointly funded project lead post with NES, NHS Quality Improvement Scotland and the Centre will be appointed in autumn 2009. It will have responsibility for progressing the work of the consortium, developing the elibrary shared space resource and to seek partners to develop and design the education and training that workers across Scotland need to access so they are enabled to better support people back to employment. NES will map existing employability training for healthcare staff, identifying the gaps and commissioning and developing, where appropriate, new training that meets the overall aims and learning for raising awareness of employability with NHS staff.

Action 11:NHS Education for Scotland to appoint a Project Lead in Education and Practice Development for Vocational Rehabilitation - autumn 2009

Equal Access in Glasgow developed an employability training pack for healthcare staff which was rolled out across Scotland in 2008. This will now be further developed to encourage further uptake and use of the pack and to allow it to be tailored for non-healthcare staff and to reflect local requirements.

Action 12: Scottish Government and NHS Education for Scotland will deliver a programme for the development of the existing employability training pack and its delivery to healthcare and other professionals, seeking formal accreditation of training - autumn 2010

There is significant variation across Scotland in the range and depth of relevant health and employability services available and in the demand for these. In many parts of the country there are third sector organisations offering employability or rehabilitation services.

Development of a 'Scottish Offer' requires that local health and employability services are able to link effectively to allow an individual to access the right services in the right order and to progress quickly and smoothly towards work. A strong and committed health presence on local Workforce Plus employability partnerships will facilitate this.

Action 13: Membership of local Workforce Plus employability partnerships to be reviewed to ensure that health is represented at an appropriate level - by summer 2010

Employability advisor pilot - West Dunbartonshire and Renfrewshire have successfully bid for funding from DWP to run a pilot over two years to provide employability advisers who will support those in work who are at risk of losing their jobs as a consequence of a mild to moderate mental health condition. Support will include access to psychological therapies, return to work, working with employers, or seeking alternative employment.

The pilot is part of a wider programme for Improving Access to Psychological Therapies across Scotland, England and Wales.

A clear picture of existing provision of occupational health and vocational rehabilitation services in Scotland is required. This will allow NHS Boards to identify how health services can be configured to allow the individual's progression towards a work outcome. It will also allow NHS Boards to look at how health services interact with other service providers across the health and work continuum.

Action 14: Scottish Government will undertake a mapping of existing NHS and other provider occupational health and vocational rehabilitation services - by autumn 2009

Development of the 'Scottish Offer' will be taken forward by a group of senior representatives from NHS Boards and from the healthcare professions, who will establish the criteria for standards of access and service delivery. A suitable performance management ( HEAT - Health Improvement, Efficiency, Access and Treatment) target will be developed to allow for performance management of service delivery by the NHS.

Action 15: Scottish Government to convene a group of senior NHS and healthcare professions representatives to take forward development of standards for the 'Scottish Offer' - by end 2009

Action 16: Scottish Government to develop a HEAT target for health services for supporting people towards work - to implement in 2011-12

As already outlined, people passing through services supporting them towards work may pass through a number of different organisations. It is essential that the role of each organisation involved in helping someone towards the workplace recognises the role of the other local partners and how they need to interact with one another.

A detailed needs assessment is needed for individual clients when they enter the system. This needs to be comprehensive to ensure that all of the potential impacts on a client's ability to return to work are considered. These would include benefit maximisation, debt counselling, housing advice, education and skills appraisal, and health assessment. This may be provided by a single point of contact or may involve a number of organisations. There is growing evidence that a case management approach to supporting a client can be beneficial in providing joined-up support for the client, simplifying the process and ensuring an holistic approach. A key worker can develop an activity plan with the client to address those areas where support is needed. National guidance on what should comprise a needs assessment is required to ensure consistency.

Action 17:NHS Education for Scotland and Scottish Government to establish working group to develop national guidance on needs assessment - by end 2010

The pathways taken by individuals to help them towards work should not be confused with the health and work continuum. The pathway is the route through the services that support people, the continuum is simply a means of illustrating that an individual's distance from work can vary and change over time.

Work has been done in a number of areas to map out these pathways, identifying a number of key stages in the person's journey and who the service delivery organisations are. Every territorial NHS Board must work with local partners (through, for example, local Workforce Plus employability partnerships) to ensure that there is a clearly defined pathway(s) covering local employability and health services. This should ensure that there is a clearly defined set of services and service providers. This will require a mapping exercise. Where gaps in the pathway are identified steps must be taken to address these locally.

The mapping work needs to identify clear access points to the services and how individuals have their progress through the services managed. Some areas have already carried out such an exercise and an example of a health and employability pathway is given at Annex D.

Action 18: Territorial NHS Boards to work with local employability service providers to define the local pathway for providing support to those for whom health is a barrier to retaining or returning to work - by end 2010