1.1 WHSS service provision
The Working Health Services Scotland ( WHSS) programme was introduced in order to provide support to employees in small and medium sized enterprises ( SMEs, <250 employees) whose health condition was affecting their ability to work. It was funded by the Scottish Government and the UK Government's Department for Work and Pensions ( DWP). The programme offered telephone based case management and some face-to-face therapeutic support to those who were either off work due to a health condition, or at risk of becoming absent due to the condition. The programme developed from the WHSS pilot programme which had been delivered in 3 NHS Health Boards from 2008-2010. These Health Boards - Borders, Dundee & Tayside, and Lothian - therefore had established services at the start of this period of data collection. Other Health Boards were introducing the programme for the first time.
The service was provided in the following Health Board areas in Scotland: Ayrshire & Arran, Borders, Dumfries & Galloway, Dundee & Tayside, Fife, Forth Valley, Grampian, Greater Glasgow & Clyde, Highland, Lanarkshire, and Lothian, with clients from outwith these areas (Orkney, Shetland and Western Isles) being managed by other Board areas.
This evaluation describes and evaluates the reach and impact of the WHSS programme, as delivered to clients enrolled into WHSS in the period between 26 th March 2010 and 31 st March 2014; discharge data up to 28 th July 2014 are included.
1.2 Data collection
Data were collected from clients at the following points while they were in the WHSS programme:
- Enrolment: The client's first contact with the service, which assessed their eligibility for it.
- Entry: A detailed telephone assessment by a case manager, concerning health condition, effect on work ability, absence status and health measures.
- Therapy provision: The services received by the client (including case management, physiotherapy, counselling, occupational therapy, self-help materials etc.).
- Discharge: Health measures, work ability, absence status were collected at the point the case manager judged the client should be discharged from the service, either because their condition had improved, or the service was not able to support them further.
- 3 month post-discharge follow-up: Recording health measures, work ability and absence status.
- 6 month post-discharge follow-up: A repeat of the data gathered at the 3 month follow-up.
Data were collected on a range of demographic details, as well as the health conditions with which the cases were presenting. Data on their employment status (at work / off sick) were also recorded. They completed up to three standard, validated health questionnaires at entry and discharge - the EQ-5D, which included a visual analogue scale ( VAS), the Hospital Anxiety and Depression Scale ( HADS) and the Canadian Occupational Performance Measure ( COPM).
2. Description of cases
There were a total of 13,463 referrals into the programme in the four year period, of which 11,748 cases (87.3%) were eligible and completed the entry assessment.
Over a quarter (26%) of referrals were from Lanarkshire Health Board; this includes some clients from other Board areas if they were case managed by the team in Lanarkshire, who managed the national implementation of the programme. Dundee & Tayside comprised 19% of cases and Lothian had 16%; both these Boards participated in the pilot of WHSS, and were therefore established services when this period of data collection began.
The majority of cases (92%) were new referrals into the service, while 5% were referring again with a new health condition; and 3% were referring again with the same health condition.
The average age of clients in the whole sample is 44 ( SD 12) years old. Altogether 43% of the clients were over 50-year-old, while only 10% are under 30.
There was a statistically significant increase in the number of cases with higher ranked scores in the Scottish Index of Multiple Deprivation ( SIMD) categories (i.e. a greater proportion of cases were in the less deprived SIMD categories), although this could partly reflect rates of employment in the SIMD categories.
Almost 20% of cases were self-employed, while 26% worked in organisations with 2-10 employees.
Other demographic data (gender, ethnicity) broadly reflects the population in Scotland.
The majority of cases referred to WHSS due to a musculoskeletal condition ( MSK) (84%); while 12% referred with a mental health ( MH) condition (depression, stress, anxiety and other mental health conditions). Altogether, 16% of cases also reported a secondary health condition, for which they may have received treatment / support while in the WHSS programme.
Altogether 25% of cases were absent at their entry assessment; with 22% of MSK cases being absent at entry, while 41% of MH cases were absent at entry.
Of those who provided information about how long they had been absent at the point they came into the programme, 36% (776 cases) had been absent for no longer than 2 weeks at the time of their entry assessment, while 20% (438 cases) had been absent for more than 12 weeks.
3. Models of WHSS delivery
The way that WHSS was implemented varied between the participating Boards, and in some cases varied over time with staffing changes. The case management function was either in-house (by an individual or a team, and the case manager may have also been a therapy provider) or contracted to Salus Occupational Health in NHS Lanarkshire (where case managers were not also therapy providers). Therapy provision (physiotherapy, counselling / psychological services and occupational therapy) could be provided from within an in-house WHSS team, provided from within the NHS therapy teams, or contracted out to private practitioners. Boards that contracted their therapy provision to external providers were responsible for ensuring that the service provided was occupationally / vocationally focussed.
The average and maximum number of sessions of therapy provided varied between Boards, although, because significant amounts of data are missing from some Boards, care should be taken when considering these differences in service delivery. The average number of physiotherapy sessions attended varied 2.8 to 5.3; for counselling / CBT / psychological services the average ranged from 2.6 to 5.2; while for occupational therapy sessions, the average ranged from 1 to 2.7.
4. Discharge outcomes
4.1 Duration in the programme
The average time between the cases' enrolment and their entry assessment was 5.2 ( SD 9.8) days.
Overall, 59.8% of those who completed the entry assessment completed at least some of the discharge paperwork. The average intervention time (i.e. time from entry assessment to discharge) is 121.0 ( SD 81.1) days. 83% of cases were discharged within 6 months of their entry assessment.
4.2 Changes in absence status while in programme
The majority of cases (75%, N=6,541) were at work both at entry and discharge from the programme, while 4% were off work at entry and discharge. However, 18% (1,188 cases) who were absent when they entered the programme were at work on discharge from it. Altogether, 94% of the cases were at work at discharge and 6% were absent.
4.3 Number of lost working days during the programme
Modelling of the data showed that the number of lost days while in the WHSS programme was related to a client's age, length of absence prior to entering the programme, primary condition and duration in the programme. The statistical model suggests that older cases took longer to return to work, with almost 5 more days of absence for every 10 additional years of age. The number of days lost due to sickness absence while in the programme is much higher in MH cases (p<0.001) than MSK cases; 50% of MSK cases are back to work in 21 days, while this is 46 days for MH cases. The statistical model also suggests that those who presented with a MSK condition had 10 days less sickness absence while in the programme than those with MH conditions.
4.4 Health issue resolved
When asked whether their health issue was resolved at discharge, 77% answered positively (34% fully resolved, 43% partly resolved, N=7,869). This was similar whether cases presented with an MSK condition (80% positive) or MH condition (83% positive). Of those who were at work at entry, 81% reported positively; this was less (74% positive) for those who were absent at entry.
4.5 Changes in health tool scores at discharge
All health assessment tool scores ( EQ-5D index, visual analogue scale ( VAS), COPM and HADS) improved statistically significantly from entry to discharge.
4.6 Other support
Over half (53%) of the 340 cases who were using other support services at the time they entered WHSS (e.g. medical professionals and allied health professionals) were no longer using these services at discharge, while 15% were still using them, but a reduced amount.
A third of cases (33%) reported at discharge no longer taking the medication for their condition that they were taking at entry, while 15% had reduced their medication use.
4.7 Work ability
Almost two thirds (64%) of cases (N=6,759) were working their normal hours at both entry and discharge. However, 19% who were off work at entry were working normal hours at discharge, while 5% who were on restricted hours at entry were working normal hours at discharge, meaning an improvement in working hours for almost a quarter of cases.
In terms of ability to do their normal duties, 21% did not have difficulty with work duties at either entry or discharge (N=4,940). However, 59% improved from struggling with their normal duties at entry to doing their normal duties without difficulty at discharge, with a further 4% improving from not able to do their normal duties to being able to do them without difficulty at discharge.
A fifth (20%, N=5,969) of cases thought at entry that they could not, or were unsure if they could do their job in 6 months' time but thought that they could when they were discharged. Two thirds (66%) thought they would be able to do their job in 6 months' time, both at entry and discharge.
4.8 Post discharge follow-up
Data collected at 3 and 6 months post discharge indicates that the improvements to health ( EQ-5D index and VAS), and ability to work were maintained following discharge.
4.9 Qualitative feedback on the service
Cases' views of the service were overwhelmingly positive. Over 98% reported 'good' or 'excellent' concerning their overall experience of the service; how helpful it was; how involved they felt; the treatment they received; and the speed and delivery of the service. Altogether 99% would use the service again and would recommend it to others. Over 84% agreed that the service had helped them to return to work more quickly than if they had not had the support of the service.
5. Discussion and conclusions
The findings of the programme indicate that it has had a positive benefit for cases, with all health measures showing a significant improvement and the qualitative feedback being very positive. Of the sample where data are available, 75% of cases were at work at entry and remained at work throughout the programme, while 18% (1,188) were absent at entry and had returned to work by the time they were discharged.
The health tool scores all showed significant improvements from entry to discharge. The extent of the positive change in EQ-5D is striking from a health economic perspective, and although there is no control group, it cannot be ruled out that the WHSS intervention has contributed to this health benefit. The benefits appear to be maintained after discharge from the service.
Recommendations relating to future programme delivery are given.