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

Australasian Faculty of Occupational and Environmental Medicine

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:

no linear causal chain

not interchangeable1. 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.

clinical representation/manifestation of disease

associated with normal or unaccustomed activities of daily living

unassociated with any identifiable disease 1,2

ubiquitous and omnipresent 3,4

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

Paradoxes1

• 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. Winkelmann and Winkelmann 19962. Clark, Georgellis, Samfey 20013. Clark and Oswald 19964. 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 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)

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 goesrotten, but when work is soulless,

life stifles and dies.

Albert Camus

Sickness and disability among main threats to full and happy life;

Work incapacity most significant impact on individual, the family, economy and society.

The Consequences

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: 19982. Black D. Inequalities in Health, HMSO: 1998

Incapacity Benefit (IB) Recipients –Diagnostic Groups

Cardiovascular10%

Diseases of the nervous system

3%

Injury 1%

Diseases of the respiratory

system2%

Other conditions or condition not

specified14%

Mental health44%

Musculoskeletal26%

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%

0

5

10

15

20

25

30

35

40

45

50

Mental healthMusculoskeletalCardio-respiratory

The changing proportion of Incapacity Benefit claimants by diagnosis

20081995

National Statistics: www.dssni.gov.uk/incapacity_benefits

Cardiff Health Experiences Survey (CHES): Face-to-Face Interviews [N=1000] GB

population: Main ComplaintOpen Question: Inventory:

LBP 8.9% 14.6%Musculoskeletal 4.6% 7.0%Mental Health 7.5% 25.6%Cardio-respiratory 3.6% 5.9%Headache 2.9% 9.3%G/I 2.4% 4.0%Without any complaint 70.1% 33.6%______________________________________________________________________________________________________________________________________________________________________

At least one complaint 20.6% 66.4%2 or more complaints 8.4% 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

PSYCHO-

BIO-

• Bio-psycho-social factors may aggravate and perpetuate disability

• They may also act as obstacles to recovery &barriers to return to work

Management of common health problems must address obstacles to recovery.

Beliefs play a pivotal role in propagating and perpetuating these illnesses

Social factors dominate

Corollary :

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

• Rather than aiming for control of a health condition, successful outcomes dependent on learning process towards self-management and independence

• 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-EfficacyBelief that “stress” is causal factor

• Social: Lone parents / unstable relationships“Victim” of modern societyRented or social housing

• General Affect: Sad or low most of the timePervasive thoughts about personal illness

Negative Influences:

• Occupational: Job dissatisfactionLimited attendance incentives (esp. work colleagues)Attribution of illness to work

• Cognitive: Minimal health literacySelf-monitoring (symptoms)False beliefs

• Economic: 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:

Positive health at work strategiesEarly detectionAccommodation of temporary functional limitationsInterventions: 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