Carol Black National Director for Health and Work

1. Healthy, Wealthy and Working 24 February 2010 National policy on health and work Carol Black National Director for Health and Work

2. What is our overall goal? Healthy engaged workforces in well-managed organisations • A quality product • A high-performing resilient workforce • Enhanced productivity Contributing to : • A well- functioning society • The national economy

3. Most of the population is of working age On current predictions, the future population will be composed of longer survivors, with more chronic disease - therefore : • We need the ratio of dependants to earners and wealth-generators to be as low as possible 0Childhood, teens 16 Majority of working people 65 Post-retirement • For a flourishing society we need the maximum number of productive years from as many of the population as possible. Health inequalities reduce this number. • A major challenge for us all, a cross-government issue.

4. Employed with a health condition Employed on sickness absence Employed and in good health People on Jobseekers Allowance with a health condition People on Jobseekers Allowance in good health People on IB/ESA Flows of people into employment and out of work benefits

5. The Fundamentals People’s social and economic circumstances affect health throughout life, so health policy must be linked to the social and economic determinants of health. Michael Marmot “Work is a social determinant of health” (Marmot 2002) Unemployment Living conditions “Work is generally good for physical and mental health and well-being” Waddell and Burton (2006)

6. 2 to 3 times risk of poor health Greater risk than many “killer diseases” Greater risk than most dangerous jobs (e.g. construction, fishing, etc) 2 to 3 times risk of mental illness - anxiety and depression Loss of self-worth and -confidence Loss of fitness and well-being Social exclusion and poverty Loss of income; possible loss of life Being out of work long-term is a great risk to health Being out of work is associated with poor mental health, increased likelihood of anxiety and depression, and increased use of medication. Proportion of deviation from perfect health by work status :

7. It impacts on the next generation too • Evidence of correlation between lower parental income and poor health in children. • Children in workless households suffer higher rates of psychiatric disorders • Evidence that behavioural/conduct disorders are more likely where no parent in the household is working • Children living in workless households are more likely to experience worklessness themselves during adult life • 30% of children who have a parent with a disability or health condition live in poverty

8. Costs of working-age ill-health Financial • Overall costs of working-age ill-health in UK exceed £100 billion per year • Around 172 million working days were lost to sickness absence in 2007, at a cost to the economy of over £13 billion (CBI) • ‘Presenteeism’ due to mental ill health is estimated to cost £15 billion per year. Social “For most people their work is a key determinant of self-worth, family esteem, identity and standing within the community, besides of course, material progress and a means of social participation and fulfilment” Working for a healthier tomorrow, 2008

9. Working for a healthier tomorrow, 2008 - a new vision for health and work “At the heart of this Review is a recognition of, and a concern to remedy, the human, social and economic costs of impaired health and well-being in relation to working life in Britain. The aim is not to offer a utopian solution for improved health in working life, but rather to identify the factors that stand in the way of good health and to elicit interventions, including changes in attitudes, behaviours and practices – as well as services – that can help overcome them.” Working for a Healthier Tomorrow Prevent illness, promote health, intervene early, improve the health of the workless.

10. Problems with the UK system in 2007 • Misconceptions about health and work • Poor retention in work of those with disabilities or chronic disease • Workplace and employers often needing a different culture or approach • A system of sickness certification that labels you as sick • No pathways of rapid intervention to keep you in work or return you to it • Poorly-informed healthcare professionals in both primary and secondary care with little understanding of work as a determinant of health. • Work, Health and Well-being not part of training or clinical practice • Rehabilitation to work not a performance measure for PCTs or boards • No Occupational Health services in Primary Care; patchy OH elsewhere. • Too many people moving into or staying within the benefit system Working for a healthier tomorrow, 2008

11. Why people are off work in the UK and many other countries • Two-thirds of sickness absence and long-term incapacity is due to mild and treatable conditions: • Depression, anxiety, stress-related mental health problems (est. cost £28.3 bn in 2008) • Musculoskeletal conditions – mild and often soft tissue (est.cost £7 bn in 2007) • Cardio-respiratory conditions • Inappropriate “medicalisation” • Poor retention in the workplace of those with disabilities or chronic disease ‘Causes of the causes’?

12. The shape of things to come Globally, over 50% of deaths are due to : - Type 2 diabetes (obesity) - Cancer - Chronic respiratory disease - Cardiovascular disease. Three main risk factors (tobacco, physical inactivity, poor diet) promote these diseases. These risk factors provide a clear focus for business. What is the total economic and social cost of chronic disease?

13. Symptomatology Often mild Symptoms not ‘diseases’ e.g. back pain anthralgia stress anxiety Few investigations required Diagnosed with relative ease Treatment needs to be early, appropriate, often non-medical, with good vocational rehabilitation, and regular contact between employee and employer. Diseases Often chronic Diseases e.g. - diabetes chronic lung disease rheumatoid arthritis cancer endogenous depression Investigations more extensive Diagnosis can be difficult Many of these diseases more prevalent in poor or deprived communities Treatment – good medicine, good flexible employers, plus vocational rehabilitation What problems are we dealing with ?

14. The workplace. Findings of the Black Review • Poor understanding of HWWB initiatives that employers can implement • Many employers are unaware of the business case for investing in health and well-being. Good health is good business! • Often there are no sickness-absence policies to enable early and sustained return to work. • Line managers’ behaviour is crucial, however there is often little training. • Often there is no policy on handling mental ill-health • Accessible and affordable sources of support and advice are rarely available for SMEs • Employers may be inflexible about necessary adjustments for those with chronic disease • No national standards are available to employers when they purchase occupational health or well-being services • Occupational Health services need to be re-aligned to current need

15. Challenges facing Occupational Health • Key challenges facing the OH profession: • detachment from mainstream health care • little communication with other specialties • limited remit • uneven provision, only in workplaces • diminishing workforce • shrinking academic base • lack of good quality data • image and perception Working for a healthier tomorrow, 2008 Working in silos The challenge for a new paradigm of OH is to examine the care pathways for working people and find new ways to support them before, during and after illness at work. What form should good OH services take in the 21st century ?

16. The government response • The Government’s Response, Improving health and work: changing lives, was published in November 2008. • The recommendations of the Black Review were accepted.

17. Black’s recommendations: progress • Electronic ‘Fit Note’ … … implementation due April 2010 • ‘Fit for Work’ service pilots … … go live April 2010 • Education and training initiatives … … rolled out for GPs from June 2009 • Regional co-ordinators of health, work and well-being .. launched Dec 2009 • Government strategy, Mental Health and Employment.. published Dec 2009 • Public sector as exemplar – Boorman review of health of NHS staff … …. published Nov 2009 • Occupational Health Adviceline for SMEs … … launched Dec 2009 • Challenge Fund for Small and Medium enterprises … launched Oct 2009 • Business Healthcheck Tool … … relaunch due March 2010 • National Standards for provision of OH services .. … published Jan 2010 • Council for Health and Work … …. now established • National Centre for Working-age Health and Well-being …tendering started. All are designed to keep people in work.

18. Statement of Fitness for Work:the “Fit Note” • Will come into effect on 6 April 2010 • Guidance published 18 February • Key changes are: • The introduction of a new option: ‘May be fit for work taking account of the following advice’; • Increased space to complete comments on the functional effects of the patient’s condition; • Tick boxes to indicate simple adjustments that could aid their return to work; and • Fewer forms and more flexibility for doctors. replacing the old ‘Sick Note’

19. Statement of Fitness for Work“Fit Note” • The new form will provide a better tool for : • doctors to advise their patients about their health and work; • patients to understand the impact of their illness or injury and to support them to return to work; and • employers to manage sickness absence and help employees return to work.

20. Fit for Work Service pilots – co-ordinated health and work support for individuals Aim - To reduce sickness absence and avoidable job loss How? • Service for people off work sick after 4 to 6 weeks • Eleven pilots in locations throughout GB, selected after stiff competition • Early access to co-ordinated health treatment and employment support, including debt, housing, learning and skills, employer liaison, conciliation • Pilots will go live by April 2010 – some already in operation • £13m pump-prime funds to co-ordinate, re-configure and procure health- and employment-related services (focus on common health conditions) • Testing different local models – case management a key component • Variety of delivery partnerships – existing and new local consortia • Robust evaluation Next Steps • Develop the learning network • Link with the Occupational Health Adviceline and the HWWB Co-ordinators

21. Working our way to better mental health: a framework for action • The strategy sets out the practical steps that government, employers, healthcare professionals, individuals and others need to take to achieve 2 key aims: • to improve wellbeing at work for everyone; and • to deliver significantly better employment results for people with mental health conditions. • This framework, published 2009, must be a long-term commitment. The wider aim is to influence future policy development across Departments and throughout the public sector and to bring about changes in behaviour in organisations and individuals.

22. Survey of attitudes: Insights from GPs Key Disincentives to Change : 1. Reluctance to disrupt relationship with patient by refusing sick notes • Inadequate training in work-related health issues • Reluctance to break patient confidentiality by engaging more directly with employers • Other Barriers to Change : • General reluctance to increase / expand workload • 5. A lack of or inconsistent access to suitable return-to-work services • No recourse / alternative action if they feel patients are capable of work • 7. Local economic conditions • 8. Benefits system which they see works against encouraging people (back) into work after Andrew Irving Associates, 2009

23. Educational Initiatives • GMC “Tomorrow’s Doctors”, published 2009 • Postgraduate medical education: ongoing work with Medical Royal Colleges and PMETB. • UK Education Programme for GPs started April 2009 • Working with RCGP, FOM and SOM, an e-learning programme for GPs and secondary care doctors is being developed with Dept of Health e-learning group – launch for GPs April 2010 • Nurse education: working with RCN and Deans of nursing schools • Manager training: Business School Deans are currently undertaking a project on content of their curricula.

24. The great Potential of the Workplace to improve Health, Well-being and Productivity • Must design with employee engagement • Need ‘buy in’ by senior management • Share best practice on what works and what doesn’t • Consider resilience - building for positive mental health • Line managers’ training is critical

25. Insights from employers/line managers • Key Disincentives to Change: • Not knowing/understanding the benefits of health and well-being initiatives • 2. Lack of awareness of the benefits of early intervention • Lack of incentive to look after low-skilled staff’s welfare • 4. Perception that you do need to be 100% fit to return to work • Other Barriers to Change : • Present economic climate • 6. Sickness Policy contributing to rather than encouraging change • 7. Line managers ill-equipped to handle sickness absence and health/well-being issues • 8. Unenlightened attitudes towards mental health / chronic pain • 9. Perception of ‘welfare and health issues’ as ‘nannying and fussing’ after Andrew Irving Associates, 2009

26. Is there an economic Case for Investment in the Workplace? What do we know? • Economic evidence of interventions and actions is promising • Much of the evidence has focused on interventions targeted at individuals rather than the workplace • The evidence to date has been US dominated: there employers pay health care costs and thus have incentive to promote better workplace health • Interventions in workplace can be of benefit to employees, employers and the public purse

27. Ginsters: Wellbeing in the workplace • Started July 2006 • On-site fitness suite: workplace coordinator • Slimming club and nutritional sessions • Health surgeries (drugs, alcohol, BP, BMI, diabetes, audio and weight management) • Around 15 regular physically-based activities • Taster sessions (e.g. canoeing, horse riding, archery, orienteering, scuba diving) • New menus in Restaurant + free fruit for all staff • Family and Community activities, e.g. allotments • Reaching out to their suppliers and neighbouring small companies

28. Business Case Ginsters are able to demonstrate to other businesses the economic viability of investment in health promotion within the workplace Health insurance Premium reductions (cost per eligible employee) This is direct result of the reduction in the number of claims by employees Reduction in cost of advertising & agency fees indicate the trend of candidates approaching Ginsters direct and the impact of excellent staff stability. Staff satisfaction 58% 78%

29. Employee Wellbeing at Somerset Council • Holistic employee wellbeing • programme • Quality-of-life working-life • audit to identify triggers • Guidelines on stress management; • restructuring skill mix for workers; • and counselling • Absence fell by 2.5 days per • employee over 2 years Source: Somerset Council, 2007

30. Case Study – introducing new health and wellbeing initiatives Digital Outlook Communications – a small company (digital marketing and creative agency) • conducted a Best Companies survey to obtain employees’ feedback on their wellbeing and the perceived quality of leadership and management • established a Wellbeing Team, supported by senior management, to gather suggestions for, and implement, initiatives which included: - Introduction of flexible working; - Revamping the agency’s charging system to ensure clients paid for work actually done, optimise profitability and enable employees to reduce working hours while still meeting financial targets. • Improved promotion of the employee benefits system; • Introduction of a mentoring and development scheme; • Improving the ergonomic working environment; • Establishing health and wellbeing as a KPI for all senior managers.

31. Case study - What were the business benefits from the new initiatives? Digital Outlook Communications (digital marketing and creative agency) • Health and wellbeing survey scores improved 11% to a score of 4.9, better than all other small media companies surveyed in 2008 • Sickness absence rates improved 95% from 4 days per person in 2006 to 0.22 days per person in 2008 • Staff turnover was reduced from 34% in 2007 to 9% in 2008, resulting in savings in recruitment, training and induction costs.

32. Business Healthcheck Tool • The Business Healthcheck Tool is a FREE online resource designed to help employers improve the health and well-being of their staff – to be re-launched in March 2010. • The tool will help organisations to: • Estimate the impact of poor health and absence from work and help build a business case for action, ranging from the simplest changes to large scale initiatives • Help identify and understand the issues and underlying causes that affect work health and well-being in an organisation • Look at some of the things that can be done to improve workplace health and well-being, using examples and case studies of successes in other organisations

33. Business Healthcheck Tool What does the Business Healthcheck Tool allow employers to do? What are my Costs? How do I compare? How can I Improve? What’s the Benefit? Measure the impact of ill health and well-being in your organisation Compare your results against benchmarks and other organisations Get practical ideas to help reduce health and well-being costs to your organisation Work out the costs and benefits of investing in a well-being programme

34. Targetted Help for SMEs • OH Adviceline: 9 pilot sites launched, on 7 December 2009 • English pilots are being delivered by NHS Direct and NHS Plus • To accompany this new service a website was launched to promote the English pilots: www.health4work.nhs.uk • All pilots are functioning well and small businesses are accessing the service. marketing began in early January 2010. • The Institute for Employment Studies are evaluating the service. • Challenge Fund for Small and Medium-sized enterprises, launched December 2009. Overwhelming response – selection in progress regionally.

35. Regional Co-ordinators of Health Work and Well-being • 9 co-ordinators are in post. The two remaining co-ordinators will follow shortly (in both cases, interim resource is in place to cover the duties of the co-ordinator). • Their role is to: • Develop and encourage partnerships between employment, health and other relevant networks within their region and country; • Co-ordinate HWWB strategies and activities within and across the English regions and Scotland and Wales; • Recognise and promote best practice and innovation within firms on health, employment and skills, working with smaller businesses and local partnerships and in particular using the HWWB Challenge Fund as a key tool to achieve this.

36. Mental Health in the Workplace Managing mental health in the workplace is a crucial skill for line managers

37. Line Manager training on Mental Health Pilot course by Sainsbury Centre for Mental Health, based on beyondblue’s programme. Course content: • Build awareness of depression and anxiety • Understand how common these symptoms are • Recognise signs and symptoms in the workplace • Build skills of managers to identify and respond appropriately to depression in the workplace through discussion and DVD case-study material to explore helpful and unhelpful behaviour • Time for discussion and thinking through effective strategies in your own workplace

38. Line manager training (cont’d)

39. Mental Health: the business case • Emphasis in NICE guidance on the business case • If mental illness costs employers £28.3 billion per annum in 2009 : • - prevention and early identification of problems should save employers at least 30%, i.e. £8 billion per annum • - for a 1,000 employee company annual costs can be • reduced by £250,000 http://www.nice.org.uk/nicemedia/pdf/PH22Guidance.pdf

40. Two Sides of a Coin

41. Macleod Review Engaging for Success 2009 Remit: An in-depth look at employee engagement and to report on its potential benefit for companies, organisations and individual employees. “We believe that it is most helpful to see Employee Engagement as a workplace approach designed to ensure that employees are committed to their organisation’s goals and values, are motivated to contribute to organisation success, and are able at the same time to enhance their own sense of wellbeing.” Macleod and Clarke, July 2009

42. Engagement Organisations with engaged employees tend to: • Have employees who have a real sense of where they are trying to get to • Have managers engaged at the front line; managers who offer clarity about what’s expected and give lots of appreciation • Have well organised work – it is hard to be engaged if work is badly organised • Have congruity between values and actions David Macleod 2009

43. Working Together We Will make a Difference “By working together, our efforts will help us to combat social exclusion, eradicate child poverty, support our ageing population, and build a workforce for tomorrow. By improving health and work we will make a real difference to people’s lives.” Government’s Response, Improving health and work: changing lives, November 2008