National Leading Health and Wellbeing Programme 2013-14 Learning Event 2

1. National Leading Health and Wellbeing Programme 2013-14 Learning Event 2 London, 15 January 2014 Challenges in improving health work and wellbeing . Dame Carol Black Expert Adviser on Health and Work Department of Health, England Principal, Newnham College Cambridge

2. What is our overall goal? Healthy, engaged workforces Well-managed safe organisations • A high-performing, resilient workforce • Enhanced productivity Contributing to: • A well-functioning society • Better economic performance

3. Work: Its Value “ Laying emphasis on work is an important technique for the conduct of life: for work at least gives the individual a secure place in a portion of reality, in the human community.” Sigmund Freud “ Working hours are never long enough. Each day is a holiday, and ordinary holidays are begrudged as enforced interruptions in an absorbing vocation.” Winston Churchill “ The saddest object in civilisation, and the greatest confession of its failure, is the man who can and wants to work but is not allowed to. ” Robert Louis Stevenson (attrib.) “ Our greatest primary task is to put people to work.” Franklin D. Roosevelt, 1933

4. What prevents us from working – or from working well ? Common mental health problems Musculo-skeletal problems high prevalence across populations little or no objective disease or impairment most episodes settle rapidly, though symptoms often persist or recur essentially whole people, should be manageable. The workplace - organisation of work - managerial behaviour and leadership - absence of ‘good work’ Other important reasons(often social or home-related) - long-term conditions – mental and physical – can be obesity-related - lack of education and/or skills - deprivation, poverty, lack of jobs.

5. All these issues are medicalised Work-related injury and disease Chronic diseases Common mental health problems Musculoskeletal problems Psychosocial Other e.g. bereavement Work Medical Certificate necessaryto sanction absence Resulting support medicalised too, leaving many psychosocial problems not dealt with. Yet a satisfactory return to work requires that all problems are dealt with. Unmet needs and sickness certification Reasons for absence:

6. Leadership Effect: Predictors of back pain in employees After adjustment for age, sex, skill level, back pain severity and other potential confounders, the most consistent predictors of back pain were: decision control(lowest OR 0.68; 99% confidence interval (CI): 0.49 -0.95), empowering leadership(lowest OR 0.59; 99% CI: 0.38-0.91) fair leadership (lowest OR 0.54; 99% CI: 0.34-0.87) Christensen JO, Knardahl S. 2012

7. The journey from work and wellbeing in the UK Too few drivers in the journey keeping people in work. 39 weeks 28 weeks ESA benefit and support GPs the gateway to benefits Work Sickness absence Work Capability Assessment Claim to Employment Support Allowance (ESA) Work Capability Assessment (WCA) Claim to Employment Support Allowance (ESA) JSA benefit and support Work SSP/OSP Inactivity Too little help here to maintain people in work. Poor and ineffective early intervention SSP = Statutory Sick Pay OSP = Occupational Sick Pay LEAVE WORK Waiting for WCA completion can be nine months. Active support here BUT too late WCA = Work Capability Assessment

8. The journey we must create Drivers to maintain employees in work As few people as possible entering the benefit system. Many people with long-term conditions and disabilities can and want to do at least some work. Sick Leave Work Work Capability Assessment Emphasis on mental and physical fitness and productivity We need co-ordinated effort to return individuals to work as soon as possible, by early, targeted intervention in a distinctive culture. GPs (family doctors) supported and mandated to act.

9. The present landscape which affects this agenda • The economic situation • Major reform of the NHS • Public Health re-organisation • Local Councils’ enhanced responsibilities • Health and Wellbeing Boards • Public Health Responsibility Deal • Major reform of the welfare system • Independent review of sickness absence (Government response and roll-out)

10. Healthy Workforces: the key players Health professionals (Primary and secondary care) Non-governmental bodies and charities Public Health (PHE, local councils, professionals) Employers (Workplaces, Line managers, Human Resources) Employees (Patients) OH professionals Trade Unions (less than 15% of the global workforce has access) Governments to initiate, support, encourage, and where necessary legislate.

11. Obstacles (for individuals) to staying in or getting back to work • Health-related After Waddell & Burton - Ineffective treatments - Waiting for tests, treatment or specialist appointments - Sick leave that is unnecessary - Advice that is unhelpful - Failure to support and encourage return to work • Personal/psychological - Negative attitudes and beliefs about health and work - Anxiety and depression - Loss of confidence - Uncertainty about what to do, and what the future holds. • Occupational/social - Poor absence management - Loss of contact with workplace - Lack of modified work - Poor social support - Litigation • Each influences what we all think and do about health and work. • Overcoming obstacles is the key to managing health at work, and to facilitating job retention and early return to work.

12. A new vision for Health and Work (Working for a Healthier Tomorrow, C.Black, 2008) Challenge :“The economic costs of sickness absence and worklessness associated with working-age ill-health are over £100 billion per year – greater than the current annual budget for the National Health Service … Left unchecked it will diminish life in Britain.” Factors that stood in the way : • Culture, beliefs and attitudes • Inadequate systems • Work not a clinical outcome for health professionals. • Lack of OH support and Primary Care involvement • Limited evidence base. Little UK research.

13. Ensuring better medical certification: the ‘fit note’ – a journey General Practitioners are the gatekeepers, their behaviour crucial. • new formulation generally well received • when used as intended, results are good • GP education and training material of high quality, face-to-face and on-line • 3,800 GPs trained since start in August 2009 • evaluation ongoing. Brought in April 2010, by law

14. Ensuring better medical certification: the ‘fit note’ – a journey Challenges remaining: • utilisation of ‘may be fit for work’ box from 2 to 20% • ‘own job’ versus capability for any work? • employers want clearer information, better OH advice • slow and patchy introduction of electronic version. • 77% of GPs sometimes felt obliged to give note for non-medical reasons • 38% said fit note had not changed their practice • only 23% had good knowledge of the benefit system • DWP evaluation April 2012 : movement in right direction, but slow A new Sickness Absence Review was commissioned in 2011.

15. GP Survey 2012: findings • 90% agreed that helping patients to stay in or return to work was an important part of their role, • 68% agreed that GPs had a responsibility to society to facilitate a return to work. • 76% agreed that staying in or returning to work was an important indicator of success in the clinical management of people of working age • only 19% agreed that there were good services locally to which they could refer their patients for advice on return to work. • only 10% of GPs reported they had received training in health and work within the past 12 months. After Department for Work and Pensions Research Report No 835

16. Early intervention : pilots of‘Fit for Work’ Service to support Fit Note Most Helpful Intervention: (Leicester FFWS pilot) Aim - To provide employees in early stages of sickness absence with case-managed multidisciplinary support to enable return to work How : • Service for people off work sick after 4 to 6 weeks (via GPs, voluntary). • Access to co-ordinated health treatment and employment support, including debt, housing, learning and skills, employer liaison, conciliation • Case-management a key component In the first year 6,700 people sought help from FfWS across the nation. Need to develop a sustainable model. i.e. 68% non-medical During the Leicester pilot, 94% of local GPs referred to the Service, which issued 2,580 Fit Notes, 47% saying fit for some work.

17. Interim Evaluation of the Fit for Work Service pilots 2012 Evidence from service providers and clients : a successful approach to helping sickness absentees back to work includes: – quick access to an holistic initial assessment; – on-going case management to identify latent concerns (often non- medical) and maintain momentum towards a return-to-work goal; – fast access to physiotherapy or psychotherapy if required; – facilitating better communication between employee and employer and providing advice for return to work options; and – advice to improve and manage longer-term health conditions. http://statistics.dwp.gov.uk/asd/asd5/rports2011-2012/rrep792.pdf

18. The vision was continued by the Coalition Government from 2010 ... hence an Independent Review of Sickness Absence was announced by the Prime Minister on 17 Feb 2011 Co-chairs: Carol Black, then National Director for Health and Work David Frost, former Director-General British Chambers of Commerce Cross-government : Dept of Work and Pensions and Dept of Business, Innovation and Skills. “ We simply have to get to grips with the sick-note culture that means a short spell of sickness absence can far too easily become a gradual slide to a life of long-term benefit dependency.”

19. Sickness Absence Review November 2011 Current system lacks coherence, wastes human/material resources Advocacy by GPs often inappropriate for employees’ long term health Lack of appropriate interventions at critical stage, 4 to 6 weeks of absence. Lower-skilled, lower-paid employees particularly vulnerable. Some employers lack confidence in the medical certificate (‘fit note’) and lack knowledge of legal rights and duties. Some people need to change employment to return to work. Late recognition of the ‘never going back’ syndrome State too slow to get the right support to individuals at the right time. Significant differences between public and private sectors. Six recommendations: all accepted in principle by Government .

20. Recommendations Six major ones … Tax relief on Vocational Rehabilitation Independent Assessment Service Abolition of Payment Threshold Scheme in SSP Job Brokering Service Sickness Absence reduction Public Sector – Review of Sick Pay Changes to Employment and Support Allowance … plus six of lesser importance.

21. Assessment GP referral At 4 weeks Telephone/face-to-face assessment Identification of issues and recommendations Work related/ workplace adjustments Health-related Non-work/non-health related Intervention Improvement/ resolution Case management Health and Work Assessment and Advisory Service: Assessment process Employers to have option to refer Return to Work

22. Essential features of the service The new Health at Work Service should be: • An expert service solving problems early - much more than a telephone triage • Mandatory apart from appropriate and necessary exceptions • Supported by a fully-functioning electronic Fit Note. Shortly the Government will announce its design for the service and seek tenders.

23. A Watershed Change is the law of life. And those who look only to the past or present are certain to miss the future. John F. Kennedy

25. Part 2 • The Employer and the Workplace

26. Healthy Workforces: the key players Health professionals (Primary and secondary care) Non-governmental bodies and charities Public Health (PHE, local councils, professionals) Employers (Workplaces, Line managers, Human Resources) Employees (Patients) OH professionals Trade Unions Governments to initiate, support, encourage, and where necessary legislate.

27. The Health of Working-age People “ The great untapped resource for enhancing the public’s health remains the workplace. In the UK there are about 27 million people between 16 and 64 years old in employment. Most of those of working age spend a significant proportion of their waking hours in their workplaces. The potential to change positively the health of the individual, the profitability of the employer, and the productivity of the nation, in workplace settings is greatly underestimated.” Editorial, Occupational Medicine 2013:63:314-9 (attrib. Richard Heron)

28. The Workplace : Health and Wellbeing Work places can be microcosms of society. All workplaces should ensure: enabling leadership towards ‘good work’ and good organisation of work that all managers are trained in effective communication, awareness and learning with respect to wellbeing and mental ill-health development of a culture of health (mental and physical), healthy lifestyles and physical activities at work and among the workforce seizing opportunities for powerful communication, and peer support. A healthy, engaged workforce with wellbeing is good for business and boosts the bottom line (increasing evidence in many countries).

29. What is Good Work? • Stable and safe work - that is not precarious • Individual control– part of decision making • Work demands– quality and quantity • Fair employment– earnings and security from employer • Flexible arrangements – for employees where possible • Opportunities – training, promotion, health, “growth” • Promotes Health and WellBeing– psychological needs, resilience, self esteem, belonging and meaningfulness • Prevents social isolation, discrimination & violence • Shares information - participation in decision making, collective bargaining, justice if conflicts • Reintegrates sick or disabled wherever possible. Both physical and psychosocial environments are critical. Emphasis: leadership, organisation of work, and managerial behaviour. (mixture of Marmot and The Work Foundation)

30. What is a good Workplace ? Key features common to those organisations which have achieved health and well-being engagement and enhanced productivity are : • Senior visible leadership • Accountable managers throughout the organisation • Attention to both mental and physical health improvements • Systems of monitoring and measurement to ensure continuous improvement • Empowering employees to care for their own health • Fairness • Flexible work Health, Well-being and Public Health need to be embedded in every aspect of an organisation’s structure and work.

31. Effect of leadership on employee stress and well-being • Leaders’ behaviour (e.g. support, encouragement, consideration, empowerment), the relationship between leaders and their employees, and specific leadership styles, all affect employee stress and well-being. See for example: Skakon, Nielsen et al. .. leaders’ behaviour and style .. A systematic review of three decades of research 1980-2009. Work and Stress, 24 (2), 107-139, 2010 • Now needed is understanding of the process linking leaders with employee stress – leading to effective interventions ?

32. Effect of Managers on Employee Well-being • A longitudinal interventional study (n = 188) in a large Danish local government organisation, where poor social support, lack of role clarity and lack of meaningful work had been identified as significant problems. • Intervention (measured at entry and 18 months later) : - improved team working with some self-management • Question: Did active middle management support for the intervention mediate its impact on well-being etc. ? • Results : - structural equation modelling showed that active middle-manager involvement, as perceived by employees, correlated with job satisfaction and well-being. K. Neilsen. National Research Centre for the Working Environment, Denmark

33. Managers and stress, anxiety, depression • Goodline management is key to good workplace mental health. Managers need not be experts or counsellors. • Managers should focus on: – effective communication with the employee and other members of staff – awareness of the issues and the ability to empathise – developing open culture, with employees feeling able to discuss their problems - ability to judge when expert help is needed. • NB. Mental Health and Physical Activity are closely related. Encourage integration of some physical activity into the working day.

34. Consider Resilience Training : e.g. GSK Resilience training is of increasing importance. Based on Human Performance Institute’s Corporate Athlete training • “Strengthen and align energy along four dimensions” -- Course at GSK lasts 2.5 days Outcome : • Work-related MH cases decreased by 60% • Mental health absences reduced by 20% • Pressure due to work/life conflicts fell by 25% • Staff satisfaction with the company increased by 21% • 14% increase in willingness among staff to experiment with new work practices

35. A positive workplace: EDF Energy • Visible senior leadership regarding well-being • Accountable, competent managers throughout the organisation demonstrating the right attitudes and behaviours (HSE standards). • Job design that recognises ‘good work’ principles such as strong relationships, , fairness, flexible working, meaningful work, etc. • Empowers employees to care for their own health – both mental and physical – resulting in high engagement scores. • Integration of Safety, Health and Wellbeing.

36. Integration: EDF Energy • Leadership and managerial training - on supporting people through change, and - use of the HSE Management Standards to design good work. • Staff initiatives included - an EAP (Employee Assistance Prog), - physiotherapy services, - ergonomic assessments, - stress and resilience training, - healthy lifestyle programmes, - ambassadorial roles, reaching into the community. • Results included large reduction in sickness absence (savings of £4m since 2006), and the proportion of workers reporting company interested in their wellbeing much higher than UK benchmark (73% against 61%) . Resilience Programme Blocks connect to 3 self-development modules

37. Engage for Success • A movement supported by the Department of Business, Innovation and Skills, delivered through a taskforce of willing contributors from business and industry plus the public sector. • Concept of Employee Engagement : • a workplace approach designed to ensure that employees are: • committed to their organisation’s goals and values • motivated to contribute to organisational success, and • also able to enhance their own sense of wellbeing. • David MacLeod and Nita Clarke www.engageforsuccess.org • evidence-based paper • video

38. Engage for Success • This is becoming a powerful movement in the UK, with regional networks and ambassadors. • Enablers: • A strong strategic narrative, on where the organisation has come from and where it is going • Managers who focus on their employees, give them scope, treat them as individuals, coach and stretch them • Effective employee voice throughout the organisation and externally • Integrity: stated values reflected in day-to-day behaviour. • Indicators of success : • if UK moves into the top quartile on the KenexaG7 engagement index • if UK becomes the Number One ‘Go to’ place worldwide on employee engagement

39. Engage for Success • Health and Safety • Organisations with engagement in the bottom quartile average 62% more accidents than those in the top quartile (Gallup 2006) • The Olympic Delivery Authority by June 2011 had an Accident Frequency Rate of 0.17 per 100,000 hours worked, less than half the average for the construction industry – this was attributed to strategies known to improve employee engagement. • NHS hospitals with high staff engagement have standardised patient mortality rates lower (by 2.5%) than hospitals with medium engagement.

40. The gradient in health and motivation in workplaces • Overall organisational productivity depends critically on workers’ aggregate performance - their contribution is essential to success. • In particular, there is a need to understand the degree of linkage, in typical pyramid-shaped organisations, between, on average, poorer health (mental and physical) and lower motivation and engagement at work. • Recognition of this needs to be properly factored in to management thinking about health to enhance productivity Top management Usually declining income and health Workforce, many more at the foot, is not uniform in health, wellbeing or motivation

41. The Heart Age Tool A simple online tool to find out your estimated Heart Age based on input of personal information on risk factors. Courtesy Mark Cobain and Holly Whelan, Unilever

42. Contrasting Data from Unilever Sites Marketing Site : Factory Site : 0 Heart Age above actual 0 + Proportion of people in sample with heart ages in different ranges above their actual age – very different distributions at the two sites.

43. Children 'forced to accept unpopular secondary schools' Almost 75,000 children have been rejected from their preferred secondary school amid a desperate scramble for the most sought-after places, official figures show. Absence management in the public sector A persistent problem, highlighted in the Sickness Absence Review 2011. Government response January 2013: “ The Government agrees that the amount and cost of sickness absence for each public sector employer must be more transparent to the taxpayer.” “ Employers are to publish their data and be accountable for managing the significant amount of public money that this staff cost represents … to drive the spread of best practice and highlight those employers not making progress. The Government will work with Education, Health and Local Government employers to secure progress in reducing sickness absence levels in their workforces.”

44. The Health and Well-being Improvement Framework (DH for NHS) …. sets out five high-impact changes that NHS organisations can follow to improve staff health and well being and reduce sickness absence: With all staff encouraged and enabled to take more personal responsibility With strong visible leadership Supported by improved management capability Better, local high-quality accredited Occupational Health services Developing local evidence- based improvement plans • The Department of Health published a Health and Well-being Improvement Framework which highlights the evidence and detail behind the 5 high impact change pathway: uptake is supported by NHS Employers. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_128691

45. HWIF 2 : Strong visible leadership • Board level involvement will make the difference • Where NHS Boards live the values they want to achieve, staff will take those values seriously. • A named board member responsible for H&WB and reviewing progress every 6 months will drive this agenda forward. • Example: York Teaching Hospitals NHS FT • Used board engagement to drive progress across the Trust • Board visibly involved in events to promote better health and well- being, and communicated this to staff. • Delivered sickness absence savings of £2.7m yearly, and 72% reduction in long-term absence.

46. HWIF 3 : Improved management capability • Line managers know their staff better than anyone. They can promote better Health and Well-being and manage absence effectively. • The best providers enable and support managers to follow good practice in building resilience, holding return-to-work interviews, recognising signs of stress, and addressing health in appraisals. • Example: South West Yorkshire Partnership NHS FT • Showed that staff H&WB is helped by better management, especially during change. • Managers now undertake a compulsory learning programme to help build team resilience and increase productivity. • Achieved big reductions in working long hours, harassment and bullying, with increases in engagement and uptake of opportunities.

47. Results on line manager training 2010 Survey by the Royal College of Physicians and NHS Employers – funded by government.

48. Occupational Health :National Standards and Accreditation Defining standards of practice to which services should aspire Credit good work by OH services, with independent validation of satisfying standards Raise standards where needed Help purchasers differentiate OH services that attain the desired standards from those that don’t. Standards published Jan 2010 Produced by Faculty of Occupational Medicine www.seqohs.org Accreditation scheme launched 2011 Overall 328 organisations registered (October 2013), 106 fully accredited. NHS in England has 150 in-house OH services: 132 are registered with SEQOHS, and 61 are fully accredited. NHS Occupational Health accounts for 40% of registrations, and 58% of fully accredited units.

49. NHS Staff Health and Wellbeing At the NHS Health and Wellbeing Summitin London on 23 April 2013 the five pledges that organisations committed themselves to were: • foster a culture that promotes better physical and mental health and wellbeing for staff in all workplaces used by the organisation • work to strengthen staff engagement both in and through these endeavours • include measures of employee health and wellbeing within KPIs and other performance-monitoring systems • sign up to the Public Health Responsibility Deal • share with other NHS organisations expertise and experience in ways of safeguarding and improving staff health and wellbeing.

50. NHS staff health pledge – signing by healthcare leaders 23 April 2013