Occupational Health: a challenge for primary health care
WHO International Conference What role for OH in Primary Healthcare? The Hague, 29 November 2011 Occupational Health: a challenge for primary healthcare Dame Carol BlackUK National Director for Health and Work
The fundamentals: work is a social determinant of healthGalen (129-200)Employment is nature’s physician • Work is generally good for healthand is essential to human happiness. Waddell and Burton, 2006 • That work is good for man is supported by evidence and consensus. The physician‟s role is to encourage work, and return to work, as part of treatment. Talmage and Melhorn, AMA Press 2005 Family doctors and other health professionals in the primary care setting should be engaged and involved.
The key players Health professionals (Primary and secondary care) Employers Employees (Line managers, (Patients)Human Resources) OH professionals (less than 15% of the global workforce has access) These are crucial relationships that vary according to process and practice in different countries
The needs of the worker• to be healthy enough to work• safe healthy workplaces - physically safe - emotionally healthy• good work: - job security - work varied and interesting - workers have some autonomy, control and task discretion - fair rewards (not just financial) for effort - supportive social relationships - worker engagement.The various countries of the world are at differentstages in providing the above.The nature of work is changing in many countries.
What do we need of OH globally in the 21st century?Occupational Health services must:• suit the current profile of employment in different countries, as work is changing• form new partnerships and find new ways of working across traditional boundaries• make a greater contribution to national economies• examine the care pathways for working people, and find new ways to support them, before, during and after illness• relate to, and be further attached to, mainstream healthcare (primary and secondary) and relevant specialties.
What do we need of ourhealth professionals in primary care? • an understanding that work is a determinant of health • return to function, therefore often to work, should be a desirable clinical outcome • a focus on capacity not incapacity • an understanding that you do not have to be 100% fit to work • ability to take a good occupational history and act upon it • communication and collaboration with other key players.
The old UK system, and the need for change Old system• Work-related ill-health is often not life-threatening, but life-diminishing, GPs issued e.g. common mental health problems „sick note‟ and musculo-skeletal problems.• No clear pathways of rehabilitation, and treatment too often slow and inefficient, often with a poor outcome for the patient.• GPs have no easy access to expert assessment or OH advice• Three-quarters of employers have no access to OH.• Repeated medical Notes can lead to (the benefit system) worklessness – this is Bad Therapy!
What are we doing in the UK for Health Professionals in Primary Care?• Education, training and information to enhance their understanding and knowledge• Encouragement of those family doctors who have special interest in OH to become more involved, with training programmes and qualifications• An improved „medical certificate‟, focusing on capacity not incapacity• Early-intervention case-managed service available, in some areas, for referral by GPs• Telephone helpline for OH and other queries• Proposal, just announced, for an early Independent Assessment Service.
Central role of education and training for healthcare professionals• „Healthy Working UK‟ – a comprehensive web-based resource for primary health professionals• „Health and Work in General Practice‟ – national education programme for GPs• „Health e-working for primary care‟ – a modular e-learning package for primary care• „Health e-working for secondary care‟ – a modular e-learning package for secondary care• Royal College of Nursing – web-based programmeProgrammes are in place for GPs, secondary care, nurses, therapists
The UK national educationprogramme for GPs – the next steps• Enhance engagement with employers across the UK• Employer-funded training model for GP health and work training• Enhances the reputation of the businesses through links with accredited RCGP training• September 2011 – August 2012, 40 workshops across the UK arranged• Attendance between 8 – 35 delegates per workshop• Further requests from businesses for training sites• GP trainees now requesting training programme as well
From „sick note‟ to „fit note‟ in UKSick note: Now GPs share responsibility with employers • GP knows health condition and impact• For the previous eighty years or • Employer knows job more, a GP (family • Employee knows complexity of absence doctor) assessed a person’s health and Adjustments being made: ability to work. • Phased return to work• The old form • Part-time working required the doctor to state whether or • Working from home not the patient could • Flexible start times work, and how long • Different tasks they should refrain from work if sick. • Practical adjustments in the• Partial ability to workplace. work was not considered. Family doctors have crucial „gatekeeper‟ functions.
GPs‟ attitudes towards patients‟ health and work GP responses to the statement: The Fit Note has…. 70% 60% 60% 54% Fully agree .... fully disagree 48% 50% 42% 40% 36% 30% 26% 20% 13% 12% 10% 10% 7% 5% 6% 0% Improved quality of Improved advice I Improved patient IncreasedIncreased Helped patients Increased lengthmyMade no changes Helped my Increased of discussions with give to patients frequency with make a phased my consultations to my practice discussionabout about their fitness which I recommend patients work patients frequency of return to make consultation for work advising to work as phased return return toImproved work work return return length Not changed advice given to to workto recovery to work aid as aid my practice Completely patients Agree to recovery Somewhat Agree Somewhat Disagree Completely Disagree 99% of GPs agree that work is generally beneficial for people‟s health – this attitude must be translated into action.Source: GP Attitudes to Health and Work Survey
Work-related health advice in primary care• Collaboration project between University Hospitals of Leicester OH lead and the Orchard Medical Centre at Broughton Astley• Provides services for 30,000 people, including NHS staff• Pre-booked 30 min appointments with two GPs with an OH background were offered for work-related heath consultations• 96 patients were referred or self-referred over 12 months – patients responded positively to the provision of an OH clinic in their general practice• 30% of consultations resulted in a letter being sent to the patients employer or line manager• 13% were referred to their workplace OH provider• None were referred to a specialist OH professional• 33% had mental health problems• 51% were on sick leave at the time of their consultation• OH services in primary care does not attract any quality framework payments De Bono et al (2011) Occupational Medicine
Fit for Work Service pilots – co-ordinatedearly health and work support for individualsAim - To reduce sickness absence and avoidable job loss, through co-ordinated services (began April 2010)How• Service for people off work sick after 4 to 6 weeks• Pilots in locations across GB, GPs encouraged to refer.• Early access to co-ordinated health treatment and employment support, including debt, housing, learning and skills, employer liaison, conciliation• Case-management a key component• Variety of delivery partnerships – existing and new local consortia• Identifying underlying problems with rapid referral• One-stop supported approach• Practical support in non-medical areas• OH input as requiredIn the first year, 6,500 people sought help To help people remain in work orfrom eleven Fit for Work Service pilots return to work more quicklyacross Great Britain.
Fit for Work Service in a region of EnglandConvenient for patients Musculoskeletal 15%• Contact within 24hrs• First appointment within a week Mental Health 7%• Mobile phone communications Mediation/Negotiation 38%• Wide choice of venue for consultationHelpful to GPs Personal Support 17%• Ease of referral – no forms Help with new 23%• Musculoskeletal interventions funded employment• Service signs Fit Notes• Service provides audit data to GP practices 60% returned to work i.e. 78% non-medical Leicester FFWS
Occupational Health Advice Helpline 0800 077 8844• Provides GPs and businesses with tailored occupational health advice, by advisers with special training in Mental Health.• Most callers are calling about an individual person’s case• 95% of callers appreciate the contact, and 92% would recommend to colleaguess 42% calls about sickness absence 24% calls are about the fit note 20% calls are about mental health (anxiety, depression, stress, and other mental health conditions) 19% calls are about health surveillance
Independent Review of Sickness AbsencePublished 21 November 2011 – recommendations to UK Government. Example:“ We therefore recommend that the Government should fund a new IndependentAssessment Service (IAS), usually to be accessed when an individual’s absencespell has lasted around four weeks. It would:• provide an in-depth assessment of an individual’s physical and/or mental function• provide advice about how an individual taking sickness absence could be supported to return to work• be provided by approved health professionals and• be appropriately quality-controlled.The IAS is intended to improve the effectiveness of medical certification and toencourage early positive intervention. “ Carol Black and David Frost, November 2011
Final thoughts....“If you keep on doing the samethings and expect things tochange, then that‟s a definition ofinsanity.” “The future has many names. For the weak it is unattainable. For the fearful it is unknown. For the bold it is opportunity.” Victor Hugo