Health Works: Supporting Health in the Working Age


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Hear about the innovative practice being developed in Scotland to allow people rapid access to case managed support to help them back to work, using a person‐centred, biopsychosocial model.

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Health Works: Supporting Health in the Working Age

  1. 1. Health Works Supporting Health In Working Age
  2. 2. Setting the Scene Roddy Duncan Scottish Government
  3. 3. Approx 2.5 million people in Scotland of working age >70% in employment Cost of ill-health approx. £10 billion p.a. to economy Approx 250,000 on incapacity benefit/ESA 1 in 6 working people have poor mental health Some Numbers:
  4. 4. Meets important biopsychosocial needs Sound evidence base Most people capable of undertaking some type of work Most people with health conditions want to work Poor work/working conditions can affect health Poor health can limit ability to work Work 1 is good for health: 1. By work we mean, more generally, any activity that give purpose to life. This could be paid work, volunteering or caring duties, for example.
  5. 5. Health Works – a patient centred approach to healthcare Needs a change in culture – work outcomes for patients Efficient and effective – opportunity to avoid over-medicalisation: biopsychosocial approach Importance of working in partnership – focus on successful outcomes for patients Quality Strategy:
  6. 6. For Patients – faster, direct access to treatment; positive advice and support; faster, fuller recovery; keep job and earnings; sustained independence. For Health Boards – efficient use of resources; reduced waiting times; reduced prescription costs; reduced inappropriate diagnostics; reduced repeat visits. For Scotland – reduced sickness absence; improved productivity; reduced demand on public services; increased workforce participation; increase in people managing own health. Benefits:
  7. 7. Some examples of activity in Scotland that is translating the ambitions of Health Works into practical examples of patient-centred, effective and innovative healthcare services. Putting it into practice:
  8. 8. The National Musculoskeletal (MSK) Programme Dr Sarah L Mitchell
  9. 9. National MSK Re-design – Part of Health Works Focus on local services redesigning their MSK pathway around patients Focus on employment, the ‘Scottish Offer’ Focus on developing a national point of access to local MSK services Focus on developing interdisciplinary teams delivering MSK
  10. 10. Why are we re-designing our MSK services? People in Scotland with MSK conditions currently experience….. Variable access to MSK services Variable management Variable measurement of outcomes No formal assistance with helping people back to work or into work And sometimes…long waits for these variable services ………………we could do so much better.
  11. 11. Impact of MSK conditions MSK – most commonly reported type of work related illness and take up more than 30% of all GP consultations. Prescription costs for MSK Result in loss of 12.5 million working days lost Low back pain is the most common musculoskeletal problem affecting an estimated 18 million people, with associated costs of £7bn p.a. to the economy due to working days lost.
  12. 12. What are we proposing? <ul><li>A National MSK Triage and Referral Management Service for NHS Scotland delivered within NHS 24 </li></ul><ul><li>Local referral management hubs within boards </li></ul><ul><li>Direct referral into WHSS for those working in SMEs </li></ul><ul><li>Development of Interdisciplinary pathways using evidence based outcome measures </li></ul><ul><li>Development of algorithms within pathway to ensure correct service provision </li></ul><ul><li>Early identification of employability issues, anxiety depression scores </li></ul>
  13. 13. Evidence states that: Approx 30% people only need advice and information NHS 24 non clinician pathways are safe STaRT Tool - Keele Free up frontline resources Rationale of Approach Using a central referral system will... Provide fast access to information and consistent national approach
  14. 14. Advice and Information Resources Patients need information to support self management Need for national resources that provide high quality, consistent information NHS inform can fulfil that role: Scottish Backs, neck, knee, shoulder sites, VideoPhysio, PhysioTools, Back in Control
  15. 15. … .is a national service helping you to find amongst other information how to access public services and search for local information and advice. Access to Scottish Backs and NHS inform via digital TV Text NHS 24 to 61061
  16. 16. MSK Service re-design – New process Self Referral (est. 15,000 patients) Call handler takes call (8x Band 3) MSK Triage Form filled in by call handler (WTE x3 on hand for support) Patient entered into SCI Gateway (by Joint, Medium/High) Review previous 24 hour referrals into SCI Gateway. Patient allocated appointment slot (Band 2) TRAK – automated letter sent to patient (and communication sent to CRMS) GP directed to Self Referral number First Contact AHP telephone consultation and EQ5D WHSS (est. 5%) (exit from system) GP referral through SCI Gateway (est. 30,000 patients Emergency Numbers Central Referral Management System (NHS24) HUB (based at Referral Management Centre - TBC) Low – routed self-management (exit from system)
  17. 17. MSK Service re-design – New process First Contact AHP telephone consultation and EQ5D HUB First Contact Physio assessment (EQ5D and outcome measures) First Contact Podiatry assessment (EQ5D and outcome measures) First Contact OT assessment (EQ5D and outcome measures) Self Management and exit from system Employability Services Available Services TRAK – automated letter sent to patient (and communication sent to CRMS) TRAK / CES Info. dump A&E Leisure Older People Services Mental Health Vocational Services Rheumatology Community Pharmacy Pain Services Dietics Ortho 2 nd AHP Appointment (intervention)
  18. 18.         NHS24 Phone Consultation (1 st appointment) Direct appointments made at hub LBP pathway 30% 8,250 ‘ NHS Lanarkshire Referral Hub’ up to 27,500 clients Require MSK services WHSS 1-2% Approx 260-575 SME + Absent Any joint <ul><li>Self management </li></ul><ul><li>Self mgmt advice </li></ul><ul><li>Community programmes </li></ul><ul><li>Web support – NHS inform </li></ul><ul><li>12,000 clients </li></ul><ul><li>All pathways will include ability to refer into the following services at any point in pathway even after first appointment / telephone consultation: </li></ul><ul><li>Pain Services– 8%, 1,100 </li></ul><ul><li>Mental Health Support – including breathing space, case management, mental health teams – 10%, 1,375 </li></ul><ul><li>Employability support – 10%, 1,375 </li></ul><ul><li>Self management – including community leisure programmes and third sector programmes – 10%, 1,375 </li></ul><ul><li>Rheumatology services – trigger questions agreed. – 1% 137 </li></ul>Knee pathway 20% 5,500 Neck pathway 10% 2,750 Shoulder pathway 15% 3,575 Hand pathway 5% 1,375 Hip pathway 5% 1,375 Foot and ankle pathway 15% 3,575 Referrals made directly into hub from GP services and other hospital services i.e. A&E, orthopaedics
  19. 19. Key Performance indicators to include:                               # referrals into secondary care     # GP MSK consultations         Improved patient experience Physio (MSK) demand         Mental Health referral # referrals into employability services   Reduction in prescription charges Reduction in investigations       Functional improvement outcomes DNA rate                
  20. 20. Baseline Activity Carried out in NHS Lanarkshire   Measurement of outcomes on all patients attending physiotherapy for 1 month – using EQ5D Measurement of the HADS score on a selection of patients attending physiotherapy. Measurement of patient experience    
  21. 21. EQ5D Analysis – JOINT
  22. 22. EQ5D Analysis – Employability Status
  23. 23. EQ5D Analysis – Employed Population Hours Worked %
  24. 24. EQ5D Analysis – Unemployed Anxiety/Depression Scores
  25. 25. EQ5D Analysis – Low Back Pain
  26. 26. Develop national Advice and Triage service during 2011 Enhance current out of hours protocols during 2011 Systems piloted in Lanarkshire and Lothian from autumn 2011 System evaluation – Spring 2012 Report consideration and national roll out Resource pack and support When will all this happen?
  27. 27. Equitable access for MSK patients to appropriate management options Consistent, high quality information and advice developed and adopted across NHSScotland Enhanced user experience A true health/employability pathway ££££ savings?? Proposed Major Deliverables of Pathway
  28. 28. NHS Quality in Action Scotland’s Bio-Psychosocial Service: National Fit For Work Service Mark Kennedy Salus Occupational Health
  29. 29. <ul><li>NHS & Economic Growth </li></ul><ul><ul><ul><li>Supporting Healthy Workforce </li></ul></ul></ul><ul><ul><ul><li>Reducing Absence </li></ul></ul></ul><ul><ul><ul><li>Ensuring those wishing to work are able to work </li></ul></ul></ul><ul><ul><ul><li>Increasing Resilience </li></ul></ul></ul>
  30. 30. Salus – Bio-Psychosocial Model <ul><li>Case Management Service… </li></ul><ul><ul><li>Supporting employability agencies across 40% of the UK </li></ul></ul><ul><ul><li>Central to the National Fit for Work Programme – Working Health Services Scotland (WHSS) </li></ul></ul><ul><ul><li>Core of NHS Lanarkshire’s Attendance Management service </li></ul></ul>
  31. 31. Principles of BPS Model <ul><li>Person Centric </li></ul><ul><ul><li>Engages patient (& family) in multiple ways </li></ul></ul><ul><ul><ul><li>Medical (conditions/disease) </li></ul></ul></ul><ul><ul><ul><li>Attitudinal (behavioural, victim syndrome, addictions) </li></ul></ul></ul><ul><ul><ul><li>Social (Relationships, housing, debt etc) </li></ul></ul></ul><ul><li>Single Case Manager </li></ul><ul><ul><ul><li>Assesses (validated clinical tools – pre &post intervention) and co-ordinates all aspects of care </li></ul></ul></ul><ul><ul><ul><li>Single point of contact and solution focused </li></ul></ul></ul><ul><ul><ul><li>Motivates/advocates and maintains direction </li></ul></ul></ul><ul><ul><ul><li>Early Intervention </li></ul></ul></ul>
  32. 32. <ul><li>Telephone based </li></ul><ul><ul><ul><li>Delivered by both clinicians and non clinicians </li></ul></ul></ul><ul><ul><ul><li>Web based dataset (paperless) </li></ul></ul></ul><ul><ul><ul><li>Has a framework of supportive agencies/interventions (physiotherapy, counselling, debt advisors, employment advisors etc..) </li></ul></ul></ul><ul><li>Highly Efficient </li></ul><ul><ul><ul><li>CM caseload = 200-250 patients per annum </li></ul></ul></ul><ul><ul><ul><li>9% DNA </li></ul></ul></ul><ul><ul><ul><li>Appointed within 2 days </li></ul></ul></ul><ul><ul><ul><li>Longest wait for intervention = 5 -7 days </li></ul></ul></ul>
  33. 33. Working Health Services Scotland <ul><li>Scot Gov & DWP funded </li></ul><ul><li>Support to individuals employed within SMEs </li></ul><ul><li>Eligible - Those sickness absent or at risk of sickness absence </li></ul><ul><li>Central Hub supported by 14 regional Health Boards </li></ul>
  34. 34. WHSS - Results
  35. 35. 28% of individuals were absent on engagement – 62% at risk of absence 78% present with MSK problem, 15% mental health, 2% Cardio-vascular (5% other)
  36. 36. Tackling Inequalities Salary Scales 403 986 705 49 20 3 268 0 200 400 600 800 1000 1200 <£10k £10-20k £21-40k £41-60k £61-100k >£100k Unknown
  37. 39. <ul><li>From a sample of 450 records: </li></ul><ul><ul><li>98% of clients reported that the service has had a positive impact on their current work situation </li></ul></ul><ul><ul><li>99% of clients would recommend the service to others </li></ul></ul><ul><ul><li>100% of clients rated their experience of case management as excellent (86%) or good (14%) </li></ul></ul><ul><ul><li>100% of clients stated that the support they received was excellent (89%) or good (11%) </li></ul></ul>
  38. 40. NHS Lanarkshire – Attendance Management <ul><li>Traditional model = </li></ul><ul><ul><li>1 week Self Certificate </li></ul></ul><ul><ul><li>At 28 days of absence- “long term” – refer to Occupational health </li></ul></ul><ul><ul><li>Further 5-10 days to appoint </li></ul></ul><ul><ul><li>Total approx 38 days absence – circa 8 working weeks </li></ul></ul>
  39. 41. <ul><li>Salus NHSL Model </li></ul><ul><ul><li>Early intervention </li></ul></ul><ul><ul><ul><li>Absentee called at home on day 1,3 & 10 </li></ul></ul></ul><ul><ul><ul><li>Referred to Occupational Health at day 11 </li></ul></ul></ul><ul><ul><ul><li>Nurse led from day 11 </li></ul></ul></ul><ul><ul><ul><li>Case Manager appointed to complex cases </li></ul></ul></ul><ul><ul><ul><li>Frequent case conferences with HR </li></ul></ul></ul>NHS Lanarkshire – Attendance Management
  40. 43. Quality Ambition <ul><li>Most appropriate treatments, interventions, support and services will be provided at the right time – wasteful variation will be eradicated. </li></ul><ul><li>Incorporates Innovation (tele & web) </li></ul><ul><li>Partnership (14 HBs and many public, private and 3 rd sector support agencies) </li></ul><ul><li>Person Centric- patient at core of all decisions </li></ul><ul><li>Measurable </li></ul><ul><li>Inexpensive </li></ul>
  41. 44. Vocational Rehabilitation is everybody ’ s business (DVD) Judy Gibson Scottish Government
  42. 45. <ul><li>Wider Context and Conclusions Roddy Duncan </li></ul>
  43. 46. Christie Commission – Efficiency and Effectiveness; customer-led Welfare Reform – reduce barriers to work? Fit Note – Encourage doctors to discuss return to work Employers – Create positive, supportive workplaces Wider context:
  44. 47. Work is a key social determinant of health People do not need to be fully “fit” to be in work Return to work can be part of the recovery process All healthcare professionals have a role to play Need to learn from current good/innovative practice Conclusions:
  45. 48. Find out who your Board’s lead for Health Works is. Find out more about current health and work initiatives. Discuss within your Board how you can adopt and introduce patient-centred, work-outcomes focussed, care pathways. Practitioners – consider work status in routine practice Speak to those who are already doing it What you should do:
  46. 49. Q&A
  47. 50. Links and further reading: Scottish Government Health and Work Web Pages: UK Government Health Work and Wellbeing Strategy Scottish Centre for Healthy Working Lives DWP Guidance on Fitnote Healthcare Professionals Consensus Statement:
  48. 51. Health & Work Continuum In work Out of work – on benefits Incapacitated Safe & Healthy At risk of losing work Ill/Injured Short-term absence long-term absence £ £ £ £ £ Cost to society