Dame Carol Black UK National Director for Health and Work

1. Health, Work and Well-being: Where are we now and What is the Future Landscape? Occupational and Environmental Medical Association of Canada, Ontario Medical Association Niagara on the Lake, 3 October 2011 Mastromatteo Oration Dame Carol Black UK National Director for Health and Work

2. The Fundamentals • Work is a determinant of health. • People’s social and economic circumstances affect health throughout life, so health policy must be linked to the social and economic determinants of health. • Work is generally good for health • Enabling people to be in productive work is a health issue • Good health is essential for a high-performing workforce • Work and health are inextricably linked • Worklessness is a greater risk to health than many ‘killer’ diseases • Improving working-age health is the business of us all.It is also a Public Health issue.

3. What we needed in the UK Healthy, engaged workforces Well-managed organisations • A high-performing, resilient workforce • Enhanced productivity • Contributing to: • A well-functioning society • Better economic performance

4. Health, well-being and work: 2005 and before, in UK • Health and work not acknowledged as related and inter-dependent • Work not considered as a determinant of health • Little connection made to Public Health or primary care/family doctors. • Of little importance to politicians, civil servants, health professionals, employers etc. • Little if any cross-government working on this agenda – lots of very-well-intentioned silo working • Little connection made, in much of UK, between Health, Well-being, Engagement and Productivity • Workplace potential for prevention and promotion unrecognised • Little recognition that enabling adults to remain healthy and in work is the first pillar of the welfare state.

5. UK Employment and Health Mental ill-health is the most common reason for claiming health-related benefits. Employed population 26% with a health condition or disability 2.4% off sick Inactive (about a third as many as are employed) 48% with a health condition or disability Source: Labour Force Survey of UK men and women aged 16-64 Unemployed (about a tenth as many as are employed) 29% with a health condition or disability Beneath these figures lie diminished lives, little aspiration, and disrupted families.

6. Incentive to rehabilitate and retain individuals in work lies with employers... GPs also play a crucial role. The State’s main interventions come after job-loss. Sickness absence: the current journey 39 weeks 28 weeks ESA benefit and support Work Sickness absence Work Capability Assessment Claim to Employment Support Allowance (ESA) JSA benefit and support Work Inactivity Employers pay sick pay and some offer rehabilitation and occupational health support. GPs provide sickness certification, typically the first healthcare professionals that sick people encounter. The State defines levels and duration of SSP and controls benefits.

7. What prevented us from working The three most common reasons in the UK : common mental health problems musculo-skeletal problems chronic diseases – mental and physical plus organisation of work, quality of line management, lack of leadership, inflexibility of the workplace, changing nature of work lack of education and/or skills deprivation, poverty, unavailability of employment. Solutions depend on collaboration between Governments, healthcare professionals, employers, employees and would-be workers, Trade Unions. Much of this is as well reported in other countries too.

8. To achieve our goals we needed to : create employment and workplaces which both protect and promote health, mental and physical enable people with disabilities and long-term conditions, especially mental health conditions, to stay close to the labour market reduce sickness absence, job loss, and flow onto benefits support people to work to a later age, and above all, enable a change in culture, attitudes and behaviour in connection with work

9. Some steps along the way • 2005 Strategy on Health, Work and Well-being (DH/DWP/HSE) • 2006 first National Director for Health and Work • 2006 Waddell et al: Work is generally good for you • 2008 Black : Working for a Healthier Tomorrow Government Response: Improving health and work: changing lives • 2008Waddell et al: Vocational Rehabilitation: What Works for Whom and When • 2009 Boorman : NHS Health and Well-being • 2010 Marmot Review: Fair Society: Healthy Lives • 2010 Macleod report : Engaging for Success Activity centrally and locally, with growing stakeholder involvement and action.

10. The strategic vision for UK Health Work and Well-being Creating a society where the positive links between work and health are recognised by all, including health professionals, and where everyone aspires to a healthy and fulfilling working life, and where health conditions and disabilities are not a bar to enjoying the benefits of work. The National Director was a cross-government appointment in 2006, without political connections, to lead this strategy.

11. A new vision for health and work A Review of the health of the working-age UK population, commissioned in 2007 by the Secretaries of State for Health and for Work and Pensions. “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 … 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, 2008 Working for a Healthier Tomorrow Prevent illness, promote health, intervene early, improve the health of the workless.

12. Factors that stood in the way Culture beliefs and attitudes – needing change Misconceptions about health and work – e.g. “need to be 100% fit” Inappropriate ‘medicalisation’ of complex psycho-social problems Poor retention in work of those with disabilities or chronic disease Managerial attitudes, organisational behaviour, leadership. Inadequate systems Inflexible system of sickness certification – the ‘sick note’ No pathways of rapid intervention to keep you in work or return you to it Health, work and well-being not part of training curricula or clinical practice Poorly-supported healthcare professionals. No OH advice for GPs. Lack of Primary Care involvement Rehabilitation to work not a performance measure for responsible local health bodies Configuration of OH services: not available in primary care. Next generation Little attention to building mental and emotional resilience in our future workforce

13. Symptoms: 2/3 of cases Often mild Symptoms not ‘diseases’: back pain musculo-skeletal symptoms stress anxiety, mild depression Few investigations required Diagnosed with relative ease Intervention needs to be early, often non-medical, good vocational rehabilitation, regular contact between employee and employer. Prevent chronicity Chronic conditions: 1/3 of cases cardio-vascular disease chronic rheumatic diseases endogenous depression bipolar disorders, schizophrenia diabetes, cancer post-trauma disability, etc. Investigations more extensive Diagnosis can be difficult Treatment – good medicine, good flexible employers, plus rehabilitation. More prevalent in people living in poorer economic conditions Prevent deterioration Different health problems need different approaches Solve the problem: contain the disease: enable people to stay in good work

14. Historical Perspective: 1957 psycho-social managerial problems “Absenteeism is a much more complex problem, mainly because, although disease initiates absence, the time taken to return to work is influenced by a multitude of social factors little to do with medicine, and the pathological diagnosis of the disease is often in doubt.” “Absence from work is an inaccurate measure of morbidity – 90% of minor illness does not lead to incapacity. Absence often depends not on a particular disease process but on the standard of health for work that the patient sets – i.e. on the patient’s ability to adjust to the working environment.” “Dissatisfaction with working conditions can often be counteracted by escape to outside interests, which unfortunately include ill-health and absence. ” Paper by Sir Walter Chiesman, Treasury Medical Adviser, Clinical Aspects of Absenteeism, R.S.H 10, 1957, p.681

15. The workplace. Findings of the Black Review (2008) • Patchy Occupational Health services • No national standards available to employers when they purchase occupational health or well-being services • Poor understanding of HWWB, engagement and productivity • Employers unaware of the business case for investing in health and well-being • Accessible and affordable sources of support and advice rarely available for small and medium-sized companies (SMEs) • Employers inflexible about necessary adjustments for those with disabilities or chronic disease • Line managers’ behaviour crucial, but often little training • Often no policy on supporting mental health • Often no sickness-absence policies to enable early and sustained return to work And yet, the workplace provides great potential for prevention & promotion

16. Occupational Health in the UK Findings of the Black Review Occupational Health is often seen as a benefit to employers which should be financed by them (but only 30% of employees have access to OH). A new OH model is needed to reflect the current profile of UK employment, requiring new partnerships and new ways of working across traditional boundaries. OH must make a greater contribution to the economy, reaching the whole working-age population, not just those in work. Challenges: • detachment from mainstream health care • little communication with other specialties • limited remit, and uneven provision (only in workplaces) • diminishing workforce and shrinking academic base • lack of good quality data • training programmes • image and perception The UK Faculty and Society of Occupational Medicine have accepted these challenges.

17. Necessary leadership by Occupational and Environmental medical professionals • The profession of OEM is positioned at the employer-employee-healthcare interface, making it a logical advocate for health-related workplace initiatives. • OEM physicians have unique training, expertise and perspective to understand the link between health and productivity, as well as how to help injured, ill and aging workers remain at work and productive. • In some countries, OEM has a high concentration of physicians trained in public health, whose focus on population-based health issues is critically important to system reform. • OEM physicians have a distinct and logical role in advocating prevention-oriented programmes that protect the health of employed and productive citizens.

18. Black Review: Health, Work and Well-being Initiatives All intended to help people remain healthy and in work.

19. From ‘sick note’ to ‘fit note’ • Sick note: • For the previous eighty years or more, a GP (family doctor) assessed a person’s health and ability to work. • The old form required the doctor to state whether or not the patient could work, and how long they should refrain from work if sick. • Partial ability to work was not considered. Now GPs share responsibility with employers • GP knows health condition and impact • Employer knows job • Employee knows complexity of absence • Adjustments being made: • Phased return to work • Part-time working • Working from home • Flexible start times • Different tasks • Practical adjustments in the workplace.

20. Ensuring better certification: the ‘fit note’ • Progresssince introduction in April 2010 • new formulation generally well received • when used as intended, results are good • GP education and training material of high quality • 53% of GPs thought it had improved advice given • Challenges remaining • utilisation of the ‘may be fit for work’ box is variable, up to 20% usage • ‘own job’ versus capability for any work • employers hope for more information and better OH advice • electronic version of the fit note is crucial, coming later this year • 77% of GPs sometimes felt obliged to give note for non-medical reasons

21. GPs’ attitudes towards patients’ health and work GP responses to the statement: The Fit Note has…. Fully agree .... fully disagree Improved patient discussion Increased frequency of advising return to work as aid to recovery Helped patients make phased return to work Increased my consultation length Improved work advice given to patients Not changed my practice 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

22. Central role of education and training for healthcare professionals Education and training are a priority. All healthcare professionals need to understand: • Good work is good for health and well-being • A return to functional capacity, and a sustained return to work where appropriate, should be key indicators of clinical success in the treatment of working-age people • The importance of work-related issues within the healthcare setting (e.g. Vocational Rehabilitation, communication with employers, etc) • How to complete the ‘Fit Note’ correctly Programmes are in place for GPs, secondary care, nurses and therapists

23. Fit for Work Service pilots – co-ordinated early health and work support for individuals Aim - 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 Eleven pilots in locations across GB 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 required In the first year, 6,500 people sought help from eleven Fit for Work Service pilots across Great Britain. To help people remain in work or return to work more quickly

24. Fit for Work Service in a region of England Convenient for patients Contact within 24hrs First appointment within a week Mobile phone communications Choice of venue for consultation: 140 surgeries, 12 MAC sites, PCT, Council and Provider premises Helpful to GPs Ease of referral – no forms Musculoskeletal interventions funded Service signs Fit Notes Service provides audit data to GP practices 60% returned to work i.e. 78% non-medical Leicester FFWS

25. The Council for Work & Health The Council facilitates the sharing of skills and expertise by gaining consensus and agreement across the professions and practitioner communities for core content for education and training in health, work and wellbeing issues. The Council first met in October 2009 and has a broad membership with representatives of all healthcare professionals involved in the delivery of health and wellbeing services. It now includes employers. • Current projects: • Guidance for employers on communication with general practitioners • Training and qualifications for occupational health nurses • Training and qualifications for allied health professionals • Fiscal disincentives to health promotion in the workplace

26. Some initiatives were targeted at employers, small and large • Realigning and revitalising UK Occupational Health • National OH Standards and Accreditation programme for providers, to help employers • Occupational Health adviceline • Challenge Fund for Small and Medium companies. • Workplace Wellbeing Tool (on business case) • Health and Wellbeing Regional Coordinators • Public sector as exemplar: the Boorman Review of the health and well-being of NHS staff

27. Improving OH provision to employers: Standards and Accreditation Enable services to identify the standards of practice to which they should aspire; Credit good work being done by high quality occupational health services, providing independent validation that they satisfy standards of quality Raise standards where they need to be raised Help purchasers differentiate occupational health services that attain the desired standards from those that do not. Standards were published in January 2010 and the accreditation scheme was launched in 2011. www.seqohs.org Produced by Faculty of Occupational Medicine

28. SEQOHS Accreditation –27 September 2011 On 12 July 2011, certificates were awarded to the first seven SEQOHS accredited services. Two of them were single-handed OH practitioners.

29. Occupational Health Advice Helpline 0800 077 8844 Provides businesses and GPs with tailored occupational health advice, by advisers with special training in Mental Health. Employers calling the service are predominantly micro (0-9 employees) and small (10-49 employees) businesses – the target group Most callers are calling about an individual employee issue So far, few GPs have used the line 95% appreciate the contact and 92% would recommend to other employers 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

30. Small Business Awards:The Challenge Fund – 70 awards For example Colebrook targeted Mental Health. They arranged Health and Wellbeing Workshops for staff, covering topics: Staying OK in Changing Times; Feeling OK: Keeping Good Mental Health; Worklife Balance and Healthy Lifestyles. Workshops were personal and bespoke, using local links and suppliers; well attended by staff from all levels. Good staff response: course to be repeated. Typical feedback: “I will hopefully be better equipped to support my team to deal with forthcoming changes, I will listen more” “I will be more assertive with myself” “That I have the motivation when I put my mind to it” “I will try to worry less – be more positive” “It reminded me that you feel so much better after exercise”

31. Local progress: Support toemployers:HWWB Co-ordinators Facilitate an integrated approach to health and business at a local level – joining things up, making local connections – able to facilitate Public Health in the workplace Encourage partnerships between businesses and health networks in the local area – signposting to funding opportunities and facilitating better links Promote best practice and encourage innovation within businesses on health, employment and skills, focusing on small and medium businesses Co-ordinate health, work and well being strategies and activities for public and private sector and working closely with other Co-ordinators, DWP and DH Support the National Director, e.g. on the Public Health Responsibility Deal Arising from the Black Review, eleven Health, Work and Well-being Co-ordinators were appointed, one for each of the English regions, Scotland and Wales, to act as champions of the Health, Work and Well-being agenda across Great Britain, and:

32. Sickness in the public sector • Black Review 2008: public sector (6m workers) should be an exemplar • 1.4 million work in the NHS; 10.3 million days lost to sickness each year, direct cost £1.7 bn yearly, temporary cover etc another £0.9 bn • Government response: Review of health and wellbeing of NHS staff, led by Steve Boorman: findings accepted by government. • Implementation of Boorman is linked to efficiency and quality of the NHS • The Audit Commission estimates that £290 million of savings could be achieved if all NHS components were able to reduce their sickness absence rates to the current lower quartile. • Other positive benefits of reduced sickness absence include increased staff productivity, better morale and improved communication between teams, leading to better quality services, improved patient satisfaction and decreased staff turnover. • Targets for reduced sickness absence have been set: for the North of England 3.4%, for the South of England 3.0%.

33. Public Sector : ‘Boorman’ HWWB Programme in the NHS National priorities: implementation being overseen by the Health and Well-being Innovation and Scrutiny Group, chaired by Carol Black : to ... 1. mobilise improvement, by setting out an Improvement Framework. 2. ensure ongoing approaches to monitor and measure health and well-being. 3. embed accountability for health and well-being into the future system design. 4. ensure staff health and well-being is supported and promoted through education and training. • use pathfinders to strengthen the occupational health market and support for heath and well-being in the NHS. • reduce sickness absence Delivery workstreams, led by NHS Employers: A. Embed an approach to support health and well being across the NHS B. Support the development of occupational health services C. Help NHS organisations meet their legal responsibilities for health and safety

34. Promoting NHS Health & Well-being • Progress to date : • Staff H&WB Innovation and Scrutiny Group, chair CMB, established. • Reports: “Healthy Staff, Better Care for Patients” and “NHS Health and Well-being Improvement Framework” (DH, July 2011) • Hospitals and local health boards have agreed trajectories to improve sickness absence, part of national standards. • NHS Sport and Physical Activity Challenge launched. • DH Health and well-being Toolkit. ‘NHS Well-being at Work’ web portal. • The Public Health Responsibility Deal promoted in the NHS. • NHS OH services work towards national OH standards and accreditation. • Next Steps: • Pathfinder sites to demonstrate optimum delivery of health and well-being and reconfigured OH services

35. Boorman in action: York Hospitals NHS Trust • Previously, absence rate 5.13%, costing £3.7 m yearly • Trust invested £100k in a team – specialist nurse, physiotherapist, counsellors, clinical psychologist, HR manager – operating in partnership with hospital managers, to help staff return to work. • Number of staff off for 4 weeks plus reduced by 42% (99 to 57 staff) • Number of staff off for 3 months plus reduced by 46% (52 to 28) • Estimated saving of £200k with this pilot project • Trust has dedicated resources for the coming year.

36. NICE public health guidance Guidance from the National Institute for Clinical Excellence (NICE) on public health has six areas of focus: • Managing long-term sickness absence and incapacity for work • Promoting physical activity in the workplace • Promoting mental well-being through productive and healthy working conditions • Workplace interventions to promote smoking cessation • Obesity: guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children • Promoting and creating built or natural environments that encourage and support physical activity

37. First audit of NICE public health guidance for the workplace The first ever national audit of NICE public health guidance in the NHS workforce – a landmark. Wide variation of implementation of NICE guidance across NHS in England (i.e. many hospitals do not support staff to address obesity through healthy eating options and physical activity). Findings show very clearly the importance of senior leadership. Where boards are actively leading staff health and well-being programmes, action follows.  Workplaces that implement the NICE guidance tend to have a healthier and more productive workforce and better patient outcomes. A separate poll found 37% of the public would not accept health advice from a healthcare professional who appeared to have an unhealthy lifestyle.

38. The workplace – its potential • There is increasing emphasis on the role of the workplace in influencing and providing the conditions necessary for healthy and fulfilling working lives … • … with persuasive evidence that the health and well-being of employees are significant determinants of the success of business enterprises and services .... • ..... and increasing evidence of a sound business case.

39. UK Employers: Investing in workplace health Other Legal Ethical Economic 0% 100% Reasons why employers invest in workplace health What is measured to calculate return on investment for healthcare spend? Two in ten organisations do not have a system to record sickness absence. DWP survey work

40. Employers’ attitudes to health and well-being amongst their employees Agree Disagree Responsible to encourage employees’ health Strongly Tend to Work, health and wellbeing are linked Health investment is financially worthwhile Employees do not welcome health interference Sickness absence is a barrier to productivity Source: Health and well-being at work: A survey of employers DWP 2010, 2,250 employers of all sizes

41. Percentage of employers citing each Adjustments employers make for employees to stay in work Measures used in the last 12 months to help keep employees with health problems in work or facilitate their return to work: No measures provided ---- Source: Employer Survey, DWP

42. Parcelforce (4,500 employees) Introduced comprehensive wellbeing and health programmes: Sickness absence reduced by one third, saving £55m Compensation claims reduced by two thirds, saving £1m Productivity increased by 12.5% Overall: £2.25m investment yielded £6m in direct cost savings Digital Outlook (27 employees) Implemented a variety of wellbeing initiatives: 95% improvement in sickness absence rates: 4 days per year in 2006 down to 0.22 days in 2008 Reduced staff turnover from 34% in 2007 to 9% in 2008 making savings in recruitment and training costs The bottom line: case studiesPrivate sector • British Gas (25,600 employees) • Implemented back care workshops: • Back-related absence reduced by 43% • 58% of staff improved their attendance • Return on investment was £31 for every £1 spent

43. Addressing Mental Health issues in the workplace • Awareness training for line managers, to increase understanding of MH issues and their ability to respond confidently and rapidly (almost 100 toolkits, training courses or guidance notes are available in UK). • Prevention of directly-work-related MH problems (around 15% of total) – e.g. by providing mentally-healthy working conditions and practices (see guidance by UK Health and Safety Executive) • Better access to help for employees, particularly to evidence-based psychological help and support while carrying on working • Effective rehabilitation for those who need to take time off, including regular contact with the employee during periods of absence Centre for Mental Health 2010

44. Mental Health Support at GSK Mental health problems caused most days lost on sickness absence. Support : • Proactive in house OH team • Case management (depression screening) • Energy and resilience programme • A comprehensive employee assistance programme • Private medical insurance with mental health cover • Global health risk appraisal • Mental health first aid model • Webinar ‘people’ training for line managers

45. GSK Return on Investment • Work related mental ill health down by 60% • Mental ill health absence reduced by 20% • Reported 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 GSK data 2004-2010

46. Macleod Review 2009: Engaging for success 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. The Prime Minister in June announced formation of a task force on engagement, chaired by David Macleod, objective to improve performance of organisations by raising levels of engagement.

47. Positive Workplaces Key features common to those organisations which have achieved success in promoting physical and mental health and well-being: • 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 and well-being need to be embedded in every aspect of an organisation’s structure and work

48. The future UK landscape which may affect Health Work and Wellbeing • A challenging economic situation • Major reform of the NHS • Public Health re-organisation • Local Councils’ enhanced responsibilities • Public Health Responsibility Deal • Major reform of welfare system • Independent review of sickness absence

49. New Coalition Government, New Initiatives:Public Health Responsibility Deal “ The Responsibility Deal is a Coalition response to challenges which we know cannot be solved by regulation and legislation alone. It is a partnership between Government and business that balances proportionate regulation with corporate responsibility.” Andrew Lansley, Secretary of State for Health The partners are working together to: recognise their vital role in improving people’s health actively support our workforce to lead healthier lives encourage and enable people to : - be healthy and in work - adopt a healthier diet - be more physically active - drink more responsibly • The Responsibility Deal is delivered through 5 networks: • Food • Alcohol • Physical activity • Behaviour change • Health at work Launched March 2011

50. Responsibility Deal : Health at Work network The aim of the Health at Work Network – one of five networks - is to find ways to help employers use the workplace to improve the health of their employees. Current work includes: • Pledges for action to help people at work lead healthier lifestyles. The Network has agreed six initial pledges. Now we are publicising them and encouraging uptake. • Local Business Partnerships: Unilever, Mars UK, Novo Nordisk, mentoring SMEs • What works for SMEs • Providing generic guides on managing chronic conditions in the workplace • Developing ways to make occupational health more proactive and preventative