Revisiting the Black report on health and work
Howard Fidderman looks at the government's implementation of the Black report on health and work.
On this page:
Health, work and
wellbeing
Staying healthy
Health,
Work and Wellbeing Coordinators
Public sector as
exemplar
Business health checks
Helpline for small and medium-sized enterprises
Getting fit
for work
The Work Capability Assessment
Involving general practitioners
Reforming the
medical statement
Sick-note trials
Box 1: The Fit For Work service pilots
Box
2: Fit For Work service principles
Box 3: Employment
support allowance
Box 4: Psychological
therapies
Table: Fitness for work - results of DWP
study.
It is now one year since the government agreed to implement - fully or partially - nearly all of the recommendations made by Carol Black in her report on the health of the working-age population1. A main factor underpinning the government's endorsement was that the recommendations of its national director for health and work chimed with its wider welfare and work philosophy and, in particular, a rolling welfare reform programme that aims to get one million people off incapacity benefits by 2015.
Currently, 2.6 million people claim incapacity benefits - with 600,000 new recipients each year - while 1.4 million people aged 50-59 have already retired due to ill health. With unemployment and lost working days caused by ill health costing the economy £100 billion a year, it is not hard to see why the government has made the issue a central plank of its political philosophy. Add in the emerging consensus that "work is good for you" and the case for intervention becomes sufficiently compelling to survive whichever party wins the next election.
Health, work and wellbeing
Most of the implementation of the Black report has been incorporated into the government-led Health, Work and Wellbeing (HWW) initiative, which aims to protect and improve the health and wellbeing of working-age people2. Launched in 2005, it involves the Department for Work and Pensions (DWP), the HSE, the Department of Health, the Scottish government and the Welsh Assembly government, and brings together employers, unions, healthcare professionals and other stakeholders to promote the positive links between health and work and help more people with ill-health conditions to find and stay in employment.
The welfare system has traditionally been of little interest to most employers - other than a place to dump sick workers - but business impetus and political intervention have made this position untenable. The "good news," advises the HWW website, "is that most common health problems can be accommodated at work and these account for two-thirds of longer-term sickness absence, incapacity for work and ill-health retirement. So this is a problem that can be tackled."
In this feature we look at the progress that has been made since the government's November 2008 response to Black. Broadly, the initiatives - several of which enjoyed significant developments this October - fall into two categories:
- Staying healthy - encouraging and helping employers to address the health and wellbeing of their staff, including: the Health Work and Wellbeing Challenge Fund; Public Sector as Exemplar; Business Healthcheck; the Health, Work and Wellbeing Coordinator scheme; a helpline for small and medium-sized enterprises (SMEs); and NHS Plus .
- Getting fit for work - "carrot and stick" approaches to reducing long-term work-related sickness absence and benefit dependency, including: the Fit For Work Service; the Work Capability Assessment; reforms to the medical statement, psychological therapies; training for GPs; and Pathways to Work.
Staying healthy
On 13 October 2009, the DWP launched one of the more eye-catching of Black's recommendations. The £4 million Health, Work and Wellbeing Challenge Fund will allow SMEs (1-249 employees) and local partnerships to bid for between £1,000 and £50,000 over the next two years to fund innovative projects to improve worker health and welfare3. Local partnerships can include trade unions and the public, private and third (voluntary) sectors. The HWW site advises that applicants should "have involved [their] employees in defining the problem [they] may be encountering and coming up with the solution".
Launching the fund, Lord McKenzie, a DWP under-secretary of state, said it would "improve conditions in the workplace and will help to prevent workers taking time off sick". The DWP is looking for ideas to tackle issues such as: providing healthy activities; ensuring work-life balance; and supportive management. The challenge fund website advises, however, that: "Projects to improve mental wellbeing in small businesses will be a priority."
Applications should be for new, not existing, projects that must not be receiving a grant elsewhere. There will be two funding rounds: applications must be made by 31 December 2009 for an award covering April 2010 to March 2011. Applications for the second round, 2011/12, must be made between September and December 2010. Successful first-round applications can apply for continuing support during the second application round, although "any award in the second year would depend on successful performance in the first year." Local assessment panels will allocate the awards. The farming, fisheries and transport industrial sectors cannot apply.
Health, Work and Wellbeing Coordinators
The government is currently recruiting a Health, Work and Wellbeing Coordinator for each of the English regions and in Scotland and Wales. One of their tasks will be to administer the challenge fund in their area. The coordinator network will centre on smaller businesses and facilitate an integrated approach to health and work (focusing on mental wellbeing). The coordinators aim to reduce the incidence of work-related ill health and promote best practice and innovation in employment, health and skills. They will highlight the benefits of good work and good health and will cement a stronger health and employment network in each locality. They will also develop and encourage partnerships between stakeholders with a keen interest in this agenda such as Regional Development Agencies, employer coalitions, Business Link, the CBI and the Trade Union Congress, and equivalents in Scotland and Wales.
Public sector as exemplar
The Public Sector as Exemplar (PSE) initiative aims to improve and promote the public sector as an exemplary employer. Central government, local government and the NHS have some of the highest levels of sickness absence and work-related stress; improvements, according to HWW, would benefit the overall national picture and "showcase the government as a more credible advocate of good practice to other employers and stakeholders". The government believes it needs to take the "lead" in: the promotion of health and wellbeing; the prevention of illness; early intervention for those who develop a health condition; and early rehabilitation of those off work.
PSE focuses on a small number of manageable, discrete areas where innovative work is already ongoing, including: the Healthier Food Mark, a standard for assessment of public sector healthy eating; the NHS Workforce Health and Wellbeing Review, which aims to investigate and improve the health of NHS staff, and their health and wellbeing provision at work; and local government activity, which involves 10 case studies of good practice that are due to be published in January 2010.
The government announced in November 2008 that Dr Steve Boorman, who is the director of corporate social responsibility and chief medical adviser to Royal Mail, would lead the independent review of the NHS. The review is particularly important as the NHS is the largest employer in Europe and the government believes there are "inconsistencies" in its OH provision. There was a call for evidence between April and June and a staff survey (11,000 responses) in the same period. Boorman published an interim report in August 20094; the final report is due out by the end of 2009, which we shall review in some detail.
Business health checks
Black concluded that a lack of information for use in a business case was proving a barrier to employers investing in their workers' health and wellbeing. As a result, the government is working with Business in the Community (BIC) and PricewaterhouseCoopers to develop BIC's Business HealthCheck, an evaluation tool that helps businesses: assess and appraise the financial benefits associated with wellness programmes and develop the business case for the investment; calculate the up-front business costs of ill health in a given year, including sickness absence, turnover, worker ill health and injury; generate scenarios for the projected future cost of ill health; monitor progress and report to company board members and in company accounts; and evaluate the financial benefits of wellness programmes. More than 1,000 organisations used the tool between its launch in July 2008 and redevelopment, and the government hopes the new version of the tool will be available "soon".
Helpline for small and medium-sized enterprises
While the government is still prevaricating over Black's recommendation of a business-led health and wellbeing consultancy service that offers tailored advice and support, and access to OH services at a market rate, it advises that pilots of an occupational health helpline for SMEs will run in nine locations between December 2009 and March 2011. The helpline will: provide advice from occupational health professionals tailored to the needs of SMEs; signpost employers to professional specialist advice and services; assist local partnerships to work collaboratively to provide occupational health services to local small businesses; and run campaigns on the benefits for SMEs of addressing health issues. The nine schemes will comprise fee and free variants; access to the helpline will be via local "gateways" set up by local partnerships and business networks.
It is still not clear whether the helplines will have a preventive role; the government's response to Black noted only that they "will offer help when something goes wrong by providing business-hours access to professional occupational health advice for individual employee health issues". (The 2008/09 Anderson review on government guidance recommended that the government establish a telephone advice service offering tailored and "insured advice" to help SMEs comply with health and safety and employment law.)
Getting fit for work
Black recommended a Fit For Work Service (FFWS), noting that there is insufficient support for people in the early stages of sickness. The aim of the service, said Black, was to make access to work-related health support available to all - "no longer the preserve of the few". The DWP secretary of state, Yvette Cooper, and the health secretary, Andy Burnham, announced the 10 pilot schemes on 13 October 2009, which will involve employers, GPs and local councils in helping people with medical conditions or disabilities return to work (see box 1). The government will provide £13 million to "pump prime" the service, both to help reconfigure existing services and develop new service elements. Although this funding runs out in March 2011, the government insists that "all of the FFWS pilots are committed to ensuring their FFWS is sustainable over the longer term." The £13 million also covers the cost of evaluation.
As there is no one solution, the government has selected different types of FFWS, although each pilot must also comply with 11 principles (see box 2). The main aim of every pilot is to provide personalised and timely back-to-work support to sickness absentees to assist recovery and a return to sustained work more quickly than would otherwise have been the case. The government also expects the pilots to reduce the number of people who lose employment and take up benefits as a result of ill health. All of the FFWS pilots include case managers "who will ensure that clients are helped to access the most appropriate forms of support in a timely fashion". The FFWS will run in addition to the access to work budget, which helps those with medical conditions or disabilities who have extra costs in order to work (such as extra travel costs or specialist equipment).
The pilots will test different models for bringing together support drawn from areas such as:
- health and wellbeing services, including NHS "usual care", psychological
therapies, occupational therapy, physiotherapy, other rehabilitative care for
longer-term sickness, and support for people with fluctuating conditions who
regularly fall in and out of work (for example, people with multiple
sclerosis), and support for people with disabilities;
- employer liaison;
- wider social support such as housing and debt advice;
- employment advice; and
- learning and skills advice.
These services may already be in place, need to be procured or be under development. They have to be in the public sector, and include primary care trusts (and the Scottish and Welsh board equivalents), local authorities and any other relevant public sector commissioners/partners.
In early 2010, the government will create a learning network that it hopes will comprise the FFWS Pilots and other interested parties, including unsuccessful applicants, in order to exchange learning, skills and expertise.
The Work Capability Assessment
The government is also overhauling the whole system for dealing with people who are unable to work due to ill health. On 13 October 2009, the DWP released the first statistics on the impact of the Work Capability Assessment (WCA), which was introduced in 2008 in an attempt to focus on what people can, rather than can't, do. The test examines whether someone is fit for work or should go onto employment and support allowance (ESA) (see box 3). It was introduced as part of the government's welfare to work reforms and has as its aim "stopping more people getting trapped on long-term sickness benefit". The government believes that the other benefits of the WCA are that it assesses people earlier in their illness and involves face-to-face, rather than paper, assessments. The DWP claims that the WCA was developed in partnership with doctors and charities that support disabled people.
The first figures show that of the 193,800 people who made a claim for ESA between October 2008 and February 20095:
- 5%, who are the most severely ill or disabled people, are going into the support group and will not be expected to undertake any work-related activity, instead being offered help to manage their condition;
- 36% were assessed as fit for work and not eligible for ESA;
- 11% were eligible for ESA with work-related activity (such as regular adviser interviews) to help them prepare to return to work in the future;
- 38% stopped claiming benefit before the assessment was completed; and
- 10% were still being assessed as the statistics were compiled.
The DWP emphasises that the results compare favourably with the previous incapacity benefit (IB) system, where the assessment resulted in just 17% of claimants being found fit for work (although as the assessment was carried out after six months rather than three months, more of those with low levels of health problems had already returned to the labour market after only a short-term claim).
Ministers have also said that the roll-out of the new assessment meant it was time to look at ways to improve and adapt the Pathways programme (see below) to ensure that people looking for work, and ESA claimants with health problems, obtain more effective help to get into work and manage their condition. Further details will be set out in the Back to work white paper, which is due in December.
Involving general practitioners
Several of the initiatives that are being implemented as a result of, or are linked to, Black's recommendations involve GPs. To help facilitate this, the Royal College of General Practitioners (RCGP) is rolling out a government-funded National Education Programme. Running from June 2009 to March 2011, the programme comprises half-day workshops to raise awareness of the positive links between health and work, and ensure GPs are equipped to provide support and advice to patients about fitness for work issues6. Each workshop is delivered by an RCGP-trained GP and specialist occupational health physician. The government envisages 100-150 workshops covering 3,000-4,500 GPs.
The college's chair, Steve Field, described the programme as a "major boost for the college and for GPs. Tackling health inequalities is a big priority for us and helping people to remain in or return to employment is clearly one of the best ways of improving the mental, physical and economic wellbeing of our patients." Helping patients return to work, Field added, "can put GPs in a difficult and stressful situation and many GPs worry about consultations on this issue. The programme will remove many of the anxieties and concerns by giving GPs increased confidence to approach and deal with difficult situations and to make the best decisions for patients in the long term."
Some GPs have been involved in return-to-work schemes that were running well before Black, such as a Pathways to Work initiative that placed employment advisers from Jobcentre Plus in GPs' surgeries. GPs referred patients to the advisers, who then acted as a gateway to the services available from Jobcentre Plus and elsewhere. An evaluation of the pilot project that was carried out in 2006 and 20077 was generally enthusiastic, concluding that the "gateway" model is a viable mechanism for connecting people with a range of employment and other support. There was strong evidence that people who would otherwise have been unlikely to make contact with Jobcentre Plus offices attended meetings with advisers, with "many going on to undertake some kind of work-related activity". Endorsement from GPs was important in moving people towards work, and GPs "increased" their knowledge.
Reforming the medical statement
A further plank in the government's welfare-reform strategy is to replace the current medical "sick note" with a "fit note". The DWP consulted on the implementing Regulations and the design of the note itself between 28 May and 19 August 20098 and is currently analysing the responses. The fit note will replace three medical statements (Meds 3, 4 and 5) with a single form and end the current practice of a GP merely stating that individuals should refrain, or not refrain, from their usual occupation. Instead, the fit note will highlight what a sick worker can do and judge the individual as "fit for work", "not fit for work" or - in what is essentially a new, third category - "may be fit for some work now". The doctor will also need to note whether the patient would benefit from a phased return to work, altered hours, amended duties or workplace adaptations. The doctor's advice will also be simple and generic; for example, states the DWP: "where an individual has moderate lower back pain, a doctor may suggest that they will be unable to lift heavy objects and should be given the opportunity to change position or take breaks regularly."
The government hopes the improved information will help inform discussions between workers and employers about whether there are any workplace or job changes that could help in achieving an earlier return to work; enhance job and skills retention; provide the worker with information that will assist an early return; and help change attitudes towards the potential role of work in aiding recovery.
The employer will not be bound by the doctor's suggestions, while any changes that are made must be introduced with the agreement of the employee. Where agreement is not possible, the diagnosis "may be fit for some work now" will constitute evidence that the patient should refrain from work for sick-pay purposes. The government advises: "As now, it will be up to employers to consider all the circumstances in order to determine if they accept that their employee is incapable of work under the terms of their contract."
Sick-note trials
The government tested a draft paper version of the fit note with 583 GPs before it issued the consultation document and an electronic version in Wales. It presented the GPs with one case of back pain and one case of depression and asked them to indicate their diagnoses using the old sick note and new fit note. Broadly, 38% of GPs would have taken the new "fit for some work" option, although this was far more pronounced for back pain than it was for depression (see table). Most of the GPs who opted for this third way had diagnosed the patient as unfit for work under the old system.
Although the DWP had hoped to introduce both versions simultaneously, it is now questionable whether the electronic form will be ready when the paper version starts up in spring 2010. On 9 July 2009, the DWP published an evaluation of the attitudes of participants in a small-scale trial of the electronic medical statements (eMed3s)9. This found: employers and employees were broadly positive about the idea of eMed3s; and GPs found the eMed3 fairly easy to use. The DWP also notes that the "general picture from non-participating GPs was of reluctant cooperation if eMed3s were to be rolled out, reflecting their views about the sick-note system in general. This finding is in keeping with previous research into GP attitudes on this topic." And, in October 2009, the size of the DWP's task became starker still when a survey of London's GPs revealed that 96% of the 452 participating GPs had received no "fit note" training and that fewer than 10% were confident they could complete the new note10.
1 Black C (2008), "Working for a healthier tomorrow: Review of the health of Britain's working-age population" (on the Working for Health website), and HM Government (2008), "Improving health and work: Changing lives. The government's response to Dame Carol Black's review of the health of Britain's working-age population" (on the Working for Health website).
2 Unless a specific reference is provided, information on most Health Work and Wellbeing initiatives (on the Working for Health website) reviewed in this article.
3 Further details, including project criteria and guidance for entries (on the Working for Health website).
4 Boorman S (2009), "NHS health and wellbeing review: Interim report" (external website).
5 WCA statistics (on the DWP website).
6 GP details and workshop dates (on the Royal College of General Practitioners website).
7 Social Policy Research Unit, University of York and National Centre for Social Research (2008), "The Pathways Advisory Service: Placing employment advisers in GP surgeries" (PDF format, 392K) (external website).
8 DWP (2009), "Reforming the medical statement: Consultation on draft Regulations" (PDF format, 2.lK) (external website).
9 DWP (2009), "Electronic medical certificate (eMed3). Proof of concept evaluation" (PDF format, 697K) (external website).
10 Londonwide LMCs survey details.
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Box 1: The fit for work service pilots Scotland-wide The pilot Fit For Work Service (FFWS) will run throughout Scotland. A freephone national advice line will act as a gateway; telephone advisers will "triage" calls to determine the support that is required, and will either provide advice and signpost self-help resources, or refer those who need more support to a local FFWS, of which there will be 14 - one in each health board area. Services that qualify as an FFWS are already up and running in three of the 14 areas, including Dundee (see below); FFWS funding will facilitate the set-up of services in the other 11 areas. Each FFWS will have a strong focus on small and medium-sized enterprises (SMEs) that do not have occupational health support, and on people in low-paid employment. Dundee This year-old health and employability service will expand the range of services it offers exclusively to SME employees in Dundee, and integrate into the Scotland-wide service (see above). The service will "identify optimal support not only for sickness absentees but also for even earlier intervention, in providing support to 'presentees' - people with poor health who continue to work but who are at risk of sickness absence and loss of employment - who currently form 72% of the current caseload." Rhyl The FFWS will provide support in a coastal, deprived area and be run by a City Strategy Partnership. It will place case managers in GP practices, "providing scope for co-location with physiotherapy, psychological therapies and other support services as a 'one-stop shop' approach". Leicester City and Leicestershire This FFWS focuses on "optimising" GP referrals of sickness absentees to the case-managed FFWS so that GPs will come to view such referrals as being a normal part of their day-to-day patient care. The pilot will also provide services to a small number of workless people whose specific health and employability needs cannot be met by the standard services for people on jobseekers allowance (JSA) or employment and support allowance (ESA). Nottinghamshire The City Strategy Partnership, led by Nottinghamshire Employment and Skills Board, will expand small pilots that have tested support for businesses and individuals. The FFWS Working for Health element will provide assistance for businesses to help them support people with ill health and facilitate a speedier return to work for people off sick. The FFWS Support into Work element will help sickness absentees and be delivered by occupational therapists specialising in common mental health problems and musculoskeletal disorders. An FFWS Work Survival element will provide vocational rehabilitation for individuals within a group environment. Central West Midlands The FFWS will operate in Birmingham, Coventry, Sandwell and Solihull. While its main aim is to provide support to sickness absentees, it will also encompass a small number of unemployed people on JSA whose specific needs would benefit from the expertise within the FFWS. The private sector will provide the case management function. North Staffordshire/Stoke-on-Trent The FFWS will expand an existing NHS team delivering a Condition Management Programme, "building on their experience of supporting unemployed people with long-term ill-health problems to return to work, to provide a service that meets the distinctly different needs of people in the earlier stages of sickness absence from work". At a later stage, the FFWS will support a small number of JSA recipients whose specific needs would benefit from the expertise within the FFWS. Eastern and coastal Kent (Margate) The FFWS will provide support to sickness absentees in the Margate area, "optimising GP referrals of sickness absentees. It is proposed that this model be part of the Total Place Initiative, which seeks to establish an innovative multi-agency approach to tackling complex local needs through a preventative 'invest to save' model." Kensington & Chelsea An NHS occupational health provider will deliver the case management function and work in partnership with the council's environmental health team, supporting in particular SME employees. The FFWS will also link into the local network of skills and employment provision, such as the prototype Adult Advancement Careers Service. Wakefield District The government has selected this pilot in a deprived area as a "test bed for developing an FFWS from scratch", providing an opportunity to demonstrate how to set up the infrastructure, using best practice from more developed services. |
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Box 2: Fit for work service principles The Fit For Work Service (FFWS) pilots must:
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Box 3: Employment support allowance The government introduced employment support allowance (ESA) in October 2008 for new claimants of what was formerly incapacity benefit (IB). ESA is accompanied by a more robust medical assessment - the Work Capability Assessment. The Welfare Reform Act 2007 brought in ESA for new claimants, and the Welfare reform white paper, published in December 2008, advised that all existing IB claimants would be transferred to ESA between 2010 and 2013. A single person receives: £95.15-£105.55 ESA if placed in the "support group" following assessment; up to £89.90 in the "work-related activity group"; and £64.30 during the assessment phase. Those in the work-related activity group can lose the work-related activity component of ESA - £24 - if they if fail to "engage in the conditionality requirements without good reason," according to the DWP. |
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Box 4: Psychological therapies As part of its response to the Black Report, the Department for Work and Pensions (DWP) announced it would fund a pilot that placed employment advisers with a dozen Improving Access to Psychological Therapies (IAPT) sites. The IAPT programme offers "talking therapies" to people with depression and anxiety disorders. The Department of Health (DH) ran two successful IAPT trials in 2006/07, leading to a nationwide roll-out across England: 35 primary care trusts established new services, 80 more follow this autumn, and the remainder in 2010. The 12 IAPT sites with employment advisers started in January 2009 and will run until 2011. Similar initiatives are being developed for Scotland and Wales. The advisers work alongside therapists, providing information, advice and support to help working people using IAPT to remain in work or return to work quickly. They also link with local employers. Where a person is out of work, the advisers help with access to Jobcentre Plus and other support. The 12 employment adviser job-retention pilots are taking place in: Camden and Ealing PCTs, Swindon PCT, Buckinghamshire PCT, West Kent PCT, Cambridgeshire PCT, East Riding and North Lincolnshire PCTs, Lincolnshire Partnership NHS Foundation Trust, Shropshire PCT, Central and Eastern Cheshire PCT and North Tyneside PCT. In March 2009, the DH and DWP announced additional funding for psychological support for those feeling worried by the economic downturn; from late 2009, every IAPT service will have linked employment support workers. |
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Table: Fitness for work - results of DWP study | ||
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|
Current form |
Trial form |
|
BACK PAIN | ||
|
Fit for work |
24% |
11% |
|
Fit for some work |
n/a |
70% |
|
Not fit for work |
77% |
20% |
|
DEPRESSION | ||
|
Fit for work |
9% |
7% |
|
Fit for some work |
n/a |
19% |
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Not fit for work |
91% |
74% |
|
COMBINED BACK PAIN AND DEPRESSION | ||
|
Fit for work |
12% |
4% |
|
Fit for some work |
n/a |
38% |
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Not fit for work |
88% |
58% |
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Source: DWP. | ||
