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How to move from sick leave to ‘good work’.
As many as a quarter of people with chronic pain go on to lose their jobs, so what can be done to make staying in work more achievable? We look for answers in this first of two episodes focusing on employment.
‘With the right support, many people on sick leave, could be in work or helped back to work faster’, says Dame Carol Black, independent expert advisor to the government. She explains why ‘good work’ – work where people are listened to, respected and have some control – is not only important for our mental well-being, but can even prevent back pain.
The result of Dame Black’s report into this issue was the government’s Fit for Work scheme. Occupational therapist Gerry McFeely describes how the programme aims to help those on sick leave to develop a Return to Work Plan.
Paul Evans: This is Airing Pain, a programme brought to you by Pain Concern, the UK charity providing information and support for those of us living with pain and for healthcare professionals. I’m Paul Evans and this edition’s been supported by a grant from the Moffatt Charitable Trust.
Louise Coupland: Forty per cent of people in Scotland live with long term conditions. The majority of those will be in the working age bracket, so it’s not about recruiting, it’s actually about supporting the employees you already have who will possibly in the future get a condition, or be diagnosed with a condition or several conditions. Or their home circumstances might change where they become an unpaid carer. And it’s not about recruitment, it’s actually looking at the workforce that is already out there, you know, in 2020 when we’re looking at so many more carers and people with diagnosed conditions. It’s going to be a real problem if people aren’t proactive and changing their mindset in what employers should provide.
Evans: That’s Louise Coupland, the Employability Development Officer of the Health and Social Care Alliance Scotland. And she’s setting out the stall for this the first of two programmes about employment issues for people living with chronic pain. And we’ll be hearing more from her in the next programme.
But first, Dame Carol Black, she’s expert advisor on health and work to Public Health England in the Department of Health and she chairs the Nuffield Trust for Health Policy.
She did an independent review of the health of the working age population in Great Britain back in 2008 and that brought the relationship between health and work into sharp focus. She and David Frost were then commissioned by the government to do a further independent review of sickness absence. This was published back in November 2011.
Black: The report that David Frost and I did for the government in 2011 had background of a rising figure for sickness absence both short term and long term and the government was worried about that and wanted to understand it.
It has always been worse in the public sector than the private sector. So we were charged with looking in detail at sickness absence and the really big issue overall is that sickness absence – whether it’s in the public or private sector – is very damaging to the British economy, because of course when people are not at work we have a reduced productivity. So it is first and foremost a big issue for the country and when you look at it in depth there are many people who are taking sickness absence, who with the right amount of help and support could either be in work or could be helped back to work much faster.
So we were looking at those things which cause people to be absent from work and what were the things that we could do things about. And the whole topic of work and whether it’s good or bad needs to be taken in the context of ‘are you in a good workplace?’ and ‘do you have good work?’. And if you have those two things then a lot of sickness absence due to stress and anxiety and depression or musculoskeletal problems would be able to be reduced.
Evans: So you talk about good work and not good work. Is good work purely to benefit the worker, if you like?
Black: Good work benefits everyone, because if you are in good work yourself, it will obviously be of benefit to the individual, it’s quite likely to be of benefit to your family because you’re likely to be in a much better condition both mentally and physically. It will be a benefit to your employer. It will be of benefit to your community because the more people we have in good work, probably the more stable that community is. And of course it will be of benefit to the economy and the government. So good work starts by benefitting the individual and then goes on to actually benefit a whole lot of other people.
A lot of people perhaps think good work is earning lots of money, or being in a nice building, but good work really is about whether you have any sense of control at work – that’s crucially important – do you feel you’re trusted? Are you given some autonomy? It’s crucial. Are you listened to? Are you respected? If you wish to have some flexibility in your work, is that at least considered as seriously as possible.
So, I want people to understand that good work is not about just the building or how much you’re paid. And does your employer care about your health and wellbeing? So that really is what good work is about.
Evans: That seems fairly straightforward to us, but that’s not always the case is it?
Black: No, no I mean, quite a lot of people are not in good work and if you take good work and good work places together, the essential thing is to have somebody healthy – mentally and physically – and in work are, one, senior managers, so does the chief executive of the organisation take health and work seriously? Does the board of an organisation have a non-exec on it, whose responsibility is to report to the board on the health and wellbeing of the employees?
So you have a board member communicating with the employees and any committee that they may be running, but brings it back to the board of the organisation. Have you trained your managers in people management and mental health? I don’t want people to be psychiatrists or psychologists, but I’d like them to understand when people are not themselves.
So in order to get these things right, they’re the first absolutely fundamental things and they’ve been very well expressed in a recent report from NICE (National Institute for Health and Care Excellence) in June 2015, which talks about the organisation of work. So I think if you get those things right then you can think about people’s physical health. So have you provided good food in the canteens? Have you looked at your vending machines? Have you cared for people’s physical activity? Have you made necessary adaptations at work if someone has a disability? All the very practical things. Do you help people if they wish to stop smoking? Have you got policies in place about alcohol? To help people understand what safe drinking is. That’s what a good employer is.
Evans: It all sounds very, very reasonable. I do know companies like that, but I know of companies that are not like that.
Black: No, of course there are companies that are not like that and our job is to really spread the word and make them see it’s the business case and that’s why I really started with the economy. Because the way you will get an employer to take an interest is ‘does it meet their bottom line?’ They won’t do it because it’s nice, soft and fluffy, but does it meet their bottom line? Will it add to their productivity? Will it give them a return on investment? That’s what their finance director asks. So you need to be able to make the business case, and I think that’s the way most successful companies have approached it. They’ve said ‘what is in it for us as a business?’
So if you take the NHS, investing in the health and wellbeing of staff will give you better quality of care for patients. You’re not producing a machine, you’re not running a business, but you do have a product. Your product is people and people’s health. So it’s perfectly reasonable to ask the question of ‘are you actually meeting your bottom line?’ And that bottom line doesn’t have to be material things.
Evans: Dame Carol Black. Of course, that bottom line for an employee with chronic pain can mean anything, from just getting through a day’s work, to long term sickness absence, or even permanent unemployment.
Black: The longer you are out of the workplace, the much less likely you are to return to it, and after 20 weeks of being away from work, you really are moving a long, long way away from the workplace. So the first thing I would say is, we have to turn the tap off. We don’t want so many people becoming long term sick, but of course we do have people who are long term sick and then it’s a really very difficult balance of how do you first of all get their general practitioner to ask the question ‘how do we get you back to work?’ rather than just issue another sick note. And that is a very difficult cultural issue because they’d been writing sick notes, they’re doing often what the patient requests. It is the patient-doctor relationship and to change that culturally is a very big problem.
When people say they’ve got back pain for example, you shouldn’t just take at face value that they’ve got just back pain. They may have back pain, but the important question to ask is why and to ask whether there is anything going on at work that exacerbates the back pain. And in a very good survey and study – a research study – in Denmark it was shown that the most likely predictor of severe back pain was lack of control at work. So, you have to take pain as a holistic thing for which there may be a physical reason, but there may be a social or psychological reason and you’ve got to address that as well.
Evans: Lack of control, that sort of implies an unhappiness in the workforce.
Black: Well of course it does, and that’s exactly what it is, but often a person will go to their GP and say ‘I’ve got back pain, I’ve got neck pain, I ache’. But these are somatic manifestations of something going on somewhere else. So you need to be quite careful that you investigate pain both for pain itself and any physical reason for the pain, but also that you examine if you like, other reasons for pain and if you’ve got lack of control at work, most of us feel pretty unhappy. I mean you may not need a great deal of control, but if you have no control over your day, if today I had absolutely no control, if I had to do that day after day, I think I might get quite fed up.
Evans: I have chronic pain and I know that pain keeps you apart in some ways from the organisation, from your colleagues, it’s invisible.
Black: It is invisible, but I think if you can be with people and you have pain the things that will take your mind – if possible – a little bit away from it, and enable you to join in, I think makes life that bit better. Because if, let’s say, you know, you may have to put up with chronic pain, you know, perhaps for several years, you don’t want to be isolated for several years. So I think the real art is how do you enable that person even with their chronic pain to participate, because, for example, if you had an amputated leg, you have a disability, but that shouldn’t stop you participating.
It will be a bit more difficult because you will need a wheelchair and you’ll need some support, but many of us have disabilities – some of it is pain, some of it is other types of physical or indeed mental disabilities – but what you want is an environment in which we all try to make it as inclusive as possible.
Evans: The trouble is that many chronic pain conditions are invisible – we don’t have our legs cut off – you talked about being in control, how do you give some of those people the control in the workplace?
Black: Well, alright, I happen to have a chronic facial pain that I’ve lived with for quite a long time. I know that with the help of certain drugs, and a certain approach to it I can quite easily manage. I wish it wasn’t there, it’s not there so badly all the time and sometimes I forget it, but it, it almost becomes part of your life. But if you’ve got diagnosable illnesses that are associated with pain, you may well need the advice of a good pain clinic, of how to live with pain, how to minimise it as best you can. Some people find CBT helpful. Some people find drugs helpful. Some people find a variety of things helpful, but often to really get to grips with chronic pain associated with illness you need a multidisciplinary approach. And I think that, if it’s used well, ought to enable someone to return to the workplace. It depends how well it’s done.
Evans: I’m not sure anybody would disagree with you but, CBT in my area for instance is an 18-month waiting list and in 18 months, an awful lot can happen.
Black: No, I agree with you. We could all say the waiting list for all kinds of things, physiotherapy, CBT are certainly too long. I think we can all come to a conclusion about what would make a difference and then of course the job is persuading those in power or within our hospitals or within our local communities, whoever is responsible for the budget, to at least put some of the budget in that direction. I mean you know, everybody’s fighting for resources.
Evans: Your report came out in 2011, it’s 2015 now. What has happened since then?
Black: Well it took the government almost two years to respond to it, so their response came out, I think, 2013. Since then they have been designing and have set up the Fit for Work service. And the whole point of that service when David and I thought about it and wanted it was that people would be treated holistically. You weren’t being sent there just because you were collecting a sick note. You were being asked to be assessed in that service, to make sure your health needs were being tended to, that your workplace relationships and needs would be attended to and that maybe if you had debt or you had carer responsibilities… we saw it as dealing with problems that keep you from work. You know, what has to be done to help you return to work and we said it should be very early. The later your leave it the more difficult the problem, the less likely you are to solve the problem.
Evans: I believe the take-up in Scotland is pretty low. GPs just aren’t referring their patients.
Black: Well, you probably know figures that I don’t know. I would expect to start with that the figures will be low. I expect they will be. I think anything that is new and different and innovative, and you’ve got to do something different in practice and you may not know whether or not this is going to be helpful, you make take a while to get people to refer in to it. I think if you can get a group of GPs that really buy into this, then you start to get traction.
Evans: One obstacle I can see is with all the welfare reforms going on at the moment, that this is just another scheme to crank up the ante, if you like, against the unemployed.
Black: Well of course if people are on sick leave they’re not the unemployed, they’re not in the benefits system and I’ve met very few people early on in their journey that don’t want to go back to work.
Of course, we’re not talking about people with cancer or serious illness. We’re talking about people who’ve got stress, anxiety, depression, back pain and there are very large numbers of those people. And most people do not go to their doctor thinking ‘I’m getting my sick certificate to leave work’. I think most people hope they will be helped sufficiently to return to work.
And what we’ve said in our review was that this needs to be early intervention. And if it was obvious when the case manager spoke to the person, that they were in a job to which they were not suited – we called it ‘square pegs in round holes’ – you know the ‘never going back’ syndrome – ‘I dislike that job, I’m not going back’ – then what the Government should consider is should you try as in one of the Scandinavian countries to have a job matching service. That if someone says, ‘I want to work, but not that job’. Now, it may be that your company is too small to offer you a different job, but you are in the labour market, you are employed. How do we maintain you there?
So one needs to be positive about this. We have a welfare state and if we want to maintain a welfare state we have to have enough people, healthy and in work, to be paying taxes, to look after those people who genuinely cannot be in work or who are children, or in education etc. So I’ve always seen my job and the work I’ve done for government and in advising them, how do I keep as many people as possible as healthy as need be both mentally and physically to be in work, so we can have a welfare state.
Evans: Dame Carol Black, Expert Advisor on health and work to Public Health England and co-author of the 2011 Health at Work independent review of sickness absence.
Now, acknowledging that early intervention can prevent long-term sickness absence. One of the recommendations in her 2008 report was for the Fit for Work service that she mentioned earlier, to help individual employees in the early stages of sickness absence return to work.
Gerry McFeely is Macmillan Consultant Occupational Therapist for Cancer and Long Term Conditions specialising in vocational rehabilitation. He’s based at the Astley Ainslie Hospital in Edinburgh.
Gerry McFeely: Fit for Work has been around in Scotland for some seven, eight months now and my staff here manage that service. It’s a government service – DWP (Department of Work and Pensions) – managed through the Scottish Government. And, in essence, it offers a case management support service for people who have a job, who are absent from that job, trying to go back to that job.
It’s not designed to see people who are at work, but those who are off work, with a reasonable expectation that they will be returning, hence the referral from the GP to the service. And it is GP referral (it’s not self-referral). There’s a reasonable expectation that they will be returning to work and that this service can aid that through case management.
Evans: So, would I be right in saying you might see somebody who’s been off work for three months, six months, who wants to go back to work, but at the moment can’t go back to work.
McFeely: Depending on the person and their situation, you can see somebody who’s been off work two to three weeks heading towards four weeks, so in the expectation that the service can help, and then those kinds of patients that GPs see a lot, who may have been off for longer who now may be returning and need that assessment. And it can be three months, it can be six months.
I think the current practice is that there is to be an expectation that there’s a return to work and if GPs aren’t referring people, it’s probably because the expectation is not strong and the service isn’t perhaps designed with the more difficult, challenging, fully three dimensional cases which require an interventionist approach because Fit for Work at the current time has a case management telephonic approach largely, towards the need. Whereas, some patients need to be seen face-to-face and need therapeutic intervention, or more extended involvement.
Evans: OK. If I were a patient with chronic pain – and I am a patient with chronic pain – and my GP referred me to you what would I expect?
McFeely: The Fit for Work service would, in that first call, see if they could with you evolve a return to work plan after that first call, because the key output for Fit for Work is a return to work plan. And if we can do that, they would issue that to you and, with your consent, for you to share it with your GP, or for them to share it with their GP and employer.
So if you were referred to us with a chronic condition, the key outcome of the service – the Fit for Work service – would be to try and put together a return to work plan with you on that first call.
If we couldn’t do that, your case would move from being a simple case after that first call, to a complex case. You would be allowed two more telephone calls, exchanges with us, to try and, again, over time to get you back to work.
Evans: That’s not a lot.
McFeely: That’s the service as it currently stands and it might be because you weren’t ready to return to work or because the service is too limited to meet your needs. And you might have to go to other services to get support.
Evans: But what could you possibly achieve with me or with someone else over three phone calls?
McFeely: The intention is, if someone has a readiness to work, that it might be possible to put together a plan – which is what the key output of the service is – to get you back so that you can share that plan with your employer. But I accept that for some patients that would not be sufficient to meet their needs.
Evans: I was quite interested in something you said earlier, about seeing people at an earlier stage who might develop a long term absence from work.
McFeely: The early intervention preventative service is going to stop people drifting towards chronic work related problems and also is going to assist an employer earlier to engage with the employee and have that interactive conversation that literally nips things in the bud, or at least manages them better, much earlier and has a common sense and a common good at the heart of that discussion, rather than allow relationships to fester and for difficulties to get stronger and absence to then occur. Because we know that the longer someone’s absent –and Dame Carol in her research found that someone absent at six months has a 50 per cent chance of not returning to work at that point – so the longer it goes on the disengagement from the work culture gets stronger and the likelihood is stronger month on month that there will be no return, or the person has drifted so far from work that they can’t envisage their return with a long term or painful condition. So it’s really important that early intervention and prevention is at the heart of this.
And in some countries around the world that’s normal, but in the UK we tend to leave it to the free market to evolve a response and we know from the number of people who have been on benefits for many years that there’s not much intervention going on at that point.
Evans: Fit for Work, especially in this current economic climate could be confused with a hammer to beat somebody who is out of work.
McFeely: Fit for Work is potentially a very good news story. We’re in the early stages and, speaking as Chair of the College of Occupational Therapists specialist section of work now, we have made representations as a college that this service will evolve and probably needs to evolve to take in more interventions for those cases that need a three dimensional response, because the problem is a three dimensional one. It involves the environment of work, it needs more engagement with the employer, it needs more attendance to the person’s employment rights, because often times having a right requires a remedy and also requires more therapeutic interventions, when it’s required.
And by that as an occupational therapist I would mean more functional capacity testing, more work conditioning and more worksite services to support the employer.
Evans: Gerry McFeely Consultant Occupational Therapist at the Astley Ainslie Hospital in Edinburgh. At this point I’ll remind you as always that whilst we in Pain Concern believe the information and opinions on Airing Pain are accurate, sound and based on the best judgements available, you should always consult your health professional on any matter relating to your health and wellbeing he or she is the only person who knows you, your circumstances and therefore the appropriate action to take on your behalf.
Don’t forget that you can download all editions and transcripts of Airing Pain from Pain Concern’s website which is painconcern.org.uk.
Now, as we’ve heard, the Fit for Work service is to help people in the early stages of sickness absence to return to work. In the next edition of Airing Pain, I’ll be speaking with those where chronic pain has prevented them from taking up full-time employment. People like Kieran McGee:
Kieran McGee: I worked full-time.
Anne Marie McGee: You went to university.
Kieran McGee: I was on a career trajectory…
Anne Marie McGee: You were doing a PHD.
Kieran McGee: I was, yeah, I effectively had a whole career planned out in front of me.
Evans: His wife Anne Marie: do you miss work?
Anne Marie McGee: Yes.
Evans: So one illness has cost two careers?
Anne Marie McGee: Yeah.
Evans: Have you had any help in getting back to work or freeing yourself up a little bit?
Anne Marie McGee: No.
Evans: And nurse Angela O’Neill.
Angela O’Neill: I had to keep attending the job centre, even though I’ve got a job. The works and pensions office, places that I’ve never been before. It was just so difficult and not feeling well and having to go through that. It was very difficult, for my husband as well who took me. And he was very angry, he felt intimidated, didn’t you?
And when I came out sobbing – I’m not a person that cries very easily – and I came out of the office absolutely sobbing, he just was really upset and frustrated by the whole process.
- Louise Coupland, Employability Development Officer and ‘My Skills, My Strengths, My Right to Work’ Programme Leader at the Health and Social Care Alliance Scotland
- Dame Carol Black, Expert Advisor on Health and Work to Public Health England in the Department of Health
- Gerry McFeely, Macmillan Consultant Occupational Therapist for Cancer and Long Term Health Conditions Specialising in Vocational Rehabilitation, Astley Ainslie Hospital, Edinburgh