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Integration has to be a mindset - starting with whole person care of the NHS workforce

Julia Manning, founder and chief executive of independent think tank 2020health.org, discusses whole person care.

Everyone is talking about integration: Integrated health and social care, integrated services, integrated commissioning. It’s crucial to the design of sustainable services, but it is also a critical mindset too. For not only have we been fragmented in our approach to delivering care, but we have been narrowminded in our management of our most important NHS asset: staff.

We talk about the burdens, the pressures, the targets and the strain on the system, but we often fail to understand that this all takes its toll on the individual’s system too, or even if we understand it, fail to do anything about it. Increasing demands or rapid, imposed changes cause stress, stress manifests itself in a spectrum of physical and mental health symptoms and staff become too ill to work. In 2009 Dr Steve Boorman highlighted that the NHS lost an average of 10.7 days through sickness per employee, more than the average of the rest of the public sector and double the private sector average.

In some cases, people remain ill for some time, leave work and become trapped in the ‘Bermuda Triangle’ of illness, unemployment and dependency. As Dame Carol Black has previously highlighted, the proportion of adults in Britain who are unable to work because of health problems has more than tripled since the 1970s.

What’s more, this is not a global trend. In our 2011 report, ‘Working Together: promoting work as a health outcome as the NHS reforms’, we found that England performs poorly by international standards in tackling sickness-related worklessness. This is not just true of countries which typically have a good reputation already, such as in Scandanavia, but efforts to address the sickness-absence issue much closer to home, in Scotland, Wales and Northern Ireland, are much more advanced than those in England. In part, this stems from their appreciation that health is a work outcome.

2020health’s latest report ‘Work as a Health Outcome in the Devolved Nations’ looks at how employers in Scotland, Wales and Northern Ireland are being proactive in supporting employees, including those directly employed in the NHS.

Both Scotland and Wales have involved a range of stakeholders in the development of policies and the delivery of programmes. In 2006 the ‘Healthy Working Lives: A Plan for Action’ strategy over saw the establishment of a ‘Scottish Centre for Healthy Working Lives’. This is a national centre of expertise on health in the workplace. Services are delivered together by a directorate of NHS Health Scotland and Scotland’s 14 local health boards. An advice line for businesses is run by NHS Lanarkshire and the centre also works with enterprise agencies to promote the importance of workplace health. Moreover, its work is overseen by the National Advisory and Advocacy Group for Health Working lives, which includes representatives from enterprise agencies, the Health and Safety Executive, the Scottish Trade Union Council, health boards and academics. Engaging the most relevant stakeholders for achieving particular objectives and securing their sign up to targets ensures goals are more likely to be met.

Scotland and Wales have also both demonstrated the value of ‘hubs’ for employers and health care practitioners. Wales have set up ‘Workboost Wales’, a government funded service that provides free advice to SMEs on workplace health and safety, management of sickness absence and return-to-work issues. Firms can also request a site visit from a Public Health Wales practitioner. Bringing these different services together, and having a onestop- shop to turn to for assistance on work retention and back to work issues makes it less time-consuming and confusing for timestrapped managers and businesses.

The ‘Glasgow Works’ Bridging Service has been extremely useful for health professionals. Its aim is to change how employability services are delivered in a city where the proportion of the working age’s population claiming incapacity benefi t is higher than in any other part of the UK.

GPs and health practitioners’ time is often limited and providing them with this single point of contact makes it easier for them to direct the patient to an appropriate service.

The successful sickness management policy of the Royal College of Nursing in Wales is run by senior management and the human resources team in partnership with trade unions.

Like the Northern Ireland Social Security Agency, the RCN uses a trigger point system to identify employees who would benefit from referral to the internal occupational health programme or from adjustments to the workplace or working schedule.

For those on long-term sick leave, the RCN team maintains close contact throughout the illness, including regular reviews with line managers, the occupational health team and counsellors, and assists with eventual return to work by providing fl exibility and a phased reintegration process. Bearing in mind the diffi culty of returning to the working environment after a prolonged absence, the RCN has a programme of ‘keeping in touch days’ where recovering employees come into work for a day to meet colleagues and reacquaint themselves with the workplace, with no obligation to begin working until they are mentally and physically ready.

These tasters are particularly valuable for staff who have been absent because of stress or violence at work. The success of the RCN programme is borne out by its sickness absence rate of 2.5% per year, compared with a national average of 4.5%.

These clear national strategies have had a signifi cant impact on decreasing sickness related worklessness, and their emphasis on collaboration and integration has been key. Northern Ireland lacks an overarching policy framework, however it does have structures in place that are likely to make effective policy implementation easier, should the issue become a priority.

Notably, unlike in other home nations, health and social care services are integrated in Northern Ireland via Health and Social Care Trusts. These fall under the remit of the Department of Health, Social Services and Public Safety which deals with commissioning, resource allocation, performance management and improvement. There is obvious potential for services designed to reduce sicknessrelated worklessness to be incorporated into this structure.

How can we, in England, learn from, and implement such policies which can help tackle sickness related absence from work?

Referring back to the case of Northern Ireland, the separation of health and social care services has in the past limited the effectiveness of such services in England. However Health and Wellbeing Boards (HWBs) offer a chance to redress this. It is hoped that the inclusion of public health directors in HWBs will help GPs and local authorities understand the connections between health and worklessness, as well as the ways in which health services can assist rehabilitation and back-to-work programmes that some local authorities have already put in place.

HWBs also have the potential to break down silos and bring together stakeholders from across the health and employment fields. England can learn from the successful schemes implemented in Scotland and Wales, which draw from a wide variety of different participants. For instance, HWBs can involve health professionals in developing local and health and wellbeing strategies; inviting local employers’ representatives to sit on the HWB, and creating work and health stakeholder forums to feed into them.

They can enable third sector involvement through publicising their back-to-work programme and training and can also encourage people recovering from health problems to consider voluntary work, where paid employment is either unavailable or they are not ready to return.

Momentum to tackle sickness related worklessness is building in England. Dame Carol Black’s work on the issue has raised its profile enormously, and the current economic climate has given governments an additional incentive to support people off costly benefits and back into productive work.

It is important that this momentum continues, perhaps more so now than ever despite the negative press that has resulted from the exclusion of GP’s evidence on suitability for work in recent work capability assessments.

The Government’s response on January 17th 2013 to Dame Carol and Lord Freud’s Sickness Absence Review includes the promises to:
• Establish a health and work assessment and advisory service to make occupational health advice more readily available to employers and employees, so they can better manage sickness absence by 2014;
• Using the Employer’s Charter to provide better guidance on what employers can do to manage sickness absence and;
• To do more to improve healthcare professionals’ knowledge and awareness of the benefit system and evidence on health and work.

The more thought given to staff support now, the more likely they will have the resilience to survive the tumult and to deliver the integrated system that is now being demanded.

The economic circumstances, the reorganisation of the NHS, the necessary integration of care roles ahead and the needs of an ageing population all mean that staff wellbeing has to rise up the priority list for employers. The NHS should lead the way.

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