The Leicestershire Fit for Work service (FFWS) is on of six DWP funded pilots in the UK that aim to reduce long term sickness absence by providing case managed early intervention that overcome the barriers to a successful return to work for employed people receiving fit notes.
The Leicestershire service is run by The Fit for Work Team, (FFWT) a 'not for profit' GP led Social Enterprise and subject to independent evaluation by the Institute of Employment Studies.
Data from 948 referrals to the Leicestershire The Fit for Work Team reveal that while 61% of referrals are for people with mental health problems, only 5% of people who have returned to work cite mental health therapy as the most important intervention. 71 % report that more practical and human interventions at the workplace are the most important intervention.
Aims and objectives
Our focus is specifically on GP referrals:
- Provide a service that GPs can access easily when signing fit notes for problems that could be categorised as long term sickness absence or at risk of such absence.
- Develop a case managed service by putting together a multidisciplinary 'core team' of non-clinical case managers, with good interpersonal and communication skills, supported by an occupational health nurse and a part time GP.
- One-to-one consultation to identify specific barriers to a return to work within a week of referral and agree an action plan with the worker and their employer to overcome these barriers.
This team to work together to provide co-ordinated assessment with one to one flexible and personalised support.
- Develop a working relationship with a network of support services such as musculoskeletal therapies, psychological therapy, debt / legal / housing advice, drug and alcohol support.
- De-medicalise the client journey where necessary and target interventions at the 'human issues' that underlie so many episodes of sickness absence.
- Access appropriate interventions quickly to reduce the risk of long term absence and monitor progress throughout these interventions.
- Support the absent worker until a return to work or an alternative outcome is clear and aim for this outcome to be a return to the workplace for 75% of referrals.
- Improve knowledge in primary care around the management of sickness absence by communicating with GPs about each referral.
- Specifically ask referred clients and Case Manager to comment on the barriers and interventions that made the return to work possible or outline the reasons where intervention was unsuccessful.
- Achieve commitment from Leicester City and Leicestershire County GP's to refer into the service and to allow us to take responsibility to sign and manage their patients 'Fit notes'.
Reasons for implementing your project
Data from DWP and employers organisations in 2011 revealed the most common cause of long term (> 6weeks) sickness absence in the UK is now 'stress'.
"The medical sickness certificate is one of the most powerful and potentially dangerous treatments in the GP armamentarium". These are the words of Professor Waddell when introducing the evidence review, Is Work Good for Your Health and Well-being'. This statement reflects the growing consensus that any national approach to reducing sickness absence levels needs to engage with mainstream primary care.
'Vocational Rehabilitation: What Works, for Whom, and When' is a systematic review of 450 scientific reviews and reports. The findings support the principle of a co-ordinated return to work plan, the importance of identifying people at risk of long term sickness absence from primary care and de-medicalising the reasons for absence. The split between mainstream primary care and vocational rehabilitation is well recognised but hitherto, has never been addressed in a systematic way. Our Fit for Work Service pilot was designed to bring these worlds closer together. Analysis of the Leicestershire Joint Strategic Needs Assessments in 2010 revealed that while the number of people moving off Incapacity Benefits was increasing, the flow of people onto such benefits was also increasing, particularly for mental health disorders.
NICE PH19 provides a framework for managing long term sickness absence. The conventional approach in primary care and by employers (with access to employee assistance schemes) towards people off work with common mental health problems is usually to arrange counseling or other talking therapies as the default intervention to facilitate a return to work. There is emerging evidence that alternative solutions may be better targeted to the rising number of people off work with stress and other common mental health problems
How did you implement the project
At discharge from the service, we record a variety of data that includes a reflection by the person referred and the Case Manager who has coordinated their journey through our interventions.
Each is asked to record the 'most important intervention that has helped them return to work from a list of options. The client records this in an anonymised questionnaire that is received and sent by post via the admin team not the Case Manager.
1). Musculoskeletal treatment (physiotherapy, chiropractor, osteopathy etc)
2). Mental Health therapy (counselling or talking therapy such as CBT)
3). Mediation/Negotiation with employer
4). Learning or new skills
5). Debt/Legal/Housing or other problem with personal life
6). Personal support/confidence building from FFWS
7). Help with leaving job/new employment
8). Better treatment or understanding of my pain.
The results are recorded and compared.
The data from 325 clients discharged up to October 2011 reveal that 61% of referrals were for mental health problems and 27% for musculoskeletal (msk) problems. The 'most important intervention that has helped them return to work was reported by Intervention as -MSK treatment (Client: 24% Case Manager: 15%) -Mental health therapy (Client: 5% Case Manager: 1%) -Mediation/negotiation (Client: 19% Case Manager: 21%) -Learning/new skills (Client: 5% Case Manager: 1%) -Debt/legal/housing/personal (Client: 5% Case Manager: 2%) -Support/confidence building (Client: 24% Case Manager: 52%) -Help to leave job/new work (Client: 10% Case Manager: 2%) -Better treatment/ -understanding of my pain (Client: 10% Case Manager: 6%) While Case Managers and clients disagree on the detail, both would seem to suggest that 'human interventions' (support, mediation, help with alternative employment) are far more important than mental health therapy.
Key learning points
While 61% of referrals to our service are for people with mental health problems, only 7% of people who have returned to work cite mental health therapy as the most important intervention.
Human interventions (support, mediation, help with alternative employment) are reported as being more important. The feedback suggests that a bespoke case managed return to work service can provide success to people off work with stress and other common mental health problems. Conflict resolution and personalised support are the key interventions towards a successful outcome.
The data reveals that Case Managers, with no medical or formal mental health training also recognise that the unmet needs of these clients were human rather than therapeutic. The pilot supports the notion that de-medicalising long term sickness absence is appropriate for the majority of people receiving fit notes for > 6 weeks and supports the proposal in the recent 'Sickness Absence Review' commissioned by the DWP that an independent advisory service to assess sickness absence at 4 weeks would be more appropriate than the health intervention routes typically chosen by GPs and employers to date.