health works: supporting health in the working age
DESCRIPTION
Hear about the innovative practice being developed in Scotland to allow people rapid access to case managed support to help them back to work, using a person‐centred, biopsychosocial model.TRANSCRIPT
Health Works
Supporting Health In
Working Age
Setting the Scene
Roddy DuncanScottish Government
Approx 2.5 million people in Scotland of working age
>70% in employment
Cost of ill-health approx. £10 billion p.a. to economy
Approx 250,000 on incapacity benefit/ESA
1 in 6 working people have poor mental health
Some Numbers:
Meets important biopsychosocial needs
Sound evidence base
Most people capable of undertaking some type of work
Most people with health conditions want to work
Poor work/working conditions can affect health
Poor health can limit ability to work
Work1 is good for health:
1. By work we mean, more generally, any activity that give purpose to life. This could be paid work, volunteering or caring duties, for example.
Health Works – a patient centred approach to healthcare
Needs a change in culture – work outcomes for patients
Efficient and effective – opportunity to avoid over-medicalisation: biopsychosocial approach
Importance of working in partnership – focus on successful outcomes for patients
Quality Strategy:
For Patients – faster, direct access to treatment; positive advice and support; faster, fuller recovery; keep job and earnings; sustained independence.
For Health Boards – efficient use of resources; reduced waiting times; reduced prescription costs; reduced inappropriate diagnostics; reduced repeat visits.
For Scotland – reduced sickness absence; improved productivity; reduced demand on public services; increased workforce participation; increase in people managing own health.
Benefits:
Some examples of activity in Scotland that is translating the ambitions of Health Works into practical examples of patient-centred, effective and innovative healthcare services.
Putting it into practice:
The National Musculoskeletal (MSK) Programme
Dr Sarah L Mitchell
National MSK Re-design – Part of Health Works
Focus on local services redesigning their MSK pathway around patients
Focus on employment, the ‘Scottish Offer’
Focus on developing a national point of access to local MSK services
Focus on developing interdisciplinary teams delivering MSK
Why are we re-designing our MSK services?
People in Scotland with MSK conditionscurrently experience…..
Variable access to MSK services Variable managementVariable measurement of outcomesNo formal assistance with helping people back to work or into work
And sometimes…long waits for these variable services
………………we could do so much better.
Impact of MSK conditions
MSK – most commonly reported type of work related illness and take up more than 30% of all GP consultations.
Prescription costs for MSK
Result in loss of 12.5 million working days lostLow back pain is the most common musculoskeletal problem affecting an estimated 18 million people, with associated costs of £7bn p.a. to the economy due to working days lost.
What are we proposing?
• A National MSK Triage and Referral Management Service for NHS Scotland delivered within NHS 24
• Local referral management hubs within boards
• Direct referral into WHSS for those working in SMEs
• Development of Interdisciplinary pathways using evidencebased outcome measures
• Development of algorithms within pathway to ensure correct service provision
• Early identification of employability issues, anxiety depression scores
Evidence states that:
Approx 30% people only need advice and information
NHS 24 non clinician pathways are safeSTaRT Tool - KeeleFree up frontline resources
Rationale of Approach
Using a central referral system will...
Provide fast access to information and consistent national approach
Advice and Information Resources
Patients need information to support self management
Need for national resources that provide high quality, consistent information
NHS inform can fulfil that role:
Scottish Backs, neck, knee, shoulder sites, VideoPhysio, PhysioTools, Back in Control
….is a national service helping you to find amongst other information how to access public services and search for local
information and advice.
Access to Scottish Backs and NHS inform via digital TV
Text NHS 24 to 61061
http://lookinglocal.gov.uk/digitv/cds/nhsscotland/Netgem/home.html
MSK Service re-design – New process
Self Referral (est. 15,000 patients)
Call handler takes call (8x Band 3)
MSK Triage Form filled in by call
handler (WTE x3 on hand for
support)
Patient entered into SCI Gateway
(by Joint, Medium/High)
Review previous 24 hour referrals
into SCI Gateway.
Patient allocated appointment slot
(Band 2)
TRAK – automated letter sent to patient
(and communication sent to CRMS)
GP directed to Self Referral
number
First ContactAHP telephone
consultation and EQ5D
WHSS (est. 5%)(exit from system)
GP referral through SCI
Gateway (est. 30,000 patients
Emergency Numbers
Central Referral Management System (NHS24) HUB(based at Referral Management Centre - TBC)
Low – routed self-management(exit from system)
MSK Service re-design – New process
First ContactAHP telephone
consultation and EQ5D
HUBFirst Contact
Physio assessment(EQ5D and
outcome measures)
First ContactPodiatry
assessment(EQ5D and
outcome measures)
First ContactOT assessment
(EQ5D and outcome
measures)
Self Management and exit from
systemEmployability Services
Available Services
TRAK – automated
letter sent to patient (and
communication sent to CRMS)
TRAK / CESInfo. dump
A&E
Leisure
Older People
Services
Mental Health
Vocational Services
Rheumatology
Community Pharmacy
Pain Services
Dietics
Ortho
2nd AHP Appointment (intervention)
NHS24
Phone Consultation (1st appointment)
Direct appointments made at hub
LBP pathway
30%8,250
‘NHS Lanarkshire Referral Hub’ up to 27,500 clients
Require MSK services
WHSS1-2%
Approx 260-575
SME + AbsentAny joint
Self management•Self mgmt advice•Community programmes•Web support – NHS inform12,000 clients
All pathways will include ability to refer into the following services at any point in pathway even after first appointment / telephone consultation:•Pain Services– 8%, 1,100•Mental Health Support – including breathing space, case management, mental health teams – 10%, 1,375•Employability support – 10%, 1,375•Self management – including community leisure programmes and third sector programmes – 10%, 1,375•Rheumatology services – trigger questions agreed. – 1% 137
All pathways will include ability to refer into the following services at any point in pathway even after first appointment / telephone consultation:•Pain Services– 8%, 1,100•Mental Health Support – including breathing space, case management, mental health teams – 10%, 1,375•Employability support – 10%, 1,375•Self management – including community leisure programmes and third sector programmes – 10%, 1,375•Rheumatology services – trigger questions agreed. – 1% 137
Knee pathway
20%5,500
Neck pathway
10%2,750
Shoulder pathway
15%3,575
Hand pathway
5%1,375
Hip pathway
5%1,375
Foot and ankle
pathway15%3,575
Referrals made directly into hub from GP services and other hospital services i.e. A&E, orthopaedics
Referrals made directly into hub from GP services and other hospital services i.e. A&E, orthopaedics
Key Performance indicators to include:
# referrals into secondary care
# GP MSK consultations
Improved patient experience
Physio (MSK) demand
Mental Health referral
# referrals into employability services
Reduction in prescription charges
Reduction in investigations
Functional improvement outcomes
DNA rate
Baseline Activity Carried out in NHS Lanarkshire
Measurement of outcomes on all patients attending physiotherapy for 1 month – using EQ5D
Measurement of the HADS score on a selection of patients attending physiotherapy.
Measurement of patient experience
EQ5D Analysis – JOINT
EQ5D Analysis – Employability Status
EQ5D Analysis – Employed Population Hours Worked %
EQ5D Analysis – Unemployed Anxiety/Depression Scores
EQ5D Analysis – Low Back Pain
Develop national Advice and Triage service during 2011
Enhance current out of hours protocols during 2011
Systems piloted in Lanarkshire and Lothian from autumn 2011
System evaluation – Spring 2012
Report consideration and national roll out
Resource pack and support
When will all this happen?
Equitable access for MSK patients to appropriate
management options
Consistent, high quality information and advice
developed and adopted across NHSScotland
Enhanced user experience
A true health/employability pathway
££££ savings??
Proposed Major Deliverables of Pathway
NHS Quality in Action
Scotland’s Bio-Psychosocial Service:National Fit For Work Service
Mark KennedySalus Occupational Health
NHS & Economic Growth
• Supporting Healthy Workforce• Reducing Absence• Ensuring those wishing to work are able to
work• Increasing Resilience
Salus – Bio-Psychosocial Model
• Case Management Service…– Supporting employability agencies across
40% of the UK– Central to the National Fit for Work
Programme – Working Health Services Scotland (WHSS)
– Core of NHS Lanarkshire’s Attendance Management service
Principles of BPS Model• Person Centric
– Engages patient (& family) in multiple ways• Medical (conditions/disease)
• Attitudinal (behavioural, victim syndrome, addictions)
• Social (Relationships, housing, debt etc)
• Single Case Manager• Assesses (validated clinical tools – pre &post intervention)
and co-ordinates all aspects of care
• Single point of contact and solution focused
• Motivates/advocates and maintains direction
• Early Intervention
• Telephone based• Delivered by both clinicians and non clinicians• Web based dataset (paperless)• Has a framework of supportive
agencies/interventions (physiotherapy, counselling, debt advisors, employment advisors etc..)
• Highly Efficient • CM caseload = 200-250 patients per annum• 9% DNA• Appointed within 2 days• Longest wait for intervention = 5 -7 days
Working Health Services Scotland
• Scot Gov & DWP funded
• Support to individuals employed within SMEs
• Eligible - Those sickness absent or at risk of sickness absence
• Central Hub supported by 14 regional Health Boards
WHSS - Results
No. of Referrals by Month
0
50
100
150
200
250
300
350
Month
No
. o
f R
efe
rrals
Heard about Service No of Referrals Received No of Referrals Engaged GP 1136 1098 Employer 58 55 Self Referral 616 614 Other 703 667
Total 2513 2434
28% of individuals were absent on engagement – 62% at risk of absence
78% present with MSK problem, 15% mental health, 2% Cardio-vascular (5% other)
Salary Scales
403
986
705
49 20 3
268
0
200
400
600
800
1000
1200
<£10k £10-20k £21-40k £41-60k £61-100k >£100k Unknown
Tackling Inequalities
EQ5D Deterioration Same Improvement McNemarMobility 28 ( 3%) 619 (64%) 323 (33%) p<0.001Self Care 24 ( 2%) 711 (75%) 232 (24%) p<0.001Usual Activity 23 ( 2%) 357 (37%) 589 (61%) p<0.001Pain 15 ( 2%) 378 (39%) 577 (59%) p<0.001Anxiety 23 ( 2%) 586 (61%) 359 (37%) p<0.001
VAS 94 ( 10%) 81 ( 8%) 786 (82%)
COPM"Clinically Significant" Deterioration Same
"Clinically Significant" Improvement
Performance 9 ( 1%) 244 (27%) 645 (72%)Satisfaction 5 ( 1%) 174 (19%) 719 (80%)
GHQ12 Pre (mean) Post (mean) Paired t-testLikert 16.9 8 p<0.001
Deterioration Same Improvement McNemarBimodal 6 ( 1%) 218 (44%) 273 (55%) p<0.001
Able to Job 6 Months Time
1153
41
285
0
200
400
600
800
1000
1200
1400
Yes No Unknown
• From a sample of 450 records:– 98% of clients reported that the service has had a
positive impact on their current work situation– 99% of clients would recommend the service to
others– 100% of clients rated their experience of case
management as excellent (86%) or good (14%)– 100% of clients stated that the support they
received was excellent (89%) or good (11%)
NHS Lanarkshire – Attendance Management
• Traditional model =– 1 week Self Certificate– At 28 days of absence- “long term” – refer to
Occupational health– Further 5-10 days to appoint – Total approx 38 days absence – circa 8 working
weeks
• Salus NHSL Model– Early intervention
• Absentee called at home on day 1,3 & 10
• Referred to Occupational Health at day 11
• Nurse led from day 11
• Case Manager appointed to complex cases
• Frequent case conferences with HR
NHS Lanarkshire – Attendance Management
NHS Lanarkshire and NHS Scotland excluding NHS Lanarkshire: SA Rates before and after the introduction of EASY (SWISS)
3.74%
6.84%
3.00%
4.00%
5.00%
6.00%
7.00%
May
June
July
Aug
Sep Oct
Nov
Dec Jan
Feb
Mar
Apr
May
June
July
Aug
Sep Oct
Nov
Dec Jan
Feb
Mar
Apr
May
June
July
Aug
Sep Oct
Nov
Dec Jan
Feb
Mar
Apr
May
June
July
Aug
Sep
2007 2008 2009 2010
Quality Ambition• Most appropriate treatments, interventions, support and
services will be provided at the right time – wasteful variation will be eradicated.
• Incorporates Innovation (tele & web)• Partnership (14 HBs and many public, private and 3rd
sector support agencies)• Person Centric- patient at core of all decisions• Measurable • Inexpensive
Vocational Rehabilitation is everybody’s business
(DVD)
Judy GibsonScottish Government
Wider Context and Conclusions
Roddy Duncan
Christie Commission – Efficiency and Effectiveness; customer-led
Welfare Reform – reduce barriers to work?
Fit Note – Encourage doctors to discuss return to work
Employers – Create positive, supportive workplaces
Wider context:
Work is a key social determinant of health
People do not need to be fully “fit” to be in work
Return to work can be part of the recovery process
All healthcare professionals have a role to play
Need to learn from current good/innovative practice
Conclusions:
Find out who your Board’s lead for Health Works is.
Find out more about current health and work initiatives.
Discuss within your Board how you can adopt and
introduce patient-centred, work-outcomes focussed,
care pathways.
Practitioners – consider work status in routine practice
Speak to those who are already doing it
What you should do:
Q&A
Links and further reading:Scottish Government Health and Work Web Pages:http://www.scotland.gov.uk/Topics/Health/workingage-1
UK Government Health Work and Wellbeing Strategyhttp://www.dwp.gov.uk/health-work-and-well-being/
Scottish Centre for Healthy Working Liveshttp://www.healthyworkinglives.com/
DWP Guidance on Fitnotehttp://dwp.gov.uk/healthcare-professional/news/statement-of-fitness-for-work.shtml
Healthcare Professionals Consensus Statement:http://www.dwp.gov.uk/docs/hwwb-healthcare-professionals-consensus-statement-04-03-2008.pdf
Health & Work Continuum
In workOut of
work – on benefits
IncapacitatedSafe & Healthy
At risk of losing work
Ill/InjuredShort-term absence long-term absence
£ ££££
Cost to society