unum aylward's 'vision' at medicolegal course
DESCRIPTION
Sickness and Incapacity are largely social not medical problems____Moving: Medical model to an integrated bio-psycho-social approach___Bio-psycho-social factors mayaggravate and perpetuate disability___They may also act as obstacles to recovery & barriers to return to work____Sickness and incapacity are social rather than medical problems____Women take more sickness absence than men_____Shift beliefs and behaviour using CBT (talking therapies)____More and better health care is not the answer_____The vision - Changing the world____Professor Mansel AylwardTRANSCRIPT
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Strategies to encourage people to return to work.
Professor Mansel Aylward CB MD FFOM FRCPDirector, UnumProvident Centre for Psychosocial
and Disability Research, Cardiff University
&
Chair, Wales Centre for Health
www.cf.ac.uk/psych/cpdr/index.html
Manchester Medicolegal Course in Occupational Health 8th February, 2006
Health, Work and Well-being: supporting workers and Occupational Health Physicians
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Challenges for Occupational Health: Promoting a Life in Work1. Work and Worklessness
2. Illness, Disability and (in)Capacity for Work
3. Illness behaviour
4. Obstacles to recovery: barriers to (return to) work
5. Absence – the burden on business and society
6. Support into Work
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Developing successful strategies: some key elements
• Unbundling: Sickness, Disability, Work and Health
• Recognition: Sickness and Incapacity are largely social not medical problems
• Moving: Medical model to an integrated bio-psycho-social approach
• Shifting: Attitudes to health and work (culture change)• Adapting: New concepts for intervention and
rehabilitation
• Integrating: Getting all stakeholders on side
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Work :
• Benefits:
Symptom managementRecovery and RehabilitationSelf-esteem and ConfidenceSocial identity and rolePromoting activities and participationSocial inclusions and functioningQuality of Life
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Worklessness:
• Risks and Harm:
Loss of fitness
Physical and mental determination
Psychological distress and depression
Loss of work-related habits
Increased suicide and mortality
Social exclusion
Poverty
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Long-term worklessness is one of the greatest known risks to public health
• Health Risk = smoking 10 packs of cigarettes per day (Ross 1995)
• Suicide in young men > 6 months out of work is increased 40 x (Wessely, 2004)
• Suicide rate in general increased 6x in longer-term worklessness (Bartley et al, 2005)
• Health risk and life expectancy greater than many “killer diseases” (Waddell & Aylward, 2005)
• Greater risk than most dangerous jobs (construction/North Sea)
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Sickness and disability among main threats to full and happy life;
Work incapacity most significant impact on individual, the family, economy and society.
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Unbundling illness, sickness, disability and (in)capacity for work
• Disease: objective, medically diagnosed, pathology• Illness: subjective feeling of being unwell• Sickness: social status accorded to the ill person by
society• Disability: limitation of activities/ restriction of participation• Impairment: demonstrable deviation / loss of structure of
function• Incapacity: inability to work associated with sickness or
disability
**The terms are not synonymous: there is no linear causal chain.
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Mental Impairment: Challenges in Understanding and Assessment:
• The subjective nature: symptoms, limitations, clinical assessment and diagnosis
• Self-reported symptoms assuming underlying psychiatric impairment (tautology)
• Mental impairment = specifically and solely abnormalities of mental function demonstrated, assessed and evaluated by objective observer (Mendelson 2004)
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Mental Impairment: Challenges in Understanding and Assessment:
• Importance of distinguishing mental impairments from subjective descriptions of symptoms / limitations
• Clinical Guidelines to the Rating of Psychiatric Impairment (Epstein et al 1998) (Intelligence, Thinking, Perception, Judgement, Mood, Behaviour)
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The need to ‘unbundle’ Sickness, Disability & Incapacity
Working
Economically Inactive
Illness
Disability
Limited Correlations:
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Prevalence of subjective health complaints in the last 30 days in Nordic adults (after, Eriksen et al, 1998)
Any complaints Substantial complaints
Men Women Men Women
Tiredness 46% 56% 17% 26%
Worry 38% 39% 13% 15%
Depressed 22% 28% 5% 10%
Headache 37% 51% 4% 9%
Neck pain 27% 41% 9% 17%
Arm/shoulder pain 28% 38% 12% 17%
Low back pain 32% 37% 13% 16%
>50% reported two or more symptoms
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Three year incidence (%) of symptoms in general practice(Total and with organic cause) (Kroenke & Mangelsdorff 1989)
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Edinburgh Neurology Study
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IB Recipients - Diagnoses
Incapacity-related benefit recipients by diagnosis group, November 2003
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UK Incapacity Benefit
• ‘Severe Medical Conditions’ <25%
• ‘Common Health Problems’
- Mental health problems 44%
- Musculoskeletal conditions 25%
- Cardio-respiratory conditions 10%
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Common health problems
• ‘Subjective health complaints’ (Ursin 1997)– symptoms - self-reported
• ‘Unexplained medical symptoms’ (Page & Wessley 2003)
– limited objective evidence of disease, damage or impairment
• ‘Regional [pain] disorders’ (Hadler 2001)– defining feature is regional symptoms (low back, upper
limb, neck etc)
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Common health problems
Less severe mental health, musculoskeletal and cardio-respiratory conditions
Limited objective evidence of disease
Largely subjective complaints
Often associated psychosocial issues
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Illness Behaviour: What ill people say and do that express and communicate their feelings of being unwell
• Not solely dependent on the underlying health condition (the limited correlation)
• People with similar illnesses may or may not be incapacitated (Nordic adults)
• Roles of attitudes and beliefs, emotions and coping, motivation and effort
• The social context and culture
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Long-term incapacity is not inevitable
• High prevalence in normal population
• Most acute episodes settle quickly; most people remain at work or return to work
• There is no permanent impairment
• Only about 1% go on to long-term incapacity
• Essentially people with manageable health problems, given the right opportunities, support & encouragement.
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Why do some people not recover as expected?
SOCIAL
PSYCHO-
BIO-
• Bio-psycho-social factors may aggravate and perpetuate disability
• They may also act as obstacles to recovery &barriers to return to work
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Traditional Concept of Rehabilitation
• Secondary intervention - after health care - separate from health care
• Address permanent impairment
• Restore function (within limitations)
• Job placement
• Essentially a ‘medical’ intervention on person
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Limitations of the Biomedical Model for Common Health Problems
• Limited evidence of objective pathology or permanent impairment
• Limited correlation physical impairment / disability / incapacity for work
• Fails to address psychosocial issues
• Treatment ineffective for vocational outcomes
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Biopsychosocial Model
SOCIAL CultureSocial interactions
The sick role
PSYCHO-Illness behaviour
Beliefs, coping strategiesEmotions, distress
BIO- Neurophysiology Physiological dysfunction
(Tissue damage?)
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Strengths of BPS Model
• Provides a framework for disability and rehabilitation
• Places health condition/disability in personal/social context
• Allows for interactions between person and environment
• Addresses personal/psychological issues.• Applicable to wide range of health problems
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Management of common health problems must address
obstacles to recoveryand barriers to (return to) work
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Components of disability
Barriers to RTW Rehabilitation interventions
Health- related Health conditionCapy –v- demands
Clinical management Occupational management
Personal Psychosocial aspects of work
Change perceptions, beliefs, behaviour
Social OrganisationalAttitudinal
Modified workSystems, attitudes
Interactions
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• Rehabilitation cannot be a second stage after health care has failed.
• Principles of rehabilitation must be integrated into:- clinical management- occupational management
General Principles
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Symptomatic relief AND restoration of function
‘Every health professional who treats common health problems should be interested in rehabilitation and occupational outcomes.’
Health care for common health problems
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Occupational management
• Common health problems are not a matter for health care alone.
• They are equally a matter of ‘occupational health’
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Timing
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Personal / psychological change
• Individual motivation and effort
• Building capacity
• Shift perceptions, attitudes & beliefs
• Change behaviour
• Improve function
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Culture
The collective attitudes, beliefs and behaviour that characterise a particular social group over time
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Whither Health Care?
• The visit to a health professional– beware iatrogenesis:
• what is said can undo what is done• More and better health care is not the answer• Health care needs to work to a new integrated
paradigm:– work with employer and worker– use fit notes instead of sick notes!
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Sickness and incapacity are social rather than medical problems
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Shifting Attitudes to Health & Work
Current: Shift to:
Work is a ‘risk’ and (potentially) harmful to physical and mental health.
Work is generally good for physical and mental health
therefore and
Sickness absence/certification ‘protects’ the worker/patient from work
Recognise the risks and harm of long term worklessness
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Health at Work:
• The key idea is that work is healthy• The workplace = environment for promoting
health; controlling ill health• Anti-discrimination policy• Health and Safety• Occupational health / VR• Absence Management• A public health issue
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PUBLIC SECTOR ABSENCE:
• Comparative surveys: average recorded absence in public sector higher than private sector
• Comparing like with like?– similar operations show no higher absence in
public sector (ie. Call Centres)– public/civil service=broadly typical of large private
firms.– In all countries absence in health service is high– Public sector absence = same kind of variation
as private sector
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Disaggregating Absence
• More pronounced among junior grades• Women take more sickness absence than men• Older men average more sickness absence (?
health related)• Civil Service
– higher SA in front-line services– related to numbers of junior staff.
• Public Sector Long-term SA rates but lower self-certified SA
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Ministerial Task Force and Report on Managing Sickness Absence
• Managing SA is not “rocket science”• TF concluded 3 fundamental systems
– 1. Boards and Senior Management:• a principal function• install strategies• progress report (efficiency reviews/performance
partnerships)– 2. MIS
• timely data, monitor absence, take action• HR to ensure procedures adhered to
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TF’s Recommendations:(fundamental systems)
– 3. HR management systems
• managers to receive training in systems and skills
• case management referral and RTW discussions
• integration of absence and performance management (a key lesson from successful private sector practice)
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TF Recommendations:
SHORT TERM ABSENCE
checks for persistent short term absences• involving OH for absence above certain number of
days in 12 month period • daily phone calls/unexpected short term sickness• Monday/Friday checks• Challenge more than 5 days absence• Flexibility around “special leave” – work/life
balance
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TF Recommendations:
LONG TERM ABSENCE:
• Collate and analyse literature on sickness causes:– job design– ergonomics– flexibility to personal/motivational problems
• Explore non-GP OH services• Intensive study of LTA (“less than full pay”) cases
– RTW potential– contract termination
• HSE in partnership with public sector on ill-health prevention.
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So What? Lessons Learned:
• Productivity and Non-attendance (presenteeism, turnover, low morale) are symptoms of wider organisational problems.
• Treating symptoms and not the underlying causes won’t improve quality of working life or business performance
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Climate:
• Moderated by leadership, culture, work organisation, openness, communication, etc
• Line Managers key – the prism through whom climate is perceived by employees.
• Promote Climate where people allowed to be well.
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Keys to health and productivity:
– Good data, trend analysis & monitoring
– Role clarity (line, HR, Occ Health, employees)
– Differentiate: presenteeism, short-term & long term absence
– Intervene early/proactive rehabilitation
– Promote the healthy workplace
– Positive job design & good line management
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UK Government “Pathways to Work” Initiative
• Return to Work Payment
£40-120 per week
• Mandatory Work-Focused Interviews (Case Managers)
• New Condition-Management Programmes:
(focus: m/s, Mental Health; Cardiorespiratory)
- helping people to understand and manage their condition
- using CBT and related interventions
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Principles of Condition Management:
• Voluntary option routed through the PA (Case Managers)
• Cognitive/educational interventions common to all conditions
• Evidence based• Tailored to individual needs – biopsychosocial
approach• Case-managed by CMP in close liaison with PA
• Goals “owned”; not imposed.
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Contents of CM Programmes
• Cognitive/Educational interventions• Understanding and Managing
• Pain management• Confidence building• General health advice• Individual and group sessions
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Pathways to Work pilots
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Pathways to Work pilots
• 6-800 new job entries / month in Pathways areas
• On a national basis, that would be equivalent to helping 100,000 IB recipients into work each year.
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Successful Strategies:
Practical Elements of Condition Management
• Address the main health conditions
• Clear work focus, vocational goals, outcome measures
• Address biological, psychosocial and social components
• Address individual’s obstacles to RTW
• Increase activity and restore function
• Shift beliefs and behaviour using CBT (talking therapies)
• Working partnership with Personal Advisors
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Condition Management – Successful Strategies:• Make sense of your condition
• Overcome stress and anxiety
• Learn to be assertive
• Promote emotional / physical wellbeing
• Living with fatigue
• Living with pain
49% patients have primary and further 39% secondary mental illness diagnosis
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GOVERNMENT GREEN PAPER:A new deal for Welfare: Empowering people to work
• Aspiration – Employment rate = 80% working population
• Reduce – By 1 million the number on IB
– Numbers leaving work place due to illness
• New – Employment and Support Allowance
Allowing payments to most severely disabled people
• Transforming the PCA (focus on mental health)• Conditionality: Work Related Interviews and Action
Plans
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A new deal for welfare: Empowering people to work
• Supporting GPs
• Improving access to good-quality Occupational Health Support
• Facilitate better absence management
• Pathways to Work – extending provision across country by 2008
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The Scientific and Conceptual Basis of Incapacity Benefits
Gordon Waddell and Mansel Aylward
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The vision - Changing the world
Changing the culture – of health, sickness, disability, incapacity and work.
• General public / society• Workers• Health Professionals• Employers• Government
Not just a matter of economics and business efficiency it is about health at work and fulfilling potential.
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Professor Mansel Aylward CB
Contact:
Email: [email protected]
Website: http://www.cf.ac.uk/psych/cpdr/index.html
http://www.wch.wales.nhs.uk