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Review urges a new approach to help patients stay in work

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An independent review argues that healthcare professionals need to look at adapting the advice they give regarding work and ill health. Nerys Hairon takes a closer look

  • This article has been double-blind peer reviewed
  • Figures and tables can be seen in the attached print-friendly PDF file of the complete article found under “related files”

An independent review by the government’s national director for health and work, Dame Carol Black, has recommended a fundamental overhaul of the support given to people who are off work through ill health (Black, 2008).

The review of the health of Britain’s working-age population estimates that sickness absence and worklessness – defined as a state that includes not being in paid employment and not actively seeking work – related to ill health costs the economy over £100bn a year. It advises that government and healthcare professionals should adopt a new approach to health and work, focusing on fitness to work.

Commissioned in 2007 by the secretaries of state for health, and work and pensions, the review makes 10 key recommendations. Those most relevant to nurses are summarised in the box (see p20).

Key findings

Although life expectancy and the numbers of people in work are higher than ever, some 175 million working days were lost to illness in 2006. The review says that while the employment rate of those with a health condition is increasing, around 7% are still on incapacity benefits and an additional 3% are off work sick at any one time.

Common mental health problems and musculoskeletal disorders are the major causes of sickness absence and worklessness due to ill health. The problem is compounded by a lack of timely diagnosis and intervention.

The review says the estimated annual £100bn cost of sickness absence and worklessness associated with working-age ill health is greater than the current annual budget for the NHS and equivalent to the entire GDP of Portugal.

It argues there is a compelling case to take decisive action to improve the health and well-being of the working-age population. Although recent evidence suggests that work can be good for health, much of the current approach reflects an assumption that illness is incompatible with being in work. The review outlines a new vision with three main aims:

  • Prevention of illness and promotion of health and well-being;

  • Early intervention for those who develop a health condition;

  • An improvement in the health of those out of work, so everyone with the potential to work has support to do so.

Changing perceptions

The review calls for a change in the widespread perception around fitness for work – namely, that it is inappropriate for people to be at work unless they are 100% fit and that being at work generally impedes recovery. It says tackling stigma around ill health and disability will be key to enabling more people with health conditions to find – and stay in – work.

Healthcare professionals have an important role in implementing the review’s recommendations as they can provide much of the support people need to stay in or return to work. Their advice is often crucial in influencing patients’ beliefs about their ability to work and the courses of action available to them.

Despite the importance of work in maintaining health, until recently, many GPs and other healthcare professionals have not seen it as their role to offer advice in this area. The report says they are often concerned that work could be bad for health or that an early return to work could exacerbate a medical condition.

The report also identifies a wider lack of understanding about the impact of work on patient health and practitioners’ roles in helping patients to stay in or return to work. In spite of a growing evidence base on the relationship between health and work, these issues have not been incorporated into training for healthcare professionals. The result is that, despite their best intentions, the advice practitioners give to patients can be naturally cautious and may not be in patients’ best interests in the long term.

Healthcare profession leaders, including the RCN, have shown their commitment to promoting the link between good work and good health by signing a consensus statement on health and work (see Described by the review as a significant step forward, this statement recognises that supporting patients in remaining in or returning to work should be part of practitioners’ clinical function. The review states that healthcare professionals, supported by government, must take responsibility for helping to translate this pledge into reality.

A key recommendation is replacement of the current paper-based sick note with an electronic ‘fit note’ to support practitioners in providing fitness-for-work advice. This new system would switch the focus to what people with ill health can do instead of what they cannot.

Early intervention

Emerging evidence suggests that, for many people, early interventions help to prevent short-term sickness absence from progressing to long-term absence and, ultimately, worklessness. The review proposes a new ‘fit for work’ service, based on a case-managed, multidisciplinary approach, to provide treatment, advice and guidance for people in the early stages of sickness absence. The service would refer people to a wide range of services, including physiotherapy and psychological therapies, as well as to support services for financial and housing issues. The review says there is a strong case for the NHS being involved in the provision of these work-related health interventions.

Pilots of the ‘fit for work’ service should test various models of service delivery, and be followed by comprehensive evaluation. If they are found to be effective, the services should be rolled out to ensure that access to work-related support is available to everyone. When appropriate models are established, access to the service should also be open to those on incapacity and other out-of-work benefits. The review says that the number of people on incapacity benefits represents a historical failure to offer healthcare and employment support for those considered ‘workless’.

Mental health

Although it has been successful overall, the report says the Pathways to Work scheme has had limited effect for those whose main health condition is a mental health problem. In addition, over 200,000 people with mental health conditions move on to incapacity benefits each year – a figure that has not changed over the last decade. The government must therefore fully integrate the option of specialist mental health provision into its employment support programmes for all people who are workless.

In the area of early intervention, much of the research has focused on back pain but similar evidence is needed for those with other conditions, especially mental ill health. The recent expansion of psychological therapies in England will provide further evidence on the efficacy of interventions for common mental health conditions. Evidence of their potential impact on clients’ recovery is emerging from demonstration sites in Doncaster and Newham. This shows that such interventions can improve their ability to work.

The Department of Health recently revealed plans for a scheme to train an extra 3,600 psychological therapists (DH, 2008). Over the next three years, this should mean 25,000 fewer people with mental health problems are on sick pay and benefits.


Delivering the recommended change in approach will depend on healthcare professionals having the skills, evidence base and organisational structures to meet current and future needs.

Developing an integrated approach to improve the health of the working-age population means occupational health must be brought into mainstream healthcare provision, and its practitioners must address a wider remit.

Recommendations relating to nurses

  • The government, healthcare professionals and others should adopt a new approach to health and work based on the foundations laid out in the review.

  • The government should launch a major drive to promote understanding of the positive relationship between health and work among employers, healthcare professionals and the public.

  • Building on the commitment in the consensus statement, GPs and other practitioners should be supported to adapt the advice they provide and, where appropriate, do all they can to help people enter, stay in or return to work.

  • The paper-based sick note should be replaced with an electronic ‘fit note’, switching the focus to what people can do.

  • The government should pilot a new ‘fit for work’ service, based on case-managed, multidisciplinary support for patients in the early stages of absence.

Source: Black, 2008.


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