A path back to work

Early intervention can play a key role in helping people to return to work after sickness. Heather Downey describes the story of one person helped by Nottinghamshire Fit for Work Service

Sarah had been working with her employer, a medium-sized packaging and logistics company, for seven years. During this time she had gained considerable experience and had been promoted to being team leader of a key sales administration activity.

She had, however, been struggling with stress, but had not taken any sickness absence. She also had work relationship issues with peers and her managers during this period.

Things became particularly difficult when Sarah was asked to take on a new team leader role which increased her workload considerably. She did not want the extra responsibilities but felt she had no option but to take on the role, fearful that she may otherwise lose her job. After taking it on she did identify to her employer that she was struggling with the role but felt that little was done to support her.

She did not at the time signal to her employer that she was struggling with work-related stress and anxiety. Her problems became worse and she went off sick for eight weeks and did not have access to occupational health support. At this point she came into contact with the Nottinghamshire Fit for Work Service.

Sarah’s experience is not uncommon. Many of those who struggle in the workplace are suffering from mild mental health issues such as anxiety, stress or depression. Around ten million in the UK are affected by a mental health condition at any one time, i.e. one in six people. There are also significant problems in the workplace for those with pain from musculoskeletal problems and these can also lead to prolonged sickness absence.

It has been estimated that of those on long-term sickness benefits about 40% could have been helped back into work through early intervention. Until recently however, employers, employees and even GPs were often in the dark as to what interventions were available and how best to implement them.

The subject came onto the government’s agenda as part of Working for a Healthier Tomorrow – Dame Carol Black’s 2008 review of the health of Britain’s working age population. As a direct consequence the government established a series of pilot Fit for Work Service projects around the country to explore mechanisms towards early intervention.

The pilots were established in April 2010 and seven remain in operation, including Nottinghamshire Fit for Work Service. It operates very much as a partnership, with the pilot hosted by Enable, a voluntary sector organisation, working with Nottinghamshire Healthcare NHS Trust to deliver its case management service, Support in Work.

The essence of the service is to provide free one-to-one case management through NHS therapists specialising in mental and physical health. The case manager will interview the client and agree an action plan involving various interventions to help get them back to work. The service involves signposting the client to wider support and providing ongoing help and encouragement, including mediation with employers, if required.

The Nottinghamshire pilot was developed from a model which originated in Nottingham, where the importance of the linkages between health and work had been established as a local economic development priority – both in terms of the impact of poor health on business productivity and the impact of not having a cross-health/work strategy to address high incapacity benefit claimant rates.

This strategy, championed by the local employment and skills board, aligned well with Dame Carol Black’s review and a bid was submitted for central government funding to enable an extension of the model to allow case management to support individuals back to work across Nottingham and Nottinghamshire.

During the first year of the pilot more than 800 individuals were supported. The second stage of the pilot had an increased focus on working with those off sick to get them back to work as opposed to ‘presentees’ struggling in the workplace; to engage with local GPs to refer patients into the service and to particularly focus on those employed in SMEs. Around 500 have been supported on this basis in the second year of the pilot.

In Sarah’s case she was referred to Nottinghamshire Fit for Work by the local improving access to psychological therapies (IAPT) NHS service. After an initial telephone conversation, a face to face assessment took place, the results of which were forwarded to Sarah, her GP and the referring service. The following course of action was then undertaken:

• ‘Stress at work’ assessment completed

• Anxiety management strategies used to grade and face anxieties

• Assertiveness strategies advised

• Signposted to Jobcentre Plus re benefits advice and support also given regarding pay issues at work

• Discussions and advice given around reasonable adjustments needed and possible alternative job roles

• An employer mediation meeting with the service team leader and Sarah one month prior to her return to work. This helped to educate the employer around stress issues for individuals in the workplace.

Sarah’s employer agreed to a phased return to work, returning to a less stressful sales administration role. She attended and completed a stress control group and has continued to receive one-to-one counselling. She has used the Support in Work service for four months to date and continues to receive ad hoc telephone support.

Sarah’s example is typical. About three quarters of people referred to Nottinghamshire Fit For Work Service are struggling with mental health issues and among this group the service has notable success in managing a return to work, with 44% making a return to the workplace.

Interestingly however, it is not typically clinical interventions, such as counselling, that this group consider the most important support that is provided to get them back to work. The large majority cite things like mediation/negotiation with their employers, personal interventions such as debt counselling, advice on housing or family problems, or help with new or amended employment, as being most important. Their feedback makes it abundantly clear that ‘human interventions’ are equally as important in getting back to work as medical ones.

Another significant referral group are people with chronic pain, often from musculoskeletal issues, and this is a major hurdle for them in returning to work. One-to-one case management can make a significant difference ensuring that the individuals can access the right therapies. Often time is needed to work with them on their perceptions of pain, or perhaps a dialogue is needed with their GP to consider changes in medication that might help or with their employer to agree workplace adjustments or changes in working patterns.

Many referrals come from GPs who can see enormous benefits to individuals and businesses in involving a third party to conduct one-to-one case management. The option for GPs to refer to such a service enables them to point those in their care to comprehensive case management, enabling them to access the support that they need, which goes beyond the medical diagnosis and treatment which GPs can provide.

The pilot phase of the Fit for Work services come to an end in March 2013 when decisions will be made about ongoing services in Nottinghamshire and elsewhere. The pilots are providing a great deal of information and practical experience on how early interventions provided through case managers can successfully impact on an individual’s ability to return and sustain in work. This must be of interest to policymakers and commissioners in the areas of public health, health commissioning and welfare.