Speech

Opportunities for occupational therapists

This speech was published under the 2010 to 2015 Conservative and Liberal Democrat coalition government

A speech by Lord Freud, Minister for Welfare Reform.

Before coming here today, I thought I’d do some prep and look at what we mean by occupational therapy and how the profession has developed.

This metamorphosis of occupational health over the years struck me as similar to the changes and reforms to the Welfare State.

Our reforms in welfare – in particular Universal Credit - are leading to work being the ultimate aim for people to become independent.

And reforms to bring about the introduction of the new State-funded health and work assessment and advice service will also allow more people to get back into the workplace.

I will return later to the new service.

Journey

Waddell and Burton’s paper posing the question “Is Work Good for your Health and Well-Being?” had a profound effect on welfare thinking.

It shone a light on an issue that many people had grappled with for years.

It was now clear that if work is good for you, and conversely, being out of work is likely to compound problems and further damage your health, then our whole stance needed to change.

It was doing no-one any favours to sign them off on the long-term sick.

Far from having to ‘protect’ people who were anything less than 100% fit from the rigours of the workplace, this research made clear we had to turn things on their head.

Work had to become the desirable state – the central presumption had to become that unless there are really good reasons to the contrary, people should remain at work if they possibly can. And get back to work as soon as they are able.

The old welfare system had elements that in many respects seemed to be stuck in the past – in particular its approach to people with sickness or disability.

Emerging new research combined with new approaches showed there was another, more effective route.

That’s how we came to realise that the old system was actively harmful to the very people it was supposed to help.

And that’s why we are seeing a transformation in the way government, and society more widely, looks at the role of sickness and health in relation to work.

This is why DWP moved to more individualised work programmes, which can offer intensive support in a flexible way.

That’s why we focused on helping lone parents back to work sooner.

And that’s why we wanted to increase the expectations of the 2.5 million or so people on Incapacity Benefit, who had up to that point been basically left to fend for themselves.

Introducing a single working-age benefit will simplify the complex web of different payments that in too many cases acted as a disincentive to work.

We are building a system where work, and an expectation of work, is at its heart.

Salutogenesis

At the heart of this approach is the ground–breaking work of Aaron Antonovsky, work which both the Chief Medical Officer of Scotland, Sir Harry Burns and I have a great respect for.

Antonovsky argued that a purpose in life – what he called coherence – was crucial to understanding human health and wellbeing.

Whether we can overcome setbacks such as losing one’s job, or dealing with an illness, or whether they overwhelm us is, for Antonovsky, a function of whether these stresses violate an individual’s sense of coherence.

If people know why things happen to them, and if they have the support and ability to manage their affairs, they have at least a fighting chance of being able to maintain their wellbeing.

A reason enough on its own to introduce Universal Credit – a simpler benefit that is designed to allow people far more insight into what the state is doing for them and to them.

But no part of the benefit system is more illuminated by Antonovsky’s theory than how we deal with illness.

He said “we are coming to understand health not as the absence of disease, but rather as the process by which individuals maintain their sense of coherence” to allow them the resilience needed to thrive.

The longer someone is out of work, the less likely their life is to have an overarching sense of purpose or meaning.

The less help people receive at vulnerable moments, the more likely they are to fall through the cracks.

And when you see wellbeing in these terms – the DWP suddenly becomes as relevant for people’s long-term wellbeing as the Department of Health.

Sickness Absence Review

But we had a big problem.

DWP has always been good at focusing on how to get people into work.

The improvements to incapacity benefits that came with the introduction of Employment and Support Allowance began to address the problems of those who had long ago fallen away from the workplace and needed help to make their way back.

But there is a gap – a black hole almost - in the way the system intervenes at the interface between work and benefits.

How do we help those people who were falling ill at work? What can we do for them in the six months before they turn up to claim ESA? Can we do more to keep people in work, or get them back to work sooner?

We should all be worried about the 300,000 people who move out of work and on to health-related benefits each year – the human cost for the individuals involved whose human potential could be wasted is reason enough in itself.

But in pure monetary terms, the potential gains from getting this right are huge: health-related unemployment benefits cost the taxpayer £13billion a year. Employers spend £9bn on sick pay and associated costs. Working age ill-health costs the economy £100bn per year.

There are great examples of what can work – BT’s Workfit Positive Mentality programme, for example, helps people look after their mental health – their absence rates due to mental health issues fell by a third over 4 years.

Large employers are able to offer their employees access to occupational health services – nearly 80% can do so.

But the problems are real too: only 11% of small and medium enterprises have the access they need.

And there can be problems for GPs in their role as the main guardians of the fit note.

Although the vast majority of GPs recognise that work can be good for their patients’ health, sometimes they can feel reluctant to translate this into challenging their patients’ assumptions about their fitness for work, because they do not want to jeopardise the doctor / patient relationship.

Some GPs also feel that they do not have the specialist occupational health knowledge that is sometimes needed in complex or work-related sickness absence cases.

Solutions

So what was our solution?

It was clear that employers and the health profession had a big stake in any answer. So we looked at these two areas and whom might provide us with the best advice.

That’s how we came to ask the then National Director for Health and Work, Dame Carol Black, and the former Director General of the British Chambers of Commerce, David Frost, to write “Health at Work” – an independent review of sickness absence.

The report produced a number of important recommendations to, among other things, improve the support for GPs and their understanding of the benefits system; increase the incentives for employers to manage their staff’s sickness effectively, and to simplify the administrative burdens.

But the most significant recommendation is the one that is most directly relevant to this audience here today – the creation of a new occupational health assessment and advice service.

We have been working with experts, Sir Harry Burns included, to design a real first – a national service providing an in-depth assessment of how an employee’s health is affecting their ability to work and advice on how people on sick leave can be supported back to work.

The assessment will be provided after an employee has been off work for four weeks, followed by signposting to interventions and case management for more complex cases. To help employers, we are also introducing tax relief for health-related interventions recommended by the service.

Crucially, this will be a service that can kick in and be effective early enough for it to be most likely to make a difference.

Implications

This is for me potentially the most exciting aspect of the report, largely because it provides the opportunity to plug a gap left over from the days of Beveridge.

Back in the day before the National Health Service, when work was to a great extent a dangerous place to be, industrial occupational medicine was largely about preventing work-related disease.

Against this backdrop, if work was dangerous and liable to make you sick, it made good sense to ‘protect’ people by keeping them away from the workplace.

With the introduction of the National Health Service, the State structures for dealing with the health of the nation were introduced, but for some reason occupational medicine remained a Cinderella service, a branch apart which has never quite caught up the lost ground.

This new assessment and advisory service will be a significant achievement because it represents an opportunity to finally bring occupational medicine into the heart of an integrated system.

It is a chance for GPs, employers, employees and occupational health professionals to work together to improve the health of the country and prevent a whole host of problems before they even begin.

I have high hopes that this will not only improve the overall health of the nation, with the personal and economic benefits that will flow from that, but that it will also help to place occupational medicine at the top table of frontline health support.

I see the new service:

  • generating more interest from young medics looking for a specialism;
  • encouraging more training and professional development; and
  • linking the service back into the mainstream.

Work provides individuals with a structure to life; financial independence; a source of support; a sense of satisfaction and feelings of hope for the future. Indeed, work ticks many of Antonovsky’s boxes.

As the population is grows older, there will be an ever increasing need to make the most of our productive workforce – in particular employers will increasingly need to rely on the skills and experience of older workers.

As it is more difficult for those over 50 to return once they are out of work, supporting those employees at the onset of health conditions to remain in work is crucial.

There will be clear benefits in spending modest amounts to maintain and promote people’s health during their working life to help them to stay healthier and enjoy the benefits of an active contribution for longer.

Mental health

And my final thought is that this work can also do much to tackle what for me is a far too often over-looked problem – that of our attitude to and support for people with mental health problems.

The numbers speak for themselves. At any one time, one in six working-age people will be experiencing a mental health condition. Stress, depression and anxiety take a huge toll – 44% of people on ESA have ‘mental and behavioural disorders’ as their primary diagnosis and it’s reckoned mental ill health costs the British economy up to £40 billion.

Yet this is largely a hidden epidemic – stigma and lack of understanding continues to dog efforts to provide the help that is needed and that we know can work. Especially as very often we know that work has to be part of the solution.

A better system to support people’s health at work could be transformative for people’s mental health.

That’s why the Minister for Care and Support and I have commissioned advice on how we can best improve the alignment of employment and health services.

We are determined to improve employment and wellbeing outcomes for people with mental health conditions, so the project will explore a number of areas including:

  • When does a mental health problem warrant specific interventions by an employment service? How can this be identified in employment services without medicalising discussions unduly?
  • And how can we truly achieve employment-focused health services and health-aware employment services?

I look forward to seeing the impact of our work on this pressing problem, and am pleased I’ve had the opportunity to share my thoughts with you all today.

Thank you very much for your time.