Work is of enormous benefit to many people with long-term conditions. But, writes Daloni Carlisle, it may soon be a lot harder for people to receive NHS support to stay in employment.
It seems such a good idea. Employment is good for health, sickness benefits are expensive, so let’s get people on long term sickness benefits back to work and help those with newly developed conditions before they end up leaving their job. So why is nearly everyone involved with this work in the NHS in such a despondent state?
The short answer is that nearly a decade’s worth of work is about to go on the shelf. The government is scrapping major welfare-to-work programmes and replacing them with a new one – but there will be a gap between one ending and the other starting.
Since 2003, the NHS has been building a series of programmes to support people with long term conditions to either stay in work or return to work. In partnership with job centres, the voluntary sector and with employers, the NHS has provided the health dimension to two programmes funded by the Department for Work and Pensions: Fit for Work and Pathways to Work.
Broadly, Fit for Work involves providing employment advice and co-ordinating support for people who have recently gone on sick leave or are about to lose their job through ill health.
Conditions management programmes within Pathways to Work focuses on those on long term benefits, working alongside employers and employment advisers to offer health interventions, such as physiotherapy for people with musculoskeletal disorders or psychotherapy for those with anxiety and depression.
Until recently, neither programme had funding beyond March 2011. Then, in February, the Department for Work and Pensions announced a review of long term sickness absence, which currently costs the public purse some £100bn a year. The review is likely to focus on how to help people stay in work through early interventions.
It also promised an additional £12m for Fit for Work and occupational health advice lines, both of which, it said, had proved highly successful in providing support for employers and individuals in the early stages of sickness absence. This offers some hope to the current Fit For Work pilots, who will be able to apply for new money. But there was no mention of the conditions management programme, while Pathways to Work looks set to be quietly sidelined. Instead, a new work programme will be launched this summer offering a complete welfare-to-work package.
Evidence on conditions management programmes is mixed. A 2008 review commissioned by the Vocational Rehabilitation Task Group, which represented unions, employers, government and insurers, questioned their effectiveness. One of the authors, Professor Kim Burton, ergonomics and occupational health consultant at the University of Huddersfield, says that while health-based interventions are effective in helping people – particularly those with musculoskeletal disorders – return to work, conditions management programmes might not be enough and may come too late.
“The problem with pathways and conditions management programmes is that they are targeting people on long term sick leave and they’re hard to help,” he says. “What we found in our review was evidence to support early intervention, but if it is to influence occupational outcomes – as distinct from just clinical outcomes – it must be work-focused and connected to the workplace.”
Other reports questioned the health service’s contribution. The National Audit Office in 2010 found that overall Pathways to Work did not offer value for money, did not get the required numbers of people back into work and that conditions management programmes added no value.
However, some evaluations showed they were successful in helping people with the most serious health problems, who had been on benefits longest, back into work – and then to stay in employment. Of the 3 per cent of referrals to Pathways to Work supported by the conditions management programme, around a quarter regained a job and remained in employment a year later.
No details are available on the health component of the new work programme. The DWP has only revealed it will be a regional service offered through private contractors that will sub-contract with local organisations. It is due to start between May and July 2011.
The government has promised that job seekers will still be supported during the transition between the old and new, but there is growing concern this gap will lead to a loss of expertise, including in the NHS. The Employment Related Services Association, which represents organisations involved in helping people with disabilities back to work, warned in February that their members were preparing to make many thousands of people redundant as Pathways to Work winds up.
Chief executive Kirsty McHugh says: “Many providers, including charities, are entering a period of consultation and this could mean job losses, which in turn means there will be a gap in provision and that it will be harder to get the new work programme going quickly in the summer.”
“The work programme will be too late for us,” says a despondent Marie Gibbons, programme director of Lancashire’s NHS conditions management programme. “The pilots will come to an end and be put on the shelf and that’s a sadness really.” Fiona Ford, GP senior lecturer at the University of Central Lancashire who evaluated the conditions management programme in East Lancashire, adds: “The big question for everyone over the last year has been ‘where now?’ As far as I can see, no one has an answer to that.”
She argues that conditions management programmes allowed a highly skilled group to develop. “The nurses, physios, occupational therapy and social workers who got involved in these programmes have become holistic biopsychosocial practitioners,” she says. “One of the anxieties that came up in the evaluation was what happens to them if the programme stops? They felt they would not be able to step back into their old roles.”
But this is already being asked of them. “These skills are being lost and that’s a tragedy for the NHS and for the people involved,” says Dr Ford.
On the sidelines
The other tragedy, she says, is these programmes dealt with the most severely ill people and offered some of them a path back to work. “When the conditions management programmes started locally, these people started to come out of the woodwork. The programmes showed that they had been left to one side by the NHS,” she adds.
Dr Ford fears these people will not be the main focus of the new work programme – which is likely to be rewarded on a payment by results system – and that these heavy users of NHS services will once again be sidelined.
“I don’t blame the DWP as it’s long past the time the NHS should shoulder the burden,” she says. “But I fear the problems will return.”
There may be a few levers for services to continue and to develop. The NHS outcomes framework for 2011-12 indicates that a quality measure based on Labour Force Survey data on the number of people with long term conditions in work may be developed.
Dr Ford has to think hard to find hope in the current situation. “There are a lot of very skilled people who have come through this in a variety of ways,” she says. “Not just clinicians but managers too who started condition management programmes and Fit for Work with a blank sheet of paper. They are used to innovating and I am sure that some of them will find a way forward.”