Evaluation of Working Health Services Scotland, 2010-2014

5 Discussion

5.1 Representativeness of the cases

Cases broadly represented the demographics of workers in Scotland in terms of gender. The service supported a greater proportion of older workers (>50 years) than is reflected in the Scottish employment statistics, as might be expected due to increased health needs of older people. This is important given that these workers are at the greatest risk of falling out of employment, and have greater need for such services in light of strategies and policies which are aimed at extending working lives.

While the distribution of SIMD of employees in SMEs in Scotland is not known it is possible that there was slightly higher uptake of the service by those in the less deprived SIMD categories, which may indicate some inequality in uptake, but generally there was reasonable distribution of SIMD categories among the cases.

Data from the HSE shows that work related MSK conditions account for 44% of all cases (prevalence) of work related illness; while work related stress accounts for 35% of all work related ill health cases ( HSE, 2015a and 2015b). This implies that there is a need for services that support those with MSK and mental health conditions which affect their ability to work. The majority of cases in WHSS had an MSK condition (84%), implying that a significant proportion of the workforce which has a mental health condition affecting their work ability did not access this service. Ways of addressing this should be considered in any future similar programmes. It should be noted that the health improvements and return to work outcomes for the mental health cases were generally better than for the MSK cases, although they generally entered the programme with worse health scores and longer absence durations prior to entry.

The majority of cases were from relatively small companies (2-50 employees, 56%) or the self-employed (20%) who would be unlikely to have any occupational health provision. The service therefore appears to fill a gap in service provision.

5.2 Differences in delivery in Board areas

The design of WHSS allowed for flexibility in how Boards provided the standardised intervention with some providing services in-house, some using externally provided interventions and / or the NHS, and others used a mixed model. There are clear differences between the Board areas both in service delivery and in completion of the paperwork. The most obvious differences relate to the timely and full completion of the discharge paperwork. The reasons for low completion of the discharge paperwork may be due to a focus on recruiting cases to the programme rather than completing the discharge paperwork, or resources.

In terms of the differences in service delivery, large variations are observed in the number and duration of treatments provided, outcomes, and utilisation of some interventions e.g. Occupational Therapy which generally was minimal. No comment can be made about the appropriateness of this as a clinical audit was not part of this evaluation.

These differences need to be considered when planning any new national programme for which there needs to be clear quality standards, a uniform approach and more consistency and equity in provision of service, and completion of discharge paperwork. Any future programmes should be subject to audit and quality assurance checks.

5.3 Duration in the programme

Most cases (75%) had their entry assessment within a week of their enrolment, with an average time between the enrolment and entry assessment being 5.2 days; this was shorter for those absent at entry (4.4 days) than those at work (5.5 days), implying that delays may relate to ability to access the client.

The time from the entry assessment to discharge was an average of 121 days, and, most cases (83%) were discharged within 6 months of their entry assessment. This is thought to be acceptable for the service.

5.4 Absence related to health condition

Health and Safety Executive ( HSE) statistics on working days lost due to work related ill health show that on average 17 working days are lost per worker who reports a work related MSK ( HSE, 2015a). The average number of working days lost per worker who reports work related stress is 23 days ( HSE, 2015b). This is the number of days lost per case i.e. including those who do not have any sickness absence related to their health condition.

The data available on sickness absence in WHSS do not allow a direct comparison with the HSE data, due to the absence data for a case not being collected over a year. However, for those who were absent at entry (both MSK and MH cases) an average of 28.2 working days were lost while in the programme (being 22.5 for MSK cases and 44.0 days for MH cases). Note that this is only for those who report absence; an average absence duration for all cases within the programme (including those who are not absent) would be more closely comparable with the HSE data.

5.5 Health improvements

All health measures show a significant improvement from entry to discharge, indicating significant improvements in cases' health. The extent of the positive change in EQ-5D is striking from a health economic perspective, and although there is no control group, it cannot be ruled out that the WHSS intervention has contributed to this health benefit.

The Canadian Occupational Performance Measure ( COPM) scores also significantly improved in 90% of cases, which provides evidence of a positive impact on functional capacity and coping.

Part of the case management process of WHSS was to identify co-morbidity which was present in 25% of cases presenting with a mental health condition and 15% of cases with presenting with an MSK condition. In usual NHS care these secondary conditions may be unlikely to be recognised and, if so, treated. The fact that this was identified in WHSS will have helped case managers providing more holistic care.

This is evident in the HADS scores of individuals with MSK conditions where there was a 23% reduction of anxiety levels and a 17% reduction in depression symptoms confirming the levels of pre-existing, generally non-caseness morbidity which is not always recognised in routine care but is likely to influence clinical and functional outcomes.

An important finding was the relationship between age and duration of sickness absence, with there being on average an additional 5 days of absence while in the programme for every 10 years of age. It is well recognised that older workers tend to have longer periods off work, although generally have fewer episodes of absence, but this finding indicates the need for improved occupational health and NHS care of older workers including programmes to maintain their functional capacity.

Cases using WHSS reported reduced medication use and use of other support services at discharge from the programme. Without a control group it is not possible to say that this was due to the programme, but the evidence is encouraging.

The follow-up questionnaires provide evidence of the durability of the health improvements seen at discharge, and of clients remaining in work after leaving the programme.

5.6 Limitations of the study

5.6.1 Control group

The main limitation in the evaluation is that, despite efforts to identify a suitable control population, no control group was available to allow the relative benefits of this programme to be evaluated. It was not possible to design the service to establish a control group, as it was not ethical to withhold services from clients with a need. However, for future evaluation of a similar intervention it will be possible to use these results for comparison purposes.

Even without a control group the indications are that those within the service have benefited from it, although it is not possible to say what the health and employment outcomes would have been for these clients without this service.

5.6.2 Data recording

Discharge data are available for 52% of those who enrolled in the service; it is known that 12.7% did not complete the entry assessment as they could not be contacted or were not eligible. A further 35.1% did not complete the discharge paperwork, mainly because they could not be contacted by the service or voluntarily withdrew from it. Reasonable confidence can be placed on the representativeness of the discharge data as it is a relatively complete set of those who finished the programme. However, the paperwork was not fully completed in some cases, and future programmes should seek to ensure that data collection is recorded as completely as possible.