Health and work strategy: review report

10 Retaining Fair and Healthy Work

Recommendation 3.1

Improve the utilisation of the fit-note and the quality of return to work advice it provides to employers and employees.

Implementation

• Encouraging more GPs to use the advisory section of the Fit Note.
• Enabling members of the wider primary care team, such as practice nurses, physiotherapists and occupational therapists to complete/contribute to the advisory section of the Fit Note

Evidence/Rationale

The Fit Note was introduced to enable GPs and hospital doctors to provide advice to an individual and their employer on measures that could be taken to enable them to return to work. Whilst accepted as being a positive initiate, research undertaken by the University of Nottingham^[65] found that only 6.7% of fit notes issued were marked as 'May be Fit,' concluding that "the fit note is not achieving its aims and is unlikely to do so without increased investment of time, money, commitment, and (should changes be required to the design of the fit note) further legislation". It made a range of recommendations, many of which resonate with the experience of the fit-note and Fit For Work Service in Scotland.

One specific action is to enable other healthcare professionals with relevant training and competency should be able to complete fit notes. There are a range members of the healthcare workforce who could make a valuable contribution in providing return to work advice but who are not currently permitted to complete a Fit Note. The UK Government, recognising that "the fit note is not fully achieving what it set out to do^[66]", has consulted on extending permission to a wider range of healthcare professionals, though this is understood to be a narrower cohort than would be preferred in Scotland.

It may, however, be possible to take forward the development of a 'Scottish Fit Note' proposition using devolved powers, which could consider wider health care participation in the process and reflect on other improvements based on research and the Scottish experience that are not taken forward at UK level.

Target Audience

Employers and their employees who are absent from work. The return to work advice aspect of the fit note should equally provide direct advice to the self-employed.

Stakeholders

GPs, the wider Primary Care Team, hospital based clinical staff.

Cost

Not likely to be significant as it would merely be extending the range of staff able to complete Fit Notes, however there would be training costs.

Complexity

The options described are technically straightforward and, unless changes were proposed to the design of the fit-note, should be achievable within devolved power. In practice, changes would require the agreement of a range of stakeholders, including specifically GPs.

Impact

There is evidence that where is its used well, the Fit Note has improved the quality of return to work discussions^[66]. Greater uptake would extend these impacts.

Recommendation 3.2

Mainstream funding for the Working Health Services Scotland 'pilot' as the single access point to OH/health and work support for employees out-with the Health & Work Support pilot areas.

Implementation

• Mainstream funding for the Working Health Services 'pilot,' ensuring appropriate governance is in place to ensure the investment in the services is maintained by NHS Boards in the long-term.

Evidence/Rationale

Working Health Services Scotland (WHS) is an important part of the 'return to work' infrastructure that focuses on SMEs (under 250 staff) and the self-employed. Since the ending of the 'Fit for Work' service it is the only such Scotland-wide provision and is an integral part of for the Health & Work Support pilot in Fife and Dundee.

Evaluation of WHSS^[6] found "that participation was associated with positive changes in health and return to work," noting that "the extent of the positive change…can be highly important economically for employees and employers". The service was also referred to positively in Dame Carol Black's Review^[2].

Interestingly, the evaluation also indicated a higher balance of referrals associated with muscular skeletal conditions and a lower level of mental health related referrals than would be expected given their relative prevalence within the population. It would be helpful to reflect on the reasons for this and other patterns of uptake, and consider what changes may be required as a consequence.

Mainstreaming funding would place Working Health Services Scotland on a permanent footing, thereby providing confidence for employers, service users, and NHS clinical staff referring patients to the service. Given the timing, there would be logic in awaiting the outcome of the Health and Work Support Pilot evaluation, though WHSS could continue to operate on a stand-alone basis even if said pilot were not rolled-out.

Target Audience

SMEs (under 250 staff) and the self-employed.

Stakeholders

SG Health and Work, SG Fair Work, NHS Boards, Employers.

Cost

Cost neutral in the sense that this would simply be mainstreaming existing 'pilot' funding.

Complexity

No real complexity, though there would need to be assurances that spending on the service would be at least maintained and governance would need to be in place to ensure consistent clinical support is in place across Scotland.

Impact

Mainstreaming finding would place Working Health Services Scotland on a permanent footing thereby provide confidence for employers, service users, and NHS clinical staff referring patients to the service.

Recommendation 3.3

Proactively support those at risk of losing work because of a health condition or disability that cannot be accommodated by their existing employer, to find appropriate employment.

Implementation

• Develop options for providing proactive job brokering and other support for people who need to move employer due to a health condition or disability.
• Develop a bursary scheme to support the retraining of employees whose condition could be accommodated elsewhere.

Evidence/Rationale

The Review of Sickness Absence by Dame Carol Black and David Frost^[22] estimated that 10% - 20% of employees absent from work with a health condition (which would equate to an estimated 5,000-10,000 people per annum in Scotland) would be best served by changing their employer, with this happening without a break in employment, something that would be all the more difficult because of their condition at this time. At present, however, a more likely trajectory for such people would be to take sub-optimal alternative employment or find their way into the benefits system, risking greater health and social impact. Black and Frost specifically proposed a job brokering service^[22] to address this issue, a recommendation that was not acted on by the UK government. The Netherland's operates a subsidised career coaching scheme for all employees over the age of 45^[67], which shares some similarities to what was proposed.

Supporting individuals in such circumstances could be considered to be analogous with the Partnership Action for Continuing Employment (PACE) model, a joint programme involving Scottish Government, DWP, local authorities, Citizens Advice, colleges and training providers, between which supports employees at risk of redundancy, indeed some individuals who have health conditions will be supported through PACE. Explicitly including those at risk of losing work due to a health condition in the target audience for PACE could provide a solution, and it could include short circuiting support from a job coach. The Health and Work Support Pilot could also provide an access point to such a service.

The Scottish Union Learning Fund currently provides support to individuals who are union members, including to those in such circumstances if it involves union members, and this could provide a model for a wider bursary scheme.

This recommendation also fits within the overall context of and Scottish Government commitment to supporting life-long learning in Scotland. Encouraging employers to support the learning of their employees as well as supporting employees directly would ensure individuals were better placed seek advancement or to adapt to change, be that through changing demand for skills or a health condition requiring an individual to take on different responsibilities.

Target Audience

Employees generally, but particularly targeting those with a health condition for which accommodation/reasonable adjustment with their current employer is sub-optimal.

Stakeholders

Scottish Government, NHS, DWP, local authorities, Citizens Advice, colleges and training providers, trades unions.

Cost

The cost of developing options would be low, though implementation, depending on the model and scale of operation could be significant. However, the Black/Frost review suggested a return on investment of £3-4 for every £1 invested, which – if only targeted on those absent from work for over 20 weeks – would result in savings to the state of £30m and deliver an additional £80m of economic growth (pro-rate estimate for Scotland based on UK figures)^[22].

Complexity

This would be a new programme for which there is not known to be a direct existing model in operation. It is therefore liable to be complex, though extending an existing service to offer such support would minimise this.

Impact

Impact would be contingent on the model developed and its scale, though reducing work related health impacts and health related worklessness, and enabling people to remain economically active, would result in savings in health care and social security costs.

Recommendation 3.4

Incentivise employers to invest in the health and wellbeing of their employees.

Implementation

• Work with UK Government to develop tax incentives for employers who invest in workplace health interventions including Occupational Health and Wellbeing support and extend the scope and visibility of Employee Assistance Programmes (EAP).
• Employ the leverage of the 'public pound' to encourage good workplace health practice linking to the Fair Work First approach.

Evidence/Rationale

There are a range of financial mechanisms available to Government to encourage employers to support the health and wellbeing of their staff, and indeed to support employees directly also such as through the Cycle to Work Scheme.

Tax free benefits in kind enable employers to provide support to their staff which does not attract a tax or national insurance charge. An example of this is EAP, which allows the provision of welfare counselling and referral services. EAP is a popular scheme with employers and employees who use it^[22,68], however it currently limited to £500 per employee per annum with some associated costs being excluded. It also suffers in terms of visibility^[67]. An extension of the scheme and better promotion could be considered, though such issues are currently reserved to the UK Government.

The Work Foundation has looked in some detail at the potential role of tax free employee benefits, recommending their extension to a wide range of health at work programmes, such as jogging clubs and obesity interventions by which government would "encourage employers to place health and wellbeing at the centre of their business plan and would show employers that government valued the public health benefits of workplace interventions^[69]."

Multiple examples of such approaches can be found in other countries and could be considered, however they may not be transferable given differences in employment, tax and social security systems. In the Netherlands, for instance, employers are required by law to pay for an employee who is absent from work due to ill-health for up to two years, something that provides a strong encouragement to investing in health and wellbeing.

A second approach to incentivising investment in Fair and Healthy Work is through the role of procurement. The Fair Work First proposal to extend Fair Work criteria into more Scottish Government contracts and support grants could easily be extended to include health and wellbeing specific requirements. This would also have the advantage of avoiding duplication of effort and having an integrated approach that would be easier to communicate to contractors.

Target Audience

Employers

Stakeholders

Scottish Government, UK Treasury, DWP, Employers.

Cost

Costs associated with tax incentives would currently fall on the Scottish Government under the Fiscal Framework, though would be offset by any improvement in workforce health and productivity. Costs associated with procurement requirements would fall upon the contractor.

Complexity

Relatively straightforward in terms of tax incentives, indeed a broad definition of what constitutes a health and wellbeing programme would be simplest for employers to understand and engage with. It would be complex in terms of the agreement that would need to be reached across several departments of reserved and devolved government.

In terms of procurement, the Fair Work First approach provides as existing mechanism that can be built upon.

Impact

Impact would be contingent on the precise nature of any intervention and evaluation would be required to assess the impact and cost benefit. Procurement conditions, backed with tax incentives for interventions that would meet said conditions, would provide a powerful combination.

Recommendation 3.5

Develop specific support in collaboration with 3^rd sector support organisations for employees with long term and life limiting conditions.

Implementation

• Improve access to specialist, condition specific advice for employers of and employees with long-term and life-limiting conditions by supporting the development of resources and staff training.

Evidence/Rationale

Third sector organisations such as the Beatson Cancer Charity have great experience in supporting patients to return to/remain in work should this be appropriate, or providing advice to enable them to be as economically secure as possible should it not be. They, and other 3^rd sector condition specific organisations have the knowledge and understanding to be able to provide advice to individuals and their employers and could be supported to develop resources, provide training for health and employment professionals, and provide advice to individuals both directly and through referral from services such as the Health and Work pilot or the Healthy Working Lives Adviceline.

Target Audience

Employers of, and Employees with, long-term and life-limiting conditions.

Stakeholders

NHS, Third Sector condition specific organisations.

Cost

In practice many materials and sources of advice already exist, therefore the focus could be on improving access to and awareness of these in the first instance.

Complexity

Relatively straightforward in principle, but this is a crowded and dynamic area of work.

Impact

Improving access to more and better resources for those who require them should enable more tailored work related advice and support for those living with long term and life-limiting conditions.