Health Works A review of the Scottish Governments Healthy Working Lives Strategy A report on implementation May 2013

2. Delivering Health Works

Health Works presents 25 actions (see Appendix). These have been delivered through a wide range of activities and initiatives building on existing practice, connecting services and developing new systems where required.

Implementation has also benefited from activities and service developments that have not directly risen from Health Works: working-age people are represented in many other work programmes, and this has been recognised across the action areas. A significant proportion of delivery has therefore been achieved through collaboration and interweaving with a range of complementary strategies and policies.

2.1 Supporting and promoting healthy workplaces

Actions: 1, 2, 3, 4, 5, 25

A number of initiatives have been launched to support and promote healthy workplaces.

Scottish Centre for Healthy Working Lives

The Scottish Centre for Healthy Working Lives (the Centre) (11) has led on delivery of a number of actions on promoting healthy workplaces. Its three-year strategic business plan (2010-2013) sets out actions originating from Health Works, all of which are being advanced.

Case studies reflecting the impact of a healthy workforce on business performance feature on the Centre's website: an example is shown in Case Study 1.

Case Study 1. Scottish Centre for Healthy Working Lives and CHAP

The Community Housing Advocacy Project (CHAP), a charitable organisation in Ayrshire, employs 15 staff. It engaged with Healthy Working Lives to improve staff well-being. Debbie Alexander, Services Co-ordinator, says: "We were unsure whether we would be able to get involved because we're a small organisation, but we realised that Healthy Working Lives was there to support us."

With support from the local Healthy Working Lives team, CHAP made several changes, including updating health and safety policies, running regular health awareness campaigns, providing more staff training on health and safety, and introducing new sickness absence procedures. The business has recorded a 15% reduction in sickness absence since it's been involved with Healthy Working Lives.

Case Study 1. Scottish Centre for Healthy Working Lives and CHAP (contd.)

CHAP consulted with staff at every step of the process. "Staff could see what we were planning and understood that they were all going to be involved from the start", says Debbie. "I think that's why there's been such a good reaction." CHAP has found that investment in the well-being of staff has other benefits for the business. "It helps with motivation and productivity as well," says Debbie.

Healthy Working Lives has also given staff at CHAP a chance to develop new skills. By organising campaigns, people get a chance to use their creative skills. This has encouraged staff to step outside their established job roles and take on new responsibilities. "We have noticed that staff are willing to undertake more tasks, to increase their own skills and knowledge, as part of personal and professional development," Debbie notes.

"Involving staff in all decisions from the start makes everyone feel included and allows the Healthy Working Lives service to be tailored to the wants and needs of the staff, even in small companies."

The full case study and others can be accessed at:
http://www.healthyworkinglives.com/award/case-studies

The website also hosts a comprehensive range of resources for the business community, healthcare professionals and the general public. Recent additions related to Health Works include information on the "fit note", WHSS and links to self-management resources on the NHS Inform website. In addition, the Centre is currently working on a web-based "talking head" to demystify occupational health for small businesses.

The Centre has taken a collaborative approach to delivering Health Works actions, working with the business community and partners such as the Scottish Trades Union Congress (STUC). The Business Gateway website section on Employee Health & Wellbeing was redesigned to reflect the range of supports available in Scotland through the Centre.

The Centre's Health Risks at Work resource (12), a DVD-based guide to assessing health and safety risks in the workplace, has proven so popular that it has been adopted for roll-out in England and Wales (see Case Study 2).

Case Study 2. Health Risks at Work and SIBCAS

SIBCAS, a manufacturer and supplier of flexible modular accommodation, was one of a number of companies in England that tried the Health Risks at Work training resource. The company was keen to communicate information on health risks to all staff and saw the resource as offering an effective means of enabling staff to access, and take on board, relevant information and advice.

Morven MacLean of SIBCAS was very impressed with the resource. "The content was really good," she says. "You need to keep it as simple as possible and so it was pitched at the right level."

The company has recently renewed its approach to health and safety, prompted by the resource. They are undertaking more training on the subject and have used resource content in training programmes. Increasing numbers of employees are coming forward to be involved in health and safety meetings, and the company is now pursuing ISO 18001 (occupational health and safety) status.

Source: NHS Health Scotland (2013) Health Risks at Work Case Study. Edinburgh, NHS Health Scotland. Access at: http://www.healthyworkinglives.com/document?PublicationID=5865

Health Profits: an introductory guide to protecting and improving employee health (13), which is specifically aimed at small and medium-sized enterprises, was produced in collaboration with the Federation of Small Businesses (FSB), Scottish Chambers of Commerce and Business Gateway in 2010 as a guide to the range of health, safety and well-being issues businesses should be considering. It is available through Business Gateway outlets, FSB branches and the Healthy Working Lives advice line: almost 10 000 copies have been distributed to date.

An evaluation of the Centre's activities (14) reported that 95% of customers experienced benefits through improved policies, behaviours and practices and 88% reported some positive business benefits.

Healthy Working Lives

Healthy Working Lives is a partnership involving the 14 territorial NHS boards and is led by NHS Health Scotland. It has continued to drive improvements in its customer focus and reach, engaging with a record number of employers. Achievements include increasing the number of organisations actively supported by over 10% to a total of 4100, most of which are small and medium-sized enterprises. Taken together, these organisations employ over one million staff and account for over 40% of employees in Scotland.

The Healthy Working Lives advice line,^[1] which predates Health Works, has been a key service for the business community and general public, providing access to information and support on health and work, occupational health, health and safety, and health improvement in Scotland. The Department for Work and Pensions (DWP) has provided additional funding over the last few years, increasing resources for support and more active promotion to businesses through a Scottish Chambers of Commerce-coordinated marketing campaign. The advice line also provides direct access to the WHSS vocational rehabilitation service hosted by NHS Lanarkshire (see Section 2.5).

Visitors to the Healthy Working Lives website (11) now stand at almost 900 000 per year, an increase of 50% on 2010−2011.

Healthy Working Lives awards scheme

This successor to the highly regarded Scotland's Health at Work Awards has been extremely successful in engaging the business community. One hundred and sixty new organisations registered their intention to achieve a Healthy Working Lives award, with a 22% increase to 297 awards in 2013. Twelve hundred employers are now engaged.

2.2 NHS and the Scottish Health Offer

Actions: 6, 15, 16

The Scottish Health Offer was developed over 2010 and 2011 by a group of experts and representatives from Scottish Government, the Convention of Scottish Local Authorities (COSLA), NHSScotland, Jobcentre Plus and others. It outlines seven principles of practice for the NHS matched to the Healthcare Quality Strategy for NHSScotland (15). The principles call for all NHS staff to:

• routinely record people's work status;
• take a whole-person, or biopsychosocial, approach within all healthcare interventions;
• consider people's ability to continue to work while managing their presenting health condition;
• remember that in most cases, "good work = good health";
• ensure early interventions to support people back to, or towards, work;
• provide access to services that support people to return to, or regain, work;
• ensure that evidence-based interventions are used.

NHS staff are being encouraged to incorporate these principles in practice through a range of initiatives. For instance:

• each NHS board has nominated a strategic lead for Health Works to provide leadership and a focal point of contact;
• many boards have set up or joined health, well-being and employability networks and fora in their area;
• many have local delivery plans incorporating the Scottish Health Offer and including service redesign and initiatives matched to local priorities and building on existing and emerging expertise.

A pilot of the Scottish Offer in NHS Grampian concludes in March 2014 (see Case Study 3). The project aims to enable health professionals working in different clinical pathways to support patients to view work as integral to recovery and encourage them to maintain healthy working lives. Achievements to date include:

• the development of a simple model to support the integration of health and work;
• delivery of training to promote practitioners' skills in "asking the work question" and meaningfully signposting or referring patients to relevant services;
• creation of a range of resources available through the local intranet (16).

A full report on the pilot will be available at the end of the project.

Case Study 3. The Scottish Health Offer in NHS Grampian

NHS Grampian secured funding for a project to integrate and embed the Scottish Health Offer principles into daily practice. Initially led by public health, the project is now a collaboration and is being delivered by a team of AHPs (the Health Works Team) working with practitioners and service teams across NHS Grampian.

A member of the community dietetics team in Aberdeen City agreed to be the link for the Health Works Team, who then began to identify attitudes, knowledge and activity around the health and work agenda.

Employability training was delivered by a member of the Health Works Team, following which staff created an action plan for incorporating employability into their clinical practice. Staff recognised the link between health and work, considered it appropriate to raise the issue of work as part of their assessment and treatment processes, and acknowledged their role in supporting patients to access appropriate support.

Patients now have an opportunity to talk about work with their dietician, who is equipped with the necessary resources to help them access appropriate support to overcome barriers to work.

A member of the dietetics team says: "I really like some of the suggestions for talking about work with patients in a conversational way. I can see that this would work in practice and will try to bring it into to my normal interaction with patients."

Other key initiatives taken forward in Scotland include a self-assessment framework (17) developed by the Scottish Government to aid local mapping and prioritisation of services and activities related to Health Works. The framework is currently being piloted by a number of NHS boards.

The development of a HEAT (health improvement; efficiency; access to services; treatment) target was part of the action plan in 2009. Following extensive consideration and scoping, it was decided in 2011 not to pursue this action due to difficulties in identifying a suitable measure (or set of measures) that could be collected consistently and would reflect the desired outcomes.

2.3 Developing standards, learning and sharing

Actions: 7, 9, 10, 11, 12, 17, 20

Practice on health and work in Scotland prior to Health Works was widely variable in terms of provision and standards. Health Works has provided the opportunity to recognise good practice and, through the Scottish Health Offer and established vocational rehabilitation and occupational health standards (largely owned by professional organisations), build a firm platform for improving and sustaining the quality of delivery of health and work interventions.

Case management approach

Case management has been cited as a key model in delivering the comprehensive range of health and work services individuals require. The case management approach is integral to WHSS and is increasingly being used as an efficient delivery model in other services (Case Study 4).

Case Study 4. WHSS case management approach

Irene, a 28-year-old woman, had been working as a nurse for two years in a care home. She had been qualified for five years as a mental health nurse, but was caring for both general and mentally unwell clients within her current job.

Irene had a history of depression and was increasingly finding her work very stressful. She felt she was losing confidence and couldn't cope.

After an absence from work of six weeks, Irene contacted WHSS. She had seen her GP several times over the period, but other than signing her off work, he was not supporting a return to work.

Irene was assessed and was allocated a case manager, Sue, who commenced a programme of psychological therapies. Sue established that Irene was suffering from back pain which flared up from time to time and affected her mood and ability to cope at work, so arranged physiotherapy for her. She was able to organise the treatments for the same day, which minimised travel issues. She also offered to speak to Irene's line manager when she started to plan a return to work. By this stage, however, Irene was confident enough to do this herself.

Sue liaised with the GP and was able to advise on fitness for return to work, which was achieved. The psychological therapist remained in contact after Irene's return to work to provide extra support and assess her coping mechanisms in the workplace. This was withdrawn after five months, by which time she was managing at work and ready for the case manager to discharge her from the service.

Irene reported that the WHSS and interventions had "helped me to turn a corner".

Networks and events

Learning from existing and emerging practice is now being shared widely through networks, events and other initiatives, including:

• the Good Work, Good Health practice community (18);
• the Health and Employability Delivery Group;
• the health section of the Employability & Tackling Poverty website (19);
• the Centre;
• professional and partner events and networks.

In addition, a national conference led jointly by Health and Social Care Alliance Scotland (the ALLIANCE) and the Scottish Government was held in Glasgow in March 2012 (20), and the Health Works National Forum, which originally developed the Scottish Health Offer, continues to operate, convening annually.

Vocational rehabilitation posts

Two national vocational rehabilitation posts (in general mental health and forensic psychiatry) have been created through Realising Potential (21), the national action plan for AHPs in mental health. This has facilitated considerable progress on developing workplace skills and increasing patient access to vocational rehabilitation through the AHP workforce. Each NHS board now has a mental health AHP vocational rehabilitation lead.

NHS Education for Scotland (NES), the Centre and Scottish Government funded a vocational rehabilitation development post between 2010 and 2011. This led to a national training needs analysis on vocational rehabilitation being undertaken, the creation of the Good Work, Good Health website and practice community (18) and the award of a number of small grants to support staff personal development and the creation of health and work information materials.

Training

The Centre sponsored a return-to-work training programme delivered by the Canadian National Institute of Disability Management and Research (NIDMAR). Thirty-five NHS staff were trained over three years and are now using their skills in the workplace.

The Employability Training for Healthcare Professionals training pack (22), using materials originally created in Glasgow, was developed in partnership with NES to promote greater awareness of employability issues across health and social care sectors (Figure 2). A "train-the-trainer" implementation model was used, with the first cohort of 18 people from territorial NHS boards being trained in 2010. This initiative is now under review and the pack has been updated in some board areas such as NHS Ayrshire and Arran, who have now trained 357 people from a wide range of clinical disciplines and services, including 30 council employees and six from local voluntary organisations.

Figure 2. Slide example from Employability Training for Healthcare Professionals training pack (22)

The STUC and the Centre collaborated on a course run by the Trade Union Congress (TUC) as a pilot for "in-work" support. The course received favourable feedback and the STUC committed to running it themselves in 2012−2013. The TUC is keen to use parts of it to augment their existing training and will look to integrate the course within their training schedule.

Healthy Working Lives advisors now include the importance of the "fit note" in their current and planned sickness absence training for small businesses.

Health Works Development Fund

The Scottish Government introduced a Health Works Development Fund in 2012−2013. It aims to support and/or enable the start-up of small initiatives or NHS service redesign projects related to Health Works implementation. Five grants have been awarded (Table 1).

Table 1. Health Works Development Fund awards, 2012−2013
Organisation	Funded initiative
NHS Fife	Trial of an accident & emergency rehabilitation pathway that identifies people who present with mild traumatic brain injury and are working. The pathway will provide early access to functional capacity assessment and vocational rehabilitation interventions where required.
NHS Forth Valley	Support to further develop and embed an employability single point of access to information and services for professionals and service users. The aim is to ensure a timely and seamless pathway into and between employability services and health (see Case Study 5, below).
NHS Tayside	A project to develop, consolidate and embed vocational rehabilitation as a core occupational therapy function within the forensic employability pathway across health, social care and employability.
NHS Highland	Promotion of employment and mental health collaboration through the secondment of an employability specialist to the NHS. The aim is to integrate employment support within the multidisciplinary team's routine clinical treatment.
Forensic Network	Development and standardisation of knowledge and practice within the area of disclosure of mental health and criminal convictions when delivering vocational rehabilitation with forensic patients.

All initiatives have a project plan with reporting structures, and each has been asked to produce an evaluation, including outcomes and learning, to be shared in 2013. The fund will be available for a second year in 2013−2014.

Case Study 5. ReACH, NHS Forth Valley

ReACH Forth Valley is a community-based multidisciplinary rehabilitation service for adults (aged 16-65 years) with physical disabilities. It provides a single point of access to consistent and appropriate health and employability information for patients and healthcare professionals across NHS Forth Valley, promoting the message "good work is good for your health", and engages with rehabilitation managers who are mapping their services to health and employability needs.

ReACH identified a time delay in obtaining information from patients about their work status during assessment. The assessment process has now been changed to ensure that "work questions" are introduced at an early stage and appropriate actions commenced in a timely fashion.

Partnership is growing between ReACH and health promotion services, with brief interventions for smoking and alcohol use being introduced early in rehabilitation patients' pathways and work questions being posed by health promotion practitioners.

The service aims to further expand its remit to house the Forth Valley Health and Employability "Pipeline".

2.4 Partnership working

Actions: 13, 14, 18, 19, 21, 22

Partnership working is crucial to Health Works' success.

The NHS has a specific role in early intervention and is often the first point of contact for a person who has health and work issues. Developing effective links to employability services that meet individual needs at the right time is imperative for successful onward referrals. The establishment of the Health and Employability Delivery Group (23), which brings together NHS health and employability staff four times a year, has been most helpful at national level.

Participation in employability networks at local level continues to grow. Engagement with employability partners has led to the development of health and work pathways, or "pipelines", in many board areas (see Case Study 6). The Scottish Government has produced a generic guide pathway (24) that aims to help NHS services to ask about work and health and support staff in making decisions, consequently guiding patients to the right services to meet individual needs. The pathway is shown in Figure 3.

Figure 3. Health and work pathway (24)

Health and work crosses the boundaries of a vast number of programmes of work in health, social care, the third sector and other areas. Considerable work has therefore been taken forward on embedding health and work into existing routine work and in programmes and pathways such as Keep Well Scotland (25), mental health integrated care pathways (26), Equally Well (27) and Modernising Nursing in the Community (9).

Case Study 6. Partnership initiatives in mental health, NHS Greater Glasgow and Clyde

A revised mental health employability framework was approved in NHS Greater Glasgow and Clyde in September 2011. The aim of the framework is to offer a range of services across the employability spectrum for people with long-term mental health conditions. It recognises that some individuals will not wish to enter full-time employment but will engage in meaningful and positive activities, or will require an extended period of support prior to considering employment. The revised framework is outlined below.

* Community mental health team

** Primary care mental health team

*** Work development team

Case Study 6. Partnership initiatives in mental health, NHS Greater Glasgow and Clyde (contd.)

Other work includes:

• developing employability and financial assessment tools on the Patient Management Information System
• supporting Jobcentre Plus staff to better understand mental health issues and increase their awareness of mental health employability services
• developing Employability Peer Support Service User Group resources, including the Journeys to Employment DVD (28) and Confidence in Disclosure booklet, which gathers the experience of people with mental health problems around disclosing relevant information to current or potential employers.

Source: Employability and Tackling Poverty. NHS Greater Glasgow and Clyde − Mental Health Employability Update. 11 January 2013. Access at: http://www.employabilityinscotland.com/news/201301-nhs-greater-glasgow-and-clyde-mental-health-employability-update

The Centre has taken a collaborative approach with workplaces to delivering a range of actions associated with Health Works. It has worked with local enterprise networks to increase awareness of healthy working lives and the services on offer. This has included targeting account managers in south east Scotland through development road shows and mapping the Business Gateway website to Healthy Working Lives, with associated promotion campaigns and various local articles aimed at advisers and customers of these agencies.

The Scottish Government produces a quarterly newsletter on health and work, Snapshot (29), which includes reports and updates on policy, local services and projects, and national information from associated work such as the UK Government's Sickness Absence Review and Welfare Reform. It is posted on the Scottish Government website and is circulated widely.

2.5 Outcomes and measuring success

Actions: 8, 23, 24

Working Health Service Scotland

The second phase of WHSS has been operating as a national service since 2010, with around 7600 clients being enrolled.

WHSS developed from a project in the east of Scotland involving NHS Tayside, NHS Lothian and NHS Borders that was evaluated and reported in May 2011 (30). The project used a case management approach and delivered physiotherapy, occupational therapy, psychological therapies and welfare and benefits advice to 1247 clients over 24 months in Dundee and 12 months in Lothian and Borders. Key findings from this vocational rehabilitation service included:

• improved health for clients, measured using standardised tools at the start and end of the programme;
• support for clients in returning to or remaining in work, with 83% of cases who were absent at entry being in work at point of discharge;
• health benefits (measured using EQ-5D™)^[2] and employment status (absence statistics) being maintained at three and six months following discharge;
• a reported reduction in general practitioner usage by clients, with on average one appointment per case fewer over a three-month period.

The second phase retains many features of the original project. For instance, clients are eligible to participate if they are employed within a small or medium-sized enterprise and are either struggling at, or absent from, work due to a mild-to-moderate health problem. Seventy-five per cent present with a musculoskeletal disorder and 16% with a mental health problem.

WHSS has retained the case management approach. Once engaged within the service, a case manager coordinates each client's journey, which may involve one or more interventions. An extensive list of interventions has been used, with physiotherapy, counselling, occupational therapy and self-help accounting for 92% of all interventions.

WHSS now operates as a telephone-based service supported by a web-based database, although face-to-face meetings between case managers and clients can be arranged. The database enables the administration of the service and client assessments at entry and discharge against a range of standardised performance measures including the EQ-5D™, the Canadian Occupational Performance Measure (COPM©)^[3]
A summary of outcomes for WHSS is presented in Box 1.

Box 1. WHSS outcomes summary

At discharge, 81% of clients reported that their health issues were either "partially" or "fully" resolved. All clients reported statistically significant improvements on each of the five dimensions of the EQ-5D™. In particular, a quarter of all clients reported fewer problems performing their usual activities and over a third with musculoskeletal problems reported a decrease in pain. Over two-thirds reported improvements in their occupational performance and satisfaction, as measured by the COPM©. All reported decreased levels of anxiety and depression, as measured by HADS. Perhaps the most noticeable finding was that while 22% of clients with mental health problems were categorised as "not anxious" at entry, this had increased to 71% at discharge. The equivalent figures for depression were 39% and 83%.

Sources: Department for Work and Pensions. The National Fit for Work Review. London, DWP. In press.

Scottish Government. Scottish Evaluation of WHSS, Edinburgh, Scottish Government. In press.

Hosted by Salus, the occupational health provider within NHS Lanarkshire, WHSS has been funded by the Scottish Government and DWP as part of the national Fit for Work service. The DWP funding ends in March 2013, with ongoing support being provided by the Scottish Government.

Individual placement and support in mental health

Redesign of mental health services has commenced in response to the growing body of evidence of positive work outcomes from the individual placement and support (IPS) approach (32) for people who would like to work. The commitment within the Mental Health Strategy for Scotland 2012-2015 (8) to promote the evidence base for what works in employability is fuelling a growing interest in this model of supporting people into work.

IPS promotes a positive response for people who would like to work regardless of their health barriers, with early activities focusing on job-finding followed by intensive support to maintain work - voluntary, paid or work experience.

Collaborations with third-sector organisations (such as the Scottish Association for Mental Health), NHS Ayrshire and Arran, NHS Greater Glasgow and Clyde, NHS Tayside and Jobcentre Plus are currently improving work outcomes through IPS services. There is also an active national IPS network across Scotland.

The NHS Lothian mental health vocational service "The WORKS", established in April 2011, uses the IPS model. It is being delivered through a knowledge transfer partnership involving Queen Margaret University, the University of Stirling and NHS Lothian. The primary focus is paid employment, but clients are also assisted with other chosen occupational pathways.

As an action research initiative, full evaluation is integral to "The WORKS", and early indicators show that more clients are returning to and sustaining work than previously. Goals met at discharge are summarised in Figure 4, and the perception of one of "The WORKS" team members in Case Study 7.

Figure 4. "The WORKS" project, NHS Lothian: goals met at discharge
(to end March 2013)

Case Study 7. "The WORKS" project, NHS Lothian

Ruth was initially employed as a senior occupational therapist in mental health rehabilitation to provide purposeful activities and social skills training for patients. She did not consider CV preparation or job-applications work part of her remit, because she "didn't believe that the folk I saw could ever work". Even when some patients managed to find jobs on leaving hospital, she never saw it as being due to "anything that I did".

Ruth listened to the arguments and evidence for a new model of rehabilitation for adults with mental health problems, IPS, when it was apparent that it was going to be introduced in her service. But she remained focused on her existing role.

Suddenly, she found herself in a minority. While colleagues were progressing with IPS and providing interventions that focused on employment for their adult patients, she was still pursuing grants to keep the horticulture project in the sheltered environment alive. She was not going with the flow.

Reluctantly, she participated in some action learning and started to hear what was being said. She realised that work is important for the patients she had been protecting from work. She realised that work was also important for mental health and well-being, so her goals could still be realised through the new model. And she realised she wasn't in a minority - all her colleagues were nervous about the new skills they would need to acquire. "It was quite a change for everyone", she recalls.

Her role changed when the new service was launched. Following training, she is now helping patients to acquire practical skills, building their confidence and supporting them to find employment. She's forming relationships with prospective employers and challenging stigma. "I'm surprised by their willingness to help, in many cases", she says.

Health Works outcomes framework

NHS Health Scotland was commissioned to develop the Health Works outcomes framework (33) in 2010 as part of the delivery strategy. Three pilots were identified, with two receiving support to develop a health and work logic model for their NHS board:

• NHS Lothian has now established a clear logic model for all activities and services related to sustaining their patients in work;
• NHS Fife embarked on a more comprehensive logic model to include those out of work; this piece of work is still progressing, with a draft framework under development;
• NHS Ayrshire and Arran has taken a different approach, agreeing an outcomes triangle that includes a range of partner organisations and encompasses all services linked to health and work (Figure 5).

Figure 5. Draft Ayrshire outcomes triangle for work health and well-being

Musculoskeletal referral pathway

NHS Lanarkshire, in collaboration with NHS 24 and WHSS, commenced a pilot redesign of the musculoskeletal referral pathway in 2011. Integral to the pathway are questions about health and work at first registration with the NHS 24 Musculoskeletal Advice and Triage service (MATs), with people being signposted to self-management resources, WHSS or local physiotherapy services through a screening algorithm. NHS Lothian and NHS Ayrshire and Arran commenced access to the services through MATs in October 2012, with other boards preparing to follow.

The project is still at an early stage, but indications are that people with issues affecting their work can be supported effectively by early access to vocational rehabilitation support. Of the 21 062 callers to the service between 1 August 2012 and 28 February 2013 (seven months), 7% were identified as meeting the WHSS criteria. Evaluation of WHSS within this redesign will seek to answer the following questions.

• Does the WHSS model result in improved health outcomes, functional ability, sickness absence and speed of return to work?
• Are any impacts on health outcomes, sickness absence and functional ability maintained three months following clients' discharge from the service?

Better Together

Questions on health and work were included in the Better Together patient experience primary care survey in 2011−2012 (34). It reported that:

• 17% of patients surveyed said they had seen a health professional about something that affected their ability to work;
• 79% of those who had (or wanted) a discussion found it useful, with those in full or part-time work more likely to do so (77% and 76% respectively);
• 21% of those who were not working due to illness did not have a discussion and did not want one (compared to 11% overall).