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Royal Free Hospital
Cancerkin Lecture
Atrium , 19 March 2013
Wellbeing and Work:
Are they compatible
with chronic diseases ?
Dame Carol Black
Expert Adviser on Health and Work
Department of Health, England
Principal, Newnham College Cambridge
Work : its value
Galen (129-200)
• Work is a social determinant of health
“Employment is
nature’s physician and
• Work is generally good for health –
is essential to human
the two are inextricably linked.
happiness.”
• Enabling people to be in productive work
is a health issue
• Work provides income: material well-being
and participation in today’s society
• Work meets important psychosocial needs
in societies where employment is the norm
• Employment and socio-economic status are the main
drivers of social gradients in health
• Work needs to be ‘good work’
For those with chronic disease or disability,
Work ...
• ... is (generally) therapeutic and can lead to better
health outcomes
• can help to promote recovery and
rehabilitation
• minimises the unwanted and harmful
effects of long-term sickness absence
• reduces the risk of chronic disability
and long-term incapacity
• reduces poverty and social exclusion
• ... improves quality of life and well-being.
You do not have to be 100% fit to be in work!
Unemployment
Long-term unemployment
can lead to:
• poorer physical health
• poorer mental health
• greater usage of medical
services
• poorer social integration
• loss of worth and selfconfidence
• less monetary resources
• trans-generational effects.
Lifespan, health, work and society
The UK needs the maximum number of productive years from as
many people as possible. Those not working depend on others.
We need the ratio of earners and wealth-generators to dependants
(children, pensioners, unemployed) to be as high as possible.
Childhood
Working life
Retirement
Being sufficiently healthy is a condition for work, and
maximising healthy life as a proportion of total life is therefore
a desirable goal for individuals and society.
Prediction: the future UK population will be composed of longer
survivors, with more chronic conditions.
This is a challenge shared by many countries.
The vision
“
We want to create a society where the
positive links between work and health are
recognised by all, where everyone aspires to
a healthy and fulfilling working life, and
where health conditions and disabilities are
not a bar to enjoying the benefits of work.
”
Improving health and work: changing lives
UK Government Response to the Black Review, 2008
This vision crosses political parties and is shared across
different Departments of state.
The UK journey
In 2005 a cross-government strategy developed to :
• create employment and workplaces which both protect and promote
health, mental and physical
• enable people with disabilities and long-term conditions, especially
mental health conditions, to stay close to the labour market
• reduce sickness absence, job loss, and flow on to welfare benefits
• support people to work to a later age
• ensure all concerned with the delivery of health
understand that work is a determinant of health
• appoint a National Director for Health and
Work for five years, to support, promote
and deliver this strategic vision.
Black Review (2008)
Challenge: “The economic costs of sickness absence
and worklessness associated with working-age ill-health
are over £100 billion per year – greater than the current
annual budget for the National Health Service … Left
unchecked it will diminish life in Britain.”
Factors that stood in the way
• Culture, beliefs and attitudes
• Inadequate systems
• Work not a clinical outcome
• Lack of OH support and Primary Care involvement
• Little concern for the next generation of workers.
What prevents us from working
The two most common reasons in many countries are :
•
•
common mental health problems
musculo-skeletal problems
– High prevalence across population
– Little or no objective disease or impairment
– Most episodes settle rapidly, though symptoms
often persist or recur
– Essentially whole people, with what should be
manageable health conditions
Psychosocial factors are important :
– managerial behaviour and leadership
- organisation of work
- absence of ‘good work’
Other important reasons:
• long-term conditions – mental and physical – e.g. cancer
• lack of education and/or skills
• deprivation, poverty, lack of jobs.
Chronic conditions and ability to work
– an EU perspective
• Work disability is recognised as a
major economic and public health problem.
• Large numbers of workers are leaving the EU
labour market earlier than desirable due to
disability resulting from chronic conditions.
• In 2002, 45 million people aged 16 to 64 were
living with a chronic condition or disability,
which prevented them from fully taking part
in society and the wider labour market.
• Successful work retention involves a complex interplay of
workplace factors, including the worker’s fears of returning to a difficult
environment, and the healthcare system supporting timely and phased
return to work at a pace suited to the individual.
Cancer Survivors and Work. The Work Foundation, 2013
Chronic conditions and work
Chronic conditions are increasing – and patients surviving longer
e.g. cardiovascular and respiratory conditions, diabetes,
rheumatic diseases, and cancers.
They do not deny the possibility of fulfilling work or
an extended working life.
They require:
•
good clinical care, Vocational Rehabilitation, well- informed workconscious healthcare professionals
•
fully-informed patients, in control, co-creating health
•
flexibility and adaptation in the workplace.
Previously fatal diseases are becoming chronic.
If managed effectively, disability can be minimised and disease progress
stopped or delayed - thus extending working life and reducing the load on
health and care services.
Long-term Conditions
in the UK Working Age Population: 2030
Rheumatoid Arthritis and Work
• 50% of UK adults with RA are of
working age.
• 75% are diagnosed when of
working age
• Work disability occurs rapidly
among people with RA
• 33% of people with RA will have
stopped working within 2 years,
and 40 to 45 % by five years.
National Audit Office Report 2009
Public Accounts Select Committee 2010
RA: Early diagnosis & treatment crucial
Earlier diagnosis and appropriate treatment mean
better retention in work.
•
• Employees with RA average 40 days sick leave per
year, but those in work who respond to treatment take
only 16 days sick leave.
• Increasing from 10% to 20% the number of people
treated within 3 months of symptoms would increase
NHS costs in England by £11 million over 5 years
BUT could result in £31 million gain for the economy
due to reduced sick leave and work-related disability.
National Audit Office Report 2009
Public Accounts Select Committee 2010
Rheumatoid Arthritis and Work in UK
Hospitals and GPs
56% of hospitals were aware of Gov’t’s ‘Access to Work’ scheme, but :
- 33% of these did not give information about schemes to those with RA
- only12% of GPs gave information about continuing in employment to
those newly diagnosed
- only 20% of those with RA considered they received sufficient
information from their Rheumatology services about employment issues.
The wider costs to the economy of sick leave and work-related disability
(lost employment) amount to an estimated £1.8 bn per year.
National Audit Office. Services for People with Rheumatoid Arthritis, July 2009
Mental Health and chronic conditions
‘Body and Soul’ report (2010) explores
the connection between physical and
mental health conditions, and the
impact these conditions have on
productivity and work participation.
Findings include:
• The rate of mental health conditions is
higher among those with a chronic
physical health condition.
• Researchers understand that physical
health influences mental health and
mental health influences physical health
– For example, about 25% of people
with arthritis report a co-morbid
mental health condition.
The Work Foundation 2010
Inflammatory Bowel Disease
and Work
•
IBD affects approx. 180,000 UK people, frequently younger people including
adolescents with impact on both education and employment.
•
Study estimates total costs of Crohn’s Disease (including lost productivity,
healthcare costs etc) to be in excess of £300m per annum.
•
Prevents people from reaching their full career potential, and impacts earning
opportunities
•
Work productivity with IBD could be as much as 20% lower than among fit
employees, which translates to over 40 days of reduced productivity or absence
from work per employee per year. (Dean et al 2003)
•
These outcomes are largely avoidable and most people with IBD can
continue active and productive working lives with :
– early diagnosis
– appropriate treatment or therapy
– enlightened interventions by GPs and employers
Cancer and work
Cancer is becoming a long term condition
most frequently found from mid-life onwards.
• 109,000 working-age people are diagnosed
with cancer in the UK each year
• 775,000 people of working age in the UK
have had a cancer diagnosis
• Long term cancer survivors are 1.4 times
more likely to be unemployed yet…
• … research shows that cancer patients
want to work
• One in four long term cancer survivors say
their cancer is preventing them working in
their preferred occupation
• The average fall in household income for a
family of working age with cancer is 50%. .
• . . . and 17% lose their home.
MacMillan Cancer Support
The number of people living with
cancer is set to double by 2030
Predicted numbers:
2010 2 million
2020 3 million
2030 4 million
(with over 2.5 m diagnosed
over five years earlier)
Source: Maddams J, Utley M, Møller H. Projections of cancer prevalence in the
United Kingdom, 2010-2040. Br J Cancer 2012; 107: 1195-1202.
Cancer Survivors and Work
– what do we already know?
• The annual cost to the NHS of treating cancer in 2008 was £5.98
billion, while work participation losses from people disabled by cancer
and unable to return to work were £7.66 billion.
• Employed cancer survivors contribute £16 bn per year to UK economy .
• A meta-analysis of 36 studies: in comparison to healthy individuals,
cancer survivors have a 37% higher chance of unemployment after
cancer and a threefold risk of receiving a work disability pension.
• Cancer type, severity of treatment, treatment-related symptoms, female
gender and increased age all affect capability for work.
• Lower employment is related to work environment, managerial,
employer and social support, and accessibility of occupational health.
National Cancer Survivorship
Initiative - Results
• Pilots showed that the health-related quality of life after a Vocational
Rehabilitation intervention improved across all areas.
• The average cost of a VR intervention per patient was £850, with a range
of £380 to £1,500.
• If an individual is supported back to work, the resulting tax returns
will, on average, outweigh the intervention cost within three months.
• Thus if a person with cancer returns to work for 12 weeks that they
otherwise might not have worked, the intervention could be argued to
have paid for itself.
• Canada and Australia have also shown VR interventions to be effective.
Cancer and Work :
National Cancer Survivorship Initiative
Vocational Rehabilitation, seven pilot sites:
(tested a model of VR with information provided, face-to-face support,
access to learning programmes, and a case manager)
Five key outputs:
•
•
•
•
•
New robust model of work-support interventions
Strategic framework for planning & delivery of work-support services
An outline of specialist Vocational Rehabilitation interventions
A competency framework to underpin delivery of specialist cancer VR
Raising the profile of work-support and VR services, through the work
of the pilot sites and the three interim evaluation reports.
These findings are transferable to other chronic diseases.
National Cancer Survivorship Initiative
National Cancer Survivorship Initiative :
Health Professionals
•
Health professionals need to:
-
raise work issues early
recognise the risk factors ‘work flags’
respond effectively to patients’ queries
revisit work issues during treatment.
•
Tailor information and advice to support self-management.
•
Support specialist Vocational Rehabilitation for people with complex
problems.
•
Use protocols and procedures for effective liaison across organisations
and local statutory/voluntary services to support cancer patients in work.
National Cancer Survivorship Initiative
National Cancer Survivorship Initiative:
Employers
Employers should appreciate that patients want:
• To keep channels of communication open
• To be kept ‘in the loop’ while on sick leave
• To understand long-term effects of treatment,
fatigue etc
• Cancer not to be stigmatised
• Negotiated return to work plan, before return
• Structured schedule to talk on return to work progress
• Reasonable adjustments in the workplace
• Flexibility about hours, tasks and responsibilities in the initial months
after return to work
• Understanding of their rights under Equality Act 2010
• Employer willing to meet health professionals who have been
involved in employee’s vocational rehabilitation
National Cancer Survivorship Initiative
NCSI Recovery Package
Vocational Rehabilitation
and Work Support
Work Support :
• Level 1: All patients of working age
should be asked about work and receive
information and signposting
• Level 2: People with specific concerns
or worries should be provided with
resources to support self-management
Vocational Rehabilitation
• Level 3: A subset of people with more
complex needs should be referred to a
VR service for specialist support .
MAKING THE SHIFT
Health, Work and Well-being:
the key players
Health professionals
(Primary and secondary care)
Employers
(Workplaces, Line
managers, Human
Resources)
Employees
(Patients)
OH professionals
(less than 15% of the global workforce has access)
Government support essential
Health and Work Assessment and Advisory Service:
- intended post Black/Frost Review
Assessment
GP referral
At 4 weeks
Telephone/face-toface assessment
Identification of issues and recommendations
Work related/
workplace adjustments
Health-related
Non-work/non-health related
Intervention
Improvement/
resolution
Return to Work
Case management
Some of the Actions Required
• Re-affirm employment as a clinical outcome for chronic conditions
• The Clinical Commissioning Groups Outcome Indicator Set needs to
have employment as an outcome.
• Increase awareness of the Government’s Access to Work programme.
• Implement the Health and Work Assessment and Advisory Service to
benefit chronic conditions.
• Continue to review the Work Capability Assessment.
• Monitor the effectiveness of the Work Programme and other
government back-to-work schemes.
Cancer Survivors and Work. The Work Foundation 2013
Final thoughts....
“If you keep on doing the same
things and expect things to
change, then that’s a definition of
insanity.”
Albert Einstein
“The future has many names. For the
weak it is unattainable. For the fearful it is
unknown. For the bold it is opportunity.”
Victor Hugo