The Health Benefits of Work Dr Steven Overmeire Occupational Physician MBBS GDOEH FAFOEM (RACP) 202 Cambridge Street Wembley, WA 6014 PO Box 337 Wembley, WA 6913 T: +61 8 9381 7171 F: +61 8 6380 1507 sovermeire@oshgroup.com.au
Employment is nature's physician and is essential to human happiness. Galen, AD 129 c.201
What is the problem? Increasing demand for GP sickness certificates 1 DSP recipients more than doubled in 20 years 2 RTW rates are declining 3 1. Britt et al. GP activity in Australia 2006-07. AIHW 2008 2. National Commission of Audit - Towards Responsible Government. Feb 2014 3. WorkCover WA Statistical Report 2009/10 2012/13
% All Claims 60 40 20 0 10-'11 11-'12 12-'13 maintained at work returned to work not working % Lost Time Claims 80 60 returned to work Source: WorkCover WA Annual Statistical Report 2009/10 2012/13 40 20 0 10-'11 11-'12 12-'13 not working
Increasing work absence Long term worklessness Source: WorkCover WA Long duration claims in the WA Workers Compensation Scheme 2009/10 2012/13
The evidence UK 2006: Dept for Work and Pensions Independent review of evidence on work, health and well being Best Evidence synthesis of >400 references Focus on common health problems mild/moderate musculoskeletal, mental health conditions
Adverse health consequences of long term worklessness Increased mortality (CVD, lung cancer, suicide) Poorer general health Poorer physical health (HT, respiratory disorders) Increased psychological distress (self esteem, anxiety, depression) Increased somatic complaints Higher rates of medical consultations, medical consumption and hospital admission Source: Waddell, Burton 2006 Is work good for health and wellbeing?
Benefits of re-employment Improved self esteem, self rated health, self satisfaction Improved general and mental health Improved physical health Improved physical functioning Improved financial status Reduced psychological distress, psychological morbidity Source: Waddell, Burton 2006 Is work good for health and wellbeing?
Evidence for Common Musculoskeletal Conditions Most people with symptoms can and do work Modest risk of MS symptoms with intense physical exposures at work Psychosocial factors are strong determinant of disability Overcoming psychosocial barriers improves pain, disability and sick leave Activity based rehabilitation and early return to/maintenance at work are therapeutic and beneficial for health and well being Reducing physical demands at work can facilitate work retention Transitional work arrangements and improved communication between health care provider & workplace can facilitate early, sustained RTW Source: Waddell, Burton 2006 Is work good for health and wellbeing?
Main Findings Strong evidence that work is generally good for physical and mental health and well being Worklessness is associated with poorer physical and mental health Work can be therapeutic and reverse the adverse health effects of unemployment Overall, the beneficial effects of work outweigh the risks of work Source: Waddell, Burton 2006 Is work good for health and wellbeing?
Recent Systematic Review - 1 Am J Public Health 2012; 102:541-556 18 high quality longitudinal studies, incl 1 RCT (English, French, Spanish) 15 showed health benefit of RTW after unemployment, 3 no effect Return to work programs may improve not only financial situations but also health
Recent Systematic Review - 2 Occup Environ Med 2014;71:730 736 Meta-analysis of 23 high quality longitudinal studies (English, German, Dutch) Strong evidence for protective effect of employment on depression, general mental health Weaker evidence for effect of employment on physical health, mortality Overall beneficial effects were found of employment on health
Realising the Health Benefits of Work AFOEM Position Statement, 2010 Call to action given poor RTW/health outcomes Using evidence to promote consensus on health benefits of work among health care organisations, service providers, unions, insurers/re-insurers, employers and statutory authorities Goal to assist people to stay in or return to work Recommendations for employers and health professionals
Realising the Health Benefits of Work AFOEM Consensus Statement, 2011 shared desire to improve the welfare of individuals, families and communities Over 100 signatories, Signatory Steering Group Forum to share information, collaborate on best practice Related position statements: Vocational rehabilitation case conferencing Helping people return to work What is good work? Improving workforce health and workplace productivity
It has to be good work Some work can be harmful to health Work should be safe Work should be of high psychosocial quality: demands / control effort / reward support & relationships security
The psychosocial work environment matters Mental health score change after RTW Source: Butterworth et al. The Psychosocial quality of work determines whether employment has benefits for mental health: results from a longitudinal national household panel survey. Occup Environ Med 2011; 68:806-812
The important role of employers work practices, workplace culture, work-life balance, injury management programs and relationships within workplaces are key determinates, not only of whether people feel valued and supported in their work roles, but also of individual health, wellbeing and productivity the spirit in which employers meet their statutory obligations has a significant impact not only on health and employment outcomes, but also on productivity and profits AFOEM Realising the Health Benefits of Work 2010 Move beyond physical RTW measures, embrace soft health & safety measures positive workplace culture, supportive leadership, procedural fairness & value personal growth
The important role of treating doctors Gatekeeper to the system Strong influence on patients beliefs Strong influence on RTW: 2x as likely RTW if GP provided guidance to prevent recurrence and re-injury 2x as likely RTW if GP contacted the workplace 3x as likely RTW if GP set a date of safe RTW Kosny A et al. Early Healthcare Provider Communication with Patients and Their Workplace Following a Lost-time Claim for an Occupational Musculoskeletal Injury. J Occup Rehab 2006; 16:27-39
But many GP s Don t consider it their role to manage work absence Feel conflicted patient advocacy vs. legal responsibility Are protective of doctor-patient relationship Have poor appreciation of therapeutic value of work Have poor understanding of their impact in WC System Find it difficult to determine work capacity Don t trust employers to do the right thing AFOEM Realising the Health Benefits of Work 2010 Dunstan D. Are Sickness Certificates Doing Our Patients Harm? AFP 2009; 38:61-63 Black C. Health Benefits of Work. Presentation to AFOEM, Wellington 1 April 2015
The importance of early RTW The longer someone is off work, the less likely they will ever return, regardless of cause 20 days off work 70% chance of returning 45 days off work 50% chance of returning 70 days off work 35% chance of returning Likelihood of return to work after various length of time off work Source: Johnson D, Fry T. Factors Affecting Return to Work after Injury: A study for WorkSafe Victoria. Melbourne Institute of Applied Economic and Social Research; 2002.
The importance of psychosocial factors Strongly influence on musculoskeletal disorders, chronic pain By 12 weeks, more important determinant of work disability than medical or injury factors Predictive of RTW outcome Can be modified if identified early, become entrenched if not Formal e.g. Örebro MPQ (4 12 weeks) Informal Do you expect to return to work? Do you like your job, feel valued? Is your job secure? Do you feel depressed? INDIVIDUAL WORKPLACE Main, C. J et al. BMJ 2002;325:534-537
Systemic issues for GP s Time Average consultation time = 6-7 min Time needed to address psychosocial issues, education, advice Time consuming paperwork, telephone discussions Training Occupational health, workers compensation, capacity certification Musculoskeletal medicine, psychosocial management Remuneration Favours rapid turnover, scripts, referrals vs. problems solving, holistic care
The treating doctor as a barrier Inadvertently, treating doctors can exacerbate psychosocial barriers & disability 2 common problems (my observations): Narrow clinical focus structure vs function increases fear avoidance Unfit certification reinforces misconception that work is harmful prevents management of return to work
Certification of capacity Sickness certification is a major clinical intervention with potentially serious long-term consequences Dame Carol Black Working for a healthier tomorrow (UK) 2008 there is a substantial discretionary element to work absence medically unnecessary disability AFOEM Realising the Health Benefits of Work 2010
Certification of capacity Initial medical certificates: GP influences for certifying unfit: 74% 3% 23% ALT DUTY UNFIT FIT Perceived physical capacity 79% Willingness to RTW 56% Enjoyment of their job 36% Relationship with employer 35% Relationships at home 16% Collie A et al. Sickness Certification of workers compensation claimants by GPs in Victoria, 2003 2010. MJA 2013; 199:480-483c Sleigh K. Sweeny GP RTW Survey Presentation to PIEF, 20 April 2015
Certificates of Capacity Focus on what patient CAN do Prompt to identify non-medical barriers Reference to Health Benefits of Work Followed Fit Note introduction in UK 2008 UK results so far disappointing More needs to be done
Guidance for health care practitioners 1. Measure and demonstrate effectiveness of treatment 2. Biopsychosocial approach 3. Empower worker to self manage 4. Goals focused on function, participation, RTW 5. Base treatment on best available evidence
AFOEM recommendations that education of treating practitioners incorporate training in workplace occupational health and vocational rehabilitation and sickness certification practices, and that the medical community provides leadership on these issues Health professionals responsibly promote the health benefits of work to their patients AFOEM Realising the Health Benefits of Work 2010? Need for GP training, accreditation, incentive-based fee structure? Will it make a difference
Key messages Good work is good for health and wellbeing Work absence is detrimental to health and wellbeing Psychosocial factors need to be addressed employers & doctors GP s are in a powerful position to influence outcomes GP s need training and incentives to improve certification practices Medical system alone cannot solve problems of work incapacity
Thank you Dr Steven Overmeire Occupational Physician MBBS GDOEH FAFOEM (RACP) 202 Cambridge Street Wembley, WA 6014 PO Box 337 Wembley, WA 6913 T: +61 8 9381 7171 F: +61 8 6380 1507 sovermeire@oshgroup.com.au