Health Works

Supporting Health In

Working Age

Setting the Scene

Roddy DuncanScottish Government

Approx 2.5 million people in Scotland of working age

>70% in employment

Cost of ill-health approx. £10 billion p.a. to economy

Approx 250,000 on incapacity benefit/ESA

1 in 6 working people have poor mental health

Some Numbers:

Meets important biopsychosocial needs

Sound evidence base

Most people capable of undertaking some type of work

Most people with health conditions want to work

Poor work/working conditions can affect health

Poor health can limit ability to work

Work1 is good for health:

1. By work we mean, more generally, any activity that give purpose to life. This could be paid work, volunteering or caring duties, for example.

Health Works – a patient centred approach to healthcare

Needs a change in culture – work outcomes for patients

Efficient and effective – opportunity to avoid over-medicalisation: biopsychosocial approach

Importance of working in partnership – focus on successful outcomes for patients

Quality Strategy:

For Patients – faster, direct access to treatment; positive advice and support; faster, fuller recovery; keep job and earnings; sustained independence.

For Health Boards – efficient use of resources; reduced waiting times; reduced prescription costs; reduced inappropriate diagnostics; reduced repeat visits.

For Scotland – reduced sickness absence; improved productivity; reduced demand on public services; increased workforce participation; increase in people managing own health.

Benefits:

Some examples of activity in Scotland that is translating the ambitions of Health Works into practical examples of patient-centred, effective and innovative healthcare services.

Putting it into practice:

The National Musculoskeletal (MSK) Programme

Dr Sarah L Mitchell

National MSK Re-design – Part of Health Works

Focus on local services redesigning their MSK pathway around patients

Focus on employment, the ‘Scottish Offer’

Focus on developing a national point of access to local MSK services

Focus on developing interdisciplinary teams delivering MSK

Why are we re-designing our MSK services?

People in Scotland with MSK conditionscurrently experience…..

Variable access to MSK services Variable managementVariable measurement of outcomesNo formal assistance with helping people back to work or into work

And sometimes…long waits for these variable services

………………we could do so much better.

Impact of MSK conditions

MSK – most commonly reported type of work related illness and take up more than 30% of all GP consultations.

Prescription costs for MSK

Result in loss of 12.5 million working days lostLow back pain is the most common musculoskeletal problem affecting an estimated 18 million people, with associated costs of £7bn p.a. to the economy due to working days lost.

What are we proposing?

• A National MSK Triage and Referral Management Service for NHS Scotland delivered within NHS 24

• Local referral management hubs within boards

• Direct referral into WHSS for those working in SMEs

• Development of Interdisciplinary pathways using evidencebased outcome measures

• Development of algorithms within pathway to ensure correct service provision

• Early identification of employability issues, anxiety depression scores

Evidence states that:

Approx 30% people only need advice and information

NHS 24 non clinician pathways are safeSTaRT Tool - KeeleFree up frontline resources

Rationale of Approach

Using a central referral system will...

Provide fast access to information and consistent national approach

Advice and Information Resources

Patients need information to support self management

Need for national resources that provide high quality, consistent information

NHS inform can fulfil that role:

Scottish Backs, neck, knee, shoulder sites, VideoPhysio, PhysioTools, Back in Control

….is a national service helping you to find amongst other information how to access public services and search for local

information and advice.

Access to Scottish Backs and NHS inform via digital TV

Text NHS 24 to 61061

http://lookinglocal.gov.uk/digitv/cds/nhsscotland/Netgem/home.html

MSK Service re-design – New process

Self Referral (est. 15,000 patients)

Call handler takes call (8x Band 3)

MSK Triage Form filled in by call

handler (WTE x3 on hand for

support)

Patient entered into SCI Gateway

(by Joint, Medium/High)

Review previous 24 hour referrals

into SCI Gateway.

Patient allocated appointment slot

(Band 2)

TRAK – automated letter sent to patient

(and communication sent to CRMS)

GP directed to Self Referral

number

First ContactAHP telephone

consultation and EQ5D

WHSS (est. 5%)(exit from system)

GP referral through SCI

Gateway (est. 30,000 patients

Emergency Numbers

Central Referral Management System (NHS24) HUB(based at Referral Management Centre - TBC)

Low – routed self-management(exit from system)

MSK Service re-design – New process

First ContactAHP telephone

consultation and EQ5D

HUBFirst Contact

Physio assessment(EQ5D and

outcome measures)

First ContactPodiatry

assessment(EQ5D and

outcome measures)

First ContactOT assessment

(EQ5D and outcome

measures)

Self Management and exit from

systemEmployability Services

Available Services

TRAK – automated

letter sent to patient (and

communication sent to CRMS)

TRAK / CESInfo. dump

A&E

Leisure

Older People

Services

Mental Health

Vocational Services

Rheumatology

Community Pharmacy

Pain Services

Dietics

Ortho

2nd AHP Appointment (intervention)

    

NHS24

Phone Consultation (1st appointment)

Direct appointments made at hub

LBP pathway

30%8,250

‘NHS Lanarkshire Referral Hub’ up to 27,500 clients

Require MSK services

WHSS1-2%

Approx 260-575

SME + AbsentAny joint

Self management•Self mgmt advice•Community programmes•Web support – NHS inform12,000 clients

All pathways will include ability to refer into the following services at any point in pathway even after first appointment / telephone consultation:•Pain Services– 8%, 1,100•Mental Health Support – including breathing space, case management, mental health teams – 10%, 1,375•Employability support – 10%, 1,375•Self management – including community leisure programmes and third sector programmes – 10%, 1,375•Rheumatology services – trigger questions agreed. – 1% 137

All pathways will include ability to refer into the following services at any point in pathway even after first appointment / telephone consultation:•Pain Services– 8%, 1,100•Mental Health Support – including breathing space, case management, mental health teams – 10%, 1,375•Employability support – 10%, 1,375•Self management – including community leisure programmes and third sector programmes – 10%, 1,375•Rheumatology services – trigger questions agreed. – 1% 137

Knee pathway

20%5,500

Neck pathway

10%2,750

Shoulder pathway

15%3,575

Hand pathway

5%1,375

Hip pathway

5%1,375

Foot and ankle

pathway15%3,575

Referrals made directly into hub from GP services and other hospital services i.e. A&E, orthopaedics

Referrals made directly into hub from GP services and other hospital services i.e. A&E, orthopaedics

Key Performance indicators to include:    

           

# referrals into secondary care    

# GP MSK consultations        

Improved patient experience

Physio (MSK) demand        

Mental Health referral

# referrals into employability services  

Reduction in prescription charges

Reduction in investigations      

Functional improvement outcomes

DNA rate                

Baseline Activity Carried out in NHS Lanarkshire 

Measurement of outcomes on all patients attending physiotherapy for 1 month – using EQ5D

Measurement of the HADS score on a selection of patients attending physiotherapy.

Measurement of patient experience   

EQ5D Analysis – JOINT

EQ5D Analysis – Employability Status

EQ5D Analysis – Employed Population Hours Worked %

EQ5D Analysis – Unemployed Anxiety/Depression Scores

EQ5D Analysis – Low Back Pain

Develop national Advice and Triage service during 2011

Enhance current out of hours protocols during 2011

Systems piloted in Lanarkshire and Lothian from autumn 2011

System evaluation – Spring 2012

Report consideration and national roll out

Resource pack and support

When will all this happen?

Equitable access for MSK patients to appropriate

management options

Consistent, high quality information and advice

developed and adopted across NHSScotland

Enhanced user experience

A true health/employability pathway

££££ savings??

Proposed Major Deliverables of Pathway

NHS Quality in Action

Scotland’s Bio-Psychosocial Service:National Fit For Work Service

Mark KennedySalus Occupational Health

NHS & Economic Growth

• Supporting Healthy Workforce• Reducing Absence• Ensuring those wishing to work are able to

work• Increasing Resilience

Salus – Bio-Psychosocial Model

• Case Management Service…– Supporting employability agencies across

40% of the UK– Central to the National Fit for Work

Programme – Working Health Services Scotland (WHSS)

– Core of NHS Lanarkshire’s Attendance Management service

Principles of BPS Model• Person Centric

– Engages patient (& family) in multiple ways• Medical (conditions/disease)

• Attitudinal (behavioural, victim syndrome, addictions)

• Social (Relationships, housing, debt etc)

• Single Case Manager• Assesses (validated clinical tools – pre &post intervention)

and co-ordinates all aspects of care

• Single point of contact and solution focused

• Motivates/advocates and maintains direction

• Early Intervention

• Telephone based• Delivered by both clinicians and non clinicians• Web based dataset (paperless)• Has a framework of supportive

agencies/interventions (physiotherapy, counselling, debt advisors, employment advisors etc..)

• Highly Efficient • CM caseload = 200-250 patients per annum• 9% DNA• Appointed within 2 days• Longest wait for intervention = 5 -7 days

Working Health Services Scotland

• Scot Gov & DWP funded

• Support to individuals employed within SMEs

• Eligible - Those sickness absent or at risk of sickness absence

• Central Hub supported by 14 regional Health Boards

WHSS - Results

No. of Referrals by Month

0

50

100

150

200

250

300

350

Month

No

. o

f R

efe

rrals

Heard about Service No of Referrals Received No of Referrals Engaged GP 1136 1098 Employer 58 55 Self Referral 616 614 Other 703 667

Total 2513 2434

28% of individuals were absent on engagement – 62% at risk of absence

78% present with MSK problem, 15% mental health, 2% Cardio-vascular (5% other)

Salary Scales

403

986

705

49 20 3

268

0

200

400

600

800

1000

1200

<£10k £10-20k £21-40k £41-60k £61-100k >£100k Unknown

Tackling Inequalities

EQ5D Deterioration Same Improvement McNemarMobility 28 ( 3%) 619 (64%) 323 (33%) p<0.001Self Care 24 ( 2%) 711 (75%) 232 (24%) p<0.001Usual Activity 23 ( 2%) 357 (37%) 589 (61%) p<0.001Pain 15 ( 2%) 378 (39%) 577 (59%) p<0.001Anxiety 23 ( 2%) 586 (61%) 359 (37%) p<0.001

VAS 94 ( 10%) 81 ( 8%) 786 (82%)

COPM"Clinically Significant" Deterioration Same

"Clinically Significant" Improvement

Performance 9 ( 1%) 244 (27%) 645 (72%)Satisfaction 5 ( 1%) 174 (19%) 719 (80%)

GHQ12 Pre (mean) Post (mean) Paired t-testLikert 16.9 8 p<0.001

Deterioration Same Improvement McNemarBimodal 6 ( 1%) 218 (44%) 273 (55%) p<0.001

Able to Job 6 Months Time

1153

41

285

0

200

400

600

800

1000

1200

1400

Yes No Unknown

• From a sample of 450 records:– 98% of clients reported that the service has had a

positive impact on their current work situation– 99% of clients would recommend the service to

others– 100% of clients rated their experience of case

management as excellent (86%) or good (14%)– 100% of clients stated that the support they

received was excellent (89%) or good (11%)

NHS Lanarkshire – Attendance Management

• Traditional model =– 1 week Self Certificate– At 28 days of absence- “long term” – refer to

Occupational health– Further 5-10 days to appoint – Total approx 38 days absence – circa 8 working

weeks

• Salus NHSL Model– Early intervention

• Absentee called at home on day 1,3 & 10

• Referred to Occupational Health at day 11

• Nurse led from day 11

• Case Manager appointed to complex cases

• Frequent case conferences with HR

NHS Lanarkshire – Attendance Management

NHS Lanarkshire and NHS Scotland excluding NHS Lanarkshire: SA Rates before and after the introduction of EASY (SWISS)

3.74%

6.84%

3.00%

4.00%

5.00%

6.00%

7.00%

May

June

July

Aug

Sep Oct

Nov

Dec Jan

Feb

Mar

Apr

May

June

July

Aug

Sep Oct

Nov

Dec Jan

Feb

Mar

Apr

May

June

July

Aug

Sep Oct

Nov

Dec Jan

Feb

Mar

Apr

May

June

July

Aug

Sep

2007 2008 2009 2010

Quality Ambition• Most appropriate treatments, interventions, support and

services will be provided at the right time – wasteful variation will be eradicated.

• Incorporates Innovation (tele & web)• Partnership (14 HBs and many public, private and 3rd

sector support agencies)• Person Centric- patient at core of all decisions• Measurable • Inexpensive

Vocational Rehabilitation is everybody’s business

(DVD)

Judy GibsonScottish Government

Wider Context and Conclusions

Roddy Duncan

Christie Commission – Efficiency and Effectiveness; customer-led

Welfare Reform – reduce barriers to work?

Fit Note – Encourage doctors to discuss return to work

Employers – Create positive, supportive workplaces

Wider context:

Work is a key social determinant of health

People do not need to be fully “fit” to be in work

Return to work can be part of the recovery process

All healthcare professionals have a role to play

Need to learn from current good/innovative practice

Conclusions:

Find out who your Board’s lead for Health Works is.

Find out more about current health and work initiatives.

Discuss within your Board how you can adopt and

introduce patient-centred, work-outcomes focussed,

care pathways.

Practitioners – consider work status in routine practice

Speak to those who are already doing it

What you should do:

Q&A

Links and further reading:Scottish Government Health and Work Web Pages:http://www.scotland.gov.uk/Topics/Health/workingage-1

UK Government Health Work and Wellbeing Strategyhttp://www.dwp.gov.uk/health-work-and-well-being/

Scottish Centre for Healthy Working Liveshttp://www.healthyworkinglives.com/

DWP Guidance on Fitnotehttp://dwp.gov.uk/healthcare-professional/news/statement-of-fitness-for-work.shtml

Healthcare Professionals Consensus Statement:http://www.dwp.gov.uk/docs/hwwb-healthcare-professionals-consensus-statement-04-03-2008.pdf

Health & Work Continuum

In workOut of

work – on benefits

IncapacitatedSafe & Healthy

At risk of losing work

Ill/InjuredShort-term absence long-term absence

£ ££££

Cost to society