The time-off trap

Getting back to work after an illness or injury often gets low priority, but take too long and you may never return.

Being a train driver on the London Underground was Dame Carol Black’s idea of a dreadful job. Repetitive, monotonous, with restricted movement and no natural light, it so epitomised her idea of “bad” work that, as the UK’s first national director for health and work, she asked to go on a shift with a train driver to see how awful it really was.

“I knew he had the same route each day. He did the Bakerloo Line from Baker Street tube station, and I said to him, ‘Wouldn’t you like a week above ground? Wouldn’t you like a different route? What about going out to Richmond?’”

“In the end he said, ‘Look, it’s my train. Nothing happens on this train without my say-so. I’m responsible for the safety of my passengers, I give out all the notices. I like my route. We’re a team. We’ve got good occupational health, I don’t want to work above ground. And, I’m well paid.”

What Black learnt from the train driver is that “good” work is not about whether a particular task is pleasant; instead, it’s about employees being trusted and valued, and having good management and organisation at work, a safe site and work practices and at least fair pay and conditions.

What Black has also learnt and become passionate about are the health benefits of working – and the adverse effects of not working. Both have been under ­discussion in Australia and New Zealand during the writing of the consensus statement on the Health Benefits of Work, whose recent launch brought Black to Wellington. The statement’s signatories include the key organisations representing doctors, nurses, physiotherapists, employers, unions and the Government.

In signing up, all have acknowledged that even though evidence shows people are better off in work, and worse off out of it, the system is not working. Getting back to work after an illness or injury does not get the health priority it should.

This happens even though the evidence is stark that the longer people spend away from work, the more likely they are never to return. The statement cites inter­national research showing that if a person is off work for 20 days the chance of ever getting back is 70%. For those off for 45 days, the chance is 50%, and those off for 70 days have just a 35% chance of returning.

Some of them, of course, have been too badly injured to be able to work again, but for many, their prolonged absence is a result of not medical reasons but “­psychosocial” problems. Eventually, not getting back to work can become a route to long-term benefit dependency, with all the associated detrimental effects on health, finances and lifestyle that brings.

“We know from our UK figures that if you’ve been out of work for two years – and by then you’d be in our benefit system – you’re more likely to retire on a benefit or die in the benefit system than you are to go back to work,” says Black. “That’s grim.”

The picture is no rosier in New Zealand, warns Accident Compensation Corporation director of clinical services Dr Kevin Morris. He says the average time people have off work after an accident notified to ACC is several months.

“That’s the sort of scale we are dealing with. We know a lot of those people are translating through into longer-term worklessness and we know now quite clearly the downside of that. The health effects are very significant and they’re not just minor mental health issues; they relate to mortality – death – by suicide and by a whole range of other causes so we’re dealing with something we can’t ignore.

“My message to GPs is usually that if you’re prescribing time off as a health intervention, you must understand the negative consequences, the side effects of that, as well as the benefits, and balance them up, just as you do with medication.
“The bit that has been missing for doctors is that the scale of the negative effects of worklessness has not really been appreciated.”

Occupational medicine specialist Dr David Beaumont would also like to see doctors treating a medical certificate with more caution. “If you go and see a doctor, he might say, ‘Right, I’m going to put you on a course of steroids but I can only give you two weeks because after that the side effects become really significant and we don’t want to risk that.’

“I would like to see GPs and their patients understand that there is also that same risk in a medical certificate – so they issue it but say, ‘I am only going to give you a couple of weeks off work because after two weeks it is going to become very difficult for you to get back to work and lots of other factors are going to start kicking in.’ That’s the sort of discussion that needs to become easy for GPs to have with their patients.”

Black acknowledges the notion that work is good for your physical and mental health and not having a job is bad for you sounds simple. “But it’s not in the education of any healthcare professional either in your country or mine.

“There is no problem in a GP or a doctor or a physio or a nurse understanding that smoking is bad for health. Whether you smoke or not, you understand that. But work? It is not seen as a determinant of our health.

“The determinants of our health are [seen as] our education, whether we live in poverty, whether we’re socially isolated, etc. Being in work is not seen like that. We need to enable our health professionals to see work as a function of a clinical outcome, so that when you have an encounter with your doctor, it should also include whether you are in work and how they help you stay there.”

GPs are not only the gatekeepers of medical certificates, but also gatekeepers of the welfare system. And those statistics show more and more people are being signed up for sickness and invalid’s benefits even though there is no related evidence that New Zealanders are on the whole getting sicker.

In the 12 months to March 2010 alone, the number of people on the sickness benefit rose 5000, or 9%. Over the previous five years, the number of working-age people receiving this benefit climbed from 44,000 to 56,000. At that time, more than 40% of people on the benefit were entitled to it because of psychological or psychiatric conditions, with the second most common reason musculoskeletal disorders, including sore backs and necks. In the same five-year period, the number of people on the invalid’s benefit has also increased – from 72,000 in 2005 to 85,000 at March last year. In 2007, one in eight households had no one in work.

Further, according to research prepared for the consensus statement, a survey of workers with work injuries shows that return-to-work rates are declining. Last year, 25% of New Zealanders who were injured at work were not in paid work six months after lodging an accident compensation claim. The statistics may indicate that doctors are certifying patients unfit for work, and thereby making them eligible for either benefits or ACC payments, when many of those patients might have at least some capacity for some type of work.

Dr Kristin Good, a trainee in occupational medicine, recently did some soon-to-be-published research into the attitude of GPs towards certifying patients fit for work.

After conducting focus groups with doctors, she sent out about 280 questionnaires, and had a 93% response rate.

“I asked, ‘How often do you think what you write on a medical certificate is a compromise between what you think is wrong medically and what is a non-medical factor?’ And something like 86% of the certificates they write are not based on medical facts. They are related to things like kids at home, bad job – there were about 10 non-medical factors that doctors considered.

“The vast majority of GPs said, ‘When I am making a decision about what to write on here, I think about everything: the house they come from, the family situation, whether there is stress in the workplace unrelated to health.’ It’s very complex.

“But if you have a system that doesn’t support people to get back to work – which according to my research includes the employer and Winz – you’re not going to get the GP buy-in, because they are disadvantaging their patients by certifying them fit to work if there is nowhere for them to go.”

She said GPs also thought employers were not interested in having discussions with them, and wanted people back at work only when they were 100% fit.

“So overall, GPs felt one of the biggest problems was a lack of employer buy-in to this process. They weren’t prepared to compromise and they weren’t prepared to have a relationship with GPs – 2% of GPs said they had ever been contacted by an employer to discuss the situation.”

Good says part of the problem may be that both GPs and employers are busy, and also there are fears of people injuring themselves if they return to work with only partial fitness.

“It has cost implications and hassle implications, and employers worry their ACC levies will rise – I think that’s where the next lot of research should be, around GPs and employers, because it’s huge
and consistent across all the groups.

‘But another major thing that almost every doctor said is the problem with Winz. The problem is not with ACC, and I’m not saying that just because I work for them, but the research shows GPs have no trust in the Winz process. Winz doesn’t offer [its clients] training or vocational rehabilitation.

“GPs tell me that when they have written something on the bottom of a form for Winz, like ‘this person needs a case manager’, or whatever, not a single one of those comments was ever followed up. Also, at Winz, there is not a case manager allocated to each person – you just talk to whoever answers the phone on any particular day, so no one’s looking after the people. They have case managers but individuals aren’t allocated to them.

“It surprised me, but GPs say they are overall happy with the ACC process but something like 96% had no trust in the processes at Winz.”

Good said Winz recently introduced a fit note, “but it’s four pages long on a computer with a drop-down menu, and if you don’t click them it wipes everything and you have to start again. Who, in a busy surgery, is going to support that on a daily basis? It’s just a waste of time.” The British form, Good says, is one page.

Winz head Mike Smith said there was no question that paid work was good for health. The research was clear and Winz was a signatory of the consensus statement.

Winz’s principal health adviser, Dr David Bratt, ­surveyed more than 800 GPs throughout the country last year. Smith says the “vast majority” had been pro­actively contacted by Winz, and the GPs valued that contact.

Clients with medical issues could have designated case managers who knew their history, he says, and GPs had endorsed that approach.

Winz used the information doctors provided so case managers could decide what support was best to help clients find employment. That could include vocational training, rehabilitation service and employment-related activities.

The Council of Trade Unions is a signatory to the new consensus statement but CTU president Helen Kelly says the decision to sign was not without controversy within the organisation. There was no question that what is in the statement is good, she says, and good people are promoting it.

But it comes in a climate where she says employees are increasingly being seen not as in a relationship with employers, but as beneficiaries of employers’ charity.

“I think there’s a narrative in New Zealand where employers are benefactors, and they are providing jobs as some sort of charity. You could see it manifested in the Hobbit dispute – ‘Peter Jackson is providing 2000 jobs for New Zealand, how dare those uppity actors want to collectively bargain, they’re ungrateful, they should be grateful for the work.’ They are somehow seen as the beneficiaries of this benevolent act.

“The narrative is that you are lucky to have a job, and it doesn’t matter if that injures you, the pay’s crap or it’s bad for you, you should be grateful. In that framework it is very difficult to improve productivity. This is affecting the whole economy, in my view.”

Kelly says the labour climate was illustrated when the minimum wage rose 25c an hour, “and TVNZ ran a news story of two McDonald’s workers saying the rise was insufficient – the headline was ‘Biting the hand that feeds them’. “This was seen as McDonald’s feeding these workers with charity and the workers should not bite the hand that feeds them by asserting that they actually want to get paid more than $13 an hour. It’s a very strong and powerful narrative that makes unions look like intruders and makes workers look ungrateful if they challenge that model.”

Kelly says it’s also worth noting that since the Pike River disaster, and excluding those killed at work in the Christ­church earthquake, 12 people have died in workplace accidents. She says it’s important to note that the consensus statement says that work is “generally” good for health and well-being. As Carol Black acknowledges, there is a difference between good and bad work.

Kelly says the statement comes on top of the CTU’s concerns about the new “experience rating” of workplaces for workplace insurance – unions fear workers will go without rehabilitation – and the recent report of the Welfare Working Group is also putting more emphasis on paid work.

Workers must be able to have a say in their own treatment, she says. If it was in the best interests of a patient that his or her medical certificate be extended, then a doctor should extend it.

“We don’t want the model to be that employers are encouraged to take workers back to work when they are injured. We want the model to be workers, employers and doctors working together, recognising the health benefits of work and together working out how to facilitate that as quickly as possible.”

Kelly likes the current ACC pilot programme Better at Work, which involves intensive intervention to get people back to work when ready, even if it means support in finding a worker a new job with a different employer. The programme, which is running in Taupo, Hawke’s Bay and Auckland, “is a very good model because the doctors employ expert occupational therapists who go out to the employer after an employee has had an accident and ask, ‘What can the employee do?’
“They might have a broken arm but it doesn’t mean they can’t walk, or they can’t see or they can’t serve or they can’t do a whole range of other things. It does possibly mean they can’t drive the forklift any more until their arm is healed. What that model has is the doctor acting in the interests of the patient, but the doctor is trained to understand that means getting them back to work.”

Dr David Beaumont is chairman of the policy and advisory committee of the Australasian Faculty of Occupational and Environmental Medicine, which, along with the Royal Australasian College of Physicians, has been a driver of the consensus statement.

He says no one asked the faculty to lead the development of consensus, but the current situation was failing and no one was doing much about it.

“So, why us, why should we do it? Well, as occupational medicine specialists we see and assess people who’ve been off work for longer periods of time than would be expected for that medical condition. We work to the bio-psychosocial model, which says that the longer somebody is off work, the more likely that the issues stopping them getting back to work are not medical, but psychosocial.”

Psychological beliefs, loss of con­fidence, loss of self-esteem, social factors, development of benefit dependency and pressures from family and communities all act as barriers to people getting back to work, he says.

“We see exactly where things go wrong. It might be in terms of a person’s workplace environment because the employer hasn’t adapted the workplace to allow them back into work. Or it could be that treatment factors are missing, perhaps in terms of addressing some psychological issues. Or it may simply be that the person has lost confidence and the GP has found it difficult to sign them off to return to work.

“Medical certificates in the UK have been a really big issue and Dame Carol Black’s review has led to the statutory change from the UK sick note to the fit note, whereby the GP has to look at the person and say, ‘How does your condition affect you and what are you capable of doing at work?’, rather than the medical certificate here in New Zealand which says, ‘No, you can’t work.’”

It’s not difficult to spot problems developing, he says. It might be a patient who has had a complex fracture of the ankle. Three months on, the doctor would expect the patient to be back at work, or ready to return, “but instead they are starting to talk as though they are not expecting to go back. They’re now starting to say they didn’t like their job in the first place, they hated their manager and, actually, being home is fitting in well with childcare.

“Suddenly, at that point, the GP needs to be saying, ‘I need help with this one. I need someone to step in and do more assessment and give advice.’”

That is the type of work Beaumont does, “but quite often we see people at six months or 12 months or 18 months and by then I’m tearing my hair out and saying why weren’t we involved earlier?”

He says it’s far easier to get a second opinion on work fitness in the ACC system than through Winz. But for doctors dealing with their patients, it is not always straightforward. Doctors can face an inherent conflict in their advocacy role on behalf of patients, especially when dealing with ACC, Winz and employers.

Beaumont says he has even seen GPs go as far as saying the best thing is for their patient to be left alone as a long-term beneficiary.

That was why in the UK, GPs are now using “consultation scripting” to learn to hold conversations with patients that otherwise might be difficult.

“The GP role in all of this is fraught with problems,” he says. “We’ve highlighted the issue and what we’ve found is that everybody knows the current system lets down individuals and leads them down a track of long-term benefit dependency. Everybody has a part to play in the system that’s currently not working properly, and we’re saying all that is required is a paradigm shift in thinking, so rather than saying, ‘You have to be 100% fit to get back to work’, the starting point should be, ‘‘Okay, what is the best thing for you? What is the best thing to help you get back to work because it’s got to be to the benefit of you and your family. It’s about your quality of life.’”

He thinks the risk of privacy breaches if GPs talk to employers is a red herring, and communication is one of the most important ways to get people back to work.

“If someone has fractured her ankle, I might be able to speak to her employer and say, ‘She’s now able to walk around with one stick, and if it’s possible for you to give her a closer car park, then I’ll sign her off to return to work next week on that basis.’

“It can be a two- to three-minute conversation. It could be that simple. But the longer it is down the track, the less likely it is to be simple.”