12 October 2004
Alan Johnson MP, Secretary of State for Work and Pensions
Pathways to Work: Enabling Rehabilitation
Royal Society of Medicine
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I’m very pleased to have this opportunity to talk to you – and grateful to the Royal Society of Medicine for hosting, what I hear from Mansel, has been a very productive day.
I am a huge admirer of the UK medical profession; the work that you do and the results you achieve – which like all MPs I hear about from constituents on a daily basis.
I’ve always cherished the provision of high quality healthcare based on need rather than on ability to pay. Our National Health Service is the envy of the world.
But just as this provision of healthcare is central to our values – so is the opportunity to work.
Work brings a range of benefits to individuals, apart from money. It provides people with a sense of dignity and purpose, brings opportunities to meet new people, develops new skills and gives something back to the community – all of which can help boost an individual’s confidence and self-esteem.
By contrast, periods of unemployment or inactivity can be damaging to both mental and physical health at all ages. For example, with mental health, suicide rates are 35 times higher among the long-term unemployed than the employed.
Today I want to talk about what more we can all do to help people stay in or return to work when they suffer sickness, injury or disability. This is the key challenge still facing us in delivering real opportunity to work for all.
We know that nine out of ten people who come onto Incapacity Benefit want, and expect, to go back into employment. They do not want to be abandoned as passive recipients of benefits disengaged from society. What’s more their aspiration can be met if the right help and support is offered early in their claim. So we begin from the premise that our role is to facilitate a return to work.
This involves:
- early intervention when someone falls ill;
- challenging psychological barriers that face the individual – often encouraging people back to work much more quickly than they would otherwise expect;
- medical treatment and rehabilitation support as part of an integrated package; and
- a society where disabled people have full civil rights, those with mental illnesses are no longer stigmatised and where there is good occupational health and safety at work.
I would like to say something about each of these.
The importance of early intervention can not be overstated. For those out of work, the passage of inactive time can hinder rather than heal.
Statistics show that once someone has been on Incapacity Benefit for 1 year, they are likely to be there for 8. And once they’ve been on it for 2 years, they are more likely to die or retire as an Incapacity Benefit recipient than they are ever to work again.
About 2 million people on Incapacity Benefit fall into that category. Yet if you look at the health conditions initially reported by most of these people – back and neck pain, depression, heart and circulatory problems – long-term inactivity was hardly inevitable.
I’m not questioning that the conditions these people have are very real – the evidence is that this level of fraud is tiny.
But what I do believe is that we can break down the barriers which prevent people from getting back to work. There is strong evidence that the psychological barriers can often be harder to overcome than the physical.
But it is in tackling these psychological barriers that healthcare professionals have a crucial opportunity to help us make further progress.
Far too often the medical profession – and GPs in particular – are seen merely as gatekeepers to a benefit, when your responsibilities are so much wider.
Sick certification is one of the most potent healthcare interventions, but, like any other intervention, it is important to consider the potential risks and side effects. Often a patient will think that they want a sick note, when the best advice a “critical friend” can give might not meet his or her initial expectations.
We need to work with you so that we move towards a situation where we have better records of what sick notes have been given and why.
It is crucial to recognise the important role that you play as healthcare professionals in this area. But I also believe that in being so very much more than mere gatekeepers, you have a powerful opportunity to help us end the sick note culture.
Many people wrongly assume that an early return to work is bad for them and will cause their condition to deteriorate.
There was the general surprise only a few weeks ago at how quickly Tony Blair returned to work with just a weekend break after his heart operation.
In fact, more generally, thanks to modern surgical techniques, evidence-based recovery times are often a lot shorter than people expect.
When people visit a GP or another healthcare professional, they are often worried – they will hang on to every word you say. It will shape their attitudes and how they approach their medical condition.
So as health professionals you have a powerful opportunity to help deliver work for all. But this must mean fully capturing the growing body of specialist evidence that getting people back to work promptly is likely to benefit long-term health.
The forthcoming White Paper on public health will recognise the beneficial role some work can have in helping people recover from illnesses or disease. And it will emphasise the damaging effects of being out of work – encouraging the NHS to see return to work as the norm.
I’m also particularly interested in initiatives such as Peter Moore’s story around the NHS Expert Patients programme, helping people self-manage their own long-term health conditions. And initiatives like the one in North London where patients can make an appointment with an employment adviser when they go and visit their GP.
I’ve been increasingly encouraged by the growing signs that many of you are taking steps to increase the focus within your profession of the importance of work as part of the clinical management of patients.
Clinical management practice has developed dramatically with a greater focus on rehabilitation.
Take back pain for example. We used to think that rest was the best response to back pain. But now, as Gordon Waddell’s work has shown, rest does not work and instead might actually delay recovery. In contrast, by advising patients to stay active and continue their ordinary activities as normally as possible, they can expect a faster recovery and return to work.
One report found that people who signed off sick with back pain for six months have only a 50% chance of working again – it’s then a 25% chance after 1 year and a statistically negligible chance after 2 years. This is irrespective of other treatments, and even if the back pain disappears the people concerned still do not return to work.
Previously rehabilitation was a second stage process carried out after medical treatment had no more to offer. In other words, it was about adapting or compensating for a permanent impairment. It can no longer be seen as a separate stage – but instead as a crucial part of the treatment process.
Last week I announced to the House the very encouraging early results from our Pathways to Work Pilots – a huge success story in which GPs and other healthcare professionals already play a prominent role.
Together with improved financial incentives to seek work and compulsory interviews with skilled personal advisers, the access to groundbreaking NHS rehabilitation support through Condition Management Programmes is crucial in the success of Pathways – enabling people to learn to manage and cope with their health conditions.
While we are already seeing improvements in recorded job entries for people on Incapacity Benefit nationally, in Pathways to Work areas this success rate is double the national average.
Furthermore, in the pilot areas six times as many people claiming Incapacity Benefit have taken up support from the New Deal or other rehabilitation programmes, which will give them the skills and confidence to move into work.
There is already very strong emerging evidence that many more people are avoiding the slide into long-term benefit receipt in these areas.
In fact, Pathways to Work is proving so successful that many people already on IB in the pilot areas who aren’t automatically required to engage with the new support package are volunteering to go through the programme.
This is tremendously encouraging and I want to see this kind of support extended – I believe I’ve seen the future and it works.
We are even seeing the first real signs of progress on Incapacity Benefit at the aggregate level. The numbers on Incapacity Benefit trebled under the last Government – but the latest figures actually show a small fall for only the second time since records began. By contrast, had the previous trend continued, there would now be 4 million claiming Incapacity Benefit in this country – 1.3 million more than the current figure.
What’s more, through Jobcentre Plus, our Ambition programme and skills strategy we are bringing together benefits and work-focus – and seeking to equip people with the skills they need to fill employers’ vacancies. The New Deal is making a real difference – with nearly 1 million participants finding work, including over 180,000 disabled people.
Enabling people to get back to work also means working with employers to challenge attitudes in the workplace and legislating to build a society where disabled people have full civil rights.
In mental health, for example, the biggest obstacle to returning to work can be fear of stigma and discrimination by employers. This is something that we are determined to tackle and in June this year we launched a new anti-stigma strategy called “From here to equality”.
Rights for disabled people saw a landmark this month – when the Disability Discrimination Act was extended to 600,000 existing disabled workers and 7 million jobs. Our draft Disability Bill will take us even further, whilst Age Discrimination Legislation will help to increase opportunities for older people to work from 2006.
In giving people greater opportunity to work, it’s important that we have good occupational health and safety in the workplace. This can reduce the chances of someone being injured or becoming ill in the first place – as well as reducing the likelihood of any illness recurring when they return to the workplace.
Most employers recognise that a motivated, healthy workforce is more likely to perform well. And employers and employees benefit through improved morale, reduced absenteeism, increased retention and enhanced productivity.
There needs to be a wider recognition of the positive benefits for individuals and their employers that can come from getting people back to work after sickness. For people who are able to work again, a job can itself be an important step in the road to recovery and rehabilitation – for those who simply cannot work because of the severity of their condition we will provide help and security.
Healthcare is about returning patients to good health and in most cases that includes getting back to work.
Failure to achieve our objectives will mean that we have needless unemployment that will be damaging economically – and in human terms – for those whose aspirations to work remain unfulfilled, whose skills depreciate and whose mental well-being deteriorates.
- But if we work in partnership and pool our knowledge to end the sick note culture, the potential gains are enormous:
- For the Medical Profession – better health and well-being will mean fewer patients trapped on an endless cycle of tests
- For Employers – reduced costs for longer-term sickness absence and improved morale
- For the tax payer – reduced health costs and fewer people on long-term benefits
And for the individuals themselves – the enjoyment of a longer, more active and healthier life.
I started by saying how much I admire your work – I want to finish by thanking you for your efforts and by urging you to join with us further in our efforts to promote social justice and attack social exclusion through removing the road blocks on the road from welfare to work for those who have so often been written off in the past.