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The. Time-Off. by Joanne Black

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B

eing 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 state-ment on the Health Benefits of Work, whose recent launch brought Black to Wellington. The statement’s signatories include the key organisations represent-ing 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 evi-dence is stark that the longer people spend away from work, the more likely they are never to return. The statement

Getting back to work after an illness or injury often

gets low priority, but take too long and you

may never return.

by Joanne Black

Working Well

Time-Off

Trap

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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.”

T

he picture is no rosier in New Zealand, warns Accident Com-pensation Corporation director of clinical services Dr Kevin Morris. He says the average time people have off work after an accident notified to ACC is sev-eral months.

“That’s the sort of scale we are deal-ing 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 bal-ance them up, just as you do with medi-cation.

“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

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 kick-ing 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 educa-tion 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 iso-lated, etc. Being in work is not seen like that. We need to enable our health pro-fessionals 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.”

G

Ps are not only the gatekeepers of medical certificates, but also gate-keepers of the welfare

system. And those statistics show more and more people are being signed up for sick-ness and invalid’s benefits even though there is no related evi-dence 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 pre-vious five years, the number of working-age people receiv-ing 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 disor-ders, including sore backs and

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 com-pensation claim. The statistics may indi-cate that doctors are certifying patients unfit for work, and thereby making them eligible for either benefits or ACC pay-ments, when many of those patients might have at least some capacity for some type of work.

Dr Kristin Good, a trainee in occupa-tional 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 question-naires, 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.

internationaL research shows that if a

person is off work for 70 days, the chance

of ever getting back is just 35%.

Dr David Beaumont getty ima ges/lis tener ill us tra tions ; j anyne harman

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“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 certi-fying 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

mar

ty mel

ville

D

ylan Owen was driving his two teenage daughters home from a party one evening in July when his aorta split. Despite the massive pain in his chest – a classic sign of cardiac trouble – it did not occur to him something might be wrong with his heart.

“I was 51 and in very good health. I do a lot of walking, tramping, that sort of stuff, and had had no illnesses pretty much all my life.” He thought perhaps he had the flu, or was suffering stress from a project at his job at the National Library.

He made it up the steps to his house, but at 5.00am the next day, having had no sleep, his wife drove him to Wellington Hospital.

From there, things moved quickly. A CT scan revealed he needed major heart surgery immediately. Owen’s three children were called in so the cardiologist could explain what the sur-geons would do. Two of the children fainted. “It was pretty bad, I can tell you,” Owen recalls now. Blood was leaking from his heart. “They said I had

Working Well

Just

the job

a textbook case of

getting back to work –

but it could easily have

been quite different.

psychoLogicaL beLiefs, Loss of seLf-esteeM, benefit

dependency and pressures froM faMiLy aLL act as coMbined

barriers to peopLe getting back to work.

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and consistent across all the groups.

‘B

ut another major thing that

almost every doctor said is the problem with Winz. The prob-lem 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 rehabilita-tion.

“GPs tell me that when they have writ-ten 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 man-ager 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 man-agers 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 compu-ter 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, apn/mark mit

chell

a long time and they were incredibly generous with their time and their gifts and book vouchers, and coming around to see me, bringing me food and all that. Where I work, or my part

of it anyway, is a close organisation and I knew I was in good hands.”

Owen appreciates that anyone with a physically demanding job would face a quite different rehabilita-tion and return-to-work scenario from his own.

“When I was in the ward, after my operation, I got to know two Maori labourers in their fifties, both recovering from heart surgery. One worked in construction and the other in roading. Although they were fit, heart surgery imposes con-straints on the upper body, especially with activities like lifting and carrying, and I have often wondered if they were able to return to work.”

He returned part-time last December and is now full-time, with flexibility if he needs it.

One of the ways he has measured his own recovery has been his ability to climb the stairs to his house in the Wellington suburb of Karori. “After the illness I at first used to stop four or five times walking up the stairs. But now I jump them two at a time like I used to do. That was my measure. I still get more tired than I used to, and my chest is still sore and that takes a while to heal, but apart from that, everything’s

pretty much back to normal.”

aged part of his aorta was repaired, and a new sleeve and heart valve were inserted. About 10 days later he was home and his wife was able to take leave from her job to look after him for three or four weeks. From there, in terms

of the recovery process and returning to work, Owen’s has been almost a textbook case of everything going well.

Fortunately, because he had a long employment history with the library and had rarely been ill, he had plenty of accrued sick leave, so his income continued in the four months he spent recovering at home.

“Work were very good, particularly my managers, and they reiterated, ‘Just

take as long as you feel you have to.’ There was absolutely no pressure on me to come back, or to work from home, which I easily could have done.”

But Owen wanted to get back to his workplace. “Bizarre as it may sound, I found being home very boring. I caught up on a lot of reading and began exercis-ing, but after that I wanted to be back in the social situation at work, with the people I knew.”

Another reason for wanting to return was to restore normality for his children, now aged 17, 15 and 13. He thinks for someone new to a workplace, or who worked in a very small company, or who did not have friends at work, a similar illness might have gone quite differently. If he had ended up on a sickness benefit, “with three teenagers and a

mortgage, I’d probably have

“Bizarre as it

may sound, i

found being

home very

boring. i

caught up on a

lot of reading

and began

exercising,

but after that i

wanted to be

back.”

Dylan owen: back at work after heart surgery.

CTU president Helen kelly and Accident Compensation Corporation’s Dr kevin Morris.

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surveyed more than 800 GPs throughout the country last year. Smith says the “vast majority” had been pro actively contacted by Winz, and the GPs valued that con-tact.

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 voca-tional training, rehabilitation service and

employment-related activities.

T

he Council of Trade Unions is a signatory to the new consen-sus 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 Zea-land 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 pro-viding 2000 jobs for New Zealand, how dare those uppity actors want to collec-tively 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 illus-trated 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 exclud-ing those killed at work in the Christ-church 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 work-ers 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, employ-ers and doctors working together, recog-nising the health benefits of work and together working out how to facilitate that as quickly as possible.”

Kelly likes the current ACC pilot pro-gramme Better at Work, which involves intensive intervention to get people back to work when ready, even if it means sup-port 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 occu-pational 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.”

D

r David Beaumont is chairman of the policy and advisory commit-tee of the Australasian Faculty of Occupational and Environmental Medi-cine, which, along with the Royal Aus-tralasian 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 special-ists we see and assess people who’ve been off work for longer periods of time than would be expected for that medical con-dition. We work to the bio-psychosocial model, which says that the longer

some-d

a

vid white; rex fea

tures

Working Well

Dame Carol Black: “good” work is about being trusted and valued and having good management.

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body is off work, the more likely that the issues stopping them getting back to work are not medical, but psychosocial.”

Psychological beliefs, loss of con-fidence, 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 condi-tion affect you and what are you capable of doing at work?’, rather than the medi-cal certificate here in New Zealand which says, ‘No, you can’t work.’”

It’s not difficult to spot problems devel-oping, 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 start-ing 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.

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.

B

ut for doctors dealing with their patients, it is not always straightfor-ward. 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 high-lighted 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 work-ing properly, and we’re saywork-ing 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 start-ing 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 con-versation. It could be that simple. But the longer it is down the track, the less likely it is to be simple.” z

“My Message to gps is usuaLLy that if you’re

prescribing tiMe off as a heaLth intervention, you

Must understand the side effects of that.”

Dr kristin good: “Something like 86%

of the certificates gPs write are not based on medical facts.”

References

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