Health CommitteeWritten evidence from The Work Foundation (LTC 68)

1. Who We Are

1.1 The Work Foundation is the UK’s leading think tank specialising in labour markets and employment policy. We have a particular interest in how policy makers can help people with long term conditions remain in the labour market, and have recently published reports focusing on long term conditions such as schizophrenia, multiple sclerosis, cancer, inflammatory bowel disease, diabetes and musculoskeletal disorders (MSDs).

2. Summary

2.1 Employment rates for people with long term health conditions are low, despite the fact that employment is both possible and beneficial for many people in this group.

2.2 As the population ages, and more people have long-term conditions and co-morbid conditions, this issue will become more pressing.

2.3 People with long term mental health conditions in particular are currently not receiving the support they need to enter, or remain in, the labour market.

2.4 Early, effective interventions have been demonstrated to lead to higher rates of recovery, particularly for people with a mental health condition.

2.5 Medical innovations should be explored, and a greater focus should be placed on the long term impacts of new technology, rather than short term cost. Wider savings, such as those made if a person is able to remain in employment, should be considered.

3. Employment can be a Beneficial Outcome for People with a Long Term Health Condition

3.1 Employment rates for people with long term conditions are low, with many people being unable to either find or maintain employment. In addition, many people with long-term conditions leave the labour market prematurely as a result of their condition, though often avoidably. For example, people with MS leave work 18 years earlier than those without MS, while up to 40% of people with rheumatoid arthritis leave work within five years of diagnosis. This is a serious issue, which a comprehensive review of the management of long-term conditions must consider. Employment can have an important positive therapeutic and economic impact on the life of someone with a long term illness. For an individual, work can provide financial autonomy, self-respect, dignity, quality of life, and a sense of self-worth.1 Whilst it should be recognised that in some cases employment is not a viable or healthy option for an individual with a long term condition, and for some it may worsen their condition, this is not universal, and should not be considered the norm. . For many people employment has been shown to have a positive impact in terms of health. For example, our recent research on schizophrenia highlighted that being in employment reduced the likelihood of relapse.

3.2 We believe that the NHS and the government need to do more to account for the importance of employment in the lives of people with long term conditions. Although employment is a measured outcome in the National Outcomes Framework, it is not part of the Clinical Commissioning Groups Outcome Indicator Set (CCG OIS). We recommend the Health Committee investigate the feasibility and appropriateness of changing this, and look at ways to encourage health care professionals to see employment as being within their remit and as something that impacts on their patients. Ultimately, we have concluded that if work is not routinely regarded as an outcome of treatment then the incentives in the health system to promote job retention or return to work among people with long-term conditions will not be strong enough.

4. The Impact of an Ageing Population and the Rise of Co-Morbidities

4.1 As the population ages, and medical innovations lead to higher survival rates, more people of working age will have long term conditions. By 2030, approximately 21 million people of working-age will have at least one long-term health condition—as much as half of the UK workforce.2

4.2 A rise in long-term conditions will result in a rise in co-morbidities—with people suffering from two or more conditions at the same time. It is common for people with a physical health condition to also suffer from some form of mental illness, and evidence suggests that there is an association between the two,3 with co-morbidity increasing healthcare costs by approximately 45%.4 There is also evidence to suggest that co-morbidities are synergistic, and can interact with each other to make both conditions worse.5

4.3 Mental health conditions are a particularly common form of co-morbidity. International studies have found that the rate of mental health problems is higher in people with chronic physical conditions6. For example, people with diabetes are 50% more likely to have some form of mental illness. It should also be noted that there is some evidence to suggest the reverse can be true as well—with mental health conditions exacerbating or worsening physical health conditions. In other words, the physical health of someone with a co-morbid mental health condition is often worse than someone without.7

5. Mental Health and Support in the Community

5.1 The recent Schizophrenia Audit found that a third of service users in England and Wales were not offered any form of psychological therapy, despite the evidence of such interventions helping with management of symptoms generally, as well as employment outcomes. This is particularly the case with Cognitive Behavioural Therapy (CBT), which has been shown to help people with schizophrenia to return to and retain employment. The Schizophrenia Commission found that only 1 in 10 people with schizophrenia who could benefit from CBT were receiving the treatment, while our own research found qualitative evidence which suggested that either this kind of support was simply not available or that health care professionals were inconsistent in prescribing it, feeling that employment was not “their area” or that whilst employment was a possibility for some patients, it would not be suitable for theirs.8 Making employment an outcome in the CCG OIS would be an important step in changing this. Employment rates amongst people with schizophrenia are low- at approximately 8%. We believe that more could be done to improve this, and that, with the effective implementation of interventions known to be successful, this could rise to 25% within a decade.

5.2 We also found a lack of access to peer support workers in Community Mental Health Teams,9 despite the fact that they were the second most popular non-pharmaceutical intervention by practitioners, service users and their families.10 That this intervention, which is also seen as having a positive influence on employment outcomes (for the service users and the peer support worker themselves) but again is often not available when wanted, and is not recommended in the NICE guidelines. Again, we would emphasise the importance of not focusing purely on the clinical aspect and symptom management of long term conditions.

5.3 Despite many of the people we interviewed as part of our research emphasising the importance of employment for them, they explained that their treatment was not personalised, with few clinicians asking what recovery meant for them. This often led to employment, an important issue for many people with a mental health conditions, being left off the table when it came to discussing treatment. We believe that recovery should be about more than simply symptom reduction, even in cases of severe mental illness, and should be about the whole person.

6. Effective Interventions can Combat Unemployment and Reduce the Impact of Long Term Conditions

6.1 Intervening early has repeatedly been demonstrated as key to higher rates of recovery. This in turn leads to a quicker and easier return to the labour market. This is particularly true in cases of severe mental health such as psychosis, in which the first three years are a critical period.11

6.2 There is evidence to suggest that the Early Intervention in Psychosis (EIP) service model is particularly successful in prevent relapse and providing a useful intervention at this crucial stage. However, concern was raised by the healthcare experts we interviewed that the EIP model was being diluted due to funding and other pressures.12 We would argue that this is a false economy, given the long terms savings that EIP can provide in terms of employment outcomes, reduced suicide rate and a reduction in relapse and remission. In a report by the NHS Confederation it concluded that comprehensive implementation of EIP in England could save up to £40 million a year.13

6.3 We would also encourage the committee to consider the strong evidence base for Individual Placement and Support (IPS)—a place then train model of employment support—which we believe to be one of the most effective methods of helping people with severe mental health conditions into employment.14

6.4 The Work Foundation welcomes the government’s response to the “Independent Review of Sickness Absence”, and the creation of the Health and Work Assessment and Advisory Service (HWAAS). We believe that this service has the potential to make an important difference helping people to remain in work. This will lead to potentially better health outcomes, reducing long term costs to the NHS.

6.5 However, we were disappointed by the lack of reference to long term conditions and the recent response from Mr Hoban which stated that the service “will not be appropriate” for people with long term conditions.15 As we have already argued, the government cannot afford to ignore this group. The government must ensure that people with long term conditions are given the support they need to remain in work.

7. Medical Innovations Must be Explored

7.1 All clinical decisions affecting someone who wants to work need to be made through the lens of work ads a possible clinical outcome. This includes decisions about use of medical technologies. Our report on medical technology, “Adding Value: The economic and societal benefits of medical technology” highlighted the conservatism in the NHS regarding the use of innovative medical technologies.16 Whilst the research looked at a number of different medical technologies, this research found that insulin pumps for people with diabetes were a particularly useful but under-utilized intervention. We found evidence to suggest that not only can insulin pumps have important clinical benefits, but that it has the potential to improve employment rates in this group.17 There was also evidence that insulin pumps reduced the likelihood of other co-morbidities such as blindness, limb loss and kidney failure from developing.18

7.2 We believe that this research clearly demonstrates a need to look at the long term impact of medical innovations such as insulin pumps when undertaking health technology assessments. Becoming too focused on short-term outcomes, not seeing the wider social policy picture, and failing to understand future benefits and cost-reduction, can lead to cultural conservatism when it comes to medical innovation. In a paper in December 2012, The Work Foundation—through its leadership of the Fit for Work Europe Coalition—examined the arguments for Health Technology Appraisal (HTA) taking a “societal” perspective. This would allow NICE, for example, to consider wider societal and labour market outcomes when assessing the benefits of treatments and therapies. Although progress seems to be being made towards this goal in the current Value-based Pricing negotiations, we believe that “work as a clinical” outcome for people with long-term conditions is more likely if HTA in the UK takes a wider societal perspective.19

8. Conclusion

8.1 We welcome the Health committee’s decision to return to the subject of long term conditions, and look at the subject once again. This is a growing problem, for which the NHS and the UK at large must be prepared for. We urge the committee to bear in mind in their research the important role that employment plays in the live of people with long term conditions.

9 May 2013

1 Freedman, R I, & Fesko, S L. “The meaning of work in the lives of people with significant disabilities: Consumer and family perspectives”. (Journal of Rehabilitation, 62(3), 49-55, 1996)

2 Helen Vaughan-Jones & Leela Barham “Healthy Work: Evidence into Action” (2010, http://www.theworkfoundation.com/assets/docs/healthy-work-evidence-into-action-report.pdf)

3 Robin McGee and Katherine Ashby, “Exploring the connection between physical and mental health conditions” (The Work Foundation, 2010 http://www.theworkfoundation.com/assets/docs/publications/260_body_soul160910final.pdf)

4 Chris Naylor, Amy Galea, Michael Parsonage, David McDaid, Martin Knapp, Matt Fossey, “Long-term conditions and mental health: The cost of co-morbidities” (The Kings Fund, LSE & Centre for Mental Health, 2012, http://www.kingsfund.org.uk/publications/long-term-conditions-and-mental-health)

5 Schmitz, N, Wang, J, Malla, A and Lesage, “A Joint effect of depression and chronic conditions on disability: Results from a population-based study”.(Psychosomatic Medicine, 69, 332-338,2007)

6 Moussavi, S, Chatterji, S, Verdes, E, Tandon, A, Patel, V and Ustun, B. Depression, chronic diseases, and decrements in health: Results from the World Health Surveys’ (The Lancet, 370, 851–-858, 2007)

7 Roy-Byrne, P, Davidson, K W, Kessler, R C, Asmundson, G J G, Goodwin, R D, Kubzansky, L et al, “Anxiety disorders and comorbid medical illness”. (General Hospital Psychiatry, 30, 208-225, 2008)

8 Bevan et al, “Working with Schizophrenia: Pathways to Employment, Recovery & Inclusion” (The Work Foundation, 2013, http://www.theworkfoundation.com/DownloadPublication/Report/330_Working_with_Schizophrenia.pdf)

9 Ibid

10 The Schizophrenia Commission, “The abandoned illness: a report from the Schizophrenia Commission”. (Rethink Mental Illness, 2012, http://www.schizophreniacommission.org.uk/the-report/)

11 Birchwood, M, Todd, P, & Jackson, C. “Early intervention in psychosis. The critical period hypothesis”. [Review]. (Br J Psychiatry Supply, 172(33), 53–59, 1998)

12 Bevan et al, “Working with Schizophrenia: Pathways to Employment, Recovery & Inclusion” (The Work Foundation, 2013, http://www.theworkfoundation.com/DownloadPublication/Report/330_Working_with_Schizophrenia.pdf)

13 http://www.nhsconfed.org/Publications/Documents/early_interventionbriefing180511.pdf

14 Bevan et al, “Working with Schizophrenia: Pathways to Employment, Recovery & Inclusion” (The Work Foundation, 2013, http://www.theworkfoundation.com/DownloadPublication/Report/330_Working_with_Schizophrenia.pdf)

15 Mark Hoban, Hansard—22 April 2013 Column 704w, http://www.publications.parliament.uk/pa/cm201213/cmhansrd/cm130422/text/130422w0006.htm

16 Stephen Bevan, Ksenia Zheltoukhova & Robin McGee “Adding Value: The economic and societal benefits of medical technology” (The Work Foundation, 2011, http://www.theworkfoundation.com/DownloadPublication/Report/296_Adding%20value%20-%20The%20Economic%20and%20Societal%20Benefits%20of%20Medical%20Technology.pdf)

17 Ibid

18 Ibid

19 “Making work count—how Health Technology Assessment can keep Europeans in work” (Fit for Work Europe, 2012, http://www.fitforworkeurope.eu/Making%20work%20count%20-%20how%20HTA%20can%20keep%20Europeans%20in%20work_FULL%20PAPER.pdf)

Prepared 3rd July 2014