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The Scottish Government Response to "Working for a healthier tomorrow" - Dame Carol Black's Review of the health of Britain's working age population
1. Introduction
The Scottish Government places a high priority on improving the health of the people of Scotland. The last 18 months have seen a range of strategies and initiatives aimed at improving health and reducing the inequalities in health between our most and least prosperous communities, and from the youngest to the oldest people. The health of Scotland's working age population is key to the wellbeing of both individuals and communities, and to the future economic success of Scotland.
The focus in Scotland on working age health is not new and initiatives have been supported by government since 1996, with additional emphasis given in 2003 [1].
The Scottish Government has worked with the other administrations in Great Britain on the Health, Work and Wellbeing strategy since its launch in 2005. We welcome the report by Dame Carol Black on the health of the working age population of Great Britain. It provides an important snapshot of the current state of the health of those of working age, both in and out of work, and provides some valuable recommendations to address gaps in ensuring that this population remains healthy and productive.
The Scottish Government's response sets out why we continue to place importance on maximising the health of our working age population and what our priorities are in achieving this. Dame Carol has provided both confirmation that the direction of our current activities is valid and some pointers to work that can be developed for the future.
The Report also throws up some challenges - for government, for healthcare professionals, for employers and for employees. Of particular note is the interface between devolved and reserved government competencies, especially around health and safety regulation and the operation of the benefits system, and how these link with devolved areas of responsibility.
The following sets out the context for the Scottish Government's response to Dame Carol's Report and then addresses the key issues for Scotland that arise from the Report. A number of key stakeholders have consulted on the drafting of this response, including CBI Scotland, FSB Scotland, STUC, Jobcentre Plus Scotland, HSE Scotland, NHS Health Scotland, CoSLA, Scottish Enterprise and the Scottish Centre for Healthy Working Lives
2. Context
The Scottish Government has set a single, over-arching Purpose:
"to focus the Government and public services on creating a more successful country, with opportunities for all of Scotland to flourish, through sustainable economic growth"[2].
Key to achieving this Purpose is increasing GDP growth and ensuring this growth is sustainable and is shared in by all. In order to measure success in achieving these outcomes, we have set a number of Purpose targets, including: improving productivity; increasing labour market participation; increasing overall income and the share of income earned by the lowest 30% as a group; narrowing the gap in participation between our best and worst performing regions; and increased healthy life expectancy in Scotland.
We recognise the strong links between the economic activity of the population and its health. A healthy population is a more prosperous one. For most individuals, being in work is better for their health and having good overall health - both physical and mental - enhances a person's ability to remain in work.
These links between health and work were recognised in Scotland's Healthy Working Lives strategy, published in 2004 [3]. More recently, the report from the Ministerial Task Force on Health Inequalities, Equally Well [4], made explicit the need to address the factors that lead to people losing work or remaining out of work as a result of poor health.
Workforce Plus [5], the Scottish Government's employability strategy, sets out how organisations can better work together at a national and local level to improve support for those facing barriers to employment, including people with disabilities and lone parents. Workforce Plus brings together partners at a national and a local level to work together to support people back into work.
In Scotland, our Healthy Working Lives strategy has already developed, or is in the process of introducing, many of the solutions that Dame Carol advocates. Notably, the Scottish Centre for Healthy Working Lives was established in 2005 to bring together a number of earlier initiatives into a centre for excellence in health and work. The "Fit for Work" service has been anticipated in our vocational rehabilitation pilots, providing rapid access to services for those in work at risk of losing their job through illness or injury.
The Scottish Government is working with a range of agencies and other stakeholders to support the development of appropriate local services for those who need them and to ensure that those most distant from the labour market can access a smooth transition through the agencies that can help them.
The public sector in Scotland is a major employer. As such it can deliver much by taking a lead as an exemplar employer, providing employment that maximises health, safety and wellbeing. As consumers of goods and services, the public sector can drive behaviour change in its suppliers through the contractual chain.
Private sector employers, the vast majority of whom in Scotland are small and medium sized enterprises, also need to understand the benefits that they can accrue from doing more to promote the health and wellbeing of their workforces. There is a compelling business case and a significant level of resource that can be drawn on to support them.
Individuals also need to understand the benefits to themselves of taking responsibility for their own health, actively making healthy lifestyle choices, understanding the links between their health and their ability to remain in work, and appreciating what they should expect from their employer in supporting good health and wellbeing.
Scotland has an excellent record of partnership working on health and work - with both a National Advisory and Advocacy Group informing the work of the Scottish Centre for Healthy Working Lives, and the Partnership on Health and Safety in Scotland bringing together representatives of the Scottish health and safety system. Both bodies draw members widely from the public, voluntary and private sectors, representing both Scottish and UK organisations.
The resources available through the many organisations already engaged in the workforce health, safety and wellbeing agenda are large, e.g. local authority Environmental Health Officers, Health & Safety Executive inspectors, NHS Board occupational health professionals, Trades Union safety representatives, etc.
In Better Health, Better Care: Action Plan [6] the Scottish Government undertook to re-energise its healthy working lives policy. Dame Carol's report has provided a useful focus for this and work is underway to review delivery of the policy over the next six months.
3. Dame Carol's Report
The approach taken by the Scottish Government to Healthy Working Lives has been to focus on three key areas: keeping those in work safe and healthy, provision of support to those at risk of losing work through ill health or injury, and support for those currently excluded from work through incapacity. The policy also recognises that there are key groups of stakeholders whose support is fundamental to successful delivery: healthcare professionals, especially those in primary care, employers and public service delivery bodies (for example, Jobcentre Plus, local authorities, third sector bodies).
3.1 The role of the workplace in health and wellbeing (Chapter 3)
The importance of the role of the employer in achieving successful return to work is noted above. This emphasises the need for employers and employer organisations to be part of the "health and work system".
As has been pointed out previously, employers have much to gain from promoting the health and wellbeing of their workforce in terms of increased productivity, improved attendance and better staff retention. There is much support and many tools available for employers to help them introduce policies and management practices that get the best out of their staff.
Key challenges are to ensure that the message for employers is received and understood, and that they know where to access the available help.
The Scottish Government is supportive of the activities through Health, Work and Wellbeing to engage the business community in Great Britain. We believe that the best advocates are those employers who already practice workplace policies that promote health and wellbeing.
We are doing…
The Scottish Centre for Healthy Working Lives delivers advice and support to promote good workplace practice in health, safety and wellbeing.
The Centre will continue to work with employers and other organisations to deliver its current range of services and to ensure that its services remain relevant to the needs of the modern workplace.
The Scottish Government will also seek to work with bodies such as the National Advisory and Advocacy Group for Healthy Working Lives to identify how employers and the business community can take greater ownership of promoting the messages through business-to-business opportunities.
We are going to do…
The Centre will continue to develop the Sickness Absence Management tool, in cooperation with Glasgow University, and will liaise with the Health, Work and Wellbeing team on providing support for the Business HealthCheck tool for corporate reporting, and will make these available to employers throughout Scotland.
The Scottish Government and the Scottish Centre for Healthy Working Lives will work with representatives from the private sector to develop a stronger message on the benefits to businesses of promoting workplace health and wellbeing.
Support for SMEs
The vast majority of businesses and enterprises in Scotland are SMEs (approx. 99% [7]). The Scottish Government recognises the continued need for the provision of clear and unbiased advice to employers on occupational health and safety issues and remains committed to supporting the work of the Scottish Centre for Healthy Working Lives (the Centre) and its network of advisors.
In further recognition of the importance of reaching SMEs, the Scottish Action Plan on Health and Safety [8] provided for additional resource to the Centre last year. In response to Recommendation 25 in Equally Well, the Centre is now looking at how its products and services can be further developed to improve accessibility and ease of use by SMEs.
A key deliverable in the next year will be a clear understanding of the health and work needs of the SME sector in Scotland and a strategy for developing and delivering products to meet these needs. Critical to this will be an improved dialogue with organisations that can represent the sector. The Centre will have a leading role in working with business organisations to achieving this.
3.2 C hanging perceptions of fitness for work (Chapter 4)
The recent review of evidence on vocational rehabilitation by Waddell et al [9]provides a strong case for early intervention to prevent people suffering the worst consequences of ill health on their ability to work. They identify that the role of employers in supporting employees undergoing rehabilitation is also vital to a successful return to work.
This underlines the strong case for improving communications between healthcare workers and employers. The Scottish Government agrees that employers need to acquire a better understanding of how work impacts on the health of their staff and of the steps they can take to promote and enhance that health.
Similarly we accept that healthcare professionals also need an enhanced understanding of how work can contribute to recovery of a patient from a condition.
The Scottish Government notes the recommendations for the development of an electronic "fit note" to replace the existing "sicknote" issued by GPs. We are supportive of initiatives to optimise people's ability to recover and return to work. However, we would wish to be assured that any changes to the current system that impact on health services in Scotland are developed with full engagement of the healthcare professions in Scotland and that the devolved nature of health and other services in Scotland is taken into account.
The proposed changes will have implications for electronic systems, administration and training and awareness of those involved, including clinicians, employers and employees. This could build on the existing experience gained from partnership working between the Scottish Government, Jobcentre plus, NHS Scotland and others through initiatives such as Pathways to Work, Condition Management Programme and the Pathways Advisory Service. The Scottish Government will require an ongoing dialogue with DWP about how any changes to the current processes will be introduced.
The introduction of a "fit note" to replace the current sicknote will require a widespread education process for healthcare professionals, employers and employees. The Scottish Government would like to ensure that there will be a comprehensive consultation on how this will be achieved, in advance of any roll-out.
3.3 Developing a new model for early intervention (Chapter 5)
The Scottish Government recognises that the most effective way of preventing people moving onto incapacity benefits is to prevent them falling out of work through ill health or injury in the first place. We agree with Dame Carol's view that early intervention and access to appropriate support is crucial in achieving this. However, the Scottish Government does not support a model that would deliver public services through private providers.
Scotland's Framework for Adult Rehabilitation [10] establishes an integrated model for rehabilitation services delivered through the NHS, including vocational rehabilitation and rehabilitation for long-term conditions. Work is ongoing to develop and deliver these services that will benefit both those in work with health-related issues as well as those at a distance from work through illness or injury.
We are doing…
The Scottish Government is providing funding for a two year pilot Vocational Rehabilitation project in Dundee, running from April 2008, delivered by NHS Tayside with support from the Scottish Centre for Healthy Working Lives. The service is targeted at employees of SMEs that do not have access to in-house occupational health services.
The pilot will be subjected to a robust evaluation to establish what, if any, benefits the approach can deliver for employers, employees and for the taxpayer.
We have provided funding for a further two pilots in NHS Borders and NHS Lothian, in order to provide additional evidence for the evaluation.
Evaluation is expected to be completed in 2010 and the Scottish Government will consult with stakeholders on further developments following this.
Pending the outcome of the evaluation, we will continue to discuss the development of other models elsewhere in Scotland. Indeed, the approach to delivering healthcare services is to allow for flexibility to take account of different needs and priorities in different parts of Scotland. The Scottish Government would welcome the opportunity to discuss with DWP the scope for developing a "fit for work" model that would be applicable in an area of need in Scotland.
3.4 Helping workless people (Chapter 6)
As outlined earlier, the Scottish Government recognises the links between worklessness, poverty, deprivation and health and social inequalities. We are determined that more people will be able to participate in and benefit from a successful Scottish economy. Helping workless people back to work requires joining up and close cooperation across a range of organisations and agencies. In particular, this highlights the need for working across the reserved area of social benefits and devolved areas such as health and economic development.
The Scottish Government has developed an excellent working relationship with other organisations involved in supporting workless people back to work, most notably Jobcentre Plus. Our Workforce Plus strategy aims to develop partnership working at a national and local level.
Equally Well recommends that economic development agencies in Scotland take a more active role in promoting improving health through work and also highlights the leadership that can be given through the community planning process.
Local partnerships and delivery
There are many examples of local initiatives for health and work, particularly in supporting those out of work back towards employment. Most of these involve partnership working across a number of agencies. The Scottish Government encourages the development of these and the sharing of good practice.
We are doing…
Local Workforce Plus Partnerships have been established in a number of areas and bring together representatives from the public, private and third sectors. The Scottish Government is supporting the ongoing development of these and the establishment of partnerships where there are currently none.
Jobcentre Plus, working with NHS Boards and the Scottish Government has placed Jobcentre Plus advisers and healthcare professionals in over 60 GP practices in Scotland to offer support and advice to patients seeking information on moving towards employment.
A national conference on health and work, "Working Together for a Healthier Scotland" was held in November 2007 to promote the messages around the benefits of work for health, to representatives from health services, employability services and local government across Scotland. This was followed by a series of 10 local conferences targeting healthcare professionals, staff from local authorities, local partnership staff and local Jobcentre Plus personnel.
Mental health and worklessness
The Scottish Government has noted the links between DWP's Pathways to Work programme and the Department of Health's Improving Access to Psychological Therapies that were announced [11] last year. We would welcome a dialogue with DWP on developing appropriate support for Pathways clients and others in Scotland. More detail on work in Scotland on mental health and employment is given below.
3.5 Developing professional expertise for working age health (Chapter 7)
As noted earlier, there is a need to raise awareness and understanding of the links between health and work in healthcare professionals. Equally Well recommends that the evidence on the health benefits of employment be incorporated into professional development and practice of occupational and public health professionals.
We are going to do…
The Scottish Government will work with agencies in Scotland to embed an understanding of the beneficial links between health and work into professional development programmes for healthcare workers.
We are happy to work with other administrations on developing common programmes that can be applied across Great Britain.
The Scottish Government agrees that there is a need to ensure that clear standards and forms of accreditation are established, and believes that this should be developed on a Great Britain-wide basis. We would require that relevant Scottish healthcare professional bodies are given the opportunity to be represented and to contribute.
Developing the evidence base
There is a need to ensure a suitably robust baseline to measure successful delivery of policy on health and work. This needs to be supported with ongoing collection of data on a consistent and coherent basis.
We are doing…
The Scottish Government is supporting the establishment of a Scottish Observatory for Work and Health. Run by the Glasgow Centre for Population Health, the observatory will initially provide an analysis of data relating to the Incapacity Benefit population in Scotland, with potential for expansion of scope in the future to provide further data to inform policy and practice on health and work.
We are doing…
A database has been developed for the vocational rehabilitation pilots. Wider use of this common platform will be encouraged to enable a comprehensive data set to be collected for analysis. This will provide detailed information on the background, needs and outcomes of the population accessing the vocational rehabilitation service and allow us to learn about the needs of the working age population for health services.
3.6 The next generation (Chapter 8)
The Scottish Government believes that promoting healthy lifestyles and choices from an early age are important to ensuring the long term prosperity of Scotland's people and communities. The Schools (Health Promotion and Nutrition) (Scotland) Act 2007 places health promotion at the heart of schools' activities. A Curriculum for Excellence [12] sets out the aims of education in Scotland. It takes a holistic approach to health and wellbeing. The main purpose of health and wellbeing within Curriculum for Excellence is to develop the knowledge and understanding, skills, capabilities and attributes necessary for physical, mental, emotional, social and physical wellbeing now and in the future.
We are going to do…
Further work will be done to explore how to incorporate messages about the links between health and work and what new entrants to the workplace should expect from employers.
3.7 Mental Health and Employment
Mental Health problems are a major cause of poor performance and sickness absence in the workplace and can be a significant part of overall ill health of those on Incapacity Benefit.
Scotland's National Programme for Mental Health and Wellbeing, launched in 2001, has sought to improve the promotion of good mental health and wellbeing in employment and working life. It has worked to mainstream mental health imperatives - for example the importance of recovery-focussed activities - into employment policies and initiatives. In addition, specific actions have included funding a local job retention pilot for people experiencing mental ill-health; and national and local work - through our national anti-stigma campaign see me - to counter the stigma and discrimination experienced by people with mental health problems in workplace settings.
We are doing…
Building on the achievements of the National Programme and following consultation, Towards a Mentally Flourishing Scotland, a mental health improvement action plan for 2008-11, will be published by the end of this year. The action plan will include a specific focus on improving the mental health and wellbeing of the working age population.
We are doing…
The Scottish Centre for Healthy Working Lives supports workplace policies to support mental wellbeing through the Healthy Working Lives Award programme which includes a Mental Health Commendation award. The Centre also delivers a Mentally Healthy Workplace training programme in collaboration with Jobcentre Plus.
Workforce Plus has a particular focus on helping clients with learning and mental health disabilities. We have appointed a learning disabilities co-ordinator who is working with local Community Planning Partnerships to help them progress their work on employability and people with learning disabilities. We have also commissioned the Scottish Development Centre for Mental Health to support Workforce Plus partnerships, locally and nationally, in achieving the objectives of Workforce Plus specifically with regard to people who have a mental health illness.
We would encourage learning to be shared across the administrations and with experts in the field of mental health and employment to inform the development of policy and services. We are please to support Scottish input into Dame Carol's national strategy group on mental health and employment.
We are going to do…
We are establishing a mental health and employability reference group that will consider developments arising from Dame Carol's strategy group in a Scottish context and will provide a Scottish perspective back to Dame Carol's group and to the Scottish Government.
3.8 Public Sector as Exemplar
The public sector is a major employer in Scotland. As such it can play a key role in developing a healthy working age population - supporting the health and wellbeing of its employees as well as offering opportunities to those wishing to return to work from benefits.
The public sector in Scotland is encouraged to attain Healthy Working Lives Awards from the Scottish Centre for Healthy Working Lives. Many local authorities and NHS Boards are already holders, including a number with Gold Awards.
We are doing…
All acute health service units in Scotland have been set a target to achieve or work towards a Healthy Working Lives Award [13].
The Scottish Centre for Healthy Working Lives will work with NHS Boards and other public sector bodies to support their achievement of the awards.
The Scottish Government is currently working towards a Gold Healthy Working Lives Award.
We are doing…
Most NHS Boards operate schemes to provide opportunities for people seeking to return to work to obtain pre-employment training to help them prepare to return to the workplace. For most people there is an opportunity to then move into a job. These "Health Academies" have met with considerable success.
There is growing interest from the local authority sector in the model and a number are working with their local health boards to develop joint academies.
Local Employer Partnerships (LEPs) have been developed by Jobcentre Plus to encourage employers to recruit some of the hardest to help client groups. Already 6000 employers including Health Boards and Local Authorities have sign up to LEPs.
We are going to do…
The Scottish Government will work with the Convention of Scottish Local Authorities (CoSLA) to explore how the role of local government can be further developed to support people to return to and remain in work.
The Scottish Government will work with Jobcentre Plus and other public sector partners in Scotland to encourage the adoption of Local Employer Partnerships by the public sector.
4. Future developments
4.1 Short term
The Scottish Government met a number of key stakeholders at the beginning of September 2008 to discuss the implications of Dame Carol's Report for Scotland and the direction for Healthy Working Lives. The group concluded that the general approach of the Report is well aligned with the current Healthy Working Lives strategy.
We are going to do…
A number of areas in need of further work have been identified:
· a need to develop the messages on the benefits of work for the health of most people and communication methods amongst key groups and stakeholders as well as ensuring accessibility to the services on offer;
· a further examination of how to align occupational health and vocational rehabilitation services to provide clear client pathways and ensure capacity in the system through addressing workforce and governance issues.
Workstreams will be established to take both of these areas forward over the next 6 months as a contribution to refreshing and re-energising the Scottish Government's Health Working Lives policy.
It is important to establish that our policies are having a positive effect on the health of the working age population and work is required to develop a set of appropriate measures to monitor delivery of the desired outcomes. These will be developed with our partners as part of the refresh of policy.
The Scottish Government agrees with Dame Carol's conclusion on the need to address the declining academic base of occupational medicine. We would welcome an opportunity to discuss with the other administrations how this can be boosted and would expect that a Great Britain-wide approach could be developed that would take advantage of the existing centres of academic work in the field.
4.2 Longer term
As noted at the beginning, Scotland's Healthy Working Lives policy is a vital contributor to achieving the Scottish Government's purpose and in tackling and reducing health and social inequalities.
The need to work across the devolved-reserved boundary on the health and work agenda has highlighted the challenges, particularly for DWP who has to work with three different administrations with responsibility for health. Similarly, for the HSE, there is a challenge in working at the boundary of the divide between reserved health and safety issues and devolved health issues.
The Scottish Government works closely with DWP on the development of welfare-to-work policy, particularly where, as in the case of health, there is a clear impact on devolved areas. While we have a shared ambition to increase labour market participation, Scottish Ministers have concerns about the mandatory nature, with the risk of benefit sanction, of a number of the proposals featured in the recent Green Paper - No-one Written Off. We will continue to work with DWP, but are clear that devolved policies can only support DWP activity where we truly believe it is in the best interests of the people of Scotland.
In light of the Scottish Government's ongoing National Conversation [14] on the constitutional settlement there is scope for considering the future arrangements for administration of the benefits system - devolving the administration of the benefits system for those out of work could allow for better alignment with devolved services such as health, education and skills. In addition, scope for the recycling of cost-savings should be considered.
Similarly, devolving aspects of health and safety regulation could allow scope for better alignment with other parts of the health and work continuum and with the delivery of Scotland's economic strategy.
5. Conclusion
The Scottish Government would like to thank Dame Carol and her team for the work that has been put into producing her report. The recommendations and the evidence behind them make a valuable contribution to the development of policy for the health and wellbeing of people of working age.
We consider this to be the start of a dialogue with the great range of stakeholders with an interest in the subject area and the Scottish Government will continue to work with those stakeholders in Scotland and beyond in order to continue to develop policy that will support a healthy, productive and motivated workforce for the 21st century.
Scottish Government
October 2008
[1] Improving Health in Scotland: the Challenge, Scottish Executive, 2003
[2] The Government Economic Strategy, Scottish Government, 2007
[3] Healthy Working Lives: a plan for action, Scottish Executive, 2004
[4] Equally Well, Scottish Government, 2008
[5] Workforce Plus - an Employability Framework for Scotland, Scottish Executive, 2006
[6] Better Health, Better Care: Action Plan, Scottish Government, 2007
[7]Federation of Small Businesses website
[8] Scottish Action Plan on Health and Safety, Scottish Executive, 2007
[9] Vocational Rehabilitation - What works, for whom and when?, G Waddell, AK Burton, NAS Kendall, TSO, 2008
[10] Co-ordinated, integrated and fit for purpose: A Delivery Framework for Adult Rehabilitation in Scotland, Scottish Executive, 2007
[11] Peter Hain, Secretary of State for Work and Pensions, 27 November 2007
[12] A Curriculum for Excellence, Scottish Executive, 2004
[13] CEL 14 (2008), Health Promoting Health Service: Action in Acute Care Settings, Scottish Government, 2008
[14] Choosing Scotland's Future: A National Conversation: Independence and Responsibility in the Modern World, Scottish Government, 2007