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Care planning and musculoskeletal conditions

Monday, December 1st, 2014

People with long-term conditions spend far more time self-managing than they do in contact with healthcare services. In recognition of this, approaches that empower people to better manage their own health and wellbeing are well established in health policy:


  • The Five year forward view  said that “even people with long term conditions, who tend to be heavy users of the health service, are likely to spend less than 1 % of their time in contact with health care professionals. The rest of the time they, their carers and their families manage on their own.”  For the future it asserts “… we will do more to support people to manage their own health – staying healthy, making informed choices of treatment, managing conditions and avoiding complications.”


  • The NHS Mandate is equally clear on the importance self-management, including a specific objective for the NHS become “dramatically better at involving patients and their carers, and empowering them to manage and make decisions about their own care and treatment.” As a step towards this, since 2013 it has included the ambition that everyone with a long term condition will be offered a personalised care plan.


Around 10 million people across the UK have a musculoskeletal condition, such as rheumatoid arthritis, osteoarthritis or osteoporosis. These are mainly long-term conditions, and many people live with their painful and fluctuating symptoms for decades. Musculoskeletal health is an important contributor to overall health and wellbeing, and symptoms including limited mobility and pain can make the impact of other long-term conditions, such as diabetes, cardiovascular disease or depression worse.

So it’s clear that there is huge potential and need for self-management by people with musculoskeletal conditions – but to what extent is this already happening? And how can we ensure that people with musculoskeletal conditions are included as approaches such as personalised care planning are more widely implemented?

  • An independent inquiry into patient centred care in the 21st century commissioned by the RCGP which reported this week proposed that “… the greatest gains of care planning may come from those who are at an earlier stage of their condition, where there is greatest scope for prevention of deterioration.” It recommended that Practices should follow a personalised care planning approach for all those patients in need of proactive care, with particular focus on at risk groups such as those with learning disabilities and patients with multiple conditions.”

How do people with musculoskeletal conditions, or people with musculoskeletal conditions and other morbidities, fit into this wider spectrum?


Table showing Care Plan possession by people with long term conditions

Table showing Care Plan possession by people with long term conditions


Our care planning and musculoskeletal health report builds on the outputs of a policy workshop, interviews with people with arthritis and healthcare professionals who have used care planning, and reviews of policy, clinical guidance and musculoskeletal standards of care. It considers aspects of the care planning process as it relates to people with musculoskeletal conditions including the healthcare professionals involved, the settings in which care planning can take place, and indicators to help identify people likely to benefit.


Our new analyses of national survey data indicate that, despite the Mandate commitment, just 12% of people with a musculoskeletal condition currently have a care plan. There is an opportunity for many more people to benefit. The report calls for:

  • Systems to deliver care planning to be designed to include those with musculoskeletal conditions and to identify and address musculoskeletal needs in patients with any long-term condition.
  • Professional bodies to ensure that the continued training of healthcare professionals involved in care planning includes core musculoskeletal skills.

For more information, or a copy of our report, please visit our website or contact us at

Dr Laura Boothman is policy manager at Arthritis Research UK


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The power of the personal account. How qualitative research offers important insights into the self-management of musculoskeletal conditions in the context of work. Part 1

Tuesday, September 9th, 2014

Work itself should be considered as a form of self-management. This is the central finding of the study that The Work Foundation and Fit for Work UK launched on Friday, 5 September  entitled “Self management of chronic musculoskeletal conditions and employment”. Individuals whom we interviewed for the report found that partaking in work was an important way in which they managed several (often psychological) aspects of living with an MSD. However, the onus for managing one’s condition at work weighed far too heavily on the individual, and participants often described foregoing their home lives, social lives, and compromising their physical health to stay in work. Work as self-management was often being undermined as individuals struggled to self-manage in the context of work.

Other stakeholders have a far greater role to play in supporting self-management, and notable among those are the government, healthcare professionals, and employers. It was only through conducting an interview based study, and talking directly to individuals, that this tension between wanting to continue to work, yet often struggling to manage one’s condition successfully, could be revealed to the researchers.

Interview studies of course have their limitations. They are designed to provide depth rather than breadth meaning that statistical representativeness is foregone. The researchers are also far more ‘present’ in that they conduct and then analyse the interviews themselves meaning it is even more important that they are aware of how they may bias the results. However, this research demonstrates the power of speaking directly to individuals with lived experience of the phenomena being studied. There were some specific, very striking findings, which would be unlikely to have arisen if individuals living with chronic MSDs had not been interviewed.

Take the implications of the invisible nature of the condition, for example. Due to MSDs often not having easily visible external symptoms, individuals described how this meant others found it harder to understand their condition, and that they often were not offered support when they needed it. Some participants even described feigning alternative, more understandable, symptoms when in fact they felt unwell because of their MSD, in order to communicate to others that they were unwell.

People wouldn’t know [I had arthritis].  Sometimes that can go against me, because it’s a bit like you’re trying to do something and then you know that you’re struggling to do something.  And people go.. they don’t accept it.”

Participant 13

Sometimes I would.. if I’m not well, if things are a bit on top of me, in front of my colleagues I will say to them I have a headache, rather than go about the arthritis thing.”

Participant 10

These findings regarding the invisibility of the condition led the report to make several recommendations, including the need to employers and line managers to be more proactive in providing support, as sometimes individuals would be unwilling to come forward and identify their MSD as being the source of their problems. In my next blog, I’m going to explore the report further by discussing a subsequent set of findings related to the self-management of chronic conditions in the context of work – the crucial, yet often overlooked, relationship between workers and line-managers.

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Major health & productivity challenge facing UK workforce

Tuesday, July 22nd, 2014

Politicians across all main political parties have today (21 July 2014) been challenged to respond to the growing burden of ill-health in the UK’s workforce. Fit For Work UK – a coalition of healthcare professionals, policymakers, employers and patient groups – has warned that by 2030, almost half of UK workers will have at least one chronic health condition which will affect their work productivity and, as a result, the competitiveness of the UK economy.

In its call to action, Is the UK Fit for Work?: Confronting the challenge of UK workforce health, the coalition argues that the costs of ill-health in the UK workforce will far exceed the current £100 billion estimate1 as long-term sickness absence, ‘presenteeism’ (attending work when ill) and work disability rise over the next twenty years. An ageing workforce and later retirement are also forecast to increase the proportion of workers leaving employment early as a result of their health.

Research already highlights the growing challenge the UK’s economy faces with around 17 million people of working-age – roughly half of the workforce – believed to face at least one long-term health condition by 2030.2 In the light of this, the coalition believes the UK urgently needs to tackle the problem with the following five-point plan:

  •  A comprehensive cross-government strategy and programme for health and work
  •  Clear national leadership with the appointment of a National Clinical Director for Health & Work
  •  Accessible information for people with long-term conditions to help them stay in work
  •  Measures that capture health and return to work in NHS frameworks, and incentivise clinicians to regard return to work as a clinical outcome of care
  •  Effective incentives to reward healthcare providers who support people with long-term conditions to return to work

Commenting on Fit For Work UK’s call to action, its President, Professor Stephen Bevan, said: “Over the next 20 years an increasing proportion of the ageing UK workforce will retire later and develop chronic illnesses. The UK requires urgent action now to prevent this trend developing into a crisis of public health and impaired labour productivity.  It is only by developing a cross-government strategy and improving the dissemination of the tools needed to empower people with long-term conditions, that this challenge can be met.”

Fit for Work Coalition member Prof Karen Middleton, CEO of the Chartered Society of Physiotherapy, commented: “Government policy focuses on reducing welfare costs, but there are millions of people in work whose ill-health threatens their job security and productivity. Simple, early and joined-up action, such as commissioning self-referral physiotherapy services, to help workers to manage conditions such as musculoskeletal disorders – the cause of 35m lost working days each year – can save money and improve the quality of working lives for millions.”


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What impact will the NICE quality standard on Rheumatoid Arthritis have on workers with the disease?

Monday, July 1st, 2013

Earlier last week the National Institute for Health and Care Excellence (NICE) published a quality standard on rheumatoid arthritis. Jamie Hewitt, government affairs manager at the National Rheumatoid Arthritis Society (NRAS), looks at the quality standard and its implications for work.

Rheumatoid arthritis (RA) is a chronic disease that occurs when the immune system attacks the body instead of defending it, causing inflammation that often results in serious damage to bones, joints and tendons, and can also affect internal organs like the heart, eyes and lungs. Currently the disease affects an estimated 690,000 people across the UK.

To date, outcomes for RA patients in the English NHS have been very mixed, resulting in very negative impacts on people’s ability to work in the long term. Although the disease can strike at any age from the age of 16 upwards, three quarters of people with RA are first diagnosed when of working age – with the largest cohort being over 40 years old – at the height of their wage earning potential.

Indeed the National Audit Office has calculated that sickness absence and worklessness caused by the disease amounting to an estimated £1.8 billion per year. Additional NRAS research has also found that almost a third of people with RA have given up work as a result of their disease, with well over a quarter doing so within one year of diagnosis, and over half doing so within six years.

Ensuring people are able to stay in work is therefore absolutely vital – but not just in pure economic terms –the psychological impact on patients is also important. For instance, an NRAS survey of members with the disease found that 88 per cent of respondents said that having a job helped them cope with the disease with incidences of depression are significantly higher among non-workers than workers.

So how does the new NICE quality standard on RA help? Put simply, it contains seven quality statements that, if implemented, should deliver high quality care to people with RA who show early signs and symptoms of the disease. We hope they will improve clinical outcomes for patients and enable them to stay in work, or make a swift return to work.

The new document places particular emphasis on early diagnosis and treatment. It recommends that people with suspected persistent synovitis be referred to a rheumatology service within three working days of presentation, be assessed by a rheumatology services within three weeks of referral, and offered disease modifying anti rheumatic drugs within six weeks of referral.

These statements reinforce the mantra of treating patients within the 12 week ‘window of opportunity’ from symptom onset as identified in existing NICE guidelines on RA. The existing guidelines point out compelling evidence that patients who are given treatment within 12 weeks of experiencing symptoms stand a much better chance of recovery. In practice, this means that patients can have a much better quality of life, including the ability to hold down employment and be free from the effects of substantial, irreversible joint damage.

By setting out the maximum time that should elapse between each stage of the referral process we hope that patients and healthcare professionals will be better able to identify delays, and put in processes to reduce and eliminate unnecessary delays. Properly implemented, the new NICE quality standard could lead to significant improvements in work outcomes for these patients.

However, a word of caution. Although we strongly welcome the introduction of the NICE quality standard, it is not a silver bullet. Earlier last week, to coincide with the launch of the first ever national RA Awareness Week, NRAS published a report about public awareness of the disease called ‘Breaking Down Barriers’. The report notes the significant challenges to improving clinical outcomes (and associated work outcomes) posed by the patient themselves. Poor public awareness of the disease symptoms means that half of all patients delay seeing their GP for around 12 weeks. A fifth delay seeing their GP for a year or more. At a stroke, the 12 week ‘window of opportunity’ can quite literally go straight out of the window.

The job is not yet finished. Yes, effective systems need to be put in place which incentivise speedy referral, diagnosis and access to appropriate, effective treatments. But at the same time this must be aligned with greater public awareness of the disease in the first place. Only through a combination of the two are we likely to see dramatic improvements in work outcomes for RA patients.

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A team effort: Employers and the Welfare State by Steve Boorman

Tuesday, June 18th, 2013

It was good to be part of a lively discussion on Monday ( 17 June) organised by Reform and hosted by the Association of British Insurers about how employers can improve welfare outcomes.

Mark Hoban, the Minister for Employment described Carol Black’s work as pivotal and spoke strongly of the need to ensure people were better off in work. He said that for those returning to work, post – employment support was key and he highlighted the value of maintaining employability and avoiding job loss.

The panel discussion was wide ranging with a range of expert views, including Dame Carol, strongly supporting the value to employers, employees and the State of promoting workplace health and well-being. A recurrent theme was competence and capability of management and leadership –more important than token fruit and gym membership!

The second session focused more on the need to plan for the future financial needs of our workers in order to reduce poverty. Stephen Timms, The Shadow Minister for Employment, focused on outlining ideas for the job guarantee scheme, but was clear in the need to be open to ideas and expressed his willingness to listen to new ideas to tackle what he described as the unemployment crisis.

The panel session which followed was spirited and talked about the frightening fact that more people in poverty were in working households than non-working. There was less consensus here with one Lord Stevenson arguing that saving for the future in the form of a pension made little economic sense when interest rates were so low that inflation exceeded savings income! There was also a suggestion that today’s welfare state was not configured to meet the needs of a 21st century workforce, where job security and uncertainties of investment drove a need for different behaviours and different ways of supporting financial needs.

A strong audience and diverse speakers made this an interesting and broad ranging meeting which included insurers, health providers and third sector representatives – and the issues covered suggest that solutions need diverse stakeholders to work together if we are to reduce sickness and improve employment rates.

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How physios can help GPs tackle sickness absence

Wednesday, May 15th, 2013

Employee ill health and sickness absence is a major drain on the UK’s productivity, with the annual cost of workplace illness estimated to be £8.2billion according to the latest Health and Safety Executive Statistics Report. But, here at the Chartered Society of Physiotherapy, we are convinced that physiotherapists can help bring down the number of days taken off work.
In a Department for Work and Pensions report  published last week (7 May), 98% of GPs agree that remaining in work is generally beneficial for people’s health and the overwhelming majority (95%) also believe worklessness is detrimental to health. Despite this, three quarters of GPs admit to issuing patients with fit notes (formerly sick notes) – even where there is a lack of medical evidence indicating that they should have time off work.

Part of the problem stems from  the fact 89% of GPs also say they have  not received training in health and work in the last 12 months, while only 18% have a good awareness of local services to which they can refer patients. Yet we know early access to physiotherapy can help prevent or reduce the amount of time off work a person needs following a musculoskeletal disorder, like neck or back pain.

With 131 million working days lost to sickness absence in 2011, according to the Office of National Statistics, the fit note epidemic is something we at the CSP feel needs tackling. To help physiotherapists play their part, the CSP has collaborated with the Society of Chiropodists and Podiatrists and the College of Occupational Therapists to develop a new tool – the Allied Health Professional’s Advisory Fitness for Work Report.

While employees will still require a Statement of Fitness for Work from a doctor to claim sick pay, the new AHP Advisory Fitness for Work Report provides an opportunity for physiotherapists to assist GPs and employers.  It identifies the specific work issues a patient has as a result of their health condition, and the adjustments needed to help them to return and remain in work. For example, something as simple as letting an employee with back pain carry lighter loads until they are better can help them get back to work instead of being signed off sick.
Employers can also do a significant amount to improve the health of their workers and thereby prevent sickness absence occurring in the first place by:

• Creating a work culture where staff feel they can report stress or ill health
• Providing fast access to a physiotherapist when staff suffer from a musculoskeletal disorder – the second biggest cause of sickness absence
• Encouraging staff to develop good work habits, such as taking regular breaks and building some physical activity into their day. This can help to prevent staff becoming overly stressed – the biggest cause of sickness absence
• Ensuring staff receive appropriate work station assessments and advice on carrying out their job safely
• Providing flexible working where this is possible

In order to drive the message home to employers, their staff and healthcare professionals, the CSP has organised Workout at Work Day on 12 June. This is an annual awareness raising campaign, which aims to help both employers and staff develop healthier work habits so that sickness absence can be avoided or reduced, helping people to remain fit for work. This year, the focus will be on the need to improve workplace health in order to prepare for the demands of a longer working life.

We have produced a free leaflet, Under Pressure, looking at the link between physical activity and mental wellbeing, as well as leaflets with advice for workers in sedentary jobs, Fit for Work, and more active roles, Fit for Active Work. Stay happy and healthy at work by taking up these simple tips.  Following the advice in these leaflets would significantly reduce the number of days of sickness absence and cut the cost to the UK economy – as well as improve the quality of life for anyone choosing to use them.

Sue Browning, Chartered Society of Physiotherapy.



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Independent Advisory Service must have the right resources and incentives to be effective

Tuesday, April 16th, 2013

Last week (11 April) Professor Stephen Bevan, Fit for Work Europe founding president and a director at The Work Foundation, highlighted why the Government’s proposed Independent Advisory Service for  helping people with health problems return to work must do more for those with long term conditions.   In an interview with Radio 4’s In Business, Professor Bevan spoke of the need for a holistic service which uses the input of occupational clinicians. He argued that tailored support for individuals would help keep people in work long term and called for the service to take a different approach to the  Work Capability Assessments. He proposed that employers and employees work together to  find ways  for individuals to return to work.

Research by Fit for Work (FfW) UK has highlighted the immense difficulties people with musculoskeletal conditions (MSDs) face trying to remain  in work.  FfW UK’s recent study of 809 people diagnosed with a MSD (published in December 2012) found that three quarters of survey respondents who were retired said their condition had influenced their decision to leave the labour market. While the majority retired before reaching the age of fifty-five. The findings revealed further barriers to employment. Within three years of diagnosis, half of people with rheumatoid arthritis are registered as work disabled.  Inability to stay in work may have a further spill over effect into the wellbeing and financial stability of entire households which is especially worrying as , 57.4 % of respondents who were not in work had been primary income earners before leaving their job. It was also clear from the FfW findings that work needs to be introduced into the CCG (Clinical Commissioning Groups) Outcomes Indicator Set as an clinical outcome for people with MSDs as early as possible.

As  Professor Bevan says, “Returning to the workforce after an absence can be incredibly hard for people with long term conditions like musculoskeletal disorders, and it gets harder the longer one is not working.  The new Independent Advisory Service will make a difference to thousands of people every year if helps  people work with their employer to find ways to stay in their job. This will require a true partnership between the service, clinicians, employers and people using it and we urge the government to encourage this approach in its design of the service, for example, by ensuring all targets incentivise keeping people at  work for the long term.”

You can listen to the programme again at this link:

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NHS incurring needlessly high sick pay costs as many staff with musculoskeletal disorders still lack support to remain working

Wednesday, March 13th, 2013

Responding to today’s publication, Fit enough for patients? from the Chartered Society of Physiotherapy, Professor Stephen Bevan, Fit for Work Europe founding president and a director at The Work Foundation said:
“We are concerned with today’s findings, which show that 90 local health trusts have spent over £1billion in three years on sickness absence. The recommendations from The Boorman Review three years ago, which identified potential savings for the NHS if sickness absence were properly addressed, have not been fully implemented. This is a missed opportunity for savings to public funds and support for workers with musculoskeletal disorders (MSDs).

“Evidence from Fit for Work UK shows that at least 40% of NHS staff sickness absence is due to MSDs. Yet today’s findings reveal that at least 15% of NHS trusts are not providing early intervention services, such as early referrals to clinicians.

“More NHS trusts should be offering early intervention services and following best practice for fitness for work assessments in order to help employees return to work as soon as is practical. Unless the NHS offers more support for workers with MSDs, it is likely to find it increasingly difficult to meet the challenges of an ageing workforce.”

Notes to editors

1. Professor Stephen Bevan is available for interviews, briefings and written comment.
2. The Boorman Review, NHS Health and Well-being,  was published in December 2009.
3. The Chartered Institute of Physiotherapy report, Fit enough for patients? is available from
4. The Work Foundation aims to be the leading independent, international authority on work and its future. The Work Foundation is part of Lancaster University  – an alliance that enables both organisations to further enhance their impact.
5. Fit for Work UK is a campaigning coalition established in 2011 with the aim to shift the treatment and care of musculoskeletal disorders (MSDs) from being disabling conditions to manageable conditions.

Media enquiries:

Tom Phillips 020 7976 3554

Anna Kharbanda 020 7976 3646
For urgent out-of-hours media enquiries: Nasreen Memon 07825 527 036


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Recent NICE proposals must do more to support workers with long-term health conditions

Wednesday, February 6th, 2013

Last week (1 February) NICE published a consultation on potential new indicators for the Clinical Commissioning Group Outcomes Indicator Set (CCGOIS), which will replace the Clinical Outcomes Framework (COF) in 2014.

Responding, Professor Stephen Bevan of The Work Foundation and the campaigning coalition, Fit For Work UK, said:

“It is disappointing that Clinical Commissioning Groups will not be incentivised to commission services that prioritise work outcomes of individuals with long-term conditions, despite the fact that work is included in most other health service indicators.  A patients’ ability to work is important for their quality of life, including independent living; supporting more people back into work has obvious benefits for the economy and society.

“This is especially critical in the case of the thousands of UK workers who have musculoskeletal health problems. For example, within three years of diagnosis, half of people with rheumatoid arthritis are registered as work disabled*, with musculoskeletal diseases costing the UK at least £7 billion a year and causing at least 10 million lost working days each year. Considering work when commissioning health services is one of the steps to reduce this economic burden of disability and productivity. “


Note to editors

1. Professor Stephen Bevan and senior researcher, Ksenia Zheltoukhova are available for interviews, briefings and written comment.
2. Fit for Work UK is a campaigning coalition established in 2011 with the aim to shift the treatment and care of musculoskeletal disorders (MSDs) from being disabling conditions to manageable conditions.
3. The Work Foundation aims to be the leading independent, international authority on work and its future. The Work Foundation is part of Lancaster University – an alliance that enables both organisations to further enhance their impact.
4. Fit for Work Europe is a unique multi-stakeholder coalition that strives to better align the work and health agendas in the EU and to shift the perception of musculoskeletal disorders (MSDs) from being disabling conditions to manageable conditions, ensuring that more European citizens stay or return to work, while helping to improve the sustainability of Europe’s health and welfare systems. Fit for Work is a partnership of organisations and individuals, and enjoys the patronage of The Work Foundation, the UN’s Bone and Joint Decade, the European League Against Rheumatism (EULAR) and RAND Europe. The Fit for Work Europe Coalition is supported by an ongoing grant from Abbott – a founding partner – and a supporting grant from GE Healthcare.

Media enquiries:

Tom Phillips 020 7976 3554

Anna Kharbanda 020 7976 3646

For urgent out-of-hours media enquiries: Nasreen Memon 07825 527 036

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Is the government’s response to the sickness absence review good enough?

Wednesday, January 23rd, 2013

Dr John Chisholm CBE is a member of the Fit for Work UK Coalition, representing the Royal College of General Practitioners.  He is also a member of the Council for Work and Health and the National Stakeholder Council for Health, Work and Wellbeing.  This commentary is written in a personal capacity.

Most GPs will have welcomed the government’s response last week to the Sickness Absence Review by Dame Carol Black and David Frost (published in November 2011). In particular, the way sickness absence is managed in the future will radically change when the independent, state-funded Health and Work Assessment and Advisory Service is rolled out in 2014. Most GPs are only too aware that the longer someone is off sick or out of work, the harder it is to get back to work. The new service can help assess individuals earlier, offer advice to employees, employers and GPs, as well as ensure each case is managed, followed up and includes appropriate interventions where necessary.

The government’s response is a significant step forward, yet it remains somewhat vague about the funding and delivery of the necessary interventions. GPs are often frustrated by delays in access to NHS services – including physiotherapy and cognitive behavioural therapy – that may result in unnecessarily prolonged sickness absence and long-term worklessness. It is therefore essential to introduce mechanisms to achieve early intervention, including obligations on employers to implement the service’s recommendations on workplace adjustments whenever possible.

It is also not clear how GPs will refer patients to the new service. The report implies that the fit note itself will trigger referrals, but also assumes that eligibility to be seen will be restricted to employees without access to occupational health services at work. At a time of rising GP workload, GPs will want the referral system to be simple and streamlined, without requirements for detailed referral letters or questioning of patients about their employers’ occupational health arrangements.

In addition, there are potential problems with using a large number of occupational health professionals in the new service at a time when they are already in short supply and when many are heading towards the end of their careers, So it is important that the new service can find the workforce it needs without detriment to other occupational health provision. In parallel with this, the quality and standards of the service must be monitored to ensure it is delivering the necessary benefits.

One of the key points of the report is the importance of data in monitoring progress. Analysis of information available from the roll-out of electronic fit notes and from the new Assessment and Advisory Service will help, as will monitoring progress on the Health, Work and Wellbeing initiative. This uses such indicators as reducing the proportion of people out of work due to ill-health and improving access to appropriate and timely health service support. However, more data could be collected on longitudinal employment outcomes through the mechanisms already in place to collect patient data, as staying in or returning to work is an important indicator of clinical success. Such attitudinal change and data collection can be incentivised through the Commissioning Outcomes Framework.

The government response will undoubtedly have a major impact on how sickness absence is managed in Great Britain, in particular through the introduction of the new Assessment and Advisory Service next year. However, there are still some issues to be resolved in respect of referrals, interventions, workforce, quality monitoring and data collection. GPs and other stakeholders will be keen to work with the Department for Work and Pensions to ensure the new processes not only lead to cultural change but produce benefits for employers, taxpayers, the economy, health care professionals and most importantly for the future of those employees and patients at risk of long-term worklessness.


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