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Investing in Healthcare: breaking down the silos

Brussels, 16 October 2013
With the endorsement of the Lithuanian Presidency of the Council of the EU In partnership with the European Economic and Social Committee Co-chaired by Antonyia Parvanova MEP & Gianni Pittella, Vice-President, EP

Investing in Healthcare: breaking down the silos

Introductory session

Introductory session
Investing in Healthcare: breaking down the silos

Prof Dr Stephen Bevan

Founding Co-President, Fit for Work Europe Director, Centre for Workforce Effectiveness The Work Foundation

Introductory session
Investing in Healthcare: breaking down the silos

Maureen ONeill
President, Section for Employment, Social Affairs and Citizenship European Economic and Social Committee (EESC)

Introductory session
Investing in Healthcare: breaking down the silos

Vytenis Povilas Andriukaitis

Health Minister, Lithuania EU Presidency

Introductory session
Investing in Healthcare: breaking down the silos

Gianni Pittella (video message)

Vice-President, European Parliament

Introductory session
Investing in Healthcare: breaking down the silos

Dr Roberto Bertollini
Chief Scientist and WHO Europe Representative to the EU

Introductory remarks

Investing in Healthcare: breaking down the silos Introductory remarks

Roberto Bertollini MD MPH Chief Scientist and WHO Representative to the EU WHO Regional Office for Europe

16 October 2013, Brussels

Overall health improvement (+ 5 years life expectancy) but with an important divide in the Region

CIS: Commonwealth of Independent States EU12: countries belonging to the European Union (EU) after May 2004 EU15: countries belonging to the EU before May 2004

Source: European Health for All database. Copenhagen, WHO Regional Office for Europe, 2010.

Health inequalities within countries: life expectancy in Sweden by education level

Burden of disease in Europe in 2010 and % change between 1990 and 2010

http://www.healthmetricsandevaluation.org/gbd/visualizations/gbd-arrow-diagram Accessed on October 14 2013

Environment-society-individual interaction on health Cardiovasc. diseases Social factors not related to Breast cancer environment Causes of the causes Diabetes Physical Trade inactivity Respiratory Lung cancer infections Respiratory Transport Proximal causes diseases COPD Radiation Lung cancer Chemicals Injuries Air pollution Climate Degraded Health change ecosystems etc. Vector Diarrhoea Malaria breeding sites Malaria Injuries Water, Dengue sanitation Cardiovasc. etc. diseases Leishmaniasis Migration etc. Malnutrition Desertification Intestinal parasites Diarrhoea Drownings Genetic factors Malnutrition etc.

Cost-effective policies using fiscal policy to improve health outcomes

Tobacco A 10% price increase in taxes could result in up to 1.8 million fewer premature deaths at a cost of between US$ 3 and US$ 78 per DALY in eastern European and central Asian countries

Alcohol In England, benefits close to 600 million in reduced health and welfare costs and reduced labor and productivity losses, at an implementation cost of less than 0.10 per capita

Source: McDaid D, Sassi F, Merkur S, eds. The economic case for public health action. Maidenhead, Open University Press (in press).

Cost-effective policies (cont`d)

-Healthy eating; -Prevention of depression; -Action across the life course; -Early action in childhood; -Prevention of road traffic accidents; -Tackle environmental chemical hazazards; -Investment in education is investment in health.

Going upstream is compelling!

(social determinants, prevention, health promotion)

The economic case for health promotion and disease prevention

Cardiovascular disease 169 billion annually in the EU; healthcare accounting for 62% of costs 125 billion annually in the EU, equivalent to 1.3% of GDP Over 1% GDP in the US; between 1-3% of health expenditure in most countries 6.5% of all health care expenditure in Europe Up to 2% of GDP in middle and high income countries
Sources: Leal (2006), DG Sanco (2006), Stark (2006), Sassi (2010), WHO (2004)

Alcohol related harm

Obesity related illness (including diabetes and CVD)

Cancer Road traffic injuries

Improving governance for health

Supporting whole-ofgovernment and whole-ofsociety approaches Learning from a wealth of experience with intersectoral action and health-in-all-policies (HiAP) work in Europe and beyond

Two studies on governance for health led by Professor Ilona Kickbusch (2011, 2012)

Intersectoral governance for HiAP, by Professor David McQueen et al.

We need wide-ranging prevention strategies addressing multiple determinants of health across social groups A combination of individual and community behaviours and conducive policy and regulatory environment is required to make the healthy choice the easy choice!

Health 2020 books published

New evidence informing Health 2020

Governance for health in the 21st century Supporting Health 2020: governance for health in the 21st century Promoting health, preventing disease: the economic case Intersectoral governance for health in all policies: structures, actions and experiences Report on social determinants of health and the health divide in the WHO European Region Review of the commitments of WHO European Member States and the WHO Regional Office for Europe between 1990 and 2010

Health 2020 strategic objectives and priorities for policy action

People enabled and supported in achieving their full health potential and well-being (value-driven)
Reducing inequalities and improving governance for health
Investing in health through life course and empowering people Tackling the Region's major health challenges Strengthening Patient-centred health systems Creating resilient communities and supportive environment s

Adding value through partnership

Reduce health inequities: biggest challenge

For richer, for poorer Growing inequality is one of the biggest social, economic and political challenges of our time. But it is not inevitable
The Economist Special Edition October 13th 2012

Equity as a measure of progress

Reducing health inequities should become one of the main criteria to measure: Health systems performance; Performance of the Government.

Thank you!

Introductory session
Investing in Healthcare: breaking down the silos

Fit for Work Co-Presidents video message

Investing in Healthcare: breaking down the silos

Session Two

Return on early intervention

Building the evidence on cross-governmental budgeting

Return on early intervention

Investing in Healthcare: breaking down the silos

Moderator

John Bowis
Health expert; former Member of European Parliament; former UK Health Minister

Return on early intervention

Investing in Healthcare: breaking down the silos

Prof Stephen Bevan

Founding Co-President, Fit for Work Europe Director, Centre for Workforce Effectiveness The Work Foundation

The case for a cross-governmental budgeting (the case of RMDs)

The Case for Cross-Governmental Budgeting

The Case of RMDs

Stephen Bevan
Director, Centre for Workforce Effectiveness, The Work Foundation (UK) Honorary Professor, Lancaster University, UK Founding President, Fit for Work Europe Coalition

A Reminder MSDs in the EU

Major cause of incapacity in the workforce

MSDs cost 240 bn each year 2% of GDP

Over 40m EU workers have MSDs Major & growing impact on productivity, labour market participation & social inclusion as the workforce ages & health spending is scrutinised

Some workplace risks for MSDs growing

MSDs cause 49% of absence from work

Pre-existing MSDs & psycho-social factors understated

Sustainability?
Across the EU, only 3% of health spending is devoted to Prevention with over 70% of spending now on chronic illness, this is unsustainable Early intervention for people of working age with chronic conditions such as MSDs can be a form of prevention which ensures patients pay rather than consume tax However, early diagnosis & treatment is still too slow Too many clinicians fail to consider Work as a clinical outcome Social Security systems are poor at supporting people with chronic conditions to remain in work Employers need to play a part too.

MSDs & Lost Productivity

UK 300k people move from long-term absence to permanent disability benefits 822 a day: 13% have MSDs 35m working days lost to MSDs each year

A Win:Win for Policymakers?

Healthcare interventions which help people remain in work reduce welfare payments, avoid lost tax revenues & avoid social exclusion BUT we still focus on health as a COST

If early interventions can reduce temporary work disability by 25% the equivalent of an extra 640k EU workers would be available for work each day If TWD was reduced by 39% this figure rises to 1 million additional workers each day

MSDs & Work Ability - UK

National Audit Office has calculated that improved clinical outcomes for people with rheumatoid arthritis could be achieved if early intervention was increased by 10 per cent. However, these gains would be need to be achieved by first increasing expenditure in the health care system (NHS) by 11 million over 5 years. A productivity payoff estimated to be 31million over 5 years from reduced sick leave and lower unemployment would accrue to individuals, employers and to the Department of Work and Pensions. This elegant and apparently persuasive economic argument was put to, and accepted by the Public Accounts Committee an influential group of MPs in the House of Commons. Despite wide support the political argument has yet to be won and no action based on this NAO example has yet been taken.

Invest to Save
By 2030 up to 45% of the EU workforce will have a long-term or chronic health condition which will affect their productivity Are we just going to wait for them all to get ill so we can then make them better or keep them functional, at massive cost? Joined-up, coordinated, cross-government action with a preventative focus and an Investment mindset is desperately needed Every Minister is a Health Minister

Return on early intervention

Investing in Healthcare: breaking down the silos

Daiga Behmane
FfW National Project Leader for Latvia

The Latvian Government approach to RMDs and the Latvian National Development plan 2014-2020 to address RMDs

Investing in Healthcare: breaking down the silos

With the endorsement of the Lithuanian Presidency of the Council of the EU In partnership with the European Economic and Social Committee

The Latvian Government approach to RMDs and the Latvian National Development plan 2014-2020 to address RMDs
Daiga Behmane, MSc Fit for Work Latvia project leader

16 October 2013, Venue: European Economic and Social Committee (EESC) Rue van Maerlant 2, Brussels

Outline of the presentation

The situation in Latvia on RMDs The Latvian National Development plan 2014-2020 to address RMDs Involvement and responsibilities of institutions to Application of HTA considering work ability as a clinical outcome Future challenges and future solutions

Latvia, country profile

Total population 2,060,000

Gross national income per capita (PPP $)

17,700

Life expectancy at birth m/f (years) Healthy life years m/f (years)

69/78 53,5 / 56,5

Total expenditure on health per capita (Intl $) 1,179 Total expenditure on health as % of GDP 6.2 %

General government expenditure as % of THE 58 %

Source: Global Health Observatory, data for year 2011

Healthy life years at birth, males, 2008-2011 (years)

EU-27: 61.8 years for men / 62.2 years for women Latvia: 53.5 years for men / 56.5 years for women The retirement age will be raised till 65 in 2015 !!!

Data source: http://epp.eurostat.ec.europa.eu/statistics_explained/index.php?title=File:Healthy_life_years_at_bir

MSDs: affect 100 million people in Europe and is the leading cause of disability among working-age population Incidence of primary disability due to MSDs, Latvia, 2003.-2010.

3000

2600
2500

2102
2000 1500 1000 500 0 2003 2004 2005 2006 2007 2008 2009 2010

1362 763 935 1058 1126

1426

Data source: The State Medical Commission for the Assessment of Health Condition and Working Ability of Latvia

FFW LV launch event on March 28, 2012, Fit for Work Latvia Coalition: politicians, doctors, patients, employers, HC managers, signed Good Will Memorandum

Fit for Work LV project structure

F4W LV National Coalition 2012 March
Patron Karlis Sadurskis, EU PM Lead by Daiga Behmane

1st Task Force group 2nd Task Force Group

Prioritization of MSDs Need for cross-budgeting approach Create National Arthritis program

3rd Task Force Group

Create no inflammatory MSDs prevention and reduction program

2013 December

Main target: Change the National policy prioritization of MSDs and workability concept

Main target: Set New Standards Main Target: Set New standards of Care (diagnostics, care, of Care and decrease sick rehabilitation) and decrease leaves days and disability disability related to MSDs related to MSDs

National MSDs Plan Supervised by the National Coalition

The National Development Plan of Latvia, 2014 - 2020 Guiding principle : economic breakthrough Incorporates FfW Coalition suggestion: Healthy and Fit for Work activity: early detection and treatment of MSDs

Forecasts for GDP per capita growth In comparison with EU-27 , Lithuania and Estonia (%)

Prioritization of MSDs in the NDP, 2014-2020

Activities for health sector include: Introduction of concepts of "workability and healthy life years Activities on early diagnostics, care and rehabilitation of non-communicable diseases, incl. MSDs Support for National MSDs programme:
Indicators for MSDs and treatment effect monitoring New standards of care, Guidelines for primary care doctors and general

Healthy life years, LV 2010, 2020, 2030

63.0 60.0 60.0

64.0 62.0 60.0 58.0 56.0 54.0 52.0 50.0 48.0 53.5

56.5

57.0 Men Woman

practitioners, Patient flow chart for MSDs patients (primary , secondary care , rehabilitation) Diagnostics, care and rehabilitation program and service package Arthritis patient registry Re-integration in work program for people with MSD's Cost of MSDs Economic model
Data source: www.pkc.gov.lv

Fit for Work LV Coalition proposals to HC decision makers:

Work ability concept in HTA Productivity costs should be included in HTA Despite the overall acceptance of the concept, there is restricted evidence of the methodological and practical application of the approach Other complementary elements: scientific approach to disese management , application of health economic methods for HC planning , development of data information systems e.t.c Further research on factors facilitating the use of workability in health care decision-making should be developed

Data source: Fit for Work Latvia project expert group conclusions, 2012

FfW Coalition: Development of Workability concept from theory to practice from Government to NGOs involvement and responsibilities
1.Political commitment
Parliament Government Ministries of Health, Welfare, Finance

Political strategy the National Development Plan, National MSDs Plan Investment policy

2.Methodology
Government Ministryes of Health, Welfare, Finance National Health Service, Riga Stradins University Latvian Association of Health Economics

Guidelines for economic evaluation Chronic disease management approach Societal perspective (productivity costs) in HTA Avoidance of silo-budgeting approach

3.Implementation
National Health Service

Disease Prevention and Control Centre - WGroup

Responsible institution Technical skills to do HTA Data availability

Thank you!
Contact details: Fit for Work Latvia project contact address: info@fitforwork-latvia.lv Daiga Behmane, MSc Riga Stradins University Vice-Dean for Masters Degree Programs Daiga.Behmane@rsu.lv

Return on early intervention

Investing in Healthcare: breaking down the silos

David McDaid
Editor, EuroHealth & Personal Social Services Research Unit, London School of Economics and Political Science and European Observatory on Health Systems and Policies

Working across government departments to promote return to work

Working across government departments to promote return to work

David McDaid Fit for Work Europe Summit on Investing in Health Care, Brussels, October 2013 Personal Social Services Research Unit, London School of Economics and Political Science and European Observatory on Health Systems and Policies E-mail: d.mcdaid@lse.ac.uk

Why collaborate across sectors?

Improved rate of employment
80 60 40 20 0 -20 -40 -60 -80 -100 Social Welfare

So why should health sector invest?

Resource Consequences Health Benefits More Employment

Costs of action to health system

Collaboration with shared goals may have a better Health Sector return on investment

Reduced costs to social welfare system

Sweden: Co-ordinated budgets for vocational rehab

Extensive experiments since early 1990s Looking at different forms of collaboration between
Regional Health services Municipal Social Services National Social Insurance Administration National Employment Services

1993- 1997 initially resources for rehab transferred from social insurance to health care aim to reduce cost of sickness benefits 1994 2002 social services & employment services also involved in 8 municipalities

Sweden: Co-ordinated budgets for return to work Initial evaluations positive Improved collaboration & co-ordination Led to 2003 Act on Financial Coordination of Rehabilitation Measures Allowed local associations to be formed for financial collaboration Resources for rehabilitation pooled in a single budget allocated for different rehabilitation services 2008 Rehabilitation Chain reforms

Swedish Rehabilitation Chain

What difference have these reforms made?

Swedish Social Insurance Authority 2013

New claims for early retirement and disability

Swedish Social Insurance Authority 2013

Rehabilitation Chain
2008 reforms rehabilitation chain Time restricted working capacity assessments have contributed Assessments at 91 and 181 days Only implemented in around 20% of cases Reduction in level of benefits after 1 year Rehabilitation guarantee with psychological support for MSD and Mental Health Helps put more focus on early intervention

Sick leave / disability benefit trends

Hagglund 2010

Are they effective?

In Sweden still a lack of hard financial incentives between public employment services and social insurance administration. Employers and occupational health services not incentivised to work with insurance system to help in return to work; problem especially for mental health problems

If employment services responsible for paying sickness benefits from its budget then more direct incentive to help reintegrate into work
Mandatory support only provided to those who have been unemployed for more than 2.5 years through Work Introduction Programme More focused on employment as an outcome target of rehabilitation

Challenges for those who do not return to work

Re a report on those who reached one year on sickness insurance (Arbetsfrmedlingen, Frskringskassan 2010 ) In following 6 months 2.5% returned to open employment 7% subsidised/sheltered employment 41% returned to sickness insurance after a waiting period 50% unemployed or unidentifiable

Joint budgeting across sectors more generally

Limited focus of evaluation on outcomes; largely on process; most experience at local/regional level
But some success in initiatives to reduce road traffic casualties in England and provide services for children

Evidence they can help overcome narrow sectoral interests by

Widening area of responsibility Obtaining engagement and interest of different stakeholders Promoting flexibility in funding Ending the cross-sectoral blame game Reduce need for complex contracts between different actors in different sectors

Arrangements can be poorly understood / implemented (UK Audit Commission 2008, 2009, Swedish Audit Commission 2010) Experience in England and Sweden suggests additional actions needed:
Inter-sectoral working relationships Highlighting multiple benefits Demonstrating economic benefits

Factors to aid in implementation

Define problem / joint benefits of action Identify all cross sectorial stakeholders / actors to be involved Understand what are their priorities and goals how would joint funding of an initiative add value from their perspectives Vital to highlight non-health benefits; speak non-public health language Sustained effort needed to build cross-sectoral working relationships
Employing co-ordinators (esp where not full integration of budgets) Co-locate team members to help trust/ working relationships develop

A role for financial incentives

Needs common set targets/performance indicators linked to appropriate outcomes E.g. incentivising employment services and employers alike

Highlight the economic case for cross-sectoral action

In Conclusion
Some evidence that mechanisms to foster cross-sector working in Sweden have been positive in promoting return to work Downward trend in long term sickness absence over recent years and supportive of early intervention strategy

New claims for long term sickness compensation (disability benefits)

falling; more noticeable for MSDs than mental health Need to incentivise employers & public employment services; issues re work capacity assessments Sickness benefit payments fallen but no definitive economic

assessment conducted;

Return on early intervention

Investing in Healthcare: breaking down the silos

Sarah Copsey
Project manager, Prevention and Research Unit European Agency for Health and Safety at Work (EU-OSHA)

Safer and Healthier Work at any age: OSH in the context of an aging workforce

Safer and Healthier work at any age: OSH in the context of an aging workforce
Sarah Copsey
Project Manager, EU-OSHA

Fit for Work Summit, 2616 October 2013, Brussels

Safety and health at work is everyones concern. Its good for you. Its good for business.

OSH challenges in the context of an aging workforce

Not OSH of Older but OSH in the context of Not only what do we need to do for older workers? but What OSH system do we need for all workers knowing that the workforce is aging? Longer working means potentially more exposure to risks OSH of young workers determines health of older workers Only way to reduce chronic work-related ill health among older workers, to allow everyone to work longer, is to improve the OSH of all young and old A preventive approach aimed at all employees is needed to cover all generations and ensure a good match with their various needs and skills. Specific measures for older workers should be introduced carefully to prevent social marginalization and stigmatization. *
* New Forms of Physical and Psychosocial Health Risks at Work Study for the European Parliament's Committee on Employment and Social Affairs, 2008 http://www.europarl.europa.eu/document/activities/cont/201107/20110718ATT24294/20110718ATT24294EN. pdf
http://osha.europa.eu

71

EU-OSHA European Project older workers and OSH 2013-2015

Background Designated within European Parliaments pilot project - "Health and safety of older workers" to enhance implementation of existing recommendations, exchange best practice, further investigation of the ways to improve OSH of older people at work, further developing work already carried out, assessment of appropriateness of further action EU-OSHS carries out the work under a cooperation agreement with the European Commission
Official Journal 29.02.2012 - 04 04 16 Pilot project Health and safety at work of older workers

http://osha.europa.eu

73

Scope of project
OSH focus, whole OSH system, all workers, build on knowledge Review OSH policies, strategies, programmes and prevention actions in member states in context of age/diversity Review rehabilitation policies, programmes, occupational health services etc. Functioning, access to etc. Investigate needs and experiences - qualitative research Experiences of intermediaries Experiences at company level (employers, trade unions workers) What support and services do S and MiEs need?

Good practices MSDs, stress, WHP Gender incorporated transversally + gender review Evidence-based conclusions
analysis and policy options proposals to Commission to assist policy

Conference in EP 2nd December 2013 Conference to discuss draft final results June 2015
http://osha.europa.eu

75

Better implementation of the Framework directive

Committment Diverse workforce an asset Avoid assumptions Look at real work done and context Consider everyone Collective measures safer, healthier for all Adapt work to workers Design/planning stage changes/purchases Link OSH to equalities Training on diversity Tailor OSH training to needs Participatory Mixture of measures Seek advice where necessary Is the advice, intervention equally relevant to all groups?

http://osha.europa.eu

77

Integrating gender into workplace risk assessement Adapting working conditions and career progression to combat MSDs
French printing company, > 225 workers, 2 main workshops: Printing & Finishing Female The Problem: jobs Womens absenteeism high, MSDs The process: gender-sensitive assessment Women got stuck in one occupation finishing assistant - by far most affected longer exposure to repetitive tasks and bad ergonomic conditions
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Women Men

The Gendered labor division - FINISHING (Binding)

Male jobs
Cutting Machine Operator Warehouseman Foreman Workshop Manager Forklift Truck Operator Machinist Assistant Machinist Office Assistant Sewing Operator Finishing Assistant

Solutions, targeted measures: Workplace and work organisation: - Upstream with the suppliers (internal & external) to limit upper limbs stress et heavy lifting - Rethinking the design of workstations
Building on recognition and career paths: - Recognise skills of finishing
http://osha.europa.eu

78

The chair increased exposure

Horizon The truth about exercise, BBC Two, 9:00PM Tue, 28 Feb 2012 Heart problems etc. from sedentary life style chair = the new killer Risks of sitting at an ergonomic workstation all day everyday until 70 years old? DANGER! DANGER! BETTER!

http://osha.europa.eu

79

Too late to start at work Im just not used to bending my knees to lift
Neck pain and lower back pain associated with school furniture features Upper back pain associated with bag weight and furniture
Buckle et al Surrey University 2007

Swedish physiotherapists promote ergonomics knowledge and application in primary schools: information to pupils, teachers, other members of staff and parents; assistance in purchasing, testing school furniture instruction in lifting techniques etc. exercise during breaks, etc.
http://osha.europa.eu

80

How to improve workability and employability components of a strategy

Joined-up policy Design of work and work- organisation

LifeLongLearning

Better prevention for all

Career development

Working time
Health programmes Leadership, involvement, preventive culture, attitudes Individual competencies
www.healthy-workplaces.eu http://osha.europa.eu

81

Working together for risk prevention

Healthy Workplaces Campaign 2012-13

Participation of old and young workers!

Resources on older workers:

https://osha.europa.eu/en/priority_groups/ageingwo rkers

Thank you
copsey@osha.europa.eu
http://osha.europa.eu

83

Investing in Healthcare: breaking down the silos

Q&A

Investing in Healthcare: breaking down the silos

Patient testimonial (video message)

Ann Christin Hansen, Norway

Investing in Healthcare: breaking down the silos

Session Three

Healthcare investment as societal investment

New pathways to deliver better healthcare and societal outcomes

Healthcare investment as societal investment Investing in Healthcare: breaking down the silos

Prof Paul Emery

Professor, Rheumatology, Academic Unit of Musculoskeletal Disease University of Leeds Co-President, Fit for Work Europe

Prof Juan Jover

Head, Rheumatology Service Hospital Clnico San Carlos Madrid

Social Return on investment: The results of the Early Intervention Clinic in Spain and Concept of the FfW EU Early Intervention Framework

Professor Paul Emery and Professor Juan Jover

Rheumatic and Musculoskeletal Diseases

More than 200 diseases

Joints
Connective Tissue Spine Soft tissue Bone

High Disease Burden

High incidence and prevalence

Chronic course
High use of Health System resources High impact in quality of life: Pain and Disability

Burden of diseases in Canada, 2000

http://www.phac-aspc.gc.ca/ph-sp/preveco-01-eng.php#fig1 Adapted from IHE, 2008; data from the Public Health Agency of Canada

Spains National Budget. 2005

Temporary Work Disability Subsidies an Other Economic Benefits of Social Security 10.000.000.000 euros

20% Musculoskeletal Temporary Work Disability

The complexity of Work Disability

Occupational Process
- Economic Activity - Employers - Unions - Occupational Health

Health System Process

- Individual factors - Collective - Public Health - Health Care System
- Primary Care - Specialized Care - Inspection

Administrative Process
Social Security Institute - Compensation - Laws - Control - Fraud - Inspection

TWD

What if?

PWD

MSD-TWD Program (98-01)

Inclusion: 12 months Control TWD initiation due to MSDs (13.000 nonselected episodes) Intervention Follow-up: 12 months Results Days of TWD Patients with PWD Direct Costs Indirect Costs Cost/efficacy Cost/benefit

Three health districts in Madrid Randomized study Voluntary program Patients maintained their group Intention to treat analysis

Early Intervention Protocolized clinical management Patient Education Self-management Administrative Duties

Research: a clinical approach to MSD-WD

39 % reduction of TWD duration (days)

% of patients back to work

100

50% reduction of PWD (cases) Increased patient satisfaction Positive Economic evaluation Decreased and indirect costs Control direct Intervention Benefit/cost at two years: 11 euros Extension of the Program (1998-2004)

25

50

75

> 38.000 processes >1 million days off-work saved

0 0

30

60

90

120 150 180 210 240 270 300 330 360

Days

Scientific Publications

Diagnostic concordance between primary care physicians and rheumatologists in patients with work disability related to musculoskeletal disorders. Candelas G, Absolo L, Len L, Lajas C, Loza E, Revenga M, Bachiller J, Collado P, Richi P, Blanco M, Jover JA.

Rheum Int . 2011 Dec; 31(12) 1549-54

Prognostic Factors for Long-Term Disability Due to Musculoskeletal Disorders

LYDIA ABSOLO, LETICIA LEN, LORETO CARMONA, CRISTINA LAJAS, GLORIA CANDELAS, MARGARITA BLANCO, AND JUAN A. JOVER1

Rheum Int . 2012 Dec; 32(12)3831-9

Dissemination and Partnerships

Policy Makers and Administrators
Senate National Rheumatic and Musculoskeletal Diseases Strategy TWD Early Intervention Programs

Ministry of Health
Autonomous Communities

Social Security and Labour

Nat. Institute of Social Security Employers, Unions, Occ. Health

Health Professional Body

Spanish Society of Rheumatology
Primary Care Societies NHS Inspection Services

Dissemination and Partnerships

Policy Makers and Administrators
Senate Ministry of Health Autonomous Communities FfW early intervention clinics

Social Security and Labour

Nat. Institute of Social Security Employers, Unions, Occ. Health

Health Professional Body

Reumatology Units
Primary Care NHS Inspection Services

FfW Early Intervention Clinics

Efficacy 32%

Efficacy 27%

FfW EIC Concept

Health Service Research

TWD

Access

Health Care Reengineering

Health Results

Very early

Specific and Specialized

Decreased TWD-PWD

FfW Early Intervention European Task Force

Professor Paul Emery

European Early Intervention for RMDs Task Force Working Group

Chaired by Professor Paul Emery and Professor Juan Jover Membership applies to European clinicians committed and interested in developing early intervention programmes/clinics in their country for people with RMDs Secretariat: Patient Central contracted by The Work Foundation Current Membership: Professor Emery (UK), Professor Jover (Spain), Professor Matucci (Italy), Professor Faustino (Portugal), Professor Fitzgerald (Ireland), Dr Steve Brennan (UK)

Task Force Purpose and short-term objectives

Support the production and expert endorsement of material that allows the development of early intervention for RMDS: Produce Evidence Base (in short-term based on Spanish early intervention programme with input in longer term from UK model) Clinical and financial analysis of Jover data: Key principles, learnings and outcomes Collation and analysis of data and activity from wider Spanish Early Intervention Programme

Early Intervention Toolkit

For clinicians interested in setting up EI clinics: The rationale for early intervention key principles How to set-up early intervention clinics lessons from Spain and UK Further elements to be informed by:
- The Working Groups meeting at EULAR 2014 - Follow-up from Summit and FfW ambassadors their needs

Early Intervention Clinic Principles

Rapid referral Rapid assessment Expert assessment:
Confirm diagnosis Confirm appropriate management Simple intervention for 90% of patients referred Patient education and engagement Early discharge to return to work

Model: Early Intervention for RA

Early intervention now established as effective in preventing disability and work loss Early arthritis clinics routine Ambition remission-induction Disease prevention now on agenda

Effect of RA Disease Duration on Inflammation and Function

Inflammation Function

Severity

Time Interventions
Emery P. Ann Rheum Dis. 1995;54:944

Early Intervention: UK

Introduction
Project to
demonstrate early intervention reduces work disability in musculoskeletal patients

demonstrate early intervention improves patient outcomes and increases patient satisfaction
deliver unique UK data on early intervention and work disability to drive a cost-effectiveness model deliver a model for treating high volume musculoskeletal problems and associated work disability

Enhancing the MSK Service: Leeds

Current Service Leeds Musculoskeletal Service receives 25,000 referrals per year; 90% are seen by physiotherapists. Accessed by three CCGs (450 GPs in Leeds) 6-8 weeks waiting time to see a physiotherapist No strict criteria or protocols relating to referral based on GP judgement

Enhancing the MSK Service: Leeds

Enhanced service Rapid confirmation of diagnosis (within 5 days of being signed off sick) Rapid assessment and initiation of appropriate management (within 5 days of being signed off sick from work)

Earlier and structured initiation of patient education, selfmanagement/coping strategies plan

Provision of simple, psychological assessment The small numbers who may need further specialist assessment and investigations will get earlier referral Discharge plan based on fit for work status or permanent disability

Enhancing the MSK Service in Leeds

GP Refers on first issue of unfit to work certificate (Med 3)
Level 1 Cohort Randomised 1,500 750 Education, Self management, basic investigations 4-6 weeks ( 2 ) Return to work Permanent Disability

Control Group=750

Level 2 Formal Rehabilitation Diagnostics 4-8 weeks ( 3 )

Return to work Permanent Disability

Level 3 Diagnostics Onward Specialist Referral

Return to work Permanent Disability

Enhancing the MSK Service in Leeds

Local-Buy In and Project Steering Group Service Enhancement Project Steering Group formed (supported by the Director of Public Health, Dr Ian Cameron). A process of stakeholder engagement undertaken to identify and confirm support and contribution of the necessary collaborators to deliver project

Managerial Representatives of Leeds Community Health Care Trust

Transformational Lead for 3 CCGs in Leeds Dr Chris Mills Clinical Lead: Dr Steve Brennan Academic Lead: Professor Paul Emery Project Lead: Rhonda Siddall

Project Phases

Phase I: Configuring an enhanced service

Phase II: Delivering an enhanced service

Phase III: Assessing the value of an enhanced service

Phase IV: Producing the service enhancement model template + communicating the results

Phase II: Delivering an enhanced service

Service Model: 6 dedicated clinics per week over 2-3 sites owned by Leeds Community Healthcare Trust Clinics run by MSK Physician Steve Brennan (Leeds Community Healthcare Trust) IT and Administrative Support Provided by Leeds Community Healthcare Trust Service Data System compatible with GP system (System 1) via a shared access agreement

Phase III: Assessing the value of an enhanced service

Project Period: 18 months Number of Patients: 750 (compared to control group of 750; control managed by GPs) Process:
- Data Capture: Integrated System 1 - Interrogation and Analysis: done by Leeds Community Healthcare Trust and Dr Steve Brennan

Outcomes Assessed:
Impact on temporary work disability (TD) Impact on permanent work disability (PD) Patient Satisfaction Impact on onward referral and investigation costs

Investing in Healthcare: breaking down the silos

Patient testimonial (video message)

Purificacin Tejeda, Spain

Healthcare investment as societal investment Investing in Healthcare: breaking down the silos

Panel discussion

Healthcare investment as societal investment Investing in Healthcare: breaking down the silos

Speakers
Dr Luis Snchez Galn Luis Carretero Alcntara Dr Francisco Jess Alvarez Hidalgo Dame Carol Black Prof Anthony Woolf David Harney Ralf Diemer

Moderator
John Bowis

Investing in Healthcare: breaking down the silos

Q&A

Investing in Healthcare: breaking down the silos

Closing session

Closing session
Investing in Healthcare: breaking down the silos

Prof Stephen Bevan

Founding Co-President, Fit for Work Europe Director, Centre for Workforce Effectiveness The Work Foundation

Closing session Investing in Healthcare: breaking down the silos

Pascale Richetta
Vice President Western Europe & Canada, AbbVie

Closing session Investing in Healthcare: breaking down the silos

Dame Carol Black

Expert adviser, Department of Health and Work England Principal, Newnham College Cambridge Co-president, Fit for Work Europe

Thank you for attending the Fit for Work Summit 2013.

@WorkFoundation:

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