Writing Fit

The news that World No 2 golfer Phil Mickelson has been diagnosed with Psoriatic Arthritis brings into sharp relief the importance of the early diagnosis and treatment of inflammatory conditions if people are to stand the best chance of living normal lives and staying in work.
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We continue to take the ‘Fit for Work’ messages to National Governments wherever we can. Already, since the launch of the Irish report, we have briefed two prominent Irish Government Ministers. We have, among other things, called for a National Clinical Director for MSDs together with the formulation of a National Service Framework on MSDs in order to cement the clinical and labour market priority which Ireland should be given to MSDs in Ireland.

Last week I was a ‘witness’ – together with John Church, CEO of Arthritis Ireland - at a session of the Oireachtas Committee on Enterprise, Trade and Employment in the Irish Parliament – the rough equivalent of a Select Committee here in the UK. I presented the Irish ‘Fit for Work’ report and John and I were questioned for an hour by several Deputies and Senators, who were very interested in the implications of our research for Irish labour market policy.

Earlier in the day Jim Higgins MEP hosted a lunch session in conjunction with Arthritis Ireland for TDs and other opinion-leaders which also focused on the findings and implications of the Irish ‘Fit for Work’ report. Chaired by John Church, the audience heard presentations from Mr Higgins who focused on the growing awareness of the MSD issue in Brussels and Geraldine McCarthy, and eminent Rheumatologist. I also presented the main Fit for Work report findings and talked the audience through our main recommendations. A good debate followed which, among other things, covered the wider labour market status of people with disabilities, the potential for a UK-style ‘Fit Note’ in Ireland and the impact of Health Technology Assessment on access to drug therapies for Rheumatoid Arthritis.

There is a real sense of momentum in Ireland and clear evidence that many of the ‘Fit for Work’ messages are having an impact on the way policy-makers are thinking.

Today was a busy day for those of us keen to spread the word about MSDs at work. In London the Work Charter was launched by the Arthritis and Musculoskeletal Alliance. The Work Foundation is happy to support it as it strongly echoes messages from our own Fit for Work? Research which has looked at the factors which help or hinder full participation at work among the 6.5 million UK citizens who have MSDs. There was good coverage of the report on the BBC website.

Meanwhile, in Brussels, I was presenting the results of our EU research to a ‘special interest group’ of MEPs in the European Parliament. Also presenting was Mr. Armindo Silva Head of Unit Social Protection and Inclusion Policies, Employment and Social Affairs Directorate. He explained how the new Directive of MSDs was being drafted and consulted on. I presented some of the key findings of the Fit for Work Europe report, highlighting in particular the need to focus on early intervention. Several MEPs spoke in favour of our findings on the links between MSDs and Mental Health and expressed interest in hearing more on this topic. Finally, Mr Marios Kouloumas, Chairman of Eular-PARE – speaking on behalf of people with Rheumatic diseases – explained the importance of taking into account the patient perspective in policy-making, emphasizing that Rheumatic and inflammatory conditions are not caused by work, but can make staying at work difficult if insufficient support is available. This was a very important point because the forthcoming MSD Directive only covers MSDs which are caused by work and not, by definition, Rheumatic conditions. I find this troubling, and it remains to be seen how this serious omission is dealt with by the European Commission.

I recently spotted coverage of this research, published in The Lancet. It suggests that ‘talking therapies’ such as Cognitive Behavioural Therapy (CBT), especially in group settings, can have a positive impact on recovery from chronic low back pain.

This chimes with the findings of our Fit for Work research which has sought to emphasise the importance of understanding the mental health issues frequently faced by people with MSDs. We found that, for some people, being diagnosed with a chronic condition can increase the risk of depression and anxiety. As a result, people at work might fear disclosing their condition to their employer. In addition, there is evidence that poor mental health can be a bigger barrier to rapid and successful return to work than the physical symptoms of an MSD.

At the launch of our European report in September 2009, Professor Jover from Spain presented data which illustrated that an early intervention for MSDs patients which included a CBT component made a significant difference to return to work rates and yielded a notable economic return. In the autumn of 2010 The Work Foundation will be publishing the results of a further study which is examining the links between chronic conditions and mental health in more detail. Watch this space!

This week I will be in Israel, having meetings and conducting interviews with national experts and public policy officials. Among those I’ll be meeting will be Prof. Tishler, Chair of the Israeli Rheumatology Physicians Union, Ron Wisinger- of the Israel Institute for Occupational Safety and Hygiene, Nachum Izkovich, CEO of the Ministry of Social Affairs, Vered Swid, Chief Advisor to the Prime Minister on Social and Welfare Affairs and Elliot Rosenberg, Head of the Department of Occupational Health in the Ministry of Health. I’ll also be catching up with my old friends Michael Yakuel and Ofra Balaban of Inbar – the Patient’s organisation.

As we finalise the Israeli Fit for Work? report, this visit will allow me to add to our understanding of the labour market status of people with MSDs and the support available to them as they try to live fulfilling working lives. I’m expecting to learn a lot.

Last week I attended two important events which focused on inflammatory conditions. The first was on Monday in London and was a conference organised by the National Audit Office (NAO) – an independent organisation which reports to the British Parliament on the effectiveness with which public money is being spent.

Earlier this year the NAO produced an influential report examining the quality of services for people with Rheumatoid Arthritis (RA). I was a member of the Advisory Group for the project, along with other friends of the Fit for Work? project such as Professor Paul Emery and Neil Betteridge of EULAR, and Ailsa Bosworth of the National Rheumatoid Arthritis Society (NRAS). Dame Carol Black, National Director for Health and Work, and herself a Rheumatologist, presented persuasively on the need to keep ‘work’ at the centre of the debate. I spoke on a panel discussion during the conference and emphasised the need to optimise early diagnosis and treatment – not just for clinical reasons – but to give people with Rheumatoid Arthritis the best chance of staying in and returning to work.

The second event was in Madrid on Wednesday evening and it focused on recent research (called Salud y Trabajo) conducted on the impact of inflammatory conditions on work disability in Spain conducted by TAISS and led by Pablo Lazaro. The event also featured two short films, made by independent film-makers, which told the compelling stories of two people recently diagnosed with Rheumatoid Arthritis and Ankylosing Spondylitis respectively. One of the aims of the event was to inform members of the audience about the impact of these conditions on both everyday functioning and on personal relationships. I hope to make these films available on the Fit for Work? website very soon.

Today I attended the first full meeting of the RMSD Interest Group in the European Parliament in Brussels. This group, initiated by EULAR, and chaired by Mrs Edite Estrela MEP (Portugal) was launched on World Arthritis Day in October this year. One of its aims is to raise the profile of Rheumatic conditions and MSDs in the Parliament and in the Commission and to help position EULAR as the authoritative source of clinical and patient voice.

The Group has a number of MEPs as members, including Jim Higgins (Ireland), Antoniya Parvanova (Bulgaria) and Marije Cornelissen (Netherlands). Senior figures from EULAR and EULAR-PARE represented included Professor Paul Emery, Professor Josef Smolen and Neil Betteridge.

The Group was addressed by Dr Gigorij Kogan, Scientific Officer from DG Research and a specialist in chronic disease. He described some of the research into rheumatic diseases and MSDs which the EU had funded during recent years and explained how research priorities were decided. The Group discussed whether rheumatic and musculoskeletal diseases were receiving enough priority given their prevalence and their economic and social impact.

The next meeting of the Group will be in March 2010 when the topic for discussion will be ‘Work’. The Fit for Work programme has been asked to provide input to this meeting and we will be working with EULAR to ensure that the content is both informative and provocative!

I attended a lunchtime Roundtable event yesterday organised by the European Policy Centre  here in Brussels. The speaker was Dr Martin Terberger, Head of Unit for Pharmaceuticals at DG Enterprise and Industry. While the focus of the discussion was the so-called ‘Pharma Package’ a set of EU proposals to deliver safe, innovative and accessible medicines, I was able to ask Dr Terberger a question about the impact which differences in Health Technology Assessment (HTA) helped or hindered accessibility, especially if one outcome was to support the labour market participation of people with long-term or chronic conditions (eg some MSDs).

He was careful to avoid using the term ‘harmonisation’ but felt that, on the science, there was more room for ‘convergence’ around the clinical evidence. He warned, however, that HTA must take care not to widen health inequalities by treating more economically ‘useful’ patients differently from, for example, elderly patients just because of differences in their productive capacity.

On Tuesday, Dame Carol Black and I participated in a Roundtable event in the House of Commons - the seat of the British Government.  This was a well attended, lively event and I was given the opportunity to make the following speech about the Fit for Work programme:

“For last 18 months The Work Foundation has been conducting research across 23 countries examining the impact of MSDs – including Inflammatory Diseases – on labour market participation. Rheumatoid Arthritis (RA) was one of the conditions we examined in detail because we know that levels of work disability and withdrawal from the labour market are high among people with RA – up to 40% within 5 years of diagnosis.

We’ve been looking at the direct and indirect costs of sickness absence from work and of permanent work incapacity attributable to RA. We have also looked at the interventions which Governments, clinicians and employers can take which can keep people with RA attached to the labour market and help them lead fulfilling working lives and make their contribution to a productive economy.

We launched our report in Brussels two weeks ago and we are trying to influence both National Governments and the European Commission to support steps which maximise the Labour Market participation of people with RA. We are doing some of this Advocacy work in collaboration with EULAR.

A key issue (one of many) is that current employment legislation in EU does not recognise MSDs which are not caused by work. Manual handling (CLBP) and Display screen equipment (WRULDs) are in scope – but the duty of care to support those with pre-existing conditions – such as RA – where poor working conditions can make these conditions worse, is currently out of scope.

Good Work is good for health: this includes control over tasks, control over pace & time; manageable physical work demands & an ergonomically suitable working environment; flexibility of working time.

We must reverse the focus of policy & practice from Incapacity to Capacity – the UK ‘fit note’ idea is intended to reinforce this message.

People with MSDs – including RA – can also experience periods of depression or anxiety which can complicate the process of returning to work. Policy-makers, clinicians & employers need to build this into the way they manage job retention & return to work (RTW).

Up to 30% of people with RA avoid disclosing their condition to their employer or colleagues – part of the self-stigma experienced by many.

Early Interventions can be critical, for example:

• Accurate & early diagnosis
• Early access to treatments and therapies – especially if early symptoms can be arrested and remission achieved
• NAO data shows that early treatment brings economic & productivity benefits
• TWF shows that early intervention can prolong careers and delay premature withdrawal from the labour market and that there is an economic ‘premium’ to early intervention.

There is considerable political focus on incapacity in the UK at the moment, especially as we are seeking to reduce public expenditure. However, as long as the debate has a punitive tone and is dominated by speeches and newspaper articles which focus on getting the feckless & ‘workshy’ off benefits and back into work, we are going to struggle to address the far more serious issue of how we avoid people with long-term and chronic health conditions becoming detached from the labour market until way after this recession is over.

During the Fit for Work study I’ve met hundreds of people with RA and other inflammatory conditions. None have been feckless or ‘workshy’. Most have been energetic, passionate, proud, determined, analytical, resourceful and dignified. I have been privileged & humbled to work with them & I am all too aware of the talent that goes to waste if people like this are lost to the world of work.”

Fit for Work truly seems to have ‘caught a  wave’.  After a launch such as we just had for Fit for Work, one always wonders what the best next steps should be to keep up the momentum, and it’s fantastic when others are working towards the same goals.  So I’m delighted to note that one of our patrons in the European Parliament, Mrs Edite Estrela, MEP, is helping us to do just that.  She today hosted the launch of an interest group on MSDs in at the Parliament in Brussels.  She notes in the invitation we saw that the “key goal of the Interest Group should be to ensure the greatest possible visibility for rheumatic (and we presume broader MSDs, since the interest group’s title covers both…) diseases on the European Parliament’s agenda and systematic consideration of the needs of professionals and patients across Europe in all relevant initiatives and legislative acts at European level.”

Equally exciting is an editorial on Fit for Work  in The Lancet, available in the journal and here online.