Norfolk JSNA Briefing Document Page 1 of 10 Support for those out of work - ESA and IB/SDA Introduction Recent evidence 1 highlights the link between work and health; being out of work is generally bad for health. Work is generally good for health and wellbeing. People in employment have higher levels of wellbeing than those unemployed or economically inactive Long term unemployment is associated with higher risk of early mortality. Moving into employment from being out-of-work can be beneficial for health. Although this may be partially because healthier people will find it easier to find a job, available studies also suggest that moving into work leads to better health. It is also known that being in work can support improvements in health. For example, a systematic review on the health effects of employment found that being in employment reduces the risk of depression and improves general mental health. Ill health among working age people preventing work has a considerable cost to the economy and individuals Disabled people are less likely to be in work than non-disabled people and therefore fewer disabled people have the potential to take advantage of the benefits that work can bring. Life expectancy at birth is increasing but some of the increase in average lifespans is time spent in poor health. In the UK the majority of people claiming the main out-of-work benefits are on ESA/IB/SDA; around two-thirds of the 3.7 million people are on out-of-work benefits. The UK employment rate is the highest since records began but the employment rate of disabled people remains significantly lower than of non-disabled people (47.9 per cent and 80.1 per cent respectively; Q2 2016). Nonetheless almost 3.4 million disabled people are in employment. Enabling people to return to suitable work will improve the financial, health and wellbeing outcomes for the individual and Norfolk. Summary Across Norfolk the gap in life expectancy between the most deprived areas and the least deprived areas is 6.2 years for men and 3.2 years for women. In the most deprived 10% of areas in Norfolk about 1 in 7 of every working age residents claim health related workless benefits and across Norfolk mental health problems account for more than half of all claims for ESA. This together with claimants for diseases of the nervous system is significantly higher than expected. The majority of districts across Norfolk have a lower than expected overall number of claimants of ESA IB/SDA given their population age and sex. However, Great Yarmouth and Norwich have a higher than expected total number of claimants. Norfolk has a higher proportion of the 16 to 64 population employed than England but the gap in employment between those with a long term medical condition and others is larger than the average gap for England. This indicates that the overall risks of poor health and wellbeing outcomes for some of the working age population of Norfolk are higher than the England average and look set to continue. There are nine Jobcentre Pus across Norfolk to help enable people into work in addition to several community advice providers who are there to help ESA IB/SDA claimants. The 2016 GP patient survey 2 shows that across Norfolk between 82% and 88% of patients with long-term conditions reported that they felt they received enough support to help them manage their conditions. However, there is variation by long term condition and CCG. For example, for patients with a long term mental health problem only about 61% of patient of Norwich CCG reported that they received enough support compared to 75% for England as a whole. 1 https://www.gov.uk/government/consultations/work-health-and-disability-improving-lives/work-health-and-disability- green-paper-improving-lives 2 http://results.gp-patient.co.uk/
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Norfolk JSNA Briefing Document
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Support for those out of work - ESA and IB/SDA
Introduction Recent evidence1 highlights the link between work and health; being out of work is generally bad for health.
Work is generally good for health and wellbeing.
People in employment have higher levels of wellbeing than those unemployed or economically inactive
Long term unemployment is associated with higher risk of early mortality.
Moving into employment from being out-of-work can be beneficial for health. Although this may be partially because healthier people will find it easier to find a job, available studies also suggest that moving into work leads to better health.
It is also known that being in work can support improvements in health. For example, a systematic review on the health effects of employment found that being in employment reduces the risk of depression and improves general mental health.
Ill health among working age people preventing work has a considerable cost to the economy and individuals
Disabled people are less likely to be in work than non-disabled people and therefore fewer disabled people have the potential to take advantage of the benefits that work can bring.
Life expectancy at birth is increasing but some of the increase in average lifespans is time spent in poor health. In the UK the majority of people claiming the main out-of-work benefits are on ESA/IB/SDA; around two-thirds of the 3.7 million people are on out-of-work benefits. The UK employment rate is the highest since records began but the employment rate of disabled people remains significantly lower than of non-disabled people (47.9 per cent and 80.1 per cent respectively; Q2 2016). Nonetheless almost 3.4 million disabled people are in employment. Enabling people to return to suitable work will improve the financial, health and wellbeing outcomes for the individual and Norfolk.
Summary Across Norfolk the gap in life expectancy between the most deprived areas and the least deprived areas is 6.2 years for men and 3.2 years for women. In the most deprived 10% of areas in Norfolk about 1 in 7 of every working age residents claim health related workless benefits and across Norfolk mental health problems account for more than half of all claims for ESA. This together with claimants for diseases of the nervous system is significantly higher than expected. The majority of districts across Norfolk have a lower than expected overall number of claimants of ESA IB/SDA given their population age and sex. However, Great Yarmouth and Norwich have a higher than expected total number of claimants. Norfolk has a higher proportion of the 16 to 64 population employed than England but the gap in employment between those with a long term medical condition and others is larger than the average gap for England. This indicates that the overall risks of poor health and wellbeing outcomes for some of the working age population of Norfolk are higher than the England average and look set to continue. There are nine Jobcentre Pus across Norfolk to help enable people into work in addition to several community advice providers who are there to help ESA IB/SDA claimants. The 2016 GP patient survey2 shows that across Norfolk between 82% and 88% of patients with long-term conditions reported that they felt they received enough support to help them manage their conditions. However, there is variation by long term condition and CCG. For example, for patients with a long term mental health problem only about 61% of patient of Norwich CCG reported that they received enough support compared to 75% for England as a whole.
For the Norfolk system as a whole evidence-based approaches to employment support can help. For example Individual Placement and Support in the mental health field and Supported Employment in the disabilities field.
Population, risk factors and outcomes related to work, health and disability ESA is a benefit for people who are unable to work due to illness or disability. This will eventually be replaced by Universal Credit. The simplified process for claiming ESA is outlined below
1. At the point of claim for ESA, the illness or disability is captured by International Classification of Diseases (ICD) (which includes codes relevant to conditions from Abdominal Pain through to Yellow Fever).
2. After the initial claim the claimant must have a work capability assessment to assess how physical capabilities and mental, cognitive and intellectual capabilities affects ability to work. This part of the process is the assessment phase.
3. After the assessment three things can then happen
The person is considered capable of work, not entitled to ESA and therefore need to claim Jobseeker’s Allowance. This group receives about five 90 minute interviews per year3
The person is considered capable of work at some time in the future and placed in ESA’s Work Related Activity Group (WRAG). Claimants are supposed to have regular interviews with a Jobcentre Plus adviser. Local anecdotal evidence suggests this is one 90 minute interview per year.
The persons is considered not capable of work, placed in the Support Group where claimants don’t receive regular interviews.
4. Currently claimants can be placed/allocated in the WRAG or Support Group for up to 2 years – during which time there is no need to provide a new ‘Fit Note’ or medical evidence.
5. The extent to which the individual is in contact with the ‘health system’ is not known Regionally about 79% of claimants are allocated to the support group. In Norfolk about 78% of claimants are allocated to the support group. The routes onto and off ESA for the 2013/14 cohort eligible for ESA are summarised in Figure 1. About 1 in 5 people eligible for ESA arrived onto ESA from employment but only 1 in 20 left ESA to return to employment.
Figure 1 Journeys onto and off ESA4
3 Anecdotal evidence from local DWP 4 https://www.gov.uk/government/statistics/work-health-and-disability-green-paper-data-pack
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The journey from work onto ESA, has been summarised in the Understanding the journeys from work to Employment and Support Allowance (ESA)5 report for the Department for Work and Pensions. This study found
Around one-fifth (19 per cent) of all claimants surveyed moved straight from work to claiming ESA without any period of sickness absence. A further 45 per cent did have a period of sickness absence prior to leaving work (36 per cent were paid and 9 per cent unpaid). The remainder, 36 per cent, were unemployed immediately before making their ESA claim.
About a third of those who were in work immediately before making their ESA claim, moved straight from work to claiming ESA without any period of sickness absence.
Most claimants (75 per cent) made the decision to stop working for health-related reasons themselves. However, 19 per cent of claimants that stopped work because of their health condition felt pressurised by their employer to stop working and were more likely to have more than one condition, or have a mental health or ‘other’ condition.
Approximately a third (34 per cent) of claimants who stopped working for health related reasons had a formal arrangement to return to their employment if or when they felt capable of doing so.
Most organisations had some form of sickness policy in place, public sector and large private sector organisations are more likely to have rigid formal policies than smaller private sector organisations
A third of all claimants (33 per cent) had access to an employer provided occupational health service (OH). Claimants that had used this service, where it was available, were more likely to have had a period of paid sickness absence, to still be formally employed when claiming ESA and to have received workplace adjustments (compared with those who had access to OH but did not use it).
Those most at risk of leaving work without a period of sickness absence were: on a casual or agency contract; new to their job or part-time workers.
Claimants with mental health conditions were more likely to report an attachment to the labour market and a greater appetite for accessing support services offered by employers. However those with mental health conditions were: less likely to have discussed their condition with their employer or to find adjustments helpful; and more likely to feel employers had not been supportive or to be unemployed immediately prior to their ESA claim.
As the number part time jobs increase and the number of zero hour contract jobs increase, this might lead to increasing numbers of ESA claimants entering the ESA process without a period of sickness absence.
Burden of ill health and gaps in services There are three indicators available in the Public health Outcomes Framework that help understand the impact of long-term illness and learning disability on employment among those in the working age life stage (Figure 2). In each case Norfolk has lower employment of people with these conditions than England but higher employment than some other members of the CIPFA comparator group. The trends indicate that the gap between Norfolk and England is closing for those with mental health conditions but not for the other indicators. This indicates that the risks of poor health and wellbeing outcomes for working age population of Norfolk are higher than the England average and look set to continue.
Gap in the employment rate between those with a long-term health condition and the overall employment rate – persons (trend above, CIPFA comparators below)
Gap in the employment rate between those with a learning disability and the overall employment rate – persons (trend above, CIPFA comparators below)
Gap in the employment rate for those in contact with secondary mental health services and the overall employment rate – persons (trend above, CIPFA comparators below)
Figure 2 PHOF indicators relevant to understanding the impact of long-term health conditions and learning disability on employment6
Figure 6 shows that Norfolk has a higher proportion of the 16 to 64 population employed than England (more than 76% compared to about 74%). Three districts in Norfolk have seen a recent decline (Breckland, Great Yarmouth and North Norfolk) and the rest have seen a recent increase. Broadland and South Norfolk have the highest proportion of 16 to 64 year olds in employment where more than 80% are employed. Considering the percentage of working age claiming ESA IB/SDA Norfolk is broadly in line with England (6.2% compared to 6%) and the trend is mostly flat. Within Norfolk the districts with highest proportion of ESA IB/SDA claimants are in Great Yarmouth (more than 9%) and Norwich (about 8%). Both Great Yarmouth and Norwich have seen a gradual increase over the last few quarters (Figure 6). This has an impact on the gap in the employment rate between those with a long term health condition and the overall employment rate. However, it is difficult to prescribe specific reasons for the changes in the gap in employment rate. Norfolk as a whole has a bigger gap than England (about 12% compared to about 9%). Within Norfolk the districts with the smallest gaps are Great Yarmouth and South Norfolk (about 7%) and the district with highest gap is Norwich (about 17%). North Norfolk has seen an increase in the gap over the last few years and it is now about 15% (Figure 6).
6 http://www.phoutcomes.info/
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In the most deprived decile in Norfolk almost 1 in 7 of the working age population claim health related benefit compared to about 1 in 50 in the least deprived decile (Figure 3). Across Norfolk mental health problems account for more than half of all claims for ESA IB/SDA. At smaller area level the number of people claiming ESA IB/SDA ranges from a minimum of about 10 for several areas to a maximum of about 305 for a small area of Central and Northgate ward in Great Yarmouth. The higher numbers of claimants are concentrated in the urban areas with some pockets elsewhere (Figure 4).
Figure 3 Proportion of the working age population claiming ESA
IB/SDA and other benefits by deprivation decile (May 2016)
For most areas of Norfolk the number of claimants is significantly less than expected or as expected. The areas where the number of claimants is significantly higher than expected are located in the urban areas of Norwich, Great Yarmouth, King’s Lynn, coastal towns and market towns (Figure 5).
Figure 4 Total number of ESA IB/SDA claimants May 2016 ()
Figure 5 Observed number of ESA IB/SDA claimants compared to expected for the age and sex profile of the population
The reasons for the claim for ESA IB/SDA are shown in Table 1. For most districts in Norfolk for most conditions the number of claimants is significantly less than expected for the age and sex profile of the population. The highest numbers of claimants are mental health conditions but this is only significantly higher than expected for Norwich and Great Yarmouth. However, diseases of the nervous system is significantly higher for all districts apart from South Norfolk. Great Yarmouth seems to have significantly higher than expected numbers for most conditions. In Norwich Mental health conditions dominate. Diseases of the nervous system includes some vascular disorders (such as transient ischemic attack -TIA), some infections (such as meningitis, encephalitis, polio), structural disorders (such as brain or spinal cord injury), functional (such as headache, epilepsy, dizziness, and neuralgia) and degenerative disorders (such as Parkinson disease, multiple sclerosis, Huntington’s disease and Alzheimer’s disease.
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Figure 6 Comparing trends by district for % of people in employment, ESA IB/SDA claimants and gap in employment rate for those with long term conditions and overall employment rate. The district is the light green line, Norfolk the dark green line and England is the blue line.
Trend in % of people aged 16 to 64 in employment
Trend in % ESA IB/SDA claimants (quarterly trend, last data May 2016)
% gap in employment between those with a long-term health condition and others
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Table 1 Standardised claimant ratio by ICD10 chapter for ESA IB/SDA claimants. Number in brackets is the total number of claimants.
Condition (May 2016, count) Breckland Broadland Great Yarmouth
Claimants without any diagnosis code on the system
0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)
All causes (count) 85 (4,260) 71 (3,420) 150 (5,420)
102 (5,640)
91 (3,420) 146 (7,420)
67 (3,250) 95 (30,840)
All causes % working age population
5.3% 4.6% 9.2% 6.4% 6.0% 7.8% 4.2% 6.2%
NHS CCG resource allocation can be used to help understand the expected Mental Health demand on the Norfolk and Waveney system (Table 2). NHS resource allocation work indicates that Mental Health should place less of a demand on the Norfolk and Waveney system compared to other areas (Mental Health Weight less than or equal to 1). However, programme budgeting data indicates that in Norwich spend per head is significantly high. This could indicate that the level of Mental Health related ESA IB/SDA claimants is a true reflection of need that is not captured by the NHS resource allocation formula.
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Table 2 Mental health weighted populations for CCGs in Norfolk and Waveney and Programme Budgeting spend. NHSE = NHS England CCG allocations (https://www.england.nhs.uk/2016/04/allocations-tech-guide-16-17/). PB = Programme Budgeting SPOT tool (http://www.yhpho.org.uk//resource/view.aspx?RID=196495)
Source Indicator Sex Age
Latest Date
NHS Great Yarmouth And Waveney CCG
NHS North Norfolk CCG
NHS Norwich CCG
NHS South Norfolk CCG
NHS West Norfolk CCG
NHSE Mental Health unweighted population Persons
All Ages 2015 236,501 171,275 215,787 233,578 171,846
NHSE Mental Health weighted population Persons
All Ages 2015 237,399 137,443 208,059 150,547 135,968
PB Index of multiple deprivation Persons
All Ages 2015 28.45 17.85 22.87 15.95 23.21
NHSE Mental Health Weight Persons
All Ages 2015 1.00 0.80 0.96 0.64 0.79
PB Mental Health Disorders Spend Per head Programme Budgeting (£) Persons
All Ages
2013/14 £164.01 £165.50 £196.91 £131.24 £130.96
Current services, local plans and strategies Services to help people return to work are available from Jobcentre Plus. There are nine Jobcentre Plus across Norfolk in Cromer, Dereham, Diss, Fakenham, Great Yarmouth, King’s Lynn, North Walsham, Norwich and Thetford. They provide support for
training, guidance and work placement programmes
work experience, volunteering and job trialling schemes
help with starting your own business
help combining work with looking after children or caring responsibilities
extra help for specific problems In addition to Jobcentre Plus there are a number of local organisations who can provide advice and guidance. For example
Equal Lives (https://equallives.org.uk/)
Norfolk Community Advice Network (http://www.norfolkcan.org.uk/)
Citizen’s Advice Bureau (https://www.citizensadvice.org.uk/benefits/sick-or-disabled-people-and-carers/employment-and-support-allowance/)
Services might be able to be more effective if some of the following were considered and developed
the importance of promoting health, and recognising that work can make a significant contribution to someone’s health
ensuring an individual can access health services, which consider their employment needs, particularly for common conditions which affect an individual’s ability to work – especially musculoskeletal and mental health conditions
strengthening the role of occupational health and related professions and services, so that people’s health and employment needs are considered together to help them get into, and stay in, work
how we can do more with organisations and people to promote health and prevent ill health
how we need to create the right conditions for joined-up support across the various statutory and voluntary organisations
how we can build on the recognition across the health and care system that work can promote good health – that work is in itself a ‘health outcome’
how best to support those in work and at risk of falling out of work, including the part employers can play
understanding how best to help those people in the Employment and Support Allowance Support Group who could and want to work
the settings that are most effective to engage people in employment and health support
how musculoskeletal treatment and occupational health interventions improve employment outcomes
Voice – the perspective from the public, service users, referrers and front line staff In the 2016 GP Patient Survey, across England 83% of respondents with long-term conditions reported that they felt they received enough support to help them manage their conditions. This is about the same for the CCGs across Norfolk and Waveney (Figure 7). However, people with long-term mental health problems (75%) were least likely to feel that they received enough support from local services to help manage their condition. Across Norfolk and Waveney fewer patients of NHS Norwich CCG (61%) and NHS West Norfolk CCG (64%) felt that they received enough support compared to England as a whole. For musculoskeletal conditions (back pain, Arthritis and other long term joint problems) 75% of patients from Norwich CCG felt as though they received enough support whereas for the other CCGs it was nearer to the England average. This shows that patients feel as though more can be done to support them with their long term conditions particularly mental health related conditions.
All long term conditions Musculoskeletal condition Mental health condition
Figure 7 In the last 6 months, have you had enough support from local services or organisations to help you to manage your long-term health condition(s)? Please think about all services and organisations, not just health services.
Considerations for Norfolk’s Health and Wellbeing Board and commissioners
Clinicians, patient support groups and charities all have a role to play in supporting people with health conditions to achieve their potential. For example, asking about work in routine clinical consultations may open an opportunity to identify individuals who might be at risk of falling out of work due to ill health and prevention strategies considered. Evidence-based approaches to employment support can help. For example Individual Placement and Support in the mental health field and Supported Employment in the disabilities field. These, together with early intervention in-work support to help individuals to retain employment, to prevent the ‘revolving door’ of sickness absence and to avoid the negative health impacts of unemployment can deliver:
Improved individual health and wellbeing
Increased personal income
Reduced use of health and social care services
Others7 have suggested that commissioners can achieve this by
Co-location of employment support within social and health services thereby maximising effectiveness of existing national provision through better partnership working between national and local providers e.g. through social prescribing and increasing access to talking therapies and other mental health support.
Making available high quality information on services so that professionals and providers can refer and signpost accordingly
Healthcare professionals have the right skills and knowledge to provide early advice about functional ability to work and the ability to provide, or easily access, the right support so that individuals, employers and work coaches have the necessary information at the earliest opportunity8
Commissioning evidenced based specialist employment support for clients not eligible for national schemes
Providing and integrating early intervention in work support for employers and employees where it is not already available
Local authorities and providers leading by example as employers The recent green paper acknowledges that firm evidence of what works to enable people back to work is relatively limited. There is a need to try different approaches and evaluate their impact. New approaches and evaluation of their impact might be supported by a “Challenge Fund” from the DWP in the future1.
References and information DWP work, health and disability green paper: https://www.gov.uk/government/consultations/work-health-and-disability-improving-lives/work-health-and-disability-green-paper-improving-lives DWP working age client group LSOA data: http://tabulation-tool.dwp.gov.uk/NESS/WACG/wacg.htm
NOMIS ESA IB/SDA data: http://www.nomisweb.co.uk/
GP patient survey: http://results.gp-patient.co.uk/
NESTA: http://www.nesta.org.uk/sites/default/files/realising-the-value-ten-key-actions-to-put-people-and-communities-at-the-heart-of-health-and-wellbeing_0.pdf NHS England resource allocation: https://www.england.nhs.uk/2016/04/allocations-tech-guide-16-17/
Author and key contacts Tim Winters, [email protected] Online feedback: Send us your query or feedback online using our online feedback form at http://www.norfolkinsight.org.uk/feedback Email: [email protected] Publication date 23rd January 2017
