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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

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?

Costs of action to health system

Resource Consequences Health Benefits

Collaboration with shared goals may have a better return on investment

More Employment

Health Sector

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;

Thank you for attending the Fit for Work Summit 2013.
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