Fit 4 Work

1. Fit 4 Work Linking re-integration and health An experimental approach to activation and re-integration in for long term welfare dependent clients Annelies Acda 03-06-2013

2. In this presentation • Why work? • Work related to health • What is the situation? • Outline Fit 4 Work • Research related to F4W • Where are we now • Conclusions

3. Why work? • The right to work is a core value of modern society Adam Smith (1776) noted in An Inquiry into the Nature and Causes of the Wealth of Nations (Book I, Chapter X) that: "The property which every man has is his own labour; as it is the original foundation of all other property, so it is the most sacred and inviolable...To hinder him from employing this strength and dexterity in what manner he thinks proper without injury to his neighbour is a plain violation of this most sacred property."

4. Modern vision: How employment facilitates recovery Employment : • Reduces stigma by providing access to a socially-valued role • Few other things can be done for 8 hours a day • Strengthens self-efficacy and self-esteem • Increases opportunities for receiving positive regard from others • Increases opportunities for social inclusion • Provides time structure and a reason to stay well • Has a positive effect on health and wellbeing • Keeping and building skills

5. And from a health perspective…

6. The labour market in the Netherlands • The unemployment-rate at the national level : 6,8% and expected to rise in 2014 • Challenges: • Only about 60 % of the workforce in the larger cities is participating in employment; • Overrepresentation of people from a non- European background on welfare rolls; • Successes: • Youth unemployment - 25% due to a more decentralised approach (2011) • Keeping people in the workforce during the crisis • Big changes expected within the next 2-3 years, caused by demographic developments. • Job-openings will occur in various sectors and within all levels of the labour market; creating substantial opening for jobs at the entry-level (lower skilled work).

7. Rotterdam – an example • Second largest city • 600.000 inhabitants • 32.000 households on welfare (65-) • 5.000 households on welfare (65+) • 2.000 migrants in integration-programs • 50.000 handicapped/disabled people on individual facilities and help in housekeeping • 7.000 persons with help on burdens of debt • 2.500 people in subsidized jobs • About 100.000 people depending on Social Welfare Rotterdam • This is 1/6 of the population of Rotterdam. • Budget = 700 Mln euro per year

8. Participation ladder Regular Job Paid work with support (eg subsidised job) Voluntaryorunpaidwork Participating in organisedactivities Socialmeeting outside yourhouse Isolated

9. Questions at the start of the Fit 4 Work experiment 1. What is the role of paid employment in health inequalities?  being unemployed has a profound impact on health 2. How does health influence paid employment?  a good health is an important prior condition to get and stay in paid employment  entering paid employment is beneficial for health 3. What are the potential benefits of interventions on working life?  better health increases work life expectancy 4. What are the challenges in the near future?  demonstrate cost-effectiveness of integrated (health and re-integration) interventions

10. Socio economic health differences

11. % people with high risk of depression or anxietya peak for lower educated people and unemployed/on welfare rolls

12. Why Fit 4 Work? • We have to perform better on the participation rates and employment rates of people who are longterm welfare dependent and live in a multiple problem situation. • Socio-economic health inequalities! Differences in educational level and household income attribute approximately 30% to 50% to these health inequalities. • Poor mental health acts as a barrier for return to paid employment through decreased motivation, lowered expectations of finding employment, and ineffective job seeking. Unemployment may lead to poorer mental health, which in turn will reduce the chance of re-employment. • The target group has been standing at the sideline for too long. • Work as a medicine. • There will be changes in the labourmarket within the next years due to demographic changes (retirement) • Target group costs 13.500 euro p.p./p.y. Staying 10 years on average on welfare rolls. This is 135.000 euro !! • No integrated and holistic based approach has been developed in the Netherlands (and Europe)

13. Fit 4 Work • Is a collaborative experimental project between the four major cities in the Netherlands (Amsterdam, Rotterdam, The Hague, Utrecht, and Capelle), and the UWV (Dutch Employment Service) • Focuses on re-integration AND health improvement within a multi problem target group with a large distance from the labour market • Is a collaboration between Social Welfare, Dutch Employment Service and Municipal Public Health departments, and includes research • Is a randomised controlled experiment (700 in F4W and 700 in other group) for four years. Evaluation on effects of integrated health and re-integration approach on self perceived (mental) health, social participation and paid employment • Includes a social cost benefit analysis (“business case”)

14. The Fit 4 Work target group • Up to the age of 50 • Long-term unemployed (social security payments through WIJ, WWB, WIA, or WAJONG) • Having mental health problems • Often experience social problems and some physical health problems. • Having various, severe and mostly related limitations in various areas • Experience of limitations with regards to psychosocial functioning - psychological health problems • Additional limitations may lie in the social area (such as parenting problems, isolation, debt, domestic violence). • Participation in regular employment is often hindered by the psychological disorder, lack of work experience, qualifications and/or competencies or more material problems with housing or debt. • But also having a development potential to participate in the employment process.

15. The elements of F 4 W 1. Integrated diagnosis on mental health problems and employment skills, with additional attention for social problems and physical health problems 2. Integral analysis in a multidisciplinary team • Intersectoral intervention plan including: • mental health interventions (short-term outclinic treatments with a guaranteed intake without waiting period); • reintegration programmes (offered through labour market organisations), and, if needed; • also health promotion programmes (offered through local health organisations); • and social interventions (offered through local organisations) • Continuity of support and care provided ("ketenbewaking”) • Immmediate intervention on perceived barriers for labour force and social participation • Availability of labour market experts for adequate mediation towards paid employment • Support and guidance to participants and their prospective employers to avoid relapse into unemployment.

16. 1 Entry 2 Screening Check recent mental health status Mental health analysis 2 Suitable Fit 4 Work Not suitable Fit 4 Work Back to case manager 3 Randomisatiom 4 1st Questionnaire (0) Fit-4-Work group Check up group Standard re-integration support 5 In depth diagnosis -Interdisciplinary case meeting Plan 6 Carry out plan Job placement with help 7 After care 8 2nd Questionnaire 12mnth 9 3rd questionnaire 24 mth

17. Objectives Fit 4 Work • Participants work according to their capacity and ability in the employment process in mainstream organisations; • Participants have a more positive health experience and/or health afterwards; • Participants have reduced healthcare consumption afterwards (thereby leading to a reduction in healthcare costs); • Participants are more self-reliant.

18. Measurable outcomes • Workplacement within 1 year • Regular Job 12 hours per week or more • Guidance and support on the ‘working floor’ • Improvement in the health situation (lifestyle, medicine usage, addiction, psych help) • Sustainable outflow to work (in regular jobs) for at least 50% of the target group • Next step on the ‘participation-ladder’ for the other 50% pf the target group • Cost-effective implementation • Working method applicable for the rest of the country

19. Costs and benefits • Costs of a Fit 4 Work traject 7.500 euro per year excl health interventions (covered by health insurances) • Duration is 3-4 years, with supported work-placement in regular job within 1 year for at least 12 hours per week + support and guidance to raise the working hours (work as a medicine) • At 12 hours sustainable job (after finishing the project) 100% return on investment after 4 years • At 24 hours sustainable job (after finishing the project ) 100% return on investment after 2 years • ESF is applicable • Not to be expressed in ‘money’ : people are working, paying taxes, developing skills etc.

20. At the long term less health consumption ? Bron: Bush et al (2009)

22. The experiment in a nutshell • Partners: UWV (Dutch DWP), G4 : Departement of Social Affairs and Employment (Amsterdam, Rotterdam, The Hague and Utrecht, and Capelle), G4 Public health • Execution by Reintegration Companies/Private Vendours Procurement) • Scientific / Academic Research : Erasmus University Rotterdam • Support : Ministry Social Affairs and Employment & Ministry of Health • Start 1-7-2011 (with procurement-phase) • Start 1-1-2013 (with inflow of clients) • Duration of experiment: 4 year • Participation of 700 people (receiving Fit 4 Work intervention) and 700 people controll Group

23. The process • Long term (financial commitment): hard to defend in current financial climate • Different organisations, different cultures, different “languages” • Different cities, different cultures, different political views • Change in staff at various departments • How do you keep everyone on board? • Belief in outcomes has to be shared • Learn from mistakes, use them for future projects • Keep spirits high by celebrating small successes

24. Conclusions • We know that being unemployed has a profound impact on a person’s health situation. Good health is an important prior condition to reach and to stay in paid employment. Entering paid employment is beneficial for health. A better health increases work life expectancy. • We need to demonstrate cost-effectiveness of integrated (health and re-integration) interventions. • The Fit 4 Work – experiment is an interesting practice with the potential to demonstrate this. • Involved partners need to belief in long term project in changing circumstances.

25. Thank you for your attention • Questions?