Aodhán Ó Ríordáin (Dublin North Central, Labour)
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I welcome Dr. Don Thornhill, Mr. John Church, Professor Oliver FitzGerald and Dr. Robert Ryan. I also welcome officials from Arthritis Ireland to discuss with us the costs of absenteeism in the workplace arising from musculoskeletal disorders.

By virtue of section 17(2)(l ) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to the committee. If witnesses are directed by the committee to cease giving evidence on a particular matter and they continue to do so, they are entitled thereafter only to a qualified privilege in respect of their evidence. Witnesses are directed that only evidence connected with the subject matter of these proceedings is to be given and they are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person, persons or entity by name or in such a way as to make him, her or it identifiable. I also advise that the opening statements submitted to the committee will be published on the committee's website after the meeting.

I remind members of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official either by name or in such a way as to make him or her identifiable. I invite Mr. John Church to make his opening remarks. I apologise for the delay in taking the presentation.

Dr. Don Thornhill:

Perhaps I can introduce the members of the delegation. I thank the Vice Chairman and the committee for the opportunity to attend the committee. It is a refreshing to come to Leinster House and for a change not have to speak about property tax.

Aodhán Ó Ríordáin (Dublin North Central, Labour)
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I fully agree with Dr. Thornhill.

Dr. Don Thornhill:

We are here to speak about musculoskeletal disease which is the comprehensive term that includes symptoms such as chronic back pain and conditions such as arthritis and particularly to speak about increasing the participation of people with MSDs, musculoskeletal disorders, in the workplace and in everyday life. This has very important implications for competitiveness, jobs, economic performance, Exchequer finances as well as for the well-being and life satisfaction of MSD sufferers. The potential savings arising from the coherent programme which we will outline are of the order of €250 million, therefore this is not trivial. This is in the same ballpark as the estimate for the local property tax this year. We are concerned here with an issue that is potentially extremely important. That estimate does not include all the personal and economic benefits that would accrue from people with MSDs who, unfortunately, in many instances find themselves out of the workforce far too early and the benefits that would accrue to them if they were able to remain in the workforce. Our colleagues are Mr. John Church, chief executive of Arthritis Ireland who will open the presentation, Dr. Robert Ryan, occupational physician who represents the Royal College of Physicians in Ireland and Professor Oliver FitzGerald, a consultant rheumatologist at St. Vincent's Hospital and the lead on MSDs in the HSE.

Mr. John Church:

Thank you Dr. Thornhill and members of the committee. In the interests of time I have left some of the slides to the background. Ireland is one of 24 countries that took part in a survey that looked at musculoskeletal diseases, following which we formed a coalition of key stakeholders and interested parties. At the back of the slides members will see that we have assembled some key stakeholders from various sectors, physicians and allied help professionals such as the Irish College of General Practitioners, ICGP, and the Royal College of Physicians of Ireland, employers represented by IBEC, employees represented by ICTU, health insurers, HSE as policy makers and patient groups. We have a good broad representation. This is not a disability lobby. We are not here to plea to save HSE money, but to present a solution to a significant problem which will save the Exchequer significant funds and we are seeking a champion within the House to take this on. We are calling for support to establish a cross-departmental group to work with the coalition on this issue. Dr. Thornhill outlined the potential savings, a sum of €250 million.

That is one third of the total bill the Minister pays out in illness benefit every year. In fact, if we put in place a solution for MSDs, we would also address every other illness. Therefore, the potential pot at issue is bigger and the amount paid out each year could be up to €940 million.

I will take the committee through the report findings. One significant finding is that MSDs are the most commonly reported cause of work-related ill-health in Ireland. The total cost to the Exchequer is €750 million per year or 7 million lost working days per annum. Of the figure of €750 million, more than €250 million is spent on illness benefit - that is to say, almost one third of the bill is spent on illness benefit related to MSDs. The condition accounts for twice the number of days lost through stress. We know from our research that 25% of people with rheumatoid arthritis stop work within five years of the first symptoms.

There is critical data indicating the prevalence of MSDs as a significant issue. The average duration of illness benefit payment is 11 weeks, but for MSDs the duration is twice that, at 22 weeks. We also know that one third of all recipients of illness benefit payments migrate to long-term disability benefit payment, which is another pot of €640 million. It is fair to conclude that MSDs must be a part of that figure of €640 million. At this stage, the committee will be beginning to understand the significant savings that could be achieved by addressing this issue.

According to the Institute of Public Health in Ireland, 12% of all adults have been clinically diagnosed with a MSD and that figure will rise to 13% in the coming ten years. Interestingly, when we compare Ireland with the other 23 countries that took part in the research, we find our contribution or our bill relating to illness benefit is 30% of the total, whereas in the rest of Europe it is 50%. I suggest we have a window of opportunity if we act now. Currently, we have no national policy on intervention or integration between the health services, employer and employee. If we simply address this issue there are potential savings, and not only for the Exchequer. This is an investment for the employer and it is also an investment in the well-being of the employee.

The report recommendations call for early and proactive intervention by the employer but also by a case manager. My colleague, Dr. Robert Ryan, will go into this in more detail. The ethos of what we are discussing is a focus on the capacity of the employee and not on incapacity. With that in mind, we advocate considering a phased return to work. We are also keen to address imaginative job design, which is central to rehabilitation. This relates to the physical layout of workstations, flexible working times and so on. We are also calling for health professionals to consider work as a clinical outcome. This means they should consider the patient before them as an employee who may wish to and have to return to work. The idea is to consider how quickly the patient can get back to work as a clinical outcome.

There are plenty of case histories showing the benefit of early intervention and why it works. Most of the data is from outside Ireland but there are some Irish examples as well, which we will go into. Generally, most companies in our research have absenteeism rates of less than 3%. The IBEC report gives a rate of between 1.6% and 3.7%, and the public sector rates run on average at 4.9%, but with some sites reporting absenteeism of 7% across large employee bases. Given the significant employee numbers at issue, even a 1% reduction in absenteeism could have a significant impact on illness benefit payments, which are a cost to the Exchequer. It would have a significant effect on employer productivity and, naturally, on employee well-being. I will leave most of the examples to my colleague, Dr. Robert Ryan. There are some significant examples to show why we should do this quickly. I will hand the committee over to Professor Oliver FitzGerald, who will go through a short piece on MSDs.

Professor Oliver FitzGerald:

What are MSDs? MSDs include, most commonly, regional musculoskeletal pain. The patients who present are people who complain of back pain, work-related upper limb disorders and hip and knee pain. It is remarkably common, with virtually all people experiencing an episode of musculoskeletal pain during their lifetime. The second commonest condition is osteoarthritis, which is estimated to affect more than 500,000 people in Ireland. This is followed by rheumatoid arthritis, a condition the committee will have heard of. It is a severe deforming arthropathy that affects up to 40,000 people in the country. Children can be affected by arthritis and an estimated 1,000 children are affected in Ireland. Finally, spondyloarthropathy is a group of disorders commonly involving the spine and the joints outside the spine. It includes conditions such as ankylosing spondylitis and psoriatic arthritis.

Broadly speaking, these are the diseases under discussion and, in each case, early intervention is central. Early intervention has been shown to result in better health outcomes, prevention of joint damage and preservation of function, including ability to work. It has been shown that the longer a patient is out of work with a MSD, the less likely he will be able to return to work. For example, if a person is out of work with back pain for more than a year, the chances of his returning to work are negligible.

Many of these patients are referred to rheumatology and orthopaedic outpatient services. Unfortunately, there are lengthy waiting lists for such services throughout the country. The waiting list is up to three years in some units, and many of these people are sitting on waiting lists. Last year, the HSE rheumatology and orthopaedic programmes appointed 24 highly trained specialist musculoskeletal physiotherapists. During 2012 more than 10,000 patients with regional musculoskeletal pain were seen by these physiotherapists and diagnosed and treated. Fewer than 20% of those patients needed to see a consultant - they could be managed effectively by the physiotherapist - and fewer than 10% required surgical intervention. We estimate that in 2013 a further 24,000 patients will be removed from the orthopaedic and rheumatology outpatient waiting lists. In time we expect that the rheumatology and orthopaedic outpatient waiting lists will become more manageable and that physiotherapists will be able to work more at the interface between primary and secondary care. This will allow us to address some of the issues related to regional musculoskeletal pain in a more expedient manner. Across the spectrum of health in both primary and secondary care, we need to target getting back to work as a clinical outcome. That is something we need to focus on.

Dr. Robert Ryan:

I am a working occupational physician. I see cases in which these medical problems arise in employment and I am involved in managing them. My task in this case was to determine whether there were examples in my practice that might give a tangible sense to committee members of the potential outcomes. In a general sense we are looking at better health outcomes for employees, but part of the process will involve an earlier return to work and substantial cost savings. I have referenced several examples to demonstrate our point.

Our role with the Dublin Airport Authority included work on an absence management programme and an early intervention programme for musculoskeletal injuries. The idea was that we would see staff members at an early opportunity when they became unwell. The programme resulted in a 25% reduction in overall absence and a 62% reduction in long-term absences, which were rather significant savings. Another project that allowed us to monitor the effect of intervention by an occupational health service involved the Department of Education and Skills. We introduced the first national occupational health service for teachers and special needs assistants. A review at the end of the first period indicated that levels of absence due to sickness had been reduced by 17% - that is, by 70,000 teacher days per annum. This benefit represented a 12-fold return on the cost of the service merely through a reduction in substitute teaching costs and without counting any other benefits that might accrue. In the next phase of our project with the Department of Education and Skills, the referral point will come down from 12 weeks to four weeks. We have introduced a team of case managers who make contact with teachers and special needs assistants who are out of work and assist them in managing the condition as well as assisting the school in managing their medical complaints and absences. My expectation is that the reduction in absence we realised in the first phase of the service will be augmented by our earlier intervention.

A well-documented example outside our jurisdiction is that of the Royal Mail in the UK, which introduced more active management not only of MSDs but of all health-related issues that resulted in work absence. Over a three-year period, its level of absence decreased from 7% to 4.5%, resulting in savings of £270 million against an outlay of £46 million. There are examples that demonstrate that early intervention using occupational health measures not only is good for the employees but should result in significant savings for the employer and perhaps the State.

The solution is to introduce nationally agreed standards for early intervention, developed by the Fit for Work coalition, under the auspices of the HSE. Ideally, intervention should be carried out as early as possible, perhaps as early as day five, by an occupational health team. The best way to achieve this is to establish a national case management system to facilitate early intervention. Large companies may be able to resource that within their existing occupational health services, but smaller companies should have access to outsourced case management services. The case manager is the link between the employee, the employer and the health professionals providing care to the individual. We also propose that we need a dialogue with general practitioners and to develop guidelines with the Irish College of General Practitioners in the area of sick certification to extend the usefulness of this and its role within the terms of rehabilitation and return to work. The coalition believes that a cross-departmental approach is necessary to implement the Fit for Work programme, and it is suggested that a high-level appointment would allow policy to be effected at a national level.

Aodhán Ó Ríordáin (Dublin North Central, Labour)
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I am quite stunned by the figures Dr. Ryan has cited. Committee members will pose questions, but there are no representatives of Fianna Fáil, Sinn Féin or the Technical Group here.

How were the figures of €750 million a year for 7 million lost working days and €280 million spent on illness benefit arrived at?

Mr. John Church:

We were one of 24 countries that took part in this research, which was done by a London-based organisation called the Work Foundation. The research was desk-based and studied the same data in each country. The €750 million was grossed up based on the payment of illness benefit, the cost to the employer, lost productivity and the cost of having to redeploy or get locum or other cover for employees who were out sick. Of that sum, we have lately focused on illness benefit payment, which is a real source of data from the Department of Social Protection. They are real figures.

Aodhán Ó Ríordáin (Dublin North Central, Labour)
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Are we talking about a recurring illness - not something that will go away overnight, but one that will dog somebody for a considerable period of time?

Mr. John Church:

Professor FitzGerald is better placed to talk about that, but that is why we are calling for early intervention. The average payment to an employee who is out of work with a MSD is 22 weeks, versus the overall average of 11 weeks. Those figures come from the Department of Social Protection. It is unacceptable to leave somebody out for 22 weeks. If one intervenes extremely early one could prevent long-term disability and damage.

Aodhán Ó Ríordáin (Dublin North Central, Labour)
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Is it the single biggest cause of absenteeism through sickness in the workplace?

Mr. John Church:

Yes; that was what the report found. There are multiple exercises, and some companies would back that up. The HSE report of November 2009 cites MSDs as the biggest cause of workplace absenteeism.

Dr. Don Thornhill:

The social protection costs are considerable but, side by side with them, from the point of view of the Exchequer, come losses in income tax revenue, universal social charge revenue, PRSI and reduced consumer expenditure because of the income hit that households take. The effects of this are quite profound.

Marie Moloney (Labour)
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I met Mr. Church several months ago at Buswells Hotel and, following our discussion, I asked him to come in here today. The more I read about this, the more I feel he should really be speaking to the Joint Committee on Health and Children. Perhaps we can put in a request to that effect. Our remit here is education and, particularly in this case, social protection.

I am interested in the phrase "create a fit note". Could Dr. Ryan please elaborate on that? What exactly is he saying? Does it refer to when a person has been out sick but is now ready to go back to work or can work only part-time?

Dr. Robert Ryan:

It may give the GP an opportunity, rather than calling it black or white - fit or unfit - to qualify that by saying what the person would be capable of doing and what he or she could not do, so that an employer could work with that or make an accommodation that would surmount the barriers to a return to work that the GP has identified.

Marie Moloney (Labour)
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That in itself would cause a lot of problems within the Department of Social Protection, because it is easier for it to say one is fit or unfit. It has introduced a partial capacity scheme whereby people can return to work and retain their social welfare payments, which is along the lines of what Dr. Ryan has described. It would probably need to last longer than ten weeks or so. Is Dr. Ryan aware of that scheme?

Dr. Robert Ryan:

There is social welfare certification but there is also certification between the GP and the employer, which allows a dialogue to take place, particularly if there is a case manager as the link person between the employee, the employer and the doctors looking after the patient. This would give an opportunity to explore the boundaries, limitations or blocks on both sides. For the individual it would be a question of what he or she is capable or not capable of doing, but the case manager would also engage with the employer, asking whether it can work with this person who is not fit to carry out all the duties he or she used to perform but is fit for, say, eight of the ten duties. The employer might be able to provide the individual with a slightly altered role while he or she is rehabilitated. It is really a question of communicating with the employee, the employer and the doctors to help a person get back to work sooner.

Mr. John Church:

I thank the Senator for the invitation. We intend to speak to everybody. This is a health issue but we also see it as a cross-departmental issue. The €750 million includes a health element, but I think the committee will agree that there is a significant bill for the Department of Social Protection, and we propose a solution to save money for the Exchequer.

Ray Butler (Meath West, Fine Gael)
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I thank the gentlemen for their presentation, which I found very interesting. I have suffered from various muscular problems throughout my life. In respect of early intervention, it is very difficult for a GP or physiotherapist to diagnose the problem at the start and to get a picture of it. When I was X-rayed I was told I had a virus. I had muscular problems in my legs. I now have a touch of arthritis in my hip, which will have to be replaced. At times I was very frustrated because the physiotherapy did not work. Then I had a problem in my back and went to a chiropractor, who sorted out my back up to a point. When I was told I had fallen arches, I spent a lot of money buying special shoes and getting physiotherapy for that problem, which was a total waste of time. I am sceptical about the suggestion that it is possible to come up with a national solution to the problem, because it is a long road and many problems will arise. The real problem is getting the final diagnosis. One will find out only by trial and error. It was very frustrating going to different GPs and consultants and so on.

We all know the one shoe will not fit in all cases. With regard to health and safety, does sending back to work somebody whose arm, leg or hip functions, for example, are not 100% not result in insurance problems? It would be very problematic to come up with a national solution. I speak from my experience of having been to doctors, consultants and various practices.

Professor Oliver FitzGerald:

Many people have experienced the frustration that Deputy Butler described. The journey for patients with various musculoskeletal complaints is often frustrating and they end up being sent in a variety of directions without a diagnosis or treatment that will address the problem. A number of solutions are being proposed. The one that I am most familiar with – intervention by very highly-trained musculoskeletal physiotherapists – involves being seen by someone who is very highly trained in musculoskeletal disease. This is very different from the experience described by the Deputy. Experience working with the therapists, both in Ireland and abroad, has shown that they are more than capable of making a good diagnosis and establishing a good treatment plan. It is critical that this be achieved as early as possible.

Ray Butler (Meath West, Fine Gael)
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I found that once one was paying, there were potential solutions for everything but that they were not solving the problem. I found that one had to keep persevering and that the process was never-ending. I am very happy to hear the practitioners in question will be qualified. I believed the people I was dealing with were qualified-----

Professor Oliver FitzGerald:

These are specialists.

Ray Butler (Meath West, Fine Gael)
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Yes.

Dr. Robert Ryan:

There is sufficient capacity to have a national system. With regard to the education sector, which has 4,000 schools spread across the country, there is intervention and the relevant period is to be reduced to four weeks. Therefore, it is possible to create a system of national intervention.

It sounds like Deputy Butler had a very difficult experience and possibly a complicated pathway. Not every difficult case will be managed easily or readily but many cases could be managed.

If I, as an occupational physician, see someone on behalf of his employer, I do not take over his care or take ownership of everything to do with his health. I work with the individual to determine what I can do to assist with his rehabilitation and the return to work. It is a case of there being an interface between the individual and employer. Despite early intervention, there will be those who continue to remain unfit for work and who will have difficult, complex medical problems. Across the board, however, the biggest cohort will have more simple problems in respect of which early intervention and working with the employer will be effective, not only for the individual but also in terms of the capacity to return to work.

Aodhán Ó Ríordáin (Dublin North Central, Labour)
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A Seanad vote has been called.

The delegation has outlined a particular problem and the figures are very stark. I am impressed by the wide coalition of employers, unions, experts, patient organisations, etc. Has the potential solution been costed? Knowing the cost could determine policymakers' reaction to it.

Mr. John Church:

I will attempt to answer that.

Marie Moloney (Labour)
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I apologise because I must attend the vote in the Seanad. We will keep in touch.

Mr. John Church:

Absolutely. This is obviously a matter that we have considered. We have examined all the case studies and histories. Each one represents a net gain. Currently, nothing is happening with intervention. There is an intervention cost and we have examined it. The reason we have included employers and employees, as pointed out by the Vice Chairman, is so we can discuss these issues. Clearly, there is a desire not to burden employers any further. Private health insurers are also part of the coalition. There are solutions and we are working on them. Dr. Ryan would be working on similar solutions. We are trying to weigh the benefit of bringing somebody back to work early against the cost. The model we are working on at present is based on a cost per head, which could very well be absorbed into a company's health insurance policy. There may be some costs for the employer. We are discussing this with IBEC. Ultimately, we see this as an investment, not a cost. It is an investment in the employers' businesses.

Aodhán Ó Ríordáin (Dublin North Central, Labour)
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Is there potential to go from public sector department to public sector department initially? It was stated large corporations might be better resourced to roll out the model before the establishment of a national plan. Could this approach be considered first?

Mr. John Church:

Yes. We realise Ireland is different from some of the other countries. I understand approximately 50% of our employers are small to medium-sized enterprises that would not be able to afford in-house occupational health services. Clearly, we are working on a solution for them. Perhaps Dr. Robert Ryan can elaborate on the arrangements already in place. Ideally, every employer should have some sort of case manager or primary care facility into which it can tap in the event of an employee being unfit to work.

Dr. Robert Ryan:

I am satisfied that there is an investment. Where we have considered the cost of intervention versus the yield, we have noted that there is a significant yield in monetary and other terms. In a year, I will be curious to know what the difference will mean in regard to education and the reduction of the threshold of referral from 12 weeks to four weeks. I believe it will make a significant difference.

At present, there are large public sector employers and other large employers that have occupational health services. They probably have the capacity to introduce the sorts of measures in question because they have sufficient resources. The SME sector does not. It is not just a question of cost as it is also a question of the practicality, feasibility and availability of a programme.

Charlie McConalogue (Donegal North East, Fianna Fail)
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I thank the delegates for attending and welcome them. I apologise for my having to leave for part of the presentation but I have been looking over what I missed. There is much merit in what the delegates are saying. They are certainly talking sense. Is there an international example of where the proposed solution, the case manager system, is working? If so, what evidence has been gleaned from such an example?

Dr. Robert Ryan:

It is a widely used model outside Ireland. Once one starts to intervene early, one is actually increasing the number of people with whom one will engage. It is simply not practical for everyone to see a doctor. The case manager represents a means of assessing people early and triaging them. It is a case of differentiating between the forms of intervention that are appropriate for particular groups. The model is such that some may be directed towards a doctor, some towards an occupational health nurse and others towards physiotherapy or occupational therapy. The model in the United Kingdom involves case management which escalates to referral to a nurse, doctor, physiotherapist or occupational therapist while linking in with the employer.

Mr. John Church:

We know from the 24 other countries that took part in the survey, including Spain, that there are countries introducing the model. Belgium is a good example.

Aodhán Ó Ríordáin (Dublin North Central, Labour)
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This is a cross-party committee of the Oireachtas that invites witnesses to discuss subjects such as that under discussion. Has Mr. Church had any face-to-face contact with departmental officials or Ministers with regard to his body of work and research?

Mr. John Church:

Yes, we have. We briefed the Minister, Deputy Burton, on our introduction to her office two years ago. I am planning to meet her on 23 April and she is also opening our Fit for Work forum, which is a national forum we are running on 24 April. We intend to make various representations across Departments, including the Department of Health.

Aodhán Ó Ríordáin (Dublin North Central, Labour)
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It can be a difficult challenge for something like this because the committee structure here is so compartmentalised. Even the previous presentation would have gone between committees dealing with health, children and education. However, Mr. Church is here from the social protection viewpoint and is focusing on those savings.

Are there any further comments in summary?

Dr. Don Thornhill:

I wish to thank you, Vice Chairman, and other members of the joint committee who, I know, have had a long afternoon. Incidentally, Professor FitzGerald had to get back to a clinic in St. Vincent's Hospital. I think the Vice Chairman was aware of that.

Aodhán Ó Ríordáin (Dublin North Central, Labour)
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Yes.

Dr. Don Thornhill:

This has been a useful experience for us. It has been useful to face the challenging questions coming from members of the committee. Implicit in the Vice Chairman's suggestion is the thought that developing experience through dealing with larger employments, first of all, seems to be a reasonable strategy. Many of the larger employments are of course public sector ones and, sadly, the rates of absenteeism in the public sector are about three times those in the private sector. There is potentially very productive territory for us to plough. Let us hope that when we are talking to the committee again we will have registered progress and will have more positive outcomes of the type that Dr. Ryan has just outlined concerning teachers.

Aodhán Ó Ríordáin (Dublin North Central, Labour)
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What helps Dr. Thornhill's case is that he has identified the problem. If this is the No. 1 reason why people are missing work, then obviously it is something that has to be corrected. All of us on this committee believe that early intervention is the key in most areas of policy.

Dr. Thornhill has identified the costs. In his initial presentation he said he was looking for champions in this regard. A champion will always be asked the hard questions - for example, if one has a model for intervention how much will it cost? That body of work will have to be done in order to get the cost structure fine-tuned.

The suggestion of going Department by Department, sector by sector or through larger private sector entities first, is a good one. Dr. Thornhill said that having 50% of employees in small or medium-sized businesses might not necessarily be the way to go yet.

I certainly think we should keep in contact with each other. We often have presentations here with a good engagement, but the relationship may not be built up or we do not come back to see where it has gone. After Dr. Thornhill has met the Minister and the conference has been held, perhaps he could communicate again with the committee. We will certainly circulate the presentation and post it on our website.

Anyone who has heard today's presentations will certainly be convinced by the validity of Dr. Thornhill's argument. I thank him and his colleagues for attending the committee.

Dr. Don Thornhill:

Thank you.

Aodhán Ó Ríordáin (Dublin North Central, Labour)
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In conclusion, I wish to thank our guests for having briefed us so comprehensively. We will send their presentations to the Minister for a written response on the issues that have been raised.

I wish all members of the committee a happy Easter. The committee now stands adjourned until 1 p.m. on Wednesday, 17 April 2013.