OECD report on Mental Health and Work in Norway - 2013 www.oecd.org/els/disability >Norway

1. MENTAL HEALTH AND WORK: NORWAY
OECD conclusions and recommendations
John Martin
Director for Employment, Labour and Social Affairs, OECD
Niklas Baer
Author of the Country Report on Norway
www.oecd.org/els/disability >Norway
Dissemination Seminar- 05/03/2013 - Oslo

2. Contents (for John - not to be shown)
1.
Mental ill-health is a key social and labour market issue (3-4; John)
2.
Reasons for mental ill-health imposing such a high burden (5; John)
3.
The Norwegian context – the broader picture (6-7; John)
4.
Problems and recommendations in detail (8-20; Niklas)
5.
Conclusions (21; John)
2

3. MENTAL ILL-HEALTH IS A KEY SOCIAL AND LABOUR
MARKET POLICY ISSUE
•
Strong employment disadvantage of people with mental disorders:
–
•
Mental health-related disability benefits have increased
–
•
Disability benefit claims due to a mental disorder are on the rise in Norway as in most
other OECD countries – in Norway from around 20% of all new claims in 2005 to around
30% in 2011.
People with mental health problems have more and longer absences
–
–
•
In Norway as in other OECD countries, the employment rate of people with a mental
disorder is between 55 and 70% (depending on the illness severity) - compared to around
85% in healthy people
In the past four weeks, 30-40% of workers with a mental disorder (depending on the
illness severity) have been absent from work - compared to around 20% of workers without
a mental health problem.
The average duration of sickness absence is higher in workers with a mental health
problem
The productivity losses of workers not absent from work are large –
this should be the main policy focus in future
–
70 to 90% of workers with a mental health problem have had productivity losses due to a health
problem – compared to only 25% of workers without a mental health problem
3

4. MENTAL ILL-HEALTH IS A KEY POLICY ISSUE …
… because it is a mass phenomenon
1 in 5 workers, 1 in 2 unemployed and 2 in 5 inactive people have a mental disorder in Norway
Prevalence of severe or moderate mental disorder (in percentage), by labour force status,
latest year available
–
Point-prevalence of mental disorders in the working population is around 20%
–
This applies more or less to all countries, regions and age-groups
–
The disorder-prevalence has not increased in the past six decades
–
This is a very robust result of many epidemiologic studies all over the world
applying professional diagnostic interviews
Source: OECD (2013), Mental Health and Work: Norway, Paris: OECD Publishing. Figure 1.3 page 26.
4

5. MENTAL ILL-HEALTH CAUSES A HIGH
INDIVIDUAL, SOCIAL AND ECONOMIC
BURDEN, BECAUSE …
•
… it mostly starts at a very young age and usually shows an enduring course
•
… it affects the brain, resulting - even at a mild level - in relevant disabilities
•
… it leads to workplace conflicts, work-related fears and avoidant behaviour
•
… it is “unvisible” and related to a still very high stigma
–
–
impeding identification and supportive behaviour of the work-environment
–
•
impeding treatment-seeking and disclosure
impeding governments to make it a high priority issue
… current policies and support systems are not yet prepared to
tackle mental health-related employment challenges effectively
5

6. THE NORWEGIAN CONTEXT
Potentials of policies, structures and interventions
•
The NAV-reform – all employment measures under one roof
•
A «National Strategy on Mental Health and Work» – pioneering and joint work
by the Health and Labour Ministeries
•
A traditional work-first approach and many support systems
•
High expenditures on Health with many GPs and psychiatrists offering
treatment
•
High expenditures on Education and a strong focus on a healthy environment in
schools
•
A strong legislation to ensure health-promotion and sick-leave prvention at the
workplace
•
The «Inclusive Working Life Agreement» which offers a structure for tripartite
co-operation
6

7. THE NORWEGIAN CONTEXT
But strong potentials do not prevent exclusion
•
A strong «First work-approach» – but Norway is highest in spending on
disability benefits as % of GDP (2.6%)
•
A strong focus on healthy work environments – but sick leave is common
•
A strong focus on healthy schools – but Norway is very high in school drop-outs
•
A strong focus on equality – but mental health-related inequalities in
employment are especially high in Norway
•
A strong tripartite structure (IWA) – but almost no obligations for employers
and employees to avoid sickness absence, or to enforce re-intergation
•
Many social and labour policy reforms – but shying away from necessary
(financial) measures
7

8. SICKNESS ABSENCES
Sick leave is a trap for people with mental disorders
Norway has the highest rate of sickness absences by far
Incidence of sickness absence of full-time employees in selected OECD countries
Mental conditions are frequent among long-term absences and their share is increasing
Share of mental health conditions in total sickness beneficiaries, by duration, 1994-2010
Source: OECD (2013), Mental Health and Work: Norway, Paris: OECD Publishing. Figures 2.1, 2.3 pages 36, 39.
8

9. SICKNESS ABSENCES
„Generous‟ conditions are a barrier to job-retention
•
The longer the absence the stronger the fear-avoidance
behaviour in employees with mental health problems
•
All actors and regulations support this negative illnessbehaviour:
–
Due to the very short employer-paid sick-pay period, employers
have no incentives to promote return-to-work
–
Due to a 100% replacement rate in case of sickness during one
year, employees have no incentives to return-to-work quickly
–
Line managers, HR managers and working colleagues are not
well-equipped to deal with mental disorders in the
workplace, and may be relieved when the mentally ill employee
is absent
–
The unions are on the healthy workers‟ side
GPs perceive sickness certification as very problematic and do
not want to endanger the doctor-patient-relationship
Source: OECD (2013), Mental Health and Work: Norway, Paris: OECD Publishing.
–
9

10. SICKNESS ABSENCES
Possible ways forward
Policy recommendations
–
Increase the duration of the employer-paid sick-pay period
–
Develop financial incentives for employers to retain employees
–
Reduce the replacement rate in case of sickness absence
–
Expand and specialise the NAV-Employer Support Centers
»
Expand early intervention training for line managers
»
Make early intervention a priority in the HR training curriculum
»
Base long-term sickness certifications on interdisciplinary assessments
»
Develop criteria on when no sick leave should be granted
»
Develop standard processes for employers, NAV professionals and physicians
on how to co-operate in „difficult‟ cases
Source: OECD (2013), Mental Health and Work: Norway, Paris: OECD Publishing.
10

11. DISABILITY BENEFITS
Disability benefits are a one-way road
Norway has very low disability benefit claim rejection rates
Share of rejected benefit claims among total applications, latest year available
Outflow from disability benefits into employment is close to zero
Annual outflows to employment as a share of the disability benefit caseload, 1999 and 2008
11
Source: OECD (2013), Mental Health and Work: Norway, Paris: OECD Publishing. Figures 3.3, 3.4 pages 63, 64.

12. DISABILITY BENEFITS
Artificial health fluctuations caused by exclusion
perspective ?
Symptoms typically improve after disability benefit award
Variation in different symptoms before, during and after disability benefit award (Z scores)
Source: Overland S, N Glozier, M Henderson, J G Maeland, M Hotopf, A Mykletun (2008)
Health status before, during and after disability benefit award: the Hordaland Health Study
(HUSK), Occupational and Environmental Medicine, 65, 769-73.
OECD (2013), Mental Health and Work: Norway, Paris: OECD Publishing. Figure 3.8 page 76.
12

13. DISABILITY BENEFITS
Wasting existing working-capacity?
The older the disability beneficiaries, the milder the mental disorder
Share of different mental disorders in permanent disability benefits, by age, 2010
Strong increase in disability benefits for young adults due to a mental disorder
Share of permanent disability benefits which are due to a mental disorder, by age, 1990 and 2010
2010
1990
45
40
35
30
25
20
15
10
5
0
18-24
25-34
35-44
45-54
55-64
65-67
Source: OECD (2013), Mental Health and Work: Norway, Paris: OECD Publishing. Figures 3.6, 3.7 pages 67, 74.
13

14. DISABILITY BENEFITS
Possible ways forward
Policy recommendations
–
Apply the already existing strict DB-eligibility criteria in practice
»
–
Expand the explicit medical, social and socio-demographic exclusion criteria (age, firm
closure or stress-reactions are not disabling per se)
Retain a work perspective by closing the gates to DB as early as
possible when indicated
»
»
–
Develop a rapid basic decision about DB-reception possibility
Restrict the access to DB after several years of vocational rehabilitation
Strengthen treatment requirements for claimants
»
Request specialised adequate treatment over a sufficient period before awarding a DB
–
Bind the DB-award to an interdisciplinary assessment including a
psychiatrist
–
Discuss a co-financing of DB costs for employers and
municipalities
–
Provide ongoing support and reassessment to DB-beneficiaries
14

15. VOCATIONAL REHABILITATION
Much training instead of workplace interventions
The use of education and training has decreased, but (more effective) wage subsidies are still scarce
Shares of vocational rehabilitation measures for clients with mental or musculoskeletal
disorders
15
Source: OECD (2013), Mental Health and Work: Norway, Paris: OECD Publishing. Figure 4.2 page 83.

16. VOCATIONAL REHABILITATION
Possible ways forward
Policy recommendations
–
Turn the focus from re-integration to early intervention in mental
health-related workplace problems
–
Develop interdisciplinary teams in the Employer Support Centers to
guarantee their competence
–
Decrease re-education and long-lasting training programmes in
favour of relevant wage subsidies to employers
–
Give incentives to municipalities to change from sheltered work
facilities to supported employment programmes
–
Insert an interdisciplinary assessment and rehabilitation planning
into the Qualification Programme for youth without diagnosis
16

17. MENTAL HEALTH CARE
Treatment potentials are not used due to
fragmentation
Very high inpatient re-admission rates …
… despite high rates of GPs and psychiatrists
17
Source: OECD (2013), Mental Health and Work: Norway, Paris: OECD Publishing. Figures 5.1, 5.2 pages 98, 99.

18. MENTAL HEALTH CARE
Possible ways forward
Policy recommendations
–
Develop a systematic collaboration between NAV offices, GPs and
District Psychiatric Centers
–
Expand the personnel and responsibilities of the medical services in
NAV
–
Install vocational rehabilitation professionals from NAV in the
District Psychiatric Centers
–
Use the strategic position of the District Psychiatric Centers and
establish employment issues as a core competence of the centers
–
Develop work-related quality indicators for mental health care
–
Improve vertical integration of the municipal, regional and
centralised mental health care
–
Start a research agenda focusing on employment issues in treatment
18

19. EDUCATION AND LABOUR MARKET TRANSITION
Not enough individual follow-up for “new” disorders
Early school-leaving is frequent in Norway partly
because of a high drop-out rate from vocational
education
Proportion of youth aged 20-24 (i) not in education
and without upper-secondary diploma
(early school leavers) and (ii) not employed and
not in education (NEET), 2009
The composition of mental disorders leading to a
disability benefit claim among young people has
changed
Share of different mental disorders in all recipients
of a disability benefit aged 18-24
with a mental disorder, 1990-2010
Source: OECD (2013), Mental Health and Work: Norway, Paris: OECD Publishing. Figures 6.2, 6.3 pages 113, 114.
19

20. EDUCATION AND LABOUR MARKET TRANSITION
Possible ways forward
Policy recommendations
–
Ensure a systematic collaboration between the pedagogical and
psychological services at school, the school health services and the
child psychiatric services
–
Increase resources of the school-based health services and integrate
more psychiatrists into these services
–
Raise awareness of mental health issues in vocational education and
train the teachers
–
Establish a close contact between NAV offices, health services and
vocational education
–
Invest more in early intervention, assertive outreach and enduring
individual follow-up with vulnerable pupils
20

21. CONCLUSIONS
–
Some features of the Norwegian Welfare system – the easy access to
longer sickness absences, the open gate to permanent disability
benefits and the lack of re-assessments
»
»
–
lower the efforts to retain the mentally ill at the workplace
undermine the potential of the rich set of Norwegian measures in
education, health and vocational rehabilitation
The high expenditures in health, education and NAV do not deliver
regarding mental health-related exclusion, partly because
»
the different services are not well integrated
»
mental health care does not feel responsible for work issues
»
medical services in NAV do not have enough responsibilities
–
Norway should complement its state-of-the-art prevention by an
effective early intervention approach targeting at job-retention of
workers with mental health problems.
–
But make sure that the financial incentives of all actors are aligned
with the need for employment integration of workers with mental illhealth
21

22. THANK YOUR VERY MUCH FOR YOUR ATTENTION !
For more information and OECD publications on the topic:
www.oecd.org/els/disability
Including free access to the Executive Summary and all tables and
charts of “Mental Health and Work: Norway”
Niklas Baer (report author), Phone: +41 79 778 28 84
Christopher Prinz (project leader), Phone: +33 6 1503 35 87
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