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FIT FOR WORK EUROPE: EU Reflection Process on Chronic Disease

Contents
1. 2. 3. Fit for Work ..................................................................................................................................... 2 Musculoskeletal Disorders: a widespread burden to Europe's economy and society.................... 3 EU Reflection Process on Chronic Disease: European Commission request for input .................... 4 3.1 What is the current situation on chronic diseases in the European Union? ................................. 5 3.2 Health Promotion and Disease Prevention: what more should be done? .................................... 6 3.3 Healthcare & Healthcare Systems: what changes can be made to respond better to the challenges of prevention, treatment and care of chronic diseases? .................................................. 7 3.4 Research priorities: meeting the challenges of chronic diseases................................................ 10 3.4 Information and Information Technology: what more can be done?......................................... 12 3.5 Roles of Member States, the EU and Stakeholders: additional activities ................................... 13 4. References ..................................................................................................................................... 15

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The Fit for Work Europe Coalition is supported by an ongoing grant from Abbott--a founding partner--and a supporting grant from GE Healthcare. For information and the opportunity to comment/blog/share your experience on making Europe Fit for Work, go to www.fitforworkeurope.eu .

1. Fit for Work


The Fit for Work Europe (FfW) Coalition is a unique multi-stakeholder platform bringing together patients, physicians, policymakers and social partners, all of whom believe in the importance of prevention, early intervention, and management of musculoskeletal disorders (MSDs)1 in the workplace. The vision of FfW is to shift the perception of MSDs from being disabling conditions to manageable conditions, ensuring that more European citizens stay in work or return to work2, while helping to improve the sustainability of Europe's health and social care systems. The Coalition aims to highlight to stakeholders the importance of making MSDs a priority at the EU and national levels as well as aiming to improve the individual, clinical, employer and related approaches for managing MSDs. FfW's core principles for people of working age living with MSDs are based on the belief that employing early intervention practices for MSDs promotes the idea that staying in work is good for health and wellbeing. The principles are as follows: Work is healthy for patients and society. Work makes economic sense, driving national economies, and is integral to health and social care systems. Healthcare professionals (HCPs) should promote work as a desirable clinical outcome for patients.

FfW at national level Since the 2009 publication of Fit for Work? Musculoskeletal Disorder in the European Workforce and more than 30 national FfW reports, there has been activity at the European and national levels among patients, physicians, policymakers and society representatives to support those living with MSDs to stay active and working, contribute to society and maintain a high quality of life. This has lead to changes in policy and practice in Europe and beyond, including the following highlights:

In the UK, the NHS Operating Framework for the first time has classified work as a clinical outcome. Wider societal costs will be considered as part of drug assessments, and higher thresholds for medicines will be allowed where it can be demonstrated that there are broader societal benefits within the new value based pricing mechanism. In France, the health Chair of the influential university Sciences Po ran a national seminar devoted to chronic diseases and work, and included recommendations from national FfW stakeholders. In Greece, the FfW Greek research inspired public-private collaboration to develop a national Guide for Citizens with Rheumatic Diseases. In Spain, the government announced a national strategy for MSDs; regional action plans were developed, with the one from the Catalunya region presented by stakeholders in Brussels as best practice to FfW national stakeholders from other European countries and regions. In Italy, the Senate Health Commission unanimously approved a national inquiry that established MSDs/chronic degenerative diseases as a public health priority. In Denmark, additional funding has been earmarked for improving the management of MSDs/chronic diseases.

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The Fit for Work Europe Coalition is supported by an ongoing grant from Abbott--a founding partner--and a supporting grant from GE Healthcare. For information and the opportunity to comment/blog/share your experience on making Europe Fit for Work, go to www.fitforworkeurope.eu .

In Austria, a think tank was formed to discuss MSD policy targets, and agreed the need for an Austrian fit note. The recommendations from the Belgian Fit for Work report have been included in a report on the legal and financial aspects of bringing people with Rheumatoid Arthritis back to work in Belgium. This report has been facilitated by the Scientific Research Body of Rheumatology in Belgium and will be launched later this year. Their main priority focus for 2011 - 2014 is on Arthritis and Work. In Croatia, the FfW report was supported by Parliament and subsequently the National Insurance Institute allocated a special fund for biologic therapy for treating rheumatic diseases. Finland has developed a Back to Work programme with an employers' organisation and patient organisations which supports people with MSDs wanting to get back to work, and for people who struggle to stay at work. In Germany, the Commissioner for the disabled in Rhineland Palatinate agreed to develop a national plan for improving working conditions for disabled people. In Ireland, a National Clinical Lead for Rheumatology was appointed, and has agreed funding for 24 physiotherapists to lead early intervention clinics for MSDs. The Israeli government agreed specific improvements to manage MSDs, set up an employerbased vocational rehabilitation programme for people with MSDs, and established work productivity as a health technology evaluation measure. In Canada, the launch of FfW was a catalyst for the development of a National Arthritis Framework.

These national FfW endeavours underline the growing consensus for change locally which should help inspire evolutions and best practice sharing across countries and at European level.

2. Musculoskeletal Disorders: a widespread burden to Europe's economy and society


MSDs is an umbrella term covering over 200 conditions that affect the muscles, joints, tendons, ligaments, peripheral nerves and supporting blood vessels, causing pain and functional impairment to sufferers.3 The impact of MSDs goes beyond the immediate physical symptoms; the conditions affect a person's selfesteem, quality of life, professional and family life and financial situation. MSDs are a major cause of disability and functional decline.4 They consume a large share of resources in healthcare systems and have an enormous impact on the social costs related to disease, worklessness, lost productivity and social exclusion. There is also a strong correlation between MSDs and other, co-morbid, long-term conditions such as mental illnesses, obesity and cardiovascular disease. Yet health and social care systems in all Member States remain fragmented and do not prioritise early interventions or work as a clinical outcome. This makes national governments frequently ill-prepared as the burden of MSDs on society increases while the labour force ages and needs to work longer.

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The Fit for Work Europe Coalition is supported by an ongoing grant from Abbott--a founding partner--and a supporting grant from GE Healthcare. For information and the opportunity to comment/blog/share your experience on making Europe Fit for Work, go to www.fitforworkeurope.eu .

Facts At least 100 million people in Europe reported chronic musculoskeletal pain in 2008 although MSDs are undiagnosed in over 40% of cases (Veale et al, 2008). Up to 80% of the adult population will be affected by an MSD at some time in their life (WHO 2003). 1 in 6 members of the EU workforce have a long-standing health problem or disability which affects their ability to work (Eurostat, 2003). MSDs affect more than 40 million workers in the EU and account for about half of all workrelated disorders in EU countries (ETUI, 2007), representing an estimated cost to society of between 0.5 and 2% of gross domestic product (GDP) annually. Up to 40 % of people with MSDs are out of work at some time in their life (Bevan et al, 2007). The European Commission estimates that MSDs account for almost 50% of all absences from work lasting three days or longer and for 60% of permanent work incapacity (EC, 2007). Reported unemployment rates are three times higher among people with MSDs than in the general population (Bevan et al, 2007).

Impacts and costs Muscle and joint pain costs European economies up to 240 billion a year (EC, 2007). PERIOD Direct costs of MSDs include the cost of prevention, detection, treatment, rehabilitation and long term care. Indirect costs of MSDs include lost work output attributable to a reduced capacity for activity, lost productivity, lost earnings, lost opportunities for family members and lost tax revenue. These indirect costs typically account for 80% of the total costs of MSDs. Intangible costs include psychosocial burdens resulting in reduced quality of life, such as job stress, economic stress, family stress and suffering (WHO, 2003). In the UK, total costs associated with MSDs in 2007 were estimated at 7 billion (HSE, 2007).

3. EU Reflection Process on Chronic Disease: European Commission request for input The FfW Europe Coalition welcomes the European Commission's request for input to the EU Reflection process on Chronic Diseases, as an opportunity to highlight the challenges facing Europe's ageing workforce. Moreover, the current economic crisis is an opportunity to bring forward an era of policy, clinical practice and other value-added solutions to the challenges facing Europe in relation to public health and national productivity. This response to the Commission's request for input has been drafted taking into account the impact of chronic conditions, including a special focus on MSDs, on health and social care systems and in particular, the importance of recognising MSDs as the leading cause of disability and long-term sickness absence in the working age population across the EU both now and for at least the next two decades.

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The Fit for Work Europe Coalition is supported by an ongoing grant from Abbott--a founding partner--and a supporting grant from GE Healthcare. For information and the opportunity to comment/blog/share your experience on making Europe Fit for Work, go to www.fitforworkeurope.eu .

FfW calls on the EU and National Governments to implement the following solutions: Early intervention in treatment and care of MSDs can lead to improved functionality and work ability and can serve as a case study for optimal care and management of a range of other Chronic Conditions, especially among citizens of a working age. Establishing European and National Directors for Health and Work can help to stimulate a more strategic integrated approach across the EU and national health, employment, social affairs and finance departments. Health Technology Assessments (HTAs) and health economic evaluation targets should be holistic and include clinical and societal impacts of regimens which support people with MSDs or other Chronic Conditions. Such evaluations can help result in health decisions that help patients to remain active and productive in the labour market, as opposed to decreased work ability and potential reliance on welfare payments. Work ability should be established as a clinical outcome of treatment and a meaningful dialogue about a patients workability status should occur regularly between people with MSDs and healthcare professionals. Better data generation and exchange is required at national and EU level on prevalence, incidence and costs of MSDs and other Chronic Conditions among the current and future EU workforce, as well as on successful solutions of improving productivity through early intervention practices and modified working conditions. Methods, tools and support networks to increase patient engagement and self management practices should be developed which support positive clinical and labour market outcomes. Cost-effective and timely physical and psychological therapies for people of working age with MSDs improves access and return to work as well as full and fulfilling labour market participation of people with MSDs. More collaboration between primary care physicians and specialists (e.g., physiotherapists and occupational therapists) is needed to ensure that healthcare professionals are supported in making decisions about work disability, job retention or return to work, including a revision of the medical statement so that work ability is part of clinical outcomes. Better enforcement of existing national legislation requiring reasonable workplace accommodations can help people to stay in work or reintegrate into the workforce. Labour market policies should be geared towards helping employees with Chronic Conditions and disabilities to remain in work or reintegrate into the workforce. This should include flexibility in welfare benefits which allows workers to earn income and claim financial support while they phase their return to work.

3.1 What is the current situation on chronic diseases in the European Union? By 2060 the proportion of the population aged 65 and over is projected to increase to 30 % from 17.4 % in 2010,5 which means that there will be just one person of working age for every dependent person aged under 19 or over 65 years in the EU.6 Hence, the role of work should be taken into account by national governments and the EU regarding chronic conditions. Work plays a crucial part in the health and wellbeing of an individual. Work is a cross-cutting issue for the reasons identified below:

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The Fit for Work Europe Coalition is supported by an ongoing grant from Abbott--a founding partner--and a supporting grant from GE Healthcare. For information and the opportunity to comment/blog/share your experience on making Europe Fit for Work, go to www.fitforworkeurope.eu .

Enabling people to be in productive work is a health issue. Work is generally good for physical and mental health. Worklessness is a greater risk to health than many killer diseases. Peoples social and economic circumstances effects their health throughout life, so health policy must be linked to the social and economic determinants of health. Work is a social determinant of health. Improving the health of the working-age population is in the interest of us all.

3.2 Health Promotion and Disease Prevention: what more should be done? More primary prevention measures can be taken to slow or forestall the onset of chronic conditions, including MSDs. For example, employers and occupational health professionals can help design and adapt workplace settings with conditions and ergonomics that are conscious of promoting workplace health and wellbeing. Individuals can proactively manage their health and act to avoid lifestyle and other risks that may result in acute and long-term chronic conditions. With the rise of co-morbidity alongside long-term conditions, health promotion including health literacy should be coupled with management of existing long-term conditions. In the case of MSDs mobility is a vital issue and there is a relationship between lack of physical exercise due to an MSD and increases in depression, stress and obesity. For example, people with arthritis may also be twice as likely as the general population to have a mood or anxiety-related disorder.7 Early detection requires a better screening and monitoring process. Genetic and hereditary factors that cause some MSDs can be detected in the early years of life and can lead to better management of diseases and disorders throughout life. Action at the EU level The EU should develop an integrated approach to early detection of chronic diseases; action at the EU level can be possible through a combination of health, social and employment policies: The importance of work and a healthy workforce should be part of future EU health policies and initiatives on health promotion, health inequalities and early detection measures. The EU's revision of the MSD Directive should take into account pre-existing MSDs which may not be caused by the workplace but can be exacerbated by some working conditions and practices. The EU can help disseminate good practices and tools which can foster better health and wellbeing for workers. For example, in 2011 British Telecommunications (BT) set up the 'BT passport' concept, which is a scheme that documents the specific requirements of some employees with special needs that can on occasion impact their working life e.g. disability and wellbeing.

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The Fit for Work Europe Coalition is supported by an ongoing grant from Abbott--a founding partner--and a supporting grant from GE Healthcare. For information and the opportunity to comment/blog/share your experience on making Europe Fit for Work, go to www.fitforworkeurope.eu .

Action at national level Work should be prioritised as a critical factor when evaluating the need for early detection of chronic diseases including MSDs. Lack of early detection can have a profound effect on the ability for the person to stay in the labour market, and delayed diagnosis can result in premature withdrawal from the labour market, with the attendant economic and social consequences. Human and financial resources should be targeted to support early intervention of chronic diseases and MSDs, based on the potential socio-economic return on investment.

FfW's Contribution FfW has conducted research in more than 30 countries across Europe and beyond. This research has also developed actionable recommendations for all relevant stakeholders, at the European and national levels in relation to MSDs. Through the FfW European Coalition, FfW has fostered dialogue and shared best practices among all relevant stakeholders to help improve the health and wellbeing of people with MSDs. This includes informing policies and practices that support early intervention of MSDs e.g. relating to job retention or reintegration into the workplace. In the UK, national FfW Coalition members, notably Dame Carol Black, have been prominent in the advent and support of initiatives such as the FfW case studies and pilot projects and the 'fit note'. In France, FfW stakeholders have access to a website (www.maladieschroniques-travail.org) which creates a platform for patients, healthcare professionals, companies and clinicians to exchange information and ideas on chronic diseases in the workplace, with chronic inflammatory rheumatisms as an example. FfW Ireland launched and distributed the Fit for Work Charter, which recognises the role that policy makers, employers, health providers and insurers, unions and other relevant stakeholders must play in addressing MSDs and work.

3.3 Healthcare & Healthcare Systems: what changes can be made to respond better to the challenges of prevention, treatment and care of chronic diseases? In most Member States, healthcare spending will continue to need to rise as a proportion of GDP due to an ageing population and growing prevalence of chronic diseases. To maximise effectiveness of such expenditures and enhance sustainability, early intervention and appropriate management of chronic diseases can help contribute. In the UK, for example, people with long-term conditions are already disproportionately higher users of health services and account for around 70% of overall health and social care spending, representing 50% of GP appointments, 60% of outpatient and emergency attendances and 70% of inpatient bed days. By 2030, 21 million people of working age in the UK (about two-thirds of the workforce) will have at least one work-limiting long-term health condition. The EU and national governments must tackle these challenges in a holistic manner taking on an integrated health, employment and social care approach.

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The Fit for Work Europe Coalition is supported by an ongoing grant from Abbott--a founding partner--and a supporting grant from GE Healthcare. For information and the opportunity to comment/blog/share your experience on making Europe Fit for Work, go to www.fitforworkeurope.eu .

Action at EU level The EU can help exchange good practices among its Member States, such as: The Statement of Fitness for Work ('fit note') which demonstrates the importance of communication between patient, physician and employer. The fit note allows a primary care physician to provide the employee with more information on how their condition affects their ability to work. This helps employers understand how they might be able to help an employee return to work sooner.8 The London 2012 Olympic and Paralympic Games Health Legacy: for the construction of the Olympic 2012 site, the organisers undertook large scale measures to ensure workers' health and safety and were active in health promotion with the view that "a healthy workforce is a productive workforce''. 9 This included the establishment of occupational health facilities on-site. Such a strategy helped to detect the early onset of long term conditions.10

Action at national level Recognising that national governments have full competence over health and social care systems highlights the need for action at national level. Policy solutions The direct and indirect impacts of MSDs can be addressed at different political levels European and national but also through different policy fields public health, employment, welfare, economic and financial affairs. There is a need for coherent policy-making to ensure that all aspects of MSDs are tackled in a comprehensive and coherent manner, avoiding inconsistencies or counter-productive policies. Many national governments across Europe have policies and/or legislation requiring reasonable workplace accommodation for people with MSDs. This can include provisions for adjusting the ergonomics, working time or work of an employee. However, data and information gathered from across Europe shows there is a lack of enforcement of these regulations, especially among smaller businesses.11 Adjusting work demands (the physical work environment, working time, psychological support, etc.) is often inexpensive and can make a big difference to the reintegration of people with MSDs or help people with MSDs to retain their job. Labour market policies should be geared towards helping employees with chronic conditions and disabilities to remain in work or reintegrate into the workforce. This should include flexibility in providing welfare benefits, which can support a phased return to work approach. Long periods away from work are generally bad for MSD patients. The longer the sick leave, the more difficult it is to get the employee to return to work and the higher the economic cost.12 Health, social and employment ministries must work together. For example, in Germany different national ministries (Ministries of Health, Labour and Social Welfare, and Trade and Industry) discussed how national programs are developed and implemented, which increased the cross-government departmental discussions on healthy ageing. The UK government appointed a National Director for Health and Work responsible for over-seeing national research, policies and initiatives aimed at improving the health of the workforce. This should serve as a good practice

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The Fit for Work Europe Coalition is supported by an ongoing grant from Abbott--a founding partner--and a supporting grant from GE Healthcare. For information and the opportunity to comment/blog/share your experience on making Europe Fit for Work, go to www.fitforworkeurope.eu .

example and other European countries should also appoint National Directors for Health and Work who can actively address joint issues and better coordinate health and social care systems. Financial Planning must take into account the need for cost-effective measures which help governments save in the long-term. Having a significant proportion of the working age population either temporarily or permanently unable to work through ill-health can reduce labour productivity in an economy and damage the competitiveness and effectiveness of private and public sector organisations. Data from the UK's National Audit Office (NAO) shows that worklessness has inter-generational persistence and that in the UK, 51% of those living in workless households have a long-term disability.13 Investing in early intervention and appropriate management of chronic diseases can help minimize other potentially greater social disbursements.

Health and social care systems solutions National governments should prioritise MSDs through developing and implementing national plans on MSDs. These plans should be created through an integrated joint policymaker and stakeholder approach to address key issues, such as the inclusion of societal perspectives in healthcare funding decision making and better financial planning between government departments. Work should also be a key element in consultations between people with MSDs and primary/secondary care physicians. Work ability should be established as a clinical outcome of treatment, and a meaningful dialogue about a patients workability status should occur regularly between people with MSDs and healthcare professionals. There also needs to be an increase in primary and secondary care healthcare professionals that have sufficient information, training and resources to tackle chronic conditions in the workplace. Health Technology Assessments (HTAs) and health economic evaluation targets should be more holistic and include clinical and societal impacts resulting from treatments and therapies, which support people with MSDs or other chronic conditions to remain active and productive in the labour market rather than relying on welfare payments. There is a need for more cost-effective and timely physical and psychological therapies for people of working age with MSDs. This should include improved access to work and return to work, as well as full and meaningful labour market participation for people with MSDs. Pilot projects need to show medium and long term value for society from patient pathway programs and cross-sector coordination. Future national plans and policies need to reflect an approach that is not limited to work that causes diseases, but also includes an approach which targets helping people with chronic conditions integrate in the work place.

FfW's Contribution In Denmark FfW stakeholders have taken a proactive approach to improve policy planning (with support from leading healthcare politicians) through a pilot project on patient pathway programs providing patient coordinators for patients with inflammatory arthritis.

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The Fit for Work Europe Coalition is supported by an ongoing grant from Abbott--a founding partner--and a supporting grant from GE Healthcare. For information and the opportunity to comment/blog/share your experience on making Europe Fit for Work, go to www.fitforworkeurope.eu .

In Germany three separate instruction manuals will be released by the national FfW Coalition, each of which is tailored to healthcare specialists, primary care physicians, occupational health physicians and other healthcare professionals, as well as patients. In Turkey the national FfW Coalition has identified the gaps in the current Turkish Healthcare system in relation to Rheumatology. An investment gap has been identified which could provide better management of care and better coordination with different specialists. A report has been prepared regarding the healthcare infrastructure and will be disseminated to policy makers in mid 2012. In the UK 'work' is included in the NHS Outcomes Framework as an outcome indicator. The government, following stakeholder consultation, will include wider social benefits in the new value-based pricing (VBP) system designed to supplant the Pharmaceutical Price Regulation Scheme (PPRS) in 2014. In addition the FfW UK Coalition will be part of a project led by Dr Debbie Cohen that will modify the existing Royal College of General Practices (RCGPs) National Education Programme (NEP) for work and health for members of the rheumatology team. In Norway patient organisations, also part of the national FfW platform, are supporting a government strategy Back to Work for people below the age of 30 years that are suffering from a chronic condition and its associated disabilities: the main focus for the initiative is helping people gain further education and encouraging labour participation. In Denmark the new government has recently presented different reform proposals on the sickness and incapacity benefits schemes. The proposals include several changes in the existing programs, including that people under the age of 40 shall no longer be granted incapacity benefits, although they have a reduced working ability. Instead they will be offered a tailor-made development course including education, training, work ability testing and social support in order for them to stay active and in education or in employment. The reform proposals also include increased focus on early intervention for chronic patients to improve workability. In Ireland FfW stakeholders have devised and delivered a series of person-centred workshops for people with MSDs to enable them to return to the workforce a Back To Work Programme. Currently the platform is developing a FfW services programme including a website to provide information and support to both employers and employees, as well as compiling a database of good practice examples with a view to developing and piloting FfW programmes in the workplace in 2012.

3.4 Research priorities: meeting the challenges of chronic diseases Research priorities should be focused on addressing fundamental gaps in knowledge. Data gathered through validated research needs to be translated into tools, guidance and models for implementation of best practice. Research priorities need to be refined both at European and national levels. This should continue the theme of an integrated approach, which addresses the need for more research on the impact of workers health on the employment and labour spheres.

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The Fit for Work Europe Coalition is supported by an ongoing grant from Abbott--a founding partner--and a supporting grant from GE Healthcare. For information and the opportunity to comment/blog/share your experience on making Europe Fit for Work, go to www.fitforworkeurope.eu .

Actions at EU level EU funding programmes should be targeted towards bridging existing gaps in research. The role of work in relation to MSDs should be investigated further and should also be part of future EU health and social care projects. Horizon 2020 With the increasing burden of MSDs on not only health and social care systems, but also the number of days lost to sick-leave and long-term absence from the labour market, funding needs to be targeted on MSDs in order to provide more effective solutions as well as effective ways for prevention and early intervention. Therefore, MSDs including rheumatic and inflammatory diseases must be prioritised in the next EU Research Framework Programme for 2014-2020 (Horizon 2020). Key areas for research funding should include more research on developing tools for prevention, early detection and screening. The next EU Research Framework Programme also needs to include specific funding for research which focuses on the linkages between health and employment. The theme addressing 'Societal Challenges' should include a special focus on health in the workplace and include funding for research on the impact of work on wellbeing. The Health for Growth programme should include funding for gathering more evidence and data on the impact of MSDs on the working age population, and formulate tools and instruments for better health and social care planning. Priority should be given to the impact of MSDs and other chronic conditions on health and social care systems. The EU could sponsor research into further understanding whether (i) there is an early intervention premium (a benefit over and above late intervention, and that this outweighs the incremental costs of early intervention) and (ii) there are additional benefits when health, welfare and work are aligned to support early intervention.

Health for Growth

Actions at national level National funding programmes should encourage further research into MSDs and work ability. This should include allocation of resources in support of early intervention and treatment and care of MSDs, as well as funding research on the epidemiology and impact of MSDs on the economy.

FfW's Contribution FfW has developed FfW country reports and a pan-European report which assesses the impact of MSDs on countries and provides recommendations for policymakers and stakeholders. These reports have provided information, data and statistics on the impact of MSDs, as well as highlighting solutions to the issues by providing recommendations for policymakers, healthcare professionals, employees and employers. FfW will continue to provide evidence-based research which can be translated into models, instruments and guidance at local and national level as solutions to address the socio-economic impact of MSDs.

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The Fit for Work Europe Coalition is supported by an ongoing grant from Abbott--a founding partner--and a supporting grant from GE Healthcare. For information and the opportunity to comment/blog/share your experience on making Europe Fit for Work, go to www.fitforworkeurope.eu .

3.4 Information and Information Technology: what more can be done? The prevalence and impact of MSDs is high and yet there are still gaps in the information and data available. To deliver effective solutions, there needs to be a renewed approach to identifying and addressing these gaps. Actions at the EU level Better data generation and exchange is required at national and EU level on the prevalence, incidence, impact and costs of MSDs and other chronic conditions among the current and future EU workforce, as well as on successful solutions for improving productivity through prevention, early intervention practices and modified working conditions. For example, in the UK, the NHS of England is moving towards an outcomes-based system; therefore outcomes improvement data (including 'patient reported outcome measures') are becoming increasingly important. Data that robustly quantifies the benefits of early diagnosis and intervention in terms of patient health and functional outcomes, cost effectiveness and cash saving abilities are critical in an outcomesfocused but cost-constrained NHS. There needs to be more data and information available on the socio-economic impact of MSDs on the community and society. This should include an analysis of the impact on the individual, on the local health and social care system and on the government.

Actions at national level There should be more analysis and information gathered on the discussion between the patient and healthcare professional, in particular taking into account the impact of the condition on the person's working life, wellbeing, productivity and ability to work. There is a need for more robust and in-depth information and data on work productivity in clinical databases, and more systematic health economic evaluations and analyses on pilot projects with patient pathway programs and patient coordinators. In some countries, this lack of data is due to stringent privacy laws which have led to gaps that must be addressed. In many countries there is a need for epidemiological information and data that provides evidence on the burden of MSDs and can lead to better policymaking and implementation of national plans.

FfW's Contribution FfW has launched interactive tools which provide information and data and demonstrate the impact of MSDs across Europe. The FfW Health Map shows the disparities in levels of sickness absence, presenteeism and work-related health in the EU. Data is sourced from a range of public databases and academic papers. The FfW Health and Economic Indicator chart shows the dynamics of various economic and health indicators across a range of European countries. FfW continues to encourage good practice sharing between countries in Europe and beyond through various events including the Annual FfW Summit, as well as issue-specific meetings such as the Conference on the Burden of Rheumatic and Musculoskeletal Diseases: Challenges in the Work Capacity and Prevention of Disability in the EU, co-organised with the European League

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The Fit for Work Europe Coalition is supported by an ongoing grant from Abbott--a founding partner--and a supporting grant from GE Healthcare. For information and the opportunity to comment/blog/share your experience on making Europe Fit for Work, go to www.fitforworkeurope.eu .

Against Rheumatism (EULAR) and the Hungarian Association of Rheumatologists in April 2011, under the auspices of the Hungarian Presidency of the EU. In France the national FfW initiative identified a strong need for data collection and is working in partnership with healthcare professionals, medical labour groups and patient representations in order to implement a national survey (HERACLES). This study will assess if workability is considered by physicians in the management of patients with Rheumatoid Arthritis (RA). Results of the HERACLES survey are expected in early 2013.

3.5 Roles of Member States, the EU and Stakeholders: additional activities Separate to the areas outlined above, the place of work in healthcare decision-making should be considered in addition to the areas mentioned above. Employment and social affairs policies should also be considered as one of the key factors affecting the EU and national approaches to chronic conditions. Health Technology Appraisals (HTAs) and health economic evaluations play an important role in the allocation of resources, particularly at a time when there are severe austerity measures. Two key factors need to be included in these assessments and evaluations: (a) the societal perspective (which includes the person's ability to work and the impact of the technology on carers), and (b) the healthcare system's perspective (which includes costs and benefits relevant to the healthcare system). Moreover, it may be important to include the benefit of the technology to other systems outside of healthcare, such as the social system. 14 Actions at the EU level The EU institutions can serve as a model for an integrated approach to addressing these issues: The EU can work with bodies EUnetHTA to help disseminate information and best practices among national HTA and health economic evaluation agencies. An EU representative responsible for EU health and employment and social affairs policies could serve as an ambassador for integrated decision making. The EU can set up a system of good practice sharing between health and social care systems, supporting stakeholders in various countries disseminate information on tools and guidance which can be transferred and adapted across borders. There are many examples of good practices, models and tools which should be shared between Member States. Examples of where outcomes are improved and costs are saved in practice, not just in theory will be hugely valuable given many European governments are wrestling with large budget deficits and cutting public expenditure

Actions at national level National governments need to work together and identify models, tools and solutions which can be shared across borders and between stakeholders. National plans on MSDs and other chronic conditions should incorporate HTAs and health economic evaluations which include both the societal perspective (including work ability) and

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The Fit for Work Europe Coalition is supported by an ongoing grant from Abbott--a founding partner--and a supporting grant from GE Healthcare. For information and the opportunity to comment/blog/share your experience on making Europe Fit for Work, go to www.fitforworkeurope.eu .

cross-government department cost-effective savings requirements. This can have a positive impact on people with MSDs, employees and employers, the community and national health and social care systems. A national ministry representative for health and work can help bridge the gap between the two areas and increase cross-governmental discussions.

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The Fit for Work Europe Coalition is supported by an ongoing grant from Abbott--a founding partner--and a supporting grant from GE Healthcare. For information and the opportunity to comment/blog/share your experience on making Europe Fit for Work, go to www.fitforworkeurope.eu .

4. References
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The definition of 'Musculoskeletal Disorders' (MSDs) varies considerably; the terminology used in this paper encapsulates all varied forms including musculoskeletal pain, diseases, conditions, disorders and work-related MSDs 2 The definition of 'work' used in this document includes paid and unemployed employment 3 Punnett, L. and Wegman, D. (2004). Work-related musculoskeletal disorders: The epidemiologic evidence and the debate. Journal of Electromyography and Kinesiology, 14(1), 1323 4 Fit for Work Europe (2009) http://www.fitforworkeurope.eu/Downloads/WebsiteDocuments/Fit%20for%20Work%20pan-European%20report.pdf 5 Fit For Work? Musculoskeletal Disorders in the European Workforce' (2009) 6 European Commission (2012). Demography report 2010. Older, more numerous and diverse Europeans 7 Mental and Physical Health Charter: http://ec.europa.eu/health/mental_health/eu_compass/policy_recommendations_declarations/mh_char ter_en.pdf 8 Statement of Fitness for Work http://www.direct.gov.uk/en/Employment/Employees/Sicknessabsence/DG_187161 9 London 2012: http://www.london2012.com/about-us/the-people-delivering-the-games/the-olympicdelivery-authority/oda-priority-themes/health-safety-and-security.php 10 Louise Brearey, Head of London 2012 Games UK Health and Safety Executive (2012) 11 Fit for Work Europe (2009) http://www.fitforworkeurope.eu/Downloads/WebsiteDocuments/Fit%20for%20Work%20pan-European%20report.pdf 12 Frank et al., 1998; Meijer, Sluiter, Heyma, Sadiraj and Frings-Dresen, 2006 13 Fit for Work Europe (2009) http://www.fitforworkeurope.eu/Downloads/WebsiteDocuments/Fit%20for%20Work%20pan-European%20report.pdf 14 The Place of Work in Healthcare Decision-making, A Fit for Work Coalition Provocation Paper, Leela Barham and Stephen Bevan (2011)

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The Fit for Work Europe Coalition is supported by an ongoing grant from Abbott--a founding partner--and a supporting grant from GE Healthcare. For information and the opportunity to comment/blog/share your experience on making Europe Fit for Work, go to www.fitforworkeurope.eu .