Location of Repository

Vocational rehabilitation – what works, for whom, and when?(Report for the Vocational Rehabilitation Task Group)

By Gordon Waddell, A. Kim Burton and Nicholas A.S. Kendall

Abstract

The aim of this review was to provide an evidence base for policy development on vocational rehabilitation:\ud • To assess the evidence on the effectiveness and cost-effectiveness of vocational rehabilitation interventions.\ud • To develop practical suggestions on what vocational rehabilitation interventions are likely to work, for whom, and when.\ud Vocational rehabilitation was defined as whatever helps someone with a health problem to stay at, return to and remain in work: it is an idea and an approach as much as an intervention or a service. The focus was on adults of working age, the common health problems that account for two thirds of long-term sickness (mild/moderate musculoskeletal, mental health and cardiorespiratory conditions), and work outcomes (staying at, returning to and remaining in work). Data from some 450 scientific reviews and reports, mainly published between 2000 and December 2007, were included in evidence tables. Using a best evidence synthesis, evidence statements were developed in each area, with evidence linking and rating of the strength of the scientific evidence.\ud Findings\ud Generic findings:\ud This review has demonstrated that there is a strong scientific evidence base for many aspects\ud of vocational rehabilitation. There is a good business case for vocational rehabilitation, and\ud more evidence on cost-benefits than for many health and social policy areas. Common health problems should get high priority, because they account for about two-thirds of long-term sickness absence and incapacity benefits, and much of this should be preventable.\ud Vocational rehabilitation principles and interventions are fundamentally the same for work related and other comparable health conditions, irrespective of whether they are classified as\ud injury or disease. Return-to-work should be one of the key outcome measures.\ud Healthcare has a key role, but vocational rehabilitation is not a matter of healthcare alone – the evidence shows that treatment by itself has little impact on work outcomes. Employers also have a key role - there is strong evidence that proactive company approaches to\ud sickness, together with the temporary provision of modified work and accommodations, are effective and cost-effective. (Though there is less evidence on vocational rehabilitation\ud interventions in small and medium enterprises). Overall, the evidence in this review shows that effective vocational rehabilitation depends on work-focused healthcare.\ud Executive summary\ud Vocational Rehabilitation: What Works, for Whom, and When? and accommodating workplaces. Both are necessary: they are inter-dependent and must be coordinated. The concept of early intervention is central to vocational rehabilitation, because the longer anyone is off work, the greater the obstacles to return to work and the more difficult vocational rehabilitation becomes. It is simpler, more effective and cost-effective to prevent people with common health problems going on to long-term sickness absence. A ‘stepped-care\ud approach’ starts with simple, low-intensity, low-cost interventions which will be adequate for most sick or injured workers, and provides progressively more intensive and structured\ud interventions for those who need additional help to return to work. This approach allocates\ud finite resources most appropriately and efficiently to meet individual needs.\ud Effective vocational rehabilitation depends on communication and coordination between\ud the key players – particularly the individual, healthcare, and the workplace.\ud Condition specific findings:\ud There is strong evidence on effective vocational rehabilitation interventions for musculoskeletal conditions. For many years the strongest evidence was on low back pain, but more recent evidence shows that the same principles apply to most people with most common musculoskeletal disorders.\ud Various medical and psychological treatments for anxiety and depression can improve symptoms and quality of life, but there is limited evidence that they improve work outcomes. There is a lack of scientific clarity about ‘stress’, and little or no evidence on effective interventions for work outcomes. There is an urgent need to improve vocational rehabilitation interventions for mental health problems. Promising approaches include healthcare which incorporates a focus on return to work, workplaces that are accommodating\ud and non-discriminating, and early intervention to support workers to stay in work and so\ud prevent long-term sickness.\ud Current cardiac rehabilitation programmes focus almost exclusively on clinical and disease\ud outcomes, with little evidence on what helps work outcomes: a change of focus is required.\ud Workers with occupational asthma who are unable to return to their previous jobs need better support and if necessary retraining.\ud Practical suggestions\ud Given that vocational rehabilitation is about helping people with health problems stay at,\ud return to and remain in work, the policy question is how to make sure that everyone of working age receives the help they require. Logically, this should start from the needs of people with health problems (at various stages); build on the evidence about effective interventions; and finally consider potential resources and the practicalities of how these interventions might be delivered. From a policy perspective, there are three broad types of clients, who are differentiated mainly by duration out of work, and who have correspondingly different needs:\ud In the first six weeks or so, most people with common health problems can be helped to return to work by following a few basic principles of healthcare and workplace management. This can be done with existing or minimal additional resources, and is low cost or cost-neutral. Policy should be directed to persuading and supporting health professionals and employers to embrace and implement these principles.\ud There is strong evidence on effective vocational rehabilitation interventions for the minority (possibly 5-10%) of workers with common health problems who need additional help to return to work after about six weeks, but there is a need to develop system(s) to deliver these interventions on a national scale. These systems should include both healthcare and workplace elements that take a proactive approach focused on return to work. To operationalise this requires a universal Gateway that a) identifies people after about 6 weeks’ sickness absence, b) directs them to appropriate help, and c) ensures the content and standards of the interventions provided. Pilot studies of service delivery\ud model(s) will be required to improve the evidence base on their effectiveness and costbenefits\ud in the UK context. This will involve investment but the potential benefits far outweigh the expenditure and the enormous costs of doing nothing.\ud For people who are out of work more than about 6 months and on benefits, Pathways to work is the most effective example to date. There is good evidence that Pathways increases the return to work rate of new claimants by 7-9%, with a positive cost-benefit ratio. Continued research and development is required to optimise Pathways for claimants with mental health problems and for long-term benefit recipients.\ud Vocational rehabilitation needs to be underpinned by education to inform the public, health professionals and employers about the value of work for health and recovery, and their part in the return to work process.\ud Conclusion\ud There is broad consensus among all the key stakeholders on the need to improve vocational\ud rehabilitation in the UK. This review has demonstrated that there is now a strong scientific\ud evidence base for many aspects of vocational rehabilitation, and a good business case for\ud action. It has identified what works, for whom, and when and indicated areas where further\ud research and development is required. Vocational rehabilitation should be a fundamental element of Government strategy to improve the health of working age people

Topics: RA0421, RA
Publisher: TSO
Year: 2008
OAI identifier: oai:eprints.hud.ac.uk:5575

Suggested articles

Preview

Citations

  1. (2008). A cost-benefit analysis of Pathways to Work for new and repeat incapacity benefits claimants (DWP RR 498). Corporate Document Services,
  2. (2001). A critical review of psychosocial hazard measures (HSE CRR 356).
  3. (2004). A literature review of cardiovascular disease management programs in managed care populations. doi
  4. (2006). A model of care for managing traumatic psychological injury in a workers’ compensation context. doi
  5. (2007). A systematic review of injury/illness prevention and loss control programs (IPC).
  6. (2004). A systematic review of the economic burden of chronic angina.
  7. (2006). A vision for change: report of the expert group on mental health policy. The Stationery Office Dublin (on behalf of Department for Health and Children), Dublin www.dohc.ie (accessed 26
  8. (2004). Assessing the quality of research. doi
  9. (2007). Beyond medicalisation. doi
  10. (2008). Building the case for wellness. PricewaterhouseCoopers LLP, London www.workingforhealth.gov.uk/Carol-Blacks-Review (accessed 16
  11. (2004). Clinical guidelines and evidence review for panic disorder and generalised anxiety disorder.
  12. (2006). Common mental disorders in the workplace: recent findings from descriptive and social epidemiology.
  13. (2001). Compensable injuries and health outcomes. The Royal Australasian College of Physicians,
  14. (2006). Computerised cognitive behaviour therapy for depression and anxiety: doi
  15. (2006). Concurrent validity of the Community Integration Questionnaire in patients with traumatic brain injury in Japan. doi
  16. (2005). Cost of anxiety disorders in Europe. doi
  17. (1997). Cost-effectiveness of cardiac rehabilitation after myocardial infarction. doi
  18. (2004). Cost-utility analysis studies of depression management: a systematic review. doi
  19. (2003). Costs of occupational asthma and of occupational chronic obstructive pulmonary disease. doi
  20. (2001). Counselling in the workplace: the facts. A systematic study of the research evidence. British Association for Counselling and Psychotherapy, doi
  21. (2007). Depression (amended): management of depression in primary and secondary care.
  22. (2004). Disability prevention and communication among workers, physicians, employers, and insurers - current models and opportunities for improvement. doi
  23. (2001). Does how you do depend on how you think you’ll do? A systematic review of the evidence for a relation between patients’ recovery expectations and health outcomes.
  24. (2003). Does workplace counselling work? doi
  25. (2006). Early intervention following trauma: a controlled longitudinal study at Royal Mail Group. Institute for Employment Studies, Brighton www.employment-studies.co.uk/pubs/ index.php (accessed 16
  26. (2007). Early intervention for depressive disorders in young people: the opportunity and the (lack of) evidence.
  27. (2006). Effectiveness and cost effectiveness of counselling in primary care (Cochrane Review). doi
  28. (2000). Employee assistance programmes: the emperor’s new clothes of stress management? doi
  29. (2001). Epidemiology of chronic obstructive pulmonary disease. doi
  30. (2006). Evidence on the effectiveness of occupational health interventions. doi
  31. (2004). Exercise based rehabilitation for heart failure (Cochrane Review). doi
  32. (2005). Exploring how General Practitioners work with patients on sick leave (DWP RR 257). Corporate Document Services,
  33. (2007). Functional restoration programs for low back pain: a systematic review. Annales de réadaptation et de médecine physique 50: doi
  34. (2001). How effective is workplace counselling? A review of the research literature. doi
  35. (2006). Impacts of the job retention and rehabilitation pilot (DWP RR 342). Corporate Document Services,
  36. (2007). Improved early pain management for musculoskeletal disorders:
  37. (2005). Improving return to work research. doi
  38. Managing stable COPD.
  39. (2002). Mental illness and workplace absenteeism: exploring risk factors and effective return to work strategies. 64686_TSO_VOCATIONAL.indb 63 8/7/08 21:37:52 Vocational Rehabilitation: What Works, for Whom, and When?
  40. (1995). Money matters: a meta-analytic review of the association between financial compensation and the experience and treatment of chronic pain. doi
  41. (2006). Mono-disciplinary or multidisciplinary back pain guidelines? How can we achieve a common message in primary care? doi
  42. (1995). Morbidity statistics from general practice: fourth national study 1991-1992 (Office of population censuses and surveys Series
  43. (2004). Multidisciplinary strategies for the management of heart failure patients at high risk for admission. A systematic review of randomized trials. doi
  44. (2006). Natural rubber latex allergy among health care workers: a systematic review of the evidence. doi
  45. (2005). Optimal search strategies for retrieving systematic reviews from Medline: analytical survey. doi
  46. (2007). Outcome of occupational asthma after cessation of exposure: a systematic review. doi
  47. (2005). Outcome of occupational asthma. doi
  48. (2007). Pathways to work: customer experience and outcomes (DWP RR 456). Corporate Document Services,
  49. (2005). Physical training for asthma (Cochrane Review). In doi
  50. (2002). Physical training for bronchiectasis (Cochrane Review). In doi
  51. (2003). Poor communication between health professionals is a barrier to rehabilitation. doi
  52. (2006). Preventing needless work disability by helping people stay employed. doi
  53. (2005). Promoting mental well-being in the workplace: a European policy perspective. doi
  54. (2006). Psychosocial aspects in the management of arthritis pain.
  55. (1999). Quality of life and the ICIDH: towards an integrated conceptual model for rehabilitation outcomes research. doi
  56. (2005). Rehabilitation approaches in fibromyalgia. doi
  57. (2005). Return to work following whiplash and back injury: a review and evaluation. doi
  58. (2002). Returning coronary heart disease patients to work: a modified perspective.
  59. (2002). Review of existing supporting scientific knowledge to underpin standards of good practice for key work-related stressors - phase 1 (HSE RR 024).
  60. (2002). Royal College of Psychiatrists. doi
  61. (2006). Short-term psychodynamic psychotherapies for common mental disorders (Cochrane Review). In Cochrane Database of Systematic Reviews, doi
  62. (2007). Standards of care for people with regional musculoskeletal pain. Arthritis and Musculoskeletal
  63. (2004). Standards of care. Arthritis and Musculoskeletal Alliance, London www.arma.uk.net (accessed 17
  64. (2002). Stress and work-related upper extremity disorders: implications for prevention and management. doi
  65. (2002). The business case for quality mental health 64686_TSO_VOCATIONAL.indb 71 8/7/08 21:37:53 Vocational Rehabilitation: What Works, for Whom, and When?
  66. (2006). The implementation of occupational health guidelines principles for reducing sickness absence due to musculoskeletal disorders. doi
  67. (1999). The medicalisation of misery: a critical realist analysis of the concept of depression. doi
  68. (2000). The role of activity in the therapeutic management of back pain. Report of the International Paris Task Force on back pain. doi
  69. (2006). The role of physiotherapy in the management of non-specific back pain and neck pain. doi
  70. (2003). The UK perspective: a review of research on organisational stress management interventions. doi
  71. (2001). The use of evidence-based duration guidelines.
  72. (2006). Too little too late. Part 2: what went wrong with the Job Retention and Rehabilitation Pilot? Occupational Health [at Work]
  73. (2007). Vocational rehabilitation for people with mental health problems. doi
  74. (2004). Vocational rehabilitation in psychiatry: a re-evaluation. doi
  75. (2007). Vocational rehabilitation: a multidisciplinary intervention. doi
  76. (2005). What works for whom? A critical review of psychotherapy research.
  77. (2007). Work in inflammatory and degenerative joint diseases. doi

To submit an update or takedown request for this paper, please submit an Update/Correction/Removal Request.