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EDITORIAL
Vocational rehabilitation, case
management and occupational health
Vocational rehabilitation is the restoration to health and
capability to work of individuals incapacitated by mental
or physical disease, or by injury. It is high on the national
agenda. Securing Health Together [1], the Health &
Safety Executive’s (HSE) long-term occupational health
strategy for England, Scotland and Wales, has made avail-
ability for rehabilitation for all who require it as one of
its key 2010 targets. Further, the Partnership Board of
Securing Health Together has a stated aim of developing a
nationwide vocational rehabilitation service. The Support
Programme Action Group, as part of a model for delivery
of nationwide occupational health services, includes
rehabilitation services as one of its priorities. There have
been calls for greater emphasis on rehabilitation both
from employers and from employees’ representatives.
Each acknowledges the central role that occupational
health must play. We, in turn, as occupational health
professionals, need to be aware of the emphasis being
placed on vocational rehabilitation. We must decide
what steps we need to take so that we can answer the
challenges ahead, hopefully with evidence-based best
practice such as that in the Faculty’s guidelines for the
management of low back pain at work [2].
Provoked by the targets set out in Securing Health
Together, some of the principal stakeholders have been
voicing their opinions on vocational rehabilitation. Many
of these echo the sentiments long held and proclaimed by
‘jobbing’ occupational health professionals. Until now,
this has only been acknowledged by a few enlightened
employers or employee representatives.
In December 2001, the CBI (formerly the Confeder-
ation of British Industry) produced a report [3] entitled
‘Business and Healthcare for the 21
st
Century’. In this
report, they sought to highlight the direct cost to UK
business of sickness absence of nearly £11 billion a year,
with an overall cost to society of nearer £23 billion a year.
They suggested three ways of tackling and reducing these
costs: by businesses taking greater ownership and re-
sponsibility for the management of sickness absence;
improving the delivery of publicly funded health care; and
innovative thinking on the longer-term funding of health
care.
The CBI point out that some businesses are better than
others at managing workplace absence and employee
health care, and that best practice needs to be shared and
encouraged. This includes policies to address long-term
sickness absence. It also includes the provision of rehabili-
tation to prevent the progression of long-term sickness
absence leading to early exit from the labour market and
dependence on benefits and/or pension schemes. CBI
research has indicated that in organizations where the
responsibility for managing absence is held at a senior
level, absence rates are significantly lower. The availability
of an appropriate level of expertise of occupational health
provision is seen as key to the delivery of these policies,
acknowledging that the case load and knowledge of
general practitioners (GPs) are such that they are not
likely to see the early return to work of their patients as a
priority. In addition, National Health Service (NHS)
waiting times to see specialists or therapists, particularly
for those with musculo-skeletal conditions, act as a
delay to recovery, and have led to employers seeking trea-
tment through the private sector. The report seeks to
stimulate further research on active rehabilitation policies
and arrangements, and to promote the benefits of such
policies. In particular, it emphasizes the benefits of com-
petent occupational health provision.
The Trades Union Congress (TUC) [4] go one stage
further than advocating increased ownership of sickness
absence by employers. They call on the government to use
the forthcoming Safety Bill to give employers a legal duty
to develop a rehabilitation policy as part of their health
and safety policy. They do not believe that the Securing
Health Together target of a 30% reduction in sickness
absence caused by work-related ill-health by 2010 will be
achieved without either a legal duty on employers to plan
rehabilitation or a major expansion of the rehabilitation
services available.
From within the medical profession there have also
been contributions to the debate. The British Society of
Rehabilitation Medicine (BSRM) [5] has highlighted the
need for greater availability of active vocational rehabili-
tation. They recognize this will reduce the costs to state
and industry, reducing the numbers of those relying on
benefits and improving the quality of life for those in-
volved. It seeks greater access to vocational rehabilitation
services, recognizing the current deficiencies in the NHS,
which it sees as having lost the culture and skills required
to appreciate facilitating employment as one of its key
roles. It points out that whilst GPs certify fitness to work,
they do not practice vocational rehabilitation as perhaps
they should. It sees the ‘uneasy relationships between
GPs, hospitals and occupational health practitioners’,
with poor recognition of the potential value of occupa-
tional health services in facilitating employment rehabili-
tation. This is highlighted by a recent discussion paper
in the British Journal of General Practice [6]. The paper
acknowledges the difficulties faced by GPs in certifica-
tion of fitness to work, with little mention of the role
that occupational health could play to facilitate this. The
Occup.Med.Vol. 52 No. 6, pp.293–295, 2002
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conclusion drawn is, perhaps simplistically, that there
needs to be greater ownership of the problems by GPs,
and more training. The BSRM advocates multi-profes-
sional liaison and the adoption of the case management
approach, which it sees as being effective in assisting
individuals back to work. It encourages further education
on these issues and calls for a new Institute for Vocational
Rehabilitation Research.
Finally, the government itself is looking at rehabili-
tation issues under the auspices of the Department of
Work and Pensions (DWP). This department is currently
completing the second feasibility stage of the Job Reten-
tion and Rehabilitation pilots, with implementation
planned for 2002. An extra £12 million has been set aside
as part of the New Deal for Disabled People initiative
to look at innovative approaches to rehabilitation, by
targeting individuals at 6 weeks following certification
and looking at the overall and relative impact of three
different intervention strategies: work-focused inter-
vention; boosting health care; or a combination of the
two by random allocation and comparison with access to
usual services. The DWP’s Chief Medical Adviser’s Bulletin
2002 [7] contains a Desk Aid for certifying medical
practitioners, which is a summary of the key points from
the guidance document, IB 204 [8]. There is also a useful
list of evidence-based recovery times from elective
surgery and cardiac illness (e.g. post-operative recovery
time to full activity including work following open
cholecystectomy, 3–5 weeks).
There is clearly a common theme emerging: sickness
absence inflicts a heavy price on UK business apart from
the more insidious and difficult-to-quantify societal costs.
Proactive vocational rehabilitation is a fundamental step
in stemming this avoidable loss. The fact that this debate
is now on the national agenda, and that it recognizes
the important contribution of properly resourced and
committed occupational health practitioners, should be
endorsed and greeted with pride and satisfaction by the
profession. Do we take the lead or simply wait for events
to unfold?
Paul Nicholson, writing in this journal [9], has
suggested that we need to move with the times and adopt
a new consumer-focused definition of occupational med-
icine. This is to give greater clarity to our clients as to what
we actually do, where we add value and ‘what our unique
contribution is’. That definition includes the description
‘case manage people who are on sick leave, working with
community health professionals to ensure the earliest
return of functional capacity and return to work’. The
profession should embrace this definition, highlighting
our support for case management, with its greater
emphasis on active rehabilitation and the role we have to
play.
In understanding our role, our unique contribution is
being in a position to influence the employee, their health
care and the employer. We know that the reasons for
long-term absence are multi-factorial and complex [10].
They involve aspects relating to the individual and their
condition, both physical and psychosocial; the attitude
and availability of primary and secondary health care;
perceived and actual job demands; and management
attitudes. Any combination of these factors may act as
a barrier to a successful return to work. In the current
climate, one way of overcoming these barriers is by case
management. A typical model to develop with existing
clients, and to promote to potential clients, is as follows:
·
Raise the profile of rehabilitation with employers, by:
bringing to their attention the common aspirations of
the key stake holders; stimulating the development of
sickness absence policies; recognizing the importance
of rehabilitation; and defining clearly the respective
roles of management, employee, employee representa-
tives and occupational health.
·
A key role for the occupational health practitioner is to
act as an informed facilitator and influencer. Responsi-
bility and accountability for employment decisions
must remain with management, but at an appropri-
ately senior level to make a difference.
·
Promoting and agreeing a common understanding of
trigger points for involvement of occupational health,
with an emphasis on discussion at an early stage of
absence so that there is proactive management of each
case.
·
Liaison with primary care and specialists, making
them aware of the provision of occupational health
services and the availability of a phased return to
work, with restricted or alternative duties to aid with
rehabilitation.
·
Exploring with employers the business case for fund-
ing of fast-track referrals, particularly where long
waiting times exist in the NHS, e.g. musculo-skeletal
and psychological therapies.
·
Liaison with management and the employee as the
employee prepares to return to work. This includes
functional assessment to determine the physical and
psychological requirements of the job to which the
employee will return [11]. Crucially, this raises the ex-
pectation of the return to work in the mind of the
employee, and fosters a sense of responsibility and
ownership for the success of the outcome.
·
Functional capacity assessment of the individual
against the physical requirements of the job with the
involvement of specialist advice where this exists, e.g.
the Disability Service Team of the Employment Service
[12], and consideration of possible adjustments/
alternatives in keeping with the Disability Discrimin-
ation Act 1998.
·
An active graduated rehabilitation programme with the
aim of sustaining a return to work and ultimately
achieving a return to normal duties or maximum
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potential. This may require appropriate discussion to
ensure the returning employee is not financially dis-
advantaged through a phased increase of working time,
which could prevent employees being able to return to
work, but may require considerable flexibility on behalf
of employers.
·
Regular review during the rehabilitation process to
monitor progress and understand any difficulties
encountered. This is important to avoid the process
being derailed and losing credibility, or to prevent
rehabilitation becoming institutionalized and stalled,
with loss of benefit to the employee and employer.
Ideally, monitoring should be carried out by occu-
pational health and line management.
Within this model for case management, there is
considerable scope for multi-disciplinary working, and
this reflects the sentiments of the Institution of Occu-
pational Safety and Health in their recent publication
‘Professionals in Partnership’ [13]. Proactive rehabili-
tation is no longer considered to be the extended role of
the occupational health nurse, but is now being taught as
a core function in some centres. Individual occupational
health services will need to define the respective role of
the occupational health nurse and physician, and other
occupational health practitioners. The relative level of
input will vary according to the complexity of each case
and with regard to the factors acting as barriers to a
return to work.
As occupational physicians, we need to assert our own
central role in rehabilitation, to ensure that we are well
placed to respond to the calls for the development of
services. We can best do this by influencing such initiatives
as Securing Health Together, agreeing evidence-based
and standardized functional capacity assessment tools,
contributing to research, and incorporating the findings
from ongoing research such as the Job Retention and
Rehabilitation Pilots.
David Beaumont
and
Ray Quinlan
Business Healthcare Limited
References
1. HSE. Securing Health Together. A Long-term Occupational
Health Strategy for England, Scotland and Wales. London:
Health & Safety Executive, 2000.
2. Faculty of Occupational Medicine. Occupational Health
Guidelines for the Management of Low Back Pain at Work.
London: Faculty of Occupational Medicine, 2000.
3. CBI. Business and Healthcare for the 21
st
Century. London:
CBI, 2000.
4. TUC. Restoring to Health, Returning to Work. London:
Trades Union Congress, 2001.
5. BSRM. Vocational Rehabilitation—The Way Forward.
London: British Society of Rehabilitation Medicine, 2000.
6. Sawney P. Current issues in fitness for work certification.
Br J Gen Pract 2002; 52: 217–222.
7. DWP. Chief Medical Adviser’s Bulletin 2002. London:
Department for Work and Pensions, 2002.
8. Department of Social Security. IB 204. Medical Evidence for
Statutory Sick Pay, Statutory Maternity Pay and Social
Security Benefit Purposes. A Guide for Registered Medical
Practitioners. London: Department of Social Security,
2000.
9. Nicholson PJ. Occupational medicine: new world, new
definition. Occup Med 2001; 51: 423–424.
10. Whitaker SC. The management of sickness absence. Occup
Environ Med 2001; 58: 420–424.
11. Rayson MP. Fitness for work: the need for conducting a job
analysis. Occup Med 2000; 50: 434–436.
12. The Institution of Occupational Safety and Health.
Professionals in Partnership. London: The Institution of
Occupational Safety and Health, 2001.
Editorial 295
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