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 Together1, the Health and Safety Executive’s (HSE) long term occupational health strategy for England, Scotland and Wales, has made availability 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 nation-wide vocational rehabilitation service. 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 in rehabilitation.
In December 2001, the CBI (formerly the Confederation of British Industry) produced a report2 entitled ‘Business and Healthcare for the 21st 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 the society of nearer £23 billion a year. They suggested three ways of tackling and reducing these costs.
· By businesses taking greater ownership and responsibility for the management of sickness absence
· Improving the delivery of publicly funded health care
· 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 the best practice needs to be shared and encouraged. This includes policies to address long-term sickness absence. It also includes the provision of rehabilitation 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 organisations 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 a key to the delivery of these policies, acknowledging that the case load and the 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 act as a delay to recovery, and have led to employers seeking treatment 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 emphasises the benefits of competent occupational health provision.
Delayed functional recovery of few patients account for the majority of workers’ compensation costs, lost time, decreased productivity and frustration for employers. Early detection and secondary prevention of delayed recovery is the key. Delays in return to work decrease the probability of successful recovery.
a) Only 50% of workers absent for more than 6 months return to work.
b) Only 25% of workers absent over 1 year return.
c) If a worker is absent for more than2 years, there is virtually no chance of his/her returning to work.
There is clearly a common theme emerging: sickness absence inflicts a heavy price on UK business. Proactive vocational rehabilitation is a fundamental step in stemming this avoidable loss. Occupational health practitioners can uniquely contribute to this because of their position to influence the employee, their health care and the employer.
The reasons for long-term absence are multi-factorial and complex 3. 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. One way of overcoming these barriers is by case management. A typical model to develop is as follows:
· Raise the profile of rehabilitation with the employer and define clearly the respective roles of management, employee, employee representatives and occupational health.
· A key role for the occupational health practitioner is to act as an informed facilitator and influencer.
· 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 funding of fast-track referrals especially for musculo-skeletal and mental health problems.
· 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 return4 and consideration of possible adjustments in keeping with the Disability Discrimination Act.
· An active graduated rehabilitation programme with an aim of sustaining a return to work and ultimately achieving a return to normal duties or maximum potential.
· Regular review during the rehabilitation process to monitor progress and understand any difficulties encountered.
Proactive rehabilitation is no longer an extended role of the occupational health nurse but is now being considered as the core function of the speciality 5.
1. HSE. Securing Health Together. A long-term occupational health strategy for England, Scotland and Wales. London: Health and Safety Executive, 2000.
2. CBI.Business and Healthcare for the 21st century. London: CBI, 2000.
3. Whitaker SC. The management of sickness absence. Occup Environ Med 2001; 58: 423-424.
4. Rayson MP.Fitness for work: the need for conducting a job analysis. Occup Med 2000; 50:434-436.
5. David Beaumont, Ray Quinlan.Vocational rehabilitation, case management and occupational health. Occup Med 2002; 52:293-295