Delivery of a range of services should be available to support individuals of working age with health issues to return to/remain in work and well, and these will contribute to improved consistency of approaches, holistic and integrated support, and timely appropriate referrals that ensure individuals are fully supported.
Where a range of relevant services are delivered in a consistent way to appropriate professional standards this will contribute to individuals with work-related health issues receiving holistic, integrated and appropriate support when needed, and more timely referrals between services through improved linkages between relevant partners and services, and through simplified pathways and processes.
Case management approaches, Fit for Work services and the use of guidance and assessment tools and processes for individuals aim to support increased consistency of approaches to supporting individuals. This might include the new Fit Note introduced in 2010, although evaluation and monitoring will be necessary to assess any related impact. There is review level evidence that personal advice and support, incorporating case management approaches, is an effective method of delivering employment services to clients with a disability or chronic illness.
Current evidence highlights a need to improve vocational rehabilitation in the UK. Vocational rehabilitation has been defined as “whatever helps someone with a health problem to stay at, return to and remain in work” 1, as this includes routine healthcare and workplace management in addition to more structured vocational rehabilitation interventions. Evidence shows that many people have common health problems and injuries (mild/moderate musculoskeletal, mental health and cardio-respiratory conditions) whose conditions should be manageable and are therefore a prime target for vocational rehabilitation in the UK. Informed by reviews of effectiveness evidence, Waddell, Burton and Kendall  set out a series of evidence statements relating to common health problems, highlighting evidence to inform practice including, for instance, the importance of coordinated action, clear communication between all players, and early intervention. This review highlights:
a strong scientific evidence base for many aspects of vocational rehabilitation. For instance, effective return to work and vocational rehabilitation intervention depend on healthcare that includes a focus on work and workplaces that are accommodating; both are necessary and inter-dependent.
that improved communication between all players leads to faster return to work and less sickness absence overall, and is cost-effective; and that the duration of sickness absence is significantly reduced by contact between healthcare provider and the workplace.
there are good epidemiological and clinical reasons and widespread acceptance throughout the literature that early return to work and stay at work approaches are appropriate and beneficial for most people with most musculoskeletal disorders.
A more recent study proposes that there remains mixed evidence in relation to the impact of return to work rehabilitation for low back pain. It was noted in this study that few studies have return to work as an outcome, but found evidence for a clinically relevant effect of multidisciplinary interventions on return to work.
Informed by reviews of effectiveness evidence, NICE public health guidance 19 Managing long-term sickness absence and incapacity for work sets out a set of generic principles and recommended actions to guide primary care services and employers. This includes a recommendation that organisations commissioning services for individuals who are unemployed and claiming incapacity benefit or employment and support allowance should commission integrated programmes to help claimants enter or return to work (paid or unpaid).
Small and Medium Sized Enterprises (SMEs) are known to have low awareness of occupational health risks and also have specific needs based on their size and potential lack of resources to support staff health and wellbeing. However, there is currently a lack of evidence on effective occupational health and vocational rehabilitation models in SMEs.
Scottish policy note:
The Scottish Government supports an increase in the use of case management approaches. The National Programme Lead for the Delivery Framework for Adult Rehabilitation, together with regional Rehabilitation Co-ordinators will ensure that all NHS vocational rehabilitation services adopt case management approaches.
In Health Works and the Framework for Adult Rehabilitation the Scottish Government set out a clear commitment to developing coordinated vocational rehabilitation and return to work services. Those in work who acquire an illness or injury that compromises their ability to work are at an increased risk of losing or regaining employment. Three Working Health Services Pilots will provide evidence on the efficacy of a dedicated, case managed vocational approach (due to report in Autumn 2010). The Scottish Government will build on learning and evidence from these. The DWP’s Fit for Work service pilots will provide further evidence of early intervention models that can support a return to work.
The Scottish Centre for Healthy Working Lives provides a range of information and advice for employers and employees through a comprehensive website, free and confidential telephone advice line, and a network of advisers. The Centre has been tasked to improve and develop its reach to SMEs with accessible and easy to use advice on workplace health and wellbeing. The Centre is working to broker services for clients with Occupational Health providers, assisting them to ensure limited resources are positioned in the most appropriate place.
Territorial NHS Boards are to work with local employability service providers to define the local pathways for providing support to those for whom health is a barrier to retaining or returning to work.
Waddell G, Burton AK, Kendall N (2008). Vocational Rehabilitation: What works, for whom, and when? A report for the Vocational Rehabilitation Task Group. The Stationary Office: London. http://www.kendallburton.com/Library/downloadpdfs.html
Norlund A, Ropponen A, Alexanderson K (2009). Multidisciplinary Interventions: Review of Studies of Return to Work after Rehabilitation for Low Back Pain. Journal of Rehabilitation Medicine 41: 115-121.
NICE (2009). NICE public health guidance 19 Managing long-term sickness absence and incapacity for work. NICE: London.
3.5 Develop relevant competencies of a range of service provider staff to support health and work issues.
Activities to develop the relevant competencies (to be defined by, for instance, local need, national and professional guidelines) should include different service provider staff in contact with individuals with work-related health issues and be delivered on an ongoing basis, and this will contribute to more staff having the relevant competencies to support individuals and workplaces, identify work-related health issues at an early stage, and deliver consistent, integrated and timely support to individuals.
Developing the competencies of a range of service provider staff will contribute to more staff have the relevant skills and confidence to support individuals, and will have greater knowledge of support and services across the system enabling timely appropriate referrals and signposting to ensure individuals receive timely, tailored support to return to and/or remain in work and well. It must also be recognised that this activity is dependent on local decisions around use of resources and priorities for training based on local need, and upon the capacity of services and staff to deliver in this field (e.g. staffing levels and workforce planning, allocation of workloads).
In relation to primary healthcare interventions there is clear review level evidence that many GPs and other healthcare professionals feel ill-equipped, and lack training and expertise on work issues, and that many GPs report insufficient time, resource and support to address work issues adequately.
Competencies of staff can be further developed and supported through the effective implementation and use of professional standards and guidance. A range of professional standards and guidance are available to support staff development and practice in the health and work agenda.
There is some evidence that guideline dissemination and implementation, computerised clinical support systems, audit and feedback, and multifaceted interventions can change health professionals’ behaviour, but the effects are small to moderate.
Informed by reviews of effectiveness evidence, NICE public health guidance 06 Behaviour change at population, community and individual levels sets out a set of generic principles and recommended actions to guide the planning and delivery and evaluation of public health activities to change health related behaviour at the individual, community or population level. This included the need to equip practitioners with the necessary competencies and skills, as set out in the guidance, to support behaviours change, using evidence-based tools. The NHS Health Scotland Commentary on this guidance supported these action points subject, where appropriate, to adaptation to fit Scottish organisational arrangements.
A recent literature review to inform discussion on the best way forward for training and education of healthcare staff supporting vocational rehabilitation in Scotland highlighted deficiencies in the current system in the UK. Evidence from a meta-analysis of studies in vocational rehabilitation which examined employment outcomes reported the positive influence of higher levels of vocational rehabilitation education for service providers on rehabilitation outcomes. Informed by evidence reviews and expert opinion, the Boorman review  recommended that “continued priority is given to attracting doctors to pursue careers in occupational health medicine so as to ensure that sufficient consultant resource is available to enable all NHS employers to access specialist advice when needed”
Scottish policy note:.
Health Works set out a specific action to increase the use of case management approaches in Scotland. Formal case management training has been recently introduced to the UK. This foundation training in vocational rehabilitation is being delivered as CPD courses for those already involved in vocational rehabilitation, primarily health care professionals or human resources personnel using the National Institute of Disability Management and Research (NIDMAR) programme. As part of the development of a Scottish Offer the Scottish Government is reviewing available professional standards for use within the Scottish context.
NHS Education for Scotland (NES) are supporting education and practice development for vocational rehabilitation in Scotland. This has included the development of an electronic community of practice within the NHS Knowledge Network.
The Scottish Government and NES will deliver a programme for the development of the existing employability training pack and its delivery to healthcare and other professionals, seeking formal accreditation of training.
Waddell G, Burton AK, Kendall N (2008). Vocational Rehabilitation: What works, for whom, and when? A report for the Vocational Rehabilitation Task Group. The Stationary Office: London.
NICE (2007). NICE public health guidance 06 Behaviour change at population, community and individual levels. NICE: London..
NHS Health Scotland (2007). Health Scotland Commentary on 06 Public Health Guidance: Behaviour change at population, community and individual levels. NHS Health Scotland: Edinburgh.
NHS Education for Scotland (2008). Getting Vocational Rehabilitation Working for Scotland: Education Needs of Staff Supporting Vocational Rehabilitation. A Discussion Document. NHS Education for Scotland: Edinburgh.
Frain MP, Ferrin JM, Rosenthal DA, Wampold BE. (2006). A Meta-Analysis of rehabilitation outcomes based on education level of the counselor. Journal of Rehabilitation, 72(1): 10–18.
Boorman S (2009). NHS Health and Well-being. Final Report. Department of Health: London.
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