Effectiveness and costs of a vocational advice service to improve work outcomes in patients with musculoskeletal pain in primary care: a cluster randomised trial (SWAP trial ISRCTN 52269669)

Musculoskeletal pain is a common cause of work absence and early intervention is advocated to prevent the adverse health and economic consequences of longer term absence. This cluster randomised controlled trial investigated the effect of introducing what was termed a vocational advice service into primary care to provide occupational advice. Six general practices were randomised, patients were eligible if they were consulting their general practitioner (GP) with musculoskeletal pain, were employed and struggling at work or absent from work <6 months. Practices in the intervention arm could refer patients to a vocational advisor embedded within the practice providing a case managed stepwise intervention addressing obstacles to working. The primary outcome was number of days off work, over 4 months. Participants in the intervention arm (n=158) had fewer days work absence compared to the control arm (n=180) (mean 9.3 (SD 21·7) versus 14·4 (SD 27·7)) days, Incidence Rate Ratio (IRR) 0·51 (95% Confidence Interval 0·26, 0·99), p=0·048). The net societal benefit of the intervention compared with best care was £733: £748 gain (work absence) versus £15 loss (health care costs). The addition of a vocational advice service to best current primary care for patients consulting with musculoskeletal pain led to reduced absence and cost savings for society. If a similar early intervention to the one tested in this trial was implemented widely, it could potentially reduce days absent over 12 months by 16%, equating to an overall societal cost-saving of about £500 million (US $6 billion), and requiring an investment of only £10 million.