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

The aim of this review was to provide an evidence base for policy development on vocational rehabilitation:
• To assess the evidence on the effectiveness and cost-effectiveness of vocational rehabilitation interventions.
• To develop practical suggestions on what vocational rehabilitation interventions are likely to work, for whom, and when.
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.
Findings
Generic findings:
This review has demonstrated that there is a strong scientific evidence base for many aspects
of vocational rehabilitation. There is a good business case for vocational rehabilitation, and
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.
Vocational rehabilitation principles and interventions are fundamentally the same for work related and other comparable health conditions, irrespective of whether they are classified as
injury or disease. Return-to-work should be one of the key outcome measures.
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
sickness, together with the temporary provision of modified work and accommodations, are effective and cost-effective. (Though there is less evidence on vocational rehabilitation
interventions in small and medium enterprises). Overall, the evidence in this review shows that effective vocational rehabilitation depends on work-focused healthcare.
Executive summary
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
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
interventions for those who need additional help to return to work. This approach allocates
finite resources most appropriately and efficiently to meet individual needs.
Effective vocational rehabilitation depends on communication and coordination between
the key players – particularly the individual, healthcare, and the workplace.
Condition specific findings:
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.
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
and non-discriminating, and early intervention to support workers to stay in work and so
prevent long-term sickness.
Current cardiac rehabilitation programmes focus almost exclusively on clinical and disease
outcomes, with little evidence on what helps work outcomes: a change of focus is required.
Workers with occupational asthma who are unable to return to their previous jobs need better support and if necessary retraining.
Practical suggestions
Given that vocational rehabilitation is about helping people with health problems stay at,
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:
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.
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
model(s) will be required to improve the evidence base on their effectiveness and costbenefits
in the UK context. This will involve investment but the potential benefits far outweigh the expenditure and the enormous costs of doing nothing.
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.
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.
Conclusion
There is broad consensus among all the key stakeholders on the need to improve vocational
rehabilitation in the UK. This review has demonstrated that there is now a strong scientific
evidence base for many aspects of vocational rehabilitation, and a good business case for
action. It has identified what works, for whom, and when and indicated areas where further
research and development is required. Vocational rehabilitation should be a fundamental element of Government strategy to improve the health of working age people.