Vocational rehabilitation

Everybody gains if injured workers are helped back into work

Blessed is he who has found his work; let him ask no other blessedness” wrote Carlyle.1 However, according to a report published last year from the British Society of Rehabilitation Medicine,2 British workers who are injured or ill find it difficult to return to this happy state, and society helps them little in their quest. The report, written by a multidisciplinary working group which explored practices in the NHS, the Employment Service, and industry that impede the return to employment of those with a recent injury, illness, or disability, makes interesting, if sobering, reading.

The need is clear: an average of 3000 British people move on to incapacity benefits weekly, and the social and economic costs of this are enormous (reaching £10bn a year3). The leading causes are familiar to any general practitioner: musculoskeletal injury (28%), psychiatric disorders (20%), and diseases of the circulatory system. Although vocational rehabilitation has been shown to expedite return to meaningful employment, minimise workdays lost, reduce premature retirement, and increase the productivity of injured workers, the authors argue that it has always been neglected in Britain. In addition the system is unwieldy and unresponsive, so that the short, critical window of opportunity for effective rehabilitation may be missed. Thereafter fit workers become physically deconditioned, and typically enter a self perpetuating cycle of hopelessness, anxiety, and depression, and the likelihood of a successful return to work varies inversely with the duration of unemployment.4

If there is inadequate vocational rehabilitation in the United Kingdom, then what will it take to develop an effective system? The working party suggests starting by increasing knowledge, improving service coordination, and allocating adequate funding. They draw attention to the virtual absence of vocational rehabilitation from undergraduate and most postgraduate teaching for health professionals, even that of general practitioners, who have a pivotal role in signing “fitness for work” certificates. NHS consultants in rehabilitation medicine, to whom other doctors can turn for help, are few, have long waiting lists, and are forced to focus their energy on discharging recently disabled patients, rather than helping those already discharged return to work. The report emphasises the lack of psychologists to deal with emotional problems after physical injury or the increasing number of workers suffering from the effects of stress in the workplace.

A national vocational rehabilitation institute is thus proposed, the first role of which would be to persuade universities and colleges to include vocational rehabilitation in their training programmes. However, busy (albeit more knowledgeable) doctors will still have time only to advise and keep a watching brief. The institute will also have to train a cadre of dedicated rehabilitation professionals, who can work within the interdisciplinary team and help disabled people navigate the resource maze. The target for this will be professionals from backgrounds such as nursing, occupational therapy, psychology, and the social sciences, who can bring their established knowledge and skills but who will also receive further training in vocational rehabilitation.

Of course, trained professionals cannot be effective unless they have adequate resources. This includes the money to employ them in the first place, and the capacity to refer their clients for specialist opinion and treatment, modify workplaces, and develop individualised training and return to work programmes. While this is not a cheap option, a community with unemployed, disabled ex-workers is likely to be even more costly.

Evidence based guidelines for vocational rehabilitation are hard to find. There is a dearth of information on vocational rehabilitation in scientific journals, and one must peruse the semantics carefully: how many hours a day constitute a successful return to work, is the job the same, or modified, and how long does it last? A search for the keywords “vocational rehabilitation” in the Cochrane database uncovered only two reports. The first showed that behavioural treatment has a positive effect on the outcome of back pain,5 but vocational rehabilitation is only a small part of such treatment. The second, still a protocol, concerns people with severe mental disorders, who have an unemployment rate of over 70%; this will address important issues such as prevocational versus on site training, and “sheltered employment.”6

Are there lessons to learn from other countries? The details of government schemes are rarely found in journals, and annual reports are not always easily accessible. In Victoria, Australia, if an employee is off work for more than 20 days after injury the employer is responsible for appointing a return to work coordinator, who must produce a written plan within 10 days thereafter. The employee must make “reasonable efforts” to comply with such a programme, while insurers provide funding for rehabilitation, salary support, and modifications to the workplace. Other Australian states have comparable schemes,7 and a national survey of injured workers seven to nine months after approval of an insurance claim showed that 86% “ever” returned to work during that period, and the “durable” return to work rate (those working at the time of interview) was 77%.8

Only 30% of workers required formal rehabilitation to achieve these positive results, which is reassuring as we could never hope to train enough professionals to treat every claimant; it also reinforces the need to streamline the whole process, not just the rehabilitation component. An important facet of the Australian system is its apparent responsiveness to regional needs, as comparable return to work rates resulted from referral of 74% of workers in the Northern Territory for rehabilitation, but only 18% in Queensland. This probably reflects the differences between these two regions in their demography, economy, and job opportunities, factors which have a critical effect on rehabilitation outcome, and which make research in this field problematic.

Great challenges thus face the vocational rehabilitation protagonist. Rehabilitation is only one of the competitors for the compensation dollar: over 25% of claims in Australia end in court, and money spent on litigation is of course not available for rehabilitation.9 Doctors may smile cynically to hear that the dispute rate doubles when lawyers are involved. However the average case has four medical specialists on each side, and duelling medical experts may not differ much from their legal colleagues in incentives and effects. The concept of involving a truly independent medical panel at the outset is thus gaining popularity in Australia.

General practitioners, as the gatekeepers of the system, have the difficult task of identifying patients whose unfitness for work could be reversed through timely referral for rehabilitation. But some patients will never have the capacity to re-enter the open labour market, and these must be counselled against perceiving this as personal failure, be spared harassment, and helped to achieve a good quality of life in other ways. Yet others will demand to be certified unfit, for a multitude of reasons, not all cogent; insurance companies will pressure for the converse. Decisions can be rational only if informed by knowledge, research, and resources. Therefore implementation of the sage recommendations of this report may bring the help that general practitioners, other vocational professionals, and, most of all, workers themselves need.