Rheumatology Advance Access originally published online on April 13, 2009
Rheumatology 2009 48(7):709-710; doi:10.1093/rheumatology/kep071
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
EDITORIAL |
Musculoskeletal problems and work in the UK—time for a new approach?
1Southampton University Hospitals NHS Trust, Southampton and 2Arthritis Research Campaign National Primary Care Centre, Primary Care Sciences, Keele University, Keele, UK
Correspondence to: Ray Armstrong, Southampton University Hospitals NHS Trust, Tremona Road, Southampton SO16 6YD, UK. E-mail: rayarmstrong{at}btinternet.com
In the UK, the impact of musculoskeletal conditions on work is demanding more attention from all stakeholders, including clinicians and policymakers. National policies directed at extending working life [1], Dame Carol Black's report ‘Working for a Healthier Tomorrow’ [2] and the subsequent government response ‘Improving health and work: changing lives’ [3] highlight the topic and the need for new approaches and attitudes. In 1999–2000, 206 million working days were lost in the UK due to ‘arthritis’, which in terms of lost production was equivalent to £18 billion [4]. Perhaps more importantly, improving work ability will not only yield individual and societal economic benefits, but in general it is also good for physical health, mental health and well-being [5]. It is essential for individual prosperity and full participation in society and is central to identity, social roles and social status. Employment and socio-economic status are the main drivers of social gradients in physical and mental health and mortality [5].
Although much attention is given to stress and mental health problems as a cause of absence from work, and although this may account for the majority of time absent from work, musculoskeletal disorders (MSDs) account for a rather higher number of episodes of absence from work. For many rheumatologists, inflammatory arthritis is the most frequently encountered condition that interferes with work. However, the cumulative burden of non-inflammatory arthropathies and disorders such as back pain, OA and limb pain as a whole, results in a much greater economic and human cost to society than inflammatory disease. As the incidence of these conditions increases with age and as working lives extend, there will be many more employees with musculoskeletal problems in years to come. The ill worker's first point of contact with the National Health Service (NHS) is primary care but the current system lacks flexibility in its response to their needs and in facilitating continued participation in work [2]. Dame Carol Black's report presented the opportunity to radically overhaul the approach to sickness absence, but do planned improvements go far enough?
Work loss need not be a consequence of musculoskeletal conditions or disability. Sickness certification may be part of the problem. The current ‘sick note’, or MED3 form, which the primary care physician provides to exempt the patient from work has been in use for over 30 years. It has severe limitations and is unhelpful in that its only requirement is to provide a plausible reason for absolving the recipient from the responsibility of going to work. However, the reason cited on the form often does not reflect the real problem. The fact that this is rarely challenged by an employer helps to perpetuate this unsatisfactory state of affairs. The general practitioner (GP) may feel that this is not a serious problem if sickness absence is short-term and justifiable. However, when the absence becomes prolonged and a return to work begins to look increasingly unlikely, GPs may feel that they are colluding in a pattern of behaviour which is not in their patient's best interests, or at least that their patient is being denied the opportunity to remain a full productive member of society. The present arrangements also favour the behaviour of those who seek to avoid work and who do not have a genuine medical reason for doing so. A switch from absence to attendance and from incapacity to ability in the form of the new electronic ‘fit note’ would represent a marked improvement but would place new demands on the GP. In recognition of this increased responsibility, higher priority has been placed on primary care training, resources and practice related to issues of work and rehabilitation [3].
An important issue is whether Dame Carol Black's report and the government's response will change the current approach to dealing with the sick worker's needs and promote a widespread incorporation of the biopsychosocial model of illness into issues of work and rehabilitation. Greater emphasis has been placed on early intervention, which is essential if a short-term problem is not to be translated into long-term sickness absence. Early diagnosis and treatment are key, but even at the early stage, the approach needs to incorporate a view of the problem wider than the purely medical by, for example, incorporating the evidence that patients’ perceptions and emotional state are powerful predictors of whether they will return to work or not [6]. A coherent and effective response to the worker's need for support in continuing to work or returning to work is necessary. A greater emphasis on a ‘joined up’ approach to the sick worker's problems involving the worker, the multidisciplinary team (e.g. the GP, physiotherapist, occupational therapist, psychologist, occupational health professional and/or employer advisor [7]) and the employer is required. Vocational rehabilitation should have a greater role in the light of evidence for its benefits for employees and employers [8]. For the long-term sick, the ‘Pathways to Work process’, which aims to enhance return-to-work for those receiving Incapacity Benefit, has demonstrated that individuals can still function in a constructive way, even when full participation in usual tasks is not possible. However, in the case of both short-term and long-term sickness, opportunities will be lost unless managers and employers can be more flexible and accommodating in their approach to the employee's condition. If the impact of illness is considered simply in terms of healthcare costs to the NHS, this detracts from consideration of the wider repercussions of ill health on the individual and society. For instance, rheumatologists will be very familiar with the frustrating inability of National Institute for Health and Clinical Excellence (NICE) to take into account such wider societal costs when undertaking healthcare economic modelling to determine the cost effectiveness of clinically effective, but expensive, new drugs [9]. It is not only the sick worker who will benefit from the new approach: there is a growing evidence of the benefits for employers of efficient rehabilitation from employee health and well-being [10].
So what else is required and what barriers exist to implement change? Can we learn from other countries with different health care, welfare and occupational systems? To ask the GP to switch overnight from identifying inability to work to making suggestions about what work might be suitable would be optimistic in the extreme. This responsibility must lie elsewhere. It is the GP's job to recognize difficulty at the earliest opportunity and to act as quickly as possible. Ideally, there should be a readily accessible and responsive occupational health service to which the GP may refer the patient. This raises two key issues: (i) where should the jurisdiction for occupational health provision lie: outside the NHS (where it currently lies—an important fact acknowledged in Carol Black's report) or inside? and (ii) access to key services (e.g. physiotherapy) is restricted by resources and staff shortages. The aspiration to provide an early intervention service for dealing with MSDs will provide a challenge to the NHS, which has an ongoing struggle to meet existing demand. Waiting times for patients with MSDs have been historically high and although under the current administration these have been very considerably reduced, providing rapid access to those in work should not be at the expense of others. Although an expanded occupational health service may have a role to play here, it may be that harnessing the experience and expertise of rheumatologists would offer a more effective approach. In addition, we should welcome increased involvement of allied health professionals to enhance patient care and reduce the pressure on GPs, where, for example, a physiotherapist could make an assessment and refer on to colleagues appropriately [7]. There is a need for piloting innovative schemes for delivering such a service.
Also, the part that employers play in preventing MSDs at work must be addressed. Occupational health services are currently more likely to be found in association with larger employers. For the rest, legislation is not enough. Support for smaller and medium-sized employers is welcomed to facilitate provision of more effective and supportive occupational health services.
Finally, there is a lack of good-quality evidence to guide the preventive, therapeutic and rehabilitative arms of the response to the whole problem of sickness and work [11]. Perhaps, generic and musculoskeletal journals have a role to play by prioritizing work as a topic for publication. Although there are signs that steps are being taken to encourage greater involvement by employers and others in considering the health of their workforce [12–14], more research is needed. For instance, although we know that being off work for a longer period increases the risk of long-term absence, more information is needed about the timing of interventions to ensure optimal outcomes. Those who have ventured into the world of medicolegal practice relating to occupation-related injury will know how the existing adversarial system thrives on a lack of hard evidence. Failure on the part of some employers to implement existing knowledge about good practice combined with uncertainties surrounding workplace MSDs allows perpetuation of something of a compensation culture in some industries. Although much is known about ergonomic factors and the role of types of work and workplace environment in predisposing to MSDs, there are many unanswered questions about prevention, causation, treatment and prognosis which must be addressed to ensure that the needs of those in work are being met.
To underpin this new approach, work, in the form of return-to-work or work capacity, should become the outcome measure of choice for the management of musculoskeletal conditions in working-age adults. Although it is important to acknowledge the importance of controlling pain and preserving and improving function, continued participation in work should be harnessed as a positive contributor to recovery and rehabilitation rather than being perceived as a barrier. Although the case for such change is strong, translating this successfully into practice will require considerable investment of time and effort to change attitudes and practice, in addition to financial resources to provide the necessary infrastructure to effect change. It is hoped that well-constructed pilot projects will show the best way forward but such costs should be recouped with interest in the longer term.
Disclosure statement: The authors have declared no conflicts of interest.
References
- Department for Work and Pensions. Security in retirement: towards a new pensions system. (2006) London: The Stationery Office.
- Working for a Healthier Tomorrow. (23 March 2009, date last accessed). http://www.workingforhealth.gov.uk/Carol-Blacks-Review/.
- Department for Work and Pensions & Department of Health. Improving health and work: changing lives. (2008) London: The Stationery Office.
- Arthritis Research Campaign. Arthritis: The big picture. Chesterfield: Arthritis Research Campaign. (2002).
- Waddell G, Burton AK. Is work good for your health and well-being? (2006) London: The Stationery Office.
- Shaw WS, Means-Christensen A, Slater MA, Patterson TL, Webster JS, Atkinson JH. Shared and independent associations of psychosocial factors on work status among men with subacute low back pain. Clin J Pain (2007) 23:409–16.[CrossRef][Web of Science][Medline]
- Campbell J, Wright C, Moseley A, Chilvers R, Richards S, Stabb L. Avoiding long-term incapacity for work: developing an early intervention in primary care. (23 March 2009, date last accessed). http://www.workingforhealth.gov.uk/documents/developing-an-early-intervention-in-primary-care.pdf.
- Waddell G, Burton AK, Kendall N. Vocational Rehabilitation Evidence Review: What works, for whom, and when? (2008) London: The Stationery Office.
- NICE. (23 March 2009, date last accessed). http://www.nice.org.uk/aboutnice/whoweare/board/boardmeetings/2002/18thseptember2002/item___ response_to_the_report_of_the_health_select_committee.jsp.
- Pricewaterhouse Coopers. Building the case for wellness. (23 March 2009, date last accessed). http://www.workingforhealth.gov.uk/documents/dwp-wellness-report-public.pdf.
- Walker-Bone K, Cooper C. Hard work never hurt anyone—or did it? A review of occupational associations with soft tissue musculoskeletal disorders of the neck and upper limb. Ann Rheum Dis (2005) 64:1112–17.
[Abstract/Free Full Text] - Management of long-term sickness and incapacity for work. Guidance for primary care and employers on the management of long term sickness and incapacity. (23 March 2009, date last accessed). http://www.nice.org.uk/guidance/index.jsp?action=byID&o=11674.
- Promoting mental wellbeing at work. Guidance for employers on promoting mental wellbeing through productive and healthy working conditions. (23 March 2009, date last accessed). http://www.nice.org.uk/guidance/index.jsp?action=byID&o=11669.
- Promoting physical activity in the workplace. Intervention guidance on workplace health promotion with reference to physical activity. (23 March 2009, date last accessed). http://www.nice.org.uk/Guidance/PH13.
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||