physios have been helping workers to avoid slipping from sick leave into long-term disability. As these pilot schemes near the end of their funding, Alison Moore investigates
Musculoskeletal problems are among the commonest reasons for time off work so it makes sense that physiotherapists are being called on to help keep people in employment.
Before the present government started talking about cutting long-term benefits, Fit for Work pilot schemes were already being set up to help people on temporary sick leave return to their jobs. By addressing the mixture of health and social problems that complicate many people’s return to work, these schemes aim to help them avoid slipping into long-term disability.
Early access to physiotherapy plays a key role, and physios have to use their ’people skills’ as well as clinical ones. Listening to patients, taking a holistic view of their health and setting it within the broader context of their home and work life all these provide insights into the problems faced by employees on sick leave. These are often more complex than just a health condition.
Physio Catriona Ross works alongside case managers, occupational therapists and counsellors for the pilot in Dundee.
‘Because patients can refer themselves and because we can offer faster access, we do see some quite acute cases,’ she says. ‘We may get them back to work within one or two weeks.’
While non-urgent cases may take six weeks or more to be seen in the mainstream NHS, Catriona is normally able to see new clients within a few days the longest wait has been two weeks. In the meantime, other professionals may also be involved, offering an OT assessment or counselling, for example.
In normal NHS practice, a physio may do no more than ask whether a patient works or not. Catriona says her service really tries to examine the relationship between a client and their work.
‘They may have a musculoskeletal problem, but we look for the reason behind it. We can go out to the workplace with an occupational therapist to assess that,’ she says. These visits can result in changes to a working environment to prevent the problem recurring.
‘We do tend to have quite a good relationship with patients certainly the ones that are more complex and may be seeing other members of the team as well. We build up quite a rapport and do a lot of telephone catch-up,’ she says.
‘We get many complex cases that do need a lot of input. When they go back into employment, it’s very satisfying.’
And with high unemployment and a government committed to cutting the bill for disability benefits, staying in a job may keep clients and their families out of poverty. More than one in five of those on long-term disability benefits have a musculoskeletal problem.
Some pilots have case managers from physiotherapy backgrounds, who draw together different skills and resources to help clients negotiate a sometimes complex route back to work.
Pam Cartwright, one of three physiotherapists working as case managers for the Fit for Work scheme in Staffordshire, will offer physiotherapy advice to clients. If they require prolonged treatment, she is more likely to refer them to specialist colleagues.
‘They are people who have been off work for four to six weeks they have gone through that point where they are going to get back to work anyhow and they are starting to struggle a bit,‘ she says.
Many clients’ cases are complex; their ability to work may be complicated by debt or family issues, which she will try to tease out at an initial meeting. ‘It is never as straightforward as “I have a bad back”,’ she says.
From then onwards, it is a matter of providing all the elements that will maximise the chances of a return to work.
These might include assessing the need for physiotherapy; involving occupational therapists and employment support advisers; getting advice on areas such as housing or employment law; or setting up group sessions where clients can offer mutual support and discuss experiences. Case managers are also trained in cognitive behavioural therapy.
A similar service covering Birmingham, Sandwell, Solihull and Coventry has been outsourced to a private company, Ingeus. Referrals are directed to the case manager with the most suitable skills, including physiotherapy, but their clinical role is limited to advice and referral to a mainstream service, if appropriate.
’We are not an intervention service in that sense,’ says programme manager Elaine Russell of Birmingham Health and Wellbeing Partnership. ’Our intervention is to return people to the workplace. If a clinical intervention is needed, then we refer onwards.’
Getting people back to work can be a long process and is not always successful.
‘We have found that the cases are a lot more complex than we anticipated,’ says Joanne Ross, who leads the East Kent Service.
‘That increases the barriers to getting back to work. There is a core group of people who, when they get signed off, have already made the decision that they are not going back to work. Often there is a personal difficulty such as bullying in the workplace and the situation has become intolerable for them.’
Pam Cartwright has found the same. ‘Some people don’t want to go back to their original job, and we support them in that,’ she says. Sometimes a slightly revised job fewer hours or different duties can work for both employer and employee and case managers can help negotiate this.
But one of the challenges has been getting enough people through the doors. Many of the schemes have seen far fewer than the projected numbers.
The East Kent service has only seen just over 10 per cent of the year‘s planned total of 500 in its first five months. It has now extended both its catchment area and the ways in which people can access the scheme, and referrals are starting to increase.
Schemes typically take self-referrals as well as referrals from GPs and, with the client’s consent, from employers. They also see many people who have a health condition affecting their work but have not yet been signed off sick the ’presentees’, as they are known.
With government funding due to finish this year, the pressure is on to prove the value of the pilots. This will be particularly difficult for those that were set up from scratch a few months ago.
So far, none has yet published an evaluation, although some plan to do so soon. A forthcoming evaluation of the Dundee scheme, versions of which have been running since 2008, is expected to show that it is effective in getting people back to work quickly and on reduced medication. The Department for Work and Pensions says that all the schemes will be ‘robustly evaluated.’
Finally, who will fund such schemes in future? Their benefits are felt outside the NHS and it’s hard to put a price on them. With the NHS facing financial pressures and structural changes, it may be difficult for schemes to get funding locally. fl
What is ‘Fit for Work’?
The pilot schemes are a response to a 2008 report by Dame Carol Black, the government’s national director for health and work.
’Working for a Healthier Tomorrow’ highlighted the cost of sick leave and worklessness in the UK £100 billion a year and suggested that a Fit for Work service could help to reduce this.
Her report showed that, although most people with back pain went back to work quickly, returning became much harder once they had been off work for four to six weeks.
A Work Foundation study called ‘Fit for Work?’ examined the barriers for those with a MSK problem and the long-term effects on their working lives. It found that a quarter of people with rheumatoid arthritis gave up work within five years of diagnosis, and sufferers from ankylosing spondylitis were three times more likely to be unemployed than the general population. Yet, the study showed, many MSK sufferers found work beneficial and wanted to remain employed.
The last government agreed to the idea of pilot schemes, testing various approaches to help people keep their jobs. In many cases, the pilots build on what is already available in the area: health services are working in partnership with other public bodies including the Department of Work and Pensions. Most are in deprived areas of England, Scotland and Wales; physiotherapy staff are generally seconded from the NHS.
Phil Gray, chief executive of the CSP, backs the pilots, pointing out that musculoskeletal disorders account for 49 per cent of sickness absence, costing the UK £7 billion a year.
The CSP’s own report, ’Sickness Costs’, makes a case for investment in physiotherapy to help return people to work.
It notes that nearly two thirds of small and medium employers do not provide occupational-health services such as physiotherapy, and calls for these services to be provided to employers at a reasonable cost.
Find ‘Sickness Costs’ at www.csp.org.uk/uploads/documents/SicknessCosts.pdf
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