Developing effective return to work programmes

Work should no longer be seen as toxic; it’s generally good for our health and wellbeing. There is a caveat of course: the benefit seemingly applies to ‘good’ jobs in a modern world. The characteristics defining a good job relate more to the context of the job than the content, incorporating such things as pay and conditions, satisfaction and fulfilment. Safety at work is a crucial consideration, but the underlying risk management model, whilst very effective when there is a clear exposure-response relationship, has not been helpful for preventing or controlling common musculoskeletal problems. During the very period when work has become physically less demanding and risk management regulations have become more pervasive, the incidence and prevalence of musculoskeletal symptoms have not reduced whilst their disabling consequences have actually increased.

Despite the hope generated by decades of ergonomics and biomechanics research, attempts to prevent common musculoskeletal problems at work have been a failure. Arguably that’s probably because we’ve been chasing the wrong goal. The very nature of musculoskeletal problems is that, like all common injury and health problems, they are ubiquitous in the general population. The symptoms tend to be recurrent, are usually not reliably related to identifiable pathology, are inconsistently associated with physical exposure, and are poorly correlated with rates of sick leave and disability. Whilst physical activity can trigger an episode of pain, it is more likely to be an everyday action than an occupational exposure. However, once present (for whatever reason) that pain can interfere with the ability to work. So perhaps we should be looking at ways to control the undesirable consequences of musculoskeletal problems rather than persist with ineffectual attempts at prevention.

Modern concepts of rehabilitation for common health problems acknowledge that work is good and prolonged absence is detrimental. The focus is firmly on encouraging activity and participation, which is embodied in facilitating early return to work (RTWReturn to work) or helping people to stay at work (SAW), and seeing work as part of the rehabilitation process. The approach is based on the biopsychosocial model, which recognises that biological, psychological and social factors all play a part in the expression of pain and disability. This helps make sense of the paradoxical relationship between musculoskeletal problems and work, leading to the notion of ‘work-relevant’ as opposed to ‘work-related’ symptoms. This is more than just semantics; the term ‘work-relevant’ emphasises the relevance of work in the personal experience of symptoms yet avoids any prejudicial implication that work is the primary source.

The accumulating evidence has led to a rethink of how best we should manage musculoskeletal problems at work. The question is not so much what has happened, but how can we facilitate participation in the face of work-relevant symptoms (irrespective of their source). The answer is about overcoming the biopsychosocial obstacles that act as impediments to staying at work or returning early. There is much here for the ergonomist to do, but there is also much to undo if we take the wrong approach. For instance, if we simply concentrate on the physical aspects of work, we reinforce the erroneous belief that the only remedy is to change the workplace. That in itself is an obstacle to early RTWReturn to work.

The Stationery Office has recently published Tackling Musculoskeletal Problems, a guide for managing work-relevant musculoskeletal problems that focuses on tackling obstacles. Sitting alongside Dame Carol Black’s review of the health of Britain’s working-age population, the Government’s response, and the forthcoming ‘Fit-note’, this guidance should help ergonomists sort out how best to integrate with these new initiatives. People usually need help to overcome or navigate round obstacles. What is known as the ‘Flags’ framework has been devised to point to the obstacles that need action. Everyone around the workplace including managers, ergonomists and healthcare professionals need to be looking for obstacles to SAW and RTWReturn to work. There are three types of flags:

• Yellow Flags are about the person: unhelpful thoughts, feelings and behaviours that impede normal recovery, e.g. distress, uncertainty, dysfunctional beliefs and expectations.
• Blue Flags are about the workplace: unhelpful interactions between the person and the workplace: e.g. low expectation of resuming work, low social support in the workplace, lack of modified work.
• Black Flags are about the context: unhelpful aspects of systems and policies: e.g. unhelpful procedures used by the company; delays due to mistakes, waiting lists, or claims; misunderstandings and disagreements between key players (employee, employer, healthcare).

The essential steps to helping people back to work are embodied in the phrase: “Identify flags, develop a plan, take action”.

Identify flags: Look for unhelpful behaviour and circumstances. Anything about the person, the workplace or the context (including influential others) that stands in the way of an early return to work.

Develop a plan: Agree goals and sort out who does what and when: set a timeline for getting back to modified duties and to usual work; list can-do tasks and jobs (not just can’t do); list who needs to tackle the obstacles; figure out the steps needed to overcome the obstacles, set a timeline, appoint someone to act as a support buddy/case manager.

Take action: Overcome obstacles using problem-solving approaches by the key people working together. Provide timely and effective treatment and an accommodating workplace, with helpful policies and coordinated actions. The action must address the identified flags and obstacles, using both healthcare and workplace interventions. Psychosocial factors, such as beliefs, fears, and avoidance behaviours need to be tackled. Psychosocial interventions such as problem-solving training and suitable coping strategies can usefully supplement exercises and information/advice, and contribute to increasing activity. Clinical intervention should take a stepped care approach providing just what’s needed when it’s needed, and should involve the workplace. Importantly, an accommodating workplace can be the key. Relatively simple temporary modifications to the job or the way it’s scheduled can impact on the success and sustainability of SAW and early RTWReturn to work outcomes. Modified work, if needed, should only be offered as a transitional arrangement for getting back to usual work.

The application of ergonomic principles fits neatly within the Flags framework, and ergonomists can be highly influential. Whilst an ergonomics approach would seem to be paramount for devising effective job and task modifications, it will not always require an ergonomist to implement them. Line managers can be trained in the ways of ergonomics, and are well placed to negotiate and devise effective transitional work arrangements. Clearly the notion of modified work does not apply just to RTWReturn to work, and can be used to help a worker with symptoms to remain at work during recovery.

None of this precludes designing work to high ergonomic standards from the start; that absolutely should be a priority. But we need to be clear about what we expect to achieve and be honest in what we promise. Where common health problems are concerned, it’s not about prevention, it’s about accommodation.

Implementing the new approaches to helping people with common health problems stay in work will require a major shift in the culture surrounding work and health. Ergonomists should not see the biopsychosocial approach as a threat, but an opportunity to contribute. The fundamental principle of making work comfortable when we are well and accommodating when we are ill or injured is at the heart of ergonomics. Fostering that is a key role with the potential to impart enormous social benefits.

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