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Rehabilitation - Keeping People in work.

Chief Medical Officer's Report 2006.

Contents.

• Introduction - Professor Michael O'Donnell, Chief Medical Officer, UnumProvident.
• Principles of Rehabilitation for Common Health Problems - Professors Gordon Waddell and Kim Burton.
• Rehabilitation - what works and what doesn't - Joy Reymond, Head of Rehabilitation Services, UnumProvident.
• Escaping from incapacity - a biopsychosocial approach to overcoming health-related unemployment - Dr Bob Grove.
• Why managing sickness absence and return to work practices is part of HSE's strategy for improving workplace health - Keith Wiley.

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Introduction to the Chief Medical Officer's Report 2006.

Professor Michael O'Donnell.

Welcome to the fifth Chief Medical Officer's report. This year, we are focusing on the initiatives that are in place to support people back into the workplace after long-term sickness absence. Often, the main obstacle that prevents people from a return to work isn't the original illness or condition but a far wider set of psychological and emotional barriers that are hindering their recovery process. We look at what these barriers are, their causes, and what is being done to enable a more timely return to work.

During my time in Occupational Health over the last twenty or so years there has been a complete change in the profile of work in the United Kingdom. Similarly, there has been a shift in the types of illnesses that people go off sick with, and also the number of people who are claiming long-term incapacity benefits. At the start of the 1980's there were fewer than one million people claiming incapacity benefit, but by the mid 1990's that number had risen to over 2.3 million.

In the latter part of the 20th century there was a trend in UK industry away from heavy industry and manufacturing to more service-based employment. With this, the demand for the traditional functions of Occupational Health professionals has reduced. Health surveillance is one such function. With fewer workers exposed to traditional hazards such as lead and asbestos, while these functions have not disappeared, they have diminished in their importance. Occupational physicians have certainly always had a role in absence management, but this has largely been a passive one, seeking information about medical conditions and advising employers on the likelihood of a return to work.

With the change in employment away from manual work to more sedentary occupations has come a move away from the traditional illnesses that causedlong-term incapacity. This means that we see far fewer serious musculoskeletal disorders as a proportion of claims, which were clearly problematic in manualjobs, and we now see that most people become incapacitated by what are now termed common mental health problems and common health problems.

It is now generally accepted that the longer people remain off work, the harder it becomes to get them back. Thus, a proactive approach early on in the illness is vitally important and significantly increases the chances of a successful return to work.

Passive information gathering is no longer as useful, as it does not address the issues of the often simple barriers to work that can be overcome. Neither does delaying intervention help. As employers face up to the problem of sickness absence in this increasingly competitive world, they need more than just advice about when return to work will happen but also how it can be facilitated. To enable this to happen, Occupational Health is starting to reinvent itself so that it plays a far more active role. This report addresses how Vocational Rehabilitation is gaining importance as one of the main planks of absence management and employee retention and the thinking behind it.

For most people off work with long-term health problems, the real issue is not what caused the sickness but what is preventing them from getting better.These barriers can take many different forms, but include environmental factors, such as difficulties at home or in the workplace. Harmful behaviours andbeliefs, such as inappropriate rest and a fear that work will make things worse are often more important than what the original illness was. In common healthproblems these factors are much more important than medical issues and are much more fruitful to address.

The articles in this report all speak to this view and demonstrate how important it is to have an enabling approach. This involves identifying the simple barriers to work, in addition to their illness, that exist in people's lives and keep them away from work.

By tackling these factors as well as the employee's diagnosed illness, rehabilitation professionals can vastly improve the chances of the employee not only returning to work, but remaining there. This new approach follows the biopsychosocial model that has emerged from a variety of sources, includingProfessor Gordon Waddell and Dr. Bob Grove who have both contributed to this report. Professor Mansel Alyward's team at the UnumProvident Centre forPsychosocial and Disability Research are exploring this further to provide an expanding academic base for the new model and to better understand thecomplex relationships between work, society and health. According to the biopsychosocial model, factors such as the medical advice received, workplaceconditions and home conditions, as well as the individual's state of mind cannot be ignored as influencing factors, and neither should they be viewed in isolation.

I believe that one of the keys to combating long-term sickness absence is the better training of managers. By teaching them to talk to employees who are off work they can strike up a level of communication and mutual understanding that is often lacking in long-term cases. An ongoing dialogue between the employer and employee allows each party to gain a better understanding of the other's needs. Professionals have their place but they should not get in the way of managers and their sick employees communicating directly with each other.

Gordon Waddell and Kim Burton explore these issues in detail in their article, Principles of Rehabilitation for Common Health Problems. They outline what is meant by this term, the problems faced and the theory behind the practical steps that they recommend to help people remain in employment when sick.

Both they and Joy Reymond, our Head of Rehabilitation Services, highlight the problems that can be caused by ill-conceived medical advice about fitness for work. Joy goes on to explain how we have adopted the biopsychosocial approach at UnumProvident to the advantage of our clients.

Bob Grove has been instrumental in leading the successful Pathways to work initiative for the Department for Work and Pensions (DWP) and stresses the importance of the psychological component of the Condition Management Programmes, which form the centrepiece of the project. One element of sicknessabsence management that he raises in his article is the lack of any recognised qualifications for professionals in Vocational Rehabilitation. Recognising theproblems this can cause, UnumProvident is currently working with a number of external organisations to establish a recognised training programme based onthe successful model pioneered by the Canadian National Institute for Disability Management and Research (NIDMAR).

Our last article is from Keith Wiley of the Health and Safety Executive (HSE) who explains why even the HSE is getting involved with promoting VocationalRehabilitation. What we have to remember is that managing absences following accident and injury is a key way of reducing the attendant financial losses both to the employer and the injured person. When this is understood, my experience is that all absence management improves as people realise that the principles are not so different, whatever the cause of the absence.

Lastly, I wish to extend a large thank you to all those who have taken the time to provide the articles for this year's report and hope that you will find them as thought-provoking and insightful as I do.

Professor Michael O'Donnell.

Michael is an accredited specialist in Occupational Medicine and holds the Diploma of Disability Assessment Medicine. He qualified in 1975 and worked in hospital medicine and General Practice before moving to Occupational Medicine in 1984. He has now worked in Occupational Medicine for 21 years, with6 of those years spent in the oil and petrochemical industries. He has experience in the public and private sectors in virtually all fields of operation.

His particular interests are in fitness for work, the biopsychosocial model of incapacity and presentation and assessment of risk - particularly in the area of psychosocial hazards.

He is honorary visiting professor in the School of Life and Environmental Sciences at Salford University.

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Principles of Rehabilitation for Common Health Problems.

Professors Gordon Waddell and Kim Burton.

'Common health problems' - mild to moderate mental health, musculoskeletal and cardio-respiratory conditions - now account for about two thirds of sickness absence, long-term incapacity and early retirement. Complaints are largely subjective, and there is often limited evidence of objective disease or permanent impairment. Without in any way denying the reality of the symptoms and their impact, these are essentially whole people, their health conditions are potentially remediable, and long-term incapacity is not inevitable. Clearly, current outcomes are far from ideal. How, then, can we improve their clinical and occupational management?

The need for a new approach to 'rehabilitation' for common health problems.

The definition of vocational rehabilitation is broad: 'the process whereby those who are ill, injured or have a disability are helped to access, maintain or return to employment or other useful occupation' (BSRM 2000).

In practice, traditional rehabilitation was designed for severe medical conditions, as a separate, second-stage intervention, after healthcare has no more to offer. The goal is then to restore patients as far as possible to their previous condition, and to develop their (residual) physical, mental and social functioning to the maximum possible (Nocon & Baldwin 1998). This is essentially a matter of overcoming, adapting or compensating for permanent impairment. That remains an appropriate approach for many severe medical conditions, but it is inappropriate for common health problems where there is no severe or permanent impairment.

• Biomedical interventions are less effective for common health problems, precisely because they are not matters of 'disease' that can be 'treated'.
• The more subjective the health condition, the more central the role of psychosocial factors.
• Illness and disability associated with common health problems can only be understood and managed according to a biopsychosocial model that takesaccount of the person, their health condition and their social/occupational context (Figure 1).
• The biopsychosocial model forms the basis of the World Health Organization's International Classification of Functioning, Disability and Health (ICF) which since 2001 has been widely accepted as the framework for disability and rehabilitation.

Figure 1: A biopsychosocial model of human illness and disability. (Reproduced with permission from Waddell & Burton 2004)

Obstacles to recovery.

The epidemiology of common health problems shows that:

• subjective health complaints have a high prevalence in normal people of working age.
• most episodes settle uneventfully, with or without healthcare.
• most people remain at work or return to work quickly, even if with some persistent or recurrent symptoms.
• long-term incapacity is rare (<1%).

Thus, for most common health problems, recovery is generally to be expected. This reverses the question: the question is not what makes some people develop long-term incapacity, but why do some people with common health problems not recover as expected? It is now widely accepted that biopsychosocial factors contribute to the development and maintenance of chronic pain and disability. Crucially, they may also act as obstacles to recovery and return to work. The logic of rehabilitation then shifts from dealing with residual impairment to addressing the biopsychosocial obstacles that delay or prevent expected recovery (Waddell & Burton 2004).

Biological obstacles.

The main biological obstacles to return to work relate to the health condition, yet for most common health problems these should not be insurmountable.Symptoms (pain, fatigue, stress, etc.) are often felt to be the main obstacle to work, but symptoms correlate poorly with impairment and disability, and do not necessarily imply incapacity.

Healthcare is usually regarded as (part of) the solution, but can itself become an obstacle, e.g. when unhelpful medical advice, inappropriate sick certification, and waiting list delays block more appropriate management and early return to work.

Personal/psychological obstacles.

Psychological factors, sometimes termed yellow flags, are central to (in)capacity associated with common health problems and may form obstacles to (clinical) recovery (Box 1).

Box 1: Personal/psychological obstacle to clinical recovery (Burton & Main 2000, Waddell et al.2003).

• Personal experience of illness and disability.
• Perceptions and expectations.
• Attitudes and beliefs, emotions, coping strategies.
• Incentives, motivation and effort.
• Uncertainty.

Perceptions about the relationship between health and work, sometimes termed blue flags, may form more specific obstacles for return to work (Box 2).

Box 2: Perceptions about health and work that may form obstacles to return to work (Burton & Main 2000, Waddell et al.2003).

• Physical and mental demands of work; occupational stress.
• Low job satisfaction.
• Lack of social support at work (co-workers and employer).
• Attribution of health condition to work (whether to an 'accidental/injury' or to the physical and mental demands of work).
• Beliefs that work is harmful, and that return to work will do further damage or be unsafe.
• Low expectations about return to work.

Social/occupational obstacles.

Return to work is a social process that depends on organisational policy, process and practice, which can also become obstacles (Box 3). These are sometimes termed black flags.

Box 3: Work-related and organisational obstacles (Burton & Main 2000, Waddell et al.2003).

• Inappropriate medical information and advice about work; sick certification practice.
• Lack of occupational health support.
• Belief by employer that symptoms can be 'cured' before they can 'risk' permitting return to work, for fear of re-injury and liability.
• Lack of suitable policies/practice for sickness abscence, return to work, etc.
• Loss of contact and lack of communication between worker, employer and health professionals; lack of modified work.

Modern approaches to rehabilitation.

Recognising and addressing all of the health-related, personal and occupational obstacles to recovery and return to work is fundamental to successfulrehabilitation for common health problems. Biopsychosocial problems need biopsychosocial solutions, and rehabilitation should address all of these dimensions (Figure 2). The same principles underpin job retention, return to work and reintegration.

More broadly, this is not just 'rehabilitation', but about the fundamental principles of effective management. It implies that rehabilitation is no longer a separate, second stage after medical treatment is complete: rehabilitation principles should be integral to clinical and occupational management from the outset.

Clinical management of common health problems.

The primary goal of healthcare for common health problems is to relieve symptoms. However, for those who do not recover quickly, continued symptomatictreatment is not enough. It is then necessary to re-think the goals of clinical management - which should be both to control symptoms and to restore function, and these go hand in hand. The immediate goal is to overcome activity limitations and restore activity levels; the ultimate goal is to improve functioning and social participation: the common element is increasing activity. This principle is equally applicable to mental health, musculoskeletal and cardio-respiratory conditions.

All health professionals should not only be interested in, but must accept some responsibility for, occupational outcomes. Too often, advice about work is unrealistic or frankly harmful, and given without consideration of its implications. It is particularly important to avoid fostering inappropriate links between common health problems and work, which are often unfounded.

Occupational Health has always had a greater focus on restoration of function and occupational outcomes, but there needs to be a fundamental shift in the culture of all healthcare. This also requires better communication and cooperation between Primary Care and Occupational Health professionals (Beaumont 2003, Sawney & Callenor 2003).

Occupational management of common health problems.

Common Health problems cannot just be left to healthcare. There is a strong business case for effective management of health and safety at work.Workers' health and well-being are linked to productivity. So, quite simply, 'good health is good business' (Coats & Max 2005).

Workers with common health problems may find their work difficult, painful, or stressful. They may find, or expect, it to be difficult to return to their normal duties. Work must therefore accommodate common health problems: "Work should be comfortable when we are well, and accommodating when we are ill" (Hadler 1997). Accepting that common health problems are an inevitable part of (working) life, occupational management may focus more realistically on thesecondary prevention of disabling consequences.

This includes several overlapping strategies:

• Positive health at work strategies;
• Early detection and treatment of mild to moderate symptoms;
• Accommodation of temporary functional limitations from persistent or recurrent symptoms;
• Interventions to minimise sickness absence and promote (early) return to (sustained) work.

This requires employers, unions and insurers to re-think occupational management for common health problems. Employers have a general 'duty of care' totheir employees. Under UK and European legislation, employers have a statutory duty to conduct suitable risk assessments to identify hazards to health andsafety, and to reduce the risks to employees as far as reasonably practicable. But health and safety should be distinguished. As well as controlling risks, it is equally important to make jobs accommodating of common health problems, sickness and disability. A 'healthy working life' goes even further: it is 'one that continuously provides working-age people with the opportunity, ability, support and encouragement to work in ways and in an environment which allows them to sustain and improve their health and well-being' (Scottish Executive 2004). Sickness absence management, assisting return to work, and promoting rehabilitation may not be legal obligations, but they are matters of good practice, good occupational management, and good business sense (Box 4).

Box 4: The main elements of sickness absence management (James et al.2003, HSE 2004).

• Development of clear corporate policy, processes and responsibilities, including accurate recording and monitoring of sickness absence.
• Commitment of senior management, and involvement, training and auditing of supervisors and line managers.
• Early (and continued) contact with the absent worker.
• Facilitating contact with healthcare, and access to occupational health services.
• Availability of temporary modified work (if required).
• Involvement of the absent worker in return to work decisions, planning and process.

A common goal.

Some people with severe medical conditions will always require specialist rehabilitation services, but for common health problems the challenge is to incorporate basic rehabilitation principles into clinical and occupational management. There is strong evidence that we could reduce sickness absence and the number of people who go on to long-term incapacity by at least 30-50% and in principle by much more (fully recognising the practical problems of delivery). To achieve this, however, depends on getting all stakeholders onside (Frank et al. 1998) and a fundamental shift in the culture of how we think about and manage common health problems - in healthcare, in the workplace, and in society.

Professor Gordon Waddell CBE, DSc, MD, FRCS.

Professor Waddell was originally an orthopaedic surgeon with a long-standing clinical and research interest in back pain. His research has ranged through clinical assessment, nonorganic signs, clinical psychology, the biopsychosocial model, clinical and occupational health guidelines, disability evaluation andmedicolegal assessment, health and social policy. He has held honorary professorial appointments in Orthopaedic Surgery in Glasgow University, Behavioural Medicine in Manchester University, and currently in the UnumProvident Centre for Psychosocial and Disability Research at Cardiff University. Since 1994, he has been a consultant to various government departments and research bodies in the UK, US, Canada and Sweden.

Kim Burton PhD DO Eur Erg.

Professor Kim Burton is Director of the Spinal Research Unit at the University of Huddersfield, Editor of the international journal Clinical Biomechanics and Associate Professor of Clinical Biomechanics at the British School of Osteopathy, London.

Present research activities involve research into the causes, prevention, and rehabilitation of occupational musculoskeletal disorders, as well as undertaking therapeutic trials in primary care. Recent work has included development of patient educational material (The Back Book and The Whiplash Book), and he is co-author of a textbook entitled The Biomechanics of Back Pain.

He was a member of the Royal College of General Practitioners' development group for the Clinical Guidelines for the Management of Acute Low Back Pain, and of the Faculty of Occupational Medicine group that prepared the Occupational Health Guidelines for the Management of Low Back Pain at Work. He is currently a member of the European COST Action B13 committee for the development of European guidelines for back pain.

He is a member of numerous biomedical societies including the International Society for the Study of the Lumbar Spine, International Society of Biomechanics, International Society for the Study of Pain, and the Ergonomics Society.

Current work includes a study exploring the nature of obstacles to recovery from musculoskeletal disorders at work, and the means of tackling them.

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Rehabilitation - what works and what doesn't.

Joy Reymond, UnumProvident.

In recent years the UK government has closely focused on the growing levels of incapacity in the working-age population and the degree of dependence on various forms of benefits, either private or public. It has undertaken a number of in-depth investigations into this issue, and on each occasion, the value of rehabilitation has been recognised. This occurred in 2002, for example, when they investigated the steep rise in Employers' Liability insurance, and again when the Better Regulation Task Force looked at the growing risk of litigation in the UK.

A number of Green Papers have also been written on reforms to the state's benefits system, and the government went as far as developing a Frameworkfor Rehabilitation. However, its efforts foundered when it endeavoured to prove that rehabilitation works. For a subject so much in the public eye, there is scant research on its effectiveness. The government undertook several large scale social experiments (the job retention and rehabilitation pilots) which failed to achieve the hoped-for effects, and although Pathways to Work has been successful, it has proven less so with some groups of clients (for example those with severe and enduring mental illnesses).

Many individual, smaller-scale rehabilitation programmes have proved immensely successful (e.g. Tomorrow's People) and other state countries have achievedimpressive cost-benefit ratios from their programmes (e.g. the Commonwealth Rehabilitation Service in Australia). These stand in stark contrast to theGovernment's recent outcomes in the UK, and it forces us to question whether rehabilitation is a worthwhile endeavour in this country. We may need to take amore nuanced approach to rehabilitation, looking at rehabilitation at a more granular level. Rather than asking whether rehabilitation works, we should look at what aspects of rehabilitation work, for whom, and by whom.

Rehabilitation, or 'rehab', is a term much abused in the UK, and everyone seems to have their own understanding of what it means. Any attempt to have a broad discussion about the value of rehab inevitably begins with trying - usually unsuccessfully - to properly define what we each mean when we use theterm. Are we referring to the treatment of drug addiction? Do we mean the medical interventions designed to restore someone's physical functioning? Or are wetalking about vocational rehabilitation, which offers workplace reintegration?

In fact, the word 'rehabilitation' carries around so much baggage, that there may be a good argument for abandoning it and finding a new term altogether.But however much we may wish to replace it, rehabilitation is in many instances a convenient shorthand for the kinds of interventions which we value and want to see more of. And a quick scan of the field internationally is enough to convince us that terminology is just as much a problem there as it is here.

Medical Rehabilitation.

The two major branches of rehab are medical and vocational. On the medical side, there are two major problems. Firstly, the NHS's medical rehab programmesare much criticised for being unable to intervene quickly enough in cases which would benefit from early intervention. Secondly, the possibility or threat oflitigation prevents the parties (the injured person, their insurer, their employer, their family) from seeking and paying for this service in the private sector. As Lord Hunt quipped - "when a car is damaged, we seek the services of a mechanic, but when we are damaged, we go to our solicitor".

The effectiveness of a rehabilitation programme will undoubtedly be influenced by the likely consequences of success or failure. So, it is important to understand the personal and financial gains associated with recovery, and with failure to recover, as these will in turn influence our motivation to get better, and without motivation, the best programme will struggle to achieve its goals. As has frequently been pointed out, it is hard to get better whenall your energies are completely consumed in proving to others how sick you are.

Since the promise or threat of litigation can have a distorting effect on rehabilitation, some personal accident insurers and employers' liability insurers are seeking to pre-empt the lure of compensation by offering early intervention rehab to any case regardless of liability. Whether this strategy is costeffective has yet to be demonstrated, but it is clearly a positive move for practitioners, who have long campaigned for earlier intervention.

Litigation is of less concern in Income Protection (IP) cases. IP insurance is designed to protect the employee's income during an extended illness or injury, regardless of cause. Because it is essentially no-fault, it is rarely subject to the threat of litigation and is therefore less subject to its negative effects. The difficulty for IP arises not so much in the determination as to whether the individual has a particular medical condition or what caused it, but whether it causes them to be unable to work.

To have the greatest benefit, medical rehab should be focusing on restoring the employee's functional capacity through various medical interventions, butmany health providers, including Occupational Health centres, are asked to concentrate instead on providing a diagnosis and making a pronouncement on fitnessto work. This has led to a sick note culture and a terrible waste of GP resources involved in writing Med 3 certificates, a process of little value inhelping someone recover and get back to work. In some organisations, this is perpetuated by further assessments by Occupational Health specialists,thereby entrenching the employee's sick role.

Vocational Rehabilitation.

One of the great strengths of vocational rehabilitation (voc rehab) is that, while respecting the medical process, it actively seeks to de-medicalise the sickness absence management process. Voc rehab recognises that a diagnosis is enormously helpful in understanding a person's condition, but that it typically is not the most important factor in influencing a return-to-work.

In addition to the medical influences, the Vocational Rehabilitation Consultant (VRC) will equally look to the social and psychological influences at work and at home that may impact on a person's recovery and return to work. He or she will look at the broad range of possible barriers and identify a plan that takes all these influences into account. In building this plan the successful VRC will search for what motivates the individual, and how those motivators may be used to good effect. Likewise, the successful VRC will be skilled in problem-solving and negotiation. Every case will have its unique attributes,and the VRC's plan must take account of these if it is to be successful.

What makes some programmes successful while others are not? One thing which reliably distinguishes many of the successful efforts is that the service provided is not standardised but rather tailored to each client's needs, and drawing on the unique strengths and skills of the individual providers. This has made it difficult to replicate the service from one provider to another, and the efforts to standardise the offerings may be why the government pilots were unsuccessful.

This also raises the question as to whether voc rehab can be delivered on a large scale, or needs to remain a 'boutique' service as it currently is for most providers. Large scale operations may well lose the distinctive and intuitive case management that individual VRCs possess. That is, the power of voc rehab might well be diluted when it is translated from a small customised business to a large standardised offering.

Another way of viewing this is the observation that a good voc rehab service may be highly dependent on the individual leading it. In many instances, it is the leader who is the driving force for success, without whom the programme would falter.

The Biopsychosocial Model for Vocational Rehabilitation.

Although it is self-evident (and perhaps very trite to say) that we all work and live within a social context, it is nevertheless true that employers handle most workplace health problems as if they magically occurred in some kind of vacuum, independent of work management concerns, social and personal problems, and issues over the quality of healthcare being received. Case management which focuses on the healthcare management of the individual alone is simply insufficient to the job of voc rehab.

As an analogy to our workplace, it may be worth looking at the largest living organism in the world, thought to be a quaking aspen living on the mountainside of the Rockies. It covers over 100 acres of forest there. Although it appears to consist of many, many individual trees, it has been shown that these are all part of the same living organism, joined invisibly underground by a common root system. Metaphorically this is a bit like us as complex individuals, and about us as members of a social organisation - our many parts and roles are inextricably linked and a problem in one area can reverberate in another seemingly quite separate part of our lives or work. If our voc rehab interventions ignore this fact they are less likely to identify the key driversto sickness absence and less likely to succeed with returning that person to work.

What is the UnumProvident approach to Vocational Rehabilitation?

So how does this play out?

When people become ill, there are a whole range of factors which determine whether they take time off work and, if they do, how much they take off and how they view the prospect of getting back into the workplace.

Despite the improvements we have witnessed in the health of the nation in general, people are still subject to developing serious medical conditions such as cancer, heart failure and strokes.

When such diseases occur, they often come on quickly and can have a devastating effect on people's lives, with all their dreams and ambitions coming under immediate threat. This is the traditional arena for income protection, ensuring we get things sorted as quickly as possible so that they receive their entitlement to income replacement with minimum delay.

But over the last few years we have seen that the majority of our income protection claims do not come from people with serious medical conditions of this sort. We have seen a big increase in the number of people suffering from what are currently referred to as common health problems, such as back pain, joint pains, fatigue and depression.

Although the impact on the lives of these people can be profound, they do not have the conditions that would be regarded as serious illnesses in the conventional medical sense.

Although an understanding of the underlying medical condition is important as a starting point in understanding a person's illness, it is only part of theoverall picture as to why someone remains absent from work. In many instances the duration of the absence could be regarded as discretionary, and that it depends at least in part on a range of non-medical factors. These factors include job demands, job satisfaction, lifestyle choices, medical beliefs, societal beliefs and the employers' attitudes to accommodating a gradual reintroduction to work. All can influence how someone will deal with a health event, and can have an important part to play in determining whether or not they will become a long-term sickness absentee.

Vocational rehabilitation takes this as its starting position. Practitioners need to have a very good understanding not only of the material facts surrounding the individual's absence, but also the influences of others, their beliefs and attitudes, needs and wants. The end result is a detailed return to work plan which meets the needs of the various parties and is based on the removal of obstacles and barriers, whether these be physical or in the form of beliefs and attitudes. The implementation is key to its success, because few plans are perfect, and most need at least minor adjustments.

The Psychology of Absence.

Early intervention is key because although things usually start out with everyone prepared to work towards a solution, this tends to degrade quite significantly with time. Negative beliefs tend to emerge over time, leading in some cases to increased alienation and hostility between employer and employee.

Humans are by nature storytellers; that's how we understand our world. And if we don't have the entire story, we tend to fill in the gaps. How we do thatdepends on how much we already know about the story, our beliefs, and our understanding of similar situations we have experienced in the past. Getting involved early means we can influence the story, and prevent negative stories emerging.

A distressingly common example of this is the good and valued employee who, receiving little contact from his manager during their absence due to illness, comes to believe that the employer doesn't care, doesn't believe he is really ill, is blaming him for getting ill, doesn't appreciate all the years he gave to the company etc. And the manager who, when he doesn't hear from the employee, or feels the employee is being surly and defensive when he does call, begins to wonder whether his faith in this employee all these years was misplaced.

The Value of Early Intervention.

It is one of those truisms that Early Intervention (EI) is better than late intervention, and we have already referred to this belief several times. But to be honest, EI in the market is the exception rather than the rule. So if it is such a good thing, why is it so rare?

One of the reasons is structural: IP policies aren't designed to kick in until the 6 month mark, and any earlier intervention would occur in the space where the insurer is not yet financially liable. Proving to insurers that they should invest where they don't (yet) have a financial liability is understandably - and rightly - a difficult argument to make. We have done it at UnumProvident, but it hasn't been a cake-walk. The probability ofsuccess in vocational rehabilitation (and the cost per case) is linked to how quickly you can intervene. Another indicator of success is the company's continued financial success. Our business invested in rehab some years ago and would not have continued to do so if it had not seen the results in terms of business acquisition and risk management of our IP portfolio.

The second reason is statutory: the way that statutory sick pay (SSP) has been established, employers feel (wrongly) that their hands are tied by a doctor's sick note for that first 26 weeks. There is a common perception that intervening after a physician has 'signed someone off work' is tantamount to harassment. Helping break this wrong belief is where voc rehab can be so effective. By taking the discussion of return-to-work outside themedical arena of 'fit' versus 'unfit', and into one where the consultant is helping the individual get their life back (and work life is a gigantic part of that), he or she can focus on what the obstacles are to doing so, and how those obstacles can be overcome.

The third reason is confusion over what constitutes good practice versus bad practice (or no practice at all). The expert VRC can provide advice and assistance to employers and employees when they are finding a particular case hard going. However, it is equally important not to infantilise either party by taking over the process entirely and excluding them from the decision-making and planning process. VRCs doing the case management should be the exception,not the rule. Voc rehab is as much about education and introducing good practice, as it is about individual case management. The development and delivery of a highly effective absence management programme is not an overnight process. It requires the development of trust between the workplace parties, the competence to manage absences appropriately, and the delivery of management and employee processes that support absence management.

Finally, inertia: doing nothing is a powerful force, which once underway, is hard for either employer or employee to change. By their very presence, the VRC can break that pattern and once a plan is set in motion, that new momentum will often keep it going to a successful conclusion.

UnumProvident is committed to Vocational Rehabilitation as an important part of its proposition, as evidenced by the growing level of resource that it is providing in this area. This is partly out of direct self-interest in that our experience shows we achieve results and thereby reduce the frequency and duration of claims. However, it is also an important part of our service to help employers protect their investment in their staff by helping them remain in work. Paying claims and helping people remain in work directly speaks to our corporate vision of keeping dreams and ambitions alive even when accident orillness strikes.

Joy Reymond.

Joy originally trained as a clinical psychologist in Australia and the US, and after an initial career working within a psychiatric hospital, moved into teaching health sciences and research methods at Curtin University. She also served as a researcher in the West Australian government's OHS & Welfare department. After completing her MBA she moved to Canada where she again worked for OH&S, and subsequently as the Chief Adjudication Officer for the Ontario Workers' Compensation Board. Moving into the private sector, she worked for a multinational financial services company Manulife Financial, as their VP for Group Life & Disability. Since moving to this country, Joy has worked with the UnumProvident team as Head of Rehabilitation Services, responsible for the provision of vocational rehabilitation services to our clients and their employees throughout the country.

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Escaping from incapacity - a biopsychosocial approach to overcoming health-related unemployment.

Dr Bob Grove.

Successive Green Papers (DWP 2002 and 2006) have set out the scale of the Incapacity Benefit (IB) problem and proposed some solutions. The problemin essence is that more than 2.6 million people of working age are out of work and on benefits because of ill health or disability. It is common ground between Government, social scientists, disability organisations and claimants that many (up to one million people according to the Department for Work and Pensions (DWP)) do not need or want to be out of work on health grounds (Waddell and Aylward 2005), and yet the numbers on Incapacity Benefit (IB) have not diminished as the economy has improved.

At the centre of the proposed solutions, alongside a new structure and name for the benefit and a tighter gateway for claimants, is a package of support and incentives known as Pathways to Work. The package has been piloted in 7 Jobcentre Plus districts which between them cover more than one in ten IB claimants in the UK. This trial, the largest of its kind in the UK and probably the world, has proved "a considerable success" in improving off-flows from the benefit and numbers of job placements (OECD 2005). If the results could be sustained, the DWP calculates that the programme would pay for itself from benefit savings and improved tax revenues (DWP 2005). The initial phase has been so successful that even before it was known whether the results from the pilots could be sustained, the Government decided to extend Pathways to Work to 14 further districts which together comprise about one third of IB claimants in Great Britain. It has also promised in its Welfare Reform Green Paper (DWP 2006 op. cit.) to extend Pathways to Work type support to the rest of Great Britain by 2008 - as a key part of the mix of support, incentives and conditionality to be associated with the reformed benefit.

Why and how is Pathways to Work different?

Pathways to Work as set out in the 2002 Green Paper is different by virtue of its acknowledgement that the reasons for claiming Incapacity Benefits arecomplex, that individuals who find themselves in welfare dependency face many barriers to returning to the labour market and that for each person the particular mix of issues is likely to be different. Surveys conducted by the DWP showed that claimants often put ill health or impairment some way down the list of barriers to employment (DWP 2002). The package of support and incentives on offer for the first time individualised the problem and the solution and also, most crucially, permitted suspension of what have always been essentially moral judgements about welfare claimants. It provided a practical way forward, which avoided being trapped in the easy polarization between those who see the issue as mainly internal to the claimant - regarding claimants as passive, inadequate, workshy, malingering or making the most of psychosomatic ailments and those who see them as external: stigma and discrimination, loss of traditional industries, inadequate medical advice and treatment, the benefits "trap", poor jobs, low pay, political expedience etc.

At the centre of Pathways is a biopsychosocial model for understanding the relationship between ill health, function and fitness for work. It gives due priority to the psychosocial elements of worklessness, challenging the victim mentality, but also takes seriously and tries to address the real world difficulties faced by people who have lost touch with what it is like to be employed and see all around them economic decline and intergenerational unemployment. Combining the authority to command attention (mandatory interviews with a Personal Advisor and a return to work action plan) with the offer of positive, practical support which seeks to understand how the individual sees their problems and help them discover solutions, has made possible a way of working that is flexible, outcome-focused and apparently very successful. This kind of approach is also congruent with modern medical thinking on the natureand treatment of low level chronic conditions (suffered by the vast majority of IB claimants). This is exemplified in the revolution over the past 10 years in the management of lower back pain which has shifted the main focus of treatment from the underlying pathology (frequently undetectable) to activation, pain management and cognitive educational support for fear and depression (Waddell 2004).

In short, Pathways to Work reflects a fundamental, but still fragile, shift in government thinking away from the simplistic and sometimes judgementalapproaches that have bedevilled such political debate as there has been, towards a more pragmatic and evidence-based approach.

Condition Management.

Choosing health.

The case management of the return to work action plans by the Personal Advisor is supplemented by a menu of support known as the Choices package. Thisis a mix of vocational preparation, job finding support, financial incentives and cognitive-educational health advice which addresses as far as possible the full range of psychosocial, economic, health and skills-related barriers to work experienced by individuals on IB. The part of the package designed to help people overcome the anxieties and problems with coping that are related to ill health has become known as the Condition Management Programme (CMP).

The CMPs are innovative, voluntary, client-led, nonstigmatising services commissioned and delivered by the NHS, often in partnership with specialist private and voluntary sector providers. They enable participants to manage their health conditions more effectively so that they feel more confident and recognise the health benefits of becoming more active and returning to work.

All CMP participants have an opportunity to talk for at least an hour with a health professional about their health and how it affects their daily functioning - often the first time they have been able to do so. They are able to explore areas to help them to manage their condition and overcome inhibiting obstacles to work, thus enabling them to attain realistic and sustainable occupational performance.

The initial assessment discussion to identify and explore solutions to the individual's problems is followed by goal setting and rapid access to an individually tailored menu of intensive support to help them understand their health condition and its impact on their normal daily activities. Working through a cognitive-educational approach, interventions aim to increase activity levels through the recognition and modification of unhelpful thoughts,feelings and behaviours on adaptive action, prior to helping the individual develop effective coping strategies, symptom control and early relapse recognition. The occupational focus enables the participant to develop improved insight into occupational areas conducive to health and helps ensure a job entry is realistic and likely to be retained.

The CMPs deliver services to people with a wide range of mild to moderate chronic conditions - mainly mental ill health, circulatory/respiratory and musculoskeletal conditions. In practice, there is often considerable ambiguity about the health reason for the IB claim and indeed practitioners often find that the condition reported on the original claim is at best an over-simplification. Thus what is provided is a holistic approach, requiring qualified practitioners with a broad range of skills and expertise to undertake a comprehensive assessment of a person's health needs based on sound professionaljudgements, in order to deliver appropriate, effective and safe health interventions.

Individualisation of the programme interventions also enables flexibility in delivery. CMPs are delivered on a one-to-one basis, in group settings, and sometimes via a computer programme, acknowledging that some people prefer privacy and security, whilst others flourish in an environment where experiences and peer support can be shared and one can learn from others. The venues are also designed to be accessible, non-threatening and normalizing - leisure centres, rented office space, church halls and other community facilities are popular choices where available.

If not a medical model.

Why involve clinicians and the NHS?

Clearly many of the interventions within CMP are nonmedical and the skills required from those delivering them do not require medical knowledge or training. In the pilots, voluntary sector providers (such as Rethink), specialist employment organisations and private sector contractors successfully provide large parts of the programmes. All the new districts in the national rollout are aiming for a mixed model of CMP provision. However, there are sound reasons why trained clinicians should be part of the CMP and why the NHS should take responsibility for commissioning and monitoring contracts. CMPs are non-treatment programmes working to a biopsychosocial model of rehabilitation, which implies that the health advice offered is underpinned by proper assessment of the risks to health of returning to work and expert knowledge of best practice in the management of the main conditions. People have the right to expect that when they are advised that it is in their best interests to become more active and consider returning to work, that the person giving that advice is qualified to recognise potential risks to health and to refer on appropriately where further treatment is needed.

At present there are no recognised standards or qualifications in rehabilitation in this country. The best safeguards we have that health advice is offered to a high standard and that proper risk management is applied are in the involvement of healthcare professionals with professional qualifications and standards of conduct operating within NHS clinical governance frameworks. This not only provides assurance that undiagnosed pathology, assessment of suicide risk etc. are routinely taken into account, but also ensures ready access and the capacity to share information with mainstream NHS provision.

There is another, more strategic, reason to retain structural links to the NHS. If Pathways to Work is to succeed it will have to be credible not only to customers, employers and the public at large, it will also - most crucially - have to have credibility with those who are primarily responsible for managing the healthcare of the population. GPs and the NHS generally have welcomed Pathways to Work as a contribution to the health and well-being of patients for whom they can often do little more in the way of treatment. Previous attempts to move people off welfare have lacked credibility with the medical profession and have often forced them into the position of "defending" patients from work. The fragile consensus that is emerging between government and the medical profession on this issue should not be cast aside lightly.

Does the CMP work?

Of those who opt for the Choices package, about half opt for CMP. The others opt mainly for help from New Deal for Disabled People Job Brokers. It may behypothesised that the latter group feel closer to being work-ready and have fewer concerns about their health. Although evaluation is at a comparatively early stage, the first reports published by the DWP show that CMP seems to be experienced as very helpful by participants, Personal Advisers and healthcare practitioners (Barnes & Hudson 2006). Preliminary investigation of health impact, consumption of health resources etc. is being undertaken at local and national levels. Some preliminary results from the Renfrewshire pilot (Christie 2006) showed evidence of improved activity levels and health gain sustained 6 months to one year after completion of the programme.

Conclusion.

Pathways to Work, and the Condition Management Programme in particular, are a bold experiment in drawing together the skills and knowledge of theemployment and healthcare sectors to deal with one of the most intractable problems of our time. The economist Richard Layard (Layard 2004), coming atthese issues from the perspective of the very high cost to society of common mental health problems, has proposed just such a partnership, combining improvedaccess to psychological therapies - especially cognitive behavioural approaches - and employment support. His conclusion is that such programmes would, over time, more than pay for themselves and the early evidence from Pathways to Work tends to confirm his analysis. However, this whole approach is at a very early stage. The impulse to tinker and "improve" ways of working before they have had a chance to bed in is ever present within the short electoral cycle (and even shorter ministerial tenures) to which Government works. The full Pathways to Work package, including the CMPs, is on current evidence a low risk investment with economic, health and social benefits that go beyond the immediate reduction of numbers on benefits. Successive Secretaries of State and Ministers have come into office as sceptics and emerged as supporters.

Both the Welfare Reform legislation and the 2006 Comprehensive Spending Review will determine the shape and extent of the national roll out of Pathwaysto Work. Almost uniquely, we seem to have a package of measures that promises a long-term solution to the huge waste of lives and resources caused by longterm unemployment related to essentially manageable health conditions. Hopefully we will not look back on this moment as the point at which defeat was snatched from the jaws of victory.

Dr Bob Grove.

Dr. Bob Grove joined the Sainsbury Centre for Mental Health in 2003 to lead the Employment Programme. He began working in the mental health and employment field in 1985, and was the founding Director of Richmond Fellowship Employment and Training. After leaving RFET in 1998 he worked at the Institute for Applied Health and Social Policy at King's College London leading a programme of consultancy, research, policy and service development. He continues with these activities at the Sainsbury Centre and is also currently seconded (part-time) to the Department of Health, working with the Department for Work and Pensions on the Incapacity Benefit Reform Pilots. He has written widely on mental health, disability and employment. His book New Thinking on Employment and Mental Health (Radcliffe Medical) was published in July 2005.

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Why managing sickness absence and return to work practices is part of HSE's strategy for improving workplace health.

Keith Wiley.

The Health and Safety Executive (HSE) has always prided itself in promoting the golden rule of prevention based on the management of risk and enforcing the law where there have been serious breaches of duty. So why is the HSE busying itself with promoting rehabilitation, managing sickness absence and return-to-work practices? These approaches are largely outside HSE's powers to enforce, and are activities that some might view as distracting effort from our core purpose.

In short, this broadening of our approach to improving workplace health is both the result of reviewing the evidence base and part of a step change in ourapproach to improving work and the workplace.

The first steps can be clearly traced back to the thinking encapsulated in Securing Health Together. Publishedin 2000, Securing Health Together portrayed a view of Occupational Health that went well beyond mainstream views. It laid out a holistic vision, to be achieved by working in partnership, that encompassed not only workplace prevention but also health improvement, and help for both those in and out of employment due to ill health in returning to work. This vision can now be seen as mainstream in the Government's recently published Health, Work and Wellbeing strategy.

HSE's decision to promote rehabilitation, managing sickness absence and return-to-work practices has been driven from two directions. Firstly, in responding to the consequences of workplace accidents and occupational diseases, and secondly as part of responding effectively to the larger numbers of people with common health problems - musculoskeletal, stress, depression or anxiety and cardio-respiratory problems.

Preventive actions have an undisputed primary role in preventing workplace injuries and industrial diseases. However, there remains a need and there is a strong moral case to ensure that when employees are injured or become ill from work activities they are properly helped, ensuring the impact of their problems are reduced and that they are able to lead as full a life as possible, including paid employment. The psychological consequences of injury are now well known and require a response beyond conventional medical care if longer-term incapacity from work is not to be an inevitable consequence. Insurers and employers are now recognising that the active provision of occupational rehabilitation provides a better response to redress, although lamentably this is by no means a universal provision in cases of workplace injury and ill health.

Secondly, one of the biggest drivers of change has been highlighted by the series of HSE self-reported work-related ill health (SWI) surveys. These surveys have recorded employees' views of the effect of their work on their health since 1990. They have shown that the scale and cost of ill health attributed to work exceeds those of injury and accident and this is largely due to sickness absence attributed to musculoskeletal problems, stress,depression or anxiety (with cardio and respiratory problems in a lower fourth place). Working days lost due to ill health attributed to work has risen since the mid 90's and although overall levels have fallen since 2001-2002, days lost to musculoskeletal and stress, depression or anxiety have seen no significant change. The rise seen in the mid 90's can be largely accounted for by average days lost per case increasing although it is important to note that not all who report work-related ill health are on sick leave.

However, looking at the bigger picture musculoskeletal problems, stress, depression or anxiety are very common in the population as a whole. Indeed it is now customary for health professionals to refer to them as common health problems. These problems are characterised by a series of symptoms, have limitedevidence of identifiable pathology and are influenced by psychosocial, cultural and work organisation factors. Epidemiology has shown that often, but not always, there is no clear relationship with work activities. Their natural history is that most cases recover often with no formal healthcare but for a minority of cases the outcome is protracted sickness absence, frequently leading to job loss. Indeed, data from HSE's SWI surveys indicated that an average of 19 working days were lost per case for musculoskeletal problems and 29 days for stress, depression or anxiety. The evidence is, therefore, that whilst the risk of ill health due to these causes can be managed to an extent by sensible workplace ergonomic interventions and good management standards, this will not prevent these symptoms occurring in all cases. Accepting this requires the additional approach of managing the problems when they occur.

The management of musculoskeletal problems has been subject to the most research and review and has given most support to an approach that aims to identify the obstacles to resumption of work - be they health, personal and work - and provides support to overcome them. This is the biopsychosocial approach and HSE's guidance on managing sickness absence and return to work takes this as a fundamental principle.

However, what is good occupational rehabilitation, sickness absence management and return to work practice? The evidence base in general stronglysupports a biopsychosocial approach but there is still limited evidence on the content of interventions especially when return to work is used as the endpoint. Although practitioners have experience of helping many employees to return to work following a wide range of health problems, the Department for Workand Pensions/Department of Health Job Retention and Rehabilitation Pilot (a randomised controlled trial designed to test interventions aimed at increasing the return to work rate of those off work sick for 6-26 weeks) disappointingly found no positive impact. This was for a free service that targeted employees through a variety of methods (but outside of the employer/employee contractual relationship) to voluntarily participate in the research project. The pilot has provided rich information on the experiences of employees on longer-term sickness and in particular the relevance of building a process that supports employees as active players.

HSE's advice on managing sickness absence and return to work provides a generic management model addressing all sickness absence whether work or nonworkrelated. It places the employer and their employees at the centre of the process with them drawing on professional advice to support and inform the return-towork process through identifying and addressing the obstacles to return-to-work. The approach was based on externally conducted research to derive a conceptual model and a series of consultations with experts and practitioners. This is a largely stepped approach that recognises many off-sick employees will return of their own volition within two to four weeks and more intensive actions outside of keeping in contact will only become cost-effective outside of this period. A key tenet is to ensure that interventions are considered at both the level of the off-sick individual and for the organisation as a whole. This ensures that the work environment is improved for all employees and the causes are tackled as well as the symptoms.

The advice identifies six elements as essential to the process:

• Recording sickness abscence.
• Keeping in contact.
• Planning and undertaking workplace adjustments.
• Making use of professional or other advice and treatment.
• Agreeing and reviewing a return to work plan.
• Co-ordinating the return to work process.

In addition, the importance of having top management commitment, open communication between management and employees and awareness of disability and ill health issues (especially mental health problems) for a policy to work is underlined.

To promote a more coherent management of sickness absence and return to work, especially in SMEs, we have produced a basic software tool to record, analyse, monitor and support the management of sickness absence . We have commissioned Glasgow University to look at the utility of improving practice in SMEs through using this tool and to identify the level and type of support they would need to maximise the benefits. It is hoped that the results of this research will enable the tool to be available through Workplace Health Connect to augment the advice it already offers on managing sickness absence and return to work.

However, occupational rehabilitation, managing sickness absence and return to work practice cannot be seen as existing in their own right and will only be effective as part and parcel of a far wider approach to delivering good health at work. This includes:

• ensuring that the effects of work on health and health on work are managed, e.g. by ergonomic approaches to the work process and environment and by meeting HSE's management standards;
• promoting a culture that encourages attendance through the provision of good jobs and a fair management and personnel practice, including fair opportunities to take time off to meet domestic responsibilities;
• providing help and support to employees to enable them to improve their own health by participating in healthier lives initiatives.

Good health at work therefore becomes a Board level performance issue and not a series of lower level issues centring on compliance with legal duties.

In conclusion, drivers from two different directions have shaped HSE's policy to promote rehabilitation, managing sickness absence and return to work. One in response to providing better redress for workers who are victims of workplace accidents and occupational diseases, and the other as part of a unified approach to dealing with today's common health problems.

It is often said that occupational rehabilitation, managing sickness absence and return to work are not rocket science but rocket science does need tobe accompanied by these practices. Delivering these practices requires skills that are not intuitive for all and organisations must show Board level commitment as well as providing resources to train and support all their employees (whether manager or staff) in delivering their responsibilities. This is a continuing and long-term process as employees move through and between organisations. HSE in collaboration and partnership with other organisations that have an interest in this area is committed to promoting and supporting the achievement of this goal.

Keith Wiley.

Keith Wiley is a unit head in the Health and Safety Executive Policy Group and is responsible for developing policy on managing sickness absence and return to work following ill-health or injury. He also has an interest in the wider issues of health at work especially those concerning common health problems. Keith was previously the research coordinator for HSE's health research programme. He originally trained as a biochemist, received a doctorate in transplantation immunology and has written scientific papers and articles ranging from transplantation to Occupational Health.

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References.

Principles of Rehabilitation for Common Health Problems by Professors Gordon Waddell and Kim Burton.

Beaumont DG 2003: Rehabilitation and retention in the workplace - the interaction between general practitioners and occupational health professionals: a consensus statement. Occupational Medicine 53: 254-255.

BSRM 2000: Vocational rehabilitation. The way forward. British Society of Rehabilitation Medicine, London.

Burton AK, Main CJ 2000: Obstacles to recovery from work-related musculoskeletal disorders. In: Karwowski W (Ed.) International encyclopedia of ergonomics and human factors. Taylor & Francis, London. pp 1542-1544.

Coats D, Max C 2005: Healthy work: productive workplaces. Why the UK needs more "good jobs". The Work Foundation, London http://www.theworkfoundation.com/research/healthy_work.jsp

Frank J, Sinclair S, Hogg-Johnson S, et al. 1998:Preventing disability from work-related low-back pain. New evidence gives new hope - if we can just get all the players onside. Canadian Medical Association Journal 158: 1625-1631.

Hadler NM 1997: Back pain in the workplace. What you lift or how you lift matters far less than whether you lift or when. Spine 22: 935-940.

HSE 2004: Managing sickness absence and return to work - an employers' and managers' guide. Health and Safety Executive [HSE Books], London.

James P, Cunningham I, Dibben P 2003: Job retention and vocational rehabilitation: the development and evaluation of a conceptual framework (HSE Research Report 106). HSE Books, London.

Nocon A, Baldwin S 1998: Trends in rehabilitation policy. a review of the literature. Kings Fund, London.

Sawney P, Challenor J 2003: Poor communication between health professionals is a barrier to rehabilitation. Occupational Medicine 53: 246-248.

Scottish Executive 2004: Healthy working lives: a plan for action. Strategy paper. Scottish Executive, Edinburgh.

Waddell G, Burton AK, Main CJ 2003: Screening to identify people at risk of long-term incapacity for work. Royal Society of Medicine Press, London.

Waddell G, Burton AK 2004: Concepts of rehabilitation for the management of common health problems. The Stationery Office, Norwich.

WHO 2001: International classification of functioning, disability and health. World Health Organisation, Geneva http://www3.who.int/icf/icftemplate/cfm

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Rehabilitation - what works and what doesn't by Joy Reymond, Head of Rehabilitation Services, UnumProvident.

1. 'Cost Benefit Analysis of Rehabilitation Services Provided by CRS Australia', a report by The Institute for Research into International Competitiveness(IRIC), for CRS Australia, Department of Health and Ageing, September 2003.

2. Speech by Lord David Hunt, "Introduction to the Compensation Bill including an overview of the importance of Rehabilitation", 14th July 2006,House of Lords.

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Escaping from incapacity - a biopsychosocial approach to overcoming health-related unemployment by Dr. Bob Grove.

Barnes, H & Hudson, M (2006): Pathways to Work: Qualitative research on the Condition Management Programme, DWP Research Report 364 http://www.dwp.gov.uk/asd/asd5/rports2005-2006/rrep346.pdf

Christie A (2006): Condition Management: Research and audit outcomes and results, conference presentation at the National Employment and Health Innovations network 27 April 2006 Edinburgh. http://www.scmh.org.uk/80256FBD004F6342/vWeb/wpKHAL6MREYP

DWP (2002): Pathways to Work: Helping people into employment, Department for Work and Pensions Cm 5960 London TSO.

DWP (2005): Department for Work and Pensions 5 year Strategy: Opportunity and security throughout life. London Department for Work and Pensions.

DWP (2006): A new deal for welfare - Empowering people to work. Department for Work and Pensions Cm 6730 London TSO.

Layard R (2004 updated 2006): Mental health: Britain's biggest social problem? Prime Minister's Strategy Unit http://www.strategy.gov.uk/downloads/files/mh_layard.pdf

OECD 2005: Economic Survey of the UK http://www.imf.org/external/np/ms/2005/121905.htm

Waddell, G (2004): The back pain revolution (2nd edition) Edinburgh Churchill Livingstone.

Waddell, G & Aylward, M (2005): The Scientific and Conceptual Basis of Incapacity Benefits London TSO.

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Why managing sickness absence and return to work practices is part of HSE's strategy for improving workplace health by Keith Wiley.

1. Securing Health Together. An occupational health strategy for Great Britain. HSE Books 2000.

2. Health Work and Wellbeing. See http://www.dwp.gov.uk/publications/dwp/2005/health_and_wellbeing.pdf

3. Psychological, personal injury and rehabilitation. The IUA/ABI rehabilitation working party, 2004.

4. Self-reported Work-related Illness survey. See http://www.hse.gov.uk/statistics/books.htm

5. Concepts of rehabilitation for the management of common health problems. G Waddell and AK Burton. TSO. 2004.

6. See UnumProvident's 2004 Chief Medical Officer's report and ref 5.

7. Managing sickness absence and return to work. An employers' and managers' guide. HSG249. HSE Books. 2004.

8. Impacts of the Job Retention and Rehabilitation Pilot. Purdon et al. DWP Research Report 342. 2006.

9. Experiences of the Job Retention and Rehabilitation Pilot. Farrrell et al. DWP Research Report 339. 2006.

10. Job retention and vocational rehabilitation: The development and evaluation of a conceptual framework. P James, I Cunningham and P Dibben.HSE Reserch Report 106. 2003.

11. HSE's webpages on sickness absence. See http://www.hse.gov.uk/sicknessabsence/index.htm

12. The SAM project. See http://www.thesamproject.org/index.asp

13. Workplace Health Connect provides SMEs with free and impartial advice on health at work in partnership with HSE. See http://www.hse.gov.uk/workplacehealth/index.htm

14. The management standards, see http://www.hse.gov.uk/stress/standards/standards.htm

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