Case study

SWAP: delivering primary care vocational advice

Primary care patients referred to a vocational advisor delivering a stepped care, case managed intervention to address obstacles to working.

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Summary

Patients consulting their GP or nurse practitioner with an episode of pain who were either struggling at work or absent from work for less than 6 months, were referred to a vocational advisor, delivering a stepped care, case managed intervention to address obstacles to working, tailored to each patients’ needs.

Background

Musculoskeletal (MSK) pain is one of the most common causes of work absence. There is a growing evidence base that suggests that absence from work is detrimental to health and delivering appropriate advice and support early can reduce absence from the workplace and the negative consequences of that.

Occupational health provision differs across Europe. Within the UK there is very limited access, making it difficult for people to receive vocational advice and support about managing their MSK pain in the context of work.

GPs are responsible for authorising absence in the UK through the fit note system and alongside this fit note the GP is expected to provide advice on managing at work. However, GPs report difficulties in providing this advice and most have little training in occupational health provision.

The National Institute for Health Research (NIHR) funded a randomised controlled trial (RCT) to address the difficulties associated with accessing occupational health for patients consulting their GP or nurse practitioner with an episode of pain who were either struggling at work or absent from work for less than 6 months.

What was involved

The study of work and pain (SWAP) RCT compared 2 arms:

  1. Intervention arm: delivery of a vocational advice service within the primary care setting, allowing the referral of patients to a vocational advisor (VA) who delivered a stepped care, case managed intervention to address obstacles to working, tailored to each patients’ needs.
  2. Control arm: delivery of best care.

Participants in the intervention arm reported fewer days off work over 4 months (mean 9.3) compared to participants in the control arm (mean 14.4). The impact of the VA service was demonstrated at 4 months with participants reporting improvements in their confidence to return to work, improved performance whilst at work and a reduction in presenteeism (working while sick).

Health economic analysis demonstrated that there was a net societal benefit of £733 for the intervention, compared to best care with the corresponding return on investment which was £49 for every £1 invested.

What works well

The VA service was acceptable to patients with 76% of those eligible to access the service agreeing to a referral.

What could be better

Interviews with participants, GPs and VAs found that for some patients the service was offered too early. Subgroup analysis found that the intervention was significantly more successful in those who had at least 10 days of absence when they accessed the VA service.

Next steps

Future work needs to focus on targeting the intervention to ensure that it is directed towards those who will benefit most, and also to testing this model of delivering vocational advice with a broader population including those reporting common mental health conditions.

Further information

  • Sanders T, Wynne-Jones G, Artus M, Ong B.N, Foster N. Acceptability of a vocational advice service for patients consulting in primary care with musculoskeletal pain: A qualitative exploration of the experiences of general practitioners, vocational advisors and patients, Scandinavian Journal of Public Health; 2017; doi: 10.1177/1403494817723194. [Epub ahead of print]
  • Wynne-Jones G, Artus M, Bishop A, Lawton S.A, Lewis M, Jowett S, Kigozi J, Main C, Sowden G, Wathall S, Burtons A.K, van der Windt D, Hay E.M, Foster N.E and the SWAP study team. Effectiveness and costs of a vocational advice service to improve work outcomes in patients with musculoskeletal pain in primary care: A cluster randomised trial (SWAP trial ISRCTN 52269669), Pain; 2017; doi: 10.1097/j.pain. 0000000000001075. [Epub ahead of print]

For further information please contact Dr Gwenllian Wynne-Jones g.wynne-jones@keele.ac.uk.

Published 6 December 2017