The first time I presented on the health benefits of work, the audience laughed. They weren’t laughing at me, they thought I was making a joke – it was an oxymoron. The words health, work, benefits, just didn’t seem to belong together.
That was in 2010, and the concept has moved on a long way since then, but the implications are still widely misunderstood. It is a topic with multiple stakeholders, workers, employers, unions, ACC, government, health, and of course, general practitioners.
It was in 2010 that I joined the Policy and Advocacy Committee of the Australasian Faculty of Occupational and Environmental Medicine (AFOEM, RACP). If you join a committee, expect to be given a job. I was asked to chair a working group of a project called The Adverse Health Consequences of Long-term Worklessness. Aside from having a clunky title, it proved to be just too easy. The evidence is clear cut; being out of work long-term is harmful to health. As an occupational physician, I have seen thousands of people whose health has been adversely impacted by being out of work.
As an example, stories like these were not unusual, “Dear Dr Beaumont, please advise if a further epidural steroid injection will help?”
John was 43 and had been out of work for three years. He has three children, two under 10. He had an annular tear at L5/S1 on MRI. He is now overweight, deconditioned, and angry. In fact, it didn’t take long to realise he was also depressed. Hardly surprising since his wife had also left with the children (the anger and drinking were the main reasons). He needed a lot more than an epidural steroid.
Based on the work of Dame Carol Black in the UK, the title of the project was changed, to Realising the Health Benefits of Work1. We set about reviewing the evidence that work is good for health. The position statement was launched by Dame Carol Black, who convinced us to add the qualifier “good”. Bad work, she told us, is worse than no work at all.
Fast forward to 2021, and the RACP has just launched two documents under the title of It Pays to Care2. The first presents a values and principles based approach to injury management and return to work following injury. The second is the evidence base to support the need to identify and address psychosocial factors from the outset. The best way for injured people to feel they are being heard and supported is by incorporating the values of honesty, respect, fairness, compassion, and collaboration.
The evidence is clear that addressing psychosocial factors early leads to better health and return to work outcomes. In John’s case, the current psychosocial factors are clear. But there was a further flag for a poor return to work outcome that could have been picked up much earlier; he had been abused as a child, and had multiple ACEs (adverse childhood experiences).
Understanding why people don’t return to work when we expect that they would is an important first step.
- It can be as straightforward as not getting on with their manager, or because of poor health literacy, “he said I had ruptured my disc.” “she said my pain was chronic. That means really bad, right?”
- The general practitioner may have important knowledge about psychosocial factors which should be fed into the rehabilitation process, but lines of communication with the rehab team are often poor.
- The workplace may be an important factor in delayed return to work, but the general practitioner only has an understanding from the patient perspective, “my boss won’t let me come back until I’m fully fit.”
- Employers get frustrated by the messages they hear from their worker, “my GP won’t let me come back until I’m fully fit.”
Occupational physicians have the advantage of time to undertake a full biopsychosocial assessment, and the potential to communicate with both the employer and the GP. To collaborate at an early stage opens the possibility to identify psychosocial risk factors and agree how best to engage with the patient so they feel their needs have been heard and are being addressed. Seeing them as a whole person with a life history which has shaped how they respond to life’s challenges is important.
The purpose of It Pays to Care is to start a dialogue between the many players in rehabilitation and return to work. The goal is a shared understanding that by collaboration between all parties, return to work is more likely to be achievable and sustainable. One obvious collaboration is between general practitioners and occupational physicians. The question we should ask ourselves is “how best can we work together to help this person return to work and get on with their life?”