Appendix C: The evidence

This appendix lists the evidence statements from three reviews and a consultation report provided by external contractors (see appendix A) and links them to the relevant recommendations. (See appendix B for the key to quality assessments). The evidence statements are presented here without references – these can be found in the full review (see appendix E for details). It also links two of the five expert papers to the recommendations (the other three contribute to 'IDE') and sets out a brief summary of findings from the economic analysis and the fieldwork.

The three evidence reviews of effectiveness and cost effectiveness and the consultation report are:

  • Review 1: 'Review of the effectiveness and cost effectiveness of interventions, strategies, programmes and policies to reduce the number of employees who move from short-term to long-term sickness absence and to help employees on long-term sickness absence return to work'.

  • Review 2: 'Review of the effectiveness and cost effectiveness of interventions, strategies, programmes and policies to reduce the number of employees who take long-term sickness absence on a recurring basis'.

  • Review 3: 'Review of the effectiveness and cost effectiveness of interventions, strategies, programmes and policies to help recipients of incapacity benefits return to employment (paid and unpaid)'.

  • Consultation report: 'Responses to the evidence consultation on long-term sickness absence and incapacity'.

Evidence statement number ER1.1 indicates that the linked statement is numbered 1 in the 'Review of the effectiveness and cost effectiveness of interventions, strategies, programmes and policies to reduce the number of employees who move from short-term to long-term sickness absence and to help employees on long-term sickness absence return to work'. Evidence statement ER2.1 indicates that the linked statement is numbered 1 in the 'Review of the effectiveness and cost effectiveness of interventions, strategies, programmes and policies to reduce the number of employees who take long-term sickness absence on a recurring basis'. EP1 indicates that the recommendation is linked to expert paper 1 'Expert patients' programme' and EP2 indicates that the recommendation is linked to expert paper 2 'Condition management'. CR1 indicates that the recommendation is linked to the consultation report: 'Responses to the evidence consultation on long-term sickness absence and incapacity'.

The reviews, expert papers, economic analysis, consultation report and fieldwork report are available online. Where a recommendation is not directly taken from the evidence statements, but is inferred from the evidence, this is indicated by IDE (inference derived from the evidence).

Recommendation 1: evidence statements ER1.2, ER1.23, ER1.26, ER1.40, ER2.1; EP1, EP2.

Recommendation 2: evidence statements ER1.2, ER1.21, ER1.23, ER1.24, ER1.26, ER1.40, ER1.45, ER1.50, ER1.52, ER1.54, ER2.1, ER2.7, ER2.10; EP1, EP2; IDE.

Recommendation 3: evidence statements ER1.2, ER1.8, ER1.11, ER1.12, ER1.13, ER1.16, ER1.17, ER1.20, ER1.21, ER1.23, ER1.24, ER1.26, ER1.28, ER1.30, ER1.33, ER1.40, ER1.45, ER1.50, ER1.52, ER2.1, ER2.7, ER2.10; IDE.

Recommendation 4: evidence statements ER3.2, CR1.1, CR1.2, CR1.3.

Evidence statements

Evidence statement ER1.2

One RCT study in Norway (+) found evidence that workers, aged between 18 and 60, on long-term sick leave with lower back pain who receive consultations with a physician (specialising in physical medicine and rehabilitation) and a physiotherapist to improve skills to cope with their condition may be effective at helping workers return to work up to a year after they start sick leave than comparable people who were treated in primary care. In the consultation, patients received information, reassurance and encouragement to engage in physical activity as normal as possible and reports were sent to their primary care physician and local national insurance office. However, there was no significant difference between the groups in terms of return to work in the second or third year. Although the study found significant differences in the average number of sick leave days at the 12-month point between the intervention group and the control group, there was no significant difference between the groups in the proportions experiencing further sickness episodes over the 3 year period.

Evidence statement ER1.8

There is limited evidence from a longitudinal before-and-after comparison study (–) that attendance at a back school programme (for up to 6 hours over a period of a year) by 200 bus drivers in Holland may be effective at reducing long-term sickness absence.

Evidence statement ER1.11

An RCT study (+) found a significant decrease in the days on 'short-term' sick leave( that is, for between 2 and 6 months) for 36 women employees in Sweden who took part in a cognitive behavioural return-to-work programme compared with a group of 36 similar women employees over a period of 6 months. The average age among the two groups was 46. However, there was no significant effect for women on long-term sick leave.

Evidence statement ER1.12

One RCT study (+) found a significant difference in the proportion of 45 employees (27% female) in the Netherlands on long-term sick leave, for up to 20 weeks, with low back pain who had returned to work after 12 months following an intervention involving behavioural-graded activity and education supplemented by problem-solving therapy (for around 3 hours a week for 15 weeks) compared with 39 comparable employees who just received behavioural-graded activity and education.

Evidence statement ER1.13

One RCT study (+) found a significant positive difference in the proportion of 109 employees (34% female) who returned to work at a Dutch post and telecommunications company 3 months after at least 2 weeks' sick leave with symptoms of mental distress after undergoing a three-stage cognitive behavioural therapy (CBT) intervention compared with 83 comparable employees who received usual care.

Evidence statement ER1.16

One RCT study (-) found no significant difference in the proportion of 53 employees (76% female, average age 38) in Oslo, Norway who had returned to work from long-term sickness absence related to psychological or muscle skeletal disorders after attending a solution-focused group-based intervention (with 8 weekly sessions, lasting 3 to 4 hours, focusing on coping strategies) compared with 50 comparable employees receiving treatment as usual.

Evidence statement ER1.17

In a controlled before-and-after study (+) significantly more of the 70 male and female (54% of the total) employees with whiplash injuries in Canada who attended a 10-week Progressive Goal Attainment Programme (PGAP) (for an hour a week) in addition to the usual physical therapy, had returned to work 4 weeks after the intervention compared with a sample of 70 comparable employees who received physical therapy only.

Evidence statement ER1.20

One RCT study (+) found that a behavioural medicine rehabilitation programme and its two constituent components: behaviour-oriented physiotherapy (for 4 weeks) and cognitive behavioural therapy (for 4 weeks) was effective compared to 'treatment as usual' in securing faster returns to work among 214 employees aged 18 to 60 (average age 43 and 55% female) long-term sick-listed for non-specific spinal pain for between 1 and 6 months in an unspecified area of Sweden for women, but not for men.

Evidence statement ER1.21

A prospective randomised control study (+) found that a graded activity programme (including workplace visits, a 'back school' and individual graded exercise for 3 days a week until return to work) was effective speeding up return to work among 51 car workers (23% female) sick listed for 8 weeks with low back pain compared with a similar group of 50 sick-listed employees in Volvo in Goteborg, Sweden.

Evidence statement ER1.23

Three linked studies (+) from an RCT involving 664 employees in Bergen Norway sick-listed for musculoskeletal pain found that a screening tool could be effectively developed to classify patients by their likelihood of returning to work. The studies show that an intensive (five, 6-hour sessions a week for 4 weeks) intervention multidisciplinary rehabilitation regime (including cognitive behavioural modification, education, exercise and 'occasional' workplace intervention) can be effective for patients with extensive problems (and a low propensity to return to work); those with a stronger likelihood of return to work benefit just as much from usual care as from a low or high intensity intervention. The studies also show that men and women respond differently to different types of treatment.

Evidence statement ER1.24

A Dutch RCT study (+), among 196 men and women aged between 18 and 65 who had been on sick leave for between 2 and 6 weeks due to lower back pain, found that a multi-stage return to work programme (involving a workplace assessment and work modifications based on participative ergonomics and counselling the employee about return to work) was effective at getting them back to work sooner than if they had just had usual care. There is also evidence that the workplace intervention was effective in reducing the total number of days taken as sick leave among the study population and that the clinical intervention (in combination with usual care or the workplace intervention) did not have a positive effect, although the clinical intervention was only adhered to by 65% of cases.

Evidence statement ER1.26

There is evidence from an RCT study (-) involving 137 workers (58%t female) off sick in Sweden for at least a week with musculoskeletal disorders that an early intervention involving a work rehabilitation interview and a workplace assessment can be effective at significantly reducing the number of days off sick in the subsequent year, although the generalisability of the study to the UK may be limited as the results of the study may have been influenced by the operation of the Swedish sick pay regulations.

Evidence statement ER1.28

A Canadian RCT study (-), among 104 workers who had been on sick leave for between 4 and 13 weeks due to lower back pain, found that a multi-stage return to work programme (involving a combination of workplace and clinical and rehabilitative interventions) was effective at speeding up their rate of return to work and in minimising the total number of days taken as sick leave.

Evidence statement ER1.30

One RCT study (-) found that a multimodal treatment (including relaxation training, psychological support and manual therapy, provided in ten 1-hour sessions over 2 weeks) was effective at securing a return to work for 60 patients (42% female) suffering from whiplash injury who were recruited within 2 months of sustaining a neck injury in and around Ancona in Italy.

Evidence statement ER1.33

There is limited evidence from a controlled before and after study (-) that a therapeutic return to work intervention which linked graded work exposure with functional restoration therapy for people aged 18 to 65 years (52% female) suffering from chronic low back pain and off sick for over 90 days in Quebec, Canada, compared with just functional restoration therapy, community services without any rehabilitation intervention or usual care (for patients denied access to the intervention by the local Compensation Board).

Evidence statement ER1.40

There is evidence from econometric secondary data analysis (+) of survey and administrative data from 1685 sick-listed (for 3 to 12 weeks) employees (56 of whom were female) randomly drawn from across Denmark that a case management approach (in which sick-listed employees are interviewed by a person or team who can direct health and occupational services to help the interviewee back to work) is effective at helping people return to work.

Evidence statement R1.45

There is evidence from one Norwegian cost benefit evaluation based on a randomised controlled trial (++) that an examination at a primary care spine clinic by physician and physiotherapist and provision of information and individual instruction, as well as advice on how to stay active, is likely to be cost effective compared to primary care treatment in returning employees back to work following sickness absence due to low back pain.

Evidence statement ER1.50

There is evidence from two economic evaluations (one Norwegian, one Swedish, both [+]) that multidisciplinary treatment is likely to be cost effective in improving return to work and reducing sickness absence for people with low back pain. The net present value of productivity gains is equal to £352,953 (2007) for light and extensive multidisciplinary treatment (results not provided individually within the paper) and the cost-benefit results of behaviour-oriented physiotherapy, cognitive behavioural therapy and the combination of these is £62,294; £98,197 and £154,475 respectively for females. The interventions are not considered cost effective for males individually; however combined the cost-benefit of behaviour-oriented physiotherapy and CBT for males is £71,024.

Evidence statement ER1.52

There is evidence from one Dutch economic RCT evaluation (+) that a multi-stage return to work programme (involving usual care plus a workplace assessment and work modifications based on participative ergonomics and counselling the employee about return to work) is likely to be cost effective in reducing the re-occurrence of absence due to low back pain when measured against usual care as outlined by Dutch occupational physician guidelines for lower back pain. The cost per return to work day gained is estimated to be £17 and the cost per quality-adjusted life year (QALY) gained is estimated to be dominating (-£1294) in comparison to usual care. However, based on the analysis, it is unlikely that physiotherapy based on operant behavioural principles provided following eight weeks of other ineffective treatment in terms of return to work is cost effective in comparison to the provision of Dutch usual care for the same indication).

Evidence statement ER1.54

There is evidence from one Canadian cost-benefit and cost-effectiveness analysis (+) based on an RCT that the clinical intervention, the occupational intervention and the Sherbrooke model (a combination of clinical and occupational interventions) is likely to be cost effective in comparison to standard care for back pain. The analysis suggests that the combination of the clinical and occupational interventions (the Sherbrooke model) is likely to better value for money than the two interventions individually.

Evidence statement ER2.1

One RCT study in Norway (+) found evidence that workers, aged between 18 and 60, on long-term sick leave with lower back pain who receive consultations with a physician (specialising in physical medicine and rehabilitation) and a physiotherapist to improve skills to cope with their condition may be effective at helping workers return to work up to a year after they start sick leave than comparable people who receive were treated in primary care. In the consultation, patients received information, reassurance and encouragement to engage in physical activity as normal as possible and reports were sent to their primary care physician and local national insurance office. Although the study found significant differences in the average number of sick leave days at the 12-month point between the intervention group and the control group, there was no significant difference between the groups in the proportions experiencing further sickness episodes over the three year period. Therefore there is insufficient evidence from this study to suggest that this intervention was effective in preventing the re-occurrence of sickness absence in the long term.

Evidence statement ER2.7

A Dutch RCT study (+), among 196 men and women aged between 18 and 65 who had been on sick leave for between 2 and 6 weeks due to lower back pain, found that a multi-stage return to work programme (involving a workplace assessment and work modifications based on participative ergonomics and counselling the employee about return to work) was effective at getting them back to work sooner than if they had just had usual care. There is also evidence that the workplace intervention was effective in reducing the total number of days taken as recurring sick leave among the study population and that the clinical intervention (in combination with usual care or the workplace intervention) did not have a positive effect, although the clinical intervention was only adhered to by 65% of cases.

Evidence Statement ER2.10

There is evidence from one Dutch economic RCT evaluation (+) that work modifications based on participative ergonomics and counselling the employee about return to work are likely to be cost effective in reducing the re-occurrence of absence due to low back pain when compared against usual care as outlined by Dutch occupational physician guidelines for lower back pain. Within this study patients are randomised to receive a clinical intervention or usual care at 8 weeks if they have not returned to work and therefore this may confound the results; although the authors have tried to calculate an adjustment for this. The cost per return to work day gained is estimated to be £17 and the cost per QALY gained is estimated to be dominating (-£1295) for the workplace intervention in comparison to usual care. However, based on the analysis, it is unlikely that graded exercise based on operant behavioural principles provided for those who remain on sickness absence after 8 weeks of receiving either the workplace intervention or usual care in terms of return to work is cost effective in comparison to the provision of Dutch usual care for the same indication.

Evidence Statement ER3.2

There is limited evidence from a non-randomised controlled trial (+) that a programme comprising attendance at a work-focused interview and access to return to work support (including further interviews, help with managing their health condition, financial support and in-work occupational health and personal support) could be effective at increasing the chances of people on incapacity benefit (IB) being in work 18 months after initially enquiring about accessing IB. The employment effects appear to be stronger for women than men, those aged under, rather than over, 50 and people without rather than with mental illness.

Evidence Statement CR1.1

There is limited evidence from a before and after evaluation study (-) using econometric analysis that a programme comprising attendance at a work-focused interview plus up to five further interviews with trained advisers and access to return to work support (including further interviews, employability training, help with managing their health condition, financial support and in-work occupational health and personal support) can be effective at increasing the chances of existing claimants of incapacity benefit (IB) being in work 18 months after the programme of intervention began.

Evidence Statement CR1.2

There is limited evidence from a before and after comparison evaluation (-) that an intervention in North East England designed to help people off incapacity benefit and into work by providing access to health and condition management, advice from a health caseworker, employment advice and a range of employability support from an employment case worker can lead to beneficiaries gaining sustained employment (that is, for at least 3 months).

Evidence Statement CR1.3

There is evidence from one UK cost benefit analysis (+) that the 'Pathways to work' intervention, comprising attendance at a work-focused interview and access to return to work support (including further interviews, employability training, help with managing their health condition, financial support and in-work occupational health and personal support), is likely to be cost saving compared to no such intervention in returning people currently receiving incapacity benefit to work if the effectiveness evidence reported by Bewley et al. (2007) on which this analysis is based is accepted.

Expert papers

  • Expert paper 1: 'Expert patients' programme'.

  • Expert paper 2: 'Condition management'.

  • Expert paper 3: 'Discrimination in the labour market'.

  • Expert paper 4: 'Regional employability programmes'.

  • Expert paper 5: 'Evaluation of Camden GP surgery pilot'.

Economic analysis

The economic literature on interventions showing a return-to-work outcome for people on long-term sickness absence is relatively sparse.

The first evidence review 'Review of the effectiveness and cost effectiveness of interventions, strategies, programmes and policies to reduce the number of employees who move from short-term to long-term sickness absence and to help employees on long-term sickness absence return to work' identified 11 economic studies. Ten of these focused on back pain or musculoskeletal pain/disorders. One focused on minor mental health disorders. All 11 studies were covered in the effectiveness component of the evidence review.

The second evidence review 'Review of the effectiveness and cost effectiveness of interventions, strategies, programmes and policies to reduce the number of employees who take long-term sickness absence on a recurring basis' identified three economic studies. (These also appeared within the 11 studies identified in the first review.) All three focused on back pain.

From these two reviews, several of the 10 studies on people with back pain show that various combinations of physical activity advice, physiotherapy, CBT and workplace assessment are cost effective, compared with usual care. The mental health study (from the Netherlands) found that an intervention where social workers help people to adopt problem-solving strategies and encourage them to resume work was cost effective, compared with usual care.

The third evidence review, 'Review of the effectiveness and cost effectiveness of interventions, strategies, programmes and policies to help recipients of incapacity benefits return to employment (paid and unpaid)', identified only one economic study on the 'Pathways to Work' scheme. This was carried out for the Department for Work and Pensions and assessed the cost effectiveness of an intervention covered in the effectiveness section of this review.

The economic analysis of the pathways scheme showed that for four initiatives targeted at recipients of new and repeat incapacity benefit, the benefits exceed the costs (from the perspective of the individual, the public sector and society). This analysis did not include any of the quality of life benefits that people may experience as a result of returning to work. The pathways scheme was more effective for women; people aged under 50 and those who did not have a mental illness. However, the reasons for being in receipt of incapacity were not given.

Other than the Pathways to Work analysis, all the economic studies from the three reviews took place outside the UK and so need to be treated with caution because of the differences in benefits systems and what is regarded as 'usual care'.

Economic modelling was carried out on:

  • a physical activity and education (including CBT) intervention (it cost £2800 per QALY compared with usual care)

  • a workplace-based intervention (which dominates usual care)

  • a physical activity, education (including psychological component) intervention combined with a workplace visit for musculoskeletal disorders. (This combination of treatments dominates usual care.)

All three of the above interventions were found to be cost effective ways of helping people return to work when compared with usual care.

A number of assumptions had to be made to determine whether or not mental health interventions were cost effective. For example, whether the quality-of-life gain for someone with mental health problems when they returned to work was the same as for someone who had been off work with musculoskeletal problems. If the same assumptions are made for both these groups, in terms of the cost and the effect of an intervention, then cost effectiveness will not depend on the condition. Hence, what is cost effective for musculoskeletal interventions will automatically be cost effective for mental health interventions.

A further analysis was undertaken of the potential cost-effectiveness of using an initial assessment and/or case worker/manager/team. It found that, if this results in at least a 1% improvement in the return-to-work rate – and costs less than about £900 per employee, then it is likely to be cost effective at a threshold of £20,000 per QALY.

No economic modelling was undertaken for Pathways to Work, because this had already been carried out in the report prepared for the Department for Work and Pensions (see above). It estimated that Pathways to Work would have a favourable benefit to cost ratio for finding employment for people on incapacity benefit.

However, in a climate of increasing unemployment, the length of time it would take for participants to find a job would substantially increase. This would, in turn, reduce the benefits of programmes and interventions to encourage this group of people to return to work. Thus Pathways to Work is less likely to be cost effective. The PDG believed employers would probably be more likely to screen out applications from such recipients when there was relatively high unemployment.

Fieldwork findings

Fieldwork aimed to test the relevance, usefulness and the feasibility of putting the recommendations into practice. The PDG considered the findings when developing the final recommendations. For details, go to the fieldwork section in appendix B and 'Testing NICE draft guidance – managing long-term sickness absence and incapacity to work'.

Participants work with people experiencing sickness absence on a long-term or recurring basis, including those in receipt of incapacity benefit.

Overall, they welcomed the development of NICE guidance on this subject. However, many felt that the recommendations did not take sufficient account of the non-medical factors that might lead to sickness absence. Examples might include interpersonal relationships (both within and outside work) and social and cultural issues.

More detail was needed about how the recommendations would be paid for in practice – and on the responsibilities and choices that employees should be offered. Participants felt that the employee was viewed as a passive recipient rather than an active partner in the process of getting them back to work. Good practice case studies and flow charts depicting, for example, the 'client journey', would have helped to outline how the recommendations could impact on both employees and employers.

There was support for a multi-disciplinary (occupational health, psychologists and GPs) and multi-agency (health care providers and Jobcentre Plus staff) approach. But clearly, good communications would be essential, given the wide-ranging issues and conditions involved.

Although there was support for the use of case workers, there was no consensus on who should take on that role. The confidential nature of information held about an individual was an issue that needed careful consideration. Some participants felt the line manager would be best placed to carry out the role, others felt that they would not be impartial enough.

However, there was consensus that the roles of each profession should be made more explicit. Similarly, the recommendations need to make it clear whether or not an assessment should be undertaken within or outside the employing organisation (or even, whether it was necessary at all for employees with an acute health condition and a known return-to-work date).

While stakeholders, practitioners and commissioners did not believe the recommendations offered an entirely new approach, some interventions may have not been implemented universally, due to lack of service availability.

Wider and more systematic implementation would be achieved if:

  • it was clear who would pay for the assessments and interventions recommended

  • both employers and employees had access to relevant resources and information

  • it was clear who should take action and which organisation or agency should take the lead

  • the employee was acknowledged as a partner in the return-to-work process (by including them in the recommendations as part of the 'who should take action' list).

  • National Institute for Health and Care Excellence (NICE)