This BMJ Leader blog series has been produced in collaboration with the Health Equity Evidence Centre (HEEC). HEEC are dedicated to generating solid and reliable evidence about what works to address health and care inequalities. By adopting innovative methodologies, they efficiently map successful strategies for reducing health and care inequalities, and subsequently empower policymakers and practitioners to make evidence-informed decisions for all.

The blog below has been written by Dr Danielle Lamb, a collaborator with the HEEC team.

Employment is not only a marker of economic growth and productivity but also a crucial determinant of health and well-being. Disadvantaged groups often experience higher rates of work-limiting conditions, compounded by poorer access to health and care interventions. Return-to-work (RTW) interventions aim to address long-term work absence, but their effectiveness in achieving equitable outcomes remains uncertain.

The NHS workforce includes higher proportions of women and people from minoritised racial and ethnic groups, who have higher rates of sickness absence, higher unemployment, and more disadvantaged living conditions that other sections of the population(1). Having effective, equitable RTW programmes is beneficial for individual workers, for the organisations they work for, and for healthcare leaders. Having a more stable workforce, with lower turnover and sickness absence, retains organisational knowledge and expertise, improving quality of care and patient outcomes and experiences, and enables better strategic planning. RTW programmes that address inequalities in the process are imperative because maintaining a diverse workforce is not only socially just but has beneficial health and care outcomes.

A review of 53 studies on health and care interventions for supporting people from disadvantaged backgrounds in returning to employment highlights key design principles that should be of note to leaders responsible for implementing such programmes, such as cultural sensitivity, return to work advisors, multidisciplinary support, and tailored interventions for individual needs.

Social, cultural, and economic factors significantly impact an individual’s ability to return to work, so RTW programmes that recognise the diverse needs of disadvantaged groups and use a biopsychosocial approach are particularly important. Cultural competency, cultural humility, and anti-racist training can help to ensure staff understand and address cultural and linguistic barriers that disadvantaged groups may face, and so support return to work of their colleagues. Making cultural competency and anti-racist care organisational priorities helps to influence staff culture and programme design. Healthcare leaders should also consider person-centred factors, as individualised approaches tend to be more successful than a one-size-fits-all approach.

There is evidence that RTW interventions with multiple components are more effective in addressing biopsychosocial factors than single-component interventions. For example, health-focused work components, such as occupational therapy or graded exercise, with service coordination that improves communication between workplaces and healthcare providers, and workplace modifications, like flexible working conditions or modified duties(3,4).  Liaising and collaborating with the employment sector and key workplace stakeholders is essential for effective RTW. It’s important to have the right systems and infrastructure in place for good service coordination, and ensuring there are channels for effective communication between components of the RTW program.

Multicomponent interventions tend to outperform cognitive behavioural therapy (CBT) or physical treatment alone, with CBT sometimes delaying RTW. That said, there is some evidence that adapting psychological therapies such as CBT so that they are work-focused can improve RTW outcomes. Work-focused CBT seems to be most effective for those with mild to moderate mental health conditions.

Workplace modifications known as ‘reasonable adjustments’, which are legally required in the UK under the Equality Act 2010, facilitate safer RTW. Reasonable adjustments include returning to work on reduced hours or workload, referred to as graded or stepped RTW. Leaders should leave space and have flexibility that allows for reasonable adjustments within their own health and care organisations. Taking time to map out the landscape of their workers’ environments and figuring out where adjustments can be made is important for equity, as different people will have different needs and pressures, inside and outside work. There are systems in place to support this already, for example reasonable adjustments ‘passports.’

Multidisciplinary interventions, involving both healthcare and non-healthcare professionals, improve return-to-work (RTW) outcomes. Evidence supports the effectiveness of multidisciplinary teams, particularly for disadvantaged groups facing complex biopsychosocial challenges. These teams often include occupational therapists (OTs), physiotherapists, psychologists, psychiatrists, vocational counsellors, and job coaches, providing holistic, coordinated care. Studies show that interventions with multiple disciplines improve RTW outcomes compared to single-discipline approaches, and leaders can support multidisciplinary teams by ensuring that everyone’s expertise is considered and used in the most appropriate way(5,6).

Having a single point of contact for multidisciplinary teams, such as RTW coordinators, can play a crucial role in managing the RTW process for various conditions, including psychological and musculoskeletal disorders. People in these roles are often referred to as case managers, disability prevention specialists, or rehabilitation counsellors. There is strong evidence that face-to-face interactions with RTW coordinators reduced sickness absence duration. Coordinators also improved workplace-healthcare integration, cultural sensitivity, and understanding of workplace processes. When RTW coordinators received training, there was evidence supporting further reductions in work absence.

Leaders should be aware that alternative, non-healthcare, routes also exist for helping people return to work. For example, supported employment can be highly effective for individuals with severe mental health conditions. Supported employment follows a “place and train” model, providing on-the-job support. Individual Placement Support (IPS), a structured version integrating occupational and health services, has been particularly successful for young people and those with severe mental illnesses like schizophrenia. Building partnerships with local job organisations and having referral pathways to SE/IPS could be beneficial options for healthcare leaders to explore.

Evidence is mixed for the cost-effectiveness of RTW programmes, but there is some suggestion that spending money on good RTW programmes has good returns. A Swedish review included 10 studies assessing cost-effectiveness, and found that healthcare-based RTW interventions led to a reduction in sick leave (over five days per person per year)(2). Supporting such research is a practical step leaders can take that can benefit their organisations. Most studies do not provide disaggregated data on non-modifiable characteristics such as sex, race, ethnicity, or socioeconomic factors, so health and care leaders should support the collection of disaggregated data to help inform where and how RTW programmes can be most effective.

Designing RTW programmes that address workforce inequalities requires a strategic, evidence-based approach. By incorporating holistic and culturally sensitive practices, fostering workplace collaboration, integrating multidisciplinary support, and tailoring interventions to individual needs, healthcare leaders can create effective RTW programmes that promote equity. RTW programmes should not only focus on economic reintegration but also prioritise health, well-being, and long-term sustainability. A well-supported, diverse workforce is key to reducing employment-related health disparities and ensuring that disadvantaged individuals receive the support they need to thrive in the workplace.

References:

1. A09: Labour market status by ethnic group – Office for National Statistics [Internet]. [cited 2025 Feb 25]. Available from: https://www.ons.gov.uk/employmentandlabourmarket/peopleinwork/employmentandemployeetypes/datasets/labourmarketstatusbyethnicgroupa09
2. Grigoroglou C, Munford L, Webb RT, Kapur N, Ashcroft DM, Kontopantelis E. Prevalence of mental illness in primary care and its association with deprivation and social fragmentation at the small-area level in England. Psychol Med. 2020 Jan;50(2):293–302.
3. Nowrouzi-Kia B, Garrido P, Gohar B, Yazdani A, Chattu VK, Bani-Fatemi A, et al. Evaluating the Effectiveness of Return-to-Work Interventions for Individuals with Work-Related Mental Health Conditions: A Systematic Review and Meta-Analysis. Healthc Basel Switz. 2023 May 12;11(10):1403.
4. Mikkelsen MB, Rosholm M. Systematic review and meta-analysis of interventions aimed at enhancing return to work for sick-listed workers with common mental disorders, stress-related disorders, somatoform disorders and personality disorders. Occup Environ Med. 2018 Sep;75(9):675–86.
5. Gkiouleka A, Wong G, Sowden S, Kuhn I, Moseley A, Manji S, et al. Reducing health inequalities through general practice: a realist review and action framework. Health Soc Care Deliv Res. 2024 Mar;12(7):1–104.
6. Khatri R, Endalamaw A, Erku D, Wolka E, Nigatu F, Zewdie A, et al. Continuity and care coordination of primary health care: a scoping review. BMC Health Serv Res [Internet]. 2023 Jul 13 [cited 2025 Mar 18];23(1):750. Available from: https://doi.org/10.1186/s12913-023-09718-8

Declaration of interests

I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.