Sunnaas Rehabilitation Hospital, under HSØ, found this RRTW project interesting and applied for permission to establish two clinics (OPC). The scientific justification for this approach is explained in chapter 1.3.2.
The practical approaches were structured as follows:
1. A former outpatient program in Askim Hospital (under Sunnaas Rehabilitation Hospital) was extended, which included a partnership with NAV in the county of Østfold. This was realised on 15 May 2007. An emphasis was shown on the close cooperation that was possible
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between the RRTW outpatient clinic and the day care ward at the department of neurology—
musculoskeletal disorders (NMS), both at the Askim Hospital.
2. A new outpatient clinic in Oslo, ready on 15 September 2007, is not included in this study.
The outpatient clinic in Askim had a multidisciplinary team consisting of a physician (specialist in neurology, physical medicine or occupational medicine), psychologist,
physiotherapist, occupational therapist, social worker, nurse and others if necessary.
The intention was that NAV should have a representative present at the clinic that could be an advisor and coordinator of the measures concerning NAV. At that time (2007), NAV was undergoing a significant reorganisation and was unable to get stable staffing of this feature.
Medical doctors in Østfold County were briefed on the upcoming offer in May 2007, and in the middle of August an information and recruitment campaign to the GPs was started in the county in cooperation with NAV. A recruitment brochure of the offer was distributed, and meetings in several parts of the county were held in cooperation with the NAV county office and the Østfold Medical Association.
GPs were asked to refer individuals in danger of going on sick leave, patients with skeletal muscle and minor mental disorders, preferably at eight weeks of sick leave or at least sick leave within 52 weeks. People who were on arrangements/follow-up when the sick leave period ended and who had an assumed ability to work were also invited to the OPC. As a result, two approaches were outlined (9):
a) Interdisciplinary outpatient review over the course of one day.
b) Day patient care with multidisciplinary consultative and treatment programmes focused on training, learning and mastering.
The scientific basis for these objectives is summarized in chapter 1.3.2. More is written about “interdisciplinary”, “multidisciplinary” and “brief intervention” in chapter 2.1.2 and 2.2.5 below.
The aim was to contribute quickly to the efficiency of the medical reports, clarify the case for treatment, and give advice to NAV regarding the degree of capacity for work and implementation of this study. To the extent necessary the OPC should be in contact with the family doctor and company health service and communicate with NAV and the employer.
The OPC could take action, referring directly to other monitoring bodies in the Sunnaas Rehabilitation Hospital system or other rehabilitation centres.
Responsibilities and roles between the RRTW OPC, the Sunnaas Rehabilitation Hospital NMS department, and NAV were planned. The OPC informed GPs in the county,
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the company health service and NAV and took care of patient data and coordination by dissemination of individual information. From the GPs the individuals were referred to a current diagnostic and treatment agency or to the OPC if there were an agreement between GP’s and the OPC on that. The OPC investigated, and if necessary, the patients were referred to another specialist or treatment centre.
The OPC gave feedback to GPs, invited region contacts to meetings on individual clients when necessary, and gave feedback to NAV through a Feature Report. The allocated project funding provided was used for activities under these guidelines.
The government’s task fitted well with the research strategy for the South-Eastern Norwegian Regional Health Authority, and Sunnaas Rehabilitation Hospital aimed to provide new knowledge on preventing long-term sickness absence. The project also fitted well with national research strategies, in which musculoskeletal and minor mental diseases were proposed to be given more attention. The present project was also a part of the research strategy at Sunnaas Rehabilitation Hospital. Apart from an initial fundamental benevolence for a research project, the Government mentioned nothing about the desirability of a research-based evaluation of the project, and there were no funds allocated for such measures. As a result, such an opportunity was specifically requested in a letter to RHA and the Ministry of Health and Social Affairs on an attempt to raise funds for a scientific evaluation of their part of the RTW-project. However, no funding was provided, see also chapter 2.1.2.
A corresponding OPC service, such as this one was not common in the health service in Norway when the OPC opened in 2007. A service such as this was demanded by medical doctors, NAV (the National Social and Welfare Administration) and employers. The National Centre, AiR—the national centre for work-oriented rehabilitation in Rauland had the benefit of a multidisciplinary approach (10) from an inpatient setting. Our project was based on an outpatient, short intervention setting with a return to work as the endpoint.
In 2013, the Ministry of Labour Affairs arranged an expert conference on the “Effect of measures under the IA Agreement”. The Faster Return to Work scheme was to prevent long-term sickness leave due to waiting periods for clinical services provided by secondary health care. The conference grumbled that the attempt in 2007 to organize the FRW scheme as a trial with a control group was not performed. Evaluations of the effects were difficult, and in our study we had to base the evaluation on registry data of sick‐listed patients being treated for similar conditions within or without the FRW scheme (11).
21 1.1.4 No randomization allowed
Budgets for the RTW projects were planned by the government for each year. The RTW project was initially not planned to meet research demands, and a scientific evaluation was not a part of the OPC mission. Our applications for financing of a scientific follow-up were denied, and we had to carry out the OPC work as an ordinary continuous clinical job without special arrangements or scientific design.
A correct randomizing of the groups would be in conflict with the national RTW programme, and also possibly outside the limits of what is acceptable from ethical considerations, departing from political and administrative presuppositions. Due to this history as a clinical project, a randomized trial would not be within limits of what was accepted for the assignment.