What helps people with musculoskeletal pain stay in the labour market, if they are self-employed, precarious or portfolio workers? Patients’ and First Contact Practitioners’ views

Chronic or musculoskeletal pain is defined as pain which lasts for over three months and may fluctuate or be perpetual, is often linked to musculoskeletal conditions, and is strongly linked to a wide range of poor physical and mental health outcomes such as limited functioning, and depression. Surveys suggest between 24-35% of adults report musculoskeletal pain at any time, and half state that MSK pain interferes greatly with their work.

For most people, including people living with MSK pain, ‘good’ work can protect against many psycho-social and physical problems, aiding esteem and functioning. In this context ‘good’ work means any work which is physically and psychologically safe and appropriate.

Because of the value of ‘good’ work to the high numbers of people living with MSK pain, there is great interest in supporting them to stay in, or return to, work. We already know that early individualised vocational rehabilitation can be effective and cost-effective. However, recent systematic reviews show return-to-work research mainly considers mainstream full or part-time contracts - we still know little about what helps a person in pain stay in the labour market if they are self-employed, or a portfolio or ‘precariat’ worker. Such workers may have several successive careers or concurrent different jobs, or have fluid employment patterns and contractual status, with different legal rights from the mainstream employed.

This is important as these working practices are increasing in prevalence - in the UK self-employment as a proportion of total employment grew to over 15% and almost 3 million people in the UK worked precariously prior to the COVID-19 pandemic. Post-pandemic, it is estimated that both pain prevalence and non-traditional working patterns are likely to continue increasing, so it is crucial that we understand in detail what helps people in pain in these working practices stay in the labour market.

A key issue is what kind of work and health conversations patients have with their healthcare practitioners. From 2021 many people with musculoskeletal pain will have important initial consultations with First Contact Practitioners (FCPs). FCPs are registered health professionals (usually physiotherapists) who can see patients in a primary care setting without GP referral, making the care pathway more efficient and timely. NHS Grampian has invested in a number of community based FCP roles across Aberdeen City, Aberdeenshire and Moray, and as their role develops, they will play a pivotal role in supporting the health and wellbeing of people with MSK conditions.

This project originally aimed to develop a better understanding of what people living with MSK pain, who are self-employed, or in flexible or otherwise ‘non-traditional’ work situations consider can best support them to stay in the labour market, with a focus on their FCP consultations. In parallel, we also sought the views of FCPs themselves to gain their perspective on work conversations as a potential outcome of their appointments.

The project was designed to address four related research questions:

1. What are the experiences of FCP consultations for people living with MSK pain, if they are self-employed, or otherwise ‘non-traditional’ worker?
2. What do these people consider helps or hinders their staying in the labour market?
3. What are FCPs’ experiences of conversations about good work as a health outcome when MSK pain patients are in flexible or ‘non-traditional’ employment
4. What do FCPs consider are the barriers and enablers to effective health and work conversations for these patients?

Due to difficulties in recruiting people who had experience of FCP consultations in the required working situations, we ultimately made the difficult decision to limit the focus of this study to questions 3 and 4. The questions posed under 1 and 2 obviously remain a very important piece of the puzzle, and will require further research in order to complete the picture provided by our study results, which remain important nonetheless.

We originally aimed to interview approximately 15 First Contact Practitioners and approximately 15 people living with MSK pain, either working in the practices listed above, or who wish to do so.

As indicated above, we did not manage to recruit to our cohort of workers with MSK pain, however we did successfully recruit 13 people working as FCPs across the UK, including 5 within NHS Grampian, and 8 in other areas of the UK including other parts of Scotland, England and Northern Ireland. We gathered a lot of rich data in these interviews (8 hours and 45 minutes of audio data in total), and by analysing as the interviews were conducted we were able to conclude that this data was sufficient for analysis to address the questions we wished to answer. This kind of iterative analyses uses a concept called information power whereby the researchers analyse data as soon as possible after conducting interviews, so the richness of the data can be quickly assessed. In turn, this assessment supports decisions about whether or not an appropriate sample size was reached, and is considered good practice for the kind of qualitative research we did.

Our aim in these interviews, therefore, was to explore First Contact Practitioners’ views of barriers and enablers to supporting people living with musculoskeletal pain to have sustainable working lives, when they are self-employed, work in precarious jobs or have portfolio working patterns like freelance or contract work. Interviews were semi-structured, following seven standardised questions, but allowing for additional points to be explored and the questions adapted according to the flow of each conversation.

Our interviews were transcribed, the transcripts anonymised, and the text analysed to identify important themes from our data.

We have now finished 13 interviews with our FCPs, and these have been transcribed and thematically analysed.

This analysis is now being pulled together for a formal write up, and a full publication will be submitted shortly. Once this is published it will be made available here, alongside a Plain Language Summary of the results.

What helps people with MSK pain stay in the labour market if they are self-employed, precarious or portfolio workers? FCPs’ views

Wainwright, Anderson, Morton, Hollick and Gibson

We have produced the following interim report which details some of our initial findings:

You can download a copy of the report here.

For further information about how we will use data obtained within this study, please see the relevant section of the study's Participant Information Sheet, which is available under 'How can I take part in this study' above.

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