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Return to work: a historical perspective.

I suspect that many rheumatologists in the UK are unaware that the origins of our speciality were closely bound up with government schemes to improve employment opportunities. The Second World War left behind injured servicemen and women and civilians; repairing both physical and mental damage was a priority. Large numbers of injured and unemployed workers needed assistance at a time when labour was required to rebuild the country and start to repay the nation’s debt. Experience in the services had shown that active rehabilitation could greatly increase the chances of achieving full employment after injury [1]. Departments of physical medicine were set up in general hospitals or attached to regional orthopaedic centres, to find answers and co-ordinate rehabilitation services [2 5] and employment rehabilitation units were built [6]. Initial finance came not just from the health department, but also from employment services, works departments and heavy industry. Much expertise came from the services: many of our leading lights in the 1950s, 1960s and 1970s originally held service appointments. In those formative years, the stock in trade were young adults with industrial or military injuries. Resettlement, retraining and alternative employment opportunities with assistance from employment resettlement officers in addition to the arcane crafts of the physiotherapist, remedial gymnast, occupational therapist, orthotist and psychologist resulted in multi-specialist ward rounds, requiring a very different approach to medicine. Being the wonderful thing that it is, medicine replaced these clinical problems with something new: articular disease caused by tuberculosis, poliomyelitis and the ravages of thalidomide embryopathy provided fresh multitudes of young adults with special employment problems that became a social focus. The very name of this journal, metamorphosing from the Annals of Physical Medicine, through Rheumatology and Rehabilitation to Rheumatology, says much about the change in our work, approach and expectations. The merger of a scientific society and a guild-type professional society to create the British Society for Rheumatology (BSR) also reflected the changing emphasis of the field—only the determined efforts of members brought the marriage off smoothly. A 1977 article from the British Medical Journal [7] gives us a historical insight, in a discussion of the importance of the employment resettlement officer and the changes occurring to rehabilitation staff and services. The authors were Derrick Brewerton, later President of the Heberden Society, who had already achieved worldwide fame for his team’s work on the frequency of the B27 antigen in AS and associated disorders, and Phillip Nichols, Harveian Professor and Director of the Disabled Living Research Unit in Oxford. Nichols died at the height of his influence on the Two Rs. His premature death had a profound effect on the development of rehabilitation science. Brewerton and Nichols took employment problems to heart and discuss possible answers at a time when rehabilitation was being given the cold shoulder for its perceived lack of scientific rigour. The subsequent correspondence read like a Who’s Who of early rehabilitation and rheumatology [8]. We are, however, getting ahead of ourselves; as the 1970s became the 1980s, the customers for resettlement and rehabilitation changed. Advances in orthopaedic surgery and the disappearance of infectious disease left a population of multiply handicapped children and older adults. Patients requiring employment advice—young adults post-illness or trauma—appeared to be a diminishing resource. Specialist training programmes turned to rheumatology in medicine, new sciences changed the outlook entirely and rehabilitation became concerned with the multiply handicapped and the elderly [9, 10]. During the 1960s, it became apparent that advances in social and financial support for the sick and unemployed were having unexpected consequences. Far from enabling the injured to return to work more quickly, the opposite was occurring. Time off work for a common, standard injury (Pott’s fracture of the ankle, for example) was getting longer. A re-examination of the relationship between impairment, disability and handicap was required. Rodney Grahame discussed these interlinked facts 30 years later, observing that the decline in rehabilitation services might be related to financial disadvantage for the disabled unemployed [11]. He also observed that by omission we had lost an important subspecialty group [12]. The majority of illnesses and injuries causing time lost from work nowadays are not complex cases with profound physical and mental pathologies; they are modest physical problems, and the demise of the physical medicine specialist has robbed us of a resource to observe these problems and teach their intricacies to younger doctors. My rehabilitation training in the 1970s was peppered by the word expectations. Patients’ and doctors’ expectations of illness and injury were becoming very different. The interaction between illness and time lost from work is