Navigating policy clashes and conceptual confusion in RTW

Background

The Social Insurance Agency and the healthcare system are differently governed by policies and institutional regulations and by organizational, economic, and professional drivers. Conceptual divergencies, policy and practice inconsistencies, as well as norms and values, make collaboration between stakeholders challenging. Incongruences may affect communication and decisions and risk jeopardizing clients’ rights and access to equal treatment. Capacity to work is a key concept in RTW and illustrative of these challenges. Although its clinical assessment is complex, it is evaluated as an objective clinical measure as the basis for RTW (Return to Work) in social insurance. Moreover, professional discretion differs between the Social Insurance Agency and healthcare system, thus influencing policy implementation and collaboration.

Aims

To explore how structural factors, policies, concepts, institutional practices and underlying norms and values influence RTW after sick absence with common mental disorders and collaboration between stakeholders. To analyze time until RTW in relation to changes in social insurance regulations and to rehabilitation measures for RTW.

More specifically we will:

1. Explore (in)consistencies in the definition and interpretation of key concepts in policy documents for RTW between and within stakeholders.
2. Explore how policy is interpreted and translated into practice at the street-level, hereby being filtered through institutional understandings and work practices.
3. Assess time to RTW after sickness absence with C MD (common mental disorders) or MSD (musculoskeletal disorders) in relation to changes in social insurance regulations between 2000 and 2025.
4. Assess time to RTW among individuals on sickness absence with C MD or MSD, comparing those who participated in vocational rehabilitation measures with those who did not.

Study design and methods

We will use both quantitative and qualitative methods:

1. A critical analysis of policy documents published in the National Board of Health and Welfare, the Swedish Association of Local Authorities and Regions, and the Social Insurance Agency between 2000 and 2025 to explore how key concepts (e.g., capacity to work and vocational rehabilitation) are constructed, and understood (e.g., explicit or implicit underpinnings).
2. Ethnographic methods including researcher participation in the Social Insurance Agency to observe and analyze how the professionals work and interact within and between their organizational and institutional contexts, capturing experiences and real-life challenges of the use of RTW policies, that possibly diverge from formal policies.
3. Epidemiological, quantitative methods will be used based on register data from LISA and MiDAS including time to RTW in sickness absence with C MD or MSD from 2020 to 2025. Analyses will be stratified on age, gender, income groups and certification diagnoses.
4. See item 3.

Expected results will lead to new knowledge informing design and content of interventions to prevent long-term sickness absence and promote RTW and sustainable and equitable RTW.

Participants

Prof. Gunnel Hensing, School of Public Health and Community Medicine, University of Gothenburg (PI)
Prof. Kerstin Jacobsson, Department of Sociolgy and Work Science, University of Gothenburg (co-PI, objective 1 & 2)
Prof. Mattias Bengtsson, Department of Sociolgy and Work Science, University of Gothenburg
Associate Professor Rasmus Broms, Department of Political Science, University of Gothenburg