Vocational rehabilitation

An all-too common effect of sickness or disability is exclusion from the world of work, and thus from ordinary society. To counter it, an approach now favoured by disability rights groups,¹ the Government² and the health professions^3,4 goes under the name of vocational rehabilitation, the aim being to facilitate working for those who are willing and potentially able. The strategies can be described as top-down and bottom-up.

Top-down approaches to vocational rehabilitation relate to government policy, and were reviewed earlier this year by the Organization for Economic Co-operation and Development (OECD).⁵ The report outlines the strategies used by member states to meet two potentially conflicting goals—to enable people with disabilities to participate optimally in society (and particularly to engage in gainful employment) and at the same time to ensure that those unable to work have income security. So what can governments do? The report calls for recognition that the status of disability is independent of an individual's ability to work; that those with disabilities have obligations to society as well as the reverse; that, to achieve employment, many need individual work/benefit packages; and that employers are crucial to this process.

An important driving force is the need to maximize the workforce, now shrinking in relation to the population of old or sick or disabled people requiring support. So governments are offering financial incentives to facilitate employment and trying to remove financial disincentives. The legislative approaches differ from country to country. In Austria, Denmark, Spain, Sweden and Switzerland a request for benefits is automatically treated as a request for vocational rehabilitation; in Germany, Norway and Poland, the degree of compulsion is slightly less; whilst in Australia, Canada, France, Italy, Korea, Mexico, Portugal, the UK and the USA vocational rehabilitation is entirely voluntary.

For health professionals, the vital message of the report concerns early intervention—the most effective measure against long-term ill health and consequent dependence on benefits. In this respect the strategy usually pursued in the UK, whereby the patient's possible return to work is considered only after completion of medical care, has come in for strong criticism.³ By contrast, Germany requires vocational rehabilitation to be part of the process before, during and after medical rehabilitation.

Increasing numbers in the UK are receiving incapacity benefits (now nearly 2.7 million) and efforts to halt or reverse the trend include strategies for minimizing work-induced injuries and illness;⁶ NHS Plus as a potential occupational health scheme for the many workers not covered by such schemes; ‘Pathways to Work’ (based on recognition that unresolved health issues, in conjunction with other factors, create barriers to returning to work);^2,7 and job retention and rehabilitation pilot schemes whereby health and employment agencies combine to help people with illness or injuries to continue with or return to work.²

What about bottom-up approaches? The OECD did not comment on differences in health provision but, according to one analysis, the escalation in disability benefits in the UK could be due to the decline of rehabilitation services.⁸ Rehabilitative approaches are bottom-up in that health professionals (particularly rehabilitation teams) work with employers, the local employment office and the voluntary sector to obtain a rapid reintegration of a person with a medical condition or disability into work.^3,9 Though the OECD document recognizes that many with disabilities are able to work, it barely acknowledges the fact that people with long-term illness, who do not necessarily consider themselves disabled, commonly require vocational assistance to remain in employment.¹⁰ There is a window of opportunity:^11,12 at first patients see themselves as ‘sick’ but with the prospect of returning to work; later they see themselves as ‘disabled’ and consequently unable to do so.¹³ The first phase is thought to last 2-4 months and is the time at which vocational rehabilitation is most likely to be effective through psychological and multidisciplinary management.^13,14

What does bottom-up rehabilitation demand of health professionals? First, all must recognize a responsibility to assist ill or disabled people back into work where practicable^9,15—a culture largely lacking in the NHS.³ Secondly, general practitioners and the primary health care team are pivotal^3,16,17 through their clinical management and their provision of sick notes which trigger or perpetuate absence from work.¹⁸ Good communication is crucial—particularly between general practitioners and occupational health physicians.¹⁸ Poor communication often results from a lack of clear rehabilitation goals from the outset. This in turn derives from the fact that, in many countries the world over, the management of work disability has not been viewed as an important part of medical practice outside the specialties of rehabilitation and occupational medicine. The Canadian Medical Association and the American College of Occupational and Environmental Medicine have both produced position statements setting out the physician's role in helping patients return to work.^9,15 In the UK a working group of the Society of Occupational Medicine, with other stakeholders, is proposing to draw up a similar statement. Employers, of course, carry great responsibility in these matters,¹⁹ especially by maintaining contact with their employee and supporting the rehabilitation strategies.⁹

In summary, top-down policies are important but cannot succeed without bottom-up efforts by health professionals and employers. All health professionals should seek to give positive advice about return to work before negative attitudes are formed. Where available, occupational health practitioners can give much assistance through job modification in arranging a phased return to work and support after return to work.²⁰ In addition, both the British Society of Rehabilitation Medicine and the Royal College of Psychiatrists are calling for designated health professionals, ‘vocational rehabilitation specialists’, with the legal and practical knowledge to navigate the difficult waters between employment and health.^3,17 Vocational rehabilitation is not merely of economic importance: it transforms lives.

Note AOF is a Medical Adviser for Kynixa Ltd. PS is a Principal Medical Adviser to the UK Department for Work and Pensions; the opinions expressed are personal.