E-19 Vocational Rehabilitation
Systematic rehabilitation was probably first developed to return injured soldiers to work. The UK government still emphasises the need for ill people to return to work. Unfortunately, the same government has significantly cut rehabilitation and other health services, increasing retirement or unemployment secondary to illness. Expert vocational rehabilitation services are now rare within the NHS. Nevertheless, returning ill people to work benefits patients; health is improved, poverty is reduced, and social integration is increased. Thus, despite the lack of specialist service, or perhaps because of that lack, it is imperative that all rehabilitation professionals are competent in assessing and advising on work to serve their patients better. Unsurprisingly, liaising and collaborating with other agencies and organisations are vital. Particular attention must be paid to conflicting interests; employers want as much work as possible, patients need money, and both parties seek your support for their cause. Helpful evidence is scarce. Last, although the explicit priority is paid employment, the clinician should also consider other activities that provide similar personal and health benefits, such as education, vocational retraining, voluntary and other unpaid work, and productive leisure pursuits such as art and pottery.
Table of Contents
The Vocational Rehabilitation competency
The expert rehabilitation professional must be “Able to give advice on a patient’s ability to work, and to liaise with employers and other about adaptations needed in work and in the physical environment, and to advise when specialist input is needed.” As part of their holistic approach, they should also consider how the many benefits of employment can be met if paid employment is no longer an option for a patient. A document summarising the indicative behaviours, knowledge, and skills associated with this competency can be downloaded; it includes some references.
Introduction
Maslow’s theory of human motivation identifies five core needs that motivate people and maintain motivation:
- Physiological needs to satisfy core basic bodily needs such as hunger and thirst,
- Safety needs to ensure that the person is secure, including physically (a home) and able to survive in society having sufficient resources and support (money),
- Love or affiliation needs, developing and maintaining close, emotionally-satisfying relationships with other people,
- Esteem needs, to be recognised and appreciated by other people as being of value and contributing to society,
- Self-actualisation needs, the achievement of one’s self-perceived potential in some role or roles.
Work, especially paid work, helps someone fulfil the last four of these needs and, through providing money, indirectly ensures that physiological needs are also satisfied. This may explain why being employed in work is associated with better physical and emotional health.
This theory also highlights the responsibility of rehabilitation professionals to enable people whose illness limits or prevents illness to satisfy these needs in other ways. Further, it shows that society should provide sufficient support to meet physiological and safety requirements. Failure to do so will likely cause distress, stress, and ill health.
Broader aspects of vocational rehabilitation.
Competency in vocational rehabilitation will inevitably involve many other considerations.
Occupational health services are specialised in supporting ill people in maintaining their employment – “Occupational health (OH) maintains the wellbeing of employees, preventing and removing ill-health and developing solutions to keep staff with health issues at work. OH professionals provide independent advice on staff unable to work due to long-term or short-term intermittent health problems, and organisational wide steps to reduce sickness absence.”
Rehabilitation services must work closely with occupational health services when they are available. The following points should be recognised:
- Occupational health services are not available in every workplace, especially small businesses, and are not available when someone is self-employed
- Occupational health will only be available to people who were in employment when they became ill
- Rehabilitation professionals usually have more expertise in managing disability, whereas occupational health has more expertise in employment matters, highlighting the importation of close liaison and collaboration.
Occupational health literature contains much that is relevant to rehabilitation, for example, a statement that “The benefits of occupational health can accrue to all involved stakeholders – employees, enterprises, healthcare payers, and society – most importantly through gain in employee health, reduction in absenteeism, presenteeism, and healthcare costs, and improvement in reputation.”
Next, the rehabilitation professional must recognise their responsibilities to the patient, the employer, and society as represented by any organisation providing support such as a disability pension or financial support to remain in work. They must always consider their legal and ethical position, drawing on rehabilitation generic capability two, seeking advice from others whenever they are uncertain about the correct decision.
Third, given that many people cannot work because of their illness, the rehabilitation professional must consider alternatives to paid employment that will satisfy the person’s needs. Perhaps the crucial need is to avoid social isolation and loneliness. The rehabilitation profession should consider and know about the following:
- Sources of financial support and other resources for unemployed people. This extends well beyond state-provided support. For example, charities associated with the person’s previous work may provide equipment or social opportunities, existing insurance policies may provide money, and prior employers may sometimes provide support.
- Opportunities to retrain or learn new skills that lead to employment.
- Voluntary work, usually unpaid but often quite challenging and offering social contact.
- Leisure pursuits offering appropriate interest and social opportunities.
Last, one must be aware of the political aspects. For example, some people consider that the biopsychosocial model of illness is used to blame people for being out of work. The model is not the cause of the alleged abuse and can equally be used to help and support patients. Unfortunately, political decisions significantly influence employment and tend to penalise failure rather than reward success.
When interacting with a patient, one should focus on professional matters and avoid expressing opinions about specific decisions or reported activities. On the other hand, in broader settings, one may influence policies that will affect patient outcomes. For example, an independent evaluation of the Work Capability Assessment used in the UK from 2010-2013 suggested its use was associated with severe adverse consequences on applicants’ mental health, including six additional suicides in every 10,000 people assessed.
Effectiveness
A recent 2023 guideline from the British Society of Physical and Rehabilitation Medicine, Vocational Rehabilitation. BSRM brief guidance considers the limited evidence on the content and the effectiveness of vocational rehabilitation. An undated report, Vocational rehabilitation. What works, for whom, and when? written by a government-funded Vocational Task Group also considers the limited evidence.
Joanna Fadyl and colleagues reviewed the evidence concerning people with mild to moderate mental health problems. The evidence was weak, suggesting an effect probably of little significance. In some countries, inpatient vocational rehabilitation is offered. A randomised trial in Norway studying 168 patients failed to find benefit from an intensive multi-component programme (two four-day stays). A review of services for people with learning disability only found one randomised trial, but the data from nine other studies suggested some possible approaches.
Most published research on vocational rehabilitation is derived from observational studies investigating the epidemiology and natural history of sickness absence or loss of employment due to illness. The research has also investigated prognostic factors, identifying ‘red flags’ for a less promising outcome, and has described services.
Research into vocational rehabilitation, especially trials investigating its effectiveness, is challenging because no one accepts responsibility for the service. Health services have other pressing problems and are not inclined to give vocational rehabilitation a high priority. Research is expensive. Many incidental factors can affect the outcome, hindering interpretation. Most research studies natural history and prognostic factors.
Clinical aspects
A recent research study highlights the challenges faced in the UK when people need vocational rehabilitation after major trauma. Strikingly and tellingly, the research team could not find an employer willing to participate in the research! They identified the vital role of the social context, primarily as a barrier: “The key barriers were: cultural norms within healthcare and employing organisations, the extent to which healthcare systems were networked with other organisations, poor transition between different organisations, and failure to recognise VR as a priority, often as a result of policies and funding.”
The same group have also studied telerehabilitation techniques in vocational rehabilitation after trauma. The difficulties associated with technology were a significant problem, and the absence of seeing people in their home and employment settings were two areas of concern. Still, the flexibility and efficiency of remote working were two advantages.
The most significant practical challenge arises from the chaotic, unorganised nature of services available to people needing vocational rehabilitation; this has been illustrated dramatically for patients seen after trauma by Jade Kettlewell and her colleagues.
The rehabilitation professional can still make a big difference without readily available vocational rehabilitation services. The vital first step is to consider employment when seeing any adult patient. Then you need to:
- Gain some understanding of the work and the abilities required to undertake it,
- Discuss the person’s wish to continue in employment,
- Ask about contacting the employer, especially any occupational health service they have,
- Consider what locally available resources you could get or use.
Driving a car is often crucial to get to work and often as part of work. Consequently, it would be best if you also discussed this. The UK Driver Vehicle Licencing Authority (DVLA) produce a useful guidance booklet, freely available.
The recent 2023 guideline from the British Society of Physical and Rehabilitation Medicine, Vocational Rehabilitation. BSRM brief guidance outlines and gives the knowledge and skills expected of a trainee in Rehabilitation Medicine. Other professions may focus less on medical factors and more on factors specific o their job, but most of the advice is applicable across occupations. The Vocational Rehabilitation Association (VRA) also has useful information on its website. More specific details on the indicative behaviours expected and the knowledge and skills needed can be seen in this document.
Conclusion
Work, paid or unpaid, is a vital aspect of life for many people, with many practical and health-related benefits. Unfortunately, the patient’s ability to work has a low priority in health services and statutory services such as the Department of Work and Pensions is concerned primarily with finances. Their services do not include any integral health or rehabilitation expertise. Some patients have access to Occupational Health services which will have some vocational rehabilitation expertise, but many patients do not. The expert rehabilitation professional must consider employment in all patients seen. When entering or retaining employment is possible, they should identify what local resources they can use and support the person in their effort. When work is impossible, the professional must consider alternatives to meet the person’s needs for personal financial security, social contact, active, fulfilling roles, and achieving their broader life goals.
