A vocational rehabilitation model using occupational therapists challenges traditional OH approaches. Gerald Mcfeely explains.
An innovative model of vocational rehabilitation is being piloted by NHS Lothian aimed primarily at employees returning to, and seeking to stay at, work in Lothian's small and medium-sized enterpirises (SMEs). The pilot challenges some key aspects of the underlying assumptions for delivering occupational health provision in the UK.
The service, one of the main Fit for Work providers in Scotland, is integral to GP efforts in Lothian to achieve return-to-work outcomes given recent policy proposals on workplace absence from Dame Carol Black ("Review of sickness absence", 2011, Black et al; Working for a healthier tomorrow, 2008, Black).
Working Health Services in NHS Lothian (WHSL) (Hanson et al, 2011) is led by occupational therapy services and is one of the national partners in the Fit for Work provision funded by the Scottish Government and the Department for Work and Pensions. It became part of the Scotland-wide Working Health Services model in 2010. The service is the single point of access for GP referrals for vocational rehabilitation services in Lothian, which fits neatly with the introduction of the fit note.
The original objective of the service was to provide an early intervention and case-managed vocational rehabilitation service to employees working in SMEs (companies with fewer than 250 employees) in Lothian, who were unlikely to have access to occupational health services and were at high risk of losing employment.
Strategy and practice
The service comprises a multi-disciplinary team with a case-management core and service delivery from dedicated occupational therapists, physiotherapists and counsellors. NHS Lothian has also chosen to accept, uniquely among health boards in Scotland, self-referrals from people working for larger employers.
The main criteria for accessing the service are age, employment status and nature of the health condition."
The NHS Working Health Services Scotland model is based on self-referral. While care has been taken to promote the availability of the service among SME employers within Lothian, employers can only make an employee aware of the service and encourage them to attend. Mandatory referral by employers is not permitted. Thus, the service is described as a vocational rehabilitation service rather than an occupational health service, which risks confusion with employer-based OH provision. Referrals can also come from within the NHS, including GP referral.
The main criteria for accessing the service are age, employment status and nature of the health condition. The focus is on mild to moderate common health problems associated with two-thirds of sickness absence from work in the UK (Black, 2008; Waddell et al, 2008; Health works: a review of the Scottish Government's healthy working lives strategy, 2009), predominantly mental health, musculoskeletal and cardiorespiratory.
Cases are enrolled and assessed through a telephone- and web-based data system. They may then be referred to an occupational therapist, physiotherapist or counsellor. A case manager is also appointed, who will follow up at three and six months to monitor work progress, which provides longitudinal data about effectiveness of outcomes and return to work.
Various team members may have an input throughout the process. Recent independent research (Hanson et al, 2011) shows that the service has good outcomes, with 83% of those absent on entry being at work when discharged, and 95% of clients who were at work on entry still being at work on discharge.
Vocational rehabilitation is related to occupational health but it is not the same thing. Recognising this difference in approach is critical to the success of WHSL's service delivery. From the user's perspective, it provides clarity on what they can expect from an NHS service where their rights and entitlements, as with any other patient-focused service, are paramount. WHSL adopted well-established concepts specific to vocational rehabilitation (College of Occupational Therapists, 2011; Vocational rehabilitation standards, 2011; Ross J, 2009; Holmes J, 2007) so that service users and referrers did not misinterpret the function of NHS vocational rehabilitation with OH.
Although vocational rehabilitation is clearly compatible with the key aspects of condition-management programmes, absentee-management systems and occupational health provision, the underlying philosophy of vocational rehabilitation as conducted by the NHS is different. While an employer cannot force an employee to use an occupational health service, failure to comply with a referral to occupational heath may lead to a breach of the employee's employment contract, or affect an employer's disciplinary, sickness absence and capability procedures. Indeed, the referral may be part of these processes, and may be viewed as such by the employee.
NHS vocational services have the facility to deliver multi-disciplinary treatments for as long as is necessary to case-manage the person back to work."
Where the health condition arises out of the workplace, the employee may lack trust and confidence in the employer-based services designed to help them. By contrast, referral to WHSL is on a voluntary basis by the employee. This may have an impact on the employee's relationship with the service compared with that of an OH provider.
Another key difference is that NHS vocational services have the facility to deliver multi-disciplinary treatments for as long as is necessary to case-manage the person back to work. These fundamental differences have allowed the service to develop innovative practices.
Similar issues of trust and confidence relate to the service's relationship with GPs. The difference in the relationship with clients is of special importance to referring GPs, in particular the neutrality of the service, and that a referral represents a continuum in access to NHS services.
GPs' confidence in the service enables the scheme to assist them in determining and addressing work capabilities, safe in the knowledge that this does not compromise their relationship with the patient. Together with the employee, and using information gained from both the case-management and rehabilitation process, the service can determine whether a client should remain absent from work, return with suggested adjustments, or, with proactive assistance, return to the workplace as normal.
The fit note has left GPs with new responsibilities for determining the adjustments that will allow an employee to return to, or remain in, work. Managing a patient's absence from work often requires more than a medical determination. This supports Dame Carol Black's hopes for the positive assessment of what employees "can do" to retain employment and reduce absence.
By contrast, even when OH provision is available, this does not usually provide the detailed analysis required to determine the answer to these questions, or provide the support to GPs, employees and employers required to address it.
Rehabilitation and occupational health
The approach challenges well-established occupational health services. In reality, OH services in the UK remain, in large, a service paid for by the employer - and the employee has little control. OH providers need to recognise and consider the potential conflicts between their role in rehabilitating employees and their role as service providers for employers.
Achieving a successful vocational rehabilitation outcome may involve challenging the employer's view about the employee, and about what they should/could provide, or do to achieve the preferred outcome. Recognising these challenges has the potential to improve outcomes for both employees and employers from a broader policy perspective of challenging absenteeism and retaining people in employment.
However, the WHSL is not intended as a substitute for occupational health provision. It does not seek to take on the cost burden or responsibility from employers and their OH service provision. Where a client refers to the service and has access to an adequate occupational health provision, with the client's consent, an attempt will be made to aid access to that provision. Where the provision does not appear adequate, this will be raised with the provider.
WHSL identified that assisting clients to begin a dialogue with employers or their OH providers could be critical to a successful intervention."
Over the past two years, about 1,100 referrals have been made to WHSL. About 60% of the clients were self-employed or from SME companies, and around 40% came from large employers, in the public and private sector. An analysis of clients attending the service in the first year has demonstrated that many complex interactions occur between employees, employers and health professionals.
First, of those employed by non-SMEs, about 40% of referrals had, rather surprisingly, no access to OH provision or their needs were apparently not sufficiently well met by the employer's response to the health problem. Second, it became apparent early on that healthcare interventions alone were not always enough. Many cases raised employment law issues concerning the client's health and disability.
A "learning needs evaluation" of vocational rehabilitation staff identified employment law as an area where practitioners needed more knowledge (NHS Scotland, "Vocational rehabilitation learning needs analysis", 2011).
WHSL identified that assisting clients to begin a dialogue with employers or their OH providers could be critical to a successful intervention. This might be because clients should be treated as having a disability in terms of the equality legislation (Equality Act 2010), or because the employee was engaged in a dispute with their employer about absence from, or return to, work, or because the employee saw their workplace as the source of their health problems.
Mediation is increasingly recognised as a means to address the need for early intervention in the resolution of disputes in the workplace ("Resolving workplace disputes", Bolt K, 2010). It is a formal process using an independent third party to assist voluntary participants to find an agreed resolution to their differences. NHS case managers within vocational rehabilitation cannot act as mediators in the formal sense; however, the skills and judgment used by mediators can be vital in assisting a client in the workplace. The NHS professional is able to provide an independent view of what is inhibiting an employee from attending or performing their work and this can form the basis for a non-adversarial dialogue between the employee and the employer.
WHSL intervenes on behalf of the employee to support discussions with an employer to retain an employee in employment, while maintaining an independent view. GPs have responded positively to this as they do not have the time or expertise to do it themselves.
While many cases simply involve encouraging a dialogue, others need a functional capacity assessment report by an occupational therapist or a workplace visit to facilitate discussions about workplace needs and reasonable adjustments. Each case is different. The main difference in the WHSL approach compared with traditional OH services is to provide a robust follow-up that brings the employer and employee to agreement on what is needed to maintain employment. In the era of OH outsourcing, there may be little incentive for an OH provider to alienate the commissioner of the OH contract by focusing too heavily on employee needs.
Trade unions, have long advocated union input given that it is employees who are recipients of the care being purchased.
Arguably, absence from work and conflict might be lessened by earlier inclusion of staff-side representatives. It is important to recognise that in large employers with OH provision, HR is responsible for equality compliance so, ultimately, NHS vocational rehabilitation issues may need to be directed to HR.
The main difference in the WHSL approach compared with traditional OH services is to provide a robust follow-up that brings the employer and employee to agreement on what is needed to maintain employment."
WHSL has acquired a working knowledge of disability law through collaboration with a local trade-union-based organisation called Support@Work. This partnership arose out of an Edinburgh employability network called Joined Up For Jobs.
WHSL staff became aware that the definition of disability in equality legislation covers a far broader range of medical conditions, both physical and mental, than might be routinely understood by healthcare professionals, employees and employers. WHSL staff are aware that there may be underlying workplace issues as a reason for a client's absence, and recognise that clients may be in conflict, with their employer and the OH provider.
GPs in Lothian are beginning to recognise that Working Health Services helps to provide a new way of resolving such issues, and conceivably sees WHSL as the "clearing house" through which a range of services are a phone call away. Given that employees self-refer to WHSL on a voluntary basis, it is in a unique position to gain the trust and confidence of clients who are themselves taking a proactive approach to resolving their health and disability needs in the workplace.
The NHS WHSL model demonstrates the dichotomy between the broader policy objectives of reducing employee absenteeism and retention of employment through effective vocational rehabilitation and the daily reality of management decisions being made by employers on health and capability issues with the assistance of their occupational health providers.
All those involved need to examine if a more interactive relationship can be established between all health providers, whether they are vocational rehabilitation specialists or occupational health.
Gerard Mcfeely is occupational therapy project manager at Working Health Services in the vocational rehabilitation service at NHS Lothian.
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