Getting Vocational Rehabilitation Working for Scotland

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					Getting Vocational Rehabilitation
Working for Scotland:
Education Needs of Staff Supporting
Vocational Rehabilitation

A Discussion Document
March 2008

Introduction                                                                   2

Purpose of the Document                                                        2

Introduction to the Concept of Vocational Rehabilitation                       3

Identification of Those Individuals Most Likely to be in Need of Vocational
Rehabilitation                                                                 6

What Education is Currently Available in Vocational Rehabilitation?            9

Review of the Literature Around Vocational Rehabilitation with Particular
Reference to Education and Training                                           12

Summary                                                                       24

References                                                                    25

Appendices                                                                    29

                                                                                   Education Needs of Staff Supporting Vocational Rehabilitation

This discussion document addresses the issue of rehabilitation in response to the
publication of the Scottish Executive’s framework document Co-ordinated, integrated
and fit for purpose. A delivery framework for adult rehabilitation in Scotland (the
Framework) in February 2007. The Framework targets three particular groups: older
people, people with long-term conditions and those returning from work absence
and/or aiming to stay in employment. It is the last group that this document focuses
on in relation to vocational rehabilitation. In particular it addresses the education and
training of NHS staff responsible for providing vocational rehabilitation services. The
perspective of other participants in vocational rehabilitation is acknowledged and the
significant contributions of voluntary and charity organisations and patients and their
carers in the field of vocational rehabilitation education needs to be explored further.

Purpose of the Document
In terms of action, the Framework requires that:

NHS Education for Scotland in partnership with NHS Boards, local authorities and
higher education/further education institutions, needs to support the development of
undergraduate and postgraduate education and training for health and social
practitioners and for support workers to underpin effective multi-professional team
working and facilitate self-management/enablement approaches within health and
social care. (Scottish Executive, 2007. p49)

The aim throughout the document is to pose questions and stimulate discussion as
to how this can best be achieved by identifying the issues, problems and challenges
involved in supporting education and training in vocational rehabilitation. In providing
answers to these questions the desired outcome will be a consensus on the best
way forward for training and education for healthcare staff. It is likely the training and
education needs of staff outside the NHS providing vocational rehabilitation services
will not be too dissimilar to those of healthcare staff. In generating discussion around

                                                                                             Education Needs of Staff Supporting Vocational Rehabilitation
these issues it is hoped that this process will open up a collaborative dialogue among
the many agencies involved in providing vocational rehabilitation services.

A literature review has been conducted to identify particular education and training
issues. The purpose of this initial discussion document is to inform a final report
which will reflect the views of the wide audience we wish to consult in drawing upon
their expertise in providing vocational rehabilitation services.

The document is divided into the following sections:

1. Introduction to the concept of vocational rehabilitation, including the policy
2. Identification of those individuals most likely to be in need of vocational
3. Scope what education is currently available in vocational rehabilitation.
4. Review the literature around vocational rehabilitation with particular reference to
   education and training.

1. Introduction to the Concept of Vocational Rehabilitation
Benefits of Work

The benefits of working, where health permits, for sick and disabled people have
been established as:
• it is therapeutic
• it helps to promote recovery and rehabilitation
• it leads to better health outcomes
• it minimises the harmful physical, mental and social effects of long-term sickness
• it reduces the risk of long-term incapacity
• it promotes full participation in society, independence and human rights
• it reduces poverty
• it improves quality of life and well-being

(Waddell and Burton. Is work good for your health and well-being? The Stationery
Office. London, 2006. p. viii)

Vocational rehabilitation has been described as a process whereby those disadvantaged
by illness or disability can be enabled to access, maintain or return to employment, or
other useful occupation (British Society of Rehabilitation Medicine, 2003).

Key elements of vocational rehabilitation have been identified as the:
• Assessment of functional, physical, psychological and cognitive work capacity
• Vocational assessment and counselling to determine suitable job options
• Counselling to support adjustment to disability
• Supervised on-the-the job training and/or a short vocational course
• Fitness and work conditioning programmes
• Confidence building/self-esteem groups or individual sessions

                                                                                          Education Needs of Staff Supporting Vocational Rehabilitation
• Assessment of workplace suitability
• Development of skills for job seeking
• Brokerage and case management
• Linkage with community-based agencies

(Scottish Executive, Co-ordinated, integrated and fit for purpose.       A delivery
Framework for Adult Rehabilitation in Scotland, Edinburgh, 2007. p35)

  Discussion Point 1

  The contribution of work for health and well-being has been established. How do we
  promote this message to NHS staff in supporting vocational rehabilitation?

The Policy Context

Vocational rehabilitation has become a priority area for government encompassing
policy initiatives in the areas of employment and health.

Employment is a reserved power giving Westminster control over policy in this area.
The Department for Work and Pensions (DWP) has the responsibility for developing
national policy to help those in the target groups enter and maintain employment.
National policy is translated into initiatives undertaken by the Scottish Government
which take into account the particular Scottish context. In contrast health is a
devolved power giving the Scottish Government full locus over its direction and
policy in Scotland.

In terms of employment the rationale for vocational employment is set out by the
DWP in Building Capacity for Work: A UK Framework for Vocational Rehabilitation
(2004). The UK framework builds upon a number of related employment
programmes which target those with health problems and assist them enter or
maintain employment.

The New Deal for Disabled People (NDDP) is the major employment programme
helping incapacity beneficiaries get back into the workforce. It is a voluntary
programme where disabled people contact an approved job broker who works as a
case manager to find suitable employment. The job broker has no involvement with
rehabilitation, but does assist with potential barriers to working such as mobility

The Job Retention and Rehabilitation Pilot (JRRP) was used to test three alternative
interventions aimed at achieving a return to work for a period of at least three
consecutive weeks by addressing either workplace or health issues or a mix of both.
A control group was also measured. The result was no significant differences
between any of the groups. However, active case management which empowers

                                                                                          Education Needs of Staff Supporting Vocational Rehabilitation
clients to take action was a valued feature of a vocational rehabilitation service.

The Pathways to Work scheme was a Jobcentre Plus programme which focussed on
Incapacity Benefits Personal Advisors role in getting people back into the workforce.

The Scottish employment context is articulated in Workforce Plus: An Employability
Framework for Scotland which was published by the Scottish Executive in June
2006. It sets out how organisations can better work together at a national and local
level to improve support for those facing barriers to employment, including people
with disabilities. Its main aim is to help 66,000 Scots off benefits and into work by

In terms of health, the policy imperative for vocational rehabilitation was outlined in
the Kerr Report (Building a Health Service Fit for the Future, Scottish Executive, May
2005) which signalled a move from an acute hospital-driven service to one that is
embedded within the community, is patient focused and is based upon a philosophy
which moves from ‘care’ to ‘enablement’. The Kerr Report received cross-party

support and the then Scottish Executive developed its healthcare policy based on its
recommendations in Delivering for Health (Scottish Executive, October 2005). In
particular Delivering for Health called for “a rehabilitation framework to support
services for older people, people with long-term conditions and people returning to
work after a period of ill health. The framework will promote a co-ordinated approach
to developing integrated care in community settings”.

The Framework document was duly published in February 2007 and sets out how
the provision of rehabilitation services in these three priority areas will be addressed.
The Framework reflects the wider health policy context which is aimed at improving
the health of the nation (Healthy Working Lives: A Plan for Action, Scottish
Executive, 2004) and targeting specific priority conditions such as cancer, diabetes,
stroke and mental health. (Cancer in Scotland, The Diabetes Action Plan, Coronary
Heart Disease and Stroke Strategy for Scotland, Delivering for Mental Health).

The commitment to vocational rehabilitation was reaffirmed by the current Scottish
Government in their health policy action plan Better Health, Better Care published in
December 2007. In particular NHS Boards are required to have in place a clear
action plan by the end of 2008 which will outline the roles that they can make at local
level to help people return to work as part of local Workforce Plus partnerships.

  Discussion Point 2

  Vocational rehabilitation is a policy imperative for Government. How can we
  harness this endorsement?

                                                                                            Education Needs of Staff Supporting Vocational Rehabilitation

2. Identification of Those Individuals Most Likely to be in
   Need of Vocational Rehabilitation
    Profile of the Target Population

    The Framework identifies the target groups for vocational rehabilitation as
    people returning from work absence and/or aiming to stay in employment. This
    means the target groups are:

    a) Those who have been absent from work for a period of time
    b) Those who are having difficulty maintaining their current employment status

    There are various ways of identifying and measuring the different target
    groups. Those conventionally used are:
    • By benefit claims
    • By self-declared health status
    • By sickness absence

    These measures can be sub-divided to give a more detailed analysis of the
    target groups:
    • By type of disability/illness
    • By individual claimant characteristics: ethnicity, gender, occupation,
        geography, type and duration of claims, etc.

    Different measurement approaches give a fairly consistent picture of who the
    target groups are although it has been noted that measuring the numbers of
    people with mental health problems and/or a physical illness/disability who wish
    to work can be difficult (Scottish Executive. Employability Framework For
    Scotland Final Report Workstream A: Workless Client Groups. Edinburgh,
    2005. p6).

                                                                                         Education Needs of Staff Supporting Vocational Rehabilitation
    Evidence to Build the Target Group Profile

    Evidence has been drawn from a number of sources which are appended for
    information (Appendix 1).

    Overall Levels of Disability and Illness

    •   The 2001 Census shows that 15.5% (489,553) of the working age
        population in Scotland (3,147,964: 16-64 male; 16-59 female) had a long-
        term illness, health problem or disability (Limiting Long Term Illness). Males
        (16.5%) and females (14.6%) have similar rates of limiting long term illness
        and the prevalence in both groups increases with age.
    •   The 2001 Labour Force Survey concluded that 20% of the Scottish
        population aged 16 to retirement age had a disability.
    •   The 2003 Scottish Health Survey estimated that two fifths of adults had a
        long-standing disability and around a quarter having a limiting long-standing

    Types of Disability or Ill-Health

    •    There are significant differences between disabled adults and those with
         long-term illnesses in terms of the type of illness or impairment they live
         with. Disabled adults are more likely to experience physical problems (legs,
         arms or backs). In contrast there are higher proportions of those with a long
         term illness facing heart, chest, breathing and mental health conditions.

    Sickness Absence

    •    A CIPD survey into sickness absence found that long-term absence (four
         weeks or longer) accounted for 19% of total absence in the survey.
    •    Breaking down responses into manual and non-manual workers revealed
         that back pain is the main cause of long-term absence among manual
         workers followed by musculoskeletal injuries, acute medical injuries and
    •    In comparison non-manual workers long-term absence sickness is most
         likely to be caused by stress, mental health, acute medical conditions and
         operations and recovery.

Disability and the Labour Market

•       Disabled people form a significant proportion of the working age population in
        Scotland. The Labour Force Survey (2003) estimated that 21% of the working
        population had a disability which equates to 662,000 people. In this disabled
        group just under half at 49% were active in the labour force. In comparison
        86% of those without a disability and 78% of the working age population as a
        whole were active.
•       In terms of the 49% of disabled people who are economically active the rate
        of activity varies significantly by disability type or health problem. For example

                                                                                             Education Needs of Staff Supporting Vocational Rehabilitation
        71% of those with diabetes are economically active whereas 75% of those
        with depression or bad nerves are inactive.
•       The 2001 Census revealed that 20.4% of those with limiting long term illness
        in the 16 to 34 year old age group had never worked or were long-term
        unemployed. The equivalent figure was 11.4% for those from 35 to 49 and
        5.6% for those from 50 to retirement age.
•       An analysis of the workless client group indicates that the largest group who
        were inactive but want to work live with musculoskeletal and mental health
        conditions (see table 1, p36).

Benefit Claims

•       Sixty-five per cent of claimants of at least one key benefit in August 2003
        were from the sick/disabled client group and this group of claimants
        represents 11% of the working age population. Thirty-one per cent of income
        support claimants were from the disabled/sick client group.

•    In 2003, 9% of working age people in Scotland were claiming incapacity
     benefit compared to only 7% for Great Britain as a whole.
•    The largest number of incapacity benefit claimants live with mental and
     behavioural disorders (41%) followed by problems with the musculoskeletal
     system (17%) (see table 2, p37).
•    47% of incapacity benefit claimants in Scotland have been receiving
     incapacity benefit for more than 5 years.
•    The areas with the highest proportion of incapacity benefit claimants are
     Glasgow, Inverclyde, North and South Lanarkshire.
•    At the start of their incapacity benefit claim 90% fully expect and want to work
     again (Institute of Public Policy Research).

    Discussion Point 3

    Those most likely to be in need of vocational rehabilitation are living with
    mental health and musculoskeletal conditions. Does this mirror your
    experience? What support in the form of education about specific conditions
    would be useful to you?

                                                                                        Education Needs of Staff Supporting Vocational Rehabilitation

3. What Education is Currently Available in Vocational
  There are a variety of sources of education and training in vocational
  rehabilitation. These include formal accredited courses and other training
  initiatives such as seminars and on-line learning. In addition the voluntary and
  charitable sectors provide a range of educational resources in this area. The
  following section places UK training and education in an international context,
  documents formal training courses and provides examples of other recent
  training initiatives. Whilst acknowledging the important role the voluntary and
  charitable sector plays in this area, the identification of such training and
  educational resources was outwith the scope of this review.

  The International Perspective

  In comparison to Scotland and the rest of the UK, vocational rehabilitation is
  much more developed in many countries (OECD, 2003), including the USA and
  Australia. Riddell (2002) summarised the education provision in these

  Training of practitioners is much better developed in the USA compared to the
  UK. A number of occupational groups, including rehabilitation counsellors and
  job evaluators have their own professional bodies with accreditation
  procedures. There are over a hundred Masters programmes and each state
  has at least one programme. Evaluation standards and performance indicators
  are applied to the State Vocational Rehabilitation Services and to Community
  Rehabilitation Programmes (CRP). However there are still gaps in provision
  with relatively few pre-service programmes in colleges and universities aimed
  at job coaches. Attempts are being made to remedy these gaps through web-
  based training, specific skills training, short courses and continuing education

                                                                                     Education Needs of Staff Supporting Vocational Rehabilitation

  There is a wide spread of qualification and skill levels among staff working in
  vocational rehabilitation. In the post-war period, professional qualifications
  existed for occupational psychologists and occupational therapists. In the early
  1970s it was recognised that training was required by vocational rehabilitation
  counsellors and post-graduate courses were developed in a number of
  universities. Undergraduate programmes have also emerged and many
  employees of CRS (Commonwealth Rehabilitation Service, a government
  agency) and Work Cover (vocational rehabilitation programme for people with
  work-related injuries) hold such qualifications. Amongst workers in the
  sheltered employment and competitive employment sectors, qualification and
  skill levels are much lower. People often have a background in social care, and
  are appointed because of a desire to work with disabled people rather than
  their knowledge of work adjustments and the vocational rehabilitation process
  more generally. New quality assurance standards state that people delivering

vocational rehabilitation services must have relevant skills and competencies,
but there are no plans to require staff to have specific qualifications.

Formal Vocational Rehabilitation Education in the UK

There are a small number of courses available in varying formats such as
degree, certificate, diploma and short courses. The modules within these
courses address a range of levels of educational needs. The courses identified
by the British Society of Rehabilitation Medicine are outlined in Appendix 2.
There are both university and private providers offering specialist courses.
Provision of courses in Scotland is limited.

  Discussion Point 4

  Education in vocational rehabilitation for healthcare and other
  professionals in Scotland and the rest of the UK lags was behind other
  nations. What can we learn from this international experience?

Other Current Initiatives in Vocational Rehabilitation Training and

As part of its Health, Work and Well-being strategy, the government has
developed a series of initiatives to support and educate healthcare
professionals on the health risks of unemployment, the consequences of
signing people off long-term sick and how they can help patients stay in or
return to work. These include a leaflet for GPs which highlights key findings of
evidence to date and will help doctors and other healthcare professionals

                                                                                       Education Needs of Staff Supporting Vocational Rehabilitation
dispel myths and offer practical support for their day-to-day dealing with
patients ( Other initiatives
include an on-line training tool for GPs to assist in difficult consultations with
patients on remaining in or returning to work. (GPs reconsider advice to
patients on sick leave. DWP Press Release 5/9/07)

A recent training programme has been designed to help nurses get their
patients ready for work following an injury, disability or period of ill-health. The
training covers the relationship between work and health, focusing on
rehabilitation and workplace adjustments. It was designed by the RCN with
input from the DWP and Department of Health. The training is on-line and is
hosted on the learning zone section of the RCN website. (New training for
nurses will help get patients back to work. DWP Press release 8/11/07)

A series of six pilot workshops were held throughout the UK during May and
July 2007 to teach GPs more about workplace ill-health and how to improve
communication with employers and occupational health staff. Workshops were

funded by the government and developed by the Royal College of General
Practitioners backed by the Faculty of Occupational Medicine and the DWP.
Each workshop was attended by around 50 GPs and covered some of the key
issues around health at work and returning to work (Paton, 2007). One of the
workshops was held in Edinburgh and an evaluation report of the initiative has
just been published (Chang and Irving, 2008).

  Discussion Point 5

  There are a number of new emerging educational initiatives around vocational
  rehabilitation. Should we concentrate resources in more of these types of

                                                                                 Education Needs of Staff Supporting Vocational Rehabilitation

4. Review     Of   The   Literature   Around   Vocational
   Rehabilitation With Particular Reference To Education
   And Training
   Analysis of the literature on vocational rehabilitation highlights a number of
   themes. Where possible the literature refers to UK experience but as vocational
   rehabilitation has been much more extensively developed and evaluated in
   Australia, Canada and the USA the literature reflects this international context.

   4.1 Deficiencies in the Current UK System of Vocational Rehabilitation

   Vocational rehabilitation in the UK came under focus at the start of the
   millennium following the publication of a report from the British Society of
   Rehabilitation Medicine (BSRM, 2000). The report entitled Vocational
   rehabilitation – the way forward suggested that vocational rehabilitation has
   always been neglected in Britain. The report highlighted the absence of
   vocational rehabilitation from undergraduate and most post graduate teaching
   for health professionals, including GPs who are pivotal in terms of sickness
   certification. In addition NHS consultants and psychologists who help in return
   to work emotional and physical issues were identified as a scarce resource
   (Disler and Pallant, 2001).

   The BSRM issued a follow-up report in 2003 which examined the response to
   its first report. The consensus view of professionals, disabled people and
   groups representing disabled people was that NHS services were too slow to
   respond in terms of vocational rehabilitation (Chamberlain and Frank, 2004).

   Frank and Thurgood (2006) reviewed the state of vocational rehabilitation in
   the UK. They conclude that close collaboration between the employment and
   health sectors are required to maintain an active and healthy workforce. In

                                                                                       Education Needs of Staff Supporting Vocational Rehabilitation
   order to facilitate this a group of trained health professionals is required. The
   Pathways to Work pilots by the government have proved that using such
   professionals can help people receiving incapacity benefits return to work.
   However there exists a shortage of appropriately trained health professionals to
   fill such roles.

   In a recent paper Higgins (2007) identifies common barriers to rehabilitation:

   •   Access to medical treatment due to extended NHS waiting lists
   •   Economic factors – generous occupational sick pay or disability benefits
   •   Lack of top-level organisational commitment
   •   Costs of workplace modifications and availability of suitable alternative
       duties, particularly for smaller firms
   •   Poor communication and common purpose among key stakeholders
   •   Lack of co-ordinated approach among rehabilitation providers

4.2 The UK Rehabilitation Model

The traditional rehabilitation model (figure 1) has been subject to criticism.
Waddell and Burton (2004) observe that vocational rehabilitation is often only
considered if the second stage of medical rehabilitation is (expected to be)
successful. In the UK, the NHS rarely considers or provides vocational
rehabilitation services. This staged approach means there is no integration and
clear pathway. This model fails those who do not recover rapidly and as a
result are left in limbo, often for months or even years, due to lack of referral
for, or availability of, rehabilitation services.

Figure 1 - The Traditional Rehabilitation Model

                                                                   Return to work

        Medical            Medical            Vocational
       Treatment         Rehabilitation      Rehabilitation


Source: Waddell and Burton. Concepts of rehabilitation for the management of
common health problems. The Stationery Office. London, 2004. p10.

4.3 The Timing of Vocational Rehabilitation

The timing of vocational rehabilitation has been identified as important as early
intervention is crucial in the six months before a person enters incapacity
benefits and once on incapacity benefits those who are in receipt of it for 12

                                                                                    Education Needs of Staff Supporting Vocational Rehabilitation
months stay on them for an average of eight years (Chamberlain and Frank,

The Organisation for Economic Co-operation and Development (OECD, 2003)
also highlights the importance of an early intervention and contrasts differing
international practice (table 3). There are a few countries, notably Germany
and Sweden, in which the vocational intervention starts early and is
implemented promptly. In Germany for example the health insurance authority
is required to check the necessity for vocational rehabilitation before, during
and after the medical rehabilitation process. In a larger number of countries,
vocational rehabilitation will only begin after stabilisation of the person’s
medical condition and rarely in the first year after the disabling condition has
commenced which is often too late. This is attributable in part to a lack of
access to the necessary information at an earlier stage, often because the
authorities responsible for vocational rehabilitation have no link to those
responsible for the medical recovery.

Table 3 - The International Timing and Focus on Vocational Rehabilitation

 Timing of                           Focus on Vocational Rehabilitation
                      Quasi (compulsory)       Intermediate          Entirely Voluntary
 Any time possible    Austria*, Denmark*
 (also very early)    Germany, Spain*
 Intervention not     Austria*, Denmark*       Belgium               Australia, France
 very early           Norway, Spain*           Netherlands           Italy, Korea, UK
                      Switzerland              Poland
 Only after long-                              Turkey                Canada, Mexico
 term sickness                                                       Portugal, USA

* Austria, Denmark and Spain straddle two categories depending upon the
circumstances of the individual case.
Source: OECD. Transforming Disability into Ability. Paris, 2003. Table 5.2, p109

  Discussion Point 6

  Deficiencies exist in the current system of vocational rehabilitation in Scotland
  and the rest of the UK, including the timing of the intervention. How can we
  promote an early intervention?

4.4 Inability of     Healthcare      Professionals      to    Initiate   Vocational

The inability of healthcare professionals to refer patients for vocational

                                                                                          Education Needs of Staff Supporting Vocational Rehabilitation
rehabilitation is particularly crucial in primary care as their clinical management
and the provision of sickness certification may initiate prolonged absence from

In an Australian study, GPs recognised the benefits of vocational rehabilitation in
the management of schizophrenia but they lacked the appropriate resources
(information and consultation time) to effect appropriate referrals to these
services (Crawley et al, 2007). The authors conclude that improved information
dissemination to GPs, in particular relating to available services and referral
pathways, may improve referral rates to appropriate vocational rehabilitation

The inability to initiate vocational rehabilitation is not just restricted to primary
care however. Gilworth et al. (2001) ran a three year UK based study to
determine whether an occupational health physiotherapist trained in vocational
assessment, added to a clinical team, had any effect on the workplace
management of the individual or the clinician’s practice. The study’s most

important finding was that rheumatologists and hospital-based therapists focused
on physical rehabilitation therapy and appeared not to recognise which patients
could benefit from referral to a Disability Employment Advisor and the
subsequent support that can be offered to working patients.

4.5 Lack of Knowledge of Vocational Rehabilitation

The literature highlights a lack of knowledge both at a general level and also in
components of the vocational rehabilitation process.

Waddell and Burton (2004) observe that family doctors and the primary care
team are the patient’s main source of advice about work. However they generally
lack adequate training or expertise in occupational health or disability evaluation.
Too often they do not understand or even consider occupational issues or the
consequences of long-term incapacity. A BSRM survey of non-governmental
organisations in 2000 identified two specific gaps in health professionals

•   Lack of understanding of the relation between health and work (both how
    work may affect health, and how illness or disability may or may not affect
•   Lack of awareness of alternatives to, or options to minimise, sickness
    absence (work adjustments, organisational and other support available,
    rehabilitation services).

Schweigert et al. (2004) undertook a Canadian study of mainly family medicine
physicians which examined the barriers their patients faced in returning to work
from illness and injury. Physicians identified themselves as potential barriers in
that their role in the return to work process was not clear, they have a lack of
occupational health training, that they possess a lack of knowledge of specific
work issues or that they are overwhelmed with too much or inappropriate

                                                                                          Education Needs of Staff Supporting Vocational Rehabilitation
information at times.

Seebhom and Secker (2003) undertook research which looked at the role of
three UK community mental health teams (CMHTs) in supporting client’s
vocational aspirations. They found that across all three sites certain elements of
interprofessional working which can be crucial in enabling clients to find and keep
work were lacking. In particular welfare rights advice was problematic and
widespread ignorance about benefits issues was of particular concern. This
echoed a Royal College of Psychiatrist’s report (2002) which noted that CMHTs
were ideally placed to take the lead in co-ordinating the vocational rehabilitation
of those with psychiatric disabilities, but they lacked sufficient expertise in welfare
advice and vocational work.

Mowlam and Lewis (2005) examined how GPs deal with patients on sick leave.
They found that GPs had very limited knowledge or use of vocational
rehabilitation services and it was recurrently said either that there were none in
the area or that the doctor did not know whether any existed. In addition they

knew little about the role and work assistance available from Jobcentre Plus.
There was a widespread assumption that Jobcentres only provide job search
support to people who are unemployed. Some GPs suggested the Jobcentre to
people who needed to consider a different job direction or retraining. Improved
knowledge did not exist among GPs with occupational health expertise who had
been involved in Medical Services or appeals tribunals.

  Discussion Point 7

  Healthcare professionals may not initiate vocational rehabilitation, partly due to a
  lack of knowledge in the subject. How can we raise awareness in this area?

4.6 The Role of the General Practitioner and Sickness Certification

The role that the General Practitioner plays in the vocational rehabilitation
process has attracted a good deal of scrutiny and in particular their handling of
sickness certification.

Rasmussen and Andersen (2005) undertook a study which sought to identify
individual, health care and social welfare related factors that play a role in the
outcome of rehabilitation programmes during the first three years of a new
vocational rehabilitation institute in Denmark. The study was based on a lack of
evidence about the effect of rehabilitation programmes for the long-term sick, and
supplemented previous research which had been directed towards process
evaluations of rehabilitation programmes. The findings were that the GP’s role
was an important predictor in a positive outcome from the programme.

Mowlam and Lewis (2005) interviewed 24 GPs and identified three different

                                                                                         Education Needs of Staff Supporting Vocational Rehabilitation
approaches to discussing a return to work with patients. The most proactive GPs
described detailed discussions with patients about returning to work. The least
proactive described no discussion of work, or limited discussion only if the patient
raised it or the absence was clearly unmerited. In between were GPs who
discussed work less emphatically than the first group and who did not proceed if
they met with resistance from the patient.

A related study by Farrell et al. (2006) with participants in the Job Retention and
Rehabilitation Pilot (JRRP) and staff of organisations providing job retention and
rehabilitation services provided similar findings. There was not always a sense,
from participants’ accounts, of GPs taking an active approach to managing their
patients’ care, and there were recurrent descriptions of long waits for treatment,
surgery or diagnostic tests. Participants generally appeared not to look to their
GPs for advice about when to return to work. GPs sometimes gave very cautious
advice which did not resonate with people’s own views that they were ready to
return, although they sometimes, on reflection, felt the GP may have been right.
Participants talked of having to ‘convince’ a GP that they could return to work and

of the GP having ‘allowed’ it or imposed conditions, or of GPs advising them
against a return. Similarly provider staff too were of the view that GPs are
sometimes too conservative in their advice, that they discouraged returns to work
and that this can undermine the efforts made by professional staff who have
worked closely with a client. They perceived a lack of active case managing,
where clients made slow progress within the NHS, were not referred to suitable
specialists and were not encouraged to take action to help themselves.

The influence of sickness certification procedures in the vocational rehabilitation
process has been acknowledged (Sawney, 2002). In effect the certificate can be
a catalyst for initiating a vocational intervention or an obstacle to a return to work.
In the former case Chamberlain and Frank (2004) observe that the certifying
doctor can always use the Doctor’s remarks section to record, for example, that
rehabilitation or workplace adjustments may be necessary. In the latter instance
providers of rehabilitation services described situations where GPs provided
long-term sick notes which they felt could deflate clients’ confidence and
discourage a focus on returning to work (Farrell et al., 2006).

4.7 Communication and Multi-professional Team Working

Vocational rehabilitation is very much a multi-disciplinary process as outlined by
Gobelet et al (2007) who note that a vocational rehabilitation team will be made
up of professionals working in the disciplines of physiotherapy, occupational
therapy, psychology, psychiatry, work counselling, work training, job teaching
and potentially others. In particular the role of the occupational therapist has
been identified as being important (Joss, 2002; Griffiths, 2005).

Given the number of occupations involved, issues of communication between
team members has been identified as a problematic issue. In particular poor
communication between GPs and occupational health physicians is a recurring
theme (Beaumont, 2003; Sawney and Challenor, 2003; Nauta et al., 2006).

Seebhom and Secker (2003) analysed the role of three community mental health              Education Needs of Staff Supporting Vocational Rehabilitation
teams (CMHTs) in vocational rehabilitation and identified the need for effective
interprofessional working within and across agency boundaries, including liaison
with welfare rights experts. They found that across all three sites certain
elements of interprofessional working which can be crucial in enabling clients to
find and keep work were lacking. They conclude that effective inter-professional
working will require changes in the attitudes of some clinicians and vocational

  Discussion Point 8

  Communication may be lacking between members of the vocational
  rehabilitation team. How can we improve communication across agencies?

4.8 Approaches to Vocational Rehabilitation Management - The Role of
    Case Management

A number of approaches have been identified in the Framework for managing the
rehabilitation process: self-management, condition management and case
management. The implementation of self-management and condition
management will generally be effective for the majority of people and those with
less complex needs. However for those with complex rehabilitation needs, case
management has been identified as the preferred approach.

Case management in vocational rehabilitation is defined as “a collaborative
process which assesses, plans, implements, coordinates, monitors and
evaluates the options and services required to meet an individual's health, care
and employment needs, using communication and available resources to
promote quality outcomes, with effective management of resource” (Hanson et
al., 2007). The important role of case management in vocational rehabilitation is
highlighted throughout the literature (Riddell, 2002; Corden and Thornton, 2002;
Russo and Innes 2002; O’Reilly 2007). In some countries, such as the US and
Australia, case management is widely employed and they have their own
education and accredited bodies. The case manager, however, is not always a
health care professional.

A recent example of case management in practice closer to home is OHSxtra
(Hanson et al., 2007). This pilot occupational health programme in NHS Scotland
tested rapid access to rehabilitation services via a case manager for employees
in NHS Fife and NHS Lanarkshire. The four case managers employed were from
varied backgrounds of occupational health nursing, occupational therapy, case
management and administration. Training of case managers was a combination
of in-house and external (14 days, delivered as 2 days per week over a 7 week
period). The training was based on a programme developed for the HealthReturn
project (Job Retention and Rehabilitation Pilot, DWP). Tutors were personnel

                                                                                    Education Needs of Staff Supporting Vocational Rehabilitation
from within the boards who had expertise in these areas, and external experts.
The pilot demonstrated that the OHSxtra service effectively helped staff stay in
work, return to work and improve health with the result that the programme has
been rolled out to an additional five NHS Boards.

Specific Issues in Training and Education Identified in the Literature

1. Training Needs
The initiation of a training needs analysis is an important precursor to designing
training in vocational rehabilitation to ensure it is relevant to the service and
those undertaking it. Thorpe (2006) identified a lack of research into the needs of
undergraduate occupational therapists wanting to work in occupational
rehabilitation in Australia. Participants perceived undergraduate programs to
primarily prepare new graduates for hospital based practice. As such,
recommendations for changes to the curriculum and delivery of the programs
were provided. In addition participants highlighted the need for support in
industry for occupational therapists in the form of training, supervision, coaching/
mentoring/ buddying and ongoing education.

In terms of specific training needs, Shafer at al. (1999) conducted a survey of
mental health and vocational rehabilitation professionals in the USA. While
respondents consistently identified multiple training and information needs, the
areas identified of greatest need were those most directly associated with
employment. The top areas for training needs were:

i)      Strategies for working with ambivalent and or/unmotivated clients
ii)     Methods of assessing the vocational needs of persons with mental illness
iii)    Planning and implementing job retention strategies
iv)     Understanding managed care and how to fund employment services under
        managed care
v)      Job development strategies

2. Level of Training and Education
There is an acknowledged need for specialised training at all levels in vocational
rehabilitation but the benefits of higher level education was demonstrated by
Frain et al. (2006). This was an American study which examined the benefits of

                                                                                       Education Needs of Staff Supporting Vocational Rehabilitation
rehabilitation counsellors having a rehabilitation counselling master’s degree. A
meta-analysis of studies in vocational rehabilitation which examined employment
outcomes was carried out. It compared the employment outcomes of those
holding master’s degrees in rehabilitation counselling with a combined group of
all other degrees which included bachelor’s degrees and masters degrees in
related and unrelated fields. The meta-analysis revealed the overall influence of
education on rehabilitation outcomes was significant with an effect size of +0.2.
Translated into practice the authors conclude that approximately 20,000 more
individuals with disabilities each year in America would have positive
employment outcomes if all rehabilitation counsellors had a master’s degree in

     Discussion Point 9

     There is a need for training and education in vocational rehabilitation at all
     levels. Given limited resources, how do we prioritise education and training at
     different levels?
Format of training
The literature identifies a number of aspects of training and education that should
be considered including the content, method of delivery, target audience.

3. Content of Training
Strong et al. (2003) surveyed Canadian Occupational Therapists (OTs) working
in vocational practice to identify the essential knowledge, skills and professional
behaviours required to operate successfully. Their suggested undergraduate and
postgraduate curriculums are presented in Appendix 3.

   To be effective OTs need to know how systems (e.g. legal, welfare) operate
   in different settings e.g. the players, the terminology used and the formal
   rules that dictate system’s operations. In addition OTs need to know more
   than the pathology and medical terminology of conditions. They need to
   understand the complex interaction of the physical and psychological self in
   terms of the recovery process and job integration. OTs stressed the
   importance of learning occupational theory, regarding human occupation,
   occupational performance, and person-environment-occupation relationships.

   The core fundamentals of OT therapy vocational practice are now used
   broadly and to a different scale (return-to-work programs, systems, workplace
   culture). Activity or occupational analysis is now applied at both the individual
   and systems levels. OT’s clinical reasoning, problem-solving and creative
   thinking skills are not limited to traditional clinical contexts e.g. OTs must be
   able to generate strategies not bound by the setting to reach an end goal.

   Working with a multitude of players with different backgrounds requires
   interpersonal and communication skills. Conflict resolution and negotiation

                                                                                       Education Needs of Staff Supporting Vocational Rehabilitation
   skills are used to deal with angry or difficult clients with tact and diplomacy.

   There is a greater emphasis on report writing ranging from writing
   comprehensive medico-legal reports, keeping records to document progress
   on targeted outcomes. Report writing requires the ability to synthesize
   multiple sources of information and make recommendations that are
   justifiable, relevant, practical and understood by the particular reader.

   Rapidly changing practice means that OTs need to have the skills to build
   resource networks to access information, critically appraise and apply it
   appropriately to problems seen in practice. As such computer skills are a
   basic necessity. Other essential generic skills required include organizational
   and time management skills. OTs spoke of working to deadlines and
   managing multiple roles all of which identify the need for stress management

   Professional Behaviours
   OTs frequently encounter ethical issues and need to balance the needs of
   the client, their family, employer, etc. plus respond to competing agendas.
   OTs talked about the importance of knowing ethical boundaries and not
   “crossing the line” when attempting to meet everyone’s interests or requests.

   Working in situations with little built in accountability highlights the need for
   self-assessment skills i.e. the ability to evaluate own skills and learning needs
   and know when to seek help from others. Part of this self-reflection extends
   to understanding personal values and having respect for differences in
   culture, values and beliefs.

   In terms of medicine, Chamberlain and Frank (2004) propose that
   undergraduate medical training programmes should include:
   • a patient’s medical history must include their occupational history
   • the relation of symptoms to the working day needs exploration
   • the NHS must respond quickly to illness causing sickness absence in
      order to preserve jobs
   • assistance is available from the Department of Work and Pensions

    Discussion Point 10

    Work is currently underway at an early stage in establishing competencies in
    vocational rehabilitation. What are the most important knowledge, skills and
    behaviours we need to address in delivering education and training in
    vocational rehabilitation?

4. Education must be Evidence Based
In highlighting deficiencies in basic medical and GP training, Sawney and

                                                                                       Education Needs of Staff Supporting Vocational Rehabilitation
Challenor (2003) recommend the development of on-line training and the
development of task orientated, evidence-based guidance. There should be
greater sharing of condition specific return to work guidelines and tools to
determine objectively patient readiness to return to work would aid
communication between clinicians. In addition best practice referral mechanisms
need to be more widely publicised.

5. The Need for Case Management Training
Formal case management training has been recently introduced by insurance
provider Unum Provident to the UK. Using the National Institute of Disability
Management and Research (NIDMAR) programme, the foundation training in
vocational rehabilitation is being delivered as CPD courses for those already
involved in vocational rehabilitation, primarily health care professionals or human
resources personnel. Unum Provident is currently in discussions with a variety of
universities in Scotland and the rest of the UK with the aim of rolling out its
programme nationwide (O’Reilly, 2007).

6. Mode of Delivery
Davis and Rinaldi (2004) illustrate how different methods of delivering training
can be successfully employed. In this case study, training was cascaded from
senior occupational therapists to occupational therapists (OTs) and subject
experts were employed. The case study in question describes how a mental
health trust actively promoted vocational rehabilitation through implementing
evidence-based principles within clinical teams. A partnership was established
between the trust’s vocational services and occupational therapy service. The
occupational therapist was responsible for leading on and promoting vocational
issues within their clinical team. The OT provided vocational expertise, guidance,
information and support to clients and other care co-ordinators within their
teams. To deliver this service the OT devoted one session per week to this role.

In terms of education, a senior OT trained the OTs on the evidence base within
vocational rehabilitation and the roles that care co-ordinators could play in
supporting people to gain and retain employment or education. In addition a
welfare benefits expert was commissioned to provide training to OTs on welfare
benefits, rules and regulations.

The advent of new technology has been explored by Karlinsky et al. (2006) in the
delivery of continuing medical education for Canadian physicians in workplace
injury management. The study compared the use of two new technologies (online
learning and video-conferencing) against traditional methods (lecture and small
group face to face) to evaluate physician knowledge. All training methods
increased physician knowledge in workplace injury management and the
videoconferencing and online training were as least as effective as lectures and
small instructor led group sessions.

7. Effectiveness of the Method of Delivery
There has been limited research in the UK as to the effectiveness of training in
vocational rehabilitation. O’Brien et al. (2003) investigated the impact of training
Community Mental Health Teams (CMHT) members in the practice of Individual
Placement and Support (IPS) on the vocational status of long-term patients. Six

                                                                                       Education Needs of Staff Supporting Vocational Rehabilitation
CHMTs received vocational training by a work co-ordinator and four teams
continued with standard care.

The training intervention consisted of three structured one-hour seminars given
by a Consultant Clinical Psychologist specialising in employment issues and a
Work Place Co-ordinator. The first seminar covered local work and the structured
activities available locally. The second covered the best ways to match individual
patients’ needs and wishes with the opportunities available. The third was about
incorporating work and education targets as a routine in the care plans. Team
members were also supplied with a directory of work and educational
opportunities and services in the local area. It may be argued that the training
intervention was too limited to be investigated and the small amount of training
may not have been a fair test. However the authors argue that this is exactly the
type of staff training in vocational rehabilitation being introduced and so
evaluation of its effectiveness is necessary.

The best vocational status of the 1,037 subjects under the care of the 10 CMHTs
was recorded after one year and factors associated with improvement in

vocational status were identified. There was no difference in the change of
vocational status between the subjects under the care of teams who received
vocational training and those who did not. The factors associated with
improvements in vocational status were age, previous employment and diagnosis
of the subjects.

The authors conclude that training in IPS at team level did not improve
employment status. It appears that a dedicated vocational worker appears
essential for successful IPS. This case study also illustrates the importance of
evaluating training initiatives to ensure their quality and relevance.

  Discussion Point 11

  There has been a lack of evaluation of vocational rehabilitation training and
  education in the UK. In your experience what are the most effective ways to
  train staff in vocational rehabilitation?

8. Multi-professional Teamwork Training
The importance of the development of multi-disciplinary teamwork in vocational
rehabilitation has been noted. Nauta et al. (2006) sought to address this issue in
the context of the different roles that GPs and Occupational Health Physicians
(OHPs) play in the Netherlands. GPs do not assess sickness absence or
evaluate fitness for work, they only give medical advice. OHPs diagnose and
prevent occupational diseases, evaluate fitness for work of people on sick leave
and draw up a proposal for reintegration if the expected sick leave exceeds 6
weeks. Due to these different roles many people on sick leave will often visit both
their GP and an OHP for the same complaint and may receive differing advice.

In order to enhance collaboration and overcome the negative effects of the
labour division a joint training programme for GP and OHP trainees was set up.
Both groups knowledge of the guidelines for the exchange of information

                                                                                      Education Needs of Staff Supporting Vocational Rehabilitation
between them increased. GP trainees’ trust increased immediately after the
training programme but this effect had disappeared three months later.

The authors concluded that this type of training programme may be effective for
increasing trust but the results do not show a long-term effect. Knowledge about
the guidelines for the exchange of information increased and remained for a
longer period. Educational expertise should be used to improve programmes
especially on attitudes such as trust and behaviour.

  Discussion Point 12

  Vocational rehabilitation will be effective when all members of the team work in
  unison. How can we best develop multi-disciplinary team working across

This review has reinforced the importance of vocational rehabilitation given the
established benefits of work and employment for health and well-being. The need for
vocational rehabilitation services is pressing given the policy priority attached to it by
Government and the numbers of people who are unable to work or maintain
employment due to illness and disablement. Those most typically in need of vocational
rehabilitation services are identified as having mental health and musculoskeletal

A review of the literature has highlighted shortcomings in the UK in both the vocational
rehabilitation system itself and the education for NHS staff that supports it. In terms of
the system there are deficiencies in the current model including the timing of the
vocational rehabilitation intervention. There is evidence of poor practice in vocational
rehabilitation and in particular the inability to initiate it and a lack of knowledge
surrounding its operation. Other themes to emerge were the importance of the primary
care role (e.g. GPs and sickness certification) and the need for good communication
and effective multi-professional team working across agencies. In generating
discussion around these issues it is hoped that this process will open up a
collaborative dialogue among the many agencies involved in providing vocational
rehabilitation services.

In relation to education provision in vocational rehabilitation, Scotland and the rest of
the UK lags way behind other nations. There is limited specialist vocational
rehabilitation education provision and a lack of research into training and education in
vocational rehabilitation indicating what type of educational interventions work. The
literature review raises a number of pertinent questions such as

•    Where are the gaps? What should the content be?
•    What are the training needs for those providing vocational rehabilitation
     services? (both generic e.g. case management and profession specific)
•    Can we prioritise at what levels education and training should be?
•    How should it be delivered? What methods should be used?

In seeking evidence around vocational rehabilitation education for NHS professionals
this exercise has not covered the voluntary/charitable sectors and patients and their
carers. We can undoubtedly learn from these groups given their significant

                                                                                             Education Needs of Staff Supporting Vocational Rehabilitation
involvement in and contribution to vocational rehabilitation, for example the
educational material that they produce. Similarly we are looking to learn from the
experience of agencies outside the NHS.

In conclusion, the overall aim of the Framework is to encourage health professionals to
think beyond their own role as part of an individual’s rehabilitation. In moving out of
traditional remits there are issues relating to professional regulation and knowledge of
specifics. The challenge to us all is how we can best address these issues.

    Final Discussion Point 13

    a) Does this review confirm your experiences of vocational rehabilitation and from
    this what is the most important factor for us to consider?
    b) Has this review missed any important issues in terms of education and training
    for vocational rehabilitation?
    c) Are you or your organisation developing or facilitating education and training in
    vocational rehabilitation that you can share?
    d) How do we take education and training forward in this area?

Anema JR, van der Giezen AM, Buijs PC, van Mechelen W. Ineffective disability
management by doctors is an obstacle for return to work: a cohort study on low back
pain patients sicklisted for 3-4 months. Occupational Environmental Medicine 2002;
59, 729–733.

Beaumont DG. The interaction between general practitioners and occupational
health professionals in relation to rehabilitation for work: a Delphi study.
Occupational Medicine 2003; 53(4), 249–253.

British Society of Rehabilitation Medicine (BSRM). Vocational rehabilitation – the
way forward. London, 2000.

British Society of Rehabilitation Medicine (BSRM). Vocational Rehabilitation – The
Way Forward. 2nd Edition. London, 2003.

Chamberlain MA, Frank AO. Congratulations but no congratulations: should
physicians do more to support their patients at work. Clinical Medicine 2004; 4(2),

Chang D, Irving A. Evaluation of the GP Education Pilot: Health and Work in General
Practice. Department for Work and Pensions Research Report No. 479. London,

Corden A, Thornton P. Employment Programmes for Disabled People: Lessons from
Research Evaluations. Department for Work and Pensions In-house Report No. 90,
London, 2002.

Crawley T, Fitzgerald N, Graham H. General practitioner’s awareness and
understanding of vocational rehabilitation in schizophrenia: A Tasmanian

                                                                                         Education Needs of Staff Supporting Vocational Rehabilitation
perspective. Journal of Vocational Rehabilitation 2007; 26(3), 189–196.

Davis M, Rinaldi M. Using an Evidence-Based Approach to Enable People with
Mental Health Problems to Gain and Retain Employment, Education and Voluntary
Work. British Journal of Occupational Therapy 2004; 67(7), 319–322.

Department for Work and Pensions, Building Capacity for Work: A UK Framework for
Vocational Rehabilitation. London, 2004.

Disler P, Pallant J. Vocational Rehabilitation, everybody gains if injured workers are
helped back into work. BMJ 2001; 323(7305), 121-123.

Farrell C, Nice K, Lewis J Sainsbury R. Experiences of the Job Retention and
Rehabilitation Pilot. Department for Work and Pensions Research Report No. 339.
London, 2006.

Frain MP, Ferrin JM, Rosenthal DA, Wampold BE. A Meta-Analysis of rehabilitation
outcomes based on education level of the counselor. Journal of Rehabilitation 2006;
72(1), 10–18.

Frank AO, Sawney P, Vocational rehabilitation. Journal of the Royal Society of
Medicine 2003; 96 (11), 522 – 524.

Frank A, Thurgood J. Vocational rehabilitation in the UK: Opportunities for health-
care professionals. International Journal of Therapy and Rehabilitation 2006; 13(3),

Gilworth G, Haigh R, Tennant A, Chamberlain M, Harvey A. Do rheumatologists
recognize their patients’ work-related problems? Rheumatology 2001; 40(11), 1206-

Gobelet C, Luthi F, Al-Khodairy AT, Chamberlain MA. Vocational rehabilitation: a
multidisciplinary intervention. Disability and Rehabilitation 2007; 29(17), 1405-1410.

Griffiths J. The perceptions of occupational therapists regarding the use of vocational
rehabilitation. Mental Health Occupational Therapy 2005; (10)2, 56–61.

Hanson M, Murray K, Wu O. Evaluation of OHSxtra, a pilot occupational health case
management programme within NHS Fife and NHS Lanarkshire. Final report on
behalf of the OHSxtra Project Steering Group, 2007.

Higgins H. The case for rehabilitation. Occupational Health 2007; 59(2), 23–25.

Joss M. Occupational Therapy and Rehabilitation for Work. British Journal of
Occupational Therapy 2002; 65(3), 141-148.

Karlinksy H, Dunn C, Clifford B, Atkins J, Pachev G, Cunningham K, Fenrich P,

                                                                                          Education Needs of Staff Supporting Vocational Rehabilitation
Bayani Y. Workplace injury management: using new technology to deliver and
evaluate physician continuing medical education. Journal of Occupational
Rehabilitation 2006; 16(4), 719–730.

Mowlam A, Lewis J. Exploring how General Practitioners work with patient on sick
leave. Department for Work and Pensions Research Report No. 257. London, 2005.

Nauta N, Weel A, Overzier P, Von Grunbkow J. The effects of a joint vocational
training programme for general practitioner and occupational health trainees.
Medical Education 2006; 40(10), 980–986.

O’Brien A, Orice C, Burns T, Perkins R. Improving the vocational status of patients
with long-term mental illness: A randomised controlled trial of staff training.
Community Mental Health Journal 2003; 39(4), 333-347.

O’Reilly S. Helping Hands. Occupational Health 2007; 59(2), 16–19.

Organisation for Economic Co-operation and Development (OECD). Transforming
Disability into Ability. Paris, 2003.

Paton N. GPs to learn about workplace ill-health in pilot workshops. Occupational
Health 2007; 59(2), 4.

Rasmussen K, Andersen J. Individual Factors and GP Approach as predictors for the
Outcome of Rehabilitation Among Long-Term Sick Listed Cases. Journal of
Occupational Rehabilitation 2005; 15(2), 227-235.

Riddell S. Work Preparation and Vocational Rehabilitation: A Literature Review.
Strathclyde Centre for Disability Research. Glasgow, 2002.

Royal College of Psychiatrists. Employment Opportunities and Psychiatric Disability.
London, 2002.

Russo D, Innes E. An organizational case study of the case manager’s role in a
client’s return-to-work programme in Australia. Occupational Therapy International
2002; 9(1), 57-75.

Sawney P. Current issues in fitness for work certification. British Journal of General
Practice 2002; 52(476), 217-222.

Sawney P, Challenor J. Poor communication between health professionals is a
barrier to rehabilitation. Occupational Medicine 2003; 53(4), 246–248.

Schweigert MK, McNeil D, Doupe L. Treating physicians’ perceptions of barriers to
return to work of their patients in Southern Ontario. Occupational Medicine 2004;
54(6), 425–429.

Scottish Executive. Healthy Working Lives: A Plan for Action. Edinburgh, 2004.

Scottish Executive. Building a Health Service Fit for the Future. Edinburgh, 2005.       Education Needs of Staff Supporting Vocational Rehabilitation

Scottish Executive. Co-ordinated, integrated and fit for purpose. A Delivery
Framework for Adult Rehabilitation in Scotland. Edinburgh, 2007.

Scottish Executive. Delivering for Health. Edinburgh, 2005.

Scottish Executive. Workforce Plus: An Employability Framework for Scotland.
Edinburgh, 2006.

Scottish Government. Better Health, Better Care: Action Plan. Edinburgh, 2007.

Seebhom P, Secker J. Increasing the vocational focus of the community health
team. Journal of Interprofessional Care 2003; 17(3), 281–291.

Shafer MS, Pardee R, Stewart M. An assessment of the training needs of
rehabilitation and community mental health workers in a six state region. Psychiatric
Rehabilitation Journal 1999; 23(2), 161–169.

Strong S, Baptiste S, Salvatori P. Learning from today’s clinicians in vocational
practice to educate tomorrow’s therapists. The Canadian Journal of Occupational
Therapy 2003; 70(1), 11–20.

Thorpe K. How to better prepare our graduates for working in occupational
rehabilitation: Occupational therapists’ perspectives. Australian Occupational
Therapy Journal 2006; 53, 62.

Waddell G, Burton AK. Concepts of rehabilitation for the management of common
health problems. The Stationery Office. London, 2004.

Waddell G, Burton AK. Is work good for your health and well-being? The Stationery
Office. London, 2006.

                                                                                        Education Needs of Staff Supporting Vocational Rehabilitation

Appendix 1
Sources of Information to Build a Profile of the Target Population

Workforce Plus: An Employability Framework for Scotland which was published
by the Scottish Executive in June 2006. It sets out how organisations can better work
together at a national and local level to improve support for those facing barriers to
employment, including people with disabilities. Its main aim is to help 66,000 Scots
off benefits and into work by 2010. The evidence presented here is mainly contained
in a sub-report which focused on the workless population Employability Framework
For Scotland Final Report Workstream A: Workless Client Groups.

Disability and Employment in Scotland: A Review of the Evidence Base. This
Scottish Executive social research report was published in 2005 in relation to
providing evidence to support the Executive’s policy of improving access to
employment for disadvantaged and excluded groups. Among its aims was to identify
and discuss the evidence that is available through research and statistical data
sources on the employment position of disabled people.

Social Focus on Disability (2004). A Scottish Executive social statistics publication
which explores the characteristics of disabled people in Scotland. It includes
chapters on the demographics of disability, the involvement of disabled people in the
labour market, their health and care and their experience of income and benefits.

Employee absence 2004. A survey of management policy and practice.

                                                                                         Education Needs of Staff Supporting Vocational Rehabilitation
Chartered Institute of Personnel Development. In February 2004 approximately
7,000 questionnaires were sent out to a sample of people management specialists.
The questionnaire included 30 detailed questions on the level, causes and cost of
absence, the ways of managing both short and long-term sickness absence,
workplace stress and sick notes.

Appendix 2 - Vocational Rehabilitation Courses
1. UK Universities - Degree, Certificate, Diploma and Short Courses

Education Provider         Course                        Modules                                    Comments
Canterbury Christ Church   Postgraduate Certificate in   1. Orientation
University                 Vocational Rehabilitation     2. Concepts in Vocational Rehabilitation
                                                         3. Assessment and Intervention
                                                              Strategies Relating to vocational
City University, London    Certificate in Disability     Part 1                                     A distance learning
                           Management at Work.           i) Disability                              programme currently being
                                                         ii) Work                                   revised taking on board many
                                                         Part 2                                     of the Vocational

                                                                                                                                       Getting Vocational Rehabilitation Working for Scotland
                                                         i) Disability Policies and Human           Rehabilitation Association’s
                                                         Resource Development                       Standards of Practice
                                                         ii) Influencing Change in Organisations    Standards. It is also proposed
                                                         iii) Disability Management at Work         to make it available on-line.
                                                         Practice                                   This is a modular programme
                                                         Part 3                                     (entry at any time). It is also
                                                         Vocational Rehabilitation in Practice      possible to (go on to) study for
                                                                                                    M.Sc, involving a dissertation,
                                                                                                    and PhD research..

Glasgow Caledonian         a) Postgraduate Certificate   Ergonomics in Occupational Health
University                 in Occupational Health and    Occupational Rehabilitation

                           b) Postgraduate Diploma in    As above plus Research Methods and

Education Provider           Course                        Modules                                     Comments
                             Occupational Health and       another negotiated module

                             c) MSc Occupational Health    As for PgD plus dissertation
                             and Ergonomics
London Metropolitan          Postgraduate Certificate in   Focus on mental health                      Half day per week
University                   Supporting People into
Sheffield Hallam             a) Postgraduate Diploma in    •   Context of vocational rehabilitation    1 year part-time
University                   Vocational Rehabilitation     •   Impact and experience of disability
                                                           •   Pathways to employment
                                                           •   Research for the working world
                                                           •   Programme planning

                                                                                                                                        Getting Vocational Rehabilitation Working for Scotland
                             b) Postgraduate Diploma in                                                2 years part-time
                             Vocational Rehabilitation

                             c) MSc Vocational                                                         2 years on completion of
                             Rehabilitation                                                            dissertation or between 3 and
                                                                                                       5 years)

                             d) BSc Vocational                                                         new undergraduate course
                             Rehabilitation                                                            from this September
University of York St John   Short Courses                 1. Vocational rehabilitation foundations    Faculty of Health and Life
                                                           2. Vocational rehabilitation assessment:    Sciences, has a five years
                             Although sequential these 2          ‘Tools of Trade’                     strategy to develop vocational
                             day courses can be studied    3. Vocational rehabilitation intervention   rehabilitation course and
                             separately.                          strategies                           services. It already has a

Education Provider         Course                      Modules                                     Comments
                                                       4. Vocational rehabilitation placement in   Centre for Enabling
                                                          work and maintaining a job               Environments and Assistive
                                                       5. Advanced vocational rehabilitation       Technology (CEEAT). The
                                                              practice                             University has indicated a
                                                                                                   willingness to work in
                                                                                                   partnership with the VRA to
                                                                                                   develop programmes to
                                                                                                   enable practitioners meet the
                                                                                                   Standards of Practice.

2. Private Providers

Provider                            Course Details

                                                                                                                                   Getting Vocational Rehabilitation Working for Scotland
Harrison Associates                 Run a series of short courses/workshops as below. Although designed with OTs in mind other
                                    related professions are welcome to attend:
                                    • Introduction to the Role of OT in vocational rehabilitation
                                    • Assessment of the Person in vocational rehabilitation
                                    • Assessment of the Workplace in vocational rehabilitation
                                    • Designing Rehab Programmes in vocational rehabilitation
                                    • Building an evidence based, vocational rehabilitation Service (1day)

KMG Health Partners Ltd.            Courses include, but not limited to:
                                    • Vocational Rehabilitation Consulting - service delivery to vocational rehabilitation
                                    • Case Management with expertise in job retention/mental health
                                    • Facilitator training a buddy system within employers for the early identification and
                                       resolution of mental health issues at work
                                    • The Value of Values - recognising key values in service delivery that enhance outcomes

Provider                             Course Details
KMG Health Partners Ltd.cont…        • Ethical decision-making
                                     • Barriers Busting - identifying and resolving barriers to client engagement with services
                                       and/or employment
                                     • Mental Health Awareness and Stress Management programmes
                                     • Mediation training for job retention
                                     • Corporate ergonomics
                                     • Introduction to functional assessments, CBT, chronic fatigue, ergonomics
                                     • Employment Preparation courses for clients.

WorkHab Europe                       Courses are London based
                                     •  Functional Capacity Evaluation training 2.5 days
                                     •  Pre-Employment Screening 1 day
                                     •  Work Site Evaluation 1 day

                                                                                                                                  Getting Vocational Rehabilitation Working for Scotland
                                        Report Writing 1 day

A number of other private sector companies also run very specific programmes, for instance on Systematic Instruction in the
Workplace (for people with learning disabilities) and MODAPTS (Modular Arrangement of Pre-Determined Time Standards).

International courses identified with a UK context

•   Certified Disability Management Professional administered by the International Disability Management Standards Council.
    Knowledge base is the NIDMAR training programme and the ILO Disability Management Standards
•   University College Dublin - Higher Diploma in Social & Vocational Rehabilitation

Source: British Society of Rehabilitation Medicine

Appendix 3 - Recommendations for entry-level and postgraduate level
  Entry Level Curriculum                                        Postgraduate Level Curriculum
  Knowledge                                                     Knowledge
   • Knowledge of work environments, jobs and                   • Advanced ergonomics
        commonly used tools                                     • Pain management
   • Ergonomics, kinesiology, biomechanics, work                • Interdisciplinary teamwork
        organization, psychosocial aspects of work                 approaches to return to work
   • Setting’s legislative and contractual requirements            issues
        regarding legal, employer, labour and insurance         • New assessment tools
        systems                                                 • Legislation updates
   • Basic anatomy & pathology; e.g. chronic pain,
        mental health issues in the workplace, post-traumatic
        stress syndrome, work-related and soft tissue
        injuries; health – illness continuum and function
   • Occupational Therapy theory and client-centred
        practice applied to vocational practice
   • Advanced ergonomics, occupational theory in case
        management role, consultant role, roles of others
        and what they offer
   • A business sense and knowledge of business culture
   • Return to work planning, disability management,
        range of work alternatives
   • Programme evaluation, statistics
  Skills                                                        Skills
     • Functional assessment skills e.g. functional             • Advanced disability
          capacity evaluation, functional ability evaluations        management
          with work trials, work simulation                     • Marketing and business skills
     • Occupational/task analysis/job analysis (Physical        • Estimating needs and costs
          Demands Analysis, jobs, worksites, systems)                e.g. future care needs analysis
     • Writing reports; written to the audiences, match         • Proposal writing
          context of the referral, objective documentation      • Publishing
     • Communication and presentation skills
     • Critical appraisal skills applied to vocational
     • More emphasis on treatment outside of institution
          e.g. work hardening, return to work programmes,
          workplace modification, work trials, work
          simplification, energy conservation techniques,
          chronic pain management, cognitive approaches,
          interventions with difficult clients
     • Conflict resolution skills, teamwork
     • Supervision of support personnel
     • Writing proposals, marketing skills
Entry Level Curriculum                                        Postgraduate Level Curriculum
Professional Behaviours                                       Professional Behaviours
   • Limitations, professional boundaries                     • Complex ethical issues
   • Awareness of the consequences of actions (e.g.           • Mentoring
       reports conclusions and recommendations)
   • Ethical issues and accountability in private practice
       with multiple clients
   • Accountability, professional association practice
   • Respect for others’ values and cultural differences
   • Self-reflection, self-assessment
   • Seek mentors, lifelong learning perspective

Strong S, Baptiste S, Salvatori P. Learning from today’s clinicians in vocational practice to educate
tomorrow’s therapists. The Canadian Journal of Occupational Therapy 2003; 70(1), 11–20.
   Table 1
                                        Workless Client Group with health problem/disability by type of health problem/disability (thousands)

                                                     30              30

                                                                                                                                                           19                                                19                                                                                            20

                                           17                                                                                            17 17
                 15000           13                                                                                                                                                                                                                                   12                13
                           10                                                                                                                                                       10                                                                                             11

                                                                                                                                                                                                                                                                                                                Getting Vocational Rehabilitation Working for Scotland
                                                                                                                                                                               8                      7                                               7
                                                                                                                                                                                                                                    6                             6
                  5000                                                                                     4            4                                                                       4                                                4

                             s                   t               k              ng                 g                   s                    s                  n                n                es           es               y                  s            cs                   c.                 s
                           nd              f   ee              ec             ei                rin               rg
                                                                                                                     ie                  m
                                                                                                                                                                              io              et            rv               ps                tie           ni                  e.              lit
                         ha             or                   rn             se                ea
                                                                                                                                                       ul                                   ab            ne              ile                ul           pa                  n.               bi
                                                                                                               lle                  ob                                   ge                                                                ic                               s
                      s,            g                       o
                                                                          in                 h
                                                                                                             ,a                  pr               irc                  di                D
                                                                                                                                                                                          i           d                 Ep              iff            s,                es                 sa
                     m            Le                   ck                                 in                                                    ,c                  y,                             ba                                d               ia                                   di
                   Ar                                Ba              ul
                                                                       ty             lty                 ns                 ng               re                                                n,                                 g               ob               illn               s,
                                                                                    u                   io               hi                                      ne                                                              in                               e
                                                                   ic             ic                 it                at                  su                 ki
                                                                                                                                                                d                           si
                                                                                                                                                                                                                               n                ph              iv                le
                                                                              iff                  nd               re                 es                                                 es                                                 s,              ss
                                                              D              D                  co               tb                  pr                   r,                                                               Le              es              re                  ob
                                                                                                                                                       ve                               pr                                                                                  pr
                                                                                                               s                  d                 li                                e                                                illn              og              er
                                                                                          Sk                                    oo               h,                                  D
                                                                                                                                                                                                                                    al                Pr              th
                                                                                                           C                 bl                ac                                                                                 nt                               O
                                                                                                                        r t,                                                                                                    e
                                                                                                                     ea                    om                                                                                 M
                                                                                                                   H                    St
                                                                                                                                                         Health Problem

                                                                                                                    Workless - want to work                               Inactive - don't want to work

Note: no figures are presented in one of the categories in the difficulty in seeing and hearing and skin conditions and allergies due to the figures
being below the reliability threshold.

Source: Annual Scottish Labour Force Survey 2003 contained in Capability Framework for Scotland Final Report Workstream A: Workless                                                                                                                                                                             36
Client Group, Scottish Executive, 2005.
Table 2

                                                                Reasons for Claiming Incapacity Benefit



 Number of Claimants


                                                                                                                                                            Getting Vocational Rehabilitation Working for Scotland

                       40000                                                                                    34860                               31950

                                                  17430                20330                                                         17430

                                Mental and    Diseases of the     Diseases of the      Diseases of the     Symptoms, signs      Injury, poisoning   Other
                                behavioural   nervous system     circulatory system    musculoskeletal      and abnormal
                                 disorders                                               system and          clinical and
                                                                                      connective tissue   laboratory findings
                                                                                      Reason for Claim

Source: Department of Work and Pensions. Adapted from Chart 5.2, Capability Framework for Scotland Final Report Workstream A:
Workless Client Group. Scottish Executive, 2005.