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Future Directions

This final chapter highlights current key issues which are of particular relevance to
occupational therapists in vocational rehabilitation (VR), and also looks to the future.
We will briefly consider the significant implications of impending policy changes,
particularly with regard to benefits claimants with a disability. We will conclude by
examining some of the challenges which may face occupational therapists in VR in
the years ahead – paying particular attention to education, training and accreditation –
and identify important areas which are in need of further research.

PLANNED WELFARE REFORMS

Earlier in the book we learned about how political and economic agendas have played
a pivotal role in matters to do with work and disability. The current Government
continues to drive forward welfare reform centred on this theme. The political spotlight
remains firmly fixed on participation in employment as an integral part of an ongoing
programme of welfare reforms. To this end, the Green Paper: A New Deal for Welfare:
Empowering people to work (Department for Work and Pensions, 2006a), proposes
a radical overhaul of the benefits system for new claimants. It builds on the changes
introduced through the Pathways to Work programme, which, you may remember,
includes Condition Management Programmes.

From 2008, incapacity benefit and income support for people with health condi-

tions, will be replaced by a new employment and support allowance (ESA). This will
be paid, in addition to the basic jobseeker’s allowance, only to those people who agree
to participate in work-related activity. These activities may include work-focused in-
terviews with the personal advisor at the Jobcentre Plus, and participation in agreed
programmes and activities which are work-related, or directed towards work return.
Suitable activities may include attending a condition management programme or
doing voluntary work.

A minority of people who are considered too unwell to work will receive additional

benefits, over and above the ESA, which are not conditional on work participation.
Expert practitioners suggest that the Welfare Reform Bill (Department for Work and
Pensions, 2006a) will help create incentives for patients to return to work, increase the
conditionality to benefit entitlement, stimulate VR through demanding that recipients
show work-related activity, and offer programmes designed to help them manage their
condition (Thurgood and Frank, 2007).

Attaching a financial inducement to promote return to work will, of course, have

both advantages and disadvantages. On the positive side, it will remove some of the

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disincentives in the current system and prevent people becoming locked in a benefits
trap. It also means that a far more pro-active approach will be pursued in supporting
people back to work. These are both positive steps and disabled workers themselves
have indicated that, despite existing strategies and support, they need access to more
structured, formalised and appropriate support (Roulstone et al., 2003). On the neg-
ative side, however, these planned reforms have significant resource implications
if they are to be delivered effectively. The funding of these resources is yet to be
clarified, although much of the provision will be out-sourced to the private and vol-
untary sector. In some parts of the country the infrastructure is not yet in place to
deliver the agenda, therefore existing services may struggle to meet these targets.
Additionally, details about the practical implementation of the reforms are currently
limited.

The Disability Rights Commission (DRC) has raised concerns about this matter,

and they are well placed to do so, since one of the Commission’s top ten priorities
is to close the employment gap between disabled and non-disabled people, including
a successful outcome from welfare reform. In this regard, during its consultations,
the DRC raises a number of vital questions about the implementation of the planned
reforms (Disability Rights Commission, 2006), which include:

r With regard to eligibility, what is the best concept to underpin the ESA which avoids

the rigidity of ‘incapacity for all work’?

r In connection with assessment, what needs to be done to reform the personal capa-

bility assessment (the medical assessment which currently determines if someone
is, or is not, capable of work) and other assessments, so that they are fit for purpose
and consistent with the new concept?

r Concerning the conditionality element of the reforms, what is the appropriate level

of responsibility that can reasonably be expected of ESA recipients, and should this
vary by type of recipient, or activity?

r Regarding activities while on benefit, how can ESA rules ensure that people do

not risk losing benefit when trying out work-related activities, volunteering or pub-
lic appointments, while avoiding people being trapped in those activities without
progressing to their full potential?

r In relation to the benefit structure, what is the best balance between means-tested

and contributory elements for both the ‘employment’ and the ‘support’ group?

r How can existing recipients of disability benefits be enabled to take the risk of

trying out work and related activities while ensuring that entitlement remains
correct?

r Finally, what are the disability implications of longer-term reform?

The DRC followed up these questions with a number of possible alternatives and

strategies in response to the Green Paper and also to the Welfare Reform Bill, and
the interested reader can find out more at: http://www.drc.org.uk/disabilitydebate/
priorities/documents/IB Discussion paper March 2006.pdf (accessed 24/10/06).

The conditional element of programme participation that will be attached to ben-

efit payments has particular relevance to occupational therapists. There are different

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viewpoints amongst members of the profession as to whether this will support or hin-
der the occupational therapist’s role. You too will, no doubt, have your own views on
the subject. Removing the voluntary aspect of participation does have the potential to
undermine the success of existing successful programmes, because it means that the
individual’s personal control and choice are diminished. As a result, the person may
feel compelled to attend therapeutic interventions, such as Condition Management
Programmes, rather than being there through personal choice. This compulsion may
counterbalance the therapeutic benefits which a number of occupational therapists cur-
rently attribute to the voluntary nature of participation within existing programmes.

The final point raised by the DRC concerns longer-term implications. It is important

to reflect on the fact that these reforms are being delivered at a time when the economy
is strong. History demonstrates that VR schemes have been swiftly dropped from
the agenda during times of recession. On this note, it is interesting to see that in
their latest departmental report, setting out a three-year target, the Department for
Work and Pensions plans to ‘increase the employment rate of disabled people, taking
account of the economic cycle, and significantly reduce the difference between
their employment rate and the overall rate, taking account of the economic cycle’
(our emphasis) (Department for Work and Pensions, 2006b, p.70). What might the
implications be, one wonders, for people with health conditions or disabilities who
are expected to engage in work activity in a less than favourable economy?

Change is, of course, also taking place elsewhere in the domain of VR, beyond the

welfare system. Employers (Tehrani, 2004), insurers (Association of British Insurers,
2005) and personal injury lawyers (Association of Personal Injury Lawyers, 2004)
are increasingly looking to healthcare and rehabilitation to meet their particular
objectives. Therefore the demand is rising for services and for practitioners with
the necessary expertise. Encouragingly, this trend looks set to continue within these
sectors. However, this increasing demand throws up issues about the knowledge and
skills which are being sought by these respective parties, since a lack of suitably
skilled and trained professionals is currently identified as a major barrier, preventing
potential growth and service expansion within the field. A report for the Association
of British Insurers, which examined the availability of rehabilitation resources in the
UK, identified that occupational therapists with experience in VR were a key gap in
rehabilitation resources (Wright et al., 2005). This concern brings us, in an oppor-
tune way, to examining salient issues with regard to the education and training of
occupational therapists in VR.

EDUCATION AND ACCREDITATION

In the earlier days of the re-awakened political interest in VR, a British Society of
Rehabilitation Medicine (BSRM) working party report recommended the need for fur-
ther development of training programmes for health professionals in this field. They
remarked that ‘As work awareness is required in all NHS professions it needs to be
part of the undergraduate training of all NHS staff. Those who need a greater input are

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undergraduate doctors, occupational therapists and physiotherapists’ (British Society
of Rehabilitation Medicine, 2000, p.63). Alongside the BSRM report, the College of
Occupational Therapists undertook its own review of work rehabilitation and occupa-
tional therapy (OT). It concluded that ‘while assessment of occupational performance
is one of the core components of pre-registration occupational therapy courses, the
demand for specific skills in work rehabilitation demands that this knowledge be ex-
tended,’ and recommended that, ‘work rehabilitation should . . . be a stronger feature
of pre-registration programmes’ (Mountain et al., 2001, p.54). More recently, a re-
port by the Association of British Insurers called on the Government to ‘establish a
transparent accreditation system for rehabilitation qualifications and provide enough
financial support to increase the number of rehabilitation specialists’ (Association
of British Insurers, 2005, p.10), although the Government has already acknowledged
that some form of accreditation system is needed (Department for Work and Pensions,
2004).

Despite these clearly stated recommendation from key parties, progress towards

addressing these proposals has been woefully slow. As a recent publication by the
College of Occupational Therapists Specialist Section

− WORK identifies, the lack

of experience of many established clinicians and academics means that education and
training in VR, at both undergraduate and postgraduate level, remains patchy, and,
in the absence of an agreed pre- and post-registration core curriculum, the content
of courses which are currently available shows considerable variation (Barnes and
Holmes, 2007). The College of Occupational Therapists has consistently maintained
the stance that occupational therapists have the skills to deliver VR, and yet potential
employers have, anecdotally, on some occasions suggested otherwise.

This viewpoint is reinforced by findings from a recent study which examined the

planned undergraduate OT curricula for 16 OT courses across England, Wales, Scot-
land and Northern Ireland. The intended aim of the research was to examine how work
and VR were represented within the curriculum. A content analysis of each course
document looked at the intended learning outcomes, module descriptions, reading
lists, reference and bibliography lists, and any assignment details. Despite the obvi-
ous limitations raised by research of this kind, it is notable that just one out of the
16 course documents analysed made reference to VR and work rehabilitation, both
within a mental health context. Terms such as occupational health, disability man-
agement, insurance sector and worker did not appear in any of the course documents.
Few references were made to approaches and interventions associated with rehabili-
tation for work. Just one final year optional module included undertaking a worksite
analysis (Ross, 2006). These findings suggest the need for further ‘movement toward
more occupation-based intervention [which] would be aided by greater inclusion of
work and productivity issues in occupational therapy curricula’ (Lysaght and Wright,
2005, p.216).

Occupational therapy education is not alone in these omissions. A study undertaken

by academics in occupational medicine showed evidence that the number of hours
spent teaching occupational medicine to undergraduate doctors had dropped from
the levels reported in 1989. Of those courses that did offer some training in the

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subject, none included workplace visits (Wynn et al., 2003). As has been stressed
throughout this book, gaining an understanding of the workplace is a core element of
any successful rehabilitation for work programme.

These concerns regarding education provision are shared by the Vocational Rehabil-

itation Association (VRA). The VRA is a small charitable organisation whose mission
is to help members working in the field of disability and employment develop their
professional practice and maintain their awareness of disability issues in this field.
The VRA has highlighted the need for the accreditation of education and training in
VR in the UK to ensure that standards are met and in order to produce competent prac-
titioners who are fit for practice. They highlight a concern regarding the numbers of
practitioners in the field with no professional qualifications whatsoever. Importantly,
they emphasise the need for education to extend beyond purely theoretical knowledge,
to support the transfer of this knowledge into the workplace, and to provide the means
to measure the effectiveness of the intervention which is delivered (Vocational Reha-
bilitation Association, 2006). Further information about the VRA and membership
can be accessed at: http://www.vocationalrehabilitationassociation.org.uk (accessed
09/11/06).

There are a number of complex reasons for these difficulties, not least the rapid

rate of change in this sector, which has outpaced education. Consequently, there is
now a need for much creative thinking to develop innovative learning opportunities
for therapists in this field, particularly at an undergraduate level. Encouragingly, a
recent survey of OT final year students at two UK universities found that over 60
per cent of respondents expressed an interest in pursuing a career in VR (College
of Occupational Therapists, 2006). This is a positive shift and demonstrates that the
work agenda is now filtering through to undergraduate students.

However, since much of VR is taking place outside of traditional service structures,

there are presently insufficient opportunities for students to gain practical skills and ex-
perience in VR during their training. We are not alone in facing these difficulties. Even
in those countries where the infrastructure is already well-established, sufficient place-
ments are not always available (James and Prigg, 2004). Additionally, the focus of OT
undergraduate education has been criticised for being directed more towards hospital-
based practice, than towards meeting the needs of those wanting to work in occupa-
tional (work) rehabilitation (Thorpe, 2006). Furthermore, it has been suggested that
the knowledge and skills learned in the undergraduate curriculum may not be sufficient
for later needs when qualified (Strong et al., 2003; Ahrens and Mulholland, 2000).

It is not unduly surprising that occupational therapists, or any other professional

group, have been unable to hit the ground running. The complexity of the arena,
as indicated in this book, can be considerable. Occupational therapists in the UK
are fortunate to have a wealth of knowledge which they may draw upon from other
countries where occupational therapists are already well-established in this field. The
drawback of this is, however, that within the UK, much of the emerging sector remains
heavily reliant on the skills and expertise of overseas therapists to deliver VR services.
This workforce is often transient in nature, and therefore, perhaps too little investment
is currently being made in creating a solid infrastructure for the future. In a number

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of regions, local initiatives, reflecting the breadth and uniqueness of VR activities in
the UK, are sorely needed for the sustainable expansion and growth of this sector in
the longer term.

CHALLENGES FOR OCCUPATIONAL THERAPISTS

To begin this section on a positive note, there is a wealth of exciting prospects within
the current market for occupational therapists with the right skill set and expertise.
To temper this enthusiasm however, ten years into the revival of VR we do not re-
ally seem to have made significant in-roads into capitalising on these opportunities.
The OT literature recently challenged us to ask ourselves whether we may be com-
plicit in the process of marginalising people with disabilities into special occupations
and employment relations. We were also confronted about whether we were overly
influenced by a traditional, Protestant work ethic and by political drives to reduce
unemployment figures (Stewart, 2004). Running through these sentiments it seems
there is a collective sense of frustration that may, perhaps, be shared by others as
they read this book. Many occupational therapists will already know that they have
a valuable contribution which they could, potentially, make within VR, but they are
not sure where, or how, to set about doing it.

Perhaps, however, it may be timely to recognise and acknowledge that ‘it takes

more than a knowledge of occupational performance to convince policy makers of
the value of occupational therapy in vocational rehabilitation. If knowledge is wisdom,
then perhaps occupational therapists, with their collective wisdom and knowledge of
occupational performance, require a major paradigm shift that integrates occupa-
tional performance and theories of career decision-making and career development’
(McDonald, 1997, p.267). In addition, there is also a need for us to be able to demon-
strate the ways in which we are effectively able to help others deliver their agenda
– whether this be employers who want to reduce their rate of sickness absence, or
Jobcentre Plus staff needing to meet their work entry targets. This is how demand for
OT services will be sustained.

Some may, perhaps, feel that they lack the confidence or essential skills in VR

(Shaw et al., 2006), others may have been powerless to persuade managers that
this should form part of their current role. A reality which has become increasingly
apparent in recent years is the fact that occupational therapists are not well-deployed
for them to be able to effectively deliver rehabilitation for work interventions (Alsop,
2004; Joss, 2002). There are over 15,000 occupational therapists in the UK, however
the vast majority of this number works in the NHS where they focus predominantly
on discharge from hospital. It has been recognised that current practice has a very
limited focus on rehabilitation of any form and even less on the vocational needs of
clients. This is in spite of the fact that estimates suggest nearly a third of OT cases
in the NHS involve individuals of working age (Wright et al., 2005), and yet more
occupational therapists will be working with young disabled people who will soon
be moving towards work.

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This concern about the numbers of occupational therapists in VR is highlighted

by the fact that, in 2002, there were thought to be just 400 occupational therapists
undertaking VR as a primary part of their role in the UK (Wright et al., 2005), although
undoubtedly this number will have expanded significantly in the intervening years.
This small number of rehabilitation practitioners must be seen within the context of
the present situation, where over 2.5 million people are on incapacity benefits, of
whom just under a third, roughly 800,000 people, are predicted to need specialist
disability support to be able to work (British Society of Rehabilitation Medicine,
2003). Many more will, of course, be absent or struggling to stay in work because of
a health condition or a disability. Despite calls to challenge existing organisational
arrangements and to establish unified schemes that ‘bridge the divide between health
and occupation’ (Alsop, 2004, p.525), at the moment regulation most certainly has
the edge over legislation. Consequently, it seems that, in the foreseeable future at
least, a major shake-up is unlikely.

In education we need to shift away from an over-reliance on sociological perspec-

tives of work (Ross, 2006) and begin to consider how we may be able to expand
our understanding of human occupation to provide us with an occupation-focused
perspective of work. A number of OT courses will already be drawing in, and make
use of, the expertise of practitioners, perhaps working as case managers or condition
management practitioners, for example. Providing this theoretical knowledge is an
important step forwards, but cannot replace the confidence and skill which are gained
through experientially taking part in a worksite visit, for example. In a number of
services, particularly within mental health, occupational therapists are acting as work
champions, providing a focal point for others within the wider team. This may also
be a useful model for education providers, who may want to ensure that work and VR
become firmly embedded across both the length and breadth of their curriculum.

Returning to the literature, we can see that, in recent years, some demonstrable

successes have been achieved, in spite of existing barriers. Throughout this book
we have learned about examples of innovative practice. Others which we may find
in the literature include: an out-patient OT service which is successfully supporting
people to return to work or education, using early intervention and speedy placement
into a familiar role when possible (Main and Haig, 2006), as well as an OT audit which
highlighted how a successful return to work can be achieved when a co-ordinated
multi-agency team is involved (Brewin and Hazell, 2004). Forging new partnerships
with other agencies such as education, training, volunteering and employment is
a highly effective way to move forwards (Devlin et al., 2006). In this regard, an
entrepreneurial approach towards service development is required.

Earlier, we discussed how calls have been made for education and training in VR

to be accredited. It is to be anticipated that, in the future, practitioners themselves will
be expected to obtain some form of accreditation too. This will ensure that therapists
have the necessary skills and competencies to practice VR effectively and safely. In
a number of other countries this is already mandatory. While there is currently no
requirement for occupational health physicians or nurses to obtain a postgraduate
qualification in this field, their respective professional bodies strongly recommend

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that this should be undertaken. What is our profession’s stance on this matter to
be? This question certainly needs to be a priority for debate and, hopefully, some
consensus.

RESEARCH

There are a number of exciting avenues for researchers to follow in the field of
VR. The Research and Development Strategic Vision and Action Plan (College of
Occupational therapists, 2003) of The College of Occupational Therapists Specialist
Section – WORK identified the following priority research areas:

r anexplorationoftheorganisationalpolicieswhichimpactonoccupationaltherapists

and their remit to work across the total spectrum of self-care, productivity and leisure

r health and economic effectiveness of OT interventions

r standardised assessments and outcome measures

r glossary of terms by an international literature review

r relevant models of practice for VR

r perceptionsofroleandexpectationsofoccupationaltherapistsinthisareaofpractice

r barriers and stigma which may impact on people with disabilities getting into work.

Reflecting the fact that this a key area of interest to occupational therapists across

specialisms, several other specialist sections have also emphasised the importance of
research in VR. While almost all of the areas identified above are concerned with
gaining a better understanding of professional practice, other highly relevant areas
include:

r Transitions – for example, how might we participate in planning for the future occu-

pations and careers of young people with chronic illness, over and above focusing
on the here and now of school (Shaw et al., 2006)? In what ways may older people
be actively supported to maintain a valued work role, if this is what they aspire to
do?

r Timings – when is the right time for a therapist to begin VR? Despite a recognition

of the fact that outcomes are greatly enhanced with early intervention, many existing
services which address work support needs are reactive and therefore seem to be
delivered too late. While on this point, how do we help the person recovering
from a life-changing illness, perhaps requiring lengthy medical rehabilitation or
convalescence, to successfully retain a worker identity?

r Effective targeting – how might we best identify who might benefit from return to

work facilitation? Clearly, it is wasteful of an expensive resource to think that every
person who is absent from work will need a therapist to facilitate their return. In the
majority of cases this will be handled by an experienced employer. But there will
be instances where additional support to re-enter work will be needed, to prevent
unnecessary long-term absence or job loss. On this note, not all individuals will need
the same level of support to return either. Are we able to identify those situations

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where a simple or a more complex intervention is likely to be required? There are
some suggestions that men achieve better outcomes from rehabilitation for work
than women (Ahlgren and Hammarstrom, 2000). Are we confident that our services
are designed to meet the needs of all who might benefit from them?

r Work and well-being at work – how can we further our understanding of the re-

lationship between the occupation of work, health, and well-being? How might
we measure the potential contribution of the workplace itself to work, health and
well-being?

These, and many other questions, have raised themselves as worthy of research in

the future. However, it is worth noting that finding the answers may not always be that
straightforward. The researcher may have particular difficulty navigating his or her
way around the electronic databases seeking out evidence on this subject, since search
terms such as occupational health, are not particularly easy to locate. Furthermore,
much of the literature on work is more likely to be found within sociological databases
rather than health ones.