Select Committee on Health Appendices to the Minutes of Evidence


APPENDIX 5

Memorandum by Mr Clive Langman (H14)

HEAD INJURY: REHABILITATION

  I wish to make the following submission to the Health Committee. Until 1989, I held a position as Head of Profession (Employment Rehabilitation Service: Department of Employment Group). I subsequently established the United Kingdom's first private sector vocational rehabilitation organisation. I am a member of the National Vocational Rehabilitation Association and currently represent the Accreditation Committee. I am an external lecturer in the UK's only dedicated vocational rehabilitation department—the Rehabilitation Resource Centre at City University. I currently have a doctoral research programme into the vocational assessment, rehabilitation and placement of people with acquired brain injury.

Vocational Rehabilitation Provision in the United Kingdom:

  There are three fundamental problems with regards to the "seamless care" of head injured people in respect of vocational rehabilitation:

    (i)  The NHS was established by the Beveridge report in the mid-1940s and the Employment Services, with its Disability Services by the report of the Tomlinson Committee. They have subsequently continued to develop along separate lines.

    There is no automatic progression from health care to the Disability Service within the Employment Service (although with around 1.6 million people in receipt of Incapacity Benefit and just 650 Disability Employment Advisors, the Employment Service could not cope with automatic referrals in any event). Many people who sustain (severe) head injury simply remain in receipt of Incapacity Benefit for years without receiving rehabilitation of any description, either clinical or vocational. In addition, because potential employment problems are not identified within the Health Service system, a number return to work (often far too soon) and are seen to have made a "successful" recovery—only to go on to fail to hold a job down before entering a long period of unemployment/sickness.

    (ii)  A lack of expertise in the UK with regards to the vocational rehabilitation of people with acquired brain injury. Unlike many other countries in Western Europe and North America, there is no vocational rehabilitation profession in the UK. The Disability Service within the Employment Service is essentially staffed by administrative staff—there are 650 Disability Employment Advisors (DEAs) at Executive Officer level backed by just 70 Occupational Psychologists (whom, themselves may have little training in disability issues). DEAs are provided with no training at all on head injury matters. The programmes which exist are also inadequate for head-injured people. Of the 118,000 or so people in the UK seen by the Disability Service every year, only around 18,000 are offered a vocational assessment. This typically consists of one day undertaking psychometric tests, work samples and being interviewed. Such a format can tell one little or nothing about such important factors affecting the resettlement of head-injured people as:

    —  appropriate adaptive behaviour;

    —  maintenance of appropriate interpersonal skills;

    —  organisation and planning (testing is in an ideal distraction-free environment);

    —  learning and working memory.

  Test of ability and aptitude do not identify the deficits associated with head injury and which require the development of compensatory strategies.

  To be fair, many Employment Service staff recognise this themselves and may refer head-injured people to work preparation courses. Naturally there are just 14,000 places per annum for all disabilities. Incidentally, since the closure of all the Employment Rehabilitation Centres (ERCs) in 1992, the Employment Service has tended to drop the use of the word "rehabilitation" and, again in fairness, this reflects the fact that it no longer provides such a service. The work preparation courses typically consist of six weeks placement with a disability organisation and training provider—even assuming that the host organisation has a knowledge of head injury (which is rare) such a time-span does not allow for any monitoring of performance or the development of compensatory strategies.

    (iii)  A lack of funding. A consequence of the lack of appropriate public sector vocational rehabilitation services is the development of private and voluntary sector provision in recent years (although it is not cheaper but more expensive than the public sector). Principal amongst these is the establishment of Brain Injury Vocational Centres by Rehab UK. These are located in Glasgow, Aberdeen, Kirkcaldy, Newcastle, Manchester, Birmingham and London. Programmes are typically of 12 months duration—consisting initially of a neuropsychological evaluation followed by development of compensatory strategies and some remedial education. This is followed by job coaching support comprising placing a client into work and providing them with on-the-job assistance. Typically, Rehab UK reports a success rate of around 60 per cent with a further 12 per cent or so moving on to voluntary or therapeutic work. This contrasts with figures of 30 per cent or less for those receiving no support shown by return-to-work studies. A programme with Rehab UK typically costs in the region of £23,000 per annum. The Employment Service will not pay for this—it will only part-fund. In the areas where it has contracted with Rehab UK to provide work preparation courses, it will, I understand, typically only pay half the weekly amount for a maximum of six weeks. In turn, I understand that Rehab UK relies primarily upon NHS funding. Many NHS Trusts are likely to have neither the funds to support Rehab UK nor will not do so. One has to bear in mind that the NHS has no statutory responsibility to fund vocational rehabilitation.

Recommendations:

  The establishment of a National Institute for Vocational Rehabilitation in the United Kingdom for research, education and training;

  A National Vocational Qualification framework (to Level 5) for training vocational rehabilitation practitioners—modules could be delivered along the way to various professions involved in this sector who currently receive no training at all in vocational rehabilitation, never mind that referring to head injured people. This includes members of the medical profession (see Vocational Rehabilitation. The Way Forward. British Society for Rehabilitation Medicine. November 2000).

  A clarification of the responsibilities between NHS Trust and the Employment Service with regards to referrals and responsibilities. This also involves an examination of the funding made available for vocational rehabilitation and the relevance of existing provision within the Employment Service.

  (I would wish to make it clear that I have no criticism whatsoever of current managerial staff within the Disability Service, Employment Service. On the contrary, my opinion is that they are the most capable and responsive of individuals I have known within 30 years experience within the vocational rehabilitation sector. However, I recognise that they are limited by a lack of funding and the lack of professional rehabilitation expertise within their organisation).

  In short, most people sustaining head injury in the UK receive no rehabilitation at all—and certainly no vocational rehabilitation. The percentage returning to work is very small indeed compared to other countries in Western Europe and North America. There is no seamless provision of services between the Health Service and the Employment Service. In any event, there is a lack of expertise for assessing the needs and providing support to head-injured people within the Employment Service. This is not a consequence of the lack of commitment from management within the Employment Service but due to a lack of funding for appropriate rehabilitation programmes and the continuing mythology that administrative staff within the Civil Service, Disability Employment Advisors, are capable of providing an appropriate service. There is further a lack of training in the vocational rehabilitation sector in the UK—and a unique injury such as a brain injury requires a specialist input. There is no recognised accreditation and training within the vocational rehabilitation sector in the UK. In my experience, the provision of a "seamless" rehabilitation service to people sustaining head injury in the UK and enabling them to make a successful return to the labour market is the worst in Western Europe and appallingly inadequate compared to services available in North America. It is an embarrassment when visitors from Europe and the United States want to visit local programmes and there is nothing to show them. None of the members of the Health Committee represent a constituency in which there is an appropriate seamless service available from the health to the employment sector.

February 2001


 
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