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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