Paul Avis questions the way that sickness, absence and disability management is being de-medicalised and asks what this means for traditional and more innovative Occupational Health programmes.
To start this article I will attempt to appease the clinicians in the membership. I will never run a sickness absence and disability management programme without routine referral to a trained clinician. But I suppose the question is, ‘is medical opinion enough required to get people back to work?’ I have long been a subscriber to the view that the Medical, Charity and Social models of disability were all flawed in the employment context and the only one that really works is the empowerment/enablement model where specific case focused changes are made to facilitate a return to work.
So I suppose I am just putting a label on the work that trained, experienced Occupational Health (OH) nurses and physicians do every day. However more formal approaches to develop academic models are now being purported where stakeholder engagement beyond the clinical is actively being considered. Two models are the bio psycho social model and the threshold model.
The point of this article therefore is to start a debate: are these approaches exciting new ground or are they just the labelling of the good practice that already exists? Furthermore does this diminish the importance of clinical management or enhance it and will the adoption of these approaches lead to a different type of OH and case management service going forward?
Traditional models of disability
There are three models that could be called traditional:
1. The medical model:
The medical model sees disabled people as ill or sick as if they were patients. Disabled people must be ‘cured’ or ‘made better.’ The only true experts are medical professionals who explain in general terms how disability ‘limits people.’ They therefore have things done for them, which ultimately leads to ‘disempowerment’ by those who ‘know best.’ Disability is often perceived as a hazard and disabled people are seen as having a greater risk of being ill.
2. The charity/tragedy model:
This model portrays disabled people as being worthy of pity. They are ‘brave’, ‘plucky characters’ who despite their disability still manage to be happy and to achieve. Disability is viewed as a personal disaster. Control and power rests with well meaning non-disabled people who strive to bring about change for the benefit of the ‘afflicted.’
The language used is something similar to that used in the medical model. People are ‘crippled’ with polio, ‘afflicted’ with arthritis, ‘suffering’ from a stroke and so forth. Disabled people are ultimately expected to be grateful for what they receive and need to act as passive recipients.
3. The social model:
The social model of disability is linked to the way in which society organises itself. Disabled people are seen as having needs, wants and aspirations. Passivity is replaced by a desire for equality. Disability is not seen as something invoking pity or in need of a cure. It may be viewed as a positive asset. Equality for disabled people is seen in the same light as other under represented groups.
Against this background we sought a workplace model as we believed that whilst the social model was absolutely correct in terms of its aspirations, in the employment context (even with the support of motivated government disability employment advisers to provide funding for adaptations) it was simply not realistic for organisations to adapt every aspect of the workplace to accommodate the diversity of potential disabilities. Some organisations struggle to even invest in accessible/disabled toilets!
Whilst attending an open training session by an organisation called Disability Matters we came across the empowerment/enablement model of disability which they had pioneered since the mid 1990s. This is a model which is fundamentally about managing change from being fully employed to becoming disabled.
It is about the different stakeholders managing the employee scenario proactively by making changes to the workspace, supporting the expectations of what can be done, and what can not, and ensuring that the employee does not lapse into benefits mentality where they are left alone without the benefit of being in work.
On the course this state of mind was described as the ditch, a place where the ends are kicked in and it becomes a grave-is watching Sky TV all night, with cornflakes at 2.00 pm really what we should be doing with our most valuable assets: writing off our people when work is so good for them is quite simply not the right thing to do ethically as well as legislatively.
The model has subsequently underpinned all of our approaches to absence management from policy writing to service provision and when we get client case histories of where a proactive approach from a wide range of stakeholders has led to work reintegration and retention of a disabled employee, often with OH support, then we know that it works in practice as well as being an academic approach.
