Widening the context:
Whilst this model has been our justification for the management style we adopt, the academic OH community has also been active about the need to engage stakeholders. In the OH guidelines for the management of lower back pain (LBP) (Waddell & Burton, 2000) the report was clear in determining that clinical interventions were not the only answer to work reintegration:

• OH should, ‘Advise employers that high job satisfaction and good industrial relations are the most important organisational characteristics associated with low disability and sickness absence rates’ based on the finding that, ‘Traditional biomedical education based on an injury model does not reduce future LBP and work loss.’
• They continue, ‘Clinical examination may aid clinical management, but is of limited value in planning occupational health management or in predicting vocational outcome’ based on evidence that ‘Individual and work related psychosocial factors play an important role in persisting symptoms and disability, and influence response to treatment and rehabilitation. Workers’ own beliefs that their LBP was caused by their work and their own expectations about inability to return to work are particularly important.’

  Whilst less evidence based, they point out, ‘There is general consensus but limited scientific evidence that workplace organisational and/or management strategies (generally involving organisational culture and high stakeholder commitment to improve safety, provide optimum case management and encourage and support an early return to work) may reduce absenteeism and duration of work loss.’

• And conclude, ‘If medical treatment fails to produce recovery and return to work by 4-12 weeks, (OH should) communicate and collaborate with primary health care professionals to shift the emphasis from dependence on symptomatic treatment to rehabilitation and self management strategies’ and ‘Where practicable such a rehabilitation programme needs to be carefully designed to fit local circumstances and should consist of a multidisciplinary ‘package’ of interventions’ based on evidence that, ‘A combination of optimum clinical management, a rehabilitation programme, and organisational interventions designed to assist the worker is more effective than single elements alone.’

Current thinking:
Perhaps building on this need for a proactive stakeholder management role supported by clinical input, rather than being purely medicalised, is the evolution of what has been termed the bio psycho social model where it is believed that such factors may aggravate and perpetuate disability.

It is based on the premise that the management of sickness and incapacity must address all of the personal, health related and social barriers to work in a cohesive approach to the case. Social factors can include culture (where you live, the importance of work, benefit entitlement mentality), social interactions and the adoption of ‘the sick role.’

Psychological factors can include beliefs, coping strategies, emotions, fears and misunderstanding the clinical position whilst the biological factors should not be looked at in isolation and would include physiological dysfunction as well as neurophysiology.

In effect an integrated approach to the case where the clinical is part of the jigsaw rather than being the whole picture. This does provide a framework on which the empowerment/enablement model can be addressed by OH support as the emphasis is on a move away from the medical model.

It is believed that the strength of the model is that it does provide both a framework for both disability and rehabilitation, contextualises the health condition, allows for interactions between the person and the environment, avoids labels such as ‘mental illness’ by addressing personal and psychological issues and can be used on a wide range of conditions.

Biological needs to address both the clinical and occupational management aspect, psychological needs to change perceptions, belief and behaviour and the social needs to facilitate changes to systems, culture and the acceptance of modified work.

Success of the approach has been found in the Pathways to Work initiatives which are to be rolled out nationally by 2008 where, ‘condition management’ has moved away from a pure rehabilitation approach and this is supported by case focus where CBT is used to enhance coping strategies, beliefs that work is a good thing and by changing the value system.

This last point is the pivotal aspect: sickness and incapacity are social rather than medical problems and that work, in whatever form, is actually good for you. Further reading on the importance of the need to address the psycho social dimensions can be found in the BOHRF report, Workplace Interventions for People with Common Mental Health Problems’ (September 2005) which expands on the LBP work by summarising what works and does not work in this context.

The world stage of Evolution
In 1990 the World Health Organisation started an attempt to achieve a more dynamic concept of the disabling process by its International Classification of Functioning, Health and Disability (ICF) in an attempt to revise the traditional international classification of impairment, disabilities and handicaps (ICD, 1980).

Launched in 2001 the ICF has a detailed system to classify a person’s functioning, activity limitations and participation, restriction as well as the health, environmental and personal factors that influence these.

Environmental factors such as age, gender, education, communications and transport are denoted and the ICF points out that even minor ailments can have a negative effect on ability to work due to psycho-emotional functioning and that where employees cannot access appropriate, safe and timely interventions activity limitations become more serious than the initial basis of incapacity would imply.

Hence it is viewed by the WHO that environmental factors are the key challenge and that macro-environmental factors such as laws, regulations and mediating factors (support availability, incentives, fiscal constrains and administration) are as important, if not more so, than the medical.

At a micro level they allude to the organisational culture, attitudes, policies etc and how these are put into practice. Hence organisations have to address how they prioritise retention, the knowledge based required to achieve this and the resources required.

Following on from this work, in 2004 the European Foundation for the Improvement of Living and Working Conditions published a paper entitled, Employment and Disability: Back to Work Strategies which says that the social model has achieved a focus, ‘On the responsibility of the system for creating negative consequences for people who differ in some way, often as a result of functional capacity’ and finds that, ‘Individuals who require these (disability service) resources must accept a category label in order to avail of supports and interventions’ concluding that, ‘These systems contract with equality legislation, underpinned by article 13 of the Amsterdam Treaty, which outlaws all discrimination on the basis of disability.’

Hence they have taken on board the ICF findings and have developed what they have termed as the ‘Threshold Model’ of disability which has four core components consisting of Retention (the process and activities by which the ill or injured employee is kept in the workplace), Reintegration (the basis on which they are retained for example same job, same employer, new job new employer), Thresholds (barriers that face the worker) and Outcomes (returning to work, unemployment or becoming economically inactive). The key element of the model is the threshold portion which is further refined into two threshold levels: