I have long been a subscriber to the view that the Medical, Charity and Social models of disability are all flawed in the employment context, particularly with a view to getting the newly disabled back into the workplace. These more ‘traditional’ models of disability are being slowly replaced – but are the new models approaching exciting new ground or just labelling the good practice that trained, experienced Occupational Health (OH) nurses and physicians do every day?
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.’
The Charity 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. 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.
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. While the Social Model is absolutely correct in terms of its aspirations, in the employment context it is simply not realistic for organisations to adapt every aspect of the workplace to accommodate the diversity of potential disabilities.
So what comes next? The academic OH community has been clear about the need to engage stakeholders, with a proactive stakeholder management role supported by clinical input, rather than being purely medicalised. As far back as 2000 OH guidelines noted that “workplace organisational and/or management strategies (generally involving…high stakeholder commitment to…encourage and support and early return to work) may reduce absenteeism and duration of work loss.” (1)
Perhaps building on this need for a proactive stakeholder role comes the Bio Pyscho Social model. In this model it is believed that biological, psychological and social 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.
The strength of this 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 and can be used on a wide range of conditions.
The Hanasaari model (favoured by us) also has a strong focus on how the wider environment can impact health. The general wider environment includes economic, political, social, ecological and organisational factors. These impact the inner triangle of ‘man, work and health’, having a significant (although occasionally indirect) effect on workplace health. Organisational cultures and strategies may exert a stronger more direct influence on workplace health. At the centre of the model lies Occupational Health Nursing, which is both flexible and proactive, having an obvious impact on individual health but also politically, socially, economically and ecologically.
So what can we take from this? Clinical input is only one part of the jigsaw and multiple stakeholders are required to support case management beyond the clinical. Secondly, case focus from all of the stakeholders needs to be coordinated to ensure that the diversity of employees’ needs are met to ensure that a return to work happens. Finally it is essential that funding is in place.
The cost of workplace adjustments to accommodate disabled employees is not as much as people think due to initiatives such as the Access to Work Scheme (ATW) (2) where the average cost is £3,000 (4). Employers with less than 50 staff – can claims 100% of the approved costs, Employers with 50 to 249 will have to pay the first £500 and ATW can then pay 80% of the approved costs up to £10,000 and large employers with 250 or more staff will have to pay the first £1,000 and ATW can then pay 80% of the approved costs up to £10,000 noting ATW would normally cover all additional costs over £10,000, subject to a cap. (3)
The benefits of a diverse workforce however are significant – research has shown disabled staff to have low absenteeism rates and long tenures, and are described as loyal, reliable, and hardworking. Diversifying work settings leads to an overall positive work environment. (5) So whichever model you follow – a successful return to work of a disabled employee is something all stakeholders must encourage and celebrate.
OH Guidelines for the Management of Lower Back Pain/LBP (Waddell & Burton, 2000/01)
and the 80% funding summary:
£3k average cost of adaptation: