Navigating the health–work interface—vocational rehabilitation in the UK

Navigating the health–work interface—vocational rehabilitation in the UK The interface between work and health is complex and poses a variety of issues for health professionals. Health factors may be congenital or inherited (or acquired at an early age) or present later in life. They may recover fully, improve partially, leave fluctuating levels of impairment (e.g. multiple sclerosis or rheumatoid arthritis) or progress inexorably (e.g. motor neurone disease) [1]. The end result of these differing health pathways may lead to difficulties working—and the numbers are huge. Government estimates indicate that there are over 7 million people with disabilities of working age in the UK, of whom 48% are out of work, with consequentially higher mortality and lower quality of life compared with 80% of non-disabled individuals who are in work [2]. This ‘disability employment gap’ is unacceptable in the caring society that health professionals strive for. Work factors may be equally important, not only if the affected individual has ever worked, is in work, or out of work, but also their previous work experience. Such prior work experience may contribute to self confidence, assertiveness, conscientiousness, motivation and resilience which are qualities valued by employers. Educational level or skills base are fundamental just like labour market conditions. There is greater understanding of the adverse health complications of unemployment and sickness absence [3] at a time when the state has less money available to support those not working due to ill-health or disability. Thus, supporting those with ill-health/disability issues in the work-place is increasingly important not just for individuals and their families but also the state. Employers gain from keeping skilled and knowledgeable workers within their workforce, through increases in workforce morale, improved teamwork, productivity and a positive impact on ‘employee turnover, loyalty, attendance, open-mindedness and attitude’ [4]. Supervisors trained to support those with disabilities improve general management skills [4]. There is a ‘strong relationship between levels of staff wellbeing, motivation and performance’ [5]. In other words, business, health professionals and government have a common objective to reduce the disability employment gap. Most importantly, work is what many individuals with disability or long-standing illness aspire to do [6]. This can be achieved with rehabilitation professionals who are trained to facilitate optimal participation in society including participation in the world of work. Those specialising in supporting chronically ill or di sabled individuals into employment are termed vocational rehabilitation professionals (VRPs) and have particular knowledge of the employment world as well as either generic or specialist health skills (e.g. in severe mental ill-health or traumatic brain injury). Rehabilitation has been an established concept since the inception of the National Health Service (NHS) [7] where it was seen as a ‘bolt-on’ following the cessation of medical treatment [8]. More recently, rehabilitation within the workplace has been seen to be an important component to ‘getting better’ [9]. Thus, developing skills from within the workforce, e.g. for those with intellectual impairments or severe mental health issues, is more effective than pre-work training—‘place then train’ is now preferred to ‘train then place’ [10]. The relative lack of good rehabilitation facilities in the NHS has led to the development of private rehabilitation services, mostly paid for by the insurance sector which realized that the lack of services to enable effective return to work (RTW) was proving expensive. Two groups of professionals were formed, representing the two main streams of rehabilitation as it developed in the private sector—the Case Management Society of the UK and the Vocational Rehabilitation Association, which has recently published the second edition of its standards [11]. Specific skills are needed to assist those who have never worked, those still employed but with work-related difficulties or those who have lost their employment because of their illness/disability. Successful vocational rehabilitation (VR) reflects the personal attributes of the individual concerned, the attitudes of the employer, the skills of the health professionals involved and the services made available by the insurer (usually the Department of Work and Pension (DWP) in the UK) [1]. Teenagers may need support and advice in order to be exposed to appropriate role models and to develop the social skills and self-confidence to secure employment [12]. Any form of work experience is of the utmost value. Apprenticeships, traineeships and supported internships are increasingly used routes into employment for disadvantaged young people. Apprentice programmes can strengthen an organization’s ‘value, culture and brand’ [4]. Others will gain work experience through the voluntary sector [1]. It is clear that inclusive policies for those with mental health [5] or disabling conditions are crucial to reducing the disability employment gap. Employers must ‘ensure that their recruitment processes are configured to encourage disabled people to apply for jobs and to en able them to participate fully in the recruitment process’ [13]. Thus, an ‘Able to Enable Programme’ to facilitate individuals with disabilities gain workplace experience can be valuable [4]. In the Barclays scheme, potential employees were offered the opportunity to participate in a confidence/resilience-building training session [4], designed to help potential employees to overcome their nervousness which may prevent them from applying for roles at the bank. This scheme is a new and fully supportive internship programme being currently piloted in two of its London branches. It was set up in conjunction with Remploy to give two people with disabilities the opportunity of learning new skills and supporting the business while growing their experience and confidence [4]. It was also aimed to ‘dispel the myth that banking is an inaccessible career for people with disabilities’ [4]. As a result of this successful pilot, the scheme is now being expanded. Job retention is an important part of occupational medicine, but only 30% of the UK total workforce has access to specialist occupational health advice [9] and this is largely provided by large employers with little provision for small businesses. Rehabilitation professionals are now recognising ‘work instability’—where there is a mismatch between an individual’s functional abilities and the demands of his or her job. This can be measured [14]. Thus, organizations can assess their workforce for vulnerable employees using work instability scales or job satisfaction/wellness tools. Good management embraces an effective health and safety policy in addition to an absence policy which is understood by all parts of the organization (including line managers) and differentiates between absence relating to disability, ill-health, social factors (e.g. family illness) and factors which point to the need for disciplinary action. Such policies should facilitate close contact between the employee and the employer from Day 1 of the absence with early involvement of occupational health, perhaps by Day 10 of a health-related absence. This has been shown to reduce sickness absence in Scotland [15]. For those employed by organizations without occupational health, health/rehabilitation professionals should encourage maintenance of contact between employer and employee and when needed, use worksite visits to resolve the difficulties raised by both employer and employee. Fundamental to every RTW is an understanding of the full physical, emotional and intellectual requirements of the job and which parts can still be performed after injury or illness. What both the employer and the employee understand to be obstacles to RTW need to be understood. Strategies to facilitate RTW are now regularly practised such as developing a RTW plan and phased RTW in terms of hours worked, tasks performed and responsibilities undertaken [1]. Helping employers understand the need for job modifications (accommodations) and their responsibility under the Equality Act may need careful explanation. Employers do not always understand the assistance that the DWP can provide. For example, Access to Work will facilitate transport of ill employees who are able to work but have difficulty in getting to work. Finding new work is more complex. The process needs to take account of any previous work experience, educational background, hobbies that might convert into a wage and the inclinations of the individual. The range of options available have been outlined elsewhere [1] and include working at either previous or new tasks with new or previous employers, home working, part time working and self employment either full time or part time, at home or at the workplace. Support is available from the government through the Disability Employment Advisors at JobcentrePlus (part of the DWP) as well as from the voluntary sector [1]. While VR is best provided when part of a rehabilitation programme (e.g. following a traumatic brain injury or rehabilitation for spinal pain), there are many occasions when this is not available or may not be appropriate, e.g. when an individual has concluded a rehabilitation programme and has been out of work for an extended period of time. The VR then is organized by an appropriate VRP who will arrange/coordinate the necessary health management together with the primary care team, liaise with potential future employers and hopefully arrange a job match between the abilities of the individual and the needs of the employer. The major challenge for health professionals, whether in the NHS or private sector, is to see work as an outcome of their interventions, and that this needs to be thought about from the beginning of a health episode and through any recovery period [1]. Encouragement that there are many ways of assisting individuals back into work (and sometimes into new or different tasks) helps to prevent ill/injured individuals from seeing a depressing future for themselves. There are enormous implications for occupational health services of the demands that are likely to be made on employers as increasing numbers of the workforce have disabilities that may (or may not) relate to the ageing workforce. The occupational health team has to influence management to provide a supportive culture for their employees, particularly if workforce pressures impact on their mental health [5]. Appropriate absence policies need to be formulated and clearly understood throughout the organization and introduced as part of the induction programme [5]. Staff well-being should be a consideration for all workplace policies and can be measured through staff consultation and surveys [5]. The Health and Safety Executive ‘Management Standards’ for work-related pressures can be adopted [5] and the organization can join the Disability Confident Scheme for employers which aims to help employers make the most of the opportunities provided by employing disabled people [16]. The scheme is voluntary and has been developed by employers and disabled people’s representatives. Employers also must recognize the change in emphasis in RTW practice. Employees may RTW before they are fully recovered with flexible planning that allows for staff taking time out for treatment, e.g. counselling or physiotherapy. When combined with a phased RTW and job modifications many employees will greatly reduce their sickness absence and its consequent burden on co-workers by these means. The opinions expressed are personal. References 1. Frank AO. Vocational rehabilitation: supporting ill or dis abled individuals in(to) work: a UK perspective. Healthcare  2016; 4. doi: 10.3390/healthcare4030046 2. Department for Work and Pensions, Department of Health. Improving Lives: The Work, Health and Disability Green Paper. London, UK: Department for Work and Pensions/Department of Health, 2016; 1– 91. https://whitehall-admin.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/564038/work-and-health-green-paper-improving-lives.pdf. (22 February 2017, date last accessed). 3. Waddell G, Burton AK. Is Work Good for Your Health and Well-being?  London: The Stationery Office, 2006; 1– 246. 4. Cohen P. Barclays Disability and Careers Toolkit. London: Barclays Bank, 2016; 1– 46. https://www.disabilityrightsuk.org/sites/default/files/pdf/Barclaystoolkit.pdf. (22 February 2017, date last accessed). 5. Business in the Community/Public Health England Mental Health Toolkit for Employers. London, UK: Business in the Community, 2016; 1– 51. http://wellbeing.bitc.org.uk/sites/default/files/mental_health_toolkit_for_employers_-_small.pdf. (22 February 2017, date last accessed). 6. McNaughton D, Symons G, Light J, Parsons A. ‘My dream was to pay taxes’: the self-employment experiences of individuals who use augmentative and alternative communication. J Vocat Rehabil  2006; 25: 181– 196. 7. Beveridge WH. Social Insurance and Allied Services. Report by Sir William Beveridge Presented to Parliament by Command of His Majesty . London: HMSO, 1942; 1– 299. 8. Chamberlain MA, Frank AO. Congratulations but no congratulations: should physicians do more to support their patients at work? Clin Med (Lond)  2004; 4: 102– 104. Google Scholar CrossRef Search ADS PubMed  9. Harrison J. Planning the Future: Delivering a Vision of Good Work and Health in the UK for the Next 5–20 Years and the Professional Resources to Deliver it—Executive Summary. London: Council for Work and Health, 2013; 1– 48. http://www.councilforworkandhealth.org.uk/images/uploads/library/Planning%20the%20Future%20-%20OH%20and%20its%20Workforce%20April%202014.pdf. (22 February 2017, date last accessed). 10. Grove B. International employment schemes for people with mental health problems. B J Psych Int  2016; 12: 97– 9. 11. Vocational Rehabilitation Association Vocational Rehabilitation Standards of Practice . Thorpe le Soken, Essex: Vocational Rehabilitation Association, 2013; 1– 14. 12. Department for Work and Pensions. Help and Support for Young Disabled People to Find and Stay in Work. London: Department for Work and Pensions, 2016. https://www.gov.uk/government/publications/help-and-support-for-young-disabled-people-to-find-and-stay-in-work/help-and-support-for-young-disabled-people-to-find-and-stay-in-work. (22 February 2017, date last accessed). 13. All-Party Parliamentary Group for MS. Employment that Works—Supporting People with MS in the Workplace. London: All-Party Parliamentary Group for MS, 2017; 1– 56. https://www.mssociety.org.uk/sites/default/files/Employment%20that%20works%20-%20APPG%20report_0.pdf. (22 February 2017, date last accessed). 14. Gilworth G, Smyth G, Smith J, Tennant A. The development and validation of the Office Work Screen. Occupational Medicine (Oxford)  2008; 58: 289– 294. Google Scholar CrossRef Search ADS   15. Brown J, Mackay D, Demou E, Craig J, Macdonald E. Reducing Sickness Absence in Scotland—Applying the Lessons from a Pilot NHS Intervention. Glasgow: University of Glasgow, 2013; 1– 24. http://www.gla.ac.uk/researchinstitutes/healthwellbeing/research/publichealth/hwlgroup/currentresearch/sickness%20absence/. (22 February 2017, date last accessed). 16. Department for Work and Pensions Disability Confident Employer Scheme and Guidance. London, UK: Department for Work and Pensions, 2014. https://www.gov.uk/government/collections/disability-confident-campaign. (22 February 2017, date last accessed). © The Author(s) 2018. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oup.com http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Occupational Medicine Oxford University Press

Navigating the health–work interface—vocational rehabilitation in the UK

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Abstract

The interface between work and health is complex and poses a variety of issues for health professionals. Health factors may be congenital or inherited (or acquired at an early age) or present later in life. They may recover fully, improve partially, leave fluctuating levels of impairment (e.g. multiple sclerosis or rheumatoid arthritis) or progress inexorably (e.g. motor neurone disease) [1]. The end result of these differing health pathways may lead to difficulties working—and the numbers are huge. Government estimates indicate that there are over 7 million people with disabilities of working age in the UK, of whom 48% are out of work, with consequentially higher mortality and lower quality of life compared with 80% of non-disabled individuals who are in work [2]. This ‘disability employment gap’ is unacceptable in the caring society that health professionals strive for. Work factors may be equally important, not only if the affected individual has ever worked, is in work, or out of work, but also their previous work experience. Such prior work experience may contribute to self confidence, assertiveness, conscientiousness, motivation and resilience which are qualities valued by employers. Educational level or skills base are fundamental just like labour market conditions. There is greater understanding of the adverse health complications of unemployment and sickness absence [3] at a time when the state has less money available to support those not working due to ill-health or disability. Thus, supporting those with ill-health/disability issues in the work-place is increasingly important not just for individuals and their families but also the state. Employers gain from keeping skilled and knowledgeable workers within their workforce, through increases in workforce morale, improved teamwork, productivity and a positive impact on ‘employee turnover, loyalty, attendance, open-mindedness and attitude’ [4]. Supervisors trained to support those with disabilities improve general management skills [4]. There is a ‘strong relationship between levels of staff wellbeing, motivation and performance’ [5]. In other words, business, health professionals and government have a common objective to reduce the disability employment gap. Most importantly, work is what many individuals with disability or long-standing illness aspire to do [6]. This can be achieved with rehabilitation professionals who are trained to facilitate optimal participation in society including participation in the world of work. Those specialising in supporting chronically ill or di sabled individuals into employment are termed vocational rehabilitation professionals (VRPs) and have particular knowledge of the employment world as well as either generic or specialist health skills (e.g. in severe mental ill-health or traumatic brain injury). Rehabilitation has been an established concept since the inception of the National Health Service (NHS) [7] where it was seen as a ‘bolt-on’ following the cessation of medical treatment [8]. More recently, rehabilitation within the workplace has been seen to be an important component to ‘getting better’ [9]. Thus, developing skills from within the workforce, e.g. for those with intellectual impairments or severe mental health issues, is more effective than pre-work training—‘place then train’ is now preferred to ‘train then place’ [10]. The relative lack of good rehabilitation facilities in the NHS has led to the development of private rehabilitation services, mostly paid for by the insurance sector which realized that the lack of services to enable effective return to work (RTW) was proving expensive. Two groups of professionals were formed, representing the two main streams of rehabilitation as it developed in the private sector—the Case Management Society of the UK and the Vocational Rehabilitation Association, which has recently published the second edition of its standards [11]. Specific skills are needed to assist those who have never worked, those still employed but with work-related difficulties or those who have lost their employment because of their illness/disability. Successful vocational rehabilitation (VR) reflects the personal attributes of the individual concerned, the attitudes of the employer, the skills of the health professionals involved and the services made available by the insurer (usually the Department of Work and Pension (DWP) in the UK) [1]. Teenagers may need support and advice in order to be exposed to appropriate role models and to develop the social skills and self-confidence to secure employment [12]. Any form of work experience is of the utmost value. Apprenticeships, traineeships and supported internships are increasingly used routes into employment for disadvantaged young people. Apprentice programmes can strengthen an organization’s ‘value, culture and brand’ [4]. Others will gain work experience through the voluntary sector [1]. It is clear that inclusive policies for those with mental health [5] or disabling conditions are crucial to reducing the disability employment gap. Employers must ‘ensure that their recruitment processes are configured to encourage disabled people to apply for jobs and to en able them to participate fully in the recruitment process’ [13]. Thus, an ‘Able to Enable Programme’ to facilitate individuals with disabilities gain workplace experience can be valuable [4]. In the Barclays scheme, potential employees were offered the opportunity to participate in a confidence/resilience-building training session [4], designed to help potential employees to overcome their nervousness which may prevent them from applying for roles at the bank. This scheme is a new and fully supportive internship programme being currently piloted in two of its London branches. It was set up in conjunction with Remploy to give two people with disabilities the opportunity of learning new skills and supporting the business while growing their experience and confidence [4]. It was also aimed to ‘dispel the myth that banking is an inaccessible career for people with disabilities’ [4]. As a result of this successful pilot, the scheme is now being expanded. Job retention is an important part of occupational medicine, but only 30% of the UK total workforce has access to specialist occupational health advice [9] and this is largely provided by large employers with little provision for small businesses. Rehabilitation professionals are now recognising ‘work instability’—where there is a mismatch between an individual’s functional abilities and the demands of his or her job. This can be measured [14]. Thus, organizations can assess their workforce for vulnerable employees using work instability scales or job satisfaction/wellness tools. Good management embraces an effective health and safety policy in addition to an absence policy which is understood by all parts of the organization (including line managers) and differentiates between absence relating to disability, ill-health, social factors (e.g. family illness) and factors which point to the need for disciplinary action. Such policies should facilitate close contact between the employee and the employer from Day 1 of the absence with early involvement of occupational health, perhaps by Day 10 of a health-related absence. This has been shown to reduce sickness absence in Scotland [15]. For those employed by organizations without occupational health, health/rehabilitation professionals should encourage maintenance of contact between employer and employee and when needed, use worksite visits to resolve the difficulties raised by both employer and employee. Fundamental to every RTW is an understanding of the full physical, emotional and intellectual requirements of the job and which parts can still be performed after injury or illness. What both the employer and the employee understand to be obstacles to RTW need to be understood. Strategies to facilitate RTW are now regularly practised such as developing a RTW plan and phased RTW in terms of hours worked, tasks performed and responsibilities undertaken [1]. Helping employers understand the need for job modifications (accommodations) and their responsibility under the Equality Act may need careful explanation. Employers do not always understand the assistance that the DWP can provide. For example, Access to Work will facilitate transport of ill employees who are able to work but have difficulty in getting to work. Finding new work is more complex. The process needs to take account of any previous work experience, educational background, hobbies that might convert into a wage and the inclinations of the individual. The range of options available have been outlined elsewhere [1] and include working at either previous or new tasks with new or previous employers, home working, part time working and self employment either full time or part time, at home or at the workplace. Support is available from the government through the Disability Employment Advisors at JobcentrePlus (part of the DWP) as well as from the voluntary sector [1]. While VR is best provided when part of a rehabilitation programme (e.g. following a traumatic brain injury or rehabilitation for spinal pain), there are many occasions when this is not available or may not be appropriate, e.g. when an individual has concluded a rehabilitation programme and has been out of work for an extended period of time. The VR then is organized by an appropriate VRP who will arrange/coordinate the necessary health management together with the primary care team, liaise with potential future employers and hopefully arrange a job match between the abilities of the individual and the needs of the employer. The major challenge for health professionals, whether in the NHS or private sector, is to see work as an outcome of their interventions, and that this needs to be thought about from the beginning of a health episode and through any recovery period [1]. Encouragement that there are many ways of assisting individuals back into work (and sometimes into new or different tasks) helps to prevent ill/injured individuals from seeing a depressing future for themselves. There are enormous implications for occupational health services of the demands that are likely to be made on employers as increasing numbers of the workforce have disabilities that may (or may not) relate to the ageing workforce. The occupational health team has to influence management to provide a supportive culture for their employees, particularly if workforce pressures impact on their mental health [5]. Appropriate absence policies need to be formulated and clearly understood throughout the organization and introduced as part of the induction programme [5]. Staff well-being should be a consideration for all workplace policies and can be measured through staff consultation and surveys [5]. The Health and Safety Executive ‘Management Standards’ for work-related pressures can be adopted [5] and the organization can join the Disability Confident Scheme for employers which aims to help employers make the most of the opportunities provided by employing disabled people [16]. The scheme is voluntary and has been developed by employers and disabled people’s representatives. Employers also must recognize the change in emphasis in RTW practice. Employees may RTW before they are fully recovered with flexible planning that allows for staff taking time out for treatment, e.g. counselling or physiotherapy. When combined with a phased RTW and job modifications many employees will greatly reduce their sickness absence and its consequent burden on co-workers by these means. The opinions expressed are personal. References 1. Frank AO. Vocational rehabilitation: supporting ill or dis abled individuals in(to) work: a UK perspective. Healthcare  2016; 4. doi: 10.3390/healthcare4030046 2. Department for Work and Pensions, Department of Health. Improving Lives: The Work, Health and Disability Green Paper. London, UK: Department for Work and Pensions/Department of Health, 2016; 1– 91. https://whitehall-admin.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/564038/work-and-health-green-paper-improving-lives.pdf. (22 February 2017, date last accessed). 3. Waddell G, Burton AK. Is Work Good for Your Health and Well-being?  London: The Stationery Office, 2006; 1– 246. 4. Cohen P. Barclays Disability and Careers Toolkit. London: Barclays Bank, 2016; 1– 46. https://www.disabilityrightsuk.org/sites/default/files/pdf/Barclaystoolkit.pdf. (22 February 2017, date last accessed). 5. Business in the Community/Public Health England Mental Health Toolkit for Employers. London, UK: Business in the Community, 2016; 1– 51. http://wellbeing.bitc.org.uk/sites/default/files/mental_health_toolkit_for_employers_-_small.pdf. (22 February 2017, date last accessed). 6. McNaughton D, Symons G, Light J, Parsons A. ‘My dream was to pay taxes’: the self-employment experiences of individuals who use augmentative and alternative communication. J Vocat Rehabil  2006; 25: 181– 196. 7. Beveridge WH. Social Insurance and Allied Services. Report by Sir William Beveridge Presented to Parliament by Command of His Majesty . London: HMSO, 1942; 1– 299. 8. Chamberlain MA, Frank AO. Congratulations but no congratulations: should physicians do more to support their patients at work? Clin Med (Lond)  2004; 4: 102– 104. Google Scholar CrossRef Search ADS PubMed  9. Harrison J. Planning the Future: Delivering a Vision of Good Work and Health in the UK for the Next 5–20 Years and the Professional Resources to Deliver it—Executive Summary. London: Council for Work and Health, 2013; 1– 48. http://www.councilforworkandhealth.org.uk/images/uploads/library/Planning%20the%20Future%20-%20OH%20and%20its%20Workforce%20April%202014.pdf. (22 February 2017, date last accessed). 10. Grove B. International employment schemes for people with mental health problems. B J Psych Int  2016; 12: 97– 9. 11. Vocational Rehabilitation Association Vocational Rehabilitation Standards of Practice . Thorpe le Soken, Essex: Vocational Rehabilitation Association, 2013; 1– 14. 12. Department for Work and Pensions. Help and Support for Young Disabled People to Find and Stay in Work. London: Department for Work and Pensions, 2016. https://www.gov.uk/government/publications/help-and-support-for-young-disabled-people-to-find-and-stay-in-work/help-and-support-for-young-disabled-people-to-find-and-stay-in-work. (22 February 2017, date last accessed). 13. All-Party Parliamentary Group for MS. Employment that Works—Supporting People with MS in the Workplace. London: All-Party Parliamentary Group for MS, 2017; 1– 56. https://www.mssociety.org.uk/sites/default/files/Employment%20that%20works%20-%20APPG%20report_0.pdf. (22 February 2017, date last accessed). 14. Gilworth G, Smyth G, Smith J, Tennant A. The development and validation of the Office Work Screen. Occupational Medicine (Oxford)  2008; 58: 289– 294. Google Scholar CrossRef Search ADS   15. Brown J, Mackay D, Demou E, Craig J, Macdonald E. Reducing Sickness Absence in Scotland—Applying the Lessons from a Pilot NHS Intervention. Glasgow: University of Glasgow, 2013; 1– 24. http://www.gla.ac.uk/researchinstitutes/healthwellbeing/research/publichealth/hwlgroup/currentresearch/sickness%20absence/. (22 February 2017, date last accessed). 16. Department for Work and Pensions Disability Confident Employer Scheme and Guidance. London, UK: Department for Work and Pensions, 2014. https://www.gov.uk/government/collections/disability-confident-campaign. (22 February 2017, date last accessed). © The Author(s) 2018. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oup.com

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Published: Jan 1, 2018

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