Injury (1989) 20, 5-9 Prinfed in Great Britain 5

Employment after severe head injury: do the Manpower Services Commission schemes help?

Roger Johnson The Rehabilitation Unit, Addenbrooke’s Hospital, Cambridge

This paper describes the use of Manpower Services Commission (MSC) employment rehubilifation schemes by a series of severely head injured people.

Most of those who achieved employment did so wifhout making use of

MSC schewm. A majority of fhose using MSC schewm remained unem- ployed af last follow-up. Those affending MSC schemes were more likely to have been in education at the time of inju y. SOme of those previously in work used schetrm, but only affer they had already failed af work or had had a long period out of work.

MSC schewm may fail to met the needs of the head-injured because many are too short or use is made of them at too long an interval after Ihe injury. They do not cater well for special fraining and the flexible approach that is necessa y for successful employment rehbilifation of those su&ing from brain inju y. The priority is for training schemes that can be carried out wifhin the workplace and for support and incentives to employers to help head-injured people refum to their previous work.

Introduction

There are at least 4000 severe head injuries (amnesia after injury of more than 24 h) annually in England and Wales (Johnson and Cleave, 1987). Estimates of the number who successfully regain employment vary greatly (Humphrey and Oddy, 1980). Many attempt work before recovery is complete and they and their employers must therefore at least cope with temporary problems. Probably about 30 per cent or more return to work with permanent handicaps (Lewin et al., 1979; Roberts, 1979; Johnson and Gleave, 1987). Intellectual and behavioural changes are more likely than physical handicap to lead to a decline in level of employment (Bond, 1975; Roberts, 1976).

Many fail at work after a head injury because of a lack of appropriate help rather than because they do not have the potential to work again. The first part of this study, reported elsewhere (Johnson, 1987a), showed that success at work depended more on the conditions encountered than on fac- tors such as age or severity of injury. A successful return to work was associated with return to the previous job, special conditions such as work trials or easier work, and a lengthy period of support.

This paper reports the use made by head-injured people

0 1989 Butterworth & Co (Publishers) Ltd 0020-1383/89/0100545 $03.00

of the Manpower Services Commission (MSC) schemes and training opportur,ities intended to assist disabled people to return to work.

Subjects

The subjects were 64 patients seen on the Rehabilitation Unit at Addenbrooke’s Hospital between January 1980 and June 1983 and who had a post-traumatic amnesia (pta) of 1 week or more. They had therefore sustained injuries of con- siderable severity with a high probability of persistent neuropsychologicaI and neurophysical disability.

Those who were of school age were included if they were over 14 years at the time of the injury. This allowed for them to be followed up for at least 2 years after school leaving age within the time-scale of the study.

All those potentially wanting to work were included. There were two people who were out of work at the time of injury but neither complied with follow-up. There were two women who had chosen not to work before their injury but who sought work afterwards, but one of these was also lost to follow-up.

Criteria for inclusion in the study were fulfilled by 75 individuals, but 11 failed to comply with follow-up or postal enquiry.

Method

The severity and nature of injury and the history of recovery and return to work, or attempts to do so, were established by direct interview during the course of follow-up. This was augmented by postal questionnaire where necessary.

Follow-up was continued for a minimum of 2.5 years after injury (mean time 3.5 years). All those who were under 16 at the time of injury were followed up for at least 2 years after they reached school leaving age.

Those who had remained in continuous employment for not less than 1 year since their injury were considered to have made a successful return to work.

A second group returned to work, or to a further educa- tion course, following injury, but failed to stay. These people tended either to hold a series of short-lived jobs or made one attempt to work and then remained unemployed.

6 Injury: the British Journal of Accident Surgery (1989) Vol. to/No. I

A third group of people made no attempt to return to their work or to a course of education at any time during follow-up.

Wherever possible the opportunity was taken to help individuals cope with their work again. This aspect of their rehabilitation and its relevance to work outcome, has been described elsewhere (Johnson, 1987a; 1987b).

Some people made use of Manpower Services Commis- sion schemes through job centres and the Disablement Resettlement Officer (DRO). Schemes that were available at the time of the study, and which were used, included atten- dance at an Employment Rehabilitation Centre (ERC); Com- munity Project work; the Youth Training Scheme (YTS) or Youth Opportunity Programme (YOP) and the Training Opportunities Scheme (TOPS). Also, from January 1983 to December 1985 there was an Employment Rehabilitation Development Unit (ERDU) run by the MSC to assess and advise on employment. This was linked to a Medical Reha- bilitation Unit at Clacton, Essex but has since closed.

Visits to a job centre or interviews with a DRO, without use of specific schemes, were not recorded, nor was use that might have been made of careers advice services, such as those provided by Education Authorities.

Results

The mean pta for the sample was 6.45 weeks. The mean age was 27.4 years. There were more males than females (Tub& I).

Use of MSC schemes Table II shows the number of people making use of MSC schemes relative to their occupational status before injury. Sixteen people (25 per cent) made use of one or more schemes. A greater number of school leavers, or those pur- suing further education at the time of injury, made use of MSC help (44 per cent) compared with those previously in work (19 per cent). This difference just falls short of signifi- cance (x2; PC 0.10; > 005).

Work outcome and schemes used Employment outcome relative to the use of MSC facilities is shown in Table III. Twenty-five people regained employ- ment, of which 21 (84 per cent) did so without MSC help. Sixteen people made use of MSC schemes but I2 (75 per cent) were not employed at a mean follow-up time of 3 years 10 months after injury. (One of these people was in shel- tered work.)

A comparison between outcome for those previously employed and those who were in education at the time of their injury, suggested that MSC schemes were more helpful

to the latter. Eighteen (3~5 per cent) of those previously employed returned to work successfully (in work for at least 1 year) but only one of these (5.6 per cent) did so through an MSC scheme (ERC). Of those previously in education, seven (43.75 per cent) became successfully employed. Three (43 per cent) of them achieved this through an MSC scheme (MS (two cases) or in one case through an ERC followed by YOP). The other four who achieved a successful outcome,

Table I. Study sample details according to occupational status at time of injury

Occupational status

Employed School Student Housewife Unemployed

N 47 9 7 1 0 Males 37 8 4 0 -

Females li.8

1 3 -

Mean age (years) 15.7 18.3 3:.0 - Mean pta (weeks) 5.8 6.5 10.9 5.0 -

Mean follow-up time (years) 3.5 3.9 3.3 3.9 -

Table II. Number using MSC schemes according to occupational status at time of injury

Occupationalstatus

Employed School Student Housewife

Those using MSC schemes 4 3 0

No use made of schemes 5 4 1

Table III. Number using MSC schemes according to occupational status at time of injury and outcome

Outcome

Previously in education

Previously in work

MSC help No MSC help

MSC help No MSC help

Successful return

3 (43%) 4 (44%)

1 (11%) 17 (44%)

Fail at work

4 (57%) 1 (11%)

4,44%) 9 (23%)

No attempt to return

3 (!3%)

4 (44%) 13 (33%)

In special education

1 (lY%)

- -

Johnson: MSC schemes after head injury 7

did so after returning to higher education or training courses and completing them.

Table IV. Age and pta of those using MSC schemes

Those in education at the time of their injury were more likely to use schemes as a stepping-stone to employment. Six (86 per cent) went on schemes before they attempted to work-this included the 3 people who subsequently were employed. A seventh individual failed at a job before going to an ERC and had made no further attempt to work at last follow-up.

N Mean age Mean pta

Use of MSC schemes

16 20.3 years

7.4 weeks

No use of MSC schemes

48 29.76 years

6.12 weeks

In comparison, the use of MSC schemes by those in work at the time of their injury was more often associated with failure to work. Out of nine people who used MSC schemes, four made no attempt to return to work afterwards (ERC, three cases; the ERDU at Clacton, one case). Four others made use of MSC services but they failed when they attempted to work (two went to the ERDU at Clacton and one of these then went on to an ERC. One was temporarily employed on a Youth Opportunity Programme and one on a Community Programme). In three of these cases they had already experienced one or more failed attempts to work before they went on MSC schemes.

Table V. Sex versus use of MSC schemes and outcome

Men Women

Use of schemes 14 2 No use of schemes 35 13 Successful outcome 21 4 Fail lo return lo work 28 11

Age and severity of injury of those using MSC facilities Tubfe IV shows age and length of pta for those who used MSC sche,mes compared with those who did not. Those on schemes had a slightly longer pta and might therefore be a slightly more severely injured group, but this was not a significant difference.

Table VI. Level of occupation versus use of MSC schemes for those in work at the time of injury (N= 47)

No use of MSC schemes MSC schemes

Those using schemes tended to be younger. This is expected because those in education at the time of injury were more likely to use MSC schemes. The age difference between the groups was not significant.

Sex of those using MX facilities Only two women (13.3 per cent) made use of MSC schemes (Table v). One was previously in education and one pre- viously employed. This compared with 14 (256 per cent) of men using schemes. This result did not reach a significant level (x2; P=Oi’3) but was noticeable as a trend for both those previously in education and for those previously in work.

I Professional Occupations 0 II Intermediate occupations 3 (33.3%) llla Skilled, non-manual 0 lllb Skilled, manual 4 (44.4%) IV Partly skilled occupations 2 (22.2%) V Unskilled occupations 0

6 (15.8%) 3 (7.9%) 9 (23.7%) 13 (34.2%) 7 (18.4%) 0

Table VII. Time between injury and use of MSC schemes and duration of schemes relative to occupational status

Overall, more men succeeded in returning to work (42.9 per cent) than women (26.7 per cent). However, amongst those previously in education more women were successful (75 per cent) than men (33.3 per cent) (x2; Pc0.5, >0.3). Amongst those previously in work, 45.9 per cent of the men were successful compared with only 9.1 per cent of the women. (x2; PC 0.1, > 0.5)

Previously in education

Previously in work

Mean time between injury and

use of scheme

25.2 months (N=6) 28.4 months (N=9)

Mean duration

of scheme

27.1 weeks (N=5) 10.0 weeks (N=8)

Occupational level of those using MSC facilities Table VI compares those using MSC facilities with those who did not, according to level of employment at the time of injury. Office of Population Censuses and Surveys (1981) criteria for level of employment were used. A rather larger proportion of those in manual jobs (categories IIIb and IV) used MSC facilities (23 per cent) compared with those in non-manual jobs (14 per cent in categories I, II and IIIa) but this difference was not significant (x2 = 0.15).

The mean time between injury and joining an MSC scheme was 27.1 months. Those in education at the time of the injury used schemes slightly earlier (four out of six did so within 2 years of injury) compared with those who were employed at the time of injury (seven out of the nine indi- viduals did not join schemes until 2 years or more after injury), but the difference was not a significant one.

Of the four people who gained employment through an MSC scheme, two obtained work in jobs in category V; one in category IIIa and one in IIIb.

Time between injury and use of MSC schemes and length of stay on schemes

The average time spent on courses was 16.6 weeks. This varied considerably from one individual who was on a YTS course for a full year to another who attended an ERC for only 2 days. There were only four cases where a scheme was attended for more than 3 months. On average, those pre- viously in education spent more than twice as long on schemes than those previously in work, but this difference did not reach a significant level (P= 0.1 Mann-Whitney U test).

Table VII shows the time interval between injury and attending an MSC scheme. Duration of schemes is also

Four people succeeded in settling back into work follow-

shown. (These data were not obtained for one individual, ing an MSC scheme. For the three for which data were available it was found that they attended schemes signifi-

and duration of schemes data were absent for two others cantly earlier (mean time 11.3 months after injury; P= 001) because they were attending a scheme at the time of follow- and they stayed significantly longer (mean time 8.3 months; UP.) P= 0.05) than the overall averaee (Mann-Whitnev I J hk1

8 Injury: the British Journal of Accident Surgery (1989) Vol. ZO/No. I

Discussion

Some of those in education at the time of their injury were helped by MSC schemes, but amongst those who had worked before their injury there was an inverse relationship between successful return to work and use of MSC schemes.

In all, only four people (6 per cent) both returned to work and made use of MSC schemes. Three were in education at the time of injury. The one person previously in employ- ment who returned to work through an MSC scheme, was exceptional. His old job was held open for him while he attended an ERC. He was not able to do his previous job as a forklift truck driver because of visual and physical disabili- ties, but was taken back anyway and his employer tried him in various departments in his company in order to find him a suitable occupation.

Similar figures suggesting poor use of MSC facilities by those recovering from head injury have been reported recently by Brooks et al. (1987).

Women made less use of schemes and were also less likely to return to work. The reasons for this are not clear but could reflect less pressure on women to work (Johnson, 1987a). Amongst those leaving education, women did as well as or better than men in gaining work. Possibly at this age the pressures to work are the same and it is only later, perhaps with increased family responsibilities, that women are less likely to work.

The first part of this study (Johnson, 1987a) suggested that most of those who attempt to work after head injury are capable of some form of employment. Those who succeed do not do so simply because they encounter no difficulties. A successful outcome is determined by the extent to which they are supported in their efforts to return to work.

The failure of MSC schemes to provide appropriate sup- port may be for several reasons. Those who made use of MSC schemes tended to be working in manual and semi- skilled jobs and return to work after injury may be less likely for those working at this level (Humphrey and Oddy, 1980; Brooks et al., 1987) but it is probably a weak effect (Oddy, 1984; Johnson, 1987a). There was also a trend for those people taking advantage of schemes to be slightly more severely injured, but this was not statistically significant.

The most likely reason for the failure of MSC schemes is that they do not meet the needs of head-injured people. The first part of this study (Johnson, 1987a) showed that those returning to their work successfully received help for signifi- cantly longer (mean time 8 months) than those who failed at work (mean time 3 months). The mean time spent on MSC courses by the people in this study, including schemes such as YTS lasting up to 1 year, was only 16.6 weeks. No one attended an ERC for more than 3 months. It is probable that time spent on schemes was too short to be effective. Also, people made use of MSC facilities when it was too late. One-third of those who took part in MSC schemes did so only after they failed in other attempts to work. This meant that they had lost confidence and were likely to be more difficult to help. The mean time to attend a scheme was over 2 years after the injury but other studies have shown that if employment has not been re-established within 2 years of injury then it is unlikely to be achieved at all (Oddy et al., 1985; Brooks et al., 1987; Johnson, 1987a).

People with head injury are particularly likely to find new situations and new learning difficult. They may be slower to learn and less likely to transfer their learning from the train- ing situation (such as an ERC) to a new one (a job). For this reason retraining someone in the context of their job is more likely to be successful.

The job introduction and job rehearsal schemes, which might cater for this sort of need, aim to prove fitness for work rather than allow training or time to adapt to per- sisting disabilities. They are too short (usually 6 and 3 weeks respectively) to be useful.

Other schemes, primarily for younger people, such as YTS and the Community Programme, last much longer and the work undertaken can progress to become a regular job. These factors may contribute to the greater success observed for the few younger people who used these schemes. The sheltered placement scheme was not used by anyone in this study. It is now more widely available and might well prove useful to some people with head injury.

Unemployment leads to a decline in emotional state and confidence (Wan, 1983). It is also associated with self- reported cognitive difficulties such as poor memory and concentration (Fryer and Warr, 1984). Those who are unem- ployed as a result of head injury may be particularly vulner- able to such processes, and this could contribute to the very poor work outcome after head injury if work has not been regained within 2 years of injury.

If MSC schemes are to be effective in the rehabilitation of head-injury victims, they must be attended before a long period out of work, or a failed attempt to work, has taken place. The effects of failure at work, combined with neuro- psychological deficit are likely to be extremely difficult to reverse.

It is equally important to avoid failure on an MSC scheme. Recovery after head injury is protracted and can continue for more than 2 years. This means that there is also good reason to delay attempts to work so that maximum recovery may be achieved. The decision about how soon after the injury a return to work should be attempted is an extremely difficult one. Few people are able to keep them- selves well-occupied while waiting for further recovery. In the absence of adequate occupation, recovery and adapta- tion cannot proceed so well and the individual can easily become demoralized.

The need is for employment rehabilitation schemes that can offer support to help the individual return to a previous job at a stage where recovery may not yet be complete. Considerable time must be allowed for a process of gradual adaptation and improvement to take place. With provision of this sort, the chances of a successful return to work after head injury could be considerably improved.

References

Bond M. R. (1975) Assessment of psychosocial outcome after severe head injury. In: Outcome of Severe Damage to the Cenfral Nervow System. CIBA Symposium 34 (new series).

Brooks N., M&inlay W., Symington C. et al. (1987) Return to work within the first seven years of severe head injury. Brain Injury I, 5.

Fryer D. and Warr P. (1984) Unemployment and cognitive diffi- culties. Br. 1. C/in. Psycho/. 23, 67.

Humphrey M. and Oddy M. (1980) Return to work after head injury: a review of post-war studies. Itijuy 12, 107.

Johnson R. P. and Gleave J. (1987) Counting the people disabled by head injury. Ijuy 18, 7.

Johnson R. P. (1987a) Return to work after head injury. hf. Disabil. Sfudies 9, 49.

Johnson R. P. (1987b) Modifying the denial of symptoms follow- ing severe head injuries. Clin. Rehabil. I, 319.

Johnson: MSC schemes after head injury 9

Lewin W., Marshall T. F. and Roberts A. H. (1979) Long term

outcome after severe head injury. Br. Med. J ii, 1533. Oddy M. (1984) Head injury and social adjustment. In: Brooks N.

(ed.), Closed Head Injury: Psychological, Social and Family Conse- 9uence.5. Oxford: Oxford University Press.

Oddy M., Coughlan T., Tyerman A. et al. (1985) Social adjustment after closed head injury: a further follow-up 7 years after injury. 1. Neural. Neurosurg. Psychiaty 48, 564.

Office of Population Censuses and Surveys. (1980) C&sification of

Ocnrpafions. London: H.M.S.O.

Roberts A. H. (1976) The long-term prognosis of severe accidental head injury. Proc. R. Sot. Med. 69, 137.

Roberts A. H. (1979) Severe Accidental Head Injury. An Assesrmolt of

I_e@erm Prognosis. London: Macmillan.

Warr P. (1983) Work, jobs and unemployment. Bull. Br. Psychol. Sot. 36. 305.

Paper accepted 13 October 1988.

Reqrresfs for reprints should be address& to: R. Johnson, Principal Clinical Psychologist. The Rehabilitation Unit, Addenbrooke’s

Hospital, Cambridge CB2 2QQ.

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