Principles and results of training and employment at Papworth

206 August 1953

Principles and Results of Training and Employment at Papworth By OWEN CLARKE

Based on a Paper read at a meeting of the British Tuberculosis Association in Leicester, April 17, 1952)

Part I I - -Resu l ts

DIAORAM I.--PRoGRAMME OF REHABILITATION

Active treatme nt

Upg~,ading W O R K

8-3o 9 lO 11 12 1 2 ~ 4- 5 6 I t I I I I I ! I

6 ,.

C O L O N { S A T I 0 N

7 hrs. ~ ~ ~ / / / ' ~ ~///',J//~///_JJ~///'////J

~/////S//d n K li-.::--;-:--?~:-i::-~-1 R E S T WO

Diagram I shows the plan of training by which the amount of work is gradually increased, rest periods being included in the early stages. The importance of a long lunch break should be noted, and the discipline enforced in the early stages is an important factor which teaches the man the sort of life which he can safely live. This discipline usually persists, even when he resumes normal active home life.

TABLE I. -- RESULTS OF TRAINING SCHEME APRIL 1948--hIARerI I952 (AS ON 31.12.52)

Per cent Total number accepted on

scheme after trial period .. 346 Colonized . . . . . . 9 ° (26) Still training . . . . . . 103 (30) Left before colonizing .. x 53 (44)

346

This report deals only with those who

joined the Ministry of Labour scheme in the first four years, April i948 to March I952: the figures refer to the position at the end of December i952 , so that the minimum follow-up is nine months.

O f the 346 men and women included, 9 ° have completed training and colonized at Papworth, io 3 are still training, and I53 have left before colonizing. This last group is of special interest because these patients left before medical and industrial opinions considered that training and rehabilitation were completed. Why did they leave? Table II gives the reasons.

Out of these i53 people, 49 left early because they had been able to find work which was more congenial to them, either because it was nearer home or because they preferred the type of work. I think this is a remarkable fact when it is remembered that every one of the trainees was sent to

August 1953 T U B E R C L E 207

TABLE I I . - REASONS FOR LEAVING PAPWORTH BEFORE COLONIZING

Per cent i To take other work or train-

ing . . . . 49 Domestic reasons (including

35 (22) ~2

marriage) .. 3 Transferred for surgery 4 Relapsed: On wards

H o m e , .

5 Death . . . . 6 Considered unsuitable 7 Undetermined ..

I I

1 2

I~2

4 I8

I53

Papworth because he could not do just that very thing. I f they had been able to get that job in the first place they would have stayed near home, but that often proves so difficult.

Why? May it not be because the man himself

is frightened to tackle the problem of his restoration to work, and is half-hearted in his attempts? That is quite natural and understandable, firstly because of his long illness and secondly because there undoubtedly still is a resistance in the outside world as well as in his own mind.

Yet 14 per cent of those who came to Papworth on the training scheme were so improved in physical well-being, and in morale, that of their own accord they made that effort and succeeded, after between six to eighteen months' rehabilitation there. That is to me a very successful outcome o

I Veeks 3 hours

a training scheme designed to re-establish financial independence. The purpose has been achieved.

The other main causes for leaving before colonizing are seen to be 'domestic' and 'relapse'. It is inevitable that some families will not stand the stress ofseparation, and the phrase 'domestic reasons' usually meant that the wife was taking exception t o - or advan- tage o f - t h e situation. It is far better to allow the husband to go home than to risk breaking up a marriage, and that was the policy i n such cases. Sometimes a brief holiday was enough, but often the long separation did prove too big a price to be paid and this had to be accepted.

The question of relapse will be considered together with absentee rates and work records.

Pattern of Training lVork and Absenteeism.-I t is difficult to decide on a standard of progress by which to judge the general response to gradually increasing work, but I think a combination which shows the time on each grade, the absenteeism during that grade, and the relapse rate during training perhaps gives the best indication.

Table I I I shows the time on each work grade, and the absenteeism. Three groups are considered, but Group I is much the most important because it includes all those who have been admitted into the rehabilitation side at Papworth since 1948 , from all

TABLE I I I . - WORK PROGRESS AND ABSENTEEISM Per cent llYeks Per cent IlZeeks Per cent Total Per cent

absenteeism 5 hours absenteeism 6 hours absenteeism training absenteeism

I (a) 233 24 4"9 24 6.2 2i 6.6 69 5"7 (b) 64 20 5.1 23 4 .8 37 4"I 80 4"9

I! (a) I6 43 4"7 4 ° 4"4 56 7"z z39 5"I (b) x 4 41 4"5 27 0"7 32 3"9 IOO 3"5

III (a) 7 44 io.2 38 2"7 58 6.8 14o 8- 3 (b) I2 39 3"7 44 4"7 29 4"I Ix2 4-2

I = Normal training. (a) = not yet colonized or re-colonized. II = Extended training. (b) = Now colonized or re-colonized.

III = Colonists relapsed. Definition: Absenteeism = any absence of less than four consecutive weeks.

Relapse = any absence of more than four consecutive weeks.

208 T U B E R C L E August 1953

over the country, and accepted as suitable for training. Ages vary from i6-5o years, there are all types and nationalities, and they represent a cross section of the sad patients in clinics who need help to get on their feet. It is this group who really illustrate the routine practised and it will be seen that the figures are remarkably constant, and that the average time to colonization is 80 weeks, or about eighteen months. The longer period on six hours, than on three or five, is due to the fact that industrial training really has most effect when the longer hours are worked. It is obviously difficult to train a bus conductor to become a skilled metal worker if he is only allowed to work three hours daily, and when it i~ remembered that the Unions accept this training for their appren- ticeship and membership it will be appreciated that colonization must be delayed until certain standards are reached. Some- times, too, it is postponed on medical grounds because the transfer to the colonist hostels inevitably loosens the discipline and self-control which have been inculcated during the preliminary stages.

Group II consists of a few older people who had tried other training at Papworth or elsewhere, and been unsuccessful. At the outset of the scheme i n i948 these 3o-odd men again tried to make the grade and, to their credit, half of them have reached the goal of colonization. You notice firstly that the period to colonization is longer, Ioo weeks as against 8o, but more important is the fact that those who have not .yet made the grade are much longer on five and six hours. Absenteeism also is higher.

Group I I I consists of previous colonists who have relapsed since 1948 and therefore again had the same building-up after treatment. O f these 19, 12 have now again colonized. Once again, it is seen that those who have not yet re-colonized show a longer period at six hours, which is when the" strain of trying to re-establish themselves really comes. Again absenteeism is higher.

The most striking fact of this table, to my mind, is the remarkably low rate of

absen t ee i sm-abou t 5 per cent or a little over one working day per month. The other fact is that, in each group, those who have reached colonization (b) have a lower absentee rate during training than those who have not yet made the grade (a), especially as the pressure of longer hours makes itself felt. This, of course, might be expected but its significance can only really be appreciated when it is remembered that there is continual progress from group (a) to (b), and that as the trainee becomes used to the harder work his absenteeism falls to the lower rate. In other words, if suitable opportunity for graded training is offered the tuberculous man can attain proficiency in his own time. This is especially obvious in the case of the man who has once relapsed and is trying again, Group I I I (a): at first he has an absentee rate as high as Io per cent, obviously due to anxiety and a reluctance to take any risks, but as he re- gains confidence in his health this rate falls.

Table IV shows that the standard of industrial effort achieved during traihing is maintained after colonization.

TABLE IV.- ABSENTEE RATE AFTER COLONIZATION

Per cent (a) Colonists still at Papworth .. 4"5 (b) Colonists subsequently left -- 4"5

In order to appreciate the significance of these figures the absentee rate should be compared with the general sickness rate for December i952 throughout the country, as shown in the Ministry of Labour Gazette.

TABLE g.- COMPARISON OF ABSENTEE RATES

Per cent I Papworth Normal training .. 4"9

Extended training to colonizing • • 3"5

Relapse]Recoloniza- tion . . . . 4.2

After colonization .. 4"5 II Post Office 1952 iX,fen . . . . 4"5

Women . . 6. I III Industry Throughout country

December 1952 (M. of. L. Gazette, February 1953) . . 4"2

IV Remploy At Hull (Hardy) . . x3.o


Figures for the Post Office have also been included because of the recent comments in the Press.

The figures for Remploy are quoted from Hardy's paper in TUBERCLE earlier this year, and of course refer only to one factory.

A recent editorial in B.~ILdT. quotes the figure of 4 per cen t throughout the country, but this excludes absences of less than four days or 'supposedly essential' attendances at football matches, family weddings or funerals, all of which count as 'absent' at Papworth.

An interesting figure is also available from the United States, the Public Health Report giving an average over ten years, 194o-49, of 1o. 4 per cent for men and 2o. 3 per cent for women, the commonest causes being respiratory diseases.

Judged by these figures, the tuberculous worker, whether in training or colonized, is a reliable worker, and this is especially to be expected once he has stabilized himself at a filll day's work, because he is maintained by the double sentiments of thankfulness for the opportunity of employment, and a determination to prove himself worthy of this trust.

Relapse TABLE V I . - RELAPSE RATES

(i.e. four consecutive weeks off work) Of the 346 trainees accepted April 1948-

I952 , IO 3 had relapsed before December 3 I, 1952 , either during training or after colonizing. .'. Relapse rate = 3 ° per cent. Still requiring treatment . . . . . . Transferred for surgery . . . . . . Died Returned to work . . . . . .

24 I I

4 64

IO 3

The figure of 3 ° per cent at first seems higher than other reports, but two-thirds of the patients are already back at work: only 35, or IO per cent, were still on the sick list.

Another factor tending to raise the relapse rate is undoubtedly the closer medical supervision possible at such a Settlement, and therefore the earlier detection of

relapse and even the over-cautious restraint of doubtful cases.

Anybody working in tuberculosis knows this problem, and a host of other reports have been published, of which two recent ones are by Hardy for a Remploy factory, and Farquharson: Hardy gave a relapse rate of 2I per cent and Farquharson 25 per cent. In both cases the criteria of relapse are less strictly defined and the number who have returned to work is not stated; but in this fickle disease comparison of different reports is of slight value, and the sage will weigh reports in the balance of human effort and happiness.

Total Work-time Lost Another aspect of the employment of partly fit labour, during training or afterwards, is the proportion of paid time which is lost for absenteeism or sickness, and in Table VI I this is shown for different lengths of total absence. One should be able to say to an employer: ' I f you employ tuberculous labour, the likelihood is that the percentage of time lost will be so much, based on the total time for which you are paying.'

TABLE VII Total tbne lost (Average for 346 employees)

Per cent (a) Up to I month's absence . . . . 4"9 (b) Including 3 months' relapse .. 12.o (c) Including 6 months' relapse .. i4.o (d) Including I2 months' relapse . . 17.o

In other words, if the employer will keep a man on his books for absence up to one month, the percentage paid time to be lost will be 5 per cent: for three months, it is 12 per cent: and in the extreme generosity of one year's support it is 17 per cent. It is perhaps justifiable to use the three-month figure, and hope that an employer might be prepared to continue support of a tuberculous employee for that period, even if only as a charge against taxation which could satisfy his natural desire for benevolence at little cost to himself: such an employer could be told that normal absentee rates are no greater than for fit employees: and

210 T U B E R C L E August 1953

that one-third of his part-fit employees are liable to relapse at some time or another, and be offwork for more than a month; and that if he is prepared to cover such absences for one month the total work lost is about 5 per cent, rising to 12 per cent if three months are included.

These figures are not very bright, but no long-term figures in tuberculosis are: at least they give some basis for discussion.

The fact that has stood out in most of these tables is that once a patient has worked himself up to six hours daily he is a reliable worker, with normal absentee rate, and experience shows him to be co- operative and seldom troublesome. The process of rehabilitation includes the separation of those who can succeed, may succeed, and are unlikely to succeed, and except in an organization such as Papworth expressly run for such a purpose, industry is mflurally loth to accept this responsibility. That period must be covered by government help, either as grants in a training scheme, or by temporary arrangements to make up the value of short earnings. The former is much the more satisfactory. It is much better to leave the control of the hours of work in the hands of those who know the job, and to allow them to be uninfluenced by financial concerns. I f there is a fixed grant during training, the doctor can vary a man's hours up or down without touching his pocket, yet always with the responsibility to push him along as fast as possible towards the goal of normal wage rates for the job. I f payment is by a combination of wage rate and subsidy there is a tendency to rather less enthusiasm in the worker who feels that the subsidy will always be available.

What is important, and has been shown by the results at Papworth and other centres, is that the training period needs financial assistance, and that thereafter it is a good bet to re-employ those who work up to a six-hour day or more.

And what o f ' t h e financial aspects of Papworth?

TABLE V I I I . - FINANCIAL ASPECT OF TRAINING SCHEraE (I95I)

A. Cost to Public Funds: £ (i) Local Authorities .. 2%ooo

(ii) Ministry of Labour .. xo,ooo (iii) Regional Hospital Board .. I4,ooo

Total £44,ooo B. Paid in Taxation b.y Papworth:

(i) Purchase Tax .. (ii) P.A.Y.E . . . . .

(iii) National Insurance

• . 4 4 , 0 0 0

• . I 0 , 0 0 0

• . 1 % 0 0 0

Total ~66,ooo Over £I9O,OOO

• . I40 C. Wages Paid by Industries D. Average number of trainees Annual cost to N.H.S. and N.A.B. if

not at Papworth- approx. .. ;£37,ooo

This table shows an approximate credit/debit account with the G o v e r n m e n t - in fact with you and me as taxpayers• In 1951 , the sums received from public funds amounted to £44,ooo, made up in part from Local Authorities, the Ministry of Labour, and the Regional Hospital Board who pay for trainees whilst still on only three hours' work. In return, £66,ooo was paid back by the industries in P.A.Y.E., Purchase Tax, and National Insurance, and over j~i9o, ooo was paid in wages which, of course, con- tribute to prosperity and further taxation on purchases.

In that year the average number of trainees was I4O , all of whom had been sent to Papworth because they could not find work at home. They would anyhow have cost the country about £5 per head per week in N.H.S. and N.A.B. payments, a total of £37,ooo in the year. In addition, of course, about another 3oo colonists were employed, some of whom might not hold down jobs elsewhere, and a proportion of fit labour. I t has always been the policy to employ some fit labour to do the heavy manual jobs, but nearly all the executive staff have been recruited from suitable colonists.

By their organization, and by the development of the best abilities of men who have had tuberculosis, these industries working


in close association with the hospitals have developed an organization with a turnover of about ;~½ million yearly, selling goods in all the markets of the world. Despite the handicap of so much unfit labour, it has been possible to show small profits, enough to allow expansion and improvements.

TABLE I X . - FINANCES OF INDUSTRIES

I Papworth 'Industries met all expenses and were able to provide a small margin for contingencies.' (Report for 195o )

II Remploy Excess of expenditure over in- come, £z,732,89z

Loss per head, ~319

Without venturing to offer any explana- tion, I would point out the great contrast of Papworth and Remploy, as shown from the White Paper issued by H.M.S.O. A loss o f ~ 3 i 9 per t ra ineeper annum is to be compared with the gain to the Exchequer from the running of Papworth. The purpose of rehabilitation is to restore a man to financial independence, and during the initial stage he needs and deserves help which the country willingly gives, but he must always have before him the fact that he can and should regain his own place in society, standing on his own feet and proud of his independence. He needs the stimulus of hope which springs from an opportunity to do a man's work, in an organization which is itself independent.

For this reason rehabilitation must be considered separately from efforts to find an occupation for those who can never, improve.

At Papworth, patients of all types, ages, nationalities and social classes have been accepted and trained, provided there seemed a reasonable possibility of progress. Young- sters and orphans have been given a chance in life, lads saved from the certainty of cosh gangs, foreigners unable to return home have been helped to independence. Neither the X-ray plate nor the sputum state is a bar to work, but the words of Pattison, of the Altro Workshop, New York, are equally applicable here:

' I t is a distinct disservice to the patient, does violence to the rehabilitation programme, and is a breach of medical ethics to unload by deceit the unsuitable, the ineligible and the undesirable case upon a rehabilitation centre.'

The best way of assessing a man's ability is to let him try, because the disease and the human being are so variabie that their re- actions cannot be narrowly foreseen. So much depends upon the will of the individual, and the opportunity available, and the examples of success in his environment.

Papworth is a centre for progress, for security, and for independence. To all patients it offers hope and opportunity, the outcome of which depends upon the will and the character of the individual.

I would like to acknowledge the support and interest given by Dr R. R. Trail during the initiation a n d development of the system of records on which this paper is based, and also to mention Mr A. T. Edney, of Papworth, whose accurate work has produced the results.

References Farquharson, M. (z952) Tubercle, ~x-xzzz, "62. Hardy, R. (1953) Tubercle, xxxrv, 54. Pattlson, H. A. (x942) Rehabilitation of the Tuberculous.

New York. Trail, R. R. 0952) Modern Practice in Tuberculosis.

Butterworth & Co. London. Varrier-Jones, P. (z943) Papers of a Pioneer. Hutchinson,

London. 3tinistry of Labour Gazette (t953) Lxt, No. 2 (February). Fourth Report from Select Committee on Estimates

0952) H.M.S.O., No. x6~. Public Health Report U.S.A. 095o) 65, No. 47- Sickness Absence in Industry (z953) B.3/.ff., Editorial,

6o4.

N O T I C E T O C O N T R I B U T O R S

Contributions are invited from authori tat ive sources on the understanding customary to medical publications.

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Opinions put forward in this Journal, unless expressly so stated, do not necessarily represent the policy of the British Tuberculosis Association,

Documents

Principles and results of training and employment at Papworth