REHABILITATION: CONCEPT AND PRACTICE*is relevant to the concept: "Thesuccessful rehabilitation ofaperson disabled by injury or sickness is not solely a medical problem. Rehabilitation

Brit. J. industr. Med., 1961, 18, 241.

REHABILITATION: CONCEPT AND PRACTICE*BY

J. A. L. VAUGHAN JONES

From the East and West Ridings Region of the Ministry ofLabour

(RECEIVED FOR PUBLICATION OCTOBER 4, 1960)

The word "Rehabilitation" has been used in many contexts and in many different ways. In themedical field its interpretation has changed considerably in the period from the years before thefirst world war to that after the second and the ensuing extensive social legislation which followedthe Beveridge Report. Changes in definition, although usually enlarging the scope, do not neces-sarily mean increased application. The multiplicity of statutory and other agencies which have apart in the method and means of returning patients to full industrial and social contact hascontributed to the failure to progress with the changes in definition.Any review of rehabilitation services in this country shows many gaps which are due primarily

to a failure by the medical profession as a whole to accept the dynamic philosophy of treatmentdemanded by rational schemes of rehabilitation and secondarily to the failure of effectiveco-ordination and integration between government departments, hospitals, general practitioners,public health services, and industry.The prevailing tendency to isolate rehabilitation in the sphere of physical medicine is criticized

as an attempt to evade a responsibility which the whole practising profession must accept. Thefundamental function of industry in the process and the importance of the role of the IndustrialMedical Officer are emphasized. Resettlement in employment is the crux of the whole process ofrehabilitation.

In choosing the title, I wondered whether to con-centrate on a purely academic approach or whetherto detail my experience in a particular branch ofmedicine relating mainly to industry. In the end Ihave compromised by a combination of both. Firstan interest in occupational health, which began as astudent, was stimulated when I was thrust into thevortex of the daily casualties of a Welsh miningcommunity. Rehabilitation was a word used inlimited circles, mostly outside medicine, and under-stood by few, but a youthful anxiety to try to getmen back to work earlier than they did in those daysof 1924 was the glimmering in my own mind of ourmodern approach. This was no pioneer work; it hadalready been undertaken by Robert Jones, AgnesHunt, Moore at Crewe, and others, but it was aninstinctive reaction to the months of suffering andwaiting which was the lot of many patients; waitinguntil the wounds healed; waiting until the claim forcompensation so bitterly fought, was settled; waiting

to be allowed to recover their sense of independence;waiting to be allowed to face death daily at theirwork. It was not the hacking coughs and the markeddyspnoea of so many which was disturbing, as muchas the poor results of the traumatic surgery of theera which constituted a major challenge.

Immobilization for months in splints and later inplaster, more months spent hobbling about aim-lessly trying to restore function in limbs too longrested and wasted, months spent wrangling in theCourts about differing and sometimes conflictingopinions of medical experts: months which em-bittered men and their families, and much of theblame could properly be stated to be the responsi-bility of a profession much too slow, or, to becharitable, too conservative to learn the lessons soclearly demonstrated to it by those pioneers inBritain before, during, and after the first world war.

It has been said that rehabilitation is physicalmedicine: how shockingly insular. I am not aphysical medicine expert. Nevertheless, I haveoccupied a somewhat privileged position to surveythe scene and watch the developments. In 1940, Ibecame Industrial Medical Officer at a Government

241

*From the Mackenzie Industrial Health Lecture of the BritishMedical Association, delivered during the annual provincial meetingofthe Association of Industrial Medical Officers, held at Southampton,September 1960.

on March 27, 2020 by guest. P

rotected by copyright.http://oem

.bmj.com

/B

r J Ind Med: first published as 10.1136/oem

.18.4.241 on 1 October 1961. D

ownloaded from

http://oem.bmj.com/

BRITISH JOURNAL OF INDUSTRIAL MEDICINE

Training Centre of the Ministry of Labour andNational Service, training all types of people forwork in thr war effort, girls, women, boys, men,able-bodied and handicapped; all who could walkand breathe were potential trainees. The adaptationof down-and-outs, social outcasts, and quite severelydisabled persons to economic working units was atremendous achievement, spurred on by the urgencyof the manpower need of the war, but it provided areal insight into the problem, an insight into thepotential of disabled or handicapped people whohad been regarded as cripples with no future. Thiswork continued during the war years, and whenpeace came, was adapted to the training of ex-servicemen for peace-time needs, for men andwomen who had lost their opportunities throughtheir period of war service.

History of Legislation concerning RehabilitationIn 1941 the interim scheme of the Ministry of

Labour and National Service in relation to disabledpersons linked hospitals and the employment ex-changes together for the first time. The TomlinsonReport was published in 1943 and greatly stimulatedmedical and lay interest in the problem. It envisageda post-war scheme to deal with the casualties of warand peace, and encouraged action on the part ofseveral government departments concerned.

In 1948 I was appointed a Regional MedicalAdviser to the Ministry of Labour and NationalService with the following duties:

(1) to act as Regional Medical Adviser to the RegionalController on general medical problems arising out of-resettlement work in respect of disabled persons;

(2) to make inquiries and advise, as found necessary,on special problems of that kind;

(3) to advise the Regional Controller on organizationand content of medical services in vocational training andat industrial rehabilitation centres;

(4) to assist in developing the fullest co-operationwithin the Region between the employment service of theMinistry of Labour and the hospital and other medicalservices and the medical profession generally, in relationto the problem of placing disabled persons;

(5) by association with appropriate departments ofuniversities or approved hospitals, or in other ways, tomaintain a research and teaching interest in medicalaspects ofthe placing and resettlement ofdisabled persons.

This appointment was made by the Ministry ofHealth, the holder being seconded to the Ministry ofLabour. The work involved a close relationship withRegional Hospital Boards and teaching hospitals,contacts with hospital staffs in two Regions, with thelocal authorities of the area, and liaison with generalpractitioners. The University relationship hadalready been established by my appointment to apart-time lectureship in occupational health.

An objective view could be taken from thisparticular position of the attitude of medical teachersto the problems of rehabilitation, of the differingapproach by two Regional Hospital Boards and theteaching hospitals together with the general reactionof the medical profession to the new demands madeupon it.Twelve years have passed and there have been

many changes, but Departments work all too slowly,and at times our own profession has moved evenmore slowly.

The Impact of Post-war LegislationPublic reactions to the social problems of the

crippled, the disabled, and the handicapped have notinherently changed, in spite of a great deal of lip-service to the concept of social welfare or to theachievement of social independence, which shouldbe the ultimate aim. Conservatism, which can be anadmirable excuse for the non-progressive in our pro-fession, has severely limited both the potential andthe ultimate successes. When distinguished membersof our profession say that consultants have nothingto learn about problems of rehabilitation, that it islargely a matter of education of the general practi-tioner-and this is uttered in a mainly lay Depart-mental Committee-when other people say that theterm " Rehabilitation " should be put into coldstorage for 20 years, it seems doubtful whether thereis any real hope that our profession will accept itssocial responsibility.The concept is best approached on a chronological

basis. First there is the Report of the British MedicalAssociation Committee on Fractures which stimu-lated the appointment of the Delevigne Committeeon the treatment of fractures, which reported in1936-37. The B.M.A. definition of 1934 was:" The word ' Rehabilitation' may be taken as applic-

able to a stage between the completion of a course ofmassage and exercises in the Massage Department andthe point where the stresses and strains of heavy workcan be undertaken. It is an active stage, directed to acomplete restoration of function."The Delevigne Committee Report resulted in the

setting up of fracture clinics throughout the country,which later developed into the Emergency MedicalService, set up in 1938-39 to deal with the expectedcasualties of an approaching war. Under thestimulus of the imperative war-time demands formanpower, public interest was aroused by the needfor the utilization of disabled or handicapped per-sons in the national effort, and many people realizedfor the first time that sub-standard individuals couldcontribute a full day's work if they were appropri-ately handled and allocated.

242



.bmj.com

/B


.18.4.241 on 1 October 1961. D

ownloaded from

http://oem.bmj.com/

REHABILITATION: CONCEPT AND PRACTICE

In 1941, Ernest Bevin, then Minister of Labourand National Service, appointed a DepartmentalCommittee on the Rehabilitation of DisabledPersons, under the Chairmanship of GeorgeTomlinson, who was Parliamentary Secretary to theMinistry. Their remit was:

(a) to make proposals for introduction, at the earliestpossible date, of a scheme of rehabilitation and trainingfor the employment of disabled persons not provided forby the interim scheme introduced by the Ministry ofLabour and National Service in October 1941;

(b) to consider and make recommendations for theintroduction, as soon as possible after the war, of acomprehensive scheme for-(i) the rehabilitation and training of rdisabled per-

I sons in all(ii) securing satisfactory employment for tcategories.

(c) to consider and make recommendations as to themanner in which the scheme proposed for after thewar should be financed.

The Tomlinson Report has been one of the greatsocial advances of our time; most of what has beendone in this country in rehabilitation and resettle-ment is a direct result of its recommendations. Theconclusions of the Tomlinson Report (1942) were asfollows:

(1) Rehabilitation in its widest sense is a continuousprocess, partly in the medical sphere, partly in the socialand industrial spheres. The medical side, in spite of thedevelopments brought about under the EmergencyHospital Scheme, still falls short of what is required, and,so long as this continues to be so, the problem of re-habilitation at the post-hospital stage, is correspondinglymore serious and extensive. In the meantime, concertedaction is necessary to see that the existing hospitalfacilities are in use to the fullest extent and to the bestadvantage for those in need.

(2) Close co-operation in the Health and IndustrialServices is necessary throughout the whole process. Thisis particularly important at the stage between the end ofmedical and the beginning of industrial rehabilitation;but it should be continued to the later stage of resettle-ment, so that the industrial services have the benefit ofmedical advice, and the medical services can acquireknowledge of the effect of disablement upon occupationalcapacity.

(3) On the industrial side, continuity of the service isessential. It should start in the hospital, it should con-tinue throughout the post-hospital stages, it should notend with the first placing in employment, but shouldfollow up until resettlement is completed. This calls fora specialist service within the Ministry of Labour andNational Service.

(4) Ordinary employment is the object and is practic-able for the majority of the disabled, with the goodwilland co-operation of the representative organizations ofemployers and workpeople, in conjunction with the

Health Services and the responsible GovernmentDepartments.

(5) A minority of the disabled require employmentunder sheltered conditions, and such employment shouldbe provided through production for Government andother public services.

These conclusions led the Committee to their finalrecommendation which was for the establishment ofmachinery to augment the work of the Departmentsresponsible for the many different aspects of thewhole scheme. These Departments were: Ministryof Labour and National Service, Ministry of Health,The Board of Education, together with the ScottishDepartments of Health and Education, Ministry ofPensions, The Home Office, and Ministry of Fueland Power.

It was suggested that an inter-Departmental Com-mittee should be appointed forthwith to ensure thatadequate preparations were made for the introduc-tion of the scheme immediately after the war. Therecommendations of the Committee dealt with eligi-bility, medical rehabilitation, post-hospital rehabili-tation, resettlement, employment under shelteredconditions, employment of the blind and the deaf,employment on own account, placing and follow-upwork, survey of occupations, and finance.The following extract from the Tomlinson Report

is relevant to the concept:

" The successful rehabilitation of a person disabled byinjury or sickness is not solely a medical problem.Rehabilitation in its strictly medical sense means a pro-cess of preventing or restoring the loss of muscle tone,restoring the full function of the limbs, and maintainingthe patient's general health and strength. The processshould begin as soon as possible after injury or operation,and, in the case of acute or prolonged illness, as soon asthe patient's condition permits, and it should continuenot only throughout the period of hospital treatment, butalso during the subsequent stage of convalescence,whether that takes place in hospital, or is provided in aseparate centre. Continuity of treatment is essential toachieve the aim of restoring a patient's mental andphysical capacity at the earliest possible date, and to thefullest possible extent."

In 1943 the Reports were published of the ScottishExperiments in Social Medicine at Gleneagles (laterat Bridge of Earn) and that on the development ofthe Miners' Welfare Rehabilitation Centres.

In 1944 the Disabled Persons (Employment) Actwas passed. It was the first positive step taken as aresult of the Tomlinson Report, and much of thesubsequent work of the Ministry of Labour andNational Service flowed from it.

In 1946 a British Medical Association Committeereported on Rehabilitation and defined the problemas follows:

243



.bmj.com

/B


.18.4.241 on 1 October 1961. D

ownloaded from

http://oem.bmj.com/


" Rehabilitation is the fullest possible restoration tonormal life and working efficiency of a person in-capacitated by disease or injury. This is primarily amedical problemn, but one in which industry and thesocial services must play an essential part. Treatmentmust be directed not only to obtaining full physical andmental recovery, but also to restoring a patient's enjoy-ment of his former cultural and social activity and hisresettlement in work best suited to his capacity."

In 1949 the Ministry of Health, in a circular sentto all Hospital Boards, Boards of Governors, andHospital Management Committees, urged themedical profession to accept an additional socialresponsibility in relation to their patients. The cir-cular stated that treatment should not end with thedeparture of a patient from hospital, or with thegetting up out of bed after severe illness, but shouldbe continued into the stage of resettlement inappropriate work. Further, that treatment was theresponsibility of the hospitals and the medical pro-fession, but that placing in work was quite clearlythe responsibility of the Ministry of Labour andNational Service through its placement and DisabledResettlement Officer Services: an excellent concept,but its implementation has not been achieved. Atthe same time it was urged that all larger hospitalsshould appoint one or two senior members of thestaff to supervise rehabilitation services within thehospital or hospital group. It is unfortunate that themedical profession found in this apparent contradic-tion between the acceptance of individual responsi-bility and the delegation of responsibility, an excusefor the lack of progress which should have beenmade. The result was that the profession acceptedindividual responsibility in theory, but was opposedto the appointment of colleagues with additionalresponsibility. That situation is largely maintainedtoday.

In 1954, the B.M.A. second Committee onRehabilitation, in giving evidence to the PiercyCommittee, produced this definition:

" The rehabilitation of a patient is an indivisibleprocess beginning with the onset of sickness or injury,and continuing throughout treatment until final resettle-ment in the most suitable work and living conditions isachieved. Its aim is to enable him to resume his place asa responsible citizen, and to contribute in the fullestpossible manner to the physical, mental and social welfareof the community. The whole man must be rehabilitated,the patient being dealt with as an individual with adistinctive constitutional make-up, with his own emo-tional life and moral values and with a particular up-bringing and social and economic background. In thissense, every aspect of medical care is a part of rehabilita-tion."

The Report goes on to say:

" It is this comprehensive conception of rehabilitationwhich places upon the medical profession special responsi-bility, for only a person who is medically trained canadvise the patient with a full understanding of his dis-ability. Similarly, the complete confidence of the patientwill be gained only if he can feel that he is being guidedby someone who understands all aspects of his problem.There must, therefore, be continuous medical supervisionof the patient throughout the process of rehabilitation."

In 1955, the Report of the expert Committee onMedical Rehabilitation of the World HealthOrganization made a statement of general aims andprinciples, which were virtually in accord with thedefinitions of the British Medical Association, andfinally there was the Report in 1956, of the UnitedNations Working Party on the Rehabilitation of thePhysically Handicapped. The following is an extractfrom this Report:

" The time has long passed when a handicapped childor a disabled adult should be regarded as a subject forcommercial exploitation, and trained for the occupationas a professional beggar, or even to be considered as amere object of charity. Modern methods of medical andsociological science have opened a new horizon ofpromise for such individuals, but if this promise is to befulfilled and the handicapped person is to have his fullchance in life, there must first be a new evaluation ofphysical disability, based on the following six theses:

(I) That the handicapped person is an individual withfull human responsibilities which he shares in commonwith the able-bodied, and that he or she is entitled toreceive from his or her country every possible measureof protection, assistance and opportunity for rehabilita-tion.

(2) That, by the very nature of his physical handicap,he is exposed to the danger of emotional and psycho-logical disturbance resulting from a deep sense ofdeprivation and frustration, and that he therefore hasspecial claims on society for sympathy and constructivehelp.

(3) That he is capable of developing his residualresources to an unexpected degree, if given the rightopportunity for so doing, and of becoming in mostinstances an economic asset to the country instead ofbeing a burden on himself, his family and the State.

(4) That handicapped persons have a responsibility tothe community to contribute their services to the economicwelfare of the nation, in a way that becomes possibleafter rehabilitation and training.

(5) That the chieflonging ofthe physically handicappedis to achieve independence within a normal communityinstead of spending the rest of his life in a segregatedinstitution, or within an environment of disability.

(6) That rehabilitation of the physically handicappedcan only be successfully accomplished by a combinationof medical, educational, social and vocational services,working together as a team."

244



.bmj.com

/B


.18.4.241 on 1 October 1961. D

ownloaded from

http://oem.bmj.com/


The changing attitudes expressed in these defini-tions indicate the developments that have takenplace in the approach to rehabilitation. Neverthe-less, unless some really positive action results fromthe dissemination of these formative ideas, definitionstend to remain mere skeletons. To appreciate all theagencies involved in the problem of the transfer ofman from bed to work provides what is probablythe real reason for a comparative failure of theservice in this country. The word " comparative " isused lightly, because we are still ahead of manycountries; we could have been ahead of all inpractice as well as theory if a little more positiveaction had been taken.The numerous bodies concerned with rehabilita-

tion include the statutory authorities, the Ministriesof Education, Health, Labour, Pensions andNational Insurance, the National Assistance Board,the Hospital Boards of the National Health Service,the General Practitioner Service, the Public HealthService, and the Local Authority Health and WelfareService. A host of voluntary bodies contribute theirparts to the solution of the problem; also univer-sities, industry, trade unions, employers' organiza-tions and, last, but not least, industrial medicalofficers.

The Present PositionIt is the lack of integration of all these services

which has been the main delaying factor in theproper development of the scheme. If the problemsofthe different services are envisaged and particularlythose of our own profession, it is realized first of allthat there is an absence of modern thought in theteaching stage when the medical student is at hismost impressionable age. The problems of theNational Health Service have almost engulfed themedical profession, which consequently has failed toappreciate the vital contribution which a dynamicphilosophy of treatment can achieve. It has showna lack of vision or even a desire to eschew anythingwhich appears new (apart from drugs) and an almostfanatical belief in the methods of the past. It maybe that the increasing fragmentation of medicine,particularly of the specialties, may have played apart in this. The welter of post-war social legislationhas almost submerged all except the cynical, the em-bittered, and the angry, but positive constructivethought or action rarely emerges from these groups.

In spite of the brilliant achievements of a fewenlightened doctors who had the courage of theirconvictions, too little has been achieved in the sphereof rehabilitation. Platitudes, professional jealousies,empire building on the part of lesser known special-ties, apathy, and plain ignorance are charges whichhave to be met. One expert has divided the medical2

profession into five groups on their attitudes torehabilitation: tolerant 30%, passive 50%, interested15 %, enthusiastic 3 %, expert 2 %.The past 12 years have been spent trying to

educate, to encourage, to cajole, even to force, col-leagues to appreciate that medicine now includessocial responsibilities towards patients. Theseresponsibilities must be accepted as a fundamentalpart of the modern concept of treatment in that thework is not completed until the patient is back atwork, properly settled in appropriate employment.This new concept of treatment also demands thatdoctors are part of a team which involves manyother agencies. Doctors are essentially individualists,but occupational health shows that success can beachieved only as members of a team; this is equallytrue in the concept of rehabilitation.There is one bright light on the horizon, and that

is the avidity with which final year medical studentsaccept the philosophy of rehabilitation and ask formore in the few lectures which are allowed in thecurriculum. The tragedy is that rehabilitation shouldnot be taught as a specialist subject, but as aninherent part of all clinical teaching; that will be toomuch to expect of this decade. Nevertheless, juniorresident medical staff are more ready to accept thiswider concept than their seniors, and one RegionalHospital Board at least, has instituted courses inrehabilitation for junior resident hospital medicalofficers during their first two years. This sensibleaction should be copied nationally.Many general practitioners are more knowledge-

able about this problem than is generally realized.Industrial medical officers play an important part

in the resettlement of the individual returning toindustry; the industrial medical officer often has theextremely difficult task of relating an employee'saltered capacity to the jobs which are available. Thedetailed results of the follow-up of these cases oncethey are back in industry can assist the other servicesengaged in rehabilitation to a very considerableextent; in addition the information available fromthe industrial medical officer has not been fully used.To turn now to the statutory authorities. The

Ministry of Labour, under the impetus of the Dis-abled Persons (Employment) Act, has probablymade a greater contribution to the subject of re-habilitation than any other Department by the pro-vision of Disabled Resettlement Officers at everylocal Employment Office, a corps whose training hasbeen steadily increased and improved since 1944; byits Industrial Rehabilitation Units which carry outthe work of reconditioning people returning to theirown or other work or assessing cases requiring achange of work or training; by its Medical Inter-viewing Committees which give medical advice to

245



.bmj.com

/B


.18.4.241 on 1 October 1961. D

ownloaded from

http://oem.bmj.com/


assist the D.R.O. in the placing of disabled persons;by its Government Training Centres, which trainboth disabled and able-bodied for new vocations,and its Remploy Factories for the more seriouslydisabled; and by its Disablement Advisory Com-mittees, dealing with local problems.

In recent years the Ministry of Health, particularlysince the publication ofthe Piercy Committee Report,has advised Regional Hospital Boards, Boards ofGovernors, and Local Authorities to tackle the prob-lem of rehabilitation, the problem of handicappedpersons of all ages. The Ministry has issued docu-ments to the Hospital Service, the Local Authorities,and to general practitioners on the general problemsof rehabilitation, and has encouraged Boards andHospitals particularly concerned, not only todevelop, but to make the best use of existing facilitiesand to provide facilities for a system of plannedconvalescence. The streamlining of these rehabilita-tion services run under the aegis of the Ministry ofHealth could save the National Health Servicemillions of pounds and would reduce the demand formore hospital beds which is often made. Theincreased use of this new concept of treatment meansa shorter hospital stay and a quicker return to work.These are basic factors in the national economy.The Ministry of Health in a Circular to Regional

Hospital Boards and Boards of Governors stated:

" Rehabilitation is not to be regarded as the applica-tion of special techniques, and still less as a separatemedical or other specialty, but above all, as a constituentpart of the thought and action of all those who are con-cerned with treating patients and the restoration ofdisabled persons to their utmost capacity."

In spite of this, the Ministry of Health in itscirculars has tended to concentrate on a thesis ofphysical medicine as expressed by physiotherapy,remedial gymnastic, and occupational therapy ser-vices, rather than to demand from the medicalprofession the individual and collective responsewhich is its right. It is important not to build arehabilitation service entirely on a basis of physicalmedicine. Of the groups which comprise the profes-sion, the orthopaedic, traumatic, and thoracicsurgeons, the chest physicians, the psychiatrists, andthe physical medicine group have shown a greaterwillingness to accept the additional responsibilitiesof treatment than others, but it is emphasized thatrehabilitation is one of every doctor's fundamentalresponsibilities.Both Departments have encouraged the use of

resettlement clinics or case conferences at everymajor hospital, i.e. clinics in which consultant,almoner, disabled resettlement officer, and doctorwith knowledge of local industry can pool their

knowledge to the benefit of the patient, but theresponse has been completely inadequate.The Piercy Committee, a mainly inter-Depart-

mental Committee, was set up by the Ministers ofLabour and Health and the Secretary of State forScotland in 1953 with the following terms ofreference:To review in all its aspects the existing provisions for

the rehabilitation, training, and resettlement of disabledpersons, full regard being had for the utmost economy inthe Government's contribution, and to make recom-mendations.The need for economy will be noted. This Com-mittee arose from the Government's wish toascertain what had happened as a result of thenumerous legislative measures passed since theTomlinson Report of 1943. The Committee finallyreported in September 1956, after holding 54 meet-ings and taking voluminous evidence. In the inter-pretation of its terms of reference there was asignificant change in the definition of rehabilitation.Paragraph 5 of the Piercy Committee's Report reads:

" The term ' Rehabilitation ' in its widest sense signifiesthe whole of the process of restoring a disabled personto a condition in which he is able, as early as possible,to resume a normal life. With this interpretation, itwould cover also training and resettlement in employ-ment. As the terms of reference specifically mentionrehabilitation, training and resettlement, the Committeedecided that its use of the term ' Rehabilitation ' shouldbe confined to medical and surgical treatment designedto restore physical and mental functions, and to theprocess of reconditioning, designed to restore thecapacity for taking up employment or vocational training.Whilst the Committee was concerned primarily withvocational training for the disabled, it decided to takeaccount also of other forms of training of the disabledmore strictly educational in content. It also decided thatthe term ' Resettlement' should be used to cover boththe placing of disabled persons in employment (includingany follow-up action to ascertain the effectiveness of theplacing) and action taken to re-settle other disabledpersons-such as housewives-who are not in theindustrial field."The separation of the terms " Rehabilitation

"Training ", and " Resettlement " may indicate adesire to preserve Departmental tidiness, but thisfragrnentation tends to promote gaps when the wholeprocess should be continuous.The Piercy Report found omissions and deficiencies

in almost every sphere and in every agency involved;deficiencies not only of personnel but also in theappreciation of the situation and its problems.Referring to administrative arrangements, theReport says (paragraph 317):

" To secure the most efficient operation of these services(from the standpoint of the individual) at the minimum

246



.bmj.com

/B


.18.4.241 on 1 October 1961. D

ownloaded from

http://oem.bmj.com/


cost in manpower and money, sensitive contact andwilling co-operation are necessary between the variousagencies and Departments concerned. This is needed at

the centre, at the local level and among the regionalauthorities. The Committee believes that some improve-ment in existing conditions at all levels may be desirable,and is attainable."

This is a most masterly understatement.The Committee finally made 46 recommendations,

covering Hospital Services, Resettlement Clinics,Regional Hospital Boards, Rehabilitation Com-mittees, Industrial Rehabilitation, ComprehensiveRehabilitation and Assessment Centres, Rehabilita-tion Services provided by employers, WelfareServices, appliances and other aids for the disabled;Vocational Training, Disabled Persons' Register,Placing of the Disabled in Employment, ShelteredEmployment including Remploy, Home Workers'Schemes and provisions for the young and otherspecial categories of the disabled.The Report was clearly a challenge to all parti-

cipating authorities, but subsequent action was con-

siderably delayed. It was not until 1958 that theMinistry of Health issued Circular H.M. (58) 57 on

Rehabilitation in the Hospital Service and its Relationto other Services, and Circular 16/58 to LocalAuthorities on Services for Handicapped Persons.The Circular to general practitioners on Rehabilita-tion of the Sick and Injured appeared in July 1959,but was not circulated until further information as

to available local facilities for rehabilitation was

included as an appendix.Several agencies, including Hospital Boards and

Local Authorities, took positive action before theissue of these circulars. Indeed one RegionalHospital Board had taken in 1949-50 the action pro-

posed by the second of the Piercy recommendations.The Regional Rehabilitation plan, evolved at thattime by the co-operation of the Leeds RegionalHospital Board and the East and West RidingsRegion of the Ministry of Labour, had reposed inthe files of the appropriate Ministries since that timealthough the Chief Medical Officer of the Ministryof Health had expressed the view that this planshould be the pattern for all Regional RehabilitationServices. It is interesting to relate that one Depart-ment denied that it had a copy of the plan.

Other Regional Hospital Boards are now engagedin an attempt to implement the recommendations ofthe Piercy Committee, and serious efforts are beingmade to improve the content of services, and toco-ordinate the various services. These efforts donot necessarily take the same pattern; for example,two adjoining Regional Hospital Boards have en-

tirely different concepts. One believes that allrehabilitation services should be based on the

establishment of physical medicine consultants andcentres at strategic points in the Region; the otherBoard feels that one of its basic functions is toimplant the ideology and philosophy of rehabilita-tion into all its consultants and hospitals. Theresults will be watched with considerable interest.

The FutureMaking the assumptions:

(1) that hospital and general practitioner servicescan be improved to the extent that the responsi-bilities of rehabilitation are fully appreciated;

(2) that Local Authorities accept in full theirresponsibilities under the various enactments;

(3) that the various Ministries co-ordinate the workmore efficiently and provide the necessary stimulifrom time to time,

what remains to be done, and what should be doneto anticipate the demand on other resources?

In the first place, is there the necessary link withindustry to obtain resettlement? The link is prob-ably there, but will not be efficient until there is acomprehensive Occupational Health Service in thiscountry. Some large firms have achieved much inthis sphere on behalf of their own workers, but atpresent their achievements cannot for numerousreasons be copied by the smaller undertakings.

There is a real need for the appreciation by allthose engaged in the service of rehabilitation (bothmedical and lay) that entry into industry (and re-entry into industry) is no longer a slap-happy event,even although that term may still be applied to anumber of school leavers.The relationship of the functional analysis of the

worker to job analysis is an essential in the resettle-ment of the handicapped person. The techniquesconcerned should not be reserved for a small numberof doctors who understand how to complete anofficial Ministry of Labour D.P. form and thedisabled resettlement officers who frequently have totry to interpret the inadequacies of the medicalprofession in the completion of these forms.

It is not sufficient for the almoner at the behest ofthe disabled resettlement officers to chase the con-sultant to complete one of these forms, which maythen be passed on to the senior registrar, the seniorhouse officer, and finally the junior house officer,who cannot pass it on to anyone else. The problemof equating a man's residual capacity to a particularjob is often difficult, but until and unless the medicalprofession learns more of the pattern and reality ofindustry, schemes of rehabilitation will never attainthe success they merit.

It may be argued that the simplest method fordealing with the problem would be to leave it to be

247



.bmj.com

/B


.18.4.241 on 1 October 1961. D

ownloaded from

http://oem.bmj.com/


settled by a few trained specialists. In my view thiswould be entirely wrong, because the philosophy ofrehabilitation and the purpose behind it must reachand be accepted by all branches of the medicalprofession.The work of the industrial medical officer in this

sphere would assume reasonable proportions if amuch clearer link existed between the agencies of theNational Health Service and industry than at present.The growing tendency of the National Health Serviceand the Industrial Health Service to developseparate entities with little or no co-ordination isunsatisfactory.

Rehabilitation services will expand in this countryalthough rather more slowly than some would like;industrial medicine and occupational health willgrow, perhaps more quickly, under the stimulus ofknowledgeable and visionary Ministers of Labourand Health, but they will never be complementary toeach other until doctors in the consultant and generalpractice services fully comprehend what employmentor work actually means; what industrial processesdemand, and, not least, that work therapy in theactual course of employment can contribute a greatdeal more to the national economy and the worker'spersonal happiness than hours spent weekly doingelementary exercises in a hospital physiotherapydepartment. Nothing is more tiresome than to seethe constant reference of people to hospital forexercises which can be done, and indeed are done,in the active performance of their ordinary work, andthis wasted time must stop.The responsibilities of industry are great, because

it must be impressed on the curative services of thiscountry that the end result of all their efforts is work,and work as quickly as possible; the social aspectwill follow.Employers and workers alike must not put

barriers in the way of resettlement of handicappedor disabled persons. The limitation of jobs, the de-marcation of jobs, the petty differences, the lack ofliaison between trade unions in relation to a man'schange of job-all these must be overcome in theknowledge that most disabled persons can contributea full day's work and in the need to return theworker to proper employment and his socialenvironment.The industrial medical officer has a special

responsibility for initiating schemes of liaison withinhis own establishment. It is part of his normalfunction, but it is sometimes neglected. Also he hasa most important role in attempting to educate hisprofessional colleagues about the actual performanceof processes which are merely names to the majorityof doctors, and in the elimination of the term " lightwork ".

The Piercy Committee reported that:" Employers can-and in many cases do-take steps to

modify the conditions or tempo of employment so as toenable the disabled person on return to employment afterillness and injury to accustom himself more gradually toindustrial conditions."Yet there are instances where an almoner hascontacted an employer in relation to a person whohas had a severe illness or injury and has mentioned" light work ". Such a patient usually gets lightwork, and, in the absence of an industrial medicalofficer, often remains at the menial task supplied bythe use of this archaic term. This fault is notconfined to almoners.The statement made at the seventh World Con-

gress of the International Society for the Care ofCripples by David A. Morse-Director General ofthe International Labour Organization-is of thegreatest importance:

" We all recognize that rehabilitation is not an end initself, but only a means to an end. Its purpose is to changethe disabled person from a state of dependence to one ofindependence, from disability and helplessness back toability and usefulness at work. Resettlement in employ-ment then is the crux of the whole process of rehabilita-tion."

Historians tell us that one of the greatest achieve-ments of mediaeval Christendom was its success inmaking work socially satisfying. Nowadays, weseem to have lost the impetus of a faith. By theacceptance of a dynamic philosophy in relation torehabilitation, we can really make work sociallysatisfying.

BIBLIOGRAPHY

Interim Report of the Inter-departmental Committee on the Rehabilita-tion of Persons injured by Accidents. (1937). Home Office,Ministry of Health, and Scottish Office.

Final Report of the Inter-departmental Committee on the RehabilitationofPersons injured by Accidents. (1939). Home Office, Ministryof Health, and Scottish Office.

Memorandum of Evidence for submission to Royal Commission onWorkmen's Compensation. (1940). British Medical Association.

Report of Committee on Industrial Health in Factories. (1941). BritishMedical Association.

Health and Industrial Efficiency. Scottish Experiments in SocialMedicine. (1943). Department of Health for Scotland.

The Organization ofa Hospital Rehabilitation Department (EmergencyMedical Services: Memorandum No. 6). (1943). Ministry ofHealth.

Rehabilitation Treatment for Injured Coal Miners. (1943). Miners'Welfare Commission.

Report of Inter-departmental Committee on the Rehabilitation andResettlement of Disabled Persons. Cmd. 6415. (1943). Ministryof Labour and National Service.

Disabled Persons (Employment) Act. (1944). Ministry of Labour andNational Service.

Second Interim Report on Social and Preventive Medicine. (1945).Royal College of Physicians, England.

Rehabilitation: The Report of the Medical Advisory Committee(Scotland). (1946). Department of Health for Scotland.

The Placement of the Disabled. (1946). Brit. med. J., 1, 803.Rehabilitation. (1946). Ibid., 1, 990.Modern Methods of Rehabilitation of the Adult Disabled: Report of a

Group-training Course held in Sweden, Finland and Denmark.(1952). United Nations with W.H.O. and I.L.O.

248



.bmj.com

/B


.18.4.241 on 1 October 1961. D

ownloaded from

http://oem.bmj.com/


The Rehabilitation and Resettlement of Disabled Persons. (1954).British Medical Association.

The Attitude of the Physician Towards Rehabilitation, chapter byShands, A. R., in Changing Attitudes Towards the Disabled,pp. 26-29. (1954). Proceedings of the Sixth World Congress ofInternational Society for the Welfare of Cripples, The Hague.

Report of the Committee of Inquiry o t the Rehabilitation, Training andResettlement of DisabledPersons. Cmd. 9883. (1956). Ministryof Labour and National Service.

Ways Back to Working Life, chapter by Morse, D. A., in Planningfor Victory over Disablement, pp. 262-270. (1957). Proceedingsof the Seventh World Congress of International Society for tLeWelfare of Cripples, London.

Expert Committee on MIedical Rehabilitation, First Report. (1958).Wld Hlth Org. Techn. Rep. Ser. No. 158.

National Health Service. Rehabilitation in the Hospital Service and itsRelation to Other Services. H.M. (58) 57. (1958). Ministryof Health.

Rehabilitation of the Sick and Injured (with Central Health ServicesCouncil). (1959). Ministry of Health.

Convalescent Treatment: Report of a Working Party. H.M. 59/53.(1959). Ministry of Health. H.M.S.O.

Unpublished Reports

Responsibility of the National Health Service in Relation to Disability.R.H.B. 49/36, H.M.C. 49/26, B.G. 49/29. Ministry of Health.

Welfare Services for Handicapped Persons other than the Blind andPartially Sighted. 32/51. Ministry of Health.

Servicesfor Handicapped Persons. 16/58. Ministry of Health.Training and Resettlement of Disabled Persons. PL/ 1941. Ministry of

Labour and National Service.Fracture Treatment and Rehabilitation. PL. 113/1942. Ministry of

Labour and National Service.

249



.bmj.com

/B


.18.4.241 on 1 October 1961. D

ownloaded from

http://oem.bmj.com/

Documents

REHABILITATION: CONCEPT AND PRACTICE*is relevant to the concept: "Thesuccessful rehabilitation ofaperson disabled by injury or sickness is not solely a medical problem. Rehabilitation