Case study 5: The manager

• Rehabilitation,
• Redeployment or ill health retirement (IHR).

Coping, control and adaptation.

Our patient has had a frightening experience with the sudden onset of right hemiporesis for which an underlying internal carotid artery stenosis appears to have been the cause. It has been treated surgically with every evidence of success. After about 9 months he is reported to be symptom free. He has been signed off work all this time.

In retrospect, whilst keeping him signed off all this time until he is "well" is the societal norm… is it necessarily a good idea? Think about this as you follow up on what has been done for him medically and as he contemplates a return to "normal" existence.

Let's look at what managers do before we consider the clinical and occupational issues.

A manager in his 50's may well be at the peak of his career, used to managing money, people and facilities, perhaps with a family dependent on him. Being a manager requires energy, self motivation and the monitoring of others. It will require working to deadlines, having performance targets and, often, extensive travel. Inherent to such jobs are surprises, setbacks and confrontations. Managers multitask: that is that they have a lot of different issues on the go all the time and they may also have to "fill in the gaps" by covering for those that they manage.

In taking your history its worth finding out about this, what your patient’s employer is like, how things are going in the patient's organisation, etc. It will all affect the likelihood of the rehabilitation that you are helping with being effective.

Clinical

• Whilst gross motor function may have fully recovered there may be residual effects both primary and secondary in terms of fine motor function, fatigue ability and speed. Also muscles and joints might have got weaker and stiffer during illness and recovery.
• Similarly and interacting with subtle motor impairments there may be equally subtle effects on speech, visio-spatial function, co-ordination, etc. Relatives and friends may remark on their experience of such subtle changes by saying things like, "he's not the man he was" or "he's had the stuffing knocked out of him".

Psychological

• He is likely to have lost a lot of confidence (most people off work for 9 months+ in the UK currently do not successfully get back to work),
• He may become clinically depressed; this is quite common and understandable!

Practical

• He could have been sacked on medical grounds; unfortunately this is quite common (and legal),
• His organisation may have changed whilst he was on sick leave,
• More specifically, occupationally he might not be considered fit for occupational driving. Higher medical standards apply to some groups of drivers. Do you know which? (and what)?

Rehabilitation services in the UK are weak, fragmented and poorly linked to the workplace. Let’s look at what support our patient may have had in the NHS.

He may have required physiotherapy and occupational therapy. For most patients that is the sum total of support they can expect to get. The main or sole focus of this support is on life skills to allow them to function as independently as possible in the home. Or to put it another way - to get them out of hospital. The objective here is "life ability" rather than "workability". Is this sensible? What's missing?

Finally, looking to the future, the pensionable age is set to rise and people will have to work longer. Inevitably this will mean more people who have had significant illness. In rehabilitation terms, what structural changes would you envisage the NHS needing to develop to deal with these eventualities?

Most people have to struggle back to work (or not) as best they can. Some organisations, usually the larger and more stable ones, have excellent occupational health facilities that you can link up with or recommend to your patient. Others don't.

If our patient is unable to return to his previous job for medical or other reasons, what outcomes do you see? Indeed, do you see it as your job to help at all?

Here are some reasons why you may see it as a medical issue:

• People who become unemployed early are poorer,
• They die younger,
• They suffer more ill-health before they die. See: Poverty and ill health: physicians can, and should, make a difference (from the Annals of Internal Medicine website).

So what about our manager?

His current employer may be able to redeploy him to an alternative post but both the employer and the employee may take some persuading. If you are asked to give advice in this situation make sure of the following factors:

• You have enough information about the robustness of his health and his limitations.
• You know enough about what he would have to do in the alternative job and what the pressures would be.
• That everyone is being realistic about how long it will take and what it will take to get our patient up to speed.
• You have all the necessary permissions to communicate between the interested parties.

If it doesn’t work out or is not a viable option then IHR comes up. The employer may, if terminating our patient’s contract of employment, take medical advice as to whether the criteria of the organisations early medical retirement scheme are met.

This can be a minefield and it is important when dealing with patients not to promise what you cannot deliver.

First of all, not everyone is even in their organisations' pension scheme. Secondly, eligibility depends on the scheme criteria not on your opinion. So if you were looking to give advice you would have to know what the particular criteria were and then you could offer an opinion on whether or not they were met in your patient's case.

There is not much point in just saying, "I think you ought to be retired because of your health". If the patient is unsuccessful in his claim all that will happen is that you will end up with a disgruntled patient. Remember also that the value of benefits varies in different schemes and may depend on time served.

Access to State benefits can also be a minefield. In general, the criteria for access to all schemes are being tightened and it is likely that this trend will continue for the foreseeable future for simple demographic reasons. All of this implies that people are being encouraged to overcome ill-health problems and to return to work. Objectively this is beneficial to societal health, as we have already noted. But of course individuals may not see it like that.

Remember the help that is available from the many employers who do have occupational health staff or, for others, the possibility of access to NHS occupational health departments.

A wealth of information is available on websites such as:

• NHS Health at Work website
• Department for Work and Pensions website
• Your local NHS hospital occupational health website

Also your patient may be able to access his own scheme website and it is worth both him and you familiarising yourselves with the helpful provisions of the The Equality Act 2010 (from the National Archives website).