Introduction
The organisation of social security for workers suffering from disabling conditions cau- sed by illness or disease in the Netherlands has undergone great changes during the past decade. These changes are expected to continue for at least another five years before a new and stable system is established.
Whereas the Netherlands, by the end of the previous century, had almost a million workers suffering from long-term work incapacity as a result of illness or disease, their number has been reduced to 850,000 in 2004 and is expected to dwindle further still in the years to come.
The causes of this reduction should be found mainly in a system modification which has resulted in a higher entry threshold. One of the major factors involved is that res- ponsibility for the reintegration of workers who have dropped out as a result of incapa- city for work has been shifted from the public domain to the private market.
This chapter will successively discuss 1) the social security system for those who, as a result of illness or disease, have lost their capacity for work, either partially or entirely;
2) the shift in responsibility from the public domain to the private market; and 3) the methods applied in the new system to realize reintegration.
The social security system
The principle underlying the social security system in the Netherlands has been to insure loss of income-generating capacity as a result of illness or disease.
The causes of illness or disease do not play any role when loss of income is assessed.
In the Netherlands, when entitlements to disability benefits are assessed, no distinction is made between “risque professionel” and “risque social”. In other words, those who have become incapacitated for work as a result of accidents in the private sphere (sports, hob- bies, household activities) have exactly the same rights and are subject to the same regu- lations as those who have become incapacitated for work as a result of industrial acci- dents or occupational diseases.
F.J.N. Nijhuis, B.A.G. van Lierop and F. Wichers
The amount of loss of income is determined by estimating the reduced capacity to earn the same income as could be earned by someone with similar knowledge and skill levels or professional qualifications (theoritical income). This reduced capacity to earn an income is expressed in six categories varying from zero to 100% (0-15, 15-35, 35-50, 50-65, 65-80, >80%) and determines the amount of disability benefit allowed.
When workers have been incapacitated for work for two years, an assessment is made to establish their work incapacity pension. The aim is to assess the worker’s disability to work. It must be objectively demonstrated that the disabilities have been caused by illness or disease. The disabilities found are used as a basis to estimate the reduction in the worker’s capacity to earn an income as compared to other workers with similar levels of training and education and experience; if a person is still able to realize 50% of his theo- ritical income, then his work incapacity is reduced by 50%.
Work incapacity is assessed two years after a worker stopped working as a result of a specific illness or disease. During the first two years of work incapacity, the employer is responsible for the employee’s reintegration process. The reintegration process may be aimed at achieving placement with the same employer in a specially adapted position or in a different position or it may be aimed at finding a place with a new employer.
The objective of the process is to motivate both employer and employee to realize early employee recovery, either in the employee’s previous position, which may be tem- porarily adapted, or in a different position, either permanently or for the time being.
If employer and/or employee have failed to make sufficient efforts during those two years to find work – in adapted form or otherwise, in a different type of work or in a dif- ferent position – a financial sanction can be imposed on the employer or the employee.
Employers may take out a reinsurance against the costs of illness and/or work incapa- city of their staff during the first two years. This reinsurance on the illness period (up to two years) must be concluded with a private insurance company. When employees receive work incapacity benefits (“WAO benefits”) after two years, they are paid by the UWV, a public social fund for the implementation of – statutory – employee insurance schemes.
Summarizing, the implication is that if diseases or disabling conditions cause workers to stop working, their employer will be responsible for their reintegration for a period of two years. At the end of that period, a review is made to establish whether employer and employee have made sufficient reintegration efforts. It is only when the review outcome is positive that the employee may be eligible for disability benefits.
The work incapacity system of the Netherlands will change greatly between now and 2007. Major principles involved in those changes will include:
– Reintegration will be of primary importance.
– Work incapacity insurance will demonstrate a shift towards a complementary and partially privately realized wage addition: everyone will be “obliged” to realize any remai- ning capacity for work.
It will be a highly restricted group who will receive disability benefits. These benefits
are intended exclusively for those people who have lost every chance of returning to
work, in whatever form.
Physical examinations will be tightened considerably and employees will receive benefits only if they have lost every capacity to earn an income while their disease results in permanent disabilities.
What are the implications of these developments for vocational rehabilitation in the Netherlands?
The effect of these developments is that reintegration in the Netherlands has turned into a two-track policy.
Firstly, if workers have become incapacitated for work at their jobs, their employer will be responsible for their reintegration for a period of two years. This type of reinte- gration can be characterized as Disability Management.
Secondly, if an employer-employee relationship no longer exists or has never existed at all – for example, when people have become disabled at an early age or when employees have lost touch with their employer after two years of being incapacitated for work – this is said to be a case of vocational rehabilitation.
Disability Management: principles
Disability Management is understood to be the sum of those activities which are desi- gned to prevent workers from being absent from work (primary prevention), to support their recovery (directing function) and to develop reintegration activities [1]. Disability Management can be seen as a coordinated and coherent strategy aimed at cost-effective prevention and early intervention, both removing the causes of work incapacity and sup- porting workers to resume work as quickly and adequately as possible. Disability Management focuses on workers suffering from chronic and/or functional disabilities, on restoring individual work and functional capacities, but also on preventing individual capacities from deteriorating. Disability Management is aimed at developing and rein- forcing the individual’s capabilities and at removing and/or reducing obstacles in the worker’s environment which might reduce functional capacities. Essentially, it combines two perspectives: utilizing, encouraging and improving the individual capacity for work of those who have disabilities on the one hand, and the methods used by the organisa- tion to deal with prevention and reintegration on the other. In this approach, the focus is on employees suffering from disabilities and Disability Management activities are desi- gned to learn to cope with disabilities and to reintegrate into the work organisation.
Special attention is paid to the continuity of the relationship designed disabled worker
and employer. In other words, the aim is to realize early resumption of work within one’s
own organisation [1]. These views correspond with the prevailing approach in the
Netherlands, which was discussed earlier, that reintegration activities should take place as
soon as possible, i.e., from day one of being incapacitated for work.
Disability Management: procedure
In Disability Management the focus is on returning to work as soon as possible. The first step in this approach, therefore, is to find or create a temporary workplace where the disabled employee can return to work as early as possible. The underlying assumption is that the disabled worker will carry out other work activities during the time between falling ill and – if possible – 100% recovery. Within the context of Disability Management policy-making, this specific type of early intervention is called “transitio- nal work”. Transitional work is started after an average of two weeks following the first day of illness.
Transitional work is designed to support the capacity for work, for example by pro- viding relevant training. It is a provisional measure and it has a hierarchy of work activi- ties in which the focus is on realizing a gradual transition to former work activities within the possibilities which the disabled worker has currently available. Transitional work can be said to exist when several preconditions have been met. Firstly, a thorough assessment should be made to establish both possibilities and impossibilities and the – potential – capacities of the worker involved. Next, job strain, job content and job requirements must be known for a great number of positions in order to realize optimum matching between job and individual. In addition, however, alternative positions may also be deve- loped, knowing their job strain, job content and job requirements. This should be follo- wed by regular monitoring in order to establish any health improvements that have occurred and to readjust work activities to newly developed conditions in order to rea- lize a gradual return to the old position [2].
Several studies have shown that beginning to work or resuming work is one of the major factors to improve health. In this respect, the function of transitional work is two- fold. On the one hand, the disabled worker is productive and, on the other hand, his/her recovery is facilitated [2].
In order to get this DM policy started in an organisation, reintegration policies within
the organisation should be arranged and coordinated with the requirements of swift
interventions. The first step to introduce a DM policy is to appoint a DM committee
which will focus particularly on early intervention by using transitional work. Both
employees and other interested parties will be on the committee. The DM committee will
closely cooperate with both the medical officer and the immediate superior of the disa-
bled worker. In addition, the DM committee also maintains relations with the other
actors who have a role to play in early reintegration (family physician, medical specialists,
etc.). The main focus will be on the disabled worker, who is invited to participate in all
activities undertaken by the DM committee. In most cases the employee is contacted
within two weeks after falling ill at most. Employees are invited to have an exploratory
interview in which the employee and, possibly, his or her superior can participate in dra-
wing up a first plan of action. In all cases, the plan is submitted to the medical officer,
who will need to give his permission to go through with it. If the medical officer feels that
the agreed transition work does not present any medical problems to the employee invol-
ved, then action can be taken to have it realized.
Thus, Disability Management distinguishes itself from existing reintegration policies by emphasizing – remaining – employee capabilities as well as the collaboration and commitment of the parties involved in order to provide custom-made solutions and to facilitate an early return.
Disability Management: preconditions
Early intervention activities such as those taking place within the context of a Disability Management programme have a chance of success only if the activities are embedded in organisational policy-making and if several specific organisational principles have been met [2].
In the first place, the DM policy principles should be supported throughout the organisation. All the groups that are part of the organisation should take their own res- ponsibilities, based on the same DM philosophy. Thus, this philosophy or approach should be adopted by both higher and middle management, staff support departments (personnel department, Occupational Safety and Health Service) and the workers themselves. Secondly, it is necessary to appoint a Disability Management coordinator who will ensure the collaboration and support of all the parties involved when a worker is in the process of resuming work. Finally, monitoring and assessment are important methods in reintegration policies as they provide some idea of the costs and benefits involved in reintegration. Apart from these three elements, what is also needed is moti- vation, commitment and flexibility on the part of both workers and managerial staff.
Employees should accept that their daily work activities may be changed temporarily while managerial staff should actively think along about alternative work activities which, perhaps temporarily, can be performed by the worker involved. At company level there must be flexibility, for example, in offering flexible working hours, lenient atten- dance requirements (e.g. teleworking), custom-made positions and tasks and the possi- bility to create new – temporary – positions.
All these things are then laid down in detailed protocols. After all, they can be incor- porated into the company structure only if all the processes, activities and responsibili- ties are formally laid down in writing. A natural consequence will be that agreements are formalised and that employees make themselves familiar with reintegration.
There is great variation in the implementation of Disability Management pro- grammes. In all cases, however, Disability Management is an inseparable part of the orga- nisation’s HRM policy, either as an addition to the existing programme or as an overall concept for reintegration policy-making [1].
Companies which have drawn up these programmes have achieved considerable cost
reductions while at the same time improving the position and commitment of their wor-
kers – both with and without disabilities [2].
Vocational rehabilitation
Vocational rehabilitation: principles
In a great number of cases, disabled workers have not yet developed relations with an employer or their relation has ceased to exist. These cases include:
Youth who, as a result of congenital or acquired disabilities, are faced with a very high threshold to enter the labour market. Mostly, they are youth with very severe physical or mental handicaps.
Previously employed or self-employed workers who, as a result of disease or disabi- lity, have been unable to work for a long time and who have lost their capacity to earn an income which they would have earned, in view of their training and experience, if they did not have their disabilities. In addition, their disease or disability has caused them to break off relations with their employer.
Both categories of disabled workers involve individuals who find themselves at a great distance from the labour market and who want to have a job again, with their disabili- ties. Typically, they mostly involve workers who have been disabled further still as a result of the social process of work incapacity. One of the effects of curative medical care has been that they tend to be strongly focused on their disabilities, i.e., what they are no lon- ger able to do, rather than on what is left of capabilities that can be developed. Even the opinions of insurance medical officers are based on limitations rather than possibilities.
Moreover, the social environment frequently is protective rather than encouraging resumption of work.
Not only the disabled worker and his environment feel trapped by obstacles and disa- bilities, the employer’s ideas, too, are framed in terms of impossibilities, additional super- vision, reduced productivity and increased absence risks. Even if studies have shown that these are highly exaggerated, preconceived ideas and stereotypes, this representation still reduces the probability of finding employment [3].
Thus, the vocational rehabilitation process can be characterized as a combination of activities aimed at:
The worker personally. In view of the preceding disabling process it is necessary to help the worker to boost both his or her confidence and self-direction (empowerment).
Achieving the best possible match between job and individual, using training, educa- tion and work adaptations.
Linking disabilities to positions available at the labour market. In a number of cases, depending on the possibilities left, it may be practical to investigate regular positions, with or without special adaptations. Or, if this is not possible, it will be necessary to find a job in a pro- tected environment, perhaps even under permanent supervision (supported employment).
Activities focused on both the prospective employer and prospective colleagues which are designed to remove any prejudices and to create an adequate working envi- ronment that presents as few obstacles as possible [4].
The objective of vocational rehabilitation can be characterized as follows. Based on
an assessment of the capabilities of potential trainees, training and support activities are
initiated which should result in improved opportunities in the labour market and which should lead to increased individual effectiveness in finding more adequate ways of dealing with the social and individual problems which persons suffering from disabilities may have to face [5].
Vocational rehabilitation: procedure
In order to realize a successful reintegration path, even if it has a difficult target popula- tion, it is based on a process model of labour integration (Fig. 1).
Assessment
Reintegration plan
Training and Education Coaching and support
Employment introduction
Placement and follow-up
Fig. 1 – Process model of labour integration [6].
The process model of labour integration entails all those activities which are designed to analyse the starting position of disabled workers and to use this analysis as a basis for developing a custom-made plan of reintegration and mediation.
The first phase in this process is a comprehensive assessment to investigate the indi- vidual’s possibilities. Next, these qualities or characteristics are compared with the demands made by employment. In doing so it is necessary to take as a starting-point the remaining capacities and the possibilities that have developing potential (potential capa- cities) rather than the disabilities that are currently present. It is on the basis of this assessment that a personal route plan is developed, taking into account work-related social and professional skills. More specifically, the disabled workers will be taught skills that are required in order to deal adequately with both their social environment and their work situation, if the latter exists. Finally, the workers will get support in terms of finding them employment in order to apply the knowledge and skills acquired.
In cases where it is impossible to find regular employment and the worker is forced to rely on permanent support then the method of supported employment is applied. The aim of this method, which is used mainly to help individuals suffering from psychiatric disorders or mental disabilities, is to find the disabled worker a regular employment posi- tion in which the individual is trained and supported on the job.
The method of job coaching has five steps:
– To explore the wishes and capabilities of the individual involved (assessment).
– To find an appropriate employment position (job finding). This requires relevant
knowledge of the local labour market as well as a thorough understanding of positions
and work processes. Having good relations with an employer in this case is a prerequi-
site. Also, the job finder must be able to estimate the capabilities of the individual invol-
ved in relation to the positions available.
– To analyse job activities and workplace (job analysis). The coach must be able to analyse jobs in order to establish whether those jobs, with or without any special adapta- tions, are suitable for the disabled worker involved.
– To bring together job and individual (job matching) in order to realize the best pos- sible match between the individual’s capabilities and the requirements made by the job.
– To coach the worker on the job with the intention of achieving long-term place- ment (job coaching). This includes “training on the job”, i.e. teaching required knowledge and skills. In addition, it may also be one of the tasks of a job coach to educate the indi- vidual worker’s environment. Depending on the needs of both the disabled worker and the company involved, a long-term coaching plan is then developed.
The difference between the two methods described is found mainly in how they see relations with the employer and with the job. In the method described first, skills are ini- tially taught which are designed to minimize current limitations in a new job. In the second method, more active matching initially takes place between a person’s disabilities and job requirements.
Vocational rehabilitation: preconditions
The process of vocational rehabilitation cannot really be successful until a number of preconditions has been met. The first one is that the professionals who are expected to build the process are able to do this properly. This requires a thorough understanding of assessment methods: the professional must be able to make adequate estimates of an individual’s capabilities or else to gather the required knowledge through other agencies.
Secondly, the professional must be able to motivate disabled workers (counselling skills), making sure that they will make a choice in relation to their capacity for work. It is also important that there is a growing understanding of how people can be motivated to start working again following a long invalidation process.
Thirdly, the professional involved must be able to coach disabled workers in making decisions about how they wish their capacity for work to be developed (counselling skills).
Finally, they should also allow for the specific problems involved. It is well-known that the total population of disabled workers is highly varied, both in terms of the nature of their disabilities and their social and demographic backgrounds. The implication is that different custom-made change strategies must be developed for the various target populations in order to bring them back to work. In addition to relevant knowledge about specific target groups, this also requires expertise in the disabilities caused by spe- cific diseases or handicaps.
The matching process
Reintegration as described here can be seen as a continuous matching process between
the employee and the job. The steps to be made can be found in Figure 2. It is possible
that the health status and the related disabilities can develop in a positive way (increase of health status through training), but also in a negative way (decrease in health status).
Therefore the model should be regarded as a continuous matching process.
Assessment
Function
Function analysis
Possibilities Function
demands Matching
No difference Little difference Large difference
Placement
Adjustments
Start again
Coaching/
guidance Person with a
disability
Fig. 2 – The matching process.
