Purpose and characteristics of vocational rehabilitation
The primary objective of vocational rehabilitation is to enable persons with a disability – whether caused by a disease or an accident – to hold a regular job position in a public or private company where they can work and interact with other employees who have no disability, with an employment contract that provides the same salary and professional rights as the other employees. Vocational rehabilitation is used in a wide range of disa- bling diseases, such as spinal cord injury, stroke, traumatic brain injury, arthritis, multiple sclerosis, congenital or orthopaedic difficulties, cumulative trauma or chronic pain disor- ders, developmental and learning disorders, mental disorders and occupational accidents and diseases.
Rehabilitation as a comprehensive medical speciality should be managed in active co- operation with the individuals affected, in order to enhance their personal, social and occupational integration. The ideal approach taken with disability policies should move toward the use of proactive actions rather than obsolete protective methods. For ins- tance, policies on rights (for residual abilities) versus compensation policies (payments, favourable discrimination for functional losses, financial benefits), training versus adap- tation, mutual benefits versus one-way benefits, self-assessment versus expert assess- ment, analysis of the person versus analysis of the disability, positive outlook versus nega- tive outlook, analysis on the basis of gender, race, ethnic origin, economic level, age, etc., versus analysis on the basis of handicaps and disabilities.
According to a survey on disabilities, impairments and health status [1] conducted by the Instituto Nacional de Estadística (INE, National Statistics Institute) of Spain in 1999, more than 3.5 million individuals in Spain have some degree of disability. This figure represents 9% of the population, with women accounting for more than half (58%) of all disabled persons in Spain. The same survey estimated that 25.8% of all individuals of working age (16 to 64 years) have some kind of disability. The problem clearly has far- reaching consequences for the economy, workforce and social health, and is causing gro- wing concern among the persons affected and those with political or professional A. Cuxart
responsibility in the field. For the first time, a collective effort to conduct an objective analysis of the problem and seek the best solutions is evident.
Legislative history
The history of vocational rehabilitation in Spain dates back to 1887 with the founding of the Asilo de Inválidos para el Trabajo (Handicapped Workers Asylum). In 1922 this orga- nisation became the Professional Work Re-education Institute for the Disabled, and in 1933 the National Re-education Institute for the Disabled. Its objective was to provide retraining and vocational re-education for disabled workers. Although the organisation has had various names and functions throughout its history, it still remains to the pre- sent day [2].
With the precedent set in Bismark’s Germany where labour laws were created in 1884, the Occupational Accident Act was passed in Spain in 1900 to protect persons disabled in their jobs. In 1903 the Regulation for certifying occupational disabilities was created.
This was followed by the Instituto Nacional de Previsión (INP, National Welfare Institute) in 1908, and the Retiro Obrero y el Plan de Seguros (Work Retirement and Insurance Plan) of the INP in 1919. These measures provided specific benefits such as indemnities, pen- sions, insurance, disability certification systems, etc., to individuals who had experienced an occupational accident.
Wars and conflicts in Europe, including World War I and II, led to the appearance of large numbers of war-related disabilities, and significant efforts were made in the field of rehabilitation, including the founding of the early rehabilitation services. This was parti- cularly evident after World War II. The goal of rehabilitation was physical and functional recovery of the patients and the possibility to return to work. In Spain, the first rehabili- tation service was created in 1933 under the name of Instituto de Rehabilitación del Inválido (Invalid Rehabilitation Institute).
In its Universal Declaration of Human Rights (1948), the United Nations (UN) devoted several of its articles to the disabled, stating that they have a right to work, social services, education and an adequate standard of living. In 1955 the U.N. approved an international rehabilitation programme for the physically disabled. In keeping with these guidelines, the Lucha Sanitaria Nacional contra la Invalidez (National Health Struggle against Disabilities) was founded in Spain in 1949 [3]. In 1961 an insurance programme was established for persons with occupational diseases or major disabilities, and for chil- dren who were orphaned as a result of occupational accidents or diseases. Since 1970 the disabled worker has been recognised and theoretically protected in the job market with a law establishing that 2% of all job positions in companies with 50 or more workers were to be reserved for disabled persons; incentives were provided for the Social Security pay- ments. However, the law was not actually implemented. The Labour Relations Act of 1976 established the special nature of jobs held by the disabled, but the administration regulated the centres providing protected work opportunities more for the subsidies they might receive than to satisfy their technical and staffing needs. No provisions were made
for personnel or for the technical, commercial and business assistance needed to carry out their activities. These places were occupational workshops rather than work centres.
The laws were founded on paternalistic, benefit-based concepts and were fragmented and biased to these ends. Moreover, the various ministry departments regulated their own areas of responsibility without relating to the other departments and without any overview of the problem as a whole.
The definitive change came when the Spanish Constitution [4] was passed by the Cortes on 31 October 1978 and ratified by the Spanish people in a referendum held on 6 December 1978. In one of the preamble sections, the Constitution states its intent to
“promote the progress of culture and of the economy to ensure a dignified quality of life for all.” Section III devotes two articles to the protection of the disabled:
– Article 41, in general terms, states that the public authorities are obliged to “main- tain a public Social Security system for all citizens guaranteeing adequate social assistance and benefits in situations of hardship”;
– Article 49, in more specific terms, indicates that “the public authorities shall carry out a policy of preventive care, treatment, rehabilitation and integration of the physically, sensorially and mentally handicapped by giving them the specialised care they require, and affording them special protection for the enjoyment of the rights granted by this Part to all citizens”.
The ratification of the Spanish Constitution also led to the restoration of the Autonomous Governments, starting with the historic autonomous areas (Catalonia, Basque Country and Galicia) and later extending this empowerment to the remaining regions of the country. This has involved a gradual transferral of powers for certain areas such as health, social affairs, transit, etc., as well as occasional differences in the applica- tion of some laws.
Based on Article 49 of the Spanish Constitution, the Social Integration Act of Disabled Persons (LISMI) was passed in 1982 to further advance the constitutional rights. This law was the first step toward addressing the assistance provided to the disa- bled in a specific, definite manner with a focus on rehabilitation and integration, and without paternalistic bias. In terms of management and funding, the Spanish govern- ment has undertaken an administrative reorganisation of its overall assistance plan for persons with a psychological, physical or sensory disability. Government funding for full assistance to the disabled is contemplated in the General Budgets of the Spanish govern- ment and in the budgets pertaining to the autonomous communities and local authori- ties.
The law regulates several occupational systems: 1) the system of regular jobs in both public and private companies, 2) protected jobs for individuals unable to work under the usual conditions, whether temporarily or permanently, and who will be employed at spe- cial job centres, and 3) occupational therapy centres not directly integrated in the job market, but offering an intermediate step for rejoining the work force in the event that the person has a temporary disability.
Two key documents have been issued since the LISMI was passed:
1. Plan of Emergency Measures for the Promotion of Employment for Disabled Persons, endorsed in 1996 by the Consejo Español de Representantes de Minusválidos (CERMI, Spanish Council of Representatives of the Disabled).
2. Action Plan for Individuals with a Disability for 1997-2000, drawn up and co-ordi- nated by the Instituto de Migraciones y Servicios Sociales (IMSERSO, Migration and Social Services Institute), approved by all the autonomous communities and social organiza- tions, and ratified by the Spanish government in 1996. This document contains the results from various previous reports written ten years after the LISMI was passed [5, 6]
and shows that there were still many gaps in the available assistance to this population, particularly with regard to rehabilitation, job creation, and implementation of a state policy for the prevention of disabilities. As a result of these previous reports, in 1991 the Ministry of Social Affairs agreed to prepare a preliminary Action Plan for Individuals with a Disability that was undertaken in December 1992 by IMSERSO. The plan has two key objectives: to achieve maximum autonomy and independence among this group, as well as greater, more active participation in the job market and in society. Its efforts focus on five areas: 1) the promotion of health and the prevention of disabilities; 2) full health care and rehabilitation; 3) integration in schools and special education; 4) participation and integration in the job market; and 5) community integration and an independent life [7]. The section on participation and integration in the job market discusses voca- tional rehabilitation, job creation and job protection policies. The priority objectives of the programme are to ensure that disabled persons have access to high-quality jobs and to promote a coherent support and adaptation system that guarantees their financial independence. This plan also addresses the need to promote transport, communication, architectural and urban accessibility as an essential factor in assisting disabled persons to join the work force and integrate in society. In this case, the IMSERSO and the Confederación Coordinadora Estatal de Minusválidos Físicos de España (COCEMFE, State Co-ordinator Confederation of the Physically Handicapped in Spain) and the Organización Nacional de Ciegos de España (ONCE, Spanish National Organisation of the Blind) have combined their efforts. The plan is funded by the General Budgets of the Spanish government, as well as by contributions from local corporations. In 1997, final budget allocations amounted to 5,984,393.76 euros (997 million old pesetas).
In November 2000, the Executive Committee of the CERMI approved “an employ- ment plan for persons with disabilities for the 21st century” which addresses the Plan of Emergency Measures on behalf of Employment for Disabled Persons of 1997, for the purposes of improving their working conditions in the early 21st century. An agreement between the Spanish government and the CERMI in 1997 has been completed and deve- loped almost in its entirety, although several major issues are still pending. These include, for instance, support for partially protected employment through working enclaves in ordinary companies, the DISCAP programme to promote extensive creation of jobs in standard working environments, and enhancement of CERMI’s participation in organi- sations that design and implement policies which affect the hiring and training of
individuals with a disability. This plan is part of a new socio-political context defined by several factors:
– new political context in Europe, resulting from the entry in force of the Treaty of Amsterdam, which contains a non-discrimination clause on behalf of the disabled (Art.
13), along with approval of an EU Council Directive to promote equal treatment in employment, and a European Strategy for Employment, whereby the common guide- lines on employment provide a general framework for co-ordinating the employment policies of the Member States;
– related to the above, a new plan of Structural Funds for 2000-2006 with major allo- cations of loans from the European Regional Development Fund (ERDF) and European Social Fund (ESF) to support training and employment programmes;
– improved job market for the general population in Spain;
– acceleration of social and technological changes in connection with the informa- tion society;
– consolidation and unification of the association movement with the creation of CERMIs in the autonomous communities;
– decentralisation of active job market policies, transferring them from the Instituto Nacional de Empleo (INEM, National Employment Institute) to the autonomous com- munities;
– growing role of the social stakeholders (labour unions and business organisations) in the management of continuous training.
General agreement signed by the ONCE and the government in 1999, whereby ONCE agrees to create 20,000 jobs and provide 40,000 training activities for disabled persons during 1999-2008.
One of the most important measures in promoting vocational integration is to encourage the creation of specialised services in the Public Employment Offices under the auspices of the INEM (or the autonomous communities, if such powers have been transferred). The provision of complete, high-quality services with vocational rehabilita- tion and counselling that targets the adaptation of job positions should be guaranteed in these services, an effort that requires co-operation with the IMSERSO and the respective organisations of each autonomous community [8].
Financial benefits
The financial benefits in Spain for sick leave and for disabilities due to occupational diseases or accidents are regulated by the General Social Security Act (LGSS) and are fur- ther advanced through the Social Security system itself and its collaborating entities (occupational accident and disease insurance programmes of the Social Security system) and the official agencies of the autonomous communities to which these powers have been transferred.
Occupational accident and disease insurance programmes of the Social Security are considered to be those that are duly authorised by the Ministry of Labour and Social
Affairs and which have been founded as non-profit organisations for this purpose. These programmes are regulated by Section 4 of the LGSS, with the Ministry of Labour and Social Affairs holding the authority for management and protection.
The joint collaboration with the Social Security system includes co-operative efforts to manage the contingencies related to occupational accidents and diseases, the perfor- mance of prevention activities, functional and professional recovery, and other efforts provided for in the LGSS, as well as co-operative efforts to manage the financial benefits for the occupationally disabled due to common contingencies. The benefits for which an employee is eligible in the event of an occupational accident or disease include the fol- lowing: a) medical and surgical treatment, pharmaceutical prescriptions, and in general any kind of diagnostic or therapeutic technique deemed medically necessary; b) ortho- paedic devices, prostheses, walking aids, wheelchairs, etc.; c) plastic surgery and surgical repairs; d) functional rehabilitation; e) vocational counselling and training for job rein- tegration; and f) therapy required for non-vocational recovery when the severity of the injury makes vocational recovery impossible [9].
There are two types of financial benefits: pensions for temporary disability or persons undergoing physiotherapy, and indemnities (e.g., lump-sum or pension, as applicable) when the worker has a non-disabling injury, or when a permanent disability (partial, total, absolute or major disability) has been certified.
In the event of sick leave taken because of an occupational accident or disease, the benefits are paid from the day after sick leave is started, and the employer is responsible for paying the full salary. When the sick leave is taken because of an ordinary illness or non-occupational accident, that is, incapacidad laboral transitoria (ILT, temporary work disability), the Social Security system pays the full benefits for a maximum period of 12 months, except for benefits provided for the 4th to 15th day, which are paid by the employer. These Social Security benefits can also be renewed for an additional 6 months.
In the case of pensions for permanent disability, there are two types of benefits:
contributory and non-contributory. A contributory benefit is the benefit received when the disabled worker has paid contributions to the Social Security system. For the contributory modality, a permanent disability is considered to exist when the worker has undergone the prescribed treatment and has received a medical discharge, but still retains severe anatomical or functional deficits that can be objectively assessed and are predicted to per- sist indefinitely, and that decrease or impede the person’s ability to work. A permanent disability is also considered to exist when the disability remains after the temporary disa- bility has ended upon completion of the maximum period of 18 months. Any permanent disability, regardless of cause, is classified as a function of the percent reduction of the individual’s capacity to work. This is assessed according to a list of diseases, approved by law, as follows: a) partial permanent disability; b) complete permanent disability; c) abso- lute permanent disability; and d) major disability.
The classification into different disability grades is determined as a function of the percent reduction in the legally established capacity to work, also taking into account the incidence of reduction in the capacity to work in the individual’s former profession. The financial benefit for partial permanent disability for the individual’s former profession consists in a lump sum and the right to return to work. The financial benefit for complete
permanent disability consists in a lifetime pension that can, as an exception, be replaced with a lump-sum indemnity if the beneficiary is under 60 years of age. If the beneficiary is likely to encounter difficulties for being hired in another vocation because of a lack of general or specialized training or because of the social situation and job market at his or her place of residence, the pension can be increased by the percentage set forth by law.
The financial benefit for absolute permanent disability consists in a lifetime pension. For major disability, a lifetime pension is awarded, along with a 50% increase for remunera- tion paid to the caregiver. If a person is classified as having a major disability and requires institutionalisation, this 50% increase is used to pay this kind of care [10].
Non-contributory benefits are understood to mean the pension received by a disabled worker who has never made payments to the Social Security system. These amounts are small. Persons eligible for the non-contributory modality are those over 18 years and under 65 years of age who have resided in Spain and for at least five years, who have insufficient income or no earnings, and who are affected by a disability or chronic disease classified as 65% or more.
Organisation and access to vocational rehabilitation
Generally speaking, individuals who have had a disease or accident that usually requires rehabilitation therapy account for 25% of all hospital admissions. A large percentage of these individuals should take part in vocational rehabilitation programmes because they are of working age. Nevertheless, the number of disabled individuals enrolled in voca- tional rehabilitation programmes is still low. The reasons for this situation include the
“subsidy culture” that still exists among many disabled persons and workers who have had an occupational accident, as well as the limited presence of multidisciplinary teams specialised in vocational rehabilitation within the public healthcare system for the various disabling conditions.
The concept of comprehensive, integrated rehabilitation goes beyond the scope of any specific sector, although partial vocational approaches and planning efforts between independent services with little co-ordination still have significant weight. The organisa- tion of, and access to vocational rehabilitation in Spain has been evolving in line with the legislative changes.
Rehabilitation efforts can fall under various ministries (Health, Education, Labour, Social Affairs). The responsibilities are divided between the central government and the autonomous communities, however. The basic problem lies in interconnecting hospital services for acute patients with other health resources (primary care, convalescent centres) and other structures that offer definitive rehabilitation, such as early care, spe- cial education, vocational rehabilitation and community integration. Despite progress in this area, much work remains to be done in order to achieve rehabilitation therapy pro- grammes with a holistic approach toward the patient and with special attention to main- taining continuous care.
In the case of occupational accidents and diseases, the patient is usually cared for at the occupational insurance hospitals and is then enrolled in the vocational retraining programme at the same hospital, while also participating in the rehabilitation therapy plan. This programme includes the social worker, the vocational counsellor and the representatives of the company where the injured person works, and often involves voca- tional re-adaptation or training courses if the employee must acquire a new profession.
Such an approach calls for the active co-operation and explicit interest of the injured per- son in rejoining the work force. At the time of hospital discharge, the patients undertake the vocational rehabilitation plan on an outpatient basis until they are able to return to the workplace.
For conditions not related to the person’s job, vocational reintegration is regulated by Spanish law through two legal standards, the LGSS and the LISMI, as detailed above in the section on legislative history.
Most disabled persons, regardless of the cause for their disability, are attended in the National Health Service acute hospitals and primary healthcare services by multidiscipli- nary rehabilitation teams responsible for prescribing the therapy plan and determining the indication for prostheses, orthopaedic devices, walking aids, wheelchairs, etc. This healthcare level has no multidisciplinary team for vocational assessment and counselling, and one of the difficulties is interlinking patient care at these levels with the various out- patient vocational assessment and counselling teams assigned to the care centres for the disabled. The vocational assessment and counselling teams are either in private organi- sations or within the public system, in which case they are included in the social services or, depending on the autonomous community, are under the auspices of the Department of Health and Social Affairs. Vocational training is provided on the basis of reports issued by the multidisciplinary teams and takes into consideration the previous training, exis- ting employment opportunities, motivation, aptitudes and preferences of the disabled person. Vocational training may include general preliminary training and may be taught at special centres or companies. When carried out at companies, a formal vocational training contract (internship) is required.
Vocational assessment and counselling teams in the public system are composed of a physician, psychologist and social worker. Assessment by this team can classify the disa- bled person as non-productive or productive, with the latter implying the possibility of an employment contract. For non-productive individuals, there are specialised care centres all over Spain for severely disabled persons that also provide healthcare services and there are occupational centres for moderately disabled persons that provide occupational the- rapy services. Catalonia also has occupational integration services for disabled persons who are eligible for the occupational centres or special work centres and who are awai- ting a vacancy.
In the productive category, including those with a mild disability who are capable of productive work, the approach taken is usually the open (ordinary) job market.
Additional measures include efforts to foster employment, for instance, subsidies, bonuses and fiscal measures for the employers (provided permanent employment contracts are signed), as well as mandatory measures in which certain companies (those employing over 50 workers) must reserve 2% of their jobs for the disabled. The job
integration services and the aided-work programmes are intended to promote hiring in the job market. These job integration services are teams that work within private organisa- tions, private endeavours and with government funding, and which have the goal of placing disabled persons in companies with ordinary jobs. In Spain these teams can be located on the premises of private organisations. In Catalonia the ECOM Federation has pioneered the creation of a job integration service network in conjunction with local organisations. These services are housed in public buildings (city halls, county boards), and the staff is composed of a job counsellor (psychologist), employment expert (labour law specialist), staff intern, job trainer, and administrative assistant. The aided-work pro- grammes, which fall under the auspices of the Labour Department, are involved prima- rily in the promotion of training courses, after which the disabled person can be hired by an ordinary company or by a specialized job centre. These centres represent another job opportunity for disabled persons classified as productive, i.e. those with a mild disability who are working. At least 70% of the workers in these companies are disabled persons.
The company receives 9,000 euros per disabled worker if 70% to 90% of the workforce is composed of disabled employees, and 12,000 euros if more than 90% are disabled.
Finally, Spain also has Centros de Recuperación de Minusválidos Físicos (CRMF, Recuperation Centres for the Physically Handicapped) that fall under the jurisdiction of the IMSERSO. Their main objective is to offer these physically and/or sensorially disa- bled persons of working age all the training and counselling they need to obtain employment. These centres teach vocational training courses in the fields of computer- aided design, jewellery, carpentry, electricity, book-binding, shoe repair, electronics, com- puter repair and data processing. IMSERSO has five CRMF centres in Albacete, San Fernando (Cádiz), Lardero (La Rioja), Salamanca and Madrid [11].
In short, although vocational rehabilitation in Spain has improved significantly in the last 25 years, there is still a need for further progress in various areas. Particular efforts must be made to co-ordinate the various assistance-providing services and enhance the National Health Service teams, within a political will to defend the public system. Such efforts do not produce optimum results in the short-term. The process is rather one of continued interaction that involves educational integration and promoting a competitive culture on the part of the disabled, a willingness to overcome prejudices on the part of employers (both public and private), removal of architectural barriers, transport and communication facilities for the disabled, and adaptation of job positions.
References
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