Developing stroke-specific vocational rehabilitation: a soft systems analysis of current service provision

Figures & data

Table 1. The seven stages of SSM [17]: Identifying the problematic situation.

1. Identifying the problematic situation

2. Researching the situation and building a “rich picture”

3. Building “root definitions” using CATWOE

4. Developing a conceptual model of the change system

5. Comparing the model with the real-world situation

6. Defining the changes to be implemented

7. Taking action*

*The last phase is beyond the scope of this current investigation.

Table 2. SSM CATWOE mnemonic with example questions; adapted from Checkland and Scholes [18].

Label	Descriptor	Example question
Customers	Who are the beneficiaries of this system?	Where and how do stroke survivors enter the pathway?
Actors	Who facilitates the transformation?	Which people deliver VR? Who else within the service is involved in return to work issues?
Transformation	Changes occurring because of this service	What methods of communication exist within this service or between these related services?
Worldview	The context in which such transformations are deemed to be desirable	How are the services you provide marketed, researched and evaluated?
Ownership	To whom the service is answerable	Who commissions the service?
Environmental	Contextual factors relating to the service	Does/do the environment(s) present any problem/barrier to the organisation and delivery of the service or services which form part of this VR pathway?

Figure 1. Flow chart of mapping and qualitative procedure.

Figure 2. Map of services offering vocational advice or support to stroke survivors showing numbers of stroke survivors seen each year in one English county.

Table 3. Themes.

Lack of sanctioned  VR pathway	Informal mechanisms of communication
	Unmet need for young and/or mild  stroke survivors
Timeliness	Early, late and responsive care
	Length of intervention
Barriers to service  development	Insufficient evidence
	Knowledge gaps
	VR is not the core business of health

Table 4. Recommendations.

1. SSVR should be delivered by an integrated cross-sector multi-disciplinary team with significantly improved cross-service collaboration. The introduction of a SSVR case manager who can to bridge gaps between different services and sectors would ensure delivery.

2. Routine collection of work-related outcomes from stroke survivors is needed to inform business case development and local commissioning.

3. Joint or integrated commissioning between health and other sectors, e.g. DWP with CQUIN targets set to ensure work outcomes are recognised locally by health services.

4. Service providers should receive adequate VR and/or stroke specific training and guidance to meet the work needs of stroke survivors. Awareness of policy and best practice guidelines needs to be raised in all sectors.

Vestling M, Tufvesson B, Iwarsson S. Indicators for return to work after stroke and the importance of work for subjective well-being and life satisfaction. J Rehabil Med 2003;35:127–31

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Checkland P, Scholes J. Soft systems methodology in action. Chichester: John Wiley; 1999

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