Vocational rehabilitation for people with multiple sclerosis in the national health service of the United Kingdom: A realist evaluation

Background: There is limited evidence about how vocational rehabilitation (VR) for people with multiple sclerosis (MS) can be delivered through the United Kingdom’s (UK) National Health Service (NHS) and how it works. Aim: To understand the mechanisms and context for implementing a VR intervention for people with MS in the NHS and develop an explanatory programme theory. Methods: A realist evaluation, including a review of evidence followed by semi-structured interviews. A realist review about VR for people with MS in the NHS was conducted on six electronic databases (PubMed, MEDLINE, PsychINFO, Web of Science, CINAHL, and EMBASE) with secondary purposive searches. Included studies were assessed for relevance and rigour. Semi-structured interviews with people with MS, employers, and healthcare professionals, were conducted remotely. Data were extracted, analysed, and synthesised to refine the programme theory and produce a logic model. Results: Data from 13 studies, and 19 interviews (10 people with MS, five employers, and four healthcare professionals) contributed to producing the programme theory. The resulting programme theory explains the implementation of VR in the NHS for MS populations, uncovering the complex interplay between the healthcare and employment sectors to influence health and employment outcomes. VR programmes that offer timely support, tailored to the needs of the person with MS, and that support and empower the employee beyond the healthcare context are most likely associated with improved employment outcomes, for example, job retention. Conclusion: Embedding VR support within the NHS requires substantial cultural and organisational change (e.g., increased staff numbers, training, and awareness about the benefits of work). This study emphasises the need to routinely identify people with MS at risk of job loss and follow a collaborative approach to address employment issues. This realist evaluation provides insight on how to improve the quality of care available to people with MS.