This qualitative study explored the views of people with MS, employers, and healthcare professionals on how best to integrate VR services for people with MS within NHS services. Offering VR support for people with MS in the NHS could have a positive impact on both employment and healthcare outcomes for people with MS.
The NHS was seen as a trustworthy organisation with trained professionals suitable to offer this support. In particular, the NHS could have a leading role in offering advice on MS and reasonable adjustments to employers. This support is particularly helpful for small to medium enterprises lacking access to occupational health services [25]. Unfortunately, pressure on current NHS services (e.g., lack of staff, long waiting lists) and approaches to healthcare (i.e., medical approach as opposed to biopsychosocial approach) can hamper the integration of VR services within the NHS.
The present study captured several barriers to implementing the intervention within the NHS, such as a lack of staff, skills to deliver specialist support, poor networks with external organisations, and lack of funding. These are common barriers previously found in the literature exploring how evidence-based interventions can be implemented in healthcare settings [26]. This study also identified potential enablers, such as using technology and upskilling staff to understand the interaction between health and work, to overcome some barriers to successful implementation.
Funding was a barrier to integrating the VR service with the NHS. VR interventions were seen as time-consuming and, therefore, expensive. Future randomised controlled trials exploring the effectiveness of VR should include health economic evaluations that adopt a health and social care perspective, thus providing valuable data to inform commissioning decisions [27]. The cost of VR, in real terms, may be offset by reductions in costs in other parts of the healthcare system (e.g., reductions in GP visits, psychological support services or antidepressant use due to poor mental health because of job loss) or from the wider social perspective (e.g., people in employment paying taxes, rather than dependent on state benefits).
There is evidence that work is good for physical and mental health, with unemployed people experiencing more psychological distress [14]. For people with MS, unemployment is associated with poorer cognitive and functional abilities and greater fatigue [16]. Therefore, a proactive approach to supporting people with MS to remain at work could directly impact health and wellbeing and, by extension, reduce NHS resource use.
Interventions with a stepped-care approach that offer resource-intense interventions only to those with complex needs could address some of the economic barriers to their integration within the NHS. A wide range of professionals could offer support such as signposting to resources and organisations and VR-trained therapists offering specialist support (e.g., disciplinary meetings, return to work after sick leave, etc.). This finding aligns with recent UK Government efforts to relieve pressure on hard-pressed NHS services. For example, legislative changes enable other healthcare professionals to certify fit notes (i.e., statement of fitness for work), thereby relieving pressure on GPs [28].
This study also explored how to inform people with MS about the availability of VR services at the time of diagnosis. This time was selected because most people with MS are not aware of what VR is and have not received such support [7, 29]. Offering only essential employment information tailored to the needs of the person with MS was seen as necessary so that people with MS realise, early in their journey, that having MS does not mean the end of their professional lives. This finding aligns with research on how to communicate MS diagnosis and how to share information at this critical point without burdening or overwhelming the person with MS [30]. Offering support with employment soon after diagnosis could expedite the return-to-work process after injury and reduce sickness absence and dependency on welfare benefits [10].
Participants suggested that secondary care was the most suitable setting to integrate the VR intervention, reporting that their interaction with primary care was usually limited to issues unrelated to their MS. Even in secondary care, the employment needs of people with MS are typically not identified early, in part because people may not be ready to receive support with employment at the point of diagnosis and because employment status is not routinely recorded as part of their usual care [6]. Additionally, there is a barrier of “expectation” when receiving support in secondary care. Most people attending these services do not expect NHS professionals to address the topic of employment. Services are structured around symptom management instead of adopting a preventative approach to address wider public health and socioeconomic problems such as job retention. Thus, to successfully implement VR within this healthcare setting, there would need to be a biopsychosocial approach to managing people with MS and a shared philosophy that views ‘work’ as a health outcome among the service providers [15].
Issues regarding the organisational structure of the NHS and links with external organisations were clearly illustrated in the interviews. There was a need for the VR service to cross healthcare and employment boundaries. Employers lack awareness about MS and its invisible symptoms and would benefit from advice to manage the needs of the employees with MS at work [7, 29]. Facilitating interaction between employers and VR therapists can help employers understand the implications of a diagnosis of MS at work and provide a platform for addressing their questions. Overcoming the barriers identified in this study requires significant organisational change and is essential to optimise the care that people with MS receive.
Links with other external organisations, such as charities working with people with MS (e.g., MS Society, MS Trust, etc.), can also improve the support people with MS receive. These national charities already offer resources and information to help people live well with MS, and individuals are naturally inclined to seek information on their websites. The role of the third sector in delivering public, social, and health services is growing [31]. Previous research has explored how charities can help deliver complex interventions, such as mental health support to hard-to-reach communities [32], and emotional support to help people with MS at the point of diagnosis [33]. To our knowledge, no research has explored how support with employment could be delivered through the charitable sector in the UK.
One limitation of this study was that most healthcare professionals included were OTs. The study could have benefited from including the views of other professionals, such as MS Nurses, Neurologists, Physiotherapists, and specialist occupational health teams within employer organisations. We could have also gained valuable insight by extending involvement beyond those ‘directly involved’ to those ‘passively involved’ [34], for example, by exploring the views of colleagues of employees with MS.
Nevertheless, for this study we used multiple recruitment methods, including social media, national MS charity groups, and personal contacts, allowed us to recruit a wide range of participants, including eight employers. Their views are particularly important given employers' critical role in supporting people with MS to remain at work. Another strength of this study is the theoretical underpinning of the analysis with the CFIR and intervention logic model, which allowed us to identify implementation barriers at the design stage as suggested by the MRC framework [17, 18]. CFIR has previously been used in research exploring integrating VR interventions within existing healthcare services [35].