Clinical governance - The care factor

With insurers increasingly investing in rehabilitation and case management services, Edward Murray explores the issue of clinical governance and the practical difficulties of regulating this sector

Getting a room full of insurers to agree on anything is difficult but adding lawyers, case managers, medical practitioners and claimants into the mix makes things almost impossible. This is one of the problems currently facing the case management and rehabilitation industries. Most people, thankfully, agree that good case management and rehabilitation works to the benefit of all involved but deciding on how to deliver it, as well as its framework, has not been so easy.

The issue of rehabilitation and how to manage it most effectively has come to the fore during the past decade, although the principles behind it have been around for much longer. The NHS and its private sector cousin have long tried to implement high standards of clinical governance, ensuring a systematic approach is taken to providing, measuring and improving the level of care on offer to patients.

As part of this, rehabilitation and its management on a case-by-case basis is key; restoring patients to their former state before their accident or illness is at the heart of everything the rehabilitation industry is trying to do.

In addition, providing effective rehabilitation should ensure that the treatment patients receive delivers the best results possible, as well as it cutting down on the time people are ill. In turn, this should free up resources for other patients, get people back into work as quickly as possible and keep costs to a minimum.

This is not about a system that rushes people through their healthcare but about providing the most efficient healthcare possible, so that it delivers practical benefits for patients and helps insurers, hospitals or claimants avoid false economies.

However, despite this, the complexity of its practical implications makes rehabilitation difficult to implement effectively. Given that rehabilitation is still in its infancy in the UK, it is not surprising that there is no formal regulatory body to oversee it on a national basis or create a framework within which the entire industry should operate.

Richard Boothman, director at rehabilitation firm RTW Plus, comments: "In the UK, rehabilitation does not fit into the clinical governance framework in either the public or private sectors."

He adds that this is not because the theory behind the practice does not hold up but simply because the administrative framework has not yet been established.

This is something that many people are pushing for but, without standards, it is impossible to have a regulatory body to oversee the industry. Without an industry-wide regulatory body in place, it is difficult to create standards to which everyone must sign up to.

Nonetheless, considerable efforts are being made to remedy this and various bodies are trying to gel the rehabilitation and case management sectors into cohesive states of readiness. For example, the Vocational Rehabilitation Association states: "We have set up an education and training task group, as well as a standards task group comprising representatives from across the vocational rehabilitation sector, seeking to address the need for learning, training, qualifications and issue standards that meet the needs of the vocational rehabilitation sector".

However, the association is only made up of voluntary members and, while it can work towards creating benchmarks, it can do little to make sure members reach them and nothing to encourage non-members to do so.

The case management sector is also considering a similar initiative, with the Case Management Society UK providing industry standards that aim to provide a regulatory framework (see box below). Again, the solution is not perfect, but Helen Merfield, chief executive of Health and Case Management, believes it goes some way to making genuine improvements. "CMS UK has standards and guidelines for best practice, and it gets members to self audit," she says.

While this does not guarantee the returns people are making, she believes that those signing up are making a genuine effort to improve standards and differentiate themselves from other organisations in the market.

Mayor problem area

This is one of the major problems insurers face - they know that good case management and rehabilitation firms can deliver huge benefits to their clients in terms of their medical treatment and its results. Insurers also know that this, in turn, will keep their own costs down and improve customer satisfaction, but getting it wrong and putting clients in the hands of firms that are unable to deliver what they promise would destroy all of these benefits and more.

For insurers, the challenge is to find firms to work with that can demonstrate the service, skills and expertise they offer.

Rayne Ward, commercial client director at Medisure, explains: "It is exactly this sort of framework that insurers should seek evidence of when appointing a company or assessing if their existing provider is working to the highest standards. Users of case management or rehabilitation services need to set standards that can be evidenced, so they can be confident that providers are operating in the way that is expected and delivering a quality service."

David Bingham, managing director of rehabilitation firm IPRS, argues that, for rehabilitation providers, the true measure of professional standards comes from whether evidence-based medical practices have been adopted. "Evidence-based medicine focuses on patient outcomes, pulling together published information to feed into more prescriptive treatment protocols. As such, it has a patient's welfare at heart and involves working to agreed guidelines," he says.

However, there are several questions over solicitors' and insurers' ability to assess the case management and rehabilitation providers they use. Rachel Griffiths, spokeswoman for the Association of Mutual Insurers, comments: "Many solicitors and some insurers still have a limited understanding of the services available and whether they will meet the specific needs of their clients."

In the instance of an injured party, she says the roles of rehabilitator and case manager are ones of extreme trust, and the needs of the injured person should be the only priority. To that end, she believes it is vital that the criteria for selection of a rehabilitation provider is stringent.

As insurers become better acquainted with the rehabilitation industry and what it has to offer, they will also become more experienced at understanding their own requirements and assessing the firms that seek to provide for them.

Basil Nally, head of business development at Bupa Recover, believes much of the improvement that will be seen during the next few years will be driven by this knowledge. "In terms of standards, the market is beginning to dictate more of what is acceptable, and rehabilitation providers have to respond to that if they are going to be successful," he says.

Looking at the wider implications, firms will increasingly have to hit certain benchmarks if they want to succeed. "There might not be a regulatory framework in place but, increasingly, there is a market requirement that if you want to remain competitive and meet the needs of clients, then you have to deliver a service that meets certain standards," Mr Nally says.

One of the problems facing those seeking to introduce standards in both the case management and wider rehabilitation sectors is the amount of practices and disciplines that are involved. Rehabilitation is concerned with every aspect of medical care, and case managers have to know their way around these if they are to be effective.

However, for practitioners, each sector of the medical world has its own best practices in place and a particular body that oversees operations within that community. To create a framework that sits on top of all of these disparate bodies is a challenge and will take time.

Causing a headache

Spencer McCabe, manager of the Zurich medical management centre, accepts this is going to provide headaches in the future, but feels it is perhaps best to have the medical world taking up such a position rather than representatives from either the insurance or legal sectors.

He says: "The people best placed to police this would be from the medical sector. However, there are many different sectors of the medical profession involved, and each one has its own code of conduct and practice that they abide by."

Looking specifically at potential regulators of the case management sector, he continues: "If it was the Association of British Insurers, then that is one side of the litigious coin and maybe claimant solicitors would not take too kindly to that. So maybe those that provide case management are the best to police it."

Alongside the development of standards and industry bodies, it will be interesting to see how insurers choose to adapt. As many improve at assessing their own needs, there is a chance they will look to bring expertise in-house. If this is not done - through the organic creation of new departments - it is likely insurers will use their financial muscle to buy the skill sets they need.

This has already been seen with Norwich Union, which has purchased a whiplash treatment services firm - and others may well follow its lead. Ms Merfield comments: "I do not know if insurers will end up setting up their own in-house rehabilitation teams but many will buy ready-made solutions to direct their cases through. I would not be surprised if insurers do not look to buy either case management or treatment services."

However, if insurers decide to develop their operations in this area, they will need to get it right as quickly as possible.

Carole Chantler, medical relationship manager at Davies Lavery, concludes: "Getting it wrong is the last thing we want. If you have been through a traumatic experience and you are trying to get your life back on track, then you want to see the right person at the right time and not be passed from one to another."


The Vocational Rehabilitation Association's aims are:

- To promote the professional knowledge, attitudes and skills of people practising in the field of vocational rehabilitation;

- To provide a vehicle for the exchange of ideas and experience across the UK;

- To contribute towards the development of quality standards and training in vocational rehabilitation practice;

- To promote equal opportunities within the field of vocational rehabilitation;

- To increase awareness and recognition of vocational rehabilitation.


The Case Management Society UK has created standards that have two main functions. The main role is to provide a key reference point for all case managers - a measuring tool against which they may monitor the quality of their services and can be included in their terms of business, continuing professional development and curriculum vitae. As well as procedural responsibilities, they also outline the case manager's duty to develop the knowledge skills and behaviour necessary for good working practice.

The standards will also have a valuable role in helping those who may be unfamiliar with case management to understand the level and standard of service expected. CMS UK has no doubt that the publication of these standards will prove an important landmark in the delivery of case management. They will be essential reading for all people working within the fields of case management, as well as an invaluable resource to those who wish to ensure managers provide competent and appropriate services.

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