Military intelligence

With the government finally putting vocational rehabilitation on its agenda, the battle to develop an efficient programme is under way. Could the armed forces' medical model be the answer? Ana Paula Nacif investigates

After years of struggle, vocational rehabilitation supporters have finally secured a prominent place on the government's agenda. But having a higher profile also means they will be under more pressure to come up with the goods.

Building Capacity for Work: A UK Framework for Vocational Rehabilitation was launched by the Department for Work and Pensions at the end of October, having had input from employers, the Trades Union Congress, the Confederation of British Industry, insurers, lawyers, healthcare professionals and the Local Government Association (PM, 4 November, p48).

The framework is not about quick results, nor does it come with an action-packed plan, but it does give key rehabilitation players a platform on which to push the agenda forward. A steering group will be set up to discuss major issues and manage the delivery of vocational rehabilitation, funds have been allocated to boost research, and guidelines will soon be published by the Health and Safety Executive, as well as the DWP, to help employers, doctors and other stakeholders play their part.

The main challenge facing insurers, employers and government bodies remains the same - finding a cost-effective way of delivering rehabilitation within a setting that would allow a greater number of people to benefit.

Armed forces

The armed forces has been successfully delivering rehabilitation for years. Its medical model operates a structured multi-layered system that joins up tiered rehabilitation provision using primary, secondary and tertiary care. This is delivered through a network of countrywide regional rehabilitation units, including the Defence Medical Rehabilitation Centre at Headley Court - the largest military centre for rehabilitation.

It has, under one roof, everything needed to make rehabilitation work - and fast. Military personnel recovering from illness, musculo-skeletal and neurological conditions are put through an intensive rehabilitation programme to get them back on duty as quickly as possible.

With a multidisciplinary team, first-class facilities and a can-do attitude, could the DMRC and the wider military rehabilitation service model offer insurers an insight into how to move rehabilitation from an ideal to reality?

Gordon Bosworth, medical services director for Quantum Managed Care, believes the military model could be transferred to the private sector, bringing benefits not only to insurers and employers but also to injured people trying to get back to work. "If the government and private companies need a concept to move rehabilitation forward, this is the place to start," he says.

The bedrock of the programme is exercise therapy group work which, apart from being cost-effective, helps keep patients motivated. "We have well-resourced group facilities. Having a positive environment is crucial to our philosophy and the exercise group dynamic makes people feel involved," explains Squadron Leader Jones. "Each patient has an individual treatment programme that provides the vehicle for delivery of vocational rehabilitation in conjunction with treatment delivered by other clinical staff. It is important to get patients into this group environment as early as possible to ensure they achieve optimum outcome and can return to military duties as quickly as possible."

The DMRC's 207 employees offer a comprehensive rehabilitation service for more than 2000 in-patients and 1500 out-patients per year. Facilities include five fully equipped gyms, a pool and the support of consultants in rheumatology, physiotherapy, occupational therapy, speech and language therapy, nursing, social work, psychological support, even a rehabilitation engineering workshop that produces more than 1500 orthotic products per year.

"Rehabilitation is not only physiotherapy or occupational therapy, it is a collective effort. When these disciplines come together, there is a far better chance of a positive outcome," Mr Bosworth points out.

Janet Reed, head of the social work department at the DMRC, which provides information on career development, legal matters and counselling, adds that having a support system in place is key for successful rehabilitation programmes. "Our job is to enhance the rehabilitation of patients. We help them find a way through and develop coping skills."

Replicating such a model in a non-military context could bring benefits for insurers, employers, government and employees. However, it would also demand a concerted effort among stakeholders, particularly in terms of funding and implementation. Mr Bosworth emphasises that a joined-up approach could help to create new market solutions for rehabilitation: "Most injured people want to have quality of life and get back to work. It is important the government and insurers work together to find ways of encouraging rehabilitation."

Feeling the benefit

The Association of British Insurers agrees it is important for employers and insurers to work in partnership but emphasises that businesses should get involved in devising, implementing and paying for rehabilitation programmes.

It says less than 8% of all employers' liability claimants receive rehabilitation - only 10% of those who would potentially benefit from it.

"The difficulty is that insurers work in a fault-based environment. By the time the fault is proven, it can be too late for rehabilitation," explains Paul Fegan, ABI head of liability. "If the government wants a bigger impact, it will have to deliver rehabilitation outside liability. In the meantime, the best thing we can do is speed up notification so insurers can make an offer of rehabilitation earlier."

Insurers are optimistic that the government's framework will fuel healthy discussions about vocational rehabilitation. "Insurers have been trying for four or five years to encourage the development of rehabilitation and at times we have felt alone," says Bob Rabbitts, technical claims manager at Allianz Cornhill. "At long last there seems to be a positive move towards joined-up government to assist the process."

Even though it seems the battle for recognition has been won, the war is far from over and stakeholders will have to work hard to keep the momentum going.

"We need to ensure that all interested parties are compelled to help drive this initiative forward," adds Mr Rabbitts, "with penalties for those who leave their heads in the sand; and financial incentives for those who adopt a positive attitude."

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