Early intervention with rehabilitation can cut the cost of sickness absence as well as insurance claims. Leigh Jackson asks whether new developments will kick start renewed interest and take up of services in the UK.
In theory, greater use of rehabilitation is a partial solution to the increasing cost of the UK's bodily injury claims, as well as its high economic bill for sickness absence. By facilitating the return of injured or unwell individuals to health and work, through early intervention, insurers can save money on claims, injured people get their lives back on track and employers improve staff productivity and retention.
However, the use of rehabilitation in the UK has historically been beset by a lack of evidence over its cost benefit, an absence of quality standards and a need to ensure that rehabilitation providers are suitably accredited.
Such issues are, of course, common to any industry in its relative infancy but they may have curbed enthusiasm for investment in and funding of rehabilitation. However, recent government and industry developments could serve to reinvigorate and renew demand for back-to-work schemes.
For example, last May, the UK Rehabilitation Council launched the country's inaugural set of standards for the provision of clinical and vocational rehabilitation — a development made possible by two sizeable government cash injections. This support has also enabled the UKRC to become a fully fledged membership body, with elected representatives to reflect the wide range of stakeholders the industry serves.
The end of this month (30 April) will also see the launch of a new UK code of practice — PAS 150 — for the delivery of rehabilitation services for all disabilities and health conditions; while the government's new 'fit note' scheme is expected to increase employer interest in working with partners to ensure staff absent through illness or injury are actively managed back into the workplace wherever possible.
On top of that, some commentators have predicted that the Ministry of Justice reforms for low-value injury claims arising from road traffic accidents, which also go live on 30 April, could engender a new spirit of speedy co-operation and focus on rehabilitation where appropriate.
With rehabilitation seemingly at a crossroads, will these latest developments spark renewed interest in its use? Swiss Re claims manager Alison McLean believes they will: "The recent developments are a step in the right direction towards creating enthusiasm and momentum by raising awareness of the health and social benefits of work and the role that rehabilitation can play in helping people to stay in or return to work.
"It is crucial that all stakeholders work together to maintain the momentum that has been created and keep rehabilitation as a key agenda item when there are many other potential competing issues and developments in the area of health and welfare."
Carole Chantler, medical relationship manager at law firm DWF and chair of the UK Case Management Society, welcomes the new measures but raises concerns around enforcement — especially with regard to PAS 150. "This will heighten awareness but who will police it? It will be an effective purchaser's and sales tool but it is only as good as the integrity of providers who use it." She adds: "Until it is regulated, this standard will not be able to be used to its fullest. PAS 150 is a useful tool but will need to be monitored."
Similar questions are raised by Argent Rehabilitation director Andrew Pemberton, who believes PAS 150 — like the UKRC standards — may suffer from a lack of universal application. "With PAS 150 we will have to wait and see but there is a plethora of standards out there the industry could adopt but hasn't done," he says.
Mr Pemberton urges insurers to do all they can to make the standards mandatory. He adds: "This is another standard that may apply across a broader sector but will providers jump up and take it on? If the purchasers dictate it, they will do."
Concerns have also been raised about the government's fit note scheme and its practical application, with employers potentially having difficulties accepting partially fit employees back into the fold. Mr Pemberton continues: "One issue is the 'may be fit' category. That will introduce a whole raft of problems because if someone turns up for work with a 'may be fit' note it is reasonable to assume they are a disabled employee — at least temporarily — and for me that introduces the Disability Discrimination Act into the equation. It will shift the burden to the employer and a lot of insurers are not adequately equipped to cope with that."
Melanie Summers, managing director of Chartis Medical and Rehabilitation, explains that her organisation will be working closely with companies to help manage the changes. "Some employers are nervous because, if someone is partially fit, they have to get them back into the workplace. They haven't really had to do that before, so we are trying to help employers in that respect."
British Association of Rehabilitation Companies chairman David Drew adds that the fit note could prove a crucial tool in fostering a return-to-work mentality in which rehabilitation providers can thrive: "Compensation has been around for a long time but there a number of cases where it is no longer appropriate and rehabilitation programmes could kick in and get people back to work. The fit note certainly encourages this."
However, it may be the introduction of the new process for low-value road traffic accident claims that has stirred the most interest for rehabilitation stakeholders. Under the rules, insurers will have just 15 days from notification to accept or deny liability in applicable fast-track cases.
Simon Margolis, chief executive of medico legal reporting company Premex, claims that the advent of the new rules could have unforeseen consequences. "There are a couple of schools of thought as to what impact the MoJ reforms may have," he explains. "The first is that it may have a negative impact on rehabilitation and the desire to consider it. Everything about the MoJ process is there to make it speedier and simpler to settle low-value claims. Consequently, all parties with a claimant representative are focused on the claim's lifecycle and meeting timescales, which could — unfortunately — disincentivise rehabilitation."
He adds: "The contrary view is that the reforms represent an opportunity to take a more holistic approach to settling claims — in particular, having a process where a claimant is receiving more than just money. The management of claims at this end of the market has become very commoditised and people are trying to settle claims sooner. The only way to make people consider rehabilitation is to put something in the rules."
There is a belief among some rehabilitation stakeholders that the MoJ reforms, if extended to employers' liability claims — as was originally proposed and consulted on — could have been fundamental to the heightened use of rehabilitation services in the UK. Plexus Law senior partner Tim Roberts says that further government intervention would be needed to create such a situation.
"The unions are more focused on the right to compensation than returning people to work, so it might take a change in government to create a fast-track in this area," he says. "It could create a process that would put the focus on rehabilitation immediately.
"What we need is the equivalent of an industry pre-litigation process, not a code or a protocol but a process. The process would drive brokers and insurers to use assistance more and drive claimant solicitors to think beyond compensation to actually getting people back to work."
So, how will rehabilitation fare in the immediate future? If it is indeed at a crossroads with these new developments, will there actually be increased use of it, as well as renewed enthusiasm? "I don't think anything significant is happening," claims Owen Gorman, director and co-owner of Delta Claims Services. "Rehabilitation companies are, once again, looking for someone else to derive solutions.
"They need to provide solutions themselves because government intervention will not add a great deal. Rehabilitation companies should not be reliant on the government and need to take a more robust approach."
QBE's rehabilitation manager Rosie Corless adds: "The MoJ reforms may raise awareness and put rehabilitation on the agenda — and that is no bad thing — but I am not sure about the other developments, especially PAS 150. I don't believe it goes far enough or will be capable of driving any real change in the market unless there is a route to redress."
Andrew Underwood, complex injury claims partner at law firm Keoghs, seems to share this view. "I don't think anything will change," he says. "If you want to look at reform, regulation around clinical case management would be a major step forward. They are influencing the value of claims rather than focusing on the rehabilitation outcome. Perhaps this is something the market should consider."
Despite recent developments and their potential to promote rehabilitation, many stakeholders seem to believe there is a long way to go before rehabilitation is used prevalently in the right way and in the most appropriate cases.
Focus on financials
Mr Gorman claims that the key to the optimum use of rehabilitation is to look at it purely as a cost benefit. "Companies involved in rehabilitation need to be more commercially aware," he says. "You are in business and the business requires you to look after the interests of the paying customers, which are predominately the insurers. This should be the true focus of rehabilitation and we need a real mind shift to get there."
David Bingham, chief executive of rehabilitation provider IPRS, also believes there should be more focus on the financial benefits of rehabilitation and urges employers to contribute to its cost. "There is evidence to show that rehabilitation works but the question insurers are still asking themselves is whether it is cost effective," he says. "This is where you have to look at the system and the stakeholders in getting someone back to work.
"If you can bring other people into the process — alongside the insurer — then you might have additional contributors. The employer should be asked for a contribution to take the pressure off the first party insurer."
In Mr Roberts' opinion, the key to making rehabilitation more effective is a joined-up and slick approach, where the benefits of getting people back to work could be accurately measured by all stakeholders. "Over the past 10 years, what has held rehabilitation back is that the industry hasn't really been good on process," he says. "How do you drive claims quickly into rehabilitation? This has been very haphazard from both an insurer's and lawyer's perspective.
"We need to have claims in a work flow model, driven from a claims management system into rehabilitation — that has been one of the single biggest blockers."
He concludes: "The whole process will shape a greater introduction of rehabilitation into the mainstream compensation process. Hopefully the next 10 years will be better than the mental block we have faced over the last 10, which indicates that there has been a broader failure of how rehabilitation has been used and measured."
First among equals
Experts ponder whether there is a 'rehabilitation first' mentality in the personal injury arena.
"I don't think we are there yet but that is what we would like to see insurers work towards. Rehabilitation has developed over the past 10 years. Back then, compensation meant just paying money but rehab processes, which have been made available through members of the BARC, have developed to such an extent that there is now a realistic alternative." David Drew, chairman, British Association of Rehabilitation Companies
"Developing a rehabilitation first mentality is about convincing people that there is an opportunity to consider it at an early stage. There are benefits to all stakeholders in doing that. Treating customers fairly is important from an insurer perspective and the use of rehabilitation can be a differentiator." Simon Margolis, chief executive, Premex
"Rehabilitation is still minor at the moment because brokers and the large insurers are risk adverse. But if we start to work through that we could end up with a position where some employment law firms seriously consider early rehabilitation". Tim Roberts, senior partner, Plexus Law
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