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Letter - Vocational rehab finds it hard to fit in

Published 26/09/2008

I read with great interest the recent piece by Matthew Beard of Medicess, the response from Ian Fulton of Proclaim and last week’s article on the Ugly Duckling. This is a debate that highlights exactly the dilemma facing UK insurers and explains why there is such a wide range of services falling under the ‘rehabilitation’ banner.

I would like to add further to the debate and pose the question: “Where does vocational rehabilitation fit into this process?” There is very little mention in any of these pieces about vocational rehabilitation. Why it is that virtually all of the largest rehabilitation case management providers in the UK have a real imbalance between medical and vocational case managers? Yet the reason a case is referred to a provider is to try to make sure that the claimant goes back to work. This is what makes rehabilitation a win-win opportunity for both claimant and defendant alike.

Therefore, I would suggest that much greater consideration is given to, and use made of, highly trained and experienced vocational rehabilitation consultants. Those consultants trained and working to the standards and satisfying the professional membership requirements of the Vocational Rehabilitation Association would be the most appropriate way to choose a provider.

Rehabilitation in the UK is very much funded by insurers. For them to continue funding in future, the rehabilitation industry needs to satisfy the needs of the insurer about its effectiveness. To do that, rehabilitation providers must return a much higher percentage of claimants to employment so that insurers might obtain a positive cost benefit. The insurers would also, I’m sure, prefer to see more providers offering fixed-rate, outcome-focused services.

Medical or clinical intervention will not achieve this in the high-value, high-profile cases that are of most concern to insurers. High-value claims generally involve people whose condition is deteriorating or has plateaued. Further medical intervention is unlikely to improve matters. At this stage, court dates are fast approaching and lots of money is being spent on CBT or similar therapies, which increases case management and settlement costs.

I do not subscribe to the view that doctors will inherently do a better job of case management than highly trained nurses or occupational therapists. Nor do I take the view that case managers are less capable of facilitating appropriate treatment. I do, however, believe they do not always make full use of the options available to them and spend too much time and insurers’ money seeking purely medical solutions to issues that are much greater than might be expected as a result of the original injury or health condition.

It is clear from evidence of other countries that the medical model of rehabilitation at the very least leaves a lot to be desired. While many providers purport to offer a biopsychosocial view of rehabilitation, it seems clear they do not always have the resources to actually provide this either in terms of staffing or geographical coverage.

Taking the example of a fractured tibia, if this injury was of a complex nature, it is at least equally likely that the reason this person will not return to work is related to the lack of focused and simultaneous vocational intervention as to any other reason. Medical goals are not necessarily vocationally appropriate. Medical case managers working at distance are unlikely to have the knowledge and experience of local employment conditions to ensure the client sets realistic vocational goals. Links with local employers can assist in facilitating work tasters or trials to ensure that recommendations are likely to achieve positive outcomes before the insurer needs to commit significant funding.

Many insurers do support invasive procedures that can compress the timeframes involved, but again this will not necessarily lead to the patient going back to work. On many occasions, private treatment is actually provided by the same NHS consultant through their private practice. However, private treatment dramatically increases the expense involved. Therefore, it is important that the rehabilitation provider ensures every possible support mechanism is put in place to take full advantage of the compressed timescales.

Waiting until medical treatment has been completed before giving consideration to vocational support is a recipe for disaster. Working closely with medical case managers from an early stage will provide better results.

Tom Cumming, Vocational rehabilitation service manager, Remploy.

This article has been reprinted with permission of the Claims Standards Council

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