A comprehensive study concludes that rehabilitation works and insurers should be looking at early intervention to help people back to work. Katie Puckett explains.

Rehabilitation is gathering more converts in the insurance industry daily, drawn by a persuasive series of studies showing dramatic improvements in claims costs and settlement periods.

The idea is that by targeting personal injury claimants early enough with a programme of care that addresses not only their medical needs but any psychological and social issues too, they’ll be back at work quicker and off an insurer’s hands.

To date, there has been a regular drip-feed of rehab reports from insurers including Norwich Union, AXA and AIG, ‘ ‘ announcing claims reductions of up to a third. But a more comprehensive picture of the evidence comes in a new report commissioned by the government. For anyone involved in the rehab debate it is essential reading.

Vocational rehabilitation: what works, for whom, and when? was compiled by three academics at the universities of Cardiff, Huddersfield, and Otago in New Zealand, and aimed to provide an independent review of all the scientific evidence to date.

If you’re looking for something to take to the beach, it is admittedly rather dry – more an academic appraisal of the evidence than a tub-thumping polemic. But there are some stand-out conclusions, and a clear message to government policymakers: “There is a good business case for vocational rehabilitation, and more evidence on cost benefits than for many health and social care areas.”

Insurers will find compelling evidence for their own calls for early intervention, a more work-focused approach from health professionals, and indirect support for the in-house services that insurers already offer to employers. More alarmingly, there’s also a call to action on vocational rehabilitation for mental illness. With claims rising fast and costing twice as much to settle, the authors warn that the situation is as serious as the problem of low back pain was in the 1980s.

To put the report in context, the authors took a very broad definition of vocational rehabilitation as “whatever helps someone with a health problem to stay at, return to and remain in work”.

They considered 450 different studies published between 2000 and 2007 from around the world that tested the effectiveness of different strategies. The review is concerned with what the authors term “common health problems” and injuries, such as, mild to moderate musculoskeletal, mental health and cardio-respiratory conditions. These account for two thirds of claims for sickness absence, long-term incapacity and ill-health retirement.

It contrasts vocational rehabilitation, which has a primary goal of improving people’s capability to work, with medical treatment, which focuses only on curing or relieving a patient’s illness.

“The NHS is very poor at providing physiological and psychological therapy. Employers and the private sector can come together to help people very significantly across the board, by picking up people early

Dudley Lusted, AXA

The take-home message of the report is that rehab works – there is a strong scientific basis for many aspects, particularly in cases of musculoskeletal injuries. Studies have found that between 60% and 80% of working age adults experience musculoskeletal symptoms at some point and, even though a minority seek treatment and only 10% describe it as a ‘limiting long-term illness’, this still represents a sizeable sample.

This is the most common cause of short- and long-term sickness absence in manual workers, and accounts for 20% of UK incapacity benefit claims. But the good news is that sufferers can be helped. The report presents strong evidence to show that a common set of approaches can help them return to and stay at work.

One of the report’s authors is Professor Kim Burton, at the Centre for Health and Social Care Research at the University of Huddersfield.

Burton says: “The message for insurers is that we found good evidence for the cost benefits of vocational rehabilitation. We want to get across that vocational rehabilitation isn’t just an expensive service or specialist treatment. It’s more like an idea, involving a stepped care approach.”

Burton backs up insurers’ own sentiments about the importance of early intervention: “Provide it early, do not wait until people have been off sick for months. The strong message must be that early intervention is what’s best and most cost effective. Doing something to help people back to work in the early stages doesn’t have to be complex or expensive.”

The evidence suggests that structured vocational rehabilitation is most effective between about six weeks and six months of sickness absence. After six months, programmes become more complex and must address social as well as clinical and occupational obstacles.

For insurers which have already read the report, this is one of the stand-out points. What struck a chord for Dudley Lusted, head of corporate healthcare development at AXA, was the author’s statement that vocational rehab is not necessarily a second-stage intervention.

“One of the problems general insurers in personal injury cases have is getting hold of people soon enough. If someone with a back problem goes to a physiotherapist, they show them some exercises and they might recover within a few days. Whereas if you leave it, they’re likely to deteriorate, and it can lead to the need to see a consultant orthopaedic surgeon.”

Convincing evidence

“There are a large number of people who don't, whether they've had an accident or whatever. A huge number of people are state dependent, and it's not good for them or the rest of society who are paying for it.

Lawrence Acaster, Norwich Union

Even though AXA has published its own research into the subject, Lusted welcomes the report’s drawing together of such a convincing body of evidence, and its attempt to draw the attention of policymakers to the current system’s shortcomings.

Lusted adds: “The NHS is very poor at providing physiological and psychological therapy. Employers and the private sector can come together to help people very significantly across the board, by picking up people early and dealing with it early.”

Another of the report’s key messages is that return-to-work should be a key outcome for any treatment. The authors say government policy should be directing healthcare professionals to consider this, as well as the control of symptoms and pathology. At present, it found there is strong evidence that general practitioners feel ill-equipped to tackle work issues, and lack training or time to do so.

Lusted complains that this is rarely a consideration when patients seek medical help. “I heard one example of a consultant who asked an employee to return after six weeks. The employee was better within four weeks, but the consultant’s got everyone coming in at six weeks because then he knows he won’t have to see them again.

“If he did it after four, three quarters of people feel better, but he might have to see some people again. It could save the employer time and the employee’s time, but it’s their own time they manage. This is a call to the profession.”

At Norwich Union, technical claims manager Lawrence Acaster welcomes the report’s message to government on the importance of such services.

“Rehab in general needs to have greater priority given to it by the government,” he says. “I can understand that when patients have severe conditions, they have to consider the physical element before the vocational element, but it should be on a holistic basis.

“Return to work can benefit society as a whole. There are a large number of people who don’t work, whether they’ve had an accident or another reason. A huge number of people are state dependent, and it’s not good for them or the rest of society who are paying for it.”

Where the report is less conclusive is in the fast-growing problem of mental illness. At any one time, it says, about a third of the working age population display symptoms such as fatigue, irritability or worry, and one sixth of them would be diagnosed with a mental illness.

“The strong message must be that early intervention is what's best and most cost effective. Doing something to help people back to work in the early stages doesn't have to be complex or expensive.

Kim Burton, University of Huddersfield

The most common problems are depression, anxiety and a combination of the two. Although only 6% seek medical help, mental health problems are now the most common reason for sickness absence in non-manual workers in the UK. One quarter of all UK sick certificates are for mental health problems. But the average time taken off is about twice as long as physical illnesses, so they account for 40% of total time reported.

Even though keeping sufferers in employment is a high priority for mental health services, there is little published evidence of the effectiveness of vocational rehabilitation to date.

Huddersfield University’s Burton says: “There’s a desperate need to do something about the occupational aspect of mental health. Stress is an ever-increasing problem and mental disorders in general seem to be an increasing cause of long-term incapacity. We need more research in these areas to find out how best we should be helping these people.

“Stress isn’t a clear-cut area and the evidence just isn’t there. There’s no absolute reason why the principles for rehabilitation from musculoskeletal problems shouldn't be applied to other disorders; they need to be tested to see if they may have similar effects.”

Mental health problems are a major challenge for vocational rehabilitation. The report describes an exponential increase in sickness absence and long-term incapacity, despite no evidence of significant change in the prevalence of mental illness itself. The spiralling costs to insurers due to mental health problems are unlikely to be stemmed by simply providing more medical interventions. The report adds: “Instead there needs to be a fundamental shift in healthcare and workplace thinking and management.”

This emphasis on the role of employers in creating an accommodating environment for people returning to work runs throughout the report. In fact, surprisingly, it found good evidence that employers’ own initiatives can be more successful in getting people back to work than healthcare – giving a boost to the in-house healthcare services insurers are now offering.

The authors believe that to make any real and lasting difference, work-focused treatment has to be combined with workplaces that can accommodate a stepped recovery programme – offering light duties or part-time work, for example, during a patient’s recovery.

“A lot of people can be helped simply by linking whatever healthcare is needed with an accommodating workplace,” says Burton. “It doesn’t have to cost, it could just be a matter of reorganising existing services. If insurers can find a way of aiding that by providing information and signposting, they can contribute quite a lot fairly easily.” IT

Superbugs drive PMI growth

Concerns over hospital cleanliness are thought to be behind continued growth in private medical insurance – even during a time of major investment in the NHS.
In its annual health check of the market, analyst Laing & Buisson found PMI growth for the second year running, with 12.3% of the population having held some form of cover in 2007.
The strongest growth was in corporate demand for traditional medical insurance, as employers seek to attract staff through lifestyle perks, and to reduce sickness absence. Individual policies continued to decline, to a low of just over 1 million at the end of 2007 from a peak of more than 1.4 million in 1996. But the pace slowed and several insurers noticed a pick-up in early 2008, leading to hopes that it will level off this year.
The number of people paying into cash plans grew significantly for the first time since 2000, at 3% year on year, to cover 2.9 million people – or 8.2% of the UK population. Again, this was driven by employer-paid plans, up 27% from a small base to reach 293,000 contributions.
The report’s author, economist Philip Blackburn, said that demand remained solid despite concrete improvements in the NHS.
“The industry has to be optimistic following two years of growth at a time when the UK’s public health service has undoubtedly improved, and economic growth has started to slow. After a period of massive investment, the NHS is highly unlikely to continue its rate of improvement going forward with smaller funding growth planned to meet rising healthcare expectations and needs.”
The private health sector was ideally placed to fill the gap, he added, and could offer many services across primary, secondary and long-term care that NHS budgets wouldn’t stretch to.
“Key will be the sector’s adaptability and ability to innovate to meet consumer demand in the future, by offering affordable products and promoting healthy lifestyle choices for customers,” he said.
PMI revenues grew more steeply in 2007, at 5.2%, after rates of 3.8% and 3.6% in 2006 and 2005, and claims costs grew just slightly, up 5.4%, leaving margins largely unchanged.
The number of subscribers to stand-alone dental care plans grew by 10% in 2007, following growth of 31% in the previous year. More than eight in 10 of these subscribed to a dental capitation plan. By the end of the year, an estimated 3.4 million people were covered by some form of separate dental plan, which is 5.5% of the population.
A separate survey of more than 1,000 people by private health provider Bupa found that hospital cleanliness was the most commonly given reason for buying medical insurance, cited by nearly three quarters of respondents. This is up 8% on last year – perhaps driven by newspaper headlines about superbugs and political campaigning on the issue.
It also indicated continued growth, with more than a third who would consider paying for an operation in the future, and 79% of those who had private medical insurance said they would recommend it to family and friends.