As the debate rages over whether rehabilitation works Katie Puckett visits a clinic to find out what it really involves.
Anyone making grand claims for a miracle cure-all is bound to be greeted with scepticism, and the ongoing argument over rehab is no different.
In this case, the ailment in question is insurers’ rising costs from personal injury or income protection claims. According to some, the remedy is to use specialist rehabilitation services to get claimants back to work as soon as possible. But others say that far from reducing costs, such treatments only increase them, as insurers throw money down a black hole of dubious therapies.
Both sides can produce the all-important numbers to back up their claims. AIG Europe conducted a review of 30,000 cases back in June 2004 and found claims costs dropped by 20% when rehabilitation was provided. Similarly, QBE reported that minor injury claims with rehabilitation were settled for a third less, on average. But Fortis found that for minor whiplash injuries, physiotherapy lengthened the average claim time from 259 to 275 days – and increased costs by £1,135 per claim.
AXA does not have any cost figures, but a pilot of 800 cases reviewed in August 2006 implied that cases where rehab was accepted had a better settlement rate – 35% had been settled within an average time of three months compared to just 10% of the control group. The research is ongoing – the University of Warwick will complete a trial on whiplash injuries for the NHS in November.
Firmly in the pro-corner is Aviva-owned Norwich Union (NU). In November 2006, it said a pilot rehabilitation centre had reduced the time taken to settle claims under £5,000 by two-thirds, and won a 90% approval rating from claimants. In the first year after it rolled out the approach nationwide, it found the physiotherapy programme saved the company £1.5m in treatment costs for 10,000 people. One of the companies used by NU and other insurers is RehabWorks, which is keen to promote its services to the industry.
It manages a rehabilitation centre for Royal Mail at its Mount Pleasant sorting office in London, a sprawling Victorian industrial and office complex that has as many basements as it does upper floors, where 5,000 postal service workers work shifts 24 hours a day.
The rehabilitation centre is on the second floor, down a warren of echoey, grey and turquoise painted corridors, next to the workers’ canteen. It’s a large room with the same dingy décor as the rest of the building, but kitted out with a mixture of gym equipment and hospital paraphernalia.
The entrance has a presentation area with a projector, and on one side there is a bank of computers for the staff. Bright art prints adorn every wall in an attempt to cheer up the fluorescent-lit drabness, and testimonials from former patients who’ve been treated successfully are pinned up around the perimeter.
Anitra Thomas, one of several physiotherapists, wearing a RehabWorks-branded polo shirt, says it is reassuring for patients to hear that they can get better. “Early on, people are sore and a bit doubtful. It’s better for them to hear it from other patients than just from us saying it,” she says.
RehabWorks runs a network of centres across the UK, including dedicated in-house services for Royal Mail, Sainsbury’s, Tesco, Honda and several police forces. Established in 1987 it now has more than 70 staff who treat 20,000 patients every year.
For insurance clients, that include Norwich Union, QBE, AXA and AIG, it also has private centres in Bury St Edmunds, Glasgow, Colchester and Basildon and an associate network of private physiotherapists.
The Mount Pleasant centre has an impressive record, and is the flagship centre for programmes helping long-term absent people return to work.
Over the four years it has been operating, 77% of workers on the programme have gone back to work within 12 weeks. The average time off by the time they’re referred to the Functional Restoration Programme (FRP) is 108 days.
Tom Ronan, RehabWorks’ London business development manager, won’t say how much the service costs the company, but he claims it gets a three-fold return on its investment.
The FRP is RehabWorks’ largest service. This is aimed at chronic musculoskeletal injuries – bone and muscle problems that refuse to heal and where medical intervention has already failed. According the ABI, such cases form just 20% of claims, but account for 80% of insurers’ costs.
The FRP takes what Ronan calls a biopsychosocial approach (BSP), which looks at the wider context of a patient’s failure to recover from an accident through conventional medicine. He says: “Most people with the same condition get better, and there’s not necessarily anything different about the injury. So you need to look at why they haven’t. The medical model is the issue, for someone with chronic problems there isn’t a single diagnosis. You can spend a lot of money sending someone for scans and not find anything. The BSP approach looks at what is stopping them from going back to work, reducing the need for experts, which is where the cost savings come in.”
Patients are referred to the FRP by their employers or insurers. They would typically be off work, on light duties due to injuries, or have recurrent absences. There’s an initial physical assessment and a structured interview about the history of their condition and their attitudes to it, and that’s turned into a quantitative assessment that can be benchmarked against later.
A functional assessment is carried out to measure the gap between their current condition and the fitness required for their job. In the Royal Mail centre there are dummy bags of letters for patients to lift; in the police centres there are bags of a similar shape and weight to people.
RehabWorks suggests several reasons why treatment may have failed so far. Patients are given yellow flags when there are psychological reasons – they might be fearful of repeating the injury and interpret pain from exercising as a signal not to move at all. They receive a combination of physiotherapy and education on their condition and the healing process so they get the most out of it.
The assessment also picks up anxieties about returning to work. People who don’t want to return to their jobs are given a blue flag. Black flags are given to those who are just seeking compensation. They are referred back to the employer or insurer as unsuitable for treatment. “We can help fix the yellow flags, influence the blue flags and highlight the black flags,” says Ronan.
Many patients have elements of two or more causes. There are also red flags for serious medical conditions that have not been picked up before, but these are rare – he estimates in 1%-5% of cases.
“If we can see people straight after the injury, we can get them straight into rehab rather than waiting for MRI scans. Often we see people who have had treatment that didnâ€™t work and you wish they had come in a year or two earlier
Anitra Thomas, RehabWorks
Thomas used to work for the NHS and says the psychosocial angle of RehabWorks treatment is a revelation. “It’s quite enlightening as a physio – you realise ‘so that’s why they didn’t all get better’. The vast majority of people don’t have a serious condition but they’re concerned that they do. It’s not that they don’t want to go back to work, they’re concerned that they can’t, or it will injure them. If they didn’t have something else affecting them, then they would have got better through normal physiotherapy.”
RehabWorks prepares a return-to-work plan for each patient which usually involves attending a centre one day a week for six to12 weeks. Then it reports back to the insurer with an estimated cost and waits for the go-ahead.
Thomas says about half of the cases she sees proceed with treatment. The programme includes exercise and physiotherapy but also education about their condition and sometimes psychological counselling too.
Ronan says: “Some people think they have to rest and are frightened of movement. We teach them about the biology of pain and pain management strategies. You could take painkillers and lie in bed or take them and use that relief from pain to move around.”
One of the intentions of the revised Rehabilitation Code launched last August is to encourage insurers to consider a claimant’s wider medical needs at the earliest opportunity, so they have the best chance of making a full recovery. Thomas backs this up: “Rehab is often seen as a last resort, in fact it should be the first resort.
“If we can see people straight after the injury, we can get them straight into rehab rather than waiting for MRI scans. Often we see people who have had treatment that didn’t work and you wish they had come in a year or two earlier,” she says.
Thomas is seeing more and more cases being referred earlier through lawyers and insurers, so perhaps the code is having some success.
The other service that RehabWorks provides to insurers is telephone triage, for recent acute injuries. Insurers refer claimants to the service immediately after an accident to assess their injuries and to give them information on recovery. “We tell them whiplash is like any other joint sprain, like spraining your neck,” says Ronan. “We’re trying to reduce fear and encourage movement. The key is early access to information.”
He says 60% of these cases don’t need any more than the telephone service. Others can be referred to one of its network of physiotherapists or a local functional restoration programme. The telephone service also screens for more serious conditions, such as instability in the neck, and callers are advised to go straight to hospital.
Another of RehabWorks’ insurance clients is a specialist HGV motor insurer, which Ronan says saw costs reduce by £2,500 per case for 32 cases over three months through the telephone service. “If you have early intervention, you don’t need to go for an MRI scan six weeks later, you can go straight into recovery.”
Specialist rehabilitation providers make much of the fact that they use only treatments that can be backed up with evidence, unlike other therapies offered by the private healthcare industry. Insurers have been justifiably wary about paying for physiotherapy in the past because it involved sending patients for endless sequences of massage treatments, for example, with little discernible result.
Thomas says that traditional physio techniques of massage, mobilisation and manipulation – the three Ms – work only in the short-term when cases are at the acute stage, and concentrate on symptoms rather than their causes. And on techniques involving ultrasound, lasers or electrotherapy, she is scathing. “It’s doubtful they have an effect, even in the short-term,” she says.
Ronan won’t quote costs for insurers as they are worked out on a case-by-case basis. For example, firms might agree to send 20 cases a month their way and each return-to-work plan will be costed individually. He says: “If you’re already paying someone £1,200 a month to stay at home, the cost of treatment with us is minimal compared to that.”
Another benefit for insurers is surely the ‘black flag’ fraud detection by-product, though Ronan plays this down and says there aren’t many cases where claimants are purely financially motivated. “It isn’t our goal to hunt out malingerers. We’re here to give them an opportunity to return to work. If they don’t comply, it’s up to the insurer to deal with that.”
One of the main reasons why the treatment sometimes fails – in 23% of Royal Mail cases for example – is because patients don’t comply with their treatment programmes. In insurance cases this can be made a condition of policies though. Ignoring treatment goals could be seen as failing to mitigate losses.
Success rates vary across different centres, according to Ronan and Thomas, and overall insurers will come somewhere in the middle of the table. In wealthier, better educated areas there is a higher success rate. For example, in Bury St Edmunds 88% of acute and simple cases recover and return to work in six weeks.
Centres linked to single companies, where all the patients are employed, have a higher rate than the programme it runs for incapacity benefit claimants for the Department for Work and Pensions (DWP) in Essex.
The DWP project is in its second year of operation and patients have been out of work for an average of 18 months, much longer than for the other centres. Nearly a third have returned to full time employment, and half have gone back to part-time or voluntary work.
There’s a chilling statistic about long-term benefit claimants that makes a powerful case for any intervention that might get people back to work. After two years living on benefits, claimants are more likely to die than ever go back to work.
For insurers trying to cut their claims bills, using rehab can make the difference not just in getting people back to work more quickly, but in giving long-term claimants a better chance at getting back to work at all.
Case study: Larry Bekoe
Until last August, Larry Bekoe worked in Royal Mail east London processing plant, opening bags of letters. Royal Mail regulations dictate that bags should filled to no more than 11kg, but there is no way of telling what is in one until it is lifted as 47-year-old Bekoe found out the hard way. I lifted a bag weighing 29kg-30kg and my back went. You freeze, you do not know what has happened. Then the ambulance came and took me to hospital.
Hours later, Bekoe was discharged in considerable pain and sent to see his GP. He was referred for an MRI scan and when the results eventually came through, he discovered he had a slipped disc. It takes ages if the doctor refers you, it takes months before every scan and meanwhile, you are suffering,Â he says.
After two months off work, Bekoe came back to light duties sitting down, sorting flat envelopes, with no bending: Even my grandma can do that.Â He started back on a four-hour day and built up to a full shift, but he is still on high dose painkillers and unable to do the overtime and nightshifts that used to supplement his income.
He is anxious to return to his old job and colleagues, not least because his is the only income in the family and he has three children to support, including his eldest at university. I need to get better because I have a mortgage. If you think about it too much, the pain gets worse,Â he adds.
Earlier this year, he began a 12-week functional restoration programme at the RehabWorks centre at Royal Mail Mount Pleasant complex, which he will complete next month. My goal is to get back to full fitness. It is little things you do with your children, you do not see. At first, I could not even put my own socks on. I wouldd say to my son, he is seven, help me put my socks on and I will give you 50p.
Bekoe comes to the centre one day a week at 9.30am, and stays until 4pm. After a warm up, he works out on two different exercise bikes, taking his pulse before and after, then a step machine, a rowing machine and some weights. It is hard work but he can now lift 5.5kg, and he has been measuring the improvement in his flexibility with satisfaction. Now I can bend and I know to sit down for a while, before I stand up. Before I came, I would be slouched in my chair, and when I went to get up, I could not get up. He has bought himself a bike and a stepper to use at home, and some second-hand weights.
The presentations and workshops have also helped. He says:It gives you an insight into your pain and what you can do to heal. At the start I was a bit apprehensive. I had been to physio before, but I was not doing much because I was a bit sore. Rehab is more disciplined and I can see an improvement. I want to get well - not working makes you feel lazy.Â