Road to recovery

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With limited rehabilitation available under the NHS, there has been major growth in private sector services. But access could be much improved, says Helen Merfield

Whether you've been ill or had an accident, the main focus during any recovery period has to be getting back on your feet and keeping a positive attitude. We are lucky in the UK to have the benefit of the NHS, which is first class for acute injuries and illnesses, staffed by dedicated professionals who do all they can to get you well as soon as possible. But, despite the scientific advancements, pioneering surgery and medical breakthroughs that have been a core element of the NHS' development, there is still one aspect that is vital to a speedy recovery that has been neglected – rehabilitation.

Vital element

Seeing the newspaper headlines, and hearing the Confederation of British Industry's president Sir John Egan describing the situation in the NHS as 'chaotic and poorly funded', it is easy to see why rehabilitation comes last in terms of providing care. The fact is that our NHS is overstretched and rehabilitation programmes are not a priority. The rights and wrongs of this policy decision are not for debate here, but it is enough to say that rehabilitation is now becoming the bastion of the private sector. That's not to say that the NHS does not supply any rehabilitation at all. But we are still a long way off the goal of an effective rehabilitation policy that could be rolled out across the country assuring or even guaranteeing the same level of service and benefits for all.

Historically the NHS has not embraced rehabilitation and more specifically 'return to work' – rather than 'return to home' as is the case now – as an outcome goal. As such it has cost itself and the wider UK economy dearly. Injured or sick people remain in the system for too long, waiting for investigations rather than receiving treatment at the optimal time, and developing secondary and unnecessary psychological problems brought on by extended absence from work and lack of adequate support.

To be fair, the Government is starting to take this issue more seriously. The Department for Work and Pensions (DWP) has set up the Job Retention & Rehabilitation Pilot (JRRP) in a bid to research the effectiveness of rehabilitation.

Accessibility

This initial study is not due to be concluded until 2006. However, figures are available from 60 years ago that show that out of 20,000 World War Two pilots admitted to RAF rehabilitation units between 1941 and 1945, 77% returned to full duty; 18% to modified duty and just 5% were invalided out of the service. Surely this gives an indication of what a properly structured rehabilitation approach can achieve, especially bearing in mind the injuries likely to have been involved.

This is not criticism of the excellent service that our health system, envied around the world, provides. However, it is an observation of a vital element that is missing and which would alleviate part of the strain on the system in the long run should it be implemented in the right way.

Treatments and accessibility vary dramatically across the country in the much reported 'postcode lottery' – especially when it comes to rehabilitation. Even in the private sector, where rehabilitation is being encouraged, it depends on your insurer whether you are offered rehabilitation or not. However, the good news is that both insurers and claimants' solicitors are really embracing rehabilitation and more people than ever are receiving better care and structured return to work programmes because of this. The number of private rehabilitation clinics and service providers has increased dramatically over the last five years, as have the number of companies offering case management services, which can only benefit the patients and claimants.

Of course, it is not only rehabilitation that affects people returning to work. As seen recently in the media, the issuing of sick notes by GPs is also a major concern to employers and insurers because of the detrimental effect on the economy. Research by Norwich Union Healthcare found that doctors believed that a quarter of the requests for a sick note were questionable, and nearly a fifth were invalid.

With GPs given a choice of either 'fully fit' or 'not fit for work' and with many of them having little or no idea what is involved in their patients' jobs, is it any wonder they err on the side of caution when issuing sick notes? Sadly many of those signed off would in fact benefit from returning to work on a graduated programme which, where necessary, incorporates some restricted duties as part of their ongoing rehabilitation and work reintegration plan. This is an area where case managers, both in the public and private sectors, can have a major impact in supporting employers and GPs in assisting those injured or too ill to return to work safely.

The private sector should be congratulated for its proactive stance on rehabilitation. Companies such as UnumProvident and AIG were among the first to fully embrace rehabilitation as part of their claims process. Many others have followed suit. It is interesting to note that a report by The International Underwriting Association of London (IUA) in June 2002 revealed that in this country, those insurers willing to share their internal research have typically reported savings of around 15% to 20%.

The support and medical assistance you are exposed to is obviously key. But the process of managing the wide array of different services and strands to the treatment available, not just within the NHS but within the social welfare system as well, can become a logistical nightmare for patients to navigate. Case management is a practice that goes the extra mile with the aim of ensuring you get what you need and when you need it – always with the patient at the centre of the process. This is however a relatively new concept in the UK and there is as yet no standardised and recognised qualification in this country for practitioners.

We can however learn a great deal from other countries both in Europe and further a field. Countries such as Australia, America, Canada and New Zealand, although administering a different system to that in the UK, have spent many years establishing best practice and cost effective solutions to the problems we are facing today.

There is no need to reinvent the wheel, when we can draw on tried and tested processes and utilise the best of the existing systems from around the world and adapt them to match the UK's unique needs. There is a lot that can be learnt from these countries in terms of legislation and techniques. Thankfully there is a growing consensus across the country that healing should not end when leaving the hospital, and that aftercare is as important as the immediate care. The UK needs a long-term rehabilitation programme that is accessible to all.

Universal standards

The changing consensus on rehabilitation is in part a result of shifting Government policy. In 1998, Health Secretary Frank Dobson launched a Labour Party health campaign by stating: "Where such permanent disability can be avoided, it is stupid not to avoid it. So I am determined to give rehabilitation high priority. This will call for a high level of co-operative effort from the clinicians and from therapists in both the NHS and social services. But it will be well worthwhile. It will help patients, help the economy and save money."

That was over five years ago and was one of the clearest signs that the Government was committed to developing rehabilitation in the UK. We still have a long way to go as much still needs to be achieved in this area.

It is interesting to see the NHS develop and sell their services as occupational therapists in the private sector. By adding occupational needs assessments and counselling, NHS trusts have increasingly sold their services into the private sector.

So it seems that even the NHS recognises the growing market of private rehabilitation and wants to be involved, further illustrating the need for continuing development in this area. At this time it would appear that the private sector is best placed to take rehabilitation forward and clearly demonstrate to the Government what can be achieved if structured, goal oriented, outcome focused and properly managed rehabilitation programmes are delivered on a cost effective basis.

What the future holds for the industry is yet to be fully determined, but with support from the Government and leading industry bodies, it seems rehabilitation is reaching the top of most agendas and is here to stay.

Key to the success of rehabilitation and case management in the UK is the ability to set universal standards of practice, which both public and private sectors must adhere to. We have a real opportunity here to set in place structures that raise the bar in delivering rehabilitation. We need early positive outcomes for patients by drastically improving quality of life and cost effective outcomes for all other stakeholders.

Working hand in hand in the future, the NHS and private sector could make a real difference to the health and wellbeing of the nation. The NHS should never shy away from using the private sector in the areas where it delivers the best solutions, which at this stage clearly includes rehabilitation. It needs to be a joint exercise and we have to ensure that a high standard is set across the board, avoiding at all costs the development of a two tier system. To achieve the full benefits for our society as a whole, the same quality of care should be available both privately and publicly, regardless of your postcode.

Helen Merfield is managing director of Health & Case Management Limited

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