As the need for rehabilitation continues to grow, Joy Reymond explains what the UK can learn from its international counterparts
When it comes to rehabilitation in the UK, we continue to do the things we know how to do, even though we realise that the best solution might lie somewhere else entirely.
One of the reasons for this is the lack of attention and funding rehabilitation has received over the past two decades. During the mid 80s, rehabilitation was a reasonably well-funded, integrated part of the health system, helping severely disabled people improve their functioning. But as the health system has become increasingly focused on services that provide more immediate outcomes, rehabilitation, with its more long-term and uncertain outcomes, lost favour and funding.
More recently, however, there are signs of a renewed enthusiasm for rehabilitation. This time, it is the insurance industry and the Government who are talking it up and they are pinning their hopes on rehabilitation as a financial panacea. Insurers are promoting rehabilitation as the cost-effective way of managing their disability claims, while the Government is pointing to rehabilitation as one of the keys to controlling employers' liability (EL) insurance costs.
Differences
This focus gives rehabilitation an opportunity to demonstrate its worth and the concern is that the UK has slipped behind our colleagues else-where in the world. But can we catch up? Australia and Canada are examples of countries whose approach to rehabilitation is well regarded both domestically and internationally, and who have made major strides in the management of sickness absence and workers' compensation. The differences between these countries and the UK are not so much to do with technological innovation or new ideas, but systemic differences - the systems of insurance and employer best practices.
The rehabilitation field in Australia and Canada has a very different landscape to the UK. The workers' compensation legislation in those countries has focused attention on workplace injuries and illnesses, many of which are only moderately disabling, and the direct financial impact on employers has meant that they are very motivated to find return to work solutions.
By contrast, rehabilitation in the UK tends to focus on helping individuals who have been severely injured or disabled through serious illnesses, and for many of these cases the focus will be on improving the individual's functioning rather than returning to the world of work.
Where there are funding arrangements these cases are likely to be covered under EL or personal injury insurance, neither of which has proactive claims management. Therefore, rehabilitation is rarely involved in the early stages of sickness absence, and by the time it does get involved, it's unlikely that the claimant can be helped to return to work.
In comparison, the Canadian and Australian rehabilitation providers have built considerable expertise in helping injured workers back to work. Even the long-term disabled, who are receiving benefits under various government programmes, receive vocational rehabilitation assistance.
Again financial incentives may be at work. The Australian government is particularly keen to help this latter group get back into the workforce, and has recently produced a cost-benefit analysis of their vocational rehabilitation interventions. The report, Cost Benefit Analysis of Rehabilitation Services Provided by CRS Australia, by the Institute for Research into International Competitiveness (IRIC), demonstrated impressive returns of between 20-1 and 30-1 for those with no active employer and who have been out of the workforce for a significant period of time.
Both Canada and Australia also have mandatory workers' compensation programmes, which ensure that all employers are motivated to manage employee absence. Employers pay substantial amounts in workers' compensation insurance premiums - typically $1-3 per $100 of payroll - and are required to report occupational sickness and injury within a few days. These and similar requirements ensure that employers are paying attention, and are motivated to find solutions to worker absence, if only to keep their premiums under control.
In addition, both parties are obligated to mitigate the losses arising from an employee's absence. In Australia for example, employers are obliged to provide suitable duties where reasonable and to explore these with the employee, while the employee is obliged to comply with these reasonable offers. There are significant financial penalties for non-participation on either side. By contrast, there is no such burden on the UK employer, if an employee goes off sick, at best, there will be some absence tracking and some informal interaction with the employee to gauge the reason for the absence. Statutory sick pay (SSP), together with a discretionary employer top-up, kick in for the next 28 weeks. By the time it becomes evident that the absence is likely to be a long-term problem, it is often too late to fix it.
In order to address the often complex HR and industrial relations issues, both Australia and Canada encourage employers to get actively involved in vocational rehabilitation. Larger employers have an on-site return to work (RTW) co-ordinator while smaller employers, usually less than 20 employees, may use the services of an external rehabilitation provider.
In either case the co-ordinator must be trained and certified, so that the employer may rely on their advice and guidance. In the state of New South Wales in Australia, this involves a two-day training course, which the workers' compensation department, Workcover, authorises. Typically this training is paid for either by the employer or the insurer, and is provided by certified, accredited rehabilitation trainers.
The idea is to get the employer and employee actively involved in finding their own solutions. Employers may hire disability management co-ordinators on staff, or they may obtain advice from independent rehabilitation providers. In either case the purpose is to ensure that the right absence management structures are in place, and to assist the employer to manage employee absence themselves.
Entitlement
With clear financial incentives and consequences, employers have been willing to invest in rehabilitation programmes to manage these risks. As a result, both countries have built a core of rehabilitation expertise, which emphasises active absence management in the workplace.
Although they have much to recommend them, these systems also have flaws. For instance, in both Australia and Canada, non-work-related injuries and illnesses receive very little attention and are generally not actively managed. Secondly, many employees view sickness absence as an entitlement. For example, employees are entitled under their employment contract to a substantial number of sick leave days each year. These provisions can be accumulated year on year; giving people the impression that sick leave is an entitlement similar to vacation pay.
Of course, incentives are an imperfect tool and do not always work. The less proactive employers often only begin to pay attention when there is already a significant financial penalty.
The Australian and Canadian rehabilitation systems have taken many years to develop, and by learning from them we could accelerate the process in the UK. In the absence of the significant funding provided by workers' compensation premiums, and in the absence of financial and legal consequences for people and companies who do not comply, how likely is it that these approaches would be adopted in the UK market?
There are no signs of legislative changes to drive this process. Employers are rarely penalised for failing to manage absence appropriately, so it's unlikely that any threats of penalty would motivate them to change. However, there has been a growing awareness among employers that a lot of money is being spent on short-term absence. Employees frequently receive full pay, not just SSP, during the first 28 weeks of absence, and each non-trivial absence can therefore cost many thousands of pounds. Employers might therefore be persuaded for financial reasons to adopt the proactive Australian and Canadian approach, and employ certified RTW co-ordinators to actively manage absence due to illness and injury, with the support of rehabilitation consultants.
If rehabilitation is to grow and develop in this country, there is a need to be able to analyse absence costs more persuasively and show how they are linked to inadequate absence management. It is here the Australian and Canadian models can help, but they will need to be modified to UK circumstances.
If employers buy in to the need for better absence management, we will need to ensure we have enough rehabilitation expertise to support them. If we adopt the model of an onsite RTW co-ordinator doing the day-to-day co-ordination of return to work plans, we will need to greatly expand the training opportunities to build an army of such RTW co-ordinators.
The rehabilitation field has never looked more promising or more daunting. Since there is no legislative imperative for a new kind of rehabilitation, any move in this direction will depend on the providers being able to convince employers to look at more active absence management techniques. We have an opportunity to deliver on the promise of rehabilitation, but there is also the possibility that the opportunity will be lost and we will continue to look for answers in the same old places.
Joy Reymond is head of rehabilitation services at UnumProvident
