Working together

A recent advertisement for a car-servicing agent ran: 'Where do you take your teeth for a check-up? Don't you think your car deserves the same level of expert service? Come to XXX Autos.' They have a point. We might call it horses for courses.

Most of the time, people will go to the professional with the qualifications and experience to deal with the problem that faces them. Logical, you would think. But sometimes individuals are aware that the person or organisation chosen was not the one needed. Although they seemed to get the job done, we, as consumers, are not convinced they were the right specialist for the job.

There is also an expectation that individuals need to be their own expert in all sorts of areas ' including health ' because otherwise, they will not get the right treatment, let alone all the information about their condition. People are now better educated and perhaps due to this they have higher expectations of those into whose hands they place what is most dear to them: their health and, indeed, their life.

The perception that private is better than State has developed and under recent governments this has not been discouraged. The emphasis and the thinking are changing to the extent that we are now seeing NHS patients sent abroad for operations.

It is also becoming more difficult to qualify for State benefits, especially incapacity benefit. These benefits are by no means a hand-out. Couple that with the fact that when individuals make a claim on their insurance policy, the insurers have different criteria from those used for State benefits. This obviously leads to confusion for all involved.

GPs and consultants are not necessarily the experts in assessing whether someone is able to do a particular type of job. Neither do they have to know everything about absence management, or have an in-depth knowledge of rehabilitation. So it is with enormous relief that welfare reform may start taking some of this heavy burden off the primary carers, GPs and nurses. It may also relieve some of the pressure on the secondary carers who are the 'next step' from the GP, leaving them to get on with what they do best.

Assessing ill health

For years, the sick note was the arbiter of whether someone was too ill to work. It has been recognised for a long time, at least by insurers, that this was a less than satisfactory way of dealing with a sensitive or emotional issue. Diagnosis of a medical condition does not necessarily mean disability or incapacity. However, for many people the connection between illness and inability to work is strong.

It is worth looking at some examples which show that emotional reaction to illness often affects the individual's ability to go back to leading a normal life ' even when the condition itself has been treated.

A woman who had intermittent chest pain for years, mostly when she was active, thought little of it until a television programme set her thinking. A visit to her GP resulted in a referral to the hospital for tests but still did nothing to raise any fears, so she continued with normal daily activities, including work.

Fortunately, her husband had the foresight to extend his private medical insurance (PMI) cover (covering all expenses related to surgery) from his employer to cover his wife, so she got an appointment for the tests within a week. These revealed moderately severe, two-vessel coronary artery disease and came with a diagnosis of effort angina and ischaemic heart disease.

It was not until the cardiologist strongly recommended surgery that her fears began to be realised. The surgery took place shortly afterwards thanks to the PMI cover and it was a success. A normal recovery and speedy return to her usual activities was expected yet this woman is now virtually confined to her home due to anxiety about her heart, even though she admits to having no pain now.

Contrast this with a woman who worked on a production line and was diagnosed with three-vessel disease, she also had CABG and is now more active than she ever was.

What is the difference between the two? The former, while benefiting from her husband's PMI cover, did not have any form of income protection (IP) insurance, while the latter did. The benefit of IP cover is that the recipient receives support during the diagnosis, treatment and, most importantly, during the rehabilitation stages. This may not be the entire reason for the disparity in outcomes, but it is a major factor.

What tests or standards do people have to meet in order to be classed as unfit for work, or disabled, or incapacitated? How subjective, or otherwise, can this judgement be? The answer depends on who you ask.

The correct diagnosis

From a medical perspective, there will be any number of tests that will be undertaken to arrive at a diagnosis. Almost the worst thing a patient can hear is the phrase 'we have got to do some more tests,' but it is absolutely essential the correct diagnosis is made so the right treatment can be given, or a referral to the right specialist made. This is as it should be and is done for the welfare of the patient and with their best interests at heart.

Then, for the patient, there may be the angst associated with benefits ' State provision (or otherwise) ' for example statutory sick pay, short-term incapacity benefit, long-term incapacity benefit and disabled living allowance. To qualify for these, patients have to visit more doctors which only adds to the already considerable stress being suffered. There is a fine line between gathering lots of information about exactly what the disability is and how it may be limiting the person's activity, while not causing further anxiety and pressure.

In the IP business, we have become all too familiar with the all work test, activities of daily living (ADLs) and activities of daily work (ADWs). Although these are very creditable, they focus too much on disability. The emphasis is on people having to prove they meet the criteria for certain benefits, which can make it difficult even for the experts to determine the extent of the disability. This can become too much for all parties involved in the process.

Then we come to those money-chasing insurance companies. But is their sole objective to deny as many claims as possible? Surprisingly, it is not. What they want is to pay each and every genuine claim. But what is it that the insurance companies need to know that isn't evident from the period leading up to the point when a claim is made? It has taken a good number of years for the industry to realise that it is what potential claimants can do and not what they are unable to do that is important. The industry has learnt that claimants should be treated as individuals and not as medical problems to be treated and then left to their own devices.

Another painful lesson for the industry is that coercion does not get people on the road to any kind of recovery, or, from an employer's perspective, back to work. This approach merely exacerbates an already tense set of complex relationships and results in all parties getting into what can become a detrimental downward spiral that is difficult to break.

Insurers are also beginning to understand it is crucial to devote the right resources both to the individual and to their family. When someone feels they are being taken seriously and looked upon as a person, rather than a viable economic unit, the spiral can be broken and reversed.

It is true that all the agencies ' the State (primary carers and those who administer benefits) and insurance companies ' will require batteries of tests to be completed, but we are at last beginning to learn that we all have the same ultimate aim albeit coming from a different perspective.

Pilot projects

There are some big areas of overlap and it is these that are being explored, for example, local pilot projects between the Department of Work and Pensions and group income protection insurers have now been introduced.

Both the State and the insurance industry must be careful not to leave claimants out of this loop. Announcements such as the one made recently about the limitation of benefit payments to a period of three years for new claimants did nothing but cause confusion and anger and further statements did little to repair the damage.

The goal is to achieve clear, understandable and sensitive communication between all parties about what they are trying to achieve, as this will determine whether or not we make progress in this area.

This process of mutual understanding and co-operation has begun and there is plenty happening in the background. We must make sure it does not fall sick itself and use our best endeavours to ensure everyone is aware of what is happening and why.

You never know, everyone involved may actually find the effort is worth the final result.

Bob Bowskill is underwriting and affinities director, Sun Life Financial of Canada