November 2006
Welcome to the HCML monthly rehabilitation news bulletin for November 2006.
Our aim in this bulletin is to give you an overview of what is happening in rehabilitation, and what is contributing either to early returns to work after injury, or causing injuries and other conditions to last longer than they need to.
We welcome users’ comment or suggestions for new subject areas we might monitor. If you would like to know more about HCML please visit our site
No pain, no gain
Deciding how best to manage symptoms of whiplash pain continues to vex many claims managers and, as Andrew Pemberton explains, it is time the industry made an assessment of the treatment available
Three words tend to preoccupy the minds of claims managers - rehabilitation, physiotherapy and whiplash. With motor insurers spending in excess of £5m annually on physiotherapy or manipulative therapies - such as chiropractors and osteopaths - to manage symptoms of low-value whiplash pain, the question is: are they getting value for money?
Two issues that merit close examination are, firstly, whether patients are receiving the most effective evidence-based treatment and, secondly, whether insurance-funded services are adding cost and delay to the claims process. In order to evaluate current procedures, it is helpful to review the medical evidence available and compare this with current practices on the ground for the management of whiplash-associated disorders, then consider if there is a viable alternative.
At the moment, insurers and claimant solicitors commonly operate a rapid access one-size-fits-all physiotherapy service. Typically, the number of face-to-face sessions initially made available varies from four to eight, a service that not only costs hundreds of pounds but can also take six or more weeks to deliver. The inevitable consequence is delay in settling cases and questionable clinical effectiveness.
Treatment within therapy sessions is also not uniform, which is hardly surprising as physical therapy practitioners are diverse in that they encompass various professions operating different therapies and approaches. Many are self-employed, single-location practices operating their techniques, such as ultrasound, for which there is no clinical evidence of effectiveness.
Spinal manipulation
Other practitioners employ manipulation therapies, something that has also recently been challenged on the grounds of efficacy. For example, a systematic - albeit controversial - review of research of spinal manipulation by Professor Ernst of the Peninsula Medical School in April this year concluded: "Spinal manipulation is not an effective intervention for any condition."
The current range of services for WADs typically lacks evidence, consistency and flexibility. Accordingly, it begs the question whether insurers ought to focus on more clinically effective models rather than attempting to reduce costs on interventions of questionable merit.
There is strong clinical evidence indicating that WADs are, in the majority of cases, self-healing injuries; that is, people recover irrespective of whether they receive treatment or not. Evidence also suggests that whiplash pain is not synonymous with serious damage and, significantly, continuing with normal activities, including work, can assist recovery. Studies further demonstrate that fear of re-injury, movement and long-term harm are common - such beliefs impede recovery and are predictors of chronic problems.
Where rehabilitation interventions are applied to WADs, educational or behavioural approaches combined with self-help exercise have been found to be the most clinically and cost-effective solution. Managing someone's beliefs about their injury and providing support to encourage them to keep moving, as well as remaining calm despite any pain, are instrumental to recovery. So, is it necessary to provide six sessions of therapy to meet the requirements of care?
The effectiveness of cognitive behavioural therapy in WADs management has been convincingly established in acute and chronic stages. It has been touted as the single most evidenced psychotherapy technique; for example, it has been shown to be as effective as anti-depressant drugs in managing depression. However, its wide application and high clinical effectiveness have also resulted in it becoming scarce and relatively expensive. Treatment is brief, highly structured and outcome-focused, with individuals actively participating - patients are empowered to take control of their situation because a passive role is not permitted.
Moreover, since CBT is highly structured, it has innovative delivery methods. It is effective in face-to-face sessions (group or individual) and, more recently, via computer-based systems. Cognitive behavioural interventions have also been shown to be effective in the form of literature such as The Whiplash Book and The Heart Manual.
In fact, in February, the National Institute for Health and Clinical Excellence formally endorsed the use of computer-based systems for the delivery of CBT for the treatment of mild to moderate depression, panic disorders and phobias. These strategies are said to offer consistent, safe, clinically-effective interventions for common health problems. Importantly, they also reduce waiting times, are less expensive and offer enhanced levels of service to patients because treatment can be delivered directly at any time.
So how might CBT or a behavioural model be applied to the treatment of WADs? Professor Kim Burton, co-author of The Whiplash Book, suggests that a "stepped-care approach" would be best. "It makes little sense to give expensive care to everyone," he says. "It is preferable to give the minimum needed to everyone at the onset, ensuring that they receive positive information and advice, then to step-up the intervention if problems persist."
He adds: "From the outset, people should receive consistent biopsychosocial messages and not purely biomedical advice. If a therapist provides contradictory advice, then this becomes an obstacle to a person's recovery."
Negative reinforcement
Could this be what happens when claimants are referred to freelance physiotherapists? Could a referral for 'treatment' actually help reinforce a person's negative health beliefs? In addition, are insurers taking the advice of such clinicians on board?
David Frost, technical claims manager at Royal and Sun Alliance, believes his company has already adopted best practice principles by developing a range of services under its RSA Care proposition for those who suffer bodily injury, and that proportionate rehabilitation is a key component.
He comments. "To meet the various rehabilitation requirements that may be appropriate following a whiplash injury, we can introduce a range of different treatment streams. Our services range from the provision of an information booklet, self-help exercises on DVD, web-based physiotherapy and, if necessary, a full case management provision."
Many of the present services for whiplash may be flawed due to inconsistency and questions of clinical quality, so a cognitive behavioural, stepped approach to treatment that is evidence-based may be preferable. The indications are that computer-based CBT is a flexible, clinically effective technique offering consistent, cost-effective methods for the management of WADs. So insurers should make sure they review the clinical effectiveness of their whiplash management services rather than simply their cost.
Andrew Pemberton is the director of Human Focus Return to Work
NU acquires Rehabilitation UK
The insurer said the acquisition would support Norwich Union Healthcare (NUHC) and would extend its capability in occupational health and rehabilitation services. The case management service will be delivered by Norwich Union Occupational Health and Dr Martin Strudley, the founder of Rehabilitation UK, will become director of rehabilitation.
Tim Baker, commercial director at Norwich Union Healthcare, said: “NU has been working with Rehabilitation UK for a number of years. This move will allow us to utilise Rehabilitation UK’s expertise in the area of rehabilitation and work with their network of physiotherapists and psychological therapists to promote evidence-based approaches to support a wider variety of cases.” The case management company will streamline the referral and treatment process, shortening the overall claim life cycle and reducing costs.
Dr Martin Strudley, director of rehabilitation, NU Occupational Health, said the development of rehabilitation services within the private sector was providing crucial support the work of the NHS.
PTSD - Peace of mind
Psychological therapies are not only effective in treating post-traumatic stress disorder but are also considerably cheaper than the untreated alternative. Dr Wilson Carswell and Joanne Allan report
"What we don't know is more important than what we do know," are the words of wisdom attributed to US Defence Secretary Donald Rumsfeld - and the same could be true for insurers and post-traumatic stress disorder. What insurers do know about PTSD are the financial costs or quantum of damages.
Insurers can readily turn to the most recent, eighth edition of the Guidelines for the Assessment of General Damages in Personal Injury Cases, compiled for the Judicial Studies Board and published this September. The financial values used in this edition refer to June of this year (see figure 1), and range from £2300 for 'minor' PTSD cases to nearly £60,000 for severe PTSD claims or cases.
Underlying these figures, especially the higher ones, is the implication that PTSD will be permanently disabling and that treatment or resolution of symptoms is not a viable possibility. Therefore, these figures clearly encapsulate what insurers know about PTSD - that it exists, certainly in judicial circles, and that it can cost a lot of money.
Publications from the National Institute for Health and Clinical Excellence, however, are not usually part of insurers' preferred reading. This is unfortunate, as Nice has published guidelines for the management of PTSD - www.nice.org.uk - that are not only relevant to insurers but potentially valuable. Although these findings might not be widely known, they are exciting and positive.
Range of recommendations
The guidelines include a range of key recommendations. Firstly, they say that people suffering with PTSD, irrespective of its duration, should be offered treatment. Nice also recommends two trauma-focused therapies - cognitive behaviour therapy and eye movement desensitisation and reprocessing. Such treatment typically lasts for eight to 12 sessions, and should only be carried out by trained mental health practitioners. Finally, but important for insurers to note, is that Nice does not recommend counselling as it is not trauma-focused treatment and there is no evidence to support its use in effectively treating PTSD.
Both CBT and EMDR are specialised treatments, still with limited availability. It is also common for the general public and professionals to be confused as to the legitimacy of clinicians' training.
As a national psychological services provider, Moving Minds has conducted its own study into the effectiveness of CBT and EMDR, which resulted in findings similar to those made by Nice.
The study in question involved a consecutive series of 337 treated cases, with seven out of 10 clients who received CBT or EMDR improving or feeling completely relieved of their symptoms. This was achieved in an average of nine treatment sessions. The overall results of treatment, based on the subjective perception of improvement by clinician and client, were that 49% achieved recovery and the treatment was deemed successful; 23% reported that good progress was achieved; 22% saw some improvement; and only 6% made no improvement.
In addition to the clients' and clinicians' judgement on any improvements that took place, the success of psychological treatment can be measured objectively through psychometric tests. One widely used objective psychometric test is the Impact of Event Scale where scores greater than 26 - out of a maximum 75 - are considered indicative of significant emotional distress. The average score recorded at psychological assessment before treatment was 40 in the sample concerned. This score fell to an average of 14 (normal) by the end of treatment, indicating successful processing of the trauma symptoms.
The cost of treatment in these cases came in at an average of less than £2000, excluding VAT. This is considerably lower than what the quantum of damages table advises in terms of awards for even the most minor cases of untreated PTSD.
If insurers become more aware of the therapeutic and financial effectiveness of modern, focused-therapy for PTSD, they could save themselves many thousands of pounds annually. By not using psychological therapy, insurers are potentially missing out on some dramatic savings, ones that would go straight to the bottom line, as well as benefiting insurance claimants.
Workplace stress responsible for 25% of sickness absence
A quarter of sick days can be attributed to work-related stress, a survey by HR consultancy Ceridian showed.
The poll of 1,050 employees revealed respondents were absent for a total of 8,918 unscheduled days over the past 12 months, an average of 8.5 days per employee. Respondents said a quarter of all these days were down to work-related stress.
Based on the CBI's estimate that the cost of absence due to ill health was costing British business £13bn per year, Doug Sawers, managing director of Ceridian in the UK, said the cost of work-related stress could potentially be as high as £4.25bn. He said: "With just 1.4% of employees in our survey accounting for 89% of the 2,222 work-related stress days taken off, employers should concentrate on the small number of employees taking many days off and devote more time to exploring the causes of their employees' work-related stress and offering stress tips.
"Typical causes of work-related stress include workload, work responsibilities, work difficulty and manager style. Responsible employers need to explore what is contributing to work-related stress in their organisations and create strategies to address identified problems."
The survey showed six out of 10 companies had provided no advice on health or wellbeing in the past 12 months.
Rehabilitation – off on the right track
Rehabilitation is a hot topic in personal injury claims, but getting the right assessment can be a minefield. That’s why it’s important to have a good case management team.
For more information, visit the Independent Case Management Consultancy website at www.icmc.org.uk Ultimately insurers are looking to minimise damages, while solicitors are trying to keep their clients happy. Believe it not there is a happy medium. In many cases the results don’t have to be a compromise. A good case management team should be able to identify the various rehabilitation needs for each claim at the right level. The starting point is making the right assessment.
Assessing the rehabilitation needs starts from the first point of contact with the insurer or the claimant solicitor. Understanding the objectives of both parties is important. Are you merely looking for some resolution to a medical problem which is holding up the expert witness process and for someone to fast track this; or is there an employment issue that is making it difficult to set a realistic reserve on the case?
An experienced case manager should be able to immediately understand the scope for intervention, i.e. does the injured person require something simple and straight forward like physiotherapy, or do they need a full needs care assessment and detailed rehabilitation plan? Decisions regarding these initial objectives should be made quickly and agreed before contacting the injured party.
Cost benefits are of paramount importance to the continuation and good reputation of the rehabilitation industry. Therefore telephone assessments may be appropriate for those with less complex needs, which can save time and money. Where necessary a face to face meeting should be arranged. It can be extremely useful to see how the person manages at home, and meeting them face to face can also help with gauging the psychological affect the accident has made.
The role of the case manager should not be confused with that of the expert witness. As rehabilitation is still relatively in its infancy in the UK there is still much debate about the grey areas between these two roles. The case manager role is part of the therapeutic process and to act as advocate on behalf of the injured person. But it is also to manage the injured person’s expectations, as these may not match what would realistically be funded by the insurer. There’s no reason why the case manager cannot be a conduit between the insurer and solicitor – a case of rehabilitation mediation?
Any intervention that is agreed needs to be administered in a timely fashion. Clear communication and problem solving skills are paramount for the ongoing rehabilitation process, with a progression to the goals which are agreed as appropriate. Both the insurer and claimant solicitor need confidence in the case manager to provide regular and accurate updates.
The ultimate outcome for the rehabilitation process is a better quality of life for the individual, and a reduction in the time taken for the claim to settle. For the insurance industry to continue supporting rehabilitation there must be a sound business benefit for them, and this means saving money and resources.
None of this answers the problem of how to get the right assessment and services. Unfortunately the solution is often found by taking a leap of faith and trialling companies. However, with organisations such as the case managers Society UK and Vocational Rehabilitation Association developing standards for their members, this should make the selection of a provider easier for everyone. Remember, if the first response you receive does not fit in with your needs, and/or you don’t feel confident that the other side will respond well to their suggestions, you can always review your selection criteria and look elsewhere. Your only compromise should be between how long it takes to complete the programme the amount it costs.
NHS cuts 'delaying treatment'
More than a million people suffer health problems caused or made worse by their work, but many face delays getting treatment because of cuts in the health service, according to a new report.
The Chartered Society of Physiotherapy (CSP) highlighted growing problems including back and neck pain as well as other joint, bone or muscle conditions. Workers in the North East of England suffer a higher rate of injury because of their jobs than those in other parts of Britain, the study found.
Alex Mackenzie, of the CSP, said: "We are concerned that many people with bone, joint and muscle problems are facing delays in accessing treatment because Government pressure on NHS trusts to balance the books is leading to longer waiting lists and panic cuts in services and staff.
"This is a real worry. Evidence shows that early access to physiotherapy and other rehabilitation services can help nip problems like back and neck pain in the bud before they really take hold. Left untreated these conditions can become chronic, debilitating and very expensive."
The society, which represents 47,000 physiotherapists, called on the Government to invest more in NHS staff who could improve the help of Britain's workforce.
All news reported in this bulletin and on the HCML site is taken from the sources quoted. It is intended to inform readers about the news that has been reported in a given month and is in no way indicative of any attitude or policy of HCML.