Rapport
Conference Special
MEDICAL SERVICES
July 2004
Looking at the big picture Chief Medical Officer Carol Hudson gives an overview of the third annual Medical Conference, held at the Celtic Manor Hotel in Cardiff. This year’s key theme was rehabilitation. “So, why do we have an annual Medical Conference?” asked a new colleague back in January – and the timing couldn’t have been better. Just four months away from the 2004 Medical Conference, and I was reminded that many of our colleagues might not know the reasons. The strategic answer is because we want our employed doctors to have an opportunity to ‘step Dr Carol Hudson back’ and, with colleagues and external experts, consider a theme that has particular relevance to Medical Services at the time. For me, the more interesting aspect is the theme itself and why we’ve chosen it. This year’s theme was Rehabilitation. Why Rehabilitation? Well, for some time there has been talk in our profession of the benefits of early intervention. During the past 12 months Medical Services has been particularly active in this area (see Panel above right) and we will continue to be so for
Fast Feedback
Medical Services – involvement in rehabilitation • IB Reforms with DWP • JRRP with DWP • Royal Mail Pilot with RehabWorks the foreseeable future. Therefore, it’s important all our doctors have a good understanding of both the work being done within Medical Services and the research and practical work being undertaken elsewhere. This brings me to a second reason for the conference. We want our doctors to be involved in the debate around a theme. Their views and contributions can, and do, shape our thinking, and influence our approach to addressing the theme. In addition to the plenary sessions where our doctors listened to speakers, we ran a number of workshops in which everyone was encouraged to debate the topics presented and have their views known by the wider audience. It was great to watch the animated discussions between our doctors, the speakers, and our customers. Our customers? Yes, we always invite medical representatives of our customers to attend the conferences, because a third
reason for holding the conference is to enable our doctors to meet with our customers’ representatives and to informally share perspectives with them. My fourth reason for the conference is to celebrate our success. Medical Services has had a great year (see Panel below) and our doctors’ contributions have been the cornerstone of that success. Several doctors received awards from the Head of Medical Services, Simon Chipperfield, but all our doctors can feel proud to be part of Medical Services. Please take time to read this Rapport Conference Special. It will act as a reminder for those who attended the conference, and as an insight for those who did not. I’m sure that in reading it you’ll understand why those who attended it gained eight CPD points!
Medical Services – successes in the past year • DWP: IB Backlog reduced to zero • DWP: EBM roll-out • DWP: IB Reforms (AACT) • DWP: KPI targets • DTI: exceeding ‘Fit for Purpose’ targets
Interactive: delegates have their say at a special interest session
This year’s conference had a strong interactive theme, in response to requests from last year. Feedback came from the floor throughout the two-day event. Laptops on tables enabled delegates to fire off questions to a panel of specalists (see page 7) and also for a Q&A session with Dr Carol Hudson and Head of Medical Services Simon Chipperfield, at the end of the event. As part of the Special Interest sessions, delegates were asked to prepare short presentations on what they had learnt. The broad and imaginative range of responses included inventive – and often humorous – role play. Other delegates found themselves on the main stage presenting to the audience in response to a challenge set by the event’s Master of Ceremonies, Geoff Kershaw (see page 7). Video round-ups were shown of the work carried out at various Medical Services sites around the country, featuring real employees talking about their jobs.
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Flagging up the issues Identifying obstacles that prevent return to work
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Spotlight on rehabilitation Just how effective is the bio-psychosocial approach?
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A time for reflection Mansel Aylward’s fond farewell to Medical Services
PRESENTATIONS
Flagging up some crucial rehab issues
Symptoms that defy explanation
Bio-psychosocial problems need bio-psychosocial solutions – that was the clear message from guest speaker Professor Chris Main, Professor of Clinical and Occupational Rehabilitation at the University of Manchester. “We also need to consider health and social factors together and their potential to help people return to work,” he said.
Seventy per cent of patients claiming Incapacity Benefits are diagnosed with symptoms that are not fully explained.
One obstacle is society’s perception of pain – for a long time pain was seen as a purely sensory event detached from the mind.
That was one of the striking facts highlighted by Dr Christopher Bass, in his presentation – The rehabilitation of patients with medically unexplained symptoms and so-called ‘minor’ illnesses. Dr Bass, Consultant in Liaison Psychiatry at the Department of Psychological Medicine, at the John Radcliffe Hospital, said it is essential to look at the patient’s psychosocial background when attempting rehabilitation for people with unexplained symptoms. Dr Bass said: “Doctors are trained to deal with organic problems yet many spend most of their time dealing with patients with non-organic problems.”
Prof Main said: “We now have a more sophisticated model for understanding pain thanks to Melzack and Wall’s gate theory. They told us that pain is an unpleasant sensory and emotional experience and is always subjective. After suffering acute pain or injury the body doesn’t always repair itself properly – and the challenge is to understand why. Taking lower back pain as an example there are three major psychological factors associated with chronic incapacity: • Distress – leading to depressive reactions • Beliefs – about pain and disability linked to fear and misunderstanding • Behavioural factors – guarded movements and coping strategies “What people believe influences how they react and what they do about it. The mind and the body interact and we need to understand how this works. We need patients to understand their situation, so they are more likely to go back to work.” The professor and other colleagues developed the coloured flag system used to identify obstacles that can prevent recovery. [see illustration, below right]
Partner power Rehabilitation specialist FirstAssist is working closely with Medical Services on the ground-breaking Job Retention and Rehabilitation Pilot. Its Managing Director, Steve Wood (pictured left), outlined how his organisation delivers rehabilitation solutions. He said: "There are challenges and resistance from the key stakekeholders. GPs say: ‘Rehabilitation isn’t about my patient it’s about saving money.’ We have to communicate clearly with GPs and educate them on what we’re trying to achieve. Employers are also highly sceptical and there is a need to change habits and culture, as there is with people who think rehabilitation may reduce their compensation money or thwart what they see as a way of leaving work. Solicitors and insurers also take a strong interest in their clients’ rehabilitation." FirstAssist believes using a case manager is vital for successful resolution. To illustrate this, Steve highlighted the case of a 58-year-old manual employee who suffered a hernia while lifting. "The patient might have been unable to work for up to two years if he had required surgery on the NHS. The FirstAssist Nurse Case Manager assessed the needs of the patient, talked to their GP, solicitor and insurer, and referred them to a consultant. Surgery and aftercare treatment was carried out privately. The employee returned to work after three months – not two years – reducing the employer’s sickness and absence costs, cutting the heads of damage for the insurer, and enabling the solicitors to fasttrack the claim within predictive fees. A win win situation."
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Astonishing facts: Dr Christopher Bass
Flying the flags: Professor Chris Main
Prof Main said: “This enables us to understand people’s emotional responses and pain behaviour, so we can identify those who need attention and look at strategies for managing their needs and get them back to work. To get people back to work we have to capture the flags. Black Flags are basically show-stoppers – but they can also provide opportunities, such as improvements in funding for certain treatments. Taken together red and yellow flag obstacles are the building blocks for early triage or early intervention,” he said. “Blue and yellow flag obstacles can prevent recovery and a return to optimal function. Interventions based on these will fail if we don’t understand the needs of the people involved, and develop sound policy and legislation to assist recovery. “More evidence-based research is needed. We need to link assessment more with decision-making on treatment and intervention and consider health and occupational outcomes and all potential obstacles to recovery.”
SIMPLE GUIDE TO THE FLAG SYSTEM Each flag represents different obstacles preventing return to work Black flag = show-stopping external events that individuals have no control over – for example, new financial and employment policies, and legislation. They can also be caused by lack of a mechanism to identify people who need treatment. Blue flag = social and vocational circumstances surrounding a person and their preconceptions of them, eg work-related issues and the social environment at work. Yellow flag = a person’s own beliefs about their condition, treatment or pain, their ability to cope and vulnerability to further injury – focusing on health and physical function. Orange flag = psychiatric problems requiring specialist treatment. Red flag = demonstrable biological or pathological pain and/or physical impairment
Some of the common medically unexplained syndromes linked to sickness absence include: • Chronic fatigue syndrome (CFS) • Fibromyalgia (chronic widespread pain) • Chronic low-back pain • RSI (repetitive strain injury) • Non-cardiac chest pain Dr Bass said: “Psychosocial factors – such as personality, life events and psychiatric disorders – are at least as important as physical factors in the onset and maintenance of these conditions. Patients can make a number of ‘secondary gains’ with these unexplained illnesses, such as: work absence as a reward for years of struggle; turning a socially unacceptable disability in to a more acceptable ‘organic’ disability caused by injury or disease beyond their control. They can blame their failures on the illness; elicit care, sympathy and concern from family and friends; avoid work or even sex; and there are financial rewards associated with disability.” Dr Bass added: “Take whiplash. In countries where no compensation is paid for whiplash, there are no official cases of whiplash recorded! Also, many patients with RSI that I have seen, appear to have a problem with their manager at work.” During his presentation he outlined broad courses of action Occupational Heath consultants can take to encourage rehabilitation with various types of medically unexplained illnesses. These are: • Make an early positive diagnosis • Flag up psychosocial questions at the first appointment • Provide a clear explanation of cause and maintaining factors • Limit the potential for iatrogenic harm • Involve the family in illness management and behavioural changes • Establish clear communication with the GP and workplace • Take a stepped approach to care if initial treatment is not effective.
Let’s communicate! For further information on the conference or articles please contact Helen Sawyer on 020 7830 4662 or helen.sawyer@atosorigin.com
Rehabilitation in the spotlight The bio-psychosocial approach to rehabilitation was placed centre stage by Professor Peter Halligan and Professor Derick Wade, two leading experts who gave the conference’s keynote presentation: Beliefs – Is The Bio-psychosocial Model Enough? Beliefs are key to understanding illness behaviour and disability. “The core of the psychosocial argument is that illness is too important to be left to traditional, disease-based bio-medical explanations alone, as these are not sufficient to explain all or many illnesses,” said Professsor Halligan, Professor Professor of Psychology at the Halligan University of Cardiff. “We need to take into account beliefs, expectations and attitudes which affect illness behaviours and disability.” Beliefs also impact on the training and approaches taken by healthcare professionals, on the family and even society’s values. “Yet, both conventional biomedical and bio-psychosocial approaches have tended to neglect human factors in the creation and maintenance of illness and disability.” He said the bio-psychosocial model needs reviewing to reflect people’s ability to moderate illness behaviour to aid their recovery, for personal gain or to avoid responsibility. Why psychosocial factors are important Of 2.7 million people claiming IB in the UK, 70 per cent have symptoms not fully explained by physical or mental disease. “We have an increasingly healthy society with safer and less physically demanding workplaces – yet we see growing levels of disability. UK Employment is at record levels and unemployment low. Yet 5.9 million people are off sick at any one time. Subjective health complaints account for most of the rise in sickness absence and social security benefit payments in the UK and, correspondingly, symptom-based diagnosis is increasing. Experiencing symptoms is normal, but today they lead to greater use of medical services.” There’s also been an increase in defined mental disorders, up from two in the 1890s to 374 by 1994. “Mental illnesses are defined on a widely-varied conceptual basis, reflecting our evolving concepts and social beliefs about disease.” He also highlighted the medical profession’s changing approach to pain, and the growth of the compensation culture, which have helped fuel changing attitudes to rehabilitation.
Professor Wade delivered some strong and clear messages on vocational rehabilitation. “Rehabilitation is a generic, problem-solving process focusing on limitations to activity, that aims Professor to optimise social participation. Wade Social contexts are powerful and often act against re-employment. Rehabilitation aims to give the patient the role of an active and productive member of society, who is an important part of an organisational structure, and an earning member of the family,” he said. Professor Wade is Professor in Neurological Rehabilitation for the Oxford Centre of Enablement. ”We need to increase their feeling of well-being, physically and emotionally, help them to adapt to their new situations by making the most of the activities they are capable of, and their new environment. This may require teaching and retraining the patient to maximise their skills. Work colleagues may also need teaching and retraining to modify their expectations and understand how to provide the right support. We have to give patients the right environment to work in – physical, social and emotional,” said Professor Wade.
“It’s vital to educate the family to modify their expectations, and to acknowledge and support the work the patient does. Equally, it’s important to alleviate the stress and distress of relatives and the burden on carers.” Professor Wade sees the rehabilitation process as: • Assessment – identifying and analysing the problem • Providing support and treatment • Setting goals • Delivering interventions that are multi-focal and spread over time. Continual reassessment For effective rehabilitation a specialist team with the right expertise and knowledge is needed, to work towards common goals for each patient, involve and educate the patient, and resolve the most common problems. For the best understanding of rehabilitation, Professor Wade advocates the use of the World Health Organisation’s International Classification of Functioning (WHO ICF) model of illness – a powerful analytical tool. “Rehabilitation is a way of thinking – not a way of doing things. It must involve all parties moving towards an agreed goal, be part of a team activity crossing all boundaries, and it must include doctors.”
The bio-psychosocial model – a definition Acute and chronic symptoms that originate from benign or mild forms of physical or mental impairment are re-experienced as amplified perceptions with accompanying distress. When
filtered through the patient’s attitudes, beliefs, coping skills, and occupational or cultural/social context, they can affect patients’ perceptions of their impairment and associated disability.
Learning lessons from pain Simon Weston is probably Britain’s best known Falklands veteran. During that conflict with Argentinian forces, he suffered massive burns when the troopship Sir Galahad was bombed by Argentinian aircraft as it took his regiment, the Welsh Guards, to shore in 1982. Simon survived and after four years of intensive treatment and 39 operations, he went on to forge a new and successful life. That success was hard-won. At the conference he shared the realities of his personal rehabilitation and delivered powerful messages. After the horror of the Sir Galahad bombing, Simon received shocking advice from an army Major. “He told me I was unemployable – he just simply wrote me off.” Simon proved that man very wrong. He went on to found and run Weston Spirit, a Liverpool-based young people’s charity, learned to fly and drive racing cars, and took part in the demanding Operation Raleigh project in New Zealand. He is a regular speaker at conferences and events, tirelessly working for his charity and for the British Legion and Star & Garter Homes. “I learned that it’s not what happens to you in life that matters, it’s what you do about it. One of the biggest steps to getting over disability is to look to the future – if you like yourself you can achieve anything you want within reason. You have to overcome your fears and believe in yourself.” But the road to this realisation was painful in every sense. He said: “The bombing took a few seconds, but it
affected the rest of my life. It took the army more than four years to build the Simon Weston who went to the Falklands, and it took nearly as long to construct a new one afterwards – not just physically, but mentally. Simon believes medical practitioners play a crucial role in the rehabilitation of disabled people. “Unfortunately, back then, the army did not really deal with us in a psychiatric way,” he said. He experienced growing isolation and loss of identity. “Everything had gone – including any vision of the future!” He began drinking heavily, stopped looking in the mirror, and wouldn’t go out in daylight. “I began to feel as terrible as I thought I looked. I even attempted suicide.” A change came when he was invited to Germany to see the regimental rugby team playing. “I realised that people had been killing me with kindness back home. I was asked to muck in and play my part with the other soldiers. They didn’t care what I looked like – they had seen it before. I woke up to the fact that life goes on and I
Simon Weston wanted to be part of it. It was a matter of attitude. I’d been afraid of failure and wasn’t looking for the positive things in life. I had allowed myself to become redundant.” In 1986 he passed his driving test, and his confidence grew. The first test of his new-found positivism came when the Guards Association of Australia asked him to take part in a goodwill tour. “It was the first time I had put myself on show in public – I started to feel useful and helpful, and enjoyed meeting new, wonderfully friendly people. Three weeks later I went off to New Zealand and Operation Raleigh. I owe Australasia a lot.” Going from strength-to-strength he went on to launch Weston Spirit, met and married his wife Lucy and started a family. “I‘ve had fantastic support from friends, family, doctors and nurses. But in the end, you have to defeat your own demons and take charge of your own destiny.”
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PRESENTATIONS
Delivering for Royal Mail A radical pilot rehabilitation scheme for Royal Mail is achieving positive results in getting people back to work The Royal Mail Bio-psychosocial Functional Restoration Pilot Scheme aims to get postal workers with chronic musculoskeletal conditions back to work.
Nikki Harris: recommends extending the pilot
Launched in October last year by Medical Services in partnership with rehabilitation services specialist RehabWorks, it has been extended by six months.The pilot focuses on London-based employees referred through existing channels to maintain continuity. Medical Services’ Principle Physiotherapist Nikki Harris, and RehabWorks’ manager Lutgen Terblanche, updated delegates on its progress. Interim results show that of 41 patients placed on the programme, 29 are back on full duties and two on modified duties. “We have actively sought and gained the support of Royal Mail line management and unions so everyone gets the right message,” said Nikki. “Looking to the future we hope to extend the trial to address lower limb injuries and are recommending it is expanded into a continuously monitored service.” To qualify for the scheme, Royal Mail employees with spinal pain must have either been absent from work for more than six weeks, be on long-term restrictions, and have recurring absences, or experienced failed secondary intervention. They must also be classed as medically fit – eg not displaying any “red flag” conditions. Candidates are identified in case conferences and seen by a Medical Services Occupational Health Adviser
“The restoration process uses active and exercise-based group therapy, Cognitive Behavioural Therapy, work conditioning and work hardening. It’s important to establish if the individual can operate in their workplace, and whether the workplace is suitable.”
(OHA). The OHA refers the person to RehabWorks for a four-hour long functional capacity evaluation, notifies their GP, sends a copy of the referral to an Occupational Therapist and provides an information pack to the candidates.
The individual is case-managed back to work with the line manager, the RehabWorks Practitioner, the OHA and HR, ensuring they keep each other informed of the patient’s improving capabilities. The Occupational Therapist pursues any workplace changes needed.
The Occupational Therapist completes a physical demands analysis of the job. This provides RehabWorks with the level of physical capability that the individual has to attain to return to full duties. “This evidence-based assessment gives the big picture about what’s wrong with the person – physically and in their beliefs,” said Lutgen. Objective tests establish physical attributes and capabilities, as well as psychological, psychosocial and work-based factors. Afterwards, a programme of physical
Lutgen added: “Evidence shows tertiary intervention does get people with chronic musculo-skeletal disorders back to work and delivers short-term business benefits. The programme has had an immediate, positive impact on patients’ psychological status, their perceptions of disability and capability, and fear of movement. However, evidence-based techniques need to be measured and audited to assess the true physical and psychological benefits to employees.”
Don’t just talk... listen understand them – communications between doctors and patients should be interactions, not transactions. Patients want three basic things from doctors – do they listen, do they care, do they get it right?” He added: “Listening is vital to the relationship and is actually physically and emotionally hard work – and we haven’t finished listening until we prove we have been listening!” Measurable feedback helps doctors understand their communications skill levels, and the Doctor’s Interpersonal Skills Questionaire (DISQ) developed by CFEP is a useful tool for achieving this. Dr Michael Greco
Dr David Jenner
Doctors should always strive to improve their communications skills with patients. That was the message from Dr Michael Greco and Dr David Jenner in their plenary session The Doctor Factor. Improved communication delivers a range of good health outcomes for patients, including symptom resolution, physiological and psychological well-being, better adherence to treatment and advice, fewer complaints and disenrolments, and reduced convalescent periods. Getting communication right also benefits doctors, leading to better time management, enhanced relationships with colleagues, greater job satisfaction, and fewer complaints and litigation.
DISQ was tested in pilot schemes with the Royal College of Physicians and Royal College of General Practitioners, and has been approved for the new General Practice contract where it is linked to appraisals and revalidation. It looks at factors such as: warmth of greeting; the degree of active listening; clarity of explanations; reassurance given; concern for the patient as a person and their personal position; allowing patients to express concerns and fears: and time spent on patients. GP Dr Jenner’s practice in Cullompton, Devon, was the first in the country to use DISQ. “I got a low score in the first test and we weren’t prepared with how to deal with those sort of results. After suitable reflection, I realised some changes needed to be made.” Changes introduced included:
“Patients do judge clinical competence – and they mostly judge it on your communication skills,” said Dr Greco, Director of Patient Experience for the National Primary Care Development Team, and Director of the Client-Focused Evaluations Programme (CFEP), Innovations Centre, University of Leicester. “Doctors face a phenomenal challenge regarding interpersonal skills. You have to show the patient you care in a way that shows you
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rehabilitation, education and support is initiated. Lutgen said: “We aim to get the patient’s body and brain together to convince them they can do their job. It takes three to four weeks for someone to move between one area of ability to the next. We set personal and work goals for the patients. Achieving personal goals – such as being able to play in the park with their kids – helps them reach work-related goals.
• No Primary Care Trust calls between seeing patients • Starting on time to avoid delays • Maintaining eye contact and carefully introducing the computer • Remembering to think about patients’ feelings – men and women need different approaches • Better structure to consultations
Communication – interesting facts • Patients need two minutes to tell their story to a doctor – on average a doctor interrupts after 26 seconds! • Sixty per cent of all direct human communication is through body language – particularly the eyes. • If eye contact is maintained, people will talk for 40 seconds – if eye contact is broken they’ll talk for more than two minutes. • On average people bring 2.8 problems to consultations – the one they mention first is probably least important to them. For further information on the DISQ, or communication workshops provided by CFEP, please visit the website: www.cfep.net
In the next survey, in 2002, scores improved by 10 per cent, and although there were still flaws, lessons had been learnt. Dr Jenner has now developed a set of top tips for patient communication: • Listen to the patient uninterrupted initially, and actively listen • Provide an active summary • Check the patient for other agendas • Establish mutual priorities • Ask directed questions to clarify presenting problems • Summarise – check you and patient understood each other. Dr Jenner said: “Once you start doing these surveys it’s like opening Pandora’s Box – everyone wants to keep on improving.”
Picture gallery – A taste of the conference
Clockwise from top left: Dr Virginia Camp and Dr Richard Welch of Welch Occupational Health; filming delegates’ responses at a special interest session; Dr Moira Henderson of the DWP Corporate Medical Group; Dr Susan Robson; (l-r) Dr Kim Daniels, Dr Joe McCarthy and Dr Barbara Clay give instant feedback via a laptop; and Dr Joan Groves.
Teamwork helps slash benefits bill Around one million people report sick every week – and the country is shelling out £12 billion a year in Incapacity Benefit payments! These are just two of the many reasons the Job Retention and Rehabilitation Pilot (JRRP) has been launched by the Department for Work and Pensions (DWP) and the Department of Health (DoH) to get people back to work. Atos Origin’s Medical Services division has teamed up with rehabilitation specialists Human Focus and FirstAssist to help the DWP and DoH identify new rehabilitation solutions for people off work for six weeks to six months. Known as the WorkCare Partnership, we have been awarded the contract to run the pilot in two locations – West Kent and Birmingham – for two years.
Healthcare Boost
Not eligible
Workplace Boost Central Contact Centre
Informed Consent
Pilot referral process
Medical Services is running the workplace-only boost, focusing only on workplace-based, non-medical intervention. FirstAssist is running the healthcare-only boost, which must deliver treatment to mind or body but does not involve liaison with the workplace. Human Focus is running a combined healthcare & workplace boost, which enables it to focus on either aspect. The performance of each boost is being measured against existing services. The pilot service is
Control = Normal services
“The biggest challenge is getting referrals, which are below projected levels. We’re not allowed to recruit participants directly – most come via employers and GPs, and only one in four makes it through the screening process. Many people are not motivated about going back to work in the first place.”
Pippa Donovan, Medical Services’ Occupational Health Service Development Manager, told delegates: “The pilot is the first randomised control trial on vocational rehabilitation. It’s being evaluated by the National Centre for Social Research. It’s free at the point of delivery for the client and free to Primary Care Trusts, GPs, NHS Trusts and employers.” Clients participate in one of three completely different interventions – known as boosts – to assist them to return to work.
Healthcare & Workplace Boost
Pippa Donovan
Ian Pemberton
advertised via leaflets and media advertisements and clients are screened via a call centre. If accepted, they are referred to one of the boost categories. Each type of boost has Case Managers who liase with either health professionals or employers, to support individuals in their return to work. Ian Pemberton of Human Focus said: “The trial evaluation will be rigorously monitored in a number of different ways to ensure it’s working as planned, and a cost benefit analysis carried out.
However, although still in its early stages, the pilot has thrown up some key learning points: • Early intervention enables better case progression • The client must be supported during the pilot • Each case must be viewed individually – Case Managers are key players • Client motivation and co-operation must be addressed and employer support is critical • Certain financial incentives (ie ill-health retirement payments) can deter people from returning to work • Team working and continuous learning is important.
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PRESENTATIONS
Pilot schemes pave the way to work New ways of dealing with Incapacity Benefit (IB) claims are being tested across the country in a bid to get more people back to work, faster. The pilot schemes are part of the Department for Work and Pensions’ Pathways to Work programme. Nick Barry, DWP Account Manager and Pathways to Work Project Board Member, and Dr Dilwyn Jones, Medical Manager Wales and Lead Medical Manager for Pathways to Work, explained how the pilots were progressing and highlighted feedback from the DWP and Primary Care Trusts (PCTs). Medical Services and the DWP have launched seven pilot schemes – handling nine per cent of IB cases – at Bridgend, Renfrewshire, Derbyshire, Gateshead, Essex, Somerset and East Lancs. The pilots reflect the national mixture of IB claims and will be completed in April 2006. Nick said: "IB clients are given work-focused interviews with specially-trained Job Centre Plus Personal Advisers. Medical Services generates sophisticated, interactive, evidence-based Capability Reports, which help the advisers to determine what work the client is capable of. When making appointments we limit overbooking of clients. We keep closely managed waiting times and
That’s one of the core beliefs of Dr Stephen Duckworth, founder and Chief Executive of Disability Matters Limited, an organisation which has expertise in rehabilitating people who have been on long-term Incapacity Benefit. He also believes that active citizenship – taking part in life – beats passivity and dependence. He said development is critical to quality of life and can help reduce IB claims. External barriers to return to work are relatively easy to remove. “But a person’s internal barriers can block all of this,” he said. “Additionally, environmental factors
Work is good for rehabilitation: Dr Stephen Duckworth
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■ 2.67 million people receive IB – 400,000 of them
say they want to work ■ After 12 months on IB there is only a 20 per
cent chance of returning to work ■ Up to 40 per cent of claimants in the early
stages of a claim do not see ill health as a key obstacle to their return to work ■ At the point of claiming 90 per cent would like to return to work ■ Mental health problems outstrip musculoskeletal problems as the main source of IB claims.
PCT. These are work-focused, last up to eight weeks and aim to support clients to overcome a range of obstacles that prevent them going back to work.
Nick Barry
Dr Dilwyn Jones
attempt to limit the number of clients sent home unseen – improving customer service. Our target is to cut the time taken from examination to getting a report to Job Centre Plus from 32 days to 15 days – and we have consistently beaten the target. Case Managers from Medical Services are attached to each pilot site to ensure cases progress well." Clients then either return to work, or receive Job Seekers’ Allowance, IB payments or a return to work credit. They may also attend a Condition Management Programme run by the
Doing a job can really help get people better “We’ve got to get people back to work to get them better, not get them better to go back to work. Employment is therapeutic.”
IB... The facts
are critical – if the work environment is hostile to a disabled person, they’re more likely to be off work.”
Dr Dilwyn Jones said feedback from Personal Advisers, doctors and PCTs has been positive. "Personal Advisers consider the Case Manager model is pivotal, and welcome the shorter timescales involved. They like the Capability Reports and say that the Medical Services/DWP relationship is now much closer. PCTs say referrals made to them are appropriate and are mostly carrying out assessments rather than active interventions. While progress on the pilots is mostly good, the referral mix needs closer analysis, referral predictions fluctuate, and attendance rates still need to improve. On the plus side PCTs are providing the right kind of interventions and Condition Management Programmes are in place and the presence of Job Centre Plus decision-makers at appeals is regarded as highly positive.”
The military way Rehabilitating people through work is a technique successfully used by the military. “Vocational rehabilitation is regarded as effective and important to productivity. It requires a lot of commitment and resources and is not an easy option,” said Group Captain David Jones, Royal Air Force Consultant in Rheumatology and Rehabilitation.
In its approach to rehabilitation, Disability Matters uses the empowerment model. In this, the disabled person reaches a period of depression or passive acceptance – likened to being at the bottom of a ditch – but is then encouraged to change their belief system and view of work. Dr Duckworth said some people can get quite comfortable at the bottom of the ditch, especially with the financial incentives available.
Dr Jones is based at RAF Headley Court, a specialist rehabilitation centre in Surrey, which handles up to 170 patients a year from all services. The military has a high incidence of injury – primarily locomotor injuries with an emphasis on back problems – accounting for up to 67 per cent of working days lost. Some 8,000 people have their jobs downgraded each year as a result of musculoskeletal injuries.
“People on long-term IB will stay put unless they are helped to get out of it. They have to realise they need to change. We work with groups of 12 to 15 people who have been on IB for eight years or more. We ask them to envisage carrying stones – representing external problems like debt and marital issues. They make it harder to get out of the ditch and have to be disposed of before progress can be made.”
“Return to work in the military is demanding because a very high level of physical movement is required,” said Dr Jones. “There may be mass casualties, requiring the maximum number of patients to be handled by a minimum number of staff. Military rehabilitation has to be pragmatic. We rely on the military ethos, compliance, competitiveness and the skills of Remedial Instructors (RIs) – physical training instructors trained in exercise therapy. The emphasis is not on physiotherapy, convalescence, rest or sympathy.”
The next stage is to understand their ‘self-talk’ – the creative part of the subconscious that says: “I can go back to work” or “I’ll never get back to work ” to help them create a more positive self-talk and to create a positive vision of themselves for the future. “Once we achieve a change in their belief system they can make a decision about their future integration into the labour market. Work is a threatening word to a longterm unemployed person – but the idea of a job is more tangible, so people are encouraged to focus on going back to a specific job,” Dr Duckworth said.
A system of group therapy, based on the multi-disciplinary biopsychosocial model of rehabilitation, has evolved with emphasis on physical training. An RI leads groups of 12 to 20 patients through an intensive theraputic exercise programme, interspersed with physiotherapy, occupational therapy and work in the remedial workshops. Psychological retraining aims to educate patients about their injury, reintroduce them to typical social activities and empower them. This approach delivers improvements in pain levels, physical strength, running ability and getting people back to work.
They are encouraged to experiment with their life, pursue voluntary activities, and more activities outside the home. Finally, they are assessed for employability before returning to work.
He said a tri-service rehabilitation authority has been established to address concerns on the impact of injury problems in the forces, creating 10 Regional Rehabilitation Units (RRU). Flexible delivery of clinical services is made through the Rehabilitation Facility at Headley Court which takes the clinical lead, and sends out consultants to the RRUs.
FEEDBACK
Expert panellists tackle tough questions on rehabilitation A panel of speakers from the conference took part in a Q&A session on Managing Sickness Absence. On the panel were: Professor Mansel Aylward (MA), Dr Christopher Bass (CB), Dr Stephen Duckworth (SD), Professor Peter Halligan (PH), Group Captain Dr David Jones (DJ), Professor Chris Main (CM), Professor Derick Wade (DW), and Steve Wood (SW). Here is a snapshot of the panel’s responses to some questions.
Q: Tell us about the Illness Protection Questionnaire (IPQ)? CB said: “It is a test about a person’s attitude to illness – how long it lasted, what caused it, how much control they have over the illness and the impact it has had on their life etc. For example, if a patient believes their illness was caused by a virus and there’s nothing they can do about it, their prognosis is not likely to be positive. But if the patient believes stress may have contributed towards their symptoms, that the symptoms won’t last long and they have control over them, then the prognosis will be better.” CM said IPQ was a useful indicator if used carefully as a research or screening tool.
Q: Is the bio-psychosocial model being included in undergraduate curriculums? PH said there was some marginal interest in including the model in undergraduate education. Q: How do you resolve the conflict between disability analysts working objectively and GPs and consultants acting as patients’ advocates? DW argued the idea of analysts working objectively was irrelevant. “There is no right and wrong – it’s a case of ‘this is the analyst’s assessment, and this is the GP’s assessment’.”
Interactive: the panel answers questions from the floor
SD concluded: “I want to see peripatetic vocational case managers made available to GP practices, so GPs can refer patients for counselling immediately – GPs simply don’t have the time.”
Q: Should it be compulsory for employers to supply a rehabilitation programme for employees, to prevent a return to work that might be ill-managed, exacerbating a condition or disability? SW said: “I think it should be compulsory. The Government may set fiscal incentives around sickness absence rates and that will drive a change of behaviour among employers. More progressive employers will adopt good practice for rehabilitation, and the trades unions also recognise this.” MA said the Government has issued a second report on employers’ liability compensation with a commitment to create a national framework for rehabilitation and publish it in the autumn. “It’s best for employers to engage actively, because there is something in it for them, rather than make rehabilitation programmes compulsory. Now, the Government is leading on vocational rehabilitation and is in the early stages of a commitment to introduce the equivalent of the National Institute for Clinical Excellence (NICE) for rehabilitation.”
Q: Does the work ethos of disease management within the NHS, particularly musculo skeletal conditions, work against proactive attempts at rehabilitation and early return to work? SD said the NHS is working from an improvement perspective, but there is a gap between what the NHS sees as rehabilitation and employers’ perceptions. DW said while the NHS is increasingly working towards a bio-psychosocial model, it needs a fundamental reform. “Unless separate rehabilitation services get a higher profile, and a new organisation is set up within the NHS, I don’t think the NHS can succeed in this area,” he said. CM said: “I think there is an opportunity for some of the primary care activities to look into the management of certain
conditions differently. There is tremendous pressure in the hospital sector. However, there are a number of initiatives trying to understand disease as part of illness – with the focus on disease, while understanding it in the broader context.”
Soundbites
Delegates share their conference highlights
“I enjoyed the session on the JRRP Pilot (page 5). Stephen Duckworth’s talk on Vocational Case Management (page 6) got the message over in an inspirational way. Getting feedback from delegates was good as it’s interesting to hear other people’s views.” Dr Nick Niven-Jenkins, Chief Medical Officer (Assistance), Corporate Medical Group, DWP (pictured above)
“Rehabilitation and return to work is so relevant right now. I think the conference got the message across strongly, and will change the way many of us work.” Dr Jenny Wintle, Medical Training Manager (pictured right) “The presentation on communication skills (page 4) was informative and relevant. It was interesting to have our profession under the microscope.” Dr Klaus Bruecker, Medical Manager, Wembley
“The highlight was Simon Weston – he was amazing and an inspiration to all of us helping people with disabilities to get the most out of life.” Dr David Beaumont, Occupational Physician with Business Healthcare
“The focus on occupational health was extremely helpful and I found the question and answer session with the expert panel enlightening (this page).” Dr Berend Rah, Wembley MSC
“I really enjoyed Chris Main’s presentation (page 2) – he really pulled everything together in an interesting and informative way.” Dr Anne Ferguson, Medical Manager, Glasgow
“The Royal Mail Rehabilitation Pilot session (page 4) was very encouraging. There’s little objective understanding of the successful rehabilitation of chronic back disorders in the UK.” Dr Richard Welch, Welch Occupational Health
Q: Awareness training for GPs – what should we be doing? MA said: “We put a lot of work into it, we’ve been engaging with physicians and talking to GPs regarding the difficulties of getting good evidence and difficulties raised by them acting as patient advocates. The issue of report fees has also frustrated our relationship with GPs.” He said an increase in report fees for GPs was due to be announced shortly, and will improve relationships further.
Centre stage It takes courage to talk about something you had only half an hour to prepare – but that’s exactly what four delegates did on the second day of the conference. They responded to a challenge set the day before, when delegates were asked to create a short presentation on what they had learnt from the conference and how it would affect the service they will provide. Dr David Beaumont, Dr Omar Ahmed, Dr George Ewen and Dr Stewart Drew led the four presentations selected by conference organisers. Each agreed early intervention was vital. Dr Beaumont said the key lesson learnt was that rehabilitation and return to work should be a fundamental part of recovery from illness or injury. GPs need to be educated on the bio-psychosocial (BPS) approach and convinced that return to work is in their patients’ best interests. Dr Ahmed said close cooperation with DWP and other bodies involved in rehabilitation – including employers – was vital. If resources can be applied to the BPS model, results could be very impressive. Dr Ewen agreed: “We have all got stuck on the idea that unless we get people back to work quickly they will never get back to work. Rehabilitation works, that’s the most important message, but resourcing is a challenge.” Dr Drew said everyone must work together to achieve better results. “GPs are not just advocates for patients, but for a totally different concept to the BPS approach – but our common goal must be to rehabilitate the patient,” he added.
Dr Beaumont
Dr Ahmed
Dr Ewen
Dr Drew
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AND FINALLY...
Professor Aylward leaves us smiling "Things were very different when I joined the Department of Health and Social Services in Cardiff in 1985," recalled Professor Aylward.
Professor Mansel Aylward is Chief Medical Adviser to the DWP, and a major client. He is retiring in the autumn and said farewell to Medical Services at the conference.
"It was ruled by senior medical officers in the days before targets and audits. In those days, we were called Delegated Medical Practitioners for Attendance Allowance and Adjudicating Medical Practitioners for Industrial Injuries Benefits. We had only two main benefits to deal with – attendance allowance and industrial injuries disablement benefit. We had medical boards, with as many as five doctors on some occasions – very efficient and economical!" Promoted in 1989 to Senior Medical Officer, M1, in London, Professor Aylward enjoyed his contact with politicians, and being in a position to influence the Government’s Welfare Agenda and develop more objective methods of assessing capacity for work and the effects of disability. Amid many amusing anecdotes about his past career, the professor had some serious points to make. He said: "I was very taken by what was discussed today at the conference about pyschosocial issues and vocational rehabilitation. I've been working hard to get this on the agenda and to get the bio-psychosocial model adopted by those in power. The fact you were talking about it today is a success I want to claim." He said the current picture compared extremely well to the situation he found in 1985. "You now have targets – we didn't. You are audited – we didn't know what that meant. Somebody looked at our work and we worked well, but we didn't know what the standard was or whether we were achieving it.
Professor profile
“You have to examine more cases than I ever did, and you have training, personal development and revalidation – things that weren't conceived of when I entered the service. Most importantly, you deliver a medical service which, in quantity and quality, is far better than anyone else has ever delivered to the DWP and its predecessors.” As a result, his meetings with the Public Accounts Committee are now less stressful, he said. “I used go along in trepidation, but the last one I went to was very relaxed. There had been an improvement in quality, quantity and all the things they'd said we were all deficient in. It was a wonderful experience to go there and not feel stressed. “They’ve published a report recently, which endorses the improvement you've demonstrated. I congratulate you. You should be proud of your achievements.”
Professsor Aylward is also Chief Medical Adviser and Head of Profession at the MoD Veterans Agency, and is Joint Honorary Professor in the School of Psychology, Cardiff University and the School of Medicine at the University of Wales College of Medicine. His key career highlights since joining the Civil Service in 1985 inlcude: ● 1996 – appointed Chief Medical Adviser, DSS ● 2000 – appointed Medical Director and Chief Scientist, DWP ● 2001 – became the Royal Society of Medicine’s Academic Sub-Dean for Wales ● Made a Companion of the Bath in the Queen’s Birthday Honours List 2002 ● October 2004 – takes up the chair in Psychosocial and Disability Research at Cardiff University and will be Director of the University’s new Centre. Professor Aylward has worked closely with Medical Services on a number of crucial projects, including: ● LiMA, an intelligent evidence-based electronic report writing programme for Incapacity Benefit ● The Viable Doctor Pool Project focusing on the recruitment and retention of disability analysts ● EPBP – Engaging Physicians and Benefiting Patients, a project aiming to educate GPs in completing reports and how to help patients claiming benefts.
Setting out our vision in challenging times The future for Medical Services is exciting but challenging, Simon Chipperfield told delegates. “The next 12 months are crucial, as we bid to re-win the DWP contract. The outcome will change the shape of the business and how we go forward," he said. “We’ve been redefining our sense of purpose – and that is to enhance individual and organisational well-being. Our vision for the future is clear. We’ll build on our position as the leading work-related healthcare provider in the UK and on our core skills, expertise and capabilities to move into new areas of healthcare service such as medico-legal. We envisage that ultimately we will be working in partnership with the NHS in managed healthcare services. This is already happening in a limited way through Pathways to Work, relationships with GPs and, to some extent, with the DTI contract.” Simon said: “A major challenge is building a sustainable and integrated OH service that delivers high-quality services to all our customers all of the time. Medical
Services is creating a stronger infrastructure and network to enable medical practitioners to operate more efficiently, face-to-face, with less paperwork. Additonally we must develop a stronger independent regional network of medical centres and continue our programme of investment and roll-out of new centres. We’ll also continue to develop partnerships with like-minded companies to enhance our service offering to customers.” He added: “However, we cannot achieve our vision without the right people and that means more medical practitioners with the right skills, experience, training and background. Having the right people will strongly influence our rate of growth." At the conference Simon gave six special awards to people for exceptional contributions to the business in the past year. He personally selected those to be awarded, and presented crystal glass trophies to them at the Conference dinner on Friday. Commitment to Quality – Dr Colin Wigley Dr Wigley drew up the quality structure for respiratory specialists in the COPD contract, enabling Medical Services to achieve the five per cent bonus for quality. He also devised the programme for the new electronic medical assessment for COPD, now being rolled out in all Medical Services’ COPD work. Professional Achievement – Dr Laura Crawford Dr Crawford set up a new professional services team, qualified as an Associate member of the Faculty of Occupational Medicine, and took the medical lead on the DWP bid – all in the space of 12 months.
Simon congratulates award-winners Carol Halliday and Dr Dave Beswick
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Team of the Year – The EBM Project Team Dr Richard Gain collected the award for the team for its outstanding implementation of the EBM project, rolled out at more than 100 DWP sites.
Award winners: (clockwise from top left) Dr Laura Crawford Dr Richard Gain Dr Colin Wigley Dr George Gow Dr George Ewen
Best performance – DWP Medical Services Delivery Team The team has delivered consistently excellent service to the customer and helped the DWP to remove the massive IB cases backlog. It also achieved green lights on a huge range of KPIs over the past 12 months. Dr Dave Beswick and Carol Halliday received the award on behalf of the team. All-round contribution – Dr George Ewen and Dr George Gow Both were recognised for going above and beyond the call of duty to deliver excellent services. Dr Ewen’s award was for improving the quality of service for the NHS Pensions Agency and developing the customer relationship, while Dr Gow’s was for his work covering the Medical Manager position in Nottingham throughout the past 12 months.