Rehabilitation: On the mend

Labour politicians have, understandably, been somewhat distracted over the past few months, what with expenses scandals, ministerial resignations, leadership plotting, a reshuffle and then a hammering in the June’s local and European elections to contend with. But, whatever you may think about prime minister Gordon Brown’s administration and its future (or lack of it), one thing that can’t be disputed has been its commitment to occupational health (OH).


At the height of the expenses turmoil in May – and with government business effect­ively paralysed in many departments – the Department for Work and Pensions (DWP) unveiled its long-awaited ‘fit note’ to the public and professions and, in the same month, DWP minister Lord McKenzie took the time to attend the launch of new DWP-commissioned rehabilitation standards introduced by the UK Rehabilitation Council (UKRC).


The fact that McKenzie saw it as important to be present clearly indicates how seriously the government, even in its current disarray and while grappling with the worst economic crisis since the 1930s, views vocational rehabilitation within its agenda for the reform of workplace health provision.


Standards honed


The UKRC’s standards – in three separate documents: one for purchasers, one for providers and one for consumers – have been put together over the past six months. They follow on and add to those drawn up in 2007 by the Vocational Rehabilitation Association, and can be seen as a further honing of what OH practitioners and others should be looking for in this area.


They can also be seen against the backdrop of the government’s stated intention that its planned Fit for Work service should have a distinct focus on vocational rehabilitation and job retention, as well as government-backed research carried out by the University of Cardiff’s Gordon Waddell, the University of Huddersfield’s Kim Burton, and the University of Otago’s (New Zealand) Nicholas Kendall last year into the evidence base for policy development on vocational rehabilitation.


Business case


This concluded that there was a strong scientific evidence base for many aspects of vocational rehabilitation, that there was also a good potential business case for it, and “more evidence on cost benefits than for many health and social policy areas”. Nevertheless, there was also a clear need to improve the provision of vocational rehabilitation in the UK, it added.


Which is, in part, where these new standards come in. As Catherine McLoughlin, chair of the UKRC, makes clear, the intention behind them has been to “create a framework which recognises that best practice and safe delivery by skilled and experienced practitioners influences the creation of cost-effective services”.


But the standards are also important because, in what is an unregulated industry with a predominance of private providers, they have the potential to act as a line in the sand. Many such firms have seen a boom in business in recent years from insurance companies, either being used as a way of minimising payouts or, more positively, as a way of circumventing NHS waiting lists to access faster treatment. The industry also has something of a reputation for variability of provision with some firms, a minority admittedly, accused of under-delivering or over-charging for their services.


“Anyone could set themselves up and say they are a rehabilitation consultant,” concedes Joy Reymond, head of rehabilitation and health management services at healthcare provider Unum and a member of the council. “The majority of them are fantastic, but how does the consumer know that they are not dealing with a maverick? So it puts some standards around the delivery of the service.”


While there have long been rehabilitation standards and codes of conduct in some areas, such as case management, these have tended to focus on the technical delivery of the service, she points out. Similarly, within occupational health nursing there has also been a long history of rehabilitation, but again normally much more from a medical perspective.


Standards template


How these new standards differ, then, is that it is hoped they will become a template for anyone – whether from OH or not – purchasing rehabilitation services or accessing such services as a user to be able to test out contracts and identify reputable providers. “The rehabilitation standards will bridge gaps and create an over-arching umbrella to help users assess the quality of what is on offer,” argues McLoughlin.


Another potentially highly valuable role of the standards will be to ensure that there is greater consistency in the delivery of rehab­ilitation services, agrees Tim Matthews, chief executive of Remploy. “For the first time in the UK commissioners, providers and users of rehabilitation services will have the opportunity to benchmark those services,” he points out.


“For the commissioner of vocational rehabilitation these standards should be showing confirmation and evidence that the service they are offering is based on best practice,” agrees Reymond. “These are designed so that people who are engaging providers know what to expect and can become more informed as purchasers,” she adds.


Outline standards


Put together, the standards outline what commissioners or purchasers should be looking for from providers and the sort of documents providers should be able to ­offer, such as a service definition document, service competency document and a working practices document. They also outline the decision-making process purchasers should ideally be going through.


They emphasise that providers should be able to furnish descriptions of the type of service they provide – for example, if they are providing physiotherapy, whether that will be a specialist intervention for, say, someone who has suffered a stroke or some other neurological condition or an amputation? Or, what exactly do they mean by “functional restoration programmes” or “condition management programmes”, with providers, again, expected to indicate exactly whether such programmes contain, for example, physiotherapy and/or other therapies and psychological support and interventions such as cognitive behavioural therapy and whether they support only people with musculoskeletal conditions or extend to other specified conditions.


But, beyond some of the detail, the standards have also brought into focus the work of the council itself, which, it has to be said, has not exactly been high profile up to now, despite the importance the government is clearly attaching to the development of vocational rehabilitation.


While McKenzie may have made himself available for the launch of the standards, there was little in the way of media coverage, or even notification to media outlets, of the launch event or the publication of the ­standards.


Resources shortfall


Part of the problem has been, at least up to now, simply a lack of resources, concedes Bob Grove, employment programme director at the Sainsbury Centre for Mental Health, which has been instrumental in helping to set up and run the council from its London headquarters.


But the decision by the Department of Health to fund the council for a further three years, agreeing a £250,000 deal, along with money from the Scottish Centre for Healthy Working Lives, opens the way for much greater activity and the opportunity to raise its profile and communicate more widely with the profession, both on the standards and on rehabilitation in general.


“For the past two years we have been engag­ing with private insurers, the government and occupational health practitioners to see what we could pull together. What we are trying to have is a single source of information that will add to and enhance the work of others within the field rather than taking it over,” agrees Grove.


The next step is to create an elected membership, with the council now seeking nominations for members. It has also been looking at ways to develop a strategic alliance of rehabilitation organisations, with the UKRC as the lead body, with national director for health and work, Dame Carol Black, offering to introduce an initial meeting aimed at agreeing the lead body as well as outlining the government’s objectives in this area.


“The government is very serious about this issue and has been very supportive from the word go. They are looking for a central point of contact within the whole arena,” agrees Reymond. “It will mean we will be able to promote our objectives more and deliver on our objectives more too, and have a much wider group.”


Evidence base


Much as within occupational health itself, a clear thread running through the standards is the need to create a viable, robust evidence base. To this end, the intention is that the standards will act as a “floor” or a benchmark for the industry and, in time, lead to much greater dissemination and communication of best practice.


“This is something that will be refined over time. It is intended to be a guide, just a starting point,” emphasises Reymond. “The intention is for it to have a very inclusive approach and for the council to be working as an umbrella organisation. The challenge is how to get vocational rehabilitation to be something of interest to and valued by a large enough group who will be prepared to support it. It has been a long, slow slog but we have made it work,” she adds.


And, while for now the standards are purely voluntary, in time that too could change, predicts Grove. “Ultimately we are looking at things like accreditation. The next phase is accreditation, perhaps by the British Standards Institution,” he points out.


This is a view echoed by McLoughlin, who stresses that providers will increasingly be expected to meet the benchmarks set out within the standards, something that will be a “powerful first step in influencing market quality”. Accreditation and regulation, she adds, will be “questions for the future”.


Framework


With increasing numbers of occupational health departments and providers looking to offer rehabilitation services and, as we have seen, rehabilitation very much a central part of the government’s vision for ­future workplace health provision, from what has been a relatively low-key start, these new standards could become increasingly important documents, as Grove ­explains.


“It is about having one framework in which we operate. The usefulness of these guidance documents is now that any kind of purchaser of rehabilitation or user of services can look at them and find out how to do this or that and what they should be looking for from a provider.


“It gives them a framework of reference against which to assess a provider. It will also help providers to make a case to justify their bids in terms of the standards,” he adds.


What practitioners should look for from a provider




  • That it has a service definition document, outlining the services, specialisms and skills it can offer, the type and setting of service, its geographical area, and whether it can be accessed directly by individuals and users.


  • That it is maintaining a service competency document, showing that its staff have the appropriate skills, knowledge and ability to deliver each of the services offered.


  • That it can demonstrate that competency is being maintained through appropriate recruitment, selection, assessment and appraisal training and development, and that employees are properly supported.


  • That it has a working practices document that clearly defines the service delivery element of each service, including its working practices for referral, assessment and reportings, any charges and rates (if appropriate), and how it monitors the effectiveness by monitoring outcomes.


  • That it offers appropriate safeguards and clear policies on the protection of users.


  • That it is running a proper business, with appropriate governance and practices in place.

20 Questions consumers should ask a provider




  1. What type of service do you provide?


  2. Do your staff have the right skills?


  3. How is the service offered?


  4. Does it cover my area?


  5. How do you ensure your staff have the necessary skills and qualifications to deliver the service?


  6. Who will be my main point of contact?


  7. What qualifications, skills or experience will this person have?


  8. What are the key elements of your service?


  9. What treatments, interventions and approaches are used?


  10. Is there good evidence for these?


  11. What evidence do you have that a particular service, programme or intervention works?


  12. How do I know this service is safe?


  13. How will I be kept informed while I am receiving the service?


  14. How can you show your business is in good order?


  15. Do you have the capacity to take my case and manage it properly?


  16. If something is not to my satisfaction, how will it be put right?


  17. What happens if something goes wrong or I sustain an injury?


  18. How will I know that the programme is progressing satisfactorily?


  19. How will I know if/when success has been achieved?


  20. What happens on the completion of my rehabilitation – will there be ongoing contact?

What purchasers of rehabilitation should consider




  • Decide why you are purchasing, who will be the potential end users, and what type of service is appropriate to your needs.


  • The qualities of the provider, including that it is person- or needs-focused, professional, has integrity, accountability, clarity of vision, is results-driven, responsive, flexible and dynamic, offers scaleability and stability, and has an ethos of continuous service improvement.


  • The type of service being provided, including its setting (such as whether it is clinic-based, residential, domiciliary or work-site, web-based or telephonic) and its geographic coverage.


  • Its competence, including how it ensures staff have the necessary skills and qualifications to deliver the service, its screening methods and provision of training.


  • How the service works in practice, including its coverage, acceptance criteria, instruction and onward referral procedures, service levels and timeframes for delivery, and how all this reflects actual working practices.


  • How it is maintained and kept up to date, including how it reflects the current evidence base, how it is compliant with legislative and regulatory requirements, that it has a robust and viable business structure, that it has the capacity to make the necessary referrals, the correct insurance, and that there are no conflicts of interest.

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