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ICAS – Working Better Together

1079 days ago
Combating occupational injury and muscular skeletal disease – the UK vs SA

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According to independent consultant, Lutgen Terblanche, South Africa can learn a lot from the UK on its approach to injury, muscular skeletal disorders and employee absence.

Bar the common cold, back pain is the most frequent reason why people visit their GP, says Lutgen Terblanche, independent consultant for ICAS. 80% of the population will suffer from back pain at some point or another, with a 50% chance of it recurring within two years. ‘In the UK they’ve long come to realise that the way that employees with injuries or muscular skeletal problems were being managed, wasn’t helping them get back to work,’ says Terblanche. ‘They understood that there was a huge problem and it was costing them billions of pounds each year. They needed to get people back to work to reduce insurance costs and disability costs for the government (which had 3.2 million people on disability benefits, with 35% of these due to muscular skeletal disorders and 35% due to mental health conditions).’ They conducted large-scale research to find out how simple accidents or injuries could lead to disability. The research showed that the system that commissions how people are being managed isn’t what it should be and so they made a huge investment to understand how to best support these employees and get them back at work.

 

The UK Solution

Firstly, they launched a huge campaign called Rehabilitation First in 2000/2001 that encouraged employers’ liability insurers, motor vehicle accident insurers as well as employers to implement an appropriate return-to-work rehabilitation service.

They also set up a service called the Condition Management Programme, specifically aimed at disability benefit claimants, which focused on educating people and getting them active again. ‘The results were fantastic,’ says Terblanche. ‘Thirty percent of people who were on disability benefits got back to work.’

They realised that early intervention is key. ‘As soon as somebody has an injury or problem, you need to reassure them and give them good advice and guidance on how to manage their condition i.e. psychological first aid.’ Terblanche says. People’s conditions were assessed telephonically and advice and guidance were provided. Just by getting the right advice and guidance, 20 to 30% of acute cases got better and went back to work with no further problems.

The remaining 70 to 80% needed a little bit more intervention or secondary treatment and were sent to a physiotherapist for a short course of therapy focused on reassuring them, getting them active, fitter, stronger, functional, educating them on what the issues are and dealing with risk factors such as postural issues and improper lifting techniques. Of this group, 88% got better and went back to work.

They realised that early intervention is key. ‘As soon as somebody has an injury or problem, you need to reassure them and give them good advice and guidance on how to manage their condition i.e. psychological first aid.’ Terblanche says. People’s conditions were assessed telephonically and advice and guidance were provided. Just by getting the right advice and guidance, 20 to 30% of acute cases got better and went back to work with no further problems.

The remaining 70 to 80% needed a little bit more intervention or secondary treatment and were sent to a physiotherapist for a short course of therapy focused on reassuring them, getting them active, fitter, stronger, functional, educating them on what the issues are and dealing with risk factors such as postural issues and improper lifting techniques. Of this group, 88% got better and went back to work.

To deal with the remaining 12%, who presented more psychosocial risk factors and more complex issues, rehab units were set up across the UK to deliver what they call bio-psychosocial functional restoration programmes. These are intense programmes focused on educating people, dealing with psychosocial barriers and also getting them fit and active. ‘They helped people to manage this condition, telling them that even though the programme could not rid them of their pain, they could do everything in life despite the pain,’ says Terblanche. And from that group, 90% recovered and got better. That left them with only 2 or 3% that did not respond to that kind of stepped pathway.

 

The impact of these reforms was tremendous, says Terblanche. Employees benefited because they were getting better, getting back to work, earning money again and looking after their families. Employers benefited because sickness absence was reduced, insurance companies were paying out less in insurance and the government had fewer people on disability grants. ‘So everybody benefits – the whole chain. This has now been implemented as common practice in the UK,’ adds Terblanche. In the UK, they’ve estimated that there has been a 30 to 40% reduction in absence costs, medical care costs, treatment costs and insurance costs if people are managed according to evidence-based practice and best practice, says Terblanche.

“THE PERSON GOES HOME, STARTING TO WORRY A LITTLE BECAUSE THE PAIN IS NOT GETTING BETTER. AND THROUGH RESTING, THEY’RE GETTING A BIT MORE STIFF AND OUT OF SHAPE AND THE PAIN INCREASES. SO IT TURNS INTO A VICIOUS CYCLE.”

The South African model

‘Before these reforms, the pathway in the UK used to be: somebody gets injured or develops a muscular skeletal problem and their first point of call is the GP, who signs the person off work for a week.

The person goes home, starting to worry a little because the pain is not getting better. And through resting, they’re getting a bit more stiff and out of shape and the pain increases. So it turns into a vicious cycle. They might even see a physiotherapist to manage the pain, but no one looks at the real risk factors, the issues causing the pain in the first instance,’ says Terblanche. ‘So when the person doesn’t get better and cannot go back to work, the psychosocial factors kick in – things like self-efficacy, fear avoidance beliefs, catastrophising – all of which are risk factors for the condition to become chronic. They then get sent to a specialist who orders MRI scans, X-rays, blood tests or surgery. When the surgery fails, the person ends up on disability.

‘But the real problem could have been solved by encouraging people to get moving, to become strong and fit enough to do what they need to do. For the majority of cases it comes down to a collection of risk factors that include strength, flexibility, endurance, aerobic fitness, lifting technique and posture – which are all non-medical issues.’ In fact for all cases that present with a musculo-skeletal condition, only 3% have red flags (serious medical conditions) that require a specialist referral for investigation and surgery. In South Africa this number is significantly higher and therefore unnecessary costs spiral out of control.

This is also typical of what we see in South Africa, says Terblanche. ‘Our model is a medical model with doctors trying to manage the medical issues when it’s not necessarily a medical issue, but a functional and psychosocial issue. And the whole system is driven by it because everybody needs a diagnosis in order to claim from insurance and get their medical aid to pay for treatment.

Very few medical aid funds actually give people the funding for early treatment – they only cover in-hospital costs. So people don’t receive early intervention and see a physiotherapist to get the right type of treatment and rehab first – they wait until the problem becomes more chronic and go straight to hospital for MRI scans or surgery. This drives up the cost and the outcomes remain poor.’

Telephone management – which is effective in reaching people quickly, consistently and early in rural areas where there’s no healthcare access or real support – is frowned upon by the South African Health Professional Council. There is also a lack of corporate involvement to introduce robust clinical governance processes and procedures that will manage things more appropriately. The majority of health professional council bodies also don’t have clinical care pathways – there is no good guidance as to what works and what doesn’t. ‘So health inflation goes up because people don’t receive proper primary and secondary care. The focus remains on tertiary hospital management. People don’t get the right treatment at the right time and therefore costs escalate, outcomes are poor and people are out of work and on disability,’ adds Terblanche.

There needs to be a big change in the system in terms of how people are managed and treated, says Terblanche. ‘The UK has done a huge amount of research on the best ways to deal with this and now everybody there has to follow that pathway. Here, nobody is really driving that process. GPs, physiotherapists and OTs are doing whatever they think is right – which isn’t necessarily right by the patient or the evidence.

‘In the UK, companies take out employers’ liability insurance. Here the company pays that to the government. The insurance fund pays three months of your salary and your medical expenses if you get injured on the job. Because there is no focus on getting people back to work, nobody measures what the clinicians do and how they do it in terms of evidence-based practice. Our main aim has to be getting people back to work for the least amount of treatment.’ ‘Then there’s the Road Accident Fund,’ says Terblanche, ‘who pays for treatment and for work loss, but again the whole system isn’t focused on managing the quality of the treatment, reducing costs, or getting people back to work’.

Employers should take the lead

‘ In South Africa, employers have already bought into employee wellness programmes (EWPs). They understand that we have psychosocial issues, from HIV to drug abuse and financial issues,’ says Terblanche. ‘But we also need to understand that 40 to 45% of all sickness absence and costs in terms of disability are due to physical health problems. And very few companies have an effective process and procedure in place to deal with it. Millions of employees are getting psychosocial support but next to zero are getting the physical support they need, although both are equally costly.

’ Terblanche’s suggestion is that bigger companies take a much more active lead in setting up programmes to get employees early support and treatment and get them back into the workplace. According to Terblanche, the return on such an investment for employers is about 300% when taking into consideration the reduction of sickness absence and medical expenses.

Effective solutions

The best solution for employers is to focus on existing cases first, advises Terblanche. This includes employees who are struggling at work or those who are off work or on restricted duties because of a physical health problem. Assess them, implement the stepped approach, understand what the issues and problems are and put them through a proper rehabilitation programme – which could either be on-site or off-site. In this way, we can get them back at work.

‘But then we also have to introduce a service that prevents people from ending up there again. People should be able to report, either via self-referral or through a manager’s referral, when they have a muscular skeletal issue or an occupational injury,’ says Terblanche. ‘We can then assess the person on the phone, understand what the issues are, support and manage them through the whole process [and] if necessary, give them a course of treatments and put them into a rehabilitation programme if they don’t get better. In that way we will get about 97% of cases back to work within six to 12 weeks. Then you know you’ve got a physically healthy and happy workforce and alongside the EWP programme, you have all the psychosocial issues dealt with as well.’

♦ End

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