Posted on July 8, 2018 in Inside OHS articles
The last time I went to Greece was on my first ever trip overseas 38 years ago. I went back in May.
A highlight was Epidaurus where the World Heritage-listed ruins of the most important sanctuary of Asclepius can be found.
Asclepius, a god, the one with the snake entwined around his staff, and often with a dog, was the son of Apollo and came to represent a new generation of a more scientific approach to medicine at the end of the sixth century BC.
This replaced the earlier versions that had been more mythically based.
Asclepia ‘functioned as sacred hospitals, nursing homes, centres of religious worship and of popular entertainment’ (Snakes, dogs and dreams).
The later Hippocratic Oath from 460 – 370 BC stated, in part, ‘I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses, making them my witnesses, that I will fulfil according to my ability and judgement this oath and this covenant’.
We can glean much from worksite visits
In 1990 I worked on a manuscript on the history of medicine, unfinished I am afraid to report. Needless to say I read a lot about the medicine of Ancient Greece, and made sense of it as follows: people would go to sleep at the temple and when they awoke a priest would interpret their dreams to make a diagnosis, and then treat them.
Patchy at best, and I never could quite understand what role the snakes played.
As we know well in workplace health and safety you glean much from a worksite visit.
I learned a lot from my inspection of Asclepius’ workplace at Epidaurus and its museum.
It turns out Ancient Greeks probably had hallucinogens and sedatives, so that explains the ‘sleep’.
The museum contained surgical instruments, including for removing stones from the bladder. Next to the rectangular temple in the sanctuary used by the public was a round building, which the priests occupied. The configuration of the rotunda’s foundations has led archaeologists to suggest this is where the snakes were bred, and it is surmised they slithered about while the patients slept.
What I found most intriguing was our guide told us that patients had to be deemed ready for treatment before they entered the temple.
This struck a chord with me.
I am currently involved in work on how to boost self-efficacy in claimants in personal injury and compensation benefit systems.
Several years ago I led some research which took training in health literacy for people with chronic disease, and adapted the program for self-management support for people with chronic musculoskeletal disorders who were receiving workers’ compensation benefits.
In other words, helping people navigate the insurance and return-to-work system, as opposed to the health services system.
We were unable to demonstrate a significant difference between our test group and the control, but it was clear to the research team that self-management support interventions had potential.
Readiness for change is vital
We concluded the readiness for change was important.
For example, if training, information or peer support was offered too early after becoming unwell, injured workers may not yet be ready to be a more active participant in their recovery; too late, and they may be experiencing significant secondary psychological problems, that created barriers to their participation.
We concluded using one of the tools available to screen for readiness for change was worth considering. One of the key researchers on the project took those ideas and further developed them with IPAR, a vocational rehabilitation services company. Their program, Positivum, is being evaluated, with promising results.
We have included employee awareness as a priority area in the Collaborative Partnership to Improve Work Participation (OHN 14/03/18). Foundation partner EML is leading this stream of work.
The project proposes to draw together examples of the emerging practices that are starting to pop up, and consider them in light of an evidence-based conceptual framework.
As always there is much to be learned from the holistic approach to health and healing of our ancient forebears – the real inventors of the biopsychosocial model. But this time round, maybe lose the snakes.
First published in Thomson Reuters Inside OHS, 03/07/2018
Inside OHS Editor: Helen Jones; (02) 8587 7683; helen.jones@thomsonreuters.com
Posted on March 26, 2018 in WHS
On Saturday I gave a seminar to AFOEM NSW. 42 people registered, 32 in the room and 10 online. My topic was Emerging best practice for case management by insurance schemes: Implications for occupational physicians (you can view the presentation here). The bulk of the presentation was on the best practice framework Safe Work Australia released in Dec. This was adapted by them from the framework for the life insurance industry SuperFriend released in 2016 (I led a consultancy team that did this work). However I spoke about the Collaborative Partnership for Improving Work Participation as well. There were two discussion points where people broke into groups and talked about the following:
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- What would be the optimum relative roles of treating doctors, IMEs, claims managers, vocational rehab advisors (insurers), vocational rehab advisors (employers) in RAW, RTW?
- Which of the following trends will have most impact on your work, and how?
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- PoC centred management led by claims manager
- Enhanced support for employers by insurers
- Greater co-ordination of key players using case conferencing, face to face meetings, online platforms
- Expectation of evidence-based healthcare from health providers by insurers
- Triaging and decision support tools/automation
- Integrated work disability management
- Better measurement of health, social and financial outcomes.
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The audience were engaged, and the discussion was good. We were fortunate to have a senior claims manager from iCare, the rest occupational physicians. A summary of discussion outcomes is below. Note the idea that we need a flexible case by case approach, depending on the capacity and capability of the various players, but there is a need to define who is going to be the conductor.
Relative roles of GPs to insurers and employers
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- Role for GPs is diagnosis, treatment, prognosis and management
- Most GPs don’t understand workplaces, so whilst they have a role in RTW, they need help from case managers, either co-ordinators in workplaces or claims managers in insurers. These decisions are not medical. Recognition that some GPs do have skills in workplace health and rehabilitation, so they may be able to play a greater role in co-ordination, but most do not and do not want this role
- They need to contribute to communication
- Occupational physicians could be playing a bigger role – especially in complex cases. Referral to them by GPs and others much earlier for treatment and management of complex cases would be a good use of occupational physicians
- Idea proposed that a flexible approach is required in that the treating doctors may or may not have skills, the employer may or may not have capacity – this would point to rather than having fixed rules about who does what, we need to a define a system where someone is ‘conducting’ the ‘orchestra’, and making decisions about how best to apply available resources. The question was posed ‘Should the conductor be the claims manager, or should it be someone else?’
- Recognised that the aim is for the insurer, the employer, the GP and the worker to all be happy
- Discussion of advocacy by GP, definitely will advocate for patient and family, not a broker between employer and employee
- Lack of confidence in claims managers, most of them seen to be unskilled, junior – occupational physicians get annoyed when they are told what to do by them
- Comment made that insurers should have lists of preferred providers in physio and psych, and use them.
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Which trends will have the most impact on occupational physicians?
All three groups nominated [3] (greater co-ordination of stakeholders) and [4] (expectation of evidence based health care). They saw this in terms of an opportunity for occupational physicians. Whether people would pay for occupational physicians (an expensive resource) to co-ordinate was raised by me, but the group considered that until online platforms are better developed they can play a useful role, particularly in relation to liaison with other health providers. The move towards greater expectations of evidence-based care was seen as a good opportunity for occupational physicians, in terms of determining guides on evidence-based care. It was recognised AFOEM could play a role here potentially.
[6] (integrated approach to work disability) was nominated by two groups
[1] (person on claim centred management), [2] (increased support for employers), and [7] (measurement of health and social outcomes) were each nominated by a group.
Posted on April 29, 2017 in Inside OHS articles
The International Convention Centre (ICC) in Birmingham is one of those in the middle-of-nowhere, vast complexes. However, the sense of desolation as I made my way from the railway station that delivers you into the heart of the complex through endless empty pavilions and past a man-made lake edged with daffodils, themselves struggling to be cheerful, was mitigated by the realisation that Crufts opened in the very same complex as the Health and Wellbeing at Work conference. Crufts, the most famous dog show in the world, the show that inspired the film ‘Best in Show’, was on my bucket list. And that is despite the fact I am a cat person. Crufts was opening the day I was leaving the ICC, and in the meantime I could watch it being set up. Tick.
I was at the conference to co-chair a session on future directions in return to work (RTW) with that honorary Australian, Dame Carol Black.
Three academics presented: Professor Mark Gabbay, University of Liverpool; Professor Alex Collie, Monash University; and Dr Agnieszka (Iggy) Kosny, Institute of Work and Health, Canada. They were joined on a panel by Dr Paul Litchfield, BT Group; Monica Garcia, Swiss Re; Professor Debbie Cohen, Cardiff University; Mark Amour, Association of Chartered Physiotherapists in Occupational and Ergonomics; and Hugh Robertson, Trades Union Centre, to discuss this issue.
This discussion was held in the context of a government focus on “what it will take to transform employment prospects of people with disabilities and long term conditions” as Gina Radford, the Deputy Chief Medical Officer, speaking on behalf of the Department of Work and Pensions and the Department of Health, had said earlier in the day.
The ‘Fit Note’ needs clarity: Panel
Consultation on a Work Health and Disability Green Paper had just closed; but according to Radford the Fit Note was already under review.
I thought the attitudes expressed during the panel discussion could be grouped into three:
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- The Fit Note needs better support to be properly implemented and achieve its potential – in the UK context this means embedding OHS expertise into primary care. After Carol Black’s review in the late 90s, OHS units were set up to provide advice on RTW to employers and general practitioners (GPs). These have been used by employers but not doctors. Alex Collie was concerned enough about the negative view of the Fit Note to write a thoughtful piece on LinkedIn after participating on the panel, essentially saying don’t throw the baby out with the bath water. Or to use epidemiology-speak, the certification of capacity is necessary but not sufficient for RTW.
- Roles of key players in the RTW system require clarification and better coordination – RTW requires medical, employment and insurance decisions, one person cannot make all of these, and currently inputs are not well co-ordinated.
- The RTW system needs to be reviewed (back to basics). This is a more disruptive view, which recognizes that there are huge changes underway in health care and work and that we need to be designing RTW for future systems, not current.
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As well as providing better support for the Fit Note, ideas for improvement were generated during the discussion.
Evidence base confirms need for broadened focus
Those ideas included:
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- Clarify roles of primary health care providers and rehabilitation providers (funded by employers, insurers and others).
- Develop a shared understanding of work as a health outcome (health benefits of good work) across all stakeholders in the community including workers and their families, via a public health type campaign;
- Eliminate certification for sickness absence. This would become a matter between employers and workers with health care providers giving advice as needed. There are examples of this in practice already; and
- Provide programs to workers via third parties to support self-management of their recovery. There are examples of this in practice already. More complex cases will require case managers, but there are many ways such services could be provided.
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In short it seems to me that we are realising an intervention that focuses on one actor alone in the system, the GP, has not worked very well. In reality we have acknowledged this in practice for a long time.
The evidence base for this was confirmed recently in a comprehensive international systematic evidence review on interventions for RTW for musculoskeletal disorders and mental health conditions undertaken jointly by the Institute of Work and Health in Canada and the Institute for Safety, Compensation and Recovery Research here. This review found there was strong evidence of effectiveness for interventions that operated across multiple domains.
Traditionally this would have meant improving co-ordination of health care providers, employers and workers compensation insurers, but in recent conversations there is growing realisation of the alignment between workers’ compensation, life insurance, superannuation and disability support.
NHS CEO: Public sector will lead by example
The potential to forge new partnerships with the aim of improving work participation of people with health conditions and disability no matter what the cause is starting to excite exploration. This is clearly the approach being taken in the UK, where the management of work-related conditions is not separated from healthcare as it is here.
Simon Stephens, the brilliant National Health Service CEO, spoke at the Health and Wellbeing at Work conference. He acknowledged that those of us who have been working in this field for a long time had been professionally marginalised, but said that now employers and workers needed our skills to improve work participation by people with health conditions.
His interest lies in the expectation by government that the public sector will lead by example in achieving this.
Collaborative partnership between govt, regulator, researchers and insurers
At a workshop in early April held by SuperFriend, insurers and employers, with a few others, came together to discuss what support the insurance industry could best offer employers.
The portrayal of the current relationship between insurers and employers was dire, especially by small to medium employers.
On the other hand the potential for insurers, employers, health care providers and superannuation funds to come together in innovative partnerships to provide work-place based support at a time of need rather than crisis, to prevent claims and a damaging long duration off work, was tantalising.
The Collaborative Partnership for Work Participation (the Partnership), something I am heavily involved with, is now underway. Chaired by Comcare CEO Jennifer Taylor, its core membership comprises the Insurance Council of Australia, EML insurance, Department of Employment, Department of Social Services, the Australian Council of Trade Unions and the Australasian Faculty of Occupational and Environmental Medicine.
Other organisations are participating in its projects, the first of which is research to explore the movement of people across the sectors in the system: workers’ compensation, life insurance, superannuation, health care and disability support; to describe the system as a whole, especially the interfaces between sectors, with the view to identifying areas for improvement.
Meanwhile Safe Work Australia (SWA) has a project focussing on developing a national approach to the provision of support to GPs for RTW.
The Partnership and (SWA) will collaborate to ensure that the national approach can be used cross-sectorally. That is, start to acknowledge and address the current problem that GPs face in having different advice and tools from workers’ compensation, life insurance, medical retirement and disability support.
There is a lot going on in this area internationally.
Whilst there will be variations driven by differences in systems between nations, there is much to be had from communication and possibly collaboration in this improvement effort. Australia can and should aim for a RTW system that is best in show.
First published in Thomson Reuters Inside OHS, 26/04/2017
Inside OHS Editor: Stephanie D’Souza; (02) 8587 7684; Stephanie.D’Souza@thomsonreuters.com
A best practice framework for the Management of Psychological Claims: But where are we up to in practice?
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Posted on October 28, 2016 in WHS
Congratulations Howard Williams, one of the organisers of this year’s ALUCA conference, on a great conference. Held in Adelaide, numbers were up this year to 400. The opening address by futurist Gihan Perera was terrific.
I spoke in one of the parallel sessions on 20 October. Recently, I was a judge on the Swiss Re, ALUCA and Insurance Council of Australia awards for innovation in return to work. As always, this was a worthwhile experience as it gave me insight into the state of best practice across the industry.
In my presentation, I compared current practice in the life insurance industry, as evidenced by submissions for the awards, to best practice as described in the framework for the management of psychological injury, which was developed for SuperFriend by Anne-Marie Feyer, Jane Palmer and myself. I concluded that the life insurance industry is off and running in innovation of claims management at the micro level (that is, making claims processes client-centric and outcomes focused), and was in the early stages of exploration of partnership with superannuation funds and employers to get earlier intervention (macro level) but was neglecting meso level interventions. Meso level interventions are things the industry could be doing themselves, such as using product design to get better client outcomes and better use of analytics to manage claims (not just triage claims). Also, there is plenty more potential in bringing evidence to medical treatment and rehabilitation. Finally I concluded that there was scope to bring more rigour to the evaluation and continuous improvement processes underpinning current innovations. EML’s winning submission in workers compensation was a good example of what can be achieved with partnership with a university. You can view my presentation here.
Watch out workers compensation, I am finding the life insurance sector is taking a more innovative approach to their work these days. In conversations I have had with the workers compensation sector, too often a lack of innovative thought is excused by the constraints of regulation.
Posted on May 12, 2016 in WHS
I attended the Northern Queensland conference on return to work (RTW) in Townsville on Friday 29 April. This was a terrific conference.
Professor Alex Collie, ISCRR, gave an update on the evidence on engaging GPs in the RTW process. He showed that the proportion of certificates in Australia that are fit certificates as opposed to sick certificates is increasing, but that contrary to expectations that proportion is not greater in doctors who see a lot of workers’ compensation cases. Furthermore the likelihood of a fit certificate being written varies hugely with the nature of the condition – not many for mental health.
Estelle Pearson from Finity talked about big data. Automation of decision making in workers compensation claims management is starting to happen. Huge potential – clone your best claims manager!
A panel discussed a nightmare of a case study and demonstrated that we really need to get out of the bog of compensation minutae and upstream to improving ability to deal with issues early in workplaces.
I spoke on the future of RTW based on some work I did in the life insurance sector for SuperFriend and some more recent work for Comcare on a national cross-sectoral approach to common issues. Click here to download my conference presentation.
But the bottom line, I think, is the question, Does workers’ compensation do more harm than good?