Rehabilitation and return to work of personal injury claimants

Abstract

This study examines the rehabilitation and return to work of patients who received severe injuries at work or in road traffic accidents and whose subsequent claims for compensation for personal injury were settled by one insurance company for £5,000 or more. The study has two anchoring points - an evaluative account of the development, scope and effectiveness of vocational rehabilitation in Great Britain and a review of the operation of the British medicolegal system.

Against this background, three analyses are reported. The first, based on a review of insurance company claims files, comprises a comparison from relevant personal, medical, occupational and procedural perspectives of (a) 209 employers' liability (EL) claimants and (b) 609 third party motor claimants who were of working age and in employment when injured. The second, based on representative samples of 93 EL and 101 motor claimants, uses stepwise logistic regression analysis to develop a model to predict return to work by settlement. It also describes the construction in accordance with basic psychometric procedures of a Vocational Rehabilitation (VR) Index to identify, amongst claimants who have not returned to work within a year of injury, those who might be helped to do so by referral to appropriate rehabilitation services. The third analysis, based on a series of 602 medical reports prepared by 388 consultants and 12 GPs on representative samples of 94 EL and 109 motor claimants, switches attention to medical contributions to the medicolegal system. Two evaluations are reported, one of consultants' compliance with published guidance on medicolegal reporting and the other a content analysis of reporting on individual claimants, paying particular attention to coverage of such occupationally relevant topics as assessment of residual disability and advice on employment handicap. Results show that the majority of personal injury claimants return to work before settlement. Involvement in litigation therefore is not the deterrent to return to work it is sometimes held to be.

Nevertheless, a substantial minority whose medical treatment is completed successfully do not re-enter the labour market before their claims are settled. Very few of the latter have any contact with relevant rehabilitation services, despite the opportunities for referral during an interval of two years, on average, between completion of medical treatment and settlement. Psychological variables highlighted by previous research, however, may be less powerful determinants of outcome than iatrogenic factors, including some medical management of disability practices. Statistical analysis of determinants of employment outcome at 12 months and at settlement suggests that clinical variables generally are poor predictors of return to work. Evidence that time away from work is the most powerful predictor of employment outcome reveals a window of opportunity around one year after injury when rehabilitative help could be most beneficial. Evaluation of the VR Index suggests that it can be used at this stage to identify which claimants might benefit most from referral to rehabilitation and, possibly, the kind of assistance they require. Analysis of medicolegal reporting reveals a high standard of coverage of clinical topics, but considerable scope to improve such other aspects as assessment of residual disability and advice on employment handicap and/or to involve other professions or services which can help with these aspects.

The study poses questions about coverage of occupationally relevant topics in medical reports and about the incorporation of early intervention strategies in the medical management of disability. In view of a continuing gulf between medical and vocational rehabilitation services in Great Britain, however, its main implications concern the need to inject new, vocationally oriented, case co-ordinating expertise into the medicolegal system, and the part that insurers can play by introducing at the earliest opportunity appropriate rehabilitation counselling services for claimants.