Injured workers kept on the radar

A dedicated team of health professionals helped apprentice plumber Scott Stokes to return to work after a debilitating accident. Photo / Natalie Slade

Apprentice plumber Scott Stokes is a guinea pig for a new way of treating injured workers.

Mr Stokes, 21, of New Lynn, lost his hearing in one ear and most hearing in the other ear in a savage assault at a party last August. His nose bled, his jaw and chest throbbed, and doctors weren't sure initially what else had been damaged.

In most other places, his doctor would simply have written a note to his employer saying he was unfit for work. But in West and North Auckland, things have changed. For the past year, doctors in the Healthwest, Waiora and Harbour Health consortiums have trialled a new Accident Compensation Corporation programme that pays doctors to get their injured patients back to work as soon as possible.

For Mr Stokes, it still took two months. But the Better@Work programme meant that everyone involved had a plan for his return almost from the start.

His ear, nose and throat specialist advised him to see his family doctor, Craig King. Dr King referred him to Healthwest Better@Work coordinator Didje Zwart, who quickly set up a joint meeting with Mr Stokes and his bosses at the property maintenance company Henshaw - chief operating officer Tom Lavery and health and safety manager Sally Romano. The bosses agreed to keep his job open even though at that stage it seemed possible he had suffered serious brain damage. His memory was affected.

Ms Zwart kept meeting him and the company every week, and then every fortnight, as it gradually became clear that his hearing was the main problem. Finally everyone agreed on a two-week unpaid trial back in his old job with a colleague alongside him. The trial revealed problems. He depended on reading text messages now that he could no longer hear properly, and the display screen on his standard company cellphone was too small.

ACC funded a new cellphone with a bigger display screen. They bought him a vibrating alarm clock to wake him up in the mornings, and new ear muffs which didn't interfere with his hearing aid. (They refused, however, to pay for the hearing aid on the grounds of a pre-existing degenerative condition.)

Satisfied at last that he could work safely, the company took him back into his old job.

"I was eager to get back to work," he says.

"Being on ACC for two months, not being allowed to do anything, is not very exciting."

Better@Work, which began in Taupo and Hawkes Bay, has been praised by the Government's Welfare Working Group as a model for getting many of our 145,000 sickness and invalid beneficiaries into work. The group's final report is due on Tuesday.

But the programme's profit-sharing incentive for doctors has sparked ethical concerns. Council of Trade Unions president Helen Kelly, who sits on the scheme's steering group, fears that its goal of helping people who want to work is being undermined by the Government's drive to cut ACC and welfare costs.

"This [programme] was all done under Labour before ACC was under pressure," she says. "I'm worried that its authenticity now will be corrupted."

As ACC clinical services director Dr Kevin Morris describes it, the scheme is inspired by a sea-change in medical thinking about the health risks of not working.

"Being out of work more than six months has an equivalent effect of smoking 10 packets of cigarettes [200 cigarettes] a day," he says.

"The suicide risk in young men aged 18 to 24 who have been out of work more than six months is 40 times higher than for those in work. We are talking about effects on mortality - people die."

ACC says on its website: "Evidence now clearly indicates that prolonged rest may be harmful - it can delay recovery, increase the risk of chronic pain, and increases the risk of adverse complications from prolonged inactivity."

NZ Medical Association chairman Dr Peter Foley agrees. "As an example, for bad sciatica [nerve-related leg pain], more than three days rest is counter-productive," he says.

Thomas O'Neill, a Hawkes Bay organiser for the Service and Food Workers Union, says most injured workers also want to get back to work and feel helpless when employers won't let them back until they're "100 per cent".

"It's the worst feeling in the world when people have basically been pushed out of a job," he says. "I think everyone recognises that people just go downhill really quick."

Until now, ACC's response has been slow. Matt Moss, Harbour Health's Better@Work manager, says the corporation typically took two or three weeks to accept a claim and get a contracted occupational therapist to assess a work site and draw up a return-to-work plan.

Raywin Head, compliance manager for Northcote-based transport and excavation company Smith and Davies, says: "ACC is so overworked I spend all my time chasing them. As soon as I find out who [an injured worker's] case manager is, I'm on to them like a shot."

"I just got one man back who was off for two and a half years and had 16 case managers in that time," she says. "Nobody had done anything until I said, 'This is enough!' He had been helping his mate in his lawnmowing business. As soon as I found out, he was back at work within three weeks!"

Better@Work steps in as soon as an injured worker turns up at a doctor's clinic. ACC pays the doctor an extra $50 to spend an extra 15 minutes with the patient to discuss their work and write a report on what they can do, as well as what they can't do.

The doctor's report is transmitted instantly to a Better@Work coordinator in the clinic's primary health organisation (PHO), who must negotiate a return-to-work plan with the injured worker and the employer within five days.

Dr Glen Davies, a Taupo doctor who worried at first that the scheme might pressure people back to work, now sees it as a rare case of "everyone wins". Workers keep their jobs, employers keep their workers, and no one loses money because workers can get partial ACC payments as long as they can't work at full strength.

ACC compo, which is 80 per cent of workers' former wages if they can't work at all, is not reduced until the employer pays more than 20 per cent of the former wage.

"The employer makes a decision about how much useful work they contribute and only has to pay for that," Dr Davies says. "So the person may be working four hours a day but only at half-strength so the employer would only pay for two hours [25 per cent of the wage]. ACC would pay the other six [75 per cent]."

Sometimes a gradual return to work is not feasible. Taupo Better@Work co-ordinator Joanne Mintoft says 30 to 35 per cent of the cases she sees just have to wait until they get better. Forestry crews are an example.

"It's a high-risk environment," she says. "They are quite strict that they want people out there to be fully fit."

But for the other two-thirds of her clients, she negotiates a gradual return. Jeremy Mihaka-Dyer, who ran the Lake Taupo PHO until last October, says the scheme cut $1.1 million off the district's ACC weekly compo costs in its first year - a saving of almost 10 per cent. The net saving to ACC, after paying the doctors' fees and Ms Mintoft's salary, was between $900,000 and $950,000.

The scheme's most controversial element is that ACC pays half of that net profit back to the doctors as an inducement to use the scheme.

Ms Kelly says unions objected to the profit-sharing because it risked "warping" the scheme.

The Medical Council said last year that the arrangement raised important ethical issues.

"Placing ourselves in a position of personal gain for decisions involving complex and imprecise clinical information invites both the reality and the appearance of biased judgment," it said. "This is not a comfortable place for a doctor to be in and is therefore best avoided."

But the five PHOs in the trial have all taken the money on the basis that it will go to projects such as equipment and professional development, and not to doctors personally.

"I get paid no more money," says Dr Foley.

Mr Mihaka-Dyer says the profit-share is only for two years. "It was only ever a kickstart to get everyone moving."

Dr Morris says it may be dropped when Better@Work is rolled out nationally from mid-year because doctors in the pilot said it was "not a big factor for them".

But the Welfare Working Group praised the profit-share in its interim report last November as "an example of how financial incentives can be used to alter general practitioner behaviour".

The group, chaired by economist Paula Rebstock, sees doctors as gatekeepers who make beneficiaries think they can't work by giving them a medical certificate.

Work and Income has already introduced a new certificate asking doctors to say whether applicants for sickness or invalid benefits will be capable of part-time or fulltime work or training in the next three, six or 12 months.

Ms Rebstock is likely to propose further changes along the lines of a recent British switch from "sick notes" to "fit notes" which encourage doctors to advise patients about what kinds of work could help their recovery. Beyond that, the main lesson from Better@Work is the value of pulling all parties together to plan a return to work from the start.

The lessons are most obvious for those who go straight from work on to a sickness or invalid benefit - about a third of those who go on to those benefits each year.

The other two-thirds of sickness and invalid beneficiaries, who may have been out of work for years because of chronic physical or mental conditions, are a tougher challenge. But doctors who work with them, such as Dr Siobhan Trevellyan at the Waitakere Union Health Centre, would love to try a Better@Work approach.

"It's a matter of practising in a holistic way. People generally are happier earning money, being productive. If we can help them to do that, we should be doing it."