REHABILITATION AND LONG TERM CARE OF SEVERE NEUROLOGICAL INJURY
The Important Role of Compensation
DR DAVID C BURKE *
INTRODUCTION
The background for this paper is over forty years’ experience as a Consultant Physician in the practice of Rehabilitation Medicine, principally in the areas of spinal cord rehabilitation and brain injury rehabilitation. My career has been roughly divided into two halves, the first half specializing in spinal cord rehabilitation at the Austin Hospital in Melbourne, and the second half principally in brain injury rehabilitation at Bethesda Hospital, Royal Talbot Rehabilitation Centre and Ivanhoe Private Rehabilitation Hospital in Victoria, and the South West Brain Injury Rehabilitation Service in Albury, New South Wales.
I have also had over forty years’ experience in preparing medico-legal reports for plaintiff and defendant solicitors, as well as to insurance and compensation organizations, work that has been undertaken in all States and Territories of Australia, though principally in recent years in Victoria, Tasmania, South Australia and Western Australia. I am familiar with the different compensation schemes throughout Australia, particularly with respect to motor accident victims, as this has been the principal cause of the injuries to the patients with whom I have been involved, either as a treating doctor or as an independent medico-legal expert.
CAUSES OF SEVERE DISABILITY FROM INJURY IN AUSTRALIA
Unlike many other countries, where industrial injuries, violence (stabbings and gunshot wounds) and of course war injuries are common, the major causes of severe disability resulting from injury in Australia are motor vehicle accidents and, to a much lesser extent, work injuries , sporting, recreational and domestic accidents. There is also a small number resulting from medical and other health service misadventure. Of course, many severe disabilities are also caused by a variety of illnesses and developmental/birth abnormalities, but I will limit this paper to discussing severe disability from traumatic causes, and in this country that is predominantly motor vehicle accidents.
What, therefore, are the causes of severe disability from trauma in Australia? These include injuries to the spinal cord, traumatic brain injury, severe musculoskeletal injuries, including particularly multiple fractures, amputations, burns, and soft tissue injuries which while rarely causing much tissue damage can result in severe disability from chronic pain. Other severe disabilities can result from impairment of vision and hearing, disfigurement, and from injuries to other nerves, such as the nerves of the brachial plexus, or peripheral nerve injuries.
Spinal Cord Injuries
A minority of injuries to the spine result in injuries to the spinal cord, but these injuries result in the particularly severe disabilities of paraplegia and tetraplegia (quadriplegia). The incidence of spinal cord injuries in Australia has decreased in recent years due to improved road safety measures, such as seatbelts, airbags, etc., but nevertheless there are still probably between 20 and 25 new spinal cord injuries per million population per year – still far too many of these severe injuries.
Paraplegia results in loss of all movement and feeling (sensation) below the level of injury and the severity of disability depends on the level of injury and the severity of the injury to the spinal cord or nerve roots of the cauda equina. A patient with an injury in the upper thoracic spine, around the nipple level, for example, has a more severe disability than somebody with a lumbar level injury, which affects the legs but not the trunk.
Spinal cord injuries also result in loss of normal control of bladder and bowel and have a severe affect on genital sexual function. Spinal cord injuries may be complete or incomplete. A complete lesion indicates that there is no motor or sensory function below the level of injury, whereas an incomplete lesion results in a partial loss of movement and/or feeling below the level. Incomplete injuries can vary from almost normal up to almost complete, and are more common than complete lesions in a ratio of about 60:40.
Tetraplegia (the more correct term, given that it is a double Greek word ,than quadriplegia, which is a bastardization of Latin and Greek) results from injuries to the spinal cord in the cervical spine (the neck), and as well as causing loss of motor control and sensation in the trunk and lower limbs, also has variable effects in the upper extremities, again the higher the lesion the more severe the disability.
Very few tetraplegics survive the injury with no use at all of their upper extremities; most retain at least some shoulder and elbow movement and perhaps wrist movement, but most lose normal control of hands. As with paraplegia, there is also loss of normal control of bladder and bowel and genital sexual function, and also there are complete and incomplete spinal cord injuries resulting in varying levels of disability and, again, the incomplete group significantly outnumber the complete group.
Overall, cervical injuries are more common than injuries to the spinal cord in the thoracic and lumbar spine.
Traumatic Brain Injury
Whereas spinal cord injuries have been well understood in the medical world (and adequately treated) since the Second World War, the understanding and treatment, including rehabilitation of traumatic brain injuries has been a more recent phenomenon, probably mainly since the 1980’s.
Injuries to the brain are much more complex than those to the spinal cord and also are far more common injuries. It is usual to refer to these injuries as injuries to the brain, rather than “head injuries”, because the head includes a variety of other structures in addition to the brain, including the nose, eyes, ears, etc., as well as the skull which encases the brain. The brain is a far more complex organ than the spinal cord, and injuries to the brain, as well as involving prolonged loss of consciousness, may also include long term severe disabilities of cognition, speech and language, behaviour control and, of course, physical function, the latter being relatively less important compared to spinal cord injuries, where the physical disabilities are dominant.
The cognitive and behavioural disabilities resulting from brain injuries are relatively more important functionally than the physical disabilities, though the latter, and speech and language disabilities ,may also be important, as well as impairments of hearing, smell and taste, and vision. Unfortunately, brain injuries often result in a mix of these various disabilities to a varying level of severity, compounded further by the fact that injuries to the brain not only involve the so called fore-brain or cerebral hemispheres, but also injuries to the mid-brain and brain stem, the latter being particularly important as most of the cranial nerves controlling eyesight, hearing, smell, taste, etc., are situated there, as well as containing important pathways in the control of conscious level (arousal) and control of muscle tone.
The cognitive disabilities resulting from injury to the brain involve impairment of memory, planning and organization, problem solving, as well as the more abstract functions of reasoning, etc. Speech and language disabilities affect not only clarity of speech (dysarthria) but also result in deficits of understanding of speech and the written word, as well as forming words and sentences, both verbally and non-verbally. That is, writing and reading can be affected as well as speech. Loss of concentration and excessive fatigue are also not uncommon cognitive deficits and, very importantly, from a functional point of view, the cognitive and/or speech language deficits affect the individual’s ability to learn. For this reason, these injuries are particularly devastating to children, whereas at least in adults they are able to retain some of their long term memory of things they have learnt before the injury.
Loss of behaviour control is also quite common after traumatic brain injury, and this can cause increased irritability and occasionally aggressiveness, as well as the opposite, of lack of initiative or adynamia, as well as a variety of other more subtle behaviour traits, such as obsessive compulsive behaviour and occasionally psychiatric-like conditions, as a variety of psychoses may be precipitated or caused by injury to the brain.
Physical deficits often are relatively minor compared to the above, but can involve severe physical disability, including loss of control of all four limbs (tetraplegia), hemiplegia (unilateral paralysis),but severe spasticity (which can also affect spinal cord injuries, but probably to a lesser extent) and a variety of movement disorders, such as ataxia or inco-ordination of movements can compound the physical disability.
Whereas the more severely disabled spinal cord injured patients (paraplegic and tetraplegic) would probably be confined to a wheelchair and would be unable to walk, or at best can only walk with difficulty with aids, the majority of patients with traumatic brain injury are not wheelchair confined and are much less likely than those with spinal cord injuries to have gait abnormalities, that is difficulty with walking.
Incidence.
Brain injuries are much more common than spinal cord injuries, but unfortunately we do not have any good statistics in this country or in any other country as to exactly how many occur in a given population. Whereas in Australia all spinal cord injuries are admitted to specialized units and can be counted reasonably accurately,
the same does not apply for patients with traumatic brain injury, who are admitted to a wide variety of hospitals, some for very short periods of time and many, with relatively minor injuries, not at all, which makes it almost impossible for any country to accurately count the number of brain injuries each year. We do know, however, that brain injuries far outnumber the spinal cord injuries.
Severity.
The effects, or the severity, of brain injuries also vary enormously and cannot be simply classified according to level or severity (complete or incomplete), as can spinal cord injuries. They are particularly difficult to classify with respect to severity because of the all prevailing cognitive deficits and behaviour disorders, which are difficult to quantify and therefore classify in a meaningful way.
There are many systems in use for classification of brain injuries, but none at this stage are widely accepted internationally as are the now well established spinal cord classifications.
Non traumatic brain injury.
In the context of brain injury, one should also include here a brief mention of hypoxic or anoxic brain injuries: injuries which occur from a brief loss of blood supply (oxygen) to the brain. This can result from near drownings, drug overdose, heart attacks and occasionally from medical misadventure. Effects of hypoxic brain damage are similar to those of traumatic brain injury, but tend to be more severe and with less chance of spontaneous recovery, as brain cells are particularly sensitive to deprivation of oxygen, whereas injured brain cells have some potential for recovery. Some patients with traumatic brain injury may also suffer additional hypoxic brain damage, from delays in resuscitation or complications, as examples.
Musculoskeletal Injuries
Multiple fractures to the lower limbs, particularly, and also to the upper limbs can result in severe and sometimes permanent disabilities, but usually the disabilities are not as severe as those that occur from injuries to the spinal cord and brain. A small number of severe musculoskeletal injuries can also result in traumatic amputation, either at the time of injury or subsequently through failed medical/surgical treatment, and of course can result in significant disabilities, particularly if multiple amputations occur in the one person.
Patients with severe burns (as has been highlighted recently in Victoria and in recent years with some of the overseas terrorist attacks) can result in severe and permanent disabilities, but the numbers in this country are relatively small compared to those affected by brain injury, particularly, and spinal cord injuries.
The very large number of patients with soft tissue injuries, resulting particularly from injuries to the neck and back, can result in a relatively small number with long term ,severe disability due to chronic pain disorders. Frequently these injuries are not associated with any significant organic injury and the complex interplay between physical injury, psychological factors and perhaps compensation issues in this large number of relatively minor injuries are beyond the scope of this paper, whilst not denying that they are an important group, particularly in the workplace rather more than from road accidents.
TREATMENT AND REHABILITATION
Spinal cord injuries
Acute treatment and rehabilitation of patients with spinal cord injuries in Australia is well co-ordinated in a small number of specialized spinal injuries units in each State, or at least in Perth, Adelaide, Melbourne, Sydney (two units) and Brisbane. Tasmanian patients are transferred immediately to the Austin Hospital in Melbourne, and the Northern Territory patients tend to be mainly treated in the Adelaide unit.
There is usually a seamless transfer of the patient from the acute care facility to the rehabilitation facility within the same city. In some cases the acute care and rehabilitation occurs at the same hospital, but where the rehabilitation facility is remote from the acute hospital there is close communication and co-ordination between the two facilities, often acting under the same service. For example, the Victorian Spinal Cord Service has its acute care facility at the Austin Hospital and rehabilitation facility at the Royal Talbot Rehabilitation Centre which is several kilometres away.
The acute treatment of spinal cord injury these days is frequently surgical, which has shortened the length of stay in hospital, but not necessarily improved the outcome with respect to recovery from the spinal cord injury to any significant degree. Rehabilitation of these patients commences from day one in the acute hospital and continues usually for some months in the rehabilitation facility, with the trend towards shorter overall stays in hospital, including the rehabilitation facility and a more active, community based rehabilitation programme after discharge from hospital.
Generally speaking, the length of stay of patients with paraplegia is shorter than those with tetraplegia.
In all States of Australia all patients with spinal cord injuries receive similar treatment, whether they are covered by a compensable scheme or not. That is, they all get the same acute treatment and rehabilitation regardless of compensation status. Significant differences, however, do occur after discharge from hospital (this will be discussed later).
Outcome.
The outcome of treatment and rehabilitation of patients with spinal cord injuries is such that little, if any, neurological recovery can be expected in those who present with a complete spinal cord lesion, whereas those with incomplete lesions can expect varying degrees of recovery, and for which early skilled surgical intervention can significantly improve outcome. Very few patients with even quite incomplete spinal cord lesions make a full neurological recovery, but significant neurological improvement can be expected in some patients and, consequently, greatly reduced disability.
Rehabilitation helps these patients overcome residual disabilities and to be able to return to the community as disabled people, but people who can return to active community life, including living independently in the community and returning to work.
Rehabilitation can take three to four months in hospital for a paraplegic and perhaps six to seven months for a tetraplegic, but with some continued rehabilitation services in the community after discharge from hospital, or occasionally to return to the rehabilitation facility at a later date for a further burst or top up of rehabilitation, or perhaps to learn a new technique.
Most paraplegic patients and some tetraplegic patients can learn to drive again, usually using specialized controls, such as hand controls.
Life expectation.
The life expectation in this day and age for most spinal cord patients is close to normal, but with some reduction likely to occur because of preventable complications, such as pressure sores, urinary infections and stones, respiratory infections, etc. The survival for paraplegic patients is better than those who are tetraplegic and those with incomplete lesions survive longer than those with complete lesions.
Spinal cord injured people are at risk of developing complications of their paralysis, some of which are mentioned above, and for this reason require lifetime follow up and support on return to the community, usually through the spinal unit in each State. This can require readmission to hospital for treatment of complications from time to time, but good follow up and support and care can do much to improve the life expectation of these patients.
Equipment.
Paraplegic and tetraplegic patients do require a certain amount of expensive specialized equipment, such as wheelchairs, which do need to be replaced from time to time, and it is in this area that the compensable patient is far better off than the non-compensable patient, so far as access to equipment after discharge from hospital is concerned (or even in some cases while still in their initial hospitalization).
Assistance with daily living.
The more disabled patients with spinal cord injuries will require assistance in their daily living on return to the community, particularly many of the tetraplegic patients, and this implies the employment of attendant carers or support workers, often on a daily basis, and for the more severely disabled, tetraplegics particularly, full-time care (24 hours a day). It is no longer appropriate for these people to be managed in aged care nursing homes, and if they are unable to manage in their own home in the community with supports, they are best provided with some form of age appropriate community housing, often group houses, where support workers can be shared. It is no longer appropriate for personal care to be provided by family members, their role should be to be family, not carer.
Follow up.
Lifelong medical follow up for these patients is required because of the risk of complications, as indicated above, and this is usually provided through the parent spinal unit in each State. In recent years the follow up of patients who live in rural and regional areas has been provided more frequently by satellite follow up centres throughout country regional centres, and this has proved to be particularly important for the Tasmanian patients and the Northern Territory patients.
The availability of ongoing carer support services, housing opportunities and ongoing rehabilitation services (where required) depends greatly on the availability of compensation, where this is available, and undoubtedly those without access to compensation do not have access to anywhere near as good backup as those with compensation claims.
Traumatic Brain Injuries
The acute management and rehabilitation of patients with traumatic brain injuries is not nearly as well organized or co-ordinated in each State as is the case with spinal cord injuries, though this does vary somewhat from State to State. One of the difficulties is that these injuries are far more common and are likely to be treated in a wide range of acute care hospitals, or perhaps not even in hospital at all.
Brain injuries can be broadly divided into three categories: mild, moderate or severe. Of these, over 80% are considered to be mild or minor brain injuries, some of which used to be called concussion, and this group can vary from almost normal, through to relatively significant disabilities, particularly with respect to cognition and behaviour. The moderately severe group, which is another 15% of all traumatic brain injuries, are significantly more disabled in physical, cognitive, speech and language and behaviour function, to a varying degree. This group often require extended periods of rehabilitation, perhaps up to a year, and may have difficulty in returning to live independently in the community without supports and may have difficulty returning to employment or education because of their disabilities. The severe group, which is only 5% of the total, are also in need of extended periods of rehabilitation, which may extend for as long as two to three years, have much poorer outcomes, even with quality rehabilitation, and are likely to require significant support services in the community, including 24 hours a day care in the most severe examples, and are unlikely to return to open employment or education.
Acute brain injury management may include emergency neurosurgery in some patients, which, if applied soon enough after injury, can result in significant recovery of function. However, a large group of patients with traumatic brain injury do not require surgery, either because their injury is not sufficiently severe to require surgery, or is too severe to justify the added risk of surgical intervention.
Rehabilitation.
Access of these patients to rehabilitation from the acute hospital is much more poorly organized and difficult to achieve in comparison with spinal cord injuries. There are a range of specialized and non-specialized rehabilitation services able to provide rehabilitation to patients with brain injuries in each State, both in the public and private sector, and the availability and quality of these services varies enormously from State to State. Because the patients are treated in a variety of acute hospitals and rehabilitation facilities, there is also much less opportunity for co-ordinated care between the acute hospital and the available rehabilitation facilities, and transfer to rehabilitation may be delayed or not possible for some patients with more severe injuries, or, alternatively, not considered necessary for the large number of those with lesser injuries Also, their compensable status can influence transfer to a rehabilitation facility For this reason, a significant proportion of patients with traumatic brain injuries in Australia never do get treated in a rehabilitation facility and will either return to the community with relatively minor but significant disabilities which are not recognized, or, if severe alternatively are sent home to their families with no support, or are “placed” in aged care nursing home facilities (which are not age appropriate) without even an opportunity for rehabilitation.
Access to rehabilitation services, particularly in some States and Territories, is also largely dependent upon whether or not the patient has a compensation claim.
As indicated above, brain injury rehabilitation often consumes much longer periods in hospital in a rehabilitation facility(as well as in acute hospitals), but pressure on hospital beds, including cost, has forced significant changes in recent years towards shorter stays and a trend more towards continuing rehabilitation in the community with what is called community based rehabilitation and, like the spinal cord group, this may include short periods of time in some form of group home facility. Unfortunately, some patients are still transferred to aged care nursing home facilities (in the absence of appropriate group housing) where unfortunately rehabilitation services are virtually non-existent.
Follow up.
The needs of the brain injured group on return to the community differ quite markedly from those with spinal cord injuries. Rather than requiring a predominantly medical based follow up service, these people will more likely require follow up by skilled occupational therapists and neuropsychologists, often with ongoing treatment needs through a physiotherapist and speech pathologist, with less recourse to specialist medical follow up, though this is also desirable, though probably not as much as with the spinal cord group. Medical complications in this group are less common than in the spinal cord group, though they do occur, and spasticity, particularly can be a major problem, as can post traumatic epilepsy.
The more frequent problems on return to the community for the brain injury group tend to fall predominantly in the psychosocial area because of their chronic cognitive and behaviour impairments. For this reason, the support workers and families needed to assist them in the community require different skills to those for the spinal cord group, as their assistance needs to be more in managing their cognitive and behaviour difficulties, rather than their physical disabilities.
Again, unfortunately, access to these support services and follow up is very much less available for the non-compensable group than those covered by a variety of compensable schemes.
Outcome.
As with the spinal cord group, the recovery from traumatic brain injury is limited in most cases, despite the latest advances in medical and surgical treatment, including rehabilitation, and, as with the spinal cord injuries, will frequently result in long term, permanent disability. The difference, however, is that recovery, to some extent, can be expected in those with brain injury, particularly the more severe injuries, over a longer period, perhaps two to three years or longer, whereas most spinal cord injury recovery will occur within a few weeks of injury, if it is going to occur.
The outcome of treatment and rehabilitation of patients with brain injury is often that the person will require ongoing support to live independently in the community, primarily for cognitive and psychological reasons rather more than physical reasons and, because of the frequent behavioural problems, can be very taxing on family members and carers over a long period of time.
Survival.
The survival of patients with brain injury is not nearly as well understood as it is with spinal cord injuries, where reasonably reliable statistical studies have enabled one to predict the expected outcome of spinal cord injury patients of different ages and severity with a reasonable degree of accuracy. Such information is simply not available for the brain injury group, probably because these people are not treated and followed up in such a closely co-ordinated and organized system as are the spinal cord patients in each State. Probably the life expectation of this group is reduced from normal also and this would be particularly true of those in the severe category, who are at a high risk of developing many of the similar complications to those with spinal cord injuries, such as chest infections, urinary infections and stones, and pressure sores, but with the added complication in the brain injured patient of post-traumatic epilepsy in some.
As with the spinal cord group, survival is to a considerable extent dependent on the quality of the follow up services and support services available on return to the community, which includes ready access to acute medical services when required.
THE ROLE OF COMPENSATION
It very apparent to those of us who work in the treatment and rehabilitation of patients with spinal cord injury and brain injury, particularly those who work with them in the community after discharge from rehabilitation, that the role of compensation varies enormously from State to State, as well as from the cause of the patient’s injury. Most of us are well aware of the gross inequities between those who receive some form of compensation and those who receive none, for example a patient with spinal cord injury from a diving accident or a patient injured as a result of assault.
Unfortunately, in Australia we have a mish mash of compensation schemes for motor accidents, varying from essentially no fault schemes in Victoria, Tasmania, Northern Territory, and now in New South Wales, to common law compensation schemes in the other States. The services available to patients who can prove fault of another person are far superior to that available for those who cannot prove fault in those States where common law systems continue. In contrast, the no fault schemes are available to all those who are injured, regardless of fault. However, the efficiency of the no fault schemes varies markedly from State to State.
In my view the Transport Accident Commission ("TAC") system in Victoria is far superior to those in the other States, such as, particularly, Tasmania and the Northern Territory, where I have had considerable experience of their schemes. I am less familiar with the relatively recently introduced lifetime care system in New South Wales. I think the jury is still out on that scheme at this time.
Having said that, I am firmly of the belief that no fault schemes are a far superior method of compensation for patients with severe neurological injuries than the common law schemes, which inevitably result in delays in compensation being received and the variability in the amount of compensation received (often depending on the skill of individual lawyers), quite apart from the undesirability of the adversarial system or approach which is inherent in the common law system. On the other hand, those who have the no fault scheme have to contend with bureaucracy, which at times can be somewhat daunting.
I will not discuss workers’ compensation schemes in this context because my theme is largely in motor accident cases, except to say that in my experience the workers’ compensation schemes in each State are much less efficient in delivering services to severely injured people than the no fault schemes of the motor accident insurers, because of an emphasis on “compensation” rather than services. In my opinion, it is far preferable for the severely disabled person to receive adequate rehabilitation and community support services than it is to receive monetary award for being disabled.
Having said that, though, one must appreciate that this support must be available to them for the rest of their life and that availability does vary in the no fault schemes of the different States, particularly in Tasmania where it is usually terminated by a lump sum settlement after a couple of years (akin to a common law settlement) and in the Northern Territory by the severe financial limitations of their scheme. Also, the disabled person will need to be compensated financially if unable to work, or at a reduced level, though one would hope that rehabilitation would include giving the person every opportunity to return to work
However, the common law compensation schemes create an even bigger problem for lifetime support because of the one-off nature of the lump sum settlement, which may prove to be inadequate over time, and of course the frequent, long delays in settlement of these claims in the courts. This is quite apart from unexpected costs which might eat into the capital sum awarded, as well as the possibility that the person or their relatives may misspend their money, or be defrauded, or worse the person dies soon after settlement and their relatives have an undeserved financial windfall. Also, one must appreciate that with the common law schemes alone there are a significant number of motor accident victims who do not receive compensation at all, for example the driver in a single vehicle accident, whereas these people are covered by no fault schemes.
One should also acknowledge that notwithstanding those fortuitously protected by a compensation scheme or have access to compensation through common law, for example in non road injuries, or workers compensation, there are still a large number of very severely disabled people each year in Australia with spinal cord injuries and brain injuries who are not eligible for any form of compensation, such as people who suffer diving injuries, are injured by assault, or in accidental falls.
CONCLUSION
It is a great pity that COAG, the Council of Australian Governments, missed a golden opportunity to correct these inequities and imbalances of compensation and rehabilitation schemes throughout Australia about four years ago when they commissioned a report to propose a no fault scheme for severe injuries throughout Australia, and to specifically include those injured in motor accidents, work injuries, sporting and recreational injuries and medical indemnity claims. Why the excellent scheme proposed ( which was based largely on the TAC motor accident compensation scheme in Victoria) failed says much of the difficulties of the States being able to agree with each other on anything, much less with the Federal government, quite apart from the well entrenched attitudes opposing such a scheme of the legal profession, the insurance industry and the union movement, who clearly would prefer to maintain the status quo.
Finally, it must be said that the role of compensation schemes are a vital part of the whole treatment and rehabilitation process of patients with these severe injuries and particularly important for their ongoing support in the community following discharge from rehabilitation. The publicly funded health system simply cannot provide the support for the severely injured that they require and is unlikely to be able to do so in the future as rehabilitation and disability support is way down the food chain in hospital and health funding.
Some form of compensation/ rehabilitation scheme for people with severe injuries is necessary to provide the ongoing support for people with severe neurological disabilities in the long term in the future. It is vitally important for those providing services for these people, either in the rehabilitation phase or subsequently in the community, that there is an ability to work closely with the insurance providers or compensation services in each State. I would reason that having a national scheme common to all States would be also allow a much easier movement of patients from one State to another, as differences in compensation schemes can seriously interfere with the movement of patients from one State to another.
It is not considered that the proposal to improve the compensation and rehabilitation services for brain injuries and spinal cord injuries in Australia is too difficult. New Zealand’s scheme does have it’s critics, perhaps we can learn from their mistakes (and successes). It need not be particularly financially hard to achieve, simply requiring the development of a closely integrated system of care, that is, integration between providers and payers of services.
Funding for such a scheme would readily be achieved through the motorist on the one hand (and other road users, such as cyclists), employers for work injuries, medical and other health professions for indemnity claims, and a modest tax surcharge for all other injuries, including recreational and domestic injuries. It is suggested that the cost of the Victorian motor accident scheme is far less than the cost to motorists in States where common law schemes alone continue and therefore that a national scheme covering all severe injuries would not be overly expensive, but its introduction does require a high level of co-operation between the States and Territories and the Federal Government on the one hand, and the various vested interest groups on the other, including the medical and allied health professions, the legal profession and the union movement.
* David Burke is a Consultant Physician in Rehabilitation Medicine
Copyright 2009. Greek Legal and Medical Conference