A warehouse picker strained her shoulder. The GP set a graded plan and the employer offered her modified duties with a light-lift limit. The physio request came back partially approved ('two sessions first’). Before they could start, the insurer paused processing to seek previous imaging and a new certificate to fix a date mismatch. The case then moved to another case manager. By week 6, the worker had more appointments than active rehab sessions. She now described herself as ‘injured’.

A ’harm-forward thesis’ — when bureaucracy is a clinical risk factor

Administrative delays aren't neutral holding patterns. As noted in other articles in this series, delays contribute to poorer outcomes, greater frustration and poorer reported health. While waiting, people learn to be patients rather than workers who are recovering. The queue is doing harm.

When approval processes fragment care into multiple decision points, each queue creates a pause. Time spent waiting is time spent deconditioning. 
These delays invite cascades that are documented elsewhere in this series:

• Imaging ordered 'to be thorough' while waiting for approvals triggers pathologising language, further referrals and treatment drift away from active rehabilitation.
• Opioids prescribed 'until physio starts' become longer-term exposures when those sessions are delayed by weeks.
• Repeated assessments to verify capacity add their own queues, shifting focus from function to defensibility.

Compensation cohorts start with higher baseline psychological distress than the general population (1). This means delays and adversarial processes have outsized impacts. Waiting periods amplify fear-avoidance, entrench protective behaviours and increase the risk of secondary mental ill health.

The patient role hardens

As queues extend, identity shifts. Workers move from being a ‘person recovering from injury’ to ‘person proving a claim’. Appointments multiply. Certificates continue. Language in reports emphasises damage and limitation rather than capacity. Over weeks and months, the sick role becomes the default.

Stepped care models — where access to higher-level interventions depends on failing lower-level treatments — can amplify this pattern in compensable settings. A typical pathway is: standard physiotherapy for 12 weeks, then specialist referral if things are not improving, then imaging, then procedures, then pain programs. At each step, approvals and scheduling add weeks. Australian trials of early, risk-stratified intervention show there are substantially fewer lost work days (around halved over 2 years) compared with usual stepped care, precisely because the wait is removed (2).

The administrative framework itself can reinforce this trajectory. When approvals slice care into many small decisions, attention stays on paperwork rather than progress. Financial and administrative settings can unintentionally favour caution: if partial recovery risks loss of income or support before sustainable work capacity is rebuilt, staying in treatment can feel safer than attempting progression.

Social networks can shift accordingly. Regular appointments, practitioner relationships, legal advisors and peer groups form around the claim itself. These provide support, but they can also normalise ongoing incapacity and raise the psychological cost of stepping away from the patient role.

What we've known — and what we overlook

For most musculoskeletal injuries, recovery depends on graded activity, self-efficacy and timely return to routine. We have service targets and approval timeframes in policy documents, but we rarely publish actual request-to-decision intervals or link them to functional outcomes. Without transparent measurement, delays remain invisible in performance reporting.

The processes exist for good reasons — audit requirements, fraud prevention, defensibility. But decades of research show that beyond short timeframes, delays predict worse outcomes regardless of injury severity.

Why this matters for schemes

Delays shift resources from restorative care to holding patterns. They lengthen time-loss, increase medication exposure and inflate costs without adding value. Workers whose straightforward injuries become complex disabilities consume disproportionate scheme resources — and represent most of the human suffering in these systems.

The perpetual patient pathway converts recoverable injuries into long claims. People spend more time away from work and ordinary life. Behind each median claim duration is someone whose confidence we've eroded and whose return to normal life we've delayed — often through administrative settings rather than clinical necessity.

Questions for discussion

• Should schemes publicly report request-to-decision times (median and 90th percentile) at scheme and agent level, linked to 3/6/12-month RTW outcomes?
• What treatments should be auto-approved within X days for common MSK injuries (for example, an initial block of physiotherapy or active rehabilitation) unless red flags are documented, with simple functional outcome checks to extend or taper care rather than multiple pre-approvals?
• Which metrics best indicate scheme performance in reducing time in limbo: days to first effective treatment, time in work-focused rehabilitation or time on certificates stating capacities rather than ‘unfit’?

Reference

1.  Collie A, Sheehan L, Lane TJ, Iles R. Psychological Distress in Workers' Compensation Claimants: Prevalence, Predictors and Mental Health Service Use. J Occup Rehabil. 2020 Jun;30(2):194-202. doi: 10.1007/s10926-019-09862-1.

2. Nicholas MK, Costa DSJ, Linton SJ, et al. Implementation of early intervention protocol in Australia for 'high-risk' injured workers is associated with fewer lost work days over 2 years than usual (stepped) care. J Occup Rehabil. 2020, 30(1):93–104. doi:10.1007/s10926-019-09849-y