D-12 Linking to other services

Every locality has many services to assist people with disability to improve their life; some will use the term rehabilitation, but many use other terms such as enablement or intermediate care. Two figures illustrate the chaos graphically for a locality and people after trauma. The challenge for all rehabilitation teams is to know what services are available in your locality. Moreover, once identified, the second challenge is to access them for your patient. Obstacles include selection criteria that often exclude many people who would benefit, byzantine referral processes, problems with funding, and ultimately a lack of resources sufficient to meet the reasonable needs of the local population. This competency might benefit your patients more than any other. It is also the most difficult, depending on personal skills, perseverance, luck, local knowledge, and tolerance of unnecessary form-filling.

The competency - linking to other services

The competency is that the rehabilitation expert is “Able to identify and then refer to and engage with other services needed to assist a patient.” There are three distinct aspects: finding services that might assist, working collaboratively with them when appropriate, and referring the patient to a service. A document giving details on expected, indicative behaviours, knowledge and skills can be uploaded.

Context - the challenges

All patients with significant long-term health problems will be in contact with many services, and in my chapter on teamwork, I refer to evidence that most patients use a network of services. Some will be better organised than others, and often no organisation gives an alternative meaning to the phrase, a virtual network! The two figures mentioned above (one can be downloaded here) also illustrate the problem.

To make it explicit, the challenges include:

The absence of any widely accepted adjective for all rehabilitation services
1. The use of a large number of alternative adjectives
The dominance of alcohol and drug rehabilitation services when searching the internet
The wide range of organisations involved outside the NHS and the severe shortage of NHS rehabilitation services
The criteria used to select people for a service and to obtain funding
1. These criteria primarily exclude patients and restrict access
The differing forms used, information requested, and general bureaucracy
Many services are small, with limited expertise and often short-lived
The lack of any substantial, up-to-date register that can be searched easily.

Evidence on linking to other services

Unsurprisingly, there is no significant research on finding services or the referral processes and how to use them effectively. The primary evidence is entirely anecdotal, but I wonder if anyone believes there are well-organised networks.

However, the Community Rehabilitation Alliance lays bare the absence of any systematic organisation. In their Community Rehabilitation Best Practice Standards, they make four key recommendations for systems by saying:

“To enable the delivery of high-quality community rehabilitation services, it is recommended that Integrated Care Systems (ICSs):

Appoint a rehabilitation director at executive level within the integrated care system
Establish a local provider rehabilitation network to include primary, secondary, tertiary health care, mental health, social care, independent and third sector providers
Review existing rehabilitation services to remove silos of care and duplication of services
Publish an annual report on rehabilitation.”

This is an indictment of the NHS, which has not managed to advance rehabilitation over the last 70 years.

Knowledge - is local and team-based

The primary knowledge needed is about services available in the locality. Referral to a distant centre is rarely justified. An occasional patient might benefit from travelling to a far remote centre for something very unusual but rarely is the separation of a patient from his family and social milieu justified, not least because behaviours seen in an exceptional environment rarely transfer to home. Usually, the reason is to access a particular piece of equipment (e,g. cochlear implant).

Thus, each local rehabilitation service must build a list of local services, what they do, how to access them etc. Individual team members who have worked in a locality for many years will often know the people to contact and may know who is good or less good, matters that cannot be written down!

Each team member should add any information they find or glean to the communal database and correct it when they see it out-of-date.

Skills; finding, contacting, referring.

The primary skill needed is the motivation and curiosity to continue looking for a service when you do not know it exists. If you need a service, many others have had the same wish. You will use a mixture of internet searching skills and personal contacts, following a trail as each person suggests you ask someone else.

Once you have identified a potential service, a second skill is needed – discovering what the service does, whom to contact, and what interests them.

A request for assistance is more likely to succeed if you know much about the other service and put yourself in their shoes when contacting or writing a referral. They must be treated with respect. You may find their process tortuous and stressful or even meaningless. Nonetheless, they will have spent time considering it and have an intention. Your job is to decipher from the form what they want to know. Before being too critical, consider your service’s forms, criteria, and processes!

Conclusion

This competency is unusual but crucial. It is only acquired from experience and through repeated use with reflection and feedback leading to learning. It must be learned from something other than tuition or reading. Furthermore, much of the competency is specific to the locality, and the factual knowledge about local resources will not transfer easily to other parts of the UK, let alone other countries. Thirdly, competence resides as much in the team as within an individual. The team’s accumulated expertise (knowledge, skills, behaviours, attitudes) is more significant than any individual’s.