Is rehabilitation healthcare?
Hospitals are a part of the healthcare system, but is rehabilitation healthcare? The UK Department of Health, responsible for all healthcare and not just hospitals, promotes the idea that a patient only has a right to reside in a hospital until specific criteria are met. The requirements are mainly physiological and do not consider the patient’s healthcare needs.
Elizabeth Sapey and her colleagues studied the “Resaon to Reside” criteria and concluded, “the performance of the Right to Reside criteria as a dichotomous test to identify patients suitable for discharge is low. Further, the Right to Reside criteria are not a stable phenomenon, with more than half of those who remain in hospital without a Right to Reside subsequently acquiring a Right to Reside during the admission.”
A more accurate, truthful term would be that hospitals can discharge patients as soon as specific physiological criteria are met. The destination must be safe, but there is no requirement that the destination is appropriate, fulfilling any ongoing needs for health care. The need for rehabilitation is one of the other healthcare needs not considered by the discharge criteria. I will discuss what needs healthcare services should meet, explicitly considering two different types of problems healthcare addresses and how they impact services.
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The UK National Health Service (NHS) is “there to improve our health and wellbeing, supporting us to keep mentally and physically well, to get better when we are ill and, when we cannot fully recover, to stay as well as we can to the end of our lives.”; this is written in its constitution. Yet the same NHS sets out criteria “for discharge to a less acute setting” that are based entirely on physiological observations. Although set in a context of care pathways, services are not required to be provided to meet needs even though discharge guidance states, “People should be supported to be discharged to the right place, at the right time, and with the right support that maximises their independence and leads to the best possible sustainable outcomes.”.
A ‘Discharge to Assess’ policy is one way to achieve this, except (a) the assessment is concerned with care and support, not continuing health intervention needs and (b) in practice “, 82% of respondents did not receive a follow-up visit, and assessment at home and almost one in five of these reported an unmet care need.”
Although many factors lead to this unsatisfactory situation, the largest must be inadequate resourcing of health and social care. In addition, the government, represented by the Department of Health and Social Care, has a severe and systemic misunderstanding of healthcare and the healthcare system. Third, some societal attitudinal, sociocultural, and philosophical reasons have an influence.
The question to be answered is, is rehabilitation healthcare? If so, it should receive more attention and resource within the healthcare system.
When founded, the NHS had three essential principles: “firstly, that the services helped everyone; secondly, healthcare was free, and finally, that care would be provided based on need rather than ability to pay.” The optimistic and unrealistic hope was that free healthcare would soon lead to a healthier population and that the cost would be sustainable once the treatment of patients whose disease had not previously been treated was complete. The price has exceeded expectations (or hopes) ever since.
The NHS was one of the significant post-war developments arising from the 1942 Beveridge report. A second was the development of a national social security framework, which was not free at the point of use.
This separation of health from social care immediately raised a question that has yet to be answered satisfactorily. What is healthcare? The question cannot be answered because health problems are inextricably linked to socioeconomic factors. This association has been well known since Victorian times and is increasingly apparent in the UK. The association is undoubtedly causal in that ameliorating poverty, and other disadvantages lead to better health. Further, commercial healthcare organisations are beginning to provide non-health support, such as housing, realising that housing is integral to good health and that it is economically advantageous to ensure patients have adequate housing.
The absence of any easy way to distinguish health care from social care remains a significant problem. In the UK, long-term health needs are met by the NHS, so, for example, all drugs needed are supplied for free. However, the care needs associated with illness are not given freely unless they are defined as a healthcare need.
The English NHS has a framework to help distinguish people who warrant free care from those who do not. The distinction is not clear-cut, and thresholds vary around England. Understanding the nature of ill health and what constitutes health-related treatments influence how the criteria are used and interpreted.
Healthcare and problem-solving
Healthcare addresses problems faced by patients as part of their illness, starting with their presenting symptoms but also considering the associated issues. As I have recently written, the problems fall into two classes. Simple problems are like detective stories; however complicated matters seem, there is a single, correct answer; one knows when the problem is solved.
Complex problems are like voyages of discovery; there is no single answer, just an increase in understanding. You can learn about the situation and indefinitely explore solutions to the problems.
In health care, the diagnosis of the disease is a simple problem; most conditions are defined by some key fact or pattern of observations, and one knows that one has achieved a solution. Treatment may be less straightforward, but usually, there is a limited range of effective or partially effective treatments. Some diseases in some people cannot be treated, but again this is generally known, and the problem is solved if not resolved.
In contrast, assessing the many other problems associated with illness and resolving them falls quickly into the class of complex issues. First, one needs to identify what problems exist. There may be inter-relationships between some, but others will be separate. Second, there is rarely a single answer. This multiplicity of issues, causative factors, and potential interventions render each case unique.
Simple problems can often be solved using reasonably standardised approaches; a computer can solve many problems using artificial intelligence because there is a definite correct answer, a necessary characteristic for learning neural networks. Complex issues cannot be solved using a standard approach because the investigation needs to adapt as more information becomes available.
I will now return to healthcare to consider what constitutes healthcare and two categorically different approaches:
Is healthcare only concerned with disease diagnosis and treatment (curative or controlling)? Disease in this context means (a) there is a structural or functional abnormality within the patient (or both) and (b) that it is the primary cause of the patient’s illness. In other words, the disease is something that, if removed or reversed or controlled, would lead to the illness going away.
Is healthcare concerned with ameliorating problems arising as part of a person’s illness so that they are minimised if not fully resolved? Illness in this context is a socially-determined state where the person and the society the person lives in (usually a country) agree that the person is ill and should have access to healthcare. Occasionally society may consider the person to be sick – in need of healthcare – when the person does not. More commonly, the person may consider themselves ill and society, represented by healthcare professionals, does not.
The biomedical model of illness is closely associated with the idea that disease is the only cause of illness. The model is often generalised to state that disease is the main, if not the only, matter of concern for healthcare services.
The biopsychosocial model of healthcare is closely associated with the idea that healthcare is concerned not only with disease but also with the person who has a disease, including people whose dis-ease does not arise from structural or functional abnormalities within the body.
Roy Acheson wrote “The definition and identification of the need for health care” in 1978. His main concern was with the nature of need and the influence of resource availability. However, Figure 4 in his article illustrates explicitly how all-encompassing his view of healthcare was. He included both care services for conditions that cannot be cured and cure services for treatable conditions. He also emphasised the conflict between a humanitarian requirement to relieve suffering and a realistic requirement to use resources responsibly.
Other evidence shows that healthcare is concerned with much more than diagnosing and treating bodily pathology. Wikipedia, for example, states that health care “is the improvement of health via the prevention, diagnosis, treatment, amelioration or cure of disease, illness, injury, and other physical and mental impairments in people.” The World Health Organisation emphasises that healthcare is centred on systems that include public health, preventative health, and direct healthcare provision to patients.
Moreover, the UK NHS constitution, the content of major medical and healthcare journals, which frequently publish research about social determinants of health, the integration of palliative medicine and psychiatry into healthcare, and the WHO definition of health all include many non-disease factors as a crucial part of healthcare.
I conclude that rehabilitation is an integral part of healthcare because
- Rehabilitation considers both disease and the many other factors impacting an ill patient;
- Healthcare organisations are all concerned with the consequences of the disease;
- Healthcare journals publish research about the importance of contextual and other matters in diagnosing and managing patients.
- Leading medical journals publish primary rehabilitation research
- The interaction between contextual, non-disease factors and disease in causing illness makes separating disease-focused care and disability-focused care impossible.
Where does this discussion take us? I will propose three axioms:
Healthcare is concerned with the health and well-being of a person. This includes diagnosing and treating identifiable bodily diseases but extends to all aspects of illness, which is a socially-determined state arising from a malady and which gives the person access to healthcare resources.
The problems considered by healthcare fall into two categories. Closed problems have only a limited and usually small number of solutions. The best example is the diagnosis and treatment of a disease. Open problems have an unlimited, typically large number of solutions. The best example is rehabilitating any patient with a significant persisting disability.
Two models of illness are used in healthcare. The biomedical model, which emphasises the importance of disease as a cause of illness, and the biopsychosocial model of illness, which considers illness holistically, emphasising that a person must be considered in their context.
These axioms are interrelated, relating to different aspects of healthcare services, and they need to be fully integrated into the whole healthcare system. At present, each separate healthcare service gives different priorities to each axiom, leading to system-wide difficulties.
Acute hospitals, for example, act as if their only concern is the diagnosis and immediate treatment of disease, working within a biomedical model of illness and only considering closed problems. They act as if they have no responsibility for other aspects of healthcare and little interest in the other issues the patient may have. The individual workers in these hospitals undoubtedly have much broader concerns. The organisation is driven to this extreme position by political and managerial pressure and the relentless demands imposed on the available inadequate resources.
In addition, there is also a morally suspect emphasis upon personal responsibility, blaming people (patients) for their illness and denying the apparent duty of the government to protect all members of society, especially the vulnerable.
The moral failure has been well illustrated by John Coggan and Jean Adams in “‘Let them choose not to eat cake…’: Public health ethics, effectiveness and equity in government obesity strategy.”, published last year. They conclude, “An in-the-round evaluation of the values and agency of individuals, different publics, and governmental and other actors must be at the core of interventions for more equitable and effective public health intervention strategies.”
Politically, the difficulty arises from a failure to consider healthcare as a national issue requiring a coherent integration of all component services. The Department of Health acts as if providing individual components is sufficient, and considering how they can or should inter-relate is unnecessary. Suggestions that the organisations should be competitive rather than cooperative, driven by contractual arrangements that do not reward collaboration, exacerbate the dis-integration of healthcare at a system-wide level to the detriment of patients.
The most obvious failure of integration of services concerns so-called social care, where inadequate public resources coupled with a lack of training and career opportunities and rates of pay that do not recognise the knowledge and skills care staff have means that patients cannot be discharged from the hospital into more appropriate care.
Politicians and managers concerned with providing excellent healthcare for the UK population need to realise that:
- Healthcare is concerned with the amelioration of illness and the promotion of health
- It is not solely concerned with disease
- Illness is a socially determined state, not defined by any single criterion or small group of measures.
- It cannot be defined independently from socio-cultural considerations
- Healthcare addresses both closed and open problems, and they cannot be addressed separately
- Open problems are associated with multimorbidity, long-term disorders, and social deprivation and all impact all healthcare
- Rehabilitation services are integral to all healthcare
- Social care and healthcare cannot be distinguished by any fair criteria or system
- This is obvious in the field of research
- The failure to accept that health and social care are both parts of the healthcare system is the root cause of all our healthcare problems.
- The government (Department of Health and Social Care and senior politicians) are simply burying their heads in the sand, pretending that the biomedical, closed problems within healthcare can be solved independently of the biopsychosocial, open problems also taken on by healthcare.