Two incidents precipitated this blog. During discussion after a talk on an evidence-based definition of rehabilitation (e.g. as here), I was asked whether services provided by Social Services (and others) could also be considered as providing rehabilitation. My reply was that rehabilitation is a process and, as its intended outcomes relate to social participation, and as its intervention cover almost all domains of the psychosocial model of illness, it was essential that other services contributed. They do contribute, to a greater or lesser extent, and so their services should also be considered rehabilitation services. This argument has appeared in an earlier blog here.
The second incident, slightly at a tangent, was a tweet relating to formulation within rehabilitation, referring to a figure taken from a page on this website (here). The tweet stated that each profession would make their own formulation, so ‘whose formulation is the true one?’
The proposal I wish to put forward here is that rehabilitation ‘belongs’ to no-one agency or organisation. Rehabilitation is a process that is the responsibility of society – including not only organisations such as the NHS and Social Services, but most public services, all employers (in relation to vocational rehabilitation), charities and support organisations (in relation to helping develop social networks and reduce loneliness (here)), nursing homes (see here) and indeed each citizen. We all have a part to play and, in as far as an organisation has a person, department or service providing some sort of rehabilitation help, that should be referred to as rehabilitation. This is little different from organisations have people or departments recognised as providing education to people within the organisation.
I will start by setting out some axioms, “statements or propositions which are regarded as being established, accepted, or self-evidently true.” [Oxford English Dictionary] The reasons behind these axioms are to be found elsewhere on the site.
The goal of rehabilitation is to maximise a patient’s quality of life through optimising their social autonomy and involvement, and through minimising their distress and discomfort (pain). Note that ‘optimising’ means that the patient’s opinion will determine what is wanted.
The patient in rehabilitation is anyone who has a persisting disability or problem recognised (by society) as being part of an illness. This could be contentious, but only society can set the rules about who is or is not considered ill, and thereby allowed to receive societal benefits such as rehabilitation. (see within this page)
The theoretical framework for rehabilitation, as a process, is the biopsychosocial theory of illness. (here). This emphasises the holistic nature of rehabilitation.
In complex cases. rehabilitation depends upon a multidisciplinary team, which may well extend well outside health services. (here)
The only axiom that lacks evidence is the first – what is the goal of rehabilitation? Evidence cannot give a goal, because a goal is something generated by a person. It is an ambition for the future. In the context of a rehabilitation service, the goal is set by society. The NHS represents society, and the NHS constitution gave its goal thus:
The NHS belongs to the people.The NHS Constitution. the NHS belongs to us al. 8 March 2012. (see here)
It is there to improve our health and well-being, 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.”
I think that the axiom, A, is supported by society,
If the four axioms are accepted, the the arguments here should follow.
The actions needed as part of rehabilitation must cover all domains within the biopsychosocial model of illness.
These rehabilitation actions will, for some patients and on some occasions, not be provided by health services but will be the responsibility of other people and organisations, outside health.
At other times, the rehabilitation actions requested will be provided by people and organisations than may not have a statutory responsibility for the actions, but the organisation will have provision of the actions as part of the organisational purpose or values. This will apply to commercial bodies, charitable bodies, and also to some educational services.
People from other organisations (outside health) will therefore join the multi-disciplinary rehabilitation team, albeit briefly.
As a team member, any and all people from any and all other organisations involved need to contribute to, and then to base their actions on, the full team formulation.
Note. For a patient there can only be one formulation at any one time, and the only one of relevance to the patient is the one that is derived from the totality of available evidence at that time. As new people become involved and as new information becomes available, the formulation should be updated.
This argument shows that people from different agencies and organisations will be joined into the rehabilitation team as full and equal members from time to time, and during that time they will be participating in the rehabilitation process. They will be delivering rehabilitation.
A social responsibility?
These arguments suggest that many organisations in society could participate in the rehabilitation process, when some of the needs of the patient align with their stated purposes or values. Some organisations have purposes given by statute, for example social services, housing services, and employment services. Some organisations have self-imposed purposes. For example the Stroke Association aims, among other things, to support people left disabled after stroke. Most organisations espouse values, which would usually require them to help an employee return to work.
Unfortunately the collaboration is not as good as it might be, for many reasons. One reason is a perception by people outside health services that they cannot and should not be involved in rehabilitation ‘because that is a health service responsibility’. Sometimes they do provide the service but only separately, and explicitly using another term such as reablement. Another reason is financial – ‘if it is part of rehabilitation, then the NHS should pay’.
Yet another is to cite clinical confidentiality – ‘we cannot share our formulation because of patient confidentiality’. A formulation should be shared with the patient who will necessarily have contributed to it: a formulation must include the patient’s views, values, experiences etc and a formulation must be shared with the patient. A formulation will rarely if ever contain detailed, intimate personal information. Therefore the patient can easily over-ride concerns about confidentiality.
I also suggested initially that ‘each citizen’ might be involved in rehabilitation for some people. I am not suggesting that members of the general public should join the team! I am suggesting that we have a responsibility as members of society not to exclude people who are different in some way from normal interactions. Just as it is unacceptable for anyone to state that they will not see a black doctor, or not to acknowledge the presence of a Japanese person, so it should be unacceptable to avoid talking to the person working in a supermarket who has slurred speech, or an obvious limp.
In other words, we all, as members of society, have a responsibility to avoid stigmatisation and exclusion of others who we perceive as being different, whatever the explanation. We need the ethos that a few companies have: “Timpson really are an equal opportunities employer. We consider anyone for our vacancies as long as they are able to do the job. This includes ex-offenders and other marginalised groups. We recruit exclusively on personality and expect all of colleagues to be happy, confident and chatty individuals.”
People needing rehabilitation are in a marginalised group.
Rehabilitation aims to return someone to a set of social roles and positions that they value, and that are attainable given their abilities. The process of entering any new social role for any person, disabled or otherwise, involves both the person entering and the other person or people. Some people need help; children are accompanied to school by parents, a friend or relative may support someone starting work, large organisations have induction processes etc. A person who has a disability is no different, except that they receive extra help from an expert service just as someone moving to a new area or company from another country might receive extra help from a special organisation.
The fact that the expert service is called a rehabilitation service and is funded by the NHS should not prevent the expert service from seeking help from outside nor should it be used as a reason for not collaborating by other agencies. Moreover it is not a reason for other organisations to set up completely separate services doing the same thing, usually less well because they have incomplete information and often less experience and expertise.
Rehabilitation has social goals and treats the person as a whole, not fragmented into different parts. Society needs also to treat both the person and the process of establishing or re-establishing a person’s social autonomy as a whole, not fragmenting the process into different parts with different names. Rehabilitation is, in a true sense of the word, a social service.