Rehabilitation expertise

Rehabilitation is not therapy, and therapy is not rehabilitation. Rehabilitation expertise is the second area of expertise acquired by some people working within healthcare. Unfortunately, there is no mechanism to demonstrate that you have specific expertise in rehabilitation unless you happen to be a doctor. In the UK, since 1997, doctors have been able to train as specialists in rehabilitation. It is time that all other professions can also achieve official recognition of many people’s expertise. Over the last five years, I was closely involved in developing a new curriculum for doctors training in rehabilitation. This activity has required much reading and learning about curricula, syllabuses, and how to establish expertise. It has made me very aware of how lucky doctors are because they can validate their expertise. I have also realised that I could quickly adapt the medical rehabilitation curriculum to all healthcare professions. (here) I have spent the last 6-8 months publishing capabilities on this site, found here and here. This post tries to draw the content together and explore how one could apply these capabilities to Advanced Clinical Practitioners. (here)

Prelude
Why am I interested in rehabilitation expertise?

When I started this website, I had no idea what it would contain. The decision was a clear example of goal adjustment in the face of goal frustration. I was unable to achieve something I wanted, felt frustrated, and decided to approach my purpose (improving rehabilitation) in another way, through a website. I think the title just emerged during the night as I thought about starting a website.

At the time, I was still immersed in getting the Rehabilitation Medicine curriculum completed and in place. (It is now.) When doing something, I usually research it. I had read and still read many articles about healthcare education and curricula. The website allowed me to consider the matter in a bit more depth and share that knowledge.

I became concerned that there was no official way for most professionals to gain recognition for their expertise in rehabilitation. Any person and any organisation can claim to be offering rehabilitation – and many do, from single therapists to large healthcare organisations. Even in the NHS, some services claim to provide rehabilitation. There is no obvious way commissioners, or patients can know or determine that an individual, team, or organisation delivers rehabilitation.

The answer depends upon another question that has fascinated me for 40 years – what is rehabilitation. That has lead to many articles and two outline my position – here and here. At the same time, it became increasingly apparent that a curriculum also gave a practical definition of rehabilitation because it sets out what knowledge and skills are needed to practice rehabilitation. The UK 2021 curriculum (available here) reflects what many, probably most UK rehabilitation doctors, think rehabilitation encompasses and helps to define what rehabilitation is.

As I was ending my work on the medical curriculum, it became apparent one could use a similar approach for all professions. Doctors all have medical expertise. Training in rehabilitation can give doctors expertise in rehabilitation, which is certified and externally validated. This qualification is in addition to (and dependent on) their professional medical expertise. The training model could apply to any profession. I published an article on it. (here)

There was also a need to develop a syllabus for the medical curriculum, which led to an interest in competencies and how one specified professional expertise. The Rehabilitation Medicine syllabus is discussed here. The framework for competencies also seemed relevant, and competencies are discussed here.

After establishing the website, I was thinking about what solid and unusual but necessary aspects of rehabilitation it could develop. The first ‘unique selling point’ I chose to create was the characteristics that could be the basis for training any professional to be an expert in rehabilitation. I have now set out the capabilities in practice. Capabilities are defined here. This post draws together some of the matters covered elsewhere on this site to act as a focus.

Context

Professionals deliver healthcare, and there are many different professions involved. Each profession has a professional body (Society, Faculty, Association etc.) that sets professional standards. There are also statutory bodies that monitor the adherence of individual professionals with professional standards set. The General Medical Council, for example, both monitors the professional behaviour of doctors and sets the educational standards needed by doctors to register as specialists. The Health and Care Professions Council (HCPC) has a similar function for many other professions, maintaining standards of professional behaviour and setting educational standards. (here)

Universities are responsible for undergraduate and early postgraduate training, with Local Educational Boards having a role in later postgraduate training. There are numerous diplomas, Masters degrees, and other qualifications to be obtained, but there is no nationally recognised way to be qualified as an expert in rehabilitation.

On the other hand, there are many services entitled as rehabilitation services: community rehabilitation teams, out-reach rehabilitation teams, early supported discharge rehabilitation, intermediate care services, etc. All are offering and providing rehabilitation, whether titled that or not.

When seeking new team members, the employing organisation can quickly determine the nature and extent of a candidate’s professional abilities. There is no way to assess their proficiency or performance in rehabilitation.

Further, those who pay for a rehabilitation service and those who use a service cannot establish the rehabilitation credentials of team members. Indeed, in the UK, there is no set of national, officially agreed (for example, by the Department of Health and Social Care) standards or credentials that can show that a service has expertise. The British Society of Rehabilitation Medicine has published standards for many different types of service, such as community rehabilitation and trauma rehabilitation. (here) NHS England has also defined ‘specialist rehabilitation services’ (here), and they have a specific definition of specialist rehabilitation for commissioning ‘specialist rehabilitation services’. (here) These definitions concern types of patients seen, resources, and outcomes but do not specify the service’s expertise.

The Commission on Accreditation of Rehabilitation Facilities (CARF – see here) does accredit organisations. Still, the accreditation seems to be a generic healthcare quality process without focusing specifically on rehabilitation. In other words, it will inform you about safety, administration, internal quality control systems, etc; it does not inform you about the expertise in rehabilitation.

In summary, there is no agreed national qualification to show that a professional has expertise in rehabilitation, except for doctors. There is also no approved national set of criteria that demonstrate that a service has rehabilitation expertise.

Three key features of rehabilitation

Three key features distinguish rehabilitation from other healthcare.

Multi-professional team
Much, probably most healthcare, is now delivered by multidisciplinary teams, with people having different areas of expertise. For example, a service for patients with cerebral tumours might include neuroradiologists, neuro-oncologists, neurosurgeons, neurologists, neuropsychologists and nurses. Four of the six members are from one profession. The teams are multidisciplinary but often only include three or four different professions.

Rehabilitation is more accurately described as being delivered by and being dependent on a multi-professional team. I have spent many hours discussing the ‘core professionals’ needed to form a stroke rehabilitation team. The number has never dropped below seven: doctor, nurse, physiotherapist, occupational therapist, speech and language therapist, clinical psychologist, social worker. And, usually, others are added: orthoptists, orthotists, dieticians, wheelchair engineers, etc.

Furthermore, the activity of all rehabilitation depends upon the team working together all the time, consistently. A neuro-oncology team comprises people who are part of other teams or services most of the time. In contrast, people working in rehabilitation are always a part of a rehabilitation team, even if at a particular time they are working in a day centre.

Biopsychosocial model
The second central characteristic of rehabilitation is its use of the biopsychosocial model of illness as its framework for everything – clinical assessment and analysis, planning of actions, organisation of records, communication within the team, research, audit and quality control etc. This model generates the need for a multi-professional team.

Using the biopsychosocial model also leads to the third central feature.

Focus on achieving patient-centred, social outcomes.
While all healthcare aims to improve quality of life, and all healthcare claims to be centred on the patient’s wishes, in rehabilitation, it is the sine qua non – nothing will happen without being centred on the patient, because patient engagement is needed to achieve change.

Other services, such as palliative care and psychiatry, will to an extent, have similar characteristics, so rehabilitation cannot claim that these characteristics are unique to rehabilitation. The extent to which these are essential and the fact that they apply at all times and in all places makes rehabilitation different.

Clinical correlates of the features

This part considers how a professional who is also an expert in rehabilitation would enact the three critical characteristics of rehabilitation. It will do so by developing a limited number of high-level abilities that encapsulate the three attributes. These high-level abilities will be called capabilities, and they refer to complex clinical activities, usually with many discrete components that may be referred to as competencies.

The expert rehabilitation professional will need to have a complete understanding of the biopsychosocial model of illness. Much more importantly, the expert will be able to base all actions and decisions on the model. rather than on the model usually used in healthcare, the biomedical model. (Capability one, here)

The biopsychosocial model covers all factors that influence behaviour. To gain a complete understanding, one needs a multi-professional team whose members cover the different areas of professional expertise required. The rehabilitation expert must be able to work within a multi-professional team. (Capability three, here)

The team needs to agree on and plan the implementation of a strategic plan to reduce, if not remove, the identified difficulties. Therefore, the rehabilitation expert needs to be skilled at formulating the situation, identifying all the different factors influencing the patient’s disability, and deciding what actions might reduce disability and distress. The plan will only succeed if the strategic goals align with the patient’s wishes, and being patient-centred is part of this skill. (Capability two, here)

The biopsychosocial model includes many components outside the remit of healthcare, yet these factors can be crucial to the success of rehabilitation. For example, the patient may need housing adaptations or a new house. The patients may need care provided by Social Services, help with returning to work or finding a new job, or need further education. Furthermore, rehabilitation can continue for months or years. The patient may move from the intensive care unit through wards in a hospital, to a rehabilitation unit or a care home, and eventually into the community. Therefore another skill needed by a rehabilitation expert is the ability to work across all boundaries. (Capability four, here)

Another inevitable consequence of using the biopsychosocial model is uncertainty, the uncertainty of prognosis, the uncertainty about the effect of an intervention, and, often, the uncertainty about the wishes of all relevant parties and the uncertainty about the availability of needed resources. Coupled with this, the rehabilitation expert often needs to consider additional ethical and legal concerns. (Capability five, here)

Returning to the team, the team must provide a ‘rehabilitation environment’ where all people interacting with a patient do so consistently and in a manner that reinforces team strategy. In a residential setting, this will primarily be paid, professional staff. At home, it will be family members and friends. Within the team, each team member should learn how to reinforce the intervention of other team members when appropriate, and all should give the same information. (Capability six, here)

Last, it is vital that each rehabilitation expert retains and increases their professional expertise and uses it to add to the team’s repertoire of expert knowledge and skills. It is imperative to maintain skills in assessments and interventions that are the primary responsibility of the team member belonging to a specific profession. (Capability seven, here)

Rehabilitation-focussed generic expertise

All healthcare professionals need a core set of capabilities. The General Medical Council proposed six for all doctors. This core set arose from a review of complaints, which identified the common problems, which often concerned general professional behaviours, not a lack of specific knowledge or skill. These six capabilities are a good foundation. All professions will need them.

The evident first important ability is the ability to work within the existing healthcare system. For rehabilitation experts, this has to extend to working not only within all parts of the healthcare system but also with other systems such as Social Services, Employment, Education, Voluntary Sector services etc. (Generic capability one, here)

The second GMC generic capability is “Able to deal with ethical and legal issues related to clinical practice“. These two issues are only a limited aspect of a more critical matter; professionals should decide and act within the patient’s social context. The patient’s social context does include general, societal, ethical and legal frameworks. However, it also consists of the patient’s own culture and behavioural expectations and the local social factors such as friends, work colleagues, and other social groups the patient may belong to. The generic capability suggested here takes this broader view. (Generic capability two)

It is self-evident that members of all professions need good communication skills. The rehabilitation expert needs additional skills to recognise and analyse patient losses affecting communication and know how to communicate best when the patient has a disorder affecting communication. (Generic capability three, here)

Healthcare is a highly complex system, and complex systems can perform well or poorly. Any complex system should be monitored to detect as soon as possible any loss in performance and to investigate it and remedy the reduction in performance. In healthcare, this process is called audit or, more recently and more appropriately, a quality improvement activity. The rehabilitation expert needs to participate in this activity. More importantly, the rehabilitation expert must recognise that the rehabilitation ‘system is larger and more complex than the healthcare system. They must highlight the performance of and changes needed in the cross-boundary work undertaken. (Generic capability four, here)

The fifth GMC capability is interesting because it explicitly recommends support of research. I agree. However, this should focus on understanding research methods, collecting, recording, analysing data, and interpreting and using data. These skills are needed outside formal research, for example, when undertaking a quality improvement project. Knowledge of research is also vital when reading and considering research papers. All articles need critical evaluation before changing a service or using a treatment based on a published report. (Generic capability five, here)

The sixth capability is teaching and training, always a professional responsibility. Unfortunately, many people do not have innate teaching skills. Learning how to teach and train effectively is essential. In rehabilitation, this responsibility extends to teaching other professions, team members from different professions and students, and postgraduates from other professions who wish to gain rehabilitation expertise. (Generic capability six, here)

I have added a seventh generic capability. For doctors, a General Medical Council document, the Generic Professional Capabilities Framework (here), covers the content of this capability in much more detail. Paragraphs 11 (page 12) and 20 (page 13) are the most important. The ability concerns maintaining and increasing professional knowledge and skills. It is essential because the team depends upon each team member having the highest levels of professional knowledge and skill.

Assessing expertise

In medical training, trainees collect evidence on their clinical performance in several ways. An educational supervisor uses this evidence to assess how a trainee is progressing. There is also a syllabus to guide the trainer and trainee on possible specific competencies needed, which the trainee can add to the evidence.

Once a year, the educational supervisor reviews the evidence to decide how entrustable the trainee is in each of the fourteen capabilities given in the Rehabilitation Medicine curriculum.

Entrustability is a valuable concept. It amounts to asking yourself, “Would I trust (this trainee) to achieve this activity without supervision or review?” Ultimately it is a judgment. You can find the reasons for using entrustability and other aspects of its assessment here.

Conclusion.

Further development

This page has brought together pages and posts that consider the expertise a rehabilitation expert should have. This expertise will be in addition to their existing professional expertise. I hope the ideas will be discussed, improved, and eventually used to develop a nationally recognised qualification of individuals from any healthcare professional as an ‘expert in rehabilitation.

One development needed is to develop a university-based course. The standards will need to be agreed upon by a national body. Other than the British Society of Rehabilitation Medicine, the Society for Research in Rehabilitation, and the Community Rehabilitation Alliance, I am unaware of any national body that can take on this role.

At the same time, we need to develop a similar set of standards to apply to services. This development is one of my outstanding projects, thought of but not (yet) started.

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