Rehabilitation in the UK started late compared with most countries. The only exception was rehabilitation after spinal cord injury. For many years, health services managed any rehabilitation problems by contacting the artificial limb and appliance centres for equipment and doing everything else as part of general medical or surgical management. Eventually, the healthcare system finally recognised rehabilitation as a separate domain of expertise. At that point, rehabilitation was distributed among different specialities, and it still is, with only a small proportion being in named expert services. Thus, it is impossible to quantify the amount of rehabilitation expertise in the UK, and it is impossible to quantify the resource devoted to managing disability within the health service. This section of the site introduces the area.
Context resources and processes
You may think defining rehabilitation is complex, but it is nothing compared to defining the available expertise and the resource committed. Throughout all inpatient healthcare, the cost of care and support given dominates cost. In an intensive care unit, the support is primarily physiological – drugs to support cardiovascular function, machines to support breathing, monitors to detect changes in oxygenation and temperature etc. The cost of actual treatments, interventions that reduce the severity and extent of the underlying tissue damage is a small proportion of the total cost.
In inpatient medical and surgical wards, the focus shifts to practical support – obtaining and giving food and water, managing excretion, washing, helping the patient with moving, protecting patients from harm, for example, from falling or immobility. The cost of antibiotics, chemotherapeutic agents, or even an operation or radiotherapy is not as high as the cost of care.
In rehabilitation, it is much the same, only less dramatically so. In many patients, the care needed is the same – ensuring food and fluid intake, managing incontinence, helping with personal activities of daily living, etc. At the same time, the person learns or relearns skills and abilities. In some patients, additional care needs secondary to cognitive, and executive impairment arise – protection from danger, avoidance of aggression, prevention of getting lost. These non-physical areas of care and support occur in most rehabilitation psychiatry settings but are also common in people with neurological problems.
In all settings, but especially in rehabilitation, the distinction between care and treatment is not straightforward. For example, giving insulin care is not a cure and carries on for life – or is it treatment – preventing hyperglycemia. If it is a ‘medical treatment’, giving regular stretches to prevent contractures or turning someone in bed to avoid skin ulceration is also a treatment. And if when helping someone to dress, wash, or feed, the carer is assisting the person in learning how to do it themselves, then it is both care and treatment.
I conclude that a clear distinction between resources devoted to direct care and resources dedicated to rehabilitation is impossible. Rehabilitation can start in the intensive care unit; it is beneficial. On an ordinary surgical ward, nurses will be doing rehabilitation as they assist the person learning to walk or dress after major trauma while also supporting them with care. This unavoidable difficulty makes it impossible to quantify how much rehabilitation is occurring. True, much of it has little need of excellent rehabilitation expertise. Nonetheless, supportive care that facilitates learning by the patients is only possible if the nurses learn what they need to know from rehabilitation professionals.
Categorisation and labelling
In most systems, contracts are attached to services, and the service has a label. Someone has put it in a category. For example, a commissioner might fund a radiology service, which initially was a purely diagnostic service but now increasingly includes interventional treatments. The service started to include nurses and therapists to help patients recover lost function but is still funded as radiology. Similarly, a commissioner may pay for an acute rehabilitation service, but many patients will be receiving ongoing medical or surgical input.
Thus, when someone wants to know how many resources we devote to rehabilitation – in this hospital or this country – the answer is simply the sum of all money given to services labelled as rehabilitation. It will not include rehabilitation provided by stroke services, or in neuroscience wards, or by geriatricians, or in psychiatry.
A further example is the equating of rehabilitation services to a doctor’s involvement with certified training in rehabilitation. The difference between the number of doctors certified as an expert in rehabilitation in the UK and most other European countries is significant. The UK has a lower number per head of population.
While I agree that we have too few trained expert doctors in the UK, we must recognise some ameliorating factors. Much rehabilitation in the UK occurs with medical input from other specialists, especially geriatricians and paediatricians. More occurs without medical input. The UK makes much greater use of highly trained people from different professions who practice independently, whereas, in many European countries, a doctor still prescribes all therapy.
Another difficulty, covered in detail here, is that commissioners and providers have given new categorical names to services that are rehabilitation services: intermediate care services, enablement services, early supported discharge services etc
I conclude that counting named services and counting only services with a trained rehabilitation medicine doctor input are both invalid and underestimate (in the UK) the amount of rehabilitation occurring and the resource devoted to rehabilitation.
Rehabilitation’s low priority in the UK
I would summarise the situation thus:
- much straightforward, low-level rehabilitation occurs throughout the healthcare system, usually as an add-on to a service with another priority
- the named rehabilitation services only provide a small proportion of all rehabilitation services
- some other services offer rehabilitation, usually with less expertise, and they have a different categorical label
- distinguishing rehabilitation from care and estimating the proportion of other service resources devoted to rehabilitation are both impossible
These facts show that rehabilitation is scarcely known, is not understood, and is usually considered an add-on that can be cut. If recognised, it is an activity done by someone else somewhere else. No one gives any attention to rehabilitation, how it should be organised to be both more effective and more efficient, and how much resource is needed.
The failure to recognise how much rehabilitation is occurring leads to the inability to develop an organisation to represent rehabilitation. The charitable sector appreciates the power associated with bringing organisations together. The Neurological Alliance has stimulated an increase in attention to neurological services.
At present, no one in the UK represents rehabilitation. The BRM is a society that does so as far as it is able but, with only 375 members, most of whom are doctors, it does not influence larger bodies. Moreover, commissioners and the Department of Health seek rehabilitation advice from many single-profession organisations who will naturally promote their own agenda. Recently the Chartered Society of Physiotherapy has recognised that a multi-professional organisation may have more influence. It has supported the development of a community rehabilitation alliance.
A recognised rehabilitation qualification
There is no mechanism for knowing whether a service has expertise in rehabilitation, whatever name it gives itself. Nor can one identify whether a professional has expertise in rehabilitation. The only exception is for doctors who can acquire a certification of expertise in rehabilitation, for example, in Rehabilitation Medicine. Doctors in other specialities can obtain evidence in one or more capabilities concerned with rehabilitation, for example, in stroke or geriatrics.
Conclusion and way forward
My conclusions are:
- rehabilitation occurs in the UK health service but
- the expertise of practitioners varies and is rarely certified
- the expertise of service delivering it varies and is not measured
- most rehabilitation is provided within another service as an add-on
- most rehabilitation is not identified and recorded in service data
- the small number of services delivering more focused, expert rehabilitation
- tend to manage specific, usually selected patients
- may not be categorised and registered as rehabilitation service
- rarely service patients in the community
- the resulting lack of data
- leads to a lack of interest in or concern about rehabilitation
- prevents any rational reorganisation because it is impossible to show the need for and the benefits of better organisation
- There is no sizeable rehabilitation organisation that
- includes and represents all professions
- includes and represents patients
- encompasses all rehabilitation across settings, conditions, and age
- The absence of a powerful organisation results in a lack of
- any political interest and pressure
- understanding and concern in commissioning organisation
- knowledge and respect in most provider organisation
- attention to improving services
- proper training with valid certification in rehabilitation expertise
We, the rehabilitation community, need to start active collaboration and work together to improve matters. The Community Rehabilitation Alliance may be a start, though the lack of formal organisation or public information makes it difficult to evaluate.
This part of the website aims to explore rehabilitation within the UK. It does or will investigate evidence that rehabilitation is already part of many specialities and services. It will also examine how much voluntary organisations representing patients are concerned about rehabilitation and in what areas.
When this (revised) version of the front page of this section was published, I did not know the outcome! I still do not know what I will add next. At present is has two subsections.