Rehabilitation practice, in the UK at least, occurs in a very piecemeal way. (here) In 1948, when the National Health Service (NHS) was founded, politicians decided that each hospital speciality would be responsible for the rehabilitation of its patients. They did not set up a rehabilitation service or medical speciality. Slowly the need for a more generic rehabilitation service became acknowledged, and ‘Rheumatology and Rehabilitation developed. In 1984, the health service finally recognised the need for a specific (medical) speciality of rehabilitation. The continued fragmentation of rehabilitation is one consequence of this approach, with ‘special interest groups’ in rehabilitation being quite common. This page explores this further and introduces a section of the website devoted to fostering more knowledge about and understanding of the many disparate professional groups focused on rehabilitation. A second page introduces a subsection of this site fostering more knowledge about and understanding of the many disparate patient and public groups focused on rehabilitation. The overall aim is to foster a community of services and people who have an interest in rehabilitation.
Why is this of any interest?
The low level of identified, named rehabilitation services and doctors in rehabilitation is one striking feature of healthcare in the UK. (here) Is the amount of rehabilitation offered as low as this would suggest? Why has this arisen? Does it matter? If so, what can we do about it?
It is improbable that the amount of rehabilitation that patients receive is as low as it appears. There are many services in healthcare delivering some parts of rehabilitation. The quantity and, more importantly, the quality of rehabilitation provided may be sub-optimal, but rehabilitation is happening. For example, most UK services for the elderly give some rehabilitation, and much is high quality. It is not called or recorded as a rehabilitation service. There may be a distinct transfer from an elderly medical to an elderly rehabilitation service in other countries. Many patients in a hospital will receive input from physiotherapists, nurses, occupational therapists and many other professions, all focused on disability, but none referred to as rehabilitation.
Nevertheless, this is an unsatisfactory arrangement. The services are almost all of a lower quality, with small teams, often without the full range of professions needed, and usually only involved transiently. Further, patients are frequently transferred from one rehabilitation service to another, leading to inefficiency and reduced effectiveness.
This situation is a direct consequence of the decision not to provide a dedicated rehabilitation service in 1948. Both the politicians who provided the money and the medical services who received the funds focused on healthcare’s direct, medical, and disease-based aspects, ignoring rehabilitation.
One rehabilitation service that exemplifies this approach is the spinal cord injury centres. These were seen politically and probably by the services themselves as a specific and exclusive service only for patients with spinal cord injury. They did not take patients with any other spinal cord damage. They were an example of a speciality taking responsibility for its patients, not an example of an expert rehabilitation service,
Gradually, as the need became overwhelming, the medical services introduced therapy services. The professions involved are still referred to as Allied Health Professions, implying (incorrectly) a subsidiary role. (A list is here.)
Even when politicians and the Department of Health recognised the need for specialised, expert rehabilitation services, they set up additional services for a minority of patients with unusual conditions. The existing services for people with spinal cord injuries and amputations were the models used. The current services providing rehabilitation were overlooked and ignored rather than being corporate into a single rehabilitation service.
The low priority and attention given to rehabilitation follow from the failure to understand that much rehabilitation occurs, albeit not of the quality or quantity needed. When considering an increase in rehabilitation, people overlook the existing sub-optimal services, and the challenge and expense seem overwhelming. Thus, we ignore or do not notice the problem and waste resources providing disjointed services.
Demonstrating, on a national basis, the extent of separate services might help. It will be a concrete example. It may also foster collaboration between the different organisations, leading to an association representing rehabilitation across all conditions. It might also breakdown some of the isolationist tendencies, demonstrated for example, in the Rehabilitation Medicine Expansion Proposal, which stated that a new name would “differentiate our area from Psychiatric Rehabilitation and Drug and Alcohol Rehabilitation” (Page 12 here)
In summary, the failure to set up rehabilitation as a separate service as part of the original NHS organisation in 1948 led to fragmented services developing as the need became apparent. Most of the fragmented services have teams lacking some essential professions, and they work in isolation. Few services delivering rehabilitation are classified as rehabilitation, which means that the resources devoted to rehabilitation and the opportunities for increasing efficiency are not appreciated.
What can be done?
The problem of fragmented services is a recurrent theme, frequently mentioned in this website (See here and here) and other places. (see here and here) Exhortations to re-organise, work collaboratively, develop pathways etc., have all failed. The recently founded Community Rehabilitation Alliance (here) appears to be having some success, though nothing has happened yet to the best of my knowledge (on October 19th 2021). However much one records and reports the extent of waste, patient suffering, and other problems, no one has the strong interest and the power needed to effect the systemic change.
This lack of political power arises from a lack of a representative organisation covering all rehabilitation. Each professional body puts forward its own profession’s interest, and others will only consult them about that. The only multi-professional rehabilitation organisation I know of is the Society for Research in Rehabilitation (here), and it is not a political or service-oriented organisation (yet!). The British Society of Rehabilitation Medicine has become multi-professional. It is small and is still primary medical. It does, however, advocate strongly for multi-professional rehabilitation services, for example, in its documents of standards. (here)
Nonetheless, some groups cover rehabilitation, usually in the context of a particular area of practice, such as with children or with people with a hearing disorder.
I have, therefore, searched for national organisations that focus on multi-professional rehabilitation, even if within the context of a specific professional or disease or condition context. I will have missed some, probably many organisations, and I welcome recommendations for inclusion here. (see bottom of the page).
National rehabilitation organisations
The organisations discussed here share the following characteristics:
- they state (usually) a specific interest in rehabilitation, usually in the context of a selected group of patients
- they usually are multi-professional, or open to different professions, and acknowledge that rehabilitation is a multi-professional team activity
- they are national, in their aspirations or goals if not in their actual reach
- they have a public, accessible place where people can learn more about them and contact them – a website, Twitter account, Facebook page, or at least an email address.
The organisations listed here are those I have found on searching, have been informed of, or know of in some other way. I have undoubted missed some organisations. Please let me know. (Note. I have not yet done pages for all these organisations.)
Community Rehabilitation Alliance
This organisation was started in 2019, in conjunction with the Chartered Society of Physiotherapy, as far as I can gather. It now has approximately 50 organisations supporting it. The page can be accessed here.
Vocational Rehabilitation Association
In the UK, vocational rehabilitation is a Cinderella service within an undersized service. Very few parts of the NHS provide full vocational rehabilitation. The Vocational Rehabilitation Association (here) and the Shaw Trust (here) are two national organisations concerned with supporting disabled people to stay in or return to work. Read more about vocational rehabilitation here.
Society for Research in Rehabilitation
The Society for Research in Rehabilitation is a truly multiprofessional society that was founded in 1978 and has had a close association with the British Society of Rehabilitation Medicine since the latter was founded in 1983. The page can be accessed here.
British Society of Rehabilitation Medicine
The British Society of Rehabilitation Medicine, the BSRM, is probably the only national UK organisation devoted to promoting rehabilitation. However, it is certainly not the only UK organisation with significant interest in rehabilitation, nor is the speciality of Rehabilitation Medicine the only speciality with significant expertise in rehabilitation. The developmental history of the BSRM, its current structure and purpose, and its role within a National Rehabilitation Community is explored in more detail here.
British Association of Sports and Exercise Medicine
Sports and Exercise Medicine has only been a medical speciality recognised by the General Medical Council since 2005. However, the specialist area of practice and the first formal organisation was the British Association of Sports Medicine founded in 1953. The recognition of it as a new speciality was probably related to two factors. The Olympic Games were coming to London in 2012. The epidemic of obesity and physical inactivity was well underway. There are now several associated specialist organisations, mentioned on the webpage here.
British Association of Childhood Disability
Faculty of Rehabilitation and Social Psychiatry
Rehabilitation psychiatry is a subspeciality within psychiatry, and it has its own medical organisation within the Royal College of Psychiatrists – the Faculty of Rehabilitation and Social Psychiatry. My review of rehabilitation undertaken within the Mental Health sector revealed two findings. First, though the Faculty has not explicitly stated it, principles of rehabilitation for people with complex psychosis are identical to those underlying most other rehabilitation fields. Second, rehabilitation psychiatry places much more emphasis on providing holistic, cross-sector integrated services aiming at the social aspects of any illness. Read more here.
British Geriatric Society
Marjory Warren started rehabilitation in the UK well before any identified speciality existed and indeed before the word existed! In 1935, faced with 714 people living in residential care in a hospital with long-term disabilities, she developed a rehabilitation approach. She also suggested the need to separate the older population. (see here for more information). Geriatricians were the primary rehabilitation providers, for example, for patients after stroke, and between 1947 and 1977, the speciality grew and, with it, rehabilitation grew.
Its focus later moved into more acute medicine such that, in my local hospital, geriatricians participate in acute medical take and see people of all ages. Nevertheless, rehabilitation is still a significant part of their work, and they have just set up a ‘task and finish’ rehabilitation group focused on Covid-19. (here)
You will find more information about rehabilitation services and the elderly and the British Geriatric Society on this page here.
British Association of Stroke Physicians
Research into rehabilitation after stroke has been vital to the development of evidence of rehabilitation effectiveness. In return, expertise in rehabilitation is vital in any complete stroke service. After the first 24 hours, there is not much more that medicine can do to help patients. Rehabilitation is essential over the succeeding days, weeks, months and years.
It is, therefore, unsurprising that stroke organisations should be central to any national rehabilitation community. The British Association of Stroke Physicians is one of many organisations. It is perhaps the only one focused on stroke services and the medical input into stroke services. Its primary focus is on hyperacute treatment and primary and secondary prevention. Training in stroke medicine is also given but at a basic level. Expert rehabilitation still has an essential part to play. See here.
Next Steps
At present, I have no ‘next step’ planned. I think that the Community Rehabilitation Alliance is possibly bringing together an organisation focused on rehabilitation, albeit in a single context.
However, I have thought up a name! The Association of Professionals Interested in Rehabilitation. TAPIR. “a nocturnal hoofed mammal with a stout body, sturdy limbs, and a short flexible proboscis” [Oxford English Dictionary] A suitably irreverent name that would stop any Association taking itself too seriously!
The purpose of the organisation (TAPIR, if so named) would be to represent the interests of all rehabilitation services and personnel working in healthcare. Its objectives would be to:
- develop and make explicit the high-level skills needed by rehabilitation experts and to develop edcational and quality-control mechanisms to validate the expertise in a professional person
- develop and make explicit the features that will identify a service ass being expert in rehabilitation, and to develop mechanisms allowing independent verification of a service’s quality
- set up and organise educational and training resources for people of any profession who wish to acquire expertise in rehabilitation
- stimulate and facilitate research across the whole range of rehabilitation
- educate politicians, commissioners and providers of healthcare services, and the public about rehabilitation
In summary, this section of the website hopes to raise awareness among the many societies, organisations and special interest groups of the other similar organisations with similar interests. The difficulty for most groups within a larger professional or other body is a lack of influence. Naturally, the host will focus its attention and resources on its primary purpose, which is not rehabilitation. We need an organisation that is devoted to supporting and promoting rehabilitation.