The Community Rehabilitation Alliance recently published some Best Practice Standards for rehabilitation aimed at the newly founded NHS Integrated Care Boards that manage the Integrated Care System. It recommended...
Healthcare was initially dependent upon one person. The wise woman, priest, medicine man, or other similar person took responsibility for diagnosing and managing illness single-handedly. This was the model of service delivery for many centuries. When hospitals changed from places for care to places for active treatment, the patient was usually under the care of a single doctor. The organisation slowly evolved with a senior doctor training other doctors and surgeons working with anaesthetists and assistants. The model of a single doctor being responsible persisted for decades despite the complexity of healthcare with teams involving all professions.
Furthermore, hospitals took on responsibility for caring for patients during and after treatment, albeit because there was no option. For a while, there were convalescent hospitals. Services to this day are usually still centred around disease treatment and acute medical and nursing care. As I have explained elsewhere, rehabilitation services have evolved piecemeal and unplanned. This category of posts concerns how rehabilitation services are organised and how they could be improved.
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Rehabilitation is the archetypical complex intervention. Any complex activity, such as building a new railway line or ship, requires planning and organisation to ensure everyone works towards the same goal and does so in a coordinated way. Much effort is put into organising acute medical and surgical services; the outcome could still be improved because many patients have needs spanning different services or departments.
Rehabilitation services have never been planned; they have emerged in response to some short-term powerful force. For example, services for people after COVID-19 could have been developed as a part of existing services, but instead, special services were set up. The emerging difficulty is that there is no unambiguous dividing line between, for example, chronic fatigue syndrome of fibromyalgia and long Covid. In some people, long Covid may be a functional disorder.
Rehabilitation faces a crucial choice; we may not be able to choose, but we should debate our preferred option.
“Does rehabilitation follow the disease-based health services, centring service on disease diagnosis (including syndromes such as fibromyalgia or chronic pain), or do we go for a holistic service design, offering patients the parts of a whole service they need?”
The former approach is typified by developing stroke rehabilitation separately from other services, such as musculoskeletal services. It leads to rehabilitation programmes such as upper limb programmes, hand therapy clinics, cognitive rehabilitation programmes, etc.
The latter approach is more challenging. It contradicts the existing framework, which is not working well, but people are familiar with it. It threatens people who fear being overwhelmed and losing control of their work and resources. It seems impossible to organise and manage. If we do not try, it will remain a challenge.
I have already published papers arguing for fully integrated services and not, for example, services specialising in traumatic brain injury. I have published posts discussing some of these issues. I have acknowledged that a fully integrated service will also pose challenges and have put forward an alternative solution, developing rehabilitation networks as a first step.
Broadening our perspective.
The dilemma posed by contrasting specific focused and supposedly better specialist services with apparently less focused and less specialist services is not unique to rehabilitation. It is faced in all healthcare. The General Medical Council commissioned a review focused on training doctors but relevant to the problem of over-specialisation within healthcare. The report, published in 2013 on The Shape of Training. Securing the future of excellent patient care was a significant factor behind the radical change in medical training curricula introduced in 2021 and 2022.
The challenge of delivering healthcare which can provide sound general care to all people and still identify people whose problems need highly specialist input faces rehabilitation, too. About ten years ago, the solution was to identify specialist rehabilitation which would be commissioned nationally. While this may have gained us extra resources for the minority of patients needing high levels of inpatient care and active therapy input, I have argued that we paid the price because the concept implies that all other rehabilitation is not specialist and can be undertaken by non-experts.
Consequently, healthcare policymakers have yet to accept that rehabilitation is an expert service with its areas of knowledge and skills. They also need to understand it is central to healthcare, not just a desirable but an essential add-on.
My central argument is that rehabilitation services must be fully integrated into all healthcare, just as geriatric medicine achieved over 20 years between 1970 and 1990. When discussing or developing rehabilitation services, they must be set in a broader perspective. Posts in this category are concerned about this.
The most recent eight posts about rehabilitation services are below; more can be loaded using the button at the end.