Rehabilitation service organisation
Most rehabilitation literature concerns research into the process. This eventually improves the patient’s experience and outcome, but only if they can access rehabilitation and the available service is good quality. Few journal publications or textbooks discuss rehabilitation services’ organisation, delivery, and quality. Yet, from a patient’s perspective, these are crucial. The UK is an excellent example of the problem. Our rehabilitation research is of high quality and is equal to that of other leading countries. Our rehabilitation service organisation and delivery is abysmal. The number of doctors and other professionals working in named rehabilitation services is far below that of other wealthy countries. Many major hospitals have minimal or no expert rehabilitation services within them. Community services are patchy and inadequate. There are few, if any, effective rehabilitation networks. Patients wait weeks or months to access expert rehabilitation after trauma. In the UK, this chaos arises from a combination of factors. Politicians and policymakers do not understand rehabilitation, nor do they try to. Most medical advice is given by professionals working within a biomedical framework. Healthcare is underfunded. This section of the website will start to redress the balance, discussing rehabilitation service organisation and how it can be improved.
Table of Contents
Introduction
In 1997, the British Medical Journal published a paper showing that an intervention “resulted in long term reductions in death, dependency, and the need for institutional care.” Furthermore, this study found “No systematic increase in the use of resources (in terms of length of stay) was apparent.” The intervention was “organised inpatient (stroke unit) care after stroke.” Other evidence suggests that people involved in the control arm of complex treatment for leukaemia and other malignancies tend to have better outcomes than people not involved in the trial, even if their specific therapies are the same.
The crucial feature is rehabilitation service organisation, which leads to better outcomes when coupled with expertise and teamwork.
The many inquiries into health and social care failures that cause harm or death provide strong evidence that disorganised service delivery is harmful.
The essential feature in all instances is complexity. The patient’s treatment is complex, involving many people, several different actions, and usually a prolonged period of activity. The person’s situation is often complex, with many factors influencing treatment and outcome.
The challenge of complexity in healthcare was recognised about 25 years ago. Formal research into ways to organise healthcare to improve patient experience and outcome may have occurred. Unfortunately, political imperatives to be seen as doing something lead to regular changes in the organisation of UK healthcare, none of which are based on sound evidence. Trisha Greenhalgh and Chrysanthi Papoutsi emphasised the need for a paradigm shift in 2018; we are still waiting!
Rehabilitation and some other areas of healthcare, such as psychiatry and much of geriatric care, are intrinsically more complex because they use a holistic approach based on the biopsychosocial model of illness. Therefore, these specialities mainly depend on a stable adaptive organisation that encompasses social services, housing, and employment services, among many others. (The ‘five giants’ identified by Sir William Beveridge in his 1942 report, Social Insurance and Allied Services.}
What is a Rehabilitation Service?
In the UK, most interventions aimed at reducing disability and facilitating adaptation to illness are delivered outside named expert rehabilitation services. Some of this rehabilitation is excellent, but much is delivered without using a whole multiprofessional team or with insufficient expertise.
When founded in 1948, the UK National Health Service expected each hospital speciality to be responsible for rehabilitating its patients. This was an excellent principle because it would result in a seamless service. Unsurprisingly, the dominance of a biomedical approach to healthcare, reinforced by the vast increase in biomedical knowledge leading to better investigations and treatments, led to rehabilitation having a low priority. Resources were limited, and medical and political pressure focused on hospitals and diseases, not disability.
Nevertheless, some specialities maintained or increased rehabilitation. Geriatrics did most adult rehabilitation and research. Paediatric services undertook all children’s rehabilitation except those cared for by learning disability services. Psychiatric services offered rehabilitation as part of their service. Later, isolated services developed rehabilitation for some of their patients. Examples include cardiac, pulmonary, rheumatological, and pain rehabilitation services.
Consequently, many services offer some rehabilitation to their patients. Rehabilitation is a significant part of the training curriculum in several medical specialities, including geriatrics, paediatrics, and stroke medicine. Unfortunately, isolated specialities do not necessarily offer complete rehabilitation training.
To answer the question, many services say they offer rehabilitation, but it is unclear whether they all offer comprehensive expert rehabilitation. The pages here discuss UK medical specialities that provide rehabilitation or aim to.
Who offers rehabilitation?
In the UK, most interventions aimed at reducing disability and facilitating adaptation to illness are delivered outside named expert rehabilitation services. Some of this rehabilitation is excellent, but much is delivered without using a whole multiprofessional team or with insufficient expertise.
When founded in 1948, the UK National Health Service expected each hospital speciality to be responsible for rehabilitating its patients. This was an excellent principle because it would result in a seamless service. Unsurprisingly, the dominance of a biomedical approach to healthcare, reinforced by the vast increase in biomedical knowledge leading to better investigations and treatments, led to rehabilitation having a low priority. Resources were limited, and medical and political pressure focused on hospitals and diseases, not disability.
Nevertheless, some specialities maintained or increased rehabilitation. Geriatrics did most adult rehabilitation and research. Paediatric services undertook all children’s rehabilitation except those cared for by learning disability services. Psychiatric services offered rehabilitation as part of their service. Later, isolated services developed rehabilitation for some of their patients. Examples include cardiac, pulmonary, rheumatological, and pain rehabilitation services.
Consequently, many services offer some rehabilitation to their patients. Rehabilitation is a significant part of the training curriculum in several medical specialities, including geriatrics, paediatrics, and stroke medicine. Unfortunately, isolated specialities do not necessarily offer complete training in rehabilitation.
To answer the question, many services say they offer rehabilitation, but it is unclear whether they all offer comprehensive expert rehabilitation. The pages here discuss UK medical specialities that provide rehabilitation or aim to.
Networks and rehabilitation service organisation.
In the UK and most countries, services have grown piecemeal, responding to immediate needs or being led by enthusiastic, visionary leaders. A similar process happened for biomedical specialities. Healthcare services were not designed from first principles. Instead, they have adapted and changed to meet needs and perceived priorities. Consequently, there has been no rehabilitation service organisation.
Second, the bureaucracy associated with funding dislikes uncertainty and complexity and imposes arbitrary boundaries and categories. A notorious example is the distinction between health care responsibility, free at the point of care, and social care responsibility, which is means-tested. This leads to criteria determining continuing healthcare and other criteria determining ‘right to reside’ (in hospital); both are contested, waste vast amounts of resources, and disrupt clinical care.
When boundaries and classifications are imposed on a complex system with no logically coherent organising principle and without providing firm organisational links across borders, the complex system fails, and isolated silos result. In healthcare, patients suffer.
One crucial distinction is between ‘medical’ care, rehabilitation, and ‘social care’; rehabilitation is considered binary, whereas it straddles many boundaries and is a continuous variable. There is a parallel with education. Professionals may leave the educational establishment but never stop learning and using academic resources.
The General Theory of Rehabilitation highlights the impossibility of isolating rehabilitation input from all other input someone may benefit from when adapting to their illness. Its central premise is that rehabilitation facilitates the adaptation of someone whose normal equilibrium is upset by an illness.
Rehabilitation facilitates adaptation by providing information and advice, including planning actions and intervening. The interventions include teaching someone how to undertake an activity, helping with psychological adaptation, and optimising the environment. A further component is advising on long-term care and support needed. Many of these actions are undertaken by non-healthcare organisations.
I have written two posts on rehabilitation networks: the first sets out the problems faced, and the second provides the solution.
Conclusion
This part of the website was started on August 19, 2024. It will develop. The first significant contribution is an analysis of what features a rehabilitation service should have and how the service might demonstrate that. I hope the system, central to the guidance on rehabilitation in nursing homes to be published in November 2024 by the British Society of Physical and Rehabilitation Medicine, will be tried and substantially improved. The second substantial contribution is giving support to the work of the Community Rehabilitation Alliance on standards for community rehabilitation, which explicitly recommends rehabilitation networks. I hope further contributions will occur!
