What is a rehabilitation service?
“How good is the rehabilitation they offer?” Anyone referred to or paying for a service should ask. In the UK, the question cannot be answered using publicly available sources; one must depend on the service’s reputation or personal recommendation, both unreliable sources. However, the question, “How do you know a doctor is a rehabilitation specialist?” has been answered in the Rehabilitation Medicine training curriculum. I have generalised it to all other professions. The British Society of Physical and Rehabilitation’s working party revising guidance on rehabilitation in nursing homes faced a similar difficulty: how could one assess whether a care home delivers expert rehabilitation? We discussed the problem, and I recently published our method. This page presents the suggested method. It needed to be tried, and undoubtedly, it can be improved. Nevertheless, nursing homes can use it to evaluate and improve their service and healthcare commissioners, including people paying for their rehabilitation, could ask any proposed service to complete an evaluation.
Table of Contents
Introduction
Between 2016 and 2020, the UK Rehabilitation Medicine Specialist Advisory Committee developed a new training curriculum focused on achieving a limited number of high-level outcomes; the General Medical Council required this for all medical training programmes. The resulting eight outcomes were, in effect, an implicit definition of rehabilitation expertise. The General Medical Council also required all medical training to achieve general professional capabilities that should avoid most complaints against doctors.
The Joint Royal Colleges of Post-graduate Training Bodies satisfied the General Medical requirements by asking every speciality to include six generic Capabilities in Practice and between six and eight specific specialist Capabilities in Practice unique to the speciality. These high-level outcomes were characterised by giving behaviours that indicated satisfactory performance.
At the same time, medical training moved away from judging a doctor’s competence at specific tasks to the concept of entrustability. Instead of saying that the doctor has undertaken a task effectively and safely without support, entrustability says that the doctor can be trusted to undertake the activity effectively and safely. The former considers the past; the latter considers the future. The evidence for entrustability is collected by the trainee; it does not depend on examinations but requires a cadre of doctors with the expertise necessary.
Thus, we now have a system for defining when a doctor (in the UK) can deliver rehabilitation, defined by eight specialist Capabilities in Practice, and has the general professional skills needed to do so to the expected standard, defined by six generic professional Capabilities in Practice. The capabilities are given in the Rehabilitation Medicine Curriculum, further explained in more detail in a Rough Guide.
I have already suggested that the system could allow other professions to validate that a professional has rehabilitation expertise in addition to their professional expertise, as doctors do. Only doctors have validated expertise in rehabilitation, though many other people from many professions undoubtedly have expertise. You can read more on this site and in a journal article.
This page and my published article suggest that the same approach can be applied to rehabilitation services. It was developed in the context of guidelines for nursing homes (care homes, skilled nursing facilities, etc.) offering residents rehabilitation. It could apply to any rehabilitation service in any setting and as part of any organisation. Moreover, the method does not require any new organisation to monitor individual services, though someone will need to monitor the system’s performance, improving it in light of experience.
Generic rehabilitation service standards
All healthcare services must meet general quality standards. These include clinical performance in relationships with patients and their families, governance and maintaining quality, and broader legal and financial requirements. In the UK, the Care Quality Commission is the leading organisation responsible for this activity. However, other organisations, such as the Department of Health and Social Care and NHS England (and similar NHS organisations in other UK nations), also do this.
Department of Health and Social Care:
“We support ministers in leading the nation’s health and social care to help people live more independent, healthier lives for longer.”
“We make sure health and social care services provide people with safe, effective, compassionate, high-quality care, and we encourage care services to improve.
We monitor, inspect and regulate services and publish what we find. Where we find poor care, we will use our powers to take action.”
“Our purpose is to lead the NHS in England to deliver high-quality services for all.”
For clinical activities, the six generic capabilities applied to all doctors are:
- Able to function successfully within NHS organisational and management systems.
- Able to deal with ethical and legal issues related to clinical practice.
- Communicates effectively and can share decision-making while maintaining appropriate situational awareness, professional behaviour, and professional judgment.
- Focused on patient safety and delivers effective quality improvement in patient care.
- Carrying out research and managing data appropriately.
- Acting as a clinical teacher and clinical supervisor.
These are derived from the General Medical Council’s Generic Professional Capabilities framework. This covers nine domains of professional performance, and it gives behaviours illustrating achievement in each domain:
- Professional values and behaviours.
- Professional skills.
- Professional knowledge.
- Capabilities in health promotion and illness prevention.
- Capabilities in leadership and team working.
- Capabilities in patient safety and quality improvement.
- Capabilities in safeguarding vulnerable groups.
- Capabilities in education and training.
- Capabilities in research and scholarship.
The generic Capabilities in Practice used in medical training curricula monitored by the Joint Royal Colleges Postgraduate Training Boards are focused on aspects of a doctor’s clinical behaviours within the settings and organisations where they work. They are more focused than the GMC generic professional capabilities and pay more attention to clinical performance than the CQC, which is more concerned with higher system-level performance.
Specialist rehabilitation doctor standards.
Clinical services are responsible for ensuring they provide safe and effective services using audit, quality improvement, and clinical governance procedures and being informed by any relevant guidance. The hospital organisation is ultimately responsible. No external organisation is responsible for monitoring standards, though national audit programmes do monitor some specific treatments or conditions.
The General Medical Council requires all doctors training in a speciality to achieve a few high-level outcomes. In medical specialities monitored by the Joint Royal Colleges of Post-graduate Training Bodies, these outcomes are called Capabilities in Practice. Trainees in Rehabilitation Medicine must show eight specialist Capabilities in Practice. They are that the doctor has the capabilities shown below.
- Able to formulate a full rehabilitation analysis of any clinical problem presented to include both disease-related and disability-related factors.
- Able to set out a rehabilitation plan for any new patient seen with any disability, this plan extending beyond the consultant’s specific service.
- Able to work as a full and equal member of any multidisciplinary rehabilitation team.
- Able to identify and set priorities within a rehabilitation plan.
- Able to diagnose and manage existing and new medical problems in rehabilitation.
- Able to recognise the need for and successfully deliver specific medical rehabilitation treatments.
- Able to work in any setting, across organisational boundaries and in close collaboration with other specialist teams.
- Able to make and justify decisions in the face of the many clinical, socio-cultural, prognostic, ethical, and legal uncertainties and influences that arise in complex cases.
Capabilities across rehabilitation professions.
The professional capabilities applied to doctors could apply to all rehabilitation professionals, with some minor alterations. I have published some adapted capabilities and expanded them elsewhere on this website.
I made two significant changes to the generic capabilities. The second capability, “able to deal with ethical and legal issues related to clinical practice,” was generalised to “adapt actions to the social context of their patients.” This was to acknowledge that ethical and legal issues are only a part of the social context and that other parts, such as culture and religion, are equally relevant.
Second, the generic standards for doctors did not include my addition, “Base all clinical practice on best available evidence and professional standards.” Although this is vital, it was presumably assumed!
Generic rehabilitation professional capabilities
Thus, seven generic capabilities apply to all people in all healthcare, including rehabilitation.
The rehabilitation healthcare professional can:
- Function within the healthcare and social support management systems.
This is vital because the patient will inevitably need assistance from several services. Every rehabilitation team member must be familiar with commonly used local services such as day centres, voluntary support organisations, Social Services, and other relevant healthcare services such as equipment and district nursing services. - Adapt actions to the social context of their patients.
Every nation, region, locality, and sometimes household will include people with different cultures, religions, dietary preferences, etc. Every rehabilitation team member should be aware of and consider these variations and how to adapt their approach if necessary. - Communicate effectively, including when sharing decision-making.
Patients and families rightly expect to be equally involved in all healthcare decisions. The NHS requires shared decision-making, and NICE guidance is available. [NICE = National Institute of Health and Care Excellence]. - Focus on quality and safety and participate in quality improvement systems.
From a patient’s perspective, the quality of their life arises from all services, and many serious failings arise from the interfaces between services: failure to continue treatment, loss of vital information, etc. Every team member should be alert to shortcomings in other services, especially during patient transfers, and draw attention to the difficulties identified. - Understand and support research.
Rehabilitation research is vital. Rehabilitation team members need to find and evaluate relevant research. They may also have ideas for research or be asked to support a project. - Teach and supervise healthcare trainees.
Every professional must train people joining their profession. Rehabilitation has an extra responsibility; each profession should educate and supervise people training in other rehabilitation, focusing on their rehabilitation skills. - Base all clinical practice on the best available evidence and professional standards.
Each team member has specific professional expertise; their rehabilitation expertise is an addition, not a replacement. Maintaining and developing professional knowledge and skills and using them is vital.
I made more changes to the specialist capabilities. The medical capabilities reflected the expectation that the specialist rehabilitation doctors would often be the first point of contact and the senior clinician in the team; this is usually expected or assumed by the organisation, the team, and the doctor. One can argue whether it is correct. I have modified the capabilities to suit any profession with few assumptions about their roles within the team.
Specialist rehabilitation professional capabilities
There are seven specialist capabilities. I will show them with a brief comment on why or how they differ.
The rehabilitation healthcare professional can:
- Use the biopsychosocial model of illness in all areas of practice.
The medical capabilities did not make this explicit; it was only implied in the ‘formulation’ capability. - Develop (with others) a rehabilitation plan for the patient.
The medical capability did not make explicit the need to involve other team members; it was aimed at doctors being the first point of contact in settings without immediate team support, such as seeing a ward referral or new out-patient. - Work as a full and equal member of any multi-professional team.
This is unchanged (except I have now changed it to emphasise multi-professional; multidisciplinary often refers to a group of doctors from different medical specialities. - Work across organisational and geographic boundaries, collaborating with other professionals and teams.
This is virtually unchanged, - Recognise, accept and manage uncertainty and complexity, with a long-term commitment to the patient if needed.
This is a slightly less specific version of the last medical capability. It draws attention to complexity, uncertainty, and long-term commitment but does not detail the many domains involved, such as culture and ethics. - Support the common, generic rehabilitation interventions.
This was not included in the medical capabilities, reflecting the much less frequent interactions between doctors and patients in rehabilitation, - Use profession-specific expertise to help the patient and assist team processes.
This replaces two doctor-specific capabilities covering medical diagnosis and medical treatment. Each profession will have its expertise in diagnosis and treatment, and this capability should cover both.
Adapting capabilities to services.
People with rehabilitation expertise should staff a rehabilitation service. Many professions will be involved, but each professional should have the knowledge and skills outlined above. This means that the service itself should have the same characteristics. Thus, a good starting point when considering a service is to adapt the existing capabilities that apply to individuals working in a service to apply to the service itself.
Each capability describes the way a person should achieve the required high-level output. Although a service is not a person, it may show behaviours. The Oxford English Dictionary [OED] describes behaviour as “the way in which one acts or conducts oneself, especially towards others”, “the way in which an animal or person behaves in response to a particular situation or stimulus:”, and “the way in which a machine or natural phenomenon works or functions”.
Although not specified in the OED, it is expected to refer to how organisations or groups of people behave, and the common thread is an implied link between activities and outcomes. For example, “The organisation behaved in a high-handed manner, ignoring the concerns of the families.”
Thus, I have adapted the 14 capabilities (seven generic and seven specialist) to apply to a rehabilitation service. The method can be used for all services, whoever manages them, whatever the setting, regardless of the types of patients or problems seen or the interventions provided.
Generic rehabilitation service capabilities.
Generic capabilities have been included, even though the Care Quality Commission monitors many of the essential general features of a service. However, some features of generic capabilities are vital parts of an effective rehabilitation service that will not be assessed by the Care Quality Commission, such as adapting treatments to a person’s social context.
The box below shows the seven generic capabilities. A table (click here) gives some indicators that should demonstrate the service has the capability, and some data that will provide supporting evidence. A Word version of the table can be downloaded.
Seven generic service capabilities
Thus, the seven generic capabilities are as follows. The rehabilitation service:
- Functions within the healthcare and social support management systems.
This is vital because the patient will inevitably need assistance from several services, and lead responsibility will change. As far as possible, the person should receive a consistent pattern and quality of care across all settings and services. - Adapts actions to the social context of their patients.
Every nation, region, locality, and sometimes household will include people with different cultures, religions, dietary preferences, etc. A nursing home must adapt to these variations; it often becomes the person’s home, at least for a while. - Communicates effectively, including when sharing decision-making.
Patients and families rightly expect to be equally involved in all healthcare decisions. The NHS requires shared decision-making, and NICE guidance is available. [NICE = National Institute of Health and Care Excellence]. - Focuses on quality and safety and participates in quality improvement systems.
From a patient’s perspective, the quality of their life arises from all services, and many serious failings arise from the interfaces between services: failure to continue treatment, loss of vital information, etc. No overarching quality improvement organisation exists, and each service should contribute to quality improvement across all services. - Understands and supports research.
Rehabilitation research pays little attention to the substantial rehabilitation needs of patients in nursing homes. Nursing homes should attract and encourage research. - Teaches and supervises healthcare trainees.
People in care homes have significant medical and rehabilitation needs. Although they are the largest single group of patients, only some trainees are exposed to them and their needs. They often have rare or challenging conditions and offer an excellent training resource; patients and staff would also benefit. - Bases all clinical practice on the best available evidence and professional standards.
Much research and guidance exists, though interpreting it and applying it to individuals is challenging. Many clinical guidelines are also available, but sometimes, they need to be more consistent and may still be challenging to use. Despite these difficulties, the evidence must be considered and applied where appropriate.
Specialist rehabilitation service capabilities.
The specialist capabilities are significantly adapted from the professional ones to ensure they are applicable. They are shown in the box below. A table (click here) gives at least three indicators for each with evidence or data that could show that the indicator is present. A Word version of the table can be downloaded.
Seven specialist service capabilities
The capabilities are that the rehabilitation service:
- Uses the biopsychosocial model of illness in all areas of practice.
This is an essential feature of all rehabilitation services. It underlies the patient-centred holistic approach. Without this feature, a service will not provide effective rehabilitation. - Uses a multi-professional team able to meet 80% of patient needs.
This is the crucial result of using the biopsychosocial model. The model requires the assessment to cover all aspects of a person’s situation and to plan interventions across all domains in the model. No profession can have the expertise to cover all this, and a multi-professional team is crucial; without one, a service will not provide effective rehabilitation. - Develops a person-centred rehabilitation plan for each patient.
Each patient has personal physical and cultural settings, hopes, strengths, losses, etc. Rehabilitation facilitates adaptation within these contextual factors and can only be effective if interventions are tailored to the person’s needs. - Works collaboratively across organisational and geographic boundaries.
Rehabilitation not only requires a service to have a multiprofessional team, but it also needs to engage other services and organisations. For example, healthcare rehabilitation services cannot directly undertake housing adaptations, tendon-transfer operations, or adapted cars, but they can identify the need and advise other services. - Provides rehabilitation interventions tailored to the person’s needs.
One essential aspect of the personalised rehabilitation plan is for each professional to provide expert rehabilitation interventions. Still, these must be adapted to the person’s overall needs and many influential factors, notably their preferences and priorities. - Ensures staff have the competencies needed for their patient caseload.
This vital capability is equivalent to the professional’s duty to keep up-to-date and maintain and develop their professional knowledge and skills. The service must ensure that its team’s knowledge and skills are broad and deep enough to deliver safe, effective rehabilitation to the patients it sees. It must regularly review its ability and take action to increase or alter its expertise in light of the patients seen. - Acknowledges and manages uncertainty and complexity.
Another central feature of rehabilitation is the complexity of each case. This arises from its holistic nature because a complex system has non-linear, bidirectional, and interacting relationships between many variables. Prediction is always uncertain. Any service that does not face complex ethical, legal, and personal challenges is not alert to them; they are universal, and the team must develop ways to gather support and help.
Capabilities and competencies.
Specialist medical (including surgical, psychiatric, etc.) services specialise in only a tiny proportion of all medicine and often only one subspecialty within their field. They have three duties:
- to recognise, diagnose, and manage their patient’s common medical problems,
- to recognise, diagnose, and manage issues within their speciality but outside their subspeciality,
- to offer a safe and effective specialist service to patients who need their highly specialist expertise.
Only the service knows what skills and knowledge it needs, and it is responsible for ensuring it meets its requirements. In this context, the management expected in the first two situations covers any urgent actions and referral to a more experienced team if necessary.
The situation is precisely the same for a service offering rehabilitation. The service is responsible for having sufficient:
- medical expertise to recognise, diagnose, and manage common medical problems seen in the patients treated,
- rehabilitation expertise to recognise, formulate (diagnose), and manage any rehabilitation problems present in patients seen,
- expertise in its subspecialist rehabilitation field to achieve the expected outcomes of a subspecialist rehabilitation service.
Similarly, only the service knows what skills and knowledge it needs and is responsible for ensuring it meets its requirements. In this context, the management expected in the first two situations covers any urgent actions and referral to a more experienced team if necessary.
The proposed rehabilitation service capabilities recognise the duty to ensure patient safety, especially in the subspecialist field, by explicitly requiring the service to specify some competencies that demonstrate safety or effectiveness.
In this context, competency is a high-level ability to diagnose and manage a specified clinical issue safely and effectively, such as managing someone whose behaviour is challenging, responding to ethically and legally demanding issues around withdrawing medical treatments or caring for people with tracheostomies or other airway issues.
The British Society of Physical and Rehabilitation Medicine’s working party on guidance on rehabilitation in nursing homes identified eleven competencies likely to be needed in different types of rehabilitation services. These competencies are exemplars and can be downloaded. Some services will require other competencies.
Anyone developing a competency should start by identifying its specialist field of practice. Next, the clinical team should consider the patients’ particular clinical characteristics and the complex issues that must be handled safely and effectively. Then, the team should select 4-6 from this list to cover the range and indicate that the service will achieve good outcomes. Crucially, only a few are required to demonstrate safety and effectiveness; showing that the service can manage every possible issue is unrealistic and unnecessary. A MindMap below provides an overview, and can be downloaded.
Finally, the team must devise a short statement summarising the competence; it should be an activity the service undertakes or achieves. One important aspect is to find three or four observable activities required to meet the high-level activity. These are, again, indicators. Their essential feature is that data to demonstrate the indicative actions are achieved must be easily found or collected.
In other words, competencies should:
- essential to meet the special rehabilitation needs of the patient population
- be encapsulated in an activity the service performs
- have three or four actions or characteristics
- closely associated with the competency
- with data to demonstrate they occur
- the data being feasible to collect without undue effort
Conclusion
This approach builds on the approach now used to assess the safety and effectiveness of fully trained doctors working in an area of specialist medical practice, including general practice, which is as specialised as all other medical roles. The underlying features in demonstrating professional and service quality are:
- Primarily considering a small number of high-level outcomes arising from many lower-level behaviours;
- Using a few selected activities needed to achieve the outcomes to demonstrate the person or service has the expected:
- General expertise associated with all professional or service activities
- Specialist expertise associated with the particular patients and issues being seen
- Monitoring performance using data items that
- Is closely related to the activity concerned
- Is feasible, within a proportionate resource requirement
- Trusting the professional or service based on limited indicative evidence.
This approach reduces dependence on outside bodies to monitor and validate performance, instead relying on trust and the duty imposed by professional or organisational guidance. It focuses on present and future performance rather than past performance. It encourages collaborative behaviours between the professional or service, those who pay for the outputs, and those who receive the professional or service activity.
The system works for training doctors and could quickly work for all other professions. It is untried for services, but the principles are the same, so it should work; this is the only available method. The MindMap below gives an overview.
