Key attributes of a specialist rehabilitation service
Last updated: October 18, 2025
We focus closely on the training and ongoing professional development of our staff to ensure they possess and sustain excellent general and specialised clinical skills. However, we notably pay little attention to the specialised clinical capabilities of services, and it is questionable whether infrequent hospital evaluations adequately assess the general clinical standards of individual services. An exemplary UK case concerns the clinical delivery of obstetric services, which have not improved despite several investigations of individual units. Similar issues occur in other services, such as cardiac surgery.
One valid reason is that the service cannot utilise any externally developed description of what is necessary to provide safe and effective management to all patients because no one has proved one. One quality improvement method, national registries of surgical outcomes, has notably improved standards; however, funding is often withdrawn after a few years, and few national registries receive adequate funding. More importantly, this technique is not generally applicable because identifying a range of simple, valid measures is impossible for most services.
To bridge this gap, I will propose some essential qualities that every expert rehabilitation service must possess.
Table of Contents
Introduction
Managers of rehabilitation services face a challenge in evaluating whether their service possesses the necessary clinical expertise to meet their patients’ needs.
They can verify the expertise of their professional staff by reviewing their professional portfolios, which may confirm their basic qualifications, scope of experience and knowledge, ongoing professional development, and likely areas of specialist expertise within rehabilitation. They could even assess staff against a series of proposed specialist rehabilitation capabilities, although these are not officially validated.
In contrast, they lack comprehensive guidance on assessing the capabilities and competence of services to provide rehabilitation generally, and on the service’s area of specialisation specifically. Organisations such as the Community Rehabilitation Alliance and the British Society of Physical and Rehabilitation Medicine (BSPRM) have issued guidance on specific practice areas. The recent guidance from BSPRM on rehabilitation in nursing homes offers some general standards; however, there remains no comprehensive guidance covering all rehabilitation services.
This page draws on a range of recent publications to propose some key characteristics that any expert rehabilitation service should have.
Terms used.
What does a specialist rehabilitation service refer to? On 1 January 2021, I published a post on specialist rehabilitation services that discussed some of the ambiguities and consequences of using the term. This post considered specialist services in the context of UK National Health Service guidance on commissioning ‘specialist rehabilitation services.
Therefore, before proceeding, I would like to clarify the meanings of specific terms, as words such as ‘specialist’ and ‘expert’ are often used interchangeably. Even rehabilitation is understood differently by each person.
Rehabilitation
This topic is discussed extensively on this website; I recommend reading ‘What is Rehabilitation‘ as an introduction and ‘General Theory of Rehabilitation’ for an up-to-date explanation..
In this context, I am referring to any activities aimed at assisting a person’s adaptation carried out by professionals who focus on improving the person’s function or participation in social activities. Therefore, this includes individuals within an acute, biomedically focused service whose goal relates to disability (activities) or other non-disease-related outcomes.
Expert rehabilitation.
The term ‘expert’ means that the person or service possesses specific knowledge and skills in rehabilitation, in addition to any other professional expertise they may have. In other words, the professional or service not only begins their process by considering the person’s functional abilities and needs but also has acquired, through education and training, additional knowledge and skills about the nature of rehabilitation.
For example, they should have the specialist capabilities associated with rehabilitation, whether as a professional or a service.
An expert service can be independent or part of a specialised acute disease clinical service. For instance, many hyperacute rehabilitation services are integrated within trauma or neurosurgical units, sharing clinical responsibility. Likewise, cardiology and respiratory services often include expert cardiopulmonary rehabilitation teams as a core element.
Specialist rehabilitation.
The term “specialist” is widely used but poorly defined and often misinterpreted. It may refer to unique knowledge and skills related to a disease, condition, treatment, or any other component of the healthcare process.
In this context, I use it to refer to a professional or service that already has expertise in rehabilitation; to be specialised, they must possess additional knowledge and skills in a specific type of problem or treatment. Examples include specialisation in neurological conditions, behavioural disturbances, assistive technology, community rehabilitation, or palliative and end-of-life care.
To conclude, I propose a hierarchy of rehabilitation knowledge and skills:
- Rehabilitation encompasses any professional, group, or service that provides attention to a person’s functional status and delivers actions specifically intended to improve the patient’s situation.
- Experts are professionals or services that possess additional knowledge and skills related to rehabilitation.
- Specialist means that, in addition to rehabilitation knowledge and skills, the professional or service has further specialised competence (knowledge and skills) in some aspect of rehabilitation.
Key Attributes of Specialist Rehabilitation – Overview.
The holistic biopsychosocial model is mathematically complex with extensive bidirectional inter-relationships between variables. Rehabilitation itself is also complex, with significant inter-relationships between interventions which span most domains of the model. Consequently, both the impact of any variable and the effect of an intervention to change a variable are unpredictable and typically nonlinear.
This crucial feature dictates the required service attributes because each person’s situation is unique, even if some features are similar.
I will discuss four aspects of any service, highlighting the key attributes for each:
- Clinical. This aspect concerns the knowledge and skills of the professionals in the multiprofessional team.
- This aspect pertains to the clinical processes and protocols employed by the team.
- Delivery. This aspect relates to the patient outcomes, delivering a safe and effective service.
- Management. A service usually manages its internal processes, but its organisation will manage finances, contracts, and human resources. As I will show, management can have a profound adverse impact on the service.
These items are shown in the MindMap below.
Specialist service attributes – clinical.
Identifying the key clinical skill in rehabilitation practice is a challenge. I have recently published an article asking, “Is rehabilitation’s unifying expertise its holistic scope and cognitive approach to the patient’s problems?”. The answer was, yes, rehabilitation thinking is the feature that links all the different types of rehabilitation.
I explored the nature of the cognitive approach, suggesting that rehabilitation thinking requires the fusion of three characteristics, as illustrated in the two figures below.
Therefore, the key clinical attribute is for all staff to have and use rehabilitation thinking. It has three components.
Rehabilitation thinking is person-centred.
Being person-centred is achieved through the use of the holistic biopsychosocial model of illness, which ensures that professionals consider all aspects of the person when collecting and using clinical data. Robert Smith et al. (2013), in An evidence-based patient-centered method makes the biopsychosocial model scientific, convincingly argued that using the biopsychosocial framework when collecting and analysing information to reach a holistic conclusion ensures a person-centred approach.
Rehabilitation thinking is facilitatory.
It recognises that rehabilitation’s role is to assist the person’s adaptation to changes associated with their malady, which is a more comprehensive term than illness to encompass the entire scope of rehabilitation. I explain this approach in my publication, A general theory of rehabilitation: Rehabilitation catalyses and assists adaptation to illness, and on this website here.
Rehabilitation thinking directs clinical reasoning.
Rehabilitation reasoning begins with a holistic formulation, arising from a systematic approach that typically focuses on problems in functional activities and is grounded in evidence. This approach to clinical reasoning inevitably leads to the planning of tailored combinations of interventions for each patient.
Specialist service attributes – service.
The service attributes cover the professionals working in the service and the processes used by the service.
Staff attributes.
The discussion above about the essential clinical attributes needed dictates the service staff attributes. To provide good rehabilitation, all staff must have expertise in rehabilitation thinking, which requires an understanding of:
- The General Theory of Rehabilitation, to appreciate the nature and role of rehabilitation
- The biopsychosocial model of illness, to undertake efficient and effective person-centred analysis and formulation of the patient
- The complex relational nature of rehabilitation necessitates a person-centred approach to patient selection and treatment, incorporating individualised interventions.
Rehabilitation thinking alone cannot achieve a good or even safe outcome. The professional needs both general knowledge and skills, for example, understanding how the health and social care systems work, as well as specific knowledge and skills in rehabilitation, such as knowing who benefits from a particular treatment, when it should be delivered, and how to administer it effectively.
Thus, the professional staff in the service must also have expertise in rehabilitation in addition to their professional expertise. One cannot assume that professional training automatically confers expertise in rehabilitation, and only doctors currently have validated training in this field.
All professionals can acquire expertise. Although there is no organisation responsible for monitoring training and certifying expertise outside medicine, the service could ensure that all staff gain experience and then develop the capability in the seven specialist capabilities in practice recommended, which are derived from and mainly based on medical capabilities. I have published a set of generic and expert capabilities that would demonstrate rehabilitation expertise.
Lastly, the clinical staff require specialist knowledge and skills tailored to the particular specialisation of the service; this issue is addressed by the delivery competencies discussed in the next section.
Service attributes.
Rehabilitation thinking is vital for managing the complexity of rehabilitation, as well as the resultant uncertainty, and the crucial need to individualise all decisions and actions. This need also applies to the service that must ensure that everything starts from the patient’s needs, not any other criterion.
The main consequence of this clinical approach is that the service must be flexible, responding to each person’s needs, and patients should not have their programmes adjusted to fit the service’s protocols or routines.
Considering each patient individually is manifest by ensuring the service does not depend on or use:
- Rigid selection criteria. No valid system can determine who will benefit. (see Rehabilitation Potential, on this site, and Rehabilitation potential: a critical review of its meaning and validity.)
- Specific treatment programmes of fixed content and length for all patients, covering a diagnosis (e.g. all people with stroke) or condition (e.g. a fatigue management programme); individual patients with the diagnosis or condition may be suitable for a fixed programme, but many will not.
Specialist service delivery attributes.
So far, we have discussed clinical staff and the processes and procedures used by the clinical team. We now need to consider its effectiveness.
The key delivery attribute of a specialist expert rehabilitation service is that it can demonstrate it delivers a safe and effective rehabilitation service to the patients it sees (i.e. its caseload). The emphasis is on demonstrating expertise and practising safely.
Capabilities.
Capabilities, which are a few high-level activities indicative of the expertise concerned, are used to demonstrate expertise. The specialist rehabilitation service should meet the capabilities proposed in the BSPRM guidance on specialised nursing homes and in Clinical Rehabilitation.
To show that a service has expertise in rehabilitation, it must demonstrate publicly that it has:
- The seven generic capabilities that every clinical service should possess
- The seven rehabilitation capabilities that indicate an expert rehabilitation service
- The clinical competencies needed to manage its specialist caseload.
The service characteristics outlined above were thoroughly described in “Rehabilitation and Complex Disability Management in Specialist Nursing Homes and Other Residential Units – Guidance to Best Practice,” published by the British Society of Physical and Rehabilitation Medicine (BSPRM) in 2024. I also discussed them in a paper titled ‘Does a service provide safe, effective rehabilitation? An evaluation method for providers and purchasers.‘ The two Mind Maps below illustrate the generic and rehabilitation capabilities required.
The BSPRM guidance explains how services can demonstrate their expertise. The system does not rely on any external supervisory organisation. Instead, it depends on the commissioning organisation hiring someone with rehabilitation expertise to assess the evidence provided, but this should not be burdensome. This approach to demonstrating specialist rehabilitation knowledge and skills requires mutual trust and collaboration between the commissioner and provider.
Competencies.
Competencies refer to the highly specialised knowledge and skills that the service possesses. They are specific to the patients being seen, and most other rehabilitation professionals will not have them. Only the service can define some indicative competencies to demonstrate their ability to provide safe, effective, specialist rehabilitation.
The BSPRM nursing home guidance gives more information about the processes involved.
Networks
However, a specialist service cannot work in isolation and will, inevitably, work with other services. These will include:
- Other rehabilitation services
- Medical services
- Social services, employers, etc
Rehabilitation services should be part of a collaborative local network; I have discussed this matter here and here. There are no large-scale effective networks, though small local networks may be emerging. Without significant support from service commissioners, they will not be sustainable.
Organisational attributes.
The key theme running through all the characteristics of a safe, effective specialist rehabilitation service is that it is person-centred, individualising all decisions and actions to the person, their circumstances, strengths, and goals.
Most healthcare systems claim to be person-centred. Claiming to be person-centred is easy when the phrase has so many meanings: two reviews show that the term has multiple meanings, some far removed from rehabilitation’s approach (Mitchell et al., 2023; Byrne et al., 2020).
A person-centred healthcare system.
The final and most difficult key attribute is for the service to operate within an organisation and healthcare system committed to a person-centred approach at all levels. The crucial importance of the whole system accepting an approach centred on the individual was the main finding in a comprehensive review of person-centred rehabilitation. The authors concluded that, unless the healthcare organisation responsible for clinical services is itself person-centred, all efforts by the clinical service are likely to fail.
Therefore, the primary management attribute of the service is that the entire healthcare system must be person-centred and that must include the organisations that purchase the service.
In the UK and most other countries, with the notable exception of the United States, this means the government’s healthcare approach must be person-centred.
Rehabilitation is more complex and unpredictable than most other specialities, which makes financial planning challenging. In the US, insurance companies are the primary funders of healthcare, and they are often hesitant due to the uncertainty associated with complex healthcare issues. Medicare, Medicaid, the Veterans Administration, and Integrated Management Care consortia such as Kaiser Permanente are more inclined to focus on patient-centred care.
Conclusion
The key feature of a specialist expert rehabilitation service is that it must be genuinely person-centred (not patient-centred). Achieving a high-quality, effective, safe, and efficient service requires trust and collaboration between every part of the service, including its management and the commissioning organisation. They must all focus on the individual in all decisions and activities. Reaching this ideal requires a significant shift in how health is viewed, from a biomedical model to a biopsychosocial approach, which I have discussed in detail here. Until a substantial paradigm shift occurs, services should strive to achieve these qualities in their operations, as many aspects are attainable through persistence and dedication.