This page considers how the setting of rehabilitation influences patient experience. Rehabilitation services are generally but not exclusively funded as part of healthcare. Healthcare comprises many different services and specialities; rehabilitation is a relatively minor part of healthcare. Healthcare has its own culture, especially in the UK National Health Service (NHS). Healthcare is one part of the social structures within any society. Societal rules and expectations within the region, state, or country will determine the resources allocated to healthcare, the assumptions about expectations of rehabilitation, and the demand within society will influence both total resources allocated to healthcare and the proportion rehabilitation can expect. All these factors will affect the rehabilitation of a patient, but many other social contextual factors will have an equal or more significant effect. These include the expectations of rehabilitation held by the referring person, the patient, the family, and the rehabilitation team. Other important factors include the specific areas of expertise available locally, the culture of the rehabilitation service, the model of illness used by managers and clinicians locally etc.
The first Generic Capability in Practice for all medical specialists in the UK is that they should be “able to function successfully within NHS organisational and management systems”, and the second is that they should be “able to deal with ethical and legal issues related to clinical practice.” (here) The priority of these two aspects of a doctor’s training demonstrates the importance of context to all medical practice. The General Medical Council also emphasises that doctors have to be aware of and consider available resources and that they are limited. (here) Other professions will have similar guidance.
Therefore, there can be no doubt that the setting where rehabilitation occurs will influence what can happen and what does happen. Improving services depends on understanding and controlling these contextual factors as much as it depends on the direct quality monitoring and improvement of clinical rehabilitation practice. This page investigated some critical factors.
Healthcare culture – model of illness.
Perhaps the most critical and pervasive and the least visible and appreciated contextual factor is the widespread acceptance of the biomedical model of illness and its associated disease-centred approach to healthcare. This model influences most healthcare planning and organisation, commissioning, decision-making, prioritising, and ways of managing patients. It pays little attention to disability and the consequences of the disease. The biopsychosocial model of illness, the conceptual framework underpinning rehabilitation, has a more holistic view of illness. I discuss models of illness more here.
The dominance of the biomedical model of illness both in healthcare and the public understanding of healthcare hinders an appreciation of rehabilitation. Its prominence is such that it can adversely affect the culture of a multi-professional rehabilitation team because some team members still base some of their ideas upon aspects of the biomedical model.
The biomedical model:
- is the basis of the organisation of most specialist healthcare services, but is an inappropriate basis for organising rehabilitation services
- is the basis for most commissioning and funding of healthcare but is inappropriate for rehabilitation services. (It is probably a poor basis for all healthcare funding.)
- underlies many research funding systems which have difficulty adapting to rehabilitation research designs, outcomes, and applications
- determines most political priorities which disadvantages rehabilitation
It is not easy to overcome this influence. In the long-term, education and constantly drawing attention to the many benefits of the biopsychosocial model of illness may have. In the meantime, all one can do is be aware, identify when the model is causing misunderstanding or other problems, and provide an alternative view based on the biopsychosocial model of illness.
People with an interest
In contrast to the influence of the biomedical model of illness, the impact of people concerned with patient rehabilitation is direct, sometimes noticeable, and usually not discussed. This part does not consider the patient; they have an apparent interest.
Family members and close friends may have a strong influence on rehabilitation. Their goals for the process may not coincide with the person’s goals, and their expectation of rehabilitation may influence the patient, the rehabilitation team, or others. The information they provide or fail to provide may also have direct effects. The absence of friends or family or the failure to involve them will always influence the process.
Other professional teams within healthcare services (e.g. the referring service) or outside healthcare (e.g. Social Services, care providers) will also have preferred goals for and expectations of rehabilitation. They may also have information, and, similarly to family members and friends, they may be able to offer resources such as additional support and care.
Managers of the organisation, such as the hospital, and the organisation funding the rehabilitation may also influence rehabilitation. This influence is discussed in more detail in a blog post here.
The interests of all these parties must be considered during the rehabilitation process, especially when formulating the situation and setting goals. I am not saying that the interests of any one of these people should determine what happens. Instead, I am saying that one must be aware of these many different interests, consider if they are having an influence and, at times, discuss openly how much weight you should give to the goals or expectations of an interested party. For example, should an early transfer of care to a community placement with inadequate rehabilitation expertise be carried out to allow new patients into the hospital?
Law and ethics
The law, professional standards and obligations, and ethical considerations influence rehabilitation. These factors are all closely interrelated and usually concur and support each other. Occasionally a personal moral stance may differ, in which case you may need to review your involvement in making a decision or retaining your role in the patient’s management.
The specific laws affecting rehabilitation include the Mental Capacity Act 2005, regulations concerning a patient’s ability to drive or work, laws about vulnerable patients, discrimination and inclusivity etc. Rules of this type may require you to take action or pursue a specific course of management or constrain the available management options. You have two responsibilities – to be aware of the law and adhere to it.
Professional guidance and regulations are almost as strong as the law, though enforced (if necessary) through legally appointed professional bodies rather than the law itself. They govern many essential clinical practice features, and they apply to rehabilitation as they do to all other clinical activities.
The law and professional rules draw on ethical principles, but they cannot wholly define moral choices and practice. Each person interprets the ethical principles themselves, and, more importantly, each person determines how they apply to a situation by, for example, selecting the relative weight attached to any competing ethical demands. Many factors influence each person’s choice, such as the normative practice of their social network, personal conscience, religious beliefs, and experience. As all rehabilitation is a team activity, the opinions of other team members and a collective view will have a significant effect.
One often-overlooked factor influencing rehabilitation is the resources available where a patient lives. If a specific treatment might help but is not available in the area, the patient can not easily benefit. For example, phenol injection for spasticity requires a person experienced in using it, and if the nearest person is 100 miles away, it is not likely to be available. More prosaically, knowing that one particular local service is very suitable or unsuitable for a specific patient, or knowing that a specific professional is especially good or bad at some activity will (or should) alter decisions made.
All possible interventions are rarely locally available. To reach a decision, the team needs to consider alternatives and then compare the probabilities of benefit or harm, the risks, and the financial costs.
When an intervention or service is not available, local services can adapt, but there is a risk. Without any experience of the missing service, the local team may not appreciate its effectiveness and, consequently, may not refer patients or act to provide the service locally.
Summary and conclusions.
The setting of rehabilitation will affect the practice of rehabilitation both with individual patients and more generally. The rehabilitation team must always consider external factors that influence what they do. Some elements have a good effect, such as laws ensuring that a patient’s wishes and safety are prioritised. Others may have a harmful impact, limiting a patient’s outcome but acknowledging the presence of this factor may lead to action that overcomes the factor’s influence.