Medical rehabilitation needs flexible commissioning

In addition to revising the definitions of RM in line with current practice and expected technological advances, the authors have, following a wide ranging review of the evidence, provided specifications for designing cost effective services that maximise opportunities for recovery.

Central to their vision is more active collaboration between commissioners and medical specialists to support integrated, personalised care in the face of an increasingly complex provider landscape. Commissioners, they suggest, must rise to the challenge of developing frameworks that reflect need, complexity and local circumstances. Equally, clinicians need to be trained to recognise the need complex packages of interventions and be able to coordinate their introduction.  They should also be able to evaluate and demonstrate the benefits that can be achieved through enabling technology, while remaining aware of their limitations in relation to complex patient groups.

Among the group’s main findings is that:

• While current initiatives on acute stroke care, critical illness rehabilitation and trauma care networks all highlight the need for early specialist rehabilitation intervention, the priority of acute provider units is often too focused on clearing beds at the expense of supporting a fully staffed acute rehabilitation service as part of the early continuum of care.
• Current trends suggest that, as the pattern of hospital based services change, more RM specialists will contribute to the working of community based rehabilitation teams. This is likely to create new challenges for the specialty, will place extra demands on current training budgets and will require expansion of specialist numbers.
• RM services provision continues to be patchy, with the quantity of service provided often falling far short of the known need. For example, a recent published audit demonstrated that 38% of patients occupying beds in a neurosurgical unit should have been transferred to specialist RM services. Addressing this need would increase capacity in acute units and reduce their need to build and staff more acute wards.

On the basis of their discoveries the working party have recommended the following:

• The provision of early access to acute RM specialist services for people with newly acquired brain injury due to major trauma, critical illness or other causation.  This is an urgent priority.
• That people with disabling new or progressive health conditions have timely access to RM specialist services to minimise their disability and enhance their quality of life. For some people this means repeated access.
• That clear commissioning structures, which facilitate the understanding, coordination, redesign and development of rehabilitation services are put into place. This would include reviewing how consortium or collaborative commissioning arrangements could support existing structures and looking again at case management arrangements to deal with gaps in service provision.

Professor Christine Collin, co-chair of the RCP Working Party, immediate past president of the British Society of Rehabilitation Medicine and a consultant in Neuro-rehabilitation at the Royal Berkshire Hospital, Reading said:

“Those who acquire a disability and their families often have huge adjustments to make to their lives. Proactive and integrated specialist rehabilitation can significantly reduce the impact of disability and prevent avoidable complications.  This requires a well coordinated, multi-professional team with the person and their family at the centre. This report reaffirms the central place that such personalised care holds in the ethos of rehabilitation medicine and the crucial role that the rehabilitation medicine specialist plays in ensuring  access to expertise whilst respecting the wishes of the individual and their families.”

Professor Anthony Ward, co-chair of the RCP Working Party and a consultant in Rehabilitation Medicine at the North Staffordshire Rehabilitation Centre, Stoke-on-Trent, added:

“The specialty of rehabilitation medicine manages complicated and expensive conditions and is likely to change markedly over the next few years. These will be exciting times, but patients must remain assured that the multidisciplinary teams and services responsible for their wellbeing are able to communicate well with them and with each other. This report provides an excellent starting point, from which to establish a framework that, building on earlier advances, will secure such an approach.”