Rehabilitation is not just an 'add on'

We know there are many good examples of adult rehabilitation services. But we also know that “rehabilitation” covers a wide spectrum of services, with variation in what services are available and how they are commissioned – and that there can be duplication across teams and services.

‘Urgent referrals are seen within three hours, compared with the previous service’s 40 days’

It is also the case that rehabilitation can often be seen as the “add on” at the end of the patient pathway, once treatment has finished. But that is to misunderstand its true potential.

Our publication earlier this year, Improving Adult Rehabilitation Services in England, highlights good practice in rehabilitation and recovery services commissioned by CCGs. The case studies suggest rehabilitation works best where it is an integral element of the patient’s care – from start to finish.

When that happens it not only improves patient outcomes, it also benefits many other parts of the service and can help both commissioners and providers to realise wider system efficiencies.

Three becomes one

At Sandwell and West Birmingham Hospitals Trust, for instance, rehabilitation services have been redesigned by bringing three separate community rehabilitation teams into a single integrated community service.

‘Those undergoing the new programme suffer significantly fewer post-operative complications’

The service, available seven days a week, has a single point of access. Referrals are triaged based on patient need, with urgent referrals seen within three hours, compared with the previous service’s waiting times, which exceeded 40 days.  

Patients receive support from integrated locality teams made up of both generic and specialist staff, who take on referrals depending on assessed patient need. As a result, the service has reduced referrals that would have been taken to hospital by 93 per cent.

By moving rehabilitation ‘upstream” – so we actually have a model of “pre-hab” – we also stand a much better chance of maximising patients’ outcomes and increasing their independence.

The Heart of England Foundation Trust, for example, has introduced pulmonary rehabilitation support for elective lung surgery patients as a key part of an enhanced recovery pathway. This approach is now standard practice at the trust and results have been impressive, with those undergoing the new programme suffering significantly fewer post-operative complications and readmissions.

It has also led to a cost saving of £244 per patient.

Flows upstream

Through NHS Improving Quality’s work on seven day services, we are also seeing how moving rehabilitation assessment upstream as part of an integrated multidisciplinary team approach can reduce delays in patients’ hospital stays and improve system flow.

Sheffield’s multiagency Right First Time programme has completely “flipped” the traditional model of assessing to discharge, to one of discharging to assess, seven days a week; this enables patients who are medically fit for discharge to have their rehabilitation and recovery needs assessed in their own home environment. 

As well as the obvious patient benefits, the wider system gains too. On wards where this has been implemented, 95 per cent of patients go home on the same day they were admitted, and average length of stay has fallen by six days.

Clearly, the 10 examples of good practice we highlight are only illustrative and some are still at an early stage, so the evidence is by no means conclusive. I would still suggest there are key learning points for commissioners and providers to consider:

• If you are thinking about redesigning rehabilitation services, the first step should be to review existing services and how they are commissioned. Develop the vision for future services before any practical change work begins, based on agreement of what is required for local need and demand.
• Recovery is an ongoing activity that starts with the patient in any setting. Rehabilitation needs to be integrated into every step of the pathway. Also, remember that patients have a key role to play in their recovery, so supporting and empowering them with appropriate information and resources is key.
• Think seven days, not five! Rehabilitation services are needed every day of the week. Evidence suggests a five day service slows patient recovery, either in ability to be discharged from hospital, in frequency of admissions or in recovering from an episode of ill health in the home. Nor does redesign necessarily have to be more expensive. Heat of England, for instance, has introduced a seven day therapy service at no extra cost through redistribution of existing funds and contract changes.
• Think differently about your workforce. Consider integrating separate teams to streamline services and better coordinate services. Think about opportunities for role redesign – for example, generalists who are supported by specialists – so that people see the person best equipped to deal with their need in a way that makes best use of resources.
• Look beyond the traditional workforce. South Tyneside Foundation Trust, for instance, has increased its workforce skills mix and capacity by drawing on NHS health trainers (in public health) and third sector agencies, in addition to more traditional therapeutic groups.

Our case studies are by no means exhaustive, but they do provide some useful pointers. We hope they will prompt commissioners and providers to think through the potential for redesigning their rehabilitation and recovery services as part of wider system transformation.

Liz Hindmarsh is improvement manager at NHS Improving Quality