1. Reflections on The Neurorehabilitation Pathway Dr John Holloway Consultant Neuropsychiatrist Medical Director Frenchay Brain Injury Rehabilitation Centre
Cambridge Annual Medico-Legal Conference
Peterhouse College
30th September 2016

2. Definition of Rehabilitation
Rehabilitation is a process of assessment, treatment and management by which the individual (and their family/carers) are supported to achieve their maximum potential for physical, cognitive, social and psychological function, participation in society and quality of living.
British Society 0f Rehabilitation Medicine (BSRM) 2015

3. 2001 Alan Milburn (Labour) Drove through PFIs
Introduced Foundation Trusts
Later, advised venture capital firms and PWC on financing private healthcare
Now, Chair of the Social Mobility and Child Poverty Commission
(Wikipedia)

4. HOUSE OF COMMONS SELECT COMMITTEE ON HEALTH
HEAD INJURY REHABILITATION
-- THIRD REPORT, 28th March 2001
Introduction
“Head injury is the foremost cause of death and disability in young people. In an age of increased motorization and violence, head injury is a healthcare problem which is not going to go away. There is a growing population of head-injured people in this country, as improved medical techniques have led to many head-injured people now surviving their accident and living into old age, with a normal life expectancy. However, a head-injured person is likely to require long term rehabilitation to live his or her life in society.”

5. HOUSE OF COMMONS SELECT COMMITTEE ON HEALTH
Third Report (2001) came up with 28 recommendations including:
People with a suspected brain injury should be assessed by specialist staff and nursed in a location appropriate to their needs.
Guidance should be issued to all acute Trusts to ensure that head-injured people are treated as soon as possible after medical stabilisation, in appropriately resourced rehabilitation beds where specialist rehabilitation staff could care for them and begin their rehabilitation interventions: this would yield long-term savings, as well as benefits to patients.
All health authorities and trusts to plan care pathways for head-injured people to enable them to move through the system as quickly as is appropriate, releasing acute beds for other patients and increasing their own potential to improve.
Every head-injured person admitted to hospital to leave with a clear care plan mapped out for him or her.
The Government should spell out clearly what steps it will take to improve the situation in the provision of rehabilitation services for head-injured people.

6. Who was managing the head injured patients in 2001 ?
Bristol Royal Infirmary - Orthopaedic Surgeons Frenchay, Bristol - Neurosurgeons Southmead, Bristol - Anaesthetists & Orthopaedic Surgeons Weston - General Surgeons Bath - Physicians Gloucester - Orthopaedic Surgeons Cheltenham - A & E Consultants Taunton - Orthopaedic Surgeons Yeovil - Orthopaedic Surgeons

7. Consultants In Rehabilitation Medicine
Numbers of accredited specialists in physical medicine and rehabilitation in 12 western European countries as expressed per of the population.
UK NHS rehabilitation consultants and associate specialists are shown for comparison. B, Belgium; E, Spain; I, Italy; P, Portugal; F, France; SF, Finland; DK,Denmark; N, Norway; CH, Switzerland; S, Sweden; ND,Netherlands; D, Germany; J R Soc Med 2002

8. HOUSE OF COMMONS SELECT COMMITTEE ON HEALTH
Third Report (2001) came up with 28 recommendations including:
People with a suspected brain injury should be assessed by specialist staff and nursed in a location appropriate to their needs.
Guidance should be issued to all acute Trusts to ensure that head-injured people are treated as soon as possible after medical stabilisation, in appropriately resourced rehabilitation beds where specialist rehabilitation staff could care for them and begin their rehabilitation interventions: this would yield long-term savings, as well as benefits to patients.
All health authorities and trusts to plan CARE PATHWAYS for head-injured people to enable them to move through the system as quickly as is appropriate, releasing acute beds for other patients and increasing their own potential to improve.
Every head-injured person admitted to hospital to leave with a clear care plan mapped out for him or her.
The Government should spell out clearly what steps it will take to improve the situation in the provision of rehabilitation services for head-injured people.

9. NO NEW FUNDING, REALLOCATE FROM EXISTING RESOURCES

10. Baron Reid of Cardowan (Labour)
2005
Baron Reid of Cardowan (Labour)
Pushed through Independent Treatment Centres
Allowed General Practitioners to opt out of out-of-hours cover
Now, Chairman of Celtic Football Club
(Wikipedia)

11. National Service Framework - Long Term Conditions DoH 2005
The National Services Framework (NSF) (2005) for Long Term neurological Conditions emphasised the need for provision of rehabilitation at all levels, planned and delivered through coordinated networks, in which specialist neuro- rehabilitation services work both in hospital and in the community to support local rehabilitation and care support teams.
Good proposals in principle but non-specific and short on any detail. More importantly it was not linked to any additional resources/funding

12. NO NEW FUNDING, REALLOCATE FROM EXISTING RESOURCES

13. MEANWHILE . . . . . Professor Keith Willett Orthopaedic Trauma Surgeon
In 2009 appointed National Clinical Director for Trauma Care
Appreciated need for rehab services as part of the MTC pathway to recovery

14. Clinical Advisory Group:
Rehabilitation:
start intensively in acute phase
complex – not based on diagnosis
create an effective flow
network responsibility
(Director for Rehabilitation)
key worker (navigator)
“prescription for rehabilitation”
vocational rehabilitation
Directory of rehabilitation services
MAJOR TRAUMA 14 14

16. 2012 Baron Lansley(Conservative)
Introduced Health and Social Care Act, removing responsibility for health from Secretary of State for Health
Oversaw transition from PCTs to CCGs
Now, advises Roche and healthcare lobbyists
(Wikipedia)

17. GOVERNMENT ANNOUNCEMENTS, - FOLLOWING MTC LAUNCH
“A network of 22 new trauma units will save 600 lives a year . .” - Andrew Lansley, April 2012
“Many patients need a personalised rehabilitation programme taking many months to help them return to an active life. From April, every major trauma patient will be given a Rehabilitation Prescription which describes their recovery plan in detail
– via DH Media Centre, April 2012

18. THE REHABILITATION PRESCRIPTION
Pros
Highlights the need for rehabilitation
Attempts to quantify patient’s potential needs
Follows patient along care pathway
Focuses attention on “gaps” in rehab services both at the MTC and in the receiving organisations
Cons
Highlights the need for rehabilitation in an individual patient - (in the potential absence of current provision)
Allows the MTC to transfer the responsibility for rehab to the receiving organisation through forced repatriation, even when rehab resources and appropriately trained staff are not available

19. NO NEW FUNDING, REALLOCATE FROM EXISTING RESOURCES

20. NOW

21. BRITISH SOCIETY OF REHAB MEDICINE (2015/2016)

22. 2016 - DIFFICULTIES IN NEUROREHAB PATHWAY
Frequent gaps in the Pathway, in particular with regard to community specialist services and appropriately trained/experienced staff.
Acute hospitals concentrating on acute services, rehab felt to be less urgent and therefore expendable or relocated (loss of specialist training opportunities)
Pressure on beds causing MTCs/acute hospitals to speedily repatriate patients back to non-specialist hospitals with less expertise/rehab experience
CCGs using mantra of “patients want to be treated close to home” as an excuse to provide only local generic services, rather than specialist community rehab
With generic/non-specialist AHPs, the risk is that “they don’t know what they don’t know”, i.e. agoraphobia vs overstimulation, or social communication vs scoring normal on SaLT testing
Lack of Consultants in Rehab Medicine, particularly in community services

23. NO NEW FUNDING, REALLOCATE FROM EXISTING RESOURCES

24. POSSIBLE RESOURCE REALLOCATION FOR REHAB SERVICES

25. POSSIBLE RESOURCE REALLOCATION FOR REHAB SERVICES
I Hospital Inpatient I
POTENTIAL SOURCE OF FUNDING FOR REHAB SERVICES
home and social care
acute
phase
recovery
phase 25 25

26. POSSIBLE RESOURCE REALLOCATION FOR REHAB SERVICES
If this model is supported to free up finance for rehab services:
Will acute services be able or prepared to give up part of tariff?
If CCGs (+/- LAs) take on rehabilitation provision, who will be responsible for post-acute care while patient still in hospital bed? Clinical Governance?
Will the Government’s/CCG’s desire for local/community services lead to funding going into generic rather than specialised rehab?
If a new, beefed-up Rehabilitation Service is introduced, where will the staff come from and who will employ them? Where will initial start-up capital come from?
Use of Independent Sector likely to further fragment care pathway – How can Independent Sector’s advantages of flexibility and access to capital be harnessed into a cohesive strategy?

27. The Medico-Legal Perspective

28. The Medico-Legal Perspective
Lawyers can help their clients and “the system” by:
Having a good understanding of the long term ramifications of poor rehabilitation and the subsequent effect on their clients / family
Reviewing whether statutory guidelines/pathways are followed
(if new Pathway Model is universally adopted) Having a clearer perspective on potential gaps in the rehab pathway and supplementing statutory care
Pushing for early interim payments (and settling of cases) to help fund client’s rehab – the earlier the rehabilitation, the better the patient’s likely recovery
Encouraging health professionals / services to reflect on their practice sometimes (- possibly being guided by the Rehab Prescription??)
Enabling case managers to use a Rehab Consultant-led interdisciplinary team to work with some patients, rather than a collection of independent AHPs

29. Thank you