The BGS has responded to the DoH Scoping Study on rehabilitation in the NHS and Social Care.

The BGS welcomes the opportunity to comment on the scoping study relating to rehabilitation in the NHS and social care.

Definition of Rehabilitation
Our preferred definition of rehabilition is that it is: "An active process by which those disabled by injury/disease achieve a full recovery, or if full recovery is not possible, realise their optimal physical, mental and social potential and are integrated into their most appropriate environment", attributed to the World Health Organisation, because the definition describes the process in a pragmatic manner. It is concise, easy to follow and motivating.

Direction of travel for rehabilitation
Our view is that rehabilitation services have probably declined in capacity, but more importantly have changed in character. That is, they are taking place in a greater variety of settings, for example community based rehabilitation suffered from a drive towards acute care in hospital settings, from declining medical involvement due to pressure on geriatricians to take part in general medical emergency work., the shift of rehabilitation into Intermediate Care settings and reduction in specialist inpatient rehabilitation beds. We believe this to be disadvantageous due to the relationship between disease and disability, and the need to optimise medical treatment to support rehabilitation.

Funding Mechanisms
Our view is that rehabilitation services probably suffer from a shortage of funding, but there is a question as to whether current resources are spent wisely to achieve maximum effect. We believe that there has been a shift of resources from rehabilitation to acute care.

Prioritising Rehabilitation
Our view will be that the priority given to rehabilitation in hospital will decline over the next 5 years, with greater emphasis on community based rehabilitation which is inadequately evaluated and lacks the evidence based multidisciplinary approach of comprehensive geriatric assessment. Pressure on budgets and to achieve 4 hour waiting targets in Accident and Emergency are likely to reduce resources available.

Current Difficulties
We believe that current barriers to effective rehabilitation include:

• the lack of comprehensive geriatric assessment processes in the community
• lack of training for colleagues in primary care in health needs of older people
• pressure to discharge from the acute sector
• lack of will on the part of primary care organisations to develop rehabilitation services in hospital
• divided responsibilities between primary care, secondary care and community based services
• divided managerial leadership for therapists in multidisciplinary teams

Good Practice Schemes
We would highlight:

• Orthogeriatric services in Peterborough and Norfolk and Norwich hospitals
• Community stroke services in Bradford (Prof J Young)
• Community services in Gloucester (Dr I Donald)
• Community services in Leeds and Nottingham (Prof G Mulley and Dr J Gladman)

Good Practice Schemes
Our view would be that rehabilitation should be given higher priority nationally and locally within acute trusts: In particular, we would urge that :

• a comprehensive assessment approach should be adopted for older frail people (this the BGS defines as a multidimensional interdisciplinary diagnostic process focused on determining a frail older person’s medical, psychological and functional capability in order to develop a co-ordinated and integrated plan for treatment and long term follow up. Comprehensive assessment has demonstrated an improvement in physical function at 6 months. Reduction in hospital readmissions and placement in care homes as well as improvement in quality of life and in cognition is shown at 12 months. Ellis. G and Langhorne P Comprehensive geriatric assessment for older hospital patients. British Medical Bulletin 2005 71(1):45-59)
• rehabilitation is a process which should start at admission and continue beyond discharge
• rehabilitation is necessary to restore daily living skills and mobility in older people recovering from acute illness
• rehabilitation is essential to aid recovery from planned or emergency surgery
• rehabilitation is an important component of Chronic Disease Management
• rehabilitation must include a medical contribution to ensure treatable illness is not missed
• rehabilitation needs to be multidisciplinary and evidence based

Dr D M Beaumont
Dr J Morris
BGS Policy Committee