Timely Discharge Series: Rethinking rehab

Sara Hazzard is assistant director of strategic communications at the Chartered Society of Physiotherapy and co-chair of the Community Rehab Alliance, a network of 50 charities and professional bodies campaigning for better access to high-quality rehab, of which BGS is a member. She tweets at @SHazzard.

This is the sixth blog in the BGS’s ‘Timely Discharge’ series. We aim to raise awareness of the detrimental effects on older people of being stuck in hospital when they are 'medically fit for discharge'. Our blog series explores the causes of delayed discharges, the knock-on effects to the wider health and social care system, and what needs to change.

Some crises are a long time coming, and the chaos of delays in hospital discharge is no exception.
 
Due to the pandemic, there is unprecedented pressure to discharge people from hospital, which means the right treatment patients need after leaving hospital is not always ready or available for them once they are discharged.
 
This leaves too many people stranded in hospital long after they are well enough to go home, risking a deterioration in their health as well as increasing social isolation.
 
But even before the pandemic, we suffered years of under-resourcing and underfunding of rehabilitation services, which are so crucial to recovery from an acute admission. Millions who’d experienced strokes and other long-term conditions were unable to access rehabilitation until they were at crisis point.
 
The rising number of older people stuck in hospital is only going to spiral over the coming weeks, as care workforce shortages continue steadily to grow. But this is not down to staff shortages alone. A major factor in delayed discharge is the withdrawal of rehab services, particularly intermediate care facilities where patients go straight after hospital to get the rehabilitation they need to recover and return home if they can. 
 
In July 2021, a snapshot survey of Chartered Society of Physiotherapy members from nearly 300 services across the UK found that one in five said their service had not restarted after the pandemic. Forty-five per cent of physios said they had lost space due to it being taken over by office and storage provision. Nearly three-quarters believed having to operate without either the space, staffing or resources of pre-pandemic levels had impacted negatively on the health of patients, including delaying them from being discharged.
 
In one Trust where the intermediate care team has been dismantled, our physio member counted 120 patients who are medically fit for discharge with rehab who are ‘stranded’ on the wards because there are no rehab facilities for them to go to. This is not an isolated example – it is happening across the UK.
 
In 2020, CSP reviewed how fit for purpose post-hospital-discharge pathways were. The system was set up to take 4% of patients into bedded units for intensive rehab but data from our members showed five times as many - 20% - needed intensive rehab in a bedded unit. Though emergency measures were a necessity in dealing with an unforeseen pandemic, we know now that we need better planning in terms of services, workforce and training to cope with future demand. And this must recognise the true picture on the need for rehabilitation, updating the planning assumptions for the four pathways.
 
While we welcome announcements of further funding for the NHS, we need a national review of current rehabilitation provision to ensure we have the right system in place to deliver the right treatments to patients at the right time. We need underlying causes of health crises to be fixed, not simply for the superficial effects to be dealt with.
 
That is why we are calling for a focused, strategic approach to rehabilitation, as part of the Community Rehab Alliance of 50 charities and professional bodies who are all committed to improving commissioning, planning and delivery of rehab.
 
This needs to be at the heart of healthcare system design. Every Integrated Care Board should have a rehab lead with responsibility for ensuring effective provision and integration of services for all rehabilitation. We need these strategic minds in place to plan ahead - without them we are doomed to a future of fire-fighting. Much better outcomes would be possible for all patients if they could access high-quality, person- centred, timely rehab, delivered by a skilled properly-resourced workforce. The need for this has never been more urgent. There are increasing reports from our physio members that rehab is being withdrawn for patients who need to get as well as they can in order to live independently.
 
People may have a short term ‘urgent response package’ of care that lasts 4-6 weeks regardless of whether they need more treatment. At the end of that, there is no support.
 
The pressures to deliver the urgent community-based response (part of NHS England’s Ageing Well programme) are having a knock-on effect on the healthcare system. There is an increase in demand but no increase in staffing, so physiotherapists diverted to urgent teams are unable to see other clients. These are often older people with frailty who need to engage in rehab to improve their strength, mobility and function, to avoid deterioration. Ultimately this leads to a rise in avoidable hospital admissions and poorer patient outcomes.
 
Abandoning patients to suffer alone at home must end. This stark fact was highlighted by the Care Quality Commission recently, which reported recently that just under a quarter of patients surveyed said they did not get enough support needed to help them recover or manage their condition once they’d left hospital and were back at home.
 
So let’s support rehab as a right for every person who needs it. As healthcare professionals, we want our patients to live as long as they can, as well as they can, not simply survive with no quality of life. Let’s get the system we need to support patients, carers and their relatives in place, and stop the cycle of crisis together.

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