The patient population
Over 11 million people in the UK have a limiting, long-term illness, impairment or disability; the impairments reported most commonly are those affecting mobility, lifting or carrying. The prevalence of disability rises with age: around 16% of working-age adults, and 45% of adults over state pension age, are disabled (Gov.UK, 2014).
Rehabilitation medicine (RM) is concerned with the prevention and diagnosis of disabling medical conditions, and the treatment and rehabilitation management of people with such conditions. RM was developed primarily to meet the needs of young adults and those of working age, but aspects of the specialty, particularly relating to environmental control and assistive technological aids, provision of wheelchairs, orthotics or prosthetics, are relevant to people of all ages.
RM is a consultant-led service that works closely with multidisciplinary teams and broadly covers five main areas of complex disability needs:
- neurological rehabilitation, accepting the most complex patients with acquired brain injuries, neurodegenerative and neuromuscular disorders
- spinal cord injury rehabilitation, provided through supraregional centres
- limb loss or deficiency rehabilitation and prosthetics
- musculoskeletal rehabilitation
- major trauma rehabilitation, provided through major trauma centres within networks.
Most consultants will specialise in one or more of the above fields, but in smaller hospitals it may be necessary to be expert in all these areas. RM has important relationships with trauma, orthopaedics, neurology, neurosurgery, vascular surgery, acute medicine and palliative medicine, and has a central role in early and ongoing management of patients within the major trauma networks.
Prevention of disease
Until recently, a lot of health policies have focused on primary prevention for the general, non-disabled population, and on strategies that promote and maintain health among people who are already healthy. Unfortunately, prevention strategies for people with disabilities have not received sufficient attention and, in the UK, individual groups based on type of underlying disease (eg multiple sclerosis, motor neurone disease, Parkinson’s disease, muscular dystrophies etc) continue to lobby for their voices to be heard.
People with disabilities are highly susceptible to secondary conditions that overlap with their primary disorders, and that minor illness could compromise their functional mobility and potentially lead to earlier decline in health and increased dependence on others for care. As the size of this population is increasing, there need to be commissioning considerations for a shift in focus from just disease and disability prevention to health promotion for people with disability, irrespective of the underlying disease condition.
The aims of a health promotion programme for people with disability are to:
- reduce and improve management of costly comorbidities, such as:
- pressure sores
- decreased balance, flexibility, muscle strength, fitness and endurance
- increased muscle spasticity and joint contractures
- depression and anxiety
- improve and maintain functional independence
- improve living standards and enhance overall quality of life
- provide opportunity to return to, get into or stay in work, education or training
- provide opportunity for leisure, enjoyment, social and cultural activities
- promote effective self-management for people with long-term conditions
- promote lifestyle changes for a heathier life, including reduction of:
- smoking, as it may impact on the number of strokes and/or amputations related to peripheral vascular diseases
- alcohol, as it affects the levels of trauma (head and spinal injuries, and amputations)
- obesity, in terms of exacerbating any disabilities etc.
Health promotion can be achieved by rehabilitation consultants continuing to advocate:
- reducing environmental barriers to good health, with greater emphasis placed on community-based health initiatives and programmes
- coordinating and treating patients holistically, in terms of individuals’ physical, psychological and mental health
- commitment from NHS England and partnership working with Public Health England, national and local government, and CCGs.
Rehabilitation medicine (RM) is an underused resource. It is key in delivering major trauma networks and the NICE guidelines on critical care. RM can:
- reduce unneeded expenditure – cost of nursing, residential and social care
- reduce length-of-stay costs and help GPs to manage patients in the community
- reduce risks of falls
- enable a person to return to work, get into work or stay in work.