Maintaining quality

The British Society of Rehabilitation Medicine (BSRM) has published standards for specialist inpatient and community rehabilitation services, which are mapped onto the National Service Framework (NSF). The standards give specific recommendations with regards to:

  • response times for transfer from acute care settings to rehabilitation services
  • minimum staffing provision for specialist rehabilitation services in inpatient and community settings
  • key elements of the rehabilitation process, including goal setting, discharge planning, follow-up and outcome evaluation within the different settings
  • staff training, appraisal, audit and research.

The BSRM standards recommend that there should be a local specialist rehabilitation service for every 160,000–200,000 population, key features of which include that:

  • it is led or supported by accredited consultants in rehabilitation medicine (RM)
  • it meets national BSRM standards for specialist rehabilitation services
  • its multidisciplinary team(s) has/have undergone recognised specialist training in rehabilitation, and its members work in a coordinated interdisciplinary way towards an agreed set of patient goals
  • it carries a caseload of patients with complex rehabilitation needs, and has specialist equipment, facilities and staffing levels to meet those needs
  • it provides support to local rehabilitation teams in hospital and the community, and has a recognised role in education and training in the field of rehabilitation
  • it routinely collects and reports clinical data for all patients as defined by the UK National Dataset for specialist rehabilitation services (including complexity and outcome data).

Resources required for a high-quality service include the following:

  • Inpatient unit: the BSRM recommends between 45 and 65 beds per million population for a specialist rehabilitation service. Variance reflects the extent to which other services, such as stroke and older adult rehabilitation services, are locally available. The BSRM recommends that the minimum size for a critical mass and viable inpatient unit is 20 beds located together, in order to provide an appropriate environment for rehabilitation and to make best use of the rehabilitation nursing complement.
  • Outpatient facilities: the majority of outpatient facilities need access to the multidisciplinary team to enable day assessments, case conferences or outreach visits. Whatever the pattern, the consultant will need access to physiotherapy, gymnasium, hydrotherapy, occupational therapy facilities including domestic environment and workshops, IT equipment, orthotics and prosthetics, specialist wheelchairs and seating, and electronic assistive technology. Other resources include access to driving assessment and training, vocational rehabilitation, counselling, and psychological and social services.
  • Role of the RM consultant: with considerable variation in job plans, a typical consultant’s working week will include (for direct clinical care): ward round (1–2 programmed activities (PAs)), inpatient MDT meeting (1 PA), referral work (1–2 PAs), interdisciplinary liaison (2 PAs), case conferences (1 PA), outpatient work (2 PAs). Additional responsibility will include a ‘non-onerous’ band for specialist on call with a unit of 20 beds running a one-in-two or a one-in-three rota.
  • Other responsibilities: clinic-related correspondence with dictation of often complex reports (0.5–1 PA), admin time (1 PA), supporting programmed activities (1.5–2.5 PAs), depending on commitment.

Maintaining standards of care

Rehabilitation medicine has a strong reputation for the development of clinical standards and guidelines in the UK. Many of these have been developed in partnership between the British Society of Rehabilitation Medicine (BSRM) and the Royal College of Physicians (RCP).

Key BSRM clinical standards include:

  • BSRM standards for rehabilitation services mapped on to the National Service Framework for long-term neurological conditions
  • Specialised neuro-rehabilitation services
  • BSRM core standards for major trauma
  • Rehabilitation for patients in the acute care pathway following severe disabling illness or injury: BSRM core standards for specialist rehabilitation
  • Amputee and prosthetic rehabilitation – standards and guidelines
  • Specialist nursing home care for people with complex neurological disability: guidance to best practice

National clinical guidelines developed in partnership with the RCP include the following.

The government’s mandate for NHS England 2016–17 includes the expectation that improvements will be demonstrated against the NHS Outcomes Framework, so as to provide evidence of progress and enable comparison of local services. Rehabilitation services in England are provided at three levels of specialisation. Level 1 and 2 services are tertiary- or district-based specialist rehabilitation services, led by consultants in RM. Level 3 rehabilitation services are local and non-specialist, and are led by therapists or non-RM consultants.

Situated in Northwick Park Hospital, the UK Rehabilitation Outcomes Collaborative (UKROC) provides the national clinical database, collating case episode data for all patients admitted for inpatient rehabilitation in specialist (levels 1 and 2) rehabilitation services in England. The database records three types of data:

  • rehabilitation needs – documenting individual rehabilitation requirement
  • input – documenting services actually provided to meet those needs, with a view to identifying unmet needs and reasons for any variance
  • outcomes – the gains that are made during rehabilitation.

The dedicated UKROC software provides tools to assist in real-time clinical decision making and to support team reflection on effective practice.

UKROC now provides the commissioning dataset for NHS England (NHSE).

  • Activity data are used to calculate the weighted bed day currency, which is used by NHSE and CCGs to commission level 1 and 2 rehabilitation services.
  • Service profile data (collated annually) are used to provide costing information to NHS Improvement and to inform tariff development.
  • Quarterly benchmarking reports provide information on response times, outcomes and care costs, which help to drive improvements in the quality of care as well as cost-efficiency.

Recently published large multicentre cohort analyses from the UKROC database confirm the benefits and cost savings that arise from specialist rehabilitation across a wide range of trauma and neurological conditions, and also the benefits of hyperacute rehabilitation services at an early stage of recovery after severe illness or injury.