The rehab prescription (RP) is a simple but effective concept. It is a plan that defines what treatment is needed for the disabled person over the future weeks and months after a traumatic injury.
According to guidelines, the RP should be an intrinsic part of the UK’s improving approach to trauma.
A landmark report by the NHS Clinical Advisory Group (CAG) for Trauma to the government in 2010 paved the way for 22 major trauma networks (MTNs) to be set up across England.
Their aim was to better coordinate pathways of care for adults following major trauma. As part of its recommendations, the CAG said all severely injured patients should have an RP, detailing their rehab needs and how these should be met after discharge from acute trauma services.
Various other bodies gave these recommendations added momentum, including the British Society of Rehabilitation Medicine (BSRM), which stipulated that a specialist RP should be completed by a consultant in rehab medicine to identify patients with complex needs requiring referral to specialist in-patient rehab units.
Patient involvement should be an important facet of the RP. Since 2013, NHS England guidelines have stated that all patients with a severe injury severity score (ISS) greater than nine, should have a formal RP which should “ideally be patient held”.
Despite the guidelines – and the behind-the-scenes push in rehab circles to get the emerging system performing as it should – RP knowledge and engagement among decision-makers varies hugely.
When asked under Freedom of Information (FOI) about its usage of RPs, the trust behind St George’s Hospital – one the country’s leading major trauma centres, covering a population of 2.6 million in the South East – said: “Neither NHS England or the BSRM requires a trust to issue a rehabilitation prescription on discharge.”
In fact, out of 124 relevant trusts questioned recently about RP under FOI, 100 offered no response.
While it may be presumptuous to suggest none of these are issuing RPs correctly, their refusal to meet the FOI’s obligation to respond is loaded with indifference and/or ignorance; especially given that, in most cases, CCGs referred the FOI request to them, confirming that they should have the relevant information.
Of the 24 trusts that responded, less than half said they gave the RP to GPs AND patients. All 211 Clinical Commissioning Groups (CCGs) were also questioned about their involvement in handing out RPs.
Around 130 said they did not hold any information about RPs and 75 remained entirely silent. Only five offered any answers – but their responses suggested confusion about the RP.
In one example, a CCG representing a large conurbation in the South East said, annually, it had only overseen five cases of brain injuries in which an RP was required.
This is a staggeringly low figure for an entire year, suggesting a misunderstanding of what an RP is. Four CCGs, meanwhile, did not know that RPs should be given to GPs.
The research was carried out by the ABI Alliance, a collective of major brain injury organisations.
Group spokesperson Professor Mike Barnes says: “The majority of CCGs are completely unaware of RPs and are therefore not monitoring or following up on ABIs.
They are basically saying ‘it is nothing to do with us’. But of course, it is their concern because ultimately they pay for the services provided via the RP.”
The issues raised by the ABI Alliance reflect those highlighted in the results of the first official audit of MTNs, published last year.
While all 22 major trauma centres (MTCs) in that study said they were routinely completing the RP, only a third said they either “always” or “sometimes” gave it to patients. Two thirds said they used it only as a clinically- held tool.
The National Clinical Audit of Specialist Rehab following Major Injury (NCASRI) also found that only two MTCs routinely completed all four of the recommended measurements of the special RP for patients with complex needs.
Unlike trauma units in local hospitals, MTCs have a financial incentive to complete RPs. Under a best practice tariff, reporting the mere existence of an RP generates a payment of at least £1,500.
Prof Barnes says: “Data suggests that 94 per cent of trauma units don’t think about the RP.
“It should be a part of good clinical practice and it’s a shame that there only seems to be a response if there is a financial incentive. It is a fundamental duty to tell complex injury patients what they need going forward.”
Of course limitations in staff resources are also a factor in RP delivery, however.
“Not all centres have rehab medicine consultants to sign off specialist rehab prescriptions, which is a challenge in itself,” says Hannah Farrell, major trauma therapy lead at University Hospitals Birmingham NHS Foundation Trust.
“There are significant numbers of patients and often very little resources and support staff within MTCs to be able to deliver this document and also to arrange timely reviews and updates of it. Some specialist RPs can take up to two hours to complete.”
Farrell, a member of the Clinical Research Group for Major Trauma, explains that the lack of tariff funding is not the only reason for limited RP activity in trauma units.
“Some centres also have the challenge of developing informatics infrastructure that enables us to populate the document electronically.”
There is also an underlying reluctance to give RPs to patients, Farrell believes. “Rightly or wrongly, there is still some anxiety and apprehension about ensuring the patient has this document in their hands.
“At a multidisciplinary working group meeting last year, the strongest message to come out of discussions was that the RP must be patient-held. There is absolutely no excuse for it not to be.
“It should be [given to] the patient at an appropriate point in the pathway. It needs to be electronic, easily updateable and accessible by professionals and patients across the pathway…Ongoing multidisciplinary involvement and coordination is also paramount.”
Despite numerous challenges facing the RP, it offers great potential as a catalyst
for improved rehab journeys. To maximise its impact, and ensure the opportunities it presents are not missed, the ABI Alliance has set out four main action points.
Firstly, the RP must be completed properly in all MTCs. Even with financial incentives, not every centre is consistently meeting its mandated RP duties.
Next, the RP’s reach must be widened; to trauma units not already engaged in the process, and also to facilities handling milder brain injuries and non-traumatic ones, such as those caused by hypoxic injury.
The group also urges that the “patient-held” part of official guidance is enacted and, finally, that the RP is a “live document”.
The RP will be a key agenda point for the new All-Party Parliamentary Group (APPG) on brain injury, launched late last year.
The ABI Alliance aims to work with the All Party Group to make sure these four recommendations become a reality and the RP becomes an invaluable aid in making sure that the disabled person receives the therapy and care they deserve.