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Interviews

Where next for rehabilitation?

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In April 2013, in the midst of widespread changes in the NHS, NHS England announced a large number of national clinical director (NCD) posts, including the appointment of
Dr Etherington as NCD for rehabilitation and recovering in the community.

Etherington,
who currently serves as director of defence rehabilitation and a consultant in rheumatology and rehabilitation medicine at the Defence Medical Rehabilitation Centre based at Headley Court, Surrey, says: “The NCDs were a group
of impressive characters but initially the NHS didn’t know how best to use them, and the NCDs weren’t sure the extent of their remit. It all took a while to settle.”

Some NCDs were responsible for conditions, whereas Etherington’s post was for a process which made it challenging as it cut across boundaries.

Three years later, following an extensive amount of work in many areas,
the NCD posts were reviewed and streamlined as part of the NHS ‘Five Year Forward Review’.

The number of NCD posts was reduced and Etherington’s role was scrapped. Once again, rehabilitation was relegated to the lower league.

The role of the NCD in NHS England is to provide leadership for a particular condition area, drive forward improvements and champion the condition widely within NHS England.

Having an NCD post assigned demonstrates that the area is seen as a priority and gives it prominence; however, rehabilitation consistently fails to gain or maintain that prominence.

Specialist rehabilitation services play a vital role in the management of people admitted to hospital with an ABI by taking them after their immediate medical and surgical needs have been met, maximising their recovery and then supporting their rehabilitation needs in the community.

Are the one million individuals who live with an ABI in the UK really so unimportant?

“No reason was given for the demise of the post,” says Etherington. “We don’t spend enough money on rehabilitation, and the loss
of the NCD post means that there’s nobody that can argue that need at a high level.

“The NHS as a whole doesn’t focus on rehabilitation, or consider it to be an important part of the healthcare we deliver – we are constantly trying to transform how people think of rehabilitation. Rehabilitation is everyone’s business and all health professionals need to understand that it’s important – but that’s a huge challenge.”

As NCD for rehabilitation and recovering in the community, Etherington, together with Suzanne Rastrick, chief allied health professions officer, co-chaired the NHS England Rehabilitation Delivery Board.

The board set out its two key priorities as; 1) rehabilitation to enable people to remain in or return to work and meaningful activity, and 2) rehabilitation to improve
the quality of life for people with long-term conditions.

There were several key working groups established including those covering commissioning guidance and rehabilitation for economic growth.

The Commissioning Guidance Working
Group launched ‘Commissioning Guidance for Rehabilitation’, a document intended for use by clinical commissioning groups (CCGs) and their local partners to support them in commissioning rehabilitation services for their local population.

The guidance sets out “what good looks like” from the perspective of patients and their families, and how rehabilitation offers local solutions.

It also advocates a ‘person-centred approach’ to deliver rehabilitation services
that take account of individual circumstances, preferences and needs.

This interactive tool was initially developed following the report produced in 2014 entitled ‘Principles and Expectations for Good Adult Rehabilitation’, describing what good rehabilitation is and offering a national consensus on what service users should expect from services.

The take-
up of services is expected to be monitored by equality data and reported annually or as agreed by service providers.

“This was an extensive piece of work and the feedback has been generally positive,” Etherington says. On the basis that the costs of brain injury are too high to be ignored and the consequences too serious to be neglected, the focus of the Rehabilitation for Economic Growth Working Group was to drive messages about the financial benefits of rehabilitation.

“We ultimately wanted to interest politicians in a subject that they would otherwise not engage in by presenting the economic argument. Rehabilitation needed to be re-aligned so it could stand alongside cancer and heart disease, and the way to do this is to convince the budget holders.”

In the past, rehabilitation was accused of not having an evidence-base; this is no longer the case with extensive clinical and economic research demonstrating solid outcomes.

The Rehabilitation for Economic Growth Working Group produced a comprehensive economic report in 2015 for the NHS Executive Group, scoping out the idea of using cross-government funding to support rehabilitation in the UK.

The consequences of brain injury impact not only on the healthcare budget but across many sectors including employment, tax revenue and disability benefits.

Etherington’s report detailed the costs of rehabilitation but also documented the long-term financial benefits to other governmental budgets such as local government, Department for Work and Pensions (DWP), Department for Education (DfE) and Social Services.

Unfortunately the report did not get the required support, says Etherington. “If the NHS invests in rehabilitation then the DWP, the DfE and even the Ministry of Justice will all benefit. I needed to get rehabilitation up the agenda and to get the resources we need to get the job done.
I thought we were nearly there, but sadly
we weren’t”.

Other projects included commissioning the ‘Improving Rehabilitation Services Community of Practice (IRSCOP)’.

The Community of Practice was provided by the NHS Clinical So Intelligence Service (NHSCSI) and hosted on NHS Networks. It was an independent platform and forum for discussion and debate for all those concerned with improving rehabilitation services.

This online resource remains open to anyone, but since August this year the site has no longer been moderated or added to by
the NHSCSI.

Four regional rehabilitation leads were also appointed to focus on the adoption and dissemination of good practice and to support the development of local networks and initiatives. These posts no longer exist.

Looking ahead, the diversity of rehabilitation makes planning and service provision challenging and complex.

However, Etherington maintains that the cost-bene t argument
for rehabilitation is the way to engage all stakeholders: “Long-term, with or without rehabilitation, our patients impact on many government departments. I firmly believe that in order to make a difference you need to be talking about the economic implications
at a senior governmental level. For example
the Trauma Audit and Research Network (TARN) data is a proving to be a useful tool to demonstrate the direct costs of trauma in terms of bene t claims and is proving to be of interest to the DWP.”

With regard to commissioning, the commissioners need to better understand
the scale of rehabilitation need.

However, rehabilitation will continue to be largely uninteresting for GPs; they do not understand how it helps them and the CCG has no data set for it. Etherington believes that until GPs have to collect data on ABI they will never show
any interest in it.

“Are we commissioning care properly? No I don’t think we are. Why are we allowing commissioners to get away with funding just three months of rehabilitation?

“We have the evidence-base to demonstrate duration is important for outcomes – why don’t we press them for more funding? Fundamentally we haven’t got the commissioning structure right – it’s complicated for specialised services and you have to question if the money follows patient need.”

The instigation of the so-called ‘rehabilitation prescription’, that follows the patient from acute care into the community seems to present
an opportunity to link specific rehabilitation
and trauma care to the needs of patients.

The mandate for change, and the development of a rehabilitation prescription is driven by the AHPs, as they are the group that will use it.

However, Etherington cautions: “We don’t want umpteen different versions. We need a standardised, uncomplicated template that can communicate across the care pathway.”

Specialised services commissioned by
NHS England are grouped into six National Programmes of Care (NPoC), of which trauma is one and includes traumatic injury, orthopaedics, head and neck and rehabilitation.

The function of the Clinical Reference Group (CRG) for the Trauma NPoC is to provide clinical advice and leadership. Etherington is hopeful that the CRG can take a fresh look at the status of rehabilitation and provide sound innovative advice to NHS England on the best way that these specialised services should be provided.

He says: “There is a need to recognise that there is a financial burden to not funding rehabilitation.”

He believes there is a need to look at more radical ways of funding rehabilitation such as co-commissioning with various collaborations currently looking at different business
models. “Radical thinking is required,” he says.

“Rehabilitation is not, and never has been, a priority. It isn’t visible, patients can’t shout loudly, the charities are small and generally we’re all not vocal enough about rehabilitation. We somehow need to shout louder and make it a priority.”

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Interviews

Inspiring a brighter future for residents

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A neuro-rehab provider which opened its first facility in Worcester shortly before the first lockdown has succeeded against the odds – and now has plans to expand in 2021, as NR Times reports.

Inspire Neurocare provides support for people with a variety of neurological conditions, offering rehabilitation, respite and palliative care.

The firm opened its first specialist care centre in Worcester in February 2020, and this will be followed by further facilities in Basingstoke and Southampton in 2021/22. Inspire prides itself on a novel model of care that has “no limitations on the possibility of recovery,” all led by director of clinical excellence Michelle Kudhail.

A key element of the centre’s approach is the team’s commitment to understanding that every patient, and the circumstances that led them there, is different.

Whether this means enabling people to leave high dependency hospital units and develop their independence in a modern, home-from-home environment, or providing long-term support or end-of-life care, the service is designed to work around the needs of each patient.

Michelle’s background means she is the ideal person to head up the Inspire team, having worked as a neuro physiotherapist in the NHS until 2010, before moving into the private sector.

Michelle Kudhail, director of clinical excellence at Inspire Neurocare.

She takes an holistic approach to patient care, which has led to the creation of a team of life skills
facilitators and therapists at the provider, who develop their care around the needs of everyone.

“The life skills facilitators support and assist the residents to do as much as they can for themselves,” she explains.

“As the name suggests, their role is more than a carer; it is to facilitate the residents in all aspects of their care, whether that’s helping them get their breakfast, choosing what they are going to wear, or taking their medication.

“Their skills are broad because we want them to be involved in all aspects of the residents’ care; and because we want to provide what they need at the time that they need it.

“Roles such as this also enable us to evaluate the outcome of any action. If a resident has been given pain medication, a facilitator can assess whether it’s been effective, rather than a nurse giving the medication and then not seeing them until the next round.

“We also know from a therapy perspective that some patients don’t respond well to having therapy at a fixed time on a particular day; they simply might not feel like doing it. Our facilitators mean we can best provide interventions for the resident when they want them.”

Alongside this role, the facility also employs a wellbeing and lifestyle coach, focussing on the health and emotional needs of both residents and their relatives, particularly during a time when COVID has caused a lot of uncertainty.

Michelle says: “We wanted somebody that had relevant experience in working with residents, particularly with neurological conditions but also with a well-rounded experience so that they would not just focus on one aspect.

“The idea is to have somebody who can offer support in all areas, whether it be psychological, emotional or physical.”

Staff are overseen by experienced rehabilitation consultant Dr Damon Hoad, who shares his clinical oversight with the interdisciplinary team and supports patients on their journeys.

The rest of the clinical team have a wealth of experience within neuro services in and around the region.

The design of the Worcester facility draws on Michelle’s years of experience, and she had the opportunity to use her skills to help develop the purpose-built home.

She says: “We’ve had a lot of involvement all the way through from knocking down the pub that was there, to seeing it grow. Having the opportunity to be involved from the ground up was fantastic.

“Within the build itself we try to consider the needs of younger people, and so the inside of the home is very much a contemporary design and a lot of research has gone into its development to ensure it has the correct, up to date, equipment.”

Adding to the sense of autonomy staff are keen to foster, is the independent living flat, which staff are able to support via environmental controls.

With soundproofed rooms, residents can enjoy listening to music or watching films without disturbing others.

In common with all care facilities, the impact of COVID means that a lot of thought has had to go into the long-term plans for the property. The recently-built visitation suite – known as the ‘family and friends lounge’ – allows visitors to meet their loved ones in a safe and COVID-compliant way.

The suite includes separate access for visitors from outside, and features a large transparent Perspex screen separating each side of the suite, while an intercom enables contact-free communication.

As well as creating an infection barrier, the screen also assists when it comes to residents who may struggle to understand that they are unable to hug their relatives, while still allowing them to communicate and see each other up close.

After each visit, the room is cleaned and decontaminated in preparation for the next visit.

As Michelle explains, human contact is essential for emotional wellbeing, adding: “We’ve tried to create an environment that is as safe as possible, because we know how important visits are to the residents but, more particularly, to their relatives.

“Supporting the residents through this time is vital. We have residents that are used to going out and doing things in the community and we have had to adjust by being creative in the ways in which they can still access things that they enjoy and still communicate with their families.”

And while the pandemic has certainly delivered some challenges, Michelle and the Inspire team have been able to look at some positive outcomes.

She explains: “One of the positives for us is that it gave the team and the residents the opportunity to really get to know each other.

“We could also develop the life skills facilitator role to its truest form, because everybody was very much working together dealing with the crisis, supporting each other and supporting the residents.

“It was a testing time but it actually it brought the team together, bearing in mind the facility opened literally as everything was going into lockdown.”

The creation of the COVID-secure visitation suite is just one example of the creativity with which all at Inspire approach care, Michelle says.

By looking to build collaborations with other organisations, Michelle also hopes to share her hard-won knowledge, potentially becoming involved in research and training in the future.

Despite the upheaval of its first few months, the Inspire team has already achieved some successful patient outcomes.

One such success story is the case of Adrian, who came to the centre for specialist neuro-rehab following a car accident in which he suffered a severe brain injury. In the months that followed, Adrian’s journey enabled him to walk out of the service and return home to his wife and children.

(See Adrian’s story below – and read more here).

While the coming months may bring more challenges, as COVID lingers and vaccinations are rolled out, the Inspire team seemingly has the skills, approach and dedication to rise to whatever the future holds.

www.inspireneurocare.co.uk

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Case management

‘I’d never imagined using Zoom as part of my physio placement’

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Tabitha Pridham is a third year student at Keele University. 

Every aspect of neurophysiotherapy has had to adapt with the onset of COVID-19, including how students prepare for a career in the profession. Here, student Tabitha Pridham discusses her experience of a pandemic placement.

Prior to the COVID-19 pandemic, the concept of physiotherapists routinely holding sessions with clients remotely was quite  unlikely.

While used to some degree in a small number of practices nationally, telerehab, as it has now become widely known, was not on the agenda of many.

But due to its seismic rise during the past few months, with physios realising the potential of digital and virtual means to see clients when meeting in person isn’t possible, it seems telerehab is here to stay. 

While it was never part of the studies of aspiring physiotherapists, they are now having to adapt to something that will most likely be part of their future careers.

“The very nature of physiotherapy is that it is hands on, so it seemed really strange to me at first that we would be using Zoom to do online physiotherapy,” says Tabitha Pridham, a third year student at Keele University.

“But I have seen how useful it can be, particularly for those patients who are very advanced in their recovery and maybe can take part in a few classes a week remotely. I think it can be valuable in addition to face to face treatment.

“I do believe it will carry on into the future, particularly in private practice, so have accepted that telerehab will be something I will be using in the longer term.”

For Tabitha, currently on a placement with neurological physio specialist PhysioFunction, telerehab is not the only big change from her expectations pre-pandemic.

“The use of PPE is something I have had to adapt to,” she admits.

“Every time you see a patient in person, you have to change gloves and thoroughly wash down equipment, to be compliant with the very high hygiene standards.

“This can be time consuming, and when you have back to back appointments I’ve found it can be quite stressful to ensure you’re doing everything you need to do in addition to your work with patients, but that’s something I’m learning as I go.

“Wearing a mask and visor isn’t always ideal for communication, but that’s something else I am finding gets better with time and use. Although it can be quite a juggle when you’re trying to treat a patient with one hand, and trying to stop your visor falling off with the other!”

Tabitha is based in the clinic four days a week, but has to work from home one day a week due to the need for a regular COVID-19 test, to ensure the safety of clients and colleagues alike.

“I have my COVID test every Monday, so I carry out consultations by Zoom that day, and providing my test comes back negative, I see patients in person Tuesday to Friday,” she says.

“I find the mix of telerehab and practical experience is really useful, especially as we are going to be using Zoom and the likes in the long term.”

Having had a previous placement cut short in April due to the pandemic, Tabitha is grateful she is able to get such experience, which accounts for vital clinical hours training for her degree course.

“Some of my year group were taken off their placements and have had to do everything virtually, so I’m lucky that I have been able to continue in a clinic,” she says.

“I’m still getting the same training, as aside from the PPE and new rules around social distancing, clients get the treatment they always have done so the practical work is the same.”

Tabitha is set to graduate in summer 2021 and has the experience of her studies, supported by three years of placements, to help her build a career in physiotherapy.

“In some ways this has been a really weird time to be working in physio, but in others it has been a very good time. This kind of experience prepares you for anything and everything, and the use of telerehab has shown me what it will be like in the future,” she adds.

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Case management

‘The challenges have been many, but we’ve found ways to overcome them’

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"The demand for digital technology going forward should mean that we can develop a better working practice"

The COVID-19 pandemic has forced huge changes within case management and the traditional ways in which clients have been supported. In our continuing series of Q&A features with case managers across the country, Martin Gascoigne of Neuro Case Management UK (NCMUK) shares his experiences.

Can you summarise how the past few months have been for you.

The past few months for NCMUK have been extremely challenging. This is due to the Government initially ring fencing all of the PPE supplies for NHS staff which made it very difficult for us to procure the necessary equipment. Also, due to our Paediatric Clients Parents furloughing, we have experienced different challenges with the type and level of care that they felt they would like us to provide whilst still working in accordance with National Minimum Standards.

How did you adapt to the restrictions of lockdown? Were you able to do this quickly or did it take a bit of time?

We managed to adapt to all of the new guidelines effective immediately as we were informed by the Government that failure to conform with these would mean that we were no longer able to deliver the care needed. NCMUK therefore reassigned staff to new roles to deal with the new daily/weekly challenges set, identifying new sources of equipment provision, medication and standards of care.

What have been the main challenges – were you able to overcome them?

The main challenges we found were that of procuring PPE at a clinical level. Unfortunately we could not identify or purchase any in the UK and so in order to overcome this it was necessary for us to establish a regular supplier overseas who was able to both meet our needs and the needs of our clients.

Has the use of telerehab been of benefit to you?

NCMUK has indeed benefited from digital technology including Zoom and Facetime. During this period of lockdown, telephone calls and digital contact was the only way the case managers/directors could maintain a high level of communication with our suppliers, clients and families.
At this time we also relied on a digital marketing organisation which made sure that our company stayed at number one on page one with Google. This meant that we could maintain our on line presence and as a result of this we would benefit from new referrals which continued to keep us busy.

How have your clients responded? Was it difficult for them to adapt to?

Our clients did find it difficult just understanding the pandemic initially, as we all did, with the obvious additional worries that they would be infected by our carers. This concern, however, was alleviated as the NCMUK team provided all care in a fully barriered manner using face masks, aprons, gloves and hand wash following the Government guidelines set.

Do you feel the lack of face-to-face contact with clients or/and colleagues has been damaging?

Our carers have been continuing to attend their home visits following the correct guidelines throughout the pandemic. This meant that they continued to have face to face contact. New links have been established via digital marketing and Zoom calls but this has been a positive addition to our communication network and as we already undertake telephone reviews with our staff, there was no change to our relationship with our colleagues.

How central do you think the use of telerehab will be for you going forward?

The demand for digital technology going forward should mean that we can develop a better working practice combining the face to face home visits and the human side of our meetings/assessments alongside digital meetings. This has the benefit of reducing the carbon emissions of our team, whose level of travel is reduced.

How do you think the future of case management has been shaped by the pandemic?

The NCMUK team will have the opportunity now to work more from home, allowing them to complete basic administrative tasks within their own environment, thus reducing emissions due to unnecessary travel.
It will also mean that when completing some assessments, these can be carried out via Zoom/Facetime meaning that more out of reach areas throughout the England/Wales can be contacted more easily. It has been necessary for us to think of alternative methods of communication moving forward and these will probably be maintained in the future as they have been a success.

Will you be doing anything differently within your business going forward, compared to your working practices pre-pandemic?

The pandemic has changed our business considerably as we are all now working more from home with the benefit of our staff reducing their overall carbon footprint. This will continue and streamline the industry as there will be more work undertaken on a virtual basis as staff are able to complete the basis administrative tasks within their own home environment in lieu of travelling to the office. It will also allow NCMUK to have clients referred to us who live in more inaccessible areas of the England/Wales which should provide more people access to more services.

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