What does the guideline cover?
The guideline covers a wide range of chronic neurological disorders, although this article will focus on acquired brain injury, and is intended to address the rehabilitation needs of children, young people and adults. Rehabilitation is defined by the World Health Organisation as “a set of interventions designed to optimise functioning and reduce disability in individuals with health conditions in interaction with their environment”. The committee responsible for producing the guideline are clear that rehabilitation should not be seen as a ‘one size fits all’ process.Why has the guideline been produced?
Before considering the guideline itself, it is worth considering some of the reasons why the committee have made their recommendations:
- Holistic rehabilitation requires collaboration;
- Rehabilitation is often only considered when symptoms start to affect functioning and only provided in the short-term for specific symptoms; and
- Navigating rehabilitation services can be challenging and poor communication between rehabilitation services leads to poor continuity of care.
Those involved in dealing with serious injury claims will be familiar with concerns that current NHS services do not routinely deliver well against those objectives. It is not unusual for a person to be discharged from hospital after suffering an acquired brain injury without any, or any adequate, provision for community rehabilitation. Improvements have certainly been made over recent years with rehabilitation prescriptions and major trauma discharge co-ordinators, but it is probably fair to say that communication and liaison between different NHS services remains a major issue. Far too many patients still fall through the net and whilst those who are involved in a serious injury claim might be able to access private provision, many are less fortunate.
What does the guideline propose?
The guideline sets out a best practice framework for rehabilitation of chronic neurological disorders incorporating the following six elements:
- Designing and commissioning rehabilitation services: This involves building local capacity and expertise to establish integrated, collaborative and flexible clinical pathways across hospital and community rehabilitation services.
- Assessing rehabilitation needs and goal setting: This involves identifying the need for rehabilitation as soon as a chronic neurological disorder is diagnosed or suspected followed by a lead practitioner undertaking a holistic rehabilitation needs assessment involving input from other relevant practitioners. However, rehabilitation interventions should not be delayed while undertaking holistic needs assessment. It may be appropriate to discuss prognosis as part of this process and practitioners should work collaboratively with the person in respect of goal setting.
- Rehabilitation planning and delivery: A personalised rehabilitation plan should then be agreed based upon the holistic rehabilitation needs assessment. The rehabilitation plan should assign a single point of contact, which could be a key worker or, if the person has severe complex and long-term rehabilitation needs, a complex case manager with specialist knowledge.
- Information advice and learning as part of rehabilitation: This requires the provision of personalised information with a focus on acceptance of diagnosis and potential for recovery. Practitioners are advised to explain what financial support is available to assist with rehabilitation related activities and personal assistance which, from experience, is often something that is overlooked currently.
- Rehabilitation to maintain, improve or support function: In this section, the guideline suggests several particular areas that the practitioner should ask about as part of the holistic rehabilitation needs assessment, including pain, fatigue, physical activity, emotional health and cognitive function to name but a few.
- Rehabilitation to support education, work, social and leisure activities, relationships and sex: Here the guideline encourages the involvement of the injured person’s education establishment or workplace. It also talks about the importance of recognising social participation goals and the impact on family life, friendships and intimate relationships.
Will the guideline make a difference?
The framework set out in the guideline is ambitious and should be welcomed, however there must be significant concerns over whether this is something the NHS will be able to deliver. The committee acknowledge the lack of funding but rely on the offset of potential savings further upstream if those with chronic neurological disorders are properly rehabilitated from the outset.
Other challenges include geographic variability in the availability and quality of NHS services, recruitment and training of complex case workers and communication between NHS services.
There is a clear evidence base to support the proposition that earlier access to rehabilitation results in better outcomes. However, aside from availability of rehabilitation services, that relies upon earlier diagnosis. In the context of acquired brain injury claims, it is usually fairly obvious when a person has suffered a moderate to severe brain injury, but mild brain injuries can be much more difficult to diagnose, particularly in the immediate aftermath of polytrauma following an accident. We have discussed in previous articles and posts about advancements in imaging techniques, the use of blood biomarkers and the new CBI-M diagnostic framework currently being rolled out across US trauma centres. These developments should help make a difference.
What are the implications for serious injury claims?
The guideline seeks to promote improvement in NHS rehabilitation services, however it seems unlikely that this will result in a significant change in how rehabilitation is arranged and funded in serious injury claims. Those with the resources to do so will probably continue to rely largely on the private sector, although making NHS provision more holistic and appointing a key contact should in theory make shared NHS and private working more achievable.
It will take time for capabilities to be developed and the rehabilitation framework to be implemented but if delivery is managed properly then there are reasons for cautious optimism.
If you wish to discuss the NICE guideline on ‘Rehabilitation for chronic neurological disorders including acquired brain injury’ or any aspect of rehabilitation in traumatic brain injury claims, please contact Edward Cleary, Myles Govan or another member of DWF’s traumatic brain injury group.
