The immediate challenges of the covid crisis have been writ large in our daily news streams – acute care bed capacity, availability of PPE, impact on health and care workers, care providers and the social and economic impact of lockdown.
But the crisis we have experienced so far is only chapter one in what will be a long running saga with a very long tail. Health trusts are now, more than ever, focusing on what happens next – to recovering covid patients and to other patients whose treatment and care has been impacted by the crisis.
What a crisis does most powerfully is expose existing weaknesses – and rehabilitation is clearly a major weakness in our current healthcare system. Sure, good practice pathways and guidance exist – from both NHSE and NICE – but there are huge gaps in actual provision and few patients have any expectation of the support they will receive after crisis medical treatment.
Despite what TV hospital dramas lead us to believe, patients’ problems are not all solved by a heroic doctor magically diagnosing them or performing life saving surgery. How you recover, and what support is in place is just as critical to the quality of life you enjoy afterwards. As the British Society of Rehabilitation Medicine have cogently argued – the pandemic provides an opportunity for the NHS to re-boot services into a more co-operative rehabilitation model ‘like a phoenix from the ashes’.
Post covid patients could be presenting with a wide range of issues from cardio-pulmonary, musculoskeletal to psychological conditions. These could be compounded by wider physical, cognitive and mental health needs and PTSD like symptoms associated with prolonged treatment in ICU – and anecdotally at least some Trusts are reporting higher rates of this in covid patients than usual.
So how these patients are discharged and ongoing recovery care is delivered is a focus of real concern. And some of the usual ways in which, for instance, hands on physiotherapy is delivered, pose real questions for delivery. One fear is that without proper support these patients will remain vulnerable to future infection.
But there are other categories of patients who are being impacted. It appears that the number of patients presenting with stroke and heart conditions have reduced during the covid crisis. Those that do are attending later and potentially could face being discharged earlier. Yet we know the outcomes for these patients depend crucially on timely and intensive rehabilitation care and this has to be a worry even in areas where good commissioned services and pathways exist.
Add to the mix the cancer patients and patients with long term conditions who have had ongoing treatment deferred, and we have some serious long term consequences – in terms of vulnerability to future waves of infection and long term health.
Of course much of the impact of the pandemic is yet to be seen. We don’t yet know the trajectory of the infection, whether it will mutate into other symptoms, how it will interact with winter flu, whether exposure confers future immunity or indeed the long term effects of what is a multi-system disease.
But its clear that its never going to just need an acute response. So recovery planning, rehabilitation prescriptions, multi-disciplinary support, step down services and community provision will all be crucial. And that care will need to integrate the needs of mind and body – since mental health and psychological resilience are crucial ingredients to achieving the best outcomes. And from a patient and carer perspective engaging patients in the co-production of recovery plans not only supports a sense of agency and independence but reinforces better mental health.
What the crisis exposes are the huge gaps that currently exist in rehabilitation. These gaps exist despite excellent work identifying ideal pathways, standards and best practice. Services vary from condition to condition and from area to area. Teenage victims of the Manchester Arena bombing, despite the availability of emergency funds, were stunned to discover that the only rehabilitation that they could be offered were falls clinics and other services designed for older patients. Not much has changed since then.
Of course, the incentives within the NHS, mental health and social care are complex and unintegrated. Unlike an insurance driven system, the long term health outcomes and reduction of reliance of health, care and welfare benefits is not felt by those who commission and fund individual services.
Despite increasing efforts to improve integration, there is not a whole system approach that measures or incentivises long term recovery. And despite the massive advances made in major trauma for instance, the benefits have not been carried forwards into enhanced rehabilitation so that lives saved are lives worth living.
What is marked however is that, where patients access insurance compensation, their access to rehabilitation services is gold standard – put simply improving their chances of meaningfully working again, is a ‘no-brainer’ when it comes to saving the insurer money later for ongoing care and support.
So whilst the bright lights of covid shine on the cracks in the system there is a huge opportunity to re-think how we deliver rehabilitation and recovery. Of course, one solution would be to move to a social insurance funded model for an integrated health and social care system. That would take huge political will and massive efforts to explain to the public how the way they pay for health and care will improve the outcomes for them.
And the British public would take some persuading since reform exposes gaps in current understanding of how the system works now (see May’s election efforts to reform the funding of social care).
One more pragmatic solution however might be to apply the DWP’s resources to the problem. Increasingly the Department of Work and Pensions has been trying to address the impact of health on work, and to seek solutions that improve the employment of people with long term disabilities. Since 80 percent of disabilities are acquired, rather than born with, DWP funding to improving rehabilitation across the whole system from acute to social care would reap downstream benefits and deliver those incentives, if accompanied by better patient data and measurement of outcomes.
This would need to entail a culture change across the whole NHS and care system to think about the long term recovery of patients – focused on person centred care, mind and body and self management.
Rehabilitation now more than ever demands radical effort. The planned National Rehabilitation Centre at Stanford Hall if it proceeds, could provide a beacon of clinical as well as research, innovation and education excellence. But reform will need to go further and wider across the whole health and care system.
Recovery needs to be planned from the moment a patient arrives in an acute bed or attends with a serious disease or long term condition, through to their return to the community, their family and work.
Ultimately, we need to move beyond an emergency response to the long term health and wellbeing response – not just because that what’s right and moral – but because of the cost of not doing so.