Challenges and opportunities for UK independent providers of neurorehabilitation services navigating the current UK NHS Commissioning Environment
Brain injury is the leading cause of death and disability worldwide; approximately one million people live with an Acquired Brain Injury in the UK. Specialist neurorehabilitation (NR) services play a vital role in the management of patients admitted to hospital by taking them after their immediate medical and surgical needs have been met, maximising their recovery and supporting safe transition back to the community. The extent of the NR programme delivered varies enormously due to the complexity of the brain and the nature and severity of the injury. This diversity makes NR planning and service provision challenging and complex.
The Department of Health Specialist Services National Definition Set (SSNDS) 3rd edition published in 2009, defined four categories of patient need (A,B,C,D) ranging from complex or profound disability (Category A), to patients with a wide range of conditions but who are usually medically stable (Category D). SSNDS also defines three levels of specialist service (1, 2 and 3); Level 1 Units are high cost/low volume services for Category A patients, Level 2 Units mainly provide services for Category B patients and Level 3 Units mainly serve Category C and D patients. This provides a framework for the planning and commissioning of specialist NR services.
Since the reorganisation of the National Health Service (NHS) following the Health and Social Care Act 2012, tertiary specialist NR for Category A patients are commissioned directly by NHS England. Local specialist and general services are commissioned by the Clinical Commissioning Groups (CCGs).
The UK specialist Rehabilitation Outcomes Collaborative (UKROC) database is a national dataset for specialist NR services. UKROC collates case episodes for inpatient rehabilitation from all specialist NR services across the UK and provides the commissioning dataset for specialist NR services and national benchmarking.
UK Independent Service Providers (ISPs) must navigate this complex NHS commissioning environment to ensure NR beds are utilised and funded 24/7; this presents many challenges and few opportunities.
ISPs provide more NR beds than the NHS and they should be recognised as providers not ‘add-ons’. Often the commissioning of NR services falls under the banner of ‘long-term conditions’. NR is a complex process of assessment, treatment and management by which the individual, and their family/carers, are supported to achieve their maximum potential for physical, cognitive, psychological and social participation in society and quality of living. Commissioners need a basic understanding of the complexities involved in the assessment, management and delivery of outcomes for individuals with brain injury.
Specialist rehabilitation or nursing care?
There are standards and guidelines for ISPs; they have to demonstrate that they can assess the complexity of NR needs, provide a level of NR interventions and have the facilities to achieve this. ISPs must evidence measurable outcomes that demonstrate a useful gain. To be eligible for Levels 1 and 2, ISPs must register with UKROC and submit a dataset for each case episode. This is challenging for those ISPs who predominantly provide neurobehavioural rehabilitation where the outcome measures do not comply with UKROC requirements.
NR care plans are designed and implemented by interdisciplinary teams who have undergone recognised specialist NR training. By law, NR providers must register with the Care Quality Commission, however, the requirements are minimal and many care homes claim to provide a NR service when they lack the necessary experienced interdisciplinary team.
Patient referral process
The patient referral process can be complex, challenging and extremely time-consuming. Currently beds are ‘under-commissioned’, despite the waiting lists of patients requiring NR. In order to ‘attract’ referrals ISPs have to maintain and grow their reputations, demonstrate robust outcomes, facilitate networking with CCGs and market their services comprehensively in the catchment area. Patients are referred via several routes; depending on the funding stream e.g. NHS Hospital Trusts, NHS Continuing Care and medico-legal. The challenge of ‘filling beds’ depends on assessing patients, developing NR programmes and then confirming funding. Many ISPs also have to make arrangements for where the patient will go post-discharge, before they can be accepted.
Cost-efficient service provision
Convincing commissioners about the cost of NR has always been a challenge. There is now a substantial body of trial-based evidence and other research to support both the effectiveness and cost-effectiveness of specialist NR which needs to be constantly communicated1 . The cost of providing early specialist NR for patients with complex needs is rapidly offset by longer-term savings in the cost of community care, making this a highly cost-efficient intervention1.
UKROC recently reported data on functional outcomes, care needs and the cost-efficiency of specialist NR for a multicentre cohort of 5739 inpatents with complex neurological disability, and compared different diagnostic groups across three levels of dependency2. Outcome measures were recorded on admission and discharge and all received specialist inpatient multidisciplinary rehabilitation. All groups showed significant reduction in dependency between admission and discharge on all measures. There was also a mean reduction in ‘weekly care costs’ and the time taken to offset the cost of NR was 14 months in the high dependency group.
The current national bed tariffs are flexible and provide ISPs with the opportunity for local negotiation.
Staff recruitment and retention
Specialist rehabilitation requires input from a wide range of NR disciplines e.g. rehabilitation-trained nurses, physiotherapy, occupational therapy, speech and language therapy, psychology, dietetics, orthotics, social work, as well as input from consultants trained in rehabilitation medicine and other relevant specialties e.g. neuropsychiatry. Having the appropriately skilled staff in sufficient numbers to provide rehabilitation at a level of intensity commensurate with the patient’s needs is on ongoing challenge. There is often a shortage of qualified staff e.g. rehabilitation-trained nurses. However, ISPs do have the opportunity to provide salaries/benefits that are not governed by the NHS.
Independent Neurorehabilitation Providers Alliance (INPA)
The Independent Neurorehabilitation Providers Alliance (INPA) was established in 2012 with the key objective of improving standards in the independent sector. For further information, please contact: firstname.lastname@example.org www.in-pa.org.uk
- http://www.bsrm.org.uk/downloads/specialised-neurorehabilitation-service-standards–7-30-4-2015-forweb.pdf (accessed 14 March 2016)
- BMJ Open2016;6:e010238 doi:10.1136/bmjopen-2015-010238