Ensuring rehabilitation is a vehicle for change

Rehabilitation is not a luxury health service that is available only for those who can afford it. (World Health Organization, 2020)

The coronavirus pandemic has highlighted more than ever the importance of rehabilitation, and the Royal College of Occupational Therapists (RCOT) has been advising government teams and stakeholders on the most effective use of occupational therapy. This spotlight has also held up a lens to many of our accepted norms – that is, the predominance of reactive, acute access to occupational therapy and the narrowing of practice leading to loss of skills and the lack of outcome data. This editorial argues why it is now the right time to challenge current practice and why rehabilitation can be a catalyst for change.

During the early stages of the pandemic, the focus was on rehabilitation for people following discharge from the ICU. Since then, however, the focus has shifted as the need for community rehabilitation has escalated due to the increasing number of people who may not have been hospitalised but are experiencing the debilitating effects of long COVID. These effects are variable and wide ranging, including respiratory or multi-system symptoms lasting over 12 weeks (NICE 2020). The impact of illness from this virus has highlighted that most people require not only physical interventions in order to recover but also psychological and cognitive rehabilitation and emotional support.

For occupational therapists and other Allied Health Professionals, the crisis has further illustrated that rehabilitation is the thread that connects services and the key to addressing some of the fundamental weaknesses of health and social care delivery, for example, transitions between services, narrow specialisms and disjointed and reactive delivery.

Rehabilitation covers a range of services and has many interpretations. The World Health Organization (2020) defines rehabilitation as addressing the impact of a health condition(s) on a person’s everyday life, by maximising their ability to function, to do what matters to them and to participate with their community, family and friends. What can complicate this in practice is that the majority of people requiring services have multiple needs (many of which are not direct health issues but impact on their health) and these communities are often poorly served.

Community rehabilitation is not universal. People may receive rehabilitation through outpatient clinics, through condition-specific pathways or following discharge from hospital. Wider determinants of health may be recognised but rarely addressed as services are primarily measured against acute, crisis criteria.

In response to demographic need, national governments in the UK have designed policies to position services towards integrated, public health delivery with pilot and case for change sites demonstrating how these might be realised. These can offer foundations to the profession to consider and action change to where and how we work with individuals and communities.

So what might change involve? Firstly, occupational therapy needs to move from acute and secondary settings to community and primary delivery, with only specialist rehabilitation offered in acute to people recovering from major trauma or with high, complex need. The wider adoption of a discharge to assess model is already driving this forwards with assessment and interventions provided by community services as soon as people are medically optimised.

Secondly, new community-based specialisms would offer careers that enable practitioners to retain their broad range of skills. Advanced occupational therapy practitioners in primary care and community rehabilitation would view need and service development through an occupation lens, and this in turn would offer the skills to work within primary care and lead integrated community services. The College is already working with Health Education England on developing aframework for advanced occupational therapy practitioners in primary care. This career pathway will involve occupational therapists maintaining and extending their broad range of skills developed since qualifying – skills that currently many in the profession lose due to service delivery constraints.

At a structural level, we need to embed approaches to population segmentation and/or stratification based on symptoms, function and need into service design. Different approaches to population segmentation such as the use of the frailty index or identification of multi-morbidity can then be linked with acuity and dependency tools to determine the complexity of need. NHS Rightcare (2020) recommends using a scale of matched interventions to different groups of patients to support an organised system of delivery that allows people to come in and out of services depending on need.

Thirdly, as a profession, we have to demonstrate and evidence our impact on the wider health and social care economy as well as capturing people’s experience. Occupational therapy provides a range of complex interventions within varying contexts (Pentland et al., 2018). Rehabilitation itself is complex but can we continue to use this complexity as an excuse? RCOT’s top 10 priorities for occupational therapy research (2020) are driving forwards this agenda. Traditional data collection and research mechanisms have failed to capture evidence of sufficient quantity or quality to convince governments for the need for greater investment. The Medical Research Council describes complexity being derived from the range of possible outcomes or their variability in the target population. It advises on the need ‘to incorporate evaluation considerations in the implementation of new initiatives’ involving a range of measures and monitoring unintended consequences (Medical Research Council, 2019: 33). It may now be time to move from individuals and services selecting outcome measures to national agreement on collecting data.

Rehabilitation does not encompass all occupational therapy practice, but it provides a vehicle for discussing where the profession is best placed to make a difference: acute, primary or community? It also demands change to our career development to meet demographic need. As occupational therapists, we have responsibility to maintain and further develop a broad range of skills as our careers advance, whilst RCOT and leaders in the profession must argue that advancing practice does not involve narrowing practice.

And finally, we need practitioners, researchers and quality improvement leads to work together to develop an information model or a data set for occupational therapy. The profession cannot continue to demand inclusion in services without demonstrating its cost-effectiveness and value.