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Rehabilitation has an uncertain status in the NHS. The Beveridge report linked ‘health and rehabilitation’ as foundational concepts, but some 60 years on, Lord Darzi’s report, High Quality Care for All, makes not a single reference to rehabilitation¹.

Rehabilitation features in the National Service Framework for Older People and is more fully developed in the NSF for Long-term Neurological Conditions, but the confusingly titled Long-term Conditions agenda dilutes the concept of rehabilitation.

Whilst recognising the vital role of physiotherapists and other members of the multidisciplinary team, my question here is this: How should doctors get involved in the rehabilitation process? There are places where engagement in rehabilitation is truly multidisciplinary: one thinks of a neurological or stroke rehabilitation unit – an outpatient example might be a Parkinson’s disease service - in which doctors, therapists, patients and family members sometimes do come together to agree genuinely shared goals and to pursue integrated rehabilitation plans. More often, rehabilitation is seen as largely the province of therapists and is sometimes even equated with physiotherapy, as though medical involvement was irrelevant. In the high-pressure environment of acute medicine, rehabilitation rarely seems to be an integral part of what goes on. It is often seen merely as an exit point. In the words of one medical discharge summary: “Nothing further could be done, so she was referred for rehabilitation".

Several medical specialties (for example, psychiatry) owe their existence to the recognition that patients were being badly served by inadequate clinical assessment. Geriatric medicine rejects the idea that old age is a sufficient explanation for ill health, disability and ‘acopia’² and comprehensive geriatric assessment should encompass not only impairment but also (in terms of the WHO’s International Classification of Functioning Disability and Health³) activity, participation, and environmental factors. Rehabilitation Medicine is in the same tradition, using medical expertise in the analysis and remediation of complex psychological and physical impairments⁴. We provide medical management and rehabilitation for people with spinal cord injury, acquired brain injury and other long-term neurological problems, and also for those with amputations or with complex musculoskeletal impairments. One point of distinction from geriatric medicine has been our responsibility for younger adults where parental roles, education and employment may give rise to specific needs. Our focus involves us in aspects of rehabilitation which are peripheral to routine medical care, for example postural management, seating, and electronic assistive technologies and we are often working on the margins of healthcare in liaison with agencies such as social and employment services.

We would like to hear your views on how Rehabilitation Medicine can contribute most usefully to outcomes for older people. Gone are the days when services could be demarcated on grounds of age alone. Just as Old Age Psychiatry is working more closely with Rehabilitation Medicine in addressing the needs of younger people with dementia, so Rehabilitation Medicine consultants are working collaboratively with geriatricians in the rehabilitation of older people with amputations and neurological conditions. There are many Trusts where good working relationships have been established between Rehabilitation Medicine, Geriatric Medicine and Psychiatry but more could be done. Dialogue between the BGS and the BSRM will enable us to improve outcomes for people with disabilities and long-term conditions, irrespective of age.

Professor Chris Ward
President, British Society of Rehabilitation Medicine

1. British Society of Rehabilitation Medicine (2008). High-Quality Care for All: Adding a Rehabilitation Dimension.

2. Oliver D (2008). ‘Acopia’ and ‘social admission’ are not diagnoses: why older people deserve better J R Soc Medicine 101:168–174

3. World Health Organisation (2001). International Classification of Functioning Disability and Health.

4. Rehabilitation Medicine: The National Position in 2007

BGS Newsletter, Oct 2008
Issue 18 ISSN 1748-6343 18