Education And Debate

Controversies in Management: Only hospitals can provide the required skillsCommentary: both hospital and community services are needed

BMJ 1994; 309 doi: https://doi.org/10.1136/bmj.309.6965.1357 (Published 19 November 1994) Cite this as: BMJ 1994;309:1357
  1. N B Lincoln
  1. Stroke Reserach Unit, City Hospita, Nottingham NG5 1PB.

    No effective treatment exists for acute stroke.1 The only consistent evidence derived from randomised controlled trials is that management on a specialist stroke unit reduces both mortality and morbidity.2 The key feature of these trials is that coordinated multidisciplinary care is better than disorganised care. The question to be debated is whether such coordinated multidisciplinary care is better provided in the community.

    Coordination is a problem

    Unfortunately both experience and formal clinical studies have taught us that coordinated rehabilitation is lacking in the community. This is confirmed by the nature of requests for information and support made to the Stroke Association.3 Coordinated care is possible in the community but difficult in practice. The professions concerned have different employers, patterns of referral, and work bases. Community nursing services offer significant input but tend to concentrate on the more disabled and those least likely to change. They provide a care service but not rehabilitation. Domiciliary physiotherapy is attractive, but the service is provided in only a few areas. Therapists have to deal with a varied caseload and many lack specialist expertise. Studies of the benefits of domiciliary physiotherapy and its cost effectiveness have produced conflicting results.4 Occupational therapy is available more often but consists …

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