Personal Views

Brain injury rehabilitation: jaw jaw not war war

BMJ 1996; 312 doi: (Published 06 April 1996) Cite this as: BMJ 1996;312:916
  1. A N Bamji

    In February 1995 Minerva expressed in the BMJ a widespread anxiety that a charity, Headway, was covering up the deficiencies of the NHS in brain injury rehabilitation. I outline here the attempted development of a brain injury rehabilitation unit in the old South East Thames Regional Health Authority—a development that seems appropriate and necessary.

    My theorem for new service development runs as follows:

    • ”If you wish to develop a new service, then I am afraid that the money will have to come out of some existing service” (director of public health, commissioning authority)

    • ”We cannot accept responsibility for funding a new service unless commissioning authorities are prepared to underwrite the development by agreeing to use it” (regional officer)

    • ”We cannot commit ourselves to funding a new service out of existing resources unless we have some evidence that it is effective” (manager, commissioning authority).

    Proof: Commissioners will not buy a new service until they can see what they are buying, but providers cannot provide it until commissioners put up the money, which they do not have. This is alternatively known as Catch 22.

    Corollary 1: He who chairs a working party must be prepared to become a non-person.

    Corollary 2: It is probably easier not to bother.

    In 1989 I was asked to chair a regional working party in brain injury rehabilitation. Our remit was to examine perceived deficiencies in service provision and suggest solutions. I expressed some reservations at spending time on a project if there was to be no money to fund the conclusions, but was assured that there was the will and the money to make certain that any recommendations would be carried through.

    We established a group of neurologists, rehabilitation consultants, psychologists, therapists, and representatives of Headway. We took advice from rehabilitation specialists around Britain, met regularly over an 18 month period, and produced a 35 page report with 57 references. We concluded that basic brain injury rehabilitation services should be provided at district level, but that a regional unit should be developed to offer a specialist service for complex cases, and provide a base for education and research.

    This conclusion was welcomed by the regional health authority and an option appraisal exercise was undertaken to determine where the new regional unit would be sited. Bids were received from several hospitals and the appraisal team's recommendation that Queen Mary's Hospital in Sidcup was a suitable site was not met with universal approval. Nevertheless, there was at least a commitment to proceed. So an approval in principle document was prepared, with the enthusiastic support of the hospital management, and many more hours were spent drawing up detailed plans and costings, after visits to and correspondence with established units.

    The document was taken to the appropriate regional committee for ratification. It was turned down. Two related excuses were offered: firstly, that the new purchaser and provider split in the NHS meant that the whole process of contracting for regional services was under review, and, secondly, that this specific project did not adduce any evidence that commissioners would place contracts. The explanation flew in the face of the clear expression of views by those who were managing patients with brain injuries—namely, consultants in neurology, rehabilitation, and orthopaedics—that they would be making tertiary referrals. But the decision was final.

    I wrote to our MP, who wrote to the secretary of state for health, who told us to submit a business plan—a pointless exercise, given the application of my theorem. So there the matter rested, and in my filing cabinets all our background research, working papers, and unit plans gathered dust. Brain injury rehabilitation continued on its ad hoc basis, with a quasiregional service offered by the department at the Queen Elizabeth Military Hospital. Other units, notably at King's College Hospital and the younger disabled units at Hither Green and Sidcup, provide perhaps a better than average deal. A unit was established at a private psychiatric hospital offering a small but excellent service.

    Meanwhile there was a continuing debate on the future of neurosciences in South East Thames, based on the premise that a single site unit would have to replace the services provided at King's College Hospital and Maudsley Hospital and the Brook Hospital in Woolwich, whose future was increasingly precarious. A perturbing factor was the amalgamation of South East and South West Thames regions, but it came as some surprise to read the 1994 Regional Neuroscience Review (which, among other things, had abandoned the single site doctrine of 20 years' standing) and discover that the question of brain injury rehabilitation had been readdressed, involving the coopting of an eminent specialist from outside the region (from whom we had taken detailed advice when preparing the approval in principle document). No new conclusions were reached, except that more work was necessary to define need. No reference whatever was made to the original working party report, option appraisal, or approval in principle exercise, where the need had already been defined. It was as if they had never been. My protests on behalf of those who had put in so much work, outlining the agreed solution, were unanswered.

    Meanwhile one consultant in the region with a special interest in brain injury rehabilitation has left for the private sector, despairing of the inability to make advances in service provision. The rationalisation of army medical services, which involves the closure of the Queen Elizabeth Military Hospital, has removed the rehabilitation unit there. The closure of the Brook Hospital in Woolwich casts a shadow over the Headway House (of which I am a trustee) based there. Far from things getting better, they are getting worse; the funding Catch 22 ensures that no service can be developed until the “money follows the patients” doctrine is sidestepped. It requires a politician to break the log jam. Is it any wonder that we do not bother?

    As for the bleating that there is no money … the NHS continues to throw it away. Nationally, we have seen huge sums frittered on useless information systems, and cash is being flooded into general practice fundholding. Locally, plans in an adjacent district for a new single site hospital on a metropolitan green belt site were turned down by the Department of the Environment. It is suggested that the plans, which had little chance of success, cost £6 million. A scanner, bought at a cost of over £400000 for the Brook Hospital, never worked and has now been written off. Our brain injury rehabilitation unit could have been built and run for four years with that money.

    Is this really the best we can do? No one can say we did not try.—ANDREW BAMJI is a consultant rheumatologist in Sidcup

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