Rehabilitation for older people

At risk in the new NHS

Fifty years ago, in a brief but powerful paper, Marjorie Warren laid down the guiding principles of what was to become the specialty of geriatric medicine.1 She emphasised the process of rehabilitation—to help elderly people regain their best possible functional independence. How is the rehabilitation of older people faring in the reformed NHS?

Elderly care medicine, like many other acute specialties, has come under considerable pressure. An established pattern of rising admissions, disproportionate to demographic changes, has been compounded by a steady reduction in acute hospital beds. The solution to these conflicting trends has been to press for shorter lengths of stay, making rehabilitation especially vulnerable. Two index conditions which provide an insight into contemporary rehabilitation for older people are stroke and fractured neck of femur.

The Department of Health's targets listed in the Health of the Nation drew particular attention to stroke, and we now know, from research, how a comprehensive stroke service should work. There is particular confidence that properly organised hospital care of stroke improves outcome. Yet, despite the opportunities for stroke patients arising from these positive findings, a recent survey of British doctors showed that disorganised stroke care prevails.2 The inertia is partly due to the focus of health planners on emergencies and waiting lists and partly due to increased demands on general physicians and geriatricians. Even more important has been the difficulty in constructing a service contract for commissioners of stroke care; a well defined specification for the organisation and delivery of the service has proved elusive.3

The Audit Commission's recent report on the care of older people with fractured neck of femur emphasised that effective collaboration between elderly care physicians and orthopaedic surgeons leads to improved outcomes.4 This view is supported by research and by audit findings. Yet two recent surveys of British orthopaedic departments showed that only a few had an effective system for shared care of patients with fractured neck of femur. 5 6 A decade ago a similar minority of districts offered formal orthogeriatric liaison.7 This does not seem to be an interprofessional issue: most orthopaedic surgeons believe orthogeriatric liaison is desirable.6

Thus, in two important marker conditions, rehabilitation is still inadequate for many elderly people despite evidence of clinical effectiveness, national guidance, and widespread agreement. In a further, more general sense the provision of rehabilitation is also being undermined. In the 1980s there was a popular trend to integrate acute care and rehabilitation within single, multipurpose wards. Continued pressure for high throughput, however, has undermined this widely adopted model of care. In effect these wards have quietly withdrawn from an emphasis on rehabilitation and become dominated by providing acute care.

The erosion of rehabilitation for older people in our acute hospitals might be understandable if it was part of a strategy to develop rehabilitation at home. But this has not been the case, and widespread concern exists that rehabilitation based in the community continues to be underdeveloped and underfunded.8 Work is now urgently needed to rehabilitate rehabilitation for elderly people. Not to do so is an injustice to older people and their families. It is also costly, as failure to achieve optimal rehabilitation increases the need for home support and risks avoidable institutional care.

What should purchasers and providers be doing to correct this? A recent policy report from the Department of Health offers a new opportunity for a collaborative re-examination of rehabilitation services.9 Health authorities are now obliged to produce local policies and guidelines for continuing health care. The report urges health authorities to include “explicit protocols and eligibility criteria for rehabilitation.” This comment is welcome, but there is a need for greater commitment from purchasers and providers and a clearer statement of their mutual responsibilities.

A simple remedy would be a return to designated rehabilitation wards designed to provide the time and space elderly people need to recover from acute illness. This approach would also help restore the threatened role of the rehabilitation nurse. A wider, more fundamental and strategic change may be required, however. A pressing need exists to determine which particular configuration of elderly care services is best for patients. For example, to what extent does rehabilitation prosper when located in community trusts compared with acute hospital trusts? Development of rehabilitation based in the community has particular appeal and fits in with the concept of an NHS led by primary care.10 The new found interest in community hospitals also has potential to sustain rehabilitation for older people but needs to be developed from a policy based on opinion to one based on evidence.

Marjorie Warren described “the proper care and rehabilitation” of older people.1 In our health service today there is little to suggest that rehabilitation is in robust health. Uncertainties remain over how the service should be commissioned, how it should be divided between primary and secondary care, and the respective roles of social services and health. A new and purposeful strategy is urgently required to prevent further drift and deterioration in rehabilitation services for older people.