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2 Specialties Rehabilitation medicineservice quality include committed management,involvement of service users and regular audit.Inpatient unitThe BSRM recommends 45–65 beds per millionpopulation for specialist RM, depending on local servicepatterns for stroke and rehabilitation of older people. The minimum size of a viable inpatient unit shouldbe 20 beds, which should be located together tofoster rehabilitation nursing expertise. Space must be available for therapy, recreation,social activities, team meetings and case conferences. The unit requires immediate access to acute medicaland surgical services, dietetics and enteral feedingservices, and radiology and pathology services. Manual and powered wheelchairs must be availableon the unit, and there must be access to specialistorthotics and wheelchair clinics.Outpatient facilitiesMost patients need access to the MDT, as well asmedical clinics, so day assessments, case conferencesand outreach visits are often required. The RMconsultant will need access to services for: physiotherapy and hydrotherapy occupational therapy, including domestic facilitiesand workshops social services information technology (IT) equipment andsoftware for patient use orthotics and prosthetics specialist wheelchairs and seating electronic assistive technology driving assessment and training counselling and psychology sexual and genetic counselling education and employment training vocational rehabilitation.Work to maintain and improve the quality of careThe role of the RM consultant in leading servicedevelopmentsThe work of the RM consultant includes more servicedevelopment than that of most other specialists, as theylead or contribute to the development of care pathways –for example, the current development of major traumanetworks in England.Consultants in RM make major contributionsto productivity and quality (as exemplified in Englandby the Quality, Innovation, Productivity and Prevention(QIPP) programme). 12 Respiratory medicinereduces hospital usage by using preventive interventionsalongside general practice and community services, andby coordinating complex hospital discharges. Consultantsin RM could play a larger role given the increaseddrive to bring cohesion to rehabilitation services. 13Consultants in RM focus on maintaining and regainingemployment, 14 contributing to the agenda of theinterdepartmental strategy Health, work andwell-being. 15Consultants in RM lead undergraduate andpostgraduate teaching on disability andrehabilitation.Education, training and continuing professionaldevelopment (CPD)The training curriculum for RM 16,17 includesdeveloping skills in the management of neurologicaland musculoskeletal disorders and comorbidities arisingfrom multiple trauma or chronic immobilisation.Consultants must also have a thorough understandingof how individual and social behaviours influencedisability. Such training overlaps with psychiatry,neurology and neuropsychology. Training must deliverhigh-level skills in communicating with individuals andgroups, analysing complex situations and incorporatingpsychological elements in therapeutic interventions.The BSRM organises an annual programme of scientificmeetings, postgraduate courses and regionaleducational meetings. The scientific meetings of theSociety for Research in Rehabilitation are anotherimportant element in CPD.Clinical governanceClinical governance raises specific issues for RM, 18including the vulnerability of people with physical andcognitive impairments and medical accountability in anenvironment in which consultant roles may be obscuredby the multidisciplinary interagency context of RM.ResearchEvaluating complex interventions has been fundamentalin rehabilitation research for the past two decades,particularly in the development of outcome measures.Most evidence for the effectiveness of rehabilitationconcerns stroke, but evidence is emerging in acquiredbrain injury, MS and community-orientedC○ Royal College of Physicians 2013 207
Consultant physicians working with patientsrehabilitation. 8,9,19,20 Gaps remain, however, and theacademic base of RM needs further development. Atpresent there are two professorial chairs in RM in theUK. A third is anticipated. There are a number ofnon-professorial academic posts as well.Local management dutiesRM consultants have a high and complex managementworkload: first, through involvement in servicedevelopment; second, because RM consultants interfacewith a wide range of services including therapies,neurosciences and community services; and third,because responsibilities must be shared among smallconsultant teams.Specialty and national guidelinesThe BSRM is the principal focus for nationally basedwork; it regularly produces reports and guidelines.The national clinical guidelines for rehabilitationfollowing acquired brain injury, 21 published jointly bythe RCP and the BSRM, provide a comprehensiveframework for the management of an important patientgroup. These evidence-based guidelines will continue tounderpin the development of rehabilitation services.The BSRM has published standards for specialistinpatient and community rehabilitation services, 22amputee and prosthetic rehabilitation, 23 spinal cordinjury, 24 use of botulinum toxin in spasticity 25 andvocational rehabilitation. 26Guidelines published by the National Institute forHealth and Care Excellence (NICE) on the managementof MS in primary and secondary care 27 (which providea framework for specialist services in MS, includingaspects most frequently undertaken by RM consultants)and on rehabilitation after critical illness 28 are of centralsignificance for the specialty.The National service framework for long-term conditions(2005) specified a 10-year implementationprogramme. 5 Rehabilitation medicine has key roles inthe delivery of all of the NSF’s Quality Requirements.Specialty and national auditThe BSRM has led development of the standardsoutlined below. Most audit work is carried out locally,but the BSRM piloted a peer-review scheme. Guidelinespublished by the BSRM strongly influence local auditactivity, and the BSRM is currently developingspecialty-appropriate parameters for Payment byResults. 29Quality standards and measures of the quality ofspecialist servicesMuch work has established measurable quality standardsfor RM. 18 Two standards ratified by the RCP are:1 For all patients entering a rehabilitation programme,a set of goals should be established and agreedbetween the team and the patient/family within adefined time from entry.2 For all patients enrolled in a rehabilitationprogramme, at least one agreed outcome measureshould be assessed on admission and discharge fromthe programme.The BSRM has developed a ‘basket’ of approvedoutcome measures, 30 because no single outcomemeasure is appropriate for all types of rehabilitation.The Barthel Index and Functional IndependenceMeasure are widely used. Goal attainment scoring isbeing explored as a patient-centred outcome measure.6 Clinical work of consultants inrehabilitation medicineHow a consultant works in rehabilitation medicineInpatient workJob plans for consultants in RM vary widely; aconsultant working in a post-acute rehabilitation facilitywill have a different emphasis from one working in acommunity setting. Draft model job specifications andjob plans for different settings are available from theBSRM. A typical consultant’s working week includes: Ward rounds: a conventional weekly medical wardround for 20 beds takes about 3 hours. Inpatient MDT meeting: a rehabilitation unit holdsat least one weekly MDT meeting to discuss patientprogress, which takes at least 3 hours. Referral work: 5–10 referrals may be seen per week,which requires 1–2 programmed activities (PAs)(more if offsite travel is required). Interdisciplinary liaison: liaising between members ofthe MDT and between the numerous medical andsurgical specialties involved requires about 2 PAs perweek. Case conferences: 2–3 cases conferences may be heldper week, which last 1–2 hours (1 PA).Outpatient work Outpatient clinics: 2–5 new patients or 4–8follow-up patients may be seen in a session of 1 PA,based on each new patient requiring 45–60 minutes,and each follow-up 30–35 minutes.208 C○ Royal College of Physicians 2013
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AbbreviationsA&EAACsAMUsARCPCCGsCCS
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