Written evidence submitted by Community Rehabilitation Alliance
About the Community Rehabilitation Alliance
The Community Rehabilitation Alliance (CRA) is made up of over 50 national charities and professional bodies across health and social care, for Allied Health Professions (AHPs), social care providers, fitness professionals, geriatricians, rehabilitation doctors and nurses. The CRA is co-chaired this quarter by founding member The Chartered Society of Physiotherapy and the British Heart Foundation. The CRA members share a commitment to expanding access to rehabilitation to all those who need it and driving quality improvements to meet people’s needs equitably.
We believe that the drive for improvement and innovation that has produced medical breakthroughs now needs to be applied to recovery and rehabilitation services across health and social care. This is essential to preventing demand on the most expensive parts of the health and care system, reducing the unfair inequities in health, and enabling people not only to survive, but live well and active lives.
To support necessary improvements and consistency of community rehabilitation we have co-designed multi-professional best practice standards for community rehabilitation in whatever sector or setting it is provided. This is underpinned by principles of inclusivity and equity, personalisation, empowering self-management and incorporating psychological support. Integrated audit tools enable the standards to be monitored and reported on. (1)
The Community Rehabilitation Alliance supports the transformation of rehabilitation services, with greater integration of rehabilitation provision between health and social care and between different medical condition pathways. We also advocate for more hospital-based outpatient services to be delivered in the community and made easier to access, and for greater partnership working between health and care services and local authorities for the greater utilisation of community-based venues including gyms and fitness centres to promote exercise participation in older adults and support rehabilitation for those living with long-term health conditions.
Our four key recommendations for Integrated Care System (ICS) development
1.1. The evidence of treatment outcomes for people with frailty, musculoskeletal, cardiovascular, respiratory, and neurological conditions, cancer, spinal injury, brain injury, and many more conditions, as well as patients who have been in intensive care, shows irrefutably that rehabilitation is as essential to good health outcomes as medicines and surgery. (2)
1.2 Yet what should be an unmissable part of treatment is inconsistently provided often too late or not at all. Significant money is invested in survival yet the benefits of this aren’t realised because of the lack of rehabilitation and support with recovery. This is a wasted opportunity on an individual level and from the tax-payer’s perspective. The gaps in rehabilitation are particularly stark outside of acute hospitals, where there is the greatest need. This need has increased sharply with the impact of the Covid pandemic, with high numbers of people with long term conditions experiencing declining health and community services in many areas still in disarray. (2)
1.3 The NHS Long Term Plan (3) made significant commitments to improving rehabilitation showing increased awareness of the importance of rehabilitation in enabling people to live well for longer and reducing demand on the most overburdened and costly parts of NHS and social care. The creation in 2021/22 of a National Director of Rehabilitation and Discharge in NHS England has also been a significant step forward. It is becoming understood at a national level that driving improvements to rehabilitation provision requires system change and cannot managed sector by sector, profession by profession or by single condition pathways. This is also recognised as a global issue by the World Health Organisation’s Rehabilitation 2030 initiative launched in 2017.(4)
1.4 The development of ICSs makes the necessary modernisation of rehabilitation across sectors a possibility. However, with a few exceptions, our experience is that this is not yet being followed through by integrated care systems in England.
1.5 For decades, rehabilitation services have been fragmented and poorly networked, developed in a piecemeal way. This can make it hard for service users to navigate and for clinicians making referrals to services. GPs and hospital doctors are often unfamiliar with what rehabilitation is, what it can achieve and the evidence supporting this. As a result, they often do not communicate its importance to their patients.
1.6 As the Government’s integration white paper (5) describes, one driver for integration is to meet population needs, and the increasing numbers of people with multiple long-term conditions. Almost everyone who has a stroke and 70% of people living with and beyond cancer has at least one other long-term physical condition; over a third of people with chronic obstructive pulmonary disease also have osteoporosis; a third of people with heart disease also have arthritis and joint pain. (6) People with long-term physical conditions are two to three times more likely to experience mental health problems than the general population. (7) There are well established relationships documented between stress, anxiety, depression, increased risks of cardiovascular disease (CVD) and disease progression. (8) People with COPD are twice as likely to suffer from depression. (6) 90% of stroke survivors experience a level of cognitive deficits that fuel post-stroke disability and 75% experience at least one mental health problem post-stroke. (9)
1.7 Rehabilitation is essential, and if timely, can prevent conditions from deteriorating and other conditions from developing. But as well as being provided too late (if at all) it is currently siloed, designed within single condition medical pathways. This is inefficient and results in a confusing system. This is ultimately bad for patients who need personalised, holistic, biopsychosocial care that is easy to access. It results in rehabilitation located in hospital department out-patients when it doesn’t need to be and inconsistency in what a ‘good’ level of provision and quality looks like, or even how services are described. This makes it harder for patients and/or carers to know what to ask for or expect. This situation both reduces the likelihood of their referring, and reduces the quality of their referrals, which results in poor take-up rates.
1.8 A current focus for the NHS is to speed up the hospital discharge process (discharge to assess policies) and rapid response to prevent admissions (urgent community response) to reduce pressure on hospital beds. We support these policies in principle. But they are not working – specifically they are not reducing the overall length of hospital stays and the associated harm and costs that go with this - because people’s rehabilitation needs are not being met in the community in a timely way, if at all. In many cases limited rehabilitation provision has become even more limited as the same overstretched teams are also implementing the new policies with the same numbers of staff.
1.9 The fact that millions of people miss out on the rehabilitation that they should be receiving is not only bad for public health outcomes, but also inefficient and costly – with duplication of rehabilitation on different medical pathways, and service gaps, long waiting times and rationing of provision. This results in higher levels of impairment and deterioration in health. The consequences of this for the public purse are significant, including avoidable increased pressure on the costliest parts of the system.
1.10 We call on the Public Accounts Committee to ensure that the potential gains from integration offered by the formation of Integrated Care Systems are fully realised in the rehabilitation realm, by addressing these challenges.
2. Meeting modern population needs equitably
2.1 Inconsistent access to services that enable rehabilitation and recovery entrenches health inequity. In England the gap between the most deprived and least deprived communities in healthy life expectancy is now 19 years. All ICBs should commit to measurably reducing the gap in healthy life expectancy by 2030 in line with mission 7 of the Levelling Up White Paper. (10) They can only achieve this by modernising rehabilitation provision across sectors.
2.2 43% of people are managing a long-term condition. The likelihood of this is 60% higher for those in the poorest communities than it is for those in the richest, and the poorest have a 30% higher chance that their condition will be more severe. People living in areas of deprivation or from marginalised communities are also more likely to develop multiple conditions, and these are developed at a younger age. For example, people in the most deprived fifth of the population develop multiple long-term conditions 10 years earlier than those in the least deprived fifth. (11, 12)
2.3 The need for rehabilitation is therefore highest among people living in the poorest and/or marginalised communities. At the same time they face the biggest barriers to access rehabilitation, for multiple reasons. For example: they are less likely to be able to fill the gaps in rehabilitation provision in the NHS and social care by paying for services privately; they can face discrimination or be offered unsuitable services; they are more likely to be of working age but less likely to be in jobs that enable them to take time off for appointments; and they are more likely to have a problem with transport to get to appointments.(2)
2.4 Whether or not an individual is supported through rehabilitation affects not only their physical and mental health but also their life chances, earning potential, likelihood of being in work, how active they are in their community, how likely they are to become socially isolated, how happy they are.
2.5 Without rehabilitation people can be stuck in a downward spiral of worsening health, loss of mobility and poor mental health and multiple medication regimes. Ensuring everyone who needs rehabilitation can access it can reverse this downward spiral.
2.6 Health and wellbeing inequity is directly linked to socio-economic inequality. ICBs need to tackle rehabilitation provision as a priority not only to address health inequity, but because it, in turn, will support their local economies. The business case for rehabilitation that actively supports an individual to remain in or return to the workplace is well established. Failing to provide this has a detrimental impact on local economies, with poor health of the workforce having a direct impact on productivity. Poor health accounts for around 30% shortfall in productivity between regions across England (13) and the impact is even greater in ‘left behind’ neighbourhoods that are within all regions. (14)
2.7 For these reasons, we call on ICBs to align their plans to reduce health inequity with plans to improve access to quality rehabilitation and recommend that the Public Accounts Committee includes this in its recommendations as a priority for ICS development.
3. Strategic leadership to drive system improvements and reduce health inequity
3.1 Integrated Care Systems tend to be overly focussed on acute health provision. A cultural change is needed within ICS leadership, with a leaders taken from across the health and care system.
3.2 Rehabilitation sits on the intersections of health and social care sectors, taking place in social care, community, intermediate and acute NHS settings, provided by multiple sectors. It is a litmus test for integrated care systems because driving change can only be done by working across the whole system.
3.3 Because of this, a single named person on ICBs is needed to lead a plan to ensure people have equitable and timely access to services from both the NHS and social care that support rehabilitation and recovery. We also strongly support the commitment for all ICBs to also have an overall accountable lead on health inequality. These roles need to at Director level and be remunerated in parity with other Board members.
3.4 Crucially this leadership is needed to enable a system redesign, in the first instance focussed on reducing length of stay in hospital (releasing acute capacity), reducing demand on long term care and reducing the inequalities in healthy life expectancy.
3.5 Single Accountable Leads for Rehabilitation must be accountable for performance on measures that show the proportions of people requiring rehabilitation being assessed, having a rehabilitation plan, days spent in hospital and demand for long term social care due to lack of rehabilitation on discharge, as well as reporting to targets to reduce the inequality gap in healthy life expectancy.
3.6 Because of the cross-cutting nature of both rehabilitation and health inequity it is critical that accountable leadership is truly collaborative, recognising that the improvement required relies on action within NHS community services, social care, public health (including local authority, voluntary sector and fitness sector partners), as well as the acute and primary care sectors.
3.7 As well as being collaborative, leadership of rehabilitation needs to operate on the principle of subsidiarity to deliver system wide plans. The expansion, integration and redesign of services will need to be happening at Place level and neighbourhood level. This needs to be supported by accountable leadership, strategic planning and performance monitoring at system level.
3.8 To meet these challenges, we recommend that all ICBs be required to appoint Single Accountable Leads for Rehabilitation to be accountable for key metrics relating to rehabilitation provision and reducing the gap in healthy life expectancy. We recommend that the Public Accounts Committee consider this in its recommendations for ICS development.
4. Data driven improvements
4.1 Single Accountable Rehabilitation Leads on ICBs must be accountable for performance on measures that show the proportions of people requiring rehabilitation being assessed, having a rehabilitation plan, equity of access, impact of rehabilitation (or lack of) on days spent in hospital and demand for social care and General Practice. These measures must be incorporated into agreed outcomes, ideally mandated in national outcomes sets.
4.2 This requires data being consistently collected and used to show who is and isn’t accessing rehabilitation services who should be, the impact of this on individuals’ health and wellbeing, including their healthy life expectancy, and demands on other parts of the system, across health and social care.
4.3 The first phase of Covid showed how shockingly poor the data – quantitative and qualitative - was on the needs and experiences of people in the community and in care homes. For too long healthcare data has been overly dominated by data on hospital bed days, admissions, discharge.
4.4. As ICSs develop data strategies, it will be important that they plan in the data infrastructure to enable the efficient collection of data about what is happening to people beyond the entrance and exits to hospitals. This must include meaningful data across systems of the rehabilitation needs, provision and impact of either receiving it or not. It will be important that system level data strategies are consistent to enable national aggregation.
4.5 Included in data strategies needs to be plans for upskilling the workforce in collection and use of data rehabilitation data to drive service improvements and redesign.
4.6 We ask that the Public Accounts Committee addresses this through the current inquiry.
The following organisations endorse this submission to the Public Accounts Committee:
Arthritis Musculoskeletal Alliance
British Association of Sports Rehabilitators
British Geriatric Society
British Psychological Society
British Society of Physical and Rehabilitation Medicine
Chartered Society of Physiotherapy
College of Paramedics
Community Therapists Network
National Care Forum
Primary Care and Neurology Society
Royal College of Occupational Therapists
Royal College of Physicians
Royal College of Speech and Language Therapists
Society of Sports Therapists
Spinal Injury Association
The UK Acquired Injury Forum
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3. NHS England. NHS Long Term Plan. London: NHS England; 2019.
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13. Bambra, Munford, Brown et al. Health for Wealth: building a healthier northern powerhouse for UK productivity. Newcastle: Northern Health Science Agency; 2018.
14. All Party Parliamentary Group: Left Behind Neighbourhoods. Left Behind Neighbourhoods. Overcoming health inequalities in ‘left behind’ neighbourhoods. London: Left Behind Neighbourhoods; 2022.