What could be done for the nation?
From the outset, the Government stated that it wished to take advantage of the opportunity that creating a 21st century version of the Defence Medical Rehabilitation Centre at Headley Court (HC) in Surrey represents, to do something for the nation as well. Ministerial support from across Government has consistently been given on the understanding that the project must encompass both a Defence establishment (the ‘D’) and a national facility (the ‘N’).
The creation of the D affords a unique opportunity to co-locate the D and the N jointly to develop an evidence-based, best practice approach to rehabilitation, underpinned by research, to benefit military, veteran and civilian patients.
"If we can transfer the knowledge, it’s only for the benefit of the country as a whole." The Surgeon General talks about the opportunities for the nation arising from the creation of the DNRC.
Expertise in Defence
Over the last 10-15 years, advances in the specialist care of severe and complex casualties made by Defence Medical Services (DMS) have resulted in many more people surviving their injuries who would have died even a few years ago. In the process, a tremendous amount has been learned about best practice in trauma care and this in turn has enabled significant results to be achieved in the field of rehabilitation through a comprehensive and occupationally/operationally focussed approach.
The contrast in care for civilians
Dean Fathers, Chair Nottinghamshire Healthcare NHS Foundation Trust talks about the benefits of a National facility.
With 85% returning to military duties, the Defence performance far outstrips that for civilians, where return to work rates have been as low as 1 in 6, or 17%. This also lags behind many other countries, with Scandinavia returning 50% of people to work after a major injury, and the USA roughly 30%.
The results from a recent pilot study in the East Midlands carried out by the Trauma Audit and Research Network (a research foundation) included the following:
|Change in ability to work at 6 month after injury
|Still able to do the same work
|Still do the same work, but have some problems
|Still work but at a reduced level
|Unable to work, or only able to work in limited capacity
March 2016 TARN PROMS pilot study
Patient Reported Outcome Measures at 6 months:
- 40% of people still experience mobility problems
- 24% of people still have difficulties with self-care
- 60% of people have problems with usual activities
The NHS East Midlands Major Trauma Centre reports that patients who require rehabilitation in-patient services experience can wait times as illustrated below for the neurological pathway.
The clinical consequences of this are that patients are not participating in rehabilitation at the optimal time in their recovery. This will have long term effects on outcomes relating to health, long term functional outcomes, mental health, return to work and social exclusion.
Why is a national rehabilitation facility needed?
Rehabilitation is an integral part of healthcare, providing people with a better quality of life. Major categories of people needing, but frequently unable to access, specialist rehabilitation include those who have suffered combat injury, accidents, strokes, severe burns or progressive neurological disease. To address these needs, fully integrated, end-to-end care pathways are required. A national specialist rehabilitation centre would be a key part of these new pathways.
The Written Ministerial Statement in October 2011 stated that:
‘It (a DNRC) presents a once in a lifetime opportunity to develop the nation’s rehabilitation capability in partnership with the MOD, which builds on Defence’s acknowledged lead in this area… A combination of Defence and civilian medicine, university-led research and development, and national disabled sporting facilities in one location could provide a combination unique in the world.’
What might the national elements be?
Extensive consultations have taken place across a wide range of interested parties about the component parts that a national facility (the ‘N’) might contain and, whilst this is still subject to further definition, these might include:
"We’ll be able to spread expertise – it will go out." Dame Carol Black, Expert Advisor to the Department of Health and the author of the influential 2008 report ‘Working for a Healthier Tomorrow’, discusses her vision for how a National facility should operate.
- An opportunity for a national programme of research and development in the field of clinical rehabilitation
- A national centre for training and education in specialist rehabilitation for clinicians and allied health professionals, to enable the expertise that will exist at the DNRC to be transferred to other centres across the country
- A regional clinical facility offering specialist rehabilitation to the general population in the Midlands
Potential economic benefits for the nation
From the outset it has been considered that significant economic benefit to the nation might be realizable through the co-location of Defence and National facilities. In her 2008 report Working for a Healthier Tomorrow, Dame Carol Black noted that the cost to the taxpayer of lost working days was estimated in 2006 to be £60bn. It is now even higher.
The specific cost to the nation of disabled people unable to work due to lack of access to rehabilitation (including the cost of their carers who are also unable to work due to the level of commitment required), has not been calculated in detail. However, the scale of the costs identified in Working for a Healthier Tomorrow suggests that there can be little doubt that this is considerable, even allowing for the fact that the majority of the calculated total cost arises from common disorders which should be compatible with work.
The British Society of Rehabilitation Medicine (BSRM) has summarised the economic benefits of rehabilitation medicine under 4 headings:
- Preventing costly complications and avoiding hospital readmissions
- Reducing the duration of hospital admissions
- Reducing costs of long term care
- Helping disabled people return to the workforce
The wider economic case associated with the final point extends beyond the realm of health however, and into the realms of welfare, taxation revenue and social care in local government. It should be possible to reduce the burden on the State through reduced benefit, health and social care expenditure; to employers through reduced absence, turnover and improved productivity; and to the wider economy and there is therefore a prima facie economic case for investment in rehabilitation.
"There are enormous wider benefits." Dame Carol Black, Expert Advisor to the Department of Health and the author of the influential 2008 report ‘Working for a Healthier Tomorrow’, reflects on the wider benefits to government, to the economy and to society as a whole that the creation of the National facility will bring.
There are strong conceptual arguments for linking the N and the D. These 2 elements would be mutually reinforcing which would lead to the creation of significant public benefit – set out in the table below:
||An important clinical benefit for co-location with the D is the impact on N patients of being able to experience the high levels of motivation, drive and energy in D patients. Sharing some of the facilities and seeing the powerful belief amongst D patients that they will get better, will act as a powerful incentive to N patients to dispel any sense of hopelessness and see their own recovery in the same way as the D patients do.
|Access to specialist facilities
||Patients in the N would benefit from access to facilities and equipment in the D which are not available at local centres.
||Establishing the D and the N on the same site could lead in time to the N becoming both a regional and a national beacon of excellence, developing ground breaking interventions and using the latest developments in science and technology which could be replicated at regional centres elsewhere in the UK. Through this hub and spoke model, with the N as the hub driving the spokes, the public benefit in terms of returning people to or keeping them in work could be multiplied and will be substantial.
||In addition to acting as a beacon of excellence in rehabilitation medicine, a DNRC would act as an education centre of excellence to which people from across the UK (and overseas) would come to train.
||There is a powerful case for clinical staff from the N and the D to undertake staff exchanges and joint training to maintain skills, particularly where this is a requirement of their professional bodies. They would need to be able to do this whilst maintaining adequate staffing levels at a DNRC and by far the most efficient way of doing this is to locate the N and the D on the same site. N facilities would benefit from access to the skills of clinicians in the D, when not on deployed operations and exercise, to meet NHS requirements. Similarly, staff in the D would be able to maintain their skills through exchanges with the N and through access to the civilian complex trauma patient base at times when military severe injury cases are lower.
|Sports & exercise medicine
||Early liaison between the DNRC Programme and Loughborough University has shown that considerable opportunities exist for collaboration between the D, the N and the University in the field of sports and exercise medicine. The University provides sports and exercise medicine programmes that are recognized as outstanding nationally and internationally and the creation of the Nation Centre for Sports and Exercise Medicine at Loughborough will significantly enhance this reputation.
||The remarkable achievements of the Royal Centre for Defence Medicine and Headley Court mean that many people are now surviving complex trauma injuries who would previously have died, even a few years ago. As they are predominantly young people however, and face a lifetime of care and the use of prosthetics to an extent not previously seen.
The effects of prosthetics use by multiple amputees, over 20, 30 or 40 years, has never been studied and it is widely recognized that there has been little research in the fields of complex trauma and vocational rehabilitation in the UK in recent years.
Co-location of the N with the D therefore provides a unique opportunity. A sufficiently large pool of people and data will be created to allow statistically valid research and clinical trials to be undertaken which should enable the research funding required to be secured.
||Use by the NHS of surplus spare capacity in the D, if it arises, can be used to significant mutual advantage and will provide a level of resilience for the D.
Having available the combined capacity of the N and the D will put the nation on a far better footing than currently to respond to a national emergency such as a major terrorist incident.
The first step (Stage 1) was to develop a Strategic Outline Case relating to clinical need across the NHS in the East Midlands which has been completed and sets out the potential benefits, and affordability, of a rationalization of clinical rehabilitation services in that region, incorporating a new build on the Stanford Hall estate (about 65 beds; 15 of them new and the rest transferred) which would share expertise and facilities with the D to mutual advantage.
This Stage 1 work has now led to Stage 2 which is an independent study to see if what holds good in the East Midlands can apply across NHS England, whilst also assessing the full range of socio-economic benefits that might accrue from improved clinical rehabilitation in England – not least in terms of getting people back to work.