Select Committee on Health Minutes of Evidence



  1.1  Severe and complex brain damage has a major impact on family life, education, work and society as well as on the long term resources required from health and social services.

  1.2  The difficulties of providing specialist care for brain injured people are multi-faceted and some will not be overcome in the short term but require long term planning.

  1.3  A fundamental barrier to developing good rehabilitation services is recruitment and retention of appropriate staff, especially consultants in rehabilitation medicine and nurses.

  1.4  There is a gross shortage of rehabilitation beds throughout the country and some financial input to this would have a significant impact on the management of people with brain damage as well as releasing beds on acute units for their more appropriate use.

  1.5  A more flexible approach to referral and funding across districts and across regions is required to take advantage of the limited specialist services that are available.

  1.6  The independent sectors play an important part in specialist rehabilitation services since they have often been the only source of the "super-specialist" skills and facilities. They should be regarded as a close partner with the NHS in planning integrated service pathways.

  1.7  The rarity of many forms of brain damage requiring specialist management creates problems of keeping the referring clinician and commissioning authority informed about availability of services. Consideration should be given to the appointment of a Complex Neuro-disability Co-ordinator to regional health authorities or consortia of Primary Care Trusts to help plan an integrated approach across specialist, district, community health and social services as well as across to vocational and educational facilities for brain damaged people.

  1.8  There is a need for clear central (district, regional and national) information database of specialist services to assist referrers, commissioners and public to know the most appropriate pathway to available services.


  2.1  The Royal Hospital for Neuro-disability is a 280 bed voluntary (charity) hospital set up in 1854 to "care for the incurables discharged from the great hospitals of the land". Over the last thirty years it has taken an innovative approach to the management of people with complex, especially neurological, disabilities and receives referrals from throughout the UK and abroad. Over the past 30 years it has opened: one of the first (if not first) young disabled units in the UK; the first brain injury rehabilitation unit; the only unit specialising in people with the vegetative and minimal conscious states; the first Transitional Living Unit for the community reintegration of people with memory disorders due to brain damage and the first unit in the UK for people with a combination of behavioural and physical disorders due to brain damage. The Hospital has a large research programme, under the direction of Professor Maria Stokes, mainly for studies of brain damage.

  2.2  Dr Keith Andrews is the Director of Medical and Research Services at the Hospital and has taken a specialist interest in profound brain damage, especially the vegetative state.

  He has been chairman or a member of a number of International Working Parties on Vegetative or Minimal Conscious states. Between 1987 and 1994 he was the Editor of the international journal Clinical Rehabilitation and was Hon Secretary (1998-99) and Chairman (1999-2000) of the UK Acquired Brain Injury Forum.

  At present he is chairman of the London Regional Specialist Commissioning Group Neuroscience Review Neuro-rehabilitation Committee (2000-01) and chairman of South West Thames Branch of the British Society of Rehabilitation Medicine.


  3.1  This evidence concerns those people with severe or profound brain damage resulting in complex disabilities which usually require long term management.

  3.2  Such people usually have a mixture of physical, medical, cognitive and behavioural problems which result in life long disabilities requiring considerable resources to support them.

  3.3  The presence of this degree of brain damage has a major impact on family life, education, work and society as well as on the long term resources required from health and social services.


  4.1  Health Authorities rarely have data on levels of disability resulting from brain damage and therefore the true extent of the problems of brain damage is unknown. It is therefore difficult to plan services without adequate information about the number of patients with specific forms and levels of brain damage.

  4.2  The annual incidence [new case a year] of severe brain injury is thought to be about 8/100,000 of the population.

  4.3  The prevalence [total cases at any one time] of severe brain injury is about 100-150/100,000 population.

  4.4  Table 1 shows the number of patients with various forms of brain damage likely to be seen by an individual General Practitioner and by a Primary Care Trust

Table 1

Disabilities due to Acquired Brain Injury related to General Practice[9]
Incidence—all Prevalance—allPrevalence—Disabling
1 DisorderGP (2,500)PCG/T (125,000) GP (2,500)PCG/T (125,000) GP (2,500)PCG/T (125,000)
Stroke5250 12\56258 400
Subarachnoid haemorrhage0.27 14?? ??
Head injury7350 4.5 225
Moderate brain injury[10] 0.4522.5
Severe brain injury0.2 103 156
Vegetative/Minimal conscious states[11] 0.021.1 0.157.5
Bacterial meningitis0.24 12??
Viral meningitis encephalitis0.5 23

  4.5  Table 1 shows that individual General Practitioners will rarely see a patient with severe disability due to acquired brain injury—on average one every five years—and possibly never see a patient with the Vegetative State or one with behavioural problems.

  4.6  Even a Primary Care Trust will see very few new patients each year with severe brain damage, subarachnoid haemorrhage, vegetative states, or meningitis which will require a complex integrated programme. Therefore, the ability to develop expertise in the commissioning of sevices for this group is extremely limited.

  4.7  20-25 per cent of those 16-45 years of age with brain damage remain severely or profoundly disabled at six months following their injury.


  5.1  In a recent survey of commissioners of neuro-rehabilitation services in the London region the problems identified by the commissioners for brain injury services were as follows:

    —  Lack of centres/units with expertise in complex forms of brain damage. Increasingly long waiting lists for admission to those specialist centres that are available.

    —  Difficulties getting brain injured people into specialist rehabilitation results in inappropriate use of general medical, surgical or orthopaedic places thus affecting the waiting list for patients for which the units do have skills.

    —  Poor discharge arrangements and lack of "move on" facilities delay discharge.

    —  Community services are either lacking or are isolated from the mainstream brain injury services making them less effective.

    —  Lack of agreement for funding for patients to specialist centres, especially when in the independent sector.

    —  Lack of priorities or understanding by Local Authorities of severe brain damage.

    —  Difficulty of obtaining Local Authority funding for people with brain damage.


  6.1  In a survey of user groups the following concerns about brain injury services were raised:

    —  Difficulty in gaining access to specialist services.

    —  Particular difficulties in getting services for people with behavioural disorders.

    —  Poor community follow up and community services.

    —  Anything which requires long-term management difficult to access.

    —  Lacking vocational support.

    —  Lack of long-term support for families.

    —  Lack of counselling.


  7.1  Available rehabilitation services respond to those patients who are the largest number (eg stroke patients,) and who have the potential for relatively rapid recovery. This is important if beds are to be used for the greater good of the largest number of patients. This inevitably means that those patients with a slower rate of recovery are given lower priority than those with the greatest potential for a speedy recovery.

  7.2  Whilst it seems a sensible approach to the use of scarce resources it neglects the fact that people with very complex and slow to recover problems are still present and have needs which are likely to require long term support. This has the implication that those with the greatest long-term costs to health and social services (as well as [uncosted] effects on families and society) take second place to those with more rapidly responding conditions [and therefore lower costs] to society.

8.  BEDS

  8.1  There is at present a gross shortage of rehabilitation beds in the UK. Appendix 1 shows the level of provision by region, country and UK. It demonstrates that throughout the UK there is, overall, only about half the recommended number of rehabilitation beds available for patient treatment.

  8.2  There are very few units for complex neurological disabilities in the UK and much of these specialist services are provided in national centres run by the independent (private and voluntary) sector [see below].

  8.3  District and Specialist provision cannot be discussed separately since specialist rehabilitation beds are often occupied because of a shortage of district services. In some cases this is because patients whose needs are not specialist are referred to specialist centres because of lack of local district services. On the other hand there are many people with specialist needs managed in district services because there is no easy access to the available specialist centres.

  8.4  Similar problems occur for the acute services which are unable to transfer patients requiring rehabilitation to either district or specialist rehabilitation units because of the lack of services. Not only do patients then not receive optimal management but other patients who then benefit from the specialist neuroscience or acute services are denied them since the bed is occupied.

  8.5  The Royal College of Surgeons Report on the Management of People with Head Injuries[12] states "There currently are insufficient resources for rehabilitation and additional services are required. . . It is unacceptable for patients to spend prolonged periods on acute surgical or medical wards awaiting a place at a dedicated rehabilitation unit. . . The expenditure of additional resources on rehabilitation units will make more acute hospital beds available for emergencies and patients on waiting lists."


  9.1  There is also a gross shortage of consultants in rehabilitation in the UK. Appendix 1 shows that throughout the UK there is, overall, less than half the recommended number of consultants in rehabilitation required to provide district rehabilitation services.

  9.2  This shortage of Consultants in Rehabilitation Medicine is not primarily a problem of funding. Rehabilitation has not yet developed the kudos and recognition of other specialties. It therefore has a recruitment problem—many funded Specialist Registrar posts in rehabilitation medicine are unfilled and therefore the recruitment base for vacant consultant posts is very limited.

  9.3.  Whilst the responsibility for building rehabilitation medicine as a respectable and attractive speciality lies very much with the professionals, rehabilitation needs to have a higher priority in the medical undergraduate curriculum. This has implications for universities to develop more academic units of rehabilitation.

  9.4  There is also a well-recognised shortage of nurses in the UK. Evidence from a survey of London rehabilitation units show vacancies of established nursing post in rehabilitation to be about 19 per cent—a very similar figure for nurse vacancies in neurosciences in general.

  9.5  The reasons for the shortage of nurses in rehabilitation medicine are well rehearsed but there is no doubt, in our opinion, that the State Enrolled Nurse had an important contribution to the management of disabled people. We feel strongly that serious consideration should be given to an additional and shorter nurse-training programme for qualified nurses being reinstated which does not require the high academic standards of present admission to nursing training but produces high quality practical nurses.

  9.6  Disability Nursing is not recognised as a nursing specialty in its own right. The importance of nurses trained in disability nursing cannot be overemphasised. Until recently, the only course on neurological disability management was in the voluntary sector (Royal Hospital for Neuro-disability). The Royal College of Nursing should take the lead in developing Rehabilitation Nursing as an important special training requirement.

  9.7  In addition there is a shortage in all rehabilitation disciplines such as physiotherapy, occupational therapy, speech therapy and clinical psychology. In a recent survey of 10 rehabilitation units in the London region only one had a (part-time) music therapist, one had biomedical engineering services, five had (all part-time) dieticians and seven had a social worker.

  9.8  These figures suggest that the major problem in developing services for people with brain damage is not necessarily a shortage of financial resources but one of people resources. Whilst an increase in financial resources to increase bed provision and staffing is definitely required this would have limited impact unless attention is paid to recruitment, training and retention of staff.


  10.1  Patients with severe brain damage need different services at the various stages in their management.

  10.2  In the acute phase they need access to specialist services for diagnosis, assessment and treatment of their medical and surgical needs, and rehabilitation during the period of "recovery". Access to acute services is generally good. Access to rehabilitation is more difficult because of the lack of general and specialist rehabilitation centres.

  10.3  Those remaining "moderately" disabled need access to a wide range of services including ongoing specialist assessment, social services, community services and, for some, education and vocational services. This complex process requires a well-planned integration of services which is often lacking.

  10.4  Those who have complex and severe disabilities which are likely to create long term disabilities require early management by a specialist rehabilitation team to prevent unnecessary complications and a disability management programme which will make long term care easier and requiring fewer long term resources. Access and funding for provision of technology is required, as well as skilled long term care in the community or in a nursing home.

  10.5  Since many of these patients will also have cognitive and behavioural problems access to expert neuropsychological assessment and management is an important aspect. Unfortunately there are few services available for this group of people and much of this service is provided by the independent sector.

  10.6  There are two conflicting requirements. Ideally patients should be treated as locally as possible whilst having access to the best skills available. On the other hand it is recognised that there is a wide variation in the availability of specialist services—the so-called "post-code" provision of services.

  10.7  Because contracts are made with specific Health Trusts for the overall provision of services those with complex problems are expected to be fitted into local services rather than treated in the most appropriate specialist unit. Thus patients are treated because of contractual arrangements rather than by need.

  10.8  In the short term human resource practicalities will prevent purely local provision of specialist services. We argue that it is more logical for patients with rare and complex problems to be treated in the most appropriate unit for their needs. Therefore, there should be greater flexibility in the commissioning of services across present contractual boundaries taking advantage of the skills and facilities available in both the NHS and the independent sectors.

  10.9  One of the problems is the many health authorities and social service departments do not have clear policies on the management of people with severe forms of brain damage and therefore local placement managers are often uncertain of the appropriate action to take.


  11.1  The skills required to treat people with complex brain injury are difficult to develop locally because staff see so few patients due to the limited number of patients available in a district service for treatment. This has been well demonstrated by research at the Royal Hospital for Neuro-disability[13] which showed that 40 per cent of those patients referred as being in the vegetative state (ie totally unconscious) were aware to some degree. This included one man who had been misdiagnosed as being in the vegetative state for seven years who was able to "dictate" a letter to his wife—two weeks after assessment in a specialist centre.

  11.2  It is well recognised that people who have rare conditions are better treated by clinicians who have taken a special interest in the problems and have seen a considerable number of similar patients previously. It is, therefore, our opinion that people with specialist needs following brain damage should be treated in the most appropriate skilled facility, whether this is in the NHS or the independent sector.


  12.1  Some units for brain injured people are beginning to be developed in the NHS but these are rarely able to take those with more complex needs because of the pressure on beds and need for a high turnover. Most of the specialist units usually have a national catchment area and arein the independent sector eg The Royal Hospital for Neuro-disability in Putney for severe head injury, vegetative state, locked-in syndrome, behaviour disorders in combination with physical disabilities Huntington's disease and late stage multiple sclerosis; the Kemsley Unit and Grafton Manor, both in Northampton, and Ticehurst Hospital in Sussex for behaviour disorders; and Tadworth Court in Surrey for brain damaged children.

  12.2  Whilst there is a need to develop more specialist services for brain injured people within the NHS to meet local (regional needs) there will be some conditions which are rare enough to require national or multi-regional provision (eg the vegetative state and brain stem syndromes) or require specialist skills (such as behavioural management). These are areas where services are already developed in the independent sectors because of their greater flexibility for national provision and ability to be focused on specific problems rather than having to run a more general service to meet the local (district or regional) needs. We argue that these services should be recognised as part of the overall provision of the NHS when planning integrated care pathways.

  12.3  Specialist services have the advantage of developing a high level of skills and expertise, carrying out research, improving training (for both their own staff and others) and provide a cost-effective use of specialist equipment and skills as well as being a source of information and advice for other units.


  13.1  Whilst it is the aim of most rehabilitation programmes to care for people at home there are few resources available to provide the necessary support. Patients admitted to Nursing Homes generally receive good nursing care but there is usually a lack of supportive therapy and psychology services. Part of this is the lack of financial resources and lack of expertise but is also partly due to the lack of agreement about the source of funding between health and social service departments.

  13.2  There is also a lack of community rehabilitation service, especially for those with complex needs, in particular those with cognitive and behavioural problems. This requires a broad based and integrated service. The Hub and Spoke or network approach (see below) may have an important contribution to make to this problem.


  14.1  The Joint Working Party of the Association of British Neurologists (ABN) and the British Society for Rehabilitation (BRSM)[14] on Neurological Rehabilitation in the United Kingdom expressed concern that "there are considerable numbers of neurologically disabled people in the community and the majority of these have inadequate health provision." It goes on to point out that "most people with a neurological disability are not able to see a consultant neurologist on a regular basis" and that "...10% of the most severely disabled population will have no contact at all with any health professional."

  14.2  In recognising the complexity of service provision and the general lack of information about available services we propose that each district/PCT (or group of districts/PCTs) has a Co-ordinator for Complex Neuro-disability who will take on the role of identifying the appropriate service and co-ordinate the process of gaining access to services and for the follow on services after discharge. We see advantages in the concept of a Co-ordinator who can be called on by the general practitioner or acute services to help plan an integrated care pathway from the acute onset through rehabilitation to community care.

  14.3  The Hub and Spoke, or networking, concept is a model of close co-operation between specialist rehabilitation services, district rehabilitation services and community services with each making their own special contribution to the total care of the patient. The Specialist service provides special skills, techniques, equipment and facilities as well as a base for staff support, training and research. Close working links are maintained with outlying parts of the service, eg shared or rotating staff. Specialist peripatetic community teams may keep their base in the hub unit, and travel out to patients in the community, or receive them for day-care in the main unit as required. This concept needs further development within the NHS to make more cost-effective use of scarce resources.


  15.1  Funding of specialist neuro-rehabilitation services is a complex issue. Many of the conditions discussed above are rare yet their management is at a high cost because of the complexity of the disorders. This creates several problems for commissioning by the Primary Care Trusts:

    15.1a  Individual GPs are unlikely to develop skills or have a knowledge base to know where to commission services.

    15.1b  The high cost of these disorders will put a great strain on PCT funding if there is even a slight increase in numbers of patients over the budget set aside for such cases. For instance a road traffic accident could easily result in four people severely brain damaged out of the annual average of 10 across a PCT—each giving an annual cost of about £100,000-£160,000 to the GP budget during the acute phase. Even a long term patient with complex neurological disabilities can cost £35,000-£60,000 a year and live for several decades. The larger the PCG/T the more likely these costs will be able to be absorbed but overall the unpredictable and high cost nature of complex disability makes budget planning difficult.

  15.2  It is therefore suggested that consideration be given to regional or sub-regional (multi-PCT consortia) funding for the acute and rehabilitation phases of conditions producing complex neuro-disability to even out the cost across the PCTs.

  15.3  It is important that the GP has responsibility for the management of the patient and therefore needs to be fully involved in the decision making programme but this has to be balanced by access to information for appropriate commissioning and protecting individual PCTs financially from disproportionate fluctuations in the number of people with these rare but costly conditions.

  15.4  One common complaint is the difficulty in getting agreement between health and social service departments as to funding responsibility. There are many anomalies eg three patients in the same nursing home with the same level of disability receiving different levels of funding: one being fully funded by the Health Authority for all care, another receiving joint funding between the health and social services department and the third being funded fully by social services department and being means tested. There are widespread variation in interpretation of the rules and decision criteria. There is at least one Health Authority/Social Service area which will not consider joint funding. This lack of clarity results in some patients not receiving optimal care.

  15.5  Another area of concern is the unwillingness of some Health Authorities to accept responsibility for the provision of communication and other technological aids. Thus funding often has to be found from charities and other funds. Some system similar to the budget provision for environmental controls needs to be set up to ensure that these essential aids to function and quality of life are available from public funds.


  16.1  One difficulty experienced by referrers and commissioners is in finding information about available services—especialy for the more complex problems which are not available locally. This is likely to be of continuing importance as commissioning of services becomes the responsibility of PCTs. Wherever the responsibility for commissioning of specialist services lies it will be important that there is a central up to date database of available services, waiting times and admission criteria covering both the NHS and the independent sector.

  16.2  It would also be useful to have centrally planned (district or regional depending on problem) clinical care pathways identifying approved providers, locally, regionally and nationally in both NHS and independent sectors, to assist in decision making.


  17.1  The independent (private and voluntary) sectors have been major providers and innovator of services for people with brain damage. For example, the only specialist unit for people with profound brain damage (vegetative state, minimal conscious state and locked-in syndrome) is in the voluntary sector (Royal Hospital for Neuro-disability). The major units for the management of people with behavioural disorders are in the independent sector (especially Kemsley Unit at St Andrew's Hospital Northampton; Grafton Manor, Grafton Regis; Royal Hospital for Neuro-disability, Putney; Ticehurst Rehabilitation Unit, East Sussex); as are those for people with cognitive impairment (Brain Injury Rehabilitation Trust and Royal Hospital for Neuro-disability, Putney). These centres have been in the forefront of innovative management and accepted patients from throughout the UK and abroad.

  17.2  Most of the services provided by the independent sector is for rare conditions requiring a national or super-regional service. In addition, much of the service is provided by voluntary hospitals, such as the Royal Hospital for Neuro-disability and the Kemsley Unit, which raise considerable sums of money from charitable donations to develop the high standards and carry out research.

  17.3  The strength of the independent sector in providing innovative services for people with rare conditions on a national basis needs to be formally recognised and encouraged. Many commissioning agents prefer to use NHS units even when the skills are not available or to refer people with complex disabilities for long term care rather than give access to specialist services because they are in the independent sector.

  17.4  We recommend that the independent sector is integrated into the planning for specialist rehabilitation services of people with complex brain damage.


  18.1  There are many difficulties in carrying out research into complex but chronic neurological disabilities. First the conditions are usually uncommon, if not rare. Secondly this group of patients are scattered around a wide variety of placement: hospitals, nursing homes and at home. These are rarely the centres that carry out research and therefore these cases go largely unreported. Thirdly the measurement tools for outcome of complex interaction of disabilities have not been well developed.

  18.2  A discussion paper from the Centre for Health Economics[15] emphasised the importance of research in rehabilitation to demonstrate its cost-effectiveness. It stated: "In rehabilitation services for patients after disabling events, for instance head injuries and strokes, providers are advocating enhanced funding in a humane and well-intentioned fashion. However, the knowledge is absent to direct that funding to those activities which can benefit patients at least cost."

  18.3  There is therefore little evidence for or against any form of treatment. This is of particular concern since complex neurological disorders produce long term disabilities at considerable cost to society.

  18.4  This is clearly an area of need requiring an academic approach. The specialist centres are likely to be able to provide the volume of patients and be academic orientated organisations and therefore could be the basis for much of the research.

  18.5  Whilst acquired brain injury in general, and complex disabilities in particular, are not included in the priority areas for research, the NHS Research and Development Directorate should recognise that acquired brain injury is the main cause of death in young adults and is the main cause of long term disability in young people. The NHS R&D funding should focus research into a specific number of research centres to carry out research into the management of people with acquired brain damage.


  19.1  The problems of the relative rarity of the condition and the chronic nature of complex disabilities results in patients being placed in a wide variety of care provision including hospitals, nursing homes and at home with family. The lack of expertise needs professional advice and training for the local services. This could be a role of the specialist centres. Good support and training should prevent some of the complications that require specialist services.


  20.1  The problems of brain damage management are a combination of poor provision of services, the broad range of disciplines and specialties involved, the shortage of professional staff, limited financial resources, the rarity of (and therefore knowledge and skills available) complex disabilities and the lack of flexibility with the commissioning services for out of area funding.

  20.2  The solutions need a combination of long term planning (such as in recruitment, training and retention of staff), immediate funding for additional beds at both district and specialist centres, and innovative use of present resources.

  20.3  Much can be achieved by ensuring that information is available about specialist services, not only in the local area but in neighbouring areas or further afield. A Complex Neuro-disability Co-ordinator for a region of consortia of Primary Care Trusts would help to ensure that there is good integration of care from the onset of the brain damage, through the acute, rehabilitation as community services as well as into employment and vocational training.


  21.1  Health Authorities should collect sufficient data on levels of disability, outcome and long-term problems of people with complex disabilities to assist in planning of services and to avoid unnecessary long-term complications developing. [4.1]

  21.2  Health Authorities should have clear policies and procedures for the management of people with complex brain damage. This should include clear pathways of service provision and identification of approved providers for each stage and type of brain damage. [10.9, 14.3]

  21.3  Health Authorities should have information about the available services to enable them to set clear pathways of care as well as nominated approved providers (both NHS and independent sectors) available to referrers, commissioners and the general public. [16.1, 16.2]

  21.4  There should be clearly agreed and documented guidelines on responsibility for of care and funding between health, social services and, where appropriate, educational services or vocational services for the management of people with long-term complex brain damage. [10.9, 15.4]

  21.5  Access to specialist services should not be dependent on where the patient lives. This will require greater flexibility in commissioning services out of area and across commissioning authority lines. It will also require a greater acceptance of the independent sector as part of the total package of available services and be included in regional planning of services. [8.2, 10.8, 12.2]

  21.6  In view of the rarity and specialist nature of complex disability the commissioning of services should be the responsibility of a regional or subregional authority. This will require appropriate transfer of funds. [15.2]

  21.7  A Complex Neuro-disability Co-ordinator should be appointed by health authorities or consortia of Primary Care Trusts to help plan an integrated care pathway from the time of admission, through the acute services, into rehabilitation and eventually to care in the community, education and vocation. They would also work across health and social services to help plan and co-ordinate the services for people with complex disabilities. This will particularly be of value to those patients with cognitive or behavioural problems who often fall through the net. [14.2]

  21.8  There is a need for more specialist expertise at regional levels with access to these centres from a wider catchment area depending on the special interests and skills of the regional centre. [10.2-10.5, 11.1, 11.2, 12.2, 12.3]

  21.9  The specialist rehabilitation facilities of the independent sectors should be accepted as part of the national framework of service provision and included as approved providers for planning purposes and in integrated care pathways. Most of the independent sector (many voluntary) specialist brain injury services provide a national service and have developed skills in the very narrow but difficult to manage area of brain damage management. Advantage should be taken of these skills and facilities by including the specialist units in the independent sectors in the planning provision and integrated service pathways for brain injury. [11.2, 12.1, 12.2, 17.1-17.3]

  21.10  People with complex disabilities due to brain damage inevitably have chronic problems which will require long term management in the community. Resources are needed to support these people in the community, with regular assessments and the necessary interventions to prevent deterioration or provide ongoing support especially those with cognitive or behavioural problems. [13.1, 13.2]

  21.11  There needs to be an increase in district rehabilitation beds to provide more rapid access to rehabilitation for people with brain injury and to prevent unnecessary occupation of acute and specialist rehabilitation beds which can be more appropriately used for other people on waiting lists. [8.1, 8.3, 8.5]

  21.12  Rehabilitation medicine should be more widely taught in medical schools. This will encourage a wider understanding of the potential of rehabilitation in the management of all disabled people and therefore change attitudes. It will also encourage a small but vital number of doctors to take up rehabilitation as a specialty thus overcoming the gross shortage of consultants in rehabilitation. These will require an increase in academic posts within medical schools. [9.2, 9.3]

  21.13  The Royal College of Nursing should develop rehabilitation nursing to encourage a broader interest in caring for disabled people and to develop higher multidisciplinary skills. [9.6]

  21.14  Consideration should be given to re-introducing the equivalent of the State Enrolled Nurse. These nurses, whilst not having the higher academic skills to enter State Registered Nurse training provided a good level of practical nursing care. [9.5]

  21.15  Funding for technological aids, such as communication aids and computers, should be a formal part of the NHS funded provision rather than having to depend, in many cases, on charitable funding. [15.5]

  21.16  It is recommended that there is a nationally based R & D policy on research and development into complex disabilities to develop evidence based practice for the effective management of patients and the planning of services. [18.1-18.5]

  21.17  That a mechanism is set in place for the training, advice and support of staff caring for people with complex disabilities in their local communities. [19.1]

Dr Keith Andrews MD FRCP
Director of Medical and Research Services


Provision of beds and consultants in rehabilitation medicine throughout the UK[16]
RegionWTE Cons Posts per M pop*
(% of recommended)
All Beds per M pop* (% of recommended)
Northern1.9 (47.5%) 18.7 (31.2%)
North West1.6 (40.0%) 28.6 (47.7%)
Mersey1.2 (30.0%)15.2 (25.3%)
Trent1.9 (47.5%)32.5 (54.2%)
Anglia1.7 (42.5%)37.3 (62.2%)
West Midlands2.2 (55.0%) 16.8 (2.0%)
Wessex2.2 (55.0%)31.6 (52.7%)
South West1.5 (37.5%) 34.5 (57.5%)
NE Thames0.9 (22.5%) 26.6 (44.3%)
NW Thames2.3 (57.5%) 14.0 (23.3%)
SE Thames1.4 (35.0%) 19.8 (33.0%)
SW Thames1.7 (42.5%) 34.7 (57.8%)
Oxford2.5 (62.5%)39.2 (65.3%)
Yorkshire1.6 (40.0%) 27.0 (45.0%)
England1.8 (45%)26.9 (44.8%)
Scotland2.9 (72.5%) 50.0 (83.3%)
Wales0.8 (20.0%)29.3 (48.8%)
N. Ireland1.2 (30.0%) 15.0 (25.0%)
UK1.7 (42.5%)30.3 (50.5%)

9   Royal College of Physicians, Physical Disability in 1986 and Beyond. A Report of the Royal College of Physicians. J Royal College of Physcians of London 1986; vol 20; July 1986. Back

10   Medical Disability Society. Working Party Report of the Medical Disablity Society on the Management of Traumatic Brain Damage. 1988. Back

11   Royal Hospital for Neuro-disability. International Working Party Report on the Vegetative State. 1996. Back

12   Royal College of Surgeons of England. Report of the Working Party on the Management of Patients with Head Injuries. June 1999. Back

13   Andrews K, Murphy, Munday R, Littlewood C. Misdiagnosis of the vegetative state: retrospective study in a rehabilitation unit. British Medical Journal 1996; 313: 13-6. Back

14   Association of British Neurologists and the British Society for Rehabilitation. Neurological Rehabilitation in the United Kingdom. 1992. Back

15   McKenna M, Maynard A, Wright K. Is rehabilitation cost effective? Centre for Health Economics Health Economics Consortium, University of York, Discussion Paper 101, 1992. Back

16   Based on survey by British Society of Rehabilitation Medicine 2000. Back

previous page contents next page

House of Commons home page Parliament home page House of Lords home page search page enquiries index

© Parliamentary copyright 2001
Prepared 3 April 2001