MEMORANDUM BY THE DEPARTMENT OF HEALTH
HEAD INJURY: REHABILITATION
The Warwick Study of Head Injury Rehabilitation
Acute Care of Head Injured Patients
The Warwick StudyOutcomes
Traumatic Brain Injury Workshop
Welfare to Work
Accident & Emergency Departments
1.1 This memorandum describes current Department
of Health policy on the rehabilitation of head injured patients,
including the outcome of the action research programme detailed
in the Warwick Report. It also briefly sets current policy action
on the acute handling of head injured patients and gives details
of forthcoming developments in neurological service policy which
will affect both acute and rehabilitation for head injured policy.
2.1 More than a million people attend Accident
and Emergency Departments each year with head injuries of varying
severity and around 100,000 need in-patient treatment. However,
with head injury the part of the brain affected can be as important
as the severity of the injury and an apparently minor head injury
can result in major changes to cognitive functioning and personality.
Putting in place systems which will identify all brain injured
people, who may not exhibit life changing symptoms immediately,
is a complex challenge for local services.
2.2 Head injuries can have a major impact
on the life not just of the injured person but also their families.
The Report of the Working Party on the Management of Patients
with Head Injuries (produced by the Royal College of Surgeons
in 1999) shows that 63 per cent of people with moderate head injuries
and 85 per cent of people with severe injuries are still disabled
a year later. Three months after sustaining minor injury, many
people still have headaches and cognitive impairments.
2.3 Head injured patients can expect to
have normal life expectancy following the injury. However, many
patients never fully recover their cognitive functioning and some
are not aware of the changes that have taken place in their personality.
Family life is frequently affected by the changes in personality
that a head injury can produce. Greatly increased irritability
and anger is common. This can lead to relationship breakdown.
Unemployment among people with head injury is high. Head injury
may also induce epileptic seizures and, because it is associated
with road traffic accidents and fights, there may well be other
physical injuries that can result in permanent disability.
3.1 Many more males than females suffer
life changing head injuries. Younger age groups are disproportionately
represented in the head-injured population. An apparent link between
head injury and low socio-economic status is recorded in the literature.
Road traffic accidents and fights, especially alcohol related,
are the main cause of head injury.
4.1 Statistics on incidence of head injury
are shown at Annex A.
5. THE WARWICK
5.1 The purpose of rehabilitation is to
restore people to normal life if possible. If this is not attainable,
the desired outcome is to achieve the maximum amount of independent
living possible for the individual patient. In the early 1990s
the Department of Health had received a considerable number of
representations on the subject of head injury rehabilitation.
Many of the representations were from the families of people with
head injuries, who felt that increased rehabilitation activity
would have restored better functioning.
5.2 These representations led to the current
programme of rehabilitation policy action, which started in 1992
with the setting up of the Warwick study. This was a national
study (the National Traumatic Brain Injury Study), commissioned
by the Department of Health and conducted by the Centre for Health
Services Studies at the University of Warwick. The study was designed
to assess the outcomes of a programme of action research, funded
by the Department over a five year period, on the development
of community based head injury rehabilitation services. It also
tested out the hypothesis that a greater input of services would
mean better outcomes for patients. The study successfully identified
a number of the good practices in rehabilitation management that
lead to better outcomes for patients. However, when the researchers
looked at the hypothesis that an increased volume of rehabilitation
led to better outcome in terms of functioning they were unable
to establish a statistically significant link. This is a difficult
area in which to conduct research but every care was taken to
make sure that the report and its conclusions were methodologically
6. ACUTE CARE
6.1 Patients almost always access services
through Accident and Emergency Departments immediately following
their injury. A&E Departments, if necessary with the help
of neurosurgeons, have to make decisions on:-
Which patients can go home;
Which patients need a short period of assessment;
Which patients require transfer to a neurological
unit and may require neurosurgery; and
Appropriate care for severely head injured patients
who have other injuries.
6.2 Problems can occur when patients have
multiple injuries and are nursed on, for example, orthopaedic
wards, where the importance of head injury symptoms may not always
6.3 Patients who exhibit apparently minor
symptoms at the time of examination may nevertheless show marked
function loss and personality change later. Such patients run
the risk of being discharged from A&E Departments without
being observed or admitted. Systems should be in place to identify
such cases. Good practice solutions include issuing leaflets giving
advice on when to seek treatment and creating a register of head
6.4 A strategic review of emergency care
is currently underway. The review will identify principles and
standards for the organisation and delivery of emergency services,
leading to improvements in care for all emergency service users,
including head-injured people. It will ensure that the emergency
care needs of head injured patients are taken fully into account.
6.5 At the same time, a joint working group,
set up by the Regional Specialised Services Commissioning Groups
and the Society of British Neurological Surgeons, is looking at
ways of implementing the key messages from the reports Safe Neurosurgery
2000 and the Royal College of Surgeons report on the management
of head injuries (the Galasco Report). The group, as part of its
work to help improve commissioning, is developing guidance on
head injury management and services, including rehabilitation
7.1 There are a number of key characteristics
of a good head injury rehabilitation service, some of which were
described by the Warwick Study.
7.2 It is, for instance, recognised good
practice that each patient should have a case manager, who will
ensure that a written rehabilitation plan, which focuses on the
patient's individual needs, is drawn up. The case manager and
other members of the rehabilitation team will actively monitor
the head-injured patient's progress.
7.3 A good head injury rehabilitation service
should be able to provide the necessary therapist and psychologist
input to assess needs and maximise patients' functioning. Devising
strategies to assist memory, for instance, would be a key component
of this work. Social work support may be needed to help resolve
7.4 Before discharging into the community,
the patient should have a care plan and all the necessary support
put into place. There should be arrangements to deal with the
situation should the community placement fail. Failure may occur,
for instance, if, despite preparation, the head injured person
is unable to cope with the complexities of life in the community
or there is a breakdown in family relationships.
8. THE WARWICK
8.1 Warwick Study was unable to establish
a statistically significant link between input and outcome, although
it did reveal that the 10 per cent of the most seriously injured
patients were absorbing 90 per cent of resources. However, because
of the nature of their injuries, it showed that there were limitations
on the amount of improvement in functioning that might be expected
and that some people engaged in the rehabilitation process were
failing to recognise the point at which no further progress might
be made. This meant that scarce resources were being used which
might be better deployed on people with lesser injuries but for
whom the expected benefits might be greater.
8.2 The Warwick Study, as part of its remit
to assess the outcomes of the research programme, identified a
number of good practice recommendations that were commended to
the NHS by the Department of Health. Dr Graham Winyard, deputy
chief medical officer at the time issued a summary report of the
research to the NHS. The summary included messages on the need
Prompt and effective acute care
Prompt referral to rehabilitation services
More community focussed services
Written rehabilitation care plans to include
clear goals and explicit success and failure criteria
Transition between services to be handled strategically
A safety net system in case people needed to
return to rehabilitation care
A case manager with responsibility for organising
care in a seamless way
8.3 The study also found that a strong social
network and interpersonal support system, especially if coupled
with a supportive employer, meant that patients were more likely
to have good outcomes following discharge.
9.1 Following the publication of the Warwick
Report, the Department of Health organised a workshop in 1998
to review the implications for future policy. The workshop examined
various aspects of head injury care including smoothing the patient
journey, commissioning, and the management of head injury teams.
A report of the proceedings, which contains further helpful good
practice messages, was published for delegates.
10. WELFARE TO
10.1 Getting people back to functional independence
following illness or injury is a high priority for the NHS. This
year, together with DfEE and DSS, the Department of Health is
planning to mount Job Retention and Rehabilitation Pilots to test
ways of helping people with prolonged illness or disability to
remain in their jobs. This will, of course, benefit people following
& EMERGENCY (A&E) DEPARTMENTS
11.1 Over the last three years the Government
has made significant investment in modernising A&E departments.
During 1999-2000 a total of £115 million was invested in
242 schemes, with a further £35 million announced by the
Prime Minister in January 2001, bringing the total investment
to £150 million. This is the biggest modernisation and expansion
of A&E services in the history of the NHS. The schemes include
completely new A&E departments, refurbishments, the upgrading
of resuscitation facilities, the extension of medical assessment
units, the installation of new diagnostic equipment, special waiting
areas for children, improved security arrangements and better
provision for primary care services. At the completion of this
programme, 90 per cent of A&E departments will have been improved.
12. NEXT STEPS
12.1 The Department of Health has commissioned
the National Institute for Clinical Excellence to produce guidelines
on the handling of brain injured patients. The guidelines will
cover care for both adults and children. The guidelines will look
at the progress of patients through Accident and Emergency Services,
surgery and on the wards.
12.2 The aim is to improve initial management
and reduce the number of patients left with significant behavioural,
cognitive, emotional and physical disabilities. Early identification
and treatment is essential to avoid life long disability. NICE
will be scoping the guidelines shortly. As yet, NICE has not published
its timetable for guidelines given to them in the current wave
of work. We expect NICE to publish this in the summer. The guidelines
are likely to take between 12 and 18 months to produce.
12.3 On 28 February, the Secretary of State
announced that a National Service Framework for people with Long
Term Conditions would be developed. The Framework will cover neurological
disability and head and spinal injury. The Framework has yet to
be scoped but we would expect it to cover rehabilitation activity.
It will be developed for implementation in 2005. This is a highly
significant development, as the publication of a national service
framework in this area will result in better co-ordinated services,
designed to maintain the health and quality of life of people
with these long-term conditions.
The following table sets out the statistical
information that is collected on head injury.
Finished consultant episodes (FCEs) by main diagnosis
NHS Hospitals, England 1995-96 to 1999-2000
|S00 Superficial injury of head||9,731
|S01 Open wound of head||20,180
|S02 Fracture of skull and facial bones||29,839
|S03 Dislocation sprain and strain of joints and ligaments of head
|S04 Injury of cranial nerves||78
|S05 Injury of eye and orbit||3,655
|S06 Intracranial injury||23,226
|S07 Crushing injury of head||30
|S08 Traumatic amputation of part of head
|S09 Other and unspecified injuries of head
|The main diagnosis is the first of seven diagnosis fields in the HES data set, and provides the main reason why patient was in hospital. These data are adjusted for both coverage and unknown/invalid clinical data.