Select Committee on Health Appendices to the Minutes of Evidence


Memorandum by Southern Derbyshire Head Injury Service (H24)


  Southern Derbyshire (population 540,000) has gone someway towards providing an integrated service for the rehabilitation and reintegration of local people with head injury. This has been possible by the active and ongoing collaboration of the local Health Service, Derbyshire County and City Social Services, Derby Headway and the Leonard Cheshire Foundation.

  The present services, although comparing favourably with most health districts that have no dedicated head injury service, are a long way short of what could be considered adequate.

  Experience over the last eight years (since we have had a service) has demonstrated:

  1.  A huge amount of previously unmet need, beyond what our small service can meet. The needs reflect the nature of the impairments resulting from head injury: ie cognitive, emotional and interpersonal problems (rather than physical disability).

  2.  The need for a range of services which are where flexible, rapidly responsive and inter agency where necessary. Also the need for these services to be available life long ie to allow regular or spasmodic contact with specialists in Head Injury.

  3.  Gross service inequity in areas adjacent to Southern Derbyshire. There is a complete absence of services in Burton-on-Trent and much better developed services in another adjacent health district (Nottingham). A more general source of inequity exists between statutory services of all kinds often a far superior level of service is available to people with access to personal injury compensation funds.

  4.  The value of a specialist Health Service case manger with a co-ordinator role, working within a multi-skilled team. The role needs expanding and is probably the key to successful services. Our colleagues in the Nottingham head injury team strongly support this view.

  5.  The value and cost-effectiveness of non-professional workers. They can be highly effective provided they have professional support and direction.

  6.  The need (as yet unmet) for a family support worker. This is currently our highest priority within our service.

  7.  The need to improve the environment, and to improve rehabilitation and care services for head injured patients in hospital on acute general wards, while in the early stages of recovery. At this stage one-to-one supervision may be required, as well as input from professionals knowledgeable about head injury rehabilitation.

  8.  The tendency for statutory services to lack personal focus. In this respect Headway services are valuable since they are targeted towards people with head injury and have the additional advantage of being in the voluntary sector, but with good Health and Social Service links.

  9.  The need to be able to occasionally fund from statutory sources comprehensive specialist community support packages for those who have serious impairments following Head Injury, who will not receive personal injuries compensation.

  10.  The need for improved vocational rehabilitation (as described in the recent British Society of rehabilitation Medicine report). Funds and access must be available for local vocational rehabilitation services but can be provided by specialist agencies such as Rehab UK.

  11.  The desirability of extending the service for people with traumatic brain injury to those with other forms of acute acquired brain injury, such as anoxic brain injury following cardiac arrests, anaesthetic misfortunes, drownings and encephalitis/meningitis. The problems these people have are often similar to those experienced by people who have head trauma. We have inadequate resources for this purpose. Inequities arise from services, which are diagnosis-based rather than needs-led.

  12.  Head injured patients with mental health needs are often unable to access mental health services. Patients who are a danger to themselves or others and who refuse treatment can often not be treated under existing Mental Health Act legislation. Furthermore, some such patients treatment needs are unable to be met within existing statutory or private sector resources.


  Southern Derbyshire was fortunate to be one of the 12 sites in England and Wales to receive DOH funding in the National TBI initiative of the early 1990's. This funding allowed for the establishment of a specialist case management post and a small dedicated therapy team for people with head injury. The project was supported from the outset by Derbyshire Social Services and the Southern Derbyshire Health Authority and the funding was subsequently picked up jointly by both Health and Social Services. There is a well-established care pathway within Southern Derbyshire (Appendix 1).

The Nature and Size of the Problem in Southern Derbyshire

  Every year in Southern Derbyshire (population 540,000) some 500 patients with head injury are admitted to the Derbyshire Royal Infirmary for at least 24 hours. Over 70 stay in for 72 hours or more and some 40-50 each year will need ongoing rehabilitation input and support following discharge from hospital. Only 10-15 will actually access the in-patient rehabilitation unit and the majority of head injury rehabilitation and recovery therefore takes place in the community and is concerned with reintegration back into ordinary every day life and resumption of social, family and employment activities. The majority of head injured people do not have physical impairments and their problems are of a cognitive, emotional and interpersonal nature and are therefore complex and frequently very distressing and disabling with a major impact on the lives of their families.

  The Nottingham area (population 600,000) immediately adjacent to Southern Derbyshire and 13 miles to the east of the city of Derby, has a comparatively well developed head injury service, whereas the Burton-on-Trent area (122,000) also immediately adjacent to Derby and some eight miles to the west has no services at all. There is therefore a considerable inequity in provision of services to this client group. Even allowing for these variations those patients who receive personal injuries compensation can expect to receive a very much superior service especially with regard to the funding of ongoing personal support packages or specific targeted rehabilitation. Arranging specialist services or care/support packages thus becomes a lottery, dependent upon where patients live, and how they received their injury.


  These currently comprise:

    1.  Head injury case management and therapy with only one full-time post (a case manager) and part-time therapy staff (currently 2.35 WTE's) for a very high intensity, difficult workload.

    2.  A rehabilitation medicine consultant (0.2 WTE) providing a roving service for in and out patients and an out-patients clinic.

    3.  A clinical neuropsychologist (0.5 WTE available for head injury).

    4.  Access to a general neurological rehabilitation unit when there is a bed available (admission is often delayed).

    5.  Leonard Cheshire support workers from a local day service provide a total of 37 hours a week for community reintegration work, and have been remarkably effective (see Anna Bristow's evaluation report) (Appendix II).

    6.  Derby Headway provides a Headway House, a drop in centre with social activities, a befriending service, counselling and confidence building activities. This has been invaluable, helping people who are being discharged from rehabilitation services and supporting individuals and their families. People with head injuries do not fit in well with local authority provision in day centres, as these services can be inappropriate to their needs.


  1.  There is the usual wide dispersal of patients in the early stages of recovery from head injury throughout the acute general and specialist wards in the Derby hospitals. There is a lack of consistent informed management and currently little or no neuro rehab therapy is available.

  2.  There is often a lack of routine one-to-one supervision/reassurance of patients who are acutely disorientated/confused and distressed (such patients will occasionally inappropriately receive medication in order to "quieten them" and make management easier). The situation is improving but needs constant vigilance because one-to-one supervision is costly.

  3.  There is a lack of ability to make a rapid response by Social Services to support families when a patient who is still confused is suffering from short term memory loss or is agitated to some extent, and insists on going home. There are not large numbers of such patients and the problems will be transient usually over a matter of weeks, but are very difficult to manage in hospital. The patients are often much more settled at home but need supervision and the families need considerable support both of which at present is not available. The situation if not managed will present potential risks of accidents, eg falls down stairs, crossing the road.

  4.  Inability to fund adequate community support packages (or any support package at all) in a timely fashion. This is usually due to funding disputes over which agencies should contribute and to what extent. Also people with head injuries often need specialist carers which increases the costs of any agreed packages. This leads to huge delays both in hospital discharge and into the provision of a package to a person who is already in the community. This produces a high-risk situation both from self-harm by the patient, harm to others and to avoidable accidents. It also increases the stress on the family carer which can lead to family breakdown. The introduction of a lead PCT locally should facilitate availability of funding from the health sector, but fragmentation of funding arrangements in social services continues.

  5.  Having a service raises expectations and stimulates referrals, but due to the small size of the team it is difficult to offer a timely service and this has led to rationing and a waiting list. We have identified that this results in stress to families and individuals and can result in relationship breakdown, job loss and longer treatment times. Lack of appropriate services to pass patients onto makes discharge difficult and compounds waiting list problems. A priority system has been introduced. It is interesting to note that nearly 90 per cent of those seen within one month of referral during 1999-2000 have been discharged, whilst only 27 per cent of those seen within two to six months, have been discharged, the remaining 73 per cent are still receiving therapy or support.

Year (April to April) Number of Referrals % Increase (on previous year) No. Clients waiting more than recommended time for assessment Min/Max wait
1997-199871 No waiting list1-4 weeks
1998-19998215.5 per cent 7 (introduced January 1999)1-18 weeks
1999-200010123 per cent 156-24 weeks

  Figures for 2000-01 indicate a similar trend and the waiting time has increased to 31 weeks.

  6.  The lack of a family support worker means staff become embroiled in trying to cope with the problems of distressed families and therefore have less time to focus on the patients' problems. Families are often under intolerable stress or strain and have different needs from the patient. Research has shown that the level of stress experienced by this group is more than any other disability group and that failure to support families leads to less successful outcomes. (Johnson 1991)


  1.  In head injury each case is unique, and it is impossible to predict service and support needs in advance of clinical contact on the basis of demographic or medical details, making service planning difficult.

  2.  People with severe head injuries require long-term specialist support from people experienced in head injury work, who are aware of their individual history and problems. Some patients require ongoing regular contact or review, whilst some can be supported on an ad hoc basis by telephone. These characteristics of the varying needs of different patients are illustrated by the local clinical neuropsychologist's current caseload. His 59 current open cases include people injured from March 1981. 14 per cent of the caseload are due to injuries occurring more than five years ago. The neuropsychologist recently had a telephone consultation with the wife of the first patient he saw in Derby 11 years ago. One patient still being seen regularly for psychotherapy in connection with the consequences of his head injury in July 1998 has been seen for a total of 86 sessions to date, whilst several are likely to only require between two and five sessions of assessment and advice.

  3.  Services around the country comment on the difficulties caused by the artificial boundary between mental health and head injury services. It is often difficult to access psychiatric support either acutely, or long term, when head injured patients present with frank mental disorder or challenging behaviours, as such patients are seen as "non-psychiatric" if they have a neurological history. Of further concern is how to contain the behaviours of people known to be, or potentially be, a risk to themselves or others, if they are unwilling to voluntarily submit themselves for treatment. Even if they are willing to have treatment, some specialist interventions are often not available. We have several local examples both of extreme incidents of deliberate or inadvertent self-harm, and of harm to others, which were predicted or predictable. These include suicide, and a sexual assault on a minor.

  4.  Local, national and international experience suggest that even if specialist head injury rehabilitation is expensive and labour intensive, its provision saves the treasury more money overall than it costs. These savings accrue from areas such as reduced uptake of state benefits, carers or patients returning to productive work and becoming taxpayers, or from patients requiring lower levels of support from other services. Some patients require access to specialist vocational rehabilitation elsewhere, such as at Rehab UK, a charity operating in Birmingham, among other sites. We have occasionally been able to fund such rehabilitation via compensation claims, but have been unable to access this via health, social services or employment resources.

  5.  Current criteria do not allow for follow up of those who sustain a Minor Head Injury. A pilot review of orthopedic patient statistics indicated that about 23 per cent did not meet current criteria but were identified as also receiving a head injury reported typical head injury symptoms and may therefore be experiencing ongoing social and vocational difficulties. The same review highlighted that 13 per cent of patients over 65 would benefit from further assessment.

  6.  In addition the small size of our local service prevents us from helping people with other forms of acute acquired brain injury, such as anoxic brain injury following cardiac arrests, anaesthetic misfortunes, drownings, and encephalitis/meningitis. The problems these people have are often quite similar to those experienced by people who have head trauma.

February 2001

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