Rehab redefined

While rehabilitation after life-changing injury or illness is widely known as being crucial in a person’s ability to rebuild their life, all too often, the full scope of what is needed is not being delivered. 

With the challenges in the NHS of hugely pressured resources and growing waiting lists continuing to mount, all too often those in need of rehab are missing out. 

Statistics show that only 40 per cent of major trauma patients who need it are accessing specialist rehabilitation and illustrates the fact that, whilst more lives are being saved than ever before, the specialist interventions that would prove so crucial in them regaining independence are simply not available. 

So, against that background, the eager anticipation around the creation of the National Rehabilitation Centre, the first of its kind in the UK, is understandable. 

Work recently got underway on the £105million project - a partnership between Nottingham University Hospitals (NUH), the University of Nottingham and Loughborough University - and is set for completion by spring 2025. . 

The centre  built on the Stanford Hall Rehabilitation Estate, already home to the hugely esteemed Defence Medical Rehabilitation Centre (DMRC) - will bring 70 beds to deliver specialist and intensive rehab to patients - including a whole floor dedicated to neuro-rehab.   

But probably more significantly is its wider impact. The delivery of training, its role in leading research, the commitment to pioneering new technologies, and the fact it has put rehab firmly on the healthcare agenda are all set to have national impact - with the potential to redefine the delivery of rehab for generations to come. 

“I think we could be on the verge of something huge,” says Miriam Duffy, NRC Programme Director. 

“This project is raising the profile and understanding of what rehab can deliver for patients. We know it works, we know it’s cost effective, and statistics show that 94 per cent of patients who did access rehab improved their function. 

“If we look at the opportunities around rehabilitation, training, research, engineering and product design the NRC brings - this is significant . 

“In releasing all of this understanding and awareness, we can really galvanise the opportunities and create a whole new approach to rehabilitation.”

The need for the NRC

Across the UK, the need for greater rehab provision on a local, regional and national levelis keenly felt. In the East Midlands alone, the home region of the NRC, there is an estimated gap of 170 beds just for neuro-rehab - a statistic which will be replicated around the country, and often to much more significant degrees. 

And with waiting times for such scarce resources continuing to grow, patients are too often missing out on crucial opportunities in their recovery. 

“We’ve done a lot of work on this over the years, and whichever angle you look at it from, there is a huge gap to fill. For neurological rehab, we know we’re not meeting the capacity recommended by the British Society of Physical and Rehab Medicine in any of our regions,” says Miriam. 

“Because of the very long waits for beds - and often people are staying in those beds longer than we actually need as people are not starting their rehabilitation at the optimal time. 

“It is not always possible for patients to have good rehabilitation in the meantime in the acute beds, as those services and therapists are very stretched. So we are seeing a level of deterioration in these patients before rehabilitation starts.”

But whilst the creation of the NRC is adding some additional provision with 70 beds and a host of facilities like a specialist gym and assistive technologies - alongside rehab flats, to offer a step-down opportunity for patients and their families - the need to ‘do rehab differently’ has been a key priority in the centre’s development. 

“The way we’re accessing rehab isn’t working at the moment,” says Miriam, whose background is in specialist neuro physiotherapy. 

“We can’t possibly create one centre in the country to meet the deficit, that just wouldn’t be possible - it’s about rethinking how we deliver rehabilitation completely, and about making it more accessible.” 

The need not just for additional resource, but for a focal point for rehabilitation, combined with years of investigation into best practice nationally and internationally, has underpinned the creation of the NRC. 

“The idea of the clinical model we have created is to bring people as early as we possibly can into rehabilitation,” says Miriam. 

“We’ve looked at a number of centres around the world, as well as at the DMRC next door - which has delivered some phenomenal outcomes for military patients - and have learned a huge amount. 

“We have looked in great detail at how we make this safe, how we can bring a patient from an acute bed into a rehabilitation bed at the earliest opportunity.”

Rehab done differently

Through the creation of the NRC, complex and intensive rehab will be delivered across the sphere of life-changing injury and illness, including provision for neuropsychiatric patients and those with tracheostomies. 

In the picturesque surroundings of the Stanford Hall estate, rehab placements will last between two weeks and three months, with a focus on intensive rehabilitation to regain functional independence. 

The team is keen to prove the efficacy of their model, which focuses on rehab interventions being delivered more quickly and efficiently. 

“We are looking at getting complex trauma patients, two- or three-days post-operation, into rehab, rather than the 70 days we’re currently seeing people waiting for,” says Miriam.

“That should then be able to shorten the overall length of stay. So in doing that, we actually release capacity in the rehab beds, because people are staying for a more productive, but shorter period of time.

“We are also looking into how we can vary the cycle of rehabilitation.. At the DMRC, they deliver rehabilitation in two-week bursts, so a person can go home or to their regiment and practice what they have learned, and then come back for another period of intensive rehabilitation. This could also prove a great concept for the NHS. 

“What is very important is setting expectations from the start. If a patient expects to be in for six months, then the likelihood is they probably will be. But we want to set different expectations. We want to help them regain independence so they can get back to their lives.”

The clinical approach, again devised following extensive consultation and global investigation, is geared around empowerment and enabling a patient to prepare for an independent live in the outside world. 

“Our clinical model takes a much more intensive approach, we’ve turned the thinking on its head,” says Miriam. 

“We will be facilitating patients to be as independent as possible. If somebody takes four hours to get up in the morning, but they’re doing it on their own with the assistance of somebody rather than somebody getting them up, then that’s what we want. Patients will be expected to make their own way down to specific sessions so that their whole day is part of their rehabilitation - it’s about enabling them to do things on their own. 

“There is also a big emphasis on mental health, we have put a much bigger focus than we do at the moment on the psychological element of rehabilitation - we will be working with the assumption that everybody entering the NRC will be in some state of distress and anxiety, given what they’ve just been through. 

“We have learned from the DMRC who do that really well, but also from European centres, who I think understand more than we do about the impact of that psychological state on the ability to enter into that rehab programme. We hope this will be very valuable.”

With the focus on independence comes the desire to support people back into work, with vocational rehab featuring heavily in the offering of the NRC. 

“Currently, we start to think about return to work quite late, in many cases after somebody has been discharged from a rehab bed,” says Miriam. 

“We have learned a huge amount from the DMRC there. There has to be a very good reason for them why someone wouldn’t carry on working during the time they’re having rehab, and where possible, we will encourage people to get back to some form of work during their stay in the NRC. 

“A lot of us work remotely now and online, so there is more scope to do jobs without being physically present in a building. So if we can enable that and provide the opportunity for people to go back to work while rehabilitating remotely, then why wouldn't we? From a mental health perspective, that could help massively. 

“We have looked at statistics that show in the UK that after six months of someone coming through major trauma, only 35 per cent are back to work. In Europe and the United States, that’s between 50 and 60 per cent - and the main difference is that we are starting the process and these conversations too late. 

“By the time they are discharged, there could already have been a number of adaptations or changes to the workplace or accommodations made, so they can then get back to work more fully. This is a really important part of the new clinical model.”

The NRC’s approach will also help to tackle some of the well-known frustrations around process experienced by clinicians, which will also translate into the delivery of better and more timely care for patients. Trusted assessment across geographical and organisational boundaries is crucial, says Miriam. 

“We also see delays in repatriating patients to a more local hospital before they can they be referred to rehabilitation - that’s an extra step that doesn’t need to be in there, in our view,” she says. 

“If we are making our beds accessible from anywhere in the region, then that will help patients to gain access to rehab much earlier. 

“So as well as our clinical model, looking at the process is also central to this.”

Research, training and innovation 

Recognising the need to look beyond the actual delivery of rehabilitation itself, the NRC is investing significantly in the factors that make this possible. 

The site will be a national hub for training and research, which will work alongside the focus on clinical excellence to deliver major advances for patients. 

“Only when we combine these three functions will we be really able to push the boundaries of what we can achieve in this specialty - and that’s what we will do at the NRC,” says Miriam. 

“We have created space for all three disciplines to work together so that academics will be working alongside clinicians, the research questions will be generated, and then we can start to look at those in real time learning from research work can be put straight into the clinical practice. 

“It still takes us ten years to get from research to practice, if at all in many cases, but the idea behind this is to make the process quicker. We’ll be pushing to see what we can achieve by doing that, and to translate the learning as quickly as we can out to the rest of the country.”

In terms of training, the centre will help to develop the next generation of specialist rehab practitioners. Among its nationally-significant initiatives are the creation, in conjunction with Birmingham City University, devising the UK’s first Rehabilitation Assistant Practitioner apprenticeship. 

“We are opening up opportunities for people really to have a very varied and interesting career within the rehab specialty,” says Miriam. 

Additionally, the NRC will have an Innovation Space, for its patients and team - supported by industry partners - to share technology-based ideas based on their own practice which could be transformative in-patient care. 

“We want industry to work with us to build on ideas that patients or staff have in terms of different products and product design,” says Miriam. 

“We have the potential to work up those products and test them in real time with patients, and then quickly get them out to market. 

“By engaging with industry in this field, particularly around tech, there are massive opportunities in what we can achieve. We’ve had a huge amount of interest from different tech companies in what we're trying to do.”

National inspiration

While the NRC is bringing hugely valuable new rehab provision and beds, the demand from its own region means that, most likely, local people will account for the majority of the patients. 

But its ‘national’ reach lies far beyond that, and in its creation of a model which could be rolled out across the country, ideally within the next ten years.  

“The creation of an NRC has been a Government commitment since 2010, but when they spoke to NHS England, it became clear we couldn’t have just one centre for the whole country - it was rather to develop a hub for the country,” says Miriam. 

“The NRC will develop the clinical model and prove the concept, which will then be passed to spokes around the country to serve each of the different regions. That is the next piece of work, and we’re already starting to have the national commissioning conversations.”

The means of doing that is not yet defined and lies in the approach of the NRC being proven once it becomes established, but one potential roll-out method could be adoption by the Major Trauma Network. 

That remains to be seen, says Miriam, although the learning from the centre is something that will be easier to filter out nationally. 

“Not everyone will have the luxury of a new building as we have, but this is about refocusing the clinical model of delivery more than anything else,” she says. 

“Also, each region will be slightly different in its needs. But I think there’s a lot of learning that can be taken, in the way that we have learned from other centres. 

“The next couple of years will be crucial really, because we’ve got to prove our model, but a lot of what we are doing is something that any unit could do in terms of adoption of practice. 

“We’re developing a model that staff  from the community and the acute Trust can rotate through at the NRC to build up the resilience of rehabilitation skills across the whole healthcare community.

“I think when we do have this model across the country, it will be transformative. We have got to start somewhere, and I think this is a really good way of starting. 

“We’re certainly starting a conversation, and we're hoping very much that people will be watching what we're doing and thinking about what that could that look like for their region.