A Nightingale Rehabilitation Service – How?
Jack Chew – Director MSKReform – Physiotherapist
As the impact of COVID-19 on the world became apparent, I was asked what I felt the optimal role of MSK specialists would be in the pandemic efforts.
I set about working on my answer by consulting respiratory and acute medical specialists about the nature of the disease and their opinions as to how helpful redeployed MSK specialist could be to their teams. The overwhelming response was that:
a) COVID-19 patients do not typically have issues that an MSK specialist with a distant background in respiratory care would be able treat with basic upskilling.
b) The system is likely to grind to a halt therefore anything MSK Therapists can do to improve the flow through the hospital by accelerating discharge would be invaluable.
Consultant Respiratory Physiotherapist and now Chief AHP at the London Nightingale Hospital, Rachael Moses was a brilliant guest on The Physio Matters Podcast and her episode reached a staggering 60,000+ people. Her call to action for MSK and associated professionals to come together and lean into their rehab skills resonated with many, not least me!
As Director of MSKR, I saw an opportunity to do what we as an organisation do best, construct and promote policy. Having taken lead from Rachael and her colleagues, we set up a landing page at MSKReform.org.uk/RehabRecruits where we made the case for rehab deployment and gave an opportunity for clinician to register their interest and support for the policy.
Within weeks we had 2,000+ registrants, thanks from hundreds of acute clinicians, managers and strategists and offers of help from many service providers.
We engaged the arms length bodies, namely NHS Improvement, and received thanks and encouragement from several departments including the Strategy and Innovation office. However, in mid March the whole system was quite understandably scrambling to assist phase 1 planning – to boost and staff ICU capacity.
Interested service providers and our rehab recruits started to press me with the question I’d be asking if I was in their shoes: ‘How would you do it?’
Every draft model sounded fanciful and impractical when considered in line with the pace and scale of peacetime NHS changes. Then I heard whispers of the Nightingale Hospitals and recognised the bold innovation and rapid planning that was going to define this period. So I stopped shying away from describing the rehab service as a Nightingale-esque project!
I was heartened to read this brilliant article in the Health Service Journal by Dr Alice Murray, Dr Clare Gerada and Dr Jackie Morris last week which also dared to use the words ‘Nightingale’ and ‘Rehab’ together! The authors make a fantastic case for rehab as a principle to be at the heart of post-COVID-19 care and explain the inpatient step-down aspects very well.
Possibly due to the working location of most of our recruits in primary care and the primacy of social distancing felt by those of us currently displaced from face to face care, I had thought up a model from the community upwards.
I had a very positive discussion with two of the aforementioned authors, Alice and Jackie, who also recognise the need to win the hearts and minds of the grass-roots workforce by promoting the unifying nature of functional rehabilitation as a concept. I’m excited by what they write next and have been pleased to share our ideas with them.
The hunger for a Nightingale Rehab Service is apparent across social media with #CovidRehab catching on following the HSJ piece promoted by OT Amanda White and Consultant Rachel Botell. A group of professional organisations and charities launched the #RightToRehab campaign on the 26th Feb 2020 which promotes an increased quantity of community rehabilitation. If this could be combined with an appeal to care quality, high competency standards and clinical excellence we could benefit greatly from the recent political lobbying.
Below is an abridged version of how a network of providers could optimally serve post-covid and covid-disrupted patients as the:
NHS NIGHTINGALE REHAB SERVICE
1. Create a national framework which includes a best-practice operating model and clinical competencies which focus on the principles of quality functional rehabilitation.
2. Operating model should include four overlapping care provisions beyond the acute setting:
i) Hospital rehab wards
ii) Community rehab facilities
iii) Domiciliary care
iv) Remote services
3. Funding and employment models could follow those seen in the Nightingale hospitals where central funding has supported infrastructure spend and NHS Professionals have been funded to employ the new workforce. However we would recommend that an improved model would be to bolster existing service provisions through local CCG channels and fund the service providers to create and manage infrastructure and employ the new workforce.
i) Hospital rehab wards – Funding channelled through Acute trusts
ii) Community rehab facilities – Funding channelled through Community Health Trusts, Community Interest Companies, Independent sector providers plus potential temporary use of community assets like leisure centres, halls and gyms.
iii) Domiciliary care – Funding channelled through Community Health Trusts, Community Interest Companies, Independent sector providers.
iv) Remote services – Funding channelled through GP practices and conglomerates, MSK Service Providers across sectors, all those with new and established remote service systems for Telehealth +/- video.
4. Workforce – A thorough multi-disciplinary team will be required. Geriatrician and other rehabilitation orientated consultant oversight would be essential. Advanced practitioners from nursing and AHP backgrounds, especially those with interest and experience in frailty, would be very well placed to support triage and pathway management.
The vast majority of treatment will be scaling each patient’s function from their personal baseline towards their individualised goals. This is the core skill-set of evidence-informed Musculoskeletal (MSK) Therapists of all stripes. MSK Therapists and many of the associated orthopaedic, pain, rheumatology and sports professionals have moved to skeleton service cover and 95%+ remote care due to COVID-19 adaptations. A workforce of existing NHS staff, returning private AHP practitioners and other graduate MSK professionals could be deployed to roles very close to their specialist skill-set without major displacement from their current roles or workplaces.
Grass-Roots MSK Think-Tank MSKReform launched their Rehab Recruits campaign three weeks ago and have signed up over 2,000 interested individuals with no external publicity. This list is fully consented for sharing with NHS bodies and the team have been liaising with NHSE/I where possible to offer support for Phase 2 and 3 COVID-19 planning.
5. Competency – Fundamental functional rehabilitation principles should be at the heart of all care with an agreement to focus on the 80+% agreement between the professions and where the evidence base is strongest. Namely education, graded exercise, judicious use of aids, facilitated functional activities and integration with social care provisions.
Up-skilling for MSK Therapists normally accustomed to working with a relatively well orthopaedic and sports patient set should include frailty, pulmonary and cardiac rehab principles as well as refreshers on the thresholds for medical opinion referral around poly-pharmacy and other multi-morbidity issues. Up-skilling for those normally accustomed to inpatient, medical and elderly patient sets should include MSK pain, loading parameters, occupational health factors and return to exercise parameters.
Facilitation of movement and other hands-on rehab skills will need to be used sparingly to support national social distancing measures and adjunct techniques such as manual therapy, taping, electrotherapy etc should be considered out of scope for the service.
6. Operating model – Due to the exceptional need to accelerate discharge away from pressured acute services which are of course also virus hotspots, the community step-down levels should be prioritised. The findings and other-nation assumptions reported in the NHSE/I COVID-19 hospital discharge service requirements reinforce this point with 95% of hospital discharged patients not expected to require inpatient care.
Greatly bolstered community services would be able to accept patients discharged with care needs at levels which in normal times would require 2-7 days longer in a facility. This is because the new workforce are implementing re-enablement with thorough remote support.
The remote triage and assessment elements of the service needn’t be geography dependant. Under the appropriate national framework, the remote elements could feed into postcode specific provisions and be led by service providers with experience delivering quality telehealth and other remote care.
This model utilises existing processes and protocols for discharge planning but with the increased capacity and scope of the rehab services then allowing for hospital staff to skip a step down bed or prolonged stay. Some of the risk factors affecting readmission are also mitigated by the current parameters around staying home and having same-home family members around more. However the social circumstances of other patients may well leave them more vulnerable with reduced access to their wider family and friend support network. This is why a bolstering of all community health and social care provisions would ideally dovetail with this proposed rehab model.
Standardised assessment protocols would help stratification and may also help non-specialised staff to cover basic questions for specialist services that have not got access to their patients at present. For example a Physiotherapist working in the rehab service assessing a recently discharged 70YO post-covid or post #NOF patient who also has long term semi-stable T2DM could collect data for sharing with the patient’s usual diabetes care team.
7. Integrated care – The suggested model is based on functional rehabilitation principles and therefore is as compatible with post-COVID ICU patients as it is Parkinson’s disease falls risk patients, post-op orthopaedic patients etc.
Joining up post-COVID rehab with COVID-displaced rehab is wise in the short and medium term for the reasons described. But it also takes the opportunity for services to return to their prior function, if not improved, far quicker than a COVID specific pathway.
8. Inpatient step down – Within acute trusts this should be the simplest piece as well as being the furthest along as things stand. Existing hospital wards are being redesignated for rehab and step down from ICU/CCU. These should be joined-up with any broader Nightingale Rehab Service in order for smooth movement upstream and downstream depending on patient need. Failure to do this would pressure EDs as they would be triaging known returning patients whose care simply need escalating with many of the same assessed findings.
Several service managers report having been contacted by gyms, community halls, leisure centres and the like offering their facilities for NHS use. The mechanism for forwarding this up the chain has not been clear so there has been no uptake to date, however we feel this demonstrates an obvious willingness by society at large to volunteer their facilities as well as their labour. Such sites could be used for step down inpatient facilities or as staff hubs if existing infrastructure for domiciliary care cannot support the scale of the community rehab workforce.
Is it feasible? Is there the political will? Are rehab personnel going to stand up and be counted?
I certainly hope so and in the mean time, MSKReform will keep making the case for the great unifier that is functional rehabilitation.
Jack Chew – Director MSKReform – Physiotherapist