Realising the right to rehabilitation—commentary on ‘reablement, rehabilitation, recovery: everyone’s business’

Abstract

Rehabilitation is a core component of comprehensive geriatric assessment and should be central to integrated care and support across the whole system. Yet access barriers and ageist practices still prevail within many rehabilitation services. This commentary reflects on a report and recommendations published by the British Geriatrics Society in May 2024. As lead author for the report, I share my personal reflection on the key messages and take this opportunity to thank the multidisciplinary contributors.

Reablement, Rehabilitation, Recovery: everyone’s business describes why rehabilitation matters to older people and their caregivers. It provides evidence and examples of practice at different care touchpoints and makes the case that rehabilitation is everyone’s business and knows no boundaries, whether by condition, profession, care setting or taxonomy. The report sets out 12 key actions for health and care systems to deliver effective and integrated rehabilitation as a right for all older people, wherever and whenever they need it. To realise that right, health and care professionals must work together, and with their local community partners, to build capacity and capability for reablement, rehabilitation and recovery across the whole workforce.

With population ageing and many more people living with frailty or multimorbidity, there is an urgent need for greater investment in rehabilitation to prevent, delay or reduce disability, caregiver burden and demand for long-term care. This timely BGS report should be essential reading for all who plan, commission, provide or assure health and care services for older people.

Key Points

• Rehabilitation should be a right for every older person, wherever and whenever they need it.

• Delay in access to rehabilitation creates dependency, further increasing demand for services that are already overwhelmed.

• Rehabilitation and reablement are critical ‘invest to save’ interventions.

• Rehabilitation is everyone’s business—it needs collaborative leadership, education and an integrated workforce.

• The rehabilitation approach should be tailored to any communication, cognitive, sensory or physical impairments.

Rehabilitation matters

Global ageing and Covid-19-related deconditioning, fatigue and disability are driving demand for new approaches to rehabilitation [1]. Delays in access to rehabilitation only create more dependency, further increasing demand on services that are already overwhelmed. Timely rehabilitation, when needed, enables older people to maintain or recover their independence and lead good lives. Although rehabilitation is a core component of comprehensive geriatric assessment (CGA), provision of geriatric rehabilitation is increasingly a postcode lottery constrained by lack of physical space, time and workforce capacity [2]. That postcode lottery is particularly evident for access to rehabilitation for residents in care homes.

Right to rehabilitation

Professional societies, advisory bodies and advocacy groups concerned about the lack of access to rehabilitation have come together as the Community Rehabilitation Alliance. This collaboration of health charities and professional bodies from across the UK launched a campaign that rehabilitation should be a right for every older person. The campaign has been supported by publication of an ambitious set of best practice standards on the development, delivery and monitoring of high-quality person-centred community rehabilitation [3]. Building on this strong multiprofessional and cross-sector collaboration, the British Geriatrics Society published their own report Reablement, Rehabilitation, Recovery: Everyone’s business.[4]. This new report identifies 12 key actions for health and care systems to deliver effective and integrated rehabilitation as a right for all older people, wherever and whenever they need it. The recommended actions, summarised in Table 1, were informed by published evidence and expert practice. Each action is both pragmatic and achievable. Implemented together, the suite of actions offers a route to more sustainable care and support.

A global issue

The 12 recommendations mirror the outputs from a workshop I convened in April 2024 at the 24th International Conference on Integrated Care, affirming their applicability in a global context. The conference workshop brought together third sector providers, caregivers, researchers, healthcare professionals and policy makers from across the UK, Europe and Canada to consider how to improve access to rehabilitation. Delegates called for a more integrated approach to workforce planning and development, valuing all partners who may have a role to play within a skill mixed, cross-sector workforce that leverages the potential of consumer technology to amplify capacity, guided by healthcare professionals. A delegate from Ethiopia urged us to learn from low- and middle-income economies that use generic workers wisely to extend the reach of services, supported by education and training. The workshop participants pledged to stay connected as an international community to maintain collective advocacy on this issue.

Everyone’s business

I am grateful to the Age and Ageing editorial team for commissioning this commentary to highlight the BGS report to an international community of academics and practitioners. This article is also an opportunity to publicly thank the excellent team who worked with me on the BGS report—drafting the content and messages was indeed everyone’s business. The report was primarily written for those planning, commissioning, leading and assuring services for older people. Accordingly, the messages and actions are mainly targeted at senior decision makers in integrated systems. However, the report will be of interest to all who work with older people, at all levels. Clinicians working within local services are well placed to raise awareness of the evidence and examples in the report as they undertake their duties at point of care. Those involved in education and training are uniquely placed to use the report to prepare staff to embed evidence based practice within rehabilitation and to adopt an enablement ethos wherever they work. I have pulled out five ‘take home’ messages that I will highlight in my own work supporting integrated systems in the UK and beyond.

Everyone matters

As a family caregiver I know that even small gains in functional ability may be life-changing for the individual and/or their caregiver, especially if the gains enable greater wellbeing, participation and enhance social connections. The report challenges the restrictive ‘no rehabilitation potential’ label that is too readily applied to older people when assessors adopt a biomedical rather than a holistic or biopsychosocial approach. We are urged to be aware of our biases when assessing the rehabilitation potential of older persons [5]. Rehabilitation goals should be meaningful, based on outcomes that matter to the individual and their caregiver. For greater inclusivity, rehabilitation should be tailored to more fully involve and support older people who have communication, cognitive, sensory or physical impairments.

Learn to let go

Widening access to rehabilitation is challenging in the face of limited resources. From many years of working in, and with, the voluntary sector, I appreciate the wide range of community supports and services that can be mobilised to enhance wellbeing, self-management skills and encourage physical activity. That elusive rehabilitation capacity can be created within a tiered, skill mixed and cross-sectoral model as described in NHS England’s good practice guidance on community rehabilitation and reablement [6]. That integrated model requires healthcare professionals and managers to cede power and funding to their community and voluntary sector partners. Supporting this culture shift is still largely work in progress in most integrated systems and will require investment in interdisciplinary education and training, collaborative leadership and workforce models that enable staff to work at the top of their licence and to view community partners as equals. Rehabilitation is everyone’s business. That means we all need skills in communication, shared decision making, goal setting, supporting self-management and identifying and signposting carers to supports for their wellbeing. Health and care settings have become highly risk-averse environments. The pursuit of patient safety is laudable but may have unintended harmful consequences if overly cautious or defensive practice disempowers older persons, prolongs their admission or exacerbates deconditioning. Staff also need education and support to build their confidence in tolerating risk and in creating safe and enabling physical environments.

Democratise rehabilitation

To improve population health, we need to invest in proactive care and earlier interventions at home and in the community. That means we must democratise and deinstitutionalise rehabilitation, at least for adults with mild to moderate levels of frailty. Simple home-based exercises are safe and may improve functional ability and quality of life in older people with moderate, but not severe, frailty [7]. Walking or tai-chi are moderately effective and easy to implement [8] but combined exercise interventions maximise impact on mobility, balance, body mass and levels of activity [9]. Studies from Sweden [10] and Catalonia [11] report promising results from combining proactive CGA and earlier rehabilitation in primary care, leading to shorter hospital stay and lower overall healthcare costs. As prehabilitation for patients awaiting planned surgery or cancer treatments improves recovery and is cost-effective [12], investing in community-based ‘waiting well’ initiatives must be a priority for the unprecedented number of older people on waiting lists for orthopaedic, surgical and cardiac procedures.

Scale up reablement

Reablement is a person-centred and goal-directed approach to home care designed to support people to regain their independence after an illness or injury. In 2017, NICE published a clear economic case for a reablement approach to home care [13]. A report by the Nuffield Trust noted that the proportion of older people at home at 91 days after discharge from hospital into reablement/rehabilitation services at home or in an intermediate care facility was consistently around 82% over almost a decade [14]. Success rates of reablement fall only slightly with increasing age in those over 85. Despite this compelling evidence for its effectiveness, in 2020/2021 only 3% of over 65 s being discharged from hospital received reablement. This is a massive missed opportunity for a relatively low-cost evidence-based intervention that improves outcomes, reduces rates of readmissions and reduces demand for long term social care. The evidence for reablement is as strong as for Hospital at Home and considerably stronger than the evidence for virtual wards—but where are the national targets for scaling up reablement? Given the current crisis in social care, I believe investment in reablement should be a system priority.

Address deconditioning

Older patients are at risk of harm in hospital wards from long periods of immobility resulting in loss of muscle mass, functional decline and increased risk of death or institutional outcomes. Prolonged trolley waits in the Emergency Department further compound the risk of deconditioning. The Active Hospitals movement aims to change the physical activity culture within hospitals to encourage patients to move more [15]. The UK ‘Sit up, get dressed, keep moving’ and the global #endPJparalysis campaigns support clinicians to encourage older people in hospital to remain active to enhance their recovery. These are low tech, low-cost campaigns and social movements that we can all get behind—and experience shows they also bring some welcome joy to our work!

Conclusions

I hope this commentary tempts you to take a deeper dive into Reablement, Rehabilitation, Recovery: Everyone’s business. Let us make some noise about the BGS report and be persuasive advocates of the right to rehabilitation for every older person, wherever and whenever they need it.

I believe the report should be essential reading and a call to action for all who plan, commission, provide or assure health and care services for older people. I hope it also prompts interest in implementation research to address some of the gaps in evidence, particularly in evaluating complex rehabilitation interventions for older adults. We need more good quality research in this subject, particularly studies using mixed methods approaches that assess service reach, inclusivity, patient and caregiver experience, and consider cost-effectiveness and social value.

Acknowledgements:

Sincere thanks to the British Geriatrics policy officers and members who contributed to the report, and also to colleagues from the third sector and specialist societies for their ‘critical friend’ advice.

Declaration of Conflicts of Interest:

None.

Declaration of Sources of Funding:

None.

References