South East London Community Neuro Rehabilitation Evaluation

The NICE scholarship evaluated South East London (SEL) Community Neuro Rehabilitation Services (CNRS) in comparison to the NICE Head Injury Quality Standard on community rehabilitation (QS74).

Aims:

• Quantify the Acquired Brain injury (ABI) population across SEL.
• Gain feedback from ABI service users across SEL regarding CNRS.
• Compare all SEL boroughs to the NICE QS74 on community rehabilitation.

Challenges:

• Gaining stakeholder commitment to provide information and be part of improvement conversations and workshops across the region.
• Obtaining completed clinical and commissioning information across six CCGs and four provider organisations.
• Difficulty with information quality and reliability, and ability to compare clinical services that are structured differently.

Key Activities:

• Designing, researching and producing the evaluation which detailed epidemiological, commissioning, clinical and service user data.
• Presenting the results to all stakeholders, including SEL CCGs, 4 provider organisations, NICE, Headway, Kings Health Partners (KHP).
• Facilitating a commissioning and provider workshop discussion utilising the evaluation, to determining future priorities for the STP.

Impact:

The evaluation and workshop has brought the STP together from a commissioning and clinical perspective for the first time. The evaluation findings, recommendations and workshop consensus has influenced the STP commissioning offer for community neuro rehabilitation for the next 5 years

Community neurological rehabilitation is a vital service the NHS offers to improve functional independence, reduce burden on carers, improve self-management and rates of returning to work following neurological injury or disease. Despite these reported benefits, neurological rehabilitation is variable across the UK. The level of variability across SEL CNRS has not been evaluated formally. Working as a Neuro Navigator across the region, I have observed the gaps and variation in CNRS services, and their impact patient journey and outcomes. There is a ‘postcode lottery’ that exists across the area, which impacts patients by:

1). Delaying acute and inpatient rehabilitation discharges

2). Long timeframes vulnerable patients are waiting for a community service

3). Variable standards of clinical assessment and intervention resulting from different service models, intensity of therapy, time periods for therapy, staffing levels, professionals available, and leadership across the STP.

The NICE scholarship researched the CNRS provision from a population, service user, clinical, and contractual viewpoint. The aim was to determine if the CNRS were meeting the NICE Head Injury Quality Standard on community rehabilitation. Through this, it could then explore whether the variability of services was based on the needs of the population.

Research Methodology:

National and local population datasets analysed:

• Headway UK
• TARN – Trauma data
• SSNAP – Stroke data
• UKROC – specialist inpatient neurological rehabilitation data.
• Community Data

Focus Groups:

• The Focus Groups had semi-structured questions and were attended by people who have experienced an ABI or their family/carers. The Framework Approach was applied by using coding and theme generation.

Clinical and Commissioning CNRS:

• Two web-based survey forms were developed to collect data at a CCG and clinical level. Both were designed using the NICE QS74, SIGN Adult Brain Injury Guidance and The National Service Framework for Long Term Conditions.
• The quantitative results were analysed using the raw data to identify trends, and the qualitative data obtained were analysed using The Framework Approach to understand themes.

Project Support Tools:

• Engagement via formal and informal discussions with stakeholders
• NICE scholar programme
• GSTT research guidance

Barriers and Successes:

Engagement with stakeholders and willingness to share information was an initial barrier. This was overcome by gaining the support of a key STP commissioning director to promote participation across the region.

The variation in service provision does not appear justifiable based on the population, service user or service provision data.

1) Impact 1, 3 & 4:

• The first time six CCGs, four providers and third sector have committed to come together to form a reference group to guide commissioning decisions in CNRS in order to develop a core offer for the STP.
• This will address gaps and fulfill recommendations of the evaluation and ensure AHPs have influence in commissioning EBP services.
• Proposal to commission a STP community neurological rehabilitation project team which will drive ongoing quality improvement.

2) Commitment 1& 2:

• The evaluation and workshop specifically highlighted the variation in service capacity and demand, neuro psychology, vocational rehabilitation, and access to third sector organisations.
• The STP has committed to commission a neuropsychology service embedded in the community.
• The reference group will be tasked with streamlining data, reporting on meaningful patient outcomes, and address highlighted variation to ensure care is individualised and close to home.

3) Priority 1 & 3:

• The evaluation and workshop has informed the next 5 years of commissioning decisions for community neuro rehabilitation for the STP, along with supporting the STP response to the NHS 10 year plan.

1). Importance of meaningful engagement with all stakeholders, as well as identifying the key influential organisation or person to support the project.

2). Barriers and time consumption to gain access to information across different NHS, private and third sector organisations. However, creatively working around barriers to gain data is possible, although takes time and persistence.

3). The impact of historical relationships and bureaucracy has on bringing people together across organisations. However, facilitating discussion that focuses on blue sky thinking and viewing improvements and priorities from a patient perspective enables positivity to flourish. In considering whether to do things differently it may have been beneficial to have brought people together sooner and throughout the project timeline.

The NICE scholarship has been extremely beneficial as an individual experience, but also to GSTT as the organisation is acknowledged as a leader across the STP in research and service improvement. I personally have encouraged professionals to engage with NICE, and their fellows and scholar programme, through presenting my experience and evaluation results to GSTT research and audit group, KHP clinical academic group, and the local community neuro rehabilitation service.