8 Service organisation

8 Service organisation


Provide access to multidisciplinary services, if available, (these could be 'one-stop' clinics) for assessing physical and mental health symptoms and carrying out further tests and investigations. Services should be led by a doctor with relevant skills and experience and appropriate specialist support, taking into account the variety of presenting symptoms. [2020, amended 2021]


Provide integrated, multidisciplinary rehabilitation services, based on local need and resources. Healthcare professionals should have a range of specialist skills, with expertise in managing fatigue and respiratory symptoms (including breathlessness). Additional expertise may be needed depending on the age and symptoms of the person. The core team could include, but not be limited to, the following specialist areas:

  • occupational therapy

  • physiotherapy

  • clinical psychology and psychiatry

  • rehabilitation medicine. [2020]


Share knowledge, skills and training between services to help practitioners in the community provide assessments and interventions, such as 1‑minute sit‑to‑stand tests and breathlessness training. [2020]


Agree local, integrated referral pathways between primary and community care, rehabilitation services and specialist services, multidisciplinary assessment clinics (where available) and specialist mental health services. [2020]

For a short explanation of why the panel made these recommendations, see the rationale section on service organisation.

Full details of the evidence and the panel's discussion are in evidence review F: service models.