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Is There a Rehabilitation Postcode Lottery?

Posted in Sponsored Feature on 28th May 2013


Colin Ettinger et al

Colin Ettinger, LLB (Hons) is a rehabilitation and serious injury law partner with Irwin Mitchell. He has over 30 years’ experience representing serious injury victims and is a vice-president of the College of Occupational Therapists. He is also an honorary research fellow at the School of Law at Lancaster University.

Emma Hawe, MSc Applied Statistics is Head of Statistics at OHE Consulting. She has published in excess of fifty peer reviewed publications. Emma has advised various organisations, including the Department of Health on her research interests, which include statistical methods for the assimilation and analysis of health related data.

Sarah Karlsberg Schaffer, MSc Economic Policy is an economist at OHE Consulting. Her research interests include the relationship between formal and informal care and the economic effects of the ageing population. She is also interested in investment decisions in the NHS, applied industrial organisation and labour economics.

Lesley Baillie, BA (Hons) Public Administration has been involved in the collation of health statistics for over 20 years and has considerable experience in the availability of sources of health and healthcare information in all countries of the UK and in conducting systematic literature reviews.

In 2011, over 13 thousand people suffered a serious injury as a result of a road traffic collision (RTC) and required three or more days1 stay in hospital (likely requiring rehabilitation). There are an estimated 1 million people living with the consequences of brain injury in the UK,2 which is reported to be associated with increased vulnerability to death for at least 13 years post-injury.3 But research carried out by OHE Consulting, on behalf of serious injury and rehabilitation specialist law firm, Irwin Mitchell,reveals that current rehabilitation provision can be a postcode lottery.

While there are programmes underway that are helping to improve access to specialist rehabilitation services, such as UK Rehabilitation Outcomes Collaborative (UKROC) and TARN databases, patients in some areas can’t access the right rehabilitation services, with a four-fold difference in the interquartile range between reported rate of specialist inpatient rehabilitation services for head injuries at the Primary Care Trust (PCT) level,4 amongst those that record rehabilitation episodes, (Interquartile range 1.4,6.8 per 100,000 population).

Our research, Counting the cost of the rehabilitation postcode lottery for road crash victims,5 draws together information from a range of sources, including the latest available Hospital Episodes Statistics (including PCT level data from 2010/2011 and 2011/2012), rehabilitation studies from different countries and the experiences and recommendations of rehabilitation healthcare professionals. It builds a national picture of use and demand for rehabilitation services across England. This review focuses on brain injuries, and those injuries sustained in RTCs.

A key finding from our research was the discrepancies and inconsistencies in the way that information about rehabilitation services is recorded, necessitating the consultation of multiple data sources.

Our research included a series of recommendations,outlined at the end of this review,and suggests that co-ordinated and intensive rehabilitation could save the NHS money; improve patients’ recovery prospects and the emotional well-being of their carers; and help patients to play a more active role in society.

Demand for rehabilitation services

In 2011/12 there were 151,678 patients admitted to hospital in England following a head injury, equivalent to 285.5 per 100,000 population. Table 1 shows that 16,551 of these individuals were admitted to a hospital in England for three or more days and may be considered likely to require rehabilitation in 2011/12. Estimates in the literature relating to the proportion of head injuries which result from RTCs is variable. Wade et al6 reported that over two-in-five admissions for head injuries were as the result of an RTC. In contrast a study by Thornhill7 noted that just 11% were injured due to an RTC. Pulling together available information relating to underlying external cause coded for head injury admissions to hospital in England in 2011/12, around 1 in 13 were recorded as being as the result of a RTC.


Variation in brain injury admissions at regional level

Tennant9 has explored variation in inpatient admissions for brain injuries for all causes at PCT level and considered underlying factors which may influence admissions rates. It noted that regional differences may result from underlying factors such as rural and urban locations and the level of deprivation.

Variability is observed in the per-population rate of patients admitted as an emergency in England in 2011/12 at PCT level (Interquartile range 178, 515).10 A correlation between the per-population rates of emergency admissions for head injuries for 2010/11 and 2011/12 is observed at a PCT level, indicating underlying factors other than the population size affect the number of admissions. Figure 1 demon- strates the high level of variability,and also indicates that underlying factors may not be adequately accounted for through the calculation of expected rates,using only the population size of the PCT.This casts doubts on the appropriateness of the confidence limits.11 Variation was also seen when considering only those admissions resulting from RTCs, with an interquartile range from 12 to 38. This indicates the variability in admissions for head injuries at PCT level resulting from an RTC, which is not explained by differences in the underlying population size.

Figure 1: Funnel plot of rate of patients admitted per 100,000 population for head injuries at PCT level, by PCT of treatment in England, 2011/1212. Notes: expected activity is based on population sizes and the national rate of rehabilitation episodes. The level of dispersion suggests that there are some underlying factors which are not properly accounted for.

Figure 1: Funnel plot of rate of patients admitted per 100,000 population for head injuries at PCT level, by PCT of treatment in England, 2011/1212.
Notes: expected activity is based on population sizes and the national rate of rehabilitation episodes. The level of dispersion suggests that there are some underlying factors which are not properly accounted for.

Rehabilitation access

There is limited evidence on access to rehabilitation services in England. Information tends to be based on small studies of patient subsets. However, rehabilitation specialists have highlighted a perceived lack of rehabilitation capacity, and a number of sources (a survey of PCTs and initial findings from a trial of rehabilitation services following intensive care) indicated fragmentation and lack of access to specialist services for those with long-term neurological conditions.13

There was a weak relationship between patient admissions for head injuries with a 3+ days’ stay and the number of patients receiving rehabilitation treatment under a rehabilitation consultant for head injuries in England in 2011/12. Inpatient admissions for rehabilitation for head injuries were found to be variable at PCT and SHA level. Rates of head injury rehabilitation admissions per population and per emergency admissions were also found to vary at PCT level.

Roundtable discussions with rehabilitation specialists suggested that access to vocational rehabilitation varies across England for those suffering an acquired brain injury, with clusters in London, the Midlands, the North of England and Scotland, but a lack of facilities in the South West of England.

Challenges facing delivery of rehabilitation services

Discrepancies and inconsistencies in the recording of information are compounded by a lack of resources, co-ordination of care pathways and disjointed funding, exacerbating access issues.

1. Resources

Rehabilitation healthcare professionals indicated that resource challenges meant that rehabilitation is often not sustained for long enough to allow a patient to continuously improve. In some cases, for example for neuropsychiatric rehabilitation, there are simply not enough services available.

One of the most common concerns was that community care is insufficient, or short-lived, with some specialists reporting that community care for a serious injury patient seemed to drop off after the first six months. One contributing factor that was suggested was a high turnover of community care staff.

2. Continuity and coordination of care pathways

A lack of continuity and coordination of care as patients are transferred from one service to another was highlighted as a key barrier to effective rehabilitation.

In the first phase of treatment, the healthcare team who treat a patient may not have the expertise to assess the long term impact of a patient’s injuries and their continuing care needs. This increases the risk of delay in getting the care pathway and specific rehabilitation requirements right. Beyond this, many attendees recounted experiences of a delay in transferring patients from an acute hospital setting to a specialist rehabilitation unit.

3. Disjointed funding

Historically, effective access to rehabilitation has also been hampered by disjointed and conflicted funding bodies, eg PCTs and social services, which mean that the financial support offered to some patients can be too little, too late. It will be interesting to see how this is addressed under Clinical Commissioning Groups.

Rules concerning when funding can be released, on the basis of a patient having met particular goals set for them, can also slow and stem the provision of adequate financial support.


Based on our full analysis, we can surmise that serious injury patients need more coordinated and sustained care. By getting patients into rehabilitation more quickly, and taking a more holistic view of his/her needs – from rehabilitation (whether on the NHS or through private companies and funded by compensation from litigated cases) through to in-home care and support in accessing Local Authority and charity services – we can improve functional recovery prospects.

We have drawn a number of recommendations to help improve access to specialist rehabilitation services and care:

1. Record rehabilitation data in a consistent way across all English Clinical Commissioning Groups to allow for easy comparison, eg by expanding the UKROC database to include community level data

2. Identify best practice and demonstrate the financial benefits to secure further funding

3. Calculate the life-long rehabilitation needs of patients, and pool funding to deliver it through a single body

4. Improve care for people once they are back at home through more specialist community rehabilitation services While some initiatives have been put in place which are beginning to better integrate services more effectively, and improve quality of care, our research suggested that much more needs to be done.

To receive the full report Counting the cost of the rehabilitation postcode lottery for road crash victims, please email:


1. Emergency admissions following a road traffic collision requiring an inpatient stay of 3 or more days and potentially requiring long-term care. Copyright © 2012, “Re-used with the permission of The Health and Social Care Information Centre. All rights reserved.”

2. Crude estimate of prevalence based on the assumptions in the Tennant 2005 paper and the estimated incidence rate calculated based on HES data.

3. McMillan TM, Teasdale GM, Weir CJ, & Stewart E. Death after head injury: the 13 year outcome of a case control study. J.Neurol.Neurosurg.Psychiatry. 2011;82(8):931-5.

4. HES data for patients treated under a rehabilitation consultant for PCTs in England for 2011/2012

5. OHE Consulting, on behalf of Irwin Mitchell, Counting the cost of the rehabilitation postcode lottery for road crash victims. London. 2013.

6. Wade DT, King NS, Wendon FJ, Crawford S, Caldwell FE. Routine follow up after head injury: a second randomised controlled trial. J Neurology, Neurosurgery and Psychiatry 1998;65:177-83.

7. Thornhill S, Teasdale GM, Murray GD. Disability in young people and adults one year after head injury: prospective cohort study. BMJ 2000;320:1631-5.

8. Copyright © 2012, “Re-used with the permission of The Health and Social Care Information Centre. All rights reserved.”

9. Tennant (2005). Project Final Report. Project Number 030/ 0067 Epidemiology of Traumatic Brain Injury. Leeds University. Sponsored by Department of Health. 31st March 2005.

10. Copyright © 2012, “Re-used with the permission of The Health and Social Care Information Centre. All rights reserved.” 11. Spiegelhalter 2005. Funnel plots for comparing institutional performance. Statist. Med. 2005;24:1185-202.

12. Hospital Episode Statistics data, 2012, Re-used with the permission of The Health and Social Care Information Centre.Graph created using Analytical tools for public health by the Association of Public Health Observatories.

13. Walsh, Salisbury, Boyd, Ramsay, Merriweather, Huby, Forbes, Rattray, Griffith, Mackenzie, Hull, Lewis, Murray (2012). A randomised controlled trial evaluating a rehabilitation complex intervention for patients following intensive care discharge: the RECOVER study. BMJ Open.