No one will be surprised to learn that rehabilitation and enablement services commissioned by the U.K.’s National Health Service and mostly provided by Allied Health Professionals shows great variation in their staffing (grades and types), general resources, modes of practice, service users catered for (types and ages), care models, and intentions. Much of this variation is associated with the history of configurations of service provision over previous decades – few, if any, services have been organised on the basis of patient outcomes as it is difficult to capture such outcomes for this heterogenous group.
Whilst there has been a substantial increase in research investigating specific interventions for specific groups of patients receiving rehabilitation including randomised controlled trials and other appropriate methodologies the evidence base is still thin given that the majority of patients receiving rehabilitation (both children through to older adults) have a range of comorbidities rendering it necessary to combine interventions, adjust goals and therapy approaches and making it unlikely that they would be included in any research project. Most research requires clear definition of those patients included and those excluded and there is a requirement to consider the fidelity to the intervention being investigated. Such research helps in establishing a better understanding of underlying conditions and the theoretical basis of different interventions but clinicians often find it difficult to inform their practice based on these due to the challenge of generalising such precise findings to the caseloads that they serve.
The Commissioning Guidance for Rehabilitation recently published by NHS England (March 2016)1 reflects the complexity of meeting the needs of a broad range of individuals who require and would benefit from rehabilitation.
‘Rehabilitation achieves this by focusing on the impact that the health condition, developmental difficulty or disability has on the person’s life, rather than focusing just on their diagnosis. It involves working in partnership with the person and those important to them so that they can maximise their potential and independence, and have choice and control over their own lives. It is a philosophy of care that helps to ensure people are included in their communities, employment and education rather than being isolated from the mainstream and pushed through a system with ever-dwindling hopes of leading a fulfilling life.’
But this guidance also acknowledges the need to ensure that services are commissioned and monitored in an appropriate fashion, services learn from best practice and the most cost-effective approaches are used.
It is not uncommon for a particular Health Service Trust to provide excellent services for particular client groups but fall down in services to other groups (NHS Atlas of Variation 2015)2. Furthermore, it may not be recognised that this is the case by either the Commissioner or the provider of the services. This is probably why The Commissioning Guidance for Rehabilitation1 emphasises the importance of collecting outcome data and engaging in audit and benchmarking which can identify strengths and weaknesses.
The objectives of benchmarking are (1) to determine what and where improvements are called for, (2) to analyse how other organizations achieve their high performance levels, and (3) to use this information to improve performance.
In order to conduct benchmarking such as has been undertaken in, for example, the very successful Stroke National Audit Programme3 and the National Audit of Intermediate Care 4 it is necessary to identify the necessary data to collect and an appropriate outcome measure. However, due to the broad number of health and social care professionals as well as the number of different client groups receiving rehabilitation there are numerous outcome measures available to choose from. But this causes the problem that different services favour different approaches to outcome measurement making it difficult to compare and contrast service provision. A generic measure which could be used alongside more specific outcome measures may assist more general comparison of services.
‘Focusing on outcomes is one way of enabling the transformational change required in the healthcare system.’ p19 Commissioning Guidance for Rehabilitation
The Therapy Outcome Measure (TOM)6 was designed to be a simple, reliable, cross-disciplinary and cross-client group method of gathering information on a broad spectrum of issues associated with therapy/rehabilitation. It has been rigorously tested for reliability and clinical validity and can be used by physiotherapists, occupational therapists, speech and language therapists, podiatrists, dieticians ,rehabilitation nurses and others involved in rehabilitation.
It aims to be quick and simple to use, taking just a few minutes to complete. It was based on examining the goals used in rehabilitation with unselected patients and their carers and has been used for treatment planning, clinical management, audit, benchmarking and research.
The TOM6 allows therapists to describe the abilities of a patient in four domains the first three of which are based on International Classification of Functioning (WHO ) definitions as detailed in the rehabilitation guidance1:
|Dysfunction resulting from pathological changes in system|
|Activity restriction/function||Functional performance /independence|
|Participation||Integration in society (including employment, education and recreation)|
The fourth domain of well-being, of both the patient and the carer was added to the TOM due to the finding that having an impact on well-being is an objective of rehabilitation in many if not all client groups and thus needs to be separately identified in the outcome measure.
TOM6 has an 11 point ordinal scale. A rating from 0 to 5 is made on each domain, where a score of 0 is profound, 3 is moderate and 5 mild. For example a score of 0 for ‘Activity’ represents a patient who is totally dependent/unable to function; a score of 3 for ‘Impairment’ represents a patient who has a moderate dysfunction resulting from pathological changes; a score of 5 for ‘Participation’ represents a patient who has is integrated and able to maintain their expected different roles in society, is valued by others, and exercises choice and autonomy. A score of 0.5 or ½ a point may be used to indicate if the patient is slightly better or worse than a descriptor.
The TOM Core Scales has been adapted into scales that relate to conditions that are familiar to a range of health care professionals involved in rehabilitation /enablement and acute care. These scales (47 are available in the third edition) have been adapted by specialists working in the relevant areas. The book provides background as to how the tool was developed, how TOMs can be introduced to a team or service, guidance on how to use the tool and guidance on how to analyse data.
Research underpinning the TOM7-17 suggest that some services emphasise and have an effect on improving the underlying condition (impairment) whereas others concentrate on having an impact upon improving activity, social participation or well-being and that services can have significantly different patterns of outcome.
The Royal College of Speech and Language Therapists are the first of the Allied Health Professional groups to review appropriate outcome measures with the objective of gathering data on all clients receiving intervention by a speech and language therapist. They considered 60 candidate outcome measures commonly used within the profession and which had been identified by their membership against 11 criteria which included a range of psychometric properties. The Therapy Outcome Measure was identified as the core measure which after piloting will be used to collect national data allowing information related to the impact of SLT to be gathered and compared.
Rehabilitation requires not only highly sensitive and specific outcome measures for use by the different professionals involved but also generic measures in order that the overall impact can be gauged, compared and integrated into continuing quality improvement.
- Commissioning Guidance for Rehabilitation recently published by NHS England (March 2016) Publications Gateway Ref No. 04919 https://www.england.nhs.uk/wp-content/uploads/2016/04/rehabilitation-comms-guid-16-17.pdf
- NHS Atlas of Variation 2015. Public Health England http://www.rightcare.nhs.uk/atlas/RC_nhsAtlas3_HIGH_150915.pdf
- Sentinel Stroke Audit. Royal College of Physicians
- National Audit of Intermediate Care. 2015 NHS Benchmarking Network. Document reference: NAIC2015
- International Classification of Functional Disability and Health. 2001. World Health Organisation, Geneva
- Enderby P, John A, 2015. Therapy Outcome Measures for Rehabilitation Professionals. 3rd Edition J&R publications. Guildford
- Enderby P, Hughes A, John A, Petheram B. Using Benchmarking data for assessing performance in occupational therapy. Clinical Governance: An International Journal 2003;8(4):290-295..
- Enderby, P. (1999) For richer for poorer: outcome measurement in speech and language therapy. Advances in speech language pathology volume 1 number one pp. 63–65.
- Enderby, P. and John, A. (1999) Therapy outcome measures in speech and language therapy: Comparing performance between different providers. International Journal of Language and Communication Disorders, 34, 417–429.
- Enderby, P., John, A., Hughes, A., and Petheram, B. (2000) Benchmarking in rehabilitation: comparing physiotherapy services. British Journal of Clinical Governance, 5(2), 86–92.
- Enderby, P. and Kew, E. (1995) Outcome measurements in physiotherapy using the World Health Organisation’s classification of impairment, disability and handicap: a pilot study. Physiotherapy. Volume 81 number four pp. 177–183.
- John, A. (1993) An Outcome Measure for Language Impaired Children Under Six Years: A Study of Reliability and Validity. MSc. Thesis, City University.
- John, A. and Enderby, P. (2000) Reliability of speech and language therapists using therapy outcome measures. International Journal of Language and Communication Disorders, 35, 287–302.
- John, A., Enderby, P., and Hughes, A. (2005a) Benchmarking outcomes in dysphasia using the therapy outcome measure. Aphasiology, 19(2), 165–178.
- John, A., Enderby, P., and Hughes, A. (2005b) Comparing outcomes of voice therapy: A benchmarking study using the therapy outcome measure. Journal of Voice, 19(1), 114–123.
- John, A., Enderby, P., Hughes, A., and Petheram. B. (2001) Benchmarking can facilitate the sharing of information on outcomes of care. International Journal of Language and Communication Disorders, 36 Suppl. 385–390.
- Ryan, A. (2003) An Evaluation of Intensity of Community Based Multidisciplinary Therapy Following Stroke or Hip Fracture for People Aged 65 and Over. PhD Thesis, University of Sheffield.