In the second article of a two-part series on the new rehabilitation code of practice, Lynn Rouse explores concerns about cost, cohesiveness and potential public sector failure to join their private provider counterparts in the journey to compliance.
Initial frustration and disappointment at the absence of an accreditation scheme attached to the new UK code of practice for rehabilitation provision, has since been dispelled to a degree. Assurances have been given that a kitemark or similar is definitely part of the long-term plan, as well as explanation as to how pilots will test and tweak the specification during its two-year existence to ensure the end product is fully functional and fit for purpose.
But the launch of PAS 150 on 30 April also gave rise to other concerns — not least scepticism over the appetite of the NHS and other public sector bodies to embrace yet another standard. A GP present at the launch — on having it confirmed that PAS 150 would not be binding on primary care trusts — expressed the view that, in the current climate of financial austerity, they are unlikely to adopt anything unless it ticks a compliance box.
Additional question marks hang over the issue of accreditation costs, including fears that 'reinventing the wheel' will inflate these unnecessarily.
Andrew Pemberton, director at Argent Rehabilitation, is strongly in favour of accreditation but comments: "My only reservation is the implicit cost attached to accrediting PAS 150. We may all jump on the bandwagon and, because of widespread adoption, it becomes 'the' standard — only to be told, if you want to formally meet this, it will cost you £5000. That sort of sum would be prohibitive to a lot of organisations operating in our space."
He adds: "If it does become a formal standard with accredited assessors, it should be made clear that it will cost a certain amount every three years or whatever — that is the level of detail we are missing at the moment."
Melanie Summers, managing director of Chartis Medical & Rehabilitation, takes a rather more hard-headed pragmatic stance on the issue of inevitable cost. "Obviously, accreditation would create expense and it would be a big step for the rehabilitation industry to start ticking compliance boxes. From talking to colleagues in the industry, there is a view that having a full and proper British standard would be too expensive. But my view is that if it costs, it costs. You can't demand accreditation and then say you can't afford it."
So, is provider consolidation a likely consequence of accreditation cost? "Yes, because the industry is currently very fragmented," she responds. "It may go the same way as the medico-legal agencies where there were loads of providers and many consolidated together to create a few big players. I suspect the same will happen here. Otherwise people will simply not be able to compete."
Additional questions arise when attention turns to who will perform the role of accreditation. Who will, ultimately, create the process and be responsible? Gail Kovacs, director and contract manager at KMG Partners, was the technical author of PAS 150 and urges everyone concerned to address these questions sooner rather than later — explaining that individual vocational rehabilitation projects are already off considering issues over accreditation processes and even suitable practitioner regulation. "We all need to talk now before these various processes get too far advanced," she says. "At the moment there is no cohesiveness, no one is pulling together, and there are too many stakeholders."
But Tony Urwin, director of vocational rehabilitation services at Shaw Trust, believes an equal danger lies in allowing the debate about accreditation to divert attention from other much-needed developments. "It's great to get a minimum standard, so now we just need to get on and comply. But we must not let it distract from our key focus, which is outcomes. This is what we are crying out for — what is the cost-benefit ratio of rehabilitation and can we prove it? Personally, I am quite happy to contribute financially to a joint resource and use an independent body, such as a university, to measure what we are doing." However, he adds that the introduction of minimum standards and industry codes of practices could well assist this process. "Standards can be a great factor in ensuring we are all working in the same way. If we all take them on board, we can enforce consistency and measure our outcomes more easily."
One potential way to contain the costs of accreditation would be to "piggy back" — as Ms Kovacs puts it — on existing established schemes. One cited by several commentators is Carf, the North American-based and internationally recognised Commission on Accreditation of Rehabilitation Facilities. Some UK providers have already invested significant time, money and resource in becoming Carf-accredited. Examples include the Brain Injury Rehabilitation Trust, the national spinal injuries centre at Stoke Mandeville hospital and Rehab Without Walls.
Carole Chantler, medical relationship manager for insurance at DWF, and current chair of the UK Case Management Society, is supportive of this approach and urges the UK not to reinvent the wheel. "Yes, Carf is a US-based organisation but it is also not-for-profit and international, covering all aspects of rehabilitation," she says. "For providers that have gone down this route it is expensive and time-consuming, with service users being part of the accreditation process. These are leading players who are voluntarily choosing to spend their own money because they recognise the need for accreditation. So, while I realise this may be a controversial point, why are we doing it on our own, trying to reinvent the wheel, when financial resource and time are already limited and only set to become more so?"
Ms Kovacs is inclined to agree, commenting: "What we all want to see is proper vetting taking place and Carf for one definitely meets that need. Why not just pick an existing accreditation scheme, adapt it and adopt it? We don't have to start from scratch. If we piggy back, we can keep it as cost effective as possible."
Over and above the understandable concerns about accreditation cost, some providers raise questions about the content of PAS 150 and their wish for clarification. For example, Mr Urwin points to an interpretation issue with the new standard. He would like to see defined what constitutes 'evidence of' certain standards. For instance, when it comes to performing the initial needs assessment, which covers cognitive function, there is no detail at present as to what would be an acceptable level of evidence. "It could be simple questions — such as 'can you think clearly?' or 'can you concentrate and focus?' — or the need to conduct a much more detailed 40-minute assessment," he says. "So, there is a lot of scope for interpretation. We may view something as meeting a standard, while others would not."
Yvonne Lane, business development manager for Corpore, also has a couple of queries having read through PAS 150. "It refers to written policies and working practice documents that should be made publicly available," she explains. "Obviously, I understand the need to document elements such as health and safety policy or data protection procedures but it could be a concern for the commercial sector to reveal all of their working practice information. Some may be regarded as unique selling points. Purchasers already expect such information in any tender as part of their due diligence process so we do provide it. But having it publicly available could make it difficult to make competitive decisions."
However, technical author Ms Kovacs is on hand to reassure providers about this point confirming that, when it comes to documenting working practices, this does only mean for the potential client in the way Ms Lane details above — as opposed to on a company's website for example.
Ms Lane's second query relates to dissemination of PAS 150 and the BSI's specific plans for raising awareness of it across all sectors. "We would welcome clarification about the marketing campaign, not least because we would like to review whether we could play an active role. We would also welcome workshops on how to apply this standard."
Brenda Williams, acting chief executive of the UK Rehabilitation Council, which sponsored the creation of PAS 150, confirms discussions have taken place with a view to putting on a conference that could cover the training element and have the BSI standard as a feature so delegates can learn how to use it. This would be in addition to workshops that have already begun on using the UKRC's own standards, which are more specifically aimed at purchasers of rehabilitation.
But perhaps the most common concern is the potential for a two-tier system to develop, referring back to the GP's comments made at the launch of the new code of practice. PAS 150 is specifically designed to cover every type of rehabilitation provider — from NHS and private hospitals, to private providers of medical and vocational interventions to community and social care-based organisations. It is feared that the code's status as a 'nice-to-have' rather than mandatory must-have will mean there is no real appetite for adherence, particularly in the public sector which is already heavily regulated and obviously lacks the incentive of purchasers, such as insurers or employers, stipulating that their provider partners comply.
"There is definitely concern and I don't know the answer to how we overcome this issue," comments Ms Lane. "Unfortunately it could result in a lack of consistency across the board with compliance left not only to the private providers but the bigger ones at that."
However, as long as those in the public sector are made aware of the new code of practice, and take the time to review it, Mr Urwin is convinced the burden of compliance would be relatively low, explaining that good clinical practice and standards would likely "cover off about 80% to 90% of this. They simply need to conduct a gap analysis."
One potential stumbling block identified by Ms Kovacs is knowing 'who to go to' with the standard in the public sector. "The Department of Health on its own is huge, for example, so, unless this is addressed at parliamentary level, who will take it forward? In the UK we need some kind of streamlining — an inter-governmental department."
Drive things forward
Ms Chantler shares these concerns, stressing that the healthcare sector involves very different types of 'purchasers' or commissioners of rehabilitation. But she does have an interesting take on how the private-funded sector could help drive things forward. If the insurance industry, as a whole, required rehab providers to sign up to the standard as a prerequisite for being granted contracts, she says: "The Association of British Insurers could then lobby the government to say 'we are doing our bit, what about the public sector?'. I've worked in the NHS and everyone wants to adhere to best practice but things are so tight. This needs someone to drive it at government level."
Personally, she would like to see the BSI piloting PAS 150 with two or three large trauma centres around the UK, "to find out whether it works for them and ensure they have reviewed the document. We really need people working within the healthcare sector to say whether this works or not."
In fact, she makes a case for why it is arguably even more important for the public sector to take up and adhere to this new code of practice than the private sector. "Looking across all practices, including GPs, the initial port of call after an accident will usually be the NHS. And if insurers do not know about an injured person until six months down the road, that makes effective intervention very difficult. If standards like this are not adhered to within the NHS, and a person does not receive appropriate care, you cannot make informed decisions or step in and are already behind the curve."
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