COVID-19 rehabilitation centre: no input from experts?

  • Edna Astbury-Ward, Medscape.com

  • UK Medical News
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The first NHS Seacole Centre, formerly Headley Court, Ministry of Defence rehabilitation centre, admitted its first patients in May. According to NHS England, the Seacole Centre in Surrey is the first of its kind in England. It is being used as a temporary hospital for local patients who are recovering from COVID-19 and who no longer need care in an acute hospital, or those who have the virus and are unable to manage their symptoms at home.

After nearly 70 years as a Defence Medical Rehabilitation Centre, Headley Court, which stands on an 82-acre site, was transformed into The NHS Seacole Centre in 35 days, with teams across Surrey Heartlands, including Surrey County Council, the military and the NHS host trust Epsom and St Helier University Hospitals. More than 100 staff members have already been recruited to work in the facility, 130 beds have been opened so far, with capacity for up to 300 if they are needed. As of June 5 they had treated the first 15 patients. The agreed occupancy of the site by the host trust ends in 3 months' time, on October 24.

Development Background

Angle Property, an independent development company, bought the 82-acre site from the Trustees of the Headley Court Charity in 2018. The cost of the purchase which was marketed by Knight Frank was estimated to be in the region of £30 million. On April 24, according to Angle Property's website, Anthony Williamson managing director of Angle Properties, told Epsom and St Helier University Hospitals NHS Trust that it could use the site for 6 months. Ongoing planning issues are yet to be resolved with Headley Parish Council which has objected to residential development of the site.

D2i Management provided project management on the recommissioning work at Headley Court. Darren Talbot, director of D2i Management, told Building, a journal of the construction industry: "It [Headley court] hadn't been decommissioned, the MoD turned the lights off and walked away. It had fallen a bit into wrack and ruin."

When the developer heard about what was needed for the COVID-19 pandemic he said: "I've got a knackered old hospital they can have if they want it."

Mr Talbot told Building that it had been necessary to recommission the whole facility.

Rehabilitation Needs of COVID-19 Patients

There is a clear need to provide rehabilitation care to patients recovering from COVID-19,  both in bedded facilities and in the community, as for many of those who have survived the virus and the treatment required to combat it there may be a lasting impact on health.

The long-term consequences of COVID-19 are likely to have implications for all parts of the health and care system including primary, secondary, and community care.

In addition to known respiratory complications, COVID-19-related cardiac complications will need to be managed. Acute myocardial injury is the most commonly described cardiovascular complication in COVID-19, occurring in 8-12% of all those discharged. Heart failure is also reported in 12% of those recovered and discharged. Approximately one-third of patients may also have neurological deficits, some of which may be long-term.

Rehabilitation Experts' Opinions

Professor Lynne Turner-Stokes, director, Regional Hyperacute Rehabilitation Unit, Northwick Park Hospital, and professor at King's College London, has a long career in rehabilitation medicine, working with the Department of Health, NHS England, the British Society of Rehabilitation Medicine (BSRM) and the Royal College of Physicians (RCP). Prof Turner-Stokes has played a key role in the development of national policy around rehabilitation medicine.

She told Medscape UK that the BSRM and RCP had very little information about the Seacole centres, and that as far as she was aware there had been "no formal discussion with consultants or rehabilitation medicine experts in terms of what was needed and what would be helpful".

Right Place, Right Time? 

Prof Turner-Stokes said that "level 1 and level 2 specialist rehabilitation centres in the UK are mostly based in hospitals, as opposed to on "green field" sites. It [Headley Court] is not the easiest place to get to, and having outpatients in the middle of the countryside where people have to travel to is only going to serve a small population." She added that "it would have been good for us all to have a clear understanding of what the programmes are, the length of stay, the type of patients they will be treating, how they will select patients, how they will be monitored, what their outcomes are etc. There also needs to be some systematic collection of information and outcomes to make sure that we understand the role of these centres and how they fit in with the other existing services within the same region."

Prof Turner-Stokes runs the UK Rehabilitation Outcomes Collaborative (UKROC) a database of over 50,000 rehabilitation episodes, and added that "it would be very helpful if the Seacole centres can contribute to that database so that we can pass data to NHSE to better understand the contribution of these services, but so far we've had no approach to use the database, which is free to use". She pointed out "for this system to work properly, there really has to be some system for coordination between these Seacole centres and the specialist Level 1 and 2 rehabilitation services in the area, to ensure that patients are properly triaged so they can be managed in the place that best meets their needs".

Whilst Prof Turner-Stokes welcomed the establishment of new rehabilitation services especially in the wake of COVID-19, and said there will be some patients who will benefit from it, she also said "we still need to understand whether this is the most cost-efficient use of a resource in the right place, for people at the right time, or whether there are other models of care that may be more useful, including local community services that people can access from their homes".

Moving funds away from community rehabilitation services is also an area of concern for the Chartered Society of Physiotherapists (CSP) which has produced a policy statement on rehabilitation and COVID-19. CSP Chief Executive Karen Middleton welcomed the new centre, while also highlighting the need for further funding in community rehabilitation. She said on the CSP website: "Bedded units, like the Mary Seacole Centre, can be a vital link for patients' recovery between the hospital and their home, and we need to see the commitment to further centres followed through.

"However, we know people recover more quickly and fully if their rehabilitation begins in their homes straight after leaving hospital. And funding rehab centres should not be in place of investing in comprehensive rehabilitation in the community."

Clinical Modelling

Clinical modelling for rehabilitation services at Headley Court recommissioning was provided by PPL, a social enterprise and management consultancy. Its website states that it developed "a model based on accepting people that were still recovering from COVID-19 and had quite high needs". PPL does not have any actively-practising NHS clinicians on its team. It has one GMC-registered doctor without a license to practice, and a registered mental health nurse (registration with the Nursing and Midwifery Council requires revalidation showing that the registrant is involved with nursing-related practice). Although PPL has an exceptionally prestigious team, it does not have anyone with an expert background in rehabilitation medicine.

Rakesh Patel, chief financial officer, Epsom & St Helier University Hospital Trust and senior responsible owner for the NHS Seacole Centre, said on PPL's website that: "PPL were an integral part of the team and I did not see them as external advisors."

Prof Turner-Stokes is concerned that "this whole national project is moving ahead without the involvement of any input from consultants in rehabilitation medicine, or of the national groups that specialise in this area".

She added that "without rehabilitation medicine consultant involvement, there is concern that some patients with more complex needs might end up being placed in these centres without proper assessment or access to the relevant onsite support to meet their medical needs while they undergo rehabilitation".

Echoing Prof Turner-Stokes concerns, Dr Krystyna Walton, president of BSRM, and rehabilitation medicine consultant specialising in neurological rehabilitation at Salford Royal NHS Foundation Trust, who has been involved in developing major trauma rehabilitation pathways in England, told Medscape UK, that she "didn't know anybody within rehabilitation medicine who had been consulted on a national level about the concept and the ethos of the centres. The BSRM hasn’t been approached for any advice, I am not aware as to how they’ve been commissioned but they have not come through the usual commissioning routes for NHS England commissioning of rehabilitation services. Usual practice is that a service specification is drafted, which would then be adapted following consultation by relevant stakeholders, such as the BSRM."

Commissioning Services for Rehabilitation Medicine 

Dr Walton added: "The commissioning depends on the level of complexity of the rehabilitation need. So, for inpatient rehabilitation, the most complex patients (level 1 and some level 2a) are commissioned in dedicated units by NHS England. Level 2b units tend to be commissioned by multiple clinical commissioning groups (CCGs). For example, in my unit (level 1), I have to assure NHS England that the patients I accept into that unit fulfil the criteria for an NHS England commissioned level 1 service, and to do that we use validated tools to evidence that level of complexity."

Dr Walton explained that other rehabilitation was classified as non-specialist or intermediate (level 3 service) and is commissioned on a local CCG level and sometimes jointly by the CCG and local authority. Dr Walton explained that: "A level 3 unit in the NHS would manage patients who are likely to go home or back to a nursing/residential home. Patients with complex needs cannot be managed in that environment. In addition, if a patient has cognitive impairment, and needs cognitive rehabilitation, intermediate care cannot usually meet their needs."

Medscape UK asked Dr Walton if she thought this was the level of rehabilitation being proposed at the Headley Court Seacole centre and she said that without any information she "was not sure where they fit in". She added: "One would expect a multi-disciplinary approach to the triage of patients, which means that the right patient gets to the right service at the right time. I would also expect consultants in RM to be involved in some way with the Seacole centres, because there will be some patients who have complexity of needs that will require the expertise of an RM consultant, but I’m not aware of any locally to the Seacole Centre in Surrey that are involved. If they are then they haven’t made that known to the BSRM, which given the importance of post-COVID rehabilitation, I would have expected.”

Dr Walton also talked to Medscape UK about her concerns for post-COVID-19 patients with cardiac and respiratory co-morbidity who may be rehabilitated too soon. She pointed to a recent consensus statement by authors from the Defence Medical Rehabilitation Centre (DMRC) Stanford Hall, Nottingham, stating that rehabilitation exercise post-COVID needs to be gauged by cardiac and respiratory status.

No one from Epsom and St Helier University Hospitals NHS Trust was available for interview.

Adapted from Medscape UK.