Rehabilitation is a way of thinking,not a way of doing

There is strong evidence that the processes used by rehabilitation services are effective at reducing mortality and morbidity, yet purchasers still feel that there is insufficient evidence to warrant buying rehabilitation. Why? Evidence in support of many individual treatments is either weak or absent, but it is important not to conflate evidence about the process with evidence about specific actions. The absence of evidence concerning specific interventions should not be interpreted as meaning that rehabilitation is ineffective, and should certainly not be used as an excuse not to purchase rehabilitation. The evidence strongly suggests that the whole system works and until we have further evidence, the system should be bought as a whole. Further research into specific interventions should continue, but in addition there should be more research attention paid to the rehabilitation process itself.     

New wine in old bottles: the WHO ICF as an explanatory model of human behaviour

The World Health Organization's International Classification of Functioning (WHO ICF) is a good but incomplete framework for describing the situation of someone with long-term ill health. Several deficiencies exist for which improvements are suggested. The WHO needs to integrate the ICF with the ICD-10 to form a comprehensive system of classification of illness. Words are needed for normality at the level of organ and person, and the words 'histology' and 'physiology', and 'anatomy' and 'capacity' are suggested for the two levels respectively. A fourth context, that of time, is needed to understand fully a person's situation. The classification framework needs to take more account of the patient. It needs to recognize two separate perspectives, that of the subject and that of external observers and it needs to recognize two other specific person-centred phenomena: free will and quality of life. With changes and additions to take account of these deficiencies, the WHO ICF can be used as a powerful analytic and explanatory model of human experience and behaviour in any situation, not only in illness and disease.     

Selection criteria for rehabilitation services

In an era of inadequate resources for all health services, rehabilitation services providers are frequently asked to produce criteria defining the patients they will accept. In principle rationing of services by ability to benefit is fair. In practice there are many difficulties. The evidence to allow selection of patients for rehabilitation does not exist and probably the best criterion of ability to benefit from rehabilitation (not 'likely to have a good outcome') is demonstration of benefit within a rehabilitation programme. Basic considerations of epidemiological statistical facts also show that criteria are likely to select too many inappropriate patients into services or exclude too many appropriate patients from services. The solution is for purchasers and providers to develop mutual trust and, in the UK at least, to ensure that patients who do not need rehabilitation can be discharged quickly into appropriate support services.