Webinar NRC

On 16 March, speakers from across the neurorehabilitation sector explored the role of the Consultant in Rehabilitation medicine, from training and areas of responsibility to the benefits and opportunities that having such an expert in a multi-disciplinary team has for patient outcomes.

Chaired by Dr Edmund Bonikowski, Founder of NRC Medical Experts, the panel included Dr Julian Harriss, a highly experienced Consultant in Rehabilitation Medicine who has worked in the UK and in Canada during his career, Ben Townsend, Partner in Personal Injury at Stewarts, Dr Inam Hai, Consultant in Rehabilitation Medicine and Anna Watkiss, Clinical Lead and Senior Case Manager, Tania Brown.

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NR Times and NRC Medical Experts Webinar Series

This webinar is the third in a series of three of discussions with NR Times and NR Medical Experts.

NRC Medical Experts provide an extensive range of medico-legal reports, services and testimony for claimant and defendant solicitors, barristers and legal teams. Through their NRC Clinical Practice, Consultants in Rehabilitation Medicine oversee an individual’s rehabilitation and recovery journey, ensuring the better outcomes, joined up care and therapeutic intervention with better oversight for legal teams.

Webinar Transcript

Please note, as this transcript is automatically created it may not be 100% accurate.

Dr Edmund Bonikowski 0:00
Today, we’re going to talk about the role of the consultant in rehabilitation medicine. And I’m very pleased to be able to say I’m joined by four colleagues, Julian Harriss, physical medicine and rehab consultant, Ben Townsend, who’s a Partner at Stewarts, Anna Watkiss senior case manager and lead psychologist and Dr. Inam Hai, who’s a consultant in rehabilitation medicine, down in Somerset, where we know a great deal about the paucity of rehabilitation expertise.

Dr Julian Harriss 0:59
So I’m very grateful to Ed and others for having arranged this. I’m a consultant, as you say, in physical medicine and rehabilitation, and been working with the BsrM to change the name in the UK, to physical and rehabilitation medicine. And that would be to reflect the international nature of our specialty and abroad, oversight. And if I can just say one thing about a specialty and what draws me to the specialty in particular draws me to work with NRC is that we are probably the last group of generalists who are truly specialists generalist in the UK, as all the silos of very narrow interests have evolved in the medical profession, rehab medicine has remained broad. And so that I think we offer a unique insight into a number of different aspects of a very complex patients case, who didn’t just bang their head, but suffered internal organ injuries and broken bones and all other things. So I think that’s why sometimes I’m asked to offer an opinion on several other very complicated issues. And I think that makes us very special.

Dr Edmund Bonikowski 2:18
That’s great. Julian, thank you for that.

Ben Townsend 2:20
Ben Townsend, I’m a partner at Stewart’s I’ve worked in personal injury now law for 28 years. And seen a lot of changes in that time. I’m very excited to talk about the subject today.

Dr Edmund Bonikowski 2:52
Thanks, Ben. Anna, would you just say a few words of introduction, please?

Anna Watkiss 2:57
So I am a clinical lead for case management company [Tania Brown]. My background is Psychology. I’m a chartered psychologist. And I’ve been in case management for actually the same amount of time has been has been a solicitor. So 28 years, I’ve been in case management and be interesting to talk to them. I’ve worked with a lot of rehab consultants, in turns, many of them generally being an inpatient. So be interesting to take the chat wider.

Dr Inam Hai 3:29
I’m Dr Inam Hai and one of the rehab consultants here in the south west. So I’ve been here for about 25 years and in Taunton. Yes, I think the speciality wise the certainly it’s a kind of speciality, which sometimes competes against the big hitters like cardiology, and cancer and trauma, just as an overview, really. And I think so it is, particularly training wise, the updated curriculum, etc. It just shows that there are a lot of complexities involved in the training process as well. And it’s one of the specialties where you always have to have an overview hat on all the time, every time you can’t let that go. Because any sort of one thing in the loop then affect the next one’s I think that would be good to have a bit of a discussion, sort of in an overall context.

Dr Edmund Bonikowski 4:45
Well, funnily enough, I’ve been a consultant in rehab medicine for 28 years as well. So there we are quite a lot of accumulated experience. And in fact, I’m currently Clinical Director of neuro rehab for the county of Somerset. So it Inam is one of my colleagues down there. And obviously, I have a role in NRC medical experts, both Julian and in our, my, my colleagues there with different hats on actually. And importantly, and Julian is very predominantly medical, legal expert orientated and in his very much more clinical service, clinical practice orientated. And those are two distinctions that will hopefully come up in the dialogue. You know, I’ve only got half a dozen or so slides. And I don’t want this to be my show. I want it to be the dialogue between the attendees and the experts here, assemble. rehabilitation medicine doctors job is to provide intervention to patients with complex disabling conditions. And of course, you know, I knew that 90% of the attendees today are Personal Injury Solicitors. And therefore, I expect that your client load is exactly this, people with complex disabling conditions, brain injuries, spinal cord injury, and so on. And our focus lies in optimising recovery, following severe injuries and improving function. And thus facilitating participation in society for individual services where we’re getting to those those formal definitions of pathology impairment, ability, participation and quality of life, we, as rehab physicians work across that whole piece substantially in our particular organisation in neurological conditions, but as Julian’s very very well pointed out, this is physical medicine and rehabilitation, physical medicine, incorporating other areas of pathology, like empty medicine, like muscular skeletal, and then the separate issue of spinal cord injury medicine, which has found and have found a home of its own. Rather than doing incorporate into neurological rehabilitation, there’s a historical reason for that.

So what I’m just going to give you a very quick summary of the roles that we have, and this this is not this is not invented from my head, I have drawn very heavily here on the training curriculum for rehabilitation medicine, as developed by the Royal College of Physicians. So we have particular skills in the diagnosis, management and prognostication of complex disabilities. And that is a very different thing from most doctors. Most doctors are oriented to a single pathological territory, and will become extremely focused on that cardiology, neurology, gastroenterology. And as Julian has already said, it’s an excellent phrase where we work as the expert generalists. And we are skilled at interpreting multiple symptoms and impairments in differing contexts social and psychological. And this is really important we operate in you’ll have heard the phrase, the bio, psychosocial model, biological factors, psychological factors, social factors, all influencing the extent to which an individual experiences, the impact of impairment, the impact of the pathology that’s caused the impairment. And using that interpretation, we formulate realistic rehabilitation plans that balance the multiprofessional input that’s required. And you know, good rehabilitation, as you will all know, this. Is it’s not a single spectrum. And I’m certainly not here, we’re not here to say that medical doctors are the be all and end all of this game. We definitely not. But I think we are here to say that we do have a very useful contribution to make to multidisciplinary team and a contribution that I think in my experience, is often overlooked. And I think it goes to Julian’s point, which I will talk about a bit later that there is a paucity of rehab physicians. So you’ve got 123 of us here. I know, there are a few of you online watching this, you probably got 10% of the total rehab physicians in the country on this call. So that’s how few we are. And it was about 180 altogether, and not all full time. So we we play a vital role in post acute care, and should be closely involved in that. This is this is where we were introduced through the rehabilitation prescription. And you know, I had a very good experience of that about 2012 When I was working in Cambridge, I was on the ITU seeing patients one day, sometimes half a day, sometimes a couple of days after really severe injuries being scraped off the road. so forth. So became an integral part of that acute management team, able to set the individual up for appropriate rehabilitation pathway within the acute care pathway and elevated rehabilitation medicine and rehabilitation to be an equal partner with the other clinical specialties, the intensive care specialties, the neurosurgeons, the orthopaedic surgeons, that was a really helpful thing for us to be involved in. So we have all the necessary experience of seeing people with brain and cord injury acutely, for example, and following them up long term to provide expert opinion on causation, condition or prognosis in these types of cases. I think one point I will just make is that oftentimes, the courts and indeed solicitors request opinions from neurologists, on condition, prognosis and causation in these type of cases. I have done some research into this and about 5%. So 5% of people with a brain injury ever see a neurologist? In other words, the neurologist don’t have a huge experience of brain injury, and its rehabilitation and the long term outcome, about 2% of spinal cord injured patients ever see a neurologist? So fundamentally, it is a a misconception that neurologists are the people to turn to for conditional causation, conditional prognosis reporting, as experts, they, and many of them will completely agree this, they simply don’t have the long term experience to be able to prognosticate about follow up, and they certainly, they certainly can’t advise on the specialty of rehabilitation.

And this is the slide that says how few rehabilitation doctors rehab consultants there are per 100,000, people look at those other numbers to 100, that’s 10 times as many per head of capita in Germany, almost four times as many in Italy three times when we are hugely under resourced. And to Julian’s point, in our earlier data, pre the webinar, it’s no wonder that you struggled to get hold of somebody to get active on your individual cases, for your clients. And in addition to gaining medical legal expertise, we are trying very hard to advance that, but you know, we’re still struggling.

And in many ways, what I’m doing here is I’m holding up the flag for the expertise that you are getting when you engage with one of us. So typically, we’ve done five years at medical school in which we are schooled in the basic sciences, the pathologies of anatomy, physiology, biochemistry, the basics of how the human body works, we’re then exposed to pathology on how that influences anatomy, physiology and biochemistry. So we have a core scientific understanding of why things go wrong with people. Now that is different. And in quantum, very different from most other clinical specialties. Many will touch upon that. But to my experience, understanding none touches on it with the same degree of focus and time spent as medical doctors. So that’s important. By the time you get a rehabilitation consultant, they have been through this process, a couple of years foundation trainee, perhaps three years in core medical training in one of those disciplines, that we’ve got things like internal medicine or surgical training, general practice, which is which is my background, even obscene Guinee, which I thought I find quite strange. But anyway, you can get into rehab medicine, having done your core training in any of these disciplines. Psychiatry, of course, a very relevant and important discipline, you then selected and then you do a minimum of four years specific training, professional training, rehabilitation medicine. So by the time you get somebody who’s got the consultant badge, they’ve got many years they’ve been in and around how the body works and what goes wrong. And then of course, you’re only really engaging with people who’ve been at it for a few years. So typically, your average at medical expert in rehabilitation medicine has probably been a consultant for five to 10 years really got their feet on the under the table, and they have been around this for 25 years. Okay, so that’s really important. This is not something that you just say, actually, I’m a rehab specialist. There’s a very clear pathway to becoming a GMC registered specialist in rehabilitation medicine.

A couple of other quickies. There are some new NICE guidelines published on 18th of January talking about rehabilitation after traumatic injury. This is a recommendation to you. It’s an excellent document, actually. And one of the headlines is, of course, that the improvements in survival rates have led to an increase in the need for rehabilitation, which think back to my prior slide is even more of a problem. There’s even more demand on our limited skills, and of course, COVID. And I’m not going to go into that now. But COVID has made a huge impact, because a lot of people have developed long term chronic problems, and rehabilitation is required for them and advice for them. And so that has complicated the picture. This is a comprehensive document, great aspirations for what good rehabilitation should look like. And the reality of how you achieve this. Of course, the reality is that achieving it’s extremely difficult, as we are finding in Somerset where we are currently restructuring our service and trying to get more resources in to provide something comprehensive for the people of Somerset. This document refers to an earlier clinical guideline from 2019 on head injury assessment and only management. These two I really come in to they’re fascinating, that part of the reason this is a self serving advert, advert there, they they are very clear about the contribution of medicine, alongside the other professions, neuro psychology, clinical psychology, psychiatry, physio OT, speech therapy, rehab, Assistant, nursing, all those things, very relevant, very important for a good well balanced team social work, of course, as well.

So our responsibilities are to formulate a full rehabilitation analysis of any clinical problem, any clinical problem presented, and that’s the key this is the generalist bit to include both disease related and disability related factors, or any patient no matter their age, conditional complexity, so very broad church this. And that’s why you need to do specialist training in this area, because it is not something that conventional medical specialties are trained to do. They just don’t approach the patient or the situation in the same way. not strictly true. I mean, psychiatrists are, are perhaps one group who who are orientate rather than more this way and general practitioners to some extent, but anyway, they are not necessarily focusing on the specialist pathologies that we are new brain injury cord injury Exactly. For example, we need to be able to set out a rehabilitation plan for any new patient with a disability extending beyond our own specific service.

As I’ve already said, the multidisciplinary team is paramount here, but we’ve got to be able to work as a full and equal member of that. And I think that because of the low numbers of rehab physicians, we have oftentimes been overlooked. And therefore the important medical contribution to a patient’s management is suboptimal. I see this all the time. I’m sure my colleagues will agree with me, but you know, it doesn’t seem to be getting any better yet. And we also have got to be able to identify and set priorities within a rehabilitation plan, because there’s a million things to do. But actually, there’s a there is a hierarchy there. And you’ve got to get the basics right. Next slide, please. Diagnose and managing system, new medical problems in rehabilitation context. So that rests on our medical skills, our diagnostic skills, our awareness of broad pathologies, like infection, and so forth, need to recognise the need for and deliver successfully specific medical rehabilitation treatments, botulinum toxin injection, so forth. We’ve got to be able to work in any setting. And this is directly relevant to our context today, isn’t it? You know, it’s all pretty well, having hospitals or clinics in which you can work, it’s nice and straightforward. Actually, the majority of patients are out in their homes, and many of your clients are out in their homes. And so we need to be able to get out there in the community and feel equally comfortable working there, and to collaborate with the other teams that are out there in the community, either general practitioners and their teams, or hospital specialty teams, but we are a we are a glue that brings all of the medical community together to the benefit of an individual patient and their rehabilitation. And then finally, we need to be able to make unjustified decisions in the face of many clinical socio cultural and prognostic and ethical and legal uncertainties and the influences that arise in complex cases. So it’s a it’s a big I take this as a big responsibility. I know that my two colleagues on screen or said do from rehab medicine.

So this is just a Very quick statement that NRC medical experts, we also have a clinical practice service. It’s trying to provide that medical expertise in rehabilitation medicine, for cases that you have in litigation during their litigation. So the ongoing rehabilitation. And also, of course, once settlement has been achieved, I don’t want to leave at this point. But there is a service here. This is what we do.

What I’d like you to do now is take part, let us have some question and answers. Have your say, through the chat dialogue. And I can then share a discussion between my colleagues particularly interested to hear that and what Chris’s view on the role of the rehabilitation physician in a in a rehabilitation team that she will case manage. And also, I’m very keen to tease out the distinction between case management expertise, and rehabilitation medicine expertise, I ought to just have a slight declaration of interest here. Between 2001 and 2010, I built and ran a case management company called konektor. And so I’m not an entirely obvious in case management and what it is and what it isn’t. But I don’t want to give my views I want to hear from an expert in case management, as I hope we all do.

Anna, would you would you like to kick us off? You know, I’ve talked a lot about my own professional angle. Would you like to give us your your perspective on that, from your long experience?

Anna Watkiss 22:13
I should clarify, to start with I am not a chartered clinical psychologist, just so that you’re aware of that because I haven’t practised as a clinical psychologist. I think that the the majority of my experience of working with rehab consultants has been where they have been in charge of the rehab unit. And I I’m actually just wondering, as we’re talking, is that something that happens across the UK? Or is that because I’m based in Edinburgh? So the Scottish brain injury rehab units generally have a rehab consultant, who will run that unit? Whether that’s this, you know, some very well, very well established units around the country, you know, in Edinburgh, in Dundee over in Glasgow and down in Asha, where I know the rehab consultants working there. Is that before I go any further, is that the case across England as well?

Dr Julian Harriss 23:17
I used to run the Frank Cooksey rehabilitation unit, which is the level two a unit at King’s College Hospital and had another another job at Guys and St. Thomas’s in that patient capacity. But the answer to the question is that the rehab units in the UK, and but particularly in England and Wales, are assigned a level on the basis of their complexity both of provision at the patient, so it goes to level one through to a to b and then now to three to qualify for NHS England funding. Because these are NHS England funded units a specialist units, then the service has to meet a very particular service specification. It’s about page long, but it clearly specifies that the unit must be run by a consultant in rehabilitation medicine. Now, there are a couple of exceptions where a neuropsychologist has that role, but that those are unusual. And they generally in those circumstances are supported by two or three other medical doctors was on board rounds for example. But so no, to answer your question, yeah, rehab medicine consultant has to be in that in that role. And trusts learn that to their costs. We have medicine consultant for whatever reason, sciences, prior practice and Harley Street because that unit then is no longer qualify qualifies for the very large amount of money that the NHS England’s funding provides me I’ve got your plane about actually doesn’t really cover the costs but 700 pounds per patient per day is quite a big sack of cash for a unit to lose if they can’t retain their rehab medicine consultants.

Dr Edmund Bonikowski 24:57
And that thank you, Julian that’s really helpful and is a very interesting point. And we’ve seen that actually happen in Somerset. It really does happen. es, yes, consultants are in the units. But many of us are also out in the community as well, or I’m involved in community services, I mean, in and we’ll probably be able to say something about that.

Anna Watkiss 25:20
So I guess one of the things that I found really valuable from rehab consultants when working as a case manager is that they will see the clients as we would say, individuals who have sustained acquired brain injury, and I’ll see them across their lifetime. And that’s where I see that it’s very useful. So the units all have lifelong referral policies up here. And where I think it is really valuable, you’re not getting you referenced earlier neurologist, anything 5% of clients, I think that the other point to make about that is that they see them as inpatients. What’s very valuable for a case management community team is having someone who does actually know long term outcomes for people with with brain injury. And of course, that’s I think, Well, for me, one of the big values that a rehab consultant can add.

Dr Edmund Bonikowski 26:12
Thank you for that. That’s very helpful Inam would you like to say a few words about that?

Dr Inam Hai 26:16
Yes, that’s right. I think that the this is a key point, in the sense is of the transitioning from, say, like the inpatient rehab units into the community. I think that that’s, that’s a very important point. Because the real rehabilitation, to be honest, over long term is carried out in the community. So obviously, post trauma post, whatever the index event, that’s obviously important. So there’s everybody knows that really, the the issue, which a lot of people, including, for example, commissioners, who are not able to pick out is that what happens to these people, particularly the word the the inverted commas, walking wounded, who look alright, who are fine, but they’re discharged. And it’s quite a common story. This is a very, very common story, they are discharged after receiving the best treatment, which you can actually imagine. But when they left in the community, that there is no really definite concrete plan as to who does what, what are the goals? Who will actually who who will help attain the patient? Who will help the patient attain those goals? What is the comeback on it? What is the follow up? How long does it go? I mean, say like, typical head injury, which is usually young people, for the next 50 years, they could be dependent for a very, very complex needs assessment.

Dr Edmund Bonikowski 27:54
Ben, this one is a question, do you as solicitors work with rehab consultants for your clients?

Ben Townsend 28:06
Yes. I mean, there’s, there’s two roles here that are relevant. First of all, there’s expert roles, providing expert evidence for the court, reporting upon our clients providing condition and prognosis reports providing evidence in court, ultimately, if the case goes to trial, the second role is having a rehab consultant on as part of the rehabilitation team around your clients. And yes, that is something that we do, and we will work with rehabilitation consultants as part of the team around our clients

Dr Edmund Bonikowski 28:49
Another question – would you say it’s better to have a medico legal expert, or rehab consultant as part of the treating team? I think what we’re saying there is you’ve got rehab consultants do you want do you want them to be the medical legal expert as well? Or just on the treating team?

Ben Townsend 29:29
My view is, you should keep them separate. I appreciate their limitations with numbers of the consultants but you want to have that separation for a number of reasons. First of all, you want that separation because you want the you want the rehabilitation consultant involved with the rehabilitation team to have the ability to the to focus in on only being involved for that patient for that patient’s medical needs, you don’t want them to be distracted by having other concerns about reporting to the court. You also want the the benefit of having two consultants if you can get them onto your case, because if you’ve got, frankly, an expert involved in your case, and a rehabilitation consultant involved in your case, and they are both have the same opinion about your particular client, that that’s giving you extra emphasis for what you’re doing it helps helps you just define what you’re doing to the court and to the defendants.

Dr Edmund Bonikowski 30:50
Thanks, Ben. That’s really helpful. Another question – Many cases don’t have a lead consultant, but have a robust MDT, what difference does the consultant make to that existing team? Julian, what you think about that, please.

Dr Julian Harriss 31:16
I fly frequently. And I feel very safe at 30,000 feet, knowing that the current technology is extraordinarily reliable. But at takeoff and landing, and reassure that there’s a pilot sitting there with a hat, holding on to a joystick should things go sadly wrong. And I think that is the very minimum role rehab medicine consultant has is that the initiation of a complicated medical case, which may or may not involve multidisciplinary rehabilitation, and at that stage, a number of investigations and further assessments might be required. And the decisions about those kinds of investigations and things can only be made by a medical doctor. Sorry. That’s the way I think that’s a definite end of it a client or when things go to Sandy wrong. When one of the engines blows, when you hear a flock of birds, it’s again, it’s reassuring to know that someone who can turn off the autopilot and jump back into the seat and say, No, we really have to do this, this and this. And you have to have a person who has, and this is, again, the world is an unfair place. But the reality is that sometimes consultants will only talk to other consultants. And you have a consultant who can pick up the phone and make arrangements for further investigations or admission, or change medications. And that can only often be done urgently by a consultant. So I think that is one role. That’s the very minimum role that the consultant has now. Because we’re so good at getting on with people, we have much better things to do with that. We can coordinate this great team and make sure everyone’s getting along well together. And then working towards goal driven and time delineated objectives. Great. That’s another role as well. And I think that can be done very well by other people too. But often, it’s also done very, very well by rehab consultants.

Dr Edmund Bonikowski 33:12
I think, Julian, that’s excellent. Thank you very much. I mean, this is a fantastic question, actually. Because what it exposes the fact that we, as a professional group, have not got across what we can contribute widely enough. That’s the first thing. I think it also exposes a fundamental weakness in certainly from our perspective. And indeed, from the guidelines perspective, in the constitution of many medical medic, multidisciplinary teams, that one is even asking a question like that. So well, my goodness, that that is it is so fundamental and important, certainly, in our view. It’s extraordinary that our world of case management and multidisciplinary rehabilitation teams on these complex cases is operating at all without medical involvement of this type. So I think that’s a really important point.

Dr Inam Hai 34:05
Yeah, that’s right. I just wanted to sort of add just a couple of points. For example, I fully I mean, obviously, I work with with MDT, but I’m coming in from a very clinical angle, mind you, not at all medical legal? And just an answer to that question. I respect the robustness of the MDT. But my sort of my point is that I would imagine having worked with MDT for a number of years, that everybody is coming from their own disciplines, the expertise of their own disciplines. The fundamental difference is if you have a rehab consultant, they will be able to take an overview of any other factors involved. If, for example, a medication review might be needed. Yeah, you never know. I mean, I have, we have all of us have come across, where we have looked at patients medication. And I’ve asked them, when did you last see the GP for a proper medication review? And a lot of the time the answer has been that well, it’s a repeat for the last six years.

Dr Edmund Bonikowski 35:24
And I’m because I can see Anna nodding, I think it’s terribly important that we take a view from a very experienced case manager on this. So that’s one an enter before you go into this. I want to just feed in the next question, which you can also asked about for us, or discuss how does the rehab consultant slot into a case management lead case? If it’s already going now? But that’s a question I know that in arm could deal with, because I know he’s done exactly that. But it’s a question perhaps you can respond to. I know, many of these cases are already running. And the question is, if you’ve got a new resource, how do you get it in? How does it integrate? What does it feel like?

Anna Watkiss 35:59
Okay, well, going back to the first question first, if you like, in terms of the value of the rehab consultant into the case management team. I think it’s really just repeating what the guys have said, you know, one of the point is where there are particular medical issues that need to be managed for that client. I think there’s particular strengths there from having your rehab consultant involved, as they say, they are a rehabilitation generalist. So it is that view across the whole of the rehab and looking at all of the areas, which again, is something that a case manager will do, in terms of overseeing that, but I think it’s very much you know, you have the input from the medical perspective there for the rehab. And I think that’s really valuable. Also, in terms of slotting into a package as it as it’s running. I think if you don’t have the rehab consultant involved at one point, and I don’t think every team needs one, I think it is different clients that will benefit I don’t think every single team that would have an MDT needs a rehab consultant in it. Sorry, there are very specific value to be added by involving a rehab consultant, but as I said, somejust don’t. So we have a package running where you have a particular need, where you go, actually what we really need here to clarify a particular issue goals or around, maybe even as we’re saying some of the medical matters, if there are elements of prosthetics to be involved, or pain or spasticity. Those are real areas where it it’s invaluable to have that input.

Dr Edmund Bonikowski 37:43
Sorry, I’m just to just to pick up on that. And so many of the very complex cases, of course, do have many of those issues. And you’re and I completely agree, I don’t know if my colleagues will say this, but of course, not every case needs to have a rehab physician in it all the time. But I think having access to as required can be extremely useful. It’s a complexity dependent situation. Can I just feed you another question? Anna, while you’re on it, there’s one here it says Can Ben and or Anna, comment on the importance of a rehabilitation prescription for a patient at the acute stage? I don’t know whether you can comment on that.

Ben Townsend 38:23
in theory, I can see them being extremely useful for our cases. But in practice, we, we don’t often see them, they’re not often produced, and they’re not often referred to when they are produced, we pay attention to them.

Dr Edmund Bonikowski 38:48
They are there this is this comes down to the resource limitation of Rehabilitation Medicine, and the fact that the whole thing didn’t ever really take off. It is something that we are producing at NRC medical experts and uh, do you do you come across the rehab prescription at all?

Anna Watkiss 39:06
Not often!

Dr Edmund Bonikowski 39:07
you know, you go. Okay. I think that answers that particular question. It’s it’s a huge opportunity to get rehabilitation on the on the right course, from the earliest moment. And I think we must try and seize that. Let me just say, there’s a couple more questions here. How long post settlement would a rehabilitation consultant typically remain involved with the patient? And how would their role evolve over time? Julian? That’s one. That’s one for you. I know the answer.

Dr Julian Harriss 39:42
A couple of things, I think to set the stage for this for this one. Yeah, I think we need to be clear in this discussion as we go forward. Whether we’re discussing rehabilitation medicine consultant, who has been appointed as part of, for example, an interim settlement and to participate with a privately appointed team of therapists and possibly other consultants. or whether we’re looking at a rehabilitation medicine consultant need, we’ve identified in the course of assessments. And then the patient is then referred back to the NHS to have regular reviews from rehabilitation medicine consultants as part of those repair NHS facility. Now that they’re both rehab beds and consultants, they’re both probably the same people in many in many geographies. But the resource availability is very different instances, you can see me next Thursday, but you can see the NHS medicine Rehab consultant in about 18 months time. That’s where the difference lies. So let’s assume then that we’re talking about just in principle, does a patient have access to rehab medicine consultant through the NHS? And it’s the first question I generally ask. I think it’s important when I’ve written a report on a patient. And so I’ve reviewed their progress. I’ve written a condition and prognosis report for the Court essentially, that if I feel is urgently needed, that they have a rehab medicine consultant, I say as much in my report, and then I might articulate that separately, the phone call or even to the lawyer saying you really should get this guy every six months to see my rehab medicine consult, especially spinal injury patients to use that a good example. Because if they’re not, if they’re only being seen by their orthopaedic surgeon or by their spinal surgeon, then they’re not well served for reasons that you touched upon earlier. But the biggest question I think we need to ask is, if a patient is to be seen by a rehab medicine consult in the NHS, and that if that availability is there, for example, if a rehab medicine consultants completed a rehab prescription on their discharge in the tertiary care hospital, and that rehab medicine consult has seen them sense in follow up, say a few weeks after they were discharged. And that’s the right thing to do. And if that has actually happened, then my advice would be, you got to get in touch with that service and make sure that patient is always followed up by that service, that they’re not promised a follow up and never happens. They’re not dropped, they don’t move away, and no one chases apart from No, I’ll add something to this discussion. That is, in my view, a central value of NHS rehab, medicine consultancy services, and that is communication access to the patient’s records.

Now, I don’t work in the NHS anymore. But one of the reasons that I was unhappy working within the NHS was that I felt that the communication even even within trusts was unreliable, that there would be a breakdown in communication of letters of referrals or follow up of reappointments in between trusts. Now that is improving, and I think people are being seen more robustly. Now, I think maybe one thing that came from COVID is we are now getting better at communicating with people in the community.

Dr Edmund Bonikowski 42:48
iLet me go on a couple of points you made there fantastically well. The issue of communication, certainly the reputation prescription is was intended to be a document that that transcended organisational barriers or boundaries rather, it moved with the patient, it should have been the the main reference document and it just never happened. So that communication connection with the medical record is absolutely right. I don’t know Do you do you? Do you agree with that?

Dr Inam Hai 43:19
Yes, I think that the the rehabilitation prescription has been really an ongoing topic, with many trust across the UK, in fact, and it really hasn’t taken off as it should have. It is essentially a training issue. There are resources issues, there are handing over issues, there are logistical issues, and it’s very common that rehab prescription is filled out, say from a tertiary centre, when you try to pick up what goals are attained about eight months down the line in the clinic. There is no communication, you actually don’t know who was involved and which goals were attained because because you don’t get the feedback. So I think that the rehab prescription if has to be implemented, it would have to be done by a real vigour in the sense that somebody takes it on and follows it down to the line really? I don’t think so you can literally say okay, we filled out the rehab prescription, and here you go. It hasn’t worked. It hasn’t worked so far. No, it hasn’t been absolutely not here.

Dr Edmund Bonikowski 44:19
Let me just there’s a couple more questions here. One of these makes me smile, I’m afraid. Does everyone that has suffered a major trauma, receive input and treatment from a rehab consultant? Well, I’ll tell you what, I almost don’t know where to go with this question. I’m going to ask Ben from his experience in the medical legal. What’s your sense, Ben?

Ben Townsend 44:42
No, absolutely not.
I can say both as a as a solicitor specialising in brain and spinal cord injury and as somebody who has involvement with their local Headway group, the charity for brain injury survivors, for those who aren’t familiar with it, that there’s an awful lot of people who have survived brain injury who never get anywhere near.

Dr Edmund Bonikowski 45:13
Thank you. Anna, have you got a comment on that from your own experience in case management?

Anna Watkiss 45:17
It’s just the same really? Yeah, it’s a sort of not everyone does.

Dr Edmund Bonikowski 45:21
So that’s that’s the point, we have a responsibility as a small group of medical specialists to find more efficient ways of delivering what we think we can deliver, and to be energetic about that. And that’s partly why we’re being why we’re having this conversation today. Let me there’s another question here. It says slightly concerning that there is a high demand for rehab, because of COVID and recovery rates. And so if you can stop and what is the NHS doing about this? Well, I mean, my perspective on that is the NHS is panicking about that. It’s, it’s a really difficult topic. The services are overloaded, the consultants are run ragged, many of them are retiring early, because they’re just done in. And, you know, a further load of patients with chronic often neurological disability arising from COVID is is really a huge pressure on the system. In arm, have you got any idea about what the NHS is doing about that?

Dr Inam Hai 46:25
No. At the moment, really, the thing is that, to be fair to the NHS, and particularly the rehab aspect of the NHS, things are still evolving, really, people are still literally learning what is long COVID? Or what is post COVID? Yeah, what used to be a what it still is, in a way long COVID, post COVID. But it’s still in, in literally the discovery, sort of phasing services are evolving. But this is going to be a major, major challenge, particularly theoretical, and the cognitive security.

Dr Edmund Bonikowski 47:07
I think that’s absolutely right. We are still learning about it. But you know, we have a whole raft of different conditions that are pressuring the rehabilitation services, the neurological rehabilitation services, functional medical disorders, for example. And you don’t long COVID, of course, has significant pathological basis. But that is just another pressure on top of it. I think the NHS is trying its damnedest to do something constructive about that. But it’s a very difficult area. There’s a very good point here. It says for those consultant rehab experts who are instructed in medical legal matters, what info Do you like to see from the solicitor in order to provide a comprehensive opinion? May I just offer a view on that?

Actually, I don’t need very much. Not really, because you’re asking me for an opinion. I’m quite used to going and seeing patients without any real preparation, without any background information, access to whatever records might be available. But I would say I like to see them as early as I possibly can. Because I can get the process going in a way that I think might be most advantageous to the patient. So I think this is this is really interesting, because I have been a medical legal expert a long time. And sometimes one gets letters of instruction that run to a dozen pages, 20 pages of typed type script. And it’s great, but actually, much of it I don’t need, what I need is to be told, what do you want me to tell you? What is it you’re asking me? Are you asking me about causation of certain things, condition or prognosis? Are you asking me about specific matters, like life expectancy? It? What do you want to know? i There are a number of things I can tell you. And I would, I would counsel solicitors to keep letters of instruction, pretty focused, because then it gives us a good starting point. And that’s all we need. Julian, why don’t you have a go that when you’re a big medical legal expert, what do you think? probably different from me?

Dr Julian Harriss 49:15
Just a couple things. I think your your point is well summarised, good questions result in good answers. If demand, particularly same bullet point questions, it demands of the referral of the lawyer, the time the thought and put into that question. And so I then respect that I have been given due consideration and I’ll put more effort more thought into my answers. That’s, that’s straight, quite, quite short, quite straightforward. It doesn’t have to run several pages. But as long as the questions are very clear and succinct, then you’ll get good answers from us. I want to go back to a couple of small things that we’ve touched upon before. And in a former life, I ran the post polio clinic for almost 10 years at a Guy’s and St. Thomas’s hospital. When I hear consultants that proclaim that long COVID New, no, it’s not. We’ve had similar post viral long term concerns, since at least polio. And we know that half the patients who were hitting the polio epidemics wind up with long polio, essentially post polio syndrome. And there are so many similarities between the conditions. So we do know how to do it. I’m startled that no one’s actually asked anyone that Guy’s and St. Thomas’s hospital to really contribute towards the programme development for long COVID Because you really do know how to do it. And the post polio syndrome clinic up Thomas is that a respiratory medicine clinic where Boris’s life was saved. So all so many points of complexity here,

Dr Edmund Bonikowski 50:43
it’s really interesting, really interesting point, Julian about in the contribution to the plan for how to deal with the aftermath of COVID. I know that I tried three times to engage with the trusts in Surrey, which is where actually lived just by working in Somerset couldn’t get in . They just didn’t, couldn’t have the dialogue about rehabilitation. And you’re absolutely right. There’s nothing new under the sun. This is another post viral condition in um, do you want to make a brief comment about that with that? At all?

Dr Inam Hai 51:15
I think that that that is absolutely right. Obviously, I think that the reason why it’s taken out the new evolution is because it’s a new other diagnosis. This is one of the problems with medicine is that people go into diagnostic silos really. And I think that is what that is one of the problems. And it’s not just with management or managers, it’s actually with medics, and that’s, that’s really the medics fault in a way.

Dr Edmund Bonikowski 51:44
And it’s really interesting, because what we’ve been talking about is as being generalist, the specialist generalist, and so we are the ideal group of medical doctors to take these conditions on. Yeah, because actually, we’re not dying. We’re not in silos, I think that’s really bad. So that’s a great point.

Dr Julian Harriss 52:06
I mean, we’re in our specialty, we don’t preoccupy ourselves with the minutiae of the diagnostics divisions. We just don’t do it. It’s not important to us. If we are still curious about the ticular sub classification of that diagnosis, then I’ll bring in neurologist into the room, and I’ll sit there quiet and listen to the neurologists not try to understand what they’re saying. But I swear to you that long enough, that neurologist is gone, the patient is still sitting in the room, none the wiser, asking me the most important question, or now what? Now, what do I do with my life? That was a consultation very valuable to you, maybe, but not to me as a patient. I’ve got 50 years to live with this. What does it mean?

Dr Edmund Bonikowski 52:47
That’s a great, that’s a great point. Julian, thank you. There’s a question here by an anonymous attendee, it says, as a group of experts, what are your thoughts on the future of Rehabilitation Services? Are they improving? My goodness? What I’m going to do is I’m going to ask Anna there. What’s your perspective on that one?

Anna Watkiss 53:09
Well, I guess I would know more about community rehabilitation services,

Dr Edmund Bonikowski 53:15
which is where most patients are.

Anna Watkiss 53:17
Yeah, yeah. I’ve got a soapbox about that. But I won’t get on it just now.

Dr Edmund Bonikowski 53:22
Well, if you want to, you’ve only got five minutes, but go for it.

Anna Watkiss 53:25
Now, I guess I I can’t say they particularly are because they’re so strapped waiting lists times are so lengthy, is incredibly difficult to get the resources. And you know, it’s not that there aren’t the skilled professionals there that absolutely are. If you if you can get them then you know, you can get fantastic services. So it’s not the the quality of what’s available. It’s literally what is available resourcing.

Dr Edmund Bonikowski 53:53
May I just tell you a very one half a minute story about what happened in Somerset, about 15 years ago, we had a dedicated 24 bedded inpatient neurological rehabilitation unit. It was shut and demolished as part of financial saving strategy. And a carpark was built over the patients were put into an acute Ward alongside neurology patients with half the number of beds. I went there, and we persuaded the trust that this was completely inappropriate. And we removed the patients out to a community hospital, which has got actually the best views any patient could possibly have in the NHS views of the Quantock Hills, and I’m painting a rather romantic picture there, but it’s that kind of thing that has happened to rehabilitation services, which appals me and I think is reflected in what Anna says you know that there are there are people out there who can do this work, but the system will sometimes just cut a swathe across it and because it doesn’t see it as a priority. The priority is you know, heart attacks, cancers stroke. Okay, that’s great and that is a priority. But my goodness, if you’re saving the lives of people, surely you want to ensure they have the optimum quality of life that follows thereafter and the maximum participation society and maximise their abilities. That’s what rehabilitation medicine does.

Question for those prepping part 35 expert reports. What tends to be your claimant defendant split? My goodness, that’s a very specific question. I mean, I’m not sure we can really answer that we’ve only got one. We’ve got two medical legal experts here. Who do that work Julian and me in um, doesn’t do that work. I’ve been my claimant defendants split, it has been about 90% claimant, 10% Defendant, and that’s not through any particular prejudice. It’s simply those are the instructions I get. But what I would say is that our responsibility and I take this credibly seriously I know Julian does and in arm does is to provide an independent view for the court. Because if you do anything other if you allow yourself to be persuaded by the by the claimants, and their team or the defendants sister and the team, it just doesn’t stand up, because ultimately, you end up in the court of your opposite number. So Julian will be on the side for the defence me on, and it’s patently obvious that you’re not doing the right thing. So that’s my particular split, but I’m happy to see anybody anytime. Julian, do you want to give a view.

Dr Julian Harriss 56:38
The litigants about 10% defendant and about 10% occasion we’re joint appointed. So I have a pointer of both sides. Those are interesting.

Dr Edmund Bonikowski 56:50
Can I just come in? I wouldn’t get terribly hung up about an expert who’s instructed more often on the claimant side than the defendant side. It doesn’t. To my mind, it doesn’t mean that that particular expert is perceived as being claimant minded. The fact of the matter is, defendants don’t instruct experts as often as claimants do. And so they’re gonna be instructed more often by claimants and defendants.

Dr Julian Harriss 57:25
I recently learned from you that that as is the case, but I kind of figured it out over the past couple of years, that that’s probably where there’s, and it’s not down to it. But to Ed’s point about being entirely impartial and trying to be utterly fair in our reports, one of the very first things I say to all of my clients when it even before I take off my coat is I’m going to write an impartial Report. If the people who appointed me don’t like it, they won’t submit it, but I won’t change it. And the day I submit a bias report is the last day of my career.

Dr Edmund Bonikowski 57:58
Yeah, absolutely. Right. And, Ben, thank you so much for that perspective that if any of us have got a takeaway from this meeting, that is my takeaway. That’s absolutely brilliant. So look, we’ve reached 530. I think we need to bring the discussion to conclusion.

So I just want to say, a great thank you to Anna, to Ben, Julian and Inam for taking part and another thank you to all of you for listening. And I hope taking away some useful messages and for your questions which have been insightful and interesting. I hope our answers have been helpful. Please do feel free to communicate with us subsequently. And otherwise, I wish you all a good evening. Thank you very much and good night.