Expert Opinion: providing high quality rehabilitation services

The provision of high-quality cancer rehabilitation services for patients from diagnosis to the end of life has been a key part of the government health services agenda for some time.^1-3 This specialised rehabilitation has been defined as 'a process by which individuals within their environments are assisted to achieve optimal functioning within the limits imposed by cancer'.⁴

For patients who receive palliative care, the focus of rehabilitation is improving quality of life, irrespective of its length. Rehabilitation can be wide ranging and address the patient's physical, psychological, social and spiritual needs. It may involve individual sessions or group work, for example, the teaching of self-management techniques.

Cancer rehabilitation requires a multidisciplinary team approach to deliver this type of needs-led, holistic care. The team composition can vary according to the scale of the service provided and be adapted to suit geographical and socioeconomic factors in different localities. However, the wider team includes key nursing staff, as well as the four allied health professions of occupational therapy, physiotherapy, speech and language therapy, and dietetics.⁵

Co-ordinated expertise
Although rehabilitation has been recognised as an integral part of cancer patients' care, NICE has noted that there is a lack of co-ordinated multidisciplinary teams that include people with specific cancer rehabilitation expertise and that specialist staff tend to be employed in cancer centres and hospices.

There is also a lack of research into the effects of cancer rehabilitation, which may influence the provision of funding. If patients are to receive appropriate, effective interventions, it is imperative that they are referred to such specialist units when indicated. The staff from these units should be encouraged to work collaboratively with, and impart knowledge and skills to, their community colleagues. As advised by the National Council for Hospice and Specialist Palliative Care Services,⁶ it is the responsibility of all health and social care professionals to consider the provision of timely, specialist rehabilitation when formulating patients' care plans.

Four stages of rehabilitation
The therapies available to patients encompass the four stages of cancer rehabilitation - preventive (reduction of the scale of expected disability), restorative (facilitation of the patient's return to their previous level of functioning without disability), supportive (limitation of functional loss, provision of support) and palliative (compensation and symptom management to reduce complications associated with illness).⁷

Owing to the complicated nature of cancer and its treatments at any of these four stages, it is vital that intervention strategies are devised as soon as possible to minimise helplessness.⁸ There is also a need for early referral to rehabilitation services, which should take equal priority with other clinical interventions.

An example of a specific rehabilitation service is outlined in box 1. The availability of services can vary, particularly if lack of funding results in limited access. As an illustration, in some localities, if patients receive continuing palliative care via community health funding, this may negate their eligibility for social services therapy. Community health funded teams are not as widely established as their social services counterparts. This might mean patients with a high level of need inadvertently being denied the opportunity to access follow-up rehabilitation, which would lessen their quality of life.

A deficiency in the provision of integrated rehabilitation services for survivors of cancer has been highlighted⁹ and this is a matter that needs to be addressed. A clear understanding of the benefits of rehabilitation, alongside the recognition of patients' rehabilitation needs, is a requirement of all front-line staff. The objective is to maximise the patient's ability to adapt to the situation and to limit possible entrenched behaviours compounded by fears associated with functional decline. In the longer term, this approach will contribute to a reduction in the health and social care burden.

Improvements in cancer survival rates mean management strategies used in other chronic conditions might now be considered and implemented in this patient group. GPs and primary care teams are in an ideal position to initiate this and have long regarded chronic care as a key part of their function.¹⁰

The current picture
As part of the implementation of the NICE guidance action plan, each cancer network completed a peer review programme of services over a four-year period. From this, the guidance³ was compiled to provide recommendations for the reconfiguration of the more complicated cancer rehabilitation services and the formation of additional multidisciplinary teams.

The Manual for Cancer Rehabilitation Services⁵ was recently published by the national cancer action team to set standards against which such services are to be peer reviewed (see box 2).

Significant (although varying) progress has been made in all four areas across the cancer networks and full implementation is required by 2010. Rehabilitation services need to be seen as a high priority by all commissioners and not as an optional extra if adequate funding is to be provided.⁶

The role of the GP
Cancer survival rates are increasing and have doubled in the past 30 years. As a result, many more patients find themselves living with the consequences of cancer and its treatments, which can be extremely debilitating.

Cancer rehabilitation is therefore more of a necessity than ever and must be seen as an integral part of care planning. Enabling patients to live as independently as possible can only benefit society.

GPs and primary healthcare teams are ideally placed to identify the rehabilitation needs of people with cancer, particularly during the living with and beyond cancer phase,⁹ and refer to the appropriate therapy services as part of the patients' care pathway.

There is also the opportunity to identify inequalities of service and lack of availability of rehabilitation, and this can be addressed via community teams through the cancer networks. This process could result in the appointment of more therapists specifically working in primary care, or the co-ordination of an allocated specialist cancer therapist to offer advice to primary care teams. For their part, specialist cancer rehabilitation therapists need to continue to be a resource for their community colleagues, to undertake research into the effectiveness of their interventions and to help patients to make the transition from being cancer patients to being cancer survivors.¹¹ This is best achieved through collaborative working in the key primary, secondary and tertiary centres.

- Barbara Biggerstaff is a clinical specialist occupational therapist and Natalie Doyle is a nurse consultant at the Royal Marsden NHS Foundation Trust

Competing interests: None declared

References
1. Calman K, Hine DA. Policy Framework for Commissioning Cancer Services. London, DoH, 1995.
2. DoH. The NHS Cancer Plan: A plan for investment, a plan for reform. London, DoH, 2000.
3. NICE. Guidance on Cancer Services: Improving Supportive and Palliative Care for Adults with Cancer. London, NICE, 2004. (accessed 22 October 2009).
4. Mayer D, O'Connor L. Rehabilitation of persons with cancer: an ONS position statement. Oncol Nurs Forum 1989; 16: 433.
5. National Cancer Action Team, National Cancer Peer Review Programme, Manual for Cancer Services; Rehabilitation Measures, 2008.  (accessed 7 October 2009).
6. Fulfilling Lives; Rehabilitation in Palliative Care. London, National Council for Hospice and Specialist Palliative Care Services, 2000.
7. Dietz JH. Rehabilitation Oncology. New York, John Wiley, 1981.
8. Cheville A. Rehabilitation of patients with advanced cancer. Am Cancer Soc 2001: 92, 1039-48.
9. DoH. Cancer Reform Strategy: Living with and beyond cancer. London, DoH, 2007.
10. Chait I, Glynne-Jones R, Thomas S. A pilot study exploring the effect of discharging survivors from hospital follow-up on the workload of general practitioners. Br J Gen Pract 1998; 48: 1241-3.
11. Hewitt M, Ganz PA (eds). From Cancer Patient to Cancer Survivor; Lost in Transition. American Society of Clinical Oncology and Institute of Medicine Symposium. Washington DC, National Academic Press, 2006.