Select Committee on Health Minutes of Evidence




  Executive Summary




  The Warwick Study of Head Injury Rehabilitation

  Acute Care of Head Injured Patients

  Rehabilitation Services

  The Warwick Study—Outcomes

  Traumatic Brain Injury Workshop

  Welfare to Work

  Accident & Emergency Departments

  Next Steps

  Annex A


  1.1  This memorandum describes current Department of Health policy on the rehabilitation of head injured patients, including the outcome of the action research programme detailed in the Warwick Report. It also briefly sets current policy action on the acute handling of head injured patients and gives details of forthcoming developments in neurological service policy which will affect both acute and rehabilitation for head injured policy.


  2.1  More than a million people attend Accident and Emergency Departments each year with head injuries of varying severity and around 100,000 need in-patient treatment. However, with head injury the part of the brain affected can be as important as the severity of the injury and an apparently minor head injury can result in major changes to cognitive functioning and personality. Putting in place systems which will identify all brain injured people, who may not exhibit life changing symptoms immediately, is a complex challenge for local services.

  2.2  Head injuries can have a major impact on the life not just of the injured person but also their families. The Report of the Working Party on the Management of Patients with Head Injuries (produced by the Royal College of Surgeons in 1999) shows that 63 per cent of people with moderate head injuries and 85 per cent of people with severe injuries are still disabled a year later. Three months after sustaining minor injury, many people still have headaches and cognitive impairments.

  2.3  Head injured patients can expect to have normal life expectancy following the injury. However, many patients never fully recover their cognitive functioning and some are not aware of the changes that have taken place in their personality. Family life is frequently affected by the changes in personality that a head injury can produce. Greatly increased irritability and anger is common. This can lead to relationship breakdown. Unemployment among people with head injury is high. Head injury may also induce epileptic seizures and, because it is associated with road traffic accidents and fights, there may well be other physical injuries that can result in permanent disability.


  3.1  Many more males than females suffer life changing head injuries. Younger age groups are disproportionately represented in the head-injured population. An apparent link between head injury and low socio-economic status is recorded in the literature. Road traffic accidents and fights, especially alcohol related, are the main cause of head injury.


  4.1  Statistics on incidence of head injury are shown at Annex A.


  5.1  The purpose of rehabilitation is to restore people to normal life if possible. If this is not attainable, the desired outcome is to achieve the maximum amount of independent living possible for the individual patient. In the early 1990s the Department of Health had received a considerable number of representations on the subject of head injury rehabilitation. Many of the representations were from the families of people with head injuries, who felt that increased rehabilitation activity would have restored better functioning.

  5.2  These representations led to the current programme of rehabilitation policy action, which started in 1992 with the setting up of the Warwick study. This was a national study (the National Traumatic Brain Injury Study), commissioned by the Department of Health and conducted by the Centre for Health Services Studies at the University of Warwick. The study was designed to assess the outcomes of a programme of action research, funded by the Department over a five year period, on the development of community based head injury rehabilitation services. It also tested out the hypothesis that a greater input of services would mean better outcomes for patients. The study successfully identified a number of the good practices in rehabilitation management that lead to better outcomes for patients. However, when the researchers looked at the hypothesis that an increased volume of rehabilitation led to better outcome in terms of functioning they were unable to establish a statistically significant link. This is a difficult area in which to conduct research but every care was taken to make sure that the report and its conclusions were methodologically sound.


  6.1  Patients almost always access services through Accident and Emergency Departments immediately following their injury. A&E Departments, if necessary with the help of neurosurgeons, have to make decisions on:-

  Which patients can go home;

  Which patients need a short period of assessment;

  Which patients require transfer to a neurological unit and may require neurosurgery; and

  Appropriate care for severely head injured patients who have other injuries.

  6.2  Problems can occur when patients have multiple injuries and are nursed on, for example, orthopaedic wards, where the importance of head injury symptoms may not always be apparent.

  6.3  Patients who exhibit apparently minor symptoms at the time of examination may nevertheless show marked function loss and personality change later. Such patients run the risk of being discharged from A&E Departments without being observed or admitted. Systems should be in place to identify such cases. Good practice solutions include issuing leaflets giving advice on when to seek treatment and creating a register of head injury patients.

  6.4  A strategic review of emergency care is currently underway. The review will identify principles and standards for the organisation and delivery of emergency services, leading to improvements in care for all emergency service users, including head-injured people. It will ensure that the emergency care needs of head injured patients are taken fully into account.

  6.5  At the same time, a joint working group, set up by the Regional Specialised Services Commissioning Groups and the Society of British Neurological Surgeons, is looking at ways of implementing the key messages from the reports Safe Neurosurgery 2000 and the Royal College of Surgeons report on the management of head injuries (the Galasco Report). The group, as part of its work to help improve commissioning, is developing guidance on head injury management and services, including rehabilitation services.


  7.1  There are a number of key characteristics of a good head injury rehabilitation service, some of which were described by the Warwick Study.

  7.2  It is, for instance, recognised good practice that each patient should have a case manager, who will ensure that a written rehabilitation plan, which focuses on the patient's individual needs, is drawn up. The case manager and other members of the rehabilitation team will actively monitor the head-injured patient's progress.

  7.3  A good head injury rehabilitation service should be able to provide the necessary therapist and psychologist input to assess needs and maximise patients' functioning. Devising strategies to assist memory, for instance, would be a key component of this work. Social work support may be needed to help resolve family problems.

  7.4  Before discharging into the community, the patient should have a care plan and all the necessary support put into place. There should be arrangements to deal with the situation should the community placement fail. Failure may occur, for instance, if, despite preparation, the head injured person is unable to cope with the complexities of life in the community or there is a breakdown in family relationships.


  8.1  Warwick Study was unable to establish a statistically significant link between input and outcome, although it did reveal that the 10 per cent of the most seriously injured patients were absorbing 90 per cent of resources. However, because of the nature of their injuries, it showed that there were limitations on the amount of improvement in functioning that might be expected and that some people engaged in the rehabilitation process were failing to recognise the point at which no further progress might be made. This meant that scarce resources were being used which might be better deployed on people with lesser injuries but for whom the expected benefits might be greater.

  8.2  The Warwick Study, as part of its remit to assess the outcomes of the research programme, identified a number of good practice recommendations that were commended to the NHS by the Department of Health. Dr Graham Winyard, deputy chief medical officer at the time issued a summary report of the research to the NHS. The summary included messages on the need for:-

  Prompt and effective acute care

  Prompt referral to rehabilitation services

  More community focussed services

  Written rehabilitation care plans to include clear goals and explicit success and failure criteria

  Transition between services to be handled strategically

  A safety net system in case people needed to return to rehabilitation care

  A case manager with responsibility for organising care in a seamless way

  8.3  The study also found that a strong social network and interpersonal support system, especially if coupled with a supportive employer, meant that patients were more likely to have good outcomes following discharge.


  9.1  Following the publication of the Warwick Report, the Department of Health organised a workshop in 1998 to review the implications for future policy. The workshop examined various aspects of head injury care including smoothing the patient journey, commissioning, and the management of head injury teams. A report of the proceedings, which contains further helpful good practice messages, was published for delegates.


  10.1  Getting people back to functional independence following illness or injury is a high priority for the NHS. This year, together with DfEE and DSS, the Department of Health is planning to mount Job Retention and Rehabilitation Pilots to test ways of helping people with prolonged illness or disability to remain in their jobs. This will, of course, benefit people following head injury.


  11.1  Over the last three years the Government has made significant investment in modernising A&E departments. During 1999-2000 a total of £115 million was invested in 242 schemes, with a further £35 million announced by the Prime Minister in January 2001, bringing the total investment to £150 million. This is the biggest modernisation and expansion of A&E services in the history of the NHS. The schemes include completely new A&E departments, refurbishments, the upgrading of resuscitation facilities, the extension of medical assessment units, the installation of new diagnostic equipment, special waiting areas for children, improved security arrangements and better provision for primary care services. At the completion of this programme, 90 per cent of A&E departments will have been improved.


  12.1  The Department of Health has commissioned the National Institute for Clinical Excellence to produce guidelines on the handling of brain injured patients. The guidelines will cover care for both adults and children. The guidelines will look at the progress of patients through Accident and Emergency Services, surgery and on the wards.

  12.2  The aim is to improve initial management and reduce the number of patients left with significant behavioural, cognitive, emotional and physical disabilities. Early identification and treatment is essential to avoid life long disability. NICE will be scoping the guidelines shortly. As yet, NICE has not published its timetable for guidelines given to them in the current wave of work. We expect NICE to publish this in the summer. The guidelines are likely to take between 12 and 18 months to produce.

  12.3  On 28 February, the Secretary of State announced that a National Service Framework for people with Long Term Conditions would be developed. The Framework will cover neurological disability and head and spinal injury. The Framework has yet to be scoped but we would expect it to cover rehabilitation activity. It will be developed for implementation in 2005. This is a highly significant development, as the publication of a national service framework in this area will result in better co-ordinated services, designed to maintain the health and quality of life of people with these long-term conditions.

March 2001


  The following table sets out the statistical information that is collected on head injury.

Finished consultant episodes (FCEs) by main diagnosis

NHS Hospitals, England 1995-96 to 1999-2000
1995-961996-97 1997-981998-99 1999-00
S00 Superficial injury of head9,731 10,82911,00010,875 11,555
S01 Open wound of head20,180 23,18623,82423,668 25,849
S02 Fracture of skull and facial bones29,839 31,41930,26527,837 29,323
S03 Dislocation sprain and strain of joints and ligaments of head 317381367 410332
S04 Injury of cranial nerves78 639496 104
S05 Injury of eye and orbit3,655 3,5033,3203,255 3,422
S06 Intracranial injury23,226 20,03616,52911,942 10,860
S07 Crushing injury of head30 161119 12
S08 Traumatic amputation of part of head 127116102 111118
S09 Other and unspecified injuries of head 40,91242,19341,102 40,16341,515
Total128,096131,742 126,615118,376123,089
The main diagnosis is the first of seven diagnosis fields in the HES data set, and provides the main reason why patient was in hospital. These data are adjusted for both coverage and unknown/invalid clinical data.

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Prepared 3 April 2001