Frameworks & Guidelines for Practice:
Recent developments in the UK
Andy Tyerman
Consultant Clinical Neuropsychologist
Community Head Injury Service
Vale of Aylesbury Primary Care Trust
Recent national guidelines / standards :
Head injury: Triage, assessment, investigation
and early management of head injury in infants,
children and adults (NICE, 2003).
Rehabilitation following acquired brain injury
(RCP, BSRM, 2003) .
Vocational assessment & rehabilitation after
ABI. (RCP/Jobcentre Plus/BSRM, 2004).
The National Service Framework for Longterm Conditions (Department of Health, 2005).
National Institute of Clinical Excellence:
Head Injury - Clinical Guidelines (2003)
Presentation and referral
Transport to A&E & pre-hospital care
Assessment/investigation in A&E (eg CT scan)
Admission to hospital
Transfer from secondary to tertiary care
Observation of admitted patients
Discharge (incl. sample discharge advice cards)
British Society of Rehabilitation Medicine
National Clinical Guidelines for
Rehabilitation following
Acquired Brain Injury
(Turner–Stokes L, ed.)
Royal College of Physicians / British Society of
Rehabilitation Medicine, Dec. 2003
BSRM Guidelines – Content
Principles and organisation of services
Approaches to rehabilitation
Carers and families
Early discharge and transition to rehabilitation
In-patient clinical care – preventing complications
Rehabilitation setting and transition phase
Rehabilitation interventions
Continuing care & support
In-patient clinical care
Optimising respiratory function
Management of swallowing impairment
Maintaining adequate nutrition & hydration
Positioning and handling
Effective bladder & bowel management
Establishing basic communication
Managing epileptic seizures
Emerging from coma and PTA
Prolonged coma and vegetative states
Rehabilitation interventions
Promoting continence
Motor function and control
Sensory disturbance
Communication & language interventions
Cognitive, emotional & behavioural
…. cont. Rehabilitation interventions
6. Optimising performance in daily living tasks
7. Leisure & recreation
8. Computer and assistive technology
9. Driving
10. Vocational/educational rehabilitation
Identified need for guidelines on long-term
community rehabilitation, care & support
Possible content:
Rehabilitation interventions in the community
Occupational, leisure and social activities
Family & sexual relationships
Neuropsychotherapy provision
Supported living (incl. aids/equipment)
Driving & other independent travel needs
Support for family and friends
Inter-Agency Advisory Group on Vocational
Rehabilitation after Brain Injury:
Vocational Assessment & Rehabilitation after
Acquired Brain Injury :
Inter-Agency Guidelines
Royal College of Physicians, Jobcentre Plus /
British Society of Rehabilitation Medicine, 2004
ABI: Vocational Service Guidelines
• Guidance and support in returning to previous
employment, education or training.
• Vocational/employment assessment to determine
alternative avenues of employment or training.
• Vocational rehabilitation to prepare for return to
alternative employment, education or training.
• Supported employment for those requiring ongoing
support and/or additional training.
• Permitted work, voluntary work or alternative
occupational / educational provision.
Brain injury vocational rehabilitation provision
ABI Team:
To Work
Inter-Agency Guidelines: Implementation
• Development of local inter-agency protocols
– NHS, JCP, SSD, vocational/educational providers
• Key staff to establish ongoing service links
– (e.g. NP/OT regular consultation with WP/DEA)
• Development of ABI vocational training
– awareness vocational needs + specialist skills training
• Need to review future provision for VR for ABI
– (NHS/SSD) NSF-LTC + DWP Framework for VR
The National Service Framework for
Long-term Conditions (NSF-LTC)
Specific focus on long-term neurological conditions
in people of working age but also wider focus on
issues common to long term conditions
(Department Health, 2005)
What are National Service Frameworks ?
NSFs are ‘blueprints’ for care which:
• Set national standards and define service models
• Highlight current best practice
• Put in place strategies to support implementation
and delivery
• Establish performance measures to monitor
(Department of Health, 2003)
The NSF for LTC aims to:
• promote quality of life and independence by
ensuring that people with long-term neurological
conditions ‘receive co-ordinated care and support
that is planned around their needs and choices’.
• transform health and social care across the care
pathway, from symptom onset & diagnosis through
acute care & rehabilitation to long-term community
support and, when required, end-of-life care.
Quality Requirements – Structure
Quality requirement
Evidence based markers of good practice
QR1. A person-centred service
Quality requirement:
People with long-term neurological conditions are
offered integrated assessment and planning of their
health and social needs. They are to have the
information they need to make informed decisions
about their care and treatment and, where
appropriate, to support them to manage their
condition themselves.
QR1 Markers of good practice – outline:
timely integrated assessment by all relevant agencies
leading to individual care plan:
covers current & anticipated needs - holistic in nature
held by person & regularly reviewed (incl. self-assessment)
named point of contact for everyone + for complex needs
named person responsible for co-ordinating input
care assessment/planning for life transitions to provide
continuity of care (e.g. transfer to adult services; across
geographical boundaries; change in social circumstances).
…cont. QR1 Markers of good practice – outline
4. Arrangements for providing information:
timely, quality assured, culturally appropriate
information on service provision, on the condition and
how to manage it ; and on wider social inclusion issues.
professionals, people with LTNC and carers receive
training on effective ways to provide & use information.
5. access to education and self-management
programmes, tailored to individual need
QR2. Early recognition,
prompt diagnosis and treatment
Quality requirement:
People suspected of having a neurological condition
are to have prompt access to specialist neurological
expertise for an accurate diagnosis and treatment as
close to home as possible.
QR2 Markers of good practice - outline:
improved access to neurological expertise (e.g. through
training, shared protocols, MD neurology clinics)
diagnostic services effectively designed with sufficient
capacity, consistent with NICE and other guidelines
improved access to appropriate treatments – guidelines,
early integrated assessment/care planning & information
prompt access to ongoing specialist neurological advice
and treatment including specialist nurse practitioners
improved access to treatment review
QR3. Emergency and acute management
Quality requirement:
People needing hospital admission for a
neurosurgical or neurological emergency are to be
assessed and treated in a timely manner by teams
with the appropriate neurological and resuscitation
skills and facilities.
QR3 Markers of good practice - outline:
1. complies with NICE & other standards/guidelines
2. local hospitals have resources for treatment &
review (ie. staff, facilities, links & protocols)
3. protocols comply with NICE guidelines (eg HI)
4. transfer to neuroscience / SCI centres when
needed (capacity - staff & facilities) + return
5. local hospitals – suitable wards, facilities &
staffing for ongoing care, supervision or rehab.
QR4. Early and specialist rehabilitation
Quality requirement:
People with long-term neurological conditions who
would benefit from rehabilitation are to receive
timely, ongoing, high quality rehabilitation services
in hospital or other specialist setting to meet their
continuing and changing needs. When ready, they
are to receive the help they need to return home for
ongoing community rehabilitation and support.
QR4 Markers of good practice - outline :
rehabilitation complies with NICE guidelines & takes
account of other nationally accepted guidelines
improved access (& re-access) to rehab. provided:
– early, at appropriate intensity, by co-ordinated team;
– trained staff support people & carers in applying skills in ADL
– person, family and rehabilitation team work to agreed goals
seamless transition of care through integrated working
specialist rehabilitation for very severe / complex needs
QR5. Community Rehabilitation & Support
Quality requirement:
People with long-term neurological conditions living
at home are to have ongoing access to a
comprehensive range of rehabilitation, advice and
support to meet their continuing and changing needs,
increase their independence and autonomy and help
them to live as they wish.
QR5 Markers of good practice – outline :
access to flexible programmes focussed on individual goals
beyond basic care which promote participation in life roles
local multi-disciplinary rehab. and support in community
by professional with the right skills and experience:
- joint working, access to specialist expertise; available long-term
support people and their family and carers to:
– live with, & develop knowledge and skills to manage condition
– achieve sense of well-being / long-term psychological adjustment
– maintain function & prevent deterioration as condition progresses
QR6. Vocational rehabilitation
Quality requirement:
People with long-term neurological conditions are to
have access to appropriate vocational assessment,
rehabilitation and ongoing support to enable them to
find, regain or remain in work and access other
occupational and educational opportunities.
QR6 Markers of good practice – outline :
co-ordinated multi-agency vocational rehabilitation
taking account of national guidance/best practice
local rehab. services: review needs; work with agencies
to provide basic vocational assessment, guidance &
support; + refer on to …..
specialist vocational services for complex needs,
providing specialist vocational assessment &
counselling, job retention and workplace support; VR
programmes; & advice for local services.
routine evaluation/monitoring of long-term outcomes
QR7. Providing equipment and
Quality requirement:
People with long-term neurological conditions are
to receive timely, appropriate assistive technology
/ equipment and adaptations to accommodation to
support them to live independently; help them with
their care; maintain their health and improve their
quality of life.
QR7 Markers of good practice – outline :
assistive technology provided and maintained in
accordance with agreed standards and guidelines
integrated community & assistive technology/equipment
services work closely with neurology & rehab. services
equipment needs documented in integrated care plan
specific funding arrangements for assistive technology
social services work closely with housing /
accommodation and Supporting People services
QR8. Providing personal care and support
Quality requirement:
Health and social care services work together to
provide care and support to enable people with longterm neurological conditions to achieve maximum
choice about living independently at home.
QR8 Markers of good practice – outline :
health and social services work together to provide full
range of accommodation, care and support options
care in all settings provided by appropriately trained staff;
who receive support / advice from specialist services
health & social services work together to help the person
remain as independent as possible as condition progresses
equitable access to services based on need and support for
people in applying for funding, care and support
QR9. Palliative care
Quality requirement:
People in the later stages of long-term neurological
conditions are to receive a comprehensive range of
palliative care services when they need them to
control symptoms; offer pain relief and meet their
needs for personal, social, psychological and spiritual
support, in line with the principles of palliative care.
QR9 Markers of good practice – outline :
specialist neurology, rehabilitation and palliative care
multi-disciplinary teams work together
specialised & generalised palliative care services at home
or in specialised setting according to choice & needs
staff providing care and support in later stages of a longterm neurological conditions have appropriate training:
neurologists/neurorehabilitation teams in palliative care skills
all staff in management of LTNCs and in palliative care
QR10. Supporting family and carers
Quality requirement:
Carers of people with long-term neurological
conditions are to have access to appropriate support
and services that recognise their needs both in their
role as carer and in their own right.
QR10 Markers of good practice – outline :
carers have choice on extent of caring role; and are offered
integrated assessment, written care plan and contact person
involving carers in care planning/delivery (partners in care)
flexible, responsive and appropriate services for carers
(emergencies; children; breaks), all culturally appropriate
help with adjustment to changes (especially cognitive or
behavioural) , when appropriate on condition-specific basis
staff training in carer awareness, education and training
which involves carers in planning and delivery.
QR11. Caring for people with long-term
neurological conditions in hospital or other
health and social care settings
Quality requirement:
People with long-term neurological conditions are to
have their specific neurological needs met while
receiving care for other reasons in any health or
social care setting.
QR11 Markers of good practice – outline :
in other care settings: integrated neurological care plan
available to all staff; close liaison with usual care team
neurological needs met in all settings: planned admissions
(pre-admission interviews); emergency admissions
(protocols for liaison); consultations between teams
consultation with person (& families/carers) about care
neuroscience, neurorehabilitation & spinal injury services
provide advice & training for staff in other settings
5. Next Steps: Implementing the NSF-LTC
Suggested early action for Primary Care Trusts:
1. Setting up managed neuroscience clinical networks
(incl. leadership, financial & accountability)
2. Stakeholder event to agree local priorities
3. Setting up a local implementation team
4. Setting up integrated planning & commissioning
arrangements with Social Services & other PCTs
5. Influencing provision of housing-related support
Clinical neuroscience networks
Key stakeholders might include:
PCTs & specialised commissioning groups
acute trusts; foundation trusts; mental health trusts
neuroscience centre and spinal cord injury centre
community and home care providers
rehabilitation services
local authority services (SSD, housing, transport, FE)
voluntary and independent sector organisations
people with neurological conditions & carers
Other possible early actions:
Assessing/auditing services, skills & training needs:
using LTC self-assessment tool for PCTs and SSD
auditing local services across all local organisations
analysing and profiling skills of local workforce
identifying key training needs for all agencies
Redesigning services:
redesigning services and considering new patterns of
working and skills mix (e.g. integrating trust & local
SSD staff in specific multi-disciplinary teams).
NSF-LTC: Good practice guide
1. Managing LTCs self assessment tool
2. ‘Tackling the issues’ - guidance papers:
Care coordination for people with LTNCs
Local provision of information
Service models for LTNC
3. Evaluated examples of good practice
(website guide -
NSF-LTC Implementation 2005/06
• Department of Health:
– Project Team + National Leads
– National Stakeholders Group
– Neurological Advisory Panel
• Professional groups
– Working parties / professional standards / audit etc.
• Regional / Local Action
– SHA Leads + ‘Neuroscience/Neurological Networks’
– PCT Leads + local implementation groups
NSF-LTC – Neurological Advisory Panel
Discussions have focused on:
• Policy integration / differentiation
• Incorporation into inspection process
• Development of specific clinical indicators
• Putting the NSF-LTC on PCT and LA agenda
• Commissioning issues
• Development of an minimum dataset for LTNCs
+ Development of models of service provision

Brain Injury: The Himalayas of Health Care