Rehabilitation Psychiatry specialises in assessment and treatment of people with particularly long term and complex mental health problems who require specialist input to optimize their recovery with integrated psychological, biomedical and social care.1 Around 20% of people diagnosed with severe mental illness will require mental health rehabilitation. The majority have a primary diagnosis of psychosis with functional impairments that lead to longer term high support needs.2,3
The complex problems these patients experience lead to functional impairment which affects activities of daily living as well as social, interpersonal and occupational functioning. These problems include treatment-resistant symptoms, co-occurring mental health comorbidity that can include substance misuse and co-occurring physical health conditions.4 Specialist rehabilitative care improves the outcome for this group of patients with highly complex and long-term needs.5,6
It is clear that the need for rehabilitative care is growing across the UK despite the disinvestment in services. There is increasing use of ‘out of area treatments’ for this group which are associated with poorer outcomes including longer lengths of stay and social exclusion.7 This has been acknowledged in the NHS Long Term Plan. 8 NHS England has implemented a national programme to enhance the provision of local rehabilitation services.9 The new specialist programmes indicate the need for better services and an adequate and appropriately skilled workforce.10
The Welsh Government’s ten-year strategy to improve mental health and well-being has identified a range of areas that require attention. The Welsh Government is focusing on the needs of people with complex and enduring mental disorder.11
The Scottish Mental Health Strategy has identified the need to shift the balance of care towards mental health. The strategy details the need to address the dramatic decrease in life expectancy of those with severe and enduring mental illnesses. Scotland aims to develop holistic services that address the effect long term mental health conditions have on functional decline to encourage recovery.12
Northern Ireland has higher levels of mental disorders than any other region in the UK13 with psychiatric morbidity 25% higher than England.14 Specialist mental health services to address enduring and severe mental health conditions are only available in Belfast City14. It has been identified that building up the range of specialist services is required to meet need.15,16
The NHS Long Term Plan stresses that building up rehabilitation support alongside core services is vital to support those with long term mental health conditions.17 In addition, the first NICE guideline on mental health rehabilitation was published in August 2020 and specifically recommends that ‘All local mental healthcare systems should include a defined rehabilitation pathway as part of their comprehensive service’. The guideline recommends that this should include inpatient rehabilitation services (high-dependency rehabilitation units and/or community rehabilitation units) and a community mental health rehabilitation team to care co-ordinate people living in mental health supported accommodation (residential care, supported housing and floating outreach).18
There is significant and accumulating evidence that provision of psychiatric rehabilitation is cost-effective for complex long-term mental illness. Around two-thirds of people supported by rehabilitation services progress to successful community living within 18 months of admission to an NHS inpatient rehabilitation unit, and two-thirds sustain this over five years without requiring further hospital admissions, and around 10% achieving independent living within this period. People receiving support from rehabilitation services are eight times more likely to achieve/sustain community living, compared to those supported by generic community mental health services.2 Without specialist rehabilitation, people with severe and complex mental health problems are at very high risk of self-neglect, exploitation from others and long term institutionalisation.19
The evidence has been collated in the recently published National Institute for Clinical Excellence (NICE) Guidance published in Aug 2020.20
The purpose of this training curriculum is to enable the Consultant Rehabilitation Psychiatrist to specialise in the assessment, diagnosis and effective management of people with complex mental health problems in order to ensure they receive appropriate treatment and are able to achieve and sustain a successful and rewarding life in the community.
The capabilities in this curriculum include longitudinal, in-depth person-centred assessment, formulation and treatment planning using evidence-based psychological, biomedical and social interventions. Specialist and targeted interventions include those to improve engagement, improve skills in activities of daily living and relapse prevention. Skills to manage transitions of patients from inpatient settings to supported accommodation and independent community living are specifically relevant. Specific training in Rehabilitation Psychiatry offers skills in working with complexity to ensure incremental gains and therapeutic change when working with patients with enduring complex needs and complex co-morbidity.
The Rehabilitation Psychiatry Endorsement Curriculum ensures that trainee doctors have appropriate and sufficient opportunities to achieve these capabilities.
After successful completion of Core Psychiatry Training and MRCPsych examinations, trainees are recruited into the Adult Psychiatry training programme to gain necessary experience and capabilities. Specific training in Rehabilitation Psychiatry focuses on working with patients with enduring complex needs and multi-morbidity. It is recommended that this training period is for 12 months (Whole Time Equivalent) of the 36 months (Whole Time Equivalent) in order to achieve the required capabilities and adequate experience to lead to an endorsement on to the specialist register.
This curriculum provides a detailed framework for training. It enables the achievement of essential rehabilitation and recovery specific clinical and professional capabilities. This will be through demonstrating professional values, attitudes, behaviours, knowledge and skills required in order to provide high-quality, evidence-based patient care for adults with complex enduring mental disorder.
Trainees will gain experience and competence in inpatient and community-based rehabilitation services, thereby ensuring the trainee gains appropriate knowledge and skills relevant to both these essential components of the rehabilitation pathway. A Consultant Rehabilitation Psychiatrist will be confident to work with and manage complex mental disorders for a diverse range of patients with long-term mental disorders. This includes multiple co-morbidities such as addictions, physical health conditions, neuro-developmental disorders and other mental disorders.
These capabilities should be acquired across both inpatient and community rehabilitation settings. Inpatient rehabilitation, community rehabilitation, supported accommodation, secure care settings such as low secure rehabilitation amongst others offer such opportunities, under specialist supervision.
Further curricula are available for the following other established psychiatry specialties:
Training in Rehabilitation Psychiatry offers specialist enhancement of skills and knowledge that are acquired in General Adult Psychiatry training. The trainee develops the capabilities needed to treat patients with longer term complex disorders, lead effective multidisciplinary teams and understand governance and commissioning structures.
The recommended indicative one year spent in training will provide appropriate development of transferable skills and experience in Rehabilitation Psychiatry.
The Rehabilitation Psychiatry learning outcomes are mapped to the Generic Professional Capabilities Framework (GPCs) ensuring ease of transfer between medical specialties. Through attainment of the High-Level Learning Outcomes (HLOs), this curriculum will guide trainees to lead and work in multidisciplinary and multi-professional teams, provide leadership, and participate in research, teaching and training in a variety of clinical settings. It will also enable trainees gain experience in formulating integrated psychological, bio-medical and social, person-centred management plans for a range of mental health presentations within diverse health care settings. It provides opportunities to develop the expertise to work with patients and their social networks and understand the need to work collaboratively with a range of allied agencies and services as needed.
Rehabilitation sub-specialty training includes all aspects of the adult curriculum while supporting the development of specialist skills and expertise in managing complex disorders and the clinical leadership and multidisciplinary working needed to achieve this. This utilises an integration of psychological, biomedical and social approaches to increase clinical effectiveness in the delivery of evidence-based treatments to improve outcomes for people and their families.
The curriculum builds on the clinical capabilities attained in Core Psychiatry and Adult Psychiatry training such as advanced communication and interpersonal skills, diagnosis, managing complex treatment regimens to treat mental and physical co-morbidities and relapse prevention work to provide better outcomes for patients, which are above and beyond what general psychiatric training offers. There are opportunities for further development of capabilities such as leadership and management, teaching, research and quality improvement that are specific to services for people with complex needs.
Rehabilitation Psychiatry patients are a distinct group of patients who, although low in numbers, consume a high proportion of available resource within the healthcare system when their specialist care needs are not met. These are patients for whom standard mental health services have not proved effective. Thus, in the absence of Rehabilitation Psychiatrists, these patients would not get effective treatment for their mental health conditions and would end up longer term in secure units, other inpatient settings, or prison settings.
This work is predominantly undertaken within the National Health Service, although in recent years, rehabilitation services have also developed in the independent sector.21
Mental health rehabilitation services provide a whole system approach to support people’s recovery, working closely with other parts of the health and social care system; for example, providing specialist clinical input to people living in supported accommodation services run by the voluntary sector, liaising with primary care and secondary services for their physical health care, and in-reaching to people placed in inpatient rehabilitation and forensic services in the independent sector, in order to facilitate their access to local rehabilitation services at the earliest opportunity.
Doctors with a Rehabilitation Psychiatry sub-specialty recognition are instrumental in developing services that allow patients to return from placements in the Independent Health Sector which have a proven higher overall cost.21 These services also often act as the final step in the pathway that allows Mentally Disordered Offenders to receive rehabilitation to return to community settings, thus forming an integral part of the Forensic Pathway. The Rehabilitation Psychiatry curriculum has some key interdependencies with Intellectual Disability, Forensic psychiatry, Addiction psychiatry, Old Age psychiatry and other disciplines across secondary and primary care interfaces, which reflects the longer term and complex clinical needs of these patient populations.
This purpose statement has been endorsed by the GMC’s Curriculum Oversight Group and confirmed as meeting the needs of the health services of the countries of the UK.