Having launched two community neurorehab teams a generation apart after career plotlines took me away from the clinical frontline for some twenty years, comparison between the experiences has thrown into striking relief some fundamental changes in the rehabilitation landscape which have affected (generally positively) how such services can work and reach more people. The RNRU Outreach Team at Homerton Hospital in the 1990s emerged from a backdrop of minimal provision, and was intended to develop a blueprint for future NHS services; Cognivate was established in 2021 within the independent sector to provide access to similar interdisciplinarity, drawing on the Outreach model.
That was then …
Thirty years ago there was no NHS community-based rehabilitation for people with acquired brain injury [ABI], only limited and geographically patchy access to some out-patient provision – and even this wasn’t easily accessible for those with limited mobility or support. Voluntary services such as Headway provided information and some social support, but in the then-absence of online platforms it relied on in-person visits or phone calls. Stretched social services did their best to help but lacked ABI expertise and resources.
After sustained lobbying, the Dept of Health eventually provided 5-year funding for several model services across the UK – and so, in the mid-90s, the Outreach Team was launched alongside other new services which included Andy Tyerman’s vocational service in Herts and a day-patient service at the Frenchay Hospital in Bristol. We had the finance and freedom to design these new services from first principles, and at Homerton Dr Richard Greenwood and I additionally won research funding from the Medical Research Council to evaluate the Outreach Team via a randomised controlled trial [RCT].
Fundamental service principles
These are as true today as they were then. Working with people in the context of their own lives means that the focus of interventions shifts from impairment to participation. Therapists have to be perceptive, attuned to family and cultural dynamics, and inventive in helping their clients achieve personally meaningful goals which more often than not require multi-faceted inputs. Our highly interdisciplinary model was constructed to foster collaboration and creativity by our neuropsychologists, OTs, physios, and SLTs, with the duration and pattern of therapies determined by a shared focus on the client’s goals and motivations. We did not impose artificial limits on the duration or intensity of our involvement, but given the huge number of people needing such help we were clear from the outset that our input would be finite and not seek to resolve every possible problem: our overarching aims were to increase clients’ independence and quality of life, equipping them with the skills and confidence to continue progressing after discharge. In practice, the median duration of rehabilitation was six months, but ranged from a few weeks to well over a year in some cases.
It worked.1 At two-year follow-up, our clients remained significantly more independent than those in a control group, and their psychological wellbeing and overall quality of life was better. The Outreach Team is now embedded within NHS provision, and there are many other such teams nationwide; the trial, which remains the only RCT of a community-based neurorehab team to have been undertaken anywhere, has also informed the development of other services internationally.
This is now
Fast forward to 2021, when I and colleagues had the opportunity to set up Cognivate in the independent sector. We drew on a lot from the successful Outreach model – the interdisciplinary approach, the client-centredness, the focus on real-world measurable goals. But by dint of being in the private sector rather than the NHS, and in a new era, other elements are strikingly different.
Geography
Most of our funding is medicolegal, and we cover a wide area which currently extends from the south coast to Hertfordshire with a concentration of clients in greater London. Given this spread, we have recruited a distributed network of highly experienced associate therapists who work alongside our directly employed core team, enabling us to put together a bespoke local rehabilitation team for each client. We have developed clear systems and processes to facilitate a consistent and integrated approach, supported by our proactive Ops team.
Funding, focus, and duration of interventions
The majority of our funding is medicolegal and informed by the Rehabilitation Code, originally introduced in 1999 to encourage lawyers and insurers to collaborate in facilitating early treatment and support. The emphasis on enabling clients to rebuild their lives as much as possible means that Cognivate is able to work with clients for more extended durations than is typically feasible for NHS teams, frequently undertaking the protracted interdisciplinary vocational rehabilitation necessary to facilitate and support resumption of education and/or employment.
Case management
Case management for people with ABI was a nascent profession in the 1990s, with the first evaluation being published in 19942 and BABICM being established in 1996; see Leonard et al3 for an interesting overview of its subsequent development and impact. Private services like ours are now most often commissioned by CMs instructed by solicitors in accordance with the Rehabilitation Code.
Our therapeutic activities are greatly facilitated by CMs, both directly and through their wider roles in liaising with all involved parties: for instance they often source and commission specialist investigations to illuminate underlying impairments; procure adaptive equipment and aids; clarify and intervene in relation to complex family dynamics or legal issues which are impacting on the client’s progress; and through their overview, inform and shape the rehabilitation programme. In Cognivate’s experience, collaborative working with CMs frequently enhances the efficacy, cost-effectiveness and impact of interdisciplinary rehabilitation.
Technological developments
Our current service would simply not have been possible without the technological advances of recent years. Our clinicians are spread over a wide geographical area, and so there is no practical benefit in having a shared office base. However this means that we have had to find alternative ways of enabling the informal catch-ups and socialising which are key to camaraderie and team-working. Whilst occasional in-person social and CPD events are part of this, we now have online resources which did not exist thirty years ago. Our fortnightly whole team Zoom meetings allow for relaxed conversation as well as client discussion. Shared electronic notes, video calls, and individual client chatrooms enable therapists to keep in touch quickly and proactively. Many clients, family members, support workers, and other professionals are able to participate in sessions and meetings remotely, with clinical and cost benefits.
Relatedly, the explosion in electronic devices and apps, and the increasing confidence with which we all – therapists and clients alike – use them, has made it easier to encourage effective use of strategies, set up prompts and reminders, and monitor associations between (e.g.) mood, fatigue and behaviours. Cognivate is now routinely utilising the Neumind app to make key therapy information/advice easily accessible to clients as well as using it interactively to support their rehabilitation and discharge.
Looking to the future
Combining therapist ingenuity with technological innovation is already helping to amplify and sustain clients’ gains, and effective collaboration between clinicians and software developers holds enormous promise for designing, refining, and successfully implementing new mechanisms to enhance our clients’ functional abilities, self-confidence, and wellbeing.
Cognivate is growing. We’re keen to recruit more associate OTs, neuropsychologists, physiotherapists and SLTs across all areas from the south coast up to and including the Midlands. Please do take a look at our website (https://www.cognivaterehab.com) for more information about how we currently work, and to find out more about opportunities.
By Professor Jane Powell, neuropsychologist and CEO
REFERENCES
1. Powell J, Heslin J, Greenwood R. Community based rehabilitation after severe traumatic brain injury: a randomised controlled trial. (2002) J Neurol Neurosurg Psychiatry, 72(2):193-202.
2. Greenwood RJ et al (1994) Effects of case management after severe head injury. British Medical Journal, 7;308(6938):1199-205.
3. Leonard R, Linden MA, Holloway M. (2025) Case management for acquired brain injury: a systematic review of the evidence base. Brain Injury, 39(5):337-358.