Gerold Stucki: “The most important thing in rehabilitation is to not treat the body but to comprehensively address the needs of the person”
Chair of the Seminar of Health Sciences and Health Policy at the University of Lucerne and Director of Swiss Paraplegic Research about why rehabilitation will take a crucial place in modern societies and healthcare, how it helps national economies and how long a healthcare reform takes
In your lecture, rehabilitation is referred to as the key health strategy of the 21st century. Why so?
If we think of the main health strategies in medicine, like promotion, prevention and cure, we notice that rehabilitation was for long time neglected. The World Health Organization’s (WHO) call for action in “Rehabilitation 2030” is the first significant initiative in the past 50 years. The situation is now changing as the need for rehabilitation is greatly increasing. There are several explanations behind this change. Firstly, the population worldwide is getting older, resulting in more people living with a decreasing functional ability. Rehabilitation can reverse or slow this decline in functional ability and prevent premature nursing home care. Secondly, the number of people living with chronic and multiple health conditions is increasing, as well as the number of people surviving previously deadly diseases and injuries. Think of cancer: it used to be a deadly disease. Thanks to advances in curative medicine it has now similarities to a chronic condition in many cases. Through rehabilitation cancer survivors can regain their functional ability and often return to their previous life including work. Also, you can think of all the injuries people did not survive in the past but do now. For instance, people with paraplegia who in the past had low chances to survive after spinal cord injury and often died of complications, have now a life expectancy approaching the life expectancy of the general population. Thanks to rehabilitation they can now often conduct a normal life, have a family, work, do sports and even become Paralympics champions.
Common to aging, many chronic conditions as well as injuries and cancer survivors experience limitation in functioning. Functioning refers to intrinsic biologic capacity on the one hand and functional ability on the other. Rehabilitation first improves intrinsic biological capacity encompassing both physical and mental capacity, and hence what people can do in principle. Secondly, rehabilitation improves functional ability. The goal is to enable people to do what they want to do in real life. Ultimately rehabilitation aims to optimize people’s participation in all life aspects, including family and friends, leisure and sport, and work. Rehabilitation thus contributes to people’s autonomy, quality of life and integration in society.
The translation of people’s potential in terms of intrinsic biologic capacity into real life is fundamental for both, the individual and the society, especially from an economic perspective
We invest so much in healthcare in economic terms. It is thus fair to ask what the added value of health care in general and more specifically of rehabilitation is. In areas like education, nobody any longer doubts whether it is a cost or an investment. It is clear that a good educational system accessible to all is an investment with high returns for society. The same is true for rehabilitation. The direct medical costs of rehabilitation are small relative to potential gains resulting from increased participation across live areas including paid work as well as unpaid work for example in the family.
Take the example of spinal cord injury. Decades ago people with spinal cord injury were seen as disables and were unlikely to be provided with the opportunity to participate in the work force. Depending on the severity of the injury, nowadays in Switzerland people with spinal cord injury participate in the workforce, both formally and informally, similar to the general population.
The economic benefits of rehabilitation can be tracked across age groups. It has been provocatively stated that a person becoming a taxpayer again is an expression of the potential people have with access to effective rehabilitation services. For the retired and elderly the benefits result from longer independent living and a respective reduction of costs for nursing home stays.
Can you give examples of national healthcare systems where rehabilitation was integrated with a visible effect?
Rehabilitation has developed differently across countries. Its evolution in continental Europe, say, Switzerland or Ukraine, has differed from that in the United States. In the latter case, it emerged as a response to the two world wars. The motivation to build a rehabilitation system in the US was to address the situation of war veterans. This is because the country needed the young soldiers coming back from war to enter the workforce. I understand that Ukraine is currently facing a similar situation.
In many parts of continental Europe rehabilitation has developed from another angle, from health resort medicine with its long tradition in Spa and Sanatorium Medicine. As I understand, this tradition exists in Ukraine similar to Switzerland and Germany. In our times it is essential to transform these traditions into a modern rehabilitation system.
In 1963 Switzerland approved a law that required the building of hospitals for rheumatic diseases that soon transformed into clinics for rehabilitation. For political-economic reasons they were built at the site of existing spa resorts. My first two years of training as a medical doctor were in one of these new rehabilitation clinics. It has provided me with an excellent basis to become a rehabilitation specialist and Professor of Rehabilitation Medicine in Switzerland and Germany. The results of the new rehabilitation clinics were a successful story, as people with musculoskeletal conditions, which is still the most important chronic condition, regained functional ability, continued to be part of the work force, and were able to live independently. Also, the clinics made a major contribution in building up of the rehabilitation workforce including doctors, physiotherapists and occupational therapists.
In the 1990’s Switzerland integrated rehabilitation in acute care through mobile rehabilitation teams. As head of the Institute of Physical Medicine and Rehabilitation at the University Hospital in Zurich and later at the Ludwig-Maximilans-University Hospital in Munich I was responsible for the provision of rehabilitation services with mobile teams for internal medicine, surgery, neurology, pediatrics and many sub-specialties. The main benefits are a reduction in medical complications such as contractures and decubitus as well as a shorter stay.
Currently Switzerland is faced with the challenge to bring rehabilitation closer to where people live, most importantly the metropolitan regions such as Zurich. A main reason is the ageing population often living with a number of chronic conditions. This population needs close and long-term access to rehabilitation services, something the peripheral rehabilitation clinics at the former Spa resorts cannot provide. Ambulatory centers are now increasingly established at local hospitals. What is still missing is a convincing concept for the provision of rehabilitation in primary care. One possibility is the provision of rehabilitation in cooperation with primary care physicians and physiotherapy practices.
Would that take a lot of retraining of doctors?
There are two ways to look at rehabilitation. On the one hand it is practiced and scientifically developed by rehabilitation doctors. They are the leaders of multi-professional rehabilitation teams at dedicated rehabilitation services. On the other hand rehabilitation is integral part of clinical practice for many medical specialties including primary care, neurology, rheumatology and orthopedic surgery to name just a few.
In my view, we need both: physicians specialized in rehabilitation medicine and physicians from other specialties with a good understanding and basic skills in rehabilitation. This ensures the integration of rehabilitation along the service continuum from emergency and acute care, to dedicated rehabilitation services, and finally to primary care in the community. The challenge is therefore not necessarily retraining but rather complementary training in rehabilitation.
The need for rehabilitation across the service continuum from acute care to the community is one reason why the WHO emphasizes the need to integrate rehabilitation in the health care system rather than the social sector.
How expensive is it to integrate rehabilitation into the general healthcare system? What countries can afford it?
I would turn the question around: what countries can afford not to provide rehabilitation services as integral part of their health care system? As already mentioned, the reason is that rehabilitation is an investment rather than a cost to society. The WHO thus advocates the inclusion of rehabilitation in universal health coverage, that is the payment for rehabilitation by the government or the insurance system.
In many countries the problem is that who pays for rehabilitation is not the beneficiary. This is the case in countries where health care and the social sector are financed separately with own budgets. The problem arises if a service like rehabilitation is paid by the health sector but the benefits like fewer social security pensions and fewer nursing home stays result in budget savings for the social rather than the health sector.
This division is a fundamental and unresolved issue in many countries as governments will always be organized in sectors and ministries. My hope for the future is that academic economists will get more involved with the health and social sector and come up with smart solutions such us transfer payments across sectors.
You speak about multidisciplinary teams involved in rehabilitation. What disciplines should this field combine?
The most important thing in rehabilitation is to not treat the body but to comprehensively address the needs of the person. The needs range from physical and mental capacity to enabling the person towards the realization of his potential in his environment including work, leisure and sports.
We can only be successful in rehabilitation if we engage with the patient and his or her family in partnership. Each person’s needs are different and must to be addressed with an individual rehabilitation plan. As soon as we understand this, we will realize that we rely on more than one person to make a difference.
The rehabilitation doctor as leader of the multi-professional team is responsible for the development, implementation and evaluation of the rehabilitation plan. He focuses on the medical side including diagnostics and pharmacological treatment as well as assistive devices. Physiotherapy focuses on the physical capacity and neuropsychology on cognitive capacity. Who translates intrinsic physical and mental capacity into real life? Here we have occupational therapy and social work. They have the expertise to understand how the person interacts with the environment and can support patients in realizing their potential in real life situations. Psychology supports the patient with coping and adjusting to the new life situation and emphasizes the positive aspects of life. These are the core functions. Sometimes, you need to add additional expertise such as speech therapy.
When you want to make such a shift in the healthcare system, where does the impulse come from? Is it the society that pushes for a change, the academic community or the politicians?
In health care systems you usually have many players and stakeholders including providers, payers and so on. At different times they push or pull back.
The model that is currently favored in Switzerland is the Learning Health System. It is led by my university, the University of Lucerne and is supported by the Swiss government through the association of Swiss Universities. The core idea is to involve all relevant stakeholders in an emerging issue towards reaching agreement on possible scenarios for implementation and change. Once an issue is prioritized the process starts with a so-called policy brief: it is a summary of the current situation and the evidence supporting change. It is indeed brief and formulated in lay expert language to ensure it is easily understood by stakeholders with varying backgrounds and experience.
Then we organize a dialogue with the stakeholders in a very structured format which has been developed by the McMaster University, in Ontario, Canada and is called the McMaster Health Forum. The dialogue may result in agreement for example with respect to a preferred scenario. In the case of dissent the alternative scenarios will be followed up and serve as information in the decision making process.
Once you have all relevant stakeholders involved, the likelihood of implementation is much higher. What we see in Switzerland is that more isolated initiatives get stuck. In our tradition of direct democracy, we usually have to involve many people in any consultation process. The Learning Health System approach can facilitate this.
If you ask me who in the future will be the most important drivers of change, I would say without hesitations that it’s increasingly the patients, the consumers. An example is the Swiss Paraplegic Foundation and its patient organization. Thanks to their advocacy the government and insurances ultimately decided to pay for wheelchair elevators at home, special beds to prevent the occurrence of decubitus, and so on.
How long does it take to bring a change like that from idea to implementation?
The political process takes time. Even with the best intention of various stakeholders you typically need some years to implement change. I can give you the example of a health information system initiative that will more comprehensively capture health by including functioning in addition to mortality and morbidity information. The achievement of this goal takes years. It depends on the steps you take. In Switzerland we’ve learned that it’s sometimes better to take small steps, ideally building on upcoming opportunities, rather than to aim for the one big change.
Very often, it’s preferable to start with a pilot or demonstration project. In rehabilitation we are planning pilot and demonstration projects across European countries towards the European wide implementation of clinical quality management for rehabilitation. The shared goal is to improve patient care both at the individual and service level in a learning system approach.
If, for example, the government said: “you have to implement this change now”, people may react negatively and oppose this change. The better approach is to start with a demonstration project, then move to a voluntary system where “first movers” participate. Once the project is implemented, other providers may see the benefits and join in. That’s what’s happened in Switzerland. Service providers now see the benefit of clinical quality management and everybody wants to join in. Your rehabilitation service is not considered high-quality if you’re not part of the national clinical quality management for rehabilitation.
Where could Ukraine start if it wanted to involve rehabilitation in a more comprehensive manner?
That is a question for my Ukrainian colleagues. But what I have learned from them is that Ukraine has made a lot of progress in many areas. One example is that Ukraine is now part of the Section and Board for Rehabilitation of the European Union of Medical Specialists (UEMS-PRM). The spring meeting in March 2018 has been hosted by our Ukrainian colleagues. This is a clear indicator of the strengthening of rehabilitation medicine in Ukraine.
An important development is the introduction of international standards such as WHO’s International Classification of Functioning, Disability and Health (ICF) by the Ministry of Health. This is of fundamental relevance as it will allow every rehabilitation specialist to specify an individual rehabilitation plan using WHO’s universal language of functioning. It also allows any physician to assess a patients functioning and to assign patients to an appropriate rehabilitation service.
The idea of health information standards sounds like a very technical one, but it’s not. This is because standards are relevant for the training of health professionals and for rehabilitation care. Most importantly they provide the basis for the development of a clinical quality management for rehabilitation at the national level and specific rehabilitation services.
I would like to emphasize that the move to an international standard such as the ICF is a very suitable starting point to bring various stakeholders together towards a joint goal, to optimize rehabilitation care for all people in Ukraine.
Gerold Stucki is Professor and Chair of the Seminar of Health Sciences and Health Policy at the University of Lucerne, Director of Swiss Paraplegic Research in Nottwil, Switzerland, and Director of the ICF Research Branch, a cooperation partner of the German World Health Organization (WHO) Collaborating Centre for the Family of International Classifications. He received his medical education at the University of Berne and obtained a Master of Science (MSc.) in Health Policy and Management from the Harvard School of Public Health and a diploma in Biostatistics and Epidemiology from the University of McGill, Montréal, Canada. During his appointment as Chair of the Department of Physical and Rehabilitation Medicine (PRM) at the Ludwig-Maximilians University from 1999-2009, Prof. Stucki pursued clinical research in PRM and musculoskeletal medicine, and developed a new research agenda for human functioning and rehabilitation research. Prof. Stucki has been collaborating with the WHO in an international effort to implement the International Classification of Functioning, Disability and Health (ICF) in rehabilitation and the health sector in general. Since 2005, he has been assigned the task of developing the Swiss Paraplegic Research (SPF) into a research institution with a comprehensive perspective. Since August 2009 he has served as Professor and Chair of the Seminar of Health Sciences and Health Policy at the University of Lucerne. In 2012, Prof. Stucki became a Foreign Associate of the Institute of Medicine, a part of the United States National Academies.