Therapies and AHPs

The standing claim

Value in therapies is functional independence gained per episode — and it is decided early. Deconditioning sets a ceiling fast; the levers that raise it are rehabilitation intensity matched to potential and, critically, delivery by a coordinated multidisciplinary team. The evidence is unusually clear about what works — and unusually honest about what is asserted but unproven.

Where practice stands

The firmest, most quantified standards in this domain are flow standards, not outcome standards: the Urgent Community Response two-hour standard (respond to ≥70% of appropriate two-hour referrals within two hours), and NICE NG74’s expectations — reablement offered as the first option, crisis response within two hours, bed-based intermediate care started within two days. NHS England’s Intermediate Care Framework organises this as therapy-led, “Home First” step-down. For stroke specifically, NICE NG236 (2023) raised the therapy-intensity expectation sharply — to at least three hours a day of multidisciplinary therapy, five days a week (up from the old 45-minute target). But community rehabilitation provision is patchy, and the profession’s own standards (the CSP’s Community Rehabilitation Best Practice Standards) are explicitly aspirational, with no numeric waiting-time or intensity targets.

What good looks like

The data-led exemplar is a model, not a country: coordinated, AHP-led stroke Early Supported Discharge (ESD). According to PubMed, the Cochrane review (Langhorne & Baylan, 2017 — 17 RCTs, n=2,422) found ESD reduced death or long-term dependency (OR 0.80, 95% CI 0.67–0.95), reduced death or institutional care (OR 0.75, 0.59–0.96) and shortened hospital stay by about six days, at roughly neutral cost. Crucially, the benefit appeared only where a coordinated multidisciplinary team delivered it, and in patients with mild-to-moderate disability — the evidence specifies precisely what “good” requires, which is exactly why it is the exemplar. It maps directly onto the Intermediate Care Framework’s therapy-led step-down. The same “keep moving early” principle holds in critical care, where structured early mobilisation shortens ICU stay and improves function (with the honest caveat that trials report more adverse events and no mortality benefit), and in dementia, where OT-led goal-oriented cognitive rehabilitation improves goal attainment (the GREAT trial).

The honest counter-case is reablement. It is the policy default (NICE NG74 makes it the first option), and it is internationally fashionable — Denmark mandates it nationally. But the evidence does not yet support the enthusiasm: a systematic review (Legg et al., 2015) found no studies meeting RCT-grade inclusion criteria and concluded reablement is “an ill-defined intervention… with no evidence to suggest it is effective” at either increasing independence or reducing care use. Some service-level evidence is encouraging — an Australian restorative home-care trial (Lewin et al., 2014) found lower ongoing home-care use and fewer admissions — but other trials are null or show gains that fade by 12 months. So reablement is sound in design and policy, unproven in sustained effect — and treating its international reputation as proof is precisely the exchange-value error this publication guards against.

Through the lenses

The measure is use value — what the person can actually do afterwards — not the count of therapy contacts (the activity unit). McGilchrist’s whole-person attention is the clinical correlate: function is a property of the whole person in their context, not of any single discipline’s silo, which is why the coordinated team, not the sum of separate inputs, is what the ESD data rewards. The VAT lever is functional independence per episode; cross-domain, this is the active defence against the deconditioning that decides acute-frailty outcomes (D01) and the rehabilitation that lets palliative patients spend their time where they choose (D03).

Confidence and limits

The stroke-ESD evidence is high-quality and meta-analysed — but condition-specific (stroke), MDT-dependent, and concentrated in mild-to-moderate disability; its benefits weaken at one and five years. The reablement evidence is genuinely weak, and we state that plainly rather than dress policy enthusiasm as proof. The firmest national standards are operational-flow targets, not therapy-outcome standards — a structural gap. (NICE NG236’s “three hours” refers to total multidisciplinary therapy, not physiotherapy alone, and itself exceeds the directly-evidenced 1–2 hour physiotherapy band — a committee consensus, honestly labelled.)

What we are watching

Whether community rehabilitation acquires outcome standards rather than only flow targets; whether reablement finally generates RCT-grade evidence to match its policy status; and whether the NG236 therapy-intensity expectation is matched by the workforce to deliver it.