El Melocotón DO Calanda en la red de mercados centrales de MERCASA …

DoH facilities known to the researcher in 2008, at the time of literature review, included the WCRC, Bishop Lavis ambulatory service and the Elangeni rehabilitation service in Paarl with features as tabled below. The researcher was aware that Worcester Hospital, although not an official rehabilitation facility, has dedicated six beds in their Family Medicine ward, accommodated in Brewelskloof Hospital, for post-acute management of patients with recent onset impairment.

Table 2.4: Rehabilitation services available at WC DoH facilities (+ = available; - = not available)

WCRC Bishop Lavis Elangeni Worcester

In patients 256 beds - - 6

Outpatients + + + -

Location Metropole, Lentegeur Metropole, Bishop Lavis

Winelands, Paarl Overberg, Worcester Clinicians: Dr _{+ - - +} Nurse + - - + Physiotherapist + + + + Occupational Therapist + + + + Speech Therapist _{+ + + +} Social Worker _{+ - - +} Clinical Psychologist + - - - Dietician _{+ - - +} Interdisciplinary discussions + + + +

As indicated in the table above, posts for therapists are available at all these sites. Doctors experienced in the management of disability are available at the WCRC and Family Physicians at the Worcester site with the researcher providing rehabilitation input.

The researcher was aware from clinical experience that the UCT private academic hospital offered inpatient interdisciplinary programmes, with a rehabilitation doctor on their team. This facility has since closed and Life Rehabilitation opened in 2011 with the similar functioning. At least two private therapy groups co-ordinate physio, occupational, speech therapy and/or clinical psychology treatments, with referral to the local GP for medical management.

The researcher has experienced that these specialised rehabilitation facilities rehabilitate patients following onset of impairment to various outcome levels. Rehabilitation programmes may continue until maximum potential is achieved (e.g. outcome level 5 if the patient is to return to work or school), a plateau in function is reached or when the patient is able to return to their residential environment with continuation of rehabilitation in the community. In-patient programmes are provided for those who cannot access community rehabilitation services or need more intensive programmes (Gregory & Han, 2009). Although the benefits of these specialised rehabilitation facilities are recognised (Gregory

& Han, 2009; Geurtsen, Van Heugten, Martina & Geurts, 2010), Langhorne, Taylor, Murray, et al (2005) in their met analysis of 11 studies from Australia, North America, Europe and Thailand showed that early discharge of stroke patients to community rehabilitation teams had better short and long term functional outcomes and were more cost effective than management in an inpatient stroke unit or rehabilitation centre. Community therapists have the advantage of being closer to the patients discharge environment and thus are more aware of the contextual factors that will impact on the patient’s outcome (Wottrich, von Koch & Tham, 2007).

In order to provide more cost effective rehabilitation services, the WC Service Plan for Rehabilitation and Disability Management Services (Hendry & Pegam, 2006) proposed a framework for seamless management of persons with disabilities from tertiary through to primary level, which relates to Cope and Sundance’s outcome levels (1995), with the establishment of community based interdisciplinary rehabilitation teams. Unfortunately, this plan did not make provision for the incorporation of medical practitioners into these teams, potentially denying the person with a disability access to comprehensive care. The lack of incorporation of doctors into these teams refutes the medical component of a bio psychosocial approach and highlights the researchers concerns of a pure social model approach and the lack of recognition of medical rehabilitation specialisation. This plan, although adopted, has not yet been fully affected.

The handful of doctors interested in disability and rehabilitation and working in these specialised or dedicated facilities include medical officers with a few specialists (Neurologists, Urologists, and Orthopaedic surgeons) who have an understanding of the principles of rehabilitation. Much of the medical treatment that these medical officers deliver is embedded in these various specialities. The essence is being able to draw on this knowledge from the various specialities and to be able to apply the knowledge and skills with an attitude encompassing the bio psychosocial approach (Ebenbichler & Resch, 2009). On informal discussion with rehabilitation doctors in SA, they agreed that they share the same philosophies and general roles as PM&R specialists internationally although specific functions may differ between rehabilitation facilities.

2.2.6.3 The clinical training platform for a rehabilitation programme

One of the educational methods by which students learn is from student-patient interaction. Any of the afore-mentioned specialised or generalised clinical sites are thus

potential teaching sites for disability and rehabilitation. As rehabilitation is relevant to many specialities including general practice, teaching at as many clinical sites as possible allows for integration of teaching across the curriculum and not only in specialised rehabilitation modules (Bloch, Blake & Fiedler, 1996; Karle, 2004).

When universities consider specialised versus generalised facilities, specialised services are often the first choice of teaching sites as it can be expected to find a large number of suitable cases from which to teach (Gledhill, 1987). However in the WC patients with disabilities with conditions that are often chronic and susceptible to complications, are largely managed at primary health care (Mash & De Villiers, 1999; Kristina, Majoor & Van Der Vleuten, 2004).

Murray, Todd and Model (1997) described how, in the UK, Family Physicians have been drawn into undergraduate teaching programmes. Primary health care is known to deal with undifferentiated cases as it is the patient’s first interface with the health system when faced with an emerging health problem. This health condition may at a later stage be identified and aligned with a body system or speciality, or as described by Carson, Ringbauer, Stone, et al (2000) and the ICF, may remain medically unexplained. In this context primary health care practitioners become facilitators of teaching for the various specialities including rehabilitation, rather than content experts. From observing the GPs involved in the Rehabilitation programme at US, who have with training and time developed content expertise which has enhanced their clinical service to persons with disabilities, they may be considered role models for students in managing and advocating for persons with disabilities in the community. Although such community based teaching is considered to be a modern educational principle, it was reported that students who receive a greater part of their training in a tertiary hospital environment, find these community orientated specialities to be less important (Ward, 1992; Jones & Helbren, 2007).

When universities consider placement at public or private services, the researcher has observed that public health facilities are primarily considered especially where university and health departments have shared service level agreements and capacity to absorb possible cost implications of accommodating student placements. However private practitioners indicated that being involved with student placements can be rewarding despite the time and cost implications (Vinson, Paden, Devera-Sales, et al 1997; Worley, Silagy, Prideaux, et al 2000) as will be discussed under 2.3.5.

As students may eventually practice in any one of these environments, public or private, generalised or specialised, the researcher considered it to be ideal that they are exposed to disability management in all these settings.