How is the audit of therapy intensity influencing rehabilitation in inpatient stroke units in the UK? An ethnographic study

OBJECTIVES: Occupational therapy, physiotherapy and speech and language therapy are central to rehabilitation after a stroke. The UK has introduced an audited performance target: that 45 min of each therapy should be provided to patients deemed appropriate. We sought to understand how this has influenced delivery of stroke unit therapy. DESIGN: Ethnographic study, including observation and interviews. The theoretical framework drew on the work of Lipsky and Power, framing therapists as ‘street level bureaucrats’ in an ‘audit society’. SETTING: Stroke units in three English hospitals. PARTICIPANTS: Forty-three participants were interviewed, including patients, therapists and other staff. RESULTS: There was wide variation in how therapy time was recorded and in decision-making regarding which patients were ‘appropriate for therapy’ or auditable. Therapists interpreted their roles differently in each stroke unit. Therapists doubted the validity of the audit results and did not believe their results reflected the quality of services they provided. Some assumed their audit results would inform commissioning decisions. Senior therapy leaders shaped priorities and practices in each therapy team. Patients were inactive outside therapy sessions. Patients differed regarding the quantity of therapy they felt they needed but consistently wanted to be more involved in decisions and treated as individuals. CONCLUSIONS AND IMPLICATIONS: Stroke unit therapy has different meanings in different hospitals. Measuring therapy time is problematic due to varied interpretations of ‘what counts’ and variation in reporting practices. Although stroke policy, guidelines and audit are potential tools of improvement, their benefits are not automatic. Their actual effects depend largely on the attitudes and values of local influential ‘street level leaders’. More work is needed to promote an integrated whole team approach to rehabilitation. Further research into contextual and human factors, including the roles and views of therapy leaders, would enable a better understanding of implementation of guidelines and service improvement.