Rebuilding lives after long hospital stays
A ground-breaking new NHS service is transforming recovery for people across Birmingham and Solihull who have spent long periods in hospital.
The Recover Well programme - one of the first of its kind in the country - focuses on helping patients not only survive but truly thrive once they return home after discharge from inpatient settings.
Every year, hundreds of people in Birmingham face prolonged hospital stays. Many leave hospital medically stable but far from fully recovered; they may struggle with fatigue, breathlessness, anxiety, and muscle loss which, in turn, creates barriers to returning to work and other activities.
Without co-ordinated support, these difficulties may escalate. Data suggests that patients who stay in hospital for more than 21 days, or have been critically unwell, can take up to two years to get better; nearly a third die within six months and many require multiple readmissions. Often, such patients do not receive the holistic ongoing, structured help needed to rebuild their lives.
Recover Well is designed to directly address that gap, bringing together hospital clinicians, community teams, psychologists, physiotherapists, GPs and voluntary sector partners, working flexibly to ensure that support continues seamlessly from ward to community.
It has evolved from the successful Post-COVID service in Birmingham that, faced with unprecedented demand following the pandemic, explored innovative ways to support people affected by symptoms such as post-viral fatigue, brain fog and complex breathing difficulties in the community.
The Recover Well team contacts patients between eight and 12 weeks after discharge from hospital to offer support, focussing on three key issues that commonly affect people after long or complex hospital stays:
- deconditioning - long periods in bed can lead to significant muscle loss, reduced mobility and a loss of independence. Recover Well provides tailored rehabilitation to help patients regain strength and confidence at their own pace;
- fatigue - the service offers specialist advice and support to help patients experiencing fatigue to make adjustments in managing daily life, helping people to stabilise their energy levels and then gently increase their functional abilities over time;
- complex breathlessness - NHS England estimates that up to 900 people in Birmingham and Solihull present each year with unexplained breathlessness - at risk of misdiagnosis and unnecessary increases in medication. Conditions such as breathing pattern disorder (abnormal over-breathing due to stressors or triggers) and inducible laryngeal obstruction (narrowing of vocal cords due to triggers such as dust, cleaning products or exercise)are common in this patient population and require specialist assessment and treatment.
The Recover Well service offers multidisciplinary clinics designed to identify such patients, treat symptoms and improve their quality of life. The service accepts patients attending healthcare settings regularly due to their symptoms or those needing therapy support to manage complex breathlessness.
Often, physical illness will have a big impact on mental health and vice versa. Recover Well integrates psychological assessment and therapy into all its pathways.
The integrated model aims to remove the need for patients to navigate multiple services or repeat their story to different teams. Instead, they receive co-ordinated, personalised care that focuses on individual goals - whether that is returning to work, managing breathlessness, rebuilding stamina or simply feeling like their old selves again.
Consultant physician and clinical lead Dr Nandan Gautam sums up the ethos behind the programme as “now you’ve survived, it’s time to thrive”.
“Recovery doesn’t end at the hospital door,” he said. “Many people need structured, compassionate support to regain confidence, rebuild strength and return to the lives they want to lead.
“People who have been in hospital a long time often feel lost once they go home. Recover Well gives them a clear pathway, a team around them and the confidence that they can get better. It’s about restoring independence and quality of life.”
Patients who are several weeks post-discharge and not recovering as well as they would hope are urged to talk to their GP about the support available.