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Professor Grahame outlines the decline in rehabilitation services and its possible relation to the increase in disability benefits in the UK (March 2002 JRSM1). We agree that often the nearest a rheumatologist gets to rehabilitation is signing a benefits form and that patient care and the specialty may be the poorer for this. However, the phenomenon may have complex origins. The post-war period saw low unemployment levels and there was an expectation that the male of the family would be the breadwinner. With rising unemployment the job market has become more competitive and traditional gender roles have changed, perhaps ‘allowing’ more males to accept sickness roles. Litigation is more common and rising benefit claims may support Hadler's view that ‘if you have to prove you are ill, you can't get well’2. Rheumatology, like other specialties, is becoming more complex and many rheumatologists also have general medical responsibilities; rehabilitation may be an additional and intolerable burden.
The expanding specialty of elderly care may be partly bridging the service gap; in our area the lower age limit for admission to rehabilitation under the elderly-care multidisciplinary team is 18 years, and rheumatology patients, among many others, have greatly benefited from the service. In addition, the National Service Framework for Older People makes specific recommendations regarding the enhancement of access to rehabilitation and makes an attempt to end ageism in the provision of services, which should benefit young and old patients in the future.