AHP National Delivery Plan - A Consultation

2. Delivering integrated outcomes: reshaping care and enabling independent living

Scotland has committed to establishing an integrated approach to planning and delivering health and social care. Scottish Government, COSLA and other key stakeholders are working together to develop a set of shared outcomes which will form the National Performance Framework. This will enable partners to jointly drive and track progress towards delivery of agreed outcomes through better integration.

Scotland's AHPs are already working at the leading edge of a paradigmatic shift towards enablement, promoting an asset-based approach and supporting self-management, resilience and independent living. Their work can and should make a significant contribution to reducing unnecessary hospital referrals and admissions and to preventing over-reliance on professional interventions in the future.

Reducing inappropriate admissions and unnecessary care costs are key to affordable and sustainable services in the future. AHP interventions can significantly reduce unnecessary admissions to hospital (through OT and physiotherapy services being based in accident and emergency departments, for instance) and reduce dependency on care services (through integration of rehabilitation and homecare services) all of which have already resulted in significant savings to health and social care.

AHPs have always worked across health and social care and organisational boundaries to focus on the needs of service users and their families. However, they have sometimes mistakenly been characterised as "support services" other than 'care', which in turn has inhibited their respective organisations from making best use of the professional capabilities of the collective AHP resource. Their expertise and that of AHP leaders is going to be vital in reshaping care for older people, supporting people with dementia and their families and, crucially, preventing current and future dependency on health and social care services.

AHP directors and leaders working across health and social care will be key to enhancing the AHP contribution to the joint planning and delivery of services, particularly for those with complex needs, long-term conditions, dementia and for children and young people. A significant proportion of the Change Fund has already been invested in services led and delivered by AHPs. Further work is required to evaluate the impact of this work to determine which services have the greatest impact on service delivery.

Our question is - Are these the right priorities for action? Are there any significant gaps in our proposals?

Proposals

• AHP directors will work towards ensuring that emergency admission services have dedicated access to physiotherapy and OT services to prevent unnecessary admissions to hospital and coordinate appropriate support/team interventions to individual patients at risk of future readmissions or falls.
• AHP directors will work in partnership with colleagues in the Scottish Ambulance Service, community alarms/telecare services and NHS 24 to ensure older people who fall and present with frailty syndromes have timely access to AHP services to prevent unnecessary admissions to hospital and further falls.
• Falls leads within each CHP/community health and social care partnership will lead implementation of the Falls Care Bundles approach by 2013 and will work within multi-professional teams and partners to integrate falls prevention, management and monitoring; reduction of falls within hospital settings should be integrated as part of systematic approaches to care improvement.
• AHP directors will work collaboratively with colleagues in social care to maximise the AHP contribution to achieving delayed discharge targets by 2013.
• AHPs from across health and social care will work to actively reduce length of hospital stay and improve patient flow through interventions to enhance recovery and early supported discharge.
• AHPs from across health and social care will actively support older people and those with complex needs to live independently in their own homes or in a homely setting for as long as possible, preventing or delaying admission into institutional care wherever possible.
• AHP directors will work in partnership with nursing and medical directors to drive improvements in the care of older people in hospitals.
• Seventy per cent of NHS AHP resource and activity will be sited within the community by 2015, and NHS rehabilitation activity in the community will increase by 50% by 2015.
• AHPs will continue to deliver faster access to diagnostics as part of the redesign of community pathways and contribute to the achievement of existing targets.