AHP National Delivery Plan - A Consultation

3. Improving health and well-being: strengthening partnerships and promoting resilience

AHPs are strongly placed to support self-management and rehabilitation and drive integration at the point of care. They have an enabling ethos that is rooted in a person-centred approach and sits in the spectrum between a "treatment-based" approach and a "care-based" model. They can be pivotal in creating a paradigm shift away from professional dependency towards resilience and an asset-based approach that strengthens the engagement of GPs and other community-based practitioners in the integration agenda.

Much has been achieved since the publication of the Delivery Framework for Adult Rehabilitation in 2007 and the AHP action plan for mental health, Realising Potential, published in 2010. A significant amount of work still has to be done, however, in strengthening partnership working at community level to enhance access to, and delivery of, enabling services and intermediate care. This will include interventions aimed at improving the health and wellbeing of adults of working age who have health conditions.

National guidance, Maximising Recovery & Promoting Independence: Intermediate Care's Contribution to Reshaping Care, A Framework for Scotland, has been developed through a partnership between the Joint Improvement Team, the CHPO and key stakeholders in rehabilitation and re-ablement across health and social care.

Our questions are - Are these the right proposals? What support might AHP's need to deliver these actions?

Proposals

• AHPs will work in partnership with GPs to ensure that the pathways developed to meet the Quality & Productivity Indicators (Quality Outcomes Framework (QOF) section of the GMS contract) include early and direct access to AHP services to prevent/reduce unscheduled admissions to hospital or long term care by 2014.
• AHP directors and local authority based lead OTs will work to ensure the multi-sectoral delivery of early intervention and post-diagnosis support for people with dementia and their families and carers in line with the national commitment, effective from 2013 onwards.
• AHPs will work within an ASSET-based model to develop partnerships with agencies, including those in the leisure and voluntary sectors, to enhance community capacity building; these will be integrated as components within new models of rehabilitation by the end of the end of 2012.
• AHPs from across health and social care will work with partners in care organisations, the voluntary sector and older people's groups to support community developments and enhance pathways through, for example, implementing the footcare guidelines within health and social care by 2013.
• AHPs from across health and social care will ask patients and service users about their work status as an essential component within their initial assessment and will initiate support to individuals to enable them to remain or return to work (to be implemented by 2012).
• AHP directors will continue to ensure redesigned musculoskeletal pathways are implemented within NHS boards.
• AHP directors will continue to ensure delivery of the 12 recommendations from Realising Potential, which support the change agenda in mental health and enable AHPs to contribute to the modernisation of mental health services in Scotland.
• The lead AHPs for children's services in NHS Boards will work in partnership with colleagues in education and with AHPs in social care to continue the implementation of the Getting it Right for Every Child programme (GIRFEC).