Co-ordinated, integrated and fit for purpose: A Delivery Framework for Adult Rehabilitation in Scotland

Foreword by Olivia Giles

I was asked to chair the steering group for this framework because I have fairly wide, first-hand experience of NHSScotland's rehabilitation services. In February 2002 I contracted the blood-poisoning form of meningitis and, as a result, my lower arms and lower legs had to be amputated. After the acute phase of my care, I spent six months in a specialised rehabilitation hospital and now my rehabilitation is ongoing in the community. Overall, my experience has been resoundingly positive. Almost every individual rehabilitation service delivered a gold standard of care. But I wonder - could the whole have been greater than the sum of the parts?

In hospital, when my team of professionals pulled together, I felt securely held in a closely woven net. But when communication with an off-site discipline or between two hospitals was poor, I instantly lost confidence in the whole system.

On discharge, I was still using physiotherapy, occupational therapy, psychology, prosthetic and nursing services. Only some of the personnel changed but the team approach, which I had taken for granted in hospital, vanished overnight. It felt like free fall!

Returning home was the most testing hurdle of my rehabilitation. Lack of co-ordination of services was only part of the challenge. From being used to having everything arranged for me, I suddenly had to work out for myself how physically (with limited mobility) and economically to get to each rehabilitation location. I also had to take instant responsibility for deciding the extent to which I would access each service. If I stopped attending, I wouldn't be able to return without going through a referral procedure. So, just at the time when I was having to plumb the depths of my inner resources to cope with the physical demands of being at home alone, the psychological challenge of creating a new life and the emotional low of coming to terms with the contrast between what I had been pre-illness and what I was now - the very time when I could have done with extra support - supervision and co-ordination simply stopped. I was ready for a two-wheeler bike, but I needed a temporary set of stabilisers.

For some of my older fellow patients (especially those with social problems), there was an added dimension to the natural pain of transition. Going home meant increased isolation and consequently reduced motivation to be active. Were psycho-social considerations adequately taken into account in structuring a rehabilitation package for a meaningful life in the community? Even if you can physically pedal the bike, you still need the confidence to go out on it, somewhere to ride it and a reason for the trip.

This framework for the future delivery of rehabilitation services in Scotland tackles all of these issues boldly and head on. Its recommendations aim to break down the traditional boundaries between health professions and professionals, between phases of care, between locations of care and between the conventional preserves of health care and social work. The driver is recognition that meeting the patient's needs as a human being in our society and managing his or her journey through the whole system has to be the primary consideration of every professional involved in rehabilitation. If this responsibility is accepted and put into practice, patients will automatically be placed at the centre of an integrated, sensitive, flexible, intelligent and multi-disciplinary network - and the potential of its excellent workforce and first-rate individual services will be maximised instead of undermined.

The new model for rehabilitation in Scotland illustrates this vision of a seamless patient journey. It also demonstrates how patients should be able to access the streamlined multi-disciplinary system easily at different points and, in particular, from the community. Genuinely facilitated access will also involve delivering services closer to people's homes, simplifying referral procedures (including self referral where appropriate) and, very importantly, providing user-friendly information to the public with constructive guidance about what is available in their locality. These features of the framework will be key to making pre-emptive health and social measures effective.

The framework's recommendations spell a huge cultural shift for health and social services and demand commitment and effort from professionals. But patients too will have to respond positively to the changes in ethos 'from care to enablement' and 'hospital to community' advocated by Delivering for Health.

This does not mean that rehabilitation professionals will be any less kind to patients or that patients will be discharged from hospital prematurely! Maximum physical, psychological, emotional and social autonomy is the goal of rehabilitation. So, in the context of rehabilitation, 'care' means 'enablement'. Old fashioned care alone will not stimulate progress. And institutionalisation is a capability-draining, mind-numbing condition to which human beings are very susceptible. Encouraging independence at home as soon as possible is the only way to counter it. It's not so much a case of being cruel to be kind as recognising that motivation is the key to tapping into patients' own restorative inner resources and natural inclination to achieve their full potential, whatever the limitations of their circumstances. If you want to ride a two-wheeler, being kept on a tricycle will never get you where you want to be.

I have been heartened by the quality of contribution from professionals and users throughout the consultation process. I am delighted to see the Scottish Executive respond to their clear messages and in particular by the commitment to a true integration of health and social care at ministerial level with the joint launch of this policy, underlined by joint funding of Rehabilitation Co-ordinators for each board area.

Olivia Giles
Steering Group Chair