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

5. Recommendations for action

The recommendations have been devised following a process of consultation which involved:

• a thematic analysis of the evidence by the Scottish School of Primary Care;
• a series of consultation events with those who use services and carers;
• a consensus event with health and social care professionals.

Six statements

A set of six statements was developed by the Chief Health Professions Officer and National Project Officer following the process of consultation detailed above. These were endorsed at the consensus event with health and social care practitioners and are set out below.

1. Rehabilitation services should be more accessible to those who use services, including direct access.

2. Rehabilitation services need to be provided locally, with a strong community focus.

3. A systematic approach to delivering rehabilitation to individuals is required, promoting independence, self management and productive activity.

4. Rehabilitation services should be comprehensive and evidence based, should reflect individuals' needs at distinct phases of care, and should identify models to ensure seamless transitions.

5. Practitioners and providers in health and social care services need to be better informed about current and evolving roles and expertise within rehabilitation teams.

6. Health and social care professionals need to critically review staff resource deployment through service re-design and skill-mix review.

In addition to endorsing these statements, individuals, carers and health and social care professionals also highlighted the need for strategic co-ordination of rehabilitation services to drive necessary changes across the boundaries between stages of care, between disciplines within the health sector and between health and social services.

The following sections address the six themes listed above, outlining recommendations for action. Many are relevant for all three target groups identified in Chapter 4, but specific issues relating to particular groups are listed separately.

The process of implementing the recommendations will be facilitated through five key actions supported by the Scottish Executive.

Five key actions

1. A National Rehabilitation Implementation Group will be formed to oversee the introduction of the rehabilitation models and other recommendations from the delivery framework. The group will report jointly to the Scottish Executive Health Department and the Social Work Services Policy Division, Scottish Executive Education Department.

2. Local Rehabilitation Co-ordinator Posts will be established and funded through the Scottish Executive Health Department and Scottish Executive Education Department. Post holders, working with the rehabilitation models, will provide leadership, direction and strategic co-ordination at local level and will work with the National Rehabilitation Implementation Group to ensure the rehabilitation models and framework recommendations are delivered locally. The co-ordinators will work closely with key stakeholders to facilitate the required organisational changes.

3. The Chief Health Professions Officer will work with the Improvement and Support Team, the Joint Improvement Team and the Joint Future Unit to explore the development of a Rehabilitation Improvement Programme to shape delivery of rehabilitation services nationally, based on the rehabilitation models. The programme will work with the relevant agencies to ensure alignment with existing education and improvement initiatives.

4. The Scottish Executive Health Department will work in partnership with NHS Education for Scotland, NHS Quality Improvement Scotland and the regional research consortia to develop a Managed Knowledge Network ( MKN). This MKN will facilitate effective access to the knowledge and evidence base for rehabilitation and the sharing and generation of new knowledge.

5. The Scottish Executive will bring together national and international rehabilitation research experts for a Rehabilitation Research Consensus Event that will explore gaps in the current research literature and make recommendations for future research bids.

Four priorities for NHS Boards and local authorities

The priority for NHS Boards and local authorities will be to:

• transform their rehabilitation services to put rehabilitation at the heart of service delivery;
• adopt a whole-systems approach to rehabilitation services;
• give greater priority to rehabilitation services;
• reflect evolving outcomes measures for community care (and any consequent targets) that impact on rehabilitation services.

1. Access

Individuals and carers consistently highlighted the importance of rehabilitation support received in specialist/hospital-based services. Challenges were perceived to relate to accessing rehabilitation services in the community or accessing specialist services once discharged, and people felt uncomfortable about the time-limited nature of some services.

Improving access to physical or mental health services requires the incorporation of innovative and novel systems into practice. Many rehabilitation and specialist services are already looking at referral criteria and access issues, building on existing good practice.

Views of users of the service

• Individuals should have better access to rehabilitation without always having to use the GP as gatekeeper to services.
• There should be one point of contact in the community - a key worker/rehabilitation co-ordinator.
• Services should be flexible to the needs of the individual, rather than being time limited by the needs of services.
• Better hospital and public transport is needed in community settings to enable people to access rehabilitation services.
• Better information and support should be offered to individuals and carers following diagnosis.
• Better communication and referral processes are needed among professionals.
• Services should be better advertised and relevant information should be available.
• More drop-in services are required.
• An NHS 24-type telephone helpline service should be set up to support people requiring rehabilitation advice and support.
• Transitions of care between primary and secondary care services and social care need to be managed better, breaking down historic boundaries that stifle innovative, co-ordinated approaches to care delivery.

Access - recommendations

Rehabilitation services should be more accessible to those who use services, including direct access when essential.

ACCESS

Recommendation	Lead responsibility	Working with	Timescale: by end of
1.1 NHS Boards, particularly CHPs, working in partnership with local authorities, should enhance access to services, information and sources of support for individuals requiring uni-professional and multi-professional rehabilitation, including developing a single point of access to services.	NHS Boards Local authorities	Rehabilitation co-ordinators SEHD SEED	2008
1.2 Access to NHS and local authority rehabilitation advice and services should be explored for individuals living in community-based care settings, such as care homes.	NHS Boards Local authorities	Rehabilitation co-ordinators Independent sector	2009
1.3 NHS Boards and local authorities should work to ensure Single Shared Assessment is available and identifies all individuals with potential rehabilitation needs.	NHS Boards Local authorities	Rehabilitation co-ordinators	2008
1.4 NHS 24's functions as a resource for rehabilitation advice and triage should be explored, as should opportunities for 'interfaced services'.	SEHD SEED NHS 24	NHS Boards Local authorities	2008
1.5 Health and social care providers should address transitions of care for older people and those with long-term conditions, particularly in relation to discharge from hospital or specialist rehabilitation services.	NHS Boards Local authorities	Rehabilitation co-ordinators	2008
1.6 NHS Boards and local authorities should consider the introduction of direct access to rehabilitation services provided by individual AHP and social work professionals as part of an integrated care pathway.	NHS Boards Local authorities	Rehabilitation co-ordinators	2008
1.7 NHS Boards and local authorities should maximise developments in eHealth, Telehealth and new technologies to ensure equitable access and service provision, especially for those in remote and rural areas.	NHS Boards Local authorities	Rehabilitation co-ordinators	2008
1.8 NHS Boards and local authorities should work in partnership to facilitate the development of suitable local transport for rehabilitation purposes.	SEHD NHS Boards Local authorities	Rehabilitation co-ordinators	2008
1.9 NHS Boards and local authorities should build on existing innovations and developments to enhance opportunities for the population to keep fit and active. They should recognise the health gain and social engagement benefits of using mainstream leisure facilities for health promotion and rehabilitation and the impact this may have in avoiding future health and social care challenges.	NHS Boards NHS Health Scotland Local authorities	Rehabilitation co-ordinators	2007
1.10 Scottish Executive and the Department for Work and Pensions should work to establish the role of vocational rehabilitation and rehabilitation co-ordinators in local employability partnerships, seeking to expand existing models and develop new models of vocational rehabilitation and condition management programmes.	NHS Boards SEETTLD Local authorities	Voluntary sector Jobcentre Plus Healthy Working Lives Rehabilitation co-ordinators	2009
1.11 The Scottish Executive Health Department should develop guidance on the establishment of models of early intervention for individuals with long-term conditions which result in absence from work, building on existing achievements through the successful 'Pathways to Work' pilots.	SEHD	Local authorities Voluntary sector Jobcentre Plus, Healthy Working Lives Rehabilitation co-ordinators	2008
1.12 NHS Boards should ensure that older people, whether being supported in the community or presenting to the acute hospital, have appropriate access to a Comprehensive Geriatric Assessment ( CGA) (see Table 4.1).	NHS Boards	Rehabilitation co-ordinators	2008

2. Local service provision

One of the key aims of Delivering for Health¹ is to bring services closer to communities and for individuals to have more choice and input into where they are treated. Changing Lives² also recognises that services should be organised around the needs of individuals, families and carers through a whole public sector approach. A clear message from the consensus events was the desire of individuals and carers to be able to utilise local amenities to better effect.

This has been tested out in a number of areas across Scotland, with health and social care providers looking to make use of existing mainstream facilities to enhance access to rehabilitation and expand service provision for these key groups. One example is increasing utilisation of state-of-the-art equipment and other resources located in many local sports and leisure facilities for rehabilitation purposes.

Views of users of the service

• Services should be provided locally, but not necessarily at home.
• Local amenities should be used for rehabilitation purposes through engagement with local authorities.
• Therapy-led rehabilitation centres should be established in communities.
• The provision of multi-disciplinary, multi-agency teams providing rehabilitation for patients at home should be expanded.
• Better links are required between specialist rehabilitation services and community services.

Local service provision - recommendations

Rehabilitation services need to be provided locally with a strong community focus.

LOCAL SERVICE PROVISION

Recommendation	Lead responsibility	Working with	Timescale: by end of
2.1 NHS Boards, particularly CHPs, and local authorities should use community planning processes to identify how rehabilitation and integrated care services can be developed to meet the needs of the growing proportion of older people in the population, people with long-term conditions and those with specialist rehabilitation needs.	NHS Boards Local authorities	Rehabilitation co-ordinators	2008
2.2 NHS Boards, particularly CHPs, and local authorities should identify how anticipatory care and rehabilitation services can be focused on 'at-risk' individuals to provide early interventions, prevent unnecessary admissions to hospital or care facilities and facilitate smooth transitions from hospital or specialist services. D	NHS Boards Local authorities	Rehabilitation co-ordinators	2008
2.3 NHS Boards, particularly CHPs, and local authorities should work in partnership to identify the provision of rehabilitation and self-management/enablement services in non-traditional local settings such as community centres and leisure services accommodation.	NHS Boards Local authorities	Rehabilitation co-ordinators	2008
2.4 NHS Boards, local authorities and voluntary services should ensure rehabilitation teams are co-located where possible to enhance accessibility and facilitate multi-agency team working and ensure effective joint learning, communication and skill mix. Agreed assessment and intervention pathways should be developed according to the needs of the local population.	NHS Boards	Local authorities Rehabilitation co-ordinators	2009

3. Enablement and self-managed care

Delivering for Health¹ recognises the need for a more systematic approach to care for people with long-term conditions. Individuals and carers also identified the key role they play as active participants in their own rehabilitation and overall progress.

Health and social care practitioners within rehabilitation teams should therefore work to enable people who have long-term conditions and their carers to take greater control of their own condition management with focused rehabilitation goals.

Views of users of the service

• Good communication channels are needed to ensure individuals and carers are included in the management of their care.
• Volunteer and special interest/support groups should have greater involvement in designing, delivering and evaluating services.
• Professionals need greater awareness of individuals' knowledge of their own condition and how it should best be managed.
• The benefits of 'buddy systems' for those with long-term conditions should be explored.
• More flexible systems should be in place to support people to get back to work following illness or injury
• The particular needs of children moving from young people's rehabilitation services to adult services must be addressed.

Enablement and self-managed care - recommendations

A systematic approach to delivering rehabilitation to individuals is required, promoting independence and self management.

Enablement and self-managed care

Recommendation	Lead responsibility	Working with	Timescale: by end of
3.1 The Scottish Executive Health Department and the Scottish Executive Education Department should work with NHSScotland, local authorities and the Long Term Conditions Alliance Scotland to support the development of models of self-managed care using the CHP Long-Term Conditions ( LTC) Toolkit as a vehicle for local implementation.	SEHD SEED	NHS Boards Local authorities Rehabilitation co-ordinators LTCAS	2008
3.2 NHS Boards and local authorities need to explore how communication and information sharing can be improved to enhance individuals' and carers' rehabilitation journey within legislative constraints such as the Data Protection Act, Human Rights Act and the Common Law of Confidentiality. This should include the use of shared assessment and, where possible, electronic information sharing.	NHS Boards Local authorities	Rehabilitation co-ordinators	2008
3.3 All staff working with people with long-term conditions and rehabilitation needs should strive to enhance and support their capacity and that of their carers to self manage to the best of their ability, with appropriate access to appropriate professional interventions when required.	All relevant staff	Rehabilitation co-ordinators	2008
3.4 People with long-term conditions and rehabilitation needs should have access to psychological expertise to ensure that individuals receive appropriate assessment and intervention to overcome emotional, cognitive or behavioural barriers to their participation in rehabilitation and to maximise their progress.	All relevant staff	Rehabilitation co-ordinators	2009
3.5 NHS Boards and local authorities should work in partnership with the voluntary sector to build on existing achievements in physical activity, smoking cessation, alcohol misbuse and healthy eating target groups.	NHS Boards Local authorities	Voluntary sector Rehabilitation co-ordinators	2008
3.6 NHS Boards and local authorities should build on existing good partnership, working with the voluntary sector to develop accessible information for users and carers on self-management support and rehabilitation services available in local areas	NHS Boards Local authorities	Voluntary sector Rehabilitation co-ordinators	2008
3.7 NHS Boards and local authorities must engage effectively with individuals and carers to ensure seamless transitions from child to adult rehabilitation services and also from adult to older people's services.	NHS Boards Local authorities	Rehabilitation co-ordinators	2008

4. Comprehensive and evidence-based services

Throughout the consultation, there was a clear message from individuals, carers and professionals that comprehensive specialist rehabilitation, often hospital based, plays an important role in helping individuals attain their immediate rehabilitation goals. Challenges often become apparent following discharge, however, when access to previous rehabilitation expertise is less likely to be available.

Transitions between hospital and home and between services were highlighted as being stressful and were often difficult for individuals to navigate. There was a strong feeling that a rehabilitation key worker/co-ordinator could ensure seamless transitions and facilitate ongoing rehabilitation requirements.

Views of users of the service

• Ongoing rehabilitation needs should be met following discharge from hospital.
• The potential benefits of a key worker/rehabilitation co-ordinator role in facilitating transitions and ongoing rehabilitation should be explored.
• Services provided should be evidence based and consistent with best practice, where possible.
• Good communication among professionals is necessary to achieve comprehensive services.

Comprehensive and evidence-based services - recommendations

A comprehensive, evidence-based rehabilitation service needs to cater for the distinct phases of care and identify models to enable seamless transitions.

Comprehensive and evidence-based services

Recommendation	Lead responsibility	Working with	Timescale: by end of
4.1 NHS Boards, particularly CHPs, and local authorities need to apply a whole-systems approach to the provision of rehabilitation services, linking together early intervention/rapid response services with community rehabilitation teams, specialist rehabilitation and nurse/therapist-led units, community hospitals and integrated care to provide seamless transitions of care.	NHS Boards Local authorities	Rehabilitation co-ordinators	2009
4.2 Rehabilitation and integrated care services should evaluate the impact of service provision from individuals' and carers' perspectives and make better use of information gathered using standardised assessment tools to enhance the evidence base.	Rehabilitation co-ordinators	Individuals and carers	2008
4.3 Scottish Executive Health Department and the Scottish Executive Education Department, in partnership with NHS Education for Scotland, NHS Quality Improvement Scotland, the Scottish Social Services Council, the Scottish Institute for Social Work Excellence and the Social Work Inspection Agency, will work with the Improvement Programme to ensure education and quality improvement programme support to underpin the rehabilitation framework.	SEHD NHSQIS NES SWIA SSCC SISWE	Rehabilitation co-ordinators	2009
4.4 Scottish Executive Health Department and the Scottish Executive Education?Department should work with the research community in Scotland to explore how best to develop further research in the field of rehabilitation.	SEHD SEED	Research community in Scotland	2008

5. Sustainable multi-professional teams

The success of service redesign and the Delivering for Health¹ agenda will to a large extent be determined by how effectively health care workers work together in teams - communicating with each other, planning jointly and adopting a teamwork ethos that places patients, families and carers at the centre of service planning, delivery and evaluation.

There is a clear need for team members to have a better understanding of each others' professional roles, which will lead to better sharing of information and reduced instances of contradictory advice being offered to individuals and carers. The message was clear that professionals and support staff need to enhance service continuity across boundaries in partnership with individuals and carers.

Views of users of the service

• More joint training is required to improve knowledge of what professionals within the team can offer and where services can be offered.
• Improved skill mix is needed within teams.

Sustainable multi-professional teams - recommendations

Practitioners and providers in health and social care need to be better informed about current and evolving roles and expertise within rehabilitation services.

SUSTAINABLE MULTI-PROFESSIONAL TEAMS

Recommendation	Lead responsibility	Working with	Timescale: by end of
5.1 Health and social care practitioners involved in the development and delivery of rehabilitation need to work with colleagues to: a. clarify roles and core competencies; b. -work flexibly to meet the needs of individuals and carers; c. -share skills with team members to enhance team efficiency; d. -develop capable and confident support staff to work across boundaries and release capacity of professionals; e. -maximise the contributions of individuals and carers, lay workers and informal support networks.	Health and social care practitioners	Rehabilitation co-ordinators NES	2008
5.2 NES, in partnership with NHS Boards, local authorities and higher education/further education institutions, needs to support the development of undergraduate and postgraduate education and training for health and social care practitioners and for support workers to underpin effective multi-professional team working and facilitate self management/enablement approaches within health and social care. E	NES	NHS Boards Local authorities Higher education institutions	2008

6. Capacity

The growing demand for rehabilitation services requires health and social care professionals to look at new and innovative ways of utilising their expertise. Individuals and carers are open to a variety of models, including new roles and, in particular, ideas for better co-ordination and support to enable them to navigate and access services that are already available - including self-help and voluntary/support groups.

All health and social care professionals involved in developing or delivering rehabilitation services should therefore look beyond traditional methods of providing services and engage in service redesign and role development in partnership with individuals and carers. This will enable them to create new models of service that reach across historical professional and service boundaries.

Views of users of the service

• The role of the key worker/rehabilitation co-ordinator should be utilised.
• More local community-based workers are needed.
• More imaginative use of resources is required.

Capacity - recommendations

Health and social care professionals need to critically review the use of the current staff resource through service re-design and skill mix review.

CAPACITY

Recommendation	Lead responsibility	Working with	Timescale: by end of
6.1 NHS Boards and local authorities should build upon existing achievements through Joint Future and Joint Funding to explore flexible use of staff and resources. They should also look to enhance outcomes for patients and their carers through redesign of services underpinned by the patient pathway, promoting best practice in integrated services across health and social care.	NHS Boards Local authorities	Rehabilitation co-ordinators	2008
6.2 AHPs with rehabilitation expertise should work in partnership with medical, nursing and social work colleagues and individuals, families and carers to expand on new ways of team working, including therapist/nurse and social worker leadership and case manager/co-ordinator roles where this will enhance outcomes.	Rehabilitation co-ordinators	NHS Boards Local authorities	2008
6.3 Rehabilitation teams should consider how they could improve continuity of care, eliminate duplication of work and enhance individuals' and carers experience of transitions through, for example, in-reach/outreach rehabilitation across community hospitals and early intervention/ discharge teams.	Rehabilitation co-ordinators	Rehabilitation teams	2008