Rehabilitation framework self-assessment tool: analysis of responses

3. Pre-pandemic rehabilitation services

3.1 This chapter discusses issues relating to the delivery of rehabilitation services prior to the pandemic. It discusses respondents' views given in response to five survey questions.

Question 1: Pre-pandemic, what specific parts of your services were you most
proud of?

Question 2: Pre-pandemic, what challenges did you experience with recruitment and retention of staff?

Question 3: Pre-pandemic, were there any specific skill gaps within the workforce
of your service?

Question 4: Pre-pandemic, in terms of service delivery – What were the biggest challenges day to day?

Question 5: Pre-pandemic, how would you describe the health and wellbeing of
your local patient groups; did you notice any emerging issues?

3.2 Responses to these questions covered a wide range of issues, with individual respondents often making multiple different points. The analysis presented below focuses on the main points raised across the responses, and focuses in turn on:

• Service delivery – sources of pride (Q1)
• Service delivery – challenges (Q4)
• Workforce issues (covering Questions 2 and 3)
• Patient health and wellbeing – emerging issues (covering Question 5)

Service delivery – sources of pride

3.3 Question 1 asked respondents about the aspects of service they were most proud of prior to the pandemic. Respondents indicated a great deal of pride in the services provided by their teams, with answers focusing on: (i) the nature of their service – its characteristics and ethos, (ii) service quality and improvement, and (iii) staff and staff development. Each of these is discussed below.

3.4 In some cases, respondents noted that the successes and achievements of their teams were made despite the challenges they faced. Such points are picked up later in this chapter.

Service characteristics and ethos

3.5 Respondents who answered this question by focusing on particular service features commonly said that they were proud of the:

• Variety of treatment and delivery options offered, and the development of particular treatment pathways
• Effective management of referrals via triaging and assessment
• Timely input that supported recovery, and helped prevent hospital admissions and facilitate discharges to the community
• Continuity of care, and 'smooth' transitions between different services
• Ease of access to services – including self-referral and drop-in services.

3.6 Respondents also mentioned a wide range of other service features on a more occasional basis. These included the use of an evidence-based approach, a positive approach to risk management, and the facilities on offer to support patient rehabilitation.

3.7 Some respondents discussed certain aspects of the ethos of their service as a source of pride. They highlighted the responsiveness, flexibility and adaptability of their service in meeting the needs of individuals. Others talked in more detail about 'ways of working', or approaches or philosophies that underpinned services. Key amongst these were:

• Multidisciplinary and joined up working: Respondents frequently referred to 'good teamwork', or their team's multidisciplinary or joined up working as points of pride. They highlighted, for example, (i) good links and working relationships between teams, and across services and sectors, (ii) good levels of understanding of the contributions made by different teams, (iii) the sharing of skills and the use of shared competencies, and (iv) the joint management of cases and the benefits this brought in terms of timely and appropriate input and improved outcomes for patients.
• Person-centred approaches to care and treatment:Person-centred care was described in many types of service but broadly involved (i) engaging and working in partnership with patients and their families, (ii) a focus on self-management, (iii) supporting patients to achieve individualised goals, (iv) offering choice in services, ease of access and timely response and referrals, and (v) ensuring input from relevant professionals.

3.8 The following two quotes illustrate some of the aspects of their services that respondents were proud of prior to the pandemic.

'Our interdisciplinary working maximising best use of resources, crossing professional boundaries and ensuring patients receive care from the right person at the right time in the right place. The team has good links with other community services both statutory and 3rd sector.' (Community rehabilitation team)

'Our personalised, client-centred programmes of rehabilitation and our ability to act quickly to change programmes to accommodate changes with our client's abilities.' (Community rehabilitation team)

Service quality and improvement

3.9 Respondents often said they were proud of the quality of service provided by their teams, citing achievements in relation to (i) waiting time targets, (ii) compliance with national standards, (iii) reducing hospital admissions or the length of stays in hospital, (iv) reducing demands on GPs, and (v) supporting people returning to work.

3.10 In some cases, respondents described specific work that had been undertaken to improve the quality of their services:

'We had previously done quality improvement work to improve our waiting times and capacity for all team members which had significantly reduced these from 28 to 14 weeks.' (Community rehabilitation team)

3.11 Additionally, respondents often noted the importance of workplace 'culture' to service improvement. They variously described an 'open learning environment', a 'supportive culture towards audit and research', 'having a quality improvement agenda imbedded in our working practice', and staff 'empowered to recognise where service[s] can improve'.

3.12 Alongside this, other respondents discussed 'quality' in a more person-centred way, citing the positive patient feedback received by their service or the difference their service made to the lives of individual patients.

Staffing

3.13 Some respondents focused on staffing and workforce-related issues in their responses, noting (i) the key contribution made by staff to the delivery of services and / or (ii) work undertaken to develop and support staff. These are covered briefly here. Other pre-pandemic workforce issues are discussed at paragraph 3.33 onwards.

3.14 Staff were repeatedly described as 'highly skilled', 'experienced', 'competent', 'flexible and adaptable' and as showing 'enthusiasm for new developments and service re-design'. Staff were also described as exhibiting specific personal qualities that made a real difference to the service (e.g. 'committed', 'highly-motivated', 'caring', 'compassionate'). Other respondents noted the importance of their 'whole team approach', describing, for example, good team dynamics, supportive managers and clear leadership, respect for all team members, staff working together in a supportive and caring way, and a 'wellbeing culture' within the team.

3.15 Some respondents noted the positive work done with regard to the learning opportunities provided to staff and students. These included, for example: (i) in-service training, CPD opportunities, and training provided to other professions, (ii) mentoring and supervision arrangements, (iii) links with universities and good quality practice-based learning placements, and (iv) contributions to national training initiatives.

Service delivery – challenges

3.16 Question 4 asked respondents about the challenges they faced in day-to-day service delivery. Respondents reported a range of challenges; however, the two main ones were in relation to (i) meeting (growing) demands on services and (ii) staffing levels and other workforce issues. Other challenges mentioned relatively frequently related to: (iii) multidisciplinary and joined up working; (iv) other (non-staff) resources; (v) geographic factors; and (vi) awareness, understanding and appreciation of rehabilitation services within other health and social care services. Each of these issues is covered below.

Meeting demands on services

3.17 The most commonly reported challenge was that of meeting demands on services. Survey respondents repeatedly said that they were dealing with increasing caseloads, and cases of increasing complexity, which often entailed additional communication and coordination with other professionals.

3.18 Respondents described 'year on year increases in referrals', and services and individual staff operating at 'full capacity' or 'above capacity'. Respondents highlighted a number of challenges related to this situation, including (i) balancing the needs of different aspects of their service or different groups of patients (i.e. acute / urgent vs more routine cases), (ii) meeting waiting times targets, (iii) balancing the time spent on patient-facing work with other activities such as case documentation, team management, staff management, staff development, service development, etc., (iv) ensuring staff wellbeing.

3.19 A number of respondents said that the issue of increasing demand was compounded by inappropriate referrals and 'scattergun' or duplicate referrals from other services. Some also expressed concern that the perceived mismatch between demand and capacity was having repercussions for service quality and patient outcomes.

Staffing

3.20 Some respondents explicitly linked the issue of staffing levels to the challenges they faced in relation to service demands. Respondents frequently referred to a 'lack of staff' or 'not enough staff' across services or in particular areas. This took different forms. In some cases, it reflected increasing demands on teams without a corresponding increase in staff. In other cases, respondents reported (i) teams operating below their full staff complement and insufficient cover for absences (planned or unexpected), or (ii) there not being the right level of skills or experience or the right overall skill mix within teams. Workforce issues are discussed in greater detail at paragraph 3.33 onwards.

Multidisciplinary and joined up working

3.21 As outlined above, some respondents saw their team's approach to multidisciplinary and joined up working as a source of pride. However, for others this was also an area that presented challenges because of the cross-service, cross-professional and cross-sector nature of rehabilitation and the needs of clients.

3.22 For some this was a practical issue that arose with regard to the effective treatment of individual patients. It could, for example, be challenging to communicate with or get input from other professionals at the appropriate time. Other respondents described challenges relating to a perceived 'lack of a collaborative approach to delivering rehabilitation', 'lack of communication between services', or absence of 'shared values' across services.

3.23 The complexity of the organisational context in which rehabilitation takes place was also seen as sometimes presenting challenges. One hospital-based respondent described dealing with multiple HSCPs and health boards as follows:

'There are [X] HSCPs within [X] area which means different community rehabilitation teams – there [are] inequalities between rehabilitation teams which influences discharges. There is also [a] difference between timing of package of care, availability of day centres, befriending service and food train services – all influencing discharge pathways.' (Inpatient front door acute team)

3.24 Additionally, the challenges of different organisations having different IT systems that did not 'talk to each other' could result in difficulties in sharing of information across services and settings.

Non-staff resources

3.25 Some respondents highlighted challenges relating to the availability of local resources – both within their own organisation, and in their communities.

3.26 Respondents discussed difficulties in accessing resources such as IT hardware and software; accommodation and facilities (i.e. clinic space, gym space, pools, etc.); equipment; and patient transport.

3.27 In relation to community resources, some respondents reported good access to community services which helped support rehabilitation (e.g. social prescribing, exercise classes, dementia cafés, men's sheds, day centres). However, more often respondents highlighted the challenges in identifying and arranging input from local services that would help patients remain safely in their community. For some this was an issue of waiting lists and delays in accessing services, and for others it was knowing what was available in the community to support individuals.

3.28 In some cases, respondents also noted issues of 'equity', saying that the availability of services varied from one area to another, within and across health board and HSCP boundaries.

Geographic factors

3.29 Most often the issue of geography was raised in connection with community teams operating in rural areas (or covering large areas), who had to travel long distances to reach patients. The issue of patients having to travel to access centrally located services (including specialist hospital-based services) was also noted, with public transport not always being available.

3.30 This was not only a practical challenge of travel time, as operating in rural areas could also leave staff feeling isolated in situations where a single representative of a profession was responsible for delivering a service over a large area; it also presented challenges for small 'generalist' teams expected to cover a wide range of conditions.

Awareness, understanding and recognition of rehabilitation services

3.31 The level of awareness, understanding and recognition of rehabilitation and AHP activities in health and social care was highlighted by some respondents. Some felt, for example, that AHPs / rehabilitation services were not always sufficiently represented in strategic and resource discussions or decision making; others felt that health and social care colleagues did not always understand the role of rehabilitation or the services offered.

3.32 The following quote illustrates these problems:

'There was frustration amongst the team that often referrals were coming through late in a person's journey which resulted in poorer outcomes for the individuals. Referrals were often dependant on when a nurse, psychologist or psychiatrist felt the person may require OT, and staff felt they had to constantly explain their roles, how they could make a difference and that timely access was essential.' (Inpatient and community specialist adult mental health team).

Workforce challenges

3.33 Question 2 in the survey asked respondents about the challenges they had experienced with staff recruitment and retention prior to the pandemic, and Question 3 asked about specific skills gaps in the workforce of their service prior to the pandemic. The main points made in the responses to each of these questions are summarised here.

Staff recruitment and retention

3.34 Recruitment and retention were commonly reported as challenges of varying degrees prior to the pandemic – and were expected to continue to do so looking ahead to the immediate future.

3.35 Factors which respondents said contributed to difficulties in recruitment and retention were wide ranging and included: (i) national shortages of graduates in some professions, (ii) limited opportunities for promotion and career progression including at senior level (iii) the use of short-term or temporary posts, (iv) the absence of local higher education courses in some disciplines, (v) competition for staff between HSCPs and NHS boards, and (vi) competition from the private sector.

3.36 Although there was a general view that recruitment posed a challenge for some services, there was a more mixed picture on the issue of staff retention. Some respondents who reported difficulties with recruitment suggested that, once in post, staff tended to remain. However, others reported success in attracting entry-level staff, who subsequently moved on to access career progression opportunities.

3.37 Problems with recruitment and retention were also reported to be associated with geography and the profile of the workforce. With respect to geography, there was a view that larger urban areas were better able to attract and retain staff because they could offer more choice of jobs and better prospects for career progress. With respect to the profile of the workforce, respondents highlighted issues relating to (i) an ageing workforce and the prospect of losing a significant number of staff to retirement in coming years, (ii) a predominantly female workforce and the related need to accommodate maternity leaves and flexible working, and the importance of taking demographic factors into account in workforce planning.

3.38 A number of respondents noted that organisation-wide policies, processes and resources could result in recruitment being slow, bureaucratic and a time-consuming process. Respondents highlighted (i) difficulties in securing approval for new posts or filling vacant posts, (ii) the time taken to advertise posts and / or appoint a successful candidate, and (iii) inflexibility (and perceived inequality) in relation to the grading of posts. Some respondents also mentioned 'Jobtrain', an IT-based recruitment platform, with the survey revealing both positive and negative experiences of using the system.

Skills gaps

3.39 Respondents addressed the question of skills gaps in their services in a variety of ways.

3.40 Some discussed very specific gaps, highlighting a need for specialist skills within individual services or professions. Examples included: neurological conditions, stroke, vocational rehabilitation and psychological therapies for OTs; mental health, allergies and adult addictions for dietitians; aquatic therapies for physiotherapists; and wound care for podiatrists.

3.41 Some respondents noted other types of skills gaps, for example, related to:

• Input from particular professions
• The balance of staff of different grades, or perceived inappropriate grading of posts
• Limited access to administrative, technical and support staff that meant that professional skills were not used efficiently.

3.42 Other respondents identified gaps elating to more generic skills, such as research, data collection, and quality improvement methodologies; digital working; and multidisciplinary working. For more senior staff, leadership and management skills were also noted by some respondents. Indeed, this was a two-sided issue with some respondents reporting that they would like to see more opportunities for AHPs to develop (or demonstrate) leadership skills within their professional roles, and be able to access more training opportunities to gain such skills.

3.43 More generally, however, respondents described a range of issues which presented challenges in ensuring the appropriate mix of skills in their teams. For example:

• The increasing complexity of caseloads has increased the need for highly or broadly skilled staff. This could be a particular challenge for teams providing a 'generalist' service to community patients in which staff typically had a broad spectrum of knowledge but may need to gain new skills in response to the demands of new cases.
• Changes in service configuration or patient pathways could lead to changes in skill requirements for staff, with, for example, patients who had previously been cared for in hospital being discharged earlier into the care of community teams.
• Rurally based teams had particular issues ensuring appropriate skill mixes among staff because of difficulties being aware of and accessing relevant training locally and / or the expense of attending training in other areas.
• Skills gaps could arise when experienced staff members left teams and/or new team members joined, and some said that appropriate planning was needed to ensure the continued availability of skills across teams, and resilience within teams. The skills mix in small teams, including those in more rural areas, was seen as particularly 'fragile' when individuals moved on or were absent for any reason.

3.44 Respondents also reported issues related to continuous professional development (CPD) for team members. They said, for example, that funding for (external) courses was not always available, and that clinical work pressures could make it difficult for staff to be released for training activities or to provide supervision and on-the-job training for other colleagues. Some noted the specific issue of teams supporting newly qualified staff while also meeting the demands of clinical work.

Patient health and wellbeing

3.45 Finally, Question 5 asked respondents about the health and wellbeing of their patient groups prior to the pandemic – and whether they had noticed any emerging issues.

3.46 Occasionally, respondents said that they saw 'no emerging issues' in their local patient populations prior to the pandemic. Instead, they said there were a number of long-standing issues (for example, relating to poverty and lifestyle) which had an ongoing impact on patient health and wellbeing.

3.47 However, more often, respondents identified a range of issues. The specifics of these varied from one type of rehabilitation service to another, but a common theme in the responses was that of Scotland's ageing population. Respondents frequently said they had observed that their patients were increasingly elderly and physically frail with:

• Poor and worsening health involving long-term conditions and multiple co-morbidities
• Complex mental health and social issues (e.g. increasing levels of depression and anxiety, cognitive decline, social isolation, poly-pharmacy and substance misuse)
• High levels of obesity and low levels of physical activity
• Poor motivation and compliance
• Greater dependence on public services (due to a lack of family or adequate carer support in the area)
• Expectations of rehabilitation that were sometimes unrealistic (often linked to a reluctance to engage in self-management).

3.48 Respondents often commented that their patients were staying longer in their own homes and, in cases where hospital admission was necessary, patients were being moved through acute services back into their own homes much more quickly. Some respondents referred to 'increasingly complex discharges'; others said that 'delayed discharges' were common when services were not readily available to support people at home. There was a recurring view that patients in these circumstances did not always have access to the necessary care, support, or internal physical and mental resources to engage fully with their rehabilitation. They were also less able to travel (to attend appointments). This meant that the primary purpose of rehabilitation for this group of patients had become to be about maintaining safety and quality of life, rather than achieving independence.

'Therapy staff were seeing clients past the point of rehabilitation. Our role was more to maintain and increase safety / comfort /quality of life of the client, family and carers, than to see progression of independence or achieving specific goals.' (Community rehabilitation service for older people).

3.49 Less often, respondents said that someof their patients (including those who were younger and / or more affluent) were keen to self-manage and follow good health advice.