Rehabilitation framework self-assessment tool: analysis of responses

4. Rehabilitation services during the pandemic

4.1 This chapter discusses respondents' views about the changes they saw (in their service, in their workforce, and in the health and wellbeing of their patients) during the COVID-19 pandemic. The chapter focus on respondents' answers to the following four survey questions.

Question 6: During the pandemic, what specific parts of your service were you most proud of? (e.g. innovation, service changes, staff skills, etc.)

Question 7: During the pandemic, how was the delivery of your services impacted by the pandemic: please discuss examples of specific changes you had to make to your service.

Question 8: During the pandemic, were there any examples of staff skills gaps that emerged?

Question 9: During the pandemic, what changes did you observe in the health and wellbeing of your patient group?

4.2 The analysis below focuses on the main issues raised in response to each of these questions and discusses, in turn:

• How service delivery changed during the pandemic
• Sources of pride in service delivery during the pandemic
• Workforce skills gaps which emerged during the pandemic
• How patient health and wellbeing changed during the pandemic.

Service delivery

4.3 Question 7 asked respondents about the impact of the pandemic on the delivery of their service. Respondents were asked to discuss examples of specific changes they had made to their service during the pandemic.

4.4 Respondents' comments at this question were very diverse and it was clear from the comments that the pandemic had a massive impact on the delivery of rehabilitation services of all types. Respondents often provided long lists of changes that were made, and they explained that their service not only changed overnight with the introduction of the first lockdown in March 2020, but it also had to continuously adapt throughout the pandemic to prevent the transmission of COVID-19.

4.5 Although the impacts of the pandemic varied in different services, there were some recurring themes and, at a very broad level, all respondents discussed the impacts of the pandemic on their services in terms of (i) activities that started or were introduced, and (ii) activities that stopped. Staffing / workforce issues, and the effects on team cohesion, communication and workload, was a third major theme; and issues relating to infection control was a fourth theme. Each of these is discussed below. (Issues relating to skills gaps in the workforce during the pandemic are discussed below at paragraph 4.27).

4.6 It is worth noting that very few respondents suggested that they had seen little or no impact on the delivery of their service during the pandemic. Overwhelmingly, respondents highlighted significant changes.

Activities that started or increased during the pandemic

4.7 By far, the most common theme in respondents' explanations of how their services changed during the pandemic related to the introduction – or increased use of – digital and telephone systems for delivering services. Even in rural areas, where the use of telephone / video was already common in some services, the complete cessation of face-to-face rehabilitation was a significant change.

4.8 Respondents working in all areas of rehabilitation and across all types of settings reported:

• The use of video for patient consultations (Near Me / Attend Anywhere^[3]) and staff meetings (MS Teams) – telephone consultations were also used where it was notpossible to use digital systems (i.e. in cases where patients were unable to use the technology or did not have a computer or laptop available)
• Providing more advice over the phone (e.g. to patients, care homes, etc.), rather than face-to-face – some services put in place daily calls to patients or their carers to ensure they were coping at home
• More time spent working with patients and their families to help them make the best use of video consultations – some teams developed digital support materials for their patients
• The need to purchase (or borrow) laptops and mobile phones and roll these out quickly to staff without adequate training (some respondents noted that their service had few laptops, initially)
• The introduction of virtual groups (some, but not all, patients found these helpful)
• Increased signposting to online resources.

4.9 Respondents discussed the variety of systems put in place to enable communication between teams, and to ensure that staff were supported, supervised, trained and kept up to date with changing guidance. Examples included (i) daily 'check-ins' between staff working from home and their managers and daily team 'huddles', (ii) a 'virtual whiteboard' to share information on work patterns, annual leave, sickness absence, etc, and (iii) staff working in 'bubbles' to minimise contacts within teams. These systems did not work well in all cases, or they took time to be implemented. Some respondents specifically said that communication within teams was difficult during the pandemic.

Activities that stopped or were adversely affected during the pandemic

4.10 Some respondents (particularly those in community and outpatient settings) said that their services ceased entirely during the first phase of the pandemic. Other respondents said that their service continued, but in a very different and much reduced form than prior to the pandemic. There was a recurring message that their focus became making people safe at home, and ensuring quality of life, rather than providing active rehabilitation.

4.11 As time went on, and the initial wave of the pandemic passed, services that had closed began to re-open, but measures had to be put in place to ensure social distancing.

4.12 Activities or other things that stopped or reduced during the pandemic included:

• Face-to-face contact with patients, except in essential or critical cases – some respondents said that their staff became very skilled at assessing patients via phone or video and deciding who needed to be seen face-to-face and who could wait; others said that their staff found this very challenging
• Collaboration with patients' families – visiting restrictions meant that families were not able to attend inpatient therapy sessions and so had to be briefed and trained by video to be able to support their family member upon discharge from hospital
• Rehabilitation clinics, groups and classes (inpatient, outpatient and in the community) – respondents reported that there were no services to refer their patients to
• Administrative support for rehabilitation practitioners
• Student placements (an exception was in some primary care services).

4.13 There were differing reports among respondents about the issue of waiting times. Some respondents said that clients in their area did not receive a timely service during the pandemic and that waiting lists grew significantly. However, others said that they had no waiting lists during the pandemic because staff were not travelling and therefore had more time to meet (virtually) with patients. Some respondents working in inpatient teams reported that delayed discharges increased because there were no community services in place to support people at home. These differing experiences are illustrated in the following two quotes.

'Group sessions were no longer allowed to run, with delivery of critical workstreams only. This resulted in many patients being abandoned mid-course, or on a waiting list for a service with no start date in sight.' (Community falls team)

'Virtual approach allowed us to make a positive impact on waiting lists which are now significantly lower than pre-pandemic despite significantly increasing referral rates in the last 5 months.' (General outpatient rehabilitation team)

4.14 Some respondents reported that, as their services began opening up again after the first wave of COVID-19, referrals increased dramatically, and most were critical in nature.

4.15 Finally, one other frequently raised issue was the loss of office accommodation during the pandemic. This was partly the result of space (in hospital or community settings) being used for other essential purposes, or because offices were too small to allow social distancing. Some respondents reported that, at the time they took part in the survey, they still had no access to office accommodation.

Staffing

4.16 Respondents made a wide range of comments about the impacts of the pandemic on their staffing and teams. Some of the recurring issues were that:

• Staff were under significant amounts of pressure.
• Staff were dispersed due to home working, shielding and sickness.
• Many staff were redeployed to assist with critical care or vaccination programmes. This led to reduced capacity in teams.
• Workloads increased as some teams stepped in to provide cover when other services were stopped.
• Student placements in some teams ceased entirely. However, there were also reports that student webinars and case study sessions were established in collaboration with universities.

Infection control

4.17 Respondents described a variety of infection control measures that were introduced in their services. These changed frequently as additional information and guidance became available. One common theme was that the use of personal protection equipment (PPE) during patient contact was seen to be a significant barrier to communication (with patients and carers), patient rapport, and to the provision of complex rehabilitation in critical care situations.

'The one difficulty I have noted is due to wearing more PPE and in particular masks. This makes communication with people more difficult. It was difficult to create solid rehabilitative rapport with patients due to them feeling distant from us and not being able to read our caring and encouraging facial expressions. One patient reported feeling the PPE to be 'scary' – particularly because all staff were wearing it – and he struggled to identify who was who (nurse, OT, physiotherapist, doctor).' (Orthopaedic inpatient rehabilitation service)

4.18 Examples of some of the specific changes put in place to prevent the spread of COVID-19 included:

• Systems for the distribution of PPE to staff, and for ensuring that staff were correctly fitted for PPE and kept up to date with changing requirements
• New risk assessments and protocols for infection control
• COVID-19 screening questionnaires for patients / carers – used prior to all face-to-face visits (in essential / critical cases)
• New guidelines regarding the cleaning of equipment in advance of it being returned to equipment stores – resulting in equipment supply and delivery delays
• New guidelines in OT kitchen environments
• Requirements to socially distance in offices – resulting in less available office space.

Service delivery – sources of pride

4.19 Question 6 asked respondents to provide details of the specific parts of their service they were most proud of during the pandemic.

4.20 Despite the significant changes and challenges experienced during the pandemic, respondents often emphasised that their team had continued to provide a high-quality service – keeping person-centred care at the heart of all they did – and that their service remained responsive within a constantly changing situation. At the same time, some respondents also made the point that what they were most proud of was that their service had been able to continue at all.

4.21 It was clear in the replies to Question 6, that the behaviour of their staff / teams was, by far, the main thing that respondents were proud of during the pandemic. Staff were described as flexible, adaptable, resilient, courageous, resourceful, professional, compassionate, forward-thinking, committed, willing to embrace change, willing to upskill, dedicated, and determined to continue to provide a high-quality service. There were reports of teams contacting every person that they worked with to make sure that they were safe.

4.22 Respondents repeatedly said that their staff 'embraced' the use of video technology and the telephone to be able to continue to deliver their service. They quickly learned how to triage patients and prioritise their workloads while at the same time having to cope (in most cases) with a very limited workforce. Staff were also reported to have 'pulled together' – supporting and looking after each other. Other respondents spoke of the 'leadership' and 'creativity' that their staff demonstrated. Respondents from inpatient services specifically praised their staff for their willingness to work with COVID-19 positive patients.

4.23 Some respondents also talked about a 'blurring of roles' which took place during the pandemic, as staff stepped up to support each other.

'There was a blurring of roles in multi-disciplinary teams in a positive way to address wider issues during essential community visits (i.e. Dietician taking OT equipment during their visit; Speech and Language Therapist weighing patient for Dietician, etc.)' (Multidisciplinary rehabilitation team – inpatients, outpatients and community)

4.24 In addition to the behaviour and responses of staff, other things that respondents said they were proud of during the pandemic included (i) the ways in which communication improved – with patients, within teams, between the rehabilitation team and other community or hospital services, and between management and frontline staff – and (ii) the wide range of new systems and resources that were introduced to support the safe, high-quality delivery of services.

4.25 Regarding the latter point, examples included (i) new digital resources for patients to support self-management, (ii) resources to support staff wellbeing, (iii) new assessment, risk assessment and triage systems to manage referrals and decisions about which patients needed to be seen face-to-face, (iv) systems to ensure adequate stocks of PPE and reliable decontamination processes, and (v) training resources for redeployed staff.

4.26 Finally, respondents also drew attention to the ongoing pandemic situation – and commented that they were proud of how their services were still continuing to adapt.

'Since returning to substantive service we have been receiving double the referrals as pre-pandemic and the majority of these are Long Covid. We have had to quickly build our expertise in this emerging clinical presentation and keep up-to-date with new evidence as it emerges. We are particularly proud of how we have been able to adapt to this and support each other and we have tried to influence future service provision based on our experience.' (Outpatient vocational rehabilitation team)

Skills gaps emerging during the pandemic

4.27 Question 8 asked about skills gaps that had emerged during the pandemic. Most respondents said that skills gaps had emerged. Comments focused on four main themes: (i) clinical skills, knowledge and experience, (ii) the adoption of virtual working, (iii) COVID-19 safe working, and (iv) staff and self-management. Each of these is discussed briefly below. In addition, issues relating to training (to address skills gaps) are also covered. A final section covers positive views on staff skills.

Clinical skills, knowledge and experience

4.28 The additional clinical skills gaps reported by survey respondents were wide ranging and varied. They covered skills directly related to the care and treatment of COVID-19 patients, as well as those of a more generic nature. Specific skills noted by respondents related to the management of critically ill patients including those in intensive care units and following discharge (for example, related to respiratory care competencies for physios, and nutritional support competencies for dietitians); moving and handling skills; and end of life care (for example, dealing with families, and dealing with emotional, psychological and mental health issues).

4.29 In some cases, skills gaps were attributed to staff redeployment during the pandemic with staff being (temporarily) assigned to different teams or roles working with different patient groups or in different settings which required different knowledge, skills and experience. Some, however, saw this as an issue of confidence or as something that could be dealt with via 'refresher' training.

Digital working

4.30 The sudden change to virtual and remote working featured heavily in the survey responses, with staff having to become proficient in using a range of different systems and software packages in order to do their jobs. Although some teams had been familiar with digital working prior to the pandemic the wholesale shift to this way of working had presented significant challenges, with some staff finding this 'overwhelming at first'.

4.31 In terms of online delivery of services to patients, respondents were clear that the challenges were not just technical but also related to skills and confidence in carrying out telephone or online consultations and assessments, the delivery of interventions (to individuals or groups) and communicating effectively with patients and families.

4.32 Some respondents said the skills gap in this area had quickly closed as staff 'had adapted to the challenges of digital working'. However, in other cases respondents said that training and support had not always been available, and that some staff continued to lack confidence and competence in this area.

Infection control

4.33 Another area in which survey respondents identified skills gaps was that of infection control and COVID-19 safe working. On this issue, respondents noted the need to ensure staff were familiar with infection controls procedures, social distancing in the workplace and the use of PPE. This was said by some respondents to have presented a 'steep learning curve' for staff, and that this had been compounded by 'constantly changing' guidance and protocols.

Staff and self-management

4.34 Respondents also commented on the emergent need for enhanced skills in the areas of staff management and self-management that took account of the new pressures and new working environments associated with the pandemic. The skills gaps identified related to contingency planning, the management of the health and wellbeing needs of staff, particularly in the virtual working environment, and building resilience and equipping staff to manage stress and anxiety.

4.35 One respondent described the uniqueness of the challenges presented by the COVID-19 pandemic, and what this meant for the skills required of staff:

'None of our team had ever managed a crisis of this nature and therefore on reflection it is apparent that the skill-set required to deal with this situation both physically and emotionally was incredibly complex. Building resilience and crisis management skills would seem to be not only relevant but necessary for all in health care.' (Inpatient and outpatient physiotherapy service in gynaecology, obstetrics and pelvic health)

Training challenges

4.36 As well as identifying specific skills gaps, respondents also highlighted the challenges in ensuring that such gaps were addressed during the pandemic. In particular, they said that training – both for new recruits and existing staff – had not always been readily available or easy to access, or that training (e.g. induction training) had been provided virtually rather than in-person. In addition, some respondents noted that providing on-the-job training and ongoing support for redeployed staff had placed an additional demand on existing teams.

Positive views on staff skills

4.37 Occasionally, respondents said that no skills gaps had emerged in their area during the pandemic or said that the skills gaps remained the same as prior to the pandemic. Indeed, in some cases, respondents said the pandemic had highlighted the good range of skills present within their teams.

4.38 Some also identified positive impacts of the pandemic in terms of staff skills as team members had, for example, learned new skills, demonstrated good leadership or gained new experience (in their current roles, or as a result of redeployment). Some had also taken the opportunity to pursue self-directed learning.

Patient health and wellbeing

4.39 Question 9 asked respondents what changes they had observed in the health and wellbeing of their patient group during the pandemic. Respondents generally replied to this question by providing a long list of changes, and there was a great deal of consistency in the points mentioned. Overall, respondents reported that the pandemic had had a significant negative impact on patient functioning and wellbeing. Specific reported impacts related to: (i) mental health, (ii) physical health, (iii) social isolation, (iv) reduced access to and reduced willingness to engage with services, and (v) carer exhaustion.

4.40 Each of these is discussed briefly below, followed by a short section which discusses some of the positive impacts on patient health and wellbeing noted by some respondents.

Mental health

4.41 Respondents repeatedly highlighted the impact of the pandemic on their patients' mental health and wellbeing. They also frequently pointed to the knock-on effect that a decline in mental health had on their patients' physical health and functioning. Respondents working in all areas of rehabilitation and with all service user groups said that they had observed a wide range of changes in their patients' mental health including increased anxiety (including fear of catching COVID-19); lower mood and depression; increased incidences of agoraphobia; increased suicidal feelings and suicide attempts among older people and patients with pre-existing mental health problems; self-neglect; loneliness; loss of confidence; poor motivation; increased confusion; boredom; grief; and distress.

4.42 Occasionally, respondents reported that some of their patients were 'stoical', and so their decline in wellbeing was less obvious.

Physical health

4.43 In terms of the physical impacts of the pandemic on patient health and wellbeing, a recurring theme was that of patients becoming 'deconditioned' as a result of inactivity and an inability to access care and support services. This deconditioning led to an increase in frailty and falls among older patients in particular. A wide range of other physical impacts were identified including weight gain (or weight loss), malnutrition and increases in eating disorders; increased alcohol and drug use; loss of fitness; reduced mobility; deterioration in communication skills; cognitive decline; increased pain; and increased incidence of diabetes.

Social isolation

4.44 Social isolation was seen to be a major impact of the pandemic and one which had a significant knock-on effect on patients' mental (and physical) health and wellbeing. Respondents often noted that their patients had to shield during the pandemic, and that the loss of contact with family, friends and services was keenly felt by all patient groups.

4.45 Very occasionally, respondents reported that some of their patients seemed to prefer to be in hospital (one respondent said they 'loved being in hospital') rather than at home because of the loneliness they had experienced at home alone. This was not a common observation, however, as most respondents stated that their patients were fearful of going to hospital during the pandemic.

Reduced access to, and reduced willingness to engage with, services

4.46 Another common theme in respondents' comments about the impacts of the pandemic on their patients was that of restricted access to healthcare services during this period. As noted in paragraph 4.10–4.12 above, face-to-face delivery of rehabilitation services (including clinics and group classes) largely stopped during the pandemic for all but the most urgent cases. Third sector support services and leisure / gym services were also unavailable.

4.47 At the same time, respondents said that many patients were reluctant – even when it was possible – to attend outpatient or other hospital appointments, for fear of contracting COVID-19. Moreover, some patients found it difficult, or were unwilling to, engage with medical and rehabilitation professionals through virtual appointments – or they struggled to articulate their needs because of technology / broadband issues.

4.48 The general unavailability of services and the reluctance of patients to engage with services that were available had a significant impact on patient health and wellbeing. Some of the reported impacts included patients being unable to take part in pre-surgery rehabilitation (prehabilitation); patients presenting to health services with more severe / complicated conditions requiring more intensive / aggressive interventions; and an increase in acute admissions (because patients had waited too long to seek help).

Carer exhaustion

4.49 Some respondents commented that carer stress and exhaustion was a further significant issue that had had an impact on the health and wellbeing of their patients. With the withdrawal of face-to-face services at the start of the pandemic, carers found themselves having to take on increased responsibilities with no access to respite services. Respondents noted that, during the pandemic, patients were often being discharged from hospital more quickly than normal, leaving families feeling unprepared to support their relatives. This situation was exacerbated in cases where family members did not live locally and were unable to visit. In addition, not all carers had access to, or had the skills to use, IT devices. These individuals were unable to engage in digital consultations.

4.50 The following quote illustrates the wide range of negative impacts of the pandemic on patient health and wellbeing reported by respondents.

'Our patient group have been quite significantly impacted mainly via the effects of shielding – which applied to the majority of our patients living with a chronic lung condition. Anxiety and depression were already closely linked with living with a lung condition, but we have found the majority of people we are now back in touch with are struggling much more with mental well-being. This is a combination of fear in relation to contracting COVID-19, loss of social contact, isolation from families including grandchildren, reduced contact with GP practices and other support groups, and a fear that their condition has worsened. We have also found the majority of our patients to be much more breathless over the pandemic which is mainly due to shielding and therefore reduced activities, increased sedentary living, reduced motivation to do home exercise and then a cycle of avoiding exertion due to breathlessness. We have had people whose breathing has deteriorated, and they have taken to their bed, assuming that their condition has progressed and not knowing where to turn. Patients have also been avoiding contacting GP practices as they assume they are too busy, or report that they don't feel supported by online GP consultations or telephone appointments therefore are asking us for support with problems that require medical attention.'
(Outpatient pulmonary rehabilitation service)

Positive impacts

4.51 Very occasionally, respondents noted positive impacts of the pandemic on the health and wellbeing of some of their patients. For example, there were examples of (i) increased walking and physical activity, (ii) patients being willing and able to self-manage and engage in virtual appointments, (iii) patients valuing and benefiting from online groups, (iv) patients with mental health problems experiencing a respite from worrying about their own inactivity, lack of social contact or absence from work.