Rehabilitation framework self-assessment tool: analysis of responses

5. The future of rehabilitation services – post-pandemic

This chapter presents findings from the survey responses in relation to post-pandemic service delivery and discusses respondents' views about what needs to be done – locally and nationally – to provide consistently good rehabilitation services. Six questions in the survey addressed general issues related to learning from the pandemic experience, opportunities for services, workforce challenges, patient health and wellbeing, and requirements for providing good rehabilitation – within services and at national level.

Question 10: Learning from the last year what will you keep doing?

Question 11: What would you say is the biggest opportunity for your service
post-pandemic?

Question 12: What would you consider as the biggest challenges within your workforce over the next couple of years? (e.g. gaps in education / training, recruitment concerns)

Question 13: Do you have concerns about the long-term impact of the pandemic
on the health and wellbeing of your patient groups?

Question 14: Within your service what needs to happen in order to consistently provide 'good rehab' – please try to be specific.

Question 15: What ambitions would you like to see collectively across Scotland
in order to consistently provide good rehab?

5.1 The responses across four of these questions covered very similar ground, and together presented a picture of respondents' intentions, aspirations and ambitions for services in the post-pandemic period. Thus, the analysis below is not presented on a question-by-question basis. Instead, the analysis looks at (i) service delivery, (ii) strategic action required to bring about the desired changes in rehabilitation services and outcomes, (iii) workforce issues, and (iv) patient health and wellbeing.

Service delivery

5.2 Respondents anticipated or were keen to see a wide range of changes in rehabilitation services in the post-pandemic period. The main themes identified in their comments related to (i) digital working; (ii) multidisciplinary and joined up working; (iii) service quality and improvement; and (iv) non-staff-related resources. Each of these is addressed below.

5.3 It should also be noted that in a few cases respondents said that it was (i) 'too early' to consider future plans and opportunities for services, (ii) that services had had 'little time to regroup' and were still working in challenging times, or (iii) that they did not feel they were yet working in a 'post-pandemic' environment. Additionally, one respondent said, 'it doesn't feel like there are many opportunities' while another said that 'staff see no opportunities due to lack of funding for outpatient services and low staff morale'.

Digital working

5.4 With few exceptions, survey respondents said they intended to continue using remote and digital working for both (i) communication with team members and colleagues in other teams and services, and (ii) patient-facing service delivery activities (e.g. telephone and online triaging, assessments and reviews, delivery of groups and classes, and providing information and advice). Respondents noted that digital working:

• Improved efficiency by saving on travel time for staff and easing the burden on accommodation and facilities, thus freeing up capacity for other work and allowing those most in need to be prioritised for face-to-face care
• Supported good quality care by facilitating regular communication with patients, offering choice (online versus face-to-face appointments, classes and interventions) and convenience to patients and making it easier to engage with and involve families and carers in a patient's care
• Allowed staff to engage with a wider range of colleagues, regardless of their location – for managing cases, for service management and development purposes
• Allowed staff easier access to training, saving on time and money, and allowed staff to provide training to other groups (e.g. care home staff)
• Gave staff flexibility to work from home – which could be more productive and could support an improved work-life balance.

5.5 Respondents saw remote and digital working as a way to further enhance patient choice, promote self-management, improve efficiency, and provide more equitable services. However, while there was widespread enthusiasm for continuing with digital working, respondents often said that this should be part of a 'blended' and / or 'balanced' approach with a range of service delivery options available to patients to meet their needs and preferences. It was noted that not all patients had access to digital devices or reliable internet connections, or the necessary skills or confidence to use technology successfully. Respondents also recognised that online service delivery had limitations and should only be used 'where appropriate'; some stressed the need for a cautious approach incorporating monitoring and evaluation of the impact of digital working. In a few cases respondents said they were looking forward to a return to face-to-face working and anticipated minimal use of digital working within their team, or they emphasised the importance of face-to-face contact.

5.6 Respondents also said that staff training, and access to reliable IT equipment and internet connections were needed to support work in this area.

Multidisciplinary and joined up working

5.7 Respondents also commonly drew attention to the move towards greater multidisciplinary and joined up working during the course of the pandemic as a positive development and something they intended to continue and build on further.

5.8 They were looking ahead to closer collaboration between teams both within and across professions, services, sites, organisations, and sectors. This type of collaboration would involve further development of their knowledge of, and working relationships with, community-based and third sector organisations – to allow early intervention, to facilitate timely discharge of patients from acute settings, and to prevent future admissions.

5.9 Respondents were keen to continue, re-establish, or explore options for: (i) more collaborative multi-agency service delivery – e.g. joint assessments and decision-making, and shared caseloads and case management, (ii) improved communication and information sharing and (iii) joint training and CPD activities. The increased use of technology was often seen as a key enabler in this.

5.10 Respondents also talked about an intention to continue with a flexible, innovative, and ambitious approach to delivering services, with staff contributing to and moving between different teams, as required, and working beyond traditional boundaries. Some saw the need for further development of a 'shared rehab ethos', which would involve social work, nursing and care staff as well as GPs and hospital staff (as appropriate) in supporting people's rehabilitation goals. Others suggested that time and space for honest conversations within multidisciplinary teams was the key to innovation in services.

5.11 Respondents identified national-level actions and initiatives that would support enhanced joined up working. Key amongst these were shared access to IT systems / electronic notes between health and social care professions, and (ii) clearer rehabilitation pathways and referral processes across Scotland to promote greater continuity of care between inpatient, outpatient and community services.

Service quality and improvement

5.12 Respondents noted how working through the pandemic had encouraged flexibility, the development of new and adaptive ways of working, and 'thinking outside the box'. Respondents were keen to build on this 'enthusiasm for change', and 'continue to support innovative [and] creative ways of working'.

5.13 Respondents said they wanted to 'do things differently' or to 'not go back to what we had been doing pre-COVID-19'. There was also a view that the pandemic had created an opportunity to be 'braver' in looking at service options, and to 'push things through more quickly'.

5.14 Respondents said they saw opportunities to: (i) reflect on and redefine services, (ii) consider service priorities – what was delivered, how and why, and the allocation of resources, (iii) review and redesign services – taking account of feedback from patients and staff and (iv) introduce efficiencies, remove duplication and streamline services.

5.15 Some respondents also saw specific service development opportunities related to the ongoing and future treatment of patients recovering from COVID-19, or suffering from long-COVID, or patients with pre-existing conditions whose health and physical and mental wellbeing had been impacted by pandemic – either because of difficulties accessing treatment or because they had been shielding. These respondents pointed out that their teams had the necessary skill-set to respond to this situation and provide the appropriate rehabilitation input to affected patients.

5.16 It was also common for respondents to identify specific areas of their service where learning from the pandemic could be used to improve current systems and approaches.

5.17 For example, in relation to case management, some respondents wished to continue to pursue (i) improved triaging systems (using telephone and virtual assessment methods), (ii) stricter application of service criteria, (iii) effective case reviews, and (iv) effective discharge planning and management. Although such approaches had sometimes been expedited by the pandemic, respondents saw opportunities for further development of case management approaches and patient pathways, supported by the use of virtual working, in order to support more efficient service delivery and improved prioritisation of resources, so that support could be focused on those most in need.

5.18 At a more general level, respondents frequently said that they intended to continue to provide evidence-based services in a person-centred way that encouraged and supported self-management and prioritised patient and family / carer engagement. Going forward, respondents wanted to see the 'right' rehabilitation service provided at the 'right' time to each individual who needs a service. Respondents highlighted the importance of a 'person-centred approach' based on the principles of Realistic Medicine (i.e. the concept that people using healthcare services feel empowered to discuss their treatment, and can engage in shared decision-making with healthcare professionals).

5.19 Respondents also repeatedly said that there was a need for a greater focus on 'prevention' – rather than the current resource-intensive focus on crisis interventions. They called for a 'proactive', rather than 'reactive' approach to service delivery. This would involve, among other things, a greater emphasis on self-management. Respondents suggested there is a need – not only to educate GPs and other professionals to refer patients 'at the right time' to facilitate proactive rather than reactive interventions – but also to educate the public about their role in managing their own conditions 'rather than expecting services to fix everything for them'. It was suggested that a change in 'language' and 'culture' would help to encourage more self-management.

'Put in place 'prevention' that works, for example: the falls prevention groups, day centres, best in class information sessions, exercise referral schemes. [Provide] easy access for patients to gyms, swimming pools, etc. Redevelop Day Rehabilitation for generalised deconditioned patients with complex health and social care needs. [Deliver] appropriate rehabilitation in the community – providing rehab to patients rather than just ensuring that they are safe.' (Outpatient musculo-skeletal rehabilitation team)

Non-staff resources

5.20 Respondents repeatedly made the point that future plans and aspirations for services were dependent on the necessary funding, resources and infrastructure being available.

5.21 Specifically, they said there was an urgent need for adequate and appropriate ('fit for purpose') space in which to see patients. There were calls for more clinic space, and greater access to gym / exercise space and equipment (including in hospital wards). Some respondents also highlighted a need for specialist rehabilitation equipment to meet the specific needs of their patient groups; quiet private space on wards; and suitable office space.

5.22 While the main need appeared to be for physical space, other resource needs identified by respondents included (i) better IT equipment, (ii) (additional) administrative support, and (iii) easier access to equipment and materials to support patient rehabilitation.

Strategic actions required to support rehabilitation services

5.23 In addition to the more operational issues outlined above, respondents also discussed a number of more strategic issues which they thought needed to be addressed in order to achieve 'good rehab'. Key amongst these were (i) equality of access to services; (ii) research, evaluation and evidence-based practice; and (iii) the contribution, profile, and future development of rehabilitation services. The need for a strategic approach to the planning of rehabilitation services was also frequently highlighted, with these comments discussed at paragraph 5.32.

Equality of access to services

5.24 Respondents often commented on inequality in services within and between areas. They reported that long waiting lists in some areas are preventing people from getting the rehabilitation service they need. Inequality of access was also noted among certain population groups – for example, poor access to podiatry services was reported for people in prisons. Concerns were also expressed about the withdrawal of certain types of rehabilitation services in some parts of Scotland for particular patient groups and the inconsistent standards which are used at local level to plan / prioritise different rehabilitation services.

5.25 In order to tackle this, respondents wanted to see national-level action to achieve more equitable services and a strategy that truly tackles health inequalities. Respondents talked about having 'national guidelines' to ensure the correct levels of staffing and 'standards of care' based on current evidence to address existing variations in practice.

5.26 As discussed above, there were some suggestions that the technology and systems that services had invested in over the past year presented an opportunity for more accessible, more equitable services. There was also a suggestion that there was a need, at national level, to develop rehabilitation services in care homes in order to focus on improving quality of life.

Research, evaluation and evidence-based practice

5.27 The importance of evidence-based practice was repeatedly highlighted by respondents across all types of rehabilitation services. Respondents thought there was a need to 'close the gap' between current evidence of best practice and existing practice. At a local level, there was a keen interest in developing research capacity and capability to enable staff to evaluate the outcomes from their services. There was also a specific suggestion that more consistent data was needed to evaluate self-management approaches.

5.28 In terms of national ambitions, respondents wanted to see national benchmarking, a national repository (or network) to share good practice, and more opportunities for rehabilitation practitioners to participate in research – to develop the evidence base for effective rehabilitation. The point was made that staff needed to have time and resources, both to participate in research / evaluation and to make changes to practice in light of evaluation findings. There was also a suggestion that any national rehabilitation strategy should be based on evidence of what works and that any such strategy should be evaluated for effectiveness in an ongoing way.

The contribution, profile and future development of rehabilitation services

5.29 A range of respondents identified opportunities to raise the profile of and highlight the contribution made by their profession or service in the post-pandemic environment. Respondents saw this as important both at organisational level and with regard to patients and the wider public. They said that the work done during the pandemic and the continuing need to support patients affected by COVID-19 had highlighted the importance of rehabilitation services, and they thought there was an opportunity, assisted by the Rehabilitation Framework, to build on this to ensure that 'the value and importance of rehab within health and social care is recognised and supported'.

5.30 Respondents saw an opportunity to 'really address the rehab agenda' by (i) promoting the needs of particular patient groups or the value of particular services, and (ii) further developing services that prioritised rehabilitation work and the principles underpinning it.

5.31 There was a broad view that good leadership and effective strategic management were important to the future development of AHP and rehabilitation services. Respondents wanted this to encompass greater recognition of the role of rehabilitation services in health and social care planning, improved workforce planning, a greater focus on preventative action and holistic person-centred care, increased funding and resources, greater consistency and equity in services.

Workforce challenges for the future

5.32 Question 12 asked respondents what they considered to be the biggest challenges within their workforce over the next couple of years. In general, respondents saw workforce issues as ongoing but said the pandemic had further highlighted these issues. At the same time, they identified specific workforce-related impacts that had emerged during the pandemic and were likely to continue into the future. Key amongst these were (i) staff morale and wellbeing and (ii) the need to adapt to new ways of working.

5.33 Respondents also raised workforce issues in their responses to Questions 14 and 15 about what needs to happen in their own service and at a national level to consistently provide 'good rehab'. In relation to these questions, they highlighted issues of (i) staff recruitment and retention, and (ii) staff training and development.

5.34 The main points made regarding these issues are covered below.

Staff morale and wellbeing

5.35 In terms of staff morale and wellbeing, respondents commonly referred to staff 'burnout' or 'fatigue', or 'disillusionment' as issues for their service going forward. This situation was linked to working through the pandemic which had been a period of intense pressure and stress for staff – because of high workloads, new ways of working, constant change and uncertainty and concerns about health risks to individuals and families. However, this was also linked to the continuing situation as Scotland emerged from the pandemic with ongoing high demands for services and long waiting lists as a result of the backlog of cases that had built up in some areas. Respondents suggested that maintaining staff wellbeing and resilience would become increasingly challenging the longer COVID-19 restrictions and the effects of the pandemic continued.^[4]

5.36 Respondents said that the pandemic had highlighted the importance of supporting colleagues, looking after the health and wellbeing of the workforce and enhancing staff resilience, and they wished to maintain a focus on this moving forward. Respondents discussed their intentions to (i) offer flexible home working as an option to staff, (ii) improve staff engagement and allow time for reflection and the sharing of concerns within teams, (iii) improve communication with individual staff members, including regular 'check-ins' and improved supervision and mentoring, and (iv) empower staff in their professional roles, to prevent overload and ensure an appropriate balance of work that allowed time for non-clinical activities.

Digital working

5.37 The introduction and expected continuation of 'blended' working incorporating remote working and the use digital technology was also seen as presenting workforce challenges. As discussed above, respondents often said they saw 'blended' approaches to service delivery as offering advantages and playing a part in re-establishing services. However, it was also common for respondents to note that this was, nevertheless, likely to present a number of challenges over the coming years, including in relation to (i) staff competence and confidence in the use of IT and (ii) the provision of suitable equipment and an appropriate working environment. Respondents also highlighted challenges in relation to:

• Staff development and training: Some noted that digital or blended service delivery offered fewer opportunities for shadowing of new or rotational staff and meant that it was harder for new staff to gain a full range of necessary experience if face-to-face work with patients was restricted. There were particular concerns that staff who had completed their undergraduate training during the pandemic would not have all the necessary skills to work safely and effectively in the workplace. However, some suggested that there were advantages – particularly for those in more remote areas – in being able to access national training remotely.
• Team and staff management: Some respondents said that remote working and virtual meetings could have an impact on communication and informal networking, and could affect team dynamics and the quality of discussion at meetings.
• Staff perceptions and job satisfaction: Some noted that staff 'do not like managing patients virtually' or that they preferred face-to-face working, and that a move away from in-person working could affect job satisfaction. There was a concern that staff who had chosen to work in a 'hands on' profession may leave if the nature of their job changed too much.

Recruitment and retention

5.38 Survey respondents saw recruitment and retention as ongoing issues within AHP and rehabilitation services. However, some respondents saw the issue of staff morale and wellbeing as potentially exacerbating existing challenges in this area. In particular, there were suggestions that the experience of working through the pandemic may lead to individual staff members (i) bringing forward retiral plans, (ii) choosing to leave NHS jobs as they reassessed their lives and prioritised their own health and wellbeing and lifestyle factors, (iii) seeking improved pay and conditions elsewhere, or (iv) being reluctant to take on the challenge of a new job. In addition, respondents anticipated that there may be increasing requests for part-time working, flexible working and remote working as staff tried to adjust their work-life balance in the wake of the pandemic.

Ensuring staff have the right skills for the job

5.39 Respondents not only said that their services needed to have enough staff to meet the demands for rehabilitation services, but they also needed: (i) staff who are appropriately trained, (ii) teams with the right skills mix (respondents highlighted the need for a 'flexible, skilled workforce'), (iii) ongoing opportunities for continuing professional development, and (iv) good pathways for career progression. Respondents saw opportunities to further consider staff training needs and to invest in developing the workforce to meet the changing demands of future services.

5.40 Respondents emphasised the importance of linking with colleges and schools and maintaining support for students. However, respondents identified a challenge in ensuring that new entrants to the workforce had the necessary skills to confidently carry out their jobs, given the increased use of 'virtual placements' and the reduced use of face-to-face working.

5.41 Looking ahead, respondents were keen that staff continued to:

• Maintain, use and build on new skills gained during the pandemic
• Keep their skills and knowledge up to date
• Develop skills to meet the physical and emotional needs of patients.

5.42 They also noted the importance of protecting staff development time, supporting new staff, and continuing to offer placement opportunities for students.

Responding to workforce challenges

5.43 At both local and national levels, respondents felt that improvements could be made to workforce planning and suggested that, at a national level, improved guidance on this subject could be provided (e.g. in relation to staffing levels and workforce planning). There was also mention of developing a 'workforce planning tool'. Respondents also wished to see a more consistent approach to training, greater use of multidisciplinary training, and adequate funding to ensure staff could access the necessary training.

Patient health and wellbeing

5.44 Finally, respondents were asked (Question 13) if they had any concerns about the long-term impact of the pandemic on the health and wellbeing of their patient groups.

5.45 Very occasionally, respondents said that they foresaw no long-term impact from the pandemic. Those who answered in this way and provided further comment suggested that long-term impacts on patient health and wellbeing could be avoided if a clear exit plan (from the pandemic) was implemented. There was also a suggestion that the negative impacts seen during the pandemic were likely to continue in the short term, but not necessarily in the long term.

5.46 However, more commonly, respondents did highlight concerns about possible long-term impacts of the pandemic, and they thought that these impacts were likely to be seen for many years to come. The main themes in respondents' comments related to (i) mental health, (ii) physical health, and (iii) social isolation. Each of these is discussed briefly below.

5.47 First, however, respondents' views about the factors that may cause or contribute to possible long-term adverse impacts are presented.

Causal factors

5.48 Respondents expected the pandemic to have a range of long-term impacts on their patients. The two main causes of these anticipated impacts were identified as (i) ongoing difficulties for patients in accessing services and (ii) patients' own disengagement from services.

5.49 Some respondents highlighted continuing delays and / or barriers for patients in accessing a wide range of services – not only rehabilitation services, but also primary care services, drug and alcohol services, and community leisure / exercise classes. Others suggested that certain support services (e.g. falls groups, lunch clubs, walking groups, etc.) were still closed, and there were concerns voiced that some of these services may, not re-open.

5.50 Respondents made the point that without better access to these key services, patients may become increasingly unwell and not come to the attention of services until a crisis occurs, by which point recovery will be more difficult. Respondents also noted that the loss of contact with services is likely to have a particularly severe impact on older people in particular.

Mental health

5.51 Respondents said that they expected to see long-term impacts on patient mental health from the pandemic, including in relation to increased anxiety, loss of confidence, bereavement, increased drug and alcohol use, and increased cognitive impairment.

Physical health

5.52 Respondents thought that the physical deconditioning of patients, which had begun during the pandemic, was likely to worsen. Some reported that improved function which they had seen in some patients had been entirely reversed during the pandemic. In addition, they expected – and were already seeing evidence of – increasing frailty and debility among older patients.

5.53 In addition, the implications of long-COVID were also a concern for respondents. Those who did provide further comment on this issue suggested that long-COVID was likely to exacerbate many long-term conditions, and to require sustained rehabilitation. There was a suggestion that services (at least in some areas) did not currently have the capacity to support people suffering from this condition.

Social isolation

5.54 Respondents also expected that, in the long term, there would be increased loneliness and social isolation within their patient groups. They attributed this partly to people's poorer mental health and a loss of confidence among their patients in engaging in social interaction, but also to the lack of structure in people's lives during the pandemic. Others pointed to the loss, for many people, of long-established friendship and support networks.