Rehabilitation and recovery: a person-centred approach

8. Recommendations

To embed the Six Principles of Good Rehabilitation in practice and to deliver good rehabilitation for all, the Once for Scotland approach sets out a number of recommendations. These recommendations will be supported by an implementation and action plan to follow. This will identify how the recommendations can be translated into practice. Scottish Government will work collaboratively with key stakeholders (including NHS Boards, HSCPs, leisure, third and independent sectors) to do this.

The table below identifies these recommendations and provides guidance on how they can be applied at a local and national level, considering the local infrastructure of rehabilitation services.

Recommendation 1

The Once for Scotland approach is inclusive of individual needs, is accessible and meets the needs of all, including seldom heard groups.

To achieve this, consideration should be given to factors such as local service provision/resources, accessible communication, physical location and access to the internet as well as language, cultural barriers and protected characteristics.

How could this be implemented locally and nationally?

Rehabilitation professionals to work with individuals with lived experience of rehabilitation services to inform local access routes.

The ALLIANCE to develop a programme of work that will develop stronger cross-sector working, deliver more sustainable pathways to third sector services and ensure any new initiatives build on solutions for those who are currently excluded.

Recommendation 2

More rehabilitation activity is provided earlier, optimising opportunities for early intervention for prevention and for prehabilitation.

How could this be implemented locally and nationally?

NHS Boards, Primary Care and HSCPs to identify first point of contact practitioner and care coordination roles within primary care. These roles will improve access to the right person first time, reduce demand on specialist services and improve patient outcomes.

Local rehabilitation and leisure services to work together to develop and deliver community-based rehabilitation and prehabilitation to help improve individuals' functional abilities and mental resilience, in advance of planned interventions and to support individuals to "wait well".

Recommendation 3

Rehabilitation is individualised taking into account both physical and mental health needs of individuals as part of a person-centred approach.

How could this be implemented locally and nationally?

Rehabilitation services to embed person-centred conversations and outcome-focused goal setting with the individual within their approach.

Rehabilitation services should ensure that their approach supports delivery of the recommendations set out in Mental Health – Scotland's Transition and Recovery^[7] relating to rehabilitation.

Recommendation 4

An enabling approach is embedded within care homes and care at home to improve physical and psychological health for older people experiencing care.

How could this be implemented locally and nationally?

Rehabilitation services to work with the Care Inspectorate to scale up and sustain CAPA (Care about Physical Activity) programme.

Recommendation 5

Rehabilitation services to optimise digital technologies as part of a digital first, not digital only, approach to service delivery.

How could this be implemented locally and nationally?

Rehabilitation services to work within national^[8] and local digital health and care strategies to support the delivery of the Digital Front Door. This will support individuals to navigate services digitally and access information and services directly enabling them to manage their own conditions.

Work with rehabilitation services and digital leaders to fully explore digital options to ensure that individuals are able to access assessments, interventions and monitoring using the most appropriate method of delivery for them and at a time that meets their needs.

Collaborate with digital programmes already in place and encourage the development of a channel to create/suggest new models and methods at a national level.

Recommendation 6

More locally based community rehabilitation is provided that supports individuals with more than one long-term condition.

How could this be implemented locally and nationally?

Support the development of multi-morbidity community rehabilitation programmes such as HARP^[9] which consider individuals with more than one long-term condition, offering a suite of options building on community assets.

Recommendation 7

Rehabilitation practitioners and leaders have the skills to deliver realistic and meaningful rehabilitation, giving consideration to workforce challenges, both current and predicted.

How could this be implemented locally and nationally?

Rehabilitation services to support early adopter teams to enable the reshaping of rehabilitation services through improvement methodologies and leadership.

Consider the education needs of the rehabilitation workforce through The National Allied Health Professions (AHP) Workforce and Education Policy Review.

Scope the development of a rehabilitation competency framework that will include advanced practice and support worker roles across sectors, embedding public health competences.

Work with relevant education stakeholders including higher education institutions, NHS Education for Scotland (NES) and professional bodies to understand the education and training available to build rehabilitation skills and competencies and address any gaps.

Work with NES and Healthcare Improvement Scotland to develop programmes that will support, build, and sustain leadership and improvement capacity to deliver whole system change.

Recommendation 8

Rehabilitation services are encouraged to develop innovative and ambitious rehabilitation strategies and services.

How could this be implemented locally and nationally?

Encourage the application of research to deliver rehabilitation that is evidence based and outcomes focused in order to push the boundaries and promote innovation.