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

1. Introduction by the Chief Health Professions Officer

Rehabilitation is a core element in the delivery of the Scottish Executive's plans to improve the health and well-being of the population of Scotland and will be instrumental in achieving some of the key national outcomes and targets that have been set for the NHS and local authorities.

When individuals face challenges to their physical or mental well-being, they experience an impact on their quality of life. Rehabilitation is fundamentally about enabling and supporting individuals to recover or adjust during this time, achieve their full potential and - where possible - to live full and active lives. Improving community-based rehabilitation services is integral to the rehabilitative approach, as is the prevention of dependency on 'care' and support services through the promotion of independent living.

While much has already been done to develop rehabilitation services that promote safe and effective discharge from hospital and to expand evidence-based rehabilitation in a number of specialties, challenges remain in areas such as meeting the needs of older people or those with multiple long-term conditions who wish to live independently in their own homes. Improving access, availability and transitions between services provided in hospital and community settings were recurring themes identified by service users involved in the development of the delivery framework. Their views and those of rehabilitation professionals and their multi-agency colleagues are core to the actions set out in this document.

Process

The delivery framework has been developed by the Scottish Executive in partnership with a wide range of stakeholders, including individuals who use services, unpaid carers and rehabilitation providers in health and social care. A National Steering Group and three Action Groups were established ( Appendix 1), each chaired by a service user. The Steering Group and Action Groups worked in support of the National Project Officer during the engagement process and the production of successive drafts.

The process of developing the framework involved:

• a thematic analysis of the evidence by the Scottish School of Primary Care;
• a series of consultation events with those who use services;
• a consensus event with health and social care professionals;
• a three-month national consultation on a draft framework document.

Purpose and vision

The purpose of this delivery framework for adult rehabilitation is to give strategic direction and support to all health and social care services and practitioners who deliver rehabilitation services to individuals and communities. The document focuses on core principles of rehabilitation specifically as they relate to older people, adults with long-term conditions and people returning from work absence and/or aiming to stay in employment.

The framework:

• concentrates explicitly on the added value offered by rehabilitation through earlier anticipatory interventions and the prevention of unnecessary admissions to hospital or other care environments;
• explores how rehabilitation can produce health gains for individuals and communities through enabling return to productive activity and employment;
• provides guidance to underpin the development of rehabilitation in a multi-disciplinary, multi-agency context;
• offers a clear vision to individuals, carers and services in delivering this agenda.

The vision underpinning the framework is the creation of a modern, effective, multi-disciplinary, multi-agency approach to rehabilitation services that are flexible and responsive in meeting the needs of individuals and communities in Scotland. These services will be facilitated by dedicated Rehabilitation Co-ordinators who will play a key role in:

• mapping existing rehabilitation services in health and social care;
• re-designing services with the support of a rehabilitation improvement network;
• integrating health and social care rehabilitation services;
• promoting case management in the rehabilitation team.

Findings

Work on developing the framework has shown us that existing rehabilitation services are highly valued and that people want rehabilitation services delivered close to their homes (although not necessarily always in their homes) by professionals and teams who are competent and have the requisite skills to support them through the rehabilitation journey. When in-patient rehabilitation services are required, they want rapid admission, effective intervention and appropriate early discharge. Most important, individuals and their carers want professionals to engage fully with them and treat them as equal partners in managing their condition(s) and making decisions about services.

There was a strong call for better co-ordination of rehabilitation services, particularly when the individual is not in hospital, and a need to explore the potential benefits of key worker/ rehabilitation co-ordinator roles was highlighted. This was reinforced during the three-month consultation process.

Impacts

Health and social care organisations across Scotland have a common purpose in addressing rehabilitation issues in the context of sustainable community services. There are clearly practical and economic benefits associated with the development of the integrated approach promoted by this framework.

Services should strive to support people in managing their own health conditions and remaining independent in their own home rather than being admitted to hospital. Current evidence would indicate that many admissions to hospital or institutional care could be avoided if anticipatory and rehabilitation services were in place. Other potential areas of impact include reducing dependency on care and support services (with decreases in associated costs), reductions in delayed discharge and avoidance of readmissions or repeated (unnecessary) admissions to hospital.

This rehabilitation framework links into ongoing work in relation to anticipatory care/early interventions, long-term condition management and unscheduled care. Effective implementation of the framework with better co-ordination of resources will help reduce emergency admissions, length of stay and delayed discharges. This will be made possible through better access to rehabilitation professionals and the wider primary care team, which in turn will support better identification and management of the at-risk population and those with complex needs. It will also ensure better engagement of service users and their carers in decision making and enable people, wherever possible, to remain in their own homes.

Integrated service redesign and role development are key to putting the rehabilitation journey at the heart of systematically planned services. They will enable multi-disciplinary, multi-agency teams to maximise the benefits of existing models of service and create approaches that focus on the shift from 'care' provision to 'enablement' and rehabilitation, using the expertise of these professions and of the whole team to work with individuals and carers to best effect.

Providing effective rehabilitation services that meet the challenges set out in Delivering for Health¹ and Changing Lives² and which comply with guidance provided by the Department for Work and Pensions ( DWP), such as Building Capacity for Work: A UK Framework for Vocational Rehabilitation, ³ requires transformational change. Health and social care professionals have already shown real commitment to integrated working and service improvement. They will need to work across organisational and professional boundaries which have previously caused disruptions to the rehabilitation journey, with Rehabilitation Co-ordinators playing a key role in facilitating this process.

I now call on health and social care professionals to build on what has been achieved, look beyond traditional methods of providing services and grasp opportunities for joint learning with health and social care colleagues.

Jacqui Lunday
Chief Health Professions Officer