4. The three target groups
There is clearly a need to build on the significant range of policy and service developments already in place that reflect the needs of our key target groups. This chapter explores this underpinning work and specific issues relating to rehabilitation service provision for:
- older people;
- people with long-term conditions;
- people returning from work absence and/or aiming to stay in employment.
There are several areas of overlap among the groups, but also specific challenges that require focused attention.
Scotland's population is growing older. The numbers of older people (aged 65 and over) is expected to increase from 830 000 in 2004 to 1.31 million in 2031. The number aged 75 and over is projected to rise from 370 000 to 650 000 over the same period. 21 The carer population is also growing as a consequence of increasing demand for support.
Old age is not an illness. Many older people are fit and well, functioning capably in their communities without professional support. The service emphasis for these people is 'habilitation' - maintaining their physical, psychological and social health and well-being and anticipating and pre-empting any decline before it becomes acute.
Older people nevertheless tend to have higher levels of ill health than those who are under 65. The Scottish Executive Information and Statistics Division reported in 2001 that rates of occurrence of limiting long-standing illnesses increased considerably with age. Fifty percent of men and 60% of women in the 75 and over age group at that time had a disability, compared to only 14% of the general adult population (aged 16 and over). 22 Care of older people accounts for 40% of the health service budget in Scotland and 60% of the social work budget 23 and is consequently a key priority for the Scottish Executive (see Box 4.1).
|Box 4.1 Health and social care policy for older people in Scotland|
The Scottish Executive has published a series of policy documents identifying the health and well-being of older people as a priority for Scotland, including:
In addition, NHS Quality Improvement Scotland has produced several recommendations for older people's services, including:
The focus of policy is to identify the growing need for integrated older people's services. Better Outcomes for Older People25 provides a lead on how to set up joint services and sets out the requirements, actions and timescales local partnerships should meet in developing joint services. It also emphasises that progress will be monitored by a national partnership involving the Scottish Executive, the Convention of Scottish Local Authorities ( CoSLA) and NHSScotland.
The key messages from Better Outcomes for Older People25 are about:
- proactively supporting older people living at home so they are not inappropriately admitted to a care home or hospital;
- providing intensive rehabilitation prior to returning home from hospital;
- ensuring a seamless transition from hospital to home;
- actively supporting older people and their carers on returning home from hospital;
- facilitating provision of appropriate rehabilitation support to people in care homes.
Reviews of older people's services carried out by several NHS Boards have reinforced the need for a coherent, integrated system of community-based rehabilitation. The reviews have recognised that flexible service delivery involving hospital discharge teams, community older people's teams, social services, day hospitals and day centres is essential in preventing unnecessary admission to hospital and supporting hospital discharge.
Better Outcomes for Older People25 outlined the principles and values of joint service provision, which relate to their:
- responsiveness to local needs;
- ability to deliver better outcomes for individuals and carers.
It also called for a stronger focus on integrated care services to provide a range of enabling, rehabilitative and treatment services in community settings.
Joint Future is the headline policy on joint working in community care. It initially focused on systems and structures, but now adopts an outcomes-based approach, promoting whole-systems working and partnerships.
Single Shared Assessment ( SSA) is central to the Joint Future initiative and is already resulting in real improvements for older people and their carers (and others) through facilitating quicker and more effective decision making. SSA aims to:
- provide direct access to services and resources across agency boundaries;
- eliminate duplication in assessment;
- ensure that information is shared across agencies with the consent of the person being assessed;
- speed up the delivery of appropriate services.
Stroke and hip fractures are particularly common causes of disability among older people and pose significant challenges for rehabilitation and community services. Specialist rehabilitation services, including comprehensive assessment and rehabilitation for frail older people, has made significant progress in demonstrating better outcomes for patients, particularly in stroke and orthopaedic rehabilitation. These services, often situated within secondary care settings, are highly valued by patients and their carers and must continue to play a key role in the future development of the rehabilitation/enablement continuum within health and social care services. C
It is also known that older people have a higher incidence of dementia, which can be misdiagnosed as depression. It is important that older people are assessed appropriately at the point of contact with health and social care services and that appropriate services are available. Delivering for Mental Health4 has committed to funding a pilot improvement programme involving NHS Forth Valley and the Dementia Services Development Centre which will look at better ways of identifying dementia early and providing services focused on supporting the person at home as long as possible. The programme will be evaluated in 2008.
It is important to reinforce the need for comprehensive in-patient assessment and rehabilitation in specialist units for frail older people. There is evidence to suggest that comprehensive care in such settings can improve the probability of return to independent living. The transition to the community thereafter needs to be seamless for older people and carers to gain maximum benefits.
There is evidence to suggest that a multidisciplinary Comprehensive Geriatric Assessment ( CGA) (Table 4.1) has significant benefits in identifying and planning rehabilitation needs. 35 Older people, whether being managed in the community or presenting to the acute hospital, should have appropriate access to CGA.
Table 4.1 Components of Comprehensive Geriatric Assessment
|Medical assessment||Problem list
Co-morbid conditions and disease severity
|Assessment of functioning||Basic activities of daily living
Instrumental activities of daily living
Gait and balance
|Psychological assessment||Mental status (cognitive) testing
|Social assessment||Informal support needs and assets
Care resource eligibility/financial assessment
|Environmental assessment||Home safety
Transportation and tele-health
|Source: http://www.bgs.org.uk/Publications/Publication Downloads/Compend_3-5 Comp Assessment hospital.doc|
While it is important to focus on the needs of the frailest older people in our communities, it is also vital to promote independence for older people who are well. Local authorities, voluntary groups and health services, working with NHS Health Scotland and using the Scottish diet action plan 36 and the national physical activity strategy, 37 are developing innovative, effective programmes designed to maintain the population's health and well-being. Programmes such as these need to become the norm across the whole of Scotland, allowing access by all communities. In addition, the links between physical and mental health are well known: older people who are physically active are more likely to remain physically and mentally healthy.
People with long-term conditions
A long-term condition is defined by the Long-Term Conditions Alliance Scotland as one that requires ongoing care, limits what the person with the condition can do and is likely to last longer than one year. As incidence increases with age, many older people are likely to be living with more than one long-term condition.
Long-term conditions have been the focus of a raft of health and social care policy from the Scottish Executive and others (Box 4.2).
Box 4.2 Health and social care policy for people with long-term conditions
The Scottish Executive has launched a series of policy initiatives identifying the health of people with long-term conditions as a priority for health and social care providers, including:
The Department of Health in England has also published useful documents on the management of long-term conditions, including:
Long-term conditions can place huge physical, social, emotional and financial pressure on individuals, families and carers. They also create significant challenges for NHS and other services and resources. People with long-term conditions are more likely to visit their GP and outpatient departments, be admitted to hospital and to remain in hospital longer. Currently, long-term conditions comprise eight of the top 11 causes of hospital admissions.
The World Health Organization has acknowledged that if not successfully managed, long-term conditions will be the leading cause of disability and the most expensive problem for health care systems by the year 2020, with depression being the number one cause of disability. 43Delivering for Mental Health4 has focused heavily on the need to reduce the incidence of depression through better assessment, early intervention and the use of a range of evidence-based psychological therapies. Work is being done to take this forward, as is work around better management of individuals who have long-term physical conditions such as coronary heart disease and diabetes with depression and anxiety.
Initiatives aimed at ensuring people with severe and enduring mental health problems have access to better health interventions such as smoking cessation services and dental and eye checks will be progressed. The evidence to support interventions in this area is very strong: we know that people with a chronic mental illness may die up to 10 years earlier than their peers in the general population due to higher incidences of coronary heart disease, diabetes and asthma, and that they tend to consume more alcohol and misuse other substances. Much work needs to be done by services in primary and community care around this agenda.
A key aim of rehabilitation for people with long-term conditions, which was reinforced strongly in the consultation process, is to equip individuals and their carers with skills, knowledge and support to self manage wherever possible in a way that enables them to participate fully in their communities, with timely access to appropriate professional interventions when required. Enabling people who have long-term conditions to take greater control of their treatment in the community, with access to appropriate support from health and social care professionals, improves their quality and length of life, reduces emergency admissions to hospital and releases inpatient capacity. 44
It is recognised that the central component in enabling people with long-term conditions to live their lives as independently as possible in their homes is the support provided by families, carers and communities. People with long-term conditions and their carers are experts in how their condition affects them and their lives. Individuals and carers must be acknowledged as partners in their management and as central members of rehabilitation teams, deciding what support they need, when they need it and how it is delivered.
Another key message from the consultation was that self-management support options should be based on comprehensive assessment of need and should include access to:
- self-monitoring devices, assistive technologies, equipment and adaptations;
- rehabilitation services as an effective alternative to traditional home care services;
- information about services in other sectors such as the voluntary sector and local authorities.
People returning from work absence and/or aiming to stay in employment (vocational rehabilitation)
Vocational rehabilitation has been defined as a process that enables people with functional, psychological, developmental, cognitive and emotional impairments or health conditions to overcome barriers to accessing, maintaining or returning to employment or other useful occupation. The emphasis is on restoration of functional capacity for work or other useful occupation rather than treatment of a clinical condition per se.
While vocational rehabilitation is relatively new to the UK, it has been extensively developed and evaluated in countries such as Australia, Canada and the US and is now beginning to emerge as a priority for policy and service development in Scotland and the rest of the UK (Box 4.3).
Box 4.3 Health and social care policy for people returning from work absence and/or aiming to stay in employment (vocational rehabilitation)
The Scottish Executive and the Department for Work and Pensions have published a series of policy documents in this field, including:
Workforce Plus: An Employability Framework for Scotland, 9 for example, sets out how a large number of agencies need to work together to help individuals who often face a complex combination of factors that keep them from finding and sustaining employment. It clearly identifies the role of NHSScotland as an employer and as a provider of rehabilitation services, working in partnership with other employment-related services through CHPs and local Workforce Plus partnerships. Partnership working involving NHS health care professionals and employment-related services has already been demonstrated in Scotland with the Department for Work and Pensions' innovative Pathways to Work programme.
Some policy activity has focused on education, training and economic development, while other initiatives have specifically targeted social exclusion, directly addressing the disadvantage implicated in disability. Vocational rehabilitation draws all of these strands together in a holistic and systematic manner. It requires a joined-up approach to provision of treatment and other interventions.
A recent review of 400 pieces of scientific evidence 47 concludes that being in work is good for people's physical and mental health, boosting self esteem and quality of life. The adverse effects of unemployment (higher rates of mental health problems and increased likelihood of suicide, disability and obesity) can be reversed: when people return to work from unemployment, their health improves to the same degree by which it was damaged by unemployment.
Delivering for Mental Health4 has identified that employment can be key to recovery for many people suffering from mental illness. Programmes to maintain employment or facilitate re-entry into the labour pool can be very effective in supporting social inclusion. Pilot work in primary care and in labour markets will be evaluated and, where appropriate, lessons will be applied. Learning from work being taken forward by the Scottish Development Centre for Mental Health on behalf of the European Commission will also be reflected in future action.
In Scotland, the Healthy Working Lives initiative has been launched to support and enable individuals to maximise their functional capacity throughout their working lives through a 'one-stop-shop' approach to accessing information, specialist advice and practical support. The Scottish Executive commissioned a working group in 2003 to look at 'fast-track' rehabilitation programmes in the NHS in Scotland. The working group produced a paper describing a scheme ( OHS Xtra) which advocated an approach to tackling long-term sickness absence in NHS staff by providing rapid access to a vocational rehabilitation programme (Box 4.4).
|Box 4.4 OHS Xtra|
OHS Xtra is a pilot project based in NHS Fife and NHS Lanarkshire. The aim of the project is to reduce work-related difficulties and absences for NHS employees who may be experiencing health and welfare problems.
NHS staff in the two NHS Board areas have rapid access to a dedicated health support service consisting of physiotherapy, occupational therapy and mental health support. The provision of heath support services has had a positive impact on the health, welfare and well-being of the NHS workforce, which in turn will benefit the consistency of care provided for NHS patients.
In addition, services such as those provided by Employee Assistance Programmes that provide early intervention for mental health conditions have been in place for 25 years in the UK, but have fallen within the remit of social policy. Usually provided by private enterprise, these services can play a critical role in job retention for employees at risk. The important contribution of the voluntary sector in promoting vocational rehabilitation is also significant.
It is estimated that the working-age population in the UK will decrease by around 8% between 2002 and 2027. This will have major implications for the productivity of the Scottish economy (both public and private sectors).
The Health and Safety Executive ( HSE) reports that over 2 million workers in the UK are suffering from an illness believed to be caused or exacerbated by their current or previous work. Around 40 million working days are lost each year due to occupational ill health and injury. The Confederation of British Industry ( CBI) estimates that sickness/absence costs the UK economy around £12 billion each year; this equates to £1 billion for Scotland, or around £800 per worker per year.
UK data from the Department for Work and Pensions show that:
- 1 million people report sick each week;
- 2.6 million people are on incapacity benefit ( IB);
- nearly 40% of IB claimants report mental health problems;
- 30% report musculo-skeletal problems.
The number of incapacity benefits claimants more than trebled between the late 1970s and the mid-1990s. Although most people coming on to benefit expect to get back to work, a very large number never do; an individual is very unlikely to return to the workplace after two years on incapacity benefit.
It is therefore important to prevent the flow of people onto benefits as a result of illness or injury while in employment. By raising awareness of the advantages of rehabilitation among health professionals, employers and employees, many more people can be assisted to remain in work while recovering from, or coming to terms with, their condition.
Innovations such as the New Deal for Disabled People48 and Pathways to Work12 show that, with the right help, support and vocational rehabilitation, many people on incapacity benefits can move back into the workplace. Early results from the Pathways to Work pilot programmes, for instance, show off-flows from incapacity benefit at six months of about 48%, compared with 40% nationally. Benefits data for the UK reveal that the number of people on incapacity benefits has fallen by 54 000 in the year to May 2006 and is now below 2.7 million for the first time in six years. 49
Research has identified features of vocational rehabilitation that are valued by people. They include:
- proactive case management, which empowers clients to take action;
- early intervention;
- operation across professional and agency boundaries;
- interventions such as psychological therapies, referrals to specialists, surgical interventions and complementary therapies, which act to boost strength, mobility, cognition, confidence and mental and emotional well-being.
Studies also support initiatives that:
- enhance the vocational rehabilitation advice available to employers;
- encourage health professionals to focus on and manage returns to work;
- enhance vocational rehabilitation training for health professionals;
- develop vocational rehabilitation services within the NHS.
Vocational rehabilitation is therefore well placed to help meet the stipulations of the Welfare Reform Bill published on 4 July 2006. Some of the key messages in the Bill relate to the need to:
- reduce the number of people who leave the workplace due to illness;
- increase the number of individuals leaving benefits;
- better address the needs of those who remain on benefits, with additional payments to the most severely disabled people.
Key elements of vocational rehabilitation include:
- assessment of functional, physical, psychological and cognitive work capacity;
- vocational assessment and counselling to determine suitable job options;
- counselling to support adjustment to disability;
- supervised on-the-job training and/or a short vocational course;
- fitness and work conditioning programmes;
- confidence building/self-esteem groups or individual sessions;
- assessment of workplace suitability;
- development of skills for job seeking;
- brokerage and case management;
- linkage with community-based agencies.