6. Concluding remarks
6.1 This report has presented an analysis of the main points raised by rehabilitation teams in their responses to a survey about rehabilitation services. The survey was commissioned by the Scottish Government on behalf of the National Advisory Board for Rehabilitation, and was carried out in May / June 2021. It captured a wealth of information from staff involved in the delivery of rehabilitation services on their experiences of and views on working before and during the COVID-19 pandemic, and on their intentions and aspirations looking ahead to the future of rehabilitation services.
6.2 The findings of the survey will be used to support the effective implementation of the Scottish Government's Framework for Supporting People through Recovery and Rehabilitation during and after the COVID-19 Pandemic (The Framework). The Framework sets out the priorities and objectives for rehabilitation services in Scotland during the ongoing pandemic and into the post-COVID-19 period.
6.3 The Framework is underpinned by eight principles which are intended to support a consistent approach to planning and re-shaping services to meet a broader range of needs and circumstances – including any health impacts associated with COVID-19. This final section considers the findings of the survey in the context of the eight principles:
- Multidisciplinary and multiagency workforce
- Education and research
- Quality improvement.
Attentive compassionate leadership at government and local levels, enabling collaboration, collective endeavour, and enabling the aspirations of the National Performance Framework, is essential because rehabilitation has far-reaching health, social and economic benefits, with the potential to enable greater participation in education, employment and community living. (Framework for Supporting People through Recovery and Rehabilitation during and after the COVID-19 Pandemic)
6.4 The findings of the survey suggest that good leadership and effective management were seen as important to the future development of AHP and rehabilitation services. While some respondents were positive about current leadership and management in their area, or highlighted examples of good leadership during the pandemic, others saw this as an issue that needed to be further addressed.
6.5 There was a view that the pandemic had highlighted the contribution made to health and wellbeing by rehabilitation services. Respondents spoke of the 'leadership' and 'creativity' that their staff demonstrated during the pandemic, and they suggested that there was now an opportunity to further raise the profile of these services and make the case for more strategically focused and better resourced services in the future.
6.6 Leadership is also needed at a national level. Respondents wished to see full recognition of rehabilitation services in strategic planning so that all patients in all areas had equal access to good services to support their rehabilitation.
Rehabilitation focuses on the person not the disease and where the individual – with their support from friends, family and / or carer – is empowered to lead and manage their situation and remain as independent as possible (Framework for Supporting People through Recovery and Rehabilitation during and after the COVID-19 Pandemic)
6.7 Providing person-centred care was a significant focus for survey respondents and many highlighted, as a point of pride, the patient-centred approach taken by their services before the pandemic. They described the key aspects of these services as: (i) engaging and working in partnership with patients and their families, (ii) focusing on self-management, (iii) supporting patients to achieve individualised goals, (iv) offering choice in services, ease of access and timely response and referrals, and (v) ensuring input from relevant professionals. They spoke of the importance of working with patients and families to devise individualised treatment plans that achieved the best outcomes for patients. Multidisciplinary and multiagency working was seen as important to this way of working, as was good local access to community services.
6.8 There was a general view that the pandemic had made it much harder to deliver truly person-centred services. However, some respondents emphasised that, despite the massive changes and challenges experienced in the pandemic, they kept person-centred care at the heart of all they did.
6.9 In terms of service delivery in the post-pandemic period, respondents identified a number of challenges that need to be overcome if rehabilitation services are to continue to provide person-centred care. There were concerns about the long-term impact of the pandemic on local services, and the implications this would have for patient health and wellbeing. Respondents described services that are under pressure and highlighted a number of resource-related issues which they felt needed to be addressed to enable rehabilitation services to be able to fully meet the increasing demands on services.
Personal outcomes approaches mean acknowledging individual strengths and working towards establishing a shared sense of purpose to which everyone can contribute, including the person, their family, carers and other community resources, as well as services. (Framework for Supporting People through Recovery and Rehabilitation during and after the COVID-19 Pandemic)
6.10 There was a strong focus on patient outcomes in the responses to this survey, and there was a clear indication that rehabilitation teams are keen to develop their research capacity in order to be able to better evaluate the outcomes from their services.
6.11 Prior to the pandemic, respondents were already aware that their patients were increasingly elderly and frail, with multiple long-term conditions and complex mental health and social issues. Respondents commented that referrals to rehabilitation were frequently made too late, resulting in poorer outcomes for the individuals. They suggested that the primary purpose of rehabilitation for patients was, increasingly, about maintaining safety and quality of life, rather than achieving independence.
6.12 This situation was exacerbated by the pandemic. During this time, services were less available, but patients were also less willing to engage with services. Respondents suggested that this situation would only be reversed if services were fully opened again and accessible, and if patients began engaging with services.
6.13 Respondents highlighted the need for a greater focus on prevention – and a move away from resource intense reactive services – at both a local and national level.
Multidisciplinary and multiagency workforce
Rehabilitation in any setting should include physical, mental, social assessment and intervention utilising a biopsychosocial model collaborating towards a common goal. This should be undertaken through a strong multidisciplinary teams approach including mental health and be multiagency including a trauma-informed workforce where a unified approach across professional groups, and systems is essential. (Framework for Supporting People through Recovery and Rehabilitation during and after the COVID-19 Pandemic)
6.14 Multidisciplinary working was seen as a point of pride for many of those involved in the delivery of rehabilitation services, with respondents often reporting this as being key to effective service delivery and describing good working relationships with colleagues and with other services, including those in other sectors.
6.15 However, some saw also identified challenges with this way of working – both in terms of 'ethos' and understanding, and in terms of practicalities relating to communication channels between teams and organisations, and variation in IT systems.
6.16 Some survey respondents suggested that multidisciplinary and multiagency working had increased during the pandemic, and there was a broad view that further development of multidisciplinary working was important to the future improvement of services.
New ways of working in response to coronavirus (COVID-19) challenges have led to creative solutions and good practice. New and evolving models of working need to be encouraged alongside the promotion and continuation of best practice supported where possible by evaluation. (Framework for Supporting People through Recovery and Rehabilitation during and after the COVID-19 Pandemic)
6.17 Survey respondents reported massive changes in their services which had been taken forward during the pandemic and reported an appetite for innovation and service improvement, and a commitment to taking stock, learning from the pandemic, and doing things differently (where appropriate) in the future. They highlighted the importance of good communication – and the time and space to be able to share learning – within multidisciplinary teams as key to making this happen.
Education and research
Partnership development of a skilled workforce considering educational, resources and emerging research evidence supporting rehabilitation outcomes for people. (Framework for Supporting People through Recovery and Rehabilitation during and after the COVID-19 Pandemic)
6.18 Respondents described a highly committed and highly skilled AHP and rehabilitation workforce, while also indicating where there were opportunities for further training and education. They highlighted the importance of further upskilling of the workforce and the need for appropriate resources to support this.
6.19 Respondents emphasised the importance of new entrants to the workforce in the post-pandemic period having the necessary skills to carry out their jobs. This was seen to be important because of the increased use the increased use of 'virtual placements' and the reduction in face-to-face working during the pandemic.
6.20 Respondents wanted to see all rehabilitation professionals delivering evidence-based services, and they expressed a commitment to the sharing of good practice across and between professions and an interest in participation in research. They voiced a need for greater capacity (and skills) to participate in research and called for greater cross-professional initiatives, and greater consistency in practice supported by appropriate guidance, standards, and training.
There can be considerable benefits associated with the use of digital platforms and the information they generate (video consultation, home and health monitoring; apps; social media; clinical records) to support direct care and self-management to promote a safe and convenient way of patients accessing services to improve efficiency and cost-effectiveness for better outcomes. There is recognition that some sections of the population are more likely to be digitally excluded and there must be caution not to reinforce social exclusion of these groups and to recognise where additional support may be required. (Framework for Supporting People through Recovery and Rehabilitation during and after the COVID-19 Pandemic)
6.21 The huge increase in digital working during the pandemic was a key theme in the survey responses. This had been used (for the most part) very successfully during the pandemic for communication within and between teams and services and for patient-facing activities. Respondents suggested that the continuation of a form of 'blended working' provided an opportunity to introduce further innovation to services and to offer patients greater choice in the post-pandemic period.
6.22 The need for appropriate funding for IT hardware and software and training for staff, was highlighted. Respondents also suggested that the increased use of digital platforms needed to be managed carefully and appropriately. In addition, respondents noted the potential (negative) impact on job satisfaction and staff wellbeing which could arise from increased digital working.
Implementation and improvement actions and supports should be informed by the elements that form part of effective quality management systems – specifically quality planning, control, assurance and improvement that is linked to leadership, learning systems and processes that promote collaboration with staff and people involved with services. (Framework for Supporting People through Recovery and Rehabilitation during and after the COVID-19 Pandemic)
6.23 The survey indicated that those involved in frontline rehabilitation services were committed to the development of high-quality effective services that took account of the views of staff and patients. They expressed an openness to innovation and change, and thought there was an opportunity, looking to the future, to review services in light of experiences and learning which took place during the pandemic. Respondents thought that research evidence, national guidelines and standards could all play a part in further improving quality in the future.
6.24 Overall, the survey responses endorsed the principles set out in the Rehabilitation Framework. However, survey respondents saw a need for strategic action – including improved leadership, greater recognition of the role of rehabilitation services in health and social care planning, improved workforce planning, increased funding and resources, greater consistency and equity in services– at both a local and national level in order for the Framework to be successfully implemented and for rehabilitation services to meet the increasing demands and challenges of the future.
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