Shifting the Balance of Health Care: The Role of Rehabilitation
The UNISON Scotland Submission to the Scottish
Parliament's Health & Sport Committee on their call for Written
Evidence on the Role of Rehabilitation Services in Shifting
The Balance of Health Care from Primary to Secondary Care
UNISON Scotland welcomes the opportunity to respond
to the call for written evidence from the Scottish Parliament's
Scottish Parliament's Health & Sport Committee on the Role
of Rehabilitation Services in Shifting the Balance of Health Care
from Primary to Secondary Care
UNISON Scotland has over 170,000 members in Scotland
most of whom work in Local Government, Health and the Voluntary
Sector throughout Scotland including a range of staff involved in
Comments for rehabilitation framework
The framework aims to examine the evidence for coordinated
and focused approaches to rehabilitation, identifying gaps and providing
direction on how these can be addressed and making recommendations
for the future. Delivering
for Health sets out the policy agenda for NHSScotland and
makes a specific commitment to the development of a Framework for
Rehabilitation as a key element of the delivery of this agenda.
Rehabilitation is a concept with broad applicability
across professions and agencies but which is interpreted in a variety
of ways within different contexts.
Key objectives will be:
- to manage long term conditions more effectively, including
the prevention of unnecessary hospital admissions;
- provision of earlier interventions in the community enabling
people to live independently at home and provide earlier access
to diagnosis treatment and rehabilitation that will enable this
Allied Health Professions have a key role to play
in delivering rehabilitation along with other health and social
care professionals. This framework will need to set out how this
shift from "care" to "enablement and rehabilitation" can be achieved
using the expertise of the whole team to best effect.
What are patients' experiences of rehabilitation
services? How will the framework change services to patients?
The Rehabilitation Framework is a positive document
which looks at the best way to deliver rehabilitation services to
patients locally within their own community.
It allows patients to receive services outwith the
acute sector and in local Community Health Partnerships (CHPs),
preventing unnecessary admissions and enabling them to manage their
conditions at home.
Occupational therapy staff already provide many rehabilitation
services in the community and work closely in multidisciplinary
teams and with colleagues in social services to deliver care to
patients in their community.
However, rehabilitation services can often be difficult
to access as GPs are not always fully aware of the range of services
available and may adopt a "gatekeeper" role. Rehabilitation
goals tend to be functional in nature not "social" There is little
support to engage in many life roles, e.g. work, socialising, driving,
accessing community resources, etc. Rehabilitation tends to
be episodic at the point of "crisis", with little thought given
to prevention. Carers are not often seen as important although
with support they can be a tremendous resource to enable people
to engage with their Rehabilitation programmes. The link between
discharges from hospital and continuing rehabilitation can be ad
hoc and far from seamless.
What changes need to be made to workforce planning
and social services to allow the framework to be implemented?
Workforce planning requires to be carried out across
social work and health services. Community OT's have a huge
role to play in the above as they have a clear understanding of
both agencies and community resources, are involved with individuals
on a daily basis with comprehensive complex care needs, and many
of them also have experience of care managing. Often
Community OT's feel that their skills are under utilised as their
role is often focussed around equipment and adaptations and the
pressures of waiting lists. There are also pressures
around the lack of capacity staff have with their present workload.
Community OT Assistants have the skills and competencies to take
on rehabilitation workers posts and certain home care colleagues
could be trained to carry out some rehabilitation in the home when
they attend to clients' personal and domestic needs, if given capacity
in their caseloads. Day care staff, social workers and social
work assistants also have a role to play.
In the NHS the framework should be implemented by
Allied Health Professionals (AHPs) but there is a shortfall of AHP
staff in many professions, especially occupational therapy.
There needs to be serious consideration as how to
develop workforce plans to increase the amount of AHPs and to develop
roles which will deliver the services required. Use of the NHS Knowledge
and Skills Framework will help with this process and close working
with workforce and learning development will also be beneficial.
In particular occupational therapy services are well
placed to deliver rehabilitation services to patients to enable
them to maintain their independence at home and prevent unnecessary
admission to hospital. This is a key role of Occupational Therapy
and health and social services and OTs work closely with each other
The Joint Future initiative should have made this
framework easy to implement but the success of joint future varies
across Scotland. There are difficulties over the issues of different
terms and conditions, secondment arrangements and for example, in
health, the difficulties with line management and clinical governance.
There are some good examples of joint working in Scotland such as
the rapid response teams in Grampian and other good initiatives
How will the framework change the role of allied
health professionals in delivering rehabilitation services?
The rehabilitation framework will change the role
of AHPs in a variety of ways. Firstly there is a huge opportunity
for extending the scope of practice, taking on roles which traditionally
have been viewed as medical or nursing duties, but because of the
rehabilitation element of existing AHP practices, could be easily
added on to these roles to deliver services to patients.
Many AHP services are already delivered in the community
to patients and this would be a way to improve and enhance existing
However, there needs to be a joint focus with the
patient on the goals and interventions to be carried out.
Staff could be involved in joint working across voluntary agencies,
community groups, local health clubs, etc. They could become
far more involved in preventative and group work relating to patients
managing their own condition. Patients may benefit form
longer term support groups.
We also need to recruit additional staff. There are
not enough professionals in Scotland to cover the potential increase
required to deliver this framework. We need to look at much better
skill mix and need to ‘grow our own'. We find difficulty recruiting
in Scotland particularly in rural parts where many posts are left
vacant because of a lack of applicants.
Are current community facilities adequate? To what
extent are they able to meet new demands that the framework places
Current provision varies between areas, but there
are some good examples of community facilities. In addition, many
health boards are currently looking at service redesign and moving
services out of the acute sector and into the community, based on
the Better Health Better Care Policies. However, there needs to
be a transfer of resources from the acute sector to the community
sector or CHPs in order to fund appropriate services. Funding is
always problematic. Many community hospitals will be overstretched
or lack space to provide all the potential services which could
be delivered in the community. Although this framework is looking
at the professional service the infrastructure behind it, such as
administrative and support staff also have to be provided. In addition,
the community infrastructure in many areas is inadequate and public
transport to community services and hospitals is non existent, especially
in rural areas.
How far are NHS boards, local authorities and associated
bodies able to fulfil their roles under the framework?
We believe that CHPs should be jointly managed by
Health and Social Care Managers, but that individual projects could
be managed by individuals from different disciplines. The
capacity issue is a large one for Community OT's, as managers may
not actively engage in rehabilitation issues if they are focussed
purely on equipment and adaptation waiting lists. As stated
above, we believe that in some areas consideration should be given
to extending the role of OT Assistants to free up capacity and give
them an important role to play in the rehabilitation framework.
What changes in financing will be required as a
result of shifts in the balance of care, particularly between acute
and primary care/community health budgets?
Previous comments on funding above all relate to this
question. In particular, Social Work budgets would be under tremendous
pressure if more support was to be given to care at home. Packages
of care would be intensive at times of active crisis which would
have big implications for home care staff. In addition, if care
was purchased from agencies greater financial resources would be
Community OT's and OT Assistants, homecare staff,
day care staff, and many other staff across social work have
many skills to offer. However greater capacity needs to be found
to allow them to manage any additional workload which would also
involve increased resources.
What barriers to the successful implementation
of the framework exist? How can these be overcome?
UNISON believes main barriers are
- Compatible IT systems across agencies to enable information
to be shared combined with a willingness to share the information
- Lack of AHP staff, in particular OTs and lack of capacity
for community staff
- Lack of workforce planning and service/role redesign to address
the above and to develop a ‘grow your own' culture, with joint
training across agencies being carried out.
- There is a need to have the right skills at the right place
and the right time - and an assessment of whether we are training
the right staff. Further education and workforce planning are
required and health boards and local authorities need to work
with the professionals to improve this. An assessment of resistance
to changing roles across all staff is needed.
- Resources need to be transferred from the acute sector to
CHPs and pooled funding between health and social services improved.
Resources in general need to be increased, as social work budgets
and care packages are currently stretched to the limit.
- Different terms and conditions between health and social services,
including pensions, etc. are a major concern and need to be
- 24/7 services in health as opposed to non-24/7 services in
social services need to be resolved
- Lack of Effective links across specialist rehabilitation,
community rehabilitation, voluntary and community services has
to be overcome.
- It is important that there is partnership involvement between
management and staff, particularly in health
- Expectations need to be realistic. Government promises cannot
always be delivered in these frameworks.
- Clarification is needed between health needs and social needs
and careful consideration given to what can be provided and
- Early rehababilitation needs to be introduced, e.g. at discharge
from hospital or when there is an increase in a care package
as this is found to be most effective at eventually reducing
the package. Where the package is in place for a long period
of time it is more difficult to withdraw it as patients become
dependent on the services provided.
- All staff should be better informed and actively engaged at
- Closed referral systems should not continue to exist
For Further Information Please Contact:
Matt Smith, Scottish Secretary
14, West Campbell Street,
Glasgow G2 6RX
Tel 0845 355 0845 Fax 0141 342 2835
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