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Shifting the Balance of Health Care: The Role of Rehabilitation Services

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

June 2008


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 rehabilitation services.


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 to happen.

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 already..

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 in Fife.

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 services.

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 on them?

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 incurred 

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 resolved.
  • 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 what not.
  • 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 all levels.
  • Closed referral systems should not continue to exist


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For Further Information Please Contact:

Matt Smith, Scottish Secretary
14, West Campbell Street,
Glasgow G2 6RX

Tel 0845 355 0845 Fax 0141 342 2835

e-mail matt.smith@unison.co.uk

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