2. Policy context and background
This delivery framework for adult rehabilitation explores the principles of rehabilitation in line with the new health and social care agendas in Scotland.
Delivering for Health1 signals transformational change in the NHS from a service that is primarily focused on providing care in hospitals to one where care is planned, delivered and evaluated close to people's homes, when this is the most appropriate option. It sets out the Scottish Executive's priorities for NHSScotland over the next decade (see Box 2.1), presenting a new vision for the NHS based on:
- delivering services close to where people live;
- offering people timely access to services;
- promoting a strong emphasis on anticipatory care;
- supporting individuals and carers in self-managing long-term conditions.
Box 2.1 Delivering for Health1
Delivering for Health1 calls for:
- a fundamental shift in the way the NHS works, from an acute, hospital-driven service to one that is embedded within the community, is patient focused and is based on a philosophy which moves from 'care' to enablement and rehabilitation;
- a focus on meeting the twin challenges of an ageing population and the rising incidence of long-term conditions;
- a concentration on preventing ill-health and treating people faster and closer to home;
- a determination to develop responses that are proactive, modern, safe and embedded in communities;
- support for health care professionals, individuals and their carers to deliver sustainable, quality services;
- best use to be made of information technology in delivering effective services closer to people's homes.
Delivering for Health1 set out a specific action to develop:
… a rehabilitation framework to support services for older people, people with long-term conditions and people returning to work after a period of ill health. The framework will promote a co-ordinated approach to delivering integrated care in community settings…
The importance of applying a more systematic approach to care for people with long-term conditions is emphasised in the policy. This calls for services to identify individuals in their local population who have long-term conditions and to tailor health and social care services to meet their requirements. Proactive, systematic approaches to rehabilitation, underpinned by good prevention, need to be adopted to further this agenda.
Various initiatives have been launched by the Scottish Executive in response to specific needs identified in Delivering for Health, 1 including those that support services for:
- people with long-term conditions and their carers;
- older people;
- people with specific conditions, such as stroke.
Rehabilitation is seen as being central to all of these initiatives.
The shift in policy direction in the health service that Delivering for Health1represents is mirrored in the social care sector by Changing Lives. 2 The review of social work in Scotland sets out a vision for social care services for the 21st century. The report outlines 13 recommendations based on the premise that 'more of the same won't work', highlighting the need for change to ensure services respond to future demographic changes, public expectations, workforce availability and financial allocations (Box 2.2).
Box 2.2 Recommendations from Changing Lives2
1. Social work services must be designed and delivered around the needs of people who use services, their carers and communities.
2. Social work services must build individual, family and community capacity to meet their own needs.
3. Social work services must play a full and active part in a public sector-wide approach to prevention and earlier intervention.
4. Social work services must become an integral part of a whole public sector approach to supporting vulnerable people and promoting social well-being.
5. Social work services must recognise and effectively manage the mixed economy of care in the delivery of services.
6. Social work services must develop a new organisational approach to managing risk which ensures the delivery of safe, effective, innovative practice.
7. Employers must make sure that social workers are enabled and supported to practice accountably and exercise their professional autonomy.
8. Social work services must develop a learning culture that commits all individuals and organisations to lifelong learning and development.
9. Social work services should be delivered by effective teams designed to incorporate the appropriate mix of skills and expertise and operating the delegated authority and responsibilities.
10. Social work services must develop enabling leadership and effective management at all levels and across the system.
11. Social work services must be monitored and evaluated on the delivery of improved outcomes for people who use services, their carers and communities.
12. Social work services should develop the capacity and capability for transformational change, both focusing on redesigning services and organisational development.
13. The Scottish Executive should consolidate in legislation the new direction of Scottish social work services.
Changing Lives2places the emphasis on service redesign, workforce training and leadership and a shift towards early intervention and prevention. It focuses on building the capacity of the workforce to deliver personalised services and create sustainable change.
Rehabilitation can therefore be seen as being pivotal to the principles of Delivering for Health1 and Changing Lives, 2 many of which are shared (see Box 2.3).
Box 2.3 Shared principles of Delivering for Health1 and Changing Lives2
Each document focuses on different aspects of transformation within the respective services, but shares common principles of:
- community capacity building;
- whole-systems approaches;
- prevention and early intervention;
- user involvement;
- carers as partners;
- self management of care;
- systematic approach to long-term conditions management;
- a competent workforce.
Other key policy statements relevant to rehabilitation services include:
- Delivering for Mental Health4
- The Scottish Executive Response to The Future of Unpaid Care in Scotland5
- The Diabetes Action Plan6
- Cancer in Scotland7
- Coronary Heart Disease and Stroke Strategy for Scotland8
- Workforce Plus - An Employability Framework for Scotland9
- More Choices, More Chances: A Strategy to Reduce the Proportion of Young People not in Education, Employment or Training in Scotland10
- Healthy Working Lives: A Plan for Action11
- Pathways to Work: Helping People into Employment12
- The Department for Work and Pensions Cities Strategy13
- The Strategy for Community Hospitals in Scotland.14
These UK and Scottish initiatives, and many more like them, indicate a significant shift in policy towards community-based services, with rehabilitation firmly defined as a central component.
Health and social care professionals now need to build on existing skills in the management of long-term conditions and co-morbidities, health improvement and anticipatory care/early intervention. The Community Health Partnership ( CHP) Long-Term Conditions Toolkit will be a useful resource in taking this forward. By focusing on rehabilitation and enablement, professionals will be in a strong position to contribute their expertise to the delivery of the new health and social care agenda, working with individuals, carers, communities and voluntary organisations.
Rehabilitation services in Scotland
Hard data on the numbers of people accessing rehabilitation services in Scotland are difficult to establish due to the diverse nature of service provision. An indication of the extent of demand, however, can be gained from the National Allied Health Professions ( AHP) Census, which took place in September 2005, and which showed that across Scotland, 59 997 people were seen by an AHP on Census Day - on average, 1:89 people in Scotland. 15 The Census covered only AHPs working in the NHS, so the actual numbers will be greater when account is taken of people accessing rehabilitation services through social services, independent and voluntary organisations.
Rehabilitation services currently are delivered in a variety of settings, often by diverse groups that cross health, local authority and voluntary sectors and which include individuals and carers, equipment and adaptation services and employers. Around 600 000 unpaid carers support individuals throughout Scotland and play a crucial role in successful self management.