Future Vision of Rehabilitation

Services What do we need to do to

meet the challenge?www.rehabilitationframework.scot.nhs.uk

Sarah.mitchell@scotland.gsi.gov.uk

A Delivery Framework ForA Delivery Framework ForAdult RehabilitationAdult Rehabilitation

Contribution of Rehabilitation Framework to the efficiency, productivity and quality agenda

• Significant cost savings potential• Reduction in inefficiencies

across boundaries (acute/primary/community care)

• Provides infrastructure to support self-management, prevention and enablement

• Reduction in sickness absence• Reduction in prescribing costs

(back pain/MSK)

High Impact Change 2

•  Health and Care Pathways provide single point of access for rehabilitation services. This will be supported by appropriate tools for screening, triage, assessment and information on availability of services with a focus on improving service user experience.

Related Policy Drivers• The Quality Strategy• 18 week referral to treatment standard• Shifting the Balance of Care – Extend the scope of services provided by non

medical practitioners outside acute hospital Improve capacity and flow management for

scheduled care• Health Works• Long term conditions action plan• Realising Potential: An action Plan For AHP’s in

Mental Health

3 Quality Ambitions• Mutually beneficial partnerships between patients, their

families and those delivering healthcare services. Partnerships which respect individual needs and values and which demonstrate compassion, continuity, clear communication and shared decision-making.

• No avoidable injury or harm from the healthcare they receive, and that they are cared for in an appropriate, clean and safe environment at all times.

• The most appropriate treatments, interventions, support and services will be provided at the right time to everyone who will benefit, with no wasteful or harmful variation.

Can we afford not to?

• A single and shared focus as a basis for prioritisation

• Quality means reducing variation, avoiding harm, reducing healthcare associated infection, being more effective and efficient, reducing wastage and actively involving people in their own healthcare.

• Getting it wrong actually costs more.

Scottish Offer – Health Works

• Consistent approach to access and transition through NHS services

• Need joining up within NHS services

• Recognise importance of work for health

• Empowered healthcare staff – clear work outcomes in patient care plan

• Need joining up with other services – clear pathways toward work

Recognised world leading quality healthcare

• caring and compassionate health services• delivering clinical excellence• collaborating with patients and everyone

working for and with NHSScotland• providing a clean and safe care environment• improved access and continuity of care• confidence and trust in healthcare services

Key service issuesKey service issues

• Services are fragmented, inaccessible and difficult to navigate

• Communication within and across services is a challenge

• Service activity is dominated by indirect activity

• Professional practice is primarily based on custom and practice

• High incidence of transition episodes leading to duplication

• Absence of whole system performance management structure

Example of variable pathways – Spinal MRIHealth Board A with back pain service and imaging pathway

• see and treat over 7000 patients with back pain per annum

• Max 1.5% referred on for spinal imaging

• Cost 100 x235= 23,500

Health Board B with no integrated spinal pathway

• No such integrated service

• Referral to once centre for spinal MRI is 2222referrals per annum

• Cost = 522, 170

Evidence of quality within the Focused National WorkstreamsDimensions of quality Musculoskeletal re-

designOlder peoples pathway

Vocational rehabilitation

Person centred Self referralShared responsibilitySupported self management (working backs website and MKN)

Supported self management

Self referralShared responsibilitySupported self management

Safe Evidence based triageIntegrated MSK team delivering service

Evidence based risk assessment screening for falls risk in a variety of settings

Evidence based triageCase management approaches

Effective Increase conversion rate to surgery to 80%Reduce unnecessary investigations and prescriptions

Reduce admissions Reduce attendances to A+EReduce length of stay

Evidence based interventions demonstrating early return to work –EASY Programme Lanark

Efficient Most appropriate intervention and health care professional

System of in-reach to reduce inappropriate transitions of care

Utilisation of case management approaches

Equitable National roll outNo queue

National roll out National roll out

Timely Early intervention Focus on primary prevention initiatives as recommended by WHO.

Early intervention

Quality / Efficiency issues to consider• Current systems of SR – is there waste in

the system?• Have we got good / equitable access to our

services?• Is there variance in type and timing of

clinical assessments?• Is the information we give to patients

consistent, evidence based and high quality?

Vision• Self referral into all AHP services• Centralised referral management system

into all rehabilitation services ---• NHS24 – Can provide a central point of

access, rapid patient access with a robust referral management system + opportunities for telerehabilitation.

• Minimum datasets for AHP services – to provide standardised information

Societal Impact of Pain Symposium 5 May 2010

14

CommunityAHPMSK

Services

Integrated MSK Team

PhysiotherapyPodiatry

OTDietician

ProstheticsRadiography

Specialist nurseGPwsi

Pain Specialist

Self Referral via NHS 24

Self management and advice

through NHS 24 web base for rehabilitation

GP Referral

Walk in Self Referral

Electronic Referral

Community Chronic Pain

Services

Orthopaedic

waiting list

Rheumatology

services

Other acute services

Electronic Referral

GP Referral Electronic

Referral

Integrated MSK and Chronic Pain Pathway

Vocational Rehabilitation

Services

Chronic Pain

Services

Present Model

• Pathway – GP onto orthopaedic waiting list. • National UK data identifies this pathway resulting in up to

70% not requiring surgical intervention. Conversion to surgery in Scotland ranges from 11% - 35%.

• Return appointments seen by orthopaedic surgeon. Cost per month = ortho OP clinic appt = £150. on av 30 patients per clinic per week =£18,000 pm. Cost for ESP = £45. Total cost = £5400pm

• What does this mean for the patient? Sickness absence? Psychological problems? Reduction in functional capacity? No active management and resulting cost!

Benefits

Orthopaedic Consultants see a higher ratio of new patients in their clinic who are likely to require surgery.

Standard conversion rate will be 80% Better utilisation of orthopaedic team

within secondary care Non complex return patients all seen by

most appropriate member of MSK team = efficiency of over £1.5 million

Developing national minimum data sets for community based rehabilitation of adults with musculoskeletal conditions

• Why are we doing this project? • Recommendations of the Rehabilitation Framework. • Large variation in practice across Scotland in the type and timing

of clinical assessment• To develop, through consensus with stakeholders, minimum

datasets

• What do we mean by minimum data sets? • A standardized assessment instrument

• What is the purpose of the project?• Collection of such standardised data should facilitate:• analysis of community musculoskeletal rehabilitation activity and

capacity planning both within and between NHS Boards • enable us to argue for resources much more affectively.

Critical success factors• A resource shift to enable MSK services to be provided

under a single system.• Scoping work to identify the most accessible new

locations where services can be provided– utilising leisure facilities as well as well CHP facilities.

• A system of in-reach into acute hospitals to allow AHP staff work with Orthopaedic Consultants in secondary care, while remaining primarily based outside acute hospitals – ensuring orthopaedic team approach

• Training to be undertaken to develop advanced practitioner skills.

Service Transformation

Service transformation will require not only the ability to influence processes, but to change mindsets, cultures, activities, and organisational power bases.

Quote – Albert Einstein

Insanity: doing the same thing over and over again and

expecting different results.

The future for the NHS

• Fit Note instead of a Sick Note- April 2010• All healthcare workers and employers will have to

consider what the worker can do• Maximising functional capacity to be considered as

part of every treatment or care plan and every clinical interaction

• Vocational advice will be offered routinely• Diagnosis, treatment AND Function• Its not just about traditional “work”- its for all ages

Worklessness is the single most important cause of health inequality, social exclusion, deprivation , and mortality

Purpose of policy

Who is affected by the the policy or who is intended to benefit from the proposed policy and how?

How have you, or will you, put the policy into practice, and who is or will be delivering it?

How does the policy fit into our wider or related policy initiatives?

Have the resources for your policy been allocated?