Future Vision of Rehabilitation Services What do we need to do to meet the challenge? A Delivery Framework For Adult 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 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 MRI Health 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 Workstreams Dimensions of qualityMusculoskeletal re- design Older peoples pathway Vocational rehabilitation Person centred Self referral Shared responsibility Supported self management (working backs website and MKN) Supported self management Self referral Shared responsibility Supported self management Safe Evidence based triage Integrated MSK team delivering service Evidence based risk assessment screening for falls risk in a variety of settings Evidence based triage Case management approaches Effective Increase conversion rate to surgery to 80% Reduce unnecessary investigations and prescriptions Reduce admissions Reduce attendances to A+E Reduce 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 out No queue National roll out Timely Early interventionFocus 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 Community AHP MSK Services Integrated MSK Team Physiotherapy Podiatry OT Dietician Prosthetics Radiography Specialist nurse GPwsi 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

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