Reablement, Rehabilitation, Recovery: Chapter two - Purpose and context

Introduction

The importance of rehabilitation was highlighted in recommendation 7 of the BGS Blueprint: “Protect and preserve the right to rehabilitation for all older people who need it, in line with the principles outlined by the Community Rehabilitation Alliance.”¹

Rehabilitation (or recovery) is a set of interventions designed to optimise functional ability, social participation, improve health and wellbeing and reduce disability in individuals with health conditions in interaction with their environment.⁵ Due to resource constraints within the NHS, rehabilitation packages are typically time-limited. Interventions include: 

• Holistic assessment considering the social determinants of health and acknowledging multimorbidity
• A personalised rehabilitation treatment plan based on shared decision-making and goal- oriented personalised interventions
• Information, advice and education to build confidence and support self-management and participation
• Medication reviews and advice to ensure medicines are used to optimise rehabilitation
• Structured exercise (one-to- one, in groups, in person or online)
• Support with diet
• Psychological support
• Support with communication, adaptations, assistive technology and digital skills.

A European consensus statement defined geriatric rehabilitation as a multidimensional diagnostic and therapeutic approach which aims to optimise functional capacity, promote activity, preserve functional reserve and social participation in older people with disabling impairments.⁶ A systematic review of 42 European studies of integrated care for older people called for a more (integrated) holistic response, blending a chronic care approach with education, enablement and rehabilitation to optimise function, particularly at times of a sudden deterioration in health, or when transitioning between home, hospital or care home.⁷ 

Comprehensive Geriatric Assessment (CGA), a highly evidence-based approach that combines assessment and multidimensional interventions, tailored to modifiable physical, psychological, cognitive and social factors, improves outcomes for older people and is the cornerstone of an integrated approach to preventing and managing frailty.^8,9 Rehabilitation should be considered a core element of CGA – not an optional add-on.

Rehabilitation is also a key component of proactive care as set out in NHS England’s new framework for proactive care for older people living at home with moderate or severe frailty.¹⁰ Average annual costs of primary and secondary care service are three to four times higher for individuals who have moderate to severe frailty, but overall system costs are highest for people with mild frailty as the largest population cohort.¹¹ Many providers and health and care systems aspire to scale up proactive care for people with all levels of frailty to prevent escalation of health and care needs, delay onset of disability, and reduce demand for emergency department attendance or admission to hospital or care home.¹² Rehabilitation capacity is critical for successful proactive care (sometimes known as pre-habilitation, as detailed in chapter three) and for scaling up intermediate care community alternatives to acute hospital care.¹³ For an individual with deteriorating health and wellbeing, rehabilitation goal-setting may overlap with future care planning or end-of-life care planning. It will be important to recognise trigger points where the goals of care may change, through shared decision-making with the individual supported by those who are important to them. 

State of rehabilitation: Reflection on policy, capacity and access in each of the four nations

BGS members across the UK report differences in access to rehabilitation for older people in their area. Variations range from different provision for reablement and community rehabilitation at home to whether or not older people can access rehabilitation in hospitals or in care homes. 

England 

There is considerable variation in the quality of and access to rehabilitation services across England. There are some key guidance documents targeted at commissioners and providers, which aim to reduce this unwarranted variation. Importantly rehabilitation services need to be given the same level of priority, resource and funding as other aspects of the healthcare system such as urgent and emergency care. Until this happens, Integrated Care Systems will find it challenging to provide consistent high-quality rehabilitation services for their local population, particularly given the multidisciplinary workforce and budgetary restraints many currently face.

NHS England’s Intermediate Care Framework¹³ focuses on intermediate care services delivering rehabilitation following hospital discharge and identifies four key priority areas. Firstly, improving demand and capacity planning with better utilisation of data metrics. Secondly, improving workforce utilisation through new ways of working such as blended roles. Thirdly, implementation of effective multidisciplinary team care transfer hubs. Finally, improving data quality and overcoming the information governance barriers, which often impede this.

NHS England have also published a community rehabilitation and reablement model¹⁹ and NHS RightCare have published a community rehabilitation toolkit.²⁰ Both documents focus on recommendations pertaining to community rehabilitation more generally. Several key aspects of the patient journey are covered including maintaining independence, preventing deterioration, the need for integrated care, the community-hospital interface, adequate workforce, and improving data quality, all of which should incorporate experience of care, timely access to services, and ensuring person-centred care is at the heart of rehabilitation. This should all be underpinned by strong leadership at all levels of the health and social care system to drive the necessary changes in behaviour and culture required for high-quality rehabilitation for all. 

The Community Rehabilitation Best Practice Standards developed by the Chartered Society of Physiotherapists (on behalf of the Community Rehabilitation Alliance) is another useful reference guide in how to run high-quality rehabilitation services.² It neatly describes what the expectations of different stakeholders should be and what is needed to deliver on the key recommendations. These include the patient, clinician, rehabilitation lead, network, commissioner and social care provider. 

In his annual report in 2023, the Chief Medical Officer for England, Professor Sir Chris Whitty, highlights the provision of rehabilitation as a key component of a coordinated treatment plan for older people which should be developed as a result of comprehensive geriatric assessment: ‘CGA is based on the premise that a full evaluation of an older adult living with frailty by a team of healthcare professionals from multiple disciplines may identify a variety of treatable health problems, resulting in a co-ordinated plan and delivery of health care, social care and rehabilitation care leading to better health and wellbeing outcomes.’²¹

Scotland 

The Scottish Government’s Once for Scotland Person-Centred Approach to Rehabilitation²² builds on their earlier Rehabilitation Framework published during the pandemic.²³ The 2022 document sets out six principles that should underpin all rehabilitation services: Easy to access for every individual; Provided at the right time; Realistic and meaningful to the individual; Integrated; Innovative and ambitious; Delivered by a flexible and skilled workforce. While these principles are laudable, there is no clear roadmap for delivery. Healthcare professionals report that rehabilitation services are struggling across Scotland, due to lack of workforce capacity and a backlog of maintenance issues within healthcare facilities. Specialist medical supervision for rehabilitation services for older people has traditionally been provided by geriatricians who are now being redeployed into services such as Hospital at Home, Frailty Units and Perioperative services, along with advanced practitioners from allied health professions and nursing. While these services provide good outcomes for patients who can access them, without a significant increase in staffing, these good outcomes for some patients will be at the expense of adverse outcomes for the increasing number of older people needing rehabilitation. Community rehabilitation services are understaffed and repeated realignments of these services have eroded the previously strong links between primary care and community services. Rehabilitation for older people with frailty is often provided in community hospitals which are impacted by the primary care and community workforce crisis. The ongoing crisis in social care compounds these challenges as older people experience a delay in being discharged from hospital and in starting their community rehabilitation.

Wales 

In 2022, the Welsh Government published the All Wales Rehabilitation Framework: Principles to achieve a person-centred value-based approach.²⁴ This document sets out principles of rehabilitation, using the acronym of WALES:

• Wellbeing – investment in the workforce to provide a holistic, person-centred, needs-based approach.
• Accessible – co-produced services that are equitable and inclusive to all.
• Living happier, healthier, longer – healthy living, prevention, supported self-management and optimisation.
• Everyone’s business – a collaborative whole workforce and stakeholder ethos.
• Sustainable – long term service planning, embracing digital innovation for societal benefit and greener ways of working and living.

This framework is supported by Health Education and Improvement Wales’s community rehabilitation standards, published in late 2023.²⁵ This document provides seven best practice standards designed to improve the quality and experience of rehabilitation: 

1. Co-produced community rehabilitation must be built around the needs of patients and their support network, delivering personalised rehabilitation to ensure people have choice and control over the way their rehabilitation is planned and delivered.
2. Effective rehabilitation adopts a biopsychosocial approach due to the diversity of needs of the person.
3. Effective partnerships and good communication are central to providing seamless rehabilitation in the right place for everyone.
4. Good data is essential to drive improvement in the quality and value of community rehabilitation services.
5. A core part of community rehabilitation is supporting people to stay well, take control of their lives, maintain independence, and support self-management as part of a sustainable health solution for Wales.
6. Rehabilitation services need to be accessible to people when and where they need so that longer term issues can be minimised, resulting in better health and wellbeing for the individual and a reduced burden on society.
7. Rehabilitation requires a motivated, engaged and valued health and social care workforce, with the capacity, competence and confidence to meet the needs of the people of Wales.

BGS members in Wales report that additional resources are needed to realise this vision including a focus on ensuring care is provided in the right setting with rehabilitation starting as early as possible to prevent deconditioning. Strong leadership and an understanding of rehabilitation are needed to ensure that rehabilitation services are coordinated and effective. Without this we risk extending length of stay in hospital, protracting the rehabilitation journey in the community and adding to the care pressure on social services and on friends and families who provide so much of the care at home. 

The Right to Rehab campaign²⁶ in Wales is led by the Chartered Society of Physiotherapy with input from other organisations in Wales interested in rehabilitation. The campaign considers the publication of the above standards as a campaign win, along with investment in the allied health professional workforce for reablement and a ministerial commitment that rehabilitation space lost during the COVID-19 pandemic should be reclaimed or a suitable alternative provided. The campaign is currently calling for consistent delivery of the rehabilitation standards across every health board in Wales, the appointment of a rehabilitation lead in every hospital and the appointment of rehabilitation voices in every Regional Partnership Board to promote integration of services in the community. 

Northern Ireland 

There is currently no national framework guiding rehabilitation services for older people in Northern Ireland. It is therefore up to individual Trusts to determine how rehabilitation is provided. BGS members in Northern Ireland report that all Trusts offer a number of rehabilitation pathways to facilitate discharge for older people. However, chronic staff shortages and competing priorities between acute and community care result in ongoing challenges for Trusts providing rehabilitation for older people with frailty. The lack of gold standard and key performance indicators for general rehabilitation has an impact on budget and resource allocation. All Trusts promote the ethos of ‘home first’, which includes discharge to the individual’s own home including residential homes, with follow-up from an acute assessment team or community rehabilitation team. While this approach is advisable, there is concern that this pathway cannot always meet the needs of patients, particularly those with complex needs or requiring intensive rehabilitation. Community rehabilitation teams often hold waiting lists of two to three weeks to response. Therapy staff are supported by care staff or rehabilitation assistants. However, input can be as infrequent as once a week.

Many acute wards, with the general exceptions of orthopaedics and stroke, struggle to provide responsive rehabilitation and deconditioning is an ongoing concern despite widespread knowledge and local endeavours. Further education and a focus on creating a culture which promotes rehabilitation as everyone’s business is required to prevent the consequences of higher dependency, higher frailty levels and increased rehabilitation resources to support patients to regain function.

Due to inherent pressures within all Trusts, the need to maintain flow continues to influence decision-making for discharge planning and rehabilitation pathways. Unfortunately there is disparity in access to comprehensive geriatric assessment for older people across Trusts. This has been further impacted by decisions to redirect geriatrician input, hence removing geriatricians from a number of rehabilitation inpatient and intermediate care facilities across Trusts. 

There is widespread concern regarding the lack of integrated delirium pathways, and access to suitable rehabilitation environments for patients with delirium and dementia. These patients often have complex needs and take time to rehabilitate. However, decisions to withdraw rehabilitation can be made too early, having a significant impact on quality of life and use of Trust resources. Intermediate rehabilitation facilities are often unsuitable for these patients and as a result, patients can be subject to lengthy waits to access inpatient rehabilitation. They often remain in acute wards and are at high risk of deconditioning and decompensation. Alternatively they may be discharged to interim nursing care facilities which vary in culture regarding rehabilitation and may provide only limited rehabilitation services due to pressures within community rehabilitation services.