As Scotland emerges from the current pandemic, the future of our health system must be a clear priority. Prior to the pandemic, there were already significant challenges facing health and social care in Scotland. The experience of the last two years has only impacted this further.
The essential challenge for our health service is to meet the increasing demand on health and social care from an ageing population, while maintaining the quality of services and continuing to provide person centred care.
The pandemic placed enormous strain on hospitals and critical care, so much so that staff were redeployed from other areas to support the acute sector. That redeployment meant having to restrict and close access to other services, particularly in primary and community care.
As services recover, Scotland needs a whole systems approach to planning that requires us to look beyond the symptoms, to the causes of service pressure. It is clear that before bolstering services for more ill health, we recognise that healthier communities are the best way to protect the NHS.
The best way to protect the acute sector is to prevent, reduce and shorten hospital admissions.
Happily, what is better for the NHS is also better for us as patients. People don’t want to be rushed to hospital when earlier intervention might have prevented it. People would prefer to stay healthy and live independently than become dependent on health and social care services.
Following an accident or acute episode of illness, people would rather return home for rehabilitation as soon as possible, and gain back their quality of life so they can return to work, or caring, and contributing to society. Scotland needs a thriving community health and social care sector if it is to improve the health of communities, reduce demand on health and social care services, avoid hospital admissions and speed up discharge from hospital.
From GP services and other primary health care professionals through to social care and the voluntary sector supporting and maintaining healthier lives.
For too long, the press and media, politicians, policy makers and commentators, have shaped a narrative that emphasises the NHS around ‘life and death’ – around maternity services and accident and emergency departments, around hospitals and operations and doctors and nurses.
What is too easily overlooked in this abbreviation of healthcare is the journey back to health following an episode of hospital care. It is what is delivered in community settings, by physiotherapists and many other health professionals. Saving a life is critical, but giving people their lives back is the outcome needed.
That is what will allow people to return to work, or community volunteering, caring for others, to live independently in their own home, and enjoy a good quality of life. That is the real story of healthier communities.
It is therefore community rehabilitation that must take centre stage; it is vital in meeting the challenge faced by health and social care because it returns people to health and keeps people healthy. Community rehabilitation ranges to healthcare at home, to supported self-management, to community led services run by local authorities and the third sector.
Let’s take the example of pulmonary rehabilitation as respiratory problems are one of the most common conditions that lead to emergency hospital admission. The right services ensure access to a community health professional who can do a home visit on a Friday to prescribe antibiotics that prevent an ambulance being called on Sunday.
Community rehabilitation provides physiotherapy to help people to learn how to self-manage their symptoms and slow or prevent deterioration. Alongside health professional intervention, pulmonary rehabilitation through local swimming and exercise classes, run by the voluntary sector, and funded by the local authority, ensure someone can enjoy a good quality of life and live independently with far less need for hospital care and social care.
The reality, however, is that this example of joined up integrated provision of rehabilitation from hospital care to living well in the community, is rare.
Community rehabilitation is predominantly provided by allied health professionals, such as physiotherapists, occupational therapists, speech and language therapists, dieticians, and others who are able to assess, diagnose and treat patients, with professional autonomy.
However, NHS staff in community settings say their services are understaffed, and feel their contribution is undervalued and lacks the necessary investment. They consistently report the need for better space, more and better IT equipment, administrative support, and easier access to equipment and materials to support them to do their vital work.
The reason for this is that these services are stratified and there is no clear funding route for community rehabilitation provision which is not captured by primary care or social care budgets. In addition to this, community services are often being delivered in ageing buildings with long waiting times that prevent people getting the service they need when they need it.
The pandemic has only compacted this; it has seen services restricted or closed, leaving many people with long-term conditions to worsen, requiring longer treatment and more complex and intervention – and this is without the additional caseload of Long-Covid patients.
At the last Scottish parliament elections, over 20 service user groups and health professional bodies came together to form the Coalition for Rehabilitation to address the need for radical improvement, and campaign for the ‘right to rehabilitation.’ The campaign drew significant support from the political parties.
However, change will require addressing some of the fundamental infrastructure, funding and decision making that has shaped the current system.
The Coalition for Rehabilitation called for action to improve community rehabilitation through investment in leadership, workforce, and strategy. The Scottish Government published the new rehabilitation framework, and is committed to improving rehabilitation services and providing good rehabilitation. But the right leadership models and funding streams will also be necessary to effect change.
A significant flaw in the current infrastructure is the absence of workforce planning for the allied health professions.
The allied health professions are core to the community health workforce. NHS vacancy rates are at a record high, and yet there is no clear workforce plan to supply the number of allied health professions needed.
But increasing preventative care, reducing GP caseloads, avoiding hospital admissions and promoting healthy communities requires more allied health professionals unable to recruit to the vacancies that already exist. Scottish healthcare must plan for the whole system, and ambitious meaningful workforce planning is essential.
Community rehabilitation cannot remain on the fringes of health and social care plans. Community rehabilitation is not just crucial to peoples’ recovery.
The recovery of our health and social care system will also need improved community rehabilitation at the heart of future strategic planning, otherwise we will continue to be planning for more pressures and worsening ill health.
Kenryck Lloyd-Jones is Public Affairs and Policy Manager for Scotland at the Chartered Society of Physiotherapy