This article looks at the way allied health practitioners can support the principles of prudent healthcare. The allied health professions have an emphasis on reablement, recovery, health and wellbeing, through supporting people to live with value and purpose.
There is a danger that healthcare systems create dependency. It is better to enable people to gain control of their own lives, instead. Clinicians across the system need to work more closely together to help people identify meaningful goals and then to achieve those goals. This could mean changes in the way clinicians provide help to people, with a greater emphasis on understanding what matters to the person being cared for.
Meaningful occupations and health
Choosing and taking part in meaningful occupations is a key component of good health, wellbeing and a fundamental human need. Meaningful occupations are those activities we choose or need to do every day. Deciding what we do with each day and our life overall gives us a sense of who we are and purpose and value to our lives. When something interrupts or prevents us carrying out meaningful occupations the loss of this activity can lead to dependency, lack of confidence and depression. Meaningful occupations affect our sense of wellbeing, self-worth and inclusion in our communities and enhance our mental and physical health as well as giving meaning to life.
Reablement, recovery and rehabilitation are well evidenced health and social care interventions which improve or restore a person’s ability to function independently, exercise choice and control over their daily activities. The key elements of each of these approaches are described below. These services are increasingly available across Wales and require health and social care staff to:
- develop a philosophy and attitude which values the person as an individual
- recognise a person’s capacity and ability to recover and rehabilitate from any illness and manage their condition in the long term
- seek to allow the person to recover by enhancing the person’s own inherent resources and capacity to direct their own recovery
- seek to allow the person to retain or develop the skills and abilities they need to do something themselves, rather than relying on it being done for them by someone else.
Principles of prudent healthcare
There is a good fit between the principles of enabling people to live meaningful lives and the principles of prudent healthcare. The principle of doing no harm is fundamental to reablement, recovery and rehabilitation and yet there is also inherent harm in providing interventions. Interventions or treatments may make people dependent on services by reducing their skill, capacity, confidence and independence. There is also a danger that services become focused on safety and preventing risk at the cost of allowing people to live their own lives, in their own way.
Wrapping care around people, protecting them and making them safe may be seen to be the easiest and best approach for staff, but can have the effect of disempowering and disabling people, creating more ill-health and dependence on support and services.
Reablement, recovery and rehabilitation services, including those provided by AHPs, all embody prudent healthcare principles.
Therapists have a long history of working with skilled assistants, carers and support staff to deliver interventions that enable people to recover. They promote active, equitable participation in health based on a co-productive relationship. Close working with third sector organisations is also a feature of AHP practice, especially from those professions based in community and social care settings.
AHPs are composed of distinct professional disciplines, who apply their expertise to diagnose, treat and rehabilitate people of all ages across health, education and social care. In Wales, AHPs include:
- arts therapists (art, drama and music)
- occupational therapists
- speech and language therapists.
Reablement is an outcome-focused, personalised approach, where the person using the service is supported by a multi-professional reablement team to set their own goals and achieve them in a set time period. It focuses on what people can do, rather than what they can’t do. It aims to reduce or minimise the need for ongoing support after reablement. It addresses the needs of the whole person, including physical, social and emotional needs.
There is a growing consensus[1-4] that properly funded and effective preventative services, such as reablement, are in people’s best interests. They can reduce dependence on long-term services and improve health outcomes, restore people’s ability to perform their usual activities and improve their perceived quality of life. Reablement can also deliver substantial cost savings to health and social services, as well as improving the lives of patients.
Reablement makes a difference to people’s lives:
- after receiving reablement services 70 per cent of people in Wales needed no ongoing support
- the Care Services Efficiency Delivery (CSED) programme found 68 per cent of people no longer needed a home care package following reablement and almost half, 48 per cent, continued to be independent two years later
- reablement helps people re-engage with their community when delivered in partnership with communities and third sector organisations
- housing adaptations reduce the need for daily visits and reduce or remove costs for home care, one study reported savings of £1,200 to £29,000 a year
- postponing entry into residential care by just one year by adapting homes saves £28,080 for each person
Reviews of existing care packages by occupational therapists have produced substantial savings. In 50% of cases reviewed, reablement allowed the care package to be removed. In the remainder of cases the care package was significantly reduced.
There is also evidence that loneliness and isolation have a significant impact on people’s wellbeing. Many reablement services now work in partnership with local third sector organisations to ensure that the full benefits are achieved by fully re-connecting and integrating people back into their communities and occupations following hospital admissions or periods of ill-health.
An evaluation of reablement, has been conducted by the Social Policy Research Unit (SPRU) at the University of York and the Personal Social Services Research Unit (PSSRU) at the University of Kent. This controlled prospective study found that people in the reablement group reported better health-related quality of life on all five domains of the EQ-5D (mobility, self-care, ability to undertake usual activities, pain, and anxiety and depression) at follow-up, compared to people in the control group who had received a standard home care service for the same period. The difference was statistically significant.
Effective reablement needs:
- focus on early intervention and prevention
- a positive, enabling, co-productive approach adopted by all
- a workforce with an ethos of working with people, rather than doing something to them
- the active participation of the service user and their family in reablement
- ongoing training for staff
- information and support for families and carers
- integration and collaborative working between health, housing and social services
- strong leadership in commissioning, and adequate funding of services to deliver sustainable outcomes
- evaluation that incorporates both social and financial service outcomes to demonstrate value
- good quality assessment by a practitioner with the right skills and abilities to determine an effective programme.
People can and do recover from severe and long-term mental ill-health. The recovery model aims to help people with mental health problems to look beyond survival and existence. It encourages them to move forward, set new goals, do things and develop relationships that give their lives meaning. It requires staff to also approach their work with the attitude of enabling occupations and giving control and responsibility to the individual. Recovery means different things to different people and should be defined by the person experiencing mental illness. However, for many people it means a way of living a satisfying and meaningful life with mental illness. The Scottish Recovery network defines recovery as ‘Recovery is being able to live a meaningful and satisfying life, as defined by each person, in the presence or absence of symptoms. It is about having control over and input into your own life. Each individual’s recovery, like his or her experience of the mental health problems or illness, is a unique and deeply personal process.’ (Scottish Recovery Network)
Working towards recovery includes hope, acceptance, control, meeting basic needs and promoting meaningful activity. The recovery process:
- provides a holistic view that focuses on the person, not just the symptoms
- believes recovery from severe mental illness is possible
- is a journey rather than a destination
- does not necessarily mean getting back to where you were before
- happens in fits and starts and, like life, has many ups and downs
- calls for optimism and commitment from all concerned
- is profoundly influenced by people’s expectations and attitudes
- requires a well organised support from family, friends or professionals
- requires services to embrace new and innovative ways of working.
Among the evidence of the link between occupation, wellbeing and recovery is evidence showing the importance of good work in promoting good health. The recent AHP Advisory Fitness for Work note is one example of how enabling people to remain in or return to good work can be promoted. It is a key goal of all AHPs to help people to safely remain in or return to work wherever possible.
Rehabilitation can be part of both recovery and reablement approaches, as well as a stand-alone intervention. Rehabilitation – or habilitation for those developing the skills for the first time – is based on the belief that people have skills, abilities and capacities they can use and adapt to allow them to participate in occupations or daily activities with meaning and value for them. Skilled assessment, which uses the person’s own goals to set agreed outcomes, leads to a programme of intervention focused on increasing activity and participation levels.
Through both general rehabilitation and specific programmes such as stroke, cardiac, pulmonary or vocational rehabilitation, AHPs offer an enabling and skill enhancing range of interventions with the key goal of enabling people to live their lives to the fullest.
- A study of Welsh patients with chronic obstructive pulmonary disease found hospital readmission rates could be cut from 33 per cent to just seven per cent through effective rehabilitation and reablement. These interventions also halved the length of hospital stays and reduced the number of GP home visits needed.
- Significant savings can be made by rehabilitation, through the prevention of hospital admission, reduced length of stay and rates of readmission as well as preventing or minimising the use of expensive domiciliary and residential care.
- Studies have also suggested for every £1 spent on preventative services, there is £1.20 gained in additional benefits from savings on emergency bed days; more recent findings point to a return on investment of over three-and-a-half times the cost of social support and home care services.
- Telecare is the use of technology and assistive equipment to enhance independence. The use of telecare services in rehabilitation saves an average of 3.29 hospital bed days per year per person, and a saving of £257 per week per person in care package costs. It results in fewer admissions to hospital and residential care, it gives peace of mind and promotes independence for carers and users, allowing economic independence for carers who can go back to work.
AHPs across Wales, in both profession-specific and in multi-professional services, are radically changing their services to integrate the principles of prudent healthcare. Specific, practical examples from innovative approaches from different professions and different areas of Wales can be found on the Welsh Therapies Advisory Committee website.
Five next steps:
1. Remodelling the relationship between services and individuals
As a starting point, professionals need to listen and understand the things that are important to someone’s life and recognise them as key to their wellbeing. A positive, enabling, co-productive approach by a workforce with a partnership ethos will allow services to move from caring for to caring about. Timely and accessible information and advocacy are essential if the power imbalance between health professionals and service users is to be altered. The outcomes services seek to deliver must also be those valued by the person themselves.
2. Equitable access to reablement, recovery and rehabilitation across Wales.
If prudent healthcare principles are to be met, greater access to services that focus on enabling the person to meet their own health outcomes will be essential. All professionals and managers need to understand that the do no harm principle also means a duty to improve quality of life. This will focus service delivery on making a difference and lead to the understanding that taking an action with someone is not the same thing as delivering an outcome.
3. High quality, skilled assessments that establish individual goals
Assessments by a professional with the right skills and abilities are needed to determine an effective personalised programme for enabling occupation. Assessment allows multidisciplinary teams to activate a reablement plan setting clear objectives and offering an analysis of likely outcomes. These teams could be organised around clusters of practices, with combined health and social care input. In many cases services professionals will need to train and support reablement or care workers to deliver the plan and promote a change in approach, from doing to, to working with. Outcomes must be determined by the person in partnership with a practitioner. The avoidance of risk alone can no longer be seen as a good enough outcome.
4. Further integration of services, in a way that makes sense from the individual’s perspective.
Systems should be configured so that services are able to work together, to help achieve an individual’s goals. A greater value needs to be placed on the roles and skills of everyone in the extended team. We need to work collaboratively. The multi-professional team must work collaboratively as a toolbox of expertise. The right tool (or intervention) can then be selected to match the person’s unique set of circumstances and needs. No one tool is more or less valuable than any other. There is little value, and huge wastage, in having everyone seeking to do the same thing, resulting in gaps and duplications in people’s care. Each practitioner must be supported in understanding and articulating the specific added value they bring to the team, so they do what only they can do. Best practice will demand some common skills so that staff can be prepared to step outside their role when needed by the person and the service outcome. To do this staff skills and expertise will need to be valued and invested in. Funding mechanisms will need to change so services can innovate and be able to do the right thing to address individual needs and problems.
5. Services in the community
Prevention and early intervention through reablement, recovery and rehabilitation have to be seen as the only reasonable and sensible way forward. We need to minimise unnecessary interventions yet be able to escalate when necessary. Skilled practitioners will be needed, to be able to make decisions based on sound judgements in any given situation and backed up by robust systems, staff training and integration in the community infrastructure. To achieve this we will need to change our existing funding patterns and even pool budgets to allow services to refocus on prevention and early intervention and deliver prudent healthcare.
Easy, timely, direct access to targeted reablement, recovery and rehabilitation services will help people maintain ability and independence in the long term. Allied health professions are already committed to this preventative approach. They have the skills and experience to deliver interventions that are person-directed and enabling. They are already able to work as integrators of care, with a range of tools and approaches available to them that allow them to offer new, creative solutions to the increasingly complex needs of an ageing population.
- Better support at lower cost: improving efficiency and effectiveness in services for older people in Wales. Wales: SSIA; 2011.
- Public Health Wales. Submission to Health & Social Care Committee inquiry into residential care of older people; 2011. Available at http://www.senedd.assemblywales.org/mgIssueHistoryHome.aspx?IId=2222
- National Association of Old Age Pensioners of Wales. Submission to Health and Social Care Committee inquiry into residential care of older people; 2011. Available at http://www.senedd.assemblywales.org/mgIssueHistoryHome.aspx?IId=2222
- Care and Social Services Inspectorate Wales & Healthcare Inspectorate Wales. Growing old my way: review of the impact of the National Service Framework (NSF) for Older People in Wales. Wales: CSSIW/HIW; 2012.
- Francis J, Fisher M, Rutter D. Reablement: a cost-effective route to better outcomes. Research Briefing 36. Social Care Institute for Excellence. [Internet]. April 2011 [cited 2014 August 2]. Available at: http://www.scie.org.uk/publications/briefings/files/briefing36.pdf
- Wood C, Salter J. The Home Cure, London: Demos; 2012.
- Position statement on reablement services in Wales. Wales: SSIA; 2013.
- Care Services Efficiency Delivery Programme, Homecare re-ablement workstream. [Homecare reablement] retrospective longitudinal study November 2007. London: Care Services Efficiency Delivery; 2007. Available at: http://eprints.whiterose.ac.uk/73250/1/Document.pdf
- Heywood F, Turner L. Better outcomes, lower costs: implications for health and social care budgets of investment in housing adaptations, improvements and equipment: a review of the evidence. London: Stationary office; 2007.
- Laing & Buisson. Care of elderly people: UK market survey 2008. London: Laing and Buisson; 2008.
- Riverside Community Health Care NHS Trust. The Victoria Project: community occupational therapy rehabilitation service: research findings and recommendations. London: Riverside Community Health Care NHS Trust; 1998.
- The Royal Voluntary Service. Involving older age: the route to twenty-first century well-being [Internet] 2013 [cited 2014 September 11]; Available at http://www.royalvoluntaryservice.org.uk/our-impact/reports-and-reviews/involving-older-age-the-route-to-twenty-first-century-well-being.
- Social Care Institute for Excellence. At a glance 53: Reablement: implications for GPs and primary care [Internet]. 2012 [cited 2014 August 2]. Available at: http://www.scie.org.uk/publications/ataglance/ataglance53.asp
- Rethink Mental Illness. What is recovery? [Internet]. 2012 [cited 2014 August 2]. Available at: http://www.rethink.org/living-with-mental-illness/recovery/what-is-recovery
- Scottish Recovery Network. What is recovery? [Internet] [cited 2014 September 11]; Available at http://www.scottishrecovery.net/What-is-Recovery/what-is-recovery.html
- Mental Health Foundation. Recovery [Internet]. [cited 2014 August 2]. Available at: http://www.mentalhealth.org.uk/help-information/mental-health-a-z/R/recovery/
- UK. Department of Work and Pensions. Health, work and wellbeing – evidence and research [Internet] 2014 [cited 2014 August 2]. Available at: https://www.gov.uk/government/collections/health-work-and-wellbeing-evidence-and-research
- Allied Health Professions Federation. AHP advisory fitness for work report [Internet] 2012 [cited 2014 August 2]; Available at http://www.ahpf.org.uk/AHP_Advisory_Fitness_for_Work_Report.htm
- Chartered Society of Physiotherapy. Physiotherapy Works – Chronic Obstructive Pulmonary Disease [Internet] 2011 [2014 September 8]; Available at http://www.csp.org.uk/professional-union/practice/evidence-base/physiotherapy-works/physiotherapy-works-chronic-obstructiv
- The economic impact of care in the home services. London: Deloitte / British Red Cross; 2012.
- Personal Social Services Research Unit. National Evaluation of Partnership for Older Peoples Projects (POPP) Final Report. London: PSSRU; 2010.
- British Red Cross. Taking stock: assessing the value of preventative support. London: British Red Cross; 2012.
- Barlow J, Bayer S, Curry R, Hendy J, Wheelock A. Telecare Capital Grant in Wales: evaluation of TCG implementation. London: Imperial College London; Available at: www.ssiacymru.org.uk/telecare