CSP Wales Office

1 Cathedral Road

Cardiff CF11 9SD

029 2038 2429

www.csp.org.uk

 

Date 12/01/22

 

Dear Colleague

 

Re:  Health and Social Care committee, written Evidence for patient discharge inquiry

 

 

The CSP welcomes this opportunity to respond in writing to Health and Social Care committee request for our views patient discharge.

Our written briefing compliments the principles in ‘A Healthier Wales’ and, the stated aim of the Welsh Government, to “whole system approach to health and social care, which is focussed on health and wellbeing, and on preventing illness.” 

Thank you for providing us with an opportunity to highlight the current state of play in patient discharge services, while offering comment on specific areas which we see the physiotherapy and the profession making a positive contribution to better patient outcomes.

 

 

Discharge and waiting time link

 

Waiting times and discharge times are interlinked, and physiotherapy waiting times relate strongly to discharge from other services such as orthopaedics.  When a patient is discharged from hospital, physiotherapy is key in meeting the rehab needs of the patient, ensuring effective outcomes and reduction in relapses of the condition they were treated for.  Rehab is key for effective discharge and every patient in wales should receive a consistent service.  The priority in recent years is to deliver as much of this at home and in the community as possible. 

 

Physiotherapy waiting times are linked to the number of patients being discharged from hospitals. The increase in physiotherapy waiting times reflects the increase in patients being discharged as they move through the treatment pathways. 

 

We hear from our members that the workforce issues in social care has an impact on discharge and the length of stay of patients in hospital. 

 

Right to Rehab

The Right to Rehab is about creating the expectation that patients and citizens in Wales should have rehabilitation services as a matter of course. It’s about the delivery of rehabilitation services to everyone that needs it. It complements the Healthier Wales strategy and does not require legislation, just a commitment to delivery of rehab services.

Rehabilitation helps people do more than just survive their condition – it helps them really live. It is vital to people living with long-term physical or mental conditions or recovering after an accident, operation or illness, in order they can live as well - and as independently - as possible.

In most cases people’s rehabilitation will require a period of intervention by health and social care professionals. It will also often extend beyond that treatment and into long-term support within communities. At that point rehabilitation can take many forms, and is determined by people’s needs and their goals.

 

Currently these needs are not being fully met: while there are excellent examples of rehabilitation, it is not consistently available. Services are not joined up between acute, residential and home settings, so people can easily be lost to the system. Where people can access services, they often have to wait too long, usually at just the time when rehabilitation would be most effective.

Without the rehabilitation they need, people are at risk of readmission to hospital, likely to need repeat visits to GPs, need additional care from their family or providers, and may struggle to return to work or live their lives to the full.

 

Multi-disciplinary working (MDT)

Effective discharge usually delivered by multi-disciplinary teams.  The CSP can provide examples of good multi-disciplinary working that has been accelerated during the pandemic.  As ever, the issue is cross Wales learning and consistency of delivery. 

 

Patients can be broadly categorised into 4 main groups, and require different levels of rehab on discharge.  

 

1)         Acute Covid patients who need considerable rehab due to the virus, including long Covid.

2)         People who have not received treatment during the lockdown but will enter the health system when it’s safe, currently self-managing their conditions.

3)         Patients who are entered the health care system late, having missed early diagnosis or waited longer for treatment.

4)         People who have deconditioned during isolation.

 

All these groups of patients have become more complex, both medically and socially.  There is less support available in the community and therefore the burden on the health and social care services has increased. 

 

Our members tell us that many more patients are accessing self-managing resources. The increase can be seen in patients who are digitally aware and with high engagement with their health services. However, his type of resource cannot cover all patients, particularly those with no digital skills or in digital poverty.

 

Physiotherapy capacity

In short, Physiotherapy services are stretched at capacity, even after adapting services to increase the number of patients self-managing and getting advice virtually. Our main concern is that physiotherapy services are at capacity, before everything has come back to full throughout the healthcare system.

 

Examples of good adaptation are the increased use of self-management resources available, including dedicated websites such as “keeping me well” in Cardiff and the Vale Health Board: https://keepingmewell.com/what-is-physiotherapy/what-is-musculoskeletal-out-patient-physiotherapy/ . As mentioned above, these resources assist a great many people, but cannot be a catch all.

 

Loss of space and moving to virtual

Loss of space in hospitals is effecting ability of physiotherapists to see patients face to face. Rehab spaces in hospitals were commandeered during the pandemic, sometimes for non-clinical use, and it’s proving to be difficult to get them back for clinical use.

While we support the move to community service delivery, there is still a need for space for patients to rehab before discharge.  For example, space to rehab a stroke patient before discharge is vital to get them in a safe condition to be discharged. Where dedicated space is no longer available the rehab is being delivered at the bedside.

 

Examples of space lost include:

• Hydrotherapy pools still closed
• Gyms taken for PPE storage
• Ward rehab space
• Staff wellbeing areas not returned

 

On discharge patients should be able to pick from a menu of services, including face to face or community activities.  While we support the increase in virtual provision, being virtual is not as time saving as may be perceived. Often, digital set up with a patient takes more time, while virtual engagement is one –to-one, and is more time consuming for the staff than delivering community classes or

 

Innovation in the way of joint working in leisure centres is welcome, although has become a challenge. As many of the centres are used as vaccination centres and therefore the space isn’t available to deliver in the community.  Discharge of patients and avoiding readmission is most effective when rehab services work with NERS to continue the benefits of exercise and rehab.  This has been a challenge for local authorities during the pandemic and we hope this can be addressed longer term. 

 

 

 

Increased use of prehab

Prehab has the benefits of preparing patients for their treatment and increasing the outcomes on discharge. As an example BCUHB has engaged joint approach Rehab Ltd to offer prehab to long wait knee patients:

 

“This will be a collaborative piece of work delivered by BCUHB and Joint Approach Rehab Ltd. The pilot will first align a prehabilitation programme to the needs of long waiters on the stage 4 (waiting over 52 weeks) knee orthopaedic pathway. For the identified cohort of long waiters, an innovative technological solution to prepare patients for surgery will be delivered, promoting independent management of their condition in their home environments. It will include evidence-based education and exercise programmes combining expertise from Physiotherapy, Psychology, Nutrition and Strength and Conditioning in a single integrated package. The information within the programme will enable patients to personalise their approach to their pre-habilitation and transform the way in which BCUB prepare their patients for arthroplasty surgery.”

Source BCUHB FOI response to the CSP and Versus Arthritis Cymru.

 

Innovative models such as this should be commonplace across Wales and will increase the number of patients being discharged successfully without further need for treatment. 

 

General Multi morbidity rehab services

Many patients have comorbidities requiring several types of rehab on discharge.  This multiplication of service requirements could be streamlined by providing multi-morbidity rehab services, allowing one waiting list and one point of contact for the patient being discharged.

 

Evaluation

At some point an evaluation of the changes made in the pandemic will show whether changes to virtual working improved outcomes for patients. The necessity of change at the time is recognised by the CSP, however taking stock of the long term changes to service delivery is becoming increasingly important as time goes on.

 

Increased presence of Physiotherapist and AHPs in primary Care

After discharge and rehab patients will generally wish to self-manage their conditions using resources and occasional expert advice. The most convenient and accessible location for further advice is in primary care.  Increasing the workforce in this setting over the longer term will benefit the wider health service and help in the preventative side of health care.

First Contact Practitioners already work in primary care, and are trained to an advanced level to be the first point of contact for a patient in a GP surgery.  Many have been funded on transformation or pilot project money across Wales.  A more consistent and sustainable funding source would expand this workforce and provide GP surgeries with advanced practice skills.  Investing in this workforce will alleviate pressures elsewhere, including readmissions.   

 

 

 

The Chartered Society of Physiotherapy is the professional, educational and trade union body for the UK’s 58,000 chartered physiotherapists, physiotherapy students and support workers.  The CSP represents 2,400 members in Wales.

 

Physiotherapists use manual therapy, therapeutic exercise and rehabilitative approaches to restore, maintain and improve movement and activity.  Physiotherapists and their teams work with a wide range of population groups (including children, those of working age and older people); across sectors; and in hospital, community and workplace settings.  Physiotherapists facilitate early intervention, support self management and promote independence, helping to prevent episodes of ill health and disability developing into chronic conditions.

 

Physiotherapy delivers high quality, innovative services in accessible, responsive and timely ways.  It is founded on an increasingly strong evidence base, an evolving scope of practice, clinical leadership and person centred professionalism.  As an adaptable, engaged workforce, physiotherapy teams have the skills to address healthcare priorities, meet individual needs and to develop and deliver services in clinically and cost effective ways.  With a focus on quality and productivity, physiotherapy puts meeting patient and population needs, optimising clinical outcomes and the patient experience at the centre of all it does.