Health and Social Care Committee
Inquiry into residential care for older people
RC34 – The Chartered Society of Physiotherapy
CSP Wales Office
1 Cathedral Road
Cardiff CF11 9SD
029 2038 2429
Committee Clerk
Health and Social Care Committee
National Assembly for Wales
Cardiff Bay
CF99 1NA
December 2011
Dear Chair and Committee Members
Health and Social Care Committee’s Inquiry into Residential Care for Older People.
General Introduction
The Chartered Society of Physiotherapy (CSP) in Wales is pleased to provide a written contribution to this review. The profession would also be prepared to provide oral contribution if requested by the committee.
Key points from the Chartered Society of Physiotherapy
The professional body cannot provide a response to all areas of the committee’s review so have concentrated answers in those areas of the review that are relevant to physiotherapy service provision.
1) The process by which older people enter residential care in Wales and the availability and accessibility of alternative community-based services, including reablement services and domiciliary care.
Physiotherapy services support older people and their families and carers through the care pathway, from living in their own home, to hospital admission, to supported return to living in their own home through to decision making to enter residential/nursing home care. Physiotherapists will be concerned with the individual’s physical capabilities and what they wish to do, how they can function with a particular ability/disability and what support (rehabilitation and equipment) they might need. They are also able to holistically identify cognitive, social environmental and emotional barriers and address these or signpost to appropriate services.
Physiotherapists will be part of reablement teams, may provide bespoke domiciliary services and will be integral to community resource teams across Wales. Physiotherapists, as part of a reablement team, can work with residential home staff to instil an enablement and empowering approach. As older people progress through the care pathway the approach of physiotherapists strives to ensure consistency of care and promotion of independence.
The profession continues to fully support reablement seeing this as a vital element to supporting older people to remain in their own home if they so wish. However, if they decide to reside in a residential/nursing home physiotherapists can still work with individuals and staff to maximise the person’s independence, function and quality of life. The CSP is part of the Wales Reablement Alliance and as part of that group supports the call for five key principles which need to underpin effective reablement services in Wales:
1. Enablement and reablement should be the starting point for all interventions.
2. Reablement improves ability. It must include physical, social environmental and emotional factors to ensure a person’s wellbeing and independence
3. Reablement and rehabilitation are a seamless continuum. Service users should not see boundaries. Easy, direct access to targeted reablement services will help people maintain their skills in the long term.
4. Reablement requires good quality assessment. This is vital to establish the specific goals of the service user and must:
a. Focus on enabling and empowering outcomes
b. Be done in partnership with the individual and their family
c. Determine the content of the reablement service
5. Reablement services require:
a. The active participation of the service user and their family
b. A workforce with an ethos of ‘working with’ people rather than ‘doing to’
c. Integration and collaboration working between health, housing and social services
d. Appropriate collaboration with services provided by the third and private sector
e. Adequate funding to deliver sustainable outcomes
f. Strong leadership of commissioning and delivery
g. A focus on prevention and early intervention in order to avert possible crisis
h. Evaluation which incorporates both social and financial service outcomes
(Wales Reablement Alliance 2011)
Reablement services present an opportunity for health and social care to work in an integrated way and successful services assist older people to maximise their capability on discharge from a hospital admission or following an acute event. However, reablement services provide many challenges.
There are challenges experienced by physiotherapists involved in reablement teams, reported to the professional body, which will need to be improved upon for these services to operate maximally across Wales and provide the best possible person centred care:
· In several areas in Wales, CSP members report examples where there is a range of reablement and intermediate care schemes operating with different names and different acceptance criteria and this is confusing for staff making referrals to the teams. A single point of access would go a long way to solving many of the difficulties that arise when people are faced with who they should refer to. This would need adequate administrative and clinical staffing and training to triage and allocate appropriately.
· Different working practices and conditions of service also impact on service provision. Issues around the requirements for consent, hours of working (7-day or 5-day provision) and cover for bank holidays can create tensions.
· Communication within teams is crucial and where successful reablement models have developed, members report that a shared team base is valuable as is easy access to third sector partners for signposting to additional support.
· CSP members point to the need for better quality and timely referrals from the acute sector when older people are being discharged from hospital. In some examples, there is a move to integrate hospital and reablement posts so there is more seamlessness of service provision from hospital into the community and in other examples, the reablement and intermediate care team members form a ‘virtual team’ with team members sited in a domiciliary physiotherapy team. Wrexham Maelor Hospital in the Betsi Cadwaladr University Local Health Board has successfully developed this model.
· Reablement teams are able to work with older people, their families and carers to maximise function within the time limits of the service model. They provide multidisciplinary team based rehabilitation programmes and place an emphasis on education to optimise any progress made and strive for longevity. Capacity issues arise where people need more extensive periods of rehabilitation, greater than that which can be provided as part of reablement. Availability varies around Wales.
· Physiotherapy service managers also suggest the need to support the skill base of clinicians delivering reablement services and offer the opportunity to rotate into different teams to gain experience. It also allows ward and outpatient based staff the chance to develop experience and skills working in the community setting. However, this is an area of tension with service leads that have managerial accountability tending to opt for static posts.
· The physiotherapy profession plays its part in supporting older people and their families to make decisions about remaining in their own homes or accessing residential/nursing home care. These decisions may be made in hospital, made in the person’s home and can be very difficult and stressful times for older people and their families. It is essential that professionals across health and social care can offer the very best information and support, through which ever medium is most suitable to the person, to help them with difficult choices, and once decisions are made, they should not have to wait for long periods for care packages to commence or for places in care homes to become available.
· The profession backs the development of telecare, telehealth and telemedicine to support community based services. These developments would give older people and their families a peace of mind. They would improve quality of care and access to services and would allow monitoring of patients with long term conditions including the ability to trigger warnings of potential acute episodes. There will be resource implications attached to the provision of telecare and there will be ‘access to IT’ issues within organisations and a range of tensions around sharing information. CSP members report that in one area where a single point of access system is in operation the system does not allow detailed enough information transfer from referrer to receiver and the social care system cannot (presently) communicate with the healthcare system.
2) The capacity of the residential care sector to meet the demand for services from older people in terms of staffing resources, including the skills mix of staff and their access to training, the number of places and facilities, and resource levels.
The CSP recognises the challenges placed on the residential and nursing home sector in terms of meeting the demand for services. These demands may increase in the future where organisations decommission community rehabilitation hospital beds and use convalescence beds in residential homes, supported by of community rehabilitation teams with the ultimate goal of discharge home instead.
The profession argues that the investment made to support people to stay in their own home is critical to the sustainability of the residential/nursing care sector.
People should be able to access rehabilitation at many points in the care pathway. Those receiving care packages, after a while, will likely benefit from a period of rehabilitation which may enable a better quality of life, more independence and the potential for a reduction in the level of care package needed. People in residential or nursing homes also need access to rehabilitation to optimise function, improve quality of life, decrease level of care, even enable discharge home or support transfer back from nursing to residential type care.
The capacity of the residential sector must include the capacity to provide services such as physiotherapy and occupational therapy as part of the care package available to residents. Access to physiotherapy for residential and nursing home residents varies across Wales. Funding for provision of services varies across Wales.
In Rhondda Cynon Taf (RCT), for example, residential homes frequently access physiotherapy services to work with residents to maximise their function, avoid the transition to nursing care and improve function after an acute medical event. RCT also safeguards 4 ‘step up/step down’ intermediate care beds which can be accessed by RCT residents upon referral from health and social care professionals.
In Powys, for example, reablement services work with people in residential homes to maintain independence and regain confidence to facilitate return to their own homes.
In Hywel Dda, for example, instead of having a referral process, a ‘transfer of care’ process is in place for many of the community resource teams. This enables those appropriate people who have an on-going rehabilitation programme in hospital to be continued in the community by support staff without the need to go on to waiting lists and having a new assessment prior to continuing rehabilitation in the community.
3) The quality of residential care services and the experiences of service users and their families; the effectiveness of services at meeting the diversity of need amongst older people; and the management of care home closures.
The CSP has no comment to make in this section of the review.
4) The effectiveness of the regulation and inspection arrangements for residential care, including the scope for increased scrutiny of service providers’ financial viability.
The CSP would like to see increased scrutiny of the range of services provided by residential and nursing homes to include provision of therapy services such as physiotherapy and occupational therapy. The profession recommends a baseline review to determine current provision which would then provide an opportunity to determine gaps and identify areas of good practice.
Access to leisure activities and exercise would also need to be included within the review. Many homes provide a wide range of activities and excursions, whilst some are more limited. Inspection and reporting at a ‘Wales wide’ level would be useful.
5) New and emerging models of care provision.
The CSP has already highlighted the importance of reablement and the use of intermediate care and being integral to the care of older people. There will always be a requirement for nursing and residential care, but every effort should be made to provide services that keep older people independent and confident wherever they may be living.
The committee might find it useful to map out the current provision of reablement and intermediate care facilities across Wales to determine progress by health and social care partners.
6) The balance of public and independent sector provision, and alternative funding, management, and ownership models, such as those offered by the cooperative, mutual sector and third sector, and Registered Social Landlords.
The CSP has no comment to make in this section of the review.
Concluding comment
The CSP hopes the committee finds this contribution useful and looks forward to following the progress of the review. If further information is required please do not hesitate to contact us.
In association with:
The CSP Welsh Board and the All Wales Physiotherapy Managers Committee
About the CSP and Physiotherapy
The Chartered Society of Physiotherapy is the professional, educational and trade union body for the UK’s 50,000 chartered physiotherapists, physiotherapy students and support workers. The CSP represents 2,000 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.
Philippa Ford MCSP
CSP Policy Officer for Wales
029 2038 2429
07990542436
Date