This chapter introduces the report with a foreword, executive summary and a roundup of our key messages.
Foreword
In spring 2023 we published our Blueprint, Joining the Dots, outlining why investing in high-quality, joined-up care for older people improves outcomes for individuals and their carers, reduces demand for services, increases the resilience of health and social care systems, and delivers economic and societal benefits.1 The Blueprint presents 12 recommendations that will support systems to design effective models of care which deliver value. One of the 12 recommendations is to protect and preserve the right to rehabilitation for all older people who need it, in line with the principles and best practice outlined by the Community Rehabilitation Alliance.2
Our new report takes a deeper dive into this recommendation and presents evidence and examples of rehabilitative approaches designed to optimise recovery and improve the functional ability, health and wellbeing and social participation of older people at home and in different care settings.
In developing this report, the BGS has been pleased to work with a multidisciplinary group of members from across the UK and with our partners from professional bodies and third sector advocacy organisations. The BGS has a wide range of resources to support the development of rehabilitation services for older people. Our 5,000 members represent a range of disciplines and work in roles within acute, primary and community care settings across the four nations of the UK. Members share the same goal – to improve healthcare for older people. We urge anyone involved in the commissioning of rehabilitation services for older people to engage with the expertise of the BGS and its members to help deliver the right to rehabilitation, at the right time and in the right setting, for all older people who need it.
People are living for longer with more complex conditions in older age and often require specialist care from a range of professionals across the multidisciplinary team. Older people access NHS and social care services more than any other age group and demand for such services will continue to grow. But across the UK, health and social care services are currently failing older people. Changes are needed across the system to address the problems of sub-optimal care for older people. One key element of this is the provision of timely, high-quality rehabilitation which is essential to improving outcomes on both an individual and system level.
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Professor Anne Hendry |
Professor Adam Gordon BGS President |
Executive summary
The case for investing in services to prevent and manage frailty is set out in the British Geriatrics Society’s Blueprint.1 Frailty is not an inevitable part of ageing, and putting in place measures to prevent or delay its onset or progression should be a priority for every health system across the UK.
Those measures include investment in well-designed rehabilitation services that enable people to live independently for longer and achieve what matters to them, and helping to reduce demand for emergency care and long-term support. The aims of rehabilitation will vary depending on the individual. However, generally rehabilitation refers to supporting somebody to recover after a period of ill health. For some older people this will be a full return to the level of health they had before becoming ill (referred to as ‘return to baseline’) while others will not make a full return to their previous health state.
Many older people are currently excluded from rehabilitation services because of restrictive access criteria, limited capacity or postcode lottery of provision.3 Systems must act now to address this inequity.
As an essential component of virtually all healthcare for older people, rehabilitation should be integral to care plans in all settings, including long term care.
Rehabilitation should start as soon as possible after the onset of illness and has a role in preventing further decline. Rehabilitation improves lives. Older people themselves report that they value the independence and autonomy that rehabilitation provides and the feeling of being stronger and preventing future injury. Every older person can benefit from rehabilitation in some way and chronological age alone should never bar access. Timely rehabilitation, when needed, is a right for every older person.
Rehabilitation for older people should involve healthcare professionals from across the multidisciplinary team and across acute, primary, community and social care. There is no ‘one size fits all’ model for rehabilitation. It must be integral to the holistic care that supports older people to live well at home, and be personalised to their situation and priorities. Rehabilitation should be viewed as a continuum of reablement, restorative and recovery approaches, not a separate service. These approaches must be a key component at every stage of health and care for older people at each of the touchpoints outlined in the Blueprint (see illustration, right):
- Enabling independence, promoting wellbeing through physical activity and participation
- Proactive care and early intervention using population health approaches
- Integrated urgent community response, reablement, rehabilitation and intermediate care
- Frailty-attuned acute hospital care that promotes recovery and prevents deconditioning
- Reimagined outpatient and ambulatory care in community hubs and multidisciplinary clinics
- Enhanced healthcare support for long term care at home and in care homes
- Co-ordinated, compassionate end of life care integrating principles of palliative, geriatric, and rehabilitative medicine.
The main focus of this report is rehabilitation for older people experiencing frailty or loss of function because of acute illness or exacerbation of a chronic health condition. We welcome the wide range of specialist rehabilitation services for specific conditions such as stroke, cardiorespiratory conditions, brain injury, neurodegenerative disease or polytrauma. We also acknowledge the role of rehabilitation to support people adapt at the end of their life.4 However, we do not focus on these types of rehabilitation in this report.
Throughout this document, we highlight evidence, call out myths to be challenged, signpost examples of good practice and offer tips for designing good-quality age-attuned rehabilitation for older people as a critical investment in both improving wellbeing and reducing future dependency.
The report will be of interest to our members and to senior decision makers who are planning and commissioning hospital or community services which respond to acute illness or injury and support recovery for older people.
Key messages
Throughout this resource, we identify 12 key messages for health and care systems to deliver effective and integrated rehabilitation as a right for all older people, wherever and whenever they need it.
The case for rehabilitation
1. Systems should invest in rehabilitation as a priority for more sustainable care. Rehabilitation for older people improves lives, delays escalation of dependency, reduces demand and costs for readmission to hospital and avoids premature long-term care.
2. Rehabilitation is an essential component of virtually all healthcare for older people and should be integral to care plans in all settings: at home, in hospital, ambulatory care, care homes and hospice.
3. Every older person can benefit from rehabilitation in some way: age alone should not bar access. The approach, intensity and pace of rehabilitation should be flexible and may need to be adapted for people with delirium, dementia, depression, sensory or communication impairments.
4. The business case for rehabilitation in older people is compelling. Future research should address the evidence gaps around older people who have been excluded from studies due to cognitive impairment or socio-economic or cultural inequalities.
Practical provision of rehabilitation
5. Most rehabilitation is delivered in the community. Rehabilitation at home allows a clearer focus on practical, real-life goals. These goals should be based on ‘what matters to me’ conversations and include the ability to take part in activities that the individual enjoys.
6. Older people with acute illness decondition rapidly so need rehabilitation to start as soon as possible – healthcare professionals should not wait for a crisis to pass before providing rehabilitation at home, hospital or care home. All staff in all care settings, including acute and virtual wards, should prevent older people deconditioning by encouraging mobility and offering early active rehabilitation.
7. Relational and informational continuity and coordination of care are the essence of person-centred integrated care. Older people should have a personalised care plan that addresses their rehabilitation needs and is contextualised to their health trajectory, social circumstances and cultural norms. This plan should be iterative, following the patient across transfers of care, and promote continuous enablement as their needs change.
Building capacity and capability
8. Rehabilitation is a multi-agency endeavour involving many health and social care disciplines, voluntary sector, volunteers, unpaid carers, housing and community leisure services. Systems should work with all partners to offer rehabilitation for older people as a key component of health and social care within age-friendly communities.
9. Rehabilitation is everyone’s business – older people themselves, carers and all health, social care, housing and voluntary sector workforce need to understand how to motivate and support enablement in later life. Systems should work with education providers to support everyone involved to work together and at the top of their licence to increase collective capacity for reablement and rehabilitation for older people.
10. Rehabilitation needs the appropriate space, equipment, facilities and IT infrastructures, including access to care records that can be shared across providers in all care settings. Systems should commission a menu of options from a range of partners in environments that are fit for purpose. Services should be of sufficient duration to enable older people to achieve their social goals as well as undertake activities of daily living at home.
11. The quality of rehabilitation services should be monitored, tracking changes in health and functional outcomes, patient and carer experience, and considering coverage and cost-effectiveness. This intelligence should be used to continually improve services. Quality indicators should acknowledge personalised goals and outcomes, and that delay of further functional decline may be a more realistic outcome than recovery of independence for people who have progressive life-limiting illness or are at the end of life.
Leadership
12. Senior leadership is critical for a strategic and sustainable approach to planning and delivering rehabilitation for older people. Systems should identify a senior officer or non-executive Board member with a specific role in assuring equitable access to rehabilitation attuned to the needs of older people and continually improving the quality of services delivered.
