Co-ordinated, integrated and fit for purpose: A Delivery Framework for Adult Rehabilitation in Scotland

6. Delivering the vision

The rehabilitation models set out in Chapter 3 and the recommendations outlined above build on the direction of travel set out in Delivering for Health, ¹Changing Lives² and other key Scottish and UK policies to describe a vision of rehabilitation services that:

• reflect individuals' and carers' needs and wants;
• maximise individuals' self-management potential;
• are delivered by competent, effective practitioners working in multi-disciplinary, multi-agency teams which include individuals and carers;
• make best use of the skills of the whole team;
• provide development and career opportunities for professionals;
• maximise community resources for rehabilitation;
• are co-ordinated, integrated and fit for purpose.

The recommendations in this delivery framework and the accompanying models fulfil a specific action from Delivering for Health¹ in focusing on the rehabilitation needs of three target groups:

• older people;
• adults with long-term conditions;
• people returning from an absence from work and/or wishing to stay in employment.

The principles underpinning the delivery framework and models, however, have applicability for rehabilitation services offered to all individuals, carers and communities.

The effective implementation of the models will call on members of multi-disciplinary, multi-agency rehabilitation teams - including individuals and carers and the voluntary sector - to grasp the potential the models present to improve services across all phases of rehabilitation. Professionals, in particular, will need to look anew at the way they design, deliver and evaluate services.

A successful, comprehensive rehabilitation service will require the integration of the acute, transitional and longer-term rehabilitation phases. The National Rehabilitation Implementation Group and the Rehabilitation Improvement Programme will support this approach at national level and Local Rehabilitation Co-ordinators will develop local leadership of integrated rehabilitation services. These key elements of service, as described in the delivery framework, will provide the impetus necessary to secure the transformational change required to deliver the rehabilitation services individuals, families, communities and professionals want and demand.