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SIGN decision support

Service organisation

Managing the long-term effects of COVID-19 (SIGN/NICE/RCGP)
Healthcare Improvement Scotland

Rationale

The limited evidence described different models of rehabilitation services. The panel agreed that some of the common elements, such as integration and multidisciplinary team working, would help provide effective, well-organised care for people with ongoing symptomatic COVID‑19 and post‑COVID‑19 syndrome.

Because symptoms are so wide-ranging, many other areas of expertise could also be added as needed and examples of these have been added for the November 2021 update as an additional remark to the recommendation.

As well as ensuring the right breadth of expertise, having a multidisciplinary team with input from other services and clear referral pathways can help prevent disjointed care and people waiting a long time for appointments with multiple specialists. This was supported by the patient experience evidence, which described the challenges of getting support for such a wide range of symptoms and a lack of co-ordinated care.

The panel agreed the core expertise that a multidisciplinary team could include. Because symptoms are so wide ranging, many other areas of expertise could also be added as needed, for example rheumatology, neurology rehabilitation, cardiology, paediatrics, dietetics, speech and language therapy, nursing and pharmacy.

Different regional and geographical challenges meant that areas have different service needs and resources, so the panel agreed that one model would not fit all areas. However, the panel agreed a multidisciplinary service for assessment could avoid multiple referrals and would provide a single point for care. This could be a ‘one-stop’ clinic to help keep appointments to a minimum, although this might not be feasible for all services or wanted by all patients.

Based on their experience, the panel wanted to encourage different services to share knowledge and expertise with each other, to help expand the choice of tests and interventions available in the community. This could be done through local clinical networks or clinical hubs.

Recommendations

  Provide access to multidisciplinary services (these could be one-stop clinics) for assessing physical and mental health symptoms and carrying out further tests and investigations. They should be led by a doctor with relevant skills and experience and appropriate specialist support, taking into account the variety of presenting symptoms.

  Provide integrated, multidisciplinary rehabilitation services, based on local need and resources. Healthcare professionals should have a range of specialist skills, with expertise in managing fatigue and respiratory symptoms (including breathlessness). Additional expertise may be needed depending on the age and symptoms of the person. The core team could include, but not be limited to, the following specialist areas:

  • occupational therapy
  • physiotherapy
  • clinical psychology and psychiatry
  • rehabilitation medicine.

Other areas of expertise could also include, but are not limited to, rheumatology, neurology rehabilitation, cardiology, paediatrics, dietetics, speech and language therapy, nursing, pharmacy, social care and support to return to education or work or usual activities
  Share knowledge, skills and training between services to help practitioners in the community provide assessments and interventions, such as 1-minute sit-to-stand tests and breathlessness training.
  Agree local, integrated referral pathways between primary and community care, multidisciplinary rehabilitation services and specialist services, multidisciplinary assessment clinics (where available) and specialist mental health services.
  This content is derived from the Scottish Government's Implementation Support Note.

The 2018 General Medical Services Contract in Scotland sets out the role of GPs as expert medical generalists, who are of particular importance in supporting and managing people with undifferentiated presentations especially in the context of multi-morbidity and complexity.

It establishes that GPs will lead and be part of an extended multidisciplinary team of primary care professionals (including but not limited to physiotherapy services, community mental health services and community links worker services). The practice will act as a patient gateway to ensure that people can access the right care.