Response to the Health, Social Care and Sport Committee Inquiry into Primary Care
From the College of Occupational Therapists
The contribution of occupational therapy to primary care and the wider multi professional team
1. “A fantastic resource that has been greatly underused by primary care but that is where they should be based....The occupational therapist manages frailty issues much better than me! An experienced Occupational therapist working directly in our practice [has] prevented unnecessary admissions for patients through the prompt review… often on the same day. It has reduced the number of times some patients were calling for a GP visit thus better utilising the GPs time. It has been a signposting service ensuring that the most appropriate member of the multidisciplinary team sees patients; it has also enhanced use of the third sector services. The occupational therapist has provided a wealth of experience, expertise and knowledge to the practice that was either unknown or under-utilised” (GP, Argyle Medical Group, College of Occupational Therapists 2016)
2. Occupational therapists can make an important contribution to the primary care work force (Donnelly et al 2014). A ‘clear fit’ has been identified between the holistic, health promoting nature of occupational therapy and primary care (Donnelly et al 2013, p1). Occupational therapists recognise the importance of meaningful activity/occupation in promoting mental and physical well-being. They are skilled in assessing the impact of developmental, physical and mental health conditions on a person’s ability to participate in activities that are important to them, and in devising intervention plans that facilitate occupational engagement. The College is a member of the Ministerial Taskforce on Primary Care and has been pleased to be able to raise the issues in this paper at that forum.
3. The challenges facing health services include ageing populations and increasing numbers of patients with long-term conditions and complex multi-morbidities (Royal College of General Practitioners 2013). Occupational therapists can support the work of General Practitioners (GPs) by offering proactive input to help people manage their conditions, stay as active as possible and continue with their daily lives and help prevent an acute episode from happening. They work in partnership with other professionals and local agencies to help respond to crises and prevent unnecessary hospital admissions.
4. The need for integrated care that empowers people to take control of their own health and wellbeing (Royal College of General Practitioners 2015) is widely recognised. The College of Occupational Therapists (2015) ‘Evidence Fact Sheet’ demonstrates how occupational therapists make a valuable contribution to GP services including:
I. Health promotion. Address a range of health issues, for example, through promoting healthy lifestyle choices (Lambert et al 2010), facilitating engagement in fulfilling and meaningful occupation (Moll et al 2015) and pproactive health promotion.
II. Empowering service users to manage their health conditions. Individual or group intervention to help people with mental or physical health issues cope with their condition within the context of their daily lives. For example, individuals with panic disorder (Lambert et al 2010), chronic obstructive pulmonary disease, diabetes (Donnelly et al 2013) or persistent pain (Carnes et al 2010).
III. Enabling people to function at home/within the community and to achieve personalised goals. improve service users’ independence and functioning, for example as part of a reablement service (Littlechild et al 2010).
IV. Contributing to the provision of integrated primary care. provide person-centred support for people with long-term or complex health and social care needs.
V. Promoting social Inclusion/community engagement. individual, group or community intervention for people at risk of isolation, for example people with mental health difficulties (Smyth et al 2011), older people (Mulry and Piersol 2014) and people living with dementia (Teitelman et al 2010.
VI. Maintaining/improving the health and mental wellbeing of older people in primary/residential care. The National Institute for Health and Care Excellence (2008) recommends that older people are offered group or individual sessions to facilitate engagement in daily routines and activities to maintain/improve health and wellbeing. Occupational therapists should be involved in ‘the design and development of locally relevant training schemes for those working with older people’ (National Institute for Health and Care Excellence 2008, p9).
VII. Vocational rehabilitation. Help people to stay in or return to work, including provision of the ‘Allied Health Professions Advisory Fitness for Work Report’ (Allied Health Professions Federation 2013).
VIII. Fitness to drive. assessing fitness to drive and, when appropriate, enabling individuals to continue to drive (Hawley 2015).
IX. Prevention of falls/other injuries. Home hazard assessments (National Institute for Health and Care Excellence 2015) and interventions to optimise functional activity and safety (College of Occupational Therapists 2015c). Falls prevention initiatives for at risk patients (Mackenzie et al 2013) and recovery intervention if a fall has occurred.
X. Preventing unnecessary hospital admissions. In partnership with other professionals such as paramedics, to help people remain safely at home and prevent unnecessary hospital admissions where appropriate by immediately intervening to avoid transfer to hospital.
Further detail, cost benefit examples and all above references are at: https://www.cot.co.uk/sites/default/files/commissioning_ot/public/GP-services-2015.pdf
The shift to primary prevention in general practice to improve population health outcomes and target health inequalities.
5. It is evident that where occupational therapists have been working in primary care there is a reduction in emergency admission rates (College of Occupational Therapists 2016). Proactive support for people in their communities helps to improve population health and reduces the costs associated with ill-health. Occupational therapists are active health enablers, focused on what matters to the person so that they can help them to participate in the occupations they need, want or are expected to do. They understand the significant impact that occupations and daily living routines have on peoples’ health and wellbeing and their intervention enables people who are frail or who are living with chronic conditions to continue with daily life.
6. As primary care teams start to access occupational therapy for the first time across Wales, they are beginning to realise the true potential of this workforce. The role of occupational therapists in reducing the pressure on primary care is being recognised, as demonstrated in “Reducing the Pressure of Hospitals: A Report of the Value of Occupational Therapy in Wales” (College of Occupational Therapists 2016).
7. In the Argyle Street Primary Care Practice in Pembroke Dock, the occupational therapist delivers an alternative, proactive model of care for identified frail, older patients. A wide range of occupational therapy interventions are required including rehabilitation programmes; assistive aids and home adaptations; advice; enabling techniques; supporting self-management of conditions; working with people to facilitate change; and engagement with other services. Placing an occupational therapist in the surgery:
• Reduced demand on general practitioners and repeat visits by addressing and resolving underlying issues that are the root cause of multiple and regular contacts
• Released GP, practice and community nursing staff time, enabling them to focus on doing what only they can do
• Proactively resolved health and social issues at an early stage, minimising crisis situations that result in presentation or admission to the acute hospital: 14 patients avoided an acute hospital admission
• Sustained people at home following discharge from hospital
• Reduced falls, improved safety and confidence, enabling people to engage in daily life: 81% of patients who had fallen reported increased safety and confidence in their ability to undertake everyday activities: 12/13 patients reported no falls in the four weeks following occupational therapy intervention.
8. In Heathy Prestatyn Iach the occupational therapists work with people who have anxiety /depression or chronic disease as well as frail older people. Intervention and therapy include: social prescribing and signposting, helping to navigate through available support as well as delivering personal goal oriented brief interventions, Expert Patient Programmes such as COPD, anxiety, diabetes and other condition specific programmes. There is a partnership with Job Centre Plus and Public Health Wales to help people back to work. The occupational therapist often coordinates care across all sectors and within the practice. These interventions help reduce GP contact time and repeat attendances, as well as enabling people to increase their ability and quality of life. Locating occupational therapists in primary care allows both rapid response to acute crises and proactive action to prevent acute episodes. This proactive intervention is vital given the increasingly complex issues being managed in primary care .This new service is being evaluated and initial findings are showing positive effect, with patient’s not returning to the practice with the same compliant
Working with Clusters and Health Boards
9. The College has had little direct engagement with clusters, which are more likely to interact with our members in their services. The publication of the primary care workforce plan with the clear statement from Welsh Government that therapists should be included as part of the wider team has increased the interaction with services across Wales. However, the different rates of development and maturity, coupled with the different ways in which clusters work, has made it difficult to identify the correct links and routes to inform clusters about the potential value of the occupational therapy contribution.
10. Occupational therapists employed in Health Boards are frequently and commonly working in community resource teams (CRT) across Wales as proposed in “Setting the Direction” (Welsh Government 2010). They are also members of other Health Board frailty, community mental health, learning disability, reablement and community rehabilitation teams as well as local authority locality teams and even integrated teams. Occupational therapists are also employed as primary care mental health practitioners to great effect. This plethora of community based services dissipates the resource of occupational therapy and diffuses its impact.
11. The ways in which CRTs interact with and provide multi-professional services for primary care is variable. As this quote from one occupational therapists identifies, the staff relocated to CRTs are in, but not part of, primary care: “within frailty teams we are already working in primary care but I don’t think we are always viewed as part of the primary care team & are often based away from other primary care services”
12. The clear finding of the Pembroke Dock Project identified above was the difference that reliably timely response makes to the value of the occupational therapy intervention. The delay in accessing services which have different priorities and timescales makes them less than useful to GPs and primary care practices as they do not respond quickly enough. “Having an occupational therapist attached to the practice has many benefits. Most of the referrals need quick turnaround as the problems are acute. The saving in social admissions [and] improved self-confidence for patients and families has already been noticed. The occupational therapist is able to respond appropriately in that 24hr period instead of the several weeks previously.”
It is only when the GP can be assured of a guaranteed rapid response that this is a viable alternative to hospital admission or calling an ambulance.
13. Our members identify that they are frequently part of planning conversations about embedding occupational therapy services in primary care, but the two routes of funding, via clusters or health boards can sometimes create complexities which delay improvements and innovation while decisions are taken over which budget should pay for it. These confusions and variabilities do not assist in making the best use of the occupational therapy workforce and neither are they conducive to person centred, well integrated care. There are now a number of different models across Wales where occupational therapists are working in primary care practices. This variability may meet local needs, but Health Boards need to agree the funding route and whether this is cluster funding or Health Board Primary Care Directorate funding.
Workforce challenges
14. Effective multidisciplinary, early intervention and preventative services require the right workforce and skill mix. Prudent Healthcare demands that staff do only what they can do and work to the top of their skillset. Ensuring occupational therapists are part of the wider primary care workforce will provide optimal access to their expertise in goal-setting and practical problem-solving in respect of barriers to independent living, in order to enable people to manage their own conditions and health and social care needs at home.
15. Occupational therapists are educated and qualified to work in any setting and under a generalist practice model: in mental and physical health services and with people of all ages They are the only Allied Health Professional to work in the NHS, Local Authority housing and social services departments, schools, prisons, voluntary and independent sectors, as well as vocational and employment rehabilitation services.
16. Current employment patterns have tended to drive practitioners to specialise as they increase their expertise. While new roles are enabling our workforce to develop expertise and a career in generalist roles, working in complex community settings requires an experienced level of practice and potentially some training/ development. There is potential as the service becomes more established and supported that second/ subsequent posts could allow wider skill mix. This will support learning and succession planning into the role
17. There are insufficient posts in primary care for occupational therapists to move into. New posts need to be created. Many of these, certainly in the short term, could come from re-designating/ re-locating existing workforce capacity. The main reason for this is that a significant proportion of existing posts already work with the same patient population. The experience around Wales at the moment is that when posts in primary care become available, occupational therapists are eager to fill them as working in primary care allows the effective employment of the profession’s philosophy and interventions to maximise citizen’s independence.
18. The College, in partnership with service managers across Wales, recommend that to make the most effective use of the existing workforce and deliver outcomes for citizens, Health Boards should remain the employers of occupational therapists and use service level agreements or commissioning arrangements to embed them into primary care. Employing the workforce in this way will enable occupational therapists to remain part of a wider workforce and career pathway. It allows access to professional governance, supervision and professional development, staff training and management for staff; to participate in other professional activities such as student learning, and meet the demands of Professional Registration. It also allows quality assurance of the quality of practice and enables cover for leave, sickness CPD time and skill demands and recruitment challenges for small or rural practices. This model also ensures access to existing community services such as integrated community equipment and adaptation services.
19. There are increasing demands for occupational therapists and Wales will need to consider how to train enough occupational therapists to meet that growing demand. This will need to include more Welsh speaking/ bilingual practitioners than at present.
Conclusion
20. As shown in the College’s Report “Reducing the pressure on hospitals A report on the value of occupational therapy in Wales” (College of Occupational Therapists 2016) making more effective use of the existing workforce, in a more integrated manner would both improve lives and save money; enabling occupational therapists to become more embedded in primary care and responsive to the needs of citizens and GPs. The profession has a significant contribution to make in primary care, but the posts need to be established, either through relocation and use of the existing workforce, or in new posts. Greater coherence and clarity of services through primary, social care and community secondary care services in a single person centred approach will deliver both improved lives for citizens and make best use of public resources.
21. Please do not hesitate to contact the college via the Policy Officer for Wales at the address below for any further information.
Ruth Crowder, Policy Officer Wales, College of Occupational Therapists, P.O. Box 4156, Cardiff, CF14 0ZA, XXXXXXXXXXXXXXXXXXXX
References
College of Occupational Therapists (2016) Reducing the pressure on hospitals A report on the value of occupational therapy in Wales. London. COT (available at http://cotimprovinglives.com/campaign-reports/
Reducing the pressure on hospitals A report on the value of occupational therapy in Wales-English
Reducing the pressure on hospitals A report on the value of occupational therapy in Wales-Welsh)
College of Occupational Therapists (2015) The Contribution of Occupational Therapy to GP Services. London. COT (available at https://www.cot.co.uk/sites/default/files/commissioning_ot/public/GP-services-2015.pdf)
(NB all other references are in this document)
Welsh Government (2010) Setting the Direction: Primary & Community Services Strategic Delivery Programme. Cardiff. Welsh Government
The College of Occupational Therapists is the professional body for occupational therapists and represents around 30,000 occupational therapists, support workers and students from across the United Kingdom and 1,600 in Wales. Occupational therapists are regulated by the Health and Care Professions Council, and work with people of all ages with a wide range of occupational problems resulting from physical, mental, social or developmental difficulties.