HC 1048-III Health CommitteeWritten evidence from the College of Occupational Therapists (PH 83)

Summary

The College of Occupational Therapists (COT) believe that an Allied Health Professions Director in Public Health England is needed as occupational therapists and other Allied Health Professionals make a significant contribution to public health.

COT believe that the proposed increase in competition in the Health and Social Care Bill will reduce collaborative commissioning for public health and exacerbate health inequalities.

COT think that Allied Health Professionals should be represented in commissioning decisions about public health. It is also unclear how “hard to reach” patient groups will be able to contribute to local decisions about public health.

COT think that the Public Health Outcomes Framework needs to consider overall lifestyle and reasons for health behaviour rather than just focus on discrete parts of a person’s life such as obesity.

COT would like to see rates of violence against disabled people added to the Public Health Outcomes Framework as it is a risk to the health and wellbeing of people with disabilities.

The future of the public health workforce is at risk by lack of understanding of professional roles by commissioners, by fragmentation of education and training and by localised workforce decisions which will marginalise smaller professional groups.

COT would like to see more qualitative evidence being considered as part of the evidence for public health interventions.

1.0 Introduction

1.1 The College of Occupational Therapists is pleased to provide a response to the Health Committee’s Enquiry into Public Health. The College of Occupational Therapists is the professional body for occupational therapists and represents about 28,000 occupational therapists, support workers and students from across the United Kingdom. Occupational therapists work in local authority social services, the NHS, housing, schools, prisons, voluntary and independent sectors, and vocational and employment rehabilitation services. Occupational therapists are one of the Allied Health Professions, the second largest staff group after nursing which consists of 12 professions including physiotherapists, speech and language therapists, podiatrists, radiographers, dieticians and art therapists (for more information please go to www.ahpf.org.uk).

1.2 Occupational therapists are regulated by the Health Professions Council, and work with people of all ages with a wide range of occupational problems resulting from physical, mental, social or developmental difficulties.

1.3 The philosophy of occupational therapy is founded on the knowledge that occupation is essential to human existence and good health and wellbeing. Occupation includes all the things that people do or participate in. For example, caring for themselves and others, working, learning, playing and interacting with others. Being deprived of or having limited access to occupation affects physical and psychological health.

1.4 The daily patterns of activities chosen by individuals can either create a balanced or imbalanced lifestyle which will influence their state of health. Many public health issues which are predicted to consume the majority of health resources in the near future are attributed to modern lifestyle and activity choices. These would include obesity, cardiovascular disease, chronic obstructive pulmonary disease, work related stress, anxiety, depression and sexually transmitted diseases. Tackling the public health challenges of the future will therefore require an understanding of how and why people choose certain activities and how to engage in the correct balance of health promoting activity. This is the speciality area of occupational therapy (Christiansen and Matuska 2006).

1.5 Occupational therapists can contribute to primary, secondary and tertiary levels of public health. Primary public health occupational therapy interventions (upstream activities for the well population to prevent ill health) are described by NICE (2008) in Occupational therapy interventions and physical activity interventions to promote the mental well being of older people. These NICE guidelines clearly show that occupational therapists have a key role in promoting the importance of activity, health and wellbeing among older people. Leisure activities that provide intellectual and social stimulation protect against dementia. Occupational therapists coordinating and delivering mentally, socially and physically stimulating activities may postpone the onset of dementia (Fratiglioni et al 2007).

1.6 Secondary public health occupational therapy interventions (to target as risk groups to prevent chronic health problems) would include falls prevention programmes for the elderly which can significantly reduce the rates of falls and increase levels of independence (Logan et al 2010). Indeed, a single visit by an occupational therapist reduces the risk of falling after hip fracture (Monaco et al 2008). Occupational therapists also offer return to work schemes for adults and for example, can get people with mental health problems into employment faster and working for longer hours than other interventions (Schene et al 2007). Occupational therapy interventions for children who are at risk academically, economically and socially can significantly improve hand writing skills and improve academic outcomes for this group (Peterson et al 2003).

1.7 Tertiary public health interventions (targeting those with chronic health problems to make the most improvements in health that are possible) would be for example, occupational therapy rehabilitation programmes that include provision of assistive technology and adaptive equipment to enable independence (Scriven and Atwal 2004). Occupational therapists can provide programmes to reduce obesity in schools and for those with mental health problems (Cahill and Suarez-Balcazar 2009, Ormston 2007). Occupational therapy led lifestyle treatment can lead to significantly reduced rates of anxiety for those in primary care (Lambert et al 2006).

2.0 Creation of Public Health England

2.1 COT believe that there is a need for an Allied Health Professions Director in Public Health England as interventions provided by Allied Health Professionals such as occupational therapists make a significant contribution to public health. Too often Allied Health Professions are represented by nurses or doctors and this is inappropriate as nursing, medical and Allied Health Professional roles can be very different. The sheer volume of nursing related activity means this could inadvertently take priority over Allied Health Professional public health initiatives.

3.0 Arrangements for Commissioning Public Health services

3.1 Collaborative commissioning for public health will be required that can reach across health, social care, justice and education. This kind of collaboration has developed in some areas and occupational therapists who are trained to work across these areas can be key to developing collaborative working practices. For example, occupational therapists working across health and social care in reablement services can demonstrate faster access to care services and significant reductions in dependence. However, COT believe that the increased emphasis on competition in the Health and Social Care Bill will reduce the ability to commission collaboratively leaving it harder to effectively plan public health services. There will also be less willingness to share good or innovative public health practice.

3.2 COT believe that the current commissioning plans for public health do not include enough clinical engagement from Allied Health Professions including occupational therapists. We believe that there should be Allied Health Profession representation at every level of decision making, commissioning and providing public health. The Department of Health will strengthen the role and incentives for GPs in preventative services both as primary care professionals and as commissioners but this cannot happen in isolation from other professionals. Although the Government suggests GPs need to work with Allied Health Professionals to improve the health and wellbeing of the local population as a whole, there is little evidence of this happening.

4.0 The Public Health Outcomes Framework

4.1 COT welcome the development of the Public Health Outcomes Framework but hope that this will not be at the cost of interventions that consider all the inter-related factors than effect public health rather than focus on discrete interventions. It is well recognised that health is influenced by activity patterns, culture, economy and the environment. Rather than trying to target specific problems overall patterns of living that promote physical, social, emotional and economic wellbeing should be developed.

4.2 COT believe that the most important indicators in the Public Health Outcomes Framework will be employment, settled accommodation, social connectedness, physical activity levels, self reported wellbeing, quality of life for older people, acute admissions due to falls and children/families in poverty. Some screening for children has been removed and the return of these would facilitate early diagnosis and more effective treatment eg spinal scoliosis, eye tests, dental checks.

4.3 COT believe that given the increase in violence against disabled people (particularly see Mencap’s campaign about hate crime against people with learning disabilities www.mencap.org.uk/campaigns/learning-disability-week), that this should be measured and reported as a subset of violent crime. The effect of violent crime against people with disabilities is an underestimated risk to their health and wellbeing.

5.0 The Future of the Public Health Workforce

5.1 COT has concerns about the future of occupational therapists ability to deliver public health interventions. This is for several reasons: firstly current commissioners of public health do not understand the role that occupational therapists have in public health. As a result of this for example, the NICE guidelines for occupational therapy to promote the mental wellbeing of older adults are not commissioned and people are denied these evidence based interventions.

5.2 Secondly, the proposed changes to education, training and workforce decisions which will rely on local networks and planning, will mean that smaller professional groups such as occupational therapists or other Allied Health Professionals will lose out and our voices will be marginalised in workforce planning.

6.0 Government Response to the Marmot Review on Health Inequalities

6.1 The Marmot review was clear that health inequalities result from social inequalities and that there is a need for action to tackle the social determinants of health inequalities. COT does not believe that the Government proposals in the Health and Social Care Bill will improve health inequalities.

6.2 The proposal to remove the cap on the level of income that Foundation Trusts can generate from private patients will create less choice and access for poorer patients and will acerbate health inequalities.

6.3 The Any Qualified Provider model will allow private providers to cherry pick the straight forward lucrative parts of care pathways. Patients with multiple needs who require complex interventions (who occupational therapists frequently work with) and who are usually the most socially deprived will get less choice. Smaller, localised providers will be unable to compete with much larger providers.

6.4 How commissioning decisions will include Allied Health Professionals or patients from “hard to reach” groups is unclear meaning that decisions about public health will be made by those with the strongest voice rather than include those with the most health inequalities.

6.5 COT is aware that in the consultation for Healthy Lives, Health People; Our Strategy for Public Health in England, there was an emphasis on how to best develop and use evidence to improve public health commissioning and interventions. Qualitative research is particularly relevant in public health where an individual's health and behaviour change is affected by many inter-related factors. Evidence about a discrete intervention such as obesity or smoking, may be almost irrelevant to a person leading a complex and ever-changing life, whereas evidence about whole care packages and programmes is more likely to be useful when helping an individual to engage with health improvement activities.

References

Cahill S M, Suarez-Balczaar Y (2009) Promoting children’s nutrition and fitness in the urban context. The American Journal of Occupational Therapy, 63, 113–116.

Christiansen C H; Matuska K M (2006) Lifestyle Balance: A Review of Concepts and Research. Journal of Occupational Science, Vol.13 (1), pp. 49–61.

Fratiglioni L, Winblad B, Struass E (2007) Prevention of Alzheimer’s disease and dementia. Major findings from the Kungsholmen project. Physiology and Behaviour , 92, 98–104.

Lambert R A, Harvey I, Poland F (2006) A pragmatic, unblinded randomised controlled trial comparing an occupational therapy-led lifestyle approach and routine GP care for panic disorder treatment in primary care. Journal of Affective Disorders, Vol 99 (1–3), pp 63–71.

Logan P A, Coupland C A C, Gladman J R F, Sahota O, Stoner-Hobbs V, Robertson K, Tomlinson V, Ward M, Sach T, Avery A J (2010) Community falls prevention for people who call an emergency ambulance after a fall: randomised controlled trial. British Medical Journal, 340 (111), 20022.

Monaco M, Vallero F, De Toma E, De Lauso L, Tappero R, Cavanna A (2008) A single home visit by an occupational therapist reduces the risk of falling after hip fracture in elderly women: a quasi-randomized controlled trial. Journal of Rehabilitation Medicine, 40(6), p446–450.

NICE (2008) Occupational therapy interventions and physical activity interventions to promote the mental well being of older people. Available at http://www.nice.org.uk/

Ormston C (2007) Developing Healthy Lifestyles—a brief account of some of the work of occupational therapists in one corner of Lancashire. Mental Health Occupational Therapy, Jul;12(2):72–3.

Peterson C Q, Nelson D L (2003) Effect of an occupational intervention on printing in children with economic disadvantages. American Journal of Occupational Therapy, 57(2), p 152–160.

Schene A H, Koeter M W, Kikkert M J, Swinkels J A, McCrone P (2007) Adjuvant occupational therapy for work-related major depression works: randomized trial including economic evaluation. Psychological Medicine, Vol. 37 (3), pp. 351–62.

Scriven A, Atwal A. (2004) Occupational Therapists as Primary Health Promoters: Opportunities and Barriers. British Journal of Occupational Therapy, 67(10):424–9.

June 2011

Prepared 28th November 2011