Health CommitteeWritten evidence from the British Association and College of Occupational Therapists (LTC 46)

Introduction and Summary

The College of Occupational Therapists, the professional body representing over 29,000 occupational therapists and OT staff, is pleased to respond to the Health Select Committee Inquiry into the Management of Long Term Conditions.

Occupational therapists (OTs) work in the NHS, local authority social care services, housing, schools, prisons, voluntary and independent sectors, and vocational and employment rehabilitation services. They play a vital role every day in the delivery of care and support services, working with people of all ages with a wide range of occupational problems resulting from physical, mental, social or developmental difficulties.

Occupational therapists assist those with long-term conditions by using their knowledge and skills in prevention and early intervention; reablement and rehabilitation; reducing the effects of a disabling environment, and enabling people’s safety and independence.

Occupational therapists prevent unnecessary hospital admissions and enable treatment to take place in the community, through early supported discharge and reablement services.

Occupational therapists take a functional approach when working with individuals, helping to treat the person “as a whole” by recognising all their needs together. This promotes increased integration across health, social care and employment, resulting in cost-savings and more effective care.

As the population ages OTs will be able to help meet and manage demand for services by working with older people to support both physical and mental wellbeing. COT believes it is important to tackle inequalities in health in order to manage future demand for services.

Occupational therapists treat the psychological as well as the physical aspects of disease and disability, which improves wellbeing and aids the effective management of long-term conditions.

Occupational therapists contribute to obesity prevention and management by working with “high risk” groups and helping people to address eating habits and activity levels.

As well as defining long term conditions, COT suggests that it would be useful to define health and health promotion, in order for interventions for people with long term conditions to be effective.

1. The scope for varying the current mix of service responsibilities so that more people are treated outside hospital and the consequences of such service re-design for costs and effectiveness

1.1 The College of Occupational Therapists believes that OTs can play a greater role in supporting people to be treated outside of hospital. OTs are already heavily involved in enabling community care and COT believes that investment in OTs is cost effective, saving the NHS money in both the short and long term.

1.2 The government should utilise occupational therapists’ skills, which are already available, and further develop their roles, in order for more people to be treated outside hospital. They should also take greater account of occupational therapists’ ability to use both a medical and a social model of health and disability when working with clients. Finally, the government should plan for the long term, so that the impact of interventions can be evaluated comprehensively.

2. The readiness of local NHS and social care services to treat patients with long-term conditions (including multiple conditions) within the community

2.1 The pattern of service provision for people with long term conditions appears to be piecemeal, with some examples of good practice and other reports of lack of investment and coordination of services. One of our members reports, for example, that specialist services provided by acute services are not followed up in the community, even when such intervention would only need to be brief. COT would like to see a consistent approach to service design and delivery, taking into account the examples of good practice which are available. For example:

2.2 Occupational therapists are involved in Early Supported Discharge (ESD) services for people who have had a stroke. “A National Institute for Health and Clinical Excellence assessment of its (Camden Reach Early Discharge Service) approach showed that savings of £83,000 per 100,000 population can be achieved through reduction of an average of 10 stroke bed days and by reducing ongoing dependence on social care packages by an average of 19 hours per week.”1

2.3 Occupational therapists working for social services also enable patients to return to, or remain in, the community by providing home adaptations, making moving and handling recommendations and delivering reablement services. Such activities also result in cost-savings.2 For example, one example of a reablement service including occupational therapy showed that outcomes improved for citizens over a four week period, increased the skills of rehab support workers and saved an estimated £780 per citizen over the reablement period.3

2.4 Occupational therapists are employed in A&E departments to prevent unnecessary admissions by conducting rapid assessments, arranging discharge home with the necessary care arrangements and equipment in place, or transferring patients to more appropriate services by using links with intermediate care and social services. This results in significant cost savings.4

3. The practical assistance offered to commissioners to support the design of services which promote community-based care and provide for the integration of health and social care in the management of long-term conditions

3.1 COT would like to see greater AHP involvement in commissioning decisions, alongside GPs, nurses and doctors based in secondary care. Useful sources of assistance in the commissioning of community based care are the Allied Health Professions (AHP) AHP Toolkits,5 developed by the AHP Leads working with NHS London. “They define exactly how each AHP, including occupational therapists, contribute to each step of the pathway, and base this on clear evidence.” (COT 2013 p7).6The toolkits have been produced for six major care pathways, including stroke, musculo-skeletal conditions, cancer and diabetes.

4. The ability of NHS and social care providers to treat multi-morbidities and the patient as a person rather than focusing on individual conditions

4.1 Occupational therapists tend to take a functional approach when working with individuals, taking into account how they may be affected physically, cognitively and psychologically by their condition or conditions. This helps the person to be seen “as a whole”; “Techniques used may be rehabilitative (enabling a person to regain reduced abilities) educational (for example, managing fatigue that may be associated with the condition) or adaptive (for example, finding new, easier ways of carrying out tasks, often using equipment or assistive technology).”.7

4.2 Many services are commissioned based on outcomes which relate to single conditions, and this negatively affects the ability of NHS and social care providers to treat people who have several long term conditions. Commissioning problems could be addressed by using functional as well as condition specific outcome measures. The NHS Outcomes Framework does include “functional ability” as one of the overarching indicators for long term conditions, but this is then measured by using employment as an indicator. Although employment is important, functional ability incorporates many factors such as mobility, self care, domestic activities. COT would like to see a greater variety of functional and occupational performance measures included within the framework.

4.3 One way in which occupational therapists work with people who may have several long term conditions is through their approach to vocational rehabilitation. In relation to this, The AHP Advisory Fitness for Work Report has been launched recently. This tool has been developed to enable AHPs to advise on the functional impact of a patient’s condition on his/her ability to work and to recommend workplace adjustments. The focus on functional ability helps to tailor intervention to the person’s needs, rather than towards specific condition(s).8

5. Obesity as a contributory factor to conditions including diabetes, heart failure and coronary heart disease and how it might be addressed

5.1 Occupational therapists are well placed to contribute to obesity prevention and management. For example in primary care, they have a role in prevention of obesity in “high risk” groups, such as people with disabilities. In tertiary care the occupational therapy role within bariatric teams includes addressing problems with daily activities, improving mobility within home and community, increasing physical stamina, teaching relaxation and communication skills and use of techniques such as motivational interviewing to change activity patterns and eating habits.9 Occupational therapists also have a major role in the prescription of bariatric equipment as necessary, making the judgement between ensuring safety and optimising activity levels.

5.2 COT would like to see occupational therapists role in health promotion and prevention work, such as obesity management recognised, for example, by including it in service and person specifications.

6. Current examples of effective integration of services across health, social care and other services which treat and manage long-term conditions

6.1 Occupational therapists have a significant contribution to make to the provision of integrated care, working across health, social care, housing, employment, charity and independent sectors.10

6.2 One example of effective integrated care is the Neuro Case Management Service in Sheffield. The service integrates care across health, social and voluntary sector, whilst providing personalised care. The team consists of three occupational therapists and one nurse, working as case managers, with the four health professionals being responsible for a case load of over 800 people. The service has been commissioned to provide:

Long term case management and care navigation without discharge.

Management of those people with a neuro diagnosis (who may also have co-morbidities) who have complex needs.

Self-management and reduction of unplanned GP activity and hospital admissions.

Reduction of duplication regarding rehab referrals made across an uncoordinated pathway.

Timely medical, rehab and social care intervention to maintain status.

Proactive MDT network plan to coordinate current and future needs.

Holistic assessment that links with health, social and 3rd sector and employment services.11

7. The implications of an ageing population for the prevalence and type of long term conditions, together with evidence about the extent to which existing services will have the capacity to meet future demand

7.1 The implications of an ageing population include that more people will be living with several long term conditions including dementia, musculo-skeletal conditions and general frailty. More people will also be living with mental health issues.

7.2 Many recommendations have already been made on how to improve capacity and quality of care for people with dementia.12 The role which occupational therapists can play includes:

Providing non-pharmacological management of symptoms such as behavioural disturbance and depression.

Working as case managers.

Assisting home carers to work “with” rather than “for” people with dementia.

Discharge planning.

Ensuring that developments for example in telecare and assisted housing are appropriate for people with dementia.

Providing “in-reach” services for people in care homes, in order to enable meaningful occupation.13

7.3 As the population ages, it is important that older people’s mental well-being is supported and maintained. OTs can improve mental well-being by promoting physical activity when working with older people, as evidenced by NICE Public Health Guidance 16.14 OTs also have a key role in reablement, admission avoidance and falls prevention.15

7.4 In the longer term, it will be important to improve health equality, both as an end in itself and to reduce the overall increases in demands on services brought about by an ageing population. This will require the social determinants of health to be addressed by occupational therapists and other health professionals.16

7.5 COT would like the government to recognise and promote the important role which occupational therapists can and do play in addressing the mental and physical health needs of older people, as well as their role in addressing the social determinants of health. The latter aspect of their role will help to manage future demands on services for older people.

8. The interaction between mental health conditions and long-term physical health conditions

8.1 Occupational therapists have always recognised the fundamental link between physical and mental health, and work to address both aspects, within the constraints of the services in which they work. COT would like to see this role recognised and supported in commissioning decisions. Examples of conditions for which occupational therapists address the psychological and cognitive aspects of long term physical conditions include rheumatologic conditions,17 limb amputation18 stroke19 acquired brain injury20and progressive neurological conditions such as multiple sclerosis21 and Parkinson’s disease.22

8.2 The Mental Health Network publication, Investing in emotional and psychological wellbeing for patients with long term conditions provides many examples of the importance of addressing the mental health needs of people with long term physical health conditions.23Many of the services mentioned are characterised by the ability to treat both the physical and psychological aspects of the condition and a multi-disciplinary approach to intervention, with teams including allied health professions such as occupational therapists, as well as physicians and clinical nurse specialists.

8.3 An example of a service which treats mental health issues arising from living with long term condition(s) is the Norfolk and Suffolk Wellbeing Service. Psychological Therapists and Psychological Wellbeing Practitioners use a CBT (cognitive behavioural therapy) based approach to treat anxiety and depression. Intervention includes delivering an eight week workshop specifically for those with anxiety and/or depression who are living with any diagnosed long term physical health condition.24

9. The extent to which patients are being offered personalised services (including evidence of their contribution to better outcomes)

9.1 The College would like to see services organised around a broad spectrum of conditions, over longer time frames, and using holistic approaches, in order for personalised care to be improved. These principles are illustrated in the example below:

9.2 Occupational therapists enabled K, a woman with learning disabilities and morbid obesity, to regain her independence. K was a 45 year old woman, living with her husband. She had a number of health and functional problems which had gone undetected, including morbid obesity (her weight was 33 stone), diabetes, respiratory failure and poor mobility. She remained in bed for 24 hours per day. OTs helped K by improving communication skills, goal setting, improving diet and exercise, and enabling mainstream health and social services to work more effectively with her. The outcome was that K lost 12 stone and is now able to manage her diabetes herself.25

Additional Comments

10. Defining long term conditions, in order to provide more effective management of interventions.

10.1 In order to provide more effective management for people with long term conditions, it may be useful to consider the definition of “health” rather than “long term condition”. The Ottawa Charter states that, “Health promotion is the process of enabling people to increase control over, and to improve, their health. To reach a state of complete physical, mental and social well-being, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment.”26Occupational therapists are well placed to promote health amongst people with long term conditions as their approach focuses on all three elements of health.

May 2013|