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The Future Direction of Occupational Therapy Post the General Election.

Suzanne RastrickChief Allied Health Professions Officer

The College of Occupational Therapists. 30 June 2015

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How ‘Big Picture’ Priorities Affect Occupational Therapy

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Government Priorities

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Government Priorities

• Obesity• Diabetes• General Practice• Culture of the NHS

Themes from Secretary of State’s recent speeches:• Leadership values• Efficiency and performance• Patient centred care• Service provision and transparency

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NHS England Priorities for 2015/16

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Overview of our first four priorities

1. Improving the quality of care and access to cancer treatment: Cancer will affect one out of every two of us at some point in our lives. Outcomes have been steadily improving but prevention, earlier diagnosis and better care offer the opportunity of saving many thousands more lives.

2. Upgrading the quality of care and access to mental health and dementia services: Mental health problems represent about a quarter of the nation’s ‘illness burden’, but access to services is worse than for physical health conditions and funding has been lower.

3. Transforming care for people with learning disabilities: There have been major improvements in the support and care for people with learning disabilities over several decades but there remains much more to do.

4. Tackling obesity and preventing diabetes: Obesity prevention, which will slow the growth of Type 2 Diabetes, will have a substantial benefit to the health of our people, and the future sustainability of the NHS.

Improving HealthOur first theme focuses on where we need to make greatest progress to deliver improved health outcomes for patients. While we will be making improvements across many outcome areas, those where we need to make a big difference this year are:• cancer – which continues to be a top priority for government and the public• mental health – to continue the drive towards greater parity with physical healthcare provision • learning disabilities – to tackle the outstanding issues highlighted at Winterbourne View• Type 2 Diabetes – to start to address this through a prevention programme.

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Overview of priorities 5-8

5. Redesigning urgent and emergency care services: We need to reshape the NHS’ urgent and emergency care services so they respond effectively to the increasing demands placed on them.

6. Strengthening primary care services: We need to strengthen primary care as the foundation for personalised NHS care.

7. Timely access to high quality elective care: We must ensure elective care continues to meet service standards and remain accessible for patients.

8. Ensuring high quality and affordable specialised care: We must reshape specialised services to improve their quality and future affordability.

Redesign CareOur second theme focuses on those service areas we need to redesign to ensure they better meet patient needs. Our priorities this year are:• to tackle local configuration and delivery of emergency services, given pressures caused by

rising demand• access to general practice as the main entry point to NHS service provision• elective care provision, given the continuing pressure on targets• specialised services given the need to tackle costs and overspend.

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Whole system change for future clinical and financial stabilityOur third theme and ninth priority focuses on galvanising the whole system change which is needed for future clinical and financial stability.

Enabling whole system change To work towards the vision of the Five Year Forward View we need to get serious about preventing ill health, empowering patients and engaging communities. This means involving all our partners to design new local ways of providing care, making better use of technology and skills. The New Models of Care programme and the 29 vanguard sites will focus on designing and demonstrating the NHS of the future. We’ll also deliver Integrated Personal Commissioning demonstrator sites to personalise patient care, and review maternity services to empower women through more choice and control.

Delivering value and financial sustainability through a step change in efficiencyThe Five Year Forward View sets out a £30bn funding gap, and the need for the NHS to deliver £22bn efficiencies over the next five years to close the gap. Our specific role and priority is to develop the financial and economic strategy; progress efficiency initiatives across the system; and take steps to underpin transformation (e.g. development of payment systems and measurement tools to help us better serve local populations).

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How Does Commissioning Work?

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NHS Outcomes Framework – 5 Domains

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NHS Commissioning Assembly…• “….as clinical commissioners we need to understand

the outcomes that matter most to people in our communities – these “citizen outcomes” should guide our decisions….”

Gateway ref 01801

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Commissioners are sighted on what “citizens” want.

Adapted from: Legatum Institute (2014) Wellbeing and Policy

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How should providers respond to delivering these “citizen outcomes”?• Ensure those with Board leadership roles fully understand the

AHP workforce in their accountability• Approach workforce planning strategically in conjunction with

CCG or Sub Regional NHSE commissioners & LETBs• Move away from easy stereotypes of just more ‘doctors and

nurses’ to ensure workforce has richness and depth of competencies that deliver ‘citizen outcomes’

• Using Organisational Development approaches to fully engage with the existing AHP workforce & their professional bodies to develop both responsive services & multi professional leadership

• Share, spread & celebrate AHP innovation

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The Policy Case for Commissioning OT Services in England…...

• The NHS Mandate

• The NHS Outcomes Framework

• Patient Choice

• The Five Year Forward View (October 2014)

• The Forward View Into Action: Planning For 2015/16 (Dec. 2014) & Supplementary Information For Commissioner Planning 2015/16 (Dec. 2014)

• ‘Intelligence’ Based Commissioning Models & Approaches

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Patient Choice….

How safe and

effective is your

service?

As a commissioner what would I want to know about your service?

What does the service actually

do? What difference does

it make?

How much does the service cost?

Is it worth buying?

Can you evidence what outcomes you

deliver?

What do you do that helps me reach my targets? Eg. To maintain people at

home

Does it serve the needs of the local population?

OTService

Can I get this service cheaper or more flexibly from someone

else?

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Can you demonstrate that your service is worth funding amongst others?

O T

Physios

Social workers

other providers

Support

workers

Nurses

P

Us! Us! Go on, you need us! We’re really nice and we do a great

job!

Influencing CommissionersMembers have access to a range of resources and evidence to enable them to influence service commissioners

You are best placed to influence service commissioners. BAOT/COT provides resources and support to help you shape service commissioning in your local area. We can help you respond to local needs and agendas in a way which will benefit the profession locally and ultimately nationally.

Saving money for service commissioners

Service commissioners are the budget holders who allocate funds for health and social care. It's important to demonstrate the value for money of OT services in order to encourage commissioners to purchase OT services to ensure OT continues to play a vital role in health and social care delivery. 

Materials available for targeting commissioners

 

Back to health, back to life leaflet

 This leaflet can be personalised for your service. Simply insert your organisation details and your own case studies in the spaces available and use this material when promoting your occupational therapy service to commissioners, influencers and your senior management. 

Occupational therapy evidence fact sheets

 The occupational therapy evidence fact sheets provide key facts, examples of cost benefits and related reference points across a range of key service areas. 

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NHS Five Year Forward View & New care models

NHS Five Year Forward View

• The NHS Five Year Forward View was published on 23 October 2014

• One of its great successes was that it is a shared vision for the future of the NHS across six national NHS bodies

• The challenge is now implementation; we know: • It will not be easy• We need to learn from the past • We’re going to need a different

approach

• AHPs are up for it!

The future NHS

The core argument made in the Forward View centres around three ‘gaps’:

Radical upgrade in prevention

• Back national action on major health risks• Targeted prevention initiatives e.g. diabetes • Much greater patient control• Harnessing the ‘renewable energy’ of communities

Health & wellbeing

gap1

New models of

care

• Neither ‘one size fits all’, nor ‘thousand flowers’• A menu of care models for local areas to consider• Investment and flexibilities to support implementation

of new care models

Care & quality gap

2

Efficiency & investment

• Implementation of these care models and other actions could deliver significant efficiency gains

• However, there remains an additional funding requirement for the next government

• And the need for upfront, pump-priming investment

Funding gap

3

Principles of the New Care Models programme

Clinical Engagem

ent

Patient Involvem

ent

Local Ownershi

p

National Support

• The programme will be developed with a co-design approach – built with patients and the health and care system

• It will seek to identify replicable standards, tool and methods so that scale can be reached;

• It will use the transformation fund to maximise progress and pace through centralised support, especially in technical areas as well as leadership support and development for those local health and social care systems;

• The national package of support to prototype sites will be offered with an agreed Memorandum of Understanding and mutual commitment to delivery on the ground, and a commitment to value for local people

• It will establish an evaluation process to support testing and rapid learning

• It will share early and continuous learning with the whole national health and care system through a wider community of support.

New Models of Care

Initially the new models of care programme will focus on:

• Multi-agency support for people in care homes and to help people stay at home

• Using new technologies and telemedicine for specialist input • Support for patients to die in their place of choice

Enhanced health in care homes

• Coordinated care for patients with long-term conditions • Targeting specific areas of interest, such as elective surgery • Considering new organisational forms and joint ventures

New approaches to smaller viable

hospitals

• Integrated primary, hospital and mental health services working as a single integrated network or organisation

• Sharing the risk for the health of a defined population• Flexible use of workforce and wider community assets

Integrated primary and acute care

systems

• Blending primary care and specialist services in one organisation• Multidisciplinary teams providing services in the community • Identifying the patients who will benefit most, across a population of at

least 30,000

Multispecialty Community Providers

First cohort Vanguard sites

Care model Applicant

PACSWirral University Teaching Hospital NHS Foundation Trust

PACSMansfield and Ashfield and Newark and Sherwood CCGs

PACS Yeovil Hospital

PACS Northumbria Healthcare NHS Trust

PACS Salford Royal Foundation Trust

PACS Lancashire North

PACs Hampshire & Farnham CCGPACS Harrogate & Rural District CCG

PACS Isle of Wight

Care model Applicant

MCP Calderdale Health & Social Care Economy

MCPDerbyshire Community Health Services NHS Foundation Trust

MCP Fylde Coast Local Health Economy

MCP Vitality

MCPWest Wakefield Health and Wellbeing Ltd (new GP Federation)

MCP NHS Sunderland CCG and Sunderland City Council

MCP NHS Dudley Clinical Commissioning Group

MCP Whitstable Medical Practice

MCP Stockport Together

MCP Tower Hamlets Integrated Provider Partnership

MCP Southern Hampshire

MCP Primary Care Cheshire

MCP Lakeside Surgeries

MCP Principia Partners in Health

Care model Applicant

Care Homes NHS Wakefield CCG

Care Homes Newcastle Gateshead Alliance

Care Homes East and North Hertfordshire CCG

Care Homes Nottingham City CCG

Care Homes Sutton CCG

Care Homes Airedale NHS FT

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• 2012 CAHPO asked by Sir Bruce Keogh to establish if there was a case of need to improve adult rehabilitation services in England

• Examples of good innovative practice and service design, but poor adoption and dissemination

• Clinicians and service users - unsure of services available and how to access them

• More recent stakeholder engagement told us:• service not always focused on patient need• lack of focus on outcomes • commissioning structures an obstacle to care

So, what are CAHPO team doing? ……Innovating Rehabilitation

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• Publish the economic arguments for rehabilitation• Take forward recommendations from C&YP scoping

project report• Publish commissioning frameworks:

• Self referral and early intervention• Supported self management• Urgent and emergency care review• Older people’s programme• Living with and beyond cancer• Elective care

• Return to work programme• Support development of regional networks

Plans for Rehab Programme 2015/16

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Rehabilitation Innovation Challenge Prizes• “Open Mind Partnership”

Leicestershire Partnership NHS Trust

Leicester Open Mind in partnership with Fit for Work

- GP referral or Open Mind therapists

- Long-term MSK pain

- Cognitive Therapy and Mindfulness techniques

- Addressing physical, social and mental barriers such as depression and anxiety

• “Fitness for Work Service”

Derbyshire Community Health Services NHS FT

- Self referral or by managers

- Assessment – physical activity, design of the workplace

- Phased return to work and duties where appropriate

- Service also offers MSK pain education and management, advice on equipment and educational resources

- ROI - £5 for every £1spent

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“It’s about occupation, stupid….” Why commissioners don’t get OT.(With apologies to James Carville, 1992)

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Can you demonstrate that your service is worth funding amongst others?

O T

Physios

Social workers

other providers

Support

workers

Nurses

P

Us! Us! Go on, you need us! We’re really nice and we do a great

job!

What can be the consequences of unclear messages?

“OTs avoided using the word occupation for fear

of misunderstanding”Wilding & Whiteford 2008

“Because OTs are concerned with the

normality of everyday activity … they see it as taken for granted and

not highly valued”Clouston & Whiteford

2008

OTs struggled to maintain their professional

identity in multidisciplinary

teams Robertson & Griffiths

2009

“A profession is not defined by expert knowledge but through the ability to

demonstrate advanced professional skills, such …… as carrying out sound and

reasoned judgments.” (p 37).Hoyle E and John P (1995) Professional knowledge and professional practice. London: Cassell in

Whitcombe SW (2013) Problem-based learning students’ perceptions of knowledge and professional identity: occupational therapists as ‘knowers’. British Journal of Occupational Therapy, 76(1), 37-42.

It is the skilled process of transferring the unique knowledge of occupation into

professional action through the use of reasoning that is the basis of the

profession’s distinct practiceTurner A and Alsop A (2015) Core Skills – Exploring occupational therapist’s hidden assets.

British Journal of Occupational Therapy, Awaiting Publication

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The core driver is the concept about occupation and its impact on health

Concept based profession

Core ideas lack visibility

Impact demonstrated through outcomes which may be qualitative and long term

Techniques/skills often not unique

Practitioner needs a strong sense of professional identity

Practical skill based profession

Core ideas are more tangible

Impact demonstrated through outcomes which may be quantifiable and short term Techniques/skills often unique

Practitioner less likely to have issues with identity

©annie turner 2015

Professional belief in the impact of occupation on health and well-being

Identifying and assessing occupational needs

Analysing & prioritising

occupational needs

Enabling occupational performance

Evaluating occupational

outcomes

Central philosophy

Unique core skills based

on reasoning

Context dependent

practice skills

Splinting Group work Wheelchair assessment

Cognitive behavioural skills

Home visits

Communication Leadership

Teaching Business skills

Research

ADL Vocational rehab

Creative skills Leisure skills

Supervision skills

Reflection Housing adaptations Mobility Management Social skills

Hidden core skills versus the public face of practice

These skills are

unchanging though tools

may vary

This is unchanging and forms

the basis of all practice

These practice skills are driven and changed by fashion, research, legislation, context and technological development

©annie turner 2015

The duality of professional practice in Occupational Therapy

The hidden reasoning of occupational

therapy is based on the

romantic concept of the positive impact of meaningful occupation on health and well

being

The visible face of

professional practice is based on rational

scientific thinking that evidences the

skills and competences used as the

media of intervention

©annie turner 2015

Occupationas a “means” andas an “outcomes”

Occupational Alienation

Occupational Balance

Occupational deprivation

A Hierarchy of Concepts related to Occupation

Expectations Motivation Life stage Culture Environment

ROLE ROLE ROLE ROLE(mother) ROLE

OCCUPATIONAL PERFORM(Occupational form and

OCCUPATION“mothering”

ANCEfunction)

Activity Activity Activity Activity(packing school

lunchbox)

Activity Activity

Etc.. TaskCleanLunchbox

TaskPrepare

drink

TaskMake

sandwiches

Etc…

Performance components Skills

Etc.. Grip flaskGrip lid

Unscrew lid

Having ingredients readyJudging amount of concentrate

Etc..

©annie turner 2015

Romantic thinking

Rational thinking

Yes we have the answers ready!

We use appropriate, consistent outcome

measures

We know what difference we make to

our service users. We’ve got the

evidence

Our practice clearly demonstrates our

professions’ uniquenesses

We use evidence informed practice.

We create evidence

Something similar may be available elsewhere

but it won’t be delivered by regulated

practitioners

We know who to tell and how to

tell them

We know how much our service

costs

You employ us because……

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Connect & share…

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OTs & other AHPs are ideally placed to deliver many of the ambitions in the 5YFV • Two fundamentals AHP’s deliver on:

InnovationEntrepreneurship

• Some areas to strengthen:Economic evaluationConsistent outcome dataDeveloping networks to spread excellent practice

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Suzanne RastrickChief Allied Health Professions Officer

…will you join me?

@SuzanneRastrick