CONTENTS
Page
1
Introduction and Summary
3
2
Current Service Delivery – the basis for change
8
3
A Framework for the Future – a community based
general practitioner service model for occupational therapy
18
References
Annexes
A
Occupational science: understanding the relationship
between occupation, health and well being
35
B
The beliefs and values of occupational therapists in the UK
36
C
Questions for change
37
PREFACE
The development of a UK-wide coherent policy by a professional body is becoming
increasingly complex. Scotland has a new Parliament, Wales and Northern Ireland have new
Assemblies. Each is taking forward the modernisation of health and social care services in
different ways (and differently from England), setting up differing structures to different
time scales and defining different priorities during the change process. The four countries
have distinct ‘Plans’ for their health services. For example, the National Service Frameworks
only apply in England. Legislative provisions for pooling budgets differ and strategies
towards the development of the Allied Health Professions are not running in parallel.
Against this background, the College’s wish to describe the different legislative environments
and policy drivers in this consultation threatened to make the document unduly complex
and distracting for the reader. We have therefore adopted a minimalist and generalised
approach. Our core purpose is to address the interface that exists between occupational
therapy services provided by health and social care agencies, especially for adults with
physical illness or disability. That interface exists and needs tackling in each country.
This document proposes an approach to a solution, a conceptual model for service delivery
to support a seamless approach for clients and organisations. The College recognises that
the mechanisms for change will need to be developed within the legislative and policy
context of each country. The priority levers described in paragraph 3.10 may be biased
towards English policy but we believe that most will have a general, if not particular,
application to the objectives of quality occupational therapy services across the UK. The
vision is to achieve joint planning of an integrated range of occupational therapy services
that will bring an end to confusion and duplication for people who need to use them. How
we travel is less important than the determination to achieve that vision.
The term occupational therapy services is used to describe the range of treatments,
interventions or services provided, or facilitated, by occupational therapy personnel within
health or social care. It is not intended to imply a single service management model but
recognises that elements of the service will be provided by occupational therapists
working in a wide variety of teams and service settings under varying line management
arrangements.
Similarly, the generic term social care is used in preference to duplicating the terms
personal social services and social work services.
1
ACKNOWLEDGEMENT
The College is indebted to Mr Bert Massie CBE, Chairman of the Disability Rights
Commission, for his encouragement during the development of this consultation document.
The term ‘rehabilitation’ is used throughout the text, primarily because it is well understood
that occupational therapists are one of the three main professions (alongside physiotherapy
and speech and language therapy) whose core knowledge and skills are applied to the
purpose of rehabilitation. Bert has reminded us that occupational therapists (and, by
implication, the services within which they operate) need to be equally concerned with
habilitation – a concept that recognises that for young people in particular, the process of
achieving life goals and aspirations may be very different from those who, in adult life,
have lost, or risk losing, living skills and opportunities they may previously have enjoyed
2
A STRATEGY FOR MODERNISING OCCUPATIONAL THERAPY SERVICES IN LOCAL HEALTH AND
SOCIAL CARE COMMUNITIES
1 INTRODUCTION AND SUMMARY
1.1
Occupational therapists are employed within the National Health Service, Local
Authority social care services, and other sectors throughout the UK. They are educated
to work across the spectrum of health and social care; across the fields of physical,
mental and social health. They can operate within the medical and social models of
disability, as well as taking a particular occupational approach to health. Instead of the
breadth of occupational therapists’ understanding and approaches being seen as a
strength, the barriers between health and social care have resulted in their dual
employment being perceived as a problem, and one that has sat heavily on the
shoulders of the profession. Occupational therapy has, in a unique way characterised
the health and social care divide – the ‘Berlin Wall’ tackled head on by Frank Dobson
when Secretary of State for Health (Dobson 1999).
1.2
The Government is now committed to removing the legislative and organisational
barriers that have created this divide. New flexibilities (of lead commissioning,
integrated provision and pooled budgets) are paving the way for a whole-system
approach that looks afresh at how services can be redesigned to meet better the needs
of service users across their experience of illness or disability. The ‘joined up’ agenda is
being taken forward through different legislative arrangements by the four UK
administrations; whatever the mechanism, the aim of achieving seamless service
provision is firmly on the national map.
1.3
Occupational therapists welcome the move to integration. It is a concept that fits with
the profession’s holistic philosophy and practitioners see the opportunity to offer
something better to their service users. The profession now has the opportunity to
step beyond the historical interface issue and modernise its contribution to health and
social care services. Many local commissioners and service providers are being
pro-active, bringing occupational therapists together to look at how their services can
be re-modelled. The temptation may be to ‘stitch together’ existing services, by having
shared assessments or shared posts for example. While such innovations are welcome,
the College does not believe they go far enough. We believe that the time is right to
develop a framework to guide the future strategic and longer-term development of
occupational therapy services.
1.4
This consultation document will propose a conceptual approach based on the revised
International Classification of Functioning, Disability and Health (ICF-2) (World Health
Organisation 2001) set within the Ottawa Charter for Health Promotion (World Health
Organisation et al 1986) (see paragraphs 3.1 – 3.3). Occupational therapy is concerned
with the everyday activities of life, activity and activity limitation, social participation
and life-style restriction as they relate to an individual’s experience, needs and
aspirations. The College therefore considers that the ICF fits well with the profession’s
philosophy, beliefs and values. It offers a framework for looking at how occupational
therapy services might better address the occupational needs of people with a lasting
health condition or disability. It also encompasses the vision of health being more than
the absence of illness, reflecting the profession’s concern with quality of life in relation
to well being.
3
1.5. Our approach is not to seek to re-define occupational therapy – that debate is healthy
and will continue within the profession. An introduction to occupational science is
given in Annexe A for those with an interest. The strategy focuses on the
organisation of statutory service delivery. This means getting occupational therapists
with the right knowledge and skills, in the right place, at the right time, delivering
services which commissioners and people who need to use services want and value.
The proposal is for a community based general practitioner model to ensure an
integrated approach that enables services to be developed as a continuum that is
focused upon, and responsive to, the needs of service users, their families and carers.
1.6
This document should be read in the context of the increasing demand for
occupational therapists and the Government’s recently announced commitment to
achieving a significant growth in the numbers of student education and training places
in England between now and 2004 (Department of Health 2000). That growth signals
the Government’s recognition of the contribution occupational therapists can make
towards achieving many of its strategic goals, principally to develop services that
promote independence, particularly for older people. The College is committed to
ensuring that the profession responds positively to this recognition and added
investment. Promoting independence is one of the core objectives of occupational
therapy and the profession wishes to play its full part in delivering on that agenda.
1.7
What the College sees, for the first time in the UK, is a policy environment that is in
tune with the profession’s beliefs and values (Annexe B) in respecting the importance
of occupation as the means of achieving personal autonomy and self-fulfilment. This
environment can provide even more opportunity to develop academic understanding
and to reassert the value of occupation and activity as a route to social inclusion.
While our educators, researchers and practitioners take forward that goal, it is critical
that future practitioners are equipped with the knowledge and skills to contribute
effectively within rapidly changing health and social care economies, in both the public
and independent sectors. The College intends therefore that the final version of this
strategic framework should guide the future development of occupational therapy
pre-registration education, as well as the continuing professional development of
current practitioners.
1.8
This document concentrates on services for adults with physical illness or disability
where the interface between health and social care has presented the greatest
obstacles for occupational therapy, particularly around the management of hospital
discharges and the integration of care for people with continuing health and social
care needs. The development of community based, integrated services for people with
a learning disability or mental health problem has been accelerated by the
de-commissioning of long stay institutions. This rapid change has, however, led to
some inconsistency in occupational therapy provision for these client groups. There are
additional challenges in services for children and young people with disabilities where
occupational therapists work in collaboration with colleagues in education. The
College recognises that these services have different needs and complexities that
cannot be fully addressed in this document. While we believe that the principles and
the proposed strategic framework could be generalised and applied broadly across the
profession, we will consider what additional action the College should take to support
the development of occupational therapy services for these important groups of service
users. Readers’ views would be most welcome.
4
The consultation process
1.9
This consultation document is being widely distributed to national policy makers,
service commissioners and providers, related professional bodies, organisations
representing service users and within the profession itself. The College hopes it will
stimulate lively debate. We want to ensure that key stakeholders inform the future
direction of the profession. Questions are raised within the document and, to assist
responses, these are summarised opposite and in Annexe C. This document can be
found on the College’s web site at www.cot.org.uk. The College would appreciate
responses and any additional comments by 31 March 2002:
Please send replies to Sheelagh Richards Chief Executive
106-114 Borough High Street
London SE1 1LB
or email jane.martin@cot.co.uk
1.10 The College will consider responses at the Council meeting in April 2002 and publish its
own response as soon as possible thereafter. Assuming that there is broad support for
our approach, we plan to publish a series of occasional papers focusing on key
implementation issues to facilitate ongoing dialogue and development.
5
Questions to Address
• Is the College’s overall assessment of the status quo a reasonable representation of
service characteristics around the country?
• Is this a sound basis for change?
• Is beginning with a conceptual model the best way to approach change?
• Is ICF-2 an acceptable approach ~ would commissioners and providers be able to use it?
• Does setting it in the wider context of the Ottawa Charter strengthen understanding of
the health benefits of occupation?
• Will it support the breaking down of rigid barriers about health and social care responsi
bilities and support the development of a continuum of integrated occupational therapy
services?
• Are the policy objectives outlined in 3.10 the right ones – are there others we should
recognise?
• Is there support for restoring the importance of occupation in the lives of service users,
and within the core role of occupational therapy practice?
• Will commissioners and planners be committed to developing the continuum we
propose ~ and is it likely to attract equal interest across health and social care?
• Is there support for the strategic development of a new community based (specialist)
occupational therapy general practitioner model?
• What kind of implementation support would it be most useful for the College to provide?
6
‘Occupational Therapy promotes and restores health and well-being in people of all ages
through using purposeful occupation, as the process or as the ultimate goal. In this
context, occupation is the meaningful use of activities, occupations, skills and life roles
which enables people to function purposefully in their daily lives’ (College of Occupational
Therapists 1994).
‘Occupational therapy is the therapeutic intervention that promotes health by enhancing
the individual’s skills, competence and satisfaction in daily occupations … to act on the
environment and successfully adapt to its challenges’ (Yerxa et al 1989 p6).
‘Occupational therapy ~ A profession whose members collaborate with clients, who may be
individuals, groups, agencies or organisations, in enabling occupation’ (Canadian
Association of Occupational Therapists 1997 p182).
‘Such ideas suggest that occupation is an innate behaviour; that it is an integral aspect of
humanness: that it may define humanness; that doing and being have an innate
relationship and that occupation has biological as well as social functions. Humans can
be described as occupational beings because of this’ (Wilcock 1998b p5).
7
2 CURRENT SERVICE DELIVERY – THE BASIS FOR CHANGE
2.1
This chapter sets out the College’s assessment of the current, albeit changing
pattern of occupational therapy services and the extent to which the health and social
care divide constrains the delivery of seamless care and the best use of occupational
therapy resources. This reflection provides the rationale for change. As indicated in
paragraph 1.8, it concentrates upon services for adults with physical illness or disability.
The focus of occupational therapy within the NHS
2.2
Within the NHS, the majority of occupational therapy resources have, historically,
been located within acute general hospital services or within specialist services (such as
services for people with a spinal injury, brain injury, mental ill health or a learning
disability for example). Data collected by the Government across the UK on
occupational therapy services are severely limited, are not comparable between
countries and do little to support analysis of needs or service trends. However, if
extrapolated nationally, Korner data in England (Department of Health 2001c) support
our belief that:
• A major proportion of resources remain locked in acute general hospital services
with occupational therapists devoting less time to a steadily rising number of
patients. More people are getting a lower level of service;
• Growth in referrals from General Practice/primary care has been relatively modest, as
has the volume of patients receiving a service in community settings. This is due to
the lack of resource transfer to primary care and/or the ease of referral mechanisms.
2.3
The Audit Commission’s study The Way to Go Home (Audit Commission 2000, p66,
exhibit 30) supports the profession’s concern that within acute general hospitals, too
often the role of the occupational therapist is limited to discharge facilitation or safe
discharge. This is to cope with the pressure on hospital throughput, reduce waiting
lists and maximise bed occupancy levels. Whilst we have no doubt that this role is
important and cost-effective when properly organised (Sutton 1998), the Audit
Commission study supports our belief that too many patients, especially older people,
are discharged before their potential for rehabilitation has been optimised. Since the
introduction of the internal market in health care, the focus has been on quantity, not
quality – on outputs rather than outcomes. Occupational therapists have witnessed the
steady decline in hospital based rehabilitation and been unwilling (and often
powerless) partners in people returning home with preventable levels of dysfunction
and dependence. Many rehabilitation units have closed down. Traditional links with
employment services to help adults with the potential to return to work (at one time a
primary role of occupational therapy services) have diminished and the emphasis has
moved to essential activities of daily living – or basic survival in self care. People with
an illness or disability have lost out as a consequence of this reductionist model.
8
‘I talk to occupational therapists and ask where the occupation in the term occupational
therapy has gone. OTs have many skills and abilities but they have been shoehorned into
adapting buildings and no longer think about how they can help people fulfil their dreams’
(Glasman 1996 p7).
‘Those who are not medically stable may be discharged inappropriately to a setting without
clinical support, or they may be transferred to ‘intermediate’ inpatient beds off the main
hospital site – such as those in small community hospitals – without either intensive
rehabilitation or specialist clinical care’ (Audit Commission 2000 p6).
‘Within acute services, too often the role of the OT is limited to ‘discharge facilitation’ or
‘safe discharge’ (Audit Commission 2000 p80).
‘Some of the wider issues are beyond the direct control of therapists themselves. They
require action at other levels … in particular, if independence is to be promoted fully,
workforce planning to make good the shortfalls will need to begin urgently’ (Audit
Commission 2000 p72).
9
2.4
During the late 1980s and early 1990s, these trends were accompanied by an
assumption that continued rehabilitation would take place in the community.
Unfortunately those services did not exist and were seldom given strategic attention or
investment by health authorities. The Commission of Inquiry on Occupational Therapy,
chaired by Louis Blom-Cooper (Blom-Cooper 1989) recommended that the College
‘… accelerate the pace of change, already taking place, towards a re-deployment of
occupational therapists to work in the community, rather than in hospitals.’
Twelve years later, it is evident that the pressure for hospital productivity has prevented
any significant shift of resources. Moreover, the presumption that capacity exists to
support such re-deployment is questionable. We are of the view that past workforce
planning has failed to plan for, and invest in, the increased numbers of occupational
therapists needed to provide additional community based services.
The focus of occupational therapy within Local Authority social care
2.5
In part, developments at a community health or primary care level have been
influenced by the presence of occupational therapists within Local Authority social
services (or social work) departments. Occupational therapists dealing with outpatients
or planning the discharge of people from hospital routinely refer those in need of
further intervention to their community counterparts. Social services occupational
therapists have been unable to provide continued therapy (or active rehabilitation)
per se. They are employed by local authorities to enable them to discharge their
statutory functions. This is largely to assess for and provide disability equipment and
housing adaptations to promote the independence of disabled people living at home.
Dealing with those discharged from hospital represents only a small proportion of their
work. Local Authorities have not expected occupational therapy personnel to
undertake active rehabilitation as this job has been traditionally perceived as the
function of the NHS. Although a considerable volume of counselling, advice and
support is provided to disabled people and their carers in the course of equipment and
housing adaptation provision, the scope and value of this role has not been sufficiently
well recognised.
2.6
In short, the work of local authority occupational therapists continues to be dominated
by a relentless pressure to respond to requests for assessment for disability equipment
and housing adaptation services needed by disabled and older people. The profession
is now dealing with around a quarter of all referrals to social services in England and
Wales and in some authorities the proportion is as high as 40% (Association of
Directors of Social Services et al 2000).
10
‘Rehabilitation is a complex construct concerned with promoting independence and quality
of life. It describes services such as community rehabilitation teams, as well as a care
process involving specific interventions. The consumer group is heterogeneous, from
children to elderly people, often with complex multiple needs (including mental illness,
learning disabilities and sensory impairments) and vulnerable to socio-economic
disadvantages such as poor housing and unemployment. Rehabilitation is an empowering
process, which promotes social inclusion and social justice. As such, rehabilitation should
support the consumers’ abilities, their rights to exercise control and contribute towards the
improvement of services’ (Mountain & Ilott 1999 p1).
‘The evidence was that promoting independence often worked best by teamwork across
the traditional dividing line between social and health care. This was partly because
rehabilitation plays a big part in promoting independence and it typically utilises a mix of
social care and health care interventions …’ (Social Services Inspectorate 2001a, p26).
‘the new emphasis on prevention and rehabilitation has led to the creation and
development of a range of services with very productive involvement of and partnership
with therapists … for some social services occupational therapists this development meant
their traditional social services roles expanded significantly’ (Social Services Inspectorate
2001a, p31).
‘Some social services occupational therapists were taking on a new rehabilitation role’
(Social Services Inspectorate 2001a, p33).
11
2.7
Following Ministerial intervention in 1994 on lengthy waiting lists in England and
Wales, the numbers waiting for assessment by an occupational therapist were reduced
from 116,000 at September 1994 to 69,000 at September 1998. Referrals were also
reduced from 706,000 to 621,000 over the same period (Association of Directors of
Social Services et al 2000, p2, table A). Although the College recognises that a
proportion of potential clients may have had their needs met by referral to alternative
services, ‘closing the door’ by tightening service eligibility criteria clouds a proper
understanding of the volume of users’ needs within local communities. We
acknowledge that an additional number of clients are dealt with by occupational
therapists acting as care managers and these may not be counted in the statistics.
2.8
As Mountain concluded in a research review of the outcomes and effectiveness of
occupational therapy in social services departments:
‘the comparatively small numbers of occupational therapists working for social services
had led to a perception of occupational therapy as a specialist service. The reality is
that occupational therapists are involved in mainstream service delivery to older people
and people with disabilities living in the community, who represent a significant
proportion of the local authority social services client base’ (Mountain 2000,
summary 2.1).
Despite this perception, local authorities have been slow to use the wider specialist
skills of occupational therapists within the broader range of family services, or in
meeting the psycho-social needs of those with mental ill health, for example (Local
Government Management Board 1995, p51, table 23).
2.9
In addition, there is little evidence that efforts to manage disability equipment and
housing adaptation services more efficiently have released occupational therapists’
time to give a broader service to their existing client base. As the Social Services
Inspectorate (SSI) concluded in a report about independent living arrangements for
younger disabled people:
‘Occupational therapists were recognised as central to the notion of promoting
rehabilitation and independence, since outside occupational therapy teams there was
little emphasis on rehabilitation. However, the potential contribution of occupational
therapy was often limited by organisational arrangements and by ambivalence and
ambiguity about whether occupational therapists were primarily assessors or providers’
(Fruin In Social Services Inspectorate 2000, 3.31)
This finding indicates that the barriers are not only organisational but also attitudinal,
something that is echoed in the Joint Future Group report (2000).
12
Developments in occupational therapy within community health and primary care
2.10 While occupational therapists within the social care sector have made a very significant
contribution to community care for disabled and older people, their presence has,
paradoxically, clouded the extent to which rehabilitation and continuing health needs
have gone unmet. There has until recent times been little incentive to develop
occupational therapy within community health settings – there has been a belief that
‘the job is done’ by those in the social care sector.
The College has therefore welcomed the growth of innovative, effective services within
primary care and community health settings (Walker et al 1999). This has inevitably
brought the interface into sharper relief; for example, when community health and
Local Authority based occupational therapists are asked to intervene in the same
household, or where health based occupational therapists are unable to access
disability equipment without a referral and second assessment being conducted by
social care services.
Figure 1 The policy and practice void in occupational therapy services
THE NHS
SOCIAL SERVICES
The policy and practice void in occupational therapy services
Treatment, rehabilitation and health
promotion in Primary Care and
Community Health settings
2.11 The picture depicted above is changing. In England, General Practice fund holding
began to drive the change, with GPs seeking a wider range of interventions for those
with lasting conditions and complex needs within their practice populations.
Additional initiatives have been stimulated by Winter Pressures, Partnership and
Prevention grant funding (though some have had difficulty securing recurring funding).
Better Services for Vulnerable People (Department of Health 1997), with its focus on
joint investment plans, multidisciplinary assessment and rehabilitation, promoted the
development of a variety of community based teams. Examples of these innovations
were published in A Directory of Developments in Occupational Therapy, Physiotherapy
and Speech and Language Therapy (NHS Executive et al 1998) and, more recently, in
The Way to Go Home (Audit Commission 2000).
13
2.12 The drive for change is consolidated by the integration agenda, set out for England
in the Health Act 1999 (Great Britain 1999). Rehabilitation will be the single
identifying feature of the Government’s investment in the development of a range of
intermediate care services (Department of Health 2001b). The College believes that
this predicates a longer-term strategic reorientation of rehabilitation services, primarily
based in the community, and potentially with a wider preventive focus than has
previously been the case. Joint health and social care development is being taken
forward in Scotland through the Joint Future initiative (Joint Future Group 2000),
although this does not yet extend to wider rehabilitation services. In Wales, the
Service Development Group has prepared guidance on Intermediate Care in Wales and
this will be issued in the near future (National Assembly for Wales 2001).
2.13 Given the central role which occupational therapists play in the provision of community
equipment and assistive technology services, the Government’s requirement that the
NHS and Local Authorities in England achieve single, integrated services by 2004 is
particularly welcome (Department of Health 2001a). Single unified services will require
agencies to address the issue of assessment, duplication, overlaps and gaps. This will
be a helpful feature towards the integration of occupational therapy service delivery.
The College welcomes the Joint Future initiative that is pursuing the closer
collaboration of equipment and adaptation services in Scotland.
A loss of focus on the importance and breadth of occupation
2.14 Reference has been made to the reductionist model that has narrowed the focus of
occupational therapy to personal activities of daily living or self-care. This has often
been to the exclusion of disabled and older people’s wider occupational needs. In
relation to working age adults, Welfare to Work for Disabled People was included in
the White Paper Modernising Social Services (Secretary of State for Health 1998) and
as Objective 3 in the 1998 National Priorities Guidance:
‘to ensure that people of working age who have been assessed as requiring community
care services are provided with these services in ways which take account of and as far
as possible maximise their and their carer’s capacity to take up, remain in or return to
employment’ (Social Services Inspectorate 2001b, C.1).
Quotations from the report of the Social Services Inspectorate’s inspection of Welfare
to Work for Disabled People Making it Work substantiate our concerns (Social Services
Inspectorate 2001b). Local Councils were required by April 2001 to produce, with other
agencies, a local Joint Investment Plan for Welfare to Work for Disabled People. Given
occupational therapists’ knowledge in this area, it would have been reasonable to
expect that local Councils would have sought to use the expertise they employ. Sadly,
there is little evidence in the report that Welfare to Work has been grasped for what it
is, namely an opportunity to restore to mainstream practice consideration of disabled
people’s occupational needs by improving their opportunities for employment.
14
‘Little help with employment was available to disabled people receiving rehabilitative
health services as a result of chronic illness or accidents. Such people are likely to have an
employment history, but assessment of and responses to their employment needs were
neglected areas’ (Social Services Inspectorate 2001b, p6).
‘Councils and other key agencies had a long way to go to achieve a co-ordinated approach
to helping disabled people with their employment needs’ (Social Services Inspectorate
2001b, p15).
‘The forms used to record assessments generally included some reference to employment
and leisure. However, the assessments we saw completed gave insufficient emphasis to
these areas of people’s lives. This was not surprising if the staff completing assessments
did not see supporting employment as an integral part of the council’s role and could not
easily access the resources necessary to do so’ (Social Services Inspectorate 2001b, p21).
‘Most councils had not seen supporting disabled people in employment as a high priority’
(Social Services Inspectorate 2001b, p20).
‘There is a strong and rapidly developing network of occupational therapy and other
discipline specific specialists in work rehabilitation in the United Kingdom … the strengths
of occupational therapy lie in assisting those with more intractable or complex problems to
identify their work needs, and helping them to achieve their goals, taking residual effects
of illness and disability into account … occupational therapy work practice in Canada,
America, Australia and Scandinavia demonstrates the potential of occupational therapy
within the work place’ (Mountain & Carman 2001 p4).
15
2.15
In the next chapter we propose using the new International Classification of
Functioning, Disability and Health (ICF) (World Health Organisation 2001) as the
framework for the new model for service delivery. However, we would summarise
this historical reflection with a depiction of the International Classification of
Impairments, Disabilities and Handicaps (ICIDH) and occupational therapy. This, we
believe, may also apply to health and social care more generally.
Figure 2 The main domains of occupational therapy service delivery
The primary focus of occupational therapy services in the NHS
Impairment
Disability
Handicap
The primary focus of occupational therapy services in
community social care
•
The principal role of occupational therapy personnel within the NHS is to treat illness,
injury or impairment. If they and others do that effectively, intervention has the
potential to avoid or reduce disability and consequent social handicap;
•
Similarly, if disability is treated or managed effectively, there is potential to reduce the
degree of disability, or to avoid or reduce handicap experienced by the individual;
•
However, within the current reductionist model of rehabilitation, occupational
therapists are required to concentrate on the impairment and a limited dimension of
disability. There is little time to focus on longer term outcomes that impact on
social handicap;
•
In social care services, occupational therapists intervene at the level of disability. They
are not expected or enabled to treat impairment and they have limited time to concern
themselves with the wider dimensions of social handicap. While they recognise the
need for therapeutic intervention, they have by and large been unable to access NHS
or hospital based treatment services (which have not been developed to meet this
out-patient demand) or additional rehabilitation services within the community;
16
ICF-2 approved as the successor of International Classification of Impairment,
Disability and Handicap (ICIDH)
‘Being complementary to the International Classification of Diseases (ICD-2), ICF will
hopefully open new aspects of great value for rehabilitation. ICIDH has undoubtedly
had a great impact from the conceptual point of view on research, teaching and
clinical work. ICF will hopefully have similar and even greater conceptual importance,
especially as it uses not only negative but also positive terms and includes
environmental factors, an aspect that was lacking in ICIDH. It makes it possible to
describe environmental facilitators as well as barriers’
(Grimby & Smedby 2001).
Brunel University uses the International Classification of Functioning, Disability and
Health as an educational framework
The ICF is used as a framework in the first year module ‘Occupational Performance’ to
develop students’ understanding of how pathology and impairments affect activity and
participation in everyday life. The ICF is presented as a model of disability with the
four dimensions providing a framework for assessment and intervention in chosen case
scenarios. Chapters from activity, participation and contextual factor dimensions
presented in the classification hypertext have determined acquisition of practical skills
and knowledge in seminars and lectures.
Students are encouraged to access the WHO ICF website as a resource for case-based
seminar work and written assignments. In the third year, students are re-introduced to
the ICF where greater discussion of the four domains has facilitated understanding of
evidence-based practice within occupational therapy and has also provided ideas for
undergraduate research projects.
(McIntyre 2001)
17
•
The historical divide between health and social care prevents services taking a whole
system approach towards the service user’s needs in the context of his/her social roles
and responsibilities and the lifestyle restrictions experienced. The NHS has not
adequately concerned itself with the consequences of avoidable disability and social
handicap for the individual and his/her carers, or for the social care sector. There has
been little incentive to measure the outcomes of service provision in terms of impact
on the wider aspects of disablement and handicap.
Questions ~
• Is the College’s overall assessment of the status quo a reasonable representation
of service characteristics around the country?
• Is this a sound basis for change?
3
A FRAMEWORK FOR THE FUTURE
A new approach
3.1
The International Classification of Impairments, Disabilities and Handicaps: a manual of
classification relating to the consequences of disease (ICIDH) (World Health
Organisation 1980), devised ‘to capture the variety of experiences of people living with
health conditions,’ is being superseded by the International classification of
Functioning, Disability and Health (ICF-2) (World Health Organisation 2001). This is a
bio-psycho-social model that emphases the universal nature of disablement. It has
moved away from the consequences of disease, taking a neutral stand with regard to
aetiology. The new classification introduces the concept that humans function at the
body, personal and social levels within their individual, personal and environmental
context. The ICF-2 considers functioning and disability to be the dynamic interaction
between health conditions and contextual factors, namely personal and environmental
factors.
Figure 3 Current understanding of interactions between the components of the
International Classification of Functioning, Disability and Health (ICF-2)
Health Condition
(disorder or disease)
Body functions
and structures
Activity
Environmental
Factors
Participation
Personal
Factors
World Health Organisation (2001)
18
3.2
The ICF-2 is not a consequential or hierarchical model but one with three distinct
and parallel dimensions of body functions and structures, activity and participation.
There is also the fourth dimension of contextual factors where interaction between
dimensions is complex and by directional. The terms body functions and structures,
activities and participation replace impairment, disability and handicap. They also
extend their meanings to include positive experiences. For further detail,
please see Box A.
BOX A Definitions from the International Classification of Functioning, Disability and
Health (World Health Organisation 2001)
•
ICF-2 provides a description of situations with regard to human functioning and
its restrictions and serves as a framework to organise this information. It provides
a structure to present the information in a meaningful, interrelated and easily
accessible way.
•
Definition of components in the context of health:
Body functions are the physiological functions of body systems (including psychological
functions)
Body structures are anatomical parts of the body such as organs, limbs and their
components
Impairments are problems in body function or structure such as a significant deviation
or loss
Activity is the execution of a task or action by an individual
Participation is involvement in a life situation
Activity limitations are difficulties an individual may have in executing activities
Participation restrictions are problems an individual may experience in involvement in
life situations
Environmental factors make up the physical, social environment in which people live
and conduct their lives.
Note:
Personal factors are the particular background of an individual’s life and living, and are
composed of features of the individual that are not part of a health condition or
health states. They are not classified in ICF but are included in the ICF’s figure to show
their contribution.
• ICF organises information in two parts; (1) Functioning and Disability, and
(2) Contextual Factors
• Functioning refers to all body functions, activities and participation as an
umbrella term; similarly disability serves as an umbrella term for impairments,
activity limitations or participation restrictions.
ICF is useful for a broad spectrum of different applications, for example social security,
evaluation in managed health care, and population surveys at local, national and
international levels. It offers a conceptual framework for information that is applicable
to personal health care, including prevention, health promotion, and the improvement
of participation by removing or mitigating societal hindrances and encouraging the
provision of social supports and facilitators . It is also useful for the study of health
care systems, in terms of both evaluation and policy formulation. (WHO 2001 A:4)
19
3.3
Since occupational therapy is concerned with activity (occupation) and activity
limitation and with participation (or life-style restriction) as it relates to an individual’s
personal experience and aspirations, the College welcomes this new model of ICF.
However, when set within the wider context of the Ottawa Charter for Health
Promotion (see Box B), as in Figure 4, it offers a broader way for looking at how
occupational therapy might better address the health and social needs of local
populations. By adopting this conceptual framework, services should be able to
embrace a more positive approach, in tune with the disability movement and the
emerging emphasis on strengthening community action in public health such as with
Health Action Zones.
3.4
ICF-2 is based on an integration of the opposing medical and social models. It is
person-centred and is therefore complementary to the occupational therapy
profession’s commitment to place clients and their carers at the centre of practice. The
use of such a framework can enhance clinical reasoning skills and communication with
professional colleagues and, at the same time, encourage a more flexible approach to
client-centred practice (Sumsion 2000).
Figure 4 ICF-2 set within the Ottawa Charter for Health Promotion (Wilcock 2001)
CLIENT CENTRED
HEALTH FOCUS
ACTION
DOMAIN OF CONCERN
Health Condition
(disorder or disease)
DEVELOP
PERSONAL
SKILLS
CREATE
SUPPORTIVE
ENVIRONMENTS
STRENGTHEN
COMMUNITY
ACTION
Body functions
and structures
Activity
Environmental
Factors
Participation
ENABLE
Personal
Factors
MEDIATE
REORIENT
HEALTH
SERVICES
BUILD
HEALTHY
PUBLIC
POLICY
Understanding of
Health through Occupation
Occupationally Just
Public Policy
ADVOCATE
Occupational Well Being
(throughout population)
20
BOX B Occupational therapy and health promotion
The Ottawa Charter for Health Promotion (World Health Organisation et al 1986) is a
central document in world health policy. It was the result of the combined wisdom of
212 delegates from 38 countries who met in Ottawa at the first WHO Health
Promotion Conference in 1986. The Charter can be seen as developing the WHO
definition and ideas of "Health For All" embodied in the Declaration of Alma Ata
(World Health Organisation 1978). It also informed the Health of the Nation
initiatives propounded by the UK Government.
The Charter stresses that the favoured roles of all health professionals should be those
of ‘advocate’, ‘enabler’ and ‘mediator’, one of which, in particular, that of ‘enabling
occupation’ has taken a strong hold in occupational therapy’s ideology and language.
Whilst in the past the profession has largely been concerned with enabling those who
have ‘medically defined’ handicap, enabling meaningful and satisfying occupation for
those who are socially and occupationally disadvantaged is an important direction for
the future.
The Charter recognises as pre-requisites for health – peace, shelter, education, food,
income, a stable eco-system, sustainable resources, and social justice and equity. Many
of these are dependent on, or manifest by, people’s occupations – occupation
encompassing all manner of ‘doing’. That raises the important notion of occupational
justice which, in a broad sense, is about the just and equitable distribution of power,
resources and opportunity so that all people are able to meet the needs of their
unique occupational natures, and so experience health and well being. In that regard,
the Ottawa Charter stresses that ‘health cannot be separated from other goals’, that
‘changing patterns of life, work and leisure have a significant impact on health’, and
that ‘to reach a state of complete physical, mental and social well-being, an individual
or group must be able to identify and to realise aspirations, to satisfy needs and to
change or cope with the environment’.
As occupation is the fundamental mechanism by which people ‘realise aspirations,
satisfy needs and cope with the environment’, this provides a clear mandate for the
further development of services to that end.
The Charter advocates five major strategies as listed in figure 4. They are that all
health professionals need to:
Build healthy public policy
Create supportive environments
Strengthen community action
Develop personal skills, and
Reorient health services towards the pursuit of health
When considering some of the possible occupational therapy initiatives within those
categories, directions for the future are apparent. To build healthy public policy, for
example, ‘health giving occupation’ is a health promotion message for everyone that
has been largely overlooked, and, in line with the Charter and the Health of the
Nation, the role of occupational therapy must move increasingly towards a community
health promotion direction and beyond its responsibility for providing clinical and
curative services.
(Wilcock 1998a), (Department of National Health and Welfare 1986)
21
3.5
To develop the application of this model, we could suggest that it be used to
achieve a better clarity between the function and purpose of occupational therapy in
the health and social care sectors. But that approach has limitations. There is no
confusion about specialist spheres of practice but clarity is needed in the common
ground described earlier. The majority of people who use occupational therapy
services have ongoing or enduring conditions, whether of physical or psychological
causation. This means that they have changing needs for health and /or social care
interventions across time. Within community mental health or learning disability
services, which have already achieved a better, even if imperfect degree of integration,
occupational therapy personnel are able to offer a more comprehensive approach,
referring to specialist colleagues when clients need help that is beyond their scope
of expertise.
3.6
The value of offering the same broad approach to older people and those with
physical disabilities leads the College to promote the development of a new model of
community based practice, delivered by occupational therapists able to provide a core
range of both health and social care interventions. The College believes that this is an
objective which health service providers, with their local authority partners, should seek
to achieve. As services are integrated for individual client groups, for example within
intermediate care for older people, they will at the very least wish to question the
continued validity of more than one occupational therapist intervening with one family
unless there is good reason to do so.
A strategic approach to integration
3.7
The College is therefore proposing that the ICF-2, set within the Ottawa Charter
for Health Promotion, be used as a framework to guide joint service reviews which
should consider:
• the importance of activity in people’s lives and how recognition of its value can be
restored within health and social care practice;
• how services focus on enabling occupation, addressing activity limitations and
life-style restrictions as experienced by service users and their families;
• how occupational therapy services should be jointly planned to achieve an
integrated continuum across health and social care. The continuum should embrace
prevention and health promotion (Clark et al 1997) as well as health and social care
service delivery.
3.8
Integration does not mean that all services have to come within one employing agency.
Imaginative solutions to multi-funded, integrated services exist within areas of health
and education that can be used as examples of good practice (Godbolt et al1997).
Such solutions may require detailed service level agreements; however, this level of
detail is for the future. What we are proposing here is an approach that brings
coherence to planning – a platform to think differently about how a valuable resource
is used to best effect.
22
3.9
Occupational therapists work as members of teams within hospitals, primary health
care, social care, education and employment services. The multiprofessional and
inter-disciplinary teams include a range of professions such as doctors, nurses, and
other allied and health professionals; teachers and psychologists; social workers and
home care staff; and housing, environmental health and technical staff. All will have
dealings with occupational therapy colleagues and a wider set of players in the
independent and voluntary sector, including representatives and groups of people who
use services. Occupational therapists are forging new partnerships with colleagues in
the health promotion area, as some are already doing in Health Action Zones. These
working relationships are vital to effective service provision. Our proposals are not
intended to cut across the continued need for good team and inter-agency working.
What our proposal for the development of a new model of community based practice
should do is:
• enable occupational therapists, in whatever team or service, to review, and achieve
clarity about, their place in the continuum of service provision, and
• collaborate with colleagues to ensure that the boundaries that necessarily exist
between services do not stand in the way of giving clients a person-centred
approach to their life-style needs and aspirations.
Questions
• Is beginning with a conceptual model the best way to approach change?
• Is ICF-2 an acceptable approach ~ would commissioners and providers be able to
use it?
• Does the wider context of the Ottawa Charter strengthen understanding of the
health benefits of occupation?
• Will it support the breaking down of barriers about health and social care
responsibilities and support the development of a continuum of integrated
occupational therapy services?
23
The context of change
3.10 If the adoption of the model of community based practice receives support, the College
will be advised by its members and others on the nature of implementation guidance.
For the moment, we would propose that commissioners, service managers and
providers start with an analysis of population needs, epidemiological trends and
current and future service demands. The need for change should be set in the context
of how occupational therapy personnel can be enabled to respond to current national
and country specific Government policies and priorities, including:
• Promoting independence1 - focusing on health and social care needs, thus enabling
disabled and older people to maintain, or achieve, the life-styles they desire;
• Preventing avoidable or unwanted dependence – providing services that help to
prevent avoidable admission to hospital, long term residential or nursing home care,
or dependence upon personal and family carers;
• Addressing social inclusion - by reasserting the wider occupational needs of disabled
and older people (including productivity and leisure);
• Reducing waiting lists – by re-focusing services to help prevent unnecessary referrals
to secondary care;
• Delivering on the objectives and standards in the National Service Frameworks (in
England);
• Working in partnership with individuals and their carers - as ‘enablers’, adopting the
concept of the ‘expert patient’ and giving people information that enables or
supports them in managing their own health conditions;
• Working collaboratively within teams, and across agencies, and sharing skills to
ensure a holistic and integrated approach to meeting people’s needs;
• Eliminating duplication that is confusing and exasperating for people who
use services;
• Supporting the public health and prevention agendas by advocating the importance
of occupational balance, including productivity, in healthy life-styles;
• Seeking to provide services on an increasingly sound evidence base that focuses on
the reduction of activity limitation and life-style restriction;
• Supporting value for money and best value regimes by demonstrating (a) the
efficiency of occupational therapy interventions, and (b) the value of timely
rehabilitation and occupational therapy input as a way of reducing the need for
additional care services, or avoidable dependence on long term state benefits;
• Promote recruitment and retention by assisting practitioners to play a full role in
undergraduate education through placements so that new graduates are well
equipped to meet the challenges of the workplace.
1
While using the Government’s policy objective of ‘promoting independence’, the College prefers the concept of
‘inter-dependence’ which recognises that human beings are essentially dependent on each other and that
‘independence’ is a personal construct which should be determined by the individual.
24
Modernising Occupational Therapy
Nottingham City Social Services Department reviewed the impact of occupational therapy skills within the
framework of assessment and care management and home care teams. The review uncovered potential savings
to SSDs through more creative use of then scarce occupational therapy resources.
The project began with an occupational therapist assessing the dependency levels of service users who were
receiving home care five to seven days a week. Using a standardised dependency index, of those assessed (n=56)
just over one half were found to have the potential to be more independent. The review found that:
Some people discharged from hospital still had intensive packages many months later suggesting the need for
structured reviews andhome care staff were performing tasks for people that they could do themselves, wasting
resource and prolonging dependency.
During the same project, 21 people were referred for long term placement in residential/nursing home care.
Joint visits were made with social work staff and an occupational therapy assessment completed. As a result, 12
people were kept at home, 8 of whom received support.
The review of the project concluded that a more creative use of community occupational therapists by
social services can lead to more effective and cost efficient community care services and can help to ensure that
expensive home care packages and long term placements are only used for people who really need them.
The success of this work has led to widespread creation of new occupational therapy posts within the assessment
and care management framework and home care teams. It has also led to therapy-led intermediate care services
based in residential local authority homes. Providing integrated community rehabilitation in people’s own homes
has enabled older people to regain their sense of autonomy as well as their independence, both values at the
heart of occupational therapy.
(McCloughry 2001)
The Joint Occupational Therapy Study
The Joint Occupational Therapy Study was grounded in a partnership between East Dunbartonshire Council,
Greater Glasgow Primary Care NHS Trust, Strathkelvin LHCC, and North Glasgow University NHS Trust – Stobhill
Hospital. The coterminous boundaries of the three agencies coincide with the Strathkelvin area with a
population of 72,843.
The study included occupational therapists working with adults and older people, excluding mental health and
learning disability. The review has enabled the development of a joint proposal for a new way of working, in
response to a number of national and local health and social care reports and policy documents emphasising the
importance of improved co-ordination of services to suit customer needs.
A multi-method review of service delivery by occupational therapists was carried out between January and March
2000. Apart from highlighting the confusion in roles between different agencies and professionals, it also stressed
the complex network of professions and organisations that they operate in, and emphasised the need to consider
the wider context of integrated health and social care.
It also emphasised the lack of knowledge about occupational therapy in general, a gap in rehabilitation
provision, the importance of localised access and the need for increased follow-up, and noted that the skills
recorded did not seem to vary considerably between the agencies.
The length of input was found to relate to three definite time spans: under a week, two weeks to two months,
and three months to two years.
Having developed a jointly agreed proposal on the basis of this work, the project is now moving in to the
implementation stage on a pilot basis and in acknowledgement of the rapidly developing Joint Future agenda.
(Buckle 2001)
25
Preparing practitioners to work in a new model of service delivery
3.11 A good body of evidence is emerging from recent initiatives in occupational therapy
service delivery about the strategic re-focusing of services, for example into accident
and emergency departments to help elderly people who have fallen (Close et al 1999).
The College will continue to give priority to enabling members to access and use the
evidence base and to be aware of best practice throughout the UK.
3.12 The College considers that the development of a new community based occupational
therapy general practitioner model is central to its wish to resolve the problems
around the interface between health and social care. We see this as pivotal to an
integrated approach that enables services to be developed as a continuum that is
focused on, and responsive to, the needs of all service users and their carers. The term
general practitioner is not intended to imply a medical model but, rather, to draw a
comparison with the GP model where the concept of the ‘specialist generalist’ is well
established.
3.13 To summarise, we believe:
• The majority of people who require occupational therapy live at home or in
supported care, within the community, and the majority have enduring
health conditions;
• That the profession has a responsibility to attempt to meet their wider occupational
needs, to challenge the limited focus on personal activities of daily living and to
address the wider aspects of activity and life-style restriction. This means restoring
an occupational perspective and its importance to disabled and older people and to
the health and well being of citizens;
• That changes in health and social care policy, and hospital practice, across the UK
(and ‘intermediate care’ in particular in England) will, and should, inevitably lead to
a reorientation of rehabilitation services to community settings, and that is where
the strategic development of the profession should lie.
3.14 Our perception of this community based, occupational therapy general practitioner
model is outlined in figure 5.
26
Figure 5 A community based, general practitioner service model for occupational therapy
HEALTH SECTOR
SOCIAL CARE SECTOR
Other NHS primary /
secondary care specialists
e.g. CPNs, district nurses,
stoma care and continence
nurses, psychologists,
orthotists, physiotherapists,
speech & language
therapists, dietitians,
chiropodists, dementia
services
Occupational therapy
knowledge and expertise:
• consultant or clinical
OT specialists e.g. in
neurology, mental
health, rheumatology,
learning disability
• specialists in prosthetic
and orthotic services
• specialists in complex
assistive technologies,
wheelchairs/seating
and environment controls
Other social care, housing,
employment, education and
voluntary sector services
and specialists e.g. social
workers, sensory services,
vocational/employment
rehabilitation, home repair
agencies, voluntary sector
user and carer organisations
Occupational therapy
knowledge and expertise:
• specialists in housing and
adaptations
• vocational and
employment
rehabilitation
• specialists in disability
equipment provision
• moving and handling
• OTs in voluntary/private
sector e.g. palliative care
services
Planned continuum of occupational therapy services
With access and direct referral
Care Pathways
Needs/Experience of people using Services
General Occupational Therapy Practitioner
The individual in
own home or
community setting
in health, social care or integrated team or
service
27
Essentially the service model proposes that:
• A new (specialist) general occupational therapy practitioner should be able to
provide immediate rehabilitation/treatment services, a sound range of disability
equipment (assistive technologies) and mainstream housing adaptations (such as
routine stair lift installations). In other words, such practitioners combine a major
element of the existing roles performed by occupational therapists in community
health and social care services. They also adopt a health promotion and prevention
approach, address occupational and activity restriction in its broadest sense and aim
to enable social participation;
• Within the planned continuum of occupational therapy services, they are able to
access and refer to other health (often hospital) based occupational therapists when
they need advice that is beyond their core competence i.e. when service users need
the input of a therapist with specialist skills in the treatment and management of
the consequences of impairment. For example, experts in seating and postural
management, managing oedema in cancer care, splinting in rheumatology, or
cognitive function;
• Similarly, the general practitioner is able to access and refer to occupational therapy
specialist counterparts within the social care sector, such as specialists in complex
housing adaptations, those working in vocational rehabilitation services and those in
specialist teams for people with sensory impairments or mental health problems –
essentially those services that provide bridges to participation.
3.15
The above examples serve to illustrate the parameters of occupational therapy
services. It is axiomatic that a community based practitioner will know about and
call upon the expertise of colleagues in other professions and other agencies
according to the needs of the individual service user. It is also implicit that this
practitioner will be able to assume the responsibilities of care management when
that is appropriate, particularly in supporting the social inclusion of those with
complex and enduring health conditions. Occupational therapists within this model
will bring a more holistic contribution to the Government’s planned introduction of
a single assessment process.
Conclusion
3.16
This proposal to establish a community based, occupational therapy general
practitioner model of service delivery will present a considerable challenge to the
profession but the College believes it will be welcomed. It needs to be taken
together with the proposal that services adopt ICF-2, set within the Ottawa Charter
for Health Promotion, as a basis for reviewing their services and working towards
integration across health and social care. We appreciate that there will be many
questions on ‘where do we go from here’? Services are configured differently
around the country. If embarking on integrating their occupational therapy services,
they will be starting from diverse points, have a range of imperatives and have
potential for change. Staff within both agencies will be loyal to their organisations
and have different perspectives on ideal outcomes. Salaries and conditions of service
are different which creates significant practical difficulty. The College does not wish
to prescribe a precise approach to implementation. We believe that the approach
needs to be organic. It needs to be driven by local ownership, in close collaboration
with the service user community, in response to a commonly developed view of
priorities and taking cognisance of the developing policy framework in each of the
four countries.
28
3.17
Occupational therapy services have grown considerably over recent years, outside as
well as inside the public sector. The marketplace is widening with the development
of vocational rehabilitation services within industry. Occupational therapists are
highly valued in the medico-legal industry providing disability cost assessment
services. There is more employment within voluntary agencies, the private residential
and nursing home sector, the disability equipment industry and housing services.
Such developments represent a positive response to meeting the needs of disabled
and older people in different ways. The College welcomes them all. In the future,
we envisage further developments as occupational therapy personnel embrace the
health promotion challenge and consider the occupational needs of people not
currently recipients of occupational therapy services.
3.18
The growth of the marketplace does however place an added pressure on the
statutory sector’s need to recruit and retain occupational therapists to meet the
demand we have referred to in this document. As both health and social services
management have been de-layered, it is evident to the College that many
occupational therapy services lack strategic direction and effective leadership. There
is considerable enthusiasm for integration but a sense of awe about turning the tide
of the last thirty years. What we have outlined is a vision and possible approach to
integration that may be useful in current negotiations. It is also a guide to the longer
term strategic development of occupational therapy services. The model will need
strategic commitment from service commissioners, service managers and the
profession. It will need clear leadership and dedicated champions at commissioner
and provider levels. There will need to be a coherent change management strategy,
with resources committed to organisational development and staff training and
development. If this Consultation attracts support, the College is committed to
playing its part in providing both leadership and practical support.
Questions
• Are the policy objectives outlined in 3.10 the right ones – are there others we
should recognise?
• Is there support for restoring the importance of occupation in the lives of service
users, and within the core role of occupational therapy practice?
• Will commissioners and planners be committed to developing the continuum we
propose ~ and is it likely to attract equal interest across health and social care?
• Is there support for the strategic development of a new community based,
occupational therapy (specialist) general practitioner model?
• What kind of implementation support would it be most useful for the College
to provide?
29
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ANNEXE A
College of Occupational Therapists (1999) Vision and Mission statements. Occupational
Therapy News, 7(10), 11
Quality Assurance Agency (2001) Subject Benchmark statements: healthcare programmes:
occupational therapy. Gloucester: QAA
Whiteford G (1997) Occupational deprivation and incarceration. Journal of Occupational
Science, 4(3) 126-130
Wilcock A A (2001) Occupation for health. Volume 1: a journey from self health to
prescription. London: COT
Yerxa E J et al (1989) An introduction to occupational science, a foundation for occupational
therapy in the 21st century. Occupational Therapy in Health Care, 6(4), 1-18
32
ANNEXE B
Barnitt R (1999) Reflect, research, revise. British Journal of Occupational Therapy,
62(9), 405-412
College of Occupational Therapists (2000) Code of ethics and professional conduct for
occupational therapists. London: COT
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guide to implementation. Edinburgh: Churchill Livingstone
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therapy and mental health. 2nd edition. Edinburgh: Churchill Livingstone
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London: Whurr
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Journal of Occupational Therapy, 62(5), 199-205
Finlay L (1997) The practice of psychosocial occupational therapy. 2nd edition. Cheltenham:
Stanley Thornes
Finlay L (1999) The challenge of teamwork. British Journal of Occupational Therapy,
62(9), 393
Godfrey A (2000) Policy changes in the National Health Service: implications and
opportunities for occupational therapists. British Journal of Occupational Therapy,
63(5), 218-224
Hagedorn R (1995) Occupational therapy: perspectives and processes. Edinburgh: Churchill
Livingstone
Hagedorn R (2000) Tools for practice in occupational therapy. Edinburgh: Churchill
Livingstone
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concepts and research. British Journal of Occupational Therapy, 62(10), 451-458
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62(8), 367-370
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perspectives. London: Whurr
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occupation. British Journal of Occupational Therapy, 63(5), 205-210
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policies? British Journal of Occupational Therapy, 63(7), 310-315
Rigney C (2000) Physical or mental health: should we divide? British Journal of Occupational
Therapy, 63(4), 177-178
33
Rose A (1999) Spirituality and palliative care: the attitudes of occupational therapists. British
Journal of Occupational Therapy, 62(7), 307-312
Savin-Baden M and Taylor C (2000) Voices from the borderlands: engaging with qualitative
evidence-based practice. British Journal of Occupational Therapy, 63(7), 303
Spalding N (2000) The empowerment of clients through preoperative education. British
Journal of Occupational Therapy, 63(4), 148-154
Sumsion T (2000) A revised occupational therapy definition of client-centred practice. British
Journal of Occupational Therapy, 63(7), 304-309
34
ANNEXE A
Occupational science: understanding the relationship between occupation,
health and well being
An evolving discipline
Occupational science emerged in the United States during the 1980s. It is an interdisciplinary
subject that aims to understand the complex relationship between doing, being and
becoming. Occupational science is defined as "the study of the human as an occupational
being including the need for, and capacity to engage in, and orchestrate daily occupations in
the environment over the lifespan" (Yerxa et al 1989).
Although the naming and framing of occupational science is relatively new, the health and
social benefits of a balance of work, rest and play has been known for a long time (Wilcock
2001). A decade of international research is contributing to a better understanding of the
human need to do, to engage in activities that hold meaning and purpose and that
contribute to a sense of personal and social worth.
Influencing occupational therapy education, practice and research in the UK
In 1999, the College of Occupational Therapists affirmed the profession’s commitment to
"the achievement of healthy outcomes through occupation". In this context, occupational
science is one of the foundation subjects studied on pre-registration programmes because it
is considered to be fundamental to everyday practice (QAA 2001).
The British Journal of Occupational Therapy contains papers that investigate occupation as
an applied as well as a basic science. In May 2000, the special issue on occupational science
attracted international contributors.
Potential impact on public health
The College believes that achieving a work-life balance is an important life style factor for
tackling health inequalities. In other countries this belief is linked to action to address
occupational deprivation, for example with prisoners (Whiteford 1997), and also to promote
occupational justice. The latter concept focuses upon the human need for, and right to be
engaged in, meaningful, satisfying and ecologically sustainable occupations.
35
ANNEXE B
The beliefs and values of occupational therapists in the UK
Introduction
The following beliefs and values were derived from an analysis of recent literature produced
by UK based occupational therapists and published in UK journals and books. Occupational
therapists based in Ireland and publishing in the UK were also included. The statements
make use of the words used by occupational therapy writers. Each concept is described in
the context of the statement. Jargon words and those that are open to different
interpretations, such as client-centred and empowerment, have been avoided.
Occupational therapists in the UK believe that:
1.
People are innately active beings who need to engage in a balanced range of
occupations in order to develop, to maintain health and to realise their fullest
potential throughout the life cycle.
2.
The performance of activities, which have purpose and meaning for the individual, can
promote and restore health and quality of life.
3.
People live and act within social and physical contexts that influence their choices of
occupation and the ways in which they perform their chosen or required range of
occupations.
4.
Each person has the capacity to adapt to circumstances and to make choices about how
she or he lives.
5.
Occupational therapists are concerned with promoting function, quality of life and the
realisation of potential, and not just with restoring or maintaining health.
6.
The role of the occupational therapist is to inform, support, facilitate and provide
opportunities for clients to perform activities in order to improve their quality of life.
7.
Occupational therapists are concerned with the total illness experience of the client
and how impairment affects all aspects of his or her life.
8.
Occupational therapy intervention is most effective when it is integrated into the life
and context of the individual, the family and carers.
9.
The occupational therapy process is most effective when it is a partnership between the
client and the therapist in which the client participates actively in setting and
realising goals.
Occupational therapists in the UK hold the following values:
1.
Occupational therapists respect and value individuality and diversity in their clients,
within their own profession and in their colleagues.
2.
Clients have a right to information, which will enable them to make informed choices
about their care and their lives.
3.
Occupational therapists listen to their clients in order to understand their needs, values,
interests and aspirations.
4.
The client’s goals take precedence in the treatment programme.
5.
Occupational therapists are concerned with all aspects of human function: physical,
cognitive, emotional, spiritual and social.
6.
Occupational therapists promote personal identity by giving information and choices to
their clients.
7.
Occupational therapy practice is culturally sensitive and culturally relevant.
8.
Occupational therapists reflect on their practice and strive to improve it.
9.
Each occupational therapist has a responsibility to ensure that she or he provides a
high quality of service that meets the client’s needs and does no harm.
10. Occupational therapy is part of the total care of the client and the occupational
therapist is a member of the multidisciplinary team.
36
ANNEXE C
Questions to Address
• Is the College’s overall assessment of the status quo a reasonable representation of
service characteristics around the country?
• Is this a sound basis for change?
• Is beginning with a conceptual model the best way to approach change?
• Is ICF-2 an acceptable approach ~ would commissioners and providers be able to use it?
• Does setting it in the wider context of the Ottawa Charter strengthen understanding of
the health benefits of occupation?
• Will it support the breaking down of rigid barriers about health and social care responsi
bilities and support the development of a continuum of integrated occupational therapy
services?
• Are the policy objectives outlined in 3.10 the right ones – are there others we should
recognise?
• Is there support for restoring the importance of occupation in the lives of service users,
and within the core role of occupational therapy practice?
• Will commissioners and planners be committed to developing the continuum we
propose ~ and is it likely to attract equal interest across health and social care?
• Is there support for the strategic development of a new community based (specialist)
occupational therapy general practitioner model?
• What kind of implementation support would it be most useful for the College to provide?