The Future Direction of Occupational Therapy Post the General Election. Suzanne Rastrick Chief Allied Health Professions Officer The College of Occupational Therapists. 30 June 2015

How ‘Big Picture’ Priorities Affect Occupational Therapy

Government Priorities

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

NHS England Priorities for 2015/16

Improving Health Our 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. Overview of our first four priorities 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. 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. 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. 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.

Redesign Care Our 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. Overview of priorities 5-8 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. Strengthening primary care services: We need to strengthen primary care as the foundation for personalised NHS care. Timely access to high quality elective care: We must ensure elective care continues to meet service standards and remain accessible for patients. Ensuring high quality and affordable specialised care: We must reshape specialised services to improve their quality and future affordability.

Whole system change for future clinical and financial stability Our 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 efficiency The 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).

How Does Commissioning Work?

NHS Outcomes Framework – 5 Domains

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

Commissioners are sighted on what “citizens” want. Adapted from: Legatum Institute (2014) Wellbeing and Policy

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

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

Patient Choice….

As a commissioner what would I want to know about your service? How much does the service cost? Is it worth buying? What does the service actually do? What difference does it make? Can you evidence what outcomes you deliver? What do you do that helps me reach my targets? Eg. To maintain people at home OT Service How safe and effective is your service? Can I get this service cheaper or more flexibly from someone else? Does it serve the needs of the local population?

Can you demonstrate that your service is worth funding amongst others? Us! Us! Go on, you need us! We’re really nice and we do a great job! other providers Support workers P Physios Social workers O T Nurses

Influencing Commissioners Members 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.

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!

Radical upgrade in prevention Efficiency & investment The future NHS The core argument made in the Forward View centres around three ‘gaps’: 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 gap Radical upgrade in prevention 1 Care & quality gap 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 2 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 Efficiency & investment 3

Principles of the New Care Models programme Clinical Engagement Patient Involvement Local Ownership 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: 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 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 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 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

First cohort Vanguard sites Care model Applicant PACS Wirral University Teaching Hospital NHS Foundation Trust Mansfield and Ashfield and Newark and Sherwood CCGs Yeovil Hospital Northumbria Healthcare NHS Trust Salford Royal Foundation Trust Lancashire North PACs Hampshire & Farnham CCG Harrogate & Rural District CCG Isle of Wight MCP Calderdale Health & Social Care Economy Derbyshire Community Health Services NHS Foundation Trust Fylde Coast Local Health Economy Vitality West Wakefield Health and Wellbeing Ltd (new GP Federation) NHS Sunderland CCG and Sunderland City Council NHS Dudley Clinical Commissioning Group Whitstable Medical Practice Stockport Together Tower Hamlets Integrated Provider Partnership Southern Hampshire Primary Care Cheshire Lakeside Surgeries Principia Partners in Health Care model Applicant Care Homes NHS Wakefield CCG Newcastle Gateshead Alliance East and North Hertfordshire CCG Nottingham City CCG Sutton CCG Airedale NHS FT

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

Plans for Rehab Programme 2015/16 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

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

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

Can you demonstrate that your service is worth funding amongst others? Us! Us! Go on, you need us! We’re really nice and we do a great job! other providers Support workers P Physios Social workers O T Nurses

What can be the consequences of unclear messages? OTs struggled to maintain their professional identity in multidisciplinary teams Robertson & Griffiths 2009 “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

British Journal of Occupational Therapy, Awaiting Publication “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 practice Turner A and Alsop A (2015) Core Skills – Exploring occupational therapist’s hidden assets. British Journal of Occupational Therapy, Awaiting Publication

Practical skill based profession 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

Hidden core skills versus the public face of practice This is unchanging and forms the basis of all practice Central philosophy Professional belief in the impact of occupation on health and well-being These skills are unchanging though tools may vary Unique core skills based on reasoning Analysing & prioritising occupational needs Evaluating occupational outcomes Identifying and assessing occupational needs Enabling occupational performance Splinting Group work Wheelchair assessment Cognitive behavioural skills Home visits Context dependent practice skills Communication Leadership Research Teaching Business skills ADL Vocational rehab Supervision skills Creative skills Leisure skills Reflection Housing adaptations Mobility Management Social skills ©annie turner 2015 These practice skills are driven and changed by fashion, research, legislation, context and technological development

The duality of professional practice in Occupational Therapy The visible face of professional practice is based on rational scientific thinking that evidences the skills and competences used as the media of intervention The hidden reasoning of occupational therapy is based on the romantic concept of the positive impact of meaningful occupation on health and well being ©annie turner 2015

(Occupational form and Occupational Alienation A Hierarchy of Concepts related to Occupation Romantic thinking Expectations Motivation Life stage Culture Environment Occupational deprivation ROLE ROLE(mother) OCCUPATIONAL PERFORM (Occupational form and OCCUPATION “mothering” ANCE function) Activity (packing school lunchbox) Occupational Alienation Etc.. Task Clean Lunch box Prepare drink Make sandwiches Etc… Occupational Balance Performance components Skills Occupation as a “means” and as an “outcomes” Rational thinking Etc.. Grip flask Grip lid Unscrew lid Having ingredients ready Judging amount of concentrate ©annie turner 2015

Yes we have the answers ready! You employ us because…… Yes we have the answers ready! We know how much our service costs We know what difference we make to our service users. We’ve got the evidence We use appropriate, consistent outcome measures We use evidence informed practice. We create evidence Our practice clearly demonstrates our professions’ uniquenesses 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

Connect & share…

OTs & other AHPs are ideally placed to deliver many of the ambitions in the 5YFV   Two fundamentals AHP’s deliver on: Innovation Entrepreneurship Some areas to strengthen: Economic evaluation Consistent outcome data Developing networks to spread excellent practice

Suzanne Rastrick Chief Allied Health Professions Officer Suzanne Rastrick Chief Allied Health Professions Officer …will you join me? @SuzanneRastrick