Growing primary care
We’ve spoken to occupational therapy leaders from Scotland and Wales who’ve developed universal coverage for primary care occupational therapy in their health boards.
We asked about their challenges, successes and how you can have influence to apply this locally and nationally. We spoke to:
- Shonaid McCabe, Occupational Therapy Care Group Lead at Primary Care, NHS Lanarkshire.
- Alex Gigg, Lead Occupational Therapist at Swansea Bay Health Board.
- Alexis Conn, Clinical Lead Occupational Therapist for Mental Health at Betsi Cadwaladr University Health Board.
- David (Dai) Davies, Professional Practice Lead for Wales from RCOT.
Why did you develop OT services in GP surgeries?
Alexis. Because it’s the right thing to do. Why do we put self-management at the end of the person’s journey rather than at the beginning?
Shonaid. There was a political driver as in Scotland there was primary care redesign as part of the General Medical Services (GMS) contract. We had the chance to have the discussion about how we could change primary care and do it differently.
We saw an opportunity to make occupational therapy accessible to people earlier in their health journeys. To develop an earlier intervention for a prevention approach to patient care. With the primary care transformation work streams underway this opened the field for conversations.
Dai. The big drive was the healthier wales strategy and its emphasis on moving services into the community and focus on prevention.
Alex. It began with the virtual ward model and a missing skill set was identified and that was occupational therapy. We could fill the gap in clusters. With that gap in the multi-disciplinary team (MDT) and occupational therapy fitting this, we thought, could we do a pilot?
How did you develop a vision and get buy in?
Alex. On my first day I turned up and they said -what are you going to do? They didn’t understand the breadth of occupational therapy. I needed to show the GPs. So, I went through the patient lists and looked at patients and said, I could see these people for you. By doing, you build alliances with people and if you choose you allies carefully, they will promote you.
Shonaid. We came at it from an angle of how we could support the GP workforce. We thought about what roles do GPs do that they don’t need to?
What can we do better for you as occupational therapists? What sort of people do you feel you don't’ have much to offer, or time to offer or skill set?
This helped GPs see the gap that occupational therapy could fill. That GPs find hard to provide or isn’t in their skill set. We found once we’d converted the GPs, shown them what occupational therapy could do for their patients, we made friends and supporters for life.
Alexis. We started working in a GP surgery that was being taken over by a health board. We looked at a model from Alaska called the nuka model with a range of different professionals. In the model they have behaviourists, and someone said, well actually occupational therapy could do this part of the model.
So, it was part of the MDT philosophy and looking at the gaps. GPs knew what the gaps were and when we were in primary care, we could understand their pressure points. Like the need for self-management, and that we can address this. Then we could show the GPs and rest of the MDT what we can do. They could leave the medical needs to other members of the team, and we can support health and wellbeing in the home.
Dai. The best visions that get the most traction are those that focus on occupation.
How have you got the right people in place?
Shonaid. We had to think about recruitment so that we got the right people. We had to think about occupational therapy staff, GP partners and patients. We got the primary care occupational therapists on board by interesting them. We excited and enthused them, saying for example, that you can work across mental and physical health. We did online sessions to educate them in advance about working in GP surgeries and what the role would involve.
The GPs who then could see what we could do, helped to promote us. Finally, the patients became our biggest advocates. They would come back and say, this has been the positive impact on my life. Use of care opinion in Scotland has enabled patient feedback to be shared widely with all sorts of stakeholders.
Alex. When we recruited the occupational therapists to the GP surgeries, we asked lots of values-based questions to get the right people.
Dai. To support getting the right people, we are working with Health, Education, and Improvement Wales (HEIW) to look at occupation therapy student placements. Also, to think about how occupational therapists can be prepared across the pipeline to work in primary care.
Alexis. It’s important to get the right people in place but it’s also about leaders. So, for example, occupation therapy strategic leads in health boards, you need people to advocate for you at that level. To say, OTs are already doing this in other parts of Wales; we could do this for you too.
Bring them on board and understand their drivers such as accelerated cluster development and the AHP framework in Wales. By working in this way, you are considering which policy drivers will get buy in with occupation therapy strategic leads.
What outcomes were most useful?
Alexis. You don’t end up collecting what you first started collecting! But just start collecting some outcomes, stop being scared. Don’t think you have to collect everything all at once. We started small, just once they have seen us are they more or less likely to come back and see someone again?
Understand the impact you’re making. As you build, you will see what you’re missing, the gaps, what’s important to people around you. For example, your impact on the services around you, how having you there supports GPs.
If we improve patients’ lives, they are less likely to use services. As you start to collect outcomes, you will start to collect in more detail, across more perspectives. Stop being bashful about the impact we have on services. We’re too cautious. We say, we think we may have had an impact. Other professions don’t do this. We need to have confidence in what we have changed.
Shonaid. I think in Scotland funding determines what outcomes you need to gather so stakeholders and funders stipulate your outcome measures.
This has led to some fragmentation problems in occupational therapy service provision in Scotland. For example, with primary care frailty services, primary care mental health occupational therapy services and vocational rehabilitation occupational therapy services. We were fortunate that our initial funding was not restrictive as it was from primary care transformation money, so we were allowed to choose.
In the early days, the primary focus asked of us was do you save GP appointments/reduce their workload? We said, we can collect this data, but we also want to collect something about patient outcomes too. So, we used the Canadian occupational performance measure (COPM) and the Warwick-Edinburgh mental wellbeing scale (WEMWBS). We also collated data on cost avoidance and savings.
Also, qualitative data; we need to think more about is the person happier because of the occupational therapy intervention. Patient and GP experiences have been invaluable for us.
Dai. Outcomes and finance are always linked. We need to understand the world view of our stakeholders and what outcomes may be related to this. When thinking about outcomes and finance, we need to think about who gets what. Also, who owns what, who does what and. who gets affected by what some people get.
We also need to think about how we adapt, and evolve services based on a grasp of others’ views, and the related outcomes and finances.
Alex. Data capture is key, and it will evolve and change. By working with allies, we can identify what is tangible here to measure. What others prioritise and what you want to prioritise may be different. For example, admission avoidance may be crucial for secondary care but not so much for GPs.
What do they get from the occupational therapy skill set? We need to take a multifaceted approach to outcomes. Think about what you can use that could useful. Like using case studies. Be ready to contribute to MDT outcomes, even if you don’t like it. The Welsh government like the EuroQol (EQ5D) so we collect it to get our voice into the picture.
What have been key challenges and solutions?
Alex. Fragility of funding; all transformational funding has a shelf life. We were able to make some of the roles permanent but when people left, there was no continuity planning. During covid it was hard because there was some reallocation of staff to places like covid testing centres. This is a consistent picture across Wales. There isn’t clarity about who takes on the ongoing funding of the occupational therapy services.
Shonaid. This fragility of funding is echoed for Scotland.
Dai. This is a challenge for governments. If they want occupational therapy, they must pay for it. We’re increasingly lobbying to raise this issue to governments.
There are also actions for occupational therapy managers. For example, lots of students want to work in primary care; they don’t want to work for six months on a medical ward. This is the evolution of the profession. We need to shape it from in-front rather than being behind the change. We need permanent funding.
Alex. One of the solutions to this is to continue to collect outcomes. Get a range of outcomes so we can put business cases across and be there. We need to be ready and opportunistic to get a foot in the door. So, we can be ready to say -we’ll give this a go. Primary care occupational therapy should be a part of core services, not a nice add on.
Alexis. A different challenge is the philosophical one. If you’re used to working in medical services, we struggle with the change to primary care. The importance of shared decision making and self-management. We’re used to being coercive and directive. In acute settings people’s goal is often just to get home and they’ll do whatever they can to get home.
In primary care people are independent decision makers and we need to change our practice alongside people. We are challenged to let go of control -we can’t control it all.
We need to support people with their own plans. If you can get your head around this as an occupational therapist, it’s really liberating. Occupational therapists say to me, I feel like I’m a proper occupational therapist! This also links to evidence; we end up trying to do treatments that we can measure in a medical model.
Shonaid. There are also challenges around infrastructure in primary care that make it difficult for new services and professions coming into it. For example, it’s difficult getting accommodation for the occupational therapists. It can be difficult to work remotely due to outdated IT systems. With it being a new area, staff need to feel connected and supported otherwise it can impact on staff health and wellbeing.
It’s an evolving area of practice. Staff need time to develop their knowledge and skills about how to deal with this new type of working. Lots of the time my focus has been trying to find ways to look after staff.
Lots of primary care occupational therapy services in Scotland are funded with temporary funding steams. We were for five years and so staff are often on temporary contracts. This is bad for staff and the occupational therapy profession.
Dai. The solution is occupational therapists thinking like occupational therapists in relation to managing primary care services. It’s that dynamic approach and understanding to being an occupational therapy manager: using occupational therapy skills to see the whole system.
What’s your vision for the next 15 years?
Alexis. I’d like to see occupational therapy embedded more into primary care and integrated into the community so we can move to a preventative approach.
In primary care we can see trends and needs more clearly in the population. We need to think, what can we do about these needs? We need to work more closely with the third sector. Then occupational therapy can become truly preventative, and we can help people before they come through the door.
Dai. My vision is that when I phone the GP surgery, the receptionists ask how is this effecting your everyday life? So, the whole GP surgery and the whole workforce understand the importance of occupation.
Shonaid. Primary care occupational therapy services will be available across the whole of Scotland at a practice or cluster level. The role of occupational therapy in primary care will be well understood so people will recognise they need to see us. They’ll be able to access this directly via the GP care navigation systems or a direct primary care occupational therapy number for their surgery.
Alex. The future focus must be on the prevention agenda. I want an occupational therapist in every cluster and network across Wales.
We need whole system change; we need to reverse the pyramid of our workforce. We need more of us in the community, less in hospital. We need more resources in the community so we can enhance and optimise all community services and social care.