Amy Edwards, Professional Affairs Officer at the College of Occupational Therapists responds to Jeanne Carlin’s article, The Arcane Workings of the Occupational Therapy Service
I read with concern Jeanne Carlin’s experience of occupational therapy services for both her parents and her adult daughter. Jeanne must have been feeling at a loss when she seemed to have the responsibility of deciding whether her parents should be seen by a health or social services-based occupational therapist, or that she should be trying to work out which occupational therapists are responsible for which pieces of equipment. Clearly it is not the intention of any service to place additional burdens onto a service user.
Jeanne’s experience highlights a number of key issues for provision of integrated occupational therapy services.
The first of these is how we define integration. Recent work has been carried out nationally, both to define integration and to describe what an ideal integrated service would be like for a service user in relation to goals/outcomes, communication, information provision, decision making, care planning and transition between services*. It is clear from Jeanne’s descriptions that her experience in these areas was far less than ideal. Although from a service user’s perspective, integration should simply mean ‘continuity of care’, in practice, the situation can be more complicated, since integration can relate to levels of care (primary, secondary, tertiary), professional boundaries, specialisms, organisational boundaries or geographical areas.
Jeanne’s experience highlights problems of integrated working in many of these areas, for example between organisational boundaries – health and social care – as well as geographical areas. In relation to organisational boundaries, occupational therapists working in health generally have to refer to social services based occupational therapists for major housing adaptations. Although this is changing in some areas, occupational therapists do need to have the necessary skills and experience to ensure they are working safely, as well as the case load capacity to follow through from the beginning to the end of the adaptation. In this instance it sounds like the health occupational therapist working with Jeanne’s daughter was able to make the correct recommendations, but did not have access to the necessary procedures to carry them out. It may also be that the health-based occupational therapist did not have capacity to follow the case through once s/he had made her recommendations.
Geographical boundaries, also discussed in Jeanne’s account, are often cited by occupational therapists as a reason why services become less efficient; a different boundary often means a different set of procedures and paperwork, which becomes problematic in the situation described, when a child’s school is in one area but her home is in another.
Integration between specialisms is a further area of concern; returning to Jeanne’s father, services for people with dementia are probably categorised under ‘mental health’ services rather than physical health, so this is a whole further area of potential integrated working. Degree of specialisation is a key concern for occupational therapists; if you integrate a service, how do you ensure that specialist skills are retained and available when needed, rather than the service becoming wholly generic?
An event was held recently to look at how to improve integrated working by occupational therapists, both within a relatively large geographical area and between health and social care. There was no lack of enthusiasm from the occupational therapists to be working more closely together; it was clear that they wanted to provide the best possible service for their clients. When determining what an ideal service would look like, they suggested that disciplines would work together from the beginning to the end of an intervention, that there would be ‘one door’ into the service, that communication between professionals would be improved, and that there would be a better experience for the service user.
Barriers to integrated working which are often cited by occupational therapists include:
• difficulty in communication, often due to electronic information systems not being compatible;
• not enough clinical involvement in decision making at the point of entry into the service, if there is involvement at this stage, people can be directed to the right occupational therapist from the beginning;
• excessive time needing to be spent on paperwork required to action interventions and referrals, leading to less time being spent on client contact;
• The expectation for occupational therapists to see more clients, meaning that they have to focus on their core responsibilities, and less time is then available for joint or integrated working.
There are certainly examples of occupational therapy services which have been integrated successfully, some for several years, whilst others are only just beginning the journey.
Ideally, for Jeanne, there should have been a referral for an occupational therapy assessment of her parents’ needs, related to their mobility, functional and cognitive ability, rather than a separate referral for each problem. There is learning to be gleaned from this. What Jeanne’s experience makes clear is that when service integration is being planned, service users need to be involved. Health and care professionals need to take account of service users’ experiences, so that they know what to do, as well as what to avoid.
* National Voices (2012) A narrative for person-centred coordinated care.
London: National Voices and Think Local Act Personal
The College of Occupational Therapists’ website is here
Update 28.08.13: Some specialist suppliers have contributed their experience of working with OT services, which you can read here