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Roots of recovery: Occupational therapy at the heart of health equity

Community rehabilitation

The World Health Organization has defined rehabilitation as ‘a set of measures that assist individuals who experience, or are likely to experience, disability to achieve and maintain optimal functioning in interaction with their environments’.69 Article 26, Habilitation and Rehabilitation, of the United Nations Convention on the Rights of Persons with Disabilities (CRPD) calls for ’full inclusion and participation in all aspects of life’.70

Rehabilitation has far-reaching health, social and economic benefits. It delivers better outcomes and improved quality of life, improving functional outcomes, reducing length of hospital stay and enabling timely return to education, work or occupation and community living.71.72.73

Community rehabilitation is now a crucial part of recovery for those people affected by COVID-19, including those presenting with Long COVID or a deterioration in pre-existing conditions and mental health. Effective rehabilitation can reduce the physical, psychological, emotional, social, and economic impacts of the pandemic.73

Rehabilitation helps people to live well with long-term conditions. It is known that people from deprived populations are more likely to have multiple long-term conditions74, and 17 per cent of the UK population is expected to have four or more chronic conditions by 2035.75

 People with low incomes and those from minority groups report difficulty accessing support to manage their long-term conditions.76 There are known inequalities in access to rehabilitation77 and poorer experiences of health services are reported by some social and ethnic groups.78 It is necessary to increase the availability of rehabilitation for those in greatest need. The routes to receiving support must be developed in partnership with communities to ensure access is inclusive for the local population reflecting diversity, cultural and personal needs.

In the community, occupational therapists may act individually or within combined allied health professions rehabilitation teams. Occupational therapists within rehabilitation are specialists in:

  • Self-management approaches: occupational therapists support people to adopt healthy behaviours and strategies that enable participation in daily life and to achieve outcomes that have meaning for them, and support people with complex needs to overcome barriers to accessing existing opportunities such as social prescribing.
  • Personalised care: occupational therapists embed personalised care through training and supervising others, including support workers, informal carers, care home and home care providers.
  • Independent living: the profession’s understanding and expertise on the relationship between occupations and the environment is pivotal in supporting people to return to living meaningful lives.79
  • Assistive technology: occupational therapists review care packages and advise on the use of assistive technology to minimise reliance on carers.80

Key components for delivery

Establish and support occupational therapists where they can:

  • Coproduce multidisciplinary community rehabilitation services that provide support based on needs rather than conditions.
  • Provide accessible and timely community rehabilitation for those in greatest need and in the most deprived areas through localities/place-based services.
  • Collaborate across primary, secondary and voluntary sectors.
  • Address physical, psychological and social needs holistically, as part of integrated rehabilitation pathways.

Return on investment

  • Community rehabilitation can save significant amounts of taxpayer money through early intervention reducing the need for more costly health and social care. It also reduces demand on residential care settings by enabling people to remain safe and well in their own homes. Conversely, without access to community rehabilitation, there is a reduction in quality of life, an increase in the risk of social isolation and greater long-term costs for health and social care budgets.77
     
  • Recent research into the cost benefits of rehabilitation in complex cases has shown that lack of investment in rehabilitation and patient support during the first year after hospital discharge increases costs to the NHS in the longer term. Failure to provide rehabilitation and support services in the first year (on average £4.1k per patient) leads to increased dependency and excess care and accommodation costs (on average £14.6k). This would suggest that investment in community rehabilitation services could save the NHS money to the tune of approximately £10k per patient, per year.81
     
  • Community rehabilitation reduces hospital admissions82 and demands on primary care by enabling people to manage their conditions and prevent deterioration in their health. Where hospital care is required, early community rehabilitation can reduce the length of admission,83 and therefore the cost.
     
  • Research from the Health Foundation estimates that if people who feel least able to manage their long-term conditions were supported to manage them as well as those who feel most able, 436,000 emergency admissions and 690,000 A&E attendances could be avoided each year.84

Case Study: Occupational Therapy Services, Glasgow City Health and Social Care

Traditional service structures employ occupational therapists in either health or social care. The creation of Glasgow City Health and Social Care Partnership (HSCP) meant occupational therapy staff came under one partnership and this offered the opportunity to review how occupational therapists worked.

Awareness

A key ambition is to ensure rehabilitation is available for people that require it, regardless of the care group they are in. To reduce hand overs between occupational therapists, duplication of assessment and waits for different occupational therapy services; occupational therapists need to use all the skills they had at the point of registration in addition to other specialist skills they may develop such as assessment for major adaptations and brief mental health interventions.

Action

A competency-based model was developed for occupational therapists working across the teams. These were based on the knowledge that all occupational therapists graduate with a common level of knowledge. The “green” competencies could be done by anyone, the “red” competencies remained very specialist but most work was focused on the “amber” tasks to ensure these areas become “green”.

Advocacy

The model is now rolling out to include more care groups, such as learning disabilities, addictions and homecare. These populations have previously limited access to rehabilitation as either viewed as having limited rehabilitation potential or requiring a specialist service. Evaluation of peoples experience of the service is used to review and develop the model and its roll out.

Outcome

Rehabilitation is offered at the right time and place and by the right person. Occupational therapists can maintain and support the care, assessment, and outcomes for an individual, where previously a person was referred to another occupational therapist based in a different part of the service. The service is widening access to occupational therapy, with shorter waiting times and fewer staff involved.

An Occupational Therapy Continuous Improvement Group has been established to take forward the findings of an evaluation of staff experience of the core competency work and use case study analysis for ongoing review.

References

69.  World Health Organization; The World Bank (2011) World report on disability. Geneva: WHO. Available at: https://www.who.int/publications/i/item/9789241564182

70.  United Nations (2006) Convention on the rights of persons with disabilities (CRPD). New York: UN. Available at: https://www.un.org/development/desa/disabilities/convention-on-the-rights-of-persons-with-disabilities.html

71.  Bradley A, Marshall A, Stonehewer L, Reaper L, Parker K, Bevan-Smith E...Naidu B (2013) Pulmonary rehabilitation programme for patients undergoing curative lung cancer surgery. European Journal of Cardio-Thoracic Surgery, 44(4), 266-71.

72   Welsh Government (2021) Rehabilitation: a framework for continuity and recovery 2020 to 2021. A framework to help organisations plan rehabilitation services following the coronavirus pandemic. Cardiff: Welsh Government. Available at: https://gov.wales/rehabilitation-framework-continuity-and-recovery-2020-2021-html

73.  Scottish Government (2020) Framework for supporting people through recovery and rehabilitation during and after the COVID-19 pandemic. Section 9. Edinburgh: Scottish Government. Available at: https://www.gov.scot/publications/framework-supporting-people-through-recovery-rehabilitation-during-covid-19-pandemic/pages/9/

74.  The King’s Fund (2019) Long-term conditions and multi-morbidity. London: The King’s Fund. Available at: https://www.kingsfund.org.uk/projects/time-think-differently/trends-disease-and-disability-long-term-conditions-multi-morbidity

75.  Pearson-Stuttard, J, Ezzati M, Gregg EW (2019) Multimorbidity – a defining challenge for health systems. The Lancet, 4(12), E599-E600.

76.  The Richmond Group of Charities (2021) You only had to ask: what people with multiple conditions say about health equity. London: The Richmond Group of Charities. Available at: https://www.richmondgroupofcharities.org.uk/wp-content/uploads/2021/07/youonlyhadtoask_fullreport_july2021_final.pdf

77.  Community Rehab Alliance (2020) Community rehabilitation: Live well for longer. London: CSP. Available at: https://www.csp.org.uk/system/files/publication_files/Right%20To%20Rehab%20Report%2C%20February%202020%20-%20web.pdf

78.  The King’s Fund (2020) What are health inequalities? London: The King’s Fund. Available at: https://www.kingsfund.org.uk/publications/what-are-health-inequalities#access

79.  Royal College of Occupational Therapists (2019) Rehabilitation. London: RCOT. Available at: https://www.rcot.co.uk/practice-resources/occupational-therapy-topics/rehabilitation

80.  Royal College of Occupational Therapists (2019) Relieving the pressure on social care: the value of occupational therapy. RCOT: London. Available at: https://www.rcot.co.uk/promoting-occupational-therapy/occupational-therapy-improving-lives-saving-money

81.  King’s College London (2021) Specialist rehabilitation: focus services early to transform lives and save money: London: King’s College London News Centre. Available at: https://www.kcl.ac.uk/news/spotlight/specialist-rehabilitation-focus-services-early-to-transform-lives-and-save-the-nhs-money

82.  National Institute for Health and Care Excellence (2018) Emergency and acute medical care in over 16s: service delivery and organisation. Chapter 13 community rehabilitation. (NICE guideline 94). London: NICE. Available at: https://www.nice.org.uk/guidance/ng94/evidence/13.community-rehabilitation-pdf-172397464600

83.  Neuburger J, Harding KA, Bradley RJD, Cromwell DA, Gregson CL (2014) Variation in access to community rehabilitation services and length of stay in hospital following a hip fracture: a cross-sectional study. BMJ Open, 4(9). Available at: https://bmjopen.bmj.com/content/4/9/e005469

84.  Deeny S, Thorlby R, Steventon A, (2018) Reducing emergency admissions: unlocking the potential of people to better manage their long-term conditions. London: The Health Foundation. Available at: https://www.health.org.uk/publications/reducing-emergency-admissions-unlocking-the-potential-of-people-to-better-manage-their-long-term-conditions