BACKGROUND
General practice faces a workforce crisis, constrained finances, unsustainable workloads, and increasingly complex medical and care needs.1,2 The Royal College of General Practitioners (RCGP) highlighted the challenge in 2015, stating that the number of consultations per year in England had increased by more than 60 million.3 The Five Year Forward View supports focusing on prevention and managing patients within the community.2 The General Practice Forward View identifies the need to build the wider workforce in primary care to address some of these challenges.4 The RCGP has supported work promoting and developing innovative roles to alleviate pressures that the system is facing.3
Occupational therapists are highly skilled practitioners working across health and social care. A clear fit with primary care regarding health promotion and holistic care has already been recognised.5 Occupational therapists value the importance of promoting mental and physical wellbeing, and are skilled in assessing the impact of developmental, physical, and mental health conditions.6 Occupational therapists are not routinely utilised within the primary care workforce in England despite their potential to provide valuable skills, support, and resource to GPs.
An article in the BJGP by Brooks and Milligan7 supports the integration of occupational therapy (OT) in the delivery of Sustainability and Transformation Plans. They argue that this offers a cost-effective solution that ‘... reduces pressure on GPs, reduces referral to secondary care, enhances timely hospital discharge, and keeps people independent at home.’.
THE INTERVENTION
The University of Southampton OT Programme has developed student placements in diverse, non-traditional areas of practice. The concept driving these placements is the establishment of an OT role in new areas to demonstrate the added value that an OT perspective may provide the service.8 These placements have also been shown to promote increased awareness of the profession,9 leading to employment opportunities.
This work explored how OT could contribute to local primary care provision. ‘Role-emerging’ placements were developed across four settings in Hampshire, each hosting one student. Three areas were identified where students could gain experience and complement their undergraduate studies: frailty and complex disease, mental health, and learning disabilities.
Two settings were within GP surgeries focusing on all three clinical areas of frailty, mental health, and learning disability. One placement was within a multidisciplinary nursing home team focusing on proactive care in residents identified as high users of unscheduled care. The fourth placement, in a community team, focused on the value of proactive care of frailty in the community.
Students undertook 10-week placements working within primary care teams. There were no qualified occupational therapists working within the services. Specialist occupational therapists in physical health, mental health, and learning disability working within local trusts provided supervision to students. Students were also supervised by the primary care clinicians on a daily basis.
The first 2 weeks consisted of an induction where students undertook an observational role, getting to know the members of the team and becoming familiar with primary care. Students sat in with GPs and members of the team to develop their understanding of the service and identify potential areas where they could enhance patient care by providing an OT perspective. This was also an opportunity for the team to better understand what the student had to offer and help identify appropriate patients for the student’s caseload.
In weeks 3–8, students developed their own service and worked on a small caseload under supervision. A referral form helped the team identify an appropriate caseload, exploring a wide breadth of skills that could be used within the setting (Box 1).
Difficulties engaging in personal, social, domestic, leisure activities Challenging or disruptive behaviours impacting daily life Social isolation Low mood, anxiety, stress management, sleep hygiene Chronic disease: health promotion, self-management, supporting and maintaining activities Safety and falls prevention Returning to work/productive roles
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Box 1. Summary of referral criteria
Students carried out assessments in the GP services and, when appropriate, in the community and in patients’ homes with the appropriate level of support and supervision. Referrals were reviewed by qualified occupational therapists and all stages of the assessment, intervention, and evaluation were discussed prior to being undertaken. In the final weeks, students continued to undertake short-term interventions as well as succession planning for the caseload.
FINDINGS
Evaluation was conducted through semi-structured interviews at the end of the placements. The aim was to evaluate and explore the value of learning in primary care for OT students from the perspectives of students, supervisors, and the primary care team. In addition, this work aimed to consider the wider implications and potential of OTs working within primary care.
Ethical approval was granted by the University of Southampton and 20 participants were recruited for interview (Table 1). Interviews were recorded, transcribed, and anonymised. Data were coded and themes were identified using thematic analysis.
GPs and primary care teams reflected on the added value of OT in primary care and what skills this offers a workforce under significant pressure:
‘We need to look at ways that we can innovate … we need someone to deal with the social issues, those complex issues that now the OT student is allowed to do, they’ve got a much wider remit and for us that’s really helpful. Learning difficulty, frailty, mental health; they are all key areas that we need help with … I think I learned that it is a much bigger role and that there is a lot of potential there.’
(GP)
Placements allowed for a deeper understanding of the breadth of skills OT could offer. Themes emerging across settings included: the benefit of a holistic approach, the role for proactive care in the community, support for mental health care, and reducing pressure on GPs and services. Mental health was widely recognised as an area where OT could provide significant support, particularly with patients not meeting the threshold for Community Mental Health Teams:
‘We seem to have an awful lot of mental health issues … most people never reach the criteria for mental health services and a lot of people are frightened about dealing with mental health, but the OTs have a skills base that gives them confidence to deal with that.’
(GP)
GPs felt that students were able to tackle some of the deeper-rooted issues that a 10-minute consultation struggles to address. GPs reflected on the work undertaken by students and the positive physical, psychological, and social impact this had on patients:
‘People we know come to see us frequently, being able to get behind some of the issues because in a 10-minute consultation you can only just skate around some of the issues and I found [the OT student] was able to get much deeper into some of the root causes … social and psychological. It’s not the medicine that’s complicated, it’s the other bit.’
(GP)
Students and occupational therapists identified the value of understanding primary care and where their skills fit within the service. The environment provided an opportunity for students to develop generalist skills as independent practitioners while consolidating their learning from previous placements. Students felt that they developed a deeper sense of professional identity and a better understanding of what primary care could offer as a potential working environment:
‘I gained a much stronger sense of self within my profession.’
(OT student)
‘My assessment skills had to evolve because I had to assess the person holistically.’
(OT student)
SUMMARY AND RECOMMENDATIONS
Through placements, we were able to further understand the added value that OT offers primary care at a time when it is under significant pressure. Students’ work provided examples of a proactive, holistic approach to addressing physical, psychological, and social aspects of patient care within primary care settings. Through placements, services were able to explore how integrating occupational therapists into their teams could help promote health and wellbeing in their communities.
The services were able to test out innovative roles through undergraduate placements with no financial commitment attached to the process. Following placements, two settings created employment opportunities for qualified occupational therapists within their teams, reflecting the value they identified within this role.
Students and occupational therapists were able to explore new work settings, and this exposure to primary care offered an insight into potential career pathways, promoting primary care as a career option. Given the positive outcomes from these placements, further work is recommended to consider the value that qualified occupational therapists could offer primary care on a longer-term basis as part of an integrated multidisciplinary workforce.
Notes
Provenance
Freely submitted; externally peer reviewed.
- © British Journal of General Practice 2019
