How occupational therapists can support the work of general practice

GP partner Dr Arvind Kochar and advanced practitioner Lisa Greer explain how occupational therapists can support GP practice teams based on the experience of a primary care occupational therapy service operating in Scotland

NHS Lanarkshire is the third largest health board in Scotland, serving a population of approximately 655,000 people across rural and urban communities in North and South Lanarkshire.

The board launched a primary care occupational therapy (OT) service in 2017, in partnership with two Lanarkshire GP practices, one of which was MacInnes Medical Centre. This work was funded by the Scottish Government’s Mental Health and Primary Care Transformation Programme, with the aim of identifying new models of practice that could reduce pressure on GPs and respond to the changing health needs of Scotland’s population.

The service has evolved since then and currently operates within two of its 10 locality areas, Hamilton and Bellshill, serving 21 GP practices and approximately 125,500 people.

Why take on occupational therapist roles in primary care?

The GPs at MacInnes Medical Centre acknowledge that their understanding of OT was limited before the service was launched. Their perception was that the workforce was hard to reach, that OT focused on the provision of adaptations and had little to offer in the way of mental health support. GPs were also concerned that the service might identify problems in patients who would then return to the practice and create more work, instead of reducing their workload.

However, as a busy urban GP training practice, functioning over two sites with a patient population of 7,857, it was keen to take up the offer of expanding its practice team and offer a wider range of treatment and care options for the adult and older adult populations. The practice’s appreciation of the full range of skills and services that occupational therapists (OTs) can offer has grown considerably in the four years since they joined.

Day-to-day role of OTs within the practices

The OTs are based on each site between one and three days a week depending on practice size and workload. Referrals for any patient aged 16 or over are accepted from all members of the practice team including GPs, trainees, practice nurses and pharmacists. Using a standard operating procedure, the OTs provide comprehensive biopsychosocial assessment and intervention to individuals aged 16 and over who are experiencing functional decline as a result of changes in health. This includes people with:

• Mild to moderate mental health issues
• Long-term conditions
• Pain or fatigue
• Falls and frailty
• Difficulties remaining at or returning to work
• Mild cognitive impairment.

Their assessment employs a ‘What Matters to You’ approach, to help identify an individual’s functional difficulties and priorities for change. Intervention very much depends on the goals identified by the patient and could include any, or all, of the following:

• Provision of small aids to reduce falls risks, improve functional mobility and increase independence within activities of daily living
• Education in pain, activity and fatigue management to enable people to self-manage long-term conditions
• Use of psychological approaches, such as behavioural activation, graded exposure, cognitive behavioural therapy strategies and mindfulness
• Vocational rehabilitation assessment, identification of reasonable adjustments, completion of the Allied Health Professions Health and Work report and liaison with employers and occupational health providers to support employment retention
• Signposting and practical assistance to reduce the barriers experienced in accessing community-based organisations in order to reduce health inequalities and improve social inclusion
• Carer support to reduce the physical, environmental, emotional and social impact of carer roles.

Qualifications and skills

OTs are qualified at BSc or pre-registration MSc level and registered with the Health and Care Professions Council. All OT clinicians are dual trained across physical health and mental health at undergraduate level to provide a ‘whole person’ approach to assessment and intervention, supporting individuals to overcome or manage the difficulties they experience with performing everyday life activities or occupations, as a result of ill health and disability. This includes activities carried out within a person’s home environment, within their workplace or within their local community.

Communication and support

The OT team has a robust clinical governance framework aligned to NHS Lanarkshire policies and a standardised supervision structure, which ensures that all clinicians receive professional clinical supervision and informal support from senior occupational therapy staff within the team.

The GPs at MacInnes Medical Centre regularly catch up with OTs for informal discussions, for example to discuss a particular referral, and are confident that the OTs bring any patient-related concerns to their attention to agree a safe and person-centred solution.

The GP partners are also consulted and informed about service evaluation and improvement, with regular GP practice-level and service-level updates and presentations.

How have patients and GP practice teams benefitted?

Evaluation completed in May 2021, and that relates to 18 GP practices across Bellshill and Hamilton localities, including MacInnes, shows that having OTs as an integral part of the practice team brings a range of benefits. These include:  

1. OTs can deal with a huge range of problems and work independently to resolve them. This has resulted in reduced return appointments for the GPs. A recent audit showed that 60% of patients discharged following an episode of OT intervention between June 2020 and March 2021 had fewer GP appointments in the six months after the intervention than prior to referral.
2. The care is holistic and patient-centred addressing physical, psychological and social needs. Our data indicates that 45% of patients referred were also experiencing mental health issues, 23% physical health issues and 32% both mental and physical health issues. These patients are managed within the service, streamlining their care and reducing the need for multiple onward referrals.
3. The model is proactive, using an early intervention for prevention approach that reduces the risk of ongoing deterioration. In total, 86% of patients reported improved performance in their everyday roles.
4. The OTs have excellent links to wider services and have opened doors to health and social care support as well as community-based opportunities for patients and their families.
5. The OTs also look at the big picture, working to promote the health of communities as well as individuals.
6. The majority of patients have seen improvement in their mental wellbeing. Use of the Warwick-Edinburgh Mental Wellbeing Scale to screen patients at assessment and discharge demonstrated that 93% of patients experienced an improvement. In addition, a detailed survey of GPs indicated that practice referrals to secondary mental health services have reduced significantly.
7. During the Covid-19 pandemic OTs were able to adapt their model to respond quickly to patient needs making a real difference to the mental health and resilience not only of patients but also of staff.

Dr Kieran Dinwoodie, GP at Calderside Medical Practice, adds that: ‘Having an OT in our practice has been transformative. It is improving patient outcomes and reducing GP stress. [Patients] are in less distress and attend less frequently.’

Future development of the role

Due to the positive outcomes achieved during the initial testing phase, the primary care OT  workforce has grown from two advanced practitioner clinicians to a team of 13. They have permanent contracts with NHS Lanarkshire to allow them to continue to provide a service to GPs in Bellshill and Hamilton localities. We would like to see the service further extended across all 10 Lanarkshire localities.

Their next challenge is to develop self-referral and care navigation pathways and a first contact practitioner role, improving direct access to occupational therapy for patients who would benefit from early intervention to reduce the functional impact of mild to moderate health and wellbeing issues.

Dr Arvind Kochar is a GP partner at MacInnes Medical Centre in Motherwell and Lisa Greer is an advanced clinical practitioner in occupational therapy based at the practice. She is employed by NHS Lanarkshire Primary Care Occupational Therapy Service

Additional Information

So, how can my PCN/ practice based in England hire an OT?

As of 2020, the Network Contract DES Additional Roles Reimbursement Scheme (ARRS) allows PCNs to be reimbursed the costs of employing OTs. There are certain criteria for the role which can be found in Annex B of the Network Contract DES guidance. 

GP practices in Networks can either hire OTs themselves or as part of an agreement with local providers.When hiring an OT, practices must ensure they have access to a clinical supervisor and another individual in the PCN to help out on a daily basis.

What qualifications does an OT need?

OTs employed under the ARRS must:

• Have a BSc in Occupational Therapy under a training programme approved by the Royal College of Occupational Therapists, 
• Be registered with the Health and Care Professions Council (HCPC) 
• Be able to operate at an advanced level of clinical practice
• Be experienced in managing an assigned caseload, completing assessments, planning and implementing patient interventions, and evaluating the impact of care plans
• Have a working knowledge of GP practice and prescribing data monitoring systems
• Be able to write comprehensive clinical notes

What salary does an OT earn?

The salary for OTs working in primary care, at an advanced level of practice, falls in band 7 on the NHS Agenda for Change pay scales. After the government’s award announced in July 2021, this lies approximately between £40,000 and £46,000. 

Advanced level of practice means being able to work across the four pillars of clinical practice, leadership and management, education and research, or be working towards gaining these skills. This is usually a MA degree or its equivalent, and a minimum of five years post graduate experience.