Academic journal article British Journal of Occupational Therapy

Occupational Therapists' Perceptions of Appropriate Therapy Aims for Service Users in Mental Health: A Survey of Therapists in the United Kingdom

Academic journal article British Journal of Occupational Therapy

Occupational Therapists' Perceptions of Appropriate Therapy Aims for Service Users in Mental Health: A Survey of Therapists in the United Kingdom

Article excerpt


Payment by results system in mental health services

Payment by Results (PbR) is 'the payment system in England under which commissioners pay health care providers for each patient seen or treated, taking into account the complexity of the patient's health care needs' (Department of Health [DH] 2012). In April 2012, the DH mandated PbR to National Health Service (NHS) mental health services in England (DH 2009, Howitt 2009). PbR offers a means of increasing accountability for targeted service delivery and documentation of outcomes in a range of service areas including occupational therapy (DH 2011a, 2011b, 2010a, 2010b, 2009).

The adoption of the PbR system is based on the care pathways and care packages approach (Self et al 2008). The approach was developed by South West Yorkshire Mental Health NHS Foundation Trust as a classification system that categorized working-age and older service users based on need. Service users were allocated to one of 20 'clusters', based on scores from the Mental Health Clustering Tool (MHCT), an instrument that incorporated items from the Health of the Nations Outcome Scales (HoNOS, Wing et al 1999) and the Summary of Assessments of Risk and Need (SARN, Self et al 2008). The 20 clusters can be broadly categorized in three subgroups: eight non-psychotic, eight psychotic, and four organic.

Mental health professionals were asked to develop discipline-specific care packages for these clusters. The United Kingdom Centre for Outcomes Research and Education (UKCORE) partnered with a working group of therapists from mental health trusts in England and with scholars from the University of Illinois at Chicago (UIC) to develop the occupational therapy indicative care packages. As the outcome of this effort, the final indicative care packages (Garnham et al 2010) were presented to the Department of Health (DH 2011c) and disseminated throughout England. These indicative care packages describe specific occupational therapy assessment areas, expected outcomes, intervention strategies, and resources for service users who belong to each of the 20 PbR clusters. Intervention planning and condition-specific intervention planning in the context of clinical clusters through the provision of the PbR system both require an understanding of the care pathways and approaches recommended by the indicative care packages.

Care pathways and care package approaches

Care pathways are guidelines or standards for an area or aspect of care (Abreu et al 1996). They may be based on theory and research evidence as well as existing, successful assessment and intervention protocols (Forsyth 2010). Care pathways aim to achieve efficiency and quality improvement (Abreu et al 1996, de Luc 2000, Duncan and Moody 2003) by focusing on desired health care outcomes and the necessary steps to achieve them (Hoffman 1993).

The guidelines or procedures specified in care pathways ensure that certain considerations are taken into account or certain actions performed to enhance the likelihood that targeted outcomes are achieved. Care pathways can help to clarify the role of care providers in the various stages of client care, including referral, assessment, intervention, goal identification, and discharge (Rigby et al 2007), and have been introduced in some areas of mental health practice (Melton et al 2008). As such, care pathways can tell service users what services to expect (Melton 2010). Changes in health care reimbursement systems, such as managed care in the United States (USA) and PbR in the United Kingdom, have mandated an increased focus on the measurable outcomes that care pathways specify. As a result, there is a growing demand for, and use of, care pathways (Kent and Chalmers 2006).

Despite this trend, occupational therapy has been relatively slow to create and use care pathways internationally. In the UK, where 86% of NHS Trusts reported using pathways as early as 1999 (Currie 1999), occupational therapists have been only marginally involved (Duncan and Moody 2003). …

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