Reflections on my Elizabeth Casson Lecture: Occupation for Health – and Wealth?

Sheelagh Richards, FRCOT OBE

On reading my Elizabeth Casson Memorial Lecture 22 years down the line, I can only marvel that conference participants stayed awake; if only I’d had the foresight displayed by Jenny Butler to  give everyone an opportunity to ‘shake about’ with some music.   An hour on Government policy would have merited When the Saints Come Marching In, or maybe Land of Hope and Glory!

Presenting the lecture is an enormous privilege and a scary experience combined – an honour bestowed by your peers, and an endeavor to be judged by them, novice and doyen alike.  Conditioned by sage advice that a good lecture should contain no more than five big ideas, and you’ll be lucky if the audience remembers one, the challenge of a long Casson lecture was daunting.  I remember now how constrained I felt at the time; as a Department of Health officer it was my duty to explain government policy; indeed to ‘sell’ it, and certainly not to criticise or question the grand ambitions.  But looking back, it was an exciting time and I set out to share that with the audience.  A year after Tony Blair’s new Labour government had come to power, grand plans were pouring out of Whitehall, and many emanating from the Department of Health spoke to our beliefs and values.  Times felt good, opportunities abounded for the profession to connect with the new agenda and demonstrate the way in which occupational therapists really do have the capacity to change service users’ lives; to contribute to the health and the wealth of the nation and its disadvantaged citizens.

Adding ‘Wealth’ to ‘Health’

 

 

Adding the ‘Wealth’ to ‘Occupation for Health’ felt risky, would the notion of saving the nation money feel vulgar to a profession committed to its moral goodness and professional purity?  I smile now to see the College’s vision on the home page of its website ‘Occupational therapists improve lives and save money for the health and social care services on a daily basis’.  Bingo, that concept has evidence, credence and respectability; bravo and thank you RCOT!

If there was one under-pinning theme throughout the lecture, it was about the power of words.  I referenced the work of leading lights at the time – Yerxa, Clark and Whiteford and paid tribute to Dr Ann Wilcock who had presented the earlier keynote address.  Occupational science and models of human occupation were taking off and presenting us with entirely new concepts and a new language for occupational therapists to use to promote the profession and its contribution to society at large.

At the end of a meeting with the then Secretary of State for Health, the very amiable Frank Dobson, I recall saying words to the effect

We humans are occupational beings; we are what we are because of what we do, we do what we do because of what we are.  You get recognition, social status, your economic independence, feelings of self-worth and a life-style full of opportunities from what you do Secretary of State.  Disabled people are so often denied opportunities to engage in occupations that add value to their lives’.

Oh so bold, but Frank got the message and agreed that was what our policies should be aiming to achieve.  How far we had come from ‘occupational therapists promote independence’ – I felt empowered by our emerging understanding of the science of occupation in human life.

Working across agencies and boundaries

Keeping in touch with news from the UK in the wilds of Costa Rica, I’ve lost count of the reorganisations the NHS has endured since my departure in 2006, never mind since the Casson lecture 22 years ago.  Every reform suggests the one before didn’t work, and one wonders why not?   Did the profession really grasp and benefit from all the policies I described?   Well, I had penned some thoughts on that but they are pointless now, Boris Johnson and Matt Hancock have just announced their plan for another major reform of health and social care – here we go again!

This time though, I like the sound of their intentions.  Super-quangos have become remote from government; ploughing their own paths, the Secretary of State has realised control and command is outside his reach.  In the initial press release, I spotted key themes and words I used in my lecture – integration, joined up thinking, working across agencies and boundaries –  ‘The changes would aim to tackle bureaucracy (of their own creation!) … and encourage GPs, hospitals and social care to work more closely’.  Heard it all before?

Much to be proud of…

I was reminded of the College’s bravery in publishing the consultation ‘From Interface to Integration’, a Strategy for Modernising Occupational Therapy in Local Health and Social Care Communities’, in January 2002.  Our profession is unique in the span of its presence in health and social care, and its ability to work and talk across the boundaries of housing, employment, the private and voluntary sectors.  We were excited about the ‘joining up’ agenda at that time, racing to take advantage of the policy agenda, but it seems it didn’t happen to the extent we had hoped.  Never-the-less, evidence of OTs breaking down barriers and developing new ways of working collaboratively is evidenced regularly in BJOT and OT News, we have much to be proud of.   But driven by the mixed-market imperative, the government simply dropped the ball on making the legislative changes which were necessary to achieve real integration.

Systems thinking

Well, I thought I should read the white paper – Integration and Innovation: working together to improve health and social care for all – to understand the substance behind the grand statements and see the shape integration might take.  Groan, it’s a turgid read:  badly structured, full of repetition, laden with well-worn clichés and riddled with bald statements that X action will produce Y outcome.  I’m horrified to read just how many organisations and structures have been developed to sustain the market model, especially over the last twenty years. The notion this has been ‘the cornerstone of best value for taxpayers’ beggars belief, and begs for proper analysis.

Leaving all the structural and legal stuff aside, one paragraph in the Executive Summary talks our language on integrating care around people and not institutionsCare that focuses not just on treating particular conditions, but also on lifestyles, on healthy behaviours, prevention, and helping people live more independent lives for longer

And that’s illustrative of the ‘admirable’ aims peppered throughout the document; wooly, ill-defined, and lacking any new paradigm of ‘whole systems’ thinking.  There is one mention of housing, no mention of employment, and no mention of the benefits system and how it may or may not serve to incentivise lifestyles and participation in society.

In the absence of a big picture, there is a clear danger that ‘lifestyles’ and ‘prevention’ will be narrowed down to imploring the population to stop drinking sodas, eating burgers, getting fat and getting diabetes?!

‘Helping people to live, not exist’

Which brings me back to reflections on my lecture, and the power of words.   I summed up my lecture with suggestions for the profession on ‘Moving Concepts – changing language’

 

All these years down the line, the Royal College has nailed it – Helping people to live, not exist

Short and powerful, the one big thought you would want to take away from any Casson lecture.  What we would want for ourselves and our nearest and dearest; what we should want for our patients and clients.

That seems a compelling paradigm, and one the profession should champion: try selling it to Matt Hancock, or at the very least use it argue for more honorable ‘outcomes’ of health and social care interventions.   Stop counting beans and start counting users’ satisfaction with their lifestyles and levels of social inclusion?

Occupational therapists know only too well that failures in the NHS – through the absence of adequate rehabilitation, or poorly planned hospital discharge, have a knock-on consequence on social care, and on the welfare and benefits system. Failures in social care, by (for example) assessing dependence rather than potential for independence, have costs to the social care and benefits systems. Most importantly, these failures have costs to our service users in terms of lost opportunities to engage in occupations of their choice and participate in society as they would wish.

Occupational therapy really is good for the Health and the Wealth of the nation

Delivering the Casson Memorial lecture was a huge privilege and I have to admit, also a huge pleasure; the appreciation of one’s peers is beyond measure.

Thank you friends at the Elizabeth Casson Trust for giving me this opportunity to reflect.

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