REDESIGNING CARE: HOW A GP-BASED OCCUPATIONAL THERAPY SERVICE IS REDUCING HOSPITAL ADMISSIONS AND IMPROVING LIVES

The challenge

Historically, patients accessed Occupational Therapy (OT) support after a crisis—such as a fall or hospital admission. This reactive model meant that many individuals with chronic health conditions and frailty were left unsupported until their needs escalated and became bigger issues. There was also a gap in joined-up care for patients whose physical health needs were closely linked with mental health challenges, such as memory difficulties, anxiety, and low mood.

Rugby Health Primary Care Network (PCN), which covers 12 GP practices, was seeking to move from this reactive approach to proactively caring for its local communities. This shift highlighted the need for new models of care that were preventative, holistic, and accessible for patients with long-term conditions.

What we did

The PCN established a GP-based Occupational Therapy service with a proactive and preventative ethos, supporting people to maintain independence, reduce risks, and live more meaningful lives.

The team supports patients to enjoy life, work, and leisure activities as independently as possible. It focuses on enabling people to gain practical skills to manage the impact of their health and wellbeing challenges so they can continue to access the everyday activities that matter most.

The OT service provides specialist advice and therapy-led sessions for conditions including Fibromyalgia, chronic fatigue and pain, low-level anxiety related to daily task completion, low mood and arthritis.

Key initiatives part of the service include: 

• Specialist symptom support: Helping people stay independent and continue daily activities that matter to them.
• Pain management service: Helping people with long-term pain, like fibromyalgia or arthritis, learn ways to manage their pain, stay active, and take part in daily life without relying only on strong pain medicines.
• Peer support groups: Connecting people to share experiences, learn from each other, and feel supported.
• Frailty outreach programme: Supporting older adults who are living with risk of frailty to access a wide range of support that can enable them to live more positively and independently. 
• Mental wellbeing hub: Supporting patients to manage the impact of low-level mental health difficulties which have arisen due to physical health conditions. 

Outcomes

By using the service patients can benefit from improved pain and symptom management, greater independence, mental health support, connections to peer groups and support programmes and more joined-up care. 

In addition, the personalisation of care and psychological approach enables the team to tailor therapy to support patients to increase their independence and reduce ongoing needs for frequent GP visits. 

People using the service have said they feel more supported, less isolated, and better able to manage their health. 

A snapshot of patient feedback:

"The support, advice and service were really welcomed. It helped me use techniques and tools to deal with pain. I now feel I have strategies in place to help.”

“I feel I have more in my ‘toolbox’ now to help me cope with the various aspects of my condition, including the many different perspectives there are to a single subject! I feel so much more positive about things going forward.”

“Occupational Therapy has been very valuable to me, and I have appreciated my time with my therapist. She has provided me with skills needed to manage my condition.”

Overall, the service helps people live more independently, reduces unnecessary hospitalisations, and improves quality of life - delivering both patient and system-wide benefits.

Listen to how a patient in Rugby has benefited from the Occupational Therapy service by watching the video below.