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Date of submission:
23 May 1997
All names of participants and of their borough have been omitted to preserve confidentiality.
Word count: 9471
Care management is a relatively new system of fieldwork used by social services departments. Care managers are commissioners of services, forming individual packages of care for clients. Some local authorities now employ occupational therapists as care managers alongside workers with social work qualifications. Occupational therapists working as care managers were interviewed to investigate their subjective experiences of the advantages and drawbacks of working as care managers. Interviews were conducted and the responses analysed. The results show that occupational therapist care managers feel that care management enables them to broaden their role, develop new skills and practice in a more holistic way than allowed by the previous form of local authority occupational therapy role. There are, however, negative aspects. They feel that they are sometimes required to play a double role as care managers and as occupational therapists. They also feel that they are sometimes disadvantaged by their minority status in the profession and by other professions' negative or misinformed notions of the occupational therapy role.
Care management first made its appearance in the USA where a wide diversity of organisational frameworks and service providers made the creation of unitary local authorities impractical. A method of co-ordinating care provision from a variety of providers was therefore needed. In the USA the new method was commonly referred to as case management, but the terms have been used interchangeably. Government publications (Audit Commission, 1992; Department of Health, 1990; Griffiths, 1988; SSI, 1994) predominantly describe the process as care management, so this term will be used throughout this report. The first significant appearance of care management in the UK was in the Kent Community Care Project (Challis and Davies, 1986). Praised for its innovation, the project's ideals were incorporated into the Griffiths Report (1988) and into subsequent community care legislation.
The introduction of care management in the UK came in the wake of the National Health Service and Community Care Act (1990). It is intended to reflect the move toward a purchaser-provider split and an increasingly mixed economy of care. Care managers are intended to act as brokers for services across both statutory and independent sectors (DOH, 1990, p24). Their role is an embodiment of the concept of the purchaser-provider split. This is intended to ensure that services commissioned for service users are a true reflection of their individual need rather than a reflection of the services offered by the local authority. It is also proposed that devolved budgets will bring spending decisions closer to users and therefore increase their power in decision making. The Audit Commission (1992) noted that "In Social Services Departments care managers are intended to relate closely to individual users and carers -- particularly those with complex needs -- and provide integrated packages of care through service agreements with service providers."
The introduction of the role of care manager has begun to transform the role of social services fieldworkers and made minor inroads in weakening the hegemony, within that role, of social work. The care manager role is notably different from the social work role although there are many overlaps. Policy guidance states that "The skills required of care managers may be found in a number of professions and will vary according to the needs of service users and the model of care management adopted." (DOH, 1990)
The most common experience of local authority fieldworkers is that of a change in title and role from social worker to care manager. In some cases local authority fieldworkers have retained the title of social worker whilst carrying out care management functions. A minority of local authorities have recruited care managers from outside the social work profession.
Although social workers occupy most care manager posts this has not come about without some anxiety. Concern has been expressed that social work training does not adequately equip social workers for care management (Clode, 1993). Others have argued that care management is a new profession that requires its own accredited training (Gupta, 1996). Still others have argued that care management damages social work's traditional worker-client relationships (Lewis, 1990). Despite this, there is still resistance to the integration of other professions into care management.
On a more positive note, many care managers have found their new role enabling. Neate (1993) questioned seven care managers to assess their experience of the role. Only one was from a background (hearing therapy) other than social work. All the care managers performed assessments and devised packages of care. None held budgets other than one who managed 22 social workers and three team leaders. This illustrates the variety of posts titled care manager. Two of the care managers approached in the initial phase of the present study were found to be senior managers rather than fieldworkers. The article also illustrates that few care managers hold budgets but are responsible for accounting for their spending decisions. Most of those interviewed spoke of the importance of negotiation in the commissioning of a care package. Most had little training for their new role but spoke positively of their increased ability to coordinate more aspects of provision and their ability to be responsive to client need.
It has been noted that the Griffiths report "made no reference to social workers and already care managers are being recruited from outside the ranks of the profession" (Hanvey and Philpott, 1994). Indeed, Griffiths (1988) stated that "The change in role of social services authorities might also allow them to make more productive use of the management abilities and experience of all their staff, including those who are not qualified social workers."
Roy Taylor, Director of Kingston-upon-Thames Social Services Department has noted that "some SSDs have found occupational therapists' organisational skills have fitted them well for care management." (George, 1994) Government publications have agreed: the Social Services Inspectorate (1994) recommended that occupational therapists should be able to move into care management.
Local authorities vary in the extent to which they have incorporated care management as a system of working. Previously, occupational therapists were employed only as occupational therapists, usually being concerned with issues related to equipment and adaptations. Some local authorities now employ occupational therapists as care managers alongside care managers with social work qualifications.
Hitherto, no published studies have specifically investigated the phenomenon of occupational therapist care managers although the issue was addressed as part of a larger study (Stalker et al., 1996). The present study set out to discover how occupational therapists who work as care managers have experienced integration into the new system.
As care managers have overall responsibility for setting up and monitoring care packages, the task differs markedly from those performed by occupational therapists working in their more traditional social services roles. However, the holistic nature of care management matches the holistic values of occupational therapy (Carnduff, 1990). The present study hypothesises that occupational therapists would have experienced some difficulties working in a field dominated by the social work profession, but also that there would be some significant advantages over the type of post usually held by occupational therapists in local authority social services departments.
Stalker (1996) found that the few occupational therapists in Tayside and Grampian who work as care managers reported an increase in job satisfaction because "they were now able to 'see things through' with clients." The study also highlights the difficulties involved in taking on the dual role of care manager and occupational therapist. Where a local authority ordered a "blitz" on occupational therapy waiting lists, difficulties were encountered in teams where the occupational therapists were integrated into the community care teams. The implication here is that occupational therapists were too encumbered with their community care tasks to be able to satisfactorily fulfil their role as occupational therapists. This implies a further question: how do these occupational therapists negotiate this dual role and manage the pressure on their workloads? This question remains for the present time unanswered but the present study suggests that it is an issue occupational therapists are keenly aware of (see below).
Some studies have cast doubt on the suitability of occupational therapists for the care management role. Ellis (1993) found that the volume of referrals faced by local authority occupational therapy teams meant that the occupational therapists were only able to fulfil the statutory obligations of their role. This meant that occupational therapists spent most of their time on providing equipment and adaptations at the expense of their role as providers of advice and training to assist clients' rehabilitation. Ellis criticised occupational therapists for making moral judgements about service users and withholding information about services because there were waiting lists for that service. She further criticised the occupational therapists for focusing on clients' physical functioning whilst paying scant attention to the emotional needs of clients and carers. The implication of these criticisms is that occupational therapists may not have either the skills or the professional attitudes to suit them to the task of care management. Ellis's study was conducted through observation of professionals' interactions with clients and carers, backed up with quotes that were deemed significant. The published results, however, are not accompanied by a detailed methodology so it is impossible to objectively assess its reliability and validity. It is not clear if the observed interactions were recorded verbatim, how they were selected or how relevant concepts within the interview were selected.
Dobson (1994) has suggested that social workers should be the profession of choice for care management and that occupational therapists are better suited to a provider role than a purchaser role. However, the case is weakly argued and pays no heed to the common perception amongst social workers that care management strips them of their provider role and causes an attrition of their skills. It is likely that occupational therapists suffer from a perception amongst their social services colleagues that they are little more than providers of equipment and adaptations (Allison, 1989).
However, Stalker (1996) reports that "in one region [...] occupational therapists were more comfortable than social workers with the notion -- and practice -- of working as a holistic, integrated group." Carnduff (1990) argues that the values of occupational therapy are almost identical to those of the white paper that preceded the NHS and Community Care Act: "OTs, with their holistic approach to care, their problem-solving abilities and their training in management skills are well equipped to be care managers across the whole range of client groups."
It is to be expected from the above that occupational therapists working in care management will have expanded their skills and taken on a broader role that allows them to co-ordinate care more fully than they did as occupational therapists. It is also to be expected that OTCMs will have experienced problems due to their minority status in the profession and other professions' restricted understanding of the occupational therapy role.
This study therefore hypothesises that:
Initially it appeared that the optimal method for the project would be a quantitative analysis of survey questionnaires. It was necessary to find a sample population of occupational therapist care managers in order to distribute the questionnaires. Because of the sporadic nature of local authorities' transition to care management it was necessary to select a geographical area from which to sample. Greater London was selected because of the large number of local authorities concentrated in a close geographical proximity to the research base. This would allow for follow-up interviews to be conducted if necessary. All 33 local authorities in the Greater London area were contacted by telephone to ascertain whether they employed occupational therapist care managers and if so, how many. Social services personnel departments were the first point of contact. If they were unable to confirm the number and location of occupational therapist care managers within their borough, they were asked for a contact who would be able to provide the information. Senior practitioners and managers were excluded as their experience, concerns and working conditions would be markedly different from those of fieldworkers. It emerged that there were not enough occupational therapist care managers in London to make a quantitative study viable. Only 10 were located: one borough employed five, two other boroughs employed two each, and another borough employed one. There are also some in Ealing, but the department was unable to satisfactorily confirm how many or where they were located.
It was apparent that qualitative methodology would be more appropriate for such a small sample. Furthermore, given that only one of the authorities employed more than two occupational therapist care managers, the other authorities had not operated the system long enough or extensively enough to give a good picture of the phenomenon.
The results of this initial survey were used to select a borough to analyse more thoroughly. The borough with the highest number of care managers was selected, as this was taken to be indicative of the highest level of integration of occupational therapists into care management. This was important as the aim of the study is best served by examining occupational therapist care managers working in an area where they are no longer a novelty and are not isolated amongst social workers. An environment where several occupational therapist care managers were in post would provide a good example of how they experience care management in an established system. To have interviewed occupational therapist care managers alone in a borough or newly incorporated into care management would have clouded the data with issues residual from the transition to care management. The name of this borough has been withheld in order to preserve the participants' confidentiality.
The selected borough had five occupational therapist care managers in post and a senior care manager with an occupational therapy background. The borough had employed occupational therapists as care managers since 1991. The care managers in that borough were contacted and asked if they would be prepared to be interviewed for the purposes of the study. The three occupational therapists from this borough who were available and willing to be interviewed formed the sample for the study. All were male and had worked as OTCMs for more than one year. The fact that all the therapists were male may be considered a weakness of the study as the subjects are not representative of the gender mix found on occupational therapy. The small size of the population is also a weakness, but it was important to restrict the survey to departments where occupational therapists have worked for a considerable time as care managers alongside similar colleagues. The reliability of the study could be improved by the inclusion of similarly sized clusters of occupational therapist care managers across a wider geographical area.
The aim of the study was to assess the participants' subjective experience of their new role. It was impossible to predict in advance the specific areas of greatest concern and relevance to their experience. It was therefore necessary to adopt an approach that allowed them to dictate the agenda. The selected methodology was one of semi-structured interviews with open-ended questions. A set of questions and prompts was prepared (Appendix 1). The questions aim to allow for participants to give their opinions without being restricted. The questions are open-ended and address issues related to skills, change of role and operating as a minority amongst social workers. They were selected drawing on the experience of the researcher of working alongside OTCMs and being supervised by one.
The participants were contacted by telephone to arrange a suitable time for interview. Interviews were conducted in private so that the participants' responses would not be influenced by the presence of others. Interviews lasted approximately twenty to thirty minutes and were recorded using a dictation recorder. The researcher explained to participants that the interviews would be confidential and that they would be transcribed with all names and identifiers removed, then the tape would be erased.
The researcher then questioned the participant using a sheet of prepared questions. Additional questions were asked when the researcher judged that a response merited further investigation. No visual cues were recorded. The participants were guaranteed by the nature of their profession, to be articulate and capable of expressing themselves.
A weakness of the study is that the interviewer was the co-ordinator of the research. Ideally, the interviewer should have been ignorant of the research hypothesis in order to remove bias. Added to this is the problem that the interviewer had worked with each of the participants in the past for up to two years. It is possible that this might have had an influence on their responses. It is also possible, however, that this might be an advantage as they may be able to be more frank and open with an interviewer they were acquainted with than with a stranger.
Due to the use of semi-structured interviews and open-ended questions, it was evident that the responses would be varied, complex and rich in subjective meaning. There would be no discrete units of data easily susceptible to quantitative analysis. It was also likely that participants would return to the theme of a previous question at a later stage in the interview.
As there have been no previous studies specifically directed at this question, it was impossible to predict with any confidence the themes of concern or significance to participants. A method would be required which would allow themes to be extracted a posteriori from the interview material. The method of analysis therefore needed to be flexible and allow participants' responses to set the agenda.
Such a method, coding, is described by Schwartzberg (1982): "the categories are extracted from the material itself rather than being based upon a previously defined and outlined 'schematic system'." It can be applied either a priori or a posteriori. In the latter case, the researcher examines the data to identify key words or concepts that are of significance. It was decided that concepts would be more useful than key-words as this would allow for answers to be correlated even when different words were being used to describe similar phenomena.
The interview transcripts were analysed for significant or recurring themes. Each response was analysed for themes that were expressed using unambiguous terms or wording suggestive of strongly held views. When an answer expressed an attitude rather than simply relating information, it was selected as a concept. When a theme recurred in more than one interview, it was selected as a concept. Each concept was expressed as a statement that responses either agreed or disagreed with. The final list of concepts can be seen in tabular form in the results section below.
The weakness of this method is that the subjective opinions and values of the researcher can not be definitively eliminated. The researcher must decide which parts of the responses are significant and then interpret phrases as forming a concept that can be identified in other responses. It is impossible to be certain that rater bias was not present. One method used to minimise this was to highlight those parts of responses that were extracted as themes and then inspect the remaining text to check that expressions of opinion had not been omitted. Most of the material remaining was ambiguous in meaning, only obliquely related to the subject of the study or straightforward relation of information. The residual material was not easily incorporated into concepts.
The strength of the method is that it allows the agenda to be at least partly set by the participants. The a posteriori method means that the only predetermination of agenda by the researcher lies in the choice of questions for prompting participants. Thus, some of the concepts derived were not anticipated in advance.
Having identified concepts and expressed them as statements, interviews were compared to identify recurrence of concepts. These concepts were used as the sets of data for analysis. A scoring system was used, in which one point was added for each response that agreed with a concept and one point subtracted for statements that contradicted the concept. This allowed results to be compared across interviews so that concepts that were raised by more than one participant could be identified (see table below). The statements that were identified with the concepts are presented below and are relatively unambiguous in their attitude to the concepts. This adds some support to the validity of the study.
The participants responses were analysed according using concept coding as discussed above. The transcribed interviews were scrutinised to find significant or definitive statements. Similar themes were compared across interviews. Themes that recurred in more than one interview were selected as a category for analysis. The themes found fell into nine categories:
The results can be presented in tabular form, showing which themes recurred in more than one interview. For the purposes of this more discrete presentation of the data, the theme of supervision had been subdivided into two categories: "supervision is adequate" and "supervision does not properly deal with the residual occupational therapy roles". Another category has been added to the table to indicate that all participants were previously employed as local authority occupational therapists.
Each statement has been given a score with one point being added for each agreement and a point subtracted for a disagreement. Where a theme has been repeated twice in one interview, only one point is recorded.
|Statement||OT 1||OT 2||OT 3||Total|
|I was a local authority occupational therapist before moving into care management.||yes||yes||yes||+3|
|Care management is a more all-round role.||yes||yes||yes||+3|
|More skills are required for care management roles.||yes||yes||yes||+3|
|There is a lack of training for the new role.||yes||yes||yes||+3|
|Supervision is adequate.||yes||yes||yes||+3|
|Supervision does not properly deal with the residual occupational therapy roles.||yes||yes||no||+1|
|There is an unrecognised dual role as care manager and occupational therapist (but the problem is receding).||yes||yes||yes||+3|
|Other professions hold negative views of occupational therapy.||yes||yes||neutral||+2|
|Occupational therapists are suited to care management.||yes||yes||neutral||+2|
|There would be difficulties in moving back to an occupational therapy role.||yes||yes||yes||+3|
|There are positive attractions in moving back to occupational therapy.||yes||yes||neutral||+2|
Each of the relevant concepts will be discussed in turn below, including quotes from interviews that relate to the concept. Each excerpt is followed by a number in square brackets indicating which interview it was extracted from.
All participants expressed the view that the post of care manager gave them the opportunity to expand their roles and intervention with clients. All had previously worked as occupational therapists in Social Services departments before taking up a care manager post.
One participant commented "I found in OT it was very much 'here's the resources that we have' and you tell the clients what we've got and that's it -- sort of thing. From the clients' point of view I was more rigid -- I was more rigid as an OT and I think partly that's because I was using more of a medical model and saying 'this is what's available and this is how you do it and there you are.' Whereas care management is much more two way..."  He later elaborated this theme: "I work probably more autonomously than I did as an OT, um, there's less of a sort of being on a treadmill. I always felt as an OT in social services that you're on this treadmill, constantly trying to get through loads and loads of referrals [...] The level that I'm working I would say is much more sort of deeper, more intense than as an OT" 
Another reported that "I actually looked on care management as being a challenge in which I could utilise a lot more of my skills as well as some of the more basic skills that I was already bringing with me. So it seemed like a more rounded challenge as opposed to a sideways step." 
The third described how he was now able to do more for clients, having greater access to resources than as an occupational therapist: "as a care manager you can put in quite a comprehensive package of care which wasn't available to me as an OT. [...] we could get grants and stairlifts and adapt the place and, you know, but we couldn't put carers in, only the social work team could do that [...] we just couldn't get the resources and, um, we used to get really ticked off over it. [...] I sometimes felt that the role ascribed to you was that you tidy up after other people" 
All of the care managers thought they were using more skills as care managers than they did as occupational therapists. However, one of them initially denied this, but went on to describe how he had to use more negotiating skills and learn to put a persuasive case for resources. All felt that additional skills were needed in the management side: "my organisational and management skills, which tended not to be used as much within occupational therapy...". ; "negotiating and diplomacy and things like that."  Two participants went no further, claiming that client-side skills such as assessment were easily transferable. The third, however, thought there were new skills required in dealing with family relationships, carers and disabled people with children, which he had not used or developed in his occupational therapy role. 
The first participant felt that "social workers have had to go back to change their training courses in order to take on board care management but OTs haven't done that" . However, he did not think this was a serious omission: "the only part of my training which was lacking was when it came down to stuff to do with the law."  And on in-house training: "most of the things for development are geared towards social workers." 
The second participant felt that his occupational therapy training did have some drawbacks as a preparation for care management: "the training, you know, the OT training is, can be quite medical, sort of medically orientated, and I think for a lot of OTs its a big enough step to work in social services at all, let alone go into care management."  He also felt that his needs for on-going training were not fully met: "a lot of it is sort of assumed -- because most people come from a social work background" 
The third participant highlighted the need for training to keep up with occupational therapy skills: "often our training needs aren't met... things like Naidex for instance... unless you keep attending these things regularly and talking to other OTs you don't really know what's going on in the OT world and there's been very little specific OT training, um, maybe its our own fault for not making a loud enough noise." 
One participant said that he felt the need for his decisions to be challenged when commissioning a non-standard piece of equipment but that his social-work-trained supervisor did not have the skills to be able to adequately supervise that area of his work. "It happens to be fortunate for my senior that I have the skills -- I believe I have the skills -- to actually work autonomously with that kind of work" 
The third expressed a similar view: "It's difficult when I want complex items of equipment or sometimes my knowledge base is wider than my supervisor's and there's nowhere much to go, because of the policy in [this borough] it's very difficult to get pieces of equipment that aren't in the catalogue and then you feel a little bit at sea..."  He did, however, claim that he felt satisfied with his supervision.
The second participant did not feel the need for supervision of the occupational-therapy-related aspects of his role but was glad of the opportunity to discuss the more unfamiliar aspects of his new role. He also felt that much supervision as an occupational therapist was aimed at "making sure that you get through your cases so that you can take on loads more." 
All participants talked of how they had been expected to perform additional roles as occupational therapists as well as performing their care manager role. They had been used as a resource by other care managers when issues arose that would require occupational therapy input. One described this as like "having to ride two horses"  and said that when additional work was pushed his way he had to "fight off advances" . Two participants expressed frustration that some of the work thought to merit his input was work that would normally be done by an occupational therapy assistant: "sometimes people see the word disability meaning that an OT's got to do this. This person needs rails on their wall -- an OT's got to do this and it's like we'll go and do an assessment and it's work that anybody could do."  They felt that they had made the effort to take on work not normally done by an occupational therapist while social workers had not made the effort to deal with relatively simple items that were not part of a traditional social work role: "You're doing your own caseloads with the same number of cases and you're then expected to help other people out as well, and there's no reciprocity: they don't do the same for you. It causes a bit of resentment."  Another added: "a lot of care managers felt that, or seemed to feel, the OTs should, you know, take on their OT role as well and if there was a problem with something that an OT should know about then they would want you to get involved in that as well... and I think there was an expectation that you would do that with your own cases as well." All agreed, however, that this problem was showing signs of abating as social-work-trained care managers began to acquire new skills. There were signs of positive attitudes. Training in equipment and minor adaptations had been provided to assistant care managers, but care managers were excluded. One participant claimed that social-work-trained care managers had requested places on this course but been refused. He said that this showed that they were aware that it was work they were supposed to be doing and that they did not feel fully competent to do it: "they've all being saying for the last [inaudible] years 'we want this training' so management are kind of turning a blind eye that this is a problem. [...] it's all too easy for people to shy away from what they're supposed to be doing and actually say 'we'll just give this to an OT care manager'" 
Two respondents thought that other professionals did not have a full appreciation of the role of occupational therapist. One participant said: "there's a strong perception of what your role is that doesn't necessarily tie up with what you think it is [...] OT is very much seen by the social work body as being providers of equipment and, you know, um, I don't know about your training but the amount of time spent on equipment was pretty negligible. And maybe it's our own fault that we're seen as providers of bits of fancy gear and it's so complex nobody else can understand it -- it isn't necessarily true but others' perceptions do govern how you can operate [...] I don't think we were being treated unfairly but their perceptions are rather narrow."  Another participant agreed: "... before care management [...] OTs were seen as having quite restricted skills [...] they're often seen as, almost as technicians" 
Another participant was more circumspect, giving a reply that was not a definitive statement that occupational therapy is viewed negatively. His answer might equally infer that failure to fully integrate occupational therapy into care management is due to inertia or entrenched habits: "If I was to make the move into management, I would have to do it within this borough and then apply to other boroughs. I'd have to prove myself in this borough by applying to another borough with a care management structure as a senior or a manager because basically they look to social work as being the only qualification to manage for some strange reason." 
Two participants felt strongly that occupational therapists were fully suited to care management. One said: "I think I've always felt OT in care management has been a positive move [...] in the respect that, um, it's one of the ways in which we can prove that we have more skills than people believe that we do have. I have always believed that OT training is totally suited to the care management role and the holistic approach that it's supposed to have."  Another participant went further: "OTs are admirably qualified, [...] I really can't imagine any better professional group to do the job [...] I think OTs should be at the leading edge of care management."  This participant qualified this statement, saying that drawing occupational therapists away from a profession in which they were already in short supply was problematic.
A third care manager made no strong statement on this matter but mentioned no problems in using his occupational therapy skills in care management.
All participants said there would be some difficulties in moving back to an occupational therapy post. Two felt that their skills had changed and that they were not up to date with occupational therapy: "if I had a pure OT case to deal with I feel that first I would have to look at it really hard and go over with a fine tooth comb, 'cause I feel that a lot of my skills, I'd have to check on what I was doing. [...] I'd be nervous, I mean I know deep down I have the skills. I'd be nervous when I went to work is what I'm saying and I didn't feel nervous making the move into care management but I'd feel nervous making the move back into OT."  They felt their knowledge of procedures and current policy was a little rusty: "I do feel more out of contact with OTs to be honest and with the way they do things, particularly within a social services OT department, I mean someone said to me the other day 'oh no, we can't do this 'cause, um, you know, it's not on the London Boroughs' guidelines' and I just thought, well, I don't care about the London Boroughs guidelines any more because, you know, what does that matter to me? But obviously if I was working as an OT I would have to probably care about that... and things like that I think 'oh yeah, London Boroughs wouldn't let me do that' and what have you, but all that becomes less, um, you forget, to be honest." 
The third saw the difficulties as being due to the less prestigious and more restricted role of local authority occupational therapists: "It could be very frustrating. Depending on... I suppose it depends on respect and prestige -- I mean I'm definitely not interested in management, but I think OTs should get the respect of their training and be given the resources to carry out the job. I think if you're employing this group of highly skilled professionals, if they can see the problems but can't address them, a holistic assessment goes out the window, if you don't have the resources to bring to bear on it." 
Two of the three participants felt positive about moving back to occupational therapy posts despite their misgivings about an attrition of skills: "Now I feel that I have something more to offer in the OT field... yeah, I would like to do that [but] if I moved back into OT it would have to be on a senior or management level. That was one of the reasons why I took the move into care management was to actually boost my managerial skills."  This participant expressed a desire to move back to occupational therapy at senior or management level.
Another wanted to eventually move to an occupational therapy post with more client contact, describing care management as "admin-tied, [..] clerical, and it's negotiating and it's not client based, [...] it's unseen communication and office work" He was quite positive about moving back to occupational therapy: "Oh, I think I will, yes, definitely... I think you miss the hands on contact with the client." 
One participant was more circumspect: "I would consider it, um... but I think it also might be quite difficult"  This is the same care manager who expressed concern about being "out of touch with OT" (above). It may be significant that he has been a care manager longer than the other two participants.
The implications of these results will be discussed below.
All of the care managers interviewed had worked as occupational therapists in social services departments before taking up a care management post. This concurs with findings by Mitchell (1992), who found that most occupational therapist care managers in Berkshire had previously worked as occupational therapists in social services departments. One of the present study's participants expanded on the theme: "care management might be intimidating for [younger occupational therapists] because it infers some understanding of how social services work -- or does not work [...] for social services OTs it's not that difficult -- you know something about the culture of social services. Um, you do need to be fairly assertive I think, or you get swamped. there is a hell of a difference between health service and social services. Once you've worked in social services, I think you learn to, you know, learn the culture." The implication here is that his previous experience as a social services occupational therapist has served a preparatory role and assisted the transition from health services to care management. Furthermore, local authority occupational therapists often have direct experience of working with care managers, often sharing offices. They are likely to have experience of care management systems and a familiarity with the care management role.
It can be inferred from this that lack of familiarity with social services generally and care management specifically is a barrier to the recruitment of occupational therapists to care management. This would be worthy of further research, perhaps aimed at assessing occupational therapy students' knowledge of and attitudes to care management. Placements in care management teams are rarely, if ever, found in occupational therapy training courses. The introduction of care management placements would be likely to increase recruitment of occupational therapists into care management, helping to bypass the route that the participants of this study have taken. As most occupational therapists work in the health service, this may be a contributory factor to the scarcity of occupational therapists in care management.
A further factor is found in patterns of recruitment advertising. Few care manager posts are advertised in occupational therapy publications. During the preparation of this research, advertisements in the British Journal of Occupational Therapy were surveyed. Only three advertisements for care manager posts were found between April 1996 and May 1997. Such posts are advertised almost every week in Community Care, which is focused more on the social work profession and much less widely read amongst occupational therapists.
It was also found, in the preparation of this research, that some local authorities (such as Barnet) had piloted the idea of occupational therapists in care management but rejected the idea because of opposition, or lack of enthusiasm, from the authorities' occupational therapists. The reasons for this were not investigated. Others, such as Barking and Dagenham, would accept occupational therapists as care managers but had none in post at the present time. Many more authorities did not employ occupational therapists as care managers. A survey of ten care manager job descriptions found that eight specified a CQSW, DipSW or CSS qualification (quoted in Dobson, 1994). Further research should investigate why occupational therapists have found care management unappealing. It would also be worthwhile to investigate why some service managers feel that social work is the only suitable qualification for care management.
It is, perhaps, surprising that occupational therapists have been unenthusiastic about care management (e.g. in Barnet), as those interviewed for this study expressed satisfaction with the role. The main reason for this, it appeared, was that workers felt able to do much more than they could as occupational therapists. All participants made this point. This confirms findings by Stalker, who found that occupational therapists derived increased job satisfaction in their new care management role. Participants in this study had greater access to resources on their clients' behalf and were able to co-ordinate areas of input that would previously have necessitated referral to another professional.
In contrast, occupational therapy posts were describe as being "rigid", "on a treadmill", and frustrating because of lack of resources and a restricted role. Carnduff (1990) suggests that the restricted role of local authority occupational therapists can be explained by huge waiting lists, which leave little time for the development of skills; their minority status in social services (1500 occupational therapists to 27800 social workers) and a poor career structure. This suggests a need to re-examine occupational therapy provision in local authorities but this is beyond the scope of the current study.
This study initially attempted to approach the problem through a postal survey of OT care managers in the 33 London boroughs. This was abandoned because only ten were located. Consequently this study reflects the experience of OTCMs in only one borough. Further research could gain more representative results by widening the geographical scope of the study to include authorities outside of London, thus reaching a sample population of suitable size for a postal questionnaire.
There is also a problem with the reliability of the information gained by the initial phase of this study. Some boroughs were unable to give precise information, while others gave names of people who were not working as OTCMs, including one nurse care manager. The unreliability of the data is due to the method of telephoning personnel departments, many of whom did not know what a care manager is. Alternative contacts were usually knowledgeable about only one area of service provision and could not confirm if OTCMs were employed with other client groups. A more reliable method, which should be considered for future research, is to use a postal survey of Social Services Directors with telephone follow up for non-responses or incomplete responses. This would make it more likely that the question would be answered by someone with the required information.
The study has identified that OTCMs have been frustrated by holding a dual role as occupational therapists and as care managers. Whilst holding the same caseloads as other care managers they have been asked to co-work on other workers' caseloads. This has been particularly frustrating when the work concerned has been seen by the occupational therapists to be not worthy of their intervention. Cases have been held back for allocation to an OTCM simply because the referral mentions grabrails. One care manager reported that cases were delayed on the duty system -- which deals with high priority, unallocated work -- because a minor aspect of the referral mentioned bathing equipment. It was also reported that social-work-trained care managers were increasingly willing to deal with equipment provision but felt their need for training had not been met. There is a clear need for management to provide basic training in this area to care managers in order to facilitate a transfer and sharing of skills. This would also benefit clients in ensuring that their needs were addressed more quickly and by a more seamless service. There is also a need for more support staff, as OTCMs claimed they had had to co-work on aspects of cases that would be well within the competency of an occupational therapy assistant. Participants stated that these staff were in short supply, with large waiting lists that mitigated against them being able to co-work on care managers' cases.
Managers need to clarify the role of OTCMs and provide clear guidance on the questions of which aspects of their occupational therapy role are to be retained and whether OTCMs should co-work on other care managers' cases. This would help to clarify OTCMs' perceptions of their own role and also reduce other professionals' confusion about the role of OTCMs.
Supervision was generally regarded as being adequate although OTCMs stated that they lacked supervision for the aspects of their work related to equipment and adaptations. All were supervised by a senior practitioner with social work training. They felt this was not a major problem as they took on less of the complex occupational therapy work than previously, so felt able to deal with this aspect of their work without supervision from an occupational therapist. There is a case, however, for ensuring that whilst an OTCM's main supervisor may be social-work-trained, they have access to professional supervision, if and when required, from a senior occupational therapist.
Occupational therapists' satisfaction with the care management role was marred by frustration at the amount of administrative and financial work they had to do: "with every year there's less and less contact with the clients themselves". Some progress has been made in this area with the increasing use of block contracts which have begun to replace an initial over-reliance on spot contracts. This has reduced the amount of time spent by care managers in checking invoices and time-sheets. Further progress could be made with increased administrative support for care managers.
Occupational therapists feel that they have a lot to contribute to care management, yet there are very few in post. In some boroughs where occupational therapists are eligible for care management posts, none have been appointed. Job descriptions often specify only social work qualifications and posts are rarely advertised in occupational therapy publications. It would appear that Social Service Inspectorate (1994) recommendations have not been fully acted on by local authorities.
All participants identified new skills involved in care management that had not featured prominently in their previous roles. Primarily, these were related to negotiation, management and coordination of care packages. One participant spoke of new skills in dealing with relationships between carers, families and children. His dealings with these others in his previous job had been, for the most part, restricted to securing their contribution to the assessment and training them in the use of equipment. There was support for the notion that OTs are suited to care management, having an opportunity to show that their skills were broader than some colleagues had realised. Most care managers receive little additional training for their role, irrespective of their background. Care managers questioned by Neate (1993) had received only small amounts of training, and participants in the present study confirmed this. Problems highlighted included an excessive "medical" orientation of occupational therapy training and a lack of on-going training. Training was said to be operating under an assumption that care managers had a social work background and not sufficiently sensitive to the needs of occupational therapists. It also failed to keep pace with occupational therapy skills, which participants felt the need to maintain. This is reflected in their comments that they would have difficulty in transferring their skills back to occupational therapy. Although roles have been transferred, some difference still remains between care managers with different professional training. Responses suggest that occupational therapist care managers want on-going training both to develop care management skills with a responsiveness to the specific needs of OTs and to retain and develop core occupational therapy skills. It is not suggested that occupational therapy basic training needs to be changed to accommodate care management.
Participants highlighted negative views of occupational therapy held by other professionals. Equally, they acknowledged that their roles as occupational therapists in social services had been characterised by limited resources, high workloads and restricted options for intervention.
If occupational therapists themselves feel that their role is restricted in this way, it can hardly be surprising that other professionals see them only as "providers of bits of fancy gear". This would suggest that rather than other professionals having a warped perspective on occupational therapy, the restricted role ascribed to occupational therapists has some basis in reality. This concurs with the findings of Stalker et al. (1996) that occupational therapists who were unable to take on care management roles reported a sense of de-skilling. There is a clear tension between the different roles. Recruitment of occupational therapists into care management may be "one of the ways in which we can prove that we have more skills than people believe that we do have." However, it may also cause difficulties in meeting the needs of occupational therapy's specialist services: "if we take on care management wholesale, who does the assessment of simple tasks, home visits... there's no-one to do it." This is also confirmed in Stalker's (1996) study, showing increased difficulties in meeting needs for equipment and adaptations where occupational therapists have been integrated into community care schemes. There are no easily apparent solutions to this other than an increase in the numbers of local authority occupational therapists in order to relieve the pressure to complete only specialist work. In this respect it is worth noting that only a small proportion of occupational therapy training funding is supplied by local authorities.
Two out of the three OTCMs interviewed wanted to move back to occupational therapy at some point. One cited a desire to return to the greater client contact that occupational therapy offers, describing care management as remote and office-based. Another felt that his experience as a care manager was a means to broaden his skills for a move back into occupational therapy at a more senior level rather than advancing his career within care management. This is perhaps a little paradoxical given that both of these care managers had highlighted the restricted role of occupational therapists within social services and the frustrations thus caused.
Another described a move back to occupational therapy as being more a matter of necessity than choice: "partly because there's not that many care management OT jobs anyway". If he needed to move to another borough, he would "probably have to anyway" because of the lack of opportunities for occupational therapists in care management, but he did not particularly relish the prospect: "it could be difficult partly because I do feel more out of contact with OTs to be honest and with the way they do things."
Participants were reasonably optimistic about opportunities for occupational therapists to advance within care management as there is already one team leader (more usually referred to as an area manager) within the department: "I think it probably would be as easy within [this borough] because I think they're quite keen to have OTs sort of within different layers". Another commented that he thought it would be as easy within this borough but it would be more difficult elsewhere because of less advanced processes of integration. One participant thought advancement might be more difficult because "in our supervision and in our appraisal it quotes social work practice manuals and social work modes of practice, which means nothing to us." Most of these replies relate back to the earlier topic of the scarcity of occupational therapists in care management structures.
The experiences of participants broadly confirm the hypotheses of the study, although further research is required if the results are to be generalised. There are opportunities for increased job satisfaction in care management when compared to the role of occupational therapist. The role allows for the coordination of diverse aspects of casework and allows occupational therapists to increase their skill base. Respondents had more dealings with informal carers as well as other agencies.
However, there are more negative aspects, particularly the increased administrative and financial tasks and a perceived decrease in "hands-on" client contact. There is scope for improvement here, if additional resources are made available for administrative support. However, since the introduction of care management, budgets have been devolved downwards. In the department studied, budgets are currently held at team manager (area manager) level. Some boroughs have devolved budgets to care manager level. This process, if pursued, needs to be managed carefully so as to avoid an increase in administrative workloads. Some boroughs have elected not to incorporate occupational therapists into care management because the occupational therapists opposed the idea. further research should investigate this.
Occupational therapist care managers have experienced problems related to their minority status, particularly with respect to the dual role of occupational therapy specialist and care manager. Participants had to perform occupational therapy functions as well as holding the same caseload as other care managers, though this has decreased over time as social-work-trained care managers became more familiar with the kind of work they had previously assumed only OTs could do. There is a need for greater clarity regarding the role of occupational therapists as care managers and the means to deal with the specialist work they had previously performed.
Advertisement of posts predominantly in social work publications perpetuates this minority status as does the practice of many authorities of only employing those with CSS, CQSW or DipSW qualifications. This goes against SSI (1994) recommendations. Further research might help to address the question of recruitment by examining occupational therapy students' knowledge of care management.
Negative views of occupational therapy also contribute to this, although these views seem to coincide with OT's experience of frustration with restricted roles and high workloads. There is an implied need to re-examine the role of the local authority occupational therapist, to expand recruitment and allow for an expansion of roles. The interests of clients would be well served by an expansion of social services occupational therapists' rehabilitative roles rather than an enforced reliance on equipment and adaptations due to pressure of workloads.
Skills and supervision are not seen as problematic despite OTCMs' minority status. Occupational therapists feel they are well suited to care management, but would benefit from additional supervision related to their residual occupational therapy functions. Training needs to be more responsive to the needs of care managers from backgrounds other than social work and also needs to enable care managers to perform minor occupational therapy assessments suited to occupational therapy assistants. Participants highlighted the problem of these tasks being added to their workloads. More occupational therapy assistants or assistant care managers are needed for the same reason.
There is still a long way to go before occupational therapists are fully accepted as care managers, but the experience of this borough shows that they can be integrated into care management teams. The presence of occupational therapists at team manager (area manager) level is indicative of this. Occupational therapists feel that their integration into care management is an opportunity to demonstrate the skills of occupational therapists and to practice more holistically. It is to be hoped that management will facilitate further integration by addressing the issues of training, recruitment and clarification of roles raised above.
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After completing the research project and qualifying as an Occupational Therapist, I worked for two years as an Occupational Therapist / Care Manager in a local authority social services department. I became quite disillusioned with the concept of Occupational Therapists as care managers.
The most obvious problem was the lack of supervision by an Occupational Therapist. My supervisor was qualified as a social worker and was very supportive. However, my clinical decisions went unchallenged and supervision was not the place to refine my intervention methods and receive new ideas. Any problematic OT issues were dealt with by informal discussions with other OT Care Managers in the department or by individual research and investigation. I felt I was developing as a social worker but not as an OT.
Initially, I was able to skew my case allocations toward those cases that needed both OT intervention and care management. However, because of the demands of the service, I also had to take on clients with functional mental health issues or dementia. Because of the nature of the care management role, my intervention with those clients was almost purely care management and very little, if any, OT.
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