Introduction

Occupational
therapy’s body of knowledge lies in human behavior and activity as well as in
the effect of pathology on behavior and the effect of activity on pathology. (Gilfoyle, 1980)

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The
basic philosophy of occupational therapy speaks to Man as an active being and
to the use of purposeful activity (as) Man’s interaction with and manipulation
of his environment.  (DiJoseph, 1982)

The
impact of societal change on OT practice

Occupational
therapy’s values come from social movements in the early 1900s, including Jane
Addams’ work at Hull-House with immigrants from other cultures adapting to
American society.(Clark F et al., 1998) Occupational therapy’s most salient feature is its focus on
assisting clients to engage in meaningful occupations in order to participate
in their community (American Occupational Therapy Association, 2002).
Therefore, understanding a patient’s sociocultural background is extremely
important as the occupational therapist helps patients identify and engage in
culturally meaningful occupational experiences.

Occupational
therapy, using culturally and personally meaningful occupations in treatment,
can assist individuals in this movement toward healing. The illness experience
is shaped by cultural local knowledge, expectations, preferences, and dislikes
about appropriate standards for living life. (Frank, 1995, Garro, 2000) An illness experience perspective involves seeing ill persons in
the world in which each one is living, that is, in context, not as separate
from their environment. As such, an illness experience is dynamically social;
it both occurs in the social setting and is changed by it. (Garro, 2000, Frank, 1995) As a social experience, the illness experience is shaped by the
culture of which one is a part.

The
impact policy and legislation on UK OT practice

The
World Health Organization, a United Nations agency, issued a report in June
2000 that ranked the health systems of 191 countries across the world, which
was the first of its kind to include such a large scope of the globe. The
United Kingdom ranked 9th and the United States ranked 17th highest in overall
system performance.

The
study also showed that only 57% of the UK population said they were either
fairly or very satisfied with their health system. That percentage was even
lower for the United States at 40% fairly or very satisfied. (Blendon et al., 2001)

The
NHS model is ”characterized by universal coverage, general tax-based
financing, and national ownership and/or control of the factors of
production.” This model is exemplified by both the United Kingdom and Canada’s
national health programs and uses general tax revenue for the majority of its
financing. In NHS countries, the government itself is most likely to own the
health care resources and employ the health care staff. (Fried and Gaydos, 2002)

The
government of the United Kingdom guarantees the right to health care access to
all citizens through its program called the National Health Service. (Fried and Gaydos, 2002) The NHS is a market-minimized, National Health Service model and
is the prominent means for one to obtain health care services in the United
Kingdom. (Sanders, 2002)

 

The
government body responsible for the NHS in England is the Department of Health.
The Department of Health’s objectives are simply to improve the overall
well-being of the people of England. This is executed by directing, supporting,
and leading NHS and social care organizations to provide fair, high-quality
health services and to offer choices to patients and value to taxpayers. (Health, 2007)

 

The
impact policy and legislation on United States OT practice

The
United States’ health system is an example of an entrepreneurial model.
Scientific medical advancement in technology and research and cost-saving
practices are both beneficial results of the entrepreneurial model. One of the
key disadvantages of the model, however, is the apparent inequality of the
distribution of health care resources. An example of this inequality is seen in
the rising number of uninsured in the United States. (Sanders, 2002) As of the most recent Census Bureau data available, there were
approximately 46 million uninsured Americans in 2005, which is approximately
15.9% of the US population. (Rosenbaum, 2006)

Comparison
between United Kingdom and United States health care systems

The
United States of America and the United Kingdom. These 2 countries have close
historical and cultural ties, but when it comes to health care, the United
States and the United Kingdom are significantly different. Because they differ
so greatly, both countries could learn from each other to create better policy
and systems and thus improve health care delivery to their respective citizens.

The
United States is the only industrialized country that does not offer universal
health care to its population(Ruger, 2007);
therefore, in direct opposition to the United Kingdom and all other
industrialized nations, access to health care in the United States is not
guaranteed by the government.(Sanders, 2002) The US government has historically played a passive role in health
care. Not only does the government not mandate universal health care, but it
also does not require citizens to obtain health insurance coverage on any
level. Under the Employee Retirement Income Security Act of 1974, the United
States allows full employer discretion on health insurance offerings.(Deborah, 2000)

Of
the approximately 300 million people in the United States, 46 million were
considered to have been uninsured in 2005.(Rosenbaum, 2006) In the United States, those without insurance coverage are meant
to pay for the health care services they receive. That being said, the most
common reason for bankruptcy in the United States is due to unmet health care
bills. A recent study done by Harvard University found that 68% of those who
filed for medical debt bankruptcy had some form of health insurance, 50% of all
bankruptcies involved medical debt, and every 30 seconds someone in the United
States files for bankruptcy because of a serious health problem.(2004)

Although
the US and the UK health systems differ significantly in the level of
government involvement and social responsibility, both systems operate very
similarly in terms of delivery. Both tend to use primary care as the first
point of entry and operate under regional, functional, and specialty
subsystems. Although these subsystems are owned and operated by the government
in the United Kingdom and by private entities in the United States, it is truly
in the responsibility of payment where there is an obvious deviation. (Roe and Liberman, 2007)

 

Although
health care funding in the United Kingdom is government controlled and health
care funding in the United States is predominantly private controlled, both
essentially are only made possible by the contributions made by the people. The
main differences are the level of government involvement and mandatory taxation
versus voluntary contributions. The United Kingdom provides health care access
to all using a similarly run health delivery system to the United States,
whereas the United States is suffering the economic burden of their uninsured.
Therefore, the United States has essentially failed in providing Americans with
affordable health care options and education on the impact it has on the
economy.(Roe and Liberman, 2007)

Types
of health care systems throughout the world

 There are many trends and patterns of health
systems throughout the world. Olin Anderson and Milton Roemer both developed
analytical models to chart these different types of systems, and each of these
2 models places the United States and the United Kingdom at opposite ends of
the spectrum. As illustrated by Anderson’s model, all health systems in the
world can be placed on a ”continuum based on the level of government
involvement in the financing and organization of health services.”(Sanders, 2002) Anderson describes the role of government as either market
maximized, characterized by limited government, or market minimized,
characterized by government programs based on distributive justice1 which
promotes the equal allocation of goods and services to all members of society.(Stanford, 1997) On this scale, Anderson places the United States at the far end of
marketmaximized and the United Kingdom’s National Health Service (NHS) at the
far end of marketminimized.(Sanders, 2002)

Challenges
faced by occupational therapists in facilitating social inclusion,
participation and improved health and wellbeing within UK and United States

More
than ever before, practitioners from a variety of fields are considering issues
of race, ethnicity, and cultural competence in their practice. This interest
reflects the fact that the United States is becoming increasingly diverse. The
2000 census figures suggest that about 30% of the total U.S. population is of
non-European White background and that people of color are becoming numerical
majorities in some of our largest cities. (Bureau., 2000) Moreover, evidence has suggested significantly higher rates of
health disparities and disability among people of color. (Brach and Fraser, 2000, Fiscella et al., 2000) Given these trends, health professionals, such as occupational
therapists, are more likely than ever to encounter individuals from diverse
ethnic backgrounds in their practices and yet may not necessarily feel the need
or be prepared to adapt their practices to the specific cultural values and
needs of these diverse groups of clients. In fact, previous research has
suggested that African-American and Latino clients are not achieving the same
positive outcomes in rehabilitation and independent living as are White
clients. (Marjorie and Jae, 2002, Keith et al., 2002, Keith, 2002)
These are compelling reasons for researchers and professionals to study
cultural competence in the context of occupational therapy as an additional
core skill necessary for effective practice.

The
U.S. Department of Health and Human Services’ Office of Minority Health has
produced new recommended standards for cultural competence in health care (BLACK and WELLS, 2007). An important change refers to the increasing demand for
clinicians to practice from a client-centered perspective that involves
matching practice to the client’s ethnic, racial, or cultural context. Another
recommendation refers to treating patients in a variety of nontraditional
contexts, such as in community-based organizations and health centers rather
than the traditional hospital setting. Occupational therapists are more likely
to work with patients who have not only differing beliefs, values, attitudes,
and behaviors but also different definitions of the nature of work, leisure,
health, and self-care (BLACK and WELLS, 2007). With the occupational therapy client population becoming
increasingly diverse, a culturally competent practitioner is essential (suarez-balcazar et al., 2007).

The
Culture Emergent Model (Bonder et al., 2004), which comes from the occupational therapy literature, recognizes
that culture is learned, localized, patterned, evaluative, and persistent,
although it also incorporates change. The combination of these factors can
allow health care practitioners, specifically occupational therapists, to
acknowledge the aspects that make up culture and influence the clients with
whom they work.

 

Global
health Challenges and opportunities facing Occupational Therapy

An
increasingly ageing population is putting a strain on the health and social
care service which has undoubtedly created a more cost-conscious working
environment for all hospital departments. To put the increased demand on the
health and social care service into context, over the next 20 years the number
of over 85’s will more than double whilst the number of people with dementia is
due to rise to 1.5million by 2042.  With
an increasing demand on the health and social care services as a result of
this, there is a focus on the associated rising costs and questioning over the
sustainability of our publicly funded health and social care system.(2005)

With
an increased focus on the economics of the NHS, services are facing increased
pressure to evidence their value which in itself creates both challenges and
opportunities for our profession. The recent Care Act has provided a shift from
a duty to provide particular services to a duty to meet needs.   The aim is to make care more responsive and
personal for patients by providing care closer to home.  Occupational Therapist within the hospital
setting, are in a prime position to show case our abilities to provide a
service that is both cost-effective and able to improve patient experiences and
outcomes. Development of a toolkit of outcome measures and patient satisfaction
feedback questionnaires has allowed them as a service to provide both
quantitative and qualitative evidence of the impact of the OT service on
patient outcomes.

One
of the biggest challenges they faced with within the hospital setting is an
increasing pressure to facilitate rapid discharges, reduce the length of stay
in hospital and the risk of readmission to hospital. A combination of limited
resources and the ageing population means that patients have increasingly
complex medical histories. The ability to use activity analysis gives them an
understanding of how current and existing occupational performance deficits can
make engagement in daily occupations more difficult. (2005)

An
intervention applied by occupational therapist to deal with the challenge of
ageing   

Ageing
in place– Occupational therapists can offer solutions, such as home
modification, adapted equipment prescription, and training of careers and
supporters to enhance living in place and stave off or eventually plan for
transition.(Dickerson et al., 2007)

There
are currently about 36 million adults age 65 and older in the United States,
with about 80% of them licensed to drive (Federal Highway Administration, 1999;
United States Census Bureau, 2006). By 2030, the number of older people aged 65
years and older in the United States is expected to reach 70 million, comprising
over 20% of the population. (Bureau., 2000)

Although
Medicare has played a critical role in decreasing the disparities in race and
income in the access to and use of preventive and therapeutic care among older
Americans, marked differences remain.(Eichner and Vladeck, 2005) Lower-income beneficiaries, for example, are less likely to be
able to afford Medicare’s deductibles, coinsurance, and uncovered services, and
hence they may not elect to have some procedures that could improve their
functional status.(Eichner and Vladeck, 2005) Overall, however, differences in access explain only a small
portion of the health differences across socioeconomic groups. (House, 2002, Isaacs and Schroeder, 2004)

With
almost 85 percent of Americans who are 55 years of age or older living at an
income level under 700 percent of the poverty line, this is not simply an issue
of very poor people having a disadvantage in health outcomes. Rather, higher
risk is demonstrated across a very large proportion of the older population, as
compared with the most advantaged. With the aging of the population, achieving
the national health goals of increasing health-related quality of life and
eliminating health disparities will require paying increased attention to a
reduction in disparities in functional status in later life. (2000)

The
idea of aging-in-place has in?uenced aging policy in many national though it
has been de?ned in various ways. Harris de?ned aging-in-place as “the effect of
time on a non-mobile population; remaining in the same residence where one has
spent his or her earlier years” (Harris, 1988).In
this de?nition, people experience changes over time but their housing remains unchanged
over their lifetime. Alternatively, Lawton under-stood aging-in-place as
changes in both the person and the environment (Lawton, 1990).

He
emphasized the interaction between the person and his or her surrounding
environments whereby changes in the person’s competence level (i.e., functional
frailty) and in the surrounding environments (i.e., modi?cations) are
dynamically related. Furthermore, supporting people to continue to live in
their own homes is generally less expensive than options such as residential
care(Sixsmith and Sixsmith, 2008).

To
promote aging-in-place, the United Kingdom government established the Disabled
Facilities Grant (DFG), which is a mandatory entitlement ad-ministered by local
housing authorities (United Kingdom Department of Communities and Local
Government DCLG, 2008). The goal of the DFG is to increase the accessibility
of the home by modifying basic facilities (i.e., providing ramps, door
widening, stair lifts and level access showers)(United-Kingdom, 2008).

 

One
of key elements in meeting the needs of older people and creating supportive
environments conducive to aging-in-place, is a physical modi?cation of home.
The built environment is directly tied to the level and equality of daily
activity and life. The relationship between daily living behavior and one’s
built environment can be seen as a chain of interactive cause-and-effect cycles
(Lawton, 1970).
Behavior is an outcome of person’s competence level interacting with the environment
(Lawton, 1986).
Considering age-related changes in later life, the competencies of older adults
are likely to decrease. The underlying assumption is that the less competent an
individual, the greater the impact that the built environment has on that
individual. By decreasing environmental barriers, the built environment
enhances an individual’s overall functional competence.

Many
countries in Europe, including the United Kingdom, have encouraged and explored
housing programs designed to reduce institutional care and to ensure that older
people should not have to leave their housing when disability occurs (Means, 2007).

Conclusion

In
this paper we evaluate the impact of societal change, policy and legislation on
medical health care system in general and occupational therapy in particular
within United Kingdom and in comparison to United States. Ageing population is
considered one of the challenges faced by occupational therapists in
facilitating social inclusion, participation and improved health and wellbeing
and it was critically evaluated in this paper considering the impact on
occupational performance, participation and engagement within United Kingdom
and United States.