Chartered Society of Physiotherapy
Submission to the Centre for Workforce Intelligence on the future
physiotherapy workforce
August 2010
Introduction
The CSP welcomes the opportunity to contribute to the discussions and analysis of
the current and future physiotherapy workforce.
Structure of this paper
This paper is divided into the following broad areas:
Key Points, page 2
Section 1: Definition of physiotherapy, page 3
Section 2: Meeting health care priorities, page 4
Section 3: Achieving service improvement, page 5
Section 4: Creating a sustainable workforce, page 6
Section 5: Future supply and demand of the physiotherapy workforce, page 9
Further information on how physiotherapy can help to address particular health care
priorities and contribute to service improvement, together with information on trends
in the development of the physiotherapy workforce is provided in the following
appendices:
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•
•
•
•
•
•
Appendix A Occupational health, page 13
Appendix B Musculo-skeletal disorders, page 16
Appendix C COPD, page 19
Appendix D Stroke, page 22
Appendix E Benefits of self-referral to physiotherapy services, page 24
Appendix F Optimising access to services, page 26
Appendix G Qualified physiotherapy staff in the NHS England 1999-2009,
page 28
The key themes of demonstrating clinical- and cost-effectiveness and meeting needs
across the health and well-being economy run through the whole. The paper is
supported by reference to policy and evidence of effectiveness documents. It is
1
illustrated by examples of the clinical- and cost-effectiveness of physiotherapy in
particular areas and modes of delivery.
Key Points
•
Physiotherapy is ideally placed to provide solutions to current healthcare
challenges. It can play a strong role in addressing healthcare priorities in a rapidly
changing health and well-being economy maximising productivity and efficiency
whilst providing high quality care.
•
Physiotherapists support self-management, promote independence and help
minimise episodes of ill health developing into chronic conditions requiring
hospital admissions. They have a central role to play in enabling people to remain
healthy at work and to support individuals’ return to work, thus reducing current
levels of sickness related work absence and incapacity benefit claims – both
major Government objectives (see Appendix A).
•
Physiotherapists are already developing and focusing their practice demonstrating
both clinical and cost effectiveness. They are assuming greater responsibility for
complex, non-routine caseloads, taking on activity previously undertaken by
medical colleagues and overseeing the delivery of care by others. (See Section 4
and Appendices A-F below for examples of cost effectiveness and new roles).
•
Demand for physiotherapy staff in the NHS has risen steadily in recent years.
Since 2000 the FTE of qualified physiotherapists employed by the NHS in
England has increased by 48%.
•
The CSP is extremely concerned by recent severe cuts to commissioned
undergraduate training places. Since 2004 there has been a 30% cut in places at
English HEIs despite clear rising demand for their services. Intakes for 2010 are
now back to the intakes of 2000, before the beginning of the expansion of the
physiotherapy workforce recognised as urgently needed in the NHS Plan. Today
we have an NHS physiotherapy workforce which is 48% larger than it was in
2000, with larger replacement needs.
•
It is clear from research the CSP has undertaken among physiotherapy service
managers that the vacancy information collected by the Department of Health
hides the serious problems of shortages, and unfilled and frozen posts at senior
levels.
•
Further cuts in the student intakes in England would be disastrous and could not
be justified. The constant danger is that in the search for cost saving
physiotherapy is seen as an easy target for cuts by commissioners as one of the
largest professions.
•
We therefore urge the CfWI to send out a strong recommendation to
commissioners in SHAs that there should be no further cuts to training
places in 2010 and beyond to avoid a repeat of the serious shortages
experienced by the profession in past years.
2
Section 1: Definition of Physiotherapy
Physiotherapy enables people to move and function as well as they can, maximising
quality of life, health and well-being. Physiotherapists use manual therapy,
therapeutic exercise and rehabilitative approaches to restore, maintain and improve
movement and activity and to support people in managing their own condition,
maintaining their independence and preventing future episodes of ill health.
Physiotherapists work with a wide range of population groups (including children,
those of working age and older people), across sectors, and in acute, community
and workplace settings.
Physiotherapy delivers high-quality, innovative services in accessible, responsive,
timely ways. It is founded on an increasingly strong evidence base, an evolving
scope of practice, clinical leadership and person-centred professionalism. As an
adaptable, engaged workforce, physiotherapy has the skills to address health care
priorities, to meet individual needs, and to develop and deliver services in clinicallyand cost-effective ways. With a focus on quality and productivity, it puts meeting
patient and population needs, and optimising clinical outcome and the patient
experience, at the centre of all it does.
Physiotherapy is excellently placed to provide solutions to current challenges. It can
play a strong role in addressing health care priorities in a rapidly changing health and
well-being economy, recognising the imperative of delivering high-quality services
and maximising productivity within difficult financial times. Its distinctive mix of
diagnostic and assessment skills, holistic approach and developed communication
and educative skills means that it can facilitate early intervention, support selfmanagement and promote independence, and help to minimise episodes of ill health
developing into chronic conditions.1
Physiotherapists have particular skills and make particular contributions in the areas
identified in the table below.
Skills
Assessment, diagnosis and problemsolving
Care planning, implementation and
evaluation
Communication, education, behaviour
management and partnership-working
Rehabilitation and enablement
Physical approaches to care
1
Service contribution
First-contact practitioners, including by enabling
patient self-referral and leading triage services
Lead and implement integrated care pathways as
part of multi-disciplinary/cross-sector teamworking
Support individuals to manage and take
responsibility for their own health and to promote
healthy living and illness prevention
Meet individuals’ needs relating to complex, longterm and chronic conditions and lead ‘fit for work’
initiatives relating to key health care priorities
Enable individuals to optimise their functional
ability, health and well-being and quality of life
Department of Health (2010) Equity and excellence: Liberating the NHS. White Paper. DoH, London.
3
The physiotherapy workforce is receptive to the need to adapt and develop. It
recognises that this needs to have various dimensions: what it delivers, how and
where it delivers services, and to whom it delivers services to maximise long-term
benefits for individuals, society and the economy. Reflecting developments already
happening within the physiotherapy workforce, these shifts can be summarised as
follows:
•
•
•
•
Developing and focusing its practice on the areas in which it can make the
biggest contribution to meeting changing needs and where it can most strongly
demonstrate its clinical- and cost-effectiveness
Developing its skill mix, optimising the value of qualified physiotherapists acting
as first-contact practitioners, taking responsibility for complex cases that require
the use of specialist and advanced-level skills and leading and managing care
planning, with physiotherapy support workers taking greater responsibility for
delivering routine, non-complex, protocol-driven care to maximise timely service
provision
Moving the balance of its service delivery from the acute to community settings,
providing care to individuals closer to home, in more convenient settings and in
more accessible ways
Optimising how it uses new communications technologies to increase the
‘reach’ of and access to its services across the health and well-being economy
and strengthening how it maintains contact with and supports individuals in selfmanaging their conditions and engaging in behaviour change relating to their
health (e.g. relating to smoking cessation and tackling obesity).
Section 2: Meeting health care priorities
Physiotherapy is excellently placed to help to meet specific identified health care
priorities and to facilitate change in how individual needs are met through the
integration of care across sectors and settings and through the promotion of selfmanagement. It is developing and using its knowledge and skills to meet changing,
projected and unmet needs in rapidly shifting environments. Building on its
expanding evidence base and strong professional values, physiotherapy can make a
strong contribution to addressing increasingly diverse and complex health needs by
leading and delivering high-quality, research-informed care.
Further information on how physiotherapy can help to address the following
particular health care priorities is provided in appendices:
•
•
•
•
Occupational health (Appendix A)
Musculo-skeletal disorders (Appendix B)
COPD (Appendix C)
Stroke (Appendix D).
4
Section 3: Achieving service improvement
The physiotherapy workforce uses its skills, interventions and approach to deliver
high-quality, timely and cost-effective care. It demonstrates real value in terms of
quality outcomes and quality of experience for individuals and society’s health and
well-being. It is also represents value for money and a sound investment for the
benefits it brings (see Appendices A to D).
Physiotherapy delivers services in settings that best ensure their timeliness and
accessibility and in ways that optimise their impact and benefit for individuals’ health
and well-being. It can lead service innovation, improvement and integration to
maximise quality, productivity and choice, and is keen to expand its role in these
increasingly important areas.
Physiotherapy services are focused on meeting user need, enhancing clinical
outcome, strengthening service integration, and optimising the quality of the patient
experience. Services are delivered via open access services, including through selfreferral, and by optimising use of new technologies to enhance access and support
to individuals (e.g. in engaging with self-management and behavioural change
programmes). It is also delivered in ways that minimise hospital admissions and
reduce length of hospital stays, with the real scope for physiotherapy to strengthen
its contribution to early intervention and enhanced recovery programmes.
In developing its services, the physiotherapy workforce is:
•
•
•
•
•
•
•
•
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Responding to the growing significance of individual choice and decisionmaking in accessing and purchasing health care and rising public expectations
about speed of access to services and the quality of services received
Acknowledging this cultural shift sits alongside significant fiscal constraint and
the imperatives this creates for optimising use of available resources
Delivering holistic care to meet individuals’ increasingly complex needs
Keen to optimise use of its expert diagnostic skills and treatment services
(including through leading triage)
Promoting patient self-referral to services wherever appropriate
Optimising access and delivery of services to all individuals and groups
(including through developing services that provide extended hour and 7-day
per week access where this enhances the quality of clinical outcome and
patient experience)
Addressing health inequalities, including by providing services between and
across agencies and organisations (including schools and charities)
Optimising its provision of occupational health and vocational rehabilitation
services to initiate, lead and sustain ‘fit for work’ schemes
Seeing clinical leadership as an integral component of physiotherapy roles (as
appropriate to career stage and job profile), with physiotherapy education and
management needing to nurture, encourage and recognise leadership across
the workforce.
Appendix E summarises the benefits of self-referral to physiotherapy services.
Appendix F provides a summary of how physiotherapy is using new
communications technology to increase access to its services, enhance group
support and help individuals to self-manage their condition.
5
Section 4: Creating a sustainable workforce
Physiotherapy is committed to engaging in an approach to workforce planning that is
founded on projected patient and population needs (including those relating to health
promotion and illness prevention, long-term conditions, and tackling health
inequalities), the implications of these for service delivery across the health and wellbeing economy, and the implications of service delivery for the skill mix and
workforce required. The logic of this sequence has to be pursued if a sustainable
workforce is to be achieved, with individuals educated to fulfil the roles required to
meet needs across the whole health and well-being economy. 2 Themes relating to
robust workforce planning are outlined below.
Skill mix
Physiotherapy recognises and embraces the need for change in how it provides
services as a workforce, in order to optimise its rich skills mix to meet individuals’
needs in the most productive and effective ways. There is increasing value in
physiotherapy support staff, with appropriate training and supervision, taking on
greater responsibility for delivering routine aspects of care. In turn, qualified
physiotherapists are able to extend their roles at advanced levels, acting as firstcontact practitioners, assuming greater responsibility for complex, non-routine
caseloads, taking on activity previously undertaken by medical colleagues, and
overseeing the delivery of care by others.
Example: A physiotherapist employed in the North West SHA as an Arthroplasty
Practitioner providing direct care to and management of the care of elective
orthopaedic patients throughout all aspects of their pathway. The job spec states
that the role will include duties previously undertaken by junior medical staff including
medical history taking and examination, ordering and interpreting diagnostic
procedures, assisting with surgery, reviewing and developing management plans for
patients.
Example: A Continence Specialist physiotherapist is working in a gynae clinic
setting assessing women with urinary incontinence referred by GPs and consultants.
These female patients would normally be seen by the Obs & Gynae medics and
referred to a Urodynamics Clinic (for investigation) or for conservative treatment
approach requiring another referral and wait for the patient.
Examples of how advanced physiotherapy practice can make a significant
contribution to service development and delivery are as follows:
•
•
•
•
Demonstrating technical mastery and specialist skills
Exercising substantial autonomy and initiative in complex and unpredictable
situations
Managing complex and unpredictable contexts and the work of others
Exercising leadership with responsibility for decision-making to optimise
outcome and the impact of change
2
See, for example, NHS National Cancer Action Team (2009) Cancer and Palliative Care Rehabilitation
Workforce Project. A Review of the Evidence. NHS National Cancer Action Team, London.
6
•
•
•
•
•
•
•
•
•
Using a wide range of information communication and technologies to support
and enhance the effectiveness of practice
Leading and developing networks to foster collaboration and enhance practice
Identifying and implementing creative solutions to develop practice and service
delivery
Advancing professional knowledge and practice to optimise clinical outcome
and patient experience. 3
As part of optimising skill mix, it is recognised that the development and
delivery of physiotherapy services does not have to be done by
physiotherapists in physiotherapy-specific roles. Services can also be provided
by physiotherapist. Practising in clinical roles mapped against care/patient
pathways (rather than defined by the profession that typically fulfils them)
Working with increasingly skilled support workers and others in multidisciplinary teams
Working in extended and advanced roles to meet changing patient/population
and service needs and to optimise service quality, innovation and improvement
Working with teams, individuals and groups (including carers) to meet individual
need across the health and well-being economy
Working in leadership, policy and management roles.
Setting
There is an increasing value in the balance of where physiotherapy is delivered
shifting to being more heavily in primary care settings (‘closer to home’) and less in
more costly acute settings. Physiotherapy also recognises the appropriateness of its
contributing to meeting individuals’ health and well-being needs in more diverse
sectors and settings (in private, independent and voluntary organisations), including
through maximising the value of its role in health promotion and illness prevention
(including by leading initiatives relating to ‘fit for work’ and supporting individuals in
engaging in self-management relating to obesity and smoking cessation).
Taking account of all the above, education commissioning has to be undertaken as a
process that is joined up with service commissioning, informed by demographic and
epidemiological projections and geographically-specific data. Workforce planning
must also take account of the increasingly diverse settings and sectors in which
services are being, and will be, delivered. It cannot be premised on an assumption
that health care students are prepared simply to supply a workforce for the NHS.
Sustainability
The future healthcare workforce must have the skills, attributes, professionalism and
expertise to deliver evidence-based case and to lead and engage with continuous
improvement and innovation. A workforce that is supported by high-quality education
and employment and sustained by opportunities for career-long development has to
underpin meeting health care needs productively and effectively.
Workforce planning must also be informed by the imperative of qualifying and postqualifying education supporting and sustaining the creation and development of a
workforce to meet current and projected patient/population needs. This raises the
need both for physiotherapy students to continue to be enabled to develop the high3
Chartered Society of Physiotherapy (2010) Physiotherapy Framework: Putting Physiotherapy
Knowledge and Skills into Practice. CSP, London.
7
level skills required for clinical-reasoning, decision-making and evidence-based
practice, and to engage in clinical leadership.
It is essential that qualifying (pre-registration) education continues to provide a solid
base both for initial practice on qualification and for on-going development and
progression into more advanced and specialist roles as individuals progress in their
career. This heightens the need for education programmes to continue to be of their
current duration and substance, obviously with curricula developed and updated to
ensure graduates are prepared for the changing environments of health and social
care. Leading and supporting this has been a key focus of recent CSP activity within
its Charting the Future project. As part of this, the CSP is supportive of approaches
to curriculum design and delivery that strengthen support for support workers’
education and development and that facilitate multiple qualification/exit points that fit
with changing workforce and job role needs.4
In addition, qualified staff and support workers have to be supported through
appropriate CPD opportunities to respond to changing needs and demands; for
example, to facilitate their shift from delivering care in acute settings to those in the
community, to enable staff to move from one specialism to another as demographic,
epidemiological and health technology advances shift where the greatest patient and
population needs lie, and to engage positively in job role re-design and continuous
service improvement. All this is essential to ensure the profile of the workforce is
responsive to changing needs and that services are sustained by robust, evidencebased processes relating to workforce supply.
Role development
Physiotherapy recognises its need to continue to develop and evolve as a workforce
to optimise its capacity to meet changing needs within changing structures. It is
receptive to
•
•
•
•
•
•
•
•
•
Taking up more advanced roles to meet patient/population and service needs
Acting as the primary assessors of individual need (building on the profession’s
assessment and diagnostic skills)
Developing its leadership roles to promote wellness and prevent ill-health
Its role as a profession often being to educate and support others in delivering
services to individuals and groups
Providing services and care traditionally provided by medical practitioners
Extending its role in triage services
Ensuring its education sustains the safe and effective integration of new areas
and approaches into its scope of practice
Adapting its practice and roles to the different environments in which individual
and group needs can most effectively be met
Delivering services in increasingly diverse settings (including within interprofessional and inter-agency teams and across care pathways), supported by
strong continuing professional development [CPD] and peer review structures.
Physiotherapy is able to rise to new challenges and opportunities, while putting
safety, quality and productivity to the fore. It is committed to optimising how it works
4
Chartered Society of Physiotherapy (2010) Learning & Development Principles for Qualifying
Programmes in Physiotherapy. CSP, London.
8
with support staff, recognising the increasing knowledge and skills base of those in
assistant roles and support workers’ capacity to deliver hands-on care within some
models of provision to enhance the timeliness, sustainability and accessibility of
care. It is also committed to ensuring that those whom it recruits to the profession
have the potential to develop excellent problem-solving and communication skills
and to take a genuinely holistic approach to working with individuals.
Section 5: Future supply and demand of the physiotherapy
workforce
5.1 NHS qualified physiotherapy workforce
Since 2000 when the NHS Plan was launched by the Labour Government, the
numbers of qualified physiotherapists employed by the NHS in England have risen
considerably showing a continuous growth in demand. According to the annual
Department of Health Workforce Census, the headcount has increased from 15,608
to 21,984 – a rise of 41%. The FTE has risen from 12,515 to 18,469 – a rise of 48%.
See Appendix G for a detailed breakdown of year on year growth since 2000.
This growth is among the highest growth rates of any of the professions in recent
years; and it is determined by REAL decisions by commissioners at local level. and
it shows how false the assumptions\predictions of "no future growth" in
physiotherapists are on which the projections made by the Workforce Review Team
in the past have been largely based.
5.2 Non NHS physiotherapy workforce
The CSP welcomes the fact that the CfWI has recognised the need to take account
of the significant physiotherapy workforce numbers employed outside the NHS. The
CSP has extracted information from its membership database which indicates that
around 24% of the CSP membership work exclusively outside the NHS, either for
private sector employers such as independent hospitals, sports clubs, occupational
health within the private sector or on a self employed basis. This indicates that
around 7,300 qualified physiotherapists who are CSP members are currently working
outside the NHS. We also know that in addition a number of CSP members who
work for the NHS also undertake some hours in non NHS employment. Given that
all physiotherapy training courses are commissioned by the NHS it is essential that
this element of the workforce is taken into account when modelling the future supply
of and demand for physiotherapists. The Government’s policy of opening up NHS
service provision to any willing provider means that this sector of healthcare
provision will be expanding significantly in coming months and years. Failure to take
account of this will mean that any workforce models will seriously underestimate
future demand for qualified physiotherapists.
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5.3
Vacancy rates
The NHS Information Centre collects vacancy data from NHS trusts in England each
year. The latest survey shows that as at March 2009 there was a slight increase in
the 3 month vacancy rate (ie posts that have been vacant for 3 months or longer that
managers are actively trying to fill). This has risen from 0.3% in March 2008 to 0.5%
in March 2009. The NHS IC also began collecting the data for "on the day" vacancy
rates (ie all posts vacant on 31 March, not just 3 month+ vacancies). This figure has
also risen from 2.4% in March 2008 to 2.8% in March 2009.
The CSP wishes to highlight the fact that the vacancy data only includes posts which
employers are actively trying to fill. It does not take account of posts which have
been frozen or which are subject to delays in being filled due to local vacancy control
procedures being introduced. The CSP was aware that anecdotal evidence from
managers indicated that the DH vacancy data did not reflect the real difficulties in
recruiting to senior posts and we there undertook a workforce survey of
physiotherapy managers in the NHS in England in October 2008.
We obtained responses from 126 NHS trusts in England covering 6,478
physiotherapists (32% of England workforce according to the DH Workforce Census
2008). Managers were asked about the difficulties they faced in recruiting to senior
physiotherapy posts:
•
•
•
34% reported some or major problems recruiting to B6
46% reported some or major problems recruiting to B7
25% reported some or major problems recruiting to B8
Clinical areas where posts hardest to fill were elderly care (26% said very or quite
hard to fill); cardio/respiratory (25%); intermediate (23%); women health (20%).
At the time that this information was collated the “on the day” vacancy rate for
qualified physiotherapists according to the DH vacancy survey for England, was just
2.4%. This shows the huge discrepancy between the DH data and the reality facing
managers in their day to day lives of recruiting to senior physiotherapy posts.
Vacancy rates for qualified physiotherapists 2006-2009
2009
On the
day
Vacancy 2.8%
%
2009
2008
2008
3 months+
On the day
3 months+ 3 months+
3 months+
0.5%
2.4%
0.3%
1.1%
Note: On the day data has only been collected since 2008
Source: NHS Information Centre from DH annual vacancy surveys
10
2007
0.4%
2006
5.4 International recruitment
In the summer of 2005 the Home Office Shortage Occupations List was amended so
that only senior physiotherapists appeared on the list. This was a direct result of the
increasing numbers of 2005 graduates who were facing difficulties in obtaining their
first physiotherapy post. It was hoped that by taking this action physiotherapists from
non EEA countries would no longer be able to apply for Band 5 posts and that this
would increase the employment opportunities for new graduates.
On 29th May 2007 physiotherapy was removed completely from the shortage
occupations list. The CSP has obtained data from the Health Professions Council
which shows the sharp decline in the number of non UK nationals who have been
registered to practice as physiotherapists in the UK. This shows that since 2005 the
numbers registering have fallen from 1,298 to 550 in 2009 – a fall of nearly 60%.
A significant number of these are physiotherapists from Australia, New Zealand and
South Africa who are here on short term working holiday visas for those under 26
before returning home.
In the past overseas physiotherapists have been instrumental in filling vacant posts
and helping to cover shortages of qualified and experienced staff. Clearly this pool
has been dramatically reduced and can no longer be relied on as a quick fix solution.
Current and future shortages will have to be filled by UK physiotherapists making it
more important than ever to ensure that sufficient numbers are being trained for the
future.
Numbers of non UK national registered to practice as physiotherapists by HPC
Year
Number
2004
1235
2005
1298
2006
1053
2007
635
2008
536
2009
550
Source: Health Professions Council response to CSP Freedom of Information
Request, July 2010
5.5 Commissioned training places
There are currently 31 Higher Education Institutes (HEI) in England offering
physiotherapy undergraduate training courses. There are 31 full time BSc
programmes, 12 Masters level accelerated programmes (one of which is noncommissioned) and 5 operational BSc level part time programmes as at 2009/10.
Intakes to physiotherapy training programmes in English HEIs peaked in 2004 at
2,427 following recognition of the need to train more physiotherapists as recognised
by the NHS Plan 2000. Since then there has been a dramatic year on year decrease
in the number of training places falling to 1,684 for the 2010 intake. This constitutes
a 30% reduction with 743 places being lost (see table below). This is why CSP is so
concerned at the indications that further cuts may be made as early as this year
which will inevitably lead to a serious undersupply in the near future exacerbating the
existing problems of recruitment at Band 6 and above.
11
England – physiotherapy commissions 2001-2010
Year
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Intake 1747
2037
2145
2427
2410
2276
2041
1796
1784
1684
Source: CSP HEI enrolment data
The CSP is particularly concerned that indications have been given by at least two
Strategic Health Authorities that further cuts may be made this year.
The CSP is concerned that the difficulties facing new physiotherapy graduates in
recent years have led SHAs to make these cuts to training places. We are firmly of
the view that the problem of unemployment among physiotherapy graduates was not
been caused by training too many physiotherapists. It was the result of poor
workforce planning and the impact of the deficits in the NHS in 2006, particularly in
England, when many posts were frozen or cut with junior posts being especially
vulnerable. The CSP has tracked the employment status of new graduates and our
surveys have found that the situation has improved enormously for graduates from
English HEIs in the last two years. Our April 2010 survey of the 2009 cohort showed
that over 80% of graduates had obtained work, on either permanent or short term
contracts, as physiotherapists, and that number is very likely to have increased
further in the intervening months. A further 7% were not currently seeking a
physiotherapy post having decided to work or travel abroad, undertake further study
or for some other personal reason, a factor that would impact on numbers actively
seeking physiotherapy posts in any year.
The danger is that the NHS will return to the position in the 1990s and early 2000s
when there was a desperate shortage of physiotherapists to fill the demand. The
result was that physiotherapists were able to pick their employer rather than the
employer choosing them. There were also a high level of vacant posts year after
year, (as recorded in surveys for the Pay Review Body). It meant that many services
could not be delivered because of a lack of staff.
CSP therefore asks the Centre for Workforce Intelligence to send out a clear
recommendation to commissioners that there should be no further cuts to
training places for physiotherapists in 2010 in order to avoid even more
serious shortages in the near future.
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Meeting health care priorities
Appendix A
Occupational health
Reducing current levels of sickness-related work absence and incapacity benefit
claims is a clear target in strengthening the productivity of the UK workforce and
strengthening the UK economy. Such absence and claims are most commonly
caused by musculo-skeletal conditions and disorders such as stress, many of which
are exacerbated by staying off work.
Physiotherapists have a central role to play in helping people to remain healthy in
work by enabling individuals to understand prevention of chronic disease, reoccurrence and strategies for self-management. They are also excellently placed to
support individuals’ return to work and help them to manage their own health in the
longer term, thereby reducing the prevalence of future episodes of ill health.
Scale of the problem
•
Musculo-skeletal disorders (MSDs) and common mental health problems are a
major cause of absence from work and benefit claims due to ill health. Musculoskeletal conditions comprise about 55 per cent of the all work-related illnesses.
A further 30 per cent are caused by common mental health problems, such as
stress. 5
•
Illness and injury accounted for an estimated 29.3 million days off work in
2008/9, with each person affected taking an average 20.8 days off work. 6
•
MSDs are consistently the most commonly reported type of work-related
illness. Each person with an MSD took an estimated 17.2 days off sick and an
estimated 9.3 million working days were lost in 2008/9 through MSDs caused or
made worse by work. 7
•
On average, NHS staff take 10.7 days’ sick leave each year, the public sector
as a whole takes 9.7 days, and the private sector 6.4 days. 8
•
The drive to tackle sickness absence aims not only to reduce pressure on
public funding, but also to improve people’s health, well-being and quality of life
and to tackle poverty and social exclusion. 9
•
A growing body of evidence shows that, on the whole, work is good for physical
health, mental health and well-being, and that those in better health earn more
and are more likely to be in work than those with poorer health. 10
5
Black, C. (2008) Working for a healthier tomorrow. Dame Carol Black’s review of the health of
Britain’s working age population. London, TSO, p.41
6
http://www.hse.gov.uk/statistics
7
http://www.hse.gov.uk/statistics
8
http://www.nhshealthandwellbeing.org/pdfs/NHS%20HWB%20Review%20Interim%20Report%20190
809.pdf
9
10
Black (2008) Working for a healthier tomorrow. p.41
Waddell G, Burton AK. Is work good for your health and well-being? London: TSO; 2006.
13
Cost
•
Sickness absence cost the UK an estimated “19.9 billion in 2007. 11
•
22 per cent of people on incapacity benefit (employment support allowance)
has an MSD. 12
•
MSDs account for up to one-third of all GP consultations and cost society
approximately £7.4 billion per year. 13
•
A survey of 76 NHS organisations found that the average estimated cost of
sickness absence was almost £5 million a year. 14
•
The Boorman Report states that by reducing current rates of sickness absence
in the NHS by one-third, there would be 33.4 million ‘additional’ available
working days per year within the NHS, equivalent to an extra 14,900 whole-time
equivalent staff, and with an estimated cost-saving of £555 million. 15
Benefits of physiotherapy in the workplace
Physiotherapists are excellently placed to help address both musculo-skeletal
disorders and stress-related conditions. Their biopsychosocial approach to
healthcare, combining mental well-being with physical rehabilitation, encourages a
more relaxed or positive outlook to improve physical health outcomes.
Physiotherapists can:
•
•
•
•
Stop people going off work in the first place
Get people back to work on full normal duties
If alternative or modified duties are required, facilitate a managed return to work
Deliver a cost-effective service.
In 2009, the CSP joined other healthcare leaders in signing a consensus statement
committing to promote the link between good health and 'good work' (defined as
work that is healthy and safe, in which the individual has some influence over how
tasks are carried out, and that provides a sense of self-worth. 16
There is a growing recognition that sickness absence is best tackled by services that
are more proactive in promoting healthy lifestyles, preventing illness, and early
intervention. Physiotherapists already follow this model, by working at every stage of
the care system, from offering prevention advice to providing therapy and
11
Confederation of British Industry (2008). Workplace absence rises amid concerns over longterm sickness (news release) London
12
http://research.dwp.gov.uk/asd/asd5/rports2007-2008/rrep469.pdf]
13
http://www.workfoundation.co.uk/research/publications/publicationdetail.aspx?oItemId=44&pa
rentPageID=102&PubType=
14
Nursing Standard 2008; 23(8): 7-7
15
16
Boorman S. NHS health and well-being: final report. London: Department of Health; 2009.
Black (2008) Working for a healthier tomorrow.
14
rehabilitation, and empowering individuals to maintain their own health going
forward. 17
The Black report found that "early, regular and sensitive contact with employees
during sickness absences can be a key factor in enabling an early return to work". It
argues that comprehensive service reform should be combined with a cultural shift in
workplaces across the economy. Employers should play a more proactive role to
ensure that their staff receive early access to the help they need, while individuals
should take more responsibility for managing their own health. 18
‘Fit for Work’ has been developed to provide an integrated service to enable people
who are not working due to ill health to be referred quickly to a range of services,
including physiotherapy and psychological therapies, to help them back to
appropriate work as quickly as possible; 10 pilot sites across England are trialling
initiatives to help people who are off sick.
Examples:
The Royal Mail’s occupational support and therapy programme, including
physiotherapy, has had substantial financial benefits, with the programme providing
a return of approximately £5 for every £1 invested. Absence was cut by 25%
between 2004 and 2007 and 3,600 employees absent through illness or injury were
brought back into work. Before the programme, the estimated cost to the Royal Mail
of the absence and restricted duties of clients in the study group was £1,384,501.
Since the programme, this has fallen to £127,738. On the premise that absence and
restricted duties would have continued at similar rates without the rehabilitation
programme, the saving is in excess of £1m a year. 19
AstraZeneca started its “Well-being in AstraZeneca” programme for its 10,000 staff
in the UK in 2000. Through the provision of rehabilitation and treatment services,
including physiotherapy and access to sports facilities and health screening, the
company has saved £200,000 a year in health insurance spend and absence levels
are 31% lower than average levels.
York Hospitals NHS Foundation Trust cut its long-term sickness rates by more
than 40 per cent through early intervention with physiotherapy and psychotherapy.
The number of staff off work for more than four weeks dropped from 99 to 57 and the
number of staff off sick for more than three months dropped from 52 to 28. The
project cost £100,000 but has saved the trust around £200,000. 20
17
18
19
20
Boorman. NHS Health and well-being.
Black. Working for a healthier tomorrow. p.41
www.royalmailgroup.com/valueofrudehealth
Nursing Standard (2009); 24(5): 11-11
15
Meeting health care priorities
Appendix B
Musculo-skeletal disorders
Speedy access to physiotherapy for people with musculo-skeletal disorders [MSDs]
is clinically and cost effective for the health service, including GPs, for employers
and for society. Physiotherapists have helped to pioneer innovative ways of
providing speedy access within existing services.
Scale of the problem
•
Based on the latest available statistics from the HSE, 227,000 people have an
MSD of the back, 215,000 of the upper limbs or neck and 96,000 of the lower
limbs. Low back pain is the number one cause of long-term absence amongst
manual workers 21
•
MSDs are the most common reason for repeat consultations with GPs,
accounting for up to 30% of primary care consultations. 22
•
Musculoskeletal disorders (MSDs) have consistently been the most commonly
reported type of work-related illness since records began. In 2008/09 an
estimated 538,000 people in Great Britain, who had worked in the last year,
believed they were suffering from a MSD that was caused or made worse by
their current or past work. An estimated 9.3 million working days (full-day
equivalent) were lost through MSDs in GB in 2008/09. 23
•
Within the NHS, half of sickness absence is caused by MSDs. 24
Cost of MSDs
•
•
22 per cent of people on Incapacity Benefit (Employment Support Allowance)
have an MSD25
MSDs cost society approximately £7.4billion a year. 26
21
http://www.hse.gov.uk/statistics/lfs/0809/swit3w12.htm
http://www.hse.gov.uk/statistics/lfs/0809/swit3w12.htm; Petty J, Davies A. (2008) Translating
the NICE and NSF guidance into practice: A guide for physiotherapists. London, MS Society.
23
http://www.hse.gov.uk/statistics/causdis/musculoskeletal/index.htm
22
24
http://www.nhshealthandwellbeing.org/pdfs/NHS%20HWB%20Review%20Interim%20Report
%20190809.pdf
25
http://research.dwp.gov.uk/asd/asd5/rports2007-2008/rrep469.pdf
26
http://www.workfoundation.co.uk/research/publications/publicationdetail.aspx?oItemId=44&pa
rentPageID=102&PubType; http://www.hse.gov.uk/statistics/pdf/costs.pdf
16
Physiotherapy
MSDs are one of the most common problems that physiotherapists treat. Early
intervention physiotherapy can reduce the amount of time people are off sick and is
vital in order to prevent an acute problem becoming chronic.
Examples
•
•
Two government departments in Northern Ireland provided early access to
physiotherapy for staff with MSDs. 80 per cent indicated that physiotherapy had
prevented them from going absent. Of those already off sick, over 80 per cent
indicated that physiotherapy had shortened their absence. Respondents
indicated that the service shortened their absence by an average of six
weeks. 27
West Suffolk hospital trust, Bury St Edmunds, was commended in the Boorman
report for having achieved savings of £170,000 through a system of priority
referrals to a local physio for injured staff. For a cost of £21,000 it had achieved
a 40% reduction in lost days through sickness absence and savings of
£170,000 in the cost of MSDs. 28
Self referral has been proven to be clinically successful with high patient satisfaction
as well as cost effective. The self-referral pilots that took place across six NHS
England sites between 2006 and 2008 were found to reduce the number of
associated NHS costs, particularly for investigations and prescribing, with 75 per
cent of patients who self-referred not requiring a prescription for medicines. In
addition there was no increase in demand for services and self referral reduced work
•
An analysis of self-referral in Scotland (2007) found that the average cost of an
episode of care was established as £66.31 for a self-referral, £79.50 for a GPsuggested referral and £88.99 for a GP referral. The average cost benefit to
NHS Scotland of self-referral was identified as being approximately £2 million
per annum. 29
•
Doncaster and Bassetlaw Trust piloted a successful self referral physio service
for 6500 staff in 2005. The service was made permanent after an evaluation
identified potential savings of more than £330,000. It is used by employees
from all corners of the trust, and it offers an average waiting time of 2.8 days.
More than half the users say they would have taken time off work if the service
were not available. 30
27
Management of Sickness Absence in the Northern Ireland Civil Service NIA 132/07-08.
http://www.niauditoffice.gov.uk/pubs/Absence/Absence-final.pdf
28
Boorman. NHS health and well-being.
29
Holdsworth LK, Webster VS, McFadyen AK (2007) What are the costs to NHS Scotland of
self-referral to physiotherapy? Results of a national trial. Physiotherapy 93(1): 3-11.
30
Department of Health. The Musculoskeletal Services Framework: a joint responsibility: doing
it differently. London: Department of Health;
2006.http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalass
et/dh_4138412.pdf
17
• In Cambridge, self-referral for MSD outpatient services has reduced costs due to
less GP use of prescribing and diagnostic tests. 75% of patient who self-referred did
not require a prescription for medicines giving an average saving of £12,000 per GP
practice. 31
31
DoH. Musculoskeletal Framework
18
Meeting health care priorities
Appendix C
Chronic Obstructive Pulmonary Disease (COPD)
The clinical and cost effectiveness of pulmonary rehabilitation programmes for
people with COPD is well documented. Awareness of COPD amongst the general
public needs to be raised as many people are unaware of the condition and the link
to smoking. The possibility of combining treatment programmes for people with
different diagnoses but similar symptoms is worth exploring in order to take
advantage of existing expertise and to deliver cost-effective services.
Scale of the problem
•
COPD is the 5th biggest killer in the UK (1) with an estimated 3.7 million
people having the disease. 32
•
24,816 people in England and Wales died as a result of COPD in 2008. The
disease kills more people every year in the UK than bowel cancer, breast cancer or
prostate cancer. 33
•
COPD is the only major cause of death the incidence of which is on the
increase. It is expected to be the third leading cause of death worldwide by 2020,
exceeded only by heart disease and stroke. 34
32
National Statistics (2006) Health Statistics Quarterly 30:
http://www.statistics.gov.uk/downloads/theme_health/HSQ30.pdf; Stang P, Lydick E, Silberman C et
al. The Prevalence of COPD: Using smoking rates to estimate disease frequency in the general 15
Online National Statistics 2008
3 Online National Statistics 2008
33
Online National Statistics, 2008; Cancer Research UK:
http://info.cancerresearchuk.org/cancerstats/mortality/ and Burden of Lung Disease 2nd Edition,
British Thoracic Society 2006population. Chest 2000; 117: 354S-359S
34
Cancer Research UK: http://info.cancerresearchuk.org/cancerstats/mortality/ and Burden of
Lung Disease 2nd Edition, British Thoracic Society 2006population. Chest 2000; 117: 354S-359S;
Murray CJL, Lopez AD. Alternative projections of mortality and disability by cause 1990-2020: Global
Burden of Disease Study. Lancet 1997; 349 1498-504; European Respiratory Society (2003)
European White Lung Book; Murray CJL & Lopez AD (1996) The global burden of disease: a
comprehensive assessment of mortality and disability from diseases, injuries and risk factors in 1990,
and projected to 2020. Harvard University Press, Cambridge MA, p.361; Mannino, DM. et al. (2006)
The natural history of chronic obstructive pulmonary disease. Eur Respir J. 27(3): p. 627-43; Lopez
AD. et al. (2006) Chronic obstructive pulmonary disease: current burden and future projections. Eur
Respir J, 27 (2): p. 188-207
19
Cost of COPD
•
One in eight (130,000) acute medical admissions in adults is due to COPD,
making it the second largest cause of emergency admission in the UK. It
accounts for one million ‘bed days’ in hospitals in the UK each year. 35
•
NICE estimates that the direct cost of providing care in the NHS for people with
COPD is almost £500 million a year. More than half this cost relates to the
provision of care in hospital. 36
•
It is estimated that in the UK COPD is responsible for 24 million lost working
days per annum estimated as costing £2.7 billion. 37
•
On average, 15 per cent of those admitted to hospital with COPD die within
three months. Although estimates vary, it is thought that 25% of patients die
within a year. 38
Pulmonary rehabilitation and physiotherapy
Pulmonary rehabilitation programmes are clinically and cost effective in improving
health and quality of life, reducing length of hospital stay and reducing the number of
hospital re-admissions for people with COPD. Physiotherapists are essential to the
multi-disciplinary teams that run these programmes.
The National Institute for Clinical Excellence (NICE) has produced various
documents supporting the use of pulmonary rehabilitation programmes in a variety of
settings, including the community, as well as making the case for commissioning the
programmes.39
The rehabilitation process should incorporate a programme of physical training,
disease education, nutritional, psychological and behavioural intervention. NICE
35
Lost in Translation – bridging the communication gap in COPD (June 2006) - British Lung
Foundation Survey; Health Care Commission report, Clearing the Air 2006
36
Commission for Healthcare Audit and Inspection (2006) Clearing the Air: A national study of
chronic obstructive pulmonary disease British Lung Foundation briefing COPD: October 2009 (UK) 6
37
38
http://www.dh.gov.uk/en/Healthcare/Longtermconditions/COPD/DH_113006
Health Care Commission report, Clearing the Air 2006
39
http://www.nice.org.uk/media/63F/4D/PulmonaryRehabCommissioningGuide.pdf; National
Clinical Guideline Centre. (2010) Chronic obstructive pulmonary disease: management of chronic
obstructive pulmonary disease in adults in primary and secondary care. London: National Clinical
Guideline Centre. Available from: http://guidance.nice.org.uk/CG101/Guidance/pdf/English; National
Institute for Health and Clinical Excellence (2006) Pulmonary rehabilitation service for patients with
COPD. Commissioning guide. Implementing NICE guidance. NICE, London.
20
have stated that all those with COPD suitable for pulmonary rehabilitation should
receive it.
Examples
•
A study in Canada found that, over one year, pulmonary rehabilitation was
associated with decreased health service use, reduced direct costs and
improved health status for COPD patients. The health status of patients
enrolled in the programme improved significantly following pulmonary
rehabilitation, irrespective of the severity of disease. The average reduction of
total costs before and after the programme was $34,367 per 100 person-years
or approximately $344 per person per year. 40
•
Glenfield hospital in Leicester has been offering a pulmonary rehabilitation
programme to patients with chronic heart failure (CHF) as well as to those with
COPD. Both sets of patients have showed a marked improvement. Combining
programmes in this way may well help to reduce costs as well as making better
use of resources.41
40
Golmohammadi K, Jacobs P, Sin DD. Economic evaluation of a community-based pulmonary
rehabilitation program for chronic obstructive pulmonary disease. Lung 2004; 182(3): 187-96.
41
http://www.csp.org.uk/director/members/newsandanalysis/frontlinemagazine.cfm?ITEM_ID=4
149D5E4
B211458585FD432F743FBE5B&article
21
Meeting health care priorities
Appendix D
Stroke
With an ageing population and increased life expectancy, the number of stroke
survivors is likely to increase. Investment in physiotherapy services that support
survivors and indirectly their families and carers is vital.
Scale of the problem
•
110,000 people have a first stroke and 20,000 mini strokes (TIAs) each year in
England, 25 per cent of whom are within the working age population (under 65
years)
•
Approximately one-third of stroke survivors are left with disabilities and
rehabilitation needs
•
Stroke is a long-term condition
•
Stroke is a major cause of mortality in the UK, with around 53,000 deaths each
year. 42
Cost of stroke
•
•
•
The total economic costs of stroke to the UK in 2006/07 were £4.5 billion
The total economic cost of mini strokes (TIAs) in 2006/07 were £440 million
Over half (56 per cent) of the total costs for stroke and 83 per cent of the total
costs for TIAs were health and social care costs. 43
Physiotherapy
Physiotherapists have a critical role to play in supporting stroke survivors, and their
carers, when they leave hospital. There is wide consensus about the beneficial
impact of physiotherapy on the physical effects of stroke. 44 Many stroke survivors
have emotional difficulties and a very real sense of both personal and physical loss.
Physiotherapists, with their holistic, person-centred approach to health and well-
42
British Heart Foundation. Stroke Statistics 2009:
http://www.heartstats.org/datapage.asp?id=8615
43
British Heart Foundation. Stroke Statistics 2009:
http://www.heartstats.org/datapage.asp?id=8615
44
Royal College of Physicians (2008) National Clinical Guidelines for Stroke. RCP, London;
Intercollegiate Stroke Working Party (2008) Physiotherapy concise guide for stroke. RCP, London
[http://www.rcplondon.ac.uk/pubs/contents/3756b29c-1001-4db1-97a6-dcd220970fd6.pdf]; Royal
College of Physicians (2009) National Sentinel Stroke Audit Phase II (clinical audit) 2008: Report for
England, Wales and Northern Ireland. RCP, London; Department of Health (2007) National Service
Framework for Long-term Conditions DoH, London..
[http://www.rcplondon.ac.uk/clinical-standards/ceeu/Current-work/stroke/Documents/stroke-auditreport-2008.pdf]
22
being, are ideally placed to support individuals in working towards re-enablement
and recovery. 45
The clinical standard for patients with motoro deficits to access physiotherapy is 72
hours.46
Early supported discharge (ESD)
Enabling stroke survivors to receive rehabilitation at home or in the community,
rather than in hospital, has been shown to be a cost-effective service when
combined with stroke unit care. Early supported discharge can reduce long-term
dependency and admission to institutional care as well as releasing hospital beds by
reducing length of stay. ESD has been shown to be most successful where there is a
co-ordinated stroke multi-disciplinary, multi agency team delivering the service. 47
Example
•
Northumbria Healthcare NHS Foundation Trust established ESD, offering a
service seven days a week with up to three visits a day. This has resulted in the
average length of stay in hospital being reduced to half the national average,
with a saving of £500k by replacing inpatient beds with ESD and a more
efficient model of care.
Economic modelling by the National Audit Office suggests that increasing the
availability of ESD from the current 20 per cent to around 43 per cent of stroke
survivors would be cost-effective over a the year period, costing about £5,800 per
each ‘quality-adjusted life year’ (QALY) gained. 48
45
CSP and the Stroke Association (2010) Moving On: a vision for community based
physiotherapy after stroke in England: http://www.stroke.org.uk/document.rm?id=2649; CSP
and the Stroke Association (2010) Aspiring to Excellence: services for the long term support of stroke
survivors: guidance for commissioners and a resource for providers [
http://www.csp.org.uk/uploads/documents/aspiring2excellence.pdf]
46
NCP. National Sentinel Audit.
Saka O, Serra V, Samyshkin Y, McGuire A, Wolfe CCDA. Cost-Effectiveness of Stroke Unit
Care Followed by Early Supported Discharge. Stroke 2009; 40(1): 24-29; Stroke Association. Moving
on.
47
48
National Audit Office (2010) Progress in improving stroke care. Report by the Comptroller and
Auditor General. HC291 Session 2009-2010. London: The Stationery Office.
[http://www.nao.org.uk/publications/0910/stroke.aspx]
23
Achieving service improvement
Appendix E
Self-referral
Self-referral is “a system of access that allows patients to refer themselves to a
physiotherapist directly, without having to see or be prompted by another healthcare
practitioner”. 49 Self-referral to physiotherapy results in high levels of service-user
satisfaction, lower NHS costs, and lower levels of work absence. 50
Key points
•
•
•
•
While physiotherapists have been able to act as first-contact practitioners since
1978, for many years it was only common within private practice. 51
Self-referral for musculo-skeletal physiotherapy has been available in parts of
Scotland for some years. In recent years, it has been developing in a small, but
growing number of areas elsewhere in the UK. In 2008, the then government
set out plans actively to promote the comprehensive roll-out of self-referral to
NHS physiotherapy services in England from April 2009. 52
Self-referral enables patients to contact NHS physiotherapy services directly,
rather than having to go through their GPs. A prospective patient completes a
short self-assessment questionnaire, which is reviewed by a physiotherapist.
Based on perceived clinical need, an appointment (which may include a waiting
time) is allocated accordingly.
The approach has a strong evidence base. Pilots in Scotland and later in
England found that self-referral benefits patients, commissioners, GPs and
employers. It brings cost-savings, reducing the need for healthcare
interventions such as x-rays and prescribing, and referrals to orthopaedic
specialists. It also lowers rates of sickness absence, and motivates patients to
manage their own health. 53
49
Holdsworth LK, Webster VS, McFadyen AK, et al. What are the costs to NHS Scotland of selfreferral to physiotherapy? Results of a national trial. Physiotherapy. 2007;93(1)
50
Department of Health. Self-referral pilots to musculoskeletal physiotherapy and the
implications for improving access to other AHP services. London: Department of Health; 2008. p 9
51
Chartered Society of Physiotherapy. Proceedings of Council: Byelaw amendments.
Physiotherapy. 1978;64(7):218.
52
Department of Health. The NHS in England: The operating framework for 2009/10. London:
Department of Health; 2009.
53
Holdsworth et al. What are the costs to NHS Scotloand of self-referral to physiotherapy?; Department
of Health (2008). Self-referral pilots to musculoskeletal physiotherapy and the implications for
improving access to other AHP services. London: Department of Health.
24
•
•
•
•
•
54
Self-referral is popular with patients. As a patient-centred approach, it increases
ease of use, convenience, portability, patient influence, choice, engagement
and involvement in care, and promotes self-management. The pilots showed
that people who self-refer to physiotherapy take fewer days off work and are
about half as likely to be off work for one month, compared with those referred
to physiotherapy by a GP. 54
Self-referral enables physiotherapists to use a wide range of their knowledge
and skills to meet patient needs effectively and efficiently. This can include
performing injections, referral on for x-rays and further investigations, writing
sick notes, and screening for red flags. When patients self-refer, the
responsibility and accountability of physiotherapists are enhanced, though they
still work closely with the wider healthcare team and the individual
professional’s autonomy remains the same whatever the route of referral.
Self-referral to physiotherapy is efficient for other healthcare providers too,
reducing their costs, time and use of resources. Patients often see a GP
several times before being referred to physiotherapy, by which time their
condition may be more longstanding and difficult to resolve. Evidence shows
that early intervention for lower back pain reduces its recurrence in the
following year by up to 40 per cent. 55
Self-referral has not led to an increase in demand for physiotherapy, apart from
in physiotherapy services that have a history of under-referral. A proportion of
people who would normally have seen their GP first simply opt for a more direct
route to solve their problem. 56
The feedback from GPs in the self-referral pilots was extremely positive, with
91 per cent in the England pilots wanting the self-referral facility to continue.
Reasons for this included savings in GP time (with nearly 24 per cent of
patients self-referring) and enhanced patient autonomy, enabling GPs to focus
their resources on those with more complex medical problems. 57
DoH. Self-referral pilots. pp.15,16
55
Black C.(2008) Working for a healthier tomorrow. Dame Carol Black's review of the health of
Britain's working age population. London: TSO. p 76
56
57
DoH. Self-referral pilots. p.16
DoH. Self-referral pilots. p.18
25
Achieving service improvement
Appendix F
Optimising access
Physiotherapy recognises the importance of facilitating access to its services by all
population groups. People with disabilities, those living in isolated areas, and people
who work long hours are just some of those who may find it difficult to visit traditional
physiotherapy clinics. Today, higher patient expectations, combined with a growing
readiness for innovative service design, raise the importance of making services
more accessible to patients, often increasing efficiency in the process.
Key points
•
•
•
Providing services centred on individual need. There is a growing
understanding that services should be 'wrapped around the patient', rather than
'wrapping the patient around the services'. Individuals are playing an
increasingly proactive role in managing their own health, and have a clear idea
of what they expect from their services. Taking a proactive approach to
designing flexible, responsive services, within acceptable waiting times, results
in better outcomes all round – not least in patient satisfaction. For example,
providing out-of-hours appointments enables people to access physiotherapy
without having to take time off work, resulting in positive health outcomes for
the individual and wider economic benefits.
Tackling local health inequalities. We have seen a shift towards empowering
local services to direct funding to their areas of need, championed by initiatives
such as world-class commissioning. This focus enables resources to be
targeted at the groups in most need of treatment. Initiatives such as direct
access and telephone advice enable practices to provide initial assessments
using minimal resources, so that remaining funding can be concentrated on
those with greatest need. For example, projects have focused on working
specifically with farming communities to provide them with appropriate access
to physiotherapy services. 58
Embracing innovation. The drive towards continuous quality improvement
within the NHS, with an emphasis on providing an environment where
innovation can flourish (for example, High Quality Care for All), ... . One of the
visions for the health service in 2022 as set out in the Wanless report Securing
our future health is that "Current service innovations such as NHS Direct, Walkin Centres and telemedicine are commonplace, enabling people to receive an
initial diagnosis in a variety of settings, moving beyond the traditional visit to the
GP surgery." 59
58
Chartered Society of Physiotherapy. Making physiotherapy count: a range of quality assured
services. Compiled as a part of the Sharing Effective Physiotherapy Practice Project. London: The
Chartered Society of Physiotherapy; 2004. p 16
59
Wanless D. Securing our future health: taking a long-term view. Final report. . London: HM
Treasury; 2002. p 15
26
•
The key innovations to improve access to services include:
o
Re-designing community services to become more responsive to patients'
needs – for example, by extending opening hours, offering appointments at a
choice of locations, and running drop-in clinics
Direct access to physiotherapy by self-referral to telephone triage and patientmanagement systems
A range of electronic and assistive technologies to support people at home and
maintain independence; these include telecare (using technology to support
individuals in their own homes; e.g. through monitors that detect falls),
telehealth (remotely monitoring and managing conditionsl e.g. measuring a
patient's heart rate through a sensor that transmits the results to an
assessment centre) and telerehabilitation (e.g. using videoconferencing
following surgery to monitor patients and offer advice).
o
o
Telephone assessment and support
Telepractice presents a significant opportunity for physiotherapy to increase
efficiency and cut costs, strengthening individuals’ access to its services and
enhancing physiotherapy support of individuals’ self-management of their health.
Findings show that a wide range of technological tools can be used to enhance
delivery of traditional physiotherapy and to help spread resources more effectively.
For example, rehabilitation classes for people with chronic obstructive pulmonary
disease have been transmitted by video link to patients living in remote rural areas,
with positive outcomes. 60 The profession recognises the increasing need to embrace
these technologies and find ways to make them work for delivering its services to
those who need and can benefit from them.
Assessing the severity of a patient’s condition over the telephone has been found to
be very resource-efficient. Telephone triage saves patient and physiotherapist time,
as well as reducing costs and ensuring those needing the most urgent treatment are
prioritised. Where appropriate, follow-up support by telephone has also been found
to be a clinically and cost effective way of enabling patients to self manage their
condition, helping to prevent relapses.
•
An occupational health physiotherapy service used telephone triage and follow
up support as part of a programme to tackle MSDs experienced by staff of NHS
Lothian. Over £350,000 was saved in salaries alone by reducing sickness
absence and there was a 74 pre cent reduction in recurrence of MSDs nine
months following the programme.
60
Duthie A. Chronic obstructive pulmonary disease (COPD) remote rehabilitation classes via
video link. Web article. Scottish Centre for Telehealth 2009
27
Appendix G
QUALIFIED PHYSIOTHERAPY STAFF IN THE NHS
England 1999 - 2009
Source: Department of Health Workforce Census NHS Information
Centre
1999
Headcount
WTE
15,070
% increase
-
12,047
-
2005
WTE
Headcount
% increase
19,997
4.5%
2000
Headcount
16,291
4.7%
WTE
15,608
3.6%
Headcount
19,820
-0.9%
12,515
3.9%
2006
WTE
16,334
0.3%
2001
Headcount
16,212
3.9%
WTE
12,989
3.8%
2000
Headcount
20,146
1.6%
WTE
16,752
2.6%
2009
Change
Change
(%)
FTE
15,608
12,515
21,984
6376
18,460
5945
41%
48%
16,885
4.2%
WTE
28
Headcount
13,586
4.6%
2007
Growth 2000 to 2009
Headcount
2002
Headcount
17,922
6.2%
2008
Headcount
21,114
4.8%
WTE
17,652
5.4%
Headcount
21,984
4.1%
2003
WTE
14,455
6.4%
2009
WTE
18,460
4.6%
Headcount
19,139
6.8%
2004
WTE
15,564
7.7%
29