One of the ways that physiotherapists have recently looked to secure greater influence in the health care system has been to take on role previously done by others.
Extended scopes now include limited prescribing rights and some invasive procedures like injecting, cannulation and bronchoscopy. We now also have new consultancy, advisory and leadership roles that are changing the nature of our practice.
And one of the most popular extensions that can be taken up by the whole profession has involved the drift towards public health medicine.
Physiotherapists and others are looking at the possibility of offering ‘wrap-around’ care where once they were specialists in discrete areas of practice, like cardiorespiratory, musculoskeletal and neurological physiotherapy.
Now, we are looking to use our access and skills to change people’s health behaviours: helping them to stop smoking, lose weight and do more exercise.
But there are real dangers in this approach that have not, as yet, been explored by the profession, as it tries to scale the rocky cliff face of traditional health care, to find the rarified air and green pastures in the New World of health promotion.
A few years ago, nurses began to take on the work of endoscopy that used to be the doctor’s domain. Practice nurses were trained up, and took over the responsibility for all of the preparation, hygiene, risk management and scoping of the patient.
Many saw this as a real sign that nursing was now respected as a scientifically-based practice, and one that had gained the clinical trust of doctors. But others, privately at least, thought otherwise.
Some asked whether doing endoscopies was really anything to do with nursing philosophy, arguing that doctors had simply passed over a role that they no longer wanted, because it was either too mundane or of limited clinical interest.
Rather than it being a sign of recognition, they argued, endoscopy was merely another episode in the long history of medical paternalism and patronage. Not something nurses should be welcoming.
The same questions might be asked about physiotherapists telling people to stop smoking and take more exercise.
It could be argued that you don’t need a three- or four-year degree and experience as a diagnostician of multiple comorbidities to take on this role, no matter how attractive it might be as a mechanism to secure public health funding.
Besides, a recent report in the Journal of Public Health has suggested that the routine health checks implemented into the NHS in 2013 have had limited impact but have been extermely costly – effectively stealing money from services that were already struggling for funding (Capewell et al, 2015).
While it is easy to see, and accept, the rhetoric that physiotherapists are perfectly placed to offer basic health promotion advice and support, we would be wise to ask more critical questions about this approach, before becoming a part of the army of health advisors that are now slowly replacing the therapists of old.
Reference
Capewell, S., McCartney, M., & Holland, W. (2015). Invited debate: NHS health checksa naked emperor? Journal of Public Health, 37(2), 187-192.
Thank you for this thought provoking piece. A few Sunday afternoon thoughts…
By taking on roles traditionally done by others I hope the aspiration has been to improve the experience of care and streamline pathways rather than seek to expand scope purely for reasons of influence, status or hierarchy. In the UK the notion of extended scope, i.e., something that sits outside of scope of the physiotherapy profession, has been replaced by the framework of advanced practice. This has been driven because of the recognition that many of the roles we once took on and saw as outside any physiotherapeutic purpose we now acknowledge as being appropriate to enhancing our core skills and specifically improving patient care, in terms of both outcomes and experience.
Physiotherapy, as an autonomous profession, has had to consider many of the sort issues you refer to and decide whether the new tasks we take on are simply delegated roles to enhance the workforce, or capacity of a service, or whether they are relevant to physiotherapy and the therapeutic outcomes we look to achieve.
I would agree that the ‘wrap-around’ care you mention is part of a growing understanding that provision of holistic and personalised care is essential if we, as autonomous and responsible professionals, are to take that responsibility and deliver quality services in a cost effective way. Engaging in dialogue with people about their lifestyle preferences, using approaches that motivate behavioural change fit well and enhance our more traditional core knowledge and skills.
Your caution about heading merrily into pastures green is wise but I would like to add some positive encouragement on how we might view this journey and that is to take a look at the starting point. Patients, people, citizens have a right to be informed about the choices that are open to them that will prevent ill health, and improve the quality of their life as well as reduce the burden on the state. In return there is a small but steadily growing sense of their responsibility to respond to this information and use it by taking appropriate measures to look after themselves. Don’t we hold a responsibility to use that breadth of knowledge and skills each one of us has to improve the life of that patient or person who we have the privilege to treat or support? Don’t we also hold a responsibility to the healthcare system generally to use the resources it employs in the most effective way possible. Could we not bring all of this together when considering the patient in front of us in whatever setting be it inpatient, outpatient, acute or long term condition. Making every contact count is part of our responsibility, it’s not an add on – a luxury service: it isn’t bidding to take on a sexy new technique or the latest fad just because we can or because we’ll feel special. There is no need for physiotherapists to become health promotion workers, we can be physiotherapists who integrate information in our dialogue with patients about the other things that might support them to live healthier lives, better quality lives and it may be just the thing that makes a difference. (Yes let’s evaluate this practice and measure its outcomes -use PREMs to understand if this makes a difference).
A final thought…
I take my car to a garage and mechanic I trust – I expect him to tell me if he spots things that could be looked at to make my car safe, to make it last longer and to make it more efficient. Indeed I trust and respect him because he doesn’t just do the bare essentials. Why should patients expect anything different from us?
Who decides which information is essential for our patients? That is one question that springs to mind. What happens to a profession that takes on a role that might just as well be performed by any “womens health magazine” or a random fitness coach? Is another important question!
When did longer life become the same as better life?