If you are a physiotherapist in the United Kingdom working in musculoskeletal (MSK) practice then you will be well aware that we are currently going through a crisis in our ability to recruit physiotherapists into primary rehabilitation roles. For many service managers it is an uphill struggle to fill many physiotherapist posts within the National Health Service. However, the same cannot be said for filling vacancies in diagnostic triage roles in orthopaedic clinics and first contact practitioner roles (FCP).
There are many reasons for the inability to recruit into these primary MSK rehabilitation roles. However, I suspect it is both structural and cultural. But in this piece, I will tackle some of the more culturally related issues.
But first I need to define what I mean by a rehabilitation role….
I am referring to a role in which the clinician is required to deliver therapeutic MSK rehabilitation and physiotherapy in either primary, community or secondary care as their primary role
The causes :
1. No career progression!
As an advance practice physiotherapist that has chosen to specialise in rehabilitation there is no defined career pathway for someone like me. This is the complete opposite for the physiotherapist whishing to pursue a career in FCP and diagnostic triage with significant resource directed to this pathway.
In order to specialise in rehabilitation, I have had to make a conscious choice to map out my own path by choosing a Masters programme that is outside of the normal continued professional development pathway for physiotherapists. So, although I already have a Masters in Neuromusculoskeletal physiotherapy I have chosen to undertake an additional Masters in strength and conditioning to develop additional expertise in human performance and rehabilitation.
Contrastingly, if you want to be an FCP physiotherapists or an advance practice physiotherapists (APP) in diagnostics then there is a well-defined path ! This is obviously a problem! Because, even though our profession was historically founded on rehabilitation we have no pathway for the progression of people that wish to pursue a career in this domain. This is problematic because it sends the wrong message to physiotherapists who want to specialise in rehabilitation. The message is sorry…. " but if you want to get to the higher bands in your profession then you won’t get there by choosing rehabilitation ".... so dont !
2. Rehabilitation is not advance practice!
My perception is that some physiotherapists in advance practice diagnostic roles and many service managers do not consider rehabilitation and physiotherapy advanced practice. Furthermore, it seems that whenever there are discussions about developing advance practice rehabilitation roles there appears to be a much higher bar attached to creating such posts. So, for example people will talk about demonstrating the effectiveness of these posts. Which is often Morse code for demonstrating how it will save money. However, it is intresting that this expectation is not ascribed to the development of new managment posts or team leader positions in therapy departments.
Notwithstanding, in the FCP and diagnostic triage space it is easier to show that your waiting list has fallen by say 10 % and that you saw said number of patients last month. But do we want to apply this method of quantification to something which is inherently less tangible and about providing high quality care which is patient centred. This is not to say that we should not strive to quantify our impact as physiotherapy and rehabilitation specialists but waiting lists may not be the best metric to use. To use this metric is to create a conveyer belt of poor-quality care and to further demoralise a jaded workforce. It should not be forgotten that a lack of patient care, low staff morale, and inappropriate targets to save money led to the tragic events at Mid Staffordshire hospital in 2013.
3. So, what is advanced practice:
Advance practice is delivered by experience clinicians who have progressed their knowledge, skills and behaviours beyond those of a senior clinician. It is underpinned by a Masters level education or an equivalent evidence of learning and it encompasses four pillars of practice:
· Clinical practice
· Education
· Leadership
· Research
These four pillars should lead to the demonstration of core and area specific capabilities relevant to the clinician’s role and scope of practice.
So, it is noteworthy that in the definition above there is no mention of the need to inject, order scans, prescribe drugs or to be trained in any other skill external to physiotherapy.
This is an important point because my experience has been that what often is considered important in the appointment of an advance practice physiotherapist to a service, is the clinical aspect of their role. So, this will be often weighted towards advanced skills in diagnostics that can be used to reduce the waiting lists of orthopaedic services. Now, I am not arguing that this is not important to the local health economy, but we need balance! Because, the healthcare economy is also enhanced by physiotherapists that are well led by advance practice physiotherapists who specialise in physiotherapy and rehabilitation. APPs in physiotherapy and rehabilitation can provide clinical and strategic leadership within a department and to the local health economy. APPs in Rehabilitation and physiotherapy can also contribute significantly to the education and research efforts of a department in line with the pillars of advance practice.
4. The clinical pillar …. its more than just exercise prescription ?
In the clinical practice pillar, I would argue that an advance practice physiotherapist specialising in physiotherapy and rehabilitation is already a diagnostician! This clinician before they can prescribe therapeutic rehabilitation has to be able to conduct a detailed physical examination of the musculoskeletal system to manage risk. This level of examination is highly skilled encompassing a traditional medical orthopaedic examination inaddition to physiotherapy centric assessments such as neurodynamic evaluations, palpation and joint accessory assessments where indicated within a biopsychosocial framework. This is the standard for expert assessment of benign musculoskeletal complaints.
However, when the patient requires longer rehabilitation or has higher than normal functional aspirations this may require addition neuromuscular assessment techniques to quantify performance such as isokinetic evaluation, power output jump tests and other muscle performance tests. This is all before any exercise or therapeutic management procedures have been undertaken!
However, the clinical pillar in not just about assessment and examination, because while clearly, the assessment is critical in regard to establishing the patient’s key impairments, the therapeutic intervention can be just as challenging for the non-specialist.
Take for example, the management of a 55yr old construction worker that wants to return to work after a total knee replacement. This would not only include their staged physical rehabilitation to a high level of function, but would also need an understanding of the vocational rehabilitation considerations in their return to work phase necessitating a solid background in the full spectrum of human performance and occupation. Another example might be the 25-year-old recreational tennis player with benign joint hypermobility that has pain in the deceleration phase of the serve. This again requires a deep understanding of human performance from a biological and psychosocial perspective to establish the root cause of local shoulder incompetence and regional contribution of the kinetic chain to their pathology.
I hope it is easy to see why both examples are challenging and would be difficult to manage to a successful conclusion due to their complexity and ambiguity. These patients are not uncommon clinical scenarios. Both require complex decision making often in the face of incomplete information relating to the evidence base. This is advance practice in physiotherapy and rehabilitation.
5. So, are we losing our way as a profession?
Well the simple answer is yes! If you work in the National Health Service as a physiotherapists in any area other than MSK triage, FCP or management then you probably don’t see the erosion of rehabilitation services. You may not see the lack of professional advancement for those that “just want to be good physiotherapists” which includes inpatient and outpatient physiotherapists.
The sprint to support the front end of the system with FCP and APPs in diagnostic clinics in my opinion has meant that we have taken our eye off the ball and forgotten that we need strength in depth. Strength in depth is similar to the Army’s organisational structure. For while it is the infantry which fights the battle at the front, it is the support services such as the logistics, engineers, cooks and medics that support them. This unfortunately has been forgotten in the sprint to reduce waiting lists at the front end and many of our senior staff have been enticed away with better remuneration and career progression.
In closing, it may be that we need to change our ways of working to integrate with existing services to provide a cost-effective solution to the current NHS pressures. In principle I have no problem with this providing this change is not Morse code for reducing quality and the moral of the workforce. This is the challenge to the profession and those protagonists that would say we need move with the times and become more flexible and agile.
High quality rehabilitation and physiotherapy has for too long not been recognised as an advanced practice. This has been the death blow for rehabilitation services both in the outpatient and inpatient setting. This will unfortunately continued to choke our pipeline of future talent, recruitment efforts and limit high quality patient care unless we face the challenge.
Yours in advance practice physiotherapy and rehabilitation
Uzo Ehiogu
MSc (Physio), BSc (Physio), BSc (Ex Sci), MMACP, ASCC
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