APPENDIX 6
Memorandum by the Chartered Society of
Physiotherapy (DD 11)
1. INTRODUCTION
1.1 The Chartered Society of Physiotherapy
(the CSP) is the professional, educational and union body for
the UK's 39,000 chartered physiotherapists, physiotherapy students
and assistants.
1.2 The CSP welcomes the opportunity to
provide written evidence to the Health Select Committee regarding
"Delayed Discharge". The Society welcomes the fact that
the Committee has chosen the term "delayed discharge"
and not "bedblocking". The Society believes the term
"bedblocking" is offensive to older people who remain
in hospital beds through no fault of their own. The Society hopes
that—in its final Report—the Committee will strongly
recommend alternative terminology.
1.3 In the past hospital discharge policies
have varied greatly. The CSP believes that such variance may reflect
discrepancies in the availability of rehabilitation services in
hospitals and also in the community.
1.4 The CSP has long been promoting the
important role played by physiotherapists in rehabilitation.
1.5 The CSP warmly welcomed the NHS Plan
and the changes it will bring to the context in which rehabilitation
is to be delivered.
1.6 This short paper highlights the role
which physiotherapists play in rehabilitating patients and explains
some of the obstacles faced by physiotherapists in this area and
makes several recommendations which the CSP hopes the Select Committee
will be able to include in its Report.
— The CSP welcomes the fact that rehabilitation
has now been defined and that the importance of physiotherapy
therein has been recognised.
— Rehabilitation requires appropriate
staffing resources—expert therapy, social work, nursing
and medical support. The CSP believes that physiotherapy shortages
and consequent varying rates of access to physiotherapy services
impact upon delayed discharge and that without investment in physiotherapy
the Government's plans to speed up delayed discharge will be hindered.
The CSP believes that more work must be undertaken by the Department
of Health in order to ensure that the anticipated increases in
physiotherapists are achieved.
— The CSP believes that it is impossible
to address the issue of delayed discharge without taking a "whole
systems approach".
— The CSP is calling on the Government
to consider ring-fencing the intermediate care funding provided
to local government through the Personal Social Services SSA.
1.7 The CSP naturally focuses on the role
of physiotherapists but wants to make it clear that tackling the
issue of delayed discharge requires a whole systems approach which
recognises the needs of an individual and their carers. Active
therapy forms one element of a rehabilitation package, but other
services/interventions (for example, social care and community
support) may also be needed to ensure a safe transition from hospital
to home.
2. REHABILITATION
2.1 The Latin roots of the verb to rehabilitate
imply that the end point of the activity is restoration of skill/ability—a
concept embraced by the physiotherapy profession.
2.2 Physiotherapy is a health care profession
that emphasises the use of physical approaches in the promotion,
maintenance and restoration of an individual's physical, psychological
and social well-being, encompassing variations in health status.
3. REHABILITATION
OF OLDER
PEOPLE
3.1 The National Beds Inquiry[5]
suggested that around 20 per cent of hospital beds occupied by
the over-65s need not be—if other services were available.
3.2 The Audit Commission[6]
in its report on rehabilitation services for older people stated
that intermediate settings between hospital and home, which provide
more active rehabilitation and confidence-building, cost half
as much as hospitals but were not uniformly available. This report
states that therapists are central to the delivery of rehabilitation
services.
3.3 Facing the dilemma of bed shortages
and growing waiting lists the government seized on this and, in
the NHS Plan[7],
announced a huge increase in investment in intermediate care to
reduce delayed discharge and to act as the "bridge between
hospital and home".
3.4 In January 2001 the Government issued
guidance[8]
setting out the development of intermediate care services to be
commissioned by NHS and local authorities in England. The guidance
states that intermediate care will have to be provided on the
basis of a comprehensive assessment, resulting in a structured
individual care plan that involves active therapy, treatment or
opportunity for recovery.
3.5 Intermediate care is not just aimed
at older people but may be a model of service delivery for other
client groups too. Examples exist (not called intermediate care)
of intensive rehabilitation being offered beyond the hospital
wall that either facilitate early discharge—for example
post orthopaedic surgery, or enabling individuals to remain in
the community and other services offered by neurology outreach
teams and community rehabilitation teams.
3.6 Many physiotherapy services are already
offering intermediate care, but it is not always labelled as such.
Such services are often known as hospital at home, crisis intervention
teams, or rehablement teams; examples are cited in Appendix 1.
3.7 However, access to physiotherapy services
varies across the country. The CSP believes this is because:
(i) Vacancy rates for physiotherapists
vary across the country. Generally the figures are high. The Department
of Health Vacancies Survey, March 2001 revealed that the three
month vacancy rate for physiotherapists was 5 per cent (as compared
to 2.6 per cent for midwives). In London the vacancy rate rose
from 5.1 per cent to 7.7 per cent.
(ii) The organisation of referrals differs
across the country. Some services accept referrals only from medical
practitioners, others adopt an open system and accept referrals
from a range of other professionals and clients.
(iii) The availability of physiotherapists
with the required specialist skills varies markedly within inpatient
district general hospitals and acute specialist centres as well
as in sub-acute rehabilitation and outpatient clinics.
3.10 The CSP welcomes the fact that the
NHS Plan for England announced the Government's intention to increase
the number of therapists in the NHS by 6,750 by 2004. And the
further announcement by the Department of Health of a rise in
the number of physiotherapists from 15,600 to 24,800 between 2000
and 2009—an increase of at least 9,200 (59 per cent)[9].
3.11 The CSP believes that these announcements
provide clear evidence of the Government's commitment to rehabilitative
services and an acknowledgement of the importance of physiotherapy
services therein.
3.12 Physiotherapy has more applications
per place than any other degree course in the UK[10]
but this does not mean increasing numbers will be easy; not only
does training take time but there are currently insufficient student
clinical places. Furthermore the profession faces a very real
problem with retention. Physiotherapists state that increased
pay as well as CPD and career opportunities would encourage them
to remain within the NHS[11].
3.13 To date there has been no break down
in how many physiotherapists will be included in the 6,750 extra
therapists by 2004 (as announced in the NHS Plan, 2000). The CSP
is calling on the Government to provide a breakdown of the figures.
3.14 To date there has been very little
detail regarding how the Government hopes to achieve a 59 per
cent increase in the number of physiotherapists by 2009.
4. INTER-PROFESSIONAL
AND INTER-AGENCY
WORKING
4.1 The Audit Commission report concludes
that provision of effective rehabilitation requires a whole systems,
multidisciplinary and interagency approach (illustrated by Figure
1).
4.2 The "Whole systems approach"
A whole systems approach is an inclusive approach
that recognises the contribution that all partners make to the
delivery of high quality care and ensures that all stakeholders
are involved in both planning and delivery.
4.3 The Audit Commission[12]
stated that "Such an approach is not just about bringing
all the key players together: it involves careful, systematic
and detailed mapping of the services, pathways and processes within
health, and across health and social care. It then requires systematic
planning of any changes needed to bring improved care across all
of those services. Finally, it means managing those changes into
being, and monitoring and evaluating the outcomes". If such
an approach is not adopted then the whole system will fail [see
Figure 2].
4.4 Interprofessional Working
The model illustrated in Figure 1 reflects the
evidence base by placing the client at the centre of service delivery.
The Pritchards' study on teamwork in primary health care highlighted
user involvement in inter professional collaboration and concluded
that this approach enabled professional and lay people to achieve
their objectives more fully and economically[13].
4.5 Rawson[14]
argues that interprofessional collaboration is of value to the
client as it has a multiplicative effect—the whole being
greater than the sum of its parts.
4.6 The drive towards interprofessional
collaboration has increased in intensity since the late 1980s.
Despite policy changes aimed at reducing the duplication of services,
identifying unmet needs, and greater co-ordination of available
services, the evolution of true interprofessional collaboration
would appear to be inconsistent.
4.7 CSP is aware that the success of interprofessional
working varies around the country and believes that there are
a number of factors which inhibit interprofessional collaboration
including:
— poor communication and language differences;
— conflicting power relationships;
— ideological differences;
— major cultural and professional differences
(decision making and the degree of autonomy available for example)
and the persistent stereotypes held by team members.
4.8 Given the fundamental nature of these
issues, it is likely that these are the root of the problem which
must be tackled so that policy changes can facilitate an improvement
in service delivery to clients. Discussion will be necessary at
a local level to clarify the nature and extent of interprofessionalism
in practice, eg telephone contact, shared documentation, single
or joint assessment and goal setting.
4.9 Research has shown that interprofessional
education enhances interprofessional collaboration[15].
It is vital that physiotherapy staff are also enabled to access
uniprofessional CPD opportunities to ensure that their professional
competencies are maintained and developed whilst also being able
to experience inter professional education/training. Consideration
should also given to the undergraduate curriculum of the professions
involved in the delivery of intermediate care to ensure that it
complements policy development and that newly qualified professionals
are fit for purpose.
4.10 Inter-Agency Working
Taking the model a stage further, the rehabilitation
team should work with the client across agency boundaries (ie
hospital inpatient, intermediate care, sheltered accommodation,
nursing home, own home etc) yet retain accountability to their
parent organisation (NHS/Social Service/Voluntary sector). As
the individual becomes more independent, the focus of service
provision would reflect this, for example there would be a reduction
in the amount of acute healthcare service needed with an increase
in social care provision (shift from inpatient rehabilitation
centre to supported housing for example). Elements of this model
are evident in practice—some examples are illustrated in
Appendix 1.
5. FUNDING OF
SERVICES
5.1 The NHS Plan announced an extra £900
million over four years for investment in intermediate care and
related services to promote independence and improved quality
of care for older people. The CSP warmly welcomed this announcement.
5.1.1 C1arification of the funding arrangements
came in a joint health service and local authority circular[16].
The circular states that—of the £900 million—£255million
is to be earmarked specifically for NHS investment in intermediate
care. The remainder is being provided to local government. The
guidance states that this will be "mostly" through the
Personal Social Services SSA. There is currently no way of ring
fencing this money to ensure that it is spent on intermediate
care services consequently it is feared that the money will end
up being spent on other services[17].
5.1.2 The CSP believes that more thought
must be given to how resources are allocated at a national level
for rehabilitation services generally. One example of the complexities
of this is that offering vocational rehabilitation reduces the
financial burden to the Social Security budget, yet this benefit
is not forwarded to the Department of Health budget that initially
funded the treatment.
5.2 Paying for Rehabilitation Services
The CSP is aware of a growing number of rehabilitation
services being provided within a nursing home setting: the rehabilitation
element of the package is provided by the NHS, with the client
being means-tested for the social care element. Unfortunately,
in some of these examples, there is not a comparable rehabilitation
service in an NHS bed; rehabilitation is therefore only available
on a means-tested basis (ie no longer free at the point of delivery).
5.3 Client Groups Excluded from The Government
Agenda
The NHS Plan offers many opportunities to develop
new rehabilitation services and targets specific client groups—for
example, mental health, older people and people with coronary
heart disease.
5.3.1 The CSP is concerned, however, that
certain client groups, who benefit from access to rehabilitation
appear to be excluded from the Government's agenda (eg young adults
with disabilities and people with learning difficulties). The
targets set by Government will be prioritised. Given the limited
resources available within the health service, it is likely that
services not targeted will be subject to severe rationing. Anecdotal
evidence suggests that this is already an issue (for example,
people with long-term needs such as MS being denied access to
physiotherapy). Such patients may end up in acute beds unnecessarily—so
exacerbating the problem of delayed discharge.
5.4 Time Limiting Rehabilitation
The CSP is concerned about the time-limiting
of rehabilitation. The Department of Health has issued guidance[18]
stating that intermediate care should normally be no longer than
six weeks and frequently as little as one—two weeks or less;
exceptions beyond six weeks should be subject to a full reassessment
and should be authorised by a senior clinician.
5.4.1 The CSP believes that it is vital
that rehabilitation services are flexible so that they can address
the needs of the client at any one time, whether this be active
intervention to address specific needs, or providing ongoing maintenance/management
programmes to ensure that the client's current abilities are maintained.
6. SUMMARY AND
RECOMMENDATIONS
6.1 CSP welcomes the fact that rehabilitation
has now been defined and that the importance of physiotherapy
therein has been recognised.
6.2 Rehabilitation requires appropriate
staffing resources—expert therapy, social work, nursing
and medical support.
6.3 The CSP believes that physiotherapy
shortages and consequent varying rates of access to physiotherapy
services impact upon delayed discharge and that without investment
in physiotherapy the Government's plans to speed up delayed discharge
will be hindered.
6.4 The CSP believes that more work must
be undertaken by the Department of Health in order to ensure that
the anticipated increases in physiotherapists are achieved.
6.5 Interprofessional working—inter-agency
working. The CSP believes that it is impossible to address the
issue of delayed discharge without taking a "whole systems
approach".
6.6 The CSP is calling on the Government
to consider ring fencing the intermediate care funding 6.6 provided
to local government through the Personal Social Services SSA.
5 The National Beds Inquiry, Department of Health,
2000. Back
6
The Way to go home: rehabilitation and remedial services for
older people. The Audit Commission (2000). Back
7
The NHS Plan, Department of Health 27 July 2000. Back
8
Intermediate Care-guidance HSC 2001/01 (19.01.01). Back
9
Investment and reform for NHS staff-taking forward the NHS Plan
(England), February 2001. Back
10
UCAS 2000. Back
11
PAM Evidence to the Pay Review Body 2001. Back
12
Way to Go Home, The: Rehabilitation and remedial services for
older people (p88), Audit Commission (2000). Back
13
Pritchard P, Pritchard J (1992) Developing teamwork in Primary
Health Care: A practical workbook. Back
14
Rawson D (1996) Models of inter-professional work: likely theories
and possibilities in Leathard A (Ed) Going inter-professional:
working together for health and welfare: London, Routledge. Back
15
Leiba T (1996) Interprofessional and multi-agency training and
working. British Journal of Community Health Nursing 1 (1) 8-12. Back
16
HSC 2001/01 (19.01.01). Back
17
Third of intermediate care funds siphoned off into "other
priorities" HSJ (p7) 15 February 2001. Back
18
Intermediate Care-guidance HSC 2001-01, Department of Health
(19.01.01). Back
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