Select Committee on Health Written Evidence


Memorandum by the Chartered Society of Physiotherapy (PC 37)


  The Chartered Society of Physiotherapy (CSP) is the professional, educational and trade union body for the United Kingdom's 42,000 chartered physiotherapists, physiotherapy students and assistants. We represent the third largest health profession in the NHS. While the majority of our practising members work in the NHS, a significant proportion is employed in independent hospitals and charities, in residential homes, higher education, private practice and in hospices.

  The Association of Chartered Physiotherapists in Oncology and Palliative Care (ACPOPC) is a clinical interest group of the CSP representing over 300 members who specialise in this area of patient care.

  The CSP welcomes the Health Select Committee's inquiry into hospice and palliative care. The inquiry is timely for a number of reasons, not least recent Government announcements of NHS reforms designed to increase the elements of choice, responsiveness and equity in the delivery of care to patients. The CSP strongly supports the new emphasis on patient-centred delivery announced over recent months. We believe that the application of those principles to the provision of palliative care will highlight the role of physiotherapists in this field.

  This short memorandum identifies the role of physiotherapy in palliative care, barriers to patients who might seek to access physiotherapy in palliative care and recommendations on how these barriers may be overcome.


  While there are a number of approaches and settings for the delivery of palliative care, certain characteristics will invariably be present. A useful definition is provided by the World Health Organisation who describe palliative care as:

    "The active total care of patients and their families by a multi-professional team when the patient's disease is no longer responsive to curative treatment. Control of pain, of other symptoms, and of psychological, social and spiritual problems is paramount. The goal of palliative care is achievement of the best quality of life for patients and their families."[9]

  Physiotherapy has a critical role to play in the management of patients throughout their journey from diagnosis through to the end stages of disease. It is a profession that adopts a rehabilitative approach, to achieve best quality of life, shifting the focus from a preoccupation with the disease to one that is led by the needs of the patient.

  Wherever possible physiotherapists establish achievable goals with patients and their families. The process of arriving at those goals expands the choice and the awareness of choice available to the patient and ensures that the care package is more responsive to those needs that patients themselves identify. Many patients, especially those with long-term conditions or in receipt of palliative care, are often in the best position to identify when they need access to physiotherapy as part of that care. The CSP believes that it must be easier for people in that position to directly access physiotherapy as part of their care package.

  ACPOPC describes the role of the physiotherapist in palliative care as being:

    "To minimise some of the effects which the disease, or its treatment has on them . . . to improve their quality of life regardless of their prognosis by helping them to achieve their maximum potential of functional ability and independence or gain relief from distressing symptoms."[10]

  Physiotherapists as rehabilitation professionals are integral members of a number of specialist palliative care teams across the UK. They provide care to people who may have a wide range of problems that can respond to a physiotherapy intervention, such as respiratory problems, neurological impairment, lymphatic complications, orthopaedic and musculoskeletal dysfunction, and pain. Physiotherapists work to restore function, reduce pain, reduce disability, increase conditioning and mobility and ultimately improve the life of their patients, regardless of life expectancy.

  Studies have shown that cancer patients perceive physiotherapy treatment as a hopeful event. They see such treatment as leading to increased activity and an increased sense of well being, with opportunities to attain functional independence.[11] Within the context of palliative care, realistic joint goal setting which occurs between patient and physiotherapist, gives the patient a measure of control, often at a time when they are experiencing helplessness and loss of independence.[12]

  Specialist physiotherapists in palliative care are highly skilled in enabling patient choice, providing clear relevant information, breaking bad news and maximising potential.

  Physiotherapy also plays a leading role in enabling patients to receive treatment at home. They improve the independence and mobility of patients, they facilitate the timely and appropriate discharge of patients from inpatient settings and they prevent inappropriate admission to an inpatient setting through supporting families at home if that is their wish. Physiotherapists support patients in maintaining their role in the family unit for as long as possible and have a strong role with the carers in coping physically and emotionally.


  However, despite the important role of physiotherapy in the delivery of effective palliative care, there are two critical barriers that prevent patients who would benefit from physiotherapeutic intervention from accessing it.

  The first barrier is the status of physiotherapy as a shortage profession. The vacancy rates are high and there are particular shortages in the more senior grades. Effective patient choice requires at least a balance between demand and supply, if not a surplus of supply. For many patients who would benefit from physiotherapy as part of their palliative care, the choice does not exist in any meaningful way.

  The second barrier is a reflection of the sometime marginal status of the profession within the specialist palliative care policy, guidance and commissioning decisions in the NHS.

1.  A shortage profession

  Physiotherapy is a shortage profession. Demand outstrips supply and vacancy rates are at an alarmingly high level. At the heart of problems in accessing physiotherapeutic services as part of palliative care is the fact that there are not enough experienced physiotherapists in post.

  Given that physiotherapy promotes independence and allows people to receive treatment in their own homes, there has been some welcome increase in the number of designated specialist palliative care physiotherapists appointed to community teams.

  However, it remains the case that specialist physiotherapy services in the community are patchy. Very few posts are funded specifically for patients with a cancer diagnosis in the Primary Care setting, either to undertake clinical work or to offer specialist support and advice to generic community physiotherapy services who are also treating people in this patient group.

  The Department of Health Vacancies Survey (England) March 2003 revealed that the vacancy rate for physiotherapists was 4.7%[13]. In one London SHA the rate was as high as 12.5%[14].

  Furthermore, the NHS continues to experience shortages of around 10% of physiotherapists in more senior grades, that is with five or more years of clinical experience. These are the staff that will be required to supervise increased numbers of physiotherapy students coming through university courses. Existing shortages within the profession mean that there are not sufficient qualified physiotherapists to oversee a greatly increased number of practice placements.

  Physiotherapy in cancer and palliative care is a specialist field of practice. Professionals working in this area usually have many years of experience before they become involved in oncology and palliative care.

  Vacancy rates and shortages of the most experienced staff are the key problems that restrict the number of physiotherapists that can be drawn upon by specialist palliative care teams. These shortages are compounded by difficulties that prevent physiotherapists from gaining meaningful experience in a palliative care setting. This adds another level of difficulty in the recruitment and retention of physiotherapists in oncological and palliative care

  A very small number of physiotherapists have the opportunity to gain experience in this area at undergraduate level, with only a handful of universities adding an "Oncology and Palliative Care" model to their syllabus for physiotherapy students. Once in post, junior rotations tend not to incorporate the specialist field of palliative care.

  Therefore neither the training nor the practical experience is available for many students or newly qualified physiotherapists looking to enter the NHS and to work in palliative care.

  Another general problem for recruitment and retention within the NHS is the debt burden that accompanies physiotherapy students. While physiotherapy students are not unique in this, and do indeed benefit from the Department of Health paying for tuition fees, a newly qualified physiotherapy student could expect to carry a debt of around £8,000 as a result of student maintenance loans

  A CSP survey showed that student debt is the major inhibitor on the continued flow of newly qualified physiotherapists. Sixty eight per cent of first year students believe that debt is the factor most likely to hinder their study.[15] The CSP is concerned that students with a debt are looking outside the NHS for better-remunerated employment either as a locum, or in the private sector.

2.  A "core" profession?

  The importance of multi-professional working in specialist palliative care teams is widely acknowledged. There is some compelling evidence that, compared to conventional care, specialist teams improve satisfaction and identify and deal with more patient and family needs. They can also reduce the overall cost of care by reducing the time patients spend in acute hospital settings.[16]

  Many such specialist teams can draw upon a broad range of health professionals; doctors, nurses, physiotherapists, occupational therapists, dieticians, speech and language therapists and others. It is the ability to call on all these professionals that provides care responsive to the patient's individual needs.

  However, physiotherapists are only infrequently a core part of specialist palliative care teams. Of great concern is the lack of mention of physiotherapy in the NHS Cancer Plan, although some of the targets set are of relevance to the profession. One of the four broad aims is to ensure people with cancer get the right professional support and care, as well as the best treatment. It specifically highlights the need for increased staffing in some areas, for example an extra 120 urologists, however it does not recognise the resulting increase in need for other support services including physiotherapy.

  On the one hand the Plan is developing specialist teams, but on the other it is failing to keep the patient-centred approach which requires a team input at all levels of care.

  Proposals in the draft NICE Supportive and Palliative Care Cancer Service Guidance, highlighted the importance of team working, including the role of physiotherapists, but unfortunately restricted the core specialist palliative care team to doctors, nurses and administrators.

  The CSP regards this restriction of the core team to be out of step with the ethos of the document, which we otherwise welcome. We hope that this omission will be amended when the document is finally published.

  Physiotherapists and other allied health professionals are key players in the delivery of specialist palliative care. To exclude them from the core team could act as a green light for the commissioners of services to do the same. The CSP is concerned that service managers may well consider the exclusion of physiotherapists as members of the core team to be an appropriate way of reducing staff costs, in keeping with the current guideline wording.

  Other national evidence-based approaches have recommended a broader core team. The Clinical Standards for Specialist Palliative Care, June 2002, NHS Scotland state:

    "Specialist palliative care is provided by a highly qualified multi-disciplinary team."

    "The core team comprises dedicated sessional input from the chaplain, doctors, nurses, occupational therapists, p [pharmacist, physiotherapist, social worker]."

  In the report of the Irish National Advisory Committee on Palliative Care, they advised that there should be one physiotherapist per 10 palliative care beds. The CSP doubts that these ratios are met in the United Kingdom, and we would value research to identify the appropriate level of physiotherapy support in a specialist palliative care setting.

  There are a number of circumstances at present that restrict the contribution that physiotherapy can make to the palliative care of patients:

    —  The omission from NICE guidance on core specialist palliative care teams.

    —  A lack of graduate and post-graduate education and training in cancer and palliative care.

    —  Few rotation opportunities at either junior or senior II level.

    —  The shortage of staff in senior I & II grades.

    —  A lack of appreciation of how physiotherapy underpins the holistic approach of palliative care by focusing on the needs of the patient rather than their condition.

  The CSP is concerned that if the attributes of specialist physiotherapists are excluded from specialist palliative care teams then it will be to the detriment of patient care, outcome and choice.


  The CSP is convinced that the shortage of physiotherapists and their marginal status within specialist palliative care teams will detract from the delivery of effective care packages to patients.

  In addition, for the Government's agenda of choice, responsiveness and equity in the NHS to be realised it will require specialist palliative care teams, including experienced physiotherapists, to be available throughout the NHS.

  The CSP believes that the issues in this memorandum need to be addressed otherwise:

    —  Specialist palliative care teams may fail to deliver patient-centred care to the cost of patients and the NHS.

    —  NHS commissioners will choose not to identify physiotherapy as an essential part of the palliative care package.

    —  Service managers will see a minimal core team as an opportunity to save on staff costs.

    —  Intermediate care will be less available and effective for patient who would choose to remain in a home environment.

    —  Patients and their carers will be denied the ability to choose the care package they feel to be appropriate.

    —  Many patients will face maximum dependency and a lesser quality of life for the time remaining to them.


  The CSP makes the following recommendations that we feel are necessary if specialist palliative care in the NHS is to be truly responsive to the needs of patients:

    —  Physiotherapists to be identified in NICE guidance as core members of specialist palliative care teams.

    —  Physiotherapy students to have their student maintenance loans written off in return for a five year commitment to the NHS.

    —  More cancer modules which would include palliative care in physiotherapy courses at graduate and post-graduate level.

    —  A recognised clinical career structure for physiotherapists working in cancer and palliative care.

    —  Self-referral so that patients and their families can directly access physiotherapy as part of their care package.

    —  Research to identify the added value of physiotherapy for patients in a palliative care setting.

February 2004

9   World Health Organisation (1990) Technical Report Series 804Back

10   ACPOPC Guidelines for Good Practice (1993) Chartered Society of PhysiotherapyBack

11   McDonnell & Shea (1993) Back and Musculoskeletal Rehabilitation 3(2). Back

12   Robinson (2000) European Journal of Palliative Care 7 (3). Back

13   DoH vacancy survey, March 2003. Back

14   North East London SHA, DoH vacancy survey, March 2003. Back

15   CSP Student Survey, December 2003. Back

16   Working Group for Palliative Care (1998) University of Liverpool, NHSE North West, Christie Hospital NHS Trust & Clatterbridge Centre for Oncology NHS Trust. Back

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Prepared 26 July 2004