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."
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
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."
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.
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.
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
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
In one London SHA the rate was as high as 12.5%.
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
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.
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
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
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
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
Patients and their carers will be
denied the ability to choose the care package they feel to be
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
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
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
Research to identify the added value
of physiotherapy for patients in a palliative care setting.
9 World Health Organisation (1990) Technical Report
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ACPOPC Guidelines for Good Practice (1993) Chartered Society
of Physiotherapy. Back
McDonnell & Shea (1993) Back and Musculoskeletal Rehabilitation
Robinson (2000) European Journal of Palliative Care 7 (3). Back
DoH vacancy survey, March 2003. Back
North East London SHA, DoH vacancy survey, March 2003. Back
CSP Student Survey, December 2003. Back
Working Group for Palliative Care (1998) University of Liverpool,
NHSE North West, Christie Hospital NHS Trust & Clatterbridge
Centre for Oncology NHS Trust. Back