Memorandum submitted by the Chartered
Society of Physiotherapy (PCT 40)
INTRODUCTION
1. The Chartered Society of Physiotherapy
(CSP) is the professional, educational and trade union body for
the 45,000 chartered physiotherapists, physiotherapy assistants
and students in the UK.
2. The CSP welcomes the Health Select Committee
inquiry into changes to primary care trusts (PCTs), particularly
as it is currently the only public scrutiny to which the proposals
have been subjected.
3. The CSP is concerned both about the content
and the manner in which the proposals were launched. We consider
that a Green Paper would have been the appropriate way in which
to proceed with such wholesale change in terms of number and function
of PCTs. Furthermore, we are disappointed that this process runs
in parallel, rather than in partnership, with the consultation
exercise leading to the forthcoming White Paper on care out of
hospitals.
4. The CSP is very keen to see the evidence
base which supports the proposals in terms of delivering more
effective patient care. While it is clear that some PCTs are not
operating and commissioning at the highest level, it is not clear
that Commissioning a Patient-Led NHS will resolve their
problems. Furthermore, it seems illogical to proceed with restructuring
PCTs when it is not yet clear what their function will be.
PHYSIOTHERAPY IN
PRIMARY CARE
5. About 52% of our NHS members (about 10,000
physiotherapists, as well as a significant number of physiotherapy
assistants) work in settings outside of hospitals, in GP practices,
in schools, leisure centres, in workplaces and in people's homes,
either with other physiotherapists or as part of a team of health
and social care workers.
6. Physiotherapists are increasingly moving
out of the acute sector, and are employed in the primary care
team. This is a trend that the CSP encourages as it involves physiotherapy
earlier in the patient journey, thereby improving patient outcomes.
It also supports multi-disciplinary working providing a seamless
service.
7. Pivotal PCT posts that were traditionally
filled by nurses are now being opened to AHPs, expanding opportunities
for staff to move into clinical management and clinical leadership
roles. This has resulted in physiotherapists and other AHPs being
involved in service development at a strategic level. Patient
services have improved as these clinicians are able to use their
frontline experience to design both innovative and modernised
services, understanding and putting together the needs of the
users of these services and the health and social care standards
and targets. We believe this critical clinical input must remain,
inputting into the commissioning process along the lines of the
current Professional Executive Committee (PEC) system, in order
to maintain and further develop clinical and cost effective patient
pathways.
8. Career openings for physiotherapists
in community and primary care settings can be expected to expand
further following the roll out of practice based commissioning
and national agendas which emphasise patient choice, public health
and better management of long-term conditions. The success of
these initiatives will depend on employing more healthcare staff
in the patients' local community, and developing their roles appropriately.
We are, however, concerned that the impact of Commissioning
a Patient-Led NHS will result in poor staff morale, retention
and recruitment difficulties and limited opportunities for continuing
professional development for physiotherapists and other AHPs working
in the community. Patient services will be significantly affected
as the cohesiveness of the current system is lost. The Secretary
of State's recent statement that PCTs will be able to decide on
a case-by-case basis whether to continue providing services does
little to allay staff's fears about the security of their jobs
and the continuity of patient services. It also means that the
principle of removing the provider function of PCTs will not be
debated at a national level.
PROPOSALS FROM
THE STRATEGIC
HEALTH AUTHORITIES
9. The CSP has examined the commissioning
submissions on proposals for the changes to primary health care
services provision from the Strategic Health Authorities. While
we recognise that this is the first step in a local consultation,
we are very concerned that:
— Physiotherapy and other Allied Health
Professions (AHPs), as providers of healthcare in the community,
are not visible in the consultation processes of a large majority
of submissions. All documents referred to GP engagement in the
commissioning process, but only 5% stated explicitly that physiotherapy
services should be consulted. Another 30% mentioned physiotherapy
or AHP services, but did not make clear on what basis they would
be considered.
— It is also apparent that the CSP
is not being properly recognised as a trade union in the consultation
process, with only two thirds of proposals including staffside
and union involvement in the commissioning consultation process.
CSP POSITION ON
COMMISSIONING A
PATIENT-LED
NHS
10. The Chartered Society of Physiotherapy
is deeply disappointed that Commissioning a Patient-Led NHS
was launched without any kind of advance consultation, despite
its profound implications for members and patients alike. We do
not see the logic of producing such a strategy before the publication
of the forthcoming White Paper on care outside hospitals. We also
believe that after many years of almost continual change, what
the NHS needs most is a period of stability and consolidation,
so that current structures can bed down and produce the further
improvements needed.
11. Of concern to the Society is the limited
evidence base to support the contention that introducing contestability
or competition improves the quality of public services. It also
seems illogical to suggest that it is inappropriate for PCTs to
continue to both commission and provide services, when GPs will
be doing precisely this under practice based commissioning. We
recognise the desire to strengthen the commissioning role of PCTs,
but it is important to recognise too that some PCTs have already
developed excellent models where there is a clear split between
provider services and commissioners. These models can be built
upon and extended to other areas as an alternative to hiving off
all provider functions.
12. A further inherent contradiction in
Commissioning a Patient-Led NHS lies in the possibility
of community services being taken over by acute trusts and Foundation
Hospitals. This is difficult to reconcile with existing policy
to develop as much care as possible in integrated primary care
settings and organisations.
13. Overall, while the Society is keen to
develop opportunities for all members around the delivery of health
care, we believe that the potential risks of dismantling current
PCT services and outsourcing them to alternative providers outweigh
any potential benefits. In our view, these potential risks include:
— Destabilisation and fragmentation
of services.
— "Cherry picking" of the
most profitable parts of services, leaving other services more
vulnerable and potential gaps in services for some client groups.
— An increase in health inequalities
due to a lack of interest by alternative providers in areas of
social deprivation where profit margins would be reduced or non
existent.
— Less opportunity for members to influence
commissioning decisions, as the involvement developed in PCTs
over recent years, including on PECs, is potentially devalued
by the changes and lack of clarity of the policy.
— An undermining of the real achievements
of PCTs to date in developing services, driven by the process
of modernisation and service improvement which the Government
has supported and facilitated in recent years.
— Diminishing of key partnerships and
collaborations which have been created by PCTs and which have
been proven to offer value to patient care and quality, especially
focusing on working across patient pathways.
— The potential for services to retract
into acute provision, thereby hindering service development in
health promotion, admission avoidance etc.
— Increasing the difficultly for new
graduates to find jobs and physiotherapy students (via higher
education institutes) to find placements.
— Undermining staff terms and conditions,
job security and development opportunities, which will be difficult
to maintain if staff end up being employed in much smaller professional
groups, across a wide range of different service providers.
— Poor staff morale, with the potential
for this to impact on recruitment and retention within community
areas, should these changes be driven through as they stand with
little effective choice given to those directly affected.
14. Physiotherapy staff across the NHS,
private and independent sectors have led and embraced innovation
and modernisation, and have pioneered many new ways of delivering
faster and more cost effective services. The Society is not therefore
opposed to change. However, we do not support the wholesale dismantling
of existing services where these are already based on effective
local partnerships, effective engagement of clinicians in commissioning,
and are delivering the modernisation agenda.
15. We will be advising members, both in
the NHS and independent sectors, to be extremely cautious about
entering into alternative models of service provision without
a full evaluation of the potential gains from these models compared
to the existing provision.
16. In terms of PCT reconfiguration, while
the Society recognises the potential economies of scale from rationalising
the number of PCTs, we believe that the focus should be on encouraging
co-terminosity with local authorities and integrated working.
We also believe that there should be maximum transparency around
the proposals being drawn up by PCTs and Strategic Health Authorities,
and a timetable which allows meaningful consultation to take place.
CONCLUSION
17. The CSP is disappointed that Commissioning
a Patient-Led NHS has been handled in such a poor manner.
We believe it is a retrograde step which will have an impact on
patient services for months and years to come. With this in mind,
we have decided to back the call by the Royal College of Nursing
for a judicial review.
18. We are pleased that there has been some
movement by the Secretary of State in her recent statement, but
we are keen that there is more in order to provide security to
both staff and patients alike.
Rachel Haynes
Head of Public Affairs
Chartered Society of Physiotherapy
9 November 2005
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