HC 1048-III Health CommitteeWritten evidence from the Chartered Society of Physiotherapy (PH 108)

1. Summary of Main Points

The CSP is committed to improving public health and welcomes the opportunity to submit evidence and information to the Health Select Committee Inquiry.

This submission is focussed on the areas in which we feel physiotherapy can most effectively contribute to the debate. We are willing to provide additional information or clarification and would welcome the opportunity to present oral evidence to the Committee. We are content for any part of this evidence to be made public or included in the Committee’s report.

Physiotherapists are already actively engaged in improving public health through early intervention; primary and secondary prevention; the treatment and rehabilitation of chronic and long term conditions; keeping people fit to work; and promoting the benefits of regular physical activity for good health and wellbeing.

The CSP supports the creation of Public Health England within the Department of Health and hopes this service will take the lead responsibility and determine clear direction for the public health agenda at both the national and local level.

There should be an Allied Health Professions (AHP) Director in Public Health England.

Physiotherapists and other AHPs are well placed to act as integrators of care and often help form the “bridge” between hospital clinicians and GPs or community based health and social care services. Given this and the important contribution that physiotherapists make to improving public health, the CSP is calling for the Health and Social Care Bill to be amended to mandate AHP involvement in commissioning at both the national and local level.

2. The Chartered Society of Physiotherapy (CSP)

2.1 The CSP is the professional, educational and trade union body for the UK’s 50,000 chartered physiotherapists, physiotherapy students and support workers.

2.2 Physiotherapists offer clinically effective and cost-efficient services for patients, across healthcare sectors and along the whole patient pathway, in the management of long term conditions, rehabilitation, return to work, mental health and public health. Physiotherapy enables people to move and function as well as they can, maximising quality of life, physical and mental health and well-being.

2.3 Physiotherapists keep people mobile, active and independent, they promote the health benefits of regular physical activity, encouraging people to adopt and maintain a healthy lifestyle. The CSP is running a long-term public education campaign called “Move for Health” to encourage people to build physical activity into their daily lives (link: www.csp.org.uk/moveforhealth).

2.4 Physiotherapy delivers high-quality, innovative services in accessible, responsive, timely ways. It is founded on an increasingly strong evidence base, an evolving scope of practice, clinical leadership and person-centred professionalism.

2.5 Physiotherapists use manual therapy, therapeutic exercise and rehabilitative approaches to restore, maintain and improve movement and activity. Physiotherapists work with a wide range of population groups; across sectors; and in hospital, community and workplace settings. Physiotherapists facilitate early intervention, support self management and promote independence, and help prevent episodes of ill health and disability developing into chronic conditions. Physiotherapy supports people across a wide range of areas including musculoskeletal disorders; many long-term conditions, such as stroke, MS, COPD, and Parkinson’s Disease; cardiac and respiratory rehabilitation; children’s disabilities; cancer; women’s health; continence; obesity management; mental health; and falls prevention.

2.6 Physiotherapists are also experts at recognising in their patients any risk factors or social determinants of preventable diseases. They address these through providing evidence based advice and behavioural change interventions and signposting or referring onto appropriate services.

3. The Contribution of Physiotherapy to Public Health

3.1 Being in work leads to better physical and mental health. The Black review identified the importance of early intervention and access to physiotherapy, and estimated that up to £100 billion a year could be saved by reducing working-age ill health.

3.2 The evidence for the long term health benefits of regular physical activity is compelling. Sir Liam Donaldson in 2009 (then Chief Medical Officer), stated “if a medication existed that had a similar effect on preventing disease, it would be hailed a miracle cure”. The CSP would like specific outcomes to be agreed to improve levels of physical activity in local populations. The CSP is concerned that approximately 27 million adults in the UK are not getting the recommended amount of physical activity, and feel this should be a priority for public health interventions and information campaigns.

3.3 Active people are up to 50% less likely to be at risk of major chronic disease such as coronary heart disease, stroke, diabetes and cancer. A recent study by Professor Kathleen Wolin of Washington University School of Medicine showed that exercise has a positive effect on bowel polyps risk.

3.4 Being overweight and inactive is also linked to an increased risk of post menopausal breast cancer. A recent new study by Dr Amanda Phipps at the US Women’s Health Initiative confirms the risk of the aggressive “triple negative” breast cancer in obese women who fail to keep active.

3.5 Despite overwhelming evidence about the health benefits of regular exercise, only a minority of the population take the recommended 30 minutes of daily exercise, five days a week. A public opinion survey commissioned by the CSP showed that one in five people (20%) exercise only once a month or less. This survey revealed confusion about how much exercise adults think they should be doing. Just 13% know how much daily exercise they need.

3.6 Being overweight can put children at risk of serious health conditions and can put an unnecessary stress on their growing bones. Physiotherapists know that children are likely to remain overweight as adults unless they exercise regularly and eat well. The CSP has learned that only one in five parents know how much time children need to spend exercising each day.

3.7 The CSP would therefore like to see Public Health England do more to raise public awareness about the recommended amounts of exercise for adults and children, and about the importance of physical activity as part of a healthy lifestyle.

3.8 As physiotherapy and other AHPs have such an important role to play in public health, we believe Public Health England will require AHP input at the highest level and the CSP is calling for an Allied Health Professions Director to be involved, at the same level as the Nurse Director post already announced.

3.9 The CSP is pleased to be contributing to the work of the new “Physical Activity Network” as part of the Public Health Responsibility Deal. We want to see local and national government protect and develop opportunities for people to take low cost or free regular exercise.

4. The public health role of the Secretary of State

4.1 The CSP understands that the ageing UK population is placing an ever increasing burden on health and social care services across the UK. Therefore the Secretary of State has a vital leadership role to ensure that long term strategies which improve the overall health of the population and prevent avoidable ill-health are put in place at national and local level, and are adequately funded.

5. The future role of local government in public health, the role of Health and Wellbeing Boards and Joint Strategic Needs Assessments

5.1 Physiotherapists will have an increasingly important role to play as the responsibility for public health moves to local authorities. Physiotherapists and other AHPs are well placed to act as integrators of care and can often help form the “bridge” for patients between hospital clinicians and GPs or community-based health and social care services.

5.2 In order to make informed decisions, local authorities, Health and Wellbeing Boards, Directors of Public Health, commissioning consortia and other commissioners will need a wide range of skills and must have broad representation from a range of healthcare professional including physiotherapists and other AHPs.

5.3 The CSP believes that the proposed new Health and Wellbeing Boards will be central to ensuring that robust strategies are developed to deliver effective public health outcomes. These strategies should tackle health inequalities, and ensure that all relevant local services are directed to collaborate to deliver long term improvements to public health in local communities.

5.4 Given the important role of AHPs in integrating care, and the key contribution that physiotherapy can make to improving public health, the CSP is calling for assurances that the Health and Social Care Bill will be amended to mandate AHP involvement. This wider clinical involvement in strategic planning, joint strategic needs assessment development and decision making will help deliver better, cost effective outcomes for patients and for public health.

5.5 The CSP supports the alignment of service development with financial and workforce planning, as one of the fundamental weaknesses of workforce planning in the past has been these two issues being considered independently. The lack of involvement of clinical service managers, such as physiotherapy managers, in workforce planning has been another fundamental weakness. We wish AHPs to have a voice on the proposed skills networks which are to be responsible for making decisions about the numbers of healthcare professionals being trained. The Skills Networks remit must take account of the workforce needs of both local government and the NHS and private sectors to ensure the future workforce is available to meet those needs.

6. Arrangements for commissioning public health services

6.1 The CSP recommends that the Health and Social Care Bill should establish wider “Clinical Commissioning Consortia”, not just “GP Commissioning Consortia”. The CSP also recommends that Consortia board members be appointed against a series of competences needed for commissioning - which include the ability to understand and commission evidence based public health interventions.

6.2 The CSP believes that Commissioning Consortia boards need to be made up of a wide range of professionals who can demonstrate the breadth of experience, knowledge and expertise across health and social care commissioning pathways, including physiotherapists and other AHPs.

6.3 The CSP is concerned about the conflict of interest that may arise from private companies being awarded contracts to undertake local needs mapping and commissioning activities when they are also competing to provide the commissioned services to the NHS. There must be clear and transparent rules introduced to ensure that no company or individual with an interest in running NHS services can be involved in any way in the process of commissioning or subsequent performance management of contracts.

6.4 The CSP recognises the importance of local authorities being able to make decisions based on the need of local populations. We also recognise the need for national monitoring and surveillance to ensure that any signals or unacceptable variations in care (or postcode lotteries) between geographic areas are avoided.

6.5 For Health and Wellbeing Boards to be effective, the CSP believes that they must have formal imput from all relevant healthcare professionals, including AHPs, such as physiotherapists. It is important that this input is published and available for public scrutiny.

6.6 Commissioning should be undertaken on the basis of whole pathways of care and not for individual single elements of care. The role of physiotherapy in spanning sectors of care can clearly demonstrate the importance of this and the need for physiotherapists and other AHPs to be involved in re-designing pathways.

7. The structure and purpose of the Public Health Outcomes Framework

7.1 The CSP has responded to the recent consultation Healthy Lives, Healthy People: Transparency in Outcomes - proposals for a Public Health Outcomes Framework.

7.2 The key points made in that submission were that the CSP would like to see:

Outcome indicators for the percentage of people in work with access to:

advice on occupational health; and

early intervention services.

Indicators for the percentage of children and teenagers meeting the recommended guidelines for physical activity.

Indicators on the levels of obesity among children and teenagers.

An indicator on the percentage of adults meeting the Food Standards Agency’s “Balance of Good Health” recommendations.

Specific indicators on working conditions and work place assessments, so that levels of health in the working population are carefully monitored. Encouraging work place assessments will help with early identification of potential problems – such as musculoskeletal disorders. Early intervention with effective physiotherapy can prevent these conditions from worsening and becoming more serious or long term.

An outcome indicator – to be shared across public health and NHS services – to measure the proportion of people living with chronic musculoskeletal disorders (preventable ill-health).

Outcome indicators shared across Public Health and the NHS for work sickness rates; acute admissions as a result of falls or fall injuries for over 65s; and health related quality of life for older people.

8. The future of the public health workforce (including the regulation of public health professionals)

8.1 GPs have until now had the most well recognised role in the management of chronic disease and the care of people with or at risk of developing these diseases. It is now well recognised that other health professionals including physiotherapists have a significant part to play in the prevention and management of chronic and preventable disease and injury.

8.2 Access to a greater range of health providers has been linked to the capacity to build more effective self management techniques and accountability in people with chronic disease. As the largest of the Allied Health Professions, physiotherapy has a significant contribution to make.

8.3 The skills and training of physiotherapists mean they are capable of working with a wide variety of conditions and disabilities and they are able to improve the health status of individuals across a lifespan. In addition they are able to positively impact on population health in the local areas where they practice.

8.4 Physiotherapists are valuable members of multidisciplinary teams, making an important contribution to primary health care through their health promotion, prevention, screening, as well as triage, assessment and treatment activities. Evidence has shown that people with heart failure enrolled in programs that feature multidisciplinary team care have shorter inpatient stays and lower rates of re-hospitalisation.

8.5 Being primary contact professionals with excellent communication skills, physiotherapists are accessible to members of their local community. They are well placed to promote physical activity guidelines and healthy lifestyle choices. However, the potential for physiotherapy to impact on chronic disease prevention and management has not currently been reached.

8.6 There are a number of ways in which physiotherapists can actively contribute to decreasing the burden of disease in England. Physiotherapists work in health promotion at public events, within hospital and communities and as first contact professional within primary care settings such as private practices. They work with clients across the age spectrum from infants and children through to the elderly population. This places physiotherapists in an ideal position to provide information and advice to people with existing conditions of those at risk of developing these conditions.

8.7 Physiotherapists manage people with chronic lung diseases including asthma and COPD through exercise prescription and cardio-pulmonary rehabilitation. Individuals with complications from cancer surgery such as lymphodema are treated by physiotherapists using complex physical therapy, and physiotherapists prescribe exercise therapy to improve glucose control in people with or at risk of developing diabetes.

8.8 Physical activity is recommended for the prevention or treatment of many conditions. Physiotherapists can prescribe and implement therapeutic exercise at an individual or group level and lead exercise and education classes for people who have been diagnosed with or who are at risk of developing chronic diseases.

8.9 Aside from the treatment of musculoskeletal conditions, physiotherapists have a well-established role to play in chronic conditions such as cardiovascular disease, chronic obstructive pulmonary disease, diabetes, osteoporosis, obesity and hypertension. The education focus they adopt in areas such as chronic disease management, self-management techniques, lifestyle and physical activity guidance aligns well with the primary health care philosophy of consumer and community empowerment.

9. How the Government is responding to the Marmot Review on health inequalities

9.1 The CSP notes that there are now three aligned frameworks; the NHS Outcomes Framework, the Outcomes Framework in Adult Social Care and the new Public Health Outcomes Framework. The Society is concerned that there may be a risk of a fragmented approach to public health, with some health inequalities “falling through the gap” between the NHS, Public Health, social care and other sectors. The proposed Health and Wellbeing Boards will be absolutely key to ensuring that effective strategies are developed – across all sectors and services – to deliver effective public health outcomes. Allied Health Professionals must have a role on these Boards.

June 2011

Prepared 28th November 2011