Is physiotherapy blog too cynical?

I wonder if this blog is too cynical when I look at some of the other offerings out there. I set this blog up in response to the lack of blogs physical therapy blogs and the few "physiotherapy" blogs out there seem to be written by people still in love with the profession and its ideas. I can see a lot more of the shortcomings in physiotherapy than they can. Some physiotherapy material seems to be an extension of the treatment room with therapists offereing advice about exercises and treatment. I heard the other day about a site (and i don't know the name) which sounds a con. For a certain amount of money it is supposed to be possible to enter a health problem and the online clinician will give professional advice and a diagnosis. Guess they must be heaps better then me to be able to give out advice to unseen individuals with vague problems and then charge them for it! It stikes me as a bit of a risk because there is no regulation of the internet and anyone can set up a website in a country which does not have any regulations of physical therapy and then take whatever money they want for dealing out any old trash for advice. The internet is cool for finding large amounts of info but poor for ensuring the quality of the info. It's all down to the individual to be careful.

Autonomy of the physiotherapy profession

I've read today that we've just passed something of a milestone for the autonomy of physiotherapy in the UK. According to Frontline it is 30 years since the British Department of Health made the first moves towards giving physios autonomy. I'm not quite clear about how some people link this with patient self referral in the NHS. The profession has had true autonomy for a number of years but this has existed in non-NHS independent healthcare. This idea of NHs self referral is not primarily an issue of autonomy but about the way free physiotherapy is accessed. It's not autonomy that's the issue but NHS housekeeping arrangements. Allowing everyone to refer themselves to an NHS physio puts local NHS departments in direct competition with private healthcare facilities but I don't suppose that in too many parts of the UK self employed physios will be losing sleep over it. Many NHS physiotherapy departments have long waiting times and opening themselves up to self referral will make no difference to the public.The service will remain effectively inaccessible. If you have to wait 4 or 5 months to be seen on the NHS for an acute problem it will make no difference if your GP decided to send you or if you decide to take yourself there.

Ultrasound

On the TV this week I saw a sports physio doing ultrasound to an injured calf muscle and I was interested in the technique being used. Whilst he talked to the camera he wizzed the treatment head round at a speed the same as if he was mixing a cake. I'm not sure this was how he learnt to do it and if the technique was changed for the sake of the camera but it would be interesting to know how effective it was. Any area of injured tissue would have received the briefest of exposure to the ultrasound waves. However it made me think about the use of ultrasound and the way it was developed. I wondered if the physio was afraid of setting up the dreaded cavitation effect in the tissues but if you want to know more about this dread effect you will have to trawl the folklore of the profession as I expect nobody has actually done the "R" word on it [research]. Please correct me if I'm wrong but I think it's all based on a limited number of in vitro tissue studies and very little on the adverse effects of ultrasound has been done in the clinical situation. No doubt the athlete receiving the treatment felt better for it but was this because someone was seen to be helping him rather than the fact that sound energy actually reached the site of injury and even if those magical soundwave got there, does anybody really knows if they make any difference to the healing?

Trade unions and professional bodies in physiotherapy

From the outset I should make it clear that the contents of this blog are a personal view (and one that is in a state of devlopment). One of the things I've often wondered is whether British physios' best interestes are being served through have their professional body and their union all within the same organisation. It's easy to assume that because things have always been done in a certain way then that is the way it should continue into the future. The CSP generally does an OK job as a union but it's strength lies more in being a professional body. As a union it is rather small and therefore cannot act in a unilateral manner when it comes to members' interests.And which member of the public has ever heard of the CSP? I think that CSP members should ask questions about what they want from a trade union and how this differs from a professional body. I'm not saying this because the CSP does a particulary bad job at being a union but what I would like to know is whether another way of doing things would be a lot better for physios. A cause for hesitation is occupational therapists. Their professinal body and unions are separate yet this does not seem to make any marked difference to them. Another cause for caution is the reality of NHS pay and conditions bargaining. There is unlikely to be much more on offer to a profession regardless of whether they are independent or members of a big union. I think it's always a good idea to look at dfferent ways of doing things but I'm not sure if change would produce any benefits but it's something we should be open to. I have never even heard it spoken of before.

Are physiotherapists flat earthers?

Are physiotherapists flat earthers? This question can be taken in two ways. Are physios people who believe the earth is flat? No. Are physios people who persist in a set of beliefs even though there is evidence to the contrary? Yes, but in physiotherapy this has some interesting dimensions.A major element of believing the earth is flat is the inability to think outside the box and the box I am refering to is the box of belief about the way that the profession does things. The flat earth thinking is unable to see that many of the things which are assumed to be obvious are in fact products of time and place, constructs which are limited in their universality. This applies to professional standards, clinical practices and theoretical models. It is possible to assume that standards, at present upheld as "best practice" might be unrecognised in other parts of the world, or be unrecognised within one's own country at a different time. One of the things which bugs me is the good old pain gate theory, now way past its shelf life but still being promoted. This as an example clarifies my arguement. The reason that physios talk about the pain gate is because they cannot think outside the box, cannot think bigger than this rather creaky old theory.

Sometimes I feel very alone thinking all these ideas (can't you hear those violins?) Looking at Frontline (new out today) I feel the twice monthly heartsink I get from the magazine when I read the course listings. The profession seems very willing to give up large amounts of time and money to learn ideas and techniques which have minimal proof. I might be alone in this belief but it occurred to me a long time ago that the sum of local knowledge and skill is worth more than the majority of courses which are run. It is important to implement ways of capitalising on local skills and knowledge both through effective continious professional development and through effective sharing of knowledge but it is more valuable than most weekend courses. Sometimes on the news you hear that the combined experience of a group of professionals is..... (last time I heard it was in realtion to a team of firefighters). Apply this to physiotherapy. Many physios will be working in teams or orgainisations with the combined experience running into many years yet they want to go on courses to listen to highly polished presentations from someone with only a small fraction of the skill and experience. The assumed authority of the course tutor is the key but this is a false assumption. It's time we stop being intimidated by these self appointed gurus and set up organised ways of both developing our own skills and capitalising on our corporate ability. Lets' stop thinking that the only way to devlop skill is to pay loads of money for a weekend course.

evidence based practice or practice based evidence?

I did not finish yesterday's rant so here is the next installment. In the car today I caught part of a really interesting discussion on Radio 4 which was about obesity research. The academic was saying how that within obesity research there is a trend being led by Government to drop high quality search in favour in favour of what was called "practice based evidence" because producing high quality research was too difficult. The academic said that practice based evidence is not evidence, yet it rang loud and clear with me because so much of what passes off within physiotherapy as "clinical effectiveness" is the same stuff, so-called evidence of effect produced from everyday practice. One of the big flaws which has crept into the profession is the use of sloppy outcome measures, adopted because they have the magic word "validated" attached to them yet often inappropriate to what needs to be measured or able to show change but unable to demonstrate this was as a result of physiotherapy (why is there always the assumption that all we need to do is to demonstrate change in the right direction on an outcome measure?) I have big problems with MYMOP, an increasingly popular measure with physios, popoular because it can be used in a wide range of circumstances but something which fails to make common sense. It's a bit like measuring patient satisfaction, the measure of which is usually high for most (therefore by assumption are we all doing a good job even whan there is evidence to the contrary?) I also have reservations because an outcome measure can achieve validation in statistical terms but does that then mean it is always going to be useful within clinical situations very different from those in which it was developed? Am I talking about staining the limits of validity?

As usual I've got more questions than answers but I thought that's part of the reason for having a blog.

physiotherapy evidence and clinical education

I've noticed something interesting within physiotherapy but I'm probably stating the obvious. There's a conflict between those who want to practice according to the best evidence available and those who argue that results and experience are more important. Arguably research evidence and experience go together, but I sometimes get bothered that despite 10 years or more of evidence based practice there 's a large number of British physios who seem too willing to be taken in by the lateast ideas when these new ideas or treatment techneques are promoted by eloquent trainers running weekend courses. Now that evidence based practice is a comfortable term , when you go on any clinical course the course tutor will always throw in how the course content is evidence based and it will do X,Y and Z if you use these techniques. There will usually be a heap of research discussed but what the course tutor will conveniently avoid is presenting sound clinical trails which show the techniques being taught can actually make people's health better in a way which is more effective than the "healing effect" of time or the power of positive thinking. The research "evidence" is evidence by proxy, usually within a related area but never actually about the techniques themselves. Then there's the inevitable using the techniques on one's fellow course participants, and leaving the course ready to be let loose on patients.

I wonder if part of the problem arises from a deep seated desire in many physios to believe in themselves, a need to believe that what they are doing is valuable, effective and skillful and perhaps an inability to deeply question something in which there is a big emotional investment. To allow for the possibility that the majority of patient recover through natural healing processes or through their thought processes is difficult. This would mean that complex "skills" requiring time and money to learn are in reality worth very little, an uncomfortable thought if you have sacrificed financially, something which also creates a feeling of insecurity at work ("if patients get better through natural recovery how can I be worth £25 000 per year?") Yet to question things in this way would be the start of something much better within the profession and for us as individuals. If we had the courage to abandon so many dubious clinical practices we could then put every effeort into those things which really do make a difference. Then we wouldno longer have to go on weekend courses which cost heaps of money to obtain a course certificate which is of dubious value.

physiotherapyblog on Google

OK here's a confession. I've largely ignored this blog for weeks but to my surprise it's on the first page of Google! In the past it came up under a search of physiotherapyblog but not physiotherapy blog. So for all you millions of Googlers out there I suppose I had better start writing something on a regular basis and putting some new material on the site . I signed up to Flickr today (not under this blog's names) but realised after than you don't get unlimited pictures on it. That takes money.

I'm not sure how someone writes on a blog bout their job in healthcare without breaking confidentiality. I've got heaps of web material I could link to but I'm not sure the world needs yet another list of good websites. I'll just have to think hard and come up with some bright ideas.

what no blogs?

I thought I ought to write another entry to the blog, but I can't say I'm particulary impressed with this whole blogging thing. I started with loads of enthusiasm in March of this year but now can't see the point of it all. I've got too many real world things to do than to sit at the computer every day thinking up bright ideas. The big project I have on the go at the moment is writing a book on bike rides , and it is time consuming trying testing out the rides. I've done 13 out of the 15 but I'm having to do them all twice. After having tried them out I am going back to masure distances. With hindsight I should have used an odometer /mileometer at the start of this project so by now I would have been well into the writing stage.

I suppose I feel some apathy towards ranting about healthcare in the UK, and over the last 6 months have come to the conclusion that blogging, at least here, is not going to change very many things. I'm not sure if most bloggers are students with heaps of time on their hands. So there's not a lot to say about physiotherapy in the UK. Perhaps we should re-visit Agenda for Change (AfC). In case any of you UK physiotherapits did not realise next month sees us all working an extra hour per week. Some physios seem to have been conned and have been forced into working an extra half day per month as a result of their employer adding all the extra time up and saying they have to do it in one go. Those with longer memories will go back to the AfC agreement and remember hours change by an extra hour PER WEEK. The problem with AfC changing our terms of employment is that now the enthusiasm and controversy over the regrading has gone the effect of the time increase is to all but negate any pay increases we had 2 years ago. Let's hope that next year's annual pay award is better than this year's, especially for English phyios who have yet to receive the original award from April.

physiotherapy news

I've not heard anything about physios in the news recently but there's a big story which won't be given much space in the newspapers or on TV. We now have another mass of newly qualified physios out there looking for jobs when 100's from the last 2 or 3 years of graduates still are not working within healthcare. I've ranted on about this in previous posts but I think it is one of THE major issues within physiotherapy in the UK. Sometimes it feels as if the problem is not being given a high enough profile but it should attact wider interest other than from just within the profession. Anyone who pays taxes is subsidising university training programmes which for many are leading nowhere.

The other issue affecting NHS physios is the pay award situation and I think this is rather gloomy situation. The Government descriminates against English physiotherapists by giving them a less favourable pay award than those in Wales or Scotland. Also within the public sector is the real term reduction of salary through paying awards below the rate of inflation. This point seems to have been lost in the issue of whether the aware will be staged or not staged.

physiotherapy blog

So somewhere I've found motivation to reschedule things in my life and start up the blog again. The biggest barrier to writing was the fact that this whole thing seems the stuff that saddos do, stuck in their bedrooms on their own typing thoughts onto blogs that no on in the whole world will read, believing that somehow what they are doing counts for something. The thing that changed my view of all this was realising that I've made it to the first page of Google if you search for physiotherapy blog. THIS changes everything! Suddenly all these meaningless rantings take on the potential of changing the course of world physical therapy, expanding knowledge, moving everyone onwards. No I don't really believe this but there's now a chance that what I'm doing will move beyond the value attributed to it within my own illusions (or should that be delusions ?) Maybe someone will read this!

Unfortunately in these last few busy months I've lost a bit of the anger at the injustices in the NHS and the way that healthcare is delivered in the UK. I doubt if it is anything to do with a change of Prime Minister. I'm just feeling distracted by some of the other things Ive got on the go.But here's something to make you English physios rant. The grand pay award of 2.5% for this year will be paid in full to nurses (and presumably AHPs) in Scotland, NE., and Wales but looks like those in England won't get it in one go. Is this something to do with the fact that the new Prime Minister is a Scot and has a lack of loyalty towards English NHS staff? And what about all Gordon's talk of the NHS, what's going to happen ? I heard he wanted to find out the views of NHS staff but as I've said before we all know this will probably mean the two professions (doctors and nurses) which the Government seems to think make up the entire NHS. will be asked what they think and the rest of us won't get a look in. There was talk of NHs staff fatigue over NHs change. Too true, the Labour years have been ones of constant NHS restructuring in the name of progress.I was talking to a patient this week about the billions that have gone into the Health Service and I said that despite the billons that have been put into the NHS the phyios where I work are under greater financial pressure than ever before.

just too busy to blog

OK so I've not done anything to this blog for ages. When i first started out I had the crazy idea I could keep 3 blogs going on different subjects but now i find that i'm too busy to keep just this blog going. I heard on TV that loads of people write blogs and send e mails in work time. There's no chance for this in the NHS, or perhaps more accurately no time to do this for fun. I spend a significant amount oftime every day sorting out e mails but they are all work related. That's just about all I've got time for. I was wiondering if excessive blogging is a sign of something, I'm not sure what, maybe not having enough going on that's more important or more interesting than sitting in front of a computer screen.

Is a ban on pain killers coming?

People are becoming addicts to over the counter pain drugs, so runs a recent news story. The last time this type of thing hit the news was over co-proxamol and it's use in suicide attempts. I have heard first hand how the ban on co-proxamol has badly affected some people and there is the risk that with the typical knee jerk reaction so prevalent in health care policy that another group of drugs which benefit many people will be removed from chemists' shelves. Drug abuse is something which needs attention but there is a massively unequal reaction to the small number of pain killer addicts compared to policy designed to address alcoholism. Alcohol has never been more readily available but UK health and social policy does not do anything to effectively reduce alcohol abuse. The Government has a vested interest in keeping alcohol consuption high because of the tax revenue it generates. There is a seriuos need to get clearer priorities in healthcare policy and to have a more transparent perspective of vested political interest.

NHS change

I get fed up with NHS changes. Just when you think that you understand how things work and there is an element of stability then everything changes again. I think this is because of the managers within the NHS and reflects the problem of management within the public sector. In the private sector a manager is judged by their contribution to company profit. However in the public sector everything is different. Because managers in public services do not produce anything (and actually cost the organisation) then they have to create the illusion of productivity by initiating change. Through changing things in the NHS they can make it look like progress or improvement. The hardest thing to accept is the way that Agenda for Change was applied to management. The biggest component of AfC scoring was for clinical activity,so in my thinking this should have made clinicians more highly paid that managers lacking clinical contact or expertise. This is definiely not what happened. I heard a rumour that one of the reaons for NHS financial problems were the large salary increases for managers under AfC. Just a rumour or near the truth?

Is wi-fi bad for your health?

There's an interesting news report currently on the BBC news website about Canada's Lakehead University,where there's a restiction in the use of wi-fi because of health concerns. If you look around various physiotherapy disussion forums you will see that discussions regulary come up about the safety of electromagnetic energy sources ( in the mainly shortwave spectrum) used within physiotherapy. I'd really like to know if there's a health risk from those things we've all been told are safe. There's probably not been any specific testing of physiotherapy equipment for it's effect on human tissue and definitely no long term studies on it. And what about the other things which are readily practiced in physiotherapy-things like TENS, acupuncture , manipulation ? Has anyone looked at potential for long term harm with these treatments? We're not talking about the immediate effects such as adverse clinical events associated with a neck manipulation or pneumothorax associated with acupuncture but the long term adverse health consequences, such as increased risk of developing certain health problems a long time after the event. Could having repeated acupuncture increase the risk of devloping cancer? Could neck manipulation increase the risk of stroke years after the event?

rescue plan

Appeared on the BBC newspage in the last few days is information suggesting that there will be a new scheme to help doctors who cannot get training places. This just reinforces the longstanding feeling that politicians believe thealthcare consists of just doctors and nurses. Where's the scheme to help the physios who can't get jobs, the 80% unemployed working in fast food outlets and other such jobs?

I'm thinking of changing this blog to one called "Blog on blog" because it's proving hard to keep it going even without problems arising from the computer like a week or so ago. I'm involved in some academic writing and trying to find time to sit down every day to write this blog is proving difficult.

News on the grapevine is that things are not looking good for physios all around the UK as a result of the PCT reorganisation last year. There seems to be a massive amount of restructuring going on all round the UK

rescue plan

Appeared on the BBC newspage in the last few days is information suggesting that there will be a new scheme to help doctors who cannot get training places. This just reinforces the longstanding feeling that politicians believe thealthcare consists of just doctors and nurses. Where's the scheme to help the physios who can't get jobs, the 80% unemployed working in fast food outlets and other such jobs?

I'm thinking of changing this blog to one called "Blog on blog" because it's proving hard to keep it going even without problems arising from the computer like a week or so ago. I'm involved in some academic writing and trying to find time to sit down every day to write this blog is proving difficult.

News on the grapevine is that things are not looking good for physios all around the UK as a result of the PCT reorganisation last year. There seems to be a massive amount of restructuring going on all round the UK

job losses

The RCN conference at Harrogate is being reported in the news as saying that 22 300 nursing posts have been lost in the NHs over the last few years. Inevitably there are the usual denials by the Dept of Health but this whole thing rings true. But that's just a fraction of the picture. Along with the nursing jobs lost there's all the other ones including physio posts. Then there's the uneployment amongst physio graduates, which if it's 80 % for the last 2 years with this next year's graduates should be reaching about the 5000 mark. But rest assured, there's no crisis in the health service! Yea right!

physiotherapy blog and software

We can only have blogs because of the taken-for-granted effectiveness of the programmes and hardware running the comupters we all use but I get fed up with the repeated errors that both of these make and the inability for the average person to sort the problems out because once we go beneath the surface veneer of pretty colors and pictures we use to make the computer work there's a totally incomprehensible world of meaningless codes and data. I have spend the last week struggling with a number of problems and these still are not resolved. Take virus protection. We're all meant to have it but the down side of this protection is that it clutters up the computer with useless items which i'd rather not have, silly pop up messages which are absolutely no use to me and a subtle forms of blackmail to ensure I keep buying updates. Why can't we have a simple ,fail safe, error free system without constantly having to try to sort out malfunctions? It almost seems as if the whole world has been conned by technology; when it works it can do fantastic things but for large amounts of time we are trying to solve problems in what is only on the surface user friendly but as soon as something goes wrong and we try to work out what to do we are faced with the language and thinking of 1970's computer geeks.

So what about physiotherapy and healthcare? There have been a lot of interesting things in the news. If you do not live in an area of the UK with a Labour MP then the chances are you will not have got a new hospital planned because 85 pence in every £1 spent on new hopsitals is in an area with a Labour MP. I cannot understand why when something like this comes to light there's no serious protest or holding Government ministers to account. It's also come to light that healthcare workers are increasingly unable to buy properties in the majority of the UK because house prices are so much higher than NHS salaries. With the average UK house price about £185 000 and starting salaries for physios in the low £20 000's then there's a massive gap between earnings and the possibility of buying. Rumors of a price collapse have been circulating for a few years but one wonders if things will eventually slow down, because with prices like these there will be no new money coming into the system.

Evidence and the BBC

An interesting piece of reporting has occurred on the BBC website. A new study is quoted describing the fact that decisions in healthcare are often not made according to the best research. If you read back over the posts in the blog you will realise that this idea runs throughout many of my entries. It bothers me that the physiotherapy profession ,despite making significant progress in it's use of evidence, still remains heavily dependent on subjective opinion rather than seeking to strictly adopt practices for which there is good evidence. And this works both ways. Not only are large amounts of what go on in physiotherapy without sound research to suport it, but there is good evidence to support many things which we don't do. Here I rest my case!

However the point I want to raise today is not the much debated role of clinicians using the best evidence but perhaps what should be called evidence based healthcare reporting. The BBC along with most other parts of the mass media have a biassed, non-evidence based approach to reporting health so that what counts for fact quoted by them is regularly biassed and hysterical, designed to create anger or anxiety in the audience and not to provide accurate analysis of an issue. Reporting of pandemics, climate change and the issues in the NHS all have a hysterical quality and do not let the public understand many of the serious issues behind the stories, nor do they encourage the public to analyse the issues themselves. These media organisations set themselves up as experts when if you look at what they are saying about just one area,health, you will realise that they selectively report those subjects likely to create the biggest reaction. Although we need more evidence based practice in health we need something even more-evidence based healthcare reoprting.

the eclipse of physiotherapy?

I keep hearing accounts from all round the UK that physiotherapy services are under increasing pressure not from weight of patient numbers (although that always remains a challenge) but from threats to the autonomy of physiotherapists employed in public health services. It feels like we might be witnessing the beginning of the end for physiotherapy as we know it. It's easy to forget that up to 18 months ago physiotherapy was an expanding profession branching out into new clinical areas and increasing in numbers. 6 or 7 years ago there was the emergence of the consultant physiohterapist role which came after at least 10 years of innovation in developing new physiotherapy roles. We now might be seeing a return to the situation which existed in the late 1970s/early 1980s. Pressure is on to gain control of physiotherapy budgets thereby removing professional autonomy and returning things to how they were in the more distant past with everything in hospitals coming under the control of all-powerful doctors and nurses. It seems highly unlikely that the situation in primary care will be better and it could be even worse within practice based commissioning. In an attenpt to maximise partners' profits there might be attempts to cut back on NHS physiotherapy by encouraging patients to go to the private sector. The fiasco of NHS dentistry could be a taste of what is to come with services like physiotherapy and other allied health professions which address quality of life rather than save lives. The thing I cannot understand is why Frontline, the mouthpiece of the CSP, remains so upbeat in what appears the greatest crisis facing the profession at any time in its history. Instead of printing fighting talk it sems to be pretending that everything is OK, that everyone is very happy and that all's well with the profession.

The Health Secretary Apologises

The Health Secretary has apologised for the confusion over doctors' training. I suspect that it would be foolish to wait with baited breath for an apology about the bad planning which has led to 80% unemployment amongst physiotherapy graduates. Despite multidisciplinary working in hospitals, despite post graduate research and professional knowledge at times like this is is still possible to believe that the NHS consists of just 2 types of staff, doctors and nurses. The Government jumps every time that the medical profession demands it , suggesting that there is a profound lack of understanding about how healthare works and how interaction in the system is more important than its more prominent (2) parts. It seems likely that the lack of real understanding of the complexity of the NHS together with adherence to old stereotypes is a major factor in NHS difficulties.

disability rights

The UK is to sign up to a Unitied National agreement on disability rights.The areas it covers include participation in culture and non-discrimination . I've got really mixed feelings about this. It seems in our society that those who shout the loudest are the ones who get what they want as far as disability is concerned. I read this to mean that there will be more pressure on employers to take quotas of people who are disabled but little attention will be given to the suitability of these people or the ways that their colleagues might have to carry them in competitive situations where they cannot cope as well because of their disability. On the other hand there are thousands of people with long term disabilities which get absolutely nothing from society and whose carers get absolutely nothing. This includes families with profoundly disabled children and elderly carers who look after relatives with chronic health problems. In reality both these groups of disabled people are getting less and less care as councils withdraw what little suppport or respite services there used to be. What I'm saying is not politically correct but in my job I've come across loads of long term disabled who are struggling to survive yet all the effort is going to go into helping a relatively small group of disabled people who are always complaining about their rights. No one is interested in those who cannot work or will never work. The irony is that 20 years ago some groups of disabled people were better supported than they are now. Non-discrimination is a myth; all that is happening is that the discrimination is being moved to a different group. The definition of discrimination is being changed to make it seem as if it has gone. It's not gone away. The loud mouthed millitants might be stopped from shouting but for the silent majority of disabled their needs are ignored.In fact their needs are not even acknowledged because we no longer have disabililty discimination.

staff confidence in NHS

There's been a lot of interesting news in the last 24 hours. Results of a Health Commission survey show that the majority of NHS workers questioned said they would not be happy to have treatment in their part of the NHS. Maybe this is something to do with the fact that their GP won't be getting a discharge report (see the last blog entry). More likely it's due to staff awareness of the flaws in NHS service. However as with all media reoprting there's likely to be a bias in this information. Might it be that staff would chose not to go to their local hospital because they want treatment at somewhere that they are not known ? It might have nothing to do with care standards and everything to do with avoiding receiving treatment from colleagues. Would you really want to be working with your colleague who has just performed your colonoscopy or D&C? I'm not so sure that physios would mind receiving physiotherapy from collagues. During training we seemed to spend large amounts of time going around in just our underwear so few of us would have an issue with the dignity side of things (if that's the correct term for it!) However it would be interesting to find out just how confident we would all be about our collagues abilities to treat a problem.

Another bit of news is about NHS staff being attacked. It would again be interesting to know how physios fit within this. It's hard to envisage this happening in hospitals under normal circumstances (Emergency Rooms/A&E Depts excepted). Physios who do home visits are at risk and we should be asking wht forms of protection these vulnerable workers are being given. Someone might phone you if you don't turn up for wotk the next day but who knows what could have heppened before then

discharging NHS responsibilty

A recent support suggests that there is a national problem with discharging patients from hospital. Apparently GPs are not getting enough information when patients are going home. And why might this be? There’s not been a study into it yet but I think that it’s the usual suspects : lack of staff time, high turnover in wards and inexperienced junior medical staff. The NHS machine is constantly being run at maximum so it’s inevitable that communication will at times suffer. There’s also an issue with clerical support. If the discharge report goes into the usual pile of medical secretarial work then it might take weeks to be done. Perhaps we should also be asking what staff are doing when it comes for a patient to go home. There’s a near iconic status given to a patient’s ability to do stairs and also all those nice little things that occupational therapists look at like dressing practice but it might be time to overhaul the discharge process and ask if it’s time for it to be brought up to date with the 21st century.

A NICE day in court

The National Insitute of Clinical Excellence (NICE) is facing a court action because of it's refusal to authorise the routine use of certain drugs to treat Alzheimer's disease. This is an interesting new development in the provision of free healthcare in the UK. Success in the court action would have major implications for many other clinical areas in the event of a service being withheld or withdrawn. It is the ulitmate expression of patient choice. Maybe in the future we might see court actions about the failure to provide physiotherapy. However. there's one problem with physiotherapy. When it comes to courts there will be few areas of physiotherapy practice which have sufficient evidence to justify their use. Which is an interesting parallel with another piece of news from the last few days; nationally there is pressure on ante-natal classes, some being reduced and even some services being withdrawn. Tise has the potential to affect physiotherapists as they are often involved in delivering the service. However, if someone decided to go to court over the withdrawl of classes they would be sadly disappointed with the outcome. As with other areas of physiotherapy I suspect there is a lack of hard evidence that these classes make a major difference to what happens later and it would be hard to prove that their reduction has any major impact as long as there is still a sufficient packageof care in place.

the genie in the bottle

I heard this week that there are plans to use genetically modified mosquitos to fight malaria. These new insects are unable to carry the malaria parasite and therefore will compete with the malaria carrying mosquitos ,the plan being that through this competition the baddies will be ousted by the goodies. However this last phrase indicates why there should be a cause for concern over this. The scheme seems too simplistic and full of dangers. Think back over the last 50 years to where species have been introduced artificially outside their natural habitat and it is possible to see a record of unparalleled disasters. The problem with a genetically modfied specied is that it is unnatural, and being unnatural we do not know what to expect. Always in the past there have been overwhelming reasons why a certain action should be taken and assurances given but once something has gone wrong it's too late. A scientist can resign or be fired but the genie won't go back into the bottle.

boom and bust in the NHS

Those of us working in the NHS realised long ago that there's something seriously wrong with the way that staffing is planned and now the Paliamentary Select Committee for Health has said the same thing, saying at present there is a "boom and bust" approach. Not so long ago there was an issue with the ethics of recruiting staff from overseas to make up for the shortfall in British staff available but now nationally there are redundancies and the cutting of posts. The whole process of staff planning is a random event and nowhere is it more evident than in the huge mess up in physiotherapy training. It's now old news how the vast majority of graduates are unable to get a job and come July there will be yet another wave of newly qualified physiotherapists looking for jobs which do not exist. It will be no comfort to them to learn that less that 3 years ago staff were being sought from overseas to fill the gaps in the labor-market. It's interesting to look at the role of the professional bodies and trade unions in all this. Maybe the time has come for them all to stop being campaigning organisations and to begin looking further than their narrow interest group agendas. Although they ultimately cannot be blamed for the shameful mess in workforce planning their past complaints about vacancies and shortages in staff to fill posts now look very naive.

physiotherapy and inactivity

A study just out has confirmed something we all already know; inactivity is bad for you. Oxford University have just published research suggesting that 3% of deaths in the UK are a direct result of inactive lifestyles. This is an area where physiotherapy could take a massive lead in affecting but the issue of inactivity does not only affect patients but can also an institutional attribute of health planning. Because healthcare in the UK is now largely driven by short term goals it seems unlikely that anyone is seriously likely to commit large amounts of phyiotherapy resources to treating something which needs a long term approach and also needs a wider strategy than just local health commissioning. Central to trying to help this problem is the quick fix, short term politically motivated way that healthcare is run because trying to change health through lifestyle will be slow and give results over years. Unfortunately this will not make good material for political speeches or manifestos. Maybe it's time for healthcare worker in the UK to start to make the case for a new approach to health, one not based on the waiting list as the absolute indicator of success, something which looks ahead further than the next election. If we can move away from the inactivity in health planning then it is likely that the physiotherapy profession can be key in promoting healthier lifestyles.

hospital car parking

It's now something of an assumption that hospital parking is something that patients and visitors have to pay to use but what's shocking is the amounts of money being made on it. Some hospitals make nearly £2.5 million and it has become a major source of revenue. What's really galling is that often hospital managers get priority parking whilst the rest of the staff have to make do with inadequate amounts of staff parking. The irony is that whereas it is unlikely to much of an effect if many managers are late in to the office if most clinicians are late it has an immediate impact on patients. Most hospitals now have staff parking which requires parking permits so staff have to pay to park their cars at work. In some places there is good public transport so there is a real alternative to driving but in many the public transport is inadequate or staff commute from over a very large area making personal transport a necessity. So what's really happening? Many clinical staff including (most physiotherapists) have to pay to use parking at work which is inadequate and they get a lower priority to use the limited parking whilst staff working in non-clinical capacities often get first choice of the parking. Something's not right .

Home held physiotherapy notes

The body responsible for information technology in the NHS, Connecting for Health, has announced that they will be running a trial study of giving patients access to computerised versions of their hospital records from home. This seems further evidence of the loss of direction with the NHS information technology programme. It sound a really nice idea to be able to look up records from home but it seems a bit of a waste of time.It's going to make little or no difference to patient care and carries with it a huge security threat. It will be only a matter of time before a determined person will compromise the security of the system and confidential records will be available to unauthorised people. There's also an issue with the rules being changed (all in the interests of national security of course) whereby the police and other government agencies will be allowed to access the computer to find people or get personal details. If this is linked with some sort of pin number or swipe card which will have to be used every time a patient sees their doctor or goes to hospital then we will always be under survailence. It will be interesting to see how this move could affect physiotherapy records and record keeping in general. It will "dumb down" records because in effect they will be on display to patients and it will force further changes in attitude to documentation. The one ray of hope is that at present it will be possible to "opt out" of the system. No one has clearly explained how the computerisation of records will be an advantage. The idea of any member of a healthcare team being able to access the record is good but that has to be offset against the inevitable paralysis of the health system on those days the computer system fails combined with the massive costs in setting up and running plus the security risk. It looks like the people who initiated this have been so seduced by the technolgy that they have lost sight of its purpose.

Health promotion

Understanding long term health problems is crucially important in the future of health services in the UK. Important long term conditions include heart disease, cancer and diabetes. In the last 2 years there has been a lot of attention given to childhood obesity as a long term health issue but it has come to light that the current short term priorities in health planning are threatening a long term study into activity and diet in children with diabetes. a study being undertaken in Plymouth will be forced to stop at less than its half way point because the Government funding body does not want to commit to long term projects yet there has been no shortage in projects on which public money has been wasted. There is serious shortsightedness in healthcare planning when something which could make such a difference to the understanding of children's health problems such as this study faces being closed down whilst so many meaningless projects are funded. This is yet one more example of how healthcare funding priorities in the UK are driven by short term political objectives rather than a real desire to change health. At the best the desire for improving health is confused and short sighted. At its worst it deliberately manipulates public fears and aspirations for narrow political gain.

media health scares

It seems that the media are always on the lookout for a health scare to fill out the contents of the evening news or the front page and the latest of these in the last few days is additives in children's medicines. A few years ago it was media scare mongering about the MMR vaccine. The main problem is that often popular reporting of health issues is distorted, sometimes deliberately to produce a good story. The last thing a journalist wants is for viewers or readers to ignore the item and go to do something else. With the latest thing about additives it's not clear if this is just a case of the reporting lacking balance or it there has been deliberate distortion to create an emotive news item. As with the MMR hype the problem with this health scare is that it ignores the problem that the treatment aims to solve. In the case of additives the idea is to make children more likely to take the medicine. If anyone has experienced the bitter taste of adult paracetamol tablets it is easy to undestand why there might be the need to improve the taste of children's medication. Which is more important, for a child to take the medicine or the child to avoid tiny amounts of additive taken on an occasional basis? It seems possible that if there is a push to make medicines additive free then things will resort to Victorian methods of having to use a teaspoon of sugar to help the medicine go down, or else brute force. Being logical about this the whole issue is somewhat contradictory; there is a fuss about children taking tiny amounts of additive on an irregular basis but no one questions the effects of the chemicals that the additive is meant to disguise.

Time to call time on the NHS?

Amongst all the pressure on the NHS and the privatisation by stealth there has just been a radically new idea suggested for regenerating a Surrey Hospital. Apparently Epsom District Hospital could be bought up by a millionaire and turned into a charitable trust. This is probably only one step away from NHS foundation trusts. It would be interesting to see if running a hospital as a charity would be any more effective than via government funding. The problem with the current funding system is that it is complex beyond belief, subject to the whims of politicians and fails to reward good practice. One idea which at the moment has not been aired but is a "fourth way" in NHS structure is having a totally independent NHS, free from Dept of Health control, a bit like the BBC where it would receive an allocation of money but it would be up to the organisation to plan it's own services without significant Government involvement. It's hard to say if this 4th way would work any better because at the heart of the problem is trying to meet infinite demand without always increasing the resources. This is something that politicians are not willing to admit.

Job losses and over regulation

The NHS crisis continues to deepen. News out today reports concern by senior NHS managers about duplicated regulation within the NHS. Also annonunced today is the loss of 100 NHS jobs in Warrington. There are myths being put about to support the over regulation and cutbacks in the NHS. Regulation is meant to bring about safer, better healthcare but it can be called another name;bureaucracy. The current levels of regulation are ineffective because they are essentially a bureaucratic process. The mistake made a long time ago by politicians is to think that healthcare is like any other service industry when in fact it is unique because of its complexity and its lack of standardisation.With the latter features millions of decisions are made daily on the basis of judgement not a predetermined set of criteria. The lapse of regulation into bureaucracy comes about because regulation is applied as if healthcare is something standardised and easily measurable. The tragedy of job losses in the NHS is underpinned by the myth that this is part of restructuring into better, more community based hospitals with patients needing shorter stays and much more being treated as day cases. That's the explanation that's give when jobs are being cut. What is totally unclear is why have these hospitals trusts and other NHS organisations gone on knowing all along that they could provide their services in a much more efficient way and it needed a crisis in the funding to make them be more efficient? Why have they only just decided that what they were doing was so inefficient that they can cut large numbers of jobs AND make their services better?

Skin cancer

Recent reports highlight the growing munbers of people getting skin cancer especially in younger age groups. Perhaps the time has come for the physiotherapy profession in the UK to embrace a wider health education role and instead of restricting its education to mainly postural and exercise education it promotes health in the widest sense. UV skin damage through sunbathing is a long recognised risk but what many members of the profession do not realise is that physiotherapists at one time undertook ultraviolet treatment, themselves not doubt contributing to patients' UV damage to their skins although in a worthy cause (usually trying to treat psoriasis or acne ) Physiotherapists being a fun loving bunch, are also are at risk of skin cancer from summer holidays spent on the beach. maybe we will be facing a situation in the future where smoking declines and with it lung cancer to be replaced by skin cancer as a higher risk. The problem is that it is possible to tax or ban smoking but you cannot do that with the sun.

NHS protests

Up to now the physiotherapy profession in the UK has been rather ineffective in its protests about the adverse effects of NHS changes. These impact on the profession in a number of ways including job losses, reorganisation and graduate unemployment. However in the last few weeks ther has been a growing amount of protest by many other workers in the NHS and it will be interesting to see how physiotherapists respond. Reading some of the things written within the profession one could almost believe that the profession is in its high summer rather than facing the biggest crisis since the foundation of the NHS. There are many outstanding individuals within the profession who are achieving massive amounts but as a group within the public sector there is a growing threat posed by managers wishing to save money and for whom physiotherapy means little because they originally were nurses or accountants. The growing voice of dissatisfaction amongst NHS staff needs to include the concerns of physiotherapists.

hamburgers and princes

So HRH Prince Charles thinks that a famous worldwide hamburger chain should be banned. Presumably he does not like fast food but there is a big threat to liberty when governments start banning things they do not like on the basis of potential health risks. Unfortunately by suggesting that hamburgers are banned the prince is confusing something which has a potential to cause ill health if abused as opposed to something which is a threat to health. The problem is not eating an oocasional hamburger but excessive consumption and in terms of social problems attention should be focused on the risks posed by alcohol and not thosed cause by a Big Mac. In democratic societies it is better to influence public behaviuor through taxation and education rather than banning something as innocent as food.

What NHS funding crisis ?

Channel 4 Dispatches has just finished inthe last few minutes and it provided a more complete analysis of the NHS financial crisis than the last blog. As well as the major funding incentives in primary care it highlighted the experience of all NHS staff who everyday are confronted with squandering of resources. This includes the plans for a massive computer system which costs billions but which really fails to serve any purpose and could have been provided for a fraction of the cost using alternative low tech. systems. Clinicians working in the NHS feel sickened with the talk of massive investment because there has been little sign of the money and every day there is the unrelenting pressure on a cash startved system. Physiotherapists are probably more aware than most of the failures because of the total lack of planning evidenced by the growing graduate uneployment in physiotherapy with the vast majority of last years' graduates still unable to find their first posts and it now being only 5 months away from the next group of graduates.According to Channel 4 things are going to get worse, because soon the money will start slowing down even further so if things seem bad now what are they going to be like in the future?

NHS funding rises

It has just been anounced that there will be a drop in the funding rises given to the NHS. It appears that since 2002 funding has been rising by 7% per year but in 2008 it will go down to 3.5% per year. The reality of this is the fact that those working in the NHS have failed to see the so called 7% rises in funding because 4 years on things are only getting worse. There should be some very hard questions being asked about where all this extra money has gone. It probably has been taken up by the growing amounts of money being paid out in primary care as well as changes in medical contracts, with the lesser part being used to fund Aganda for Change. It is a myth to believe that there has been a major expansion of NHS services over the last 4 years because the reality is a daily struggle against increasingly difficult problems. In effect this is an anouncement of a funding cut to the NHS and will come as no consolation to the large numbers of unemployed phyiotherapy graduates or qualified staff facing threats of redundancy. The Kings Fund seems to think that with good planning should be possible to avoid problems but at present the situation is one where financially solvent trusts are having to give up money to balance the books of overspent trusts so in the current NHS success or failure is not a matter of financial prudence but the whims of ministers and Department of Health managers.

hospital acquired infection

A recent report has highlighted that there has been a 69% rise in reported cases of C.Diff and MRSA. This should come as no surpise to anyone who works in the NHS. Once an issue becomes fodder for politicians then very close attention is paid to the slightest change so since MRSA went live then it was inevitable that it would become a growing problem within the NHS. To a certain extent politicians need to create a problem so that they can then be seen to be doing something by addressing the problem. In part some of the rising figures for hospital acquired infection come from the political nature of the problem so that there is now an incentive to report it. The problem has not developed overnight but in the past it was ignoreed and expecially on death certificates it would not have appreared as a cause of death. The other big factor is the major problem in the NHS . An all out push to shrink waiting lists is the main prority. This high turnover, low investment NHS comes at a cost, and part of this cost is the risk of greater infection. The other big factor is NHS staffing policies and the present attempts to cut staffing to a minimum. Hospital staff are an easy target for politicians who want to blame someone for MRSA ("it's because staff don't wash their hands") but the real issue is that a whole system constantly run at close to breaking point is inevitably going to beging to fail and MRSA/C Diff. is evidence of this failure. Instead of politicians treating the symptoms of these infections they should seek to treat the cause.

physiotherapy regulation

see below

physiotherapy regulation

It has been announced that the medical profession is now to have external regulation. Perhaps we should be asking "what took you so long?" The allied health professions have been regulated by the Health Professions Council (HPC) for a number of years and before that by the CPSM. It seems strange that doctors have remained under their own regulation for so long depite the fact that quite a few years have passed since the the terrible events which led to plans for regulation (Harold Shipman, organ scandals and so on). As with the allied health professions, the principle of regulation is a sound one but the application of the principle is full of difficulties. The HPC takes disproportionate amounts of fees from those it regulates and shows signs of serious inefficiencies. Examples include having to repeat a physiotherapy office election due to mistakes in the election process, delaying of registration renewal of those on the register and lack of accountability. And this last point is key. Who regulates the regulator and to whom are they accountable?

Street Doctors and Street Physios

There has been a recent BBC series called Street Doctors where a group of 4 doctors has done consultations with the general public on the streeets of UK cities instead of doing this in hospitals or surgeries. It was surprising how many times they said that the person consulting with them needed physiotherapy. Perhaps the BBC should do a series called "Street Physios" because there would be no shortage of potential candidates to act as consultants nor a lack pf people wanting advice. On one occasion they gave some sightly misleading advice about clicking joints saying that these arose from nitrogen gas formation. Whilst true in a general sense for benign clicks, repeated painful clicks can indicate some form of joint pathology, a point that the BBC did not make. Your average Street Physio would have know this. However as a profession it is interesteing to speculate what sort of image that physios would project. Would Street Physios be excessively bogged down by obscure, unproven theories or would they be able to provide reassurance and education in a positive manner?

smoking and physiotherapy

The British government is going to give large amounts of money to environmental health departments around the UK to enforce it's smoking ban. No doubt this will also have some impact on hospitals as well. There will soon be a total ban on smoking on NHS sites. There is an irregularity in the current attitude to health promotion and the creation of a public health agenda in the UK. on the one hand smoking is singled out as one of the greatest health risks facing society but on the other hand there is uncontrolled access to alcohol with an increasing problem of alcohol related crime and social dysfunction. What should we conclude from this? Why this almost fanatical oppression of smokers but on the other hand the increasing liberalisation of alcohol consumption? Alcohol is a growing health problem but somehow this has been missed.

art vs. science in physiotherapy

There is a conflict within physiotherapy between art and science. On the one hand the professions seeks to promote itself as modern, scientific and international but on the other hand it is heavily dependent on unproven methods introduced by charismatic individuals such as Maitland and Bobath. And charisma rather than science is the way that new ideas tend to be promoted. Usually what happens is that an individual will come to prominence through teaching their methods and then as popoularity for the methods grows someone decides that there needs to be research into why the method works for its enthusiastic pratitioners . In the past research has tended to be very much "after the event" taking place after the particular school of thought has already gained a lot of followers and usually after it is being promoted in post graduate courses.

There is a massive flaw in the profession's way of developing new practice. New ideas tend to spread on on the basis of their apparent effectiveness but initally this is never subjected to rigorous evaluation and the early perception of effectiveness is based on the subjective impression of the theraist using the techniques.There is a natural bias in interpreting outcomes [if this was not the case there would be no need for blinding in reseach trials]. Clinicians will tend to over-estimate outcome effectiveness. This is because something else is going on in the clinical situation, something which up to now has received very little attention in research. Therapists' behavior in the clinical setting is affected by their need to feel self esteem about their performance as a clinician. This means that the decision making process about clinical effectiveness is not an entirely rational process and there is something to be gained at an emotional level if the therapist thinks she is exercising great skill using a particular technique. The "emotional reward" achieved through clinical technique will create bias towards techniques which produce a high level of emotional satisfaction even if that technique might lack objective research to show it works; the combination of emotional satisfaction and perceived effective outcome ensures that the technique is continued. The charismatic promoter of techniques trades at an emotional level of acceptance before the rational processes are fully engaged. This emotional engagement creates a pathway for later acceptance at a rational, conscious level.

Uk physiotherapy crisis

Uk physiotherapy crisis

Is there a crisis in UK physiotherapy? I think so. There's a serious problem with the number of new graduates qualifying when there's nearly no new physiotherapist posts in the whole of the UK. I think there is the serious possibility that the next thing we will see is the closure of university training departments because in the short to medium term there will be no growth in the number of new jobs available. The other thing to look out for is the downward pressure on job gradings. Because of the surplus in potential candidates for jobs and the prevailing crisis in finances there will be a growing tendancy to lower the grade of jobs to make financial savings and take advantage of the surplus in the labor market. There is a fundamental problem with job grading levels because there is no objective measure of the grade a given job should be. Ultimately the grading given is what an employer was willing to pay. Knowledge and Skills Framework reveals how arbitrary the grading system is and how it isopen to wide local interpretations. The final thing we might see is the gradual abolition of the rotational post. And just one question to finish with. If a band 5 physiotherapist is non-rotational, in a post for a number of years, supported with good post graduate training, how will their level of skills and clinical outcomes be different to someone doing the same post for the same time at a higher grade?

start of a new blog

this is the first page of a new blog. i hope that you stick with it. over the weels i hope to discuss all ther major issues affecting physical therapy