Reducing pressures on the NHS: the emerging role of the physiotherapist in healthcare reform

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Emergency Care

Training/ Qualifications

Integration of roles requires training at masters level in addition to being signed off as competent. McMillan (2013) reports the role as a challenging varied environment with a high degree of responsibility and that previous MSK experience will assist with the management of what comes literally through the front door. Conditions can include minor head or rib injuries which if dealt with incorrectly can mean dealing with life or death situations (McMillan, 2013). Richard Parris a consultant in emergency medicine is optimistic about the future of physiotherapists in the emergency department: “the physiotherapists are a real asset…we don’t have any hierarchy or boundaries”, however reports that it is not for the faint hearted (McMillan, 2013).

In Australia, emergency physiotherapists must have a minimum of 5 years clinical practice post-graduation including 3 years spent in a relevant specialist area. Additional training or postgraduate study in a relevant clinical area is also desirable (Crane & Delany, 2011). However, there is currently a lack of a clear direct career pathway to get to this position meaning that practitioners are responsible for developing their own range of specialist skills. MSK postgraduate or masters certificates tend to be more directed at outpatient and private physiotherapy roles instead of for use in the emergency department. In Australia, most emergency physiotherapists are undertaking short courses such as plastering, sports, spinal and vestibular to complement their practice.

It has been realised that educational requirements for this sort of role placed within the broader health system network, however, needs to be standardised across settings in order to establish the wider effect of the service. Educational support including onsite training and supervision can be used as part of the programme in addition to certified courses in the absence of specific qualifications however this still means there is a lack of overall structure of training and defines the need for evidence-based regulatory.

Evidence to support

The UK is the worldwide leader in innovative physiotherapy practice (Crane&Delany, 2013). Services are continuously changing to meet the growing and changing patient demands while increasing workforce flexibility (Crane & Delany, 2013). As a result there is an evolving need to provide practitioners with an ethical and evidence-based framework to support changing practice such as the development of the emergency physiotherapist role. Within Australia, career paths are widening for physiotherapists as they try to establish similar counterparts (Crane&Delany, 2013) due to an increasing demand on emergency departments. Some would argue the emergency physiotherapist role has been better suited to the political need to improve patient waiting times rather than patient outcomes, however, Taylor et al. (2011) found that patients with musculoskeletal problems presenting at A&E were just as, if not more satisfied to see a physiotherapist as the first point of contact. Crane and Delany (2013) suggested that musculoskeletal physiotherapists expand their physiotherapy practice in the emergency department by requesting and interpreting radiology results, blood tests,x-rays managing minor wounds and fractures, applying plaster, managing analgesia and referring on to the most appropriate option in an efficient manner. Although predominantly involved with the management of MSK conditions, Anaf and Sheppard (2007) comment on the emergency Physiotherpists role in effectively managing minor chest fractures, whiplash, recent burns limiting functional movement and torticolosis.

Similar to the UK, in Australia Crane and Delany (2013) found that EPs enabled doctors to treat more critical and complex patients faster and reduced overall waiting time through the emergency department. Taylor et al. (2011) found that when operating as primary contact practitioners, patient length of stay could be reduced by up to 59.5 minutes compared with secondary contact practitioners. In the same non-randomised controlled trial, waiting time and treatment time of those attending A&E was also reduced following treatment by an emergency physiotherapist compared to secondary contact. This was thought to be a result of bypassing the initial doctor’s assessment. In addition to reducing the workload of other staff, this system improved patient flow and had no significant impact on re-presentation rate (Taylor et al. 2011) When satisfaction rates were investigated in this study, 85% of patients attending a physiotherapist in the emergency department were satisfied with the treatment they received as were 82% of patients who first saw a doctor followed by a physiotherapist. However, those receiving the primary physiotherapy contact felt things were explained more effectively and that they were given more time to ask questions and discuss their condition (Taylor et al. 2011).

The systematic review conducted by Kilner (2011) analysed the literature surrounding physiotherapists working as emergency practitioners, specifically its effect on health outcomes. Despite the previous findings, this research review did not fully support the engagement of physiotherapists in the emergency care setting. The ‘access block’ (figure. 1) experienced across emergency departments worldwide requires government, economic and societal input overtime with physiotherapists working in emergency departments only a short-term solution to a long-term problem. However, Jogodka and Lebec, (2008) argue the need for mobility and exercise experts in the emergency departments and that when used appropriately, physiotherapists seen here can facilitate healing and prevent secondary complications. Kilner (2011) analysed that emergency physiotherapy affects outcomes on three main levels: system, provider and client. It was determined that although physiotherapists working in A&E were more likely to give advice to patients and arrange for follow up physiotherapy that doctors or nurses working in the same area, at a system and provider level, there is insufficient existing evidence regarding the effects of physiotherapy in A&E. Richardson et al. (2005) for example conducted a randomised controlled trial which failed to establish the cost-effectiveness of such a service. Kilner (2011) agreed that emergency physiotherapy resulted in increased patient satisfaction, decreased waiting times and improved clinical outcomes in the short term, however were not convinced of the reliability of its long term effects.

Injection Therapy

Cost Effectiveness

With the average cost of an A&E visit costing the NHS approximately £115 this method of service provision reduces direct costs with similar clinical outcomes (CSP, 2011). The CSP evidence-based briefing found that in 2012-2013 of the 18.3million people that attended A&E, around 21% presented with musculoskeletal (MSK) related injuries, an estimated £440 million worth of healthcare costs. It was recorded that 446000 more people attended emergency departments throughout the UK in 2014 compared to 2013 (Reesᵃ, 2015). Winter 2014-2015 therefore saw huge negative media coverage of A&E provision with increased demand and rises in missed targets with higher reported major incidents (Jenner, 2015; Reesᵃ, 2015). Incapacity in emergency departments was quoted as being “the biggest operational challenge facing the NHS” (Reesᵃ, 2015).In light of this, it is being more accepted that in order to lower the pressures and direct costs of these deficiencies, the skill mix of AHPs should be exploited (Jenner, 2015). If used properly, the abilities of physiotherapists could bring huge benefits in the assessment, diagnosis and treatment of MSK and chronic respiratory exacerbations such as Chronic Obstructive Pulmonary Disorder, in addition to providing vast experience and learning opportunities for the physiotherapists themselves (Jenner, 2015).

Training/ Qualifications

Integration of roles requires training at masters level in addition to being signed off as competent. McMillan (2013) reports the role as a challenging varied environment with a high degree of responsibility and that previous MSK experience will assist with the management of what comes literally through the front door. Conditions can include minor head or rib injuries which if dealt with incorrectly can mean dealing with life or death situations (McMillan, 2013). Richard Parris a consultant in emergency medicine is optimistic about the future of physiotherapists in the emergency department: “the physiotherapists are a real asset…we don’t have any hierarchy or boundaries”, however reports that it is not for the faint hearted (McMillan, 2013).

In Australia, emergency physiotherapists must have a minimum of 5 years clinical practice post-graduation including 3 years spent in a relevant specialist area. Additional training or postgraduate study in a relevant clinical area is also desirable (Crane & Delany, 2011). However, there is currently a lack of a clear direct career pathway to get to this position meaning that practitioners are responsible for developing their own range of specialist skills. MSK postgraduate or masters certificates tend to be more directed at outpatient and private physiotherapy roles instead of for use in the emergency department. In Australia, most emergency physiotherapists are undertaking short courses such as plastering, sports, spinal and vestibular to complement their practice.

It has been realised that educational requirements for this sort of role placed within the broader health system network, however, needs to be standardised across settings in order to establish the wider effect of the service. Educational support including onsite training and supervision can be used as part of the programme in addition to certified courses in the absence of specific qualifications however this still means there is a lack of overall structure of training and defines the need for evidence-based regulatory.

References

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