Discussing regulation of advanced and specialist practice in the UK, Australia and New Zealand

Introduction

The Department of Health and Social Care states that professional regulation is required to assures the public that professionals who provide healthcare are qualified, capable and competent. In the UK, physiotherapy practice is regulated by the Health and Care Professions Council (HCPC). The HCPC protects the public in the following ways:

  • By setting standards for professionals’ education, training and practice.
  • By keeping a register of professionals, known as ‘registrants’, who meet HCPC standards.
  • By taking action if professionals on the Register do not meet the standards.

This role definition and these objectives are shared by regulatory bodies in both New Zealand and Australia. In Australia the Physiotherapy Board of Australia and AHPRA work in partnership to deliver the National Registration and Accreditation Scheme. In New Zealand physiotherapy is regulated by the Physiotherapy Board of New Zealand (PBNZ).

Regulators and professional bodies hold different roles for the health professions. Regulation is often confused by the public and professionals as credentialing, qualifications or professional development. To clarify, Kim Gibson, Chair of the Physiotherapy Board of Australia, describes the role of Australian regulatory board as two fold; public safety and public interest. Kim separates the regulators role from the professional body’s role:

“The Australian Physiotherapy Associations (APA’s) role is promotion of the profession. Protection of the public is not their role. There is a natural tension between what they do and what we do. As a regulator we don’t credential, we protect title”

Damon Newrick, Professional Advisor at PBNZ, agrees:

“The protection of the public, that’s our job. It’s not actually for the profession”.

Once we are clear on the role of the regulator we next need to understand how they regulate professions. Kim and Damon reflected on the importance of self-awareness within a profession as a way to manage risk and the level of individual accountability required by clinicians when regulated using a high trust model.

“We just require them (physiotherapists) to understand that they’re going beyond what they would usually do. We’re only interested in them being competent to practice where they’re practicing. We don’t say ‘okay have you changed from working in orthopaedics to working in neuro?’ We don’t care as long as they do the educational piece”

“We run a high trust model. You skill yourself up however you want. You call yourself whatever you want. You do whatever you want within the realm of physio. If something goes wrong, we’ll come knocking”

Regulation of Advanced Practice

AT the time of writing, ‘Advanced Practice’ was not a designated title in Australia, New Zealand or the UK. However there are discussions in the PBNZ and HCPC and there is a move to embrace Advanced Practice as a level of practice.

Where there is a general physio here, and specialist at the other end of the sliding scale, there could be something in between

 

The themes which were highlighted throughout my conversations with clinicians and leaders about Advanced Practice regulation fell in the following categories: Value, Additional skills and Education.

Value

Regulators exist to protect the public and not to further the profession, as discussed above. Contributors from across the three counties debated where the value and drive for further regulation originated.

“The difficulty being, where Advanced Physiotherapy Practice (APP) sits within that realm. Is it a vocational title that is being used because some people want it as a career progression or is it a mechanism or a particular title, with competence, by which we protect the public?”

Damon’s point here queries whether additional titles add any level of protection for the public or whether they are instead addressing a need of the profession.

The financial value of advanced practice was also discussed by contributors. In New Zealand discussions with the regulator about a move towards separate titling started with private MSK clinicians and businesses rather than public health organisations. This may be due in part to a unique system of health funding in New Zealand called Accident Compensation Corporation. ACC funds a certain amount of assessments and treatments for patients involved in accidents through private health providers. This model offers a unique driver towards progression of professional titling and regulation for private health providers. Understanding this model may also explain why the drive for further titling has not come from public healthcare providers in New Zealand.

Kim Gibson explains the importance of financial reward for health care providers to drive change in this arena:

“There is no financial rewards, as employers it means nothing so there’s no industrial reward. The challenge in this country is linking it to workforce and employment

Jon Warren, Physiotherapist and previous Professional Advisor at the Physiotherapy Board of New Zealand (PBNZ) agrees that change needs to be incentivised:

“It needs some people within that space to say it’s worthwhile to drive it. So there’s been no incentive from what they’re going to do which could be different, and what they’re going to get paid”

 

There are different drivers in play in different organisations. Barbara Saipe, Professional Lead at Capital and Coastal District Health Board (DHB) in New Zealand, highlighted the specific difficulties faced by public health providers in moving forward with Advanced Practice agendas.

“As a DHB we’re struggling with recruitment and retention in the kind of experienced place where people are starting to diverge and choose their niches. So in terms of advanced roles and things, that’s sometimes quite hard”

 

Barbara described the process of securing the first and only expert role within their DHB. They have one Haemophilia Expert physiotherapist role, there are three in New Zealand in total. These roles were nationally funded through the national haemophiliac treating committee and the training required for these roles was funded largely from pharmaceutical companies. Without this external financial support these valuable roles would not exist in the public sector and this further demonstrates the perceived value and financial cost of advanced practice roles.

 

“I would love to say that we had done something like that in DHB land nationally, but we haven’t. We’ve just really benefited from the pharmaceutical funding for her (haemophiliac role) to be able to do those things.”

 

The value of further regulation and titling needs to be embraced by employers in the public and private sector, the profession as a whole, individual clinicians and the public. For individual clinicians they have to weigh up the time commitment and cost versus the potential financial and career rewards. Financial and time commitment for the individual is also something the regulators consider because increasing the regulatory burden for individual clinicians may not be positive in the long term.

“Part of our governance process is the consideration of regulatory burden.”

“I would speculate that the public space has not said they’ll pay for it and the individual physios say well it’s not worth it.”

The public also needs to understand the value of additional titling. Physiotherapy is an international brand and there is the possibility of diluting this with titling which may move away from specific professions and towards more generic titling.

“The problem is if you lose the branding, or name of your profession, because now you’re morphing into a generic health practitioner, and that’s not of any benefit to the profession, and it really to a certain extent, doesn’t benefit the public”

Another perspective considers whether value will be understood with time and after implementation. In our conversation about the value of additional titling, Jon Warren explains how the profession cannot expect to see immediate benefits when starting out on any progressive agenda and instead the profession may need to show its value before any incentives are created. This is how the specialist agenda played out in New Zealand. A handful of physiotherapists lobbied for additional titling and regulation with no financial reward initially but this did come with time after the system understood their value.

We can see from these wide ranging discussions that a conversation on titling needs to consider whether further titling provides added value in terms of patient safety first and foremost. Further consideration includes financial incentives for organisations and individuals, public and professional perceptions of any titling considered, regulatory burden to clinicians and the drivers of progression, be that from the healthcare model, patient need or professional identity.

Additional skills

Although Advanced Practice as a level of practice does not define any particular skills assigned to that level there are a number of physiotherapy skills which may be more suited for experienced clinicians such as injection therapy or independent prescribing.

In the UK, physiotherapy has independent non-medical prescriber rights and the HCPC annotates individuals who have passed a validated prescribing course. In Australia and New Zealand this is not the case.

I discussed the process of moving to regulate a new advanced practice skill for the profession with Kim Gibson. She explained that the physiotherapy board would form a view as to whether it was appropriate timing for the profession. The profession would have to conduct and present the research to indicate the need and address any educational or training issues. The profession would indicate a preferred model and the board would decide whether this skill was to be endorsed. If endorsement was reached the board would assess the safety and quality of the proposal and develop registration standards and CPD standards.

This is a reassuring reflection of the pathway to regulation as it mirrors some of the work being done in the UK by HEE and CSP who have been generating interest and discussion regarding the advanced practice agenda which has now been noted by the regulator who recently began a policy project to identify regulatory challenges for registrants advancing their practice.

Kim goes on to explain that the board would work alongside the professional body to facilitate and ensure all stakeholders who needed to be consulted were involved. However, this process is complicated by the breadth of physiotherapy practice and not only would the models be potentially different between different roles and specialties but also the agreed formularies would be different. As Kim explains there are many factors which need to be considered:

“The public safety has to come first and the community benefit has to be established.”

She also raises the important point that the value of an additional skill may not be fully realised without other skills firstly being endorsed and implemented into practice. One view holds that additional skills as part of a separately regulated level of practice are imperative. One contributor suggested that without additional skills all levels of regulated practice can do the same interventions which is confusing for the profession and the public.

Education

Contributors discussed the difficulty in validating programmes which would lead to further regulation of title. They also discussed the difficulty in maintaining and running programmes for specialised areas of practice across a large geographical area.

One contributor gave the example of a radiation therapy course in Western Australia. They mentioned the challenges to get the programme started in the first place and to ensure it was taken up as a post graduate programme in keeping with advanced practice levels of practice. However, due to low numbers and difficulties delivering the course it had to be pulled into the universities undergraduate stream. This example highlights the difficulty for Higher Education Institutes (HEI) in developing and maintaining highly specialist courses for small numbers of experienced clinicians.

“It has become really difficult for programmes because they are now dispersed throughout the country. So to have that pathway and framework and structure and not be able to match it with the education is really challenging”

In the UK Health Education England (HEE) has provided guidance around Advanced Practice as a level of practice through workshops, conference talks and webinars over the last few years. All of which seems to be in agreement with the levels of practice clinicians and leaders in Australia and New Zealand discussed; agreeing that Advanced Practice would fall at a Masters level (level 7). However, there was recognition regarding a certain amount of debate among groups about whether this level of education was too high. In New Zealand the title Specialist is regulated and although most of the small number of Specialists in New Zealand hold a PhD this is not an agreed level of educational attainment. Jon Warren explains how the perception of the physiotherapy community can shape the understanding and implementation of a role and also its potential uptake.

“I think also there’s been an optics, that’s bar one, maybe bar two, they’ve (Specialists) all been PhDs so it’s been thought that, you know, this is the holy grail being a specialist rather than it’s something that’s more achievable”

Barbara Sapie reflects on the preparation and commitment needed by the individual to apply for an advanced practice position even once a role has been prioritised by the organisation. She discusses how it can be difficult as a medium sized public health provider to ensure adequate depth of knowledge throughout the breadth of specialities in which physiotherapy services are offered. Retention and recruitment can be difficult and in some areas there is not an adequate level of mentoring and supervision to support advanced practice widely.

“We might have the opportunity to create a role and we might even get so far as to scoping it up and advertising it but we don’t necessarily have people falling off the tree or ready to go.”

 

This highlights to the important interaction between funding models, educational opportunities and the physiotherapy workforce which all interact around the discussion of Advanced Practice in physiotherapy.

 

Regulation of Specialist

New Zealand has the only physiotherapy regulatory body within the areas I travelled which regulates a separate title of physiotherapist from the general physiotherapist. In New Zealand this is the role of Specialist. In Australia, Specialist is a route which can be achieved through a 2 year, College of Physiotherapy ratified, course but Specialist is not a designated title in Australia. The term Specialist Physiotherapist could be used interchangeably with terms like Consultant Physiotherapist in the UK context.

Specialisation in Australia is an interesting topic because despite APA endorsement and ratification of the Specialisation course the uptake of the programme has been low. There are a number of potential reasons for this including the significant level of experience and clinician commitment required from the course, the cost of the course and lack of remuneration and the drive behind the agenda towards Specialisation.

“There’s no appetite from a ministerial level for specialisation of physio and the board is not pursuing that at this time. It was driven from the profession, there was no demand from the public”

Specialisation in New Zealand is different to both the UK and Australia because it is a designated title which is regulated by PBNZ. Contributors outlined New Zealand’s journey to a ‘Specialist’ regulated title and their ongoing work considering Advanced Practice as an additional regulated title which may fit between the general physiotherapy registrant and Specialist.

In New Zealand the term ‘Specialist’ was described by participants as an advanced level, seeing complex patients, assessing patients, providing tertiary care and second opinions, teaching, mentoring and developing evidence based practice.

The journey New Zealand took to regulating Specialist as an additional designated role highlights important factors in the advanced practice agenda. In 2004, New Zealand had a College of Physiotherapy which looked into the possibility of additional titling. They understood that additional titling would recognise a level of additional qualification, continuing education in a specified area and a certain amount of verified experience. Jon Warren explains:

“What the College and Physiotherapy New Zealand did was say, okay let’s go to the next step and see how we embed this and make the system a little bit better.”

In 2014 the title Specialist gained further momentum and was discussed by PBNZ which is the regulatory body. It was understood that if a specific role would require specific qualifications and a specific criteria this may require further discussions on scope of practice for these roles and therefore further regulation. Physiotherapy New Zealand conducted a scoping exercise and developed a working group to consider what a scope of practice would mean for advanced practice, a recommendation was then given to PBNZ. Jon Warren summarises some of the questions posed:

“Is this (advanced and specialist practice) a thing which could be of value? Does it fulfil the criteria of looking after the health and safety of the public?”

A roadshow was then conducted which was attended by approximately 50 physiotherapists at each locations and was hosted by PNZ. The aim was to discuss this level of practice, the recommendations from the scoping exercise and working group, the change in recertification and the questions arriving from the profession and the public. This roadshow was hosted in 5 centres across New Zealand which were oversubscribed.

Despite this process the title of Specialist has not been widely adopted in New Zealand. This is also true of the Specialist role and educational level in Australia. In the next section I will explore some of the discussions which took place among contributors around this issue.

Barriers to further regulation of physiotherapy designated titles.

When a profession or group of individuals are pushing forwards a progressive agenda it can be easy to ride on the slipstream of this work. Engaging in discussions with interviewees from many levels and perspectives of the physiotherapy profession throughout three different countries has encouraged me to think about the alternatives.

I believe physiotherapists to be a very optimistic group of people, we work with individuals to improve their function and quality of life, our efforts are always engaged in moving the individual forward towards their goal and we apply this to the movements within our profession. However, to think critically we also need to think cautiously about the potential options and learning from others experience is a valuable way to understand possible weaknesses within a specific movement or agenda.

The perspectives outlined here are drawn from the interviews I conducted during my Fellowship. I was particularly interested in understanding the opinion of physiotherapists working in different areas of the profession from clinicians to professional advisors, from public and private healthcare providers.

Contributors posed several reasons why they felt advanced practice titles, roles and educational levels had not been widely attained in New Zealand and Australia. These discussions fell into the following main themes: perception of the role, implementation of the role and burden.

Perception of advanced practice

Participants sensed that public and private health providers perceived advanced practice differently from one another and that general registrant clinicians had a different understanding of advanced practice compared to clinicians in advanced practice roles.

One explanation within the New Zealand context which was explored by contributors for this difference in perception was due to the existing career frameworks which were in use in the public system. Career frameworks in many of the DHBs included advanced and expert role titles and so additional frameworks and differing terminology could not be easily absorbed into their ways of working. Barbara Saipe describes how even within different DHBs terminology was not interchangeable.

“Up in Auckland they’re using advanced and expert as well but they’re using it the other way around. So it’s expert and then it’s advanced. And down here it’s advanced and then expert. Okay, so we’re lacking consistent terminology, nationally, even within DHBs, never mind when you start align with the private sector.” Barbara Saipe

 

“The difficulty with that title already being in the public space and there was a bit of a pushback from the public space wondering how that would work.”

Multi-professional career frameworks were a significant reason for the difficulty in slotting the terminology around the career framework already in use in the DHBs. In Capital and Coastal DHB they had tried to align their physiotherapy career framework with the Clinical Nurse Specialist roles. Also their career framework was not specific to one profession, it encompassed all Allied Health services.

“Our career framework is for Allied Health, not profession specific. So then we had a bit of juggling around because we originally chose specialist because we were trying to align with the clinical nurse specialist. So then we couldn’t use that.”

Equally for some private providers they may not have perceived the added value of additional titling. Also, there was also a sense that individual clinicians may not have fully embraced the change.

“If I’m a business owner and I’m doing really well, and I’m full. What’s the point of me becoming a Specialist?”

 

“You’re not now going to treat, you’re just going to assess and refer back to other physiotherapists that do the treatment. People haven’t been that excited about making that transition.”

Implementation and sustainability

Contributors discussed how advanced practice levels and roles were implemented in their context and reflected on how this may have impacted the potential uptake and sustainability of advanced practice in physiotherapy in these areas.

“I think the barriers, probably were implementation and process driven. Okay, not necessarily due to problem with the concept or the system” Jon Warren

In New Zealand the journey to implementing advanced levels of practice and titling was led jointly by the College of Physiotherapy and Physiotherapy New Zealand however the college is no longer in operation and it was suggested this was because the College was not financially sustainable. The College of Physiotherapy no longer exists (at time of writing) and therefore clinicians who went through the process to become recognised at an advanced level cannot now be recognised as such. Therefore, the extra burden individual clinicians experienced to develop an advanced level of practice no longer held any value.

There will also be different priorities and needs depending on the size and scale of the health provider and its main function. The value of advanced practice roles and titles held by small business owners will likely be in contrast to that of a large scale public service providers. There may be an assumption that larger organisations fair better in promoting more advanced approaches to healthcare and workforce but this may not always be the case.

 

“I think the other challenge with this DHB is we are kind of medium size. So we are big enough to be offering a whole range of tertiary services. But we might only have one or two people in those areas. And so if you’re coming in without this support and you’re trying to grow someone in that role, you don’t necessarily have enough depth to provide the mentoring and support that we need.”

 

Burden of advanced practice

Regulators and clinicians cautioned about the potential burden of further regulated titles.

“I would suggest that credentialing and portfolio will play into the massive regulatory burden. And so what’s the justification for that? For us it’s about risk. We’re a risk based regulator”

There was a recognition that specific qualifications or levels of education may disadvantage certain groups, particularly those working part time due to family commitments and there may therefore be some gender differences.

Barbara reflects on her workforce and the difficulties they might find in committing to an advanced practice career path:

“They are also coming in and out of the workforce if they’re having families or they’re travelling for various reasons. So a lot of this they have to turn and drive themselves”

 

Drivers for developing practice

Drivers to improve practice and implement advanced practice will be different in each country, region or workplace they are considered. In the UK context the First Contact Practitioner agenda has benefited from a number of specific drivers including national support from the Long Term Plan, followed by a sustained growth funding plan, which was all preceded by an acknowledgement that primary care was facing a workforce crisis. This provides a clear driver and sustainable model for these advanced practice role. However, this route to advanced practice may not be reflected in other specialities and roles.

In Australia, I observed fantastic examples of widespread advanced practice services and skills throughout many physiotherapy specialities and hospital departments. Despite this there was recognition among contributors that although the profession advocated for additional titling, the regulator was not making this a priority. There was also a recognition of the dichotomy of advancing practice in advance of evidence, policies and regulation and that in some cases practice must first demonstrate value, sustainability and opportunity.

“You want to be evidence based in what you’re implementing but the politics and the environment don’t necessarily allow you to do things the right way round”.

“My question to you is does it work the other way though? Because would all that (governance and policy) be in place before and my gut feeling is the answer’s no.”

“Seeing things for the collective good of physiotherapy and health, rather than to the individual good on what it might do for me in my career. They’ve had to be the trailblazers, which you know is, always difficult.”

Mapping to the UK Context

In the UK registrants are required to meet standards of conduct, performance and ethics, standards of proficiency and standards of continuing professional development (CPD). The HCPC randomly selects 2.5% of registrants every year who submit a portfolio to be assessed against these standards.

In agreement with this approach Damon Newrick, from PBNZ, explains how regulatory controls represent a high trust model. The think tank MSK Reform suggests a high trust approach is not appropriate for professional regulation. They propose the need for further cheques and balances with a policy recommendation for mandatory annual appraisals which would be linked to the HCPC. Kim Gibson, Chair of the Physiotherapy Board of Australia, warns of the potential for regulatory burden and a consideration of risks to staff wellbeing if further regulation is introduced versus the risks to patient safety if further regulation is not adopted.

A key debate within regulation surrounds how professional regulation is managed. A recent consultation from the UK Department of Health and Social Care has published a document titled “Promoting professionalism, reforming regulation”. This consultations suggestions were welcomed by the HCPC. They included process changes to increase public confidence and advice for employers to assist professionals in maintaining their competence. This mantle has been taken further by the MSK Reform group which addresses the importance of reforming regulation and proposing a policy of protected Continuing Professional Development time for clinicians which would help them maintain competence.

A key difference between the term Specialist in the New Zealand context and the term Advanced Practice in the UK context is about role and level of practice. In New Zealand, Specialist represents a role which Specialists and other physiotherapists are clear represents a tertiary assessment role broadly in MSK practice and broadly in private practice. This role-specific title may be one explanation for the lack of adoption of the title in New Zealand because during my visit there were only 9 Specialists in New Zealand. In contrast, the UK has adopted Advanced Practice as a level of practice, not a role. This may circumnavigate the problems with role-specific titling which New Zealand has perhaps struggled with. Advanced Practice as a level of practice which is not aligned to a specific clinical area, not aligned to any specific clinical skills and not aligned even to a specific profession may encourage wide spread adoption and pursuit of this regulatory title within our healthcare industry.

Recommendations

The value of the physiotherapy brand

Physiotherapist is a profession which can be proud of its history, with 100 years of Royal Charter in the UK. Physiotherapists are identified by the public as a profession who help improve quality of life and mobility. The findings discussed above reinforce the importance of maintaining the professional name in any additional titling.

The publics’ perception of our profession

As physiotherapists take on more wide ranging roles it is important that the public has a greater understanding of physiotherapists scope of practice. For physiotherapists to be acceptable as an alternative to other professionals such as medics or nurses patients need to be aware of the diversity of skills and levels of practice at which physiotherapists work.

Advocating for advanced practice in the multi-professional space

One difficulty within the public health system in Australia and New Zealand was the perception of advanced practice skills and roles from outside of the physiotherapy profession. It was also important to align advanced practice movements between different professions in order to drive further conversations and attention to this development. Allied Health leadership roles are becoming more widespread and so aligned advanced practice agendas will be important to ensure a stronger presence can be felt in important conversations.

Consider individual regulatory burden

Throughout my discussions with regulators, employers and clinicians the burden of further regulations was touted as a potential reason for lack of uptake among the profession and among individuals. If additional educational attainments are to be required careful consideration of additional burden to individuals needs to assessed. The potential impact of the personal time commitment may impact the overall wellbeing of staff and this should be proactively monitored. Equally, if additional attainment is required there should be a national monitoring scheme to ensure diversity within advanced levels of practice. We need to be aware of the potential for advanced levels of practice to be highly focused in certain groups, such as men rather than women and also in certain specialities, such as MSK rather than elderly care. This potential for inequitable access to opportunities should be monitored and addressed nationally and within organisations.

Conclusion

In conclusion, several themes impacting the engagement of the profession, employers and individuals were raised during these interviews. Themes included the divergent perception of physiotherapy and advanced practice roles and the value added by such roles and how this can be demonstrated. Contributors discussed the different opportunities which were taken in different contexts to pursue an advanced practice agenda. They discussed the implementation of roles and skills and how this has impacted on the sustainability of advanced practice in their context. They also discussed education about how this can be difficult to regulate within colleges or Higher Educational Institutes and difficult to maintain in specialist areas. Many of the differences between the contributors experience of advanced practice within their own professional capacity related to the drivers for advanced practice in the areas they worked. In some areas the drivers were funding related, in some areas the drivers were to align with other professions and some areas the drivers were around workforce and responding to service need. Despite the forward momentum provided by these external drivers the final question of additional regulation for designated advanced practice titles asserts patient safety as the foundation for further regulation.

References

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/820566/Promoting_professionalism_reforming_regulation_consultation_reponse.pdf

 

https://www.hcpc-uk.org/standards/

Digital Innovation in Advanced Practice

Featured

Introduction

Data and technology is one of the fastest growing industries in healthcare. In recent years we have seen the focus on digital healthcare increase with the development of NHS Digital and the focus on technology in the Long Term Plan. In physiotherapy we have seen the emergence of the first digital network group within the Chartered Society of Physiotherapy (CSP), the first app library and a new digital physio series hosted on the CSP website. Data is driving more and more healthcare decisions than ever before and in an increasingly automated way. The effective use of data to make clinical commissioning decisions is changing the way funding is allocated and how organisations are incentivised.

While on my Churchill Fellowship I spent time with advanced practice services who had implemented innovative ways of working and many of these innovative practices involved data, technology and digitalisation. In this article I will discuss some of the services and solutions I found interesting and more importantly that clinicians and patients found effective.

Brisbane, Queensland

Telehealth

Telehealth is a mode of delivering health care related services to patients using technology. It can be used to deliver rehabilitation assessment and treatment using video consultation software and can mitigate many of the traditional environmental barriers to patients accessing services (Cottrell et al. 2018).

Simon Whitehart is the Telehealth Coordinator for the Royal Brisbane and Womens Hospital (RBWH) in Brisbane, Queensland. They run a telehealth service for patients referred to the Spinal Physiotherapy Screening Clinic & Multidisciplinary Service (SPSC & MDS). The SPSC & MDS telehealth service mirrors their face to face services with physiotherapy, occupational therapy, psychology, dietetics and pharmacy clinicians working as a multidisciplinary team for both assessment and treatment services.

RBWH implemented this service in 2017 to achieve two main aims. Firstly, to improve access for patients to treatment services and secondly to reduce waiting times for rehabilitation. Around 60% of patients referred to the SPSC reside outside of a metropolitan area. Patients living away from a regional centre behave differently when making healthcare choices to those with more readily available services. They might wait until the problem becomes unbearable before seeking specialist opinion, they might not attend an appointment or they might decline physiotherapy management due to travel distances. One patient who attended while I was visiting had travelled for 9 hours, including a flight and an overnight stay in order to access the clinic. This can be a huge disincentive to accessing care.

Regional and local treatment services had long waiting lists and although large regional centres such as Brisbane were not struggling to staff their treatment departments there were staff shortages at treatment centres outside of the metropolitan areas. Referring more patients’ to the regional centres to avoid long waits locally risks increasing waiting times all round. Telehealth can be cost and time effective and so telehealth services were implemented to help with waiting times in these areas.

Simon reflects:

“if that patient has no access to follow up and they might live in the Queensland interior, 200km to their nearest hospital. Or their local hospital has a two year waiting list for chronic. You think, right, I’m going to have to refer you to telehealth. To improve access we refer to telehealth”.

Alongside the implementation of telehealth for their multi-disciplinary assessment and treatment services RBWH also established a research fellow position which has resulted in a proliferation of evidence around the implementation of telehealth. Through this research they found a lack of clinician acceptance, resistance to change and poor technological self-efficacy were barriers to implementation of technological solutions or services. Before using telehealth clinicians were often concerned about safety and privacy and how they would establish the clinician-patient rapport online.

To address these barriers the RBWH team implemented a telehealth induction programme which included individualised training in the use of the telehealth platform and 3-5 days of offline time allowing clinicians to become familiar with the software and gather patient resources for online use before clinicians went live with patients. Cottrell et al. (2018) found that clinicians’ knowledge and confidence in using the technology and in delivering assessments and treatments via telehealth increased after this induction period.

In RBWH they use a web based telerehab platform called NeoRehab. I observed a patient telehealth session with Steven who is the telehealth treatment physio at RWBH. We are sat in a small office with a computer and a webcam attached to the top of the monitor. After Steven and the patient had logged into the system we could see into the patients’ home and she explained how her neck exercises had been helping her pain. Steven asked the patient to demonstrate her exercises side on to the camera so we could see her neck retraction exercise. Steven could take pictures or videos of the patient doing her exercises and either play them back to her or annotate on the pictures for her to see. This enabled a further means of coaching the exercise using the web-based programme.

Through my discussions with clinicians at RBWH and from the research they have published in this area a number of benefits to utilising telehealth as a mode of service delivery have been identified. For example, initial concerns such as safety and privacy of using telehealth were displaced after induction and once clinicians had been using the software. Clinicians felt clinical outcomes were similar with telehealth and face to face interventions and telehealth physiotherapists felt patients engagement levels were often higher when using telehealth rather than face to face rehab.

This assumption was tested by Cottrell et al. (2016 and 2018) by looking at agreeableness between telehealth and face to face outcomes and decisions in both treatment and assessment. They found that telehealth services improved physical function and pain outcomes. For physical function, telehealth in addition to face to face was more favourable than face to face alone. Telehealth alone was equivalent to face to face for improvements in physical function. Outcomes for pain were comparable between face to face and telehealth modes of delivery.

For services such as SPSC & MDS and orthopaedic assessment services they looked at agreement on a number of measures between face to face and telehealth assessments. They found substantial agreement (83%) for decisions regarding management pathways and diagnosis, moderate agreements (81%) for decisions regarding referral for further investigations and near perfect agreement for onward referral to other Allied Health Professionals. This suggests telehealth is a reasonable consideration for both treatment and assessment services in the future.

Overall there was a high level of satisfaction from clinicians who felt telehealth was cost and time effective and accepted that telerehab would be of clinical benefit to the majority of patients.

Education

Education of advanced practice physiotherapists is another area in which I found innovative practice being developed digitally. In Queensland they have developed a statewide education programme which has been covered in detail elsewhere in this report however here I would like to discuss the educational programmes digital capabilities.

Participants applying for the Extension Programme (the statewide education programme for SPSC & MDS teams) must ensure their work space is enabled with video conferencing equipment and software. The educational coordinator, Patrick Swete-Kelly, has learnt that using a laptop or substandard equipment is not sustainable for a 12 month distance learning course. The quality of the equipment and the users familiarity with it allows participants to engage in clinical debate, presentations to their peers and even observed assessments with patients while their peers give real-time feedback.

I was able to experience this digitally enabled medium several times during my visit through talks and presentations which were routinely broadcast to other hospitals and departments with colleagues logging in from several venues at once to watch the slides, see the presenter, engage with their colleagues and ask questions.

Utilising digital technology to run established education programmes such as the Extension programme and to share more informal presentations and gatherings like those I was involved with enables an equitable educational offering across organisations regardless of distance from the main hub. This approach is also time and cost effective allowing more clinicians to be involved from a more diverse area. Although there may be an initial outlay to ensure each site has the most useful equipment it can be used in many ways and is certainly beneficial for both educators and learners.

Christchurch, New Zealand

While in Christchurch I spent time with a number of services involved in innovative projects including community integration services, Canterbury Clinical Network and the Design Lab. These projects have been discussed in more detail elsewhere in this report but here I would like to highlight some of the digital and technological solutions they have implemented.

Integrated Community Services

The Integrated Community Service is led by Mardi Postill who shared with me her teams’ unique approach to identifying complexity within their community. In the aftermath of the Christchurch earthquake in 2011 Ms Postills’ team were involved with approximately 6000 clients who were in immediate danger. Despite this risk the team knew they couldn’t access all their clients at once. They needed to prioritise but they didn’t know who to go to first.

In response Ms Postills’ team has since created a complexity mapping system. This system allows teams to immediately assess the most in need by area code enabling individualised levels of risk to be assessed and care to be modified specifically for each client. This was achieved by analysing data the team already held due to national standardised data collection requirements combined with data sets which provided additional prioritisation knowledge such as medication, living situation and area code.

They used a nationally standardised frailty index called the interRAI as a key metric of patients’ complexity. The data provided by interRAI incorporates physical, mental, cognitive, clinical and psycho-social elements of frailty and provides a more holistic view of the patients’ complexity. The team overlaid the complexity assessment onto a map of the city. This allowed teams to identify which patients were most at need due to their frailty and which patients were most at need due to their proximity to any potential disaster.

The team now felt more prepared for any further disasters. Ms Postill suggested:

“if we get a notification a tsunami is coming and we know which area it’s going to affect we can quickly pin point who we need to evacuate”

This demonstrates the immediate benefit of the interRAI system in a disaster response scenario but they have also found this to be effective in long term strategic views.

“On a planning level we can see the complexity of the client, we can be strategic about where the population is that needs us.” Mardi Postill.

This unique approach to prioritisation in a disaster response has been maintained as a key metric in the years post disaster and has improved care quality from providers and changed the conversation around funding. Ms Postill considers how using data has allowed them to see the bigger picture:

“It (the data) has been a significant driver in us being able to see the system.” Mardi Postill.

The Integrated Community Team use provider organisations to provide care directly to their clients. Maintaining the use of the interRAI data sets has fuelled competition between providers which has driven up quality standards. Each provider submits basic data such as hours per client. This is compared on a dashboard to improvements in the interRAI assessment. If a provider introduces a new initiative which improves the interRAI for the same provider expense the open nature of interactions between the team and their providers encourages other providers to improve their offering equally. This approach drives an improvement in care quality for the clients.

Using data as their key metric has also changed the way they communicate with their providers about funding. They are able to use the data and the competition it creates between providers to analyse disparity between providers. Ms Postill reflects the ease of bringing providers to account when the team have objective data sets which demonstrate any outliers and help to bring care and costs into agreement.

Data Analysists

Dr Greg Hamilton is Team Lead for Planning and Funding, Transformation and Business Intelligence in Canterbury District Health Board. His team is involved in system-wide planning and funding for community services across commissioning, funding and service providers. They see themselves as future-focused system problem solvers. Their goal, as Dr Hamilton describes it, is “to allow citizens to fulfil their grand plan of keeping them at home as long as possible”.

The team includes an analytics team who are concerned with how data is collected and used from the provider networks. Data analysts work with clinical teams to test hypotheses. Dr Hamilton suggests that the best analyst is in the room with the clinician co-discovering the outcome and building trust between the data teams and the clinicians. This approach also assists with the transformation process because clinicians can find change difficult. Often feeling that change has been imposed rather than discussed and solutions discovered together. However, using this workshop style approach brings clinicians on board from the beginning.

The transformation team also provide clinical teams with a project management resource. Using a project manager directly involved with a clinical team drives projects forward by allowing someone from a portfolio background to step into the team, do some of the ground work and keep the project moving even if clinical needs increase. The project manager can process and manage the data which helps the transformation work go faster and clinical teams feel supported.

Dr Hamilton expresses his ambitions to be a truly data driven system. This is evident when heading into their headquarters where you are greeted by a wall of monitors showing the live admissions and discharges from any of the facilities in Christchurch. This database allows teams to predict bed blocking and plan for suspected increases in admissions. It also allows them to analyse the impact of small scale changes such as an additional role in ED, to large scale changes such as the expansion of their Acute Demand Management Service.

Recommendations

A specific and individualised induction programme is recommended for the implementation of telehealth services. This should include time for clinicians to familiarise themselves with the technology offline prior to use with patients. In recent times we have seen the dramatic shift of face to face consultations to online mediums such as AccuRx and Attend Anywhere in response to the Covid-19 pandemic. My observations and reading suggests that for telehealth to remain sustainable the choice of technology is importance and may be different for different professions or purposes. There is also a need to support ongoing skill development and provide technical support to ensure these changes remain a positive part of our service choices in the future.

Digitalised education programmes allow for more equitable educational opportunities and should be encouraged in all organisations. They can also be more time effective allowing clinicians to finish clinic lists prior to attending rather than having to cut patient lists short to travel to other sites. Investing in the most appropriate equipment is highly recommended as this is a key enabler to the success and sustainability of utilising technology in education.

Combining datasets already collected and using these to prioritise immediate care and strategise for future need has been successful in the Christchurch model and may be effective if applied in other contexts. It is important to develop the clinical question prior to engaging with the data rather than collecting or analysing without a clear purpose. This process should be linked to key strategic priorities in the organisation and the national direction of travel.

A clear ambition towards a data driven system and data driven innovation is admirable and the approach in Christchurch has been to encourage their transformation teams to reach out to the frontline, to provide support for clinicians, to collaborate with them on their projects and to graft alongside. This is not an innovative use of data or technology but an innovative use of resource and skill mix to reach data and technology goals.

Conclusion

Data and technology impacts all areas of healthcare. The innovative projects I have observed spanned the fields of education, integrated services, transformation and analytics, strategic planning and patient consultations. Collaborating with the available data, planning data collection aligned to organisational priorities and scanning the horizon for possible technological solutions are constant and evolving goals for any individual, team or organisation.

References

https://onlinelibrary.wiley.com/doi/abs/10.1002/gps.5171

Hospital avoidance: an integrated community system to reduce acute hospital demand

https://www.researchgate.net/publication/336877712_Hospital_avoidance_an_integrated_community_system_to_reduce_acute_hospital_demand

The impact of the Canterbury earthquakes on dispensing for older person’s mental health

https://www.researchgate.net/publication/334384424_The_impact_of_the_Canterbury_earthquakes_on_dispensing_for_older_person’s_mental_health

Impact of integrated health system changes, accelerated due to an earthquake, on emergency department attendances and acute admissions: A Bayesian change-point analysis

 

https://www.researchgate.net/publication/302984289_Impact_of_integrated_health_system_changes_accelerated_due_to_an_earthquake_on_emergency_department_attendances_and_acute_admissions_A_Bayesian_change-point_analysis

Analysis of educational programmes for Advanced Practice Physiotherapists: Queensland, Victoria and Christchurch examples.

Introduction

I have been aware of the scaling up of the advanced practice agenda in the UK has for a number of years with work of Health Education England (HEE) and the Chartered Society of Physiotherapy (CSP) continuing to provide fantastic leadership in this area.

I was first aware of advanced practice in the clinical setting during my first junior rotational position. I was based at St Woolos Hospital in Newport outpatient physiotherapy department. To the right side was the treatment room with standard plinths surrounded by polo-shirt clad physios chattering away to their patients behind wispy curtains. To the left was the physio gym, but only the bravest polo-shirt wearing physios frequented this area as it was the territory of the shirt and tie wearing MPT3 team. At this embryonic point in my career I knew I wanted to be in that room but had no idea how to get there.

Thankfully, I made my way there with the help of some great mentors to point the way but there was certainty no career framework, structured mentorship or education programme to follow. When planning or developing educational frameworks for advanced practice we should remember this mesmerised new grad looking to the years ahead.

How do we develop a programme of education which is meaningful to the participant and their current and future employers? How do we develop a programme which stretches the limits of education and advanced practice? Participants and educators dedicate incredible time and energy into these programmes and so we have a responsibility to ensure that effort is transferable and widely recognised across organisations and geographies.

In this article I will explore the range of educational programmes I came across during my Fellowship and compare these approaches. I will make several recommendations which could be considered when developing or improving the advanced practice educational programme within our organisations.

Queensland, Australia

Patrick Swete-Kelly is the Educational Coordinator for the state-wide Extension Programme. A comprehensive educational programme for aspiring advanced practice physiotherapists. The programme has high standards with participants requiring nomination by their clinical lead and mentor.

Committing to the programme

There is a single intake per year and competition is high, as is the participant commitment. Participants and their managers commit 0.1 FTE to the programme every week for 12 months and the participants themselves are advised to limit their annual leave during this period and to be prepared for 3-6 hours study outside of work and the programme hours per week. Participants do not typically hold an advanced practice position when they embark on the programme but their managers are required to give them increasing experience of the role and service during their programme. They are also not guaranteed an advanced practice position when graduating from the programme but in a follow-up of programme graduates all clinicians who sought a position in the 12months after their programme were successful.

State-wide roll out

The programme is designed specifically to address potential future workforce problems in the Neurosurgical and Orthopaedic Physiotherapy Screening Clinics (N/OPSC) throughout Queensland. During the state-wide roll out of the N/OPSC the team conducted a workforce analysis which demonstrated that many facilities did not have sufficient capacity to provide backfill for planned or emergent situations or to meet future expansion plans. This was the motivation for developing the Extension Programme which is a centrally co-ordinated and delivered program, supplemented with local support and supervision. The programme also tackles another difficulty many employers face; the retention of skilled staff and sustainability of the recruitment pool.

Using Technology to Bridge the Distance

The Extension Programme is unique and innovative in a number of ways. It is a state-wide educational programme from Cairns in the North to Brisbane in the South. Queensland is seven times the scale of the UK so this endeavour is truly impressive and requires some ingenious developments including extensive use of video-conferencing and telehealth.

Participants sit alone or with their local colleagues in a room with a fully equipped video-conferencing suite which is a requirement of sites wishing to admit clinicians onto the course. They receive the majority of their educational instruction and engage in clinical debate through video conferencing. Participants are also required to attend 3 face to face education sessions, 2 days each and attend a one day annual forum during the 12 month programme.

Observed assessments are an important part of the programme but the distance between sites is clearly a barrier to this. This is overcome by using video-conferencing integrated into clinical observations. Participants and the educational coordinator draw around their screens as the participant being observed carries out their patient assessment. Patients are aware of the benefit which their participation has for the development of the workforce and it offers the opportunity for observing colleagues to pause the assessment at any time to ask questions of the clinician and to reflect in action.

The design and contents

The curriculum for the programme aligns with the Physiotherapy Career Pathway Competence Framework from the Australian Physiotherapy Association (APA) and International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) standards. The programme delivery is based on adult learning principle of doing rather than watching, immediate relevance, active involvement, clear goals and objectives, constructive feedback, opportunities for reflection. The programme can be flexed to suit the needs of the participant using tools such as a Learning Needs Analysis.

The programme provides consistency across a large area, reduces duplication of time and effort by clinicians and their teams and promotes equity of educational provision for all MSK clinicians across the state. The programmes structured requirements of both the learner and their team ensures a robust approach to governance, mentorship and continued professional development. The small group size and length of the programme encourages peer support and means the programme can be adapted to meet the needs of the learner and the group.

Victoria, Australia

In 2015 a team led by Paula Harding were funded by the Department of Health and Human Services and Health Workforce Australia to develop the Advanced Musculoskeletal Physiotherapy (AMP) Clinical Education Framework (CEF). The team approached this task in a methodological way and published their results in the Australian Health Review Journal.

A step-based approach

They used a step-based approach by conducting literature searches and focus groups. In the focus groups they discussed the key attributes needed as an AMP and the education and training required for AMP roles. The analysis of the scoping review and the focus group led to the teams’ decision to develop a competency based training and assessment approach in a workplace setting.

The Clinical Education Framework assumes that clinicians meet the pre-requisite of the Australian Standards for Physiotherapy and builds additional knowledge, skills and behaviours for AMPs on top of this. The key components of the CEF include competency standards, a learning needs analysis, learning and assessment plan, self-directed learning modules and a competency assessment. The competency standards were developed by an experienced team of subject matter experts.

Implementation and evaluation

Once the CEF was developed it was implemented in a small number of test sites and its use and feedback closely monitored and a formal evaluation carried out. Once the CEF had been developed a follow-up focus group with AMPs was conducted for further feedback and verification. The CEF was then adopted across Victoria as a formal assessment component and is used to credential AMPs. It allows prior learning and clinical expertise to be recognised and supports the transferability of staff between organisations.

The CEF consists of a manual which is applicable to a number of AMP roles and services including Rheumatology Screening Clinic, Neuro-Surgery Clinic and Post-op Clinic, Paediatric Orthopaedic Screening Clinic, Joint Arthroplasty Review Clinic, ED Soft Tissue Review Clinic, Primary Contact ED Service, Pain Services and the Osteoarthritis Hip and Knee Service. The attributes identifies from the focus group are summarised into operational, interpersonal skills, attitude and communication, experience and clinical expertise. The pathway was also split into a continuum from pre-entry, supervision, independent to clinical lead. This model provides a simple over-arching structure to the CEF.

Evaluation of the CEF found that clinicians struggled to fully understand the structure initially. During our conversations Paula Harding reflected that some clinicians struggled to identify their specific learning needs and instead could be overwhelmed by the sheer volume of material and options hence the importance of a strong mentorship and supervision element to the programme.

Christchurch, New Zealand

In Christchurch I met with Vince Barry, CEO of Pegasus Health. Pegasus is a charitable organisation which supports general practice and community based health providers in Canterbury. They run an Educational Rounds series to support educational development for their general practice staff. This is not specifically for advanced practice physiotherapists but as it is a different model which may have application to advanced practice and specifically FCP services in the UK I felt it important to share here.

The Educational Rounds have been such a success they have expanded out of Canterbury and there are now groups in different areas of New Zealand using this methodology. An Educational Round consists of a group of clinicians from different GP practices. They are split into teams and the teams are mixed with clinicians from different practices, different interests and different levels of experience. Clinicians stick with the same team throughout the different rounds. The group decides on a number of “Wicked Issues” which they come across in their practice which they would like to focus on. Wicked Issues have included topics such as, supporting people from and managing illness in the transgender community, talking to men about mental health and coaching for lifestyle choices. These topics are not the most common problems clinicians will come across in their practice but they require deeper discussions and the creation of a safe space within a diverse group of clinicians has been a very productive way to move conversations around these wicked issues forward.

The specifics of how the educational rounds function is also unique. They take place before or after clinic, sometimes 730am sometimes 730pm. All attendees are paid are small amount for their attendance, this amount has not changed in the years that the rounds have been running but Mr Barry feels this has helped attendance even as a token gesture. There is an educations team which supports the organisation and administration for the rounds. This team also provides the research and reading material which is sent in a pack prior to the event. This pack contains brief summaries and longer reading extracts or articles. The pack also proposes questions which should be worked through during the round. A facilitator supports the discussion and debate at the event. Events can be an hour to a few hours depending on the aim of the session and the topic.

Educational rounds and how they address wicked issues using debate, discussion and adult learning principles is unique and an approach which could be of benefit to many aspects of advanced practice education.

Specialisation

In New Zealand and Australia a separate specialisation level has been implemented. I have not approached this topic in line with my discussion about advanced practice education because in the New Zealand and Australian context “specialisation” and advanced practice are not comparable.

In Australia, Specialist is a protected title and the title is accompanied by a 2 year course taught by the Physiotherapy College. I spoke to a number of physiotherapists who had been through the costly course and did not feel it offered them anything over and above their previous title in terms of the roles they could pursue and opportunities available to them. I am sure there are many physiotherapists who hold an opposing view and certainly the breadth and depth of teaching on the specialisation course is excellent but the views that were expressed to me offers the opportunity to debate value and meaningfulness when considering educational developments.

In New Zealand, Specialist is a regulated level of practice which is assessed through a competency based portfolio and a panel interview. This is a very specific title and there are only 9 specialists in New Zealand (at time of writing), all practicing within a derivative of private MSK practice. I spoke to a number of specialists who defined the role as a referral only service in the majority with increased elements of assessment compared to rehabilitation and an increased emphasis on complex patients. Complexity was represented by chronicity of the MSK condition and failed treatments. I would offer that complexity in advanced practice roles in the UK, such as orthopaedic triage and first contact practitioner (FCP) roles, are also defined by high co-morbidity, mental health concerns, social difficulties and first contact assessments. This difference in complexity and the roles of advanced practice or specialist practice may be due to the differences between the structure of our health systems and how patients access care.  Of interest several public health leaders (District Health Boards) offered lack of value and meaningfulness to the specialist title within public health provision as a reason why specialists in New Zealand are largely in private organisations. New Zealand is now looking at regulating Advanced Practice as a separate regulated title as, as well as Specialist, this was being discussed by the Physiotherapist Board of New Zealand when I visited and it will be interesting to see how this conversation evolves.

From a UK perspective the developments in credentialing and regulating different levels of advanced practice in physiotherapy in other countries should lead us to question the benefits of pursuing this line of development. Particularly in terms of meaning and understanding for patients and in terms of value and cost for organisations and clinicians.

Mapping

In the UK we can consistently look to the leadership and support of HEE for guidance around educational requirements for advanced practitioners. HEE has provided us with the MSK core capabilities framework for FCPs and the Multi-professional professional framework for advanced clinical practice in England. These documents provide a framework for local educational developments to align around.

The Queensland Extension Programme provides a centralised coordinated educational programme. They were able to navigate the great distances between staff and services using teleconferencing. This is a fantastic way to coordinate educational programmes and their innovative solutions to peer learning and observational assessments provide an opportunity for UK based programmes.

In the UK there is innovative work being tried and tested around online education. For example, Project ECHO is an online community of practice offering tailored education and case-based learning for participating teams. Another example is TherapyLive, this is a virtual online summit offered by the Physio Matters team streaming debate and conversation around MSK practice free for all registrants. I have also had the great opportunity to complete my Masters in Pain Management with Cardiff University which was offered as an online MSc programme with all cohort discussion and debate through discussion boards and an app and all lectures uploaded onto a portal. These examples show that although virtual education is not the standard offering there are many examples of this work being embraced across the profession.

In both Queensland and Victoria education for advanced practice physiotherapists is focused on the skills and knowledge required by physiotherapists in advanced practice roles and even more specifically in musculoskeletal advanced practice roles. In the UK we do have the MSK Core Competencies for FCP Framework which is specifically designed for FCPs. However, all other work which I have come across seems purposefully generalisable to other advanced practice professions. Perhaps this approach is ahead of the curve in broadening skillsets across professions however it seems pertinent to highlight this as a specific difference between the countries in educational programmes and opportunities for advanced practice physiotherapists.

Recommendations

Frameworks and guidelines

In Queensland they conducted a workforce analysis and found that they would soon be struggling with their workforce numbers. This was the motivation for the development of their Extension Programme. Thanks to the CSPs workforce calculator we are well aware of the possible workforce requirements for FCP if every Primary Care Network (PCN) opts to use the Additional Roles Reimbursement Scheme to implement FCP services and yet we have not used this information to map to the current staffing available for these positions and those ready and waiting to fill them in the years to come. We have the MSK Core Competencies for FCP document but we have not followed this calculator and competency framework to its natural end point in establishing a national curriculum or educational guideline to support the implementation of FCP roles. This is an activity which could be led nationally, regionally or even locally through NHS Trusts, CCGs or groups of PCNs.

Career Pathways

The Victoria model provides a clear pathway from pre-entry to clinical lead advanced practitioner and the Queensland programme supports clinicians prior to achieving a position in their advanced practice teams. I have am not aware of a currently published document for advanced practice physiotherapy which provides this clarity of progression, although I am aware of work being conducted by the advanced practice and consultant practice groups in this area and look forward to their work.

Educational Coordinators

Coordination of educational opportunities outside of Higher Educational Institutes (HEI) is difficult for many reasons including large geographical areas, multiple service providers within the NHS and across the public and private sector and staff retention. However, in Queensland they have overcome some of these barriers and one factor in their success may be the allocation of a specific Education Coordinator role which is funded by the organisation for 0.4FTE in recognition of the benefits to staff experience and retention. This is an approach which I have not come across used in UK advanced practice teams. We are used to a senior member of the team being responsible for collaborative efforts towards continued professional development for the team but what about the CPD of advanced practitioners across a locality or region? Could this be a role supported by commissioners to develop advanced practice services across their jurisdiction or by training hubs to develop and retain staff within a group of PCNs?

Credentialing

The CEF in Victoria is used a credentialing framework. Once a clinician completes their CEF they are credentialed as an Advanced Musculoskeletal Practitioner and these credentials and this title is transferable across organisations which use the AMP CEF. At present we do not have a credentialing process nationally or regionally in the UK. This means that if an organisation works with its partners and clinicians to develop a Clinical Educational Framework or Programme it is not transferable to other roles or organisations. This makes it less desirable for staff as they may find themselves having to complete several service specific educational processes.

This is a barrier which could be replicated in the UK if we are not fully aware of the potential consequences. In England we are fortunate to have a centralised organisation for educational governance in health, HEE. The path towards advanced practice recognition which HEE seem to be exploring is closely linked with universities. This is not a path which was taken by AMP services and organisations which I studied during my Fellowship. Instead they adopted a centrally co-ordinated and delivered programme in Queensland and a competency based training and assessment approach in Victoria. The lack of similar programmes of HEI supported advanced practice programmes in my Fellowship studies leaves me wondering whether there could be an difficulty with transferability and grandfathering in this method.

Conclusion

Education of advanced practice clinicians could be a burden for many organisations but with some detailed thinking around structures and processes, with some supporting guidelines and frameworks and with robust evaluation advanced practice education is also a fantastic opportunity.

I hope my analysis of some of the educational programmes and approaches observed in other health systems can support some of the thinking and planning around advanced practice development, the increasing need for FCP workforce and the ongoing improvement of our clinical and strategic offering to the wider health system.

I have combined the educational curriculums from the service areas I visited. This combined curriculum offers principles, methods of delivery and assessment and curriculum content for advanced practices education. I would be happy to share this combined curriculum so please email me or reach out on social media if you would like access to this combined curriculum document.

References

https://www.qld.gov.au/about/about-queensland/statistics-facts/facts

https://www.hee.nhs.uk/our-work/advanced-clinical-practice/multi-professional-framework

Advanced musculoskeletal physiotherapy clinical education framework supporting an emerging new workforce, Harding et al. 2015

Advanced musculoskeletal physiotherapy clinical education framework supporting an emerging new workforce. Harding et al. 2015

Physiotherapists’ perceptions of workplace competency: A mixed-methods observational study.

A governance structure to aspire UK Advanced Practice and First Contact Practitioner Services: learning from each other

Clinical governance is a mysterious concept to many. My practical understanding, after spending a decade in the NHS, was mixed. The importance of clinical governance is fully embedded in the clinical psyche but its tangible elements are more difficult to grasp.

A number of years ago I took on a role to develop a physiotherapy exercise service integrated with local council services. However, when my assessment of the governance structure revealed significant holes it took a lot of unpicking to address them. This experience showed me how clinical governance is a true swiss cheese problem. Each element on its own may not lead to a significant misstep but if all the holes line up then every level of the organisation feels it from the patient and the clinician to the organisation and their partners.

More recently I have been involved in leading the implementation of the First Contact Practitioner/Physiotherapy (FCP) service and structure in Gloucestershire. FCP roles offer a glimpse into the potential of integrated services across primary, secondary and community care but equally they offer the possibility of a perfect storm from a clinical governance perspective. Each GP surgery, Primary Care Network, Clinical Commissioning Group, NHS Trust and clinician will have different priorities and experiences which could lead to a variety of implementation models across the country. Keeping patient safety and clinical effectiveness at the forefront of any implementation is therefore imperative.

I have scoured NHSE, NHSI, HEE and CSP documentation to find the holy grail of clinical governance. A standardised, universal, regulated support document providing guidance on implementing clinical governance structures for Advanced Practice, MSK or FCP services. I haven’t found it.

In the absence of this golden chalice I read the available literature and documents from the UK and travelled to parts of Australia and New Zealand through my Churchill Fellowship to discuss what clinical governance arrangements advanced practice services had implemented there. I have detailed my Fellowship findings and amalgamated the guidance available from the UK, Australia (specifically Victoria) and New Zealand.

This essay concludes by drawing together the available supporting information and making some recommendations specifically relevant to FCP and/or advanced practice MSK services taken from my reading of the literature, available documents and observations during my Churchill Fellowship.

 

Victoria, Australia

The landmass of the state of Victoria in Australia is approximately equivalent to the land mass of the UK and the population is slightly less than the South West Region of England (4.7 million Victoria versus 6 million SW England). I was fortunate to spend time with the Australian Physiotherapy Associations (APA) Advanced Musculoskeletal Practitioner (AMP) Network. The networks members have been prolific in publishing details of education, patient outcomes, state-wide implementation and competency frameworks for advanced practice services.

Internationally, first contact physiotherapy is accessed in different ways depending on the structure of the health service. In Australia, GP visits are chargeable and this means many patients access immediate care through their Emergency Departments (ED), rather than through primary care. This has seen the growth of FCP in ED rather than GP surgeries. In a benchmarking of AMP roles in Victoria ED roles were the second most popular AMP service and had the largest proportion of senior (level 3a) roles.

 

Clinical risk management.

Governance arrangements in AMP roles in ED in Victoria included close relationships with medical teams. Imaging varied between independent or through predefined pathways for ordering xrays, ultrasound, CT scans, MRI and pathology. To support education for imaging some sites utilised online radiology education tools, one site required a formal assessment of radiology training and another required an external radiology course to be undertaken. During orientation into a new FCP ED role one site required initial image requests to be checked by the ED consultant. In one site an annual audit of 500 x-ray requests was required to be deemed independent. Although methods varied each site had a governance structure to provide quality assurance for image requesting.

Other advanced practice skills in FCP roles in ED included wound assessment and management, providing a single dose of analgesia (paracetamol or ibuprofen) and reduction of fractures and dislocations independently or under direct supervision from an ED consultant.

Induction plans for new starters in AMP roles also varied across sites. All sites had a local orientation process and some had an orientation checklist, introduction to competencies and review of clinical guidelines as part of their induction period. Induction included a selection of supervised shifts for 8-12 weeks. Supervision hours varied between 8 to 40 hours minimum across different site and was dependent on FCP experience level. Supervision took place either during or after patient contact with observations and/or discussion of the session and/or documentation. One site offered monthly personal development discussions and one site offered group supervision with medical colleagues. In the roll out of further ED sites lead sites were allocated an implementation site to mentor and support providing a buddy system.

 

Education and training

Education and training options also varied but were formalised in some sense across most sites. Formal competency documents were utilised in all but one ED FCP service in Victoria, 64% required clinicians to have completed or be working towards a Masters of MSK Physiotherapy and some sites required seven years of clinical experience to apply. Competency documents in some sites were consistent between FCPs and Medical Registrars. Levels of competency allowed practitioners being inducted or supervised to independently assess and manage patients who fitted an inclusion criteria for uncomplicated MSK conditions, cases not fitting this criteria were discussed with the medical team. This allowed the gradual exposure of new clinicians to more complex presentations.

Assessment of competence was different between sites but most included a formal assessment. Case based presentations were widely used and varied in frequency (from one or two annually, to 8 initially or on rotation) and structure.  Presentations topics covered upper limb, lower limb, spinal, radiology, pathology and pharmacology. Clinical logs were required by the majority of sites and included procedures, radiology requests and fracture reductions.

Credentialing was offered to FCPs through the Allied Health Credentialing and Scope of Practice Committee. Recredentialing was required in some sites, either annually or every 2-3 years through audit, radiology quiz, portfolios or work based observations.

The documents, guidelines and frameworks available to support the implementation of a robust clinical governance programme in Victoria were numerous and comprehensive. There were some similarities with our practice in the UK but also some suggestions that could be made which I will draw attention to in the recommendations section.

 

Wellington, New Zealand

The population of New Zealand is less than 5 million at the time of writing, this compares to a population of over 9 million in London and 6 million in the SW England. The West Coast District Health Board of South Island New Zealand covers a patient population of 32,400 this compares to around 50,000 patients in the St Pauls PCN, a cluster of 5 GP practices in Cheltenham where I work as an FCP. I document these stats to demonstrate the possibility of comparisons between the New Zealand governance structures as a whole compared to a region of England or even single PCN.

In New Zealand, like Australia, GP visits are chargeable and so FCP services have developed in ED departments in a similar way. However, a particular nuance of the New Zealand’s health system, the Accident Compensation Corporation (ACC), has created a unique model in which FCP and advanced practice has developed in a different way.

After spending time with advanced practice services and specialist clinicians in New Zealand there are significant differences in the context and application of first contact and advanced practice in New Zealand compared to the UK and Australia due to the health system and regulation of roles. Therefore, in this conversation I will separate the definition of advanced practice and first contact physiotherapy from the conversation of clinical governance. Instead, I would like to use this space to study the governance support and guidance offered by the New Zealand Board of Physiotherapy (NZBP) for all physiotherapy practitioners and consider the application to FCP services in the UK.

Planning

The NZBP provide not only a framework for clinical governance but also a guide to developing a clinical governance framework specific to the organisation. In this guide they recommend identifying key stakeholders and communities who may be able to contribute, identifying existing structures and processes and understanding the organisations vision and values.

The guidance also suggests questioning the framework that is developed and offers a set of questions to reflect on. The approach of the NZBP guidance is one of curiosity and exploration. It encourages seeking out established procedures, sharing and reviewing in order to develop safe and effective processes.

I was once asked, in what I perceived as an aggressive manner, whether my service and practice was safe. I felt affronted which may partly be due to the culture and environment in which this question was posed. However, a culture of open exploration and safe collaborative review, as is proposed by the NZPB guidance, encourages this level of questioning as a way of supporting the adherence of practice to clinical guidance principles. This is something the NZBP guidance does well, it understands the effort required in developing positive culture.

The guidance talks about intent, meaning, value and alignment with expectations and principles. The guidance also draws out the importance of linking processes, providing connections and making joining up clinical governance activities in order to identify gaps to create a coherent, coordinated framework which complements existing processes. This approach seeks to embed vision, mission and value into the implementation process and offers a foundation of collaborative connections.

 

Principles

“Whānau are those to whom the person relates in terms of shared experiences, values and beliefs. The people and relationships that comprise a person’s whanau may be lifelong, or time-limited and specific to the person’s life circumstances. ”

An aspect of clinical governance modelling detailed in PTNZs guidance which is unique to New Zealand is Whanua. Whanua is a Maori word (see above) roughly meaning family, community and environment. The guidance impresses the need for an organisation-wide commitment to person and whanua engagement and participation in the development and implementation of clinical governance frameworks.

The NZBPs clinical governance guideline and domains have a principled tone, particularly in comparison to the Australian and UK documents. From their “Person, whanua and staff safety” domain they highlight the need for a “no-blame” approach in an environment of continuous learning focus. In their “Clinical effectiveness” and “Engaged and effective workforce” domain they set out processes needed for sharing learning and improvements and suggest staff partner in clinical governance initiatives to increase their awareness and participation.

They also discuss the importance of engaging with “person and whanau” in culturally appropriate ways by actively seeking opportunities to understand the views, needs and perspectives of others and use these insights to inform service delivery and evaluation. NZBP stresses the importance of developing meaningful relationships with patients, their whanau and staff in order to gather meaningful engagement at every level of governance. The language used is one of inviting discussion and understanding citizens’ experience of care and collaborating with citizens.

 

Mapping across the globe

Mapping these requirements onto the UK perspective we can look to Health Education England (HEE) and the Chartered Society of Physiotherapy (CSP) for some of these governance pieces. The CSP provides an implementation checklist, staff induction checklist, documentation audit template and Standard Operating Procedure xray investigation template. HEE provides an implementation guide, core competency document, multi-professional framework and an advanced clinical practice toolkit with e-learning modules on the e-lfh website. HEE’s MSK competency document is in agreement with the majority of Victoria’s FCP ED sites in requiring a level of Masters study and the British Medical Association (BMA) GP contract (Jan 2019) and guide for implementation co-authored by CSP, BMA and Royal College of GPs recommends FCP posts be graded at UK Band 7 or 8 which is equivalent to a Australian level 3a or 4.

 

Recommendations

There are several suggestions which could be implemented taking the best bits from this exploration of clinical governance arrangements in Victoria, New Zealand and UK Advanced Practice FCP services. I will outline some areas for development and learning here.

Visions and Values

Let’s begin at the start: taking a leaf from the NZPBs book and giving some headspace to understanding the vision and values of the organisation. Also being aware of your own values and those you would like to see reflected in the team and the service you work in. It also helps to understand the goals of the commissioner. If the commissioner is a PCN their goals for an FCP service may be different than if the commissioner is the secondary care organisation. By having clear values, differing goals can still be achieved in a way which aligns with the principles of good governance and best practice.

Citizen engagement: cultural competence

The principles and values shared in NZBPs guidelines demonstrate the importance of citizen (person, whanua and tangata whanua) engagement in their process. They also stress the need for meaningful engagement and collaboration. The AHP in Action document, produced by NHSE, discusses the involvement of AHPs in the health and wellbeing of the population, community, families and carers and the importance of using citizen outcomes to develop individual care. One way to build on this approach would be an acknowledgement of the cultural diversity of our citizens as demonstrated in the NZ documentation.

The NZPB also address the importance of wide citizen engagement and recognition more directly. In their professional development clinical governance table NZPB list cultural competence, diversity and inclusion, unconscious bias and mental health as mandatory training. Another suggestion made by NZPB is cultural supervision, also known as reverse mentoring.

Our guidance and frameworks should recognise the range of approaches which may be required to meaningfully engage with a more diverse range of citizens. We could follow this example by including these areas as part of mandatory training for all staff. This is something the NZ approach tries to address by discussing it openly in their frameworks and may allow a more open and realistic expression of our communities.

Credentialing

Credentialing is widely used in advanced practice in Australia. In NZ specialist physiotherapists are separately regulated and they are debating whether to create another regulatory level for advanced practitioners. A credentialing programme is not available in the UK at this time for advanced practitioners or FCPs however there is the possibility of an Advanced Clinical Practice Academy or Centre for Advanced Practice which could oversee this process in the future. Keep an eye out for the work led by Richard Collier for developments in this area.

Competencies, Supervision, Mentorship

I have not found any recommendation or evidence of FCP competencies or development plans being consistent between FCPs and GP Registrars and this could be worth some consideration. There is also a current lack of guidance for levels of supervision, mentorship and competency assessment methods within the UK literature although I understand there is a project with HEE underway to address this (look out for work led by Amanda Hensman-Crook here).

Risk register

One document I found very helpful was a risk register shared by Paula Harding, Clinical Lead for AMP Services in The Alfred Hospital, Melbourne. A risk register attempts to foresee all the possible negative outcomes and risks an approach, service or role could have and allows these to be planned for in advanced. It is a great tool for developing clinical governance structures and assists in the development of escalation plans which can be put in place in response.

Conclusion

In conclusion, the development and implementation of a regional (if not national) framework for clinical governance of FCP services in primary care would be hugely beneficial. A very worthwhile read is the recently published HEE document offering a retrospective review of FCP MSK model which has a similar recommendations. This document emphasises the importance of clear governance discussions to ensure standardisation and quality assurance in an environment when the MSK workforce in primary care may comprise of different implementation models and employment structures.

From this exploration of governance documentation and framework I have complied a Combined Clinical Governance checklist which I would be happy to share, please message me directly for access.

References

https://www.onlymelbourne.com.au/size-and-population-comparison

http://docs2.health.vic.gov.au/docs/doc/9713E9D3E616DE94CA257902000DD34C/$FILE/clin_gov_pol_framework-guide.pdf

https://www.england.nhs.uk/integratedcare/stps/view-stps/

https://www.csp.org.uk/system/files/001404_fcp_guidance_england_2018.pdf

https://www.hee.nhs.uk/sites/default/files/documents/FCP%20How%20to%20Guide%20v21%20040919%20-%202.pdf

https://www.appn.org.uk/cms/wp-content/uploads/2015/08/ALP-in-physiotherapy-final.pdf

http://arma.uk.net/wp-content/uploads/2020/04/MSK-march-2020-v2.pdf?utm_content=buffer043a7&utm_medium=social&utm_source=twitter.com&utm_campaign=buffer

https://www.appn.org.uk/research/publications

https://www.appn.org.uk/cms/wp-content/uploads/2020/04/CSP-briefing-statement-on-advanced-level-practice-Final-1.pdf

https://www.csp.org.uk/professional-clinical/improvement-innovation/first-contact-physiotherapy-2/implementation-tools

https://www.england.nhs.uk/wp-content/uploads/2019/01/gp-contract-2019.pdf

https://www.nhsemployers.org/news/2019/04/consultation-on-the-academy-for-advancing-practice

https://www.england.nhs.uk/wp-content/uploads/2017/01/ahp-action-transform-hlth.pdf

 

Crises, disasters and recovery: learning from New Zealand’s approach

I cannot count the number of times I have heard a newsreader use the word unprecedented and the use of this word is accurate, we have not been in times like these before. There are daily comparisons to war times and blitz mentality in the media but I would like to make the suggestion that health systems around the world do deal with large scale crises on a fairly regular basis.

In 2014 I worked in Surrey Memorial Hospital near Vancouver BC. The hospital had just opened a brand new Inpatient Tower with 7 floors of the best infrastructure, technology and architecture for acute patient needs. Staff were called into an urgent meeting in “The Tower” and told that our hospital had been designated the Ebola centre. We quickly got used to seeing people wearing beekeeper style hats in corridors as they were Fit Tested and we carried our perfect fit 3M mask with us at all times.

I reflect on this just to share that we have been through similar experiences in the past and we came through. Perhaps not me or you personally, perhaps not your NHS Trust or our country but systems and healthcare organisations have successfully dealt with crises before and there are things we can learn from these experiences.

Churchill Fellowship

At the start of this year I embarked on my Churchill Fellowship researching international Advanced Practice in Physiotherapy. My investigations took me to Christchurch, New Zealand and I would like to share the experiences and reflections of clinicians and leaders who lived and worked through the most traumatic years of Christchurch’s recent past. The city of Christchurch has had its fair share of crises in the last decade, namely the Christchurch earthquakes in 2011 and the Christchurch terrorist attack in 2018. I hope my interviewees stories can open a discussion about what we can learn from others experiences of how health systems cope with disaster.

Similarities with Covid-19

On a superficial level I can understand the opinion that a natural disaster is not the same crisis as a pandemic. However, the similarities in the cultures and systems of commonwealth countries allow a certain degree of comparison between different crises. A comparison made between countries previously impacted by epidemics, such as SARs or MERS, and the UK may not be as insightful due to potential differences in culture and systems.

 

System Burdens

  • Surge capacity (huge casualty numbers)
  • Fatality management
  • Transfer of non-disaster related patients
  • Health and safety of staff
  • Supplies
  • Maintaining other services
  • Long term impact

 

Citizen Burdens

  • Long lasting health implications
  • Inequality
  • Fear

 

 

Long term Impacts: mental health and rehabilitation needs

 

The high number of casualties, known as surge capacity, is similar in all forms of natural disaster and pandemic. The benchmark for surge capacity in a disaster is 300% of average patient load. During the Christchurch earthquake, which struck at 12:51pm on a weekday on February 22nd 2011, 182 people died and 6659 were injured in the first 24 hours, 185 people died in total. Repercussions of this disaster were still being felt 4 years later when the local health system recognised a 67% increase in new child and young mental health assessments.

 

As I am writing this over 27,500 people have lost their lives in the UK due to the Covid-19 pandemic. If a death toll of 185 can have a mental health sequelae over 4 years for young people we should expect the impacts of this pandemic on our health system, health staff, patients, citizens and society to be long and deep. We need to prepare for the long haul.

 

Emergency plans tends to lack foresight of long term impacts, especially psychological impacts (Al-Shaqsi et al. 2013). In Christchurch they were dealing with the psychological and emotional effects for years post-earthquake including grief, loss, fear, low confidence and lack of self-determination.

Professor Brian Dolan and Ken Stewart introduced me to the Design Lab in Christchurch which is a large warehouse with movable parts. Clinicians and leaders come together in the Design Lab to workshop ideas to clinical problems and design services. There I met Maya, Christchurch’s hypothetical pre-teen around whom the young persons’ mental health initiative, Mana Ake (meaning Stronger Together) was designed in response to the long term mental health impact of the earthquake disaster. The flexible and responsive approach of Christchurch’s health system using methods such as the Design Lab has allowed them to address the needs of its citizens post-crisis.

The needs of post-ICU patients are well documented. Data emerging from Italy suggests 16% of all patients admitted with Covid will require ICU admission (Grasselli, Pesenti and Cecconi, 2020). Anxiety, depression and PTSD post-ICU can be as high as 33% or 1/3 patients. It is suggested up to 67% of these patients will suffer ARDS, be left with lung scarring, breathlessness, high levels of fatigue, significant muscle deconditioning and loss of strength (Yang et al. 2020).

Due to these long term effects we will be managing the fall out of this pandemic within society for many years to come.

I would like to take this opportunity to share some of the systems and approaches which Christchurch leaders and clinicians identified as being key to helping their city heal from the trauma of disaster.

Integration and Collaboration

Every leader you meet will impress upon you the Trust values and workstreams or networks which demonstrate the organisations dedication to integrated care and collaboration. This is well intended but too often these efforts lead to more meetings than actions. In Christchurch the Canterbury Clinical Network and Alliances approach was repeatedly highlighted to me as a working example of these principles and their tangible outcomes.

An Alliance of principles and vision

The Canterbury Initiative was birthed around 2007 when it was estimated that by 2020 Canterbury would need twice the number of acute care beds, 20% more GPs and 40% more residential care beds. This is a narrative familiar to those working strategically in our health system. Workshops were happening and plans were being made for changes within Canterbury before the earthquake occurred but after the quake interviewees told me how the Chief Exec of Canterbury District Health Board, David Meates, recognised the new urgency of these changes and moved the timelines from Vision 2020 to Vision 2012 with the goal to deliver the changes 8 years earlier than planned.

One of these developments included the proliferation of the Canterbury Clinical Network (CCN) and their Alliances. Kim Sinclair-Morris, Executive Director of CCN describes the Network as “A shared vision, one around a connected system that’s focused fundamentally on people.” The CCN identifies the need for Alliances based on the population needs. The CCN will then invite partners relevant to that population need to form an Alliance.

Kim describes an Alliance as “a very simple concept about agreeing to work collectively on common goals for mutual benefit. A really important part of the Alliance Approach (is) around bringing everything back to integrating and connecting us.”

Alliances are not new concepts to our health system. The Chartered Society of Physiotherapy, prior to Covid-19, had already established a Rehabilitation Alliance with 25 partners from across the rehab spectrum. Alliances such as this will be crucial in tackling the system wide approach needed to healing our society in the years to come. I hope to see the influence of the CSPs Rehab Alliance grow and their members continue to advocate for patients impacted by Covid-19 whether through experiencing the virus or missing out on rehab because of it. I hope the CSPs Rehab Alliance can have a more local flavour and that Trusts across the country adopt this way of working for the future.

Here are some the of key principles which leaders continually highlighted as successful elements of the CCN and Alliance approach in my interviews which I hope we can integrate into our conversations and organisations:

  • Collective responsibility: we all win or we all lose. Kim describes a few methods which help to keep the conversations on track and away from organisation specific or funding specific focuses. These include having an independent chair or clinician chair on each Alliance group and citizens involvement. The funder attends all Alliances to ensure there are no surprises and no inappropriate resource expectations
  • Citizen focused: one or more citizens, Agnes or Maya (hypothetical patients) help to form a common view and avoid tribalism
  • Citizen outcomes: they use citizens time as a key metric, the aim is to not waste their time which helps the system view time efficiency from the citizens perspective.
  • Data informed: they use data to drive and monitor change.

My immediate question is whether we can adopted some of the concepts which leaders and clinicians who have lived and worked through disasters identify as key to the successes of bouncing back after crisis.

Can we all be more citizen focused?         

A colleague recently shared her experience of being on the receiving end of a health system reaching out its citizens. She describes receiving 6 phone calls in one week from different health professionals checking in because her child ordinarily attends a SENCO school. This level of “checking in” was not required or requested and may actually add to the burden rather than relieve it. This leaves me wondering if we are asking our citizens what we can do to help rather than paternalistically providing what we think they need.

There has been a proliferation of shared work spaces and groups developed to respond to this crisis. Should we be asking for citizen representation in these arenas? Around 10-70% of all responders in a disaster are volunteers and we have seen the incredible offer our citizens have extended to the NHS in the huge numbers of volunteers signing up in the last few weeks. Could some of these volunteers be used more strategically to represent the voice of wider society as has so aptly been demonstrated by the CCN and their Alliances.

Can we be more data savvy?

I was recently advised that the Electronic Staff Record system only identified 2 physiotherapists in the UK as respiratory physiotherapists. This is a shocking example of we undervalue the need for accurate data and information in our healthcare system. Accurately recording someone’s job role seems like such an insignificant data piece but it is also very simple and its inaccurate input has made the job of predicting the need of the workforce much more difficult than it needed to be.

In Christchurch I saw multiple examples of how data input and analysis was respected and allowed predictive modelling and planning to evolve with the new pace of change required:

  • Live data updates: screens of live admissions and discharges were visible across the organisation allowing managers to see where the blocks were occurring and where the slower areas were. This allows real-time decisions to be made about workforce redeloyment and any changes can be evaluated easier. It also allows managers to predict potential blockages developing in the pathway.
  • Mapping complexity: the Integrated Community Older Persons Team sued nationally collected frailty indexes to assess patient complexity and overlaid this data on a map of worse effected areas. This allowed them to prioritise visits and interventions. Could we use frailty indexes matched to covid diagnoses to direct rehab support to those most in need?
  • Analytics in the moment: the Transformation Team collaborates data analysts with clinicians to address current clinical problems on the ground. This collaborative approach allows clinicians, leaders and analysts to co-discover solutions together making the change process more efficient and effective. This is critical because emergency planners report that the disinterest of clinical staff in emergence planning can be a huge barrier (Al-Shaqasi, 2013).

What could we be doing now to collect the information which could shape our predicted models for rehabilitation and funding in the future?

Can we adopt an attitude of collective responsibility?

Another important aspect of the CCN is that it spans organisational boundaries. It is not answerable to a single master. It was created through a shared vision between the public and private health organisations servicing the Canterbury community. Pegasus Health’s CEO, Vince Barry, expresses that “Pegasus’ greatest achievement of recent times has been its relationship with CCN”.

An announcement this week confirmed that Cancer Hubs will be set up around the country to allow patients to continue their cancer treatment in lower risk environments. This demonstrates the collaboration between the private and public health sector. These measures are crucial to maintaining vital services during the pandemic but I wonder if we could expand this ethos of collective responsibility to maintain rehab for post-op patients or those with long term conditions who have been discharged or put on hold from their NHS physiotherapy. Perhaps this could also support private physiotherapy businesses. Thinking as a collective health system could also allow us to develop relationships we can continue to nurture after the peak of the epidemic has past.

Despite the difference between a pandemic and a natural disaster our health systems may respond in much the same way due to similar pressures. We would benefit from learning from the example of Christchurch as well as planning for the Alliances of the future.

References:

Yang et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centred, retrospective, observational student. The Lancet, 2020

Grasselli, Pesenti and Cecconi. Critical Care Utilization for Covid-19 Outbreak in Lombadry Italy. Jama Network. 2020

Al-Shaqsi et al. Challenges of New Zealand healthcare disaster preparedness prior to Canterbury earthquakes: a qualitative analysis. The New Zealand Medical Journal. 2013

 

Let’s work together: when primary care innovation works for the ED (A&E)

In Canterbury and The West Coast, Dr Greg Hamilton, Team Leader of Intelligence and Transformation, explains how their Acute-demand service has helped make their District Health Board (DHB) the lowest in country for Emergency Department (ED) presentations.

The Acute-Demand Service is a high trust approach. It allows GPs to provide services or activities for patients who would otherwise need to go to hospital but could be managed in the community with extra resources (they then bill the DHB for this activity).

Every year the DHB supports approximately 34,000 episodes of Acute-Demand care. This innovative approach has resulted in ED presentation rate in this area being 25% below the national average and acute medical admissions being 30% below by enabling GP teams to manage care closer to home for these patients.

An Acute-Demand intervention may be as simple as arranging medication to be collected for a patient with pneumonia so they can manage their condition at home or a nursing or support staff visiting the patients’ home to make sure there’s food in the fridge.

Dr Greg Hamilton explains that “Having the resource to do that is the way we work”

Dr Hamilton also explains how clinicians in general practice embrace the Acute-Demand model because it provides variety and a break in the 15 minute wall-to-wall consultations which can cause dreariness to set in. It allows GPs to be involved in an aspect of care that is more in-line with old fashioned family practice medicine. The model of the Acute-Demand Service enables GP teams to maintain their skill sets of and for staff to work at a broader scope.

“It allows us to provide the care you wouldn’t do otherwise with a 15 minute consult”.

The Acute-Demand service runs as a high trust model reporting to the DHB the number of care activities they have provided under this arrangement. But with all this high-trust, arms-length monitoring how does the funder and the provider monitor the services? The data Canterbury DHB collect allows the team leads to approach practices for a “peer-to-peer conversation”. I was able to see from the data sets and graphical displays how easy it is for the teams to identify which practices were charging more for which services and, in a very relaxed approach to monitoring, the team leads can point out to the practices that they are above the charging average for that service. Dr Hamilton reports that this feedback tends to bring practices back in line. In fact, through running simulation models this approach appears to be up to four times more cost effective for the DHB than the admissions that would occur otherwise.

Canterbury DHB has an inspiring approach to innovation and care provision and Dr Hamilton’s ending remarks sum up their approach:

It’s become part of the way we operate, it all comes back to trust.

How to educate the educated?

 

“ I have never let my schooling get in the way of my education”

This is a quote which is often attributed to Mark Twain and perhaps there is some wisdom to be taken from this when thinking about the education of advanced practice clinicians.

I want to focus on two methods of advanced practice (AP) education here and in both these methods education has moved out of the school and the reins have been handed to the clinician, their peers and their mentors.

 

This doesn’t mean there is no place for “school” in AP. In fact, every discussion I have had about education in Australia, New Zealand and the UK has started with the assurance that all AP clinicians should start with a MSc as a minimum  (In Australia this is a MPhty). Some discussions suggest a level of grandfathering or equivalence route and some discussions are more specific about where or what that MSc should look like. Across nations and levels of practice there is wide agreement with Health Education England (HEE) which asserts the importance of Level 7 education. However, we should keep our patients needs and safety at the beginning of all these conversations- do patients automatically have access to better care and services because their AP has achieved a level of education within a university structure?

 

In Queensland and Victoria they think not. During my Fellowship I was fortunate to spend time with Patrick Swete Kelly who is the Education Coordinator for Neurosurgery and Orthopaedic Physiotherapy Screening Clinics (N/OPSC) in the state of Queensland. Pat and others I have met with believe that an educational qualification at this level demonstrates that a clinician is prepared to work hard, can read, understand and interpret literature and is aware of research processes. Pat suggests that a postgraduate Masters qualification represents a foundation on which to build advanced practice skills and capabilities. In developing the Extension program focus groups were held with APs and service Directors in Queensland; they identified a gap between what Masters programs provide and the requirements of AP roles. A number of my contributors are in agreement with this premise including Paula Harding who was responsible for implementing the AP educational programme in Victoria, Jon Warren who is the previous president of Physiotherapy NZ (professional body) and Damon Newrick who is a member of the Physiotherapy Board of NZ.

 

Let’s focus on two different methods of assessing quality of AP clinicians’ clinical knowledge and skills. In Queensland I spent time with Maree Raymer and Mark Cruickshank and their AP teams in the Royal Brisbane and Women’s Hospital. Maree is the statewide coordinator for the Neurosurgical and Orthopaedic Physiotherapy Screening Clinics and Multi-disciplinary service in Queensland. Mark Cruickshank is the physiotherapy director at the Royal Brisbane and Women’s Hospital. As discussed above I was also fortunate to meet with the N/OPSC Education Coordinator, Pat Swete Kelly.

 

Pat has developed, implemented and runs the Extension Programme which is an educational programme delivered to aspiring APs across Queensland. Queensland is 3x the size of the UK and the sheer size of the state has its own challenges which Pat and the team meet through innovative digital solutions including using video conferencing services for training and observational assessments.

 

Working in Canada I regularly used conference calls to connect the dispersed sites for meetings but in Brisbane I had the pleasure of delivering a presentation to sites across Queensland using their video conferencing facility which was smooth, easy to use and easy for staff to engage with the speaker.

 

Pat and the program participants (Physiotherapists) use this technology to run their Extension programme. The program is offered annually and runs with dedicated contact time, one morning a week for 12 months. A particularly clever adaption, considering the distance between the participants, is their peer observation process. Patients agree to be observed and the physiotherapists turn on their webcams and their peers observe their assessment on-screen. Participants ask questions, provide feedback and then they reflect on their observations as a group afterwards. Participants present case studies to each other regularly and once a year they present at a Queensland-wide Forum for AP staff working in Neurosurgery and Orthopaedic screening clinics. They also contribute to professional development for other physiotherapists with an MSK interest who access the conference digitally from across the state. Each participant works through the curriculum which has been designed and tweaked over the years. They undertake formative assessment by their peers, local supervisors and Education Co-ordinator and are independently assessed by their educators at the end of the programme.

 

The participants tend to be aspiring APs, rather than already holding AP roles. During the Extension Program they undertake a graduated exposure to the AP role but are not guaranteed an AP role on completion. They do, however, undertake the program only with the sponsorship of their local health service, who are looking to sustain and build their AP services. Participants receive a letter upon completion which recognises  their AP skills and knowledge, providing demonstration of completion and attainment of the level of expertise required of AP roles which is well recognised by physiotherapy service managers . This method also ensures there are AP ready staff in the pipeline ready to step into any AP roles which may arise.

 

In Victoria their educational process and credentialing system takes a different turn. Research conducted by Paula Harding and colleagues has resulted in the creation of a set of AP competencies which can be used alongside an array of modules. Clinicians self-identify appropriate modules to supplement their learning and achieve a level of expertise and practice which is relevant to their role and their individual needs. This model is flexible and has been adapted to suit AP staff working in different contexts including spinal screening and the Emergency Department. This model is an ongoing process and relies heavily on the adult learning principles of self-awareness and the clinician’s ability to self-select areas for key development. Clinicians receive a workbook as well as the competency framework which they work through at their own pace carrying out a Learning Needs Assessment to help guide their focus.

 

These two models demonstrate local approaches to the professional issue of equity within MSK post-graduate education which is meaningful to the service and the patients it serves. I challenge readers to consider whether a specified programme of study is appropriate, sufficient and meaningful for every service and every individual clinician. Does this approach automatically equate to safer and more evidence based practices?

Consider Mark Twain’s musing…should we let our schooling get in the way of our education?

 

Hannah Morley
Advanced Physiotherapy Practitioner

First Contact Practitioner

Winston Churchill Fellow

 

 

 

 

 

 

 

We need to talk about your credits

I recently met with a Kim Gibson, Chair of the Physiotherapy Board of Australia.  The Physiotherapt Board of Australia and AHPRA work in partnership to deliver the National Registration and Accreditation Scheme in Australia to regulate all Australian physiotherapists through protection of title rather than regulation of practice scope. I have also had the pleasure of meeting with and discussing these topics with Damon Newrick from the Physiotherapy Board of New Zealand and members of the Australian Physiotherapy Association Advanced Practice Network.

I equate theAustralian and New Zealand Boards to to the UKs HCPC. Discussions drift towards two opposing views of regulation. One view highlights that the majority of physiotherpaists will not be called to prove the quantity or quality of CPD and ongoing learning processes. This can allow poor practice to remain hidden and therefore can put patients at risk. This is the view I heard discussed on the recent Health Matters podcast with Sandra Harding and Sarah Tribe and to which I listened with interest. This view is also discussed within the Reforming Clinical Governance chapter of the MSK Reform Manifesto. 

The opposing view is that the risk level to the public from physiotherapy is minimal  with the majority of our intervention being education and movement based therefore the risk of serious harm to the public is minimal. This view suggests the bigger risk may be an overburdening of the profession which could have mental health impacts for staff and a wider societal impact if professionals feel this process is too burdensome and therefore leave the profession for periods of time or early.

In this view, regulation is a minimal requirement for safe practice and should not be too specifically tied to credentialing or educational credit structures. Within this approach credentialing is seperate to regualtion and it is credentialing processes which demonstrate a clinicians’ advanced level within a profession, unless Advanced (or Specialist as in NZ) becomes a regulated title.

I have been fortunte to hear Dr Richard Collier present his work with HEE on a number of occasions and we have discussed the potential difficulties in regulating advanced pracitce in the UK. My understanding from our discussions is that The Academy, which is being developed as a credentialing body for Advanced Clinical Practitioners, will provide a voluntary register for Advanced Clinical Practice but that this is not linked to a move to regulate Advanced Practice through The Academy or through HCPC.

The Academy would credential a level of practice rather than specific roles and this level of practice is often talked about as being at Level 7, in terms of an MSc or equivilent. It is reassuring to see this is mirrored in the educational achievements of advanced practice physiotherapists in other countries such as Australia and New Zealand.

The supporting documentation being released from the various UK organisations advocate strongly for the 4 pillars of advanced practice. However, this is not a model I have seen strongly replicated during my Fellowship interviews and discussions. In Queensland, practitioners working in Advanced Practice MSK settings are credentialed through a peer learning process which is purely clinically focused. In Victoria, practitioners working in these same settings work through a competency based portfolio framework supported by self-learning modules, this framework is again purely clinical.

My observation is that there are similarities between the regulation of Physiotherapy in these specific countries. All regulators explain that risk in our profession is low and therefore a light touch method is taken to regulation which should be the minimal standard of practice expected by a qualified physiotherapist. However, there are inconsistencies in how we manage accreditation of all qualified physiotherapists and very mixed approaches to the accreditation or recognition of clinicians with advanced skills or working in advanced practice environments.

It again comes back to terminology, we need to be mindful about whether we are talking about regulation, credentialing or governance.

 

 

Telehealth Technology

We have all seen movies
or read dystopian fiction which pits Will Smith or Domhall Gleeson
against a sinister robot and paints an apocalyptic picture. Despite
these scary predications, my experience of future technology
has (until now) pinnacled in a hoover-robot which scares the cat and
gets itself stuck in the bathroom!

But now, thanks to Simon
Whitehart who is the Telehealth Service Coordinator at the Royal
Brisbane Women’s and Children’s Hospital (RBWH) I have expanded my
understanding. The telehealth services at RBWH is helping patients,
staff and services and there are no Turing tests or household cleaning
devices in sight.


RBWH knew it had 2 main issues to contend with in getting patients to
improve access to
outpatient MSK physiotherapy treatment as a means of non-surgical
management of their MSK condition after an Orthopedic Physiotherapy
Screening Clinic appointment (AKA interface
or MSK/Ortho advanced practice service).


Problem 1: patients live
so far away they either wait until the problem is so bad they can no
longer cope before seeking specialist opinion or they do not attend or
decline physiotherapy management because of the
distances they would have to travel regularly to gain the benefit.
During the time I spent with the screening clinic in RBWH one patient
had traveled for 9 hours, including a flight and an overnight stay in
order to access the clinic. This can be a huge disincentive
to accessing care.


Problem 2: waiting lists
were long and getting longer in regional centres where these patients
were traveling from. It is difficult to staff rural or remote clinics
and therefore services can be sparse and waiting
lists long.


Simon Whitehart:
“if that patient has no access to follow up and they might live in the
Queensland interior, 200k to their nearest hospital. Or their
local hospital
has a two year waiting
list for chronic. You think, right, I’m going to have to refer you to
telehealth. To improve access we refer to telehealth”.


Michelle Cottrell has
done a fantastic series of publications which provide evidence for the
use of telehealth technology. Dr Cottrell and her team have found that
clinicians found Telehealth increasingly easy
to use and effective as time progressed after implementation and
patients were willing to access telehealth if it reduced the costs and
time required to attend in-person appointments. Even more innovatively,
Dr Cottrell looked at the agreement between in-person
and telehealth assessments of patients with chronic MSK conditions
accessing an orthopaedic triage/interface service and found substantial
agreement between the two methods of assessment when deciding on
management pathways. Incredibly there was near perfect
agreement for referral to allied health colleagues. Diagnostic
agreement was 83.3% and onward referral for investigations was in
agreement in 81% of cases. In terms of outcomes a systematic review
found telehealth rehab improved physical function and improved
pain scores comparatively to in-person rehab.


I sat in on a patient
telehealth rehabilitation session with Steven who is the telehealth
treatment physio at RWBH. We are sat in a small office with a computer
and a webcam attached to the top of the monitor.

On the screen we can see into the patients’ home and she is explaining
how her neck posture exercises have been helping her upper traps pain.
Steven asks the patient to demonstrate her exercises side on to the
camera so we can see her neck retraction exercise.
Steven can even take a picture or video
of her doing the exercise and either play it back or annotate on the
picture as a means of further coaching the exercise using a web
-based
programme called neorehab.com. Steven feels patients engagement levels
are often higher when using telehealth rather than in-person rehab.
Simon also reports that results are similar or virtually the same as an
in clinic session.

“It allows for a really contextual experience”. Simon Whitehart

Success is not final

After months of preparation I am finally in Australia. Touched down in Sydney last night.

The in flight entertainment gave me some food for thought watching the film Darkest Hour which I have wanted to see since first applying for my Winston Churchill Memorial Trust Fellowship. The film depicts the dramatic entrance of Britain to the war, how Churchill becomes PM and the critical moment when the nation decided to fight rather than surrender to the Nazis. Im not a history geek but I enjoyed the reflection of Churchill as a master orator with some gem speeches including…

‘You can’t negotiate with a tiger while your head is on its mouth.’

AND

‘Those that never change their mind never change anything.’

I won’t be negotiating with any tigers but do stay tuned to have your mind changed (or knowledge updated) about the fantastic work being done by advanced practitioner physios out here.

As Churchill said, success is not final, so, although I’m here now, starting my trip there is lots more work to do.

Thanks all,
Hannah