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.
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.
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.
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.
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.
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.