2 P H Y S I O T H E R A P Y DECEMBER, 1975 HOSPITAL ADVISORY SERVICE This paper w as read at the Jubilee Congress South A frican Society o f Physiotherapy Johannesburg July 1975, b y L O IS D Y E R , M .C.S.P., Chairman o f the Council of The C hartered Society o f P hysiotherapy, Eng., H on. L ife V ice-President S.A .Sp Community Care 1 think I must interpret the phrase com m unity care as m eaning care o f those in need outside the hospital setting. This seems to be th e general understanding of the phrase, although I hope the time is coming when we will consider the hospital as p a rt of the com m unity and m erely adapt the resources to the needs. T his is a subject which is interesting the whole world at th e m om ent an d I w ould like to tell you of the ideas being bandied ab o u t in the U nited K ingdom and perhaps mention a few developments' which 1 know are occurring in other parts of the w orld. Perhaps this m ay form the basis of later discussion as to how services could develop in South A frica w here there is a unique m ixture of highly sophisticated and simple living standards. V ery largely because of the difficulties in im plem enting the westernised systems which have been geared fo r m any years to the dom inance of hospital based care for the sick and injured, new thoughts have been stim ulated by the m ethods developing in the T hird W orld. Much more im portance is being attached to the prim ary health care team s and use of auxiliary workers. T he N ational H ealth Service in B ritain started from the premise that everyone has a right to a comprehensive and coherent service to m eet th eir needs. In health care, all are entitled to benefits, including physiotherapy. In fact, because dem ands are insatiable, this ideal has been im possible to im plem ent, bu t th a t is an o th er story, for another talk and discussion. In 1971 A melia H arris undertook a survey to estim ate the num ber of disabled in B ritain. T hose classified as “very severely”, “severely” or “ appreciably” handicapped totalled 1,128,000, ie 3% of the population. O f these, m ore than tw o-thirds were women and m ore than tw o-thirds were over the age of 65. This num ber m ore than doubles and rises to 3 m illion over 16 if all disability is counted. O f these five-sixths are over 65. One of the most striking dem ographic changes in B ritain is the steady rise in num ber of the elderly w ith a dram atic increase of those in their eighth, ninth and tenth decades. So much so th a t it is estim ated th at between 1973 and 1993 there will be 4% overall increase in the population, but an increase of 5,6% 'over 60, 26,5% over 75 'and 42,2% over 85. W hilst considering this vast num ber of elderly it is significant th at a present 1,8% over 65 are in hospitals and nursing homes, 1 % in psychiatric hospitals and 1,7 % in residential homes. T his totalis 4,5% so th at 95,5% over 65 are at hom e in the com m unity. T here is also evidence that those in dependent age groups will increase. People are staying at school longer and at the end of their working life are retiring earlier. Surely this must indicate the pattern of the future dem and. A long with this statistical w arning goes a steady rise in the expectations of care for all ages. T he function and role of the rem edial professions m ust be influenced by these facts. W hat we m ust think ab o u t is w hat sort of physiotherapy is relevant and where it should be given. In the past it has been the policy of the D epartm ent of H ealth and Social Security in B ritain to restrict the physiotherapy service to hospitals on the grounds that this was the best way to utilise the time of the therapists In fact, I understand this was w orked out on the numbers of patients a physiotherapist could treat if she had 3 cubicles under her control. I do n o t need to elaborate on all the fallacies of th at thinking to this audience. A nother factor which m ay have influenced thinking y the type of w ork som etimes being undertaken by o rg a ly isations such as the M obile Physiotherapy Service, w hich is a voluntary organisation which sponsors m obile units and tends to be equated with “here comes m y friendly physiotherapist with a smile and a heat lam p” . This may be an outm oded image but it is one which lingers with those responsible at the D epartm ent of H ealth for changes in policy. T he tight control of physiotherapists in hospitals must deny very large num bers the benefit o f help from us particularly in the early stages of disability. We must also rem em ber that m ost people prefer to “ live” at home rath er than be “cared fo r” in institutions. M any physio­ therapists have been aware of and disturbed by the needs of people outside hospital and a few sporadic and unco-ordinated efforts are being m ade up and down the country to provide a service. Let us think about the advantages and benefits of a com m unity physiotherapy service. (1) Patients would be treated earlier if the therapist were used as a mem ber o f the prim ary health care team , e.g. if an elderly person who falls but does no m ajor damage, a p art from losing confidence, could be seen early one m ay be able to prevent the too com m on sequence o f events which results in im m obility, incontinence, m ental confusion and hospital admission. (2) R elatives could be instructed and the patients lea,- to adapt to their disabilities in their own surround­ ings. In the past there have been far too m any self- satisfied pronouncem ents ab o u t patients being in­ dependent because they can get in and out of a hospital bed or climb the hospital stairs. Treatment in hospital has been unrealistic and therefore largely purposeless. (3) T he exhausting journeys to hospital by a m b u l a n c e w ould be avoided. These journeys are incidentally becoming intolerably expensive. (4) H ospital admissions may be avoided or delayed and adequate follow -up after essential hospital care could be instituted. H ow often is independence lost because the stim ulus and encouragem ent is taken abruptly away from patients on discharge. (5) O pportunity is provided for the contact with other com m unity services, which is so often lacking, ye* is so essential. (6 ) T he opportunities for preventive advice and treat­ m ent are endless and this is a field where our skills are virtually undem anded and unused. (7) C ertainly in Britain, and this m ust be true e ls e w h e r e , there are increasing num bers of physiotherapist R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) dESEMBER 1975 F I S I O T E R A P I E 3 who c a n n o t o r d o n o t w ish to w o rk in h o sp ita ls because o f d istan c es o r th e rig id ity o f h o sp ita l h ours. O ne c o u ld c o n sid e r lin k in g th e services of p rivate p ra c titio n e rs w ith h o s p ita l p ra c titio n e rs ’ work. P h y s io th e ra p is ts a re m a rry in g y o u n g e r, s p in ­ sters are b e c o m in g few er, a n d th e service m ay well have to d e p e n d m u c h m o re in th e fu tu re on p a rt- tim ers. * physiotherapy service outside hospital can be of lue in hom es, fa c to rie s, sc h o o ls, e v e n p riso n s, in fa ct Wherever the n e ed is. P r o b le m s of Organisation I There are different m ethods of m anaging the physio­ therapy service and these are being discussed. It seems th a t it w ould be w rong to have rigid schemes. There m ust be flexibility in the way they are organis­ ed. Many people favour the attachm ent o f a physio­ therapist to group practices of general practitioners, some work being done a t their surgeries or health centres, and som e in patients’ homes. I O thers th in k a c o m m u n ity service s h o u ld be based a t the lo ca l h o s p ita l. T his h a s m a n y a d v a n ta g e s fro m an a d m in istra tiv e a n g le b u t c a re m u s t b e ta k e n to consider th e m a n y w h o w o u ld b enefit b u t n e v e r c om e near a h o sp ita l. 3. O thers c o n sid e r th a t a n y su ita b le staffed c e n tre c o u ld act as a h e a d q u a rte rs fo r th e staff a n d e q u ip m e n t which m a y be n e ed e d . T he e sse n tia l is to h a v e a 24-hour te le p h o n e service a nd a n efficient c o ­ ord in ato r. It s h o u ld be p o ssible to g io u p p e o p le o f different disc ip lin es a n d e m p lo y e rs to av o id o v e rla p and im p ro v e c o m m u n ic a tio n be tw ee n th em . T h e greatest deficiency o u tsid e h o sp ita l is th e a b se n c e of a c o m p re h en siv e p ro g ra m m e fo r p a tie n ts . From Whom Would Referrals Come? They could come from anyone appropriate and general practitioners, consultants, nurses, social w orkers, teachers and other health care colleagues might wish to refer people as potential patients. These w ould be essentially referrals for assessm ent purposes. N aturally if any tre a t­ ment in the traditional sense is considered appropriate, then the general practitioner m ust be contacted and the problem discussed. To Whom Would a Service Be of M ost Value? - F o r pre-school and school children, guidance can be 'Iven on handling, basic exercises, equipm ent, play materials and as links between hospital and com m unity services. A dvice can be given to teachers and parents and post-surgical treatm ent can be given to avoid missing school. Adults Following cerebrovascular accidents treatm ent can be started early; patients can be follow ed-up from hospital. Advice can be given on handling and lifting to those coping with deteriorating neurological conditions and the elderly with m ultiple handicaps. Relatives can be taught transfers and lifts. A dvice can be given about graded activity. M any patients m ay be helped to com bat stress incontinence. Sufferers from chronic chest conditions can be taught how to manage. Orthopaedic problem s can be treated at hom e; advice can be given to those w ith rheum atic conditions. T he list is endless. In nursing and residential hom es and day centres, lay staff can be taught simple m anoeuvres. Preventive w ork ran include advice on safety program m es. Exercises can be. given to help com bat the threat of im m obility in aging. Health Education T alks can be given to nurses, doctors, h ealth visitors; in fact to any one who asks for guidance. What Sort o f Physiotherapy Only minim al equipm ent w ould be needed, such as splints and walking aids since it is n o t envisaged th at the “ treatm ent” at hom e w ould or should equate w ith th a t traditionally given in a hospital. O bviously anyone need­ ing intensive and specialised therapy would have to go to centres where this w ould be available. It is extrem ely im portant th a t adequate records are kept. T here m ust be conscientious treatm ent planning follow ing initial assessm ent and then careful n otation of progress and responses. T he physiotherapist m ust be able to com m unicate so th at all can understand w hat is being related. She must function as a m em ber of a m u lti­ disciplinary health team , aw are of the p a tie n t’s social and em otional environm ent. She w ould need to be a senior m em ber of th e profession and suitable retraining should be made available if necessary. T h e com m unity physiotherapist should have access to and be integrated with her colleagues elsewhere in the district and she should have the advantages of post-registration education on equal terms with those in hospital. W hat sort of person can fulfil this role? T he m odem therapist is predom inantly useful in training patients to help them selves in overcom ing disability. In the com ­ m unity the work will be prim arily, but n o t entirely, advisory and educational. She m ust w ork closely w ith relatives and nurses in the continuing process of re­ habilitation and be prepared to delegate less skilled w ork to anyone appropriate. F o r too long we have clung to sanctim onious clap trap phrases like “m aintenance of standards” when we do not really know w hat we m ean. D elegation of appropriate w ork to supervise helpers enhances rath er than dilutes professional standards and status. M any will say that the general practitioner will take advantage of such a service and ask for inappropriate treatm ent. M uch will devolve on the general practitioner who m ust be taught modern concepts of physiotherapy by the therapists. Provided there is m utual respect between the doctor and therapist and acceptance of each o th er’s responsibilities, difficulties should be few. M y enquiries aro u n d B ritain have shown th at this bogey of abuse of the therapy service is grossly exaggerated and great strides have been made in m utual understanding between m em ­ bers o f the health team . T he therapist outside hospital has a different outlook. She needs to be socially minded and scornful o f dem arca­ tion lines. T he p atient’s standard of living m ust be accept­ ed and she must be ingenious ab o u t working w ithout equipm ent. T h e therapist will need clinical proficiency and com petence to teach, supervise and adm inistrate. She m ust be good at inter-personal relationships. T his may all need a broader preparation than traditional professional education has given until now, but certainly responsibilities in com m unity care and public service must be accepted. A t present practice is n o t biased tow ards health m aintenance and prevention, but the physio­ therapist has the knowledge and skills needed to prom ote these concepts. T here is no clear policy from the D epartm ent of H ealth and Social Security at present which can guide the developm ent of com m unity services so th a t they are regrettably proliferating in a h aphazard m anner. T o help clarify the situation a w orking p arty to establish the role and function of the therapists in the com m unity was established by the C hartered Society of Physiotherapy in conjunction with the British A ssociation o f Occu­ pational T herapists. It has just reported and its recom ­ R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 4 P H Y S I O T H E R A P Y DECEMBER, 19^ m endations include: (1) A n urgent survey of current practice. (2) A regional program m e of education to teach other m em bers of the health care team the value of rem edial therapy. (3) A change in student training to appreciate the value of prophylaxis. (4) T raining o f therapists in the extraction of relevant inform ation from various sources and in w riting reports. (5) R esearch into the needs o f handicapped adolescents. (6 ) A reassessm ent by the rem edial professions of their priorities, with particular regard to adequate provi­ sion for the elderly. (7) M ore em phasis during training on teaching methods. (8 ) C onsideration of the use of flying squads or p eri­ patetic team s, particularly in rural areas or where therapists are very scarce. (9) Efforts should be m ade to prom ote better u n d er­ standing of the potential and needs of the young disabled, the m entally handicapped and psychiatric patients. (10) Increased post-registration activities should be en­ couraged in several areas, including paediatrics. (11) E xisting services should be evaluated and th orough­ ly reassessed in view of changing needs. (12) A ppropriate professional structures should be fo r­ m ulated to avoid isolation of those w orking outside hospital. Finland In F inland there has recently been a com plete re ­ appraisal of education of all health personnel, including th at of doctors. T heir health services have been sim ilarly reassessed. One result is th at there will be some hospital beds for prim ary medical care, but the m ain p ropo rtion of ser­ vices are in the com m unity. M uch m ore use is to be made o f people who can contribute w ithout an expensive and lengthy training. A pproxim ately h a lf the physiotherapists are now allo ­ cated fo r more traditional treatm ents, whilst the rest undertake indirect, preventive, m aintenance and educative services. Since 1973, a one-year postgraduate course • com m unity health and adm inistration has been availa^ 1 to physiotherapists and m any have taken advantage of Australia In this country a num ber of experim ents on the us of physiotherapy outside the hospital have been initiated' Some are hospital based, som e use peripatetic teams 0j therapists and social workers. A ll agree th a t it is essentia to have a co-ordinator. New Zealand H ere they are experim enting with the concept of the hospital at home, ra th e r on the lines of pilot schemes which have been undertaken in Paris. In Britain this scheme has m any supporters and m ay finally be the most econom ic and efficient use of staff and m oney available Scotland In Scotland the developm ent has been inconsistent anA the organisation arb itra ry . T h e w ording of their NatioiU] H ealth Service R egulations has been interpreted more liberally than south of the bo rd er in England and Wales Sometim es there is a structure fo r the therapists but often there are no official channels of com m unication. In 1973, 98 physiotherapists w orked in the community in Scotland, an equivalent of 80 w hole tim e workers They had 12,785 new patients and carried out 190,189 treatm ents, an average of 14,875 p e r person. M ost refer­ rals were from general practitioners and all ages were treated in different situations. Summary So, things are on th e move. C ertain factors must be accepted if we are to provide the necessary service. Firstly, it must be recognised th a t com m unity care de­ pends on a caring com m unity. Secondly, we m ust always ■be aw are th at “Inside the hospital, the status and liveli­ hood of a large body of employees requires the patients presence. I t could indeed be th a t th e hospitals need of the patient transcends th e p atien ts’ need of the hospital”. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )