T h e M o l l y L e v y E p o n y m o u s L e c t u r e T h e C h a n g in g P r o f e s s io n A n In t e r n a t io n a l P e r s p e c t iv e INTRODUCTION Coincidentally with the invitation to deliver this prestigious address in honour o f M olly Levy, I cam e across an article by M ichael W right in the London D aily Telegraph under the title, “Unaccustomed as we are, the lecture stages a come back” w hich caused m e som e im m ediate concern as to w hether it w ould be w ise to accept the invitation. The w riter pointed out that there was a tim e w hen public lec­ tures w ere an op po rtu n ity fo r grand B ritish explorers to share their n ew ­ fo u n d k n o w le d g e w ith ex p ec tan t Victorians, or for O scar W ilde to w ow A m e ric a w ith his n ew -m in ted A estheticism , but m ore recently, T V and radio had m ade the “ live” talking head alm ost redundant: “E ven for university students, lectures are often a tedious anachronism , strictly for sad people: the endless attended by the frien d less”. I was not encouraged by these o b ser­ vations, but m ore was to come! The w riter was quick to point out that despite a num ber o f attem pts to abolish the uni­ versity lecture it persists largely because if it is done aw ay with the students don't do anything and there is still the dem and for the sham anic figure in front o f them. “It seem s to be a deep hum an need to be bored by som eone w ho is actually pre­ sent” . H ardly reassuring! But, as you see, I did accept. Two rea­ sons overcam e m y reservations; firstly, I knew that, d esp ite M ich ae l W right's observations, I w ould be in the com pany o f friends and, m ost im portantly, the occasion w ould provide the opportunity to pay my tribute to M olly Levy - a lady for w hom w e all share the m ost profound respect for her w arm th, hum anity, loving spirit and dedication to our profession. I first m et M olly w hen 1 cam e to South A frica in connection with the selection o f visually im paired students for m y p ro ­ gram m e in London. M olly served on the South A frican N ational C ouncil for the Blind Physiotherapy Selection Panel in w hich capacity she was respected for her integrity, understanding and the good­ ness reflected in her gracious counsel. I greatly appreciated the w arm th o f her personality. The essence o f M olly Levy is encapsulated in a description o f her that I received from another friend and colleague, as the “The M other o f South A frican Physiotherapy” . THE CHANGING PROFESSION - AN INTERNATIONAL PERSPECTIVE In years to com e there will be no doubt in the m ind o f anyone review ing your Congress as to the prim ary interests of South A frican physiotherapists in 1997. The titles and content o f the lectures, w orkshops and other elem ents o f the pro­ g ram m e e m p h asise new ap p ro ach es, techniques and the changes w hich are currently taking place in the profession as it is practiced in South A frica. It is a tim e o f great change for us all and the changes w hich are taking place here are reflected throughout the world. A t this tim e o f so m uch change I w ould be sur­ prised if there w ere not m ixed em otions and som e reaction to it; for ju st as change can bring a new vitality to practice it can also be threatening for those w ho prefer the status quo. The follow ing quotations are apposite: “Change is not m ade w ithout inconve­ nience, even fro m worse to better.” D r Johnson's preface to the English Dictionary. “A State w ithout the m eans o f som e change is w ithout the m eans o f its con­ serva tio n .” E dm und Burke (1729-1797) Reflections on the R evolution in France. Perhaps som e w ould find an echo o f their true feelings in the im m ortal w ords o f the second verse o f H enry Francis Lyte's hym n, ‘A bide W ith M e ’: “Change a n d decay in all around I see; 0 Thou who changest not, abide with m e .” A recent article in the Jo u rn a l o f the R o ya l S ociety o f M edicine under the title, ‘Responding to Change - or D espondent and E stra ng ed ’ (Coni - 1997), the w riter draw s attention to the sagging m orale of co n su ltan t p h y sicia n s in the U K as rep o rted by th e R o y al C o lleg e o f Physicians. It pinpoints the reason as too m u ch c h an g e h a p p en in g to o fast. Consultant physicians are not alone in this view. DAVID PG TEAGER PRESIDENT WCPT Every profession has to face the incon­ venience o f change to preserve its rele­ vance in and for the society it seeks to serve. Furtherm ore, w e all need to con­ sider the international dim ensions o f our co ntem porary p rofessional practice in the context o f the changes taking place in the “global village” in w hich w e all oper­ ate. W hat is the “global village”? W hat are the forces that now im pact on the national and international dim ensions o f our health practice? T hese are issues that dem and our fullest consideration. THE HISTORICAL PERSPECTIVE T he unstable nature o f our contem po­ rary practice can perhaps be best appreci­ ated in the context o f an historical p er­ spective and an assessm ent o f our future prospects. Physiotherapy had one o f its m ost im portant origins in physical education; the k n o w led g e and fu n ctio n s o f the hum an body and the effect o f exercise on its system s in health and disease. A com ­ p reh en siv e study and k n o w led g e o f an ato m y and p hysiology, p articularly tha t o f the m u scu lo -sk e le ta l system , being essential to our practice. The p ro ­ fession ow es m uch to a long line o f edu­ cators w ho recognised and saw the teach­ ing o f anatom y and the study o f hum an m ovem ent as the fundam ental bases o f our clinical practice. H ere, I w ould like to pay personal trib ­ ute to m y friend lon e Sellars w ho, as a staff m em ber o f UCT, gained the utm ost respect o f colleagues and students as an anatom ist o f the highest order w ho con­ veyed the love and relevance o f her sub­ je ct to all those w ho cam e under her influence both as undergraduates and post graduates. I see no reason to shift this em phasis in physiotherapy education program m es. In fact, there is every reason to reinforce the central position o f living anatom y and kinesiology in the education o f the phys­ iotherapists o f the future. I also have no doubt that teachers o f physiotherapy are best placed to em phasise anatom y and m o v em en t stu d ies in a relev an t and m eaningful w ay w ithin the practice o f 4 SA J o u r n a l o f P h y s io th e ra p y 1998 V o l 54 No 1 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. ) physiotherapy. The other roots in o u r healing tradition o f w hich we should be unasham ed are m assage and the use o f physical agents including hydrotherapy. R esearch devot­ ed to the appropriate use and efficacy of these m odalities is now justifying phys­ iotherapy as an essential elem ent in all health care program m es. T he know ledge and handling skills we possess are reco g ­ nised as vital in the rehabilitation o f physically h an dicapped people. W ars, epidem ics and accidents occasioned by industry and the m o to r car together with the surviving generations o f physically handicapped children m ade, and contin­ ue to m ake, physiotherapists evident as full and essential m em bers o f the health care team . In recent years increased social equality and the efforts being m ade to integrate disabled people and the chronically ill into the com m unity have contributed to a grow ing aw areness that physiotherapists fulfil a vital role as key w orkers in the rehabilitation process and that their practice outcom es are m orally justified and socially significant. The Standard Rules for the E qualisation of O p p o rtu n ities fo r P erso n s w ith D isa b ilities ad o p ted by the U n ited N ations G eneral A ssem bly at its 48th sessio n on 20 D ece m b e r 1993 (R esolution 48/96) w ere unanim ously endorsed by the W orld C onfederation for Physical T herapy at the 13th G eneral M eeting in W ashington. P h y sio th e ra p ists h av e alw ay s seen th e ir c o n trib u tio n to h e a lth care as greater than the sum o f its parts. They w ill continue to have a significant influ­ ence in regenerating the m axim al quality o f life fo r their patients w hich is the u lti­ m ate gdal o f all rehabilitation processes. M y picture o f the developm ent o f the p ractice o f our p ro fessio n w ould be in com p lete w ith o u t refe ren ce to the increasing role o f physiotherapists in p re­ v e n tiv e m edicin e, h e alth p ro m o tio n , h e a lth ed u ca tio n and co u n se llin g . Physiotherapists have a unique k n ow ­ ledge o f norm al and im paired m ovem ent patterns and their relationship to injury. This is beautifully articulated in a recent study u n d e r the title, ‘P h y sioth erap y p ractice: P ractitio n e rs p e rs p e c tiv e s ’ (Sarah B eeston and H elen Sim onds - Physiotherapy Theory and P ra c tic e ). The physiotherapists involved in the study view ed their practice as, “W orking for change in relation to com plex practical problem s and w orking in harm ony with others in order to m axim ise a patient's functional ab ility ”. In their view, the unique contribution o f the physiotherapist w ithin the m ulti­ disciplinary team was to m anage the m usculo-skeletal system o f the patient. “There was no gold standard to be attained. The goal was change in patient status.” In sum m ary it is m y b elie f that the p ro ­ fessional goals we pursue find ju stific a­ tion in w hat is good fo r hum ankind and what all people have a right to dem and o f life. Physiotherapists w ork in an open and equal partnership with their patients, their relatives and carers and other health professionals to achieve these goals. THE CONTEMPORARY REALITY “We live in a m om ent o f history where change is so speeded up tha t we begin to see the p resen t only when it is disappear­ ing" RD Laing - The Politics o f Experience. It is im portant to sense the urgency w ith w hich w e need to address contem ­ porary professional problem s so that we are not overtaken by events. I am not alone in highlighting the im portance of this consideration w hich finds an echo in the lectures o f Ruth G rant and other speakers at y o ur Congress. But, this is not a new them e for physiotherapists: H eidi Paatero in h e r keynote address to the W C PT Stockholm Congress m ade the follow ing statem ent: “A profession should not be regarded as an institution which protects acquired m odes o f functioning in its own niche. It should not be regarded as a body o f knowledge and skills the possessors o f which are conservative and fea rfu l o f change. Instead it should be regarded as developing a n d changing functions - as som ething both open and dynam ic. It defin es its own go als - an ticip ates change, participates in the developm ent o f society and readily re-examines its bound­ aries and the content o f its activities”. H eid i P a ate ro - P h y sio th e ra p y in fu tu re Prospect. WHERE ARE WE AND WHERE ARE WE GOING? Physiotherapy is a practice-based p ro ­ fession and differences in practice and levels o f practice are inevitable. These differences can be identified both w ithin and outside national boundaries. In fact, the strength o f contem porary p rofession­ al practice lies in the ability o f individual physiotherapists to respond to the v ary ­ ing needs o f each patient in the m ost effective and appropriate w ay and to adapt their practice to take account o f the society in w hich they and their patients function. If physiotherapy is to fulfil its early prom ise as a dynam ic profession every physiotherapist m ust have an open m ind and the readiness to change their practice. H ow ever the tensions inherent in the flexibility o f autonom ous practice, w hich m ould the character o f the con­ tem p o ra ry p ro fessio n , h av e also the potential to pull it apart. It is therefore im perative to identify, validate and seek to preserve the key ele­ m ents of our practice w hich distinguish it from other professions. E veryone has a view as to w hat physiotherapy is from the perspective o f their ow n practice but in such a dynam ic, evolving profession it is extraordinarily difficult to focus the n a tio n al and in tern a tio n a l co m m o n d en o m in a to rs o f c o rp o rate p ractice. Studies w hich introduce objective crite­ ria into the analysis o f w hat p h ysiothera­ p ists are ac tu ally d oing w ith th e ir patients m ake a vital contribution to the national and international debates that are taking place to determ ine the essen ­ tial elem ents o f contem porary physio­ th e rap y p ractice. H o w ev er, w e m ust resist the tem ptation to m ake a definition o f physiotherapy that fossilises our p ro ­ fessional activity w ithin its current scope o f practice. QUALITY T he first objective o f W C PT is to encourage high standards o f physiothera­ py education and practice and I am delighted that the 13th G eneral M eeting o f the C o n fe d eratio n in W ash in g to n established a w orking group on Quality. T heir draft report was endorsed by our recent E xecutive C om m ittee M eeting in Istanbul. The report outlines a vision and p rin­ cip les fo r q u a lity in p h ysio th erap y, describes W CPT's role in quality in phys­ io th erap y and o u tlin e s a p ro je c t to achieve the vision. Im portant activities w ithin the project are conducting an inventory o f quality initiatives w ithin our M em ber O rganisations, the identification o f potential leaders in the field and the developm ent o f an assessm ent tool. In developing standards W C PT will recom m end the consideration o f a num ­ b er o f elem ents including: • Prevailing values, conditions and goals to advance the profession. • Valid principles w ith their m easures. • Strategies to m eet the changing needs o f the profession. SA J o u r n a l o f P h y s io th e ra p y 1998 V o l 54 No 1 5 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. ) • N etw orking the agreed standards to m em bers o f the profession, em ployers o ther health professionals, governm ents and the public. Perhaps it is tim ely to rem ind o u r­ selves that we m ust constantly w atch the “quality” o f our practice fo r its equity, efficien cy , e ffe c tiv en ess, a p p ro p ria te ­ ness, acceptability and accessibility. In any reflection o f our contem porary p ro ­ fessional situation we m ust resist the tem ptation to be insular and take account o f the trans-national nature o f the soci­ eties in which w e now operate. The im pact on our professional practice is likely to be considerable. THE GLOBAL VILLAGE R e cen tly I cam e acro ss D o n ella M eadow s concept o f the “ global village” in w hich she gives a snapshot o f a co m ­ m unity o f a thousand people based on the rigours o f a statistical analysis o f the m a c ro -ec o n o m ic and g eo -eco n o m ic forces that affect us all. It's a riveting study! So, if the w orld w ere a village o f a thousand people w hat w ould it be like? Such a v illag e w o u ld include 584 A sians, 124 A fricans, 95 E uropeans, 84 Latin A m ericans, 55 inhabitants o f what used to be the Soviet U nion, 52 North A m e ric an s, 6 A u stralia n s and N ew Zealanders. The village w ould have considerable difficulty in com m unicating. 165 people w ould speak M andarin, 86 English, 83 Hindi/U rdu, 64 Spanish, 58 R ussian and 37 A rabic... The o th er h alf o f the village w ould speak 200 other languages in a descend­ ing order o f frequency from Bengali, P o rtu g u ese, In d o n e sian , Jap an ese, Germ an and French, etc. O ne third o f the village w ould be c h il­ dren and only h a lf o f those children w ould be im m unised against preventable infectious diseases such as polio. Two thirds o f the total p o pu latio n w ould not have access to clean, safe drinking water. The village w ould have a total budget each year, public and private, o f over $3 m illion - the top 200 people w ould receive 75% o f the incom e o f the village and the bottom 200 people w ould receive only 2% o f the incom e. O f the total bud­ get o f $3 m illion, $181,000 w ould be spent on w eapons and w arfare, $159,000 on education and $132,000 on health care. In the next year, 28 babies w ould be bom only 3 o f w hom w ould be b o m to the richest 200. Ten people w ould die; three from starvation and one from can ­ cer. O ne w ould be infected w ith the HIV virus but w ould probably not develop Aids until a later date. O f the 650 adults in the village, 50% w o u ld be illite rate ... m o st o f th ese wom en living in the poorer part o f the village. The village w ould have enough explo­ sive pow er to blow itself to sm ithereens m any tim es over. T hese w eapons w ould be under the control o f 10% o f the popu­ lation. 83% o f the fertiliser w ould be allocat­ ed to the 40% o f the croplands ow ned by the richest and best fed 270 people. The grain yield o f this land w ould account for 72% o f the total harvest o f the village. T he rem aining 60% o f croplands w ould be allocated the rem aining 17% o f the fertiliser as a result o f w hich the average grain yield on that land w ould be 28% of the total harvest gathered to feed 73% of the population. D onella M eadow s in “I f the World W ere a V illage” Independent on Sunday 20.10.96. BRIDGING THE GAPS W H O R eport 1995 “The worlds biggest killer a n d the great­ est cause o f ill health a n d suffering across the globe is listed alm ost at the end o f the In ternational C lassification o f D iseases. It is given the code Z59.5 - extrem e p o v e r ty ” So opens the 1995 W H O Report... “Bridging the G aps” . It continues, “F o r m ost people in the w orld every step o f life, from infancy to old age, is taken under the tw in shadow s o f poverty and inequity and under the double burden o f suffering and d isease” . Largely as a result o f this report there is a w orldw ide professional activity to reduce the harm ful effects o f poverty. Why? Firstly, anybody interested in health has to pay attention to w ealth. It is the single m ost im portant driver o f health w orldw ide. Secondly, a great deal o f research is under way into inequalities in health. It affects every part o f m edicine and it is becom ing clear that even in developed countries, relative poverty (having an incom e substantially below the m ean for that society) has as great, if not greater influence on health as absolute poverty (lacking the basic m eans to live). This research is leading to im portant discover­ ies on how social pressures lead to d is­ ease outcom es. Thirdly, things are getting w orse not better. The gap betw een the rich and the p oor is tending to w iden both betw een and w ith in c o u n tries w ith in e v itab le effects on health. Lastly, there is increasing evidence as to w hat health w orkers and health ser­ vices can do to dim inish the harm ful effects o f inequalities in health. A t the sam e tim e as the net worth o f the w orlds 358 richest individuals has risen to equal the com bined incom e o f the poorest 45% o f the w orlds popula­ tion, the overall gains in health are being overshadow ed by a num ber o f factors. T hese are a decrease in life expectancy in eastern and central E urope, a rise in infant m ortality in som e areas, dram atic in c rea ses in d ip h th e ria, ty p h o id and w hooping cough and one third o f the w o rld ’s children under 5 show evidence o f m alnutrition as ju d g ed by their w eight fo r age. W C P T is a m em b er o f A ctio n in International M edicine. A conference in L ondon, join tly sponsored by A IM and W H O , w hich I recently attended prom pt­ ed the follow ing statem ent: "THE LONDON DECLARATION" A ll institu tio n s and asso ciatio n s of H ealth P rofessionals should: • U rge p o litical leaders o f their coun­ tries to m ake public com m itm ents to reduce poverty and im prove the health o f their populations. • E xchange and dissem inate inform a­ tion on trends in health and poverty and on successful and failed interventions d irected at tackling th e ir causes and effects. • R ecognise, harness and enhance the potential energy resource o f p o or people them selves. • W ork to direct m ore health resources to the district level o f their healthcare system s. • Foster and coordinate intersectoral and interagency collaboration, especially at district level. • W ork to elim inate the m arginalisation o f p o pu latio n gro u ps such as lonely eld e rly p eo p le , d isab led p eo p le and refugees. • E nsure that front line health workers have appropriate training and the ability to access and use relevant inform ation. 6 SA J o u r n a l o f P h y s io th e r a p y 1998 V o l 54 No 1 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. ) • Influence public opinion by liaising w ith national and international media. • Lobby governm ents to reduce their econom ic dependence on harm ful activi­ ties, such as the arm s trade, narcotics, nicotine and alcohol. I believe that w e can all play a part in this im portant initiative by m aking a per­ sonal response to its challenge. T hese are prim e issues that m ust be addressed both at a corporate and personal level. M any argue that our services should: • be directed to those w ith m ost health n eed s w h ich w o u ld au to m atically include people living in poverty, • be m ore accessible, appropriate and user-friendly for those least w ell o ff in society and • incorporate “m easures o f poverty” into our practice profiles to establish the connection betw een poverty and health status. Perhaps the least w e can do is to reflect on the need fo r equity in o u r ow n prac­ tice. A FRAMEWORK FOR THE FUTURE In this analysis I w ould like to draw y o u r atte n tio n to the w ork o f John N aisbitt, an A m erican social forecaster who m akes predictions for the future based on a dynam ic analysis o f w hat the w orld is today. It is such a sensible ana­ lysis that it has an irresistible appeal. Furtherm ore, his analysis has already been seen as uncannily accurate in m any respects, particularly the m ore general trends w hich are w ell docum ented and can be recognised w ithin our present day living experience. They will have an equally profound effect on our profes­ sional developm ent and the bureaucra­ cies w ithin w hich m ost o f us function. Som e o f the changes are sum m arised as follows: • The m ove from an industrial society to an econom y based on the creation and distribution o f inform ation; the com puter age. • A society m oving in dual directions tow ard “high tech” but with the w ill to m oderate its influence on o u r lives by the com pensating em phasis on the value o f “high tou ch ” . • G lobal interaction in w hich individ­ ual states cannot operate in econom ic isolation. • The restructuring o f a society run on short term considerations to one run on the basis o f a m uch longer tim e frame; forw ard planning. • The pressure in cities, states and organisations to act from the bottom up; grass roots pow er and netw orking. • The shift from institutional depen­ dence to m ore self-reliance. • The challenge to the relevance o f rep­ re sen tativ e d em o cracy in the era o f instantaneously shared inform ation; con­ sensus politics based on referenda. • The m ove from hierarchical struc­ tures w hich are failing in favour o f infor­ mal netw orks in w hich rew ards com e by em pow ering others, not by clim bing over them. • The m ove o f people from the indus­ trial heartlands; we are w here w e live. • The establishm ent o f a new society - from one with a lim ited range o f person­ al choices to a freew heeling m ultiple option society. John N aisbitt “M egatrends - Ten N ew D ire c tio n s T ra n sfo rm in g O ur L iv e s ” M acdonald & Co London and Sydney. E ach trend deserves some exploration fo r its effect on the future developm ent of our profession. M any are interrelated and im pinge on each other. U nfortunate­ ly tim e prevents a com prehensive an a­ lysis. However, there are two trends of particular relevance fo r physiotherapists that I w ould like to draw to your atten­ tion: 1. The shift from institutional depen­ dence to more self-reliance. T he present tendency to m eet every health challenge with m ore pow erful, costly drugs and highly expensive tech­ nological interventions will have to be balanced by the prom otion o f self help system s in w hich prevention is seen as a cheaper, preferable option to cure. In short, the em phasis has to shift from national sickness to national health initia­ tives directed to achieve an im proved quality o f life fo r all peoples. If the tran ­ sition is to be com pleted successfully it will be necessary to recognise that health education and prom otion, w hile longer term o b jec tiv e s, are m o re effe c tiv e options than reactive clinical practice. It is my b elief that physiotherapists will w elco m e the ev o lu tio n o f th is new em phasis in health care provision p artic­ ularly if it allow s them to direct their skills to w here they know they can be m ost effectively and efficiently used. We already play an im portant part in health care education and fitness program m es from coronary care to sports fitness; we are already involved in the physical, intellectual and spiritual em pow erm ent o f our patients; we are in an ideal situa­ tion to assist o u r patients, their relatives and their carers to m ove away from insti­ tutional buffers to self-help system s in w hich they can take increased responsi­ bility fo r their ow n health needs... we have been doing it for years! In the changing pattern o f health care, p h y sio th erap ists have a cred ib le and im portant role to play... confirm ing a fu n d am en tal p rincip le o f our cu rren t practice that physiotherapists do things w ith rather than for their patients. B ut are we reaching all the patients w ho could benefit from our service ? 2. A society moving in dual direc­ tions toward “ high tech” but with the will to moderate its influence on our lives by the compensating em phasis on the value o f “high touch”. It will be obvious to you that now here is the high tech revolution m ore evident than in our health care system s. The advantages are m any and obvious but unfortunately the m ore technology that enters our system s the less personal they becom e and for m any patients our hospi­ tals are no longer desirable places in w hich to be bom , treated or to die. It is also evident that despite the technologi­ cal advantages, society believes that the m edical institutions are failing them at a personal level. A s a result people are m oving away from the m edical m odel of health care to alternative practitioners w here they perceive their needs are m ore appropriately met. People w ant tim e and technology and it is no surprise to phys­ iotherapists that patients value the tim e elem ent o f care as m uch, if not m ore, than the technology. Taking an international perspective it has been observed that in the past two decades the affluent world responded to the health care needs o f the developing w orld w ith aids program m es that, in gen­ eral, featured high technology and high cost. This pattern o f aid resulted in the recipients concentrating their health ser­ vices in m ajor cities and universities thus having no real im pact on the health care needs o f the m ajority o f their peoples residing in the rural areas. This was p o w ­ erfully illustrated in an article w ritten by Professor Sm ilkstein o f the U niversity of W ashington and o ther authors w ho had w orked as physiotherapists in developing countries. ( ‘T he R ole o f Physical T h erap ists in Prim ary C are in the D ev elo pin g W o rld ’. S m ilkstein et al C linical M anagem ent, Vol.4, N o. I SA J o u r n a l o f P h y s io th e ra p y 1998 V o l 54 No 1 7 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. ) Figure 1 A m erican Physical Therapy A ssociation). The authors use a pyram idal m odel to illustrate the w eakness and d isad v an ­ tages o f this pattern o f health care p ro v i­ sion. (Figure 1) It was the injustice o f this pattern o f provision w hich led to initiatives to shift the em phasis o f aid to the prim ary care sector. The initiative becam e know n as the ‘H ealth fo r A ll by the Year 2 0 0 0 ’ cam paign. In the current w orld recession the race to ‘high tech ’ health care has im pover­ ish ed all o u r h e alth care system s. Increasingly health services are seen to be in turm oil as a result o f infinite dem ands being placed on system s with increasingly lim ited resources available to fund them. There is an international im perative to shift the balance from high tech tertiary provision to high touch p ri­ m ary care. RESTRUCTURING HORIZONTALLY W ithin any restructuring process it is im portant to rem em ber that physiother­ apy is the profession o f high touch and it is appropriate for us to exert our leverage to shift the axis o f health care in ways that we know will im prove the quality o f life for those in o u r care. We can do this in the c o n te x t o f the W orld H ealth O rganisation’s recognition o f rehabilita­ tion as an essential com ponent o f prim a­ ry care. Priority should be given to the social, econom ic and m edical needs o f all handicapped people in our com m uni­ ties. Strategies to m eet these needs m ust be developed. The question is how our system s can be restructured horizontally, w hat effect this will have on our professional p rac­ tice and w hether we have the w ill to effect the necessary change? There is only tim e to item ise som e o f the contem porary issues that need to be addressed: • Political and professional initiatives have to be taken to facilitate adequate health care provision at com m unity level. • Physiotherapists need to be increas­ ingly involved in prim ary health care issues and practice involving health p ro ­ m otion, disease prevention, delivery o f care and the direction o f rehabilitation program m es. • In crea sin g ly p h ysio th erap ists w ill function as part o f a m ultidisciplinary health care team each m em ber o f w hich w ill contribute to the practice objectives. • Physiotherapists m ust develop appro­ p riate p o licie s and train in g fo r the em ploym ent o f support personnel to be able to provide effective and efficient services dem anded throughout a wide range o f com m unity based program m es. • E m ploym ent structures and practices will need to be redefined to allow those w orking at a tertiary level to contribute w ithin com m unity based program m es by teaching, research and service projects. T h ose w o rk in g at c o m m u n ity level should be facilitated to participate in ter­ tiary education and practice program m es. Such horizontal structuring has the potential to im prove the quality o f life for m any handicapped people w ho m ight o th erw ise rem ain u n to u ch ed by the d e v elo p m en t o f h ig h tech m edical resources. T here is no doubt in m y mind that such horizontal structuring is prefer­ able to o th er o p tio n s in c lu d in g the rationing o f services w ithin the available funding. THE MANAGEMENT OF CHANGE N o one can ignore the m acroeconom ic and geoeconom ic forces that are affect­ ing us all. No one can ignore the exis­ tence o f the com puter and inform ation technology. The inability o f governm ents and politicians to find solutions does not isolate us from the need to seek solutions from w here we are as individuals and corporately as m em bers o f an im portant health care profession. In the p ast m ore stable era o f our p ro ­ fession everyone “knew their p lace” and as a profession we had little room to m anoeuvre o r the opportunity to apply political leverage. In these less stable tim es we can exert far m ore professional and political influence. It is a tim e filled w ith opportunity to shift the axis o f health care in w ays that w e know can im prove the quality o f life fo r m any more people. Change m ay m ean learning new skills, creating new relationships and adopting new routines. It m eans abandoning the p redictable and know n w ays o f doing things in favour o f new approaches and techniques. A t best it will be unsettling - at w orst a disruptive experience, but change will not occur if we are so intox­ icated w ith o u r present success that we fail to catch a vision o f the place w e wish to head for. “The engine fo r change is d issatisfac­ tion, the brake is fear” . ( ‘M an ag in g to S u rv iv e ’ S ir Jo hn H arvey Jones.) I w o u ld like to th in k tha t as we approach the m illennium the profession is in good h eart both nationally and internationally to face the challenge of the next century. It is m y b elie f that the profession is ready for change and cap a­ ble o f taking a lead role in the m anage­ m ent o f that change in our health care system s. In m y professional education I was taught the im portance o f the pause or period fo r recovery betw een periods of m axim al activity. We all need o f to reflect on the part we can play in effect­ ing the changes we know to be necessary. We started w ith M olly Levy and p er­ haps it is appropriate to finish w ith her, that is, to em ulate the exam ple o f her faith in the profession o f physiotherapy, to m atch her dedication to it and like her, find the general goodness w ithin o u r­ selves to drive the changes necessary for its survival. O n b eh alf o f the W orld C onfederation fo r Physical T herapy I salute the past ac h ie v e m e n ts o f the S o u th A frican Society o f Physiotherapy, I congratulate you fo r the ev idence o f y o ur present excellence and I look forw ard w ith confi­ dence to your future health in partnership w ith y o u r c o lle ag u e s th ro u g h o u t the world. 8 SA J o u r n a l o f P h y s io th e r a p y 1998 V o l 54 No 1 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. )