Responding to Changing Population Needs. Professional Specialisation. Helen French, PhD, MISCP

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1 RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn Responding to Changing Population Needs Professional Specialisation Helen French, PhD, MISCP

2 My Perspective Currently Senior Lecturer in School of Physiotherapy, RCSI, Dublin, Ireland. Previously: Clinical Specialist in MSK in public healthcare setting Specialist member of ISCP MSK clinical interest group Ireland rep to IFOMPT (International Federation of Orthopaedic Manipulative Physical Therapy (WCPT subgroup)) Member of ER-WCPT Education WG

3 Overview What is Specialisation? Benefits and Challenges Competencies required Changing Population needs Generalist vs Specialist Emerging Competencies Moving Forward

4 What is Specialisation? Specialist Physiotherapist Formally demonstrated an ability to apply advanced clinical competence Defined clinical area Within the scope of practice recognised as physical therapy. Specific area of clinical and /or teaching practice Research/evaluation and practice/service development (WCPT, 2011)

5 WCPT guidance on Specialisation Formal process for testing and acknowledging the advanced clinical knowledge and skills of the speciality. Formal recognition of his/her knowledge and skills through a MO or accredited agent. Specialisation is not to be considered, or implied, to mean a limitation on practice.

6 Terminology Advanced Practitioner Clinical Specialist Physiotherapist Specialist Extended Scope Practitioner

7 Stakeholders Public Legislators Professional body Physiotherapist Educators Regulatory Authority

8 How do you define a specialist? Recognised Role/Pay grade Recognised by Professional Body Years of Experience? Achievement of Competencies

9 ER-WCPT Attributes of a Specialist Advanced Knowledge and Skills within specified area of of practice Demonstrates EBP through the processing of clinical reasoning and decision-making. Allows knowledge to be applied to complex/different situations. Demonstrates an education role Generates new knowledge and skills (by critical evaluation of practice) Demonstrates leadership Demonstrates a critical understanding of the context in which practice occurs (e.g social, political, inter-professional collaboration). Clients with complex needs Complex and unpredictable contexts (CSP, 2016)

10 Autonomy is a pre-requisite Physical therapists, as autonomous professionals, should have the freedom to exercise their professional judgment and decision making, wherever they practice, so long as this is within the physical therapist's knowledge, competence and scope of practice. (WCPT, 2011)

11 Shifting Models of Care Traditional Model Doctor is key decision maker Long Wait times Emerging Models HSCP is a first point of contact Key clinical skills Drivers European Working Time Directive Rising healthcare costs Value for money

12 Examples of Specialisation Role substitution related to traditionally performed medical acts First contact practitioner Soft tissue injuries in ED Preventing hospital admission (e.g. Frail Elderly in ED) Triaging potential surgical candidates (e.g. orthopaedics) Gatekeeper: Primary Care MSK service Ordering & Interpreting Diagnostic Imaging/laboratory tests Prescribing Medication/Oxygen Therapy Injecting medication (Corticosteroid/ Botulinum Toxin) Advanced clinical care Complex case management

13 Benefits of Specialisation Integrated Care High Quality Care Cost-Effective

14 Evidence for Specialisation: Role Substitution Equivalent /More Beneficial than Doctors Treatment effectiveness Diagnostic accuracy Ordering /Interpreting investigations Patient Satisfaction Indirect Medical Costs Consultation times (McClellan et al, 2012; Daker-White et al, 1999; Richardson et al, 2005; Kennedy et al, 2010; Taylor et al, 2011; Samsson et al, 2016; Marks et al, 2016; )

15 Challenges to Specialisation Profession Professional Visibility Governance Costs Regulation Standardisation Education /Training needs Deprofessionalism Individual Therapist Perceived Hierarchy Achieving Competencies Maintaining Core Competencies Recognition/Role Professional Identity Employer/Service Succession Planning Education /Training Professional Visibility

16 Emerging Challenges to Health Systems (Frenk et al, 2010)

17 Emerging Competencies? Leadership Inter-Professional Working Critical Thinking /Reflective Practice Innovation Technological competence Professionals are falling short on appropriate competencies for effective teamwork, and they are not exercising effective leadership to transform health systems (Frenke et al, 2016).

18 Changing Population Needs

19 Lifestyle Conditions

20 Epidemiology of Multi-morbidity (Barnett et al, 2012)

21 Modifiable Risk Factors for Lifestyle Conditions Smoking Nutrition Physical Inactivity Obesity Hypertension Alcohol

22 The Role of the Generalist Physiotherapist 90% of healthcare needs addressed in Primary Care Not all patients are complex Client mix from Cradle to Grave Physical Therapists have a significant role to play in health promotion and building healthy lifestyles...irrespective of diagnosis or practice setting (Dean et al, 2013) 2 nd Physical Therapy Submit on Global Health ( 2011) DOES THIS REQUIRE A SPECIALIST ROLE?

23 ADDRESS Modifiable Risk Factors for Lifestyle Conditions Smoking Nutrition Physical Inactivity Smoking Cessation Optimal Nutrition Increase Physical Activity + Exercise Obesity Weight control Hypertension Stress Management Alcohol Counselling on Alcohol/Substance abuse Dean et al, (2014): 2 nd Physical Therapy Summit on Global health

24 56 yo Male with Chronic Knee Pain X-ray shows Joint Space narrowing BMI = 28 Co-Morbidities: Diabetes/COPD Smokes 10/day Reduced Physical Activity ALL Physiotherapists ideally placed to facilitate health behaviour change

25 ALL Physiotherapists ideally placed to facilitate health behaviour change

26 A strong, generalist primary care system based around an appropriately skilled multi-professional team is the most obvious way to deliver holistic, longitudinal care for most people with multiple disorders, and should seek to maximise quality of life and minimise future disability and morbidity (Barnett et al, 2012)

27 Going Forward: Across ER-WCPT Role of ER-WCPT Education WG Updating the Current ER-WCPT Guidance on Specialisation Review Specialist Competencies Provide Best Practice examples Promote future methodologically robust research to demonstrate the positive impact Formalised, internationally recognised training to develop expertise WCPT Clinical Interest Subgroups Recognise Role of the Generalist Physiotherapist

28 Implications for MOs Start locally Identify need Leadership skills Build relationships Find an Advocate Be brave Use available evidence/good practice examples Make strong business case Collect your own data

29 Summary Physiotherapy has an important role in global health. Specialisation is an ever-growing and evolving component of physiotherapy practice BUT represents a small area of practice Evidence is building but dominance of MSK evidence Specialist competency framework should be aligned to changing health system and population needs. We also need to recognise the key role of the generalist physiotherapist in global health

30 References Barnett K, Mercer SW, Norbury M, Graham Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and implications for health care, research, and medical education: a crosssectional study. Lancet 2012; Aitken A.B. and Mc Coll M.A. Diagnostic and treatment concordance between a physiotherapist and an orthopaedic surgeon- A pilot study, J InterProf Care 2008: 22 (3): G Daker-White, A J Carr, I Harvey, G Woolhead, G Bannister, I Nelson, M Kammerling. A randomised controlled trial. Shifting boundaries of doctors and physiotherapists in orthopaedic outpatient departments. J Epidemiol Community Health McClellan CM, Cramp F, Powell J, Benger JB. A randomised trial comparing the clinical effectiveness of different emergency department healthcare professionals in soft tissue injury management. BMJ Open 2012;2 Marks D, Bisset L, Comans T, Thomas M, Kay S, O Leary S et al. Increasing Capacity for the Treatment of Common Musculoskeletal Problems: A Non-Inferiority RCT and Economic Analysis of Corticosteroid Injection for Shoulder Pain Comparing a Physiotherapist and Orthopaedic Surgeon. PloS One 2016; 11(9). Samsson KS, Bernhardsson S, Larsson MEH. Perceived quality of physiotherapist-led orthopaedic triage compared with standard practice in primary care: a randomised controlled trial. BMC Musculoskelet Disord. 2016; 17: 257.

31 References Napier C, Robert G. McCormack RG, Michael A. Hunt MA Brooks A. A Physiotherapy Triage Service for Orthopaedic Surgery: An Effective Strategy for Reducing Wait Times. Physiother Can 2013; 65(4): CSP (2016). Advanced practice in physiotherapy. Frenk J, Lincoln Chen L. Bhutta, Cohen J, Crisp N, Evans T, Fineberg H, Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet 2010; 376: Desmeules F, Roy JS, MacDermid, Champagne F, Hinse, Woodhouse LJ. Advanced Practice Physiotherapy in patients with musculoskeletal disorders: a systematic review. BMC Musculoskel Dis 2012; 13; 107.