I look after older people with complex needs for a living. Alongside multiple co-morbidities, many have social vulnerability, functional impairment or communication difficulties which complicate the acute problem they presented with. This is the reality of modern hospital case-mix. Both Francis Inquiries recognised that it was the care of such frail older patients that had caused most concern.
I know I can’t do a ward round or be on call without drawing on the knowledge of AHPs constantly. In my clinical care of older people, I find that the comprehensive geriatric assessment – an interdisciplinary bio-psychosocial diagnostic tool that AHPs use with older patients when they present to hospital – means that they are more likely to be alive, independent and in their own home up to a year later. The AHPs are critical in getting patients back to their own home quickly from the front door of the hospital and ensuring good inpatient rehabilitation and discharge planning. They also play a vital role in stroke units, intermediate care, re-ablement and virtual wards.
AHPs, pharmacists and specialist nurses are highly skilled, autonomous professionals. I am always impressed by the way that even newly qualified therapists take full professional ownership and accountability for patient care. Unlike many overseas health systems, the NHS doesnt require doctors to 'prescribe' input from other members of the multidisciplinary team. These other specialists are rightly able to challenge doctors, often flagging problems that we have failed to recognise, and to advocate for patients. They add great value to teams – often leading them and acting as a safety net.
Yet, whenever the quality of health care is debated – whether in the media, in parliament, or even in the Francis Report and the Department of Health response, these vital staff are written out of the conversation. Everything is reduced to ‘doctors and nurses’, generally with falsely polarised praise for the technical medical advances and ‘medical’ care (despite many doctors’ failure to adjust their practice to care adequately for frail older people) and poor ‘basic’ nursing care, accompanied by half-truths about ‘matrons’, an imagined ‘golden age’ of nursing and the terrible consequences of introducing degrees as a requirement for nursing.
In the recent Health Service Journal list of influential NHS clinicians there was only one AHP – Karen Middleton, the professions officer for NHS England – who has responsibility for 12 different professions, while NHS England is stuffed full of doctors and nurses. This needs to change.
Despite my admiration for the work of AHPs, I do have some small criticisms.
First, they could be better self-advocates. I realise that there are a large number of nurses and that doctors are a powerful group, but I think that AHPs could be more visible in promoting their roles and skills. In repeated scandals around poor care, AHPs could keep their heads down amid the nurse-bashing, but they are best placed to claim a stake in accepting responsibility for deficiencies in care and be seen to be part of the solution.
Second, I do think there are times when graduate practitioners (for instance in occupational therapy and physiotherapy) are doing work that could be delivered by generic rehabilitation assistants and supervised by them. For some aspects of rehabilitation, boundaries could be flexible.
Third, we need to move towards one common set of clinical records and trusted assessments, avoiding duplication of assessments, which bewilder patients and introduce delays. Sometimes it is therapists who maintain this territorialism.
Finally, they suffer the same issue as nursing – that once people move into senior leadership roles they generally stop hands-on clinical practice – and possibly therefore lose clinical credibility – in a way that doctor-leaders do not.
Despite these quibbles, it’s high time we gave AHPs overdue recognition as key players in services that are now team ventures. Population demographics mean that increasingly the business of health care will be the business of caring for older people who require a genuinely multidisciplinary approach. We can’t do it without them.