Let’s hear it for allied health professionals

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Reflecting on our recent paper on the NHS and social care workforce, modern health care is a team venture. It is impossible to deliver effective care without the crucial contribution of highly trained allied health professionals (or AHPs).

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.

Comments

george coxon

Position
independent healthcare advisor / care home owner,
Organisation
classic care homes devon
Comment date
09 August 2013
As well as the above roles I am also a MHN and CPN during the 80s and 90s (currently am still chair of the MHNA - mental health nurse association) - I was a senior commissioner during the noughties too for many years and have a wide and varied continuing role working across primary, community secondary and specialist care areas as well as a pluralist working with pharma organisations - enough of me setting the scene for my comment !! my comment is about what we are all doing to address the plight of older people not just AHPs. I am leading some work on dementia kite marking across Devon with a growing group of likeminded care providers - mostly independent sector colleagues where we are trying hard to contribute to better integration of health and social care for older people with a disconnected system seeing too many people with dementia especially going to hospital too easily, staying too long, not doing well there and many dying there - only very exceptional circumstances should have a person dying in hospital with dementia. the word I used earlier was plural - this for me is the key to addressing the inevitable challenge ahead re A&E, hospital activity explosions and NHS bankruptcy - true integration must become a reality for us all AHPs, care home providers, CCGs and most critically frail older people inc those with BPSD. I hope my thoughts add some value in a debate we must all continue to have many thanks

Michael Dimov

Position
Interim Assistant Director - Clinical Services (Bedfordshire),
Comment date
09 August 2013
Excellent article and perfectly valid points! Can AHPs respond with a single voice? The "doctors and nurses" stereotype leaves many excluded. It would be very difficutl to integrate pathways and services without achieving a shared identity for those involved in delivering various aspects of care.

Liz Mowbray

Position
Head of Therapies and Rehabilitation,
Organisation
Oxford University Hospitals NHS Trust
Comment date
09 August 2013
Thank you for your support David and recognition of the crucial and vital role AHPs can play. Locally, I'm advocating the same, creating and gaining some support for the appointment of band 8a, AHP clinical leadership posts; physiotherapists and occupational therapists who are experienced enough to make complex decisions that may be considered too greater risk by those who are less experienced. These posts also have an impact on patient goal setting, the development of rehabilitation plans for elderly patients in the acute sector; too many have been left immobile and dependent during a hospital admission.

Commonly, there is a lack of inter- professional working, professional silos with in organisations and across boundaries. Each profession should trust and respect each other whilst working together to develop a safe patient environment. True MDT working and the creation of “great teams” takes cultural transformation and leadership development to achieve. Look at the amazing work at the UCLP Staff NHS Leadership College and the impact made clinically to MDT working at UCLH. This all impacts on the delivery of high quality patient care.

I do support what you say about the strong nurse and doctor representation; AHPs are often represented by nurses and are not considered to be able to represent themselves. We need to gain more AHP representation at Board and Director Level, to influence what should be important multi-professional decisions which will then filter down to the clinical coal face. Once this works well within a single organisation then it will filter out across boundaries and help to bring to integration gap ever closer and more patients remaining safely within their own homes.

Helen Whiteside

Position
Clinical Care Home Pharmacist and Independant Prescriber,
Organisation
Leeds West CCG
Comment date
09 August 2013
Brilliant article
Great to see pharmacists mentioned. As an ex hospital pharmacist, I loved working alongside other AHPs on acute admission, long term elderly care and stroke wards over 20 years. AHP were extremely helpful in prioritising patients who needed my support.

In this time I am please to have witnessed a gradual change to patient care to a less medical management model to reflect the need for and impact of all the teams' skills. Sadly, in particular discharge decisions remain too often within the "medically fit" model but more and more acute wards now regulary have pharmaceutical care team represented at decision making ward rounds and meetings.

Our willingness to undertake patient assessment, counselling and overseeing medicines element of rehab e.g. self medication of medicines schemes is rarely in doubt - but it is still hugely hindered by our time input still required by the other elements of a pharmacists and pharmacy staff jobs.

This patient support element of our role in hospitals requires review and extension or teams built up in community settings primed to support patients, especially those unable to get to GPs, community pharmacists and others who are fixed in specific sites in primary care.

Medicines safety and risk management in many hospitals is still underpinned on a daily basis by pharmacists role in prescription/ chart review and supply authorisation. Our roles within Trusts have expanded in recent years to include essential medication reconcilliation and clinical medication review to meet the challenge of the safety agenda when dealing with highly complex, elderly and frail patients, their medicines and the risks of information mistransfer across the interface.

The current position of (in my experience) insufficient pharmacy input into practical medicines support and rehab will remain until electronic prescribing and changes to pharmacy department supply procedures, policies and staffing structures are wholesale across the NHS.

Our voice on the subject of MDT integration is often quiet as our pharmaceutical professional body is not a cohesive animal given the diversity of the profession and the miriad of different 'types' and specialities of pharmacists - across hospital, primary care and industry.

As for patient notes, most hospital pharmacists I know gave up using their own notes several years ago and simply use handover sheets/ computer tracking to ensure essential tasks are completed for each patient, using the medical notes to record all other information but I am aware that all the therapy teams I worked with had not made that move.

Now, as a medication review pharmacist and IP in primary care I use either the GP record and / or the care home patient record for all my notes. I do not keep anything seperate.

We are a relatively new arrival to the primary care scene but one which is very much welcomed by GPs when they see what we can do to help them and their patients.

Iain Cockley-Adams

Position
Business Manager,
Organisation
Gloucestershire Care Services
Comment date
09 August 2013
I wholeheartedly endorse your message. I’d like to take it a small step further too. You say that “increasingly the business of health care will be the business of caring for older people who require a genuinely multidisciplinary approach”, whilst this is true, the need to shift the focus away from admission into acute hospitals goes beyond how we meet the needs of any one age group – and greater emphasis on the AHPs in many pathways will ensure that the cash savings are made with improved outcomes.
In areas such as the management of the diabetic foot and the diagnosis and treatment of MSK conditions, multidisciplinary teams with a primary/community care mindset supported by the relevant AHP services are the way forward. Of course, they must work well with the consultant-led services (and ideally have consultant engagement) but I contend that patient needs and financial imperatives can be better met be a conscious move away from the consultant led model.
I work with a multidisciplinary team of AHPs (Podiatrists and Physios) and GPSI providing a MSK Clinical Assessment & Treatment service. We have built up a body of Patient Reported Outcome Measure scores from more than 2,800 patients evidencing that we not only reduce secondary care admissions but we deliver significant and long term improvements in patients’ conditions. Saving £millions in avoidable secondary care treatment and repeat attendance at GP surgery.
And yet some still say that our model should be consultant led – in the interests of patient safety and clinical outcomes, despite the lack of evidence to support this view. In other parts of the country CCGs continue to tender for MSK interface services specified as consultant led. Perhaps there is a danger that one consequence of the NHS reforms will be that greater clinical leadership will come to mean even more focus on “doctors and nurses”.

Emma J

Position
Senior OT,
Comment date
09 August 2013
As I have read the recent reports on the healthcare system I have become more and more disillusioned being an AHP in the NHS. With no mention of therapy in particularly the Keogh report and even my trusts aim do not mention us I end up feeling a little bit of a spare part in a very big wheel. I do what I can at my level but as you mention promotion comes with less clinical time, and I don't want to loose this limiting me to a band 6, seemingly for the rest of my career.

David Oliver

Position
consultant physician/Visiting fellow,
Organisation
Royal Berks/Kings Fund
Comment date
09 August 2013
Thanks for all the posts so far. I can only endorse Helen's point about the vital role pharmacists have to play and i think we could make more use of their skills and knowledge - including those in the high street pharmacies. I agree with Liz from Oxford that we need far more joined up care and fewer silos and that sadly, silos exist even between groups of therapists in many parts of the country with community rehab teams or community hospitals or single points of access insisting on referrals, documentation of rehab goals etc etc from colleagues who have already done all this. We need to do a good comprehensive asssessment once, add to it where we need to, share it and trust one another rather than creating a whole load of extra steps and "death by assessment". For Ian, i completely agree that musculoskeletal conditions are also an important test bed for interdisciplinary and interagency working. My focus happens to be old people because thats been my career but integration and continuity can benefit other groups to as clearly can AHPs. For Michael, and the "single voice" i guess my point was that if we look at some of the big issues that patients and carers complain about then they include big-time nutrition (dietetics), safe discharge from hospital (OT), people losing function and independence whilst in hospital [PT], communication around changes in drugs and side effects to look out for [Pharmacy] etc etc I could go on but you get the point. In all of those common complaints i would like to see the various AHP organisations saying loud and proud "we have a key stake in getting this right and we can help deliver many of the solutions" [but doing so also means that you cop the flack that nurses and doctors have taken over the numerous scandals aorund poor or unsafe car]. For Emma J, i completely sympathise with your predicament and it isnt easily in your gift to solve. But ultimately nurses and therapists have some control over their own national pay scales and career structures. I was able to be the national clinical director in the DH and still do 2-3 days hands on clinical work [as do most divisional directors in hospitals who are doctors and many CCG leads and as did other NCDs]. I dont see why careers couldnt be restructured so that even a director of nursing or a manager of a big hospital OT service couldnt do a day or two a week clinical work to keep their hand in and remain grounded in frontline reality. As for George, of course i agree with all you say about the need for integrated and preventative care closer to home for those with Dementia, but it just didnt happen to be the subject of my blog which was very much focussed on greater recognition for allied health professionals.

David Oliver

Rosalie Boyce

Position
Principal Research Fellow (Allied Health),
Organisation
Australian University
Comment date
12 August 2013
David thank you for an inspiring blog.

I’d like to respond to the point you and Michael raise about allied health ‘speaking with one voice’ and offer a view from Down Under.

Since the late 1980’s the Australian health system has invested in developing the Director of Allied Health (or equiv) role as a crucial leadership and structural/governance approach to bringing together all the creative intelligence and clinical skills of the various health professions into the managerial and policy domain of health services and the health system more broadly. I’m going to propose that if you want allied health ‘speaking with one voice’ then you have to have the leadership and infrastructure there to support and nourish it.

An important part of our pathway to that outcome has been through leadership positions such as the Director of Allied Health (similar but bigger than your Director of Therapy or equivalent but I’m not sure you have many of them left in England at least?). Not more costly managers I hear some say. No, these positions pay for themselves through driving change at clinical and corporate level and saving money by doing such things as ensuring clinical programs have the right skill mix of professional services (aka Ian's comments) or closing down ineffective services and directing resources elsewhere. They wouldn’t prosper here if they weren’t effective. Yes, it is a ‘cop the flack’ role equivalent to that of the most senior medical and nursing position in the organisation and one of the many roles is to support the development of, and be accountable for, quality, performance improvement and safety issues for patient care.

These roles didn’t come about in Australia because the professional associations or the health service organisations wanted them. No! They came about because individual allied health professionals saw that there could be a better way and they clubbed together (often in the face of strong barriers) to form interprofessional leadership groups and organisations under the identity of ‘allied health’ and fight for these positions (and to keep them).

The guiding vision for these developments was “Allied Health: Allied to Each Other and the Communities we Serve”. Across Australia today we have more than a hundred people with the responsibility of Director of Allied Health type positions (all with an allied health background) working together with medical, nursing and management colleagues to create better care for patients and stronger health care policy. The majority of our hospitals and health services have these roles, as well as Chief Allied Health Advisors in the Government. In addition to these leadership positions we have fantastic organisations such as ‘SARRAH (Services for Rural and Remote Allied Heath); IAHA (Indigenous Allied Health Australia), both member-based associations created by the drive, passion and commitment of individual allied health professionals joining together to create change.

Health Workforce Australia and the federal, state and territory governments have supported the development of ‘allied health’ as they know you can’t progress patient care or workforce planning etc. if you don’t have all the ‘shareholders’ at the table. For allied health it is essential that they speak with one voice to be heard.

Our latest innovation is the formation of an individual member association called AHLANZ: Allied Health Leaders of Australia and New Zealand. Allied Health is taking the fledgling step to internationalise across borders and there is a lot of sharing between Australia, New Zealand and the UK in particular. The creation of ICHPO: International Chief Health Professions Officers group is another example of that vision. However, there is more work to do, much more to do. Next international meeting is the 2nd International AHP Conference Edinburgh on 3/10/13 if you’d like to get on board with allied health ‘speaking with one voice’. See you there??

Note 1: Allied Health is broader than a ‘therapy’ concept in Australia. In any hospital or health service, allied health would typically consist of at least 10-12 professions and perhaps up to 20 or 30 depending on how it is constituted.

David Oliver

Position
consultant geriatrician/visiting fellow,
Organisation
royal berks/kings fund
Comment date
12 August 2013
Dear Rosalie

I am sure everything you have said will be of immense interest to the readers. Just to be clear, when we discuss AHPS in the UK, although i have a particular interest in OT/PT/SALT/Dietetics/Pharmacy because they are the professions i deal with day in day out in the care of my patients, we do define it more widely - so for instance Podiatry, Audiovestibular clinical scientists etc would also be in my thinking. I don't have the right expertise to comment in detail on career progression to senior leadership roles among AHPS in the UK and other readers will have views. What i can say is that when i have been to Australia and New Zealand to speak at conferences it has always struck me how PT and OT are very prominent researchers (for instance several of the world's leading falls/exercise researchers are from PT/OT in Australasia) often presenting as many papers and posters as the medics and seemingly on a level playing field. In terms of career progression, and as i say i am not an expert so speak just anecdotally from experience, there appears to be a long tradition over here of nurses progressing from clinical roles, becoming operational/general managers no longer practicing clinically and often going all the way to CEO posts. I have seen several OTs and PTs go down the same route, or moving into consultancy. And of course, nurses and therapists can progress to senior hands on clinical roles such as nurse consultants/advanced practitioners/highly specialised senior therapists. What i have not seen is the equivalent of what doctors commonly do which is to be a senior medical manager running a large section of a hospital or a clinical commissioning group, or a royal college or being a senior government official, whilst continuing to practice clinically on the wards, on call, in clinic etc. It was a disconnect from the coalface and operational matters that was behind many of the problems at Mid Staffs and my view is that to keep registration, continuing clinical practice should be a requirement, Its also good for morale among the troops to see that their leaders can still do what they do
But maybe thats just me

David

Fiona Jenkins

Position
Executive Director Therapies and Health Science,
Organisation
Cardiff and vale University Health Board
Comment date
12 August 2013
Thanks David for being such an advocate for AHPs, this is welcomed., as you say we dont often make ourselves as visible as we should - but Exec Director roles for AHPsin Walesis a step in the right direction. Career paths for AHPs have not often enabled the maintenance of clinical practice while moving into more senior roles, as Agenda for Change banding for AHPs as with Nurses rewards different element that the medical consultant contract., and the relatively few consultant AHP posts we have tend to focus on expert pracrice and R&D. However I agree we must maintain clinical credibility and ensure that those leading the professins maintain their clinical expertise and patient focus. You will be pleased to know that research I am currently undertaking identifies that the majority of most senior physiotherapy leaders in England and Wales do undertake some element of clinical practice.

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