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

Lynne Douglas

Position
Director Allied Health Professionals,
Organisation
NHS Lothian
Comment date
13 August 2013
David, thank you for your sharing your thoughts and insightful view on AHPs in our modern healthcare system. As a clinical leader and one of 14 directors of AHPs in NHS Scotland I come from a perspective that we can speak with one voice certainly in a political and strategic sense. We probably don't market the 'brand ' enough and the public on a 1:1 interface with an AHP rightly think of us as a OT, PT, Dietitian..etc
In part the defensiveness I think can come from a distinct lack of clinical respect afforded at times within the 'system'. We are small in number and often investment has not kept up with the shifting needs of a different case mix as you point out.
I feel privileged to to lead this highly professional group of staff, and recognize that we are fortunate and well developed at attaining board level leadership in Scotland. I agree we have some modernizing to do with regard to workforce and models of care but most importantly we will continue to deliver person centered, outcome focussed quality care to the patients we serve.
We have many advocates who promote innovation, enhancing the evidence base and happy to fly the AHP leadership flag. With the onset of personalization, integration and a rapidly changing population demography I am confident the skills of AHPs will be required for a very long time to come.

Camilla

Comment date
13 August 2013
David,
I absolutely agree, and the reports that you mention are such an important platform for public conversation, with patient care at the centre of discussion. I also think your point about being armed with solutions is a subtle but valuable suggestion in the context of innovating culture.
Many thanks for your response,
Camilla

Christine Whittaker

Position
Assistant Director for Service improvement,
Organisation
Bridgewater Community Healthcare NHS Trust
Comment date
13 August 2013
What a refreshing blog and about time the issue of the "invisibility" of AHP's was raised. As a physiotherapist who went into management in the mid Nineties and general management in the mid Noughties I also held a clinical caseload for 6 years. It became impossible to maintain, as I took on additional work, as AHP services simply do not have the flexibility of approach that medical colleagues have maintained. Perhaps adopting a “job plan” approach to structuring the delivery of AHP services might make this easier for younger AHP colleagues to do in the future.
In managing medical and nursing services after managing AHP’s I was struck by the difference in cultures between professions, once I stepped away from my own. The characteristics of many AHP's of a problem solving approach and a willingness to take properly assessed and mitigated "risks" is what the NHS should be encouraging, in the current circumstances. Too often the concentration is on problem identification with little resulting action. More AHP's at Board or sub-Board level would bring a proactive approach to the changes we need to make to our services to ensure we continue to deliver high quality patient care whilst improving efficiency and effectiveness.
Time to harness the enthusiasm and energy of the AHP professions. Doctors and nurses may save lives but it is AHPs who can make that life worth living again.

David Oliver

Position
consultant physician/visiting fellow,
Organisation
royal berks/Kings fund
Comment date
13 August 2013
Hello Again

To Vi Nu, I am a consultant myself and spend most of my time in secondary care, but i do have consultant colleagues who work almost full time in the community. My personal view (and it is a personal view) is that there is no need for people to get hung up on an MSK service being "consultant-led". The majority of MSK are already dealt with in primary care in any case and the last thing most consultants want is to be spending lots of time seeing patients who could be dealt with perfectly well in primary and community care. What IS important is to ensure that patients have full access as part of any programme or pathway to the full diagnostic and acute care facilities of secondary care when this is required and that there is adequate access to specialised diagnosis for more complex cases. I dont ever for instance want to see older people denied access to secondary or acute care expertise on the grounds of age alone. But if secondary care/the consultant is at the top of the apex of demand - with many people being dealt with lower down the pyramid, i can see no need for a consultant to lead the entire MSK programme. What is crucial though is for secondary care experts to be part of designing the pathway so their expertise is used from the outsed and for there to be clear mechanisms for accessing specialist expertise.

With regard to Camilla's point, its one i recognise. Speech and Language therapists are highly skilled and provide an invaluable service (on my ward now they have been very helpful in assessing and following up 5 of my current inpatinets for instance) and you are right, even compared to other AHPs such as PT/OT/Radiography they are small in number. I dont think i ever advocated in my own comments that there should be some kind of "one voice" coalition between AHPs and each discipline does have distinct skills and messages. And inevitably, you arent going to see many Speech and Language therapists ascending the corporate ladder and moving away from the bedside when they ar already busy enough trying to maintain a core clinical service. But what would have been refreshing in the wake of Francis, Ombudsman's Report, Patients Association Reports, Keogh Reviews, Dementia Strategy, Government Push on integration, etc etc is a really strong set of messages coming from each of the disciplines about their crucial role in getting some of the care right and really pushing themselves into the "public conversation" armed with solutions but also saying (as nurses have done) that they might not have the numbers and support in many places to do their job as well as they would like

David

vi nu

Comment date
13 August 2013
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”.

C

Position
Research Speech and Language Therapist,
Comment date
12 August 2013
David,
Thank you for this blog, championing the role of AHP’s and the important discussion that has followed. The mention of cultural innovation is very interesting, but equally complex to achieve. For a protracted period of time, AHP’s have worked hard to ensure their specialist clinical skills are recognised, their voices are heard, and their expertise are reflected in pay scales and within hospital hierarchy. Clinical posts are frequently frozen for cost saving measures, or downgraded, and much effort is spent by professional leads, protecting small specialisms, such as my own, speech and language therapy. I believe the inherent awareness of being a vulnerable underfunded, small service which managers don’t really ‘understand’, has resulted in a reluctance to blur the boundaries of our clinical expertise, and rather, actively retain our skills and identity. It is in my opinion that we are hesitant to become part of the monolithic ‘doctors and nurses’ group due to our perceived vulnerability. In reality, our independent position on the health care spectrum actually exacerbates the issues we are most concerned about, as we are less likely to have representation via influential positions within health care trusts, people have less exposure to our skills due to limited integration etc etc. The shift in culture required to change this situation undoubtedly needs to come from within our professional groups, however, I think this will be a difficult task in such challenging economic times. Do you have any suggestions for tacking this complex cultural situation? Camilla

David Oliver

Position
consultant physician/visiting fellow,
Organisation
royal berks/kings fund
Comment date
12 August 2013
Fiona

That sounds like a really positive development you are describing and i can only commend it. The interesting thing regarding agenda for change or the renegotiation of the GP or Consultant Contract is to what extent clinicians were involved in negotiating what they wanted out of the deal. Clearly, doctors, and in particular the BMA have been quite successful in negotiating favourable terms and conditions. What I don't know and am interested in is whether when nurses or therapists via their own colleges/societies were influencing agenda for change whether they lobbied hard for career structures that enabled people to work in clinical practice alongside management roles. It strikes me as unfair that a doctor is able to progress his or her career into senior leadership roles while continuing to be a hands on doctor, but that for others they are often effectively forced to stop clinical work - which is the reason most of use came into the caring professions. I wonder how many senior nurses and therapists would really like to continue in clinical practice alongside divisional or board level roles but find that their career structure doesnt allow it. Anyway, i can only say keep up the good work

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.

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

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.

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