Physiotherapists as Role Models

It was great to see the Role Model article in Frontline this week and really interesting to read Professor Phil Reed's response to the question.

Asking Difficult Questions; Shall I, Shan't I?

The role of the physiotherapist in delivering health messages has had a lot of attention recently.  The prevalence of lifestyle diseases alongside rising concern about the sustainability of health and social care systems has brought preventative care into the spotlight.  AHPs make up approximately 6% of the NHS workforce and they have been identified as an untapped public health resource. 

As AHPs find themselves increasingly reflecting on their role in public health we have cause to consider our role in wider health promotion and Physiotalk hosted an interesting tweetchat about this just last night.  I've mentioned in previous blog posts  the huge role that health behaviours are thought to have in contributing to overall health (McGinnis et al 2002).  This challenges us to consider the balance between reactive treatment of the presenting complaint and proactive, preventative care of the whole person.

The Royal Society for Public health & Public Health England recently published a joint report on AHPs & healthy conversations.  In brief, the results from the survey show clear collective ambition amongst AHPs to be recognised for their role in public health.  It also shows that many AHPs frequently initiate healthy conversations with their patients.  This was matched with positive views from the public about the perceived credibility and trustworthiness of the advice AHPs give.

However, a number of barriers to initiating healthy conversations were raised in the report, these include being embarrassed to raise the issue and feeling that it is not appropriate or could be insensitive.  If we are to promote behaviour change we first have to identify risky behaviours and then openly discuss them and this can be awkward for both clinician and patient. We may want to ask about tobacco use, alcohol consumption, weight/nutrition or drug use, in some areas of practice it may be appropriate to ask about risky sexual practice or domestic abuse.

This blog post was published in BMJ recently, it gives an interesting patient perspective; the author asks healthcare professionals to;

Think twice before offering unsolicited advice in the guise of “education,” particularly when your patient is consulting you about something unrelated. If your patients hear the same potted advice during every appointment, it’ll soon lose its impact; and if you insist on bringing up a subject that they find traumatic you could put them off seeking your advice in future.

The author of the blog post had many negative experiences of receiving well intentioned, but poorly delivered, advice.  In contrast to this perspective, a sub-analysis of a large US study explored patients' reactions to being asked questions about smoking, diet/exercise and alcohol during primary care consultations.  The vast majority of participants stated that they felt "very comfortable" answering these questions.  They were then asked how important they thought it was for their care provider to know about these health behaviours and the vast majority considered it to be "very important". 

So, in this study, participants didn't mind being screened for health behaviours and they considered it to be an important process, I think the important thing here is about offering a service and allowing the patient to make an informed choice about whether or not they want it.  This would avoid unwanted, paternalistic advice (as per the above blog post) but would fulfil our moral and professional obligation to promote health.

In contemporary health care, health behaviour change is a key clinical skill and we need to take it seriously.   We need to look at best practice and reflect on our own strengths and weaknesses so that we can plan our development accordingly (as we would with any other important clinical skill). 

As frontline practitioners we have a real opportunity to impact on unhealthy behaviours and there is evidence that this is acceptable, desirable and effective.  We need to move this practice from being opportune and optional to being a core part of our assessment with every new patient.  If we get used to having these conversations then they might not feel quite so "difficult".  If we are to fulfil our potential role as health promoting practitioners I believe that we do have a duty of care to ask......but there is a big difference between asking and telling.

 

 
 

What does public health mean to you? Frontline Interview

I recently did an interview with Frontline magazine about public health and what it means for physios.

 The full interview can be read here

Exercise, at the heart of Physiotherapy? (Tweetchat debrief)

On Monday 12th January Physiotalk hosted the first tweetchat of 2015.  My colleague Rachel Young (@youngphysio) and I (@annalowephysio) were guest hosts for the session.  Rachel & I chose this topic because we are both passionate about exercise and about Physiotherapy and we share concern that the two things seem to be on divergent paths.

The Tweetchat was fast and furious; my head is still spinning!  The analytics suggest that there were 756 tweets from 88 participants and I have to say, at times I didn't have a clue what was going on! Participants were varied; it was great to see that physio students were represented along with physios from all specialisms and from across the globe.  We were also joined by Osteopaths and Speech and Language Therapists whose tweets added a different perspective.

The aim of this blog post is to organise the information from the Tweetchat and to highlight & expand upon some of the key discussions.  I've added peoples' Twitter handles so that you can find and follow them if you wish.  I've mentioned a number of contributors and embedded tweets, I hope that I have represented your views accurately.

Question 1: Are we actually any good at prescribing exercise?

First off, there were a few calls to unpack what we mean by exercise prescription, this is a valid point and something I'd love to do but probably not over Twitter, apologies for ignoring these tweets!

Mel Stewart (@melrosestewart1) suggested that there is variety in knowledge and skills and that some standards might be useful, this was reinforced by Mandy Dunbar (@physiodunbar) who felt that minimum standards for Universities might be helpful.

The general feeling seemed to be that we are perfectly positioned to lead on exercise but that we seem to have lost some of our skills in this area.  Zara Hansen (@cbtskills) suggested that this might be due to the scope and breadth of practice expanding.  Lack of knowledge of strength training principles and lack of expertise with use of gym equipment were highlighted as issues.  Grainne O'Donoghue (@odonogr) raised the issue of confidence and shared findings from her PhD;

I did my PhD on this subject and found that most students and practitioners wold welcome more "exercise" education #physiotalk
— Grainne ODonoghue (@odonogr) January 12, 2015

Alan Taylor (@tayloralanj) posted a list of 10 reasons why we should be leading on exercise this stimulated a great discussion.  Dave Nicholls (@davenicholls3) added in our ability to cope with co-morbidities and I'd also add our ability to acknowledge and balance risk, we are less risk averse than some other exercise professionals and we understand that there is a risk inherent in doing nothing.  

Question 2: What do we need to do to become better at exercise prescription?

Rachel Young (@youngphysio) suggested that we might have become "functional to a fault", whilst function is our main driver, in order to restore function we need people to engage with exercise and sometimes function takes all the fun away.  One of the key things that came through was that exercise needs to be fun; I think we have work to do on our ability to sell exercise!

Other factors that were identified as important in engaging patients were;

• making it realistic, less can be more, there was talk of no more than 3 exercises,
• making it easy for patients, seeing them in their own environment,
• adopting a flexible approach,
• giving patients choice, acknowledging patients' preferences,
• encouraging honesty about what's achievable,
• planning for relapse,
• tailoring, no more bog-standard photocopies, no more 3x10 for everyone.

Bex Townley (@bextownley) raised an important point below and went on to highlight the importance of partnertship working with other professionals to meet patients' needs.

physiotherapy/services cannot achieve the required duration of evidence based programmes/required adherence to ex. #physiotalk
— Bex Townley (@BexTownley) January 12, 2015

Mike  Stewart (@knowpainmike) drew our attention to the issue of behaviour change (see previous blog post) and I agree, it is the essence of what we do. 

Question 3: How do we become recognised as exercise experts?

One of the key things to come out of the tweets related to this question was the need to value exercise as an intervention in its own right.  It's not just an adjunct, it's not something that we just tell people to do at home, it's not what we spend the last 2 minutes of an appointment doing.  We need to walk the walk and that means making exercise central to our interventions and that will convey our belief in its value to patients.

Another discussion that cropped up was the idea of exercising with patients, I love this idea, what a great way to raise our profile and show patients how much we value exercise. There were lots of calls to "get out of our treatment rooms" and exercise with patients in the best environment for them.  Does anyone run general exercise classes for patients and NHS staff?  Do any departments run physical activity challenges that staff and patients can participate in?   
There were a number of tweets suggesting that we need to strengthen UG curricula if we want to be recognised as exercise experts, again this comes back to the point about minimum standards and whether this would help curriculum design.  

How become Exercise experts #physiotalk strengthen the undergraduate curriculum @MelroseStewart1
— Ann Green (@AGreenCovPhysio) January 12, 2015

There was a suggestion that adding basic fitness qualifications into UG courses might help and this was followed with a short discussion about the HEIs that have embedded vocational qualifications into their courses.

Access to exercise-related CPD that is accessible, affordable and high-quality was identified as a factor.  Gareth Liversidge (@gazliverphysio) made the following suggestion, I'm going to have a think about this one, what a great idea!

@annalowephysio @physiotalk A structured CPD pathway maybe by the @CSP so we're covering all key aspects of ET enduring key competencies met
— Gareth Liversidge (@gazliverphysio) January 12, 2015

Rachael Lowe (@RachaelLowe) also suggested running an open on-line course through Physiopedia as one way of improving knowledge and confidence.  

Question 4: What essential exercise prescription skills should be taught at UG?

It was suggested that students need to understand the importance of being realistic (fewer exercises performed well).  

@DaveNicholls3 @annalowephysio physios often set people up for failure by prescribing exercise that people won't do. #physiotalk
— Paul Westwood (@TriathlonPhysio) January 12, 2015

Tweeters felt that students need to be exposed to underpinning principles of exercise training including FITT principle, measurement of intensity and principles of strength training.  I would add to this that I think students need to be taught about normal response to exercise before considering pathology.

Other key skills identified were using appropriate means of imparting information, written, text, online, phone call etc.  An understanding of behaviour change theory and practice was also considered essential.

This discussion came back to the point of valuing exercise, if Educators value exercise students are far more likely to value exercise too.

To conclude.....
All in all it was a really stimulating Tweetchat, loads of great ideas and such enthusiasm!  I came away with a renewed sense of just how much exercise unites our profession.  There are lots of opportunities for us to secure and develop our practice in this area and there are certainly a lot of passionate physios who are out there making it happen!

Increasing Physical Activity Levels in Children and Young people: What can AHPs do?

My latest blog post was written  for the Department of Health and Public Health England's week of action focussing on Children and Young People.  The aim of this joint initiative is help support families to give children and young people the best start in life.  

The blog post is on the Department of Health website and can be accessed by clicking on the link below;


https://vivbennett.blog.gov.uk/2014/11/21/increasing-physical-activity-levels-in-children-and-young-people-what-can-ahps-do-by-anna-lowe/

Changing Health Behaviours

There has been much talk recently about Behaviour Change.  This is, in part I think, due to the realisation that health care alone does not determine health, it influences it, but not nearly as much as we thought. These pie charts from The King's Fund show estimates of how much (or little) health care contributes to overall health.  Click here & scroll down to see the images more clearly.

The first pie chart suggests that health behaviour patterns may contribute to overall health by 40%, compared to health care at 15% (McGiniss et al 2002).  It's information like this that has brought techniques that facilitate changes in behaviour into sharp focus.

I really like this infographic from Evans Health Lab, it summarises some of the key ways in which we already encourage healthy behaviours.  It highlights the fact that it's usually clusters of behaviour that we are targeting and it advocates an individual, intuitive and tacit approach.

Earlier this year NICE published guidance on Behaviour Change,  I've mentioned in previous blog posts that I think physios are natural facilitators of behaviour change but I think that to date our approaches have been intuitive.  The NICE guidelines clearly state the importance of engaging with behaviour change strategies but this needs to be done in a way that is recognised outside of physiotherapy practice.

This week Quality Watch published their report "Allied health professional.  Can we measure quality of care?" the authors of the report acknowledge the need for AHPs in view of the ageing population and the increasing numbers of people with long-term conditions.  However, they also acknowledge that the contribution made by AHPs is often "hidden, overlooked or potentially undervalued" this is something I can relate to and it makes our services vulnerable.  We simply have to be able to demonstrate that we are effective and that our contributions count but this is no longer limited to treatment of the presenting complaint.  We have the opportunity to be recognised a key "deliverers" of public health priorities and we have the opportunity to establish ourselves as an integral part of the public health workforce.

With this in mind, rather than taking an intuitive approach to changing behaviour we may need to formalise what we do so that it is very clear to other people (managers, commissioners etc) exactly what we are doing.  I think that for this to happen we probably need to do some or all of the following;

1. Clinical staff need training in this area and need supporting in their practise.
2. Decide the scope of our remit, we can't change everything, which health behaviours are we going to target.  The four biggies are smoking, alcohol, activity and nutrition, we need a strategy and I can't help feeling that focusing on Physical Activity would be the sensible option for physiotherapists.
3. Decide which approach works best in our clinical environment, one size does not fit all, does your service lend itself to very brief interventions or to high intensity interventions?
4. Develop a consistent approach.
5. Record what we do.
6. Collate our records, at an individual level, a team level a departmental level and a national level.
7. Evaluate what we are doing.
8. Tell the world!

We need to be canny about this, we need to be able to demonstrate our activity and effectiveness in a universal language.  We can't change our practice suddenly or dramatically, there are HUGE constraints on our time & resources, but we can subtly shift the way in which we deliver behaviour change interventions to ensure that we are ticking the right boxes and getting the recognition we need and deserve.

Local Knowledge

Physios can be quite a mobile profession, it's good to move around and work in different places, we locum, we travel abroad all of which are great opportunities but they can mean that we end up working in geographical areas that we don't know anything about.  There are a number of reasons why it's good to understand your local area and your local population; it's good for your patients and it's good for your service.

The SOCIAL bit of the biopyschosocial approach doesn't get much attention in physio yet it essential to understand the wider social and economic context that a patient comes from.  Our values, experiences of pain, expectations and healthcare outcomes are all influenced by the environment in which we live.  The King's Fund provide some great information on how the broader determinants  of health (summarised in the above picture) are likely to impact on future trends in health.

Understanding this gives our assessments and interventions context, it helps us communicate effectively with patients, it allows us to make informed recommendations about local services and facilities.  For example, we might say to a patient "try and get out for a 20 minute walk every evening" when in certain areas local parks are poorly lit, covered in dog poo and dangerous at night.  Most areas have masses and masses of brilliant physical activity options and these are often a perfect "next step" after physio treatment but keeping updated on local events, groups and charities is time consuming and it's something that is often left to patients.  One local Physiotherapy Department has appointed one member of the team to collate this information and to brief the team about community events & groups at regular intervals; what a great idea!

Being aware of local health priorities can also help your services, health care services are commissioned in response to local need and understanding the health priorities in your area is an essential way of ensuring that your services match local need.  The Health Profiles created by Public Health England (PHE) provide an overview of local health priorities.  Here in Sheffield for example, statistics are significantly worse than the average for England in the areas of deprivation, smoking, educational attainment, mortality in under 75s from both cancer & CVD.

Deprivation is higher than the national average and life expectancy is lower than the national average.  Sheffield is known as a city in inequalities and there is a massive 10 year difference in life expectancy in males in the most deprived and least deprived areas of the city.  We need to show how our services are addressing these inequalities and in doing so demonstrate that this is a priority for our profession.

Another key document is the local Joint Needs Assessment Strategy, these can usually be found on your local government website.  This document provides an analysis of the current health needs of the local area, it informs the local health & wellbeing strategy and it informs commissioning activity in health and social care.  In Sheffield the JSNA builds on the information in the local health profile and a key aspiration is to bring life expectancy in line with the national average, it analysis the causes of premature death and highlights trends in areas including neurological conditions, diabetes, dementia and COPD.  It concludes that long term conditions are a leading cause of premature death and states that these must be a priority for commissioners.

We need to keep up with population health trends and understanding local health prioroties and developing links with local communities can help our services evolve to meet the needs of the local population.