Tidys Physiotherapy 14Th Edition Form PDF Details

Are you looking for a comprehensive resource to help with your physical therapy treatments? The new edition of Tidys Physiotherapy is here, providing the latest and most comprehensive range of assessment tools and treatment techniques available. Developed to help physiotherapists provide safe and effective patient care, this 14th edition also comes with all-new detailed illustrations and several key revisions to ensure it stays up-to-date with current best practice guidelines. Find out what makes this textbook an essential reference guide for physical therapists in 2021.

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Porter: Tidy's Physiotherapy, 14th Edition


Chapter 1

The responsibilities of being a physiotherapist

Ralph Hammond and Julie Dawn Wheeler




















This chapter aims to provide the reader with an insight














into what it means to be a professional (in the context

Characteristics of being a professional



of this


a physiotherapist),

focusing on the


responsibilities, both ethical and practical, that are








Responsibilities of being a professional



inherent in claiming to be a professional working in

Becoming an autonomous profession



the UK.





























The current status and privilege of physiotherapists

Clinical governance





as autonomous professionals will be placed in the con-












Evidence-based practice 8



text of the history of the profession, and the impact of



autonomy on clinical practice will be explored. The







Clinical effectiveness




chapter will reflect on the implications for physiothera-



pists of the increasing expectations of both the general













public and the government for health professionals to

Applying national standards and guidelines


locally 10






deliver high-quality health services. Explanations of

Evaluating services






physiotherapists can


these expectations




through clinical governance will be provided. Finally,








Continuing professional development



the reader will be offered a look at the possible future






CONTENTof the profession in light of the changing shape of

Having the right workforce (and using it


health services in the UK.




appropriately) 14













Physiotherapists come into the profession because









Monitoring clinical governance




they have an underlying sense of

and commitment

The future








helping others and improving

their quality of






life. Indeed, Koehn (1994) argues that professionals








Sources of critical appraisal tools




can be


of as being


by a distinctive




commitment to

benefit the client.







want to be able to use their acquisition of knowledge,
















and attributes from qualifying

programmes to





benefit people, in whatever specialty or with whichever















patient group they wish to work once qualified








for example, elite athletes, older people, people with








developmental or acquired conditions, people with








mental health problems. This chapter will help readers








understand how they can


benefiting patients








a reality in the context of the expectations of society








for the provision of high-quality, safe and effective

















Porter: Tidy's Physiotherapy, 14th Edition




While earlier editions of Tidy’s Physiotherapy may


The professional body for physiotherapists, the

have been popular for their prescriptive descriptions

Chartered Society of Physiotherapy (CSP), provides a


of what physiotherapists should do in particular situa-

framework for the curriculum of physiotherapy educa-


tions or for specific conditions, this edition demands

tion and approves those physiotherapy programmes


more from the reader. No two patients are quite the

that meet the requirements of the framework on behalf


same; each requires the skills of the physiotherapist to

of the profession.





carry out a full and accurate assessment, taking account


The CSP also publishes rules of professional conduct


of the individuality of the patient, and then to use clini-

and standards of physiotherapy practice derived from


cal reasoning to problem-solve and offer appropriate

within the profession, which are in harmony with those


options for treatment, on which the patient will make

of the HPC. Anyone on the HPC physiotherapist regis-


a decision. A professional is required to have the matu-

ter may call themselves a physiotherapist; only those


rity to take full responsibility for the privilege of auton-

who are members of the CSP may call themselves a


omy. This will be by maintaining a competence to

chartered physiotherapist.




practise through career-long learning and through


The breadth of activity and resources that the CSP


self-evaluation, as well as through the evaluation of

undertakes and provides seek to establish a level of excel-


present practice; by keeping up to date with the most

lence for the profession. Its education and professional


effective interventions; and by maintaining the trust of

activity is centred on leading and supporting members’


patients by doing good. Readers should realise that

delivery of high-quality, evidence-based patient care. This


while this approach is more challenging, it will also










activity emanates from its status as the professional body


be more rewarding.





for physiotherapy in the UK and therefore as the primary








holder and shaper of physiotherapy practice. The CSP







works on behalf of the profession to protect the chartered






status of physiotherapists’ standing, which is one denot-



























ing excellence. It is worth noting that the relationship with



Becoming a professional requires an acceptance, often











the HPC is one of registrant; with the CSP it is one of



implied, of certain responsibilities, in return for certain

















privileges. These responsibilities require certain beha-


While the principles of professionalism should be



viours and attitudes of individuals in whom profes-

aspired to by physiotherapists anywhere in the world,



sional trust is placed. Broadly, professionalism requires

the existence and/or role of regulators and professional



these attributes:





bodies and the way these characteristics are manifested







may vary, depending on political, social and financial


a motivation to deliver service to others














adherence to a moral and ethical code of practice

















striving for excellence, maintaining an awareness of


Belonging to an organisation that sets



limitations and scope of practice











standards and ideals of behaviour


the empowerment of others (Hodkinson 1995 and























Medical Professionalism Project 2002, both cited in


The Rules of Professional Conduct (the Rules) were



CSP 2005b).






endorsed at the very first council meeting of the CSP



To practise in the

profession of




in 1895

(Barclay 1994)


and have been revised and




updated at intervals since. The Rules define the profes-


the UK, registration

with the statutory regulator





sional behaviour expected of chartered physiothera-


required. The Health Professions Council (HPC) sets




pists. The current Rules set out a number of principles,


standards of professional training,

performance and




the basis for all of which is to safeguard patients (CSP


conductPROPERTYfor thirteen professions, including physiother-





They include

requirements that chartered


apy (HPC 2006). It keeps a register of health profes-




physiotherapists should:





sionals that meet its standards, and it takes action if



















respect the dignity and individual sensibilities of


registered health professionals do not meet those stan-


dards. It was created by the Health Professions Order


every patient






2001 (HPC 2002). Only those registered with the HPC

work safely and competently


may call themselves a physiotherapist/physical thera-

ensure the confidentiality of patient information


pist (HPC 2006). It is the duty of registrants to keep

report circumstances that might otherwise put


up to date with the processes and requirements decreed


patients at risk





by the Regulator; this is particularly important currently

not exploit patients





because of the changing attitudes to, and legislation of,

act in a way that reflects credit on the profession and


healthcare professions in recent times.




does not cause offence to patients.


Although the CSP has had Rules of Professional Conduct since its inception, agreed national standards were not published until 1990. The CSP Standards of Physiotherapy Practice provides statements about the practical application of the ethical principles set out in the Rules. The fourth edition (CSP 2005a) has evolved to place more emphasis than in earlier editions on practitioners:

Porter: Tidy's Physiotherapy, 14th Edition

Characteristics of being a professional 3

on informed consent. This is a good example of how

the Standards and Rules complement each other. They 1 should be used together to ensure compliance with

the characteristics and actions required of members of the physiotherapy profession.

Commitment to discipline other members

As of 15 October 2006 the CSP no longer handles com- plaints concerning the professional conduct or fitness to

involving patients in decision-making



practise of its members, except those described in the

being fully abreast of the evidence of effectiveness

next paragraph. The HPC considers all complaints of

in order to inform patients and offer the most effec-

this nature.



tive interventions















The Society

does however, handle complaints or

evaluating their practice and measuring a patient’s

consider matters of fitness to practise concerning mem-

health gain as a result of treatment.







bers of the Society who are not regulated by the HPC.










This reflects the increasing expectations of the public to

(This includes physiotherapist’s physiotherapy treat-

be active partners in their healthcare, the expectations

ment of animals, students and the CSP’s associate

of clinical governance to provide more effective care,

members (CSP 2006).)


and the growing demands of funders of services, as



Possessing knowledge and skills not shared

well as patients, to be able to demonstrate the benefits

by others



or ‘added value’ of physiotherapy. All these will be dis-









cussed later in the chapter.






Any profession possesses a range of specific knowledge

Standards of Physiotherapy Practice is written in a way

and skills that are either unique, or more significantly

that offers a broad statement of intent (the Standard




developed than in other professions. The World Congress

statement), which is followed by a number of measur-




for Physical Therapy (WCPT) has described the nature of

able statements about expected performance or activity

physiotherapy as ‘providing services to people and popu-











by the physiotherapist, student or assistant (known as

lations to develop, maintain and restore maximum move-

‘criteria’). For example, Core Standard 2 states ‘Patients

ment and functional ability throughout the lifespan’

are given relevant information about the proposed

(WCPT 1999).





taking into account


It adds, in a detailed description, that physical ther-









apy is ‘concerned with identifying and maximising

age, emotional state and cognitive ability, to allow

informed consent.’ The criteria for this standard include

movement potential, within the spheres of promotion,

the following:








prevention, treatment and rehabilitation’ (ibid, p28).

The patient’s consent is obtained before starting any

WCPT identifies the interaction between ‘physical

therapist, patients or clients, families and care givers,













CONTENTin a process of assessing movement potential and in


options, including



establishing agreed upon goals and objectives’ as cru-

risks and side-effects, are discussed with the patient.

cial and acknowledges that

this requires knowledge

The patient







and skills unique to physical therapists (ibid, p28).


















In the UK,

one approach

to conceptualising phy-

The patient is informed of the right to decline phys-

siotherapy has been to focus on three core elements: mas-





without that prejudicing

sage, exercise and electrophysical modalities (CSP 2002a).

future care.















For physiotherapy, the roots of the profession can be





The patient’s consent to the treatment plan is docu-

found in massage, the founders of the profession having

mented in the patient’s record.









been a group of nurses who carried out massage. The sig-










nificance of therapeutic touching of patients still sets

These measurable criteria allow performance to be

assessed against them, through clinical audit, described

physiotherapy aside from other professions. Physiothera-

in more detail later.







pists continue to use massage therapeutically as well as a

The content of this standard and accompanying

wide range of other manual techniques such as manipu-

criteria set out the specific actions required in order to

lation and reflex therapy. Therapeutic handling under-

conform, in this case, to an aspect of Rule 2 of Rules of

pins many aspects of rehabilitation, requiring the

Professional Conduct: ‘Chartered physiotherapists shall

touching of patients to facilitate movement.

respect and uphold the rights, dignity and individual

Another description of the profession’s knowledge

sensibilities of every patient,’ which includes guidance

and skills can be found in the Curriculum Framework


Porter: Tidy's Physiotherapy, 14th Edition




for Qualifying Programmes in Physiotherapy (CSP 2002b).

the ability to think critically about practice, to learn


This sets out the underpinning knowledge and skills

from experience and apply that learning to future sit-



required of newly qualifying physiotherapists, setting

uations. It is the relationship between the physiothera-



this in the context of their application in professional

pist’s knowledge, his or her ability to collect, analyse



practice areas and environments. These are, in turn,

and synthesise relevant information (cognition), and



underpinned by a set of professional attributes, identity

personal awareness, self-monitoring and reflective



and relationships, such as understanding the scope of

processes, or metacognition (Jones et al. 2000).




practice and active engagement with patient partner-

This professional autonomy has, however, to be



ship. Finally, the framework sets out the outcomes that

balanced with the autonomy patients have to make



graduates should be able to demonstrate: for example,

their own decisions. Patient-centred decisions require a



‘enable individual patients and groups to optimise their

partnership between patient and professional, sharing



health and social well-being’ and ‘respond appropri-

information, with patients’ values and experience being



ately to changing demands’.






treated as equally important as clinical knowledge









and scientific facts (Ersser and Atkins 2000). Higgs and

















Titchen (2001) describe the notion of the professional’s



Physiotherapy is a healthcare profession concerned



role as a ‘skilled companion’. The professional is char-



with human function and movement and maximising



acterised as a person with specialised knowledge which



potential. It uses physical approaches to promote,



can be shared with the patient in a reciprocal ‘working



maintain and restore physical, psychological and social











with’ rather than ‘doing to’ relationship, and as someone



well-being, taking account of variations in health status.


who ‘accompanies the patient on their journey towards



It is science-based, committed to extending, applying,



health, adjustment, coping or death’. This patient-



evaluating and reviewing the evidence that underpins



centred model facilitates the sharing of power and



and informs its practice and delivery. The exercise of



responsibility between professional and patient.




clinical judgement and informed interpretation is at its











A history of how the physiotherapy profession’s



core (CSP 2002b).

















autonomy evolved in the UK can be found later in this



































Cott et al. (1995) have proposed an overarching






framework for the profession: the movement continuum

Licensed by the state




theory of physical therapy,

arguing that the

way in






As previously mentioned, physiotherapists in the UK


which physiotherapists conceptualise movementOFis what


have to be registered with the HPC in order to use the


differentiates the profession from others. They suggest


title physiotherapist and therefore to work in any setting


that physiotherapists conceive of movement on a contin-


in the UK. This is a government measure to protect


uum from a micro (molecular, cellular) to a macro (the


patients from unqualified or inadequately skilled health-


person in his or her environment or in society) level.


care providers.





The authors argue that the theory is a unique approach










to movement rehabilitation


CONTENTIn 2006, the HPC put in place a system requiring


because it incorporates

re-registration at intervals of two years, linked to an


knowledge of pathology with a holistic view of move-


individual’s commitment to

Continuing Professional


ment, which includes the influence of physical, social


Development (CPD), whereby individuals must under-


and psychological factors in an assessment of a person’s


take and maintain a record of their CPD activities and,


maximum achievable movement potential. They argue


if required, submit evidence

of this and of the



that the role of physiotherapy is to minimise the differ-


comes of their CPD on their practice, service



ence between a person’s current movement capability


and service. Re-registration is in response to a lessen-









and his or her preferred movement capability.




ing of public confidence in the National Health Service



Exercising autonomySAMPLE











(NHS) following, for example, the report into children’s







heart surgery in Bristol (Bristol Royal Infirmary Inquiry



Autonomy, or ‘personal freedom’ (Concise Oxford



2001). Equally disturbing were the revelations about



Dictionary, 7th edn) is a key characteristic of being a

the murders of so many patients by Harold Shipman, a



professional. It allows independence, but is mirrored

man who had been a previously trusted general practi-



by a responsibility and accountability for action. Cen-

tioner, where health systems failed to detect an unusu-



tral to the practice of professional autonomy is clinical

ally high number of deaths (Department of Health 2004).



reasoning, described as the ‘thinking and decision-

This has led the government to introduce a number



making processes associated with clinical practice’

of measures, including the requirement for all health



(Higgs and Jones 2000). Clinical reasoning


professionals to re-register at specified intervals, in


Porter: Tidy's Physiotherapy, 14th Edition







Responsibilities of being a professional











order to be seen to be protecting the public through a

about meeting needs. Being a professional is a





more explicit and independent process (Department



in particular the trust that is bestowed by


of Health 2002). It aims to identify poor performers

the public

which underpins

the patient’s ability to



who may be putting the public at risk, as well as

benefit from treatment. However, this brings with it



providing an incentive for professionals to keep up to

weighty responsibilities.






date, maintaining and further developing their scope










of practice and competence to do their job. Disciplinary

Doing only those things you are competent



processes are in place to remove, ultimately, an indi-



to do









vidual from the register (HPC 2005). The means by


















Every physiotherapist has her or his own personal



which individuals can maintain their competence are



discussed later in the chapter.

‘scope of practice’ (CSP 2002a)

that is, a range (or


















scope) of professional knowledge and skills that can



Making a commitment to assist those in need

be applied competently within specific practice settings



As stated earlier, one of the characteristics of a profes-

or populations.











When a person is newly qualified, this scope will be











sional is to want to ‘do good’. This is reflected in the

based on the content of the pre-qualifying Curriculum



ethical principles of

the physiotherapy profession,

Framework, but will also be informed by the indivi-



where there is a ‘duty of care’ incumbent on the indi-

dual’s experience in clinical placements, and the amount



vidual towards the patient, to ensure that the therapeu-

of teaching and reflective learning that has been possible



tic intervention is intended to be of benefit, as set out

as part of those placements.






in Rule 1 (CSP 2002a). This is a common-law duty,

As a

career progresses,

and as a

result of CPD,



a breach of which (negligence) could lead to a civil



some physiotherapists will become competent in high-



claim for damages.







ly skilled areas such as intensive care procedures, or




More generally, Koehn (1994) suggests, professionals















children with

cerebral palsy, which



demand from the client the responsibilityCONTENTto provide,








are perceived to have moral authority, or trustworthi-

are unlikely to have been taught before qualification.



ness, if they:



Others will extend their skills in areas in which they



use their skills in

the context of the client’s best

already had some experience: for example, dealing with




interests and ‘doing good’

people with neurological problems. Others will enhance



are willing to act as long as it takes for assistance

their communication and life skills, as well as refining




to achieve what it set out to achieve, orOFfor a decision

their physiotherapy skills by, for example, working





constantly evolving, based on professional and life




to be made that nothing more can be done to help

with elderly people or people with learning difficulties.




the client



It is the responsibility of the professional to under-



have a highly developed internalised sense of respon-

stand his or her personal scope of practice as it changes




sibility to monitor personal behaviour: for example,

and evolves throughout a career. To practise in areas in




by not taking advantage of vulnerable patients

which you are not competent puts patients at risk and





is a breach of the CSP’s Rules of Professional Conduct,




for example, sufficient information to allow decisions

and the

standards of the profession’s regulator, the




HPC (2003).









to be made (compliance)


















are allowed to exercise discretion (judgement) to do











the best for the client, within limits.

Maintaining competence to practise




Koehn (1994) argues

that trustworthiness is what











An individual’s scope of practice and competence are




stands out as a particularly unique characteristic of














being a professional

to do good, to have the patient’s


learning from


from evaluating




best interests at heart and to have high ethical stan-






reflecting on


or more formal




dards. Physiotherapists not prepared to maintain such




ways of learning. It includes undertaking programmes




ethics, even in difficult and stressful situations, run




of structured CPD. Clinical reasoning skills are contin-




the risk of losing the respect as well as the trust of their




ually refined

and further

developed throughout a




patients and the public.




career through evaluative and reflective practice, lead-













ing to the ability to deal with increasingly complex




and unpredictable situations.





Physiotherapists have a duty to keep up to date









Physiotherapists in the UK are granted the right to

with new information generated by research, with what



make their own decisions, in partnership with patients,

their peers are thinking and doing, and by formally




Porter: Tidy's Physiotherapy, 14th Edition




evaluating the outcome of their practice. The responsi-

standards (CSP 2005a). Where they do not, programmes


bility for this is dictated by the


(2003) and

of professional development should be put in place



reflected in the Standards of Physiotherapy Practice (CSP

to facilitate full compliance, as part of the individual’s



2005a). In particular, Core Standards 19 22 are con-

professional responsibility.






cerned with a requirement that individuals assess their

Physiotherapists should not be critical of each other,



learning needs, then plan, implement and evaluate a

except in extreme circumstances. However, they do



programme of CPD based on that assessment.




have a duty to report circumstances that could put











patients at risk. In the NHS, there are procedures and



Responsibility to patients







a nominated officer within each trust from whom











advice can be sought. Outside the NHS, advice can be



This chapter has already discussed the importance of



sought from the CSP. Physiotherapists are encouraged



the individual physiotherapist as well as the profession



to be proactive in supporting each other’s professional



as a whole in maintaining the attributes of




development and in promoting the value of the profes-



sionals. Trust is perhaps the most essential characteris-



sion in local workplace

settings, in policy-making



tic with which to develop a sense of partnership with



forums and in the media.






patients; in turn, this will optimise the benefits of inter-













vention. For physiotherapy, many of the other hall-








marks for building and securing trust are set out in




the profession’s Rules and Standards. For example:












The CSP was founded in 1894, under the name of the












to provide safe and effective interventions (safety of

Society of Trained Masseuses. This section will not



application as well as safe and effective)

Rule 1

attempt to relate the history of the profession, except



and Core Standards 4, 8, 16







in the context of developing autonomy. However, more


to treat patients with dignity and respect

Rule 2

about the early days of the profession can be found in



and Core Standard 1





















the book In Good Hands (Barclay 1994).


to provide patients with information about their







For many years, doctors governed the profession.



options for treatment/interventions


Rule 2 and

One of the first rules of professional conduct stated



Core Standard 2



















‘no massage to be undertaken except under medical


to involve patients in decisions about their treatment

direction’ (ibid). Even in the 1960s doctors were assert-



(informed consent)

Rule 2 and Core Standard 2.

ing that they must take full responsibility for patients









in their charge

and ‘professional and technical staff








have no right to challenge [the doctor’s] views; only



Responsibility to those who pay for services





Physiotherapists have an ethical responsibility to those

he is equipped to decide how best to get the patients



fit again’ (ibid). It is hard to believe now that it took



who finance services, whether these are commissioners



more than 80 years to escape the paternalism of doctors,



of healthcare, taxpayers or individual patients, to pro-



on whom physiotherapists were dependent for referrals.



vide efficiently delivered, clinically and cost-effective










interventions and services, in order


CONTENTThe first breakthrough came in the early 1970s, when a



to give value in

report by the Remedial Professions Committee, chaired



an era when resources for healthcare are limited. This



by Professor Sir Ronald Tunbridge, included a state-



is embedded within Rule 1 of the CSP’s Rules of Profes



ment that while the doctor should retain responsibility



sional Conduct in relation to the establishment of a ‘duty



for prescribing


more scope in application



of care’ towards the patient (CSP 2002a).











and duration should be given to therapists.













Responsibility to colleagues and






The McMillan report (DHSS 1973) went further, by









that therapists should be allowed to











the profession








decide the nature and duration of treatment, although













A profession has legitimate expectations of its members

doctors would remain responsible for the patient’s wel-









fare. There was recognition that doctors who referred



to conduct themselves in a way that does not bring the



profession into disrepute, but rather enhances public

patients would not be skilled in the detailed application



perceptions. Physiotherapists have a duty to inform

of particular techniques, and that the therapist would



themselves of what is expected of them. Indeed, the

therefore be able to operate more effectively if given



Rules of Professional Conduct state that knowledge of

greater responsibility and freedom.



and adherence to the Rules are part of the contract of

Eventually, a Health Circular called Relationship



membership of the CSP. The Standards of Physiotherapy

between the Medical and Remedial Professions was issued



Practice make it clear there is an expectation that all

(DHSS, 1977). This acknowledged the therapist’s com-



physiotherapists should be able to achieve all the core

petence and responsibility for deciding on the nature


Is clinical governance something new?
Yes and no. Its component parts are all familiar activ- ities, but there is also an underpinning philosophy in clinical governance to reduce risks for patients, a new and more focused emphasis that was not previously articulated. It can be argued that clinical governance is, at least in part, a response to a loss of public confi- dence in the NHS, as discussed earlier, which has undermined people’s perceptions of the NHS as an organisation they can rely on to ‘do good’ and of the government as a protector of the public. In addition, the public has become more litigious, suing doctors
Clinical governance

Porter: Tidy's Physiotherapy, 14th Edition



of the treatment to be given. It recognised the ability of

The accountability of chief executives




the physiotherapist to determine the most appropriate

for quality




intervention for a patient, based on knowledge over




Although some chief executives of NHS trusts claim

and above that which it would be reasonable to expect

they were always responsible for quality, this had not

a doctor to possess. It also recognised the close relation-

been a statutory responsibility in the way it was for a

ship between therapist and patient, and the importance

trust’s finances. Chief executives now have a statutory

of the therapist interpreting and adjusting treatment

responsibility for quality.




according to immediate patient responses.













Autonomy was only achieved by being able to

The introduction of a philosophy of




demonstrate competence to make appropriate deci-

continuous improvement




sions, building up the trust of doctors and those paying

One-off improvements are not enough

the NHS

for physiotherapy services. The need to acquire skills

has to move to a culture of continuous improvement

of assessment and analysis became a key component

to achieve excellence. In addition, the emphasis


of student programmes from the 1970s. Today, qualify-

shifted from improving a particular aspect of care in

ing programmes stress even further the development

isolation, to examining the whole system of care, cross-

of skills, knowledge and attributes required for auto-

ing professions, departments, organisations



nomous practice.







tors, to ensure the whole process meets the needs of









patients through an integratedFINALapproach to healthcare.





An aspiration to achieve consistency of services

So far, this chapter has explored the responsibilities

across the NHS




of being a physiotherapist from a professional perspec-

This is founded on two principles:




tive. The focus has been on the individual’s personal














responsibility as a professional. This section will put

If one trust can provide excellence in a service, then














all that in the context of a professional’s responsibilities

so can all trusts.




Local services should, where possible, be based on

to the employer organisation, whether it be in the public







or the independent sector.




national standards: for example, National Service




Frameworks or nationally developed clinical guide-

In the NHS, responsibility for the clinical safety of






patients and the quality and effectiveness of services










is maintained via a system of clinical governance. It

There is some evidence to suggest that nationally devel-





seems probable this will apply equally to the indepen-

oped standards or clinical guidelines are likely to be

dent sector in the near future. However, even though

more robustly developed (Sudlow and Thomson 1997)

clinical governance is the responsibility of NHS trusts,

and that their universal implementation locally


its foundation is based on ‘the principle that health pro-

ensure consistency and effectiveness.




fessionals must be responsible and accountable for their









own practice’ (Secretary of State for HealthCONTENT1998). The An emphasis on continuing professional




individual’s professional responsibility is therefore still

development (CPD) and life-long learning (LLL)





Clinical governance acknowledges the importance of





What is clinical governance?




CPD/LLL for all healthcare workers, in order to keep




up to date and deliver high-quality services.













the quality ofSAMPLEtheir services and safeguarding high








Clinical governance is a framework through which NHS organisations are accountable for continuously improving

standards of care by creating an environment in which excellence in clinical care will flourish (Secretary of State for Health 1998). (While this definition has been used in England, similar interpretations of the term have been made in Scotland, Wales and Northern Ireland.)

A number of key themes were introduced as part of clinical governance.


Porter: Tidy's Physiotherapy, 14th Edition




and trusts more readily for mistakes, thus drawing


In 1991, Sir Michael Peckham, then Director of


money away from front-line clinical services. So clinical


Research and Development for the Department of



governance is about rebuilding the public’s confidence


Health, noted that ‘strongly held views based on belief



in health services, providing high-quality and effective


rather than sound information still exert too much



care and, above all, reducing the risk of harm through


influence in healthcare. In some instances the relevant



negligence, poor performance or system failures.




knowledge is available but is not being used, in other















situations additional knowledge needs to be generated



The components of clinical governance




from reliable sources’ (Department of Health 1991). At















about the same time, a relatively small group of doctors



Although clinical governance should be seen as a pack-





began to write about evidence-based medicine.



age of measures that together ensure excellence and a









reduction in risk, it can also be viewed as a number of


























component parts, some of which have been in place for






a number of years and are already familiar (Figure 1.1).


An early definition of evidence-based medicine stated




They include:










that it is the ‘conscientious, explicit and judicious use


















evidence-based practice and clinical effectiveness



of current best evidence in making decisions about



applying national standards and guidelines locally


the care of individual patients’ (Sackett et al. 1996).



evaluating the effectiveness and quality of services


A recent definition has updated this, drawing on









criticisms of the initial position and stating that















evidence-based practice requires that ‘decisions about



having the right workforce and using it appropri-


health care are based on the best available, current,




valid and relevant evidence. These decisions should be




























made by those receiving care, informed by the tacit



















The following sections deal with these aspects.




and explicit knowledgeNOTof those providing care, within
















the context-of available resources’ (Dawes et al. 2005).







CONTENTus about their condition, which treatments they find effec-



























What do we mean by evidence? Is research the only



At the beginning of this chapter, it was asserted that




form of evidence? Certainly for some questions, such





want to become





as the efficacy of particular drugs, or a particular modality



an inherent desire to ‘do good’. But how do we know



such as exercise programmes for the management of back
















encounter, will develop such expertise (Jones et al.



what works

what interventions have OFbeen shown

pain, research studies which compare one intervention



to be effective? It is hard to comprehend that health

with another or a placebo (randomised controlled trials)



professionals have not always sought evidence for the

can provide reliable information about the degree to



effectiveness of the treatments they use. Perhaps they

which an intervention is effective. But other forms of evi-




but until

the early 1990s this ‘evidence’


dence are also important (Figure 1.2). What patients tell



based on personal experience and on opinions derived























from that experience, together with the experience of

tive, the degree to which interventions improve their abil-



colleagues, or those perceived to be experts and opin-

ity to get on with their lives also provides important



ion leaders. Is that good enough?





evidence. The physiotherapist also contributes evidence














in the form of clinical expertise, derived from clinical














reasoning experience. Thinking and reflecting on what






Clinical audit







you are doing, as a practitioner during or after a clinical











































2000). Knowledge which arises from and within practice














(practice-based and practice-generated knowledge) will




Using nationally








become part, along with research evidence, of your ratio-












nale for practice (Higgs and Titchen 2001). Sackett and




















colleagues reflected this in concluding their definition




and guidelines


















that evidence-based practice requires integration of ‘clini-

















The right








cal expertise with best available external clinical evidence




workforce and



National Service



from systematic research’ (Sackett et al. 1996).




using it right










A hierarchy of evidence is often described or used in














the literature. This ranges from (1) systematic reviews,



Figure 1.1 Components of clinical governance.







in which evidence on a topic has been systematically


Adapted from National Institute for Health and Clinical Excellence (2001).
FINALClinical reasoning, practice-generated
Evidence-based practice
Skills and

Porter: Tidy's Physiotherapy, 14th Edition



Research evidence








Clinical expertise























Past experience,


























beliefs and values
































































Figure 1.2 What do we mean by ‘evidence’? (Adapted from Bury 1998, with permission.)

identified, appraised and summarised according to




from clinical reasoning experience, discussed above.

predetermined criteria (usually limited to randomised

Physiotherapists need to contribute to an ongoing

controlled trials)

said to be the strongest evidence

debate to develop a hierarchy that reflects more appro-

(the most reliable estimate of effectiveness) to (2) expert

priately a patient-centred approach to practice.

opinion, perceived as the least reliable. An example is


So what-does evidence-based practice mean for phy-


Type of evidence

CONTENTpopulation (e.g. people with multiple sclerosis with

shown in Table 1.1.






siotherapists? Core Standard 4 (CSP 2005a) states that:

However, such a hierarchy fails to recognise that dif-

‘In order to deliver effective care, information relating

ferent research methods are needed to answer different

to treatment options is identified, based on the best

types of question and that, while a qualitative study

available evidence.’ A range of sources of information

may be the best research method for a particular ques-

the physiotherapist may need to draw on, including






get the best results from a literature search (his or

tion, it still receives a low rating. The hierarchyOF also

research evidence, patient organisations and clinical

fails to recognise the importance of expertise derived

guidelines, is listed. What practical steps need to be









taken to identify and use research evidence?

Table 1.1 A hierarchy of evidence




about the clinical question you are trying


EvidenceSAMPLEobtained from well-designed non-


to answer in your information search. Identify the



symptoms of urinary incontinence), the intervention


Evidence obtained from a systematic review or



you are looking for (e.g. neuromuscular electrical


meta-analysis of randomised controlled trials




stimulation) and the outcome (e.g. a reduction in


Evidence obtained from at least one randomised



symptoms), and use this information to formulate a


controlled trial








search strategy.


Evidence obtained from at least one well-designed


Work in partnership with an information scientist to


controlled study without randomisation










Evidence obtained from at least one other type of


her information skills and knowledge combined


well-designed quasi-experimental study




with your clinical skills and knowledge).











experimental descriptive studies, such as

Look first for evidence that has already been synthe-




systematic reviews, nationally developed


comparative studies, correlation studies and




clinical guidelines or standards. This saves a lot of


case studies















searching for individual studies. If it is a


Evidence obtained from expert committee reports



high-quality synthesis, it will also provide a more


or opinions and/or clinical experience of










respected authorities

reliable estimate of effectiveness.

Know your databases well enough to know which will have the most relevant information on any particular topic.


Porter: Tidy's Physiotherapy, 14th Edition



Check the titles and abstracts for relevance.





Is the practitioner sufficiently skilled to apply the


appraise any relevant papers you



intervention safely and effectively?




found to assure yourself of their quality and of the

Is the practitioner an effective communicator?



reliability of their conclusions. (A list of appraisal

Does the practitioner give the patient an opportunity



instruments can be found at the end of this chapter.)


to describe the symptoms fully, to explain the


When you find the ‘best available evidence’, think


impact of the problem on daily life, and to ask



about it in relation to your patient and your past








experience. Is it appropriate for that patient, will

Does the patient have enough information to be able



you be able to quantify for the patient the degree


to give informed consent?





of likely benefits and harms (if any)?






Are other options discussed that may have been


Discuss the evidence

with the patient and



more acceptable to the patient, even if less effective?




















the preferred intervention(s) together.






Would treatment in a hospital setting mean a long,


Implement the preferred intervention(s).






exhausting and expensive journey for the patient?


Evaluate the effect of the intervention(s) and act

Would the patient feel intimidated by a hospital








































Would treatment be more effective if it were














provided closer to home: for example, in the GP’s













surgery or health centre?
































Would treatment be more relevant if it were given in



More information about evidence-based practice can





a patient’s own home, to be able to develop a



be found in Herbert et al. (2005) or at www.






programme tailored to the person’s lifestyle and



nettingtheevidence.org.uk/, a catalogue of useful






environmental needs?





















electronic learning resources and links to organisations




Wherever treated, does the patient have adequate



that facilitate evidence-based healthcare. See also






privacy, warmth and comfort?




fact that an intervention has been provedCONTENTto work in







‘Sources of Critical Appraisal Tools’ towards the end of




How long has the patient had to wait for treatment



this chapter.










and will a delay alter the effectiveness of the


























The answer to each of these questions can have an



from anPROPERTYintervention.




impact on the patient’s ability to benefit from an inter-









vention, however effective the research evidence might



Clinical effectiveness, as





suggest an

intervention is. This also

illustrates the




of the clinical reasoning

process, where



of Health,

sounds very






highly skilled judgements have to be made based on a




doing things

you know


be effective



consideration of the whole person, physically, emotion-



for a particular patient or group of patients. But the



ally and within society, as well as the environment,


















practitioner skills and resources available, in order to



research studies, in a relatively

controlled environ-



provide truly effective treatment.




ment, does not necessarily mean that it will work for





So while evidence-based practice is a key component



a particular

patient. Both patients and





of clinical effectiveness, clinical effectiveness also takes



are unique beings, and there are many additional fac-



account of a range of other influences that could affect



tors, practical and behavioural, that need to be consid-



the patient’s ability to benefit from an intervention based



ered to ensure the patient gets the maximum benefit



on high-quality research evidence.

























































































Clinical effectiveness was defined by the Department of









Health in 1996 as ‘the extent to which specific clinical
















One of the tenets of clinical governance is consistency



interventions, when deployed in the field for a particular








for the public, being confident that they will experience



patient or population, do what they are intended to do —








the same quality of care and have access to the most



that is, maintain and improve health and secure the













effective interventions, regardless of where they live.



greatest possible health gain from the available













There should be no postcode lottery, where some treat-



resources’ (NHS Executive 1996).



















ments might be available in some parts of the country















Porter: Tidy's Physiotherapy, 14th Edition

Applying national standards and guidelines locally 11

and not others; the quality of the average and worst ser-

Clinical guidelines







vices should be raised to that of the best. Where there are






























high-quality national standards, therefore, these should









be used locally. Two examples are set out below.




Clinical guidelines are ‘systematically developed



Nationally developed standards






statements to assist practitioner and patient decisions








about appropriate healthcare for specific circumstances’













The CSP’s Standards of Physiotherapy Practice provides a


(Field and Lohr 1992).







universal framework for the delivery of services





















throughout the UK, to which it is expected all phy-











siotherapists will conform. So, for physiotherapy,



The key factors in the development of clinical guide-

patients can expect similar values and processes within

lines are the systematic process for identifying and

a healthcare experience.





quality-assessing research evidence, and the systematic

National Service Frameworks (NSFs)




and transparent process used for the interpretation of




the evidence in the context of clinical practice, in order

This government initiative aims to provide the NHS

to formulate reliable recommendations for practice.

with explicit standards and principles for the pattern

National Institute for Health and Clinical

and level of services required for a specific service or

Excellence (NIC )



care group. The NSFs aim to address the ‘whole system







of care’ and each will set out where care is best






NICE is a Special Health Authority for England and

provided and the standard of care that patients should

Wales, established by the government in 1999 to pro-

be offered in each setting. They provide ‘a clear set of

vide health professionals and the public with authorita-

priorities against which local action can be framed’

tive information about the clinical effectiveness and

and seek to ensure that patients will get greater consis-

cost-effectiveness of healthcare. One of its work pro-

tency in the availability and quality of services, right










grammes is to develop clinical guidelines, which are

across the NHS (Secretary of State for Health 1998).











carried out by a series of collaborating centres. The

Table 1.2 lists the NSFs that have been developed.

Department of


and the Assembly for Wales












They provide broad statements of expected services.

have given NICE the remit for developing ‘robust and

For example, the NSF for older people states: ‘Older

authoritative’ clinical guidelines, taking into account

people who

have fallen receive

effective treatment

clinical effectiveness and cost effectiveness. More infor-

and rehabilitation and, with their carers, receive advice

mation about the key principles that underpin the way







NICE approaches clinical guideline development can

on prevention through a specialised falls service.’



Physiotherapists will therefore need to address the

be found on its website.






implementation of this standard in any services they











provide to older people. Implementation will also pro-




















vide opportunities to promote the value of physiother-

















apy to this

patient population

and CONTENThighlight the









physiotherapists can

make to a trust’s


National Institute for Health and Clinical Excellence (NICE):












compliance with this particular standard.
























Scottish Intercollegiate Guidelines















Table 1.2 National service frameworks developed by


Network (SIGN)







the Department of Health





SIGN was formed in 1993. Its objective is to improve





the quality of

healthcare for patients in

Scotland by

Coronary heart disease (including cardiac





reducing variation in practice and outcome, through










the development and dissemination of national clinical









guidelines containing


for effective





Paediatric intensive care









practice based on current evidence. Further information

Mental health









can be found on its website.






Older people (including falls, osteoporosis and stroke)


































Long-term conditions














































































Scottish Intercollegiate Guidelines Network (SIGN):




Chronic obstructive pulmonary disease (2008)



























Physiotherapists use the results of audit to assess their learning needs (Core Standard 19.1) and/or as a means to achieve their personal learning objectives (Core Standard 20.3h).
All evaluation is about learning which leads to improvements in the quality and effectiveness of prac- tice. It should be carried out, and the results used, in the context of CPD and reflective practice, to improve

Porter: Tidy's Physiotherapy, 14th Edition




Professionally led clinical guidelines






an individual practitioner’s personal practice and/or

The physiotherapy profession has developed national,

the delivery of a whole service. Set out below are four


by which physiotherapists can evaluate their



physiotherapy-specific clinical

guidelines. To ensure



practice. They are not mutually exclusive.



quality and provide confidence for users, the CSP has









established a process for the

endorsement of



Evaluating the process of care (clinical audit)



clinical guidelines. The criteria for assessing whether










the quality of a guideline warrants CSP endorsement


In order to evaluate the process of care, it is necessary to



can be found in an appraisal questionnaire developed


have a reliable benchmark with which to compare your



by a European consortium, known as the AGREE instru-


practice. Earlier, the importance of the local implemen-



ment. For users of clinical guidelines, CSP-endorsed


tation of nationally developed standards and evidence-



clinical guidelines can be considered of high quality


based clinical guidelines was discussed. These provide



and should be implemented locally. Further informa-


such a reliable benchmark. Clinical audit is a tool with



tion about the process for the development of clinical


which to measure your own performance (or more



guidelines in physiotherapy is available from the CSP


often, the performance of the service) against standards











or criteria based on the ‘best available evidence’ of


@ Weblink








effectiveness. This will enable you to identify the extent









to which you adhere to those standards or criteria, from



AGREE Collaboration (Appraisal of Guidelines Research




which recommendations can beFINALput in place to improve






adherence, if necessary.



and Evaluation):














































Chartered Society of Physiotherapists (CSP):
















Clinical audit is a cyclical process involving the




































identification of a topic, setting standards, comparing
























practice with the standards, implementing changes, and










monitoring the effect of those changes (CSP 2005a).





















How do you know whether you are being effective?


Further information about clinical audit can be found in



Knowing whether you are or not is part of your profes-


an information paper published by the CSP (2002d) and in



sional responsibility as a physiotherapist. Rule 1 of


Principles for Best Practice in Clinical Audit published by



Rules of Professional Conduct (CSP 2002a) describes the


NICE (2001).
















responsibility a physiotherapist has to ensure that any







intervention offered to a patient is intended to be of







benefit. Several of the CSP’s standards of physiother-


Evaluating the health outcomes of care



apy practice include criteria that relate to evaluation,











This will determine the impact of the process of care on
















CONTENTthe patient’s life by using specific measures before and


As part of the assessment process, physiotherapists


after treatment. The use of a test, scale or questionnaire



consider and critically evaluate information







records what it aims to record (is valid and



effective interventions relating to the patient’s condi-





responsive) and is sufficiently well described to ensure



tion (Core Standard 4.1).

















that everyone who uses it does so in the same way (is


A published, standardised, valid, reliable and respon-




reliable) will help to give physiotherapists the chance



sive outcome measure is used to evaluate the change





to see whether the aims of their intervention have had



in the patient’s health status (Core Standard 6).











the impact intended.










All physiotherapists participate in

a regular and


A database of outcome measures can be found on



systematic programme of


audit (Service





the CSP website. This will facilitate the selection of



Standard 3.2)SAMPLE.


















the most appropriate measures for a specific patient or patient group. More information on using measures can be found in a CSP information paper (CSP 2001a).

As well as patients themselves having an interest in an objective assessment of their improvement, it is increasingly important for managers and team leaders to present such information to commissioners of health- care, to demonstrate the benefits of physiotherapy ser- vices and their value for money.


Porter: Tidy's Physiotherapy, 14th Edition








Continuing professional development














Using patient feedback



behind the information recorded in the patient docu-








mentation can be explored. Guidance on peer review


Another mechanism for evaluating practice is to ask the


be found in the clinical audit

tools document


patient for feedback. This could be through the use of a



contained in the Standards of Physiotherapy Practice pack



validated patient-assessed outcome measure to provide



(CSP 2005a).








information about the patient’s perception of health


















gain, or through the use of a structured questionnaire




to determine the patient’s perception of the quality



of the treatment. The CSP’s Standards of Physiotherapy











Practice pack includes a ready-made Patient Feedback



















Questionnaire, designed to measure criteria in the core









standards, for which only patients can judge compli-


Continuing professional development (CPD) is the




work-oriented aspect of life-long learning and should



ance. Patients are asked to respond to statements that





be seen as a systematic, ongoing structured process of



mirror the criteria (Table 1.3).









maintaining, developing and enhancing skills, knowledge



Responses from the feedback questionnaires can be





and competence both professionally and personally in



used by individuals or services to reflect on the extent





order to improve performance at work (CSP 2003).



to which the criteria are being met, and to introduce














new processes or development opportunities to secure










greater conformance, if necessary.



































Another valuable source of patient feedback is









patients’ complaints. These should be considered posi-


Life-long learning (LLL) is a theme the government



tively as opportunities to address the issues contained


promulgates across all sectors of the population, in order



within them, in order to introduce a service improve-


to ensure the workforce is equipped to do the jobs that



ment. Any issue that becomes a problem for a patient















will contribute to high-quality public services and



is a problem for the service, which should be analysed.















promote prosperity in the UK.




The involvement of the patient making the complaint





















in this process, if willing, will facilitate the finding ofELSEVIERa






solution that can then be embedded into systems and

In healthcare, the connection between CPD/LLL and



the quality of services is at the centre of the govern-











ment’s view of a new, modernised NHS. Physiothera-








Peer review




have always had

a strong

commitment to





CPD evidenced by the clear statement in Rule 1 of














Peer review provides an opportunity to evaluate the



Rules of Professional Conduct: ‘Chartered physiothera-



clinical reasoning behind your decision-making with a

pists shall only practise to the extent that they have. . .



trusted peer. It can be applied most effectively to the

maintained. . . their ability to work safely and compe-



assessment, treatment planning and evaluative compo-

tently.’ The Core Standards of Physiotherapy Practice, with



nents of physiotherapy practice, whereCONTENTthe reasoning which all physiotherapists should conform, include



Table 1.3 Extract from a patient feedback questionnaire




















Patient feedback questionnaire


Response option
















Core Standard 5.3


By the end of your first visit, were


Yes, no, don’t know



The findings of the clinical assessment are explained to


the results of the assessment






the patient














I felt involved in deciding about my


Strongly disagree, disagree,



Core Standard 8.1





Physiotherapists ensure that the patient is fully


treatment plan




uncertain, agree, strongly



involved in any decision-making process during












treatment planning













Core Standard 12.3


The physiotherapists used words


Strongly disagree, disagree,



All communication, written and verbal, is clear,


I didn’t understand




uncertain, agree, strongly



unambiguous and easily understood by the recipient


























(Adapted from CSP 2000.)


What to delegate? Physiotherapists need to use their own skills and knowledge to carry out an assess- ment of a patient in order to formulate a clinical diagnosis and a programme of treatment derived from those findings. This process requires skills of analysis and clinical reasoning, key professional attributes. However, an appropriately trained assis- tant may well have the attributes required to be able to carry out some or all elements of the treatment programme, based on existing knowledge and skills. This would include the monitoring of the patient’s

Porter: Tidy's Physiotherapy, 14th Edition



standards for the assessment, planning, implementation

skills such as self-awareness, open-mindedness and

and evaluation of a CPD programme. Service Standards

critical analysis.


6 and 7 require that all physiotherapy services should
































have a programme of CPD/in-service training for staff.







The requirement for re-registration of physiothera-


Reflective practice is the process of reviewing an episode

pists and other healthcare professionals, discussed ear-


of practice to describe, analyse, evaluate and inform


lier, makes CPD an essential component of professional


professional learning; in such a way, new learning



life. A philosophy of LLL and individual responsibility


modifies previous perceptions, assumptions and



for this will be introduced in qualifying programmes,


understanding, and the application of this learning to


equipping students for a lifetime of learning in order


practice influences treatment approaches and outcomes

to maintain and continually improve their competence


(CSP 2002b).





to practise. Written evidence of learning and develop-













ment, and its impact on improving practice, is now an







essential requirement. Every physiotherapist must







establish a portfolio containing such evidence, which



will need to be maintained throughout a career. Guid-







on this can





a Portfolio:








Physiotherapists have a professional responsibility

a Guide for CSP Members (CSP 2001b).









to use their skills appropriately.FINALThis reflects Rule 1























of Rules of Professional Conduct, which states that phy-


Some key characteristics of continuing professional





siotherapists should ‘only practise to the extent that


development (CSP 2003)







they have established, maintained and developed their


It should comprise a broad range of learning




ability to work safely and competently’. But there is





also a professional responsibility to use resources


















activities (courses, in-service education, reading,




(human as well-as financial) appropriately in delivering



supervision, research, audit, reflections on





healthcare. This means giving consideration





experience, peer review — this is not an exhaustive







whether you need to refer a patient on, either because
























he or she requires a higher level of skill than you


It is based on individual responsibility, trust and self-






possess, or needs a specialist in a different clinical area.






















qually, consideration should be given as to whether



It links learning with enhancement of quality of








there are elements of the treatment programme that













patient care and professional excellence whilst




can be delegated to a physiotherapy assistant or other



ensuring public safety.















support worker. (The word ‘assistant’ is used in the


It should recognise the outcomes of CPD with a








following section to mean both of these.)





focus on achievement.

















The decision about whether to delegate, and which























tasks or activities to delegate, is entirely the responsi-













The emphasis


the importance of



bility of the physiotherapist making that decision. The




also takes

full responsibility



within clinical governance is a welcome development.



application of

the tasks or

activities carried



The challenges for physiotherapists in keeping up to



the person who has been delegated. So choosing tasks

date are huge, with the fast pace of change in health-



to be undertaken by an assistant is a complex element


in particular the rapid increase in the volume



of professional activity, which depends on an informed

of information




be evaluated and



professional opinion.




incorporatedPROPERTYinto practice. It is hoped that protected























time for CPD, including time in the workplace, will become a reality in the NHS, as recommended by the Kennedy Report (Bristol Royal Infirmary Inquiry 2001) and the CSP (2003).

Another form of professional development is reflec- tive practice, a process in which practitioners think crit- ically about their practice and as a result may modify their action or behaviour. ‘Reflection enables learning at a sub-conscious level to be brought to a level where it is articulated and shared with others’ (CSP 2001b). Learning from experience requires the development of


Porter: Tidy's Physiotherapy, 14th Edition













The future

















condition and progress with the plan, and advising


The Healthcare Commission is an independent stat-








the physiotherapist of any variations in either of

utory body established to raise standards throughout



these. As there are no hard and fast rules about what

England and

Wales. In Scotland a similar function




to delegate, the physiotherapist should consider

is provided by NHS Quality Improvement Scotland,




carefully the scope and nature of the task and ensure

the Health and Personal Social Services Regulation




that these are clearly defined and communicated to

and Improvement Authority (HPSSRIA) undertakes




the assistant.




regular reviews of the quality of services in Northern



Who to delegate to? The factors to be considered here

Ireland. The Healthcare Commission is tasked with




are the competence of the assistant and the nature of

assessing the implementation of clinical governance




the task. The competence of the assistant will be

in every NHS trust and making its findings public.




affected by the person’s length of service, prior expe-

Teams of trained reviewers visit trusts every 3 5 years




rience and training received, coupled with judge-

(and can be called in at any time should concerns be




ments by the physiotherapist about the assistant’s

raised) to review trust information and data, talk to




ability to deal with that particular patient in those

staff and patients, and consider the trust’s performance




particular circumstances.




in specified categories. The Healthcare Commission has




The decision about what to delegate and who to del-

added to its existing responsibilities those for inspect-




ing hospitals and care homes in the private sector and



egate to is one that, while ultimately the responsibility



carrying out value-for-money studies and performance



of the physiotherapist, also requires the active involve-











ment of the person to whom the task is being delegated.

management within the NHS.












The assistant, therefore, must be allowed to make an


xamples of a physiotherapy manager’s








assessment of his or her own competence in relation to






responsibilities within a clinical governance




the particular task. The task should not be delegated if


























either the physiotherapist or the assistant is concerned















about the assistant’s competence. The physiotherapist








will then need to decide whether training is required.


Check staff are currently on the state register.





Deal with and learn from complaints.





Newly qualified physiotherapists should recognise















and value the skills and knowledge many assistants


Carry out programmes for quality improvement,





including clinical audit and evaluation, and report





particularly those who have

long service






how these have led to improvements for patients.




within the profession, so that effective







Ensure that nationally produced, high-quality




between physiotherapists and assistants canOFcontribute






standards and clinical guidelines are implemented




to the efficient and effective delivery of physiotherapy













services. Physiotherapy assistant members of the CSP









Have an appropriate skill mix and staffing level to




have a Code of Conduct (CSP 2002c) to which they are






ensure the safety of patients, making appropriate use




expected to adhere in the same way physiotherapists






of human and financial resources, in order to provide




are to the Rules. Users of physiotherapy services have






effective care.





























a right to expect those who deliver them to be compe-


Have a process for identifying and supporting staff




tent to

do so. The physiotherapist has

the ultimate






members whose competence is in question.




responsibility to the patient for ensuring this is the case,






Provide an in-service training programme and time




but also needs to consider competence in the context of






for individual CPD activities.





resource use, in terms of both

finance and






Ensure appropriate participation in multiprofessional

















clinical audit and quality improvement activities.











































So, being a competent physiotherapist who displays










the essential

characteristics of a professional in the



NHS physiotherapy managers are responsible for devis-



current climate is a complex and demanding process.



ing, implementing and reporting on a




Figure 1.3 attempts to summarise the elements of pro-



clinical governance programme, which should reflect



fessionalism described in this chapter.



all the aspects of clinical governance discussed in this












chapter. Physiotherapists should play an active part










in contributing to physiotherapy clinical governance








programmes and also participate in relevant multi-
















professional clinical governance activities such as clini-

The health service continues to be a high priority for the



cal audit or local protocol/clinical pathway design.

government. Change is constant and a key challenge for




Porter: Tidy's Physiotherapy, 14th Edition





Patient-focused practice, underpinned by sound clinical





reasoning and professional judgement, ongoing reflection,





and critical application of the evidence base














Professional responsibility, manifested in










adherence to a professional code of









conduct/standards of practice, undertaking



Professional privilege, expressed through



structured, evaluated CPD to meet identified



professional autonomy and self-regulation



learning needs, and engagement with the full










implications of clinical effectiveness









Figure 1.3 Elements of professionalism. (With thanks to Dr Sally Gosling.)






physiotherapists is to respond to the opportunities and

community settings. The success of domiciliary and



risks presented to ensure that high-quality services are

community-based physiotherapy services in avoiding



delivered to patients. Many of the government’s priority

hospital admissions and allowing speedier discharges



health programmes will be dependent for their success

will be further reinforced through the introduction of



on the provision of effective rehabilitation in order to

intermediate care. The musculoskeletal physiotherapy



ensure people can continue to lead independent lives,

services delivered in GP practices and health centres,



including services for older people, children and those







where trust is already established between doctors



with long-term conditions. Physiotherapists also have

and physiotherapists, has facilitated more direct access



a key contribution to make to keeping people fit for

to patients and better referrals, making services more



work through, for example, the effective management

efficient as well as effective.




of musculoskeletal problems or the delivery of cardiac

The challenges, however, will lie with greater team




programmes. Ensuring







working and delegation of tasks, with physiotherapists



safe environments in the workplace and offering a rapid







having to be prepared to be more flexible, often taking



work-based response when treatment is needed provide

on teaching roles in order to allow other staff such as



other examples of the value of the profession.







rehabilitation assistants to deliver services. There will








be a need to take on some non-physiotherapeutic roles,



Structural changes




such as key worker or case manager, in order to deliver






a more consistent approach to care to vulnerable people





















living in the community.




Continued investment in healthcare will bring with it an




increase in the expectations of the public whose money

Another challenge will be the experience of working



is being used, and challenges from the government

in more isolated settings, with less easy access to peer



and the public about the need to change and modernise

support, supervision or shared CPD with colleagues.



the way in which healthcare is delivered. Services will

At a time when clinical governance, the requirement



need to be more responsive to patients’ needs,CONTENTprovided for re-registration and the need for systems to assure



in settings closer to patients’ own environments, and

patients of practitioners’ competence and safety are to



delivered more speedily to maximise health benefits

the fore, physiotherapists will need to work hard to cre-



and utilise available resources more effectively.



ate systems to support their ongoing learning, while



Many more physiotherapy services will be provided

also ensuring their managers accept their responsibil-



in primary care and community settings. Primary Care

ities too. Networking with colleagues with similar



Trusts ( CTs) will hold 60 per cent of the total budget

interests and case mix at a local and national level will







become more important. Where face-to-face contact is



for healthcare in their local area, and local people will



have a much stronger voice in the decision-making pro-

not possible, the use of electronic networks for commu-



cess about how those funds are used. In addition, the

nication and accessing learning resources will need to








be embraced.






government has committed itself to increasing integra-






tion between

health and social care,

through Care

Delivering clinically effective and cost-effective



Trusts, where budgets are pooled in order that they









can be used more flexibly to meet the needs of the local

















The profession can thrive only if it can clearly demon-



More services delivered in primary care and



strate the ‘added

value’ it offers to patients through





increasing their independence, shorter hospital stays,


community settings








fewer work days lost and so on. In order to achieve










Physiotherapy already has a track record of delivering

this, the profession needs a two-pronged approach.



responsive and effective services in primary care and

First, it needs to

increase its knowledge base about


Porter: Tidy's Physiotherapy, 14th Edition










Sources of critical appraisal tools










the effectiveness of specific interventions, through

will continue to be highly complex, ever-changing and





research. Second, it needs to use information from the

resource-challenged. Qualifying programmes are tasked


evaluation of practice to demonstrate the benefit to

with equipping physiotherapy students ‘with the atti-



patients of those interventions. The profession urgently

tude, aptitude and capacity to cope with change, uncer-



requires high-quality researchers who can access NHS

tainty and unpredictability and with a commitment to



and other funding in order to increase the knowledge

the concept of quality improvement’ (CSP 2002b). Quali-



base of the profession. Challenges from commissioners

fying physiotherapists of today will therefore be better



of services, to provide evidence of the effectiveness of

equipped than ever to cope. The NHS is increasingly



physiotherapy for particular patient or diagnostic

looking for leaders who are innovative, clear, lateral



groups, will not go away and physiotherapy services

thinkers and problem-solvers. Physiotherapists are well



are in increasing jeopardy without it.




placed to adopt such roles and should be proactive in



The profession must be brave enough to look critically

looking for opportunities to do so. The skill is to turn



at the outcomes of interventions. Where research evi-

challenges and pressures into opportunities to demon-



denceshows that particular interventions are ineffective,

strate the ‘added value’ of physiotherapy, which in turn



these should cease to be provided. Where patient out-

will provide job satisfaction, recognition and benefit for



comes are used as a determinant and demonstrate little

patients and the profession.




or no effect, consideration should be given to possible








alternative strategies for securing benefit to those








patients which may lie outside physiotherapy. For phy-











siotherapists to continue to provide services in areas









where there is little benefit weakens the image of the pro-

Critical Appraisal Skills Programme



fession to the public and to colleagues from other












































There is a growing emphasis in the NHS on working















smarter, looking at systems

of care

from a patient’s









Qualitative research:




perspective, breaking down

what are perceived as












tribal boundaries between professions, and redesigning


Randomised controlled trials:




patient-centred delivery systems rather than ‘doing





things that way because we always have’. Physiothera-


Systematic review:




pists will need to embrace new ways of working with-


















out feeling defensive or appearing to be protectionist.









Opportunities will emerge from redesign for physio-

Scottish Intercollegiate Guidelines Network



therapists to adopt new and highly skilled roles in just

@ Weblink





the same way as the successful creation of extended-





scope practitioner and physiotherapy consultant roles.


Case-control study:













Influencing the agenda

















To make any of this work, physiotherapists need to be


Cohort study:










confident about their roles and able

to articulate to






Diagnostic study:




others the value of physiotherapeutic interventions or










approaches from a science-based as well as a holistic






Randomised controlled trial:




point of view. Physiotherapists must adopt a political










astutenessPROPERTYthat makes them aware of the wider national






Systematic review:




and local drivers for change in order that opportunities










for the profession and for services can be identified and




































seized positively. They need to be seen to be engaged

Users’ guide series




with and responsive to current agendas through con-




Guyatt GH, Sackett DL, Cook DJ 1993 Users’ guides to the



tacts with patient and public representatives as well





medical literature. II: How to use an article about therapy



as senior managers and local politicians.











or prevention, pt A. JAMA 270(21): 2598 2601

















Guyatt GH, Sackett DL, Cook DJ 1994 Users’ guides to the



Characteristics of the profession required to



medical literature. II. How to use an article about therapy



maximise the opportunities being presented





or prevention, pt B. JAMA 271(1): 59 63








Oxman AD, Cook DJ, Guyatt GH 1994 Users’ guides to the



One thing is certain. The delivery of healthcare within





medical literature. VI: How to use an overview. JAMA



organisations, whether funded by the state or privately,



272(17): 1367 1371





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