71 Implications for physiotherapy

Reform and change are nothing new in physiotherapy, but the post-professional era will be symbolised by the ways in which the professions were incrementally de-centred from healthcare. Some of the changes affecting patient centred care, for instance, show this process clearly. Others, like the adoption of the biopsychosocial model, and the emphasis on neoliberal self-care, are de-centring the professions in more subtle ways. There are examples already of physiotherapists fighting back, by claiming higher levels of professional specialisation and graduate entry qualifications. And there are examples of bland acquiescence in the face of relentless reform (see Chapter 8).

But the ability to understand the drivers of post-professionalism, in the context of a century of sociological critique, could be enormously important in the coming decades. Not least because physiotherapy is very much implicated in the change taking place, and the conscious, thoughtful, and compassionate involvement of the profession in shaping healthcare in the future is an important ethical responsibility, given the power and prestige that the profession currently holds.

Some have suggested that trusting the health professionals to bring about reform themselves is akin to the ‘rabbits guarding the lettuce’ ^[1], particularly given how adept the health professions have been in the past at ensuring their territorial security. But if this book is anything, it is an argument that it is physiotherapists’ ethical responsibility to consider what will be in the best interests of our societies in the future, even if that means embracing a post-professional world in which our influence is de-centred. What are the implications of post-professionalism for physiotherapy, then? And how can we best support the post-professional promise of a very different healthcare in the future?

Below are three sociological ’tests’ that can be applied to changes now being instituted in and around physiotherapy. Although post-professionalism can be read from a number of different positions (culturally, economically, environmentally, or philosophically, for instance), I have retained the focus of this book on sociological issues. Drawing on the issues raised over the last six chapters, a number of critical questions emerge that may help us distinguish post-professional practices that work in the interests of people’s health and wellbeing, from those that do not:

• Firstly, we should ask how the profession is looking to divest its power and prestige and de-centre itself to allow its knowledge and skills to be used and shared by the community. All too often, defensive professional self-interest has allowed groups to claim new markets and territories, and to find new ways to entice clients/patients to value the profession over its competitors. We should ask, is the profession using this practice innovation to secure or grow its territorial claim to authority, expertise, specialisation, or coverage, or build on its historically advantageous relationships with other elites in the hope of securing its future? If so, this works entirely against the spirit of post-professionalism, and will, in all likelihood, see the profession increasingly sidelined and criticised for unethical conduct;
• Secondly, we should ask whether the profession is working to enhance its networks and connections, and make its boundaries more porous. Is it looking to demystify its language, systems, and processes, to make it easier for people to access it as students and practitioners, as well as clients/patients? Is it looking to reach beyond its traditional territory to explore new possibilities for collaboration and growth, in the arts, the humanities, history, philosophy, and sociology, for example? Or, by contrast, is it looking to progress its claims to autonomy, distinctiveness, specialisation, and independence, and carve out an ever-more-distinctive niche for itself as different from its allies and competitors, clients and consumers, regulators and managers? Is it looking to consolidate its scientific, biomedical credibility and, through this, convince service users, funders, and legislators, that it is ‘better than’ others, and more deserving of special treatment? Is it looking to stabilise and ossify the profession, or perturb it, disrupt it, and keep it in motion? Again, such attempts, when tied to claims of goodness and expertise, may be seen as increasingly hollow attempts at enclosure and protectionism, and the profession’s prestige may suffer accordingly.

• And thirdly, we should ask whether the profession is actively encouraging its members to think critically against themselves, questioning their professional socialisation and the discourses that have made their existence possible, in order that they can better understand their culture, history and philosophy ^[2]. Is the profession developing a culture of appreciation for difference, encouraging innovation, and creative disruption? Does it ask questions about whose voices are not heard by the profession, and whose interests are not being served? Is it working directly to enhance its role as an advocate for social justice, tackling entrenched power asymmetries and disrupting traditional power structures that reinforce social oppression? Or is it reinforcing the mechanisms that have historically perpetuated these systems, by promoting normalisation and other hallmarks of Western, patriarchal, colonial, ‘Northern’ privilege? Or is it doing this ‘passively’, by seeing the profession as beyond the scope of social action, or someone else’s concern? Is the profession stifling creative disruption through standardisation, regulation, and bureaucratisation, designed to retain the status quo, or only bring about change that enhances the status of the profession and does not threaten to undermine it?

These are perhaps some of the most difficult questions now being posed by post-professionalism. At their root, they revolve around active efforts on the part of the professions to relinquish their power in service of a greater good: to embody the spirit of the ‘post’ in post-professionalism. Ironically, if health professionals were true to the functionalist logic that says they are driven by altruism and public spiritedness, they would have been doing this work for decades already; effectively bringing about the conditions of their own de-centring. But decades of critical, Neo-Weberian, and postmodern sociology, have shown us that the professions are, first and foremost, protective enclosures that have the greatest difficulty letting go of their hard-won social capital. And so post-professionalism can seem like a threat to the professions because it exposes the conceit that the health professions are, in reality, anything but person-centred.

The greatest fear of the professional, who has invested years in training and practice and comes to believe that they are important and necessary to society, is that people will no longer want them. And this is the process that post-professionalism seems to be accelerating. How can we begin to contemplate demystifying our knowledge and sharing our skills with anyone who wants to use them, the professional asks if the end result is our demise? But if it were in the public’s interest to close the physiotherapy profession down completely, for instance, then of course we should do it because the key phrase here is that it would be in the public’s interest. The healthcare system is not there to serve the interests of the professions, but the people who they claim to serve.

So, how do we turn defensive professionals into advocates for a new kind of healthcare? Why would a profession entertain the idea of a practice designed to drive physiotherapy into obsolescence? The first answer to this has already been stated: because it might be in the public’s interest. And so, in the very first instance, we need to test the virtue of this idea. In some cases, it would be hard to imagine a community ever wanting to lose access to some experts and specialists. But in many cases, there is nothing particularly mystifying or intangible about the knowledge and skills that the professionals possess. The physical therapies — therapeutic touch, manipulation, exercise, electromagnetism, and so on — are a prime example of this. As some of humanity’s oldest-known health remedies, the physical therapies have been practiced by peoples around the world for millennia, and will, almost certainly, be needed by people for years to come. So, physiotherapists’ attempts to ‘colonise’ these knowledges and skills, and attempts to protect this knowledge from the public, increase specialisation and legislative protection in order to take physical therapies beyond the reach of ‘ordinary’ people, may be seen as distinctly cynical self-interest in the future.

But asking what physiotherapists might do themselves to advance post-professional healthcare also implies that they will be the primary agents of change. This would be a mistake though because one of the main effects of post-professionalism has been the realisation that health professionals are just one agent among many; one ‘effect’ and ‘achievement’ of broader and deeper cultural, economic, political, and social discourses, amidst a myriad of overlapping, complementary, and competing forces initiating change. Post-professionalism has cast doubt on the fundamental basis of any claims to autonomy and independence on the part of individual professions ^[3], and, instead, reinforced the inherently interwoven, collaborative, distributed, and complex nature of healthcare. Physiotherapists will undoubtedly play a part in shaping the future of healthcare, but we will be one voice among many, and post-professionalism suggests that healthcare will be all the better for the modesty and self-awareness that this implies.

What is clear is that we are already seeing the effects of significant reforms in contemporary physiotherapy thinking and practice. The move towards person-centred care, and the drift away from the management of acute, self-limiting, soft-tissue injuries, to a focus on the kinds of pain and disability that cannot be cured; the renewed emphasis on more holistic models of practice, like the biopsychosocial model; the growing concern for the UN’s Sustainable Development Goals; the growth of publishing in the emerging field of critical physiotherapy, rehabilitation, and the humanities; extended scopes and advanced practitioner roles; the turn towards inter-, multi-, or trans-disciplinary practice (a subject we will return to in the next chapter), and more boundary-testing practices like vocational rehabilitation, acceptance and commitment therapy, and acupuncture; digital technologies in shaping how physiotherapy is being learned and disseminated; and a focus on stigma, power, privilege and disadvantage in physiotherapy, are all opening a space for critical conversations around the post-professional future for the physical therapies.

But we should be careful not to see anything that breaks with tradition as being necessarily post-professional. For something to be post-professional, it cannot merely be ‘old wine in new bottles’. Post-professionalism requires the profession to be de-centred, and any change that seeks to merely enhance the profession’s standing, whilst appearing to be based on altruism and public spiritedness, will increasingly be seen as a kind of ‘care-washing’.

What follows over the final two chapters is an exploration of what post-professionalism might look like for future physiotherapy. In the final chapter, I propose the radical opening of the physical therapies as one of a thousand possible futures. The arguments build directly on the work of the previous chapters, and ask what an otherwise physiotherapy might look like if it broke free from its historical enclosure. How might the physical therapies be developed in a way that makes them more available to people, and returns them to a place at the heart of everyone’s understanding of bodies and movement, in health and illness: a physical therapy in common, so to speak?