96 Closing words

It would be perfectly understandable if physiotherapists were worried that the healthcare system they have been such an important part of over the last century is now moving away from them. They should be worried because it is. The key, though, is what we do next. We can turn our gaze inwards, and try to preserve the profession at all costs, or we can try to anticipate what is coming and draw on the best knowledge available to us. I believe sociology holds a key to this process, but it is no panacea. Nursing has been engaging with sociology for decades now, with decidedly mixed results ^[1][2][3][4], and it has caused many uncomfortable conversations about the fundamental nature of nursing theory and practice. Sometimes the sharpest knife cuts well, but it might not be the best thing for putting meat in your mouth ^[5]. But this is a conversation for another time because the purpose of this book was never to use sociology to shape a better physiotherapy.

Had it been thirty years ago, this might have been a valid pursuit. We could have used our new sociological knowledge to turn away from our focus on the body-as-machine and our quest for more professional autonomy, and embraced a broader view of the physical therapies as a social construct. But that time has passed now ^[6]. Healthcare has become too expensive, too patriarchal, and too bureaucratic. The world has become too big, and people’s tastes have become too postmodern. People today want so much more from their bodies and their health than the ‘old’ professions allow. The public no longer unquestioningly accepts the claims of the health professionals that their work is fundamentally good, expert, altruistic, and public-spirited. And they no longer have an appetite for the professions governing themselves. The professions are empires in decline, and the physical therapies have been under occupation for too long.

All of the theories and criticisms presented in this book lead me to one inescapable conclusion: that the future of high quality, person-centred, trustworthy healthcare, no longer resides with professions like physiotherapy. But as Deleuze says; ‘There is no need to fear or hope, but only to look for new weapons’ ^[7]. And new weapons are certainly needed, not least because many of the problems people are now experiencing with healthcare stem not from the breakdown of the ‘old’ system, but from what is replacing it. We face a crisis of care, not of cost, in healthcare ^[8]; a problem made worse by the hubris of the professions and their desire to focus on their professionalisation projects, and not the underlying problems being caused by the state and the atomisation of late capitalism ^[9].

But if we really want to find some new weapons, we could do much worse than remind ourselves of a very ancient concept. In Greek, the word therapeia means ‘to serve, show attention, honour, show respect or reverence’ ^[10]. It means to accompany much more than it means to heal. It is an act of conviviality and reciprocity. Therapeia, as Steen Lykke argues, ‘is an attitude to the Other without authority; it does not rely on any scientific expertise about humanity’ (ibid).

‘This is the horizon that the discourse and the politics of the commons opens for us today’, Silvia Federici argues ^[11]. This is ‘not the promise of an impossible return to the past, but the possibility of recovering the power of collectively deciding our fate on this earth. This is what I call re-enchanting the world’ (ibid).

Clare Kell and Gwyn Owen argued in 2008, that ‘Rather than comparing our professional project with (functionalist) descriptors created for a different time we must look forward and generate the future for ourselves’ ^[12]. It has always struck me as interesting, then, that, in the past, when I have asked my colleagues whether they would shut down the physiotherapy profession if it were in the public’s interest, many have had to think about their answer. Our affinity with our professional identity has been so strong, that it seems, sometimes, to override even the most fundamental of ethical considerations: as if preserving physiotherapy against the public’s interest could ever be justified.

But, in truth, this is exactly what is happening. We know, for instance, that there is enormous demand for people to train as physiotherapists, and most university programs are vastly over-subscribed. We also know that there is an enormous unmet need for physical therapy in the community. In most countries there are as few as 10 physiotherapists for every 10,000 people ^[13], and even then, the expertise of the best is only available to a select few. Given the global burden of lifestyle diseases ^[14][15], there are vast numbers of people and communities in need who will never see a physiotherapist. And yet, at the same time, the profession works extremely hard to protect its ‘brand’, and works assiduously to restrict people’s access to the physical therapies. Its colleges have for years restricted entry into programmes, and used content-heavy curricula, passive learning designs, over-assessment, and clinical socialisation strategies to ensure only a select few students succeed. And regulators have assiduously policed the profession’s boundaries to ensure only registered practitioners have access to the privileges of being a physiotherapist. A thorough examination of the ethics of such practices, and the myriad other professionalisation strategies employed by physiotherapists, is overdue. This might ‘not be easy for physiotherapists’, as Sarah Barradell suggests, ‘But in doing so, new possibilities are uncovered for what the profession might become’ ^[16].

‘There is no reason’, John Maynard Keynes once wrote, ‘why we should not feel ourselves free to be bold, to be open, to experiment, to take action, to try the possibilities of things’ ^[17]. But, of course, freedom comes with its own anxieties. All of the orthodox, Western health professionals are having difficulty imagining modern society in their absence ^[18], and there are some enormous risks for the future of healthcare as we move into the post-professional era. But that does not mean we should not try.