Physiotherapy in crisis

A critical sociology of physiotherapy — Updating models of change: Doing nothing, Modern heritage, Renaissance physiotherapy, Hybrid physiotherapy — So, what can be done?

Mirko Noordegraaf suggested in 2015 that, ‘the contemporary study of professionalism is lively because much is at stake’ ^[1], and, indeed, even a cursory glance at some of the challenges now facing physiotherapy would lead most people to conclude that the profession has a lot on its plate.

Years of austerity and neoliberal economic reforms have bitten into public funding. Wards and services have closed, and the threat of more cuts, more reforms, and more competition always hangs over ‘non-essential’ services. And yet, healthcare has fared better than most. By comparison with some other industries, healthcare is booming. Add the fact that health professionals are trained to believe their work is a ‘calling’ (and so should never complain), and it is easy to see why so many have acceded to the creeping bureaucratisation of their work, brought on by decades of New Public Management, risk culture, and managerialism, undermining their clinical autonomy, and transferring treatment decisions to insurers, case managers, and accountants, who seem to want to actively disincentivize optimal care.

Pressure on physiotherapists’ day-to-day work has increased massively ^[2][3]. Many are working longer hours, and offering fewer, shorter appointments. Treatment advice is becoming more generic and formulaic, and client/patient self-care is becoming more necessary. It is becoming increasingly difficult to feel satisfied with practice, and few people feel they are doing the job they trained so hard for ^[4][5][6]. They know that routinised care dumbs down their work and makes them easier to replace. They know that a raft of advanced practice nurses, osteopaths and chiropractors, exercise physiologists, therapeutic masseurs, personal trainers, acupuncturists, and counsellors are pushing hard to take over from them. And now the threat of AI and robotics, and other rapidly advancing technologies are challenging physiotherapists in new ways, forcing them to innovate and be creative, when the underpinning ethos of their training and practice has reinforced the need to conform and follow, avoid being disruptive or break the mould.

Added to this, shifts in the nature of healthcare are making physiotherapists feel that they are losing their distinctiveness and are being pulled out of their comfort zone. Treating ageing populations with increasingly complex chronic and lifestyle illnesses, requires more care and less cure, more wellness, more health promotion, and the generic ‘soft’ skills common in concierge-type health practices, and not the technical, pathology-based knowledge prized by physiotherapists for so long. And so, physiotherapy is slowly losing its status as ‘first choice for medically trained rehabilitation… and an essential part of the continuum of care’ ^[7].

Physiotherapists, like all orthodox professionals, are under ever greater pressure to remain up-to-date and reflect on their practice. But they are overwhelmed by the volumes of material they are expected to keep abreast of, and feel, increasingly, that, today, you can either be a clinician or evidence-based, but you cannot be both (ibid). The public are increasingly aware of health professions’ fallibilities, and are far more skeptical about their claims to be the best people to manage the health of the population. People are much more comfortable seeking their own health solutions, and bypassing traditional health authorities (until a crisis occurs, of course).

Roth R, Edwards I. Scarcity of resources and inequity in access are frequently reported ethical issues for physiotherapists internationally: An observational study. BMC Med Ethics. 2021;22:97.[/footnote]. Even though physiotherapy is one of the largest professions allied to medicine, only 7% of the countries worldwide have more than one physiotherapist for every 500 people. One third of the world’s population has less than one physiotherapist for every 10,000 people ^[8]. Physiotherapists are clustered in the Global North, and gravitate towards urban centres where people have the most disposable income and time ^[9][10][11]. In Sweden, there are 20,000 physiotherapists, three-quarters of whom work in the public system. They have direct access, and can offer heavily subsidised, government-funded treatment. People who need extended periods of treatment have it for free after a period of time. There is little unemployment of physiotherapists and physiotherapy jobs are secure. But very few other countries around the world compare with this.

Physiotherapists have come to realise that no-one is coming to save them; that no-one will speak up for physiotherapists if they do not do it themselves. Which would be OK if everyone in the profession agreed how we should move forward. But, in reality, there appears to be no ‘grand plan’, and physiotherapy, like healthcare generally, appears to be increasingly incoherent and fractured. Some have committed to dramatic shifts in training and education, but this has only served to ramp up student debt without offering guarantees of higher status or pay. Similarly, physiotherapists have committed vast amounts of energy and money to demonstrating the efficacy of their practice, but this has not made us more secure or more confident. If anything, it has undermined our sense of worth, and our value in the eyes of the public. Much of the research focuses on abstract clinical concerns removed from the real world of clinical practice, bypassing the kinds of knowledge that the profession needs to shape its future. Given all of this, perhaps it is understandable that many physiotherapists now feel that the ‘centre will no longer hold’; that the healthcare that we fought so hard to support, is slipping away.

Clearly, this is a bleak reading of the current situation, however much it reflects the realities for some therapists for some of the time. But there is also something wrong with this picture. Because surely physiotherapy is also a highly respected, popular, well-supported, and growing profession, with lots of things to offer the changing landscape of healthcare? In EoP, for instance, I suggested that;

’One of the first question physiotherapists might ask themselves about their future role in the changing economy of healthcare, is whether there is currently anyone better placed to take advantage of the changing economy of healthcare? Who else can claim to be a highly respected, orthodox, first-contact diagnostician; with a focus on the whole body, and skills in the assessment, treatment and rehabilitation of activity, movement and functional disorders; with discretion in day-to-day practice and a long history of working within today’s health priorities, and the delivery of highly personal, low-cost skills; in a manner that the public trusts, and sits comfortably alongside the work of doctors, nurses and other allied health professionals? Physiotherapy is, in many ways, perfectly positioned to be a major force in the healthcare services of the future’ ^[12].

There are now more than two-thirds of a million physiotherapists practicing worldwide, and nearly 250,000 physical therapists in the United States alone ^[13][14]. There are now more practicing physiotherapists in Australia than there are general practitioners, and the profession is estimated to increase in size by 28% in the next 10 years (ibid). And to this, we might now add that the COVID-19 pandemic has reminded people how important well-trained health professionals are to a country’s infrastructure; how popular health professional careers are becoming in the face of technological disruption in other sectors ^[15][16], and how much physiotherapists might contribute to mitigating the costs of climate change, with their relatively low-tech, ‘low-carbon’ approach to healthcare ^[17][18].^[19] Surely, as the NHS report Allied Health Professions into Action suggests, professions like physiotherapy ‘are everything that a rejigged, refocused, public healthcare sector should focus on’ ^[20]?

There is also, surely, a case to be made that we have seen this upheaval and talk of crisis before; that if one travelled back to any point in the history of modern healthcare, you would be likely to find similar talk of unprecedented change and complaints about the failure of healthcare to adapt. This passage from physiotherapists Joy Higgs, Kathryn Refshauge and Elizabeth Ellis was written 20 years ago;

’The current context of health care is one of contradictions: of highly advanced medical technology and increasing globalisation but lack of universal availability of solutions to health problems, of a growing number and range of health solutions but for many people, limitation of funds to purchase adequate health (Higgs, J. et al., 1999). Internationally, the practices of health and health care are changing dramatically. ‘In global terms, there is a considerable shift away from the cure of individuals presenting for service towards the prevention of illness in populations and the strengthening of the community’s capacity to deal with its own health’ (Lawson et al., 1996, p. 11)’ ^[21].

And so, although it would be fair to say that physiotherapists have little of the foundation mythology of professions like medicine and nursing (we have no Pasteurs or Nightingales), physiotherapists have secured their place within orthodox healthcare by being highly adaptive; moulding the physical therapies to their social purpose for generations. Physiotherapists are great responders. So, is physiotherapy in crisis or is it not? Is there anything new about the current moment that marks it out as different from all of the other ruptures met before by physiotherapists? Is physiotherapy at a tipping point, or is it on the cusp of a new period of growth and expansion? And if it is, how would we know?