Written evidence from the Chartered Society
of Physiotherapy (CFI 27)|
The Chartered Society of Physiotherapy (CSP) is the
professional, educational and trade union body for the UK's 50,000
chartered physiotherapists, physiotherapy students and support
Physiotherapy enables people to move and function
as well as they can, maximising quality of life, physical and
mental health and well-being.
Physiotherapists use manual therapy, therapeutic
exercise and rehabilitative approaches to restore, maintain and
improve movement and activity. Physiotherapists work with a wide
range of population groups (including children, those of working
age and older people); across sectors; and in hospital, community
and workplace settings, facilitating early intervention, supporting
self management, promoting independence and helping prevent episodes
of ill health and disability developing into chronic conditions.
Physiotherapy supports people in a wide range of areas including
musculoskeletal disorders (MSDs); many long term conditions, such
as stroke, MS and parkinson's; cardiac and respiratory rehabilitation;
children's disabilities; cancer; women's health; continence; mental
health; and falls prevention.
Further to the written evidence submitted on 6 October
2010 to the Committee's earlier inquiry, the Chartered Society
of Physiotherapy is pleased to offer the following evidence to
the Committee as part of its follow-up inquiry into commissioning.
We have restricted our comments to the questions where we feel
we can most effectively contribute to the debate.
1. The Committee intends to examine further
the assurance regime which it is proposed to establish around
commissioning consortia in order to satisfy itself that the NHS
Commissioning Board has sufficient authority to deliver its objectives
defined in its Commissioning Outcomes Framework.
1.1 It is currently unclear as to whether the
NHS Commissioning Board will have a regional structure. The CSP
believes that regional level organisation, on a par with the current
provision of Strategic Health Authorities, will be important to
ensure the GP Consortia have appropriate support to carry out
their commissioning functions, particularly in those areas where
services are best commissioned at a regional level. In addition,
it would provide a strategic overview across the number of different
sized GP consortia covering each region.
1.2 The CSP believes that the NHS Commissioning
Board should be required to have a permanent Allied Health Professions
(AHP) director. This post is vital to ensure that the important
role of Allied Health Professionals, in delivering effective and
cost efficient healthcare across all sectors, is not overlooked.
1.3 GP Consortia will be required to commission
services which meet the quality standards set by NICE. The CSP
broadly agrees with this approach, however, is concerned that
the initial set of 150 quality standards will not be completed
until 2015, by which time the structural changes and new commissioning
arrangements will have been in place for at least two years.
2. The Committee intends to review the
arrangements proposed in the Bill for defining the lines of accountability
between the NHS Commissioning Board, the Department of Health
and the Secretary of State to prevent potential future conflicts
2.1 The CSP has nothing further to add on this
3. The Committee believes it is essential
for clinical engagement in commissioning to draw from as wide
a pool of practitioners as is possible in order to ensure that
it delivers maximum benefits to patients. GPs have an essential
role to play as the catalyst of this process, and under the terms
of the Government's changes they, through the commissioning consortia,
will have the statutory responsibility for commissioning. They
should, however, be seen as generalists who draw on specialist
knowledge when required, not as the ultimate arbiters of all commissioning
decisions. The Committee therefore intends to review the arrangements
proposed for integrating the full range of clinical expertise
into the commissioning process.
3.1 The CSP welcomes the Committee's assessment
of the need for a wide range of clinical input into the commissioning
3.2 We believe it will be important for commissioning
decisions to be based on knowledge about which services are proven
to provide best outcomes for patients - for example the provision
of community based stroke rehabilitation, provided by physiotherapists,
to support the recovery of stroke survivors.
3.3 The CSP is concerned that the knowledge and
skills of GPs will vary and this could lead to a postcode lottery
for patients. We would, therefore, argue for a statutory duty
for other healthcare professionals to be involved in GP consortia
3.4 Furthermore, we would argue that to effectively
deliver real long term improvements in the health of local communities,
and to tackle health inequalities, it will be crucial to ensure
the expert contribution of Allied Health Professionals, such as
physiotherapists, is included on all Health and Wellbeing Boards,
which will take a strategic overview of the commissioning and
delivery of local services.
4. Although the Committee understands
the value of the separation of the commissioner and provider functions
it believes it is important that this function separation is not
allowed to obstruct the development of high quality and cost effective
service solutions. The Committee therefore intends to review the
arrangements proposed in the Bill for reconciling these conflicts.
4.1 The CSP believes that while the split between
the commissioning and provision of health services can bring benefits,
the evidence to demonstrate that it delivers higher quality services
is mixed and in some cases value for money is not served because
of the higher transaction costs associated with it.
4.2 The CSP is very concerned that the separation
of the commissioner and provider functions in a context of enforced
competition will make it harder for NHS staff to work collaboratively
in multi-disciplinary teams, across organisational boundaries,
to create the integrated care pathways that patients want and
need, and that make services more efficient.
4.3 We believe that the sound principles of sharing
best practice to drive up standards of care will be hard to maintain
when different commercial entities are competing to provide services
and will view innovations as competitive advantage. This was the
experience of the NHS in the early 1990's when nursing and physiotherapy
managers were instructed not to share best practice innovations
with any other NHS organisations that might be rivals in competitive
tenders for NHS contracts.
4.4 We are also concerned that the provisions
in the Health and Social Care Bill which require Monitor to have
regard for improvements in the quality of services are not strong
enough. Clause 54 in the Bill places a duty on Monitor to have
regard for the 'desirability' of securing continuous improvement
in the quality of healthcare services. The CSP would argue that
this should be a necessity, not merely desirable, particularly
when, in Clause 52, one of Monitor's core functions is defined
as promoting competition.
5. The Committee agrees that local engagement
with the commissioning of primary care services is important and
therefore welcomes this development. The potential conflict of
interest between consortia and local primary care providers does
however remain. The Committee therefore intends to review the
arrangements proposed in the bill for the commissioning of primary
5.1 A fundamental choice which the CSP believes
should be available to patients is self-referral into physiotherapy.
Self-referral is a system for patients to make an appointment
direct with their local NHS physiotherapy department, without
seeing their GP first, which has been proven to reduce costs and
time for GPs. Self-referral is readily available throughout the
independent sector and private practices and recent research shows
it is available in just under 50% of NHS physiotherapy departments.1
Physiotherapy self-referral started in Scotland and has spread
very successfully internationally to Holland, Australia, Canada,
the USA and many other countries. It has been proven to be cost
effective and particularly beneficial, as highlighted above, for
patients with both short and long term conditions, who understand
their healthcare needs and are able to identify when they need
access to further physiotherapy treatment. This includes both
short term musculoskeletal disorders, women's health, and longer
term neurological conditions, such as stroke, MS or parkinson's.
NHS Evidence has recently included self-referral to physiotherapy
for musculoskeletal conditions in QIPP,2 based on evidence
of its ability to improve quality and productivity. Furthermore,
self-referral to physiotherapy for NHS staff, to reduce sickness
absence, is a major part of the Boorman Review3 proposals
which have been accepted by the current Government.
5.2 The CSP is concerned that the need to expand
and develop effective NHS self-referral schemes could be halted
by the adoption of contracting out via the "any willing provider"
approach for services that need to be part of integrated physiotherapy
pathways. Furthermore, we would be concerned as to how the funding
arrangements would work for self-referral to physiotherapy. The
CSP believes that patient self-referral should be comprehensively
available across England and would argue that it is a service
that should be commissioned by the National Commissioning Board,
under its responsibilities to commission primary care services.
5.3 We would urge a greater adoption and roll
out of the patient self-referral to physiotherapy schemes across
all of England, as this has proved successful in increasing timely
access to physiotherapy services, improving outcomes for patients
through early intervention and ultimately preventing costly onward
referral to specialists in secondary care.4
6. The commissioning of services that
either work across [health and social care] boundaries, or are
intimately linked is therefore an issue to which the Committee
attaches great importance, and we intend to review the effectiveness
of the structures proposed in the Bill which are designed to safeguard
co-operative arrangements which already exist and promote the
development of new ones.
6.1 The CSP would argue, that if the move is
made to GP-led consortia commissioning, the consortia groups should
be geographically coterminous with local authorities, to best
support partnership working on Health and Well Being Boards. We
would also argue that the consortia should have minimum and/or
maximum population sizes, on which budgets can be based to ensure
the financial risks are minimised.
7. The Committee intends to review the
arrangements proposed in the Bill to enable commissioning consortia
to address these issues [cross-area collaboration by consortia
in reconfiguring services] effectively; this will include a review
of the ability of the new system to encourage commissioning consortia
to cooperate in achieving the benefits to patients which may be
available from major service reconfiguration.
7.1 The CSP has nothing further to add on this
8. The Committee intends to review the
arrangements proposed in the Bill for enabling consortia to reconcile
this potential conflict [between patient choice and commissioning]
by enhancing patient choice at the same time as delivering the
consortium's clinical and financial priorities.
8.1 The CSP is concerned that the 'any willing
provider' model potentially restricts and/or impedes patient choice.
With an increase in the potential number of providers, patients
may have little information on each of them, or lack the ability
to evaluate one against another. This may result in the most vulnerable
patients being unable to exercise the choice envisaged by this
reform and, in effect, still reliant on the recommendation of
their GP, who may no longer be a truly 'independent or neutral'
advisor in the new system.
8.2 We are also concerned that patient choice
may be limited by the current economic climate. The impact of
the £20 bILLIOn of savings the NHS is being asked to find
may be reductions in the capacity of some services, and the closure
8.3 The CSP believes that any increase in patient
choice needs to be supported by robust and accessible mechanisms
for patients, the public and staff to effectively challenge commissioning
decisions to ensure they are based on evidence that they will
result in an improvement in the quality of services, and health
outcomes, for the local population.
9. The Committee does not find the current
stance on patient and public engagement in commissioning persuasive.
The National Health Service uses taxpayers' resources to deliver
a service in which a high proportion of citizens take a close
interest both as taxpayers and actual or potential patients. While
the Department may be right to point out that there is no special
virtue in uniformity of structure, the Committee regards the principle
that there should be greater accountability by commissioners for
their commissioning decisions as important. The Committee therefore
intends to review the arrangements for local accountability proposed
in the Bill.
9.1 As indicated in point 3.4 above, the CSP
is concerned that the Health and Social Care Bill does not make
any provision for the inclusion of Allied Health Professionals
(AHPs), such as physiotherapists, on Health or Wellbeing Boards,
instead leaving the decision of who should be appointed to the
board to the discretion of local authorities. We are concerned
that this could lead to the voice of AHPs not being heard in many
localities which will impact commissioning decisions and the development
of Joint Strategic Needs Assessments.
9.2 We remain concerned about the mechanisms
proposed to involve patients and the public more closely in local
commissioning decisions. We are particularly concerned that the
formal arrangements proposed will favour the well-educated over
those who lack skills to interrogate local health decisions.
9.3 The Health and Social Care Bill is unclear
as to whether Health and Wellbeing Boards will have the necessary
powers to intervene in decisions about service reorganisations.
We would like to see these powers clarified and where possible
10. The Government must support consortia
and existing commissioning organisations to form clear and credible
plans for debt eradication and for tackling structural deficits
within their local health economy. The Committee intends to further
review this issue in its further work.
10.1 We support the aims to secure financial
stability in the local health economy. However, we are concerned
that the additional costs associated with the reorganisation of
the NHS, estimated at up to £1.45 billion by the Department
of Health, will create additional burdens on the NHS at a time
when it has to make unprecedented efficiency savings. We are concerned
that these funds are being diverted away from delivering frontline
services, which may impact negatively on patient care.
1 Jones, R, Jenkings,
F (2011) "A survey of NHS Physiotherapy Waiting times and
musculoskeletal workload in England 2009-2010 report", CSP:
2 NHS Evidence
(2011) Musculoskeletal physiotherapy: patient self-referral
3 Boorman, S.
NHS Health and Well-being, Final Report, November 2009, DH; London.
4 Department of
Health (2008) Self-referral pilots to musculoskeletal physiotherapy
and the implications for improving access to other AHP services.
5 Department of Health
(2011) Health and Social Care Bill 2011: combined impact assessments.