CF WI PHYSIOTHERAPY WORKFORCE REVIEW CENTRE FOR WORKFORCE INTELLIGENCE. Andrew Beddow

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1 CF WI CENTRE FOR WORKFORCE INTELLIGENCE PHYSIOTHERAPY WORKFORCE REVIEW Andrew Beddow

2 TABLE OF CONTENTS Table of contents... 1 Executive summary Specialty description and pattern of training Current workforce Overview Analysis Demand drivers and estimates Policy Service reconfiguration and settings of care Skill mix Demography Workforce supply Commissioning trends and scenario comparison Physiotherapy graduate employment Vacancy rates International recruitment Conclusion and recommendations CfWI 1

3 EXECUTIVE SUMMARY The physiotherapy workforce in the NHS has seen significant growth in the past ten years, with the full-time equivalent (FTE) of qualified physiotherapists employed by the NHS in England increasing by 48% between 2000 and With an ageing population, the shift towards care closer to home and increased patient choice, demand for the services of physiotherapists in the NHS is likely to at least remain stable, or slightly increase, in the future. The same period has seen a concurrent rise in the number of physiotherapists working exclusively outside the NHS. All physiotherapy training places in England are commissioned by the NHS, so demand from other sectors affects the availability of and demand for NHS staff. Physiotherapy training course commissioning levels have dropped by 30% between 2005 and 2010, after peaking in The number of training places commissioned for physiotherapists by the NHS in 2010 is lower than it was in CfWI modelling suggests that if the current level of commissioning is maintained, the supply of physiotherapists to the NHS will increase slightly over the next five years, then plateau, remaining broadly in balance with estimated future requirements. If the number of training places commissioned significantly decreases any further, CfWI supply forecasts suggest the NHS physiotherapy workforce will decline in numbers from If the current level of training places is maintained, demand and supply of physiotherapists are projected to remain broadly in balance. As such, the likely future demand for physiotherapy services needs to be strongly considered in commissioning decisions. There is evidence of difficulties recruiting to senior NHS physiotherapist posts. Increasing access to continuing professional development opportunities and post-qualifying training for the current band 5 and 6 workforce will allow more to achieve promotion to senior posts, freeing up band 5 positions for newly qualified graduates. 1 NHS Information Centre census CfWI 2

4 1 SPECIALTY DESCRIPTION AND PATTERN OF TRAINING Physiotherapists use manual therapy, therapeutic exercise and rehabilitative approaches to restore, maintain and improve movement and activity and to support people in managing their own condition, maintaining their independence and preventing future episodes of ill health. Members of the physiotherapy workforce physiotherapists and support workers - undertake many different roles, in a range of sectors and settings across the UK, very often in multidisciplinary and integrated teams. They work with a wide range of population groups (including children, those of working age and older people), across sectors, and in acute, community and workplace settings. They do this throughout all stages of the patient care pathway - undertaking assessment, diagnosis, treatment, discharge, referral, rehabilitation and management of longterm conditions. For other clients, they have a key role in promoting and maintaining health, preventing disease and enabling people to stay in and return to work. In addition to having clinically-focused roles, members of the physiotherapy workforce are also educators, researchers, managers and leaders. Some physiotherapists extend their individual scope of practice to undertake specialist and advanced roles. There are various routes into the profession, with 29 higher education institutions (HEIs) in England providing qualifications in physiotherapy. The shortest route is a two-year, fast-track postgraduate course for those with a first degree in a relevant subject; there are currently 13 of these programmes in England. Data provided by the Chartered Society of Physiotherapy (CSP) shows that 52% of physiotherapists currently graduating in England have undertaken a standard three-year, full-time undergraduate programme. The remainder (48%) do so through a number of routes: part-time, flexible, accelerated, situated and work-based learning. Part-time/flexible routes are available from 11 providers in England. Anecdotal evidence suggests that most people undertaking this route are already employed as physiotherapy support workers. CfWI 3

5 2 CURRENT WORKFORCE 2.1 Overview The physiotherapy workforce has undergone significant growth over recent years. Data from the NHS Information Centre census shows the headcount of physiotherapists has increased by 41% between 2000 and 2009, with the fulltime equivalent (FTE) increasing by 48% within the same time period 2. The Health Professions Council (HPC) recorded 44,734 registered physiotherapists as of January The current physiotherapist workforce in the NHS (as of the end of May 2010) is comprised of the following numbers of staff: Headcount FTE Source Physiotherapist* 21,855 18,490 NHS iview, Aug 2010 Support workforce** 4,235 3,265 NHS iview, Aug 2010 * Occupation codes S0E, S1E, S6E, S7E, S8E, SAE ** Occupation codes H1J, H2J, S5E, S9E 2.2 Analysis As can be seen in the table above, significantly more physiotherapists are registered with the HPC than currently practise within the NHS. According to information held on the Chartered Society of Physiotherapy s workforce database, approximately a quarter of the qualified physiotherapy workforce 7,300 of CSP s members work exclusively outside the NHS (for example, in private hospitals, sports clubs or their own private practice). Figure 1, below, illustrates the split between NHS and non-nhs physiotherapists, and forecasts its possible course over the next ten years. 2 NHS Information Centre census, CfWI 1

6 Figure 1: Forecast physiotherapist workforce, showing demand from NHS and non-nhs workforce 40,000 Forecast physiotherapist workforce, showing demand from NHS and non-nhs workforce 35,000 30,000 25,000 Non-NHS workforce, supplied by NHS commissions 20,000 15,000 10,000 Estimated supply of physiotherapist s to NHS workforce 5, Sources NHS Information Centre census 2009, SHA commissioning trends, CPS workforce database All physiotherapy training in England is currently commissioned by the NHS, yet there is significant demand for their services in other sectors. Government policy is likely to increase the involvement of private sector providers in healthcare provision: this may lead to an increased proportion of physiotherapists being employed outside the NHS. Little data is currently held on the workforce outside the NHS; the CSP is currently running an information gathering exercise. The current NHS workforce has an 84% female to 16% male gender split. Information from the CSP shows that a larger proportion of students entering training are male (27% in the 2008/09 intake, in line with other recent cohorts). 54% of students entering training in 2008/09 were mature students, with an average age of entry to training of CfWI 2

7 The NHS workforce has a relatively young age profile, with the majority of NHS physiotherapy staff being 40 or under, and no impending bulge in retirements likely (see Figure 2). Figure 2: NHS physiotherapy & support workforce age profile 6,000 NHS physiotherapy & support workforce age profile 5,000 4,000 3,000 2,000 FTE Headcount 1,000 0 Under to to to to to to to to to and over Source NHS iview, Figure 3 shows a Christmas tree chart for the NHS physiotherapy and support workforce in the NHS. A majority of posts are at bands 6 and 7, with the support workforce mainly occupying bands 2 to 5. The skill mix of the physiotherapy workforce is discussed further in section 3.3. CfWI 3

8 Agenda for Change Band Physiotherapy workforce review Figure 3: NHS physiotherapy staff in England by AfC pay band NHS physiotherapy staff in England by AfC pay band Workforce (FTE) Source NHS iview, CfWI 4

9 3 DEMAND DRIVERS AND ESTIMATES Analysis indicates that demand for physiotherapists is likely to increase slightly over the next 5-10 years. 3.1 Policy With the recent change in government, health policy is currently in a transitory stage, and it is difficult to accurately gauge which policies and priorities from the previous administration will be continued. However, the Next Stage Review s 4 focus on quality will remain. The expansion of the patient choice agenda in the Government s recent White Paper 5 is likely to lead to an increased role for external providers in providing services, which may cause employment of physiotherapists in sectors outside the NHS to rise. Ensuring the working age population remains healthy and able to contribute economically 6 is likely to remain a priority. Physiotherapists are able to make key contributions to tackling workplace ill-health and help keep people in work. Muscoskeletal disorders (MSD) account for a large proportion of sickness absence, with 22% of people on incapacity benefit registered as having an MSD 7. Physiotherapy is a key part of successfully treating and managing MSD. The Boorman Report 8 states that by reducing current rates of sickness absence in the NHS by one-third, there would be 33.4 million additional available working days per year within the NHS, equivalent to an extra 14,900 whole-time equivalent staff, and with an estimated cost-saving of 555 million. 3.2 Service reconfiguration and settings of care Delivery of physiotherapy services is increasingly shifting from acute to primary care settings to strengthen the provision of accessible, personalised care. 4 Department of Health, NHS Next Stage Review: High Quality Care for All, Department of Health, Equality and excellence: liberating the NHS, Black, C. Working for a healthier tomorrow, Kemp, P. & Davidson, J., Routes onto Incapacity Benefit, Department for Work and Pensions, Available at 8 Boorman S. NHS health and well-being: final report., 2009 CfWI 5

10 Physiotherapy is a strong enabler of self-care, reducing GP consultation times and hospital length of stay. Physiotherapy services are also currently reconfiguring to seven day working patterns (as opposed to traditional five day working). Physiotherapy services that are staffed seven days a week have been shown to reduce average hospital length of stay and produce cost savings, but implementing them will increase overall demand for staff, although this demand can be attenuated by careful use of rotas and adopting new ways of working. Physiotherapists are also increasingly working as first-contact practitioners. Patient self-referral has been proven to be clinically successful, with high levels of patient satisfaction reported, as well as being cost-effective Skill mix Skill mix within Physiotherapy is currently being developed. Qualified physiotherapists are taking more responsibility for complex cases and managing overall patient care planning. Information from CSP indicates that at bands 6 and 7 many physiotherapists will be the first point of secondary care patient contact for some patients in place of a consultant. In complement, physiotherapy support workers taking on more responsibility for delivering non-complex protocol-driven care, form an increasingly important part of delivering front-line NHS physiotherapy services. As the increasing importance is placed on the band 4 workforce, pressure may be placed on the number of band 5 roles available to graduates. This situation should be carefully monitored. However, if development opportunities are promoted, progression within the service could lead to more band 5 posts being opened up for graduate level applicants. 3.4 Demography England s population is ageing. By 2024, 23% of the population is expected to be 65 and over, compared to 18% aged 16 and under 10. Physiotherapists provide important services to older patient groups, helping to make care both more efficient and improving patients quality of life through reducing hospital admissions and length of stay, increasing patient function and mobility, enabling 9 Department of Health, The Musculoskeletal Framework: a joint responsibility: Doing it differently, 2008.; Holdsworth LK, Webster VS, McFayden AK, What are the costs to NHS Scotland of self-referral to physiotherapy? Results of a national trial, Office for National Statistics National Population Projections 2008 CfWI 6

11 self management and independence and reducing the number of admissions to care homes. In November 2008, CSP surveyed physiotherapy managers in the NHS. 26% of respondents said that senior posts in elderly care were very or quite hard to fill. With an ageing population, the absolute number of cases of stroke and chronic obstructive pulmonary disease (COPD) will both rise. Physiotherapy plays a central part in the successful management of both. Pulmonary rehabilitation programmes are clinically and cost effective in improving health and quality of life, reducing length of hospital stay and reducing the number of hospital readmissions for people with COPD. Physiotherapists are essential to the multidisciplinary teams that run these programmes. Physiotherapists also have a critical role to play in supporting stroke survivors and their carers. There is wide consensus about the beneficial impact of physiotherapy on the physical effects of stroke. The current clinical standard for patients with motor deficits to access physiotherapy is 72 hours. CfWI 7

12 Physiotherapists Physiotherapy workforce review 4 WORKFORCE SUPPLY If current commissioning levels are maintained, the supply of physiotherapists in the NHS is forecast to plateau, increasing slightly over the next five years and slightly decreasing from 2015 (see Figure 4, below). Figure 4: Historical and anticipated physiotherapy workforce supply Historical and Anticipated Future Physiotherapy Supply 35,000 30,000 25,000 20,000 15,000 Net Total NHS-Staff Headcount in year TOTAL physiotherapist headcount (NHS & non-nhs) actual NHS requirement 10,000 5,000 0 Year Sources NHS Information Centre census 2008, SHA commissioning figures, CPS workforce database As can be seen, the supply of physiotherapists working inside the NHS is forecast to be less than the projected NHS requirement for physiotherapists in the medium term. This may be somewhat alleviated by the physiotherapy workforce operating in other sectors, contingent on the impact of government policy. However, it is important to note that the total physiotherapy workforce supply line shown in Figure 4 is based on a simple extrapolation of current trends within the CSP registered workforce (ie, 24% of physiotherapists practising outside the NHS). This may no longer be the case in future years the NHS workforce could shrink at the expense of other sectors, or vice versa. 4.1 Commissioning trends and scenario comparison Commissioning trends for physiotherapy have followed a clear trajectory over the past decade, increasing steadily between 2001 and 2004 following the CfWI 8

13 recommendation to train more physiotherapists in the NHS plan - a 39% cumulative increase in training numbers. Commissioning numbers then decreased at a similar rate from 2005 to 2010, following concerns about graduate employment from 2005 to 2010 a 31% cumulative decrease. Year Intake 1,747 2,037 2,145 2,427 2,410 2,276 2,041 1,796 1,784 1,684 Change 17% 5% 13% -1% -6% -10% -12% -1% -6% Source CSP HEI enrolment data As shown in Figure 4, if commissioning levels are kept at their current rate, the number of physiotherapists available to the NHS is likely to plateau then slightly decrease over the next 10 years. 4.2 Physiotherapy graduate employment As noted in section 4.1, concerns about levels of physiotherapy graduate unemployment contributed towards the reduction in commissioned training places from 2005 onwards. However, over recent years this concern has been alleviated. Research by CSP demonstrates increasing proportions of graduates are finding employment as junior physiotherapists on permanent or short-term contracts. There is a clear trend year on year: after only 31% of the 2006 cohort of students had found work as a junior physiotherapist by December 2006, 53% of the 2007 cohort had by December 2007, 60% of the 2008 cohort had by November 2008 and 80% of the 2010 cohort had obtained work as a junior physiotherapist by April This proportion is likely to have increased in the intervening months. The oversupply seen in 2005 has been eased through a combination of posts being unfrozen and the impact of physiotherapy commissioning cuts made from 2005 onwards reducing the number of newly qualified physiotherapists available to hire each year. Data from the NHS Information Centre census shows that the number of physiotherapists employed by the NHS in terms of headcount has grown every year between 2000 and 2009 (a cumulative increase of 41%) with the exception of 2006 the year in which graduate unemployment peaked where the workforce shrank by 1%. 4.3 Vacancy rates The table below summaries vacancy data from the NHS Information Centre collected over the past four years. CfWI 9

14 Three month 1.1% 0.4% 0.3% 0.5% Overall % 2.8% Source: NHS Information Centre vacancy surveys, Two types of vacancy are shown: three month vacancies, where the organisation has been actively attempting to recruit to an unfilled post for three months or more, and overall vacancies, all vacancies the organisation is currently actively recruiting. However, the NHS Information Centre vacancy survey covers only posts to which an employer is actively trying to recruit it does not measure posts or vacancies that have been frozen. Information collected from physiotherapy managers by the CSP via a workforce survey in October 2008 (covering 126 NHS trusts and 32% of the physiotherapy workforce in England) found a high proportion of managers reporting difficulties recruiting to senior posts. Many respondents reported some or major problems recruiting to various levels of senior posts (25% at band 8, 34% at band 6 and 46% at band 7). This suggests that vacancies captured by the NHS Information Centre may not accurately reflect the recruitment situation across all levels of the NHS workforce, with a separate set of issues affecting recruitment to graduate and experienced level posts. 4.4 International recruitment Physiotherapy posts were removed from the Home Office s Shortage Occupation List in May Following this development, there has been a significant decline in the number of non-uk nationals registering with the HPC to practise as physiotherapists in the UK (from 1053 in 2006 to 550 in 2009). This suggests that overseas physiotherapists played a significant role in filling senior posts. With non-eu physiotherapists no longer readily able to apply to vacant senior posts in the UK, these posts should be filled by EU/UK workers, freeing up more Band 5 posts for graduates. However, as discussed in section 4.3, many physiotherapy managers were still reporting difficulties recruiting to senior posts in October CfWI 10

15 5 CONCLUSION The last decade has seen a significant expansion in the number of physiotherapists employed by the NHS. Demographic and policy factors mean that, relative to the financial challenges facing the NHS, demand for physiotherapists is likely to at least remain stable, or slightly increase. Due to concerns about an oversupply of graduate physiotherapists, places on physiotherapy training courses were cut significantly (by 30%) between 2005 and Over the same time period, the number of physiotherapists employed by the NHS has continued to expand. Evidence suggests that physiotherapy graduates are no longer having such acute difficulty finding relevant employment within the NHS. SHAs and Trusts could consider finding new ways of recruiting recent physiotherapy graduates, including graduate talent pools (a database of graduate healthcare workers that enables them to be matched with service providers looking to fill posts). NHS physiotherapy managers report difficulties recruiting to senior physiotherapist posts since their removal from the Home Office s Shortage Occupation List. Increasing access to continuing professional development opportunities and post-qualifying training for the current band 5 and 6 workforce will allow more to achieve promotion to senior posts. This should also free up band 5 positions for newly qualified graduates. CfWI modelling and analysis suggests that if current commissioning levels are maintained, the supply of the physiotherapy workforce will continue to grow in the short to medium term, reaching a plateau over the next decade. If there is a decrease in the commissioning levels of physiotherapy training places, there is a risk that the number of physiotherapists available for employment within the NHS and beyond will begin to decrease within the next five years. As such, the likely future demand for physiotherapy services within and outside the NHS needs to be strongly considered in commissioning decisions. CfWI 11

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