31% of people experience pain at work at least once a week 1

Chartered Society of Physiotherapy Health and Social Care Bill Lords Report Stage briefing: Impact of NHS reforms on musculoskeletal physiotherapy February 2012 The Chartered Society of Physiotherapy (CSP) has been very concerned from the outset about the direction of the Government s NHS reforms and remains concerned that these are the wrong reforms at the wrong time. We believe that when the NHS is being asked to make unprecedented efficiency savings of 20bn, it should not be distracted by implementing a costly reform programme which has no evidence base. When we surveyed our members, 81 per cent said they were opposed to the reforms and 58 per cent said they feared patient care would be damaged if they were implemented. We have carefully considered the latest list of amendments tabled by the Government. We do not feel these go far enough in addressing the grave concerns already expressed by physiotherapists and many other health professionals. Therefore, we feel that the best course of action at this stage is for the Health and Social Care Bill to be withdrawn. This briefing sets out the role of physiotherapy services in improving the outcomes and quality of life for people with musculoskeletal disorders and gives an overview of the issues we would like Members of the House of Lords to scrutinise should the Health and Social Care Bill continue its passage through Parliament. Value of physiotherapy for people with musculoskeletal disorders Physiotherapy helps restore movement and function to as near normal as possible when someone is affected by injury, illness or by developmental or other disability. It covers a broad and varied range of work which involves supporting people to promote their own health and wellbeing. Physiotherapy is the largest of the Allied Health Professions (AHPs). AHPs are an essential part of the NHS workforce, delivering high quality care to patients across health and social care services. There is already extensive evidence that ensuring early access to physiotherapy services can deliver clinical improvements and cost effective care. Physiotherapy is particularly effective in the management and treatment of musculoskeletal disorders. It can prevent many problems from becoming chronic, and get people back to work more quickly. 31% of people experience pain at work at least once a week 1 7.4 billion estimated cost to the UK of the time taken off work by people with a musculoskeletal disorder 2 Musculoskeletal disorders refer to a group of conditions characterised by pain and a loss of physical function in the body. Musculoskeletal disorders cover a wide range of symptoms and may include arthritis, lower back pain, joint injuries, muscular aches and strains and non-specific arm pain (a term for some types of pain found in the fingers and/or wrists, forearms, neck and shoulders, previously commonly called RSI). 1

According to a recent study undertaken by the CSP, 31% of people experience pain at work at least once a week, with back pain reported as the most common physical problem (65%), followed by shoulder pain (37%), and neck pain (37%) 1. The time taken off work by people with a musculoskeletal disorder such as back pain or arthritis, has been calculated as costing the UK economy 7.4 billion a year 2. Based on the latest available statistics from the HSE 3 227,000 people have a musculoskeletal disorder of the back, 215,000 of the upper limbs or neck and 96,000 of the lower limbs. Low back pain is the number one cause of long term sickness absence amongst manual workers and musculoskeletal disorders are the most common reason for repeat consultations with GPs, accounting for up to 30 per cent of primary care consultation 4. These economic and personal costs could be greatly reduced by encouraging better working habits and also by providing early access to services such as physiotherapy for people who develop musculoskeletal disorders. Patient self-referral to physiotherapy Self-referral to physiotherapy has been proven to be both clinically effective and cost efficient, with high patient satisfaction. Self-referral is a system which empowers patients to better manage their condition by allowing them to make an appointment direct with their local physiotherapy department, without seeing their GP first; delivering increased patient choice and better patient outcomes through early intervention and by avoiding unnecessary referral to specialists in secondary care 5. The patient self-referral pilots that took place across six NHS England sites between 2006 and 2008 were found to reduce the number of associated NHS costs, particularly for investigations and prescribing, with 75% of patients who self-referred not requiring a prescription for medicines. In addition there was no increase in demand for services and self-referral reduced work absence amongst patients 6. NHS Evidence has recently included self-referral to physiotherapy for musculoskeletal disorders in QIPP 7, based on evidence of its ability to improve quality and productivity. However, efforts to continue to develop such initiatives are being hampered by both the demand for short-term efficiency savings and the speed with which the NHS reforms are being implemented. In our 2010 survey of NHS physiotherapy managers, 41% agreed or strongly agreed with the statement Inadequate physiotherapy staffing levels are obstructing me from redesigning and modernising our service. Currently, self-referral is readily available throughout the independent sector and private practices and in a number of NHS physiotherapy departments. The CSP is calling for greater adoption and roll out of patient self-referral. A recent report by the CSP and National Rheumatoid Arthritis Society (NRAS) found that one in three people with rheumatoid arthritis waited more than a year for a referral to physiotherapy, with a similar number having never been referred. Half the respondents said they could not self-refer to physiotherapy, 24% had to get permission from their GP 8. The CSP is concerned that the need to develop effective NHS self-referral schemes will be delayed or reversed by the expansion of the any qualified provider model. This could, in turn, lead to a rise in demand for welfare benefits, disability payments and an increased reliance on other NHS services. 2

Case Studies 1 The Royal Mail set up a national occupational support and therapy programme, which includes physiotherapy, and has had substantial financial benefits with the programme providing a return of approximately 5 for every 1 invested. Absence was cut by 25% over three years and 3,600 employees, absent through illness or injury, were brought back to work. Paul, a postman for 16 years, started experiencing back pain that eventually graduated to severe spasms. His employer put him on a 12-week course which used physiotherapy and included circuit training, in-depth talks on how the body works, diagnosing problems and painmanagement. Paul was able to return to work and his employer has now built in a 15-minute stretch to the start of each shift to maintain the progress he has made. Anglian Water has reduced direct absence costs by 289,000 through the use of physiotherapy based services, with a return on investment of 3 for every 1 spent. In addition, claims for back pain reduced by 50% and ill health retirement by 90%. When Anglian Water office worker Carly s hands started swelling up, the pain made it hard to pick up objects. She immediately reported it this to her employer who agreed to her accessing the physiotherapy service Anglian Water had in place through their Occupational Health scheme. Carly was able to have her workstation assessed and was given exercises to help treat her injury. Over the course of three sessions with the physio, the swelling went down, which enabled her to work pain-free. Role of Allied Health Professionals in Commissioning The Health and Social Care Bill requires clinical commissioning groups to seek appropriate advice from a broad range of professional expertise. However, in response to amendments tabled by Baroness Finlay of Llandaff during the Lords Committee Stage the Minister argued that he did not want the Bill to be too prescriptive over the membership of the new commissioning structures. The CSP is concerned that without clear direction from the Government, many health professionals may be excluded from the commissioning process. We believe that in order to deliver the best outcomes for patients with chronic conditions, such as musculoskeletal disorders, individuals who can demonstrate a breadth of experience and expertise should be involved. Physiotherapists and other Allied Health Professionals have a unique role, working across care pathways, and often providing a bridge between hospital, primary, community and social care, helping patients navigate their way through their treatment. We would like to see clear processes established to ensure Allied Health Professionals are able to inform and influence commissioning decisions at both the national and local level. The CSP would urge you to support the amendments to Clauses 22 and 24 tabled by Baroness Finlay of Llandaff regarding the role of allied health professionals in commissioning: Clause 22: The NHS Commissioning Board: further provision Page 18, line 39, 13J Duty to obtain appropriate advice, at end insert "() The National Commissioning Board must have regard to advice from a range of healthcare practitioners from across the patient pathway, including local clinical specialists and allied health professionals." Clause 25: Clinical commissioning groups: general duties etc. Page 37, line 18, 14V Duty to obtain appropriate advice, at end insert 3

"() A Clinical Commissioning Group must have regard to advice from a wide range of healthcare practitioners from across the patient pathway, including local clinical specialists and allied health professionals." Competition and the any qualified provider model The CSP like many other health groups has serious concerns about the extension of choice of provider in the NHS and the significant risk this presents to patients in terms of fragmentation of care and the quality of the services they receive. For people with long-term conditions, such as musculoskeletal disorders, it is vital that care is delivered through integrated pathways across primary, acute and social care. We are concerned that the AQP model fragments integrated pathways of care. The CSP is gravely concerned about the increasing reports of rationing we are hearing from our members in areas where care has been commissioned using the AQP model. We do not believe increasing competition will deliver greater choice, but instead will lead to a postcode lottery of services, fragmentation of care, and a decline in patient outcomes. Competition between healthcare providers is potentially destructive to patient care and we are concerned that competing providers will not share best practice or innovations that they will see as competitive advantage. The CSP is calling for safeguards to be put in place which will protect against these unintended negative consequences of competition on healthcare services. Ensuring a well-trained workforce The CSP supports an NHS which aims to deliver high quality education and training that supports safe, high quality care and greater flexibility 9. However, we do not believe that the current proposals for the education and training system will support these aims. Physiotherapy is made up of a national workforce, with staff moving around the country throughout their careers. As a result, effective co-ordination and future planning cannot be delivered solely at a local level. We believe that effective workforce planning requires national leadership with strong regional planning. We are also concerned over the lack of any contractual or statutory requirement for providers of NHS-funded care to provide student placements, undergraduate training or rotation posts. Without such a requirement the range and quality of training will suffer and impact on the wider workforce. Investment in the existing workforce is essential to sustain and improve standards and quality or care. It is important to ensure due recognition/support of Continuing Professional Development for sustaining service delivery and delivering a quality service. We welcome the fact that the Government did table amendments to place a duty on the Secretary of State as to education and training. However, further scrutiny of this issue is required at Report Stage to ensure that the Government will take into account the impact of the reforms on funding of training and allocation of student placements and rotations for newly qualified staff and will demonstrate clearly how it will guarantee a sufficiently trained NHS workforce. For further information, please contact: Donna Castle, Head of Public Affairs and Policy, Chartered Society of Physiotherapy Telephone: 020 7306 6624, Email: castled@csp.org.uk, Website: www.csp.org.uk 4

References: 1 Chartered Society of Physiotherapy: Sickness Costs, 2009 2 Health and Safety Executive, Health and Safety statistics 2009/10, 2009-10 3 Health and Safety Executive. Table SWIT3W12 2008/09. URL: www.hse.gov.uk/statistics/lfs/0809/swit3w12.htm 4 National Institute for Health and Clinical Excellence. Low back pain: early management of persistent non-specific low back pain. London. National Institute for Health and Clinical Excellence; 2009. URL: www.nice.org.uk/nucemedia/live/11887/44343/44343.pdf 5 Department of Health, Self-referral pilots to musculoskeletal physiotherapy and the implications for improving access to other AHP services, 2008 6 Department of Health, Self-referral pilots to musculoskeletal physiotherapy and the implications for improving access to other AHP services, 2008 7 NHS Evidence. Musculoskeletal Physiotherapy: patient self-referral. 2011. URL: www.library.nhs.uk/qipp/viewresource.aspx?resid=406806&tabid=289 8 National Rheumatoid Arthritis Society (NRAS) and the Chartered Society of Physiotherapy. Rheumatoid Arthritis and Physiotherapy: a national survey. October 2011 9 Department of Health, Liberating the NHS: Developing the Healthcare Workforce, December 2010 5