Physiotherapy and older people
Submission to Chartered Society of Physiotherapy (3 March 2015)
The British Geriatrics Society (BGS) is the professional body of specialists in the healthcare of older people in the United Kingdom. Membership is drawn from consultant geriatricians, old age psychiatrists, doctors in training, general practitioners, nurses, therapists, academics and students with a particular interest in the care of older people and the promotion of better health in old age. It has over 3,000 members and is the only society in the United Kingdom which draws together experts from all the relevant disciplines in the field.
We write here to respond to request for comments, presented on behalf of the Chartered Society of Physiotherapy(CSP). The comments are sought in the context of two projects, conducted by Allied Health Solutions on behalf of the Chartered Society of Physiotherapy. The projects are considering issues related to safe and effective levels in physiotherapy and data workforce modelling. The BGS has been asked to address three specific questions and these questions, as presented to the Society, are set out below.
Question 1: What the views are of the impact physiotherapy intervention has on older people under the care of doctors working in primary care, community services and secondary care?
There is a well-established evidence base for physiotherapy interventions to improve outcomes for older people, particularly those with falls, stroke disease, arthritis and frailty. There is robust evidence on the effectiveness of primary care/community-based falls prevention interventions for older people, for example the internationally established Otago Exercise Programme, with benefit demonstrated for delivery by a physiotherapist or by a trained nurse under physiotherapy supervision. There is also an international evidence base for the benefit of exercise interventions for older people with frailty, which are predominantly physiotherapy-led, or supervised.
Physiotherapy is a core component of successful, multidisciplinary, comprehensive geriatric assessment (CGA), which has been demonstrated to improve outcomes for older people, particularly those with frailty in secondary care. A CGA approach is also embedded within successful orthogeriatric care, and in the emerging discipline of perioperative surgical care for older people, for example the Proactive Care of Older People having Surgery (POPS) model of care. The BGS Fit for Frailty guideline recommends designing primary/community pathways care for older people living with frailty that include rapid access to CGA, including availability of physiotherapy services.
Alongside specialist elderly care wards, physiotherapists are core members of the stroke unit multidisciplinary team, providing therapy input for patients on acute stroke units, stroke rehabilitation units and community stroke teams. Multidisciplinary stroke care has been demonstrated to be highly effective at improving outcomes.
Question 2: What the views are of the role of physiotherapy in the care of older people under the care of doctors working in primary care, community services and secondary care? This includes surgical specialities.
In secondary care, physiotherapists work as an integral member of the multidisciplinary team to assess mobility problems and functional needs of older people, identify rehabilitation goals and provide person-centred, tailored therapy to restore movement and function. This is clearly evident in the setting of specialist elderly care wards, stroke units, orthogeriatrics, and also in the emerging area of perioperative surgical care for older people. Therapy-based rehabilitation is also a core constituent of both home-based and bed-based intermediate care services, and physiotherapists are key members of new emerging models of care, for example discharge to assess/virtual ward models to facilitate safe discharge from hospital and as a 'step-up' facility to provide home-based support for older people who have experienced a sudden decline in their function as an alternative to hospital admission.
In primary/community care, physiotherapists provide specialist, tailored therapy for older people with mobility and functional problems to improve day-to-day function and overall quality of life. They are core members of specialist falls prevention teams and have the specialist skills required to provide targeted exercise interventions for older people with frailty. Physiotherapists also provide specialist services for conditions which are common in older age (e.g. pulmonary rehabilitation; cardiac rehabilitation; Parkinson's disease) and play an important role in managing chronic, painful conditions that impact on mobility and function, for example osteoarthritis and rheumatoid arthritis.
Question 3: What factors are thought to affect future workforce demand for physiotherapy?
Future workforce demand for physiotherapy should take into account projections for a growing older population, particularly amongst the oldest old. Workforce planning in the context of older people is likely to be predominantly influenced by:
- The potential expansion of intermediate care services for older people, including both bed-based and home-based models.
- The likely expansion of 'discharge to assess' models of care, which have been demonstrated to improve outcomes for this group.
- The BGS Fit for Frailty guidelines, which recommend the development of better pathways of care for older people with frailty, including availability of routine physiotherapy services to provide targeted exercise interventions as part of a CGA approach.
- The likely expansion of perioperative surgical care for older people, particularly those with frailty, which will require physiotherapy input as part of a CGA approach.
- The potential for expansion in falls prevention and physical rehabilitation services for older people living in care homes. There is ongoing UK research into these important areas and the research outputs/future implementation may influence workforce planning.
All plans for workforce demand should consider the wider integrated care agenda and the possibility of cross-disciplinary working. It may be possible to plan for some future changes through re-organisation of existing therapy services, but it is likely that plans will need to include expansion of the physiotherapy workforce if demand is to be met. Ongoing dialogue between the BGS and CSP will be mutually beneficial, as it is likely that workforce planning needs will be closely aligned because of the cross-cutting theme of an approach based on specialist, multidisciplinary CGA for older people with frailty.
Enquiries about this submission
This submission has been prepared on behalf of the BGS by Dr Andrew Clegg MBBS BSc MD MRCP, Senior Lecturer & Honorary Consultant Geriatrician, Academic Unit of Elderly Care & Rehabilitation, University of Leeds.