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JOINT COMMITTEE ON HEALTH AND CHILDREN díospóireacht -
Wednesday, 28 Jan 2009

Irish Society of Chartered Physiotherapists.

We will move immediately to the final group, the Irish Society of Chartered Physiotherapists. I welcome Ms Annette Shanahan, Ms Fiona McGrath and Ms Mary Gorman to the meeting. I am conscious of the fact that the delegation had sought a meeting with the committee some time ago. We have invited it to talk to us in the context of our deliberations on the primary health care strategy because the society will have a key role in that strategy. I am sure the delegation will have an opportunity in the course of its presentation to address some general issues.

I draw the attention of witnesses to the fact that members of the committee have absolute privilege but this privilege does not unfortunately extend to them. Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against an individual or an official so as to make him or her identifiable.

The members of the committee have studied the submission paper and I invite Ms Shanahan to give a brief synopsis after which members may ask questions.

I ask the Chairman to ask speakers to identify their roles. We can read their names.

I invite Ms Shanahan to introduce herself and her colleagues.

Ms Annette Shanahan

I thank the committee for the invitation to attend today. I am president of the Irish Society of Chartered Physiotherapists. Mr. Ruaidhrí O'Connor is chief executive officer of the society, Ms Fiona McGrath is chairperson and Ms Mary Gorman is vice chairperson.

Chartered physiotherapists play a pivotal role in the delivery of primary care services. We rely on evidence-based treatment and treat a wide range of conditions from the very young prenatal patient right up to the elderly patient. We need to be readily accessible at local level, working as an autonomous profession in conjunction with our GP and other health professional colleagues. The primary care setting is the optimum position for physiotherapy services, the reason being that it is essential for us to have early intervention as this is critical to retain the function and independence of the patients who need our services. The presentation will show there is evidence to justify why we need to be in the front line. This is clearly evident in both the sports arena and in occupational health where many companies will fund physiotherapy services because they are cost effective. It is important to have ready access to patients when they need us within a very short space of time.

The slide on the screen will show we really only have a three-month window during which physiotherapy practice should have been commenced and completed because then there will be a 100% return to work. This relates to low back pain disability. I will describe a case study. This work was done in the UK. If patients are off work for six months their chances of ever working again reduce to 50%. If somebody is a year off work — which is not unusual in Ireland — with something as simple as a musculo-skeletal low back problem, their chances of ever working again, regardless of their age, occupation, qualifications, is as low as 25%.

The next slide shows that the UK situation was one where they prompted an expansion of physiotherapy services in order to try to reduce the level of disability and consequently the number of days lost due to back pain. A total of 22% of UK health care expenditure is expended on chronic pain. This is significant. A better roll-out of physiotherapy services would have a significant societal impact not just for back pain but for all chronic disability such as the arthritic knee or the early onset neck problems, hip problems and problems faced by stroke patients. There is no need to inform the committee of the excessive need for physiotherapy services for children with disabilities and for the elderly who want to stay at home in preference to using health care services in institutions.

The society welcomes the primary care strategy published in 2001 and we advocate that this is necessary. We can reduce acute service uptake both in accident and emergency departments but also in the long-term disability sectors if people can be retained in their own homes which is where they want to be. The problem is there are still significant waiting times for our services. There has been a delay in roll-out of the primary care centres and we advocate that they be expedited.

According to our survey conducted last week, waiting lists ranged from 16 weeks to one year across our acute services which means there is an unmet need for physiotherapy services. Out-patient physiotherapy departments are having to juggle and prioritise. The unmet need is even more critical for us because 59% of our 2008 graduates are unemployed or working outside of physiotherapy. Unfortunately the range of occupations in which they are working include care assistant and Burger King. We need to retain and harness this highly educated, highly motivated group of people, many of whom are trying for work on a pro bono basis. This is very inadequate when we know that people need our services. The increase in places was provided on foot of the Bacon report and it is unacceptable that we are putting so much capital and expertise into educating people but not utilising a group of people who are badly needed in the service.

The society has been very patient with the confusion between the titles of physiotherapist and physical therapist which has been the case over the past 12 to 15 years. We have been looking for State registration since the early 1980s. A Millward Brown survey indicated that one in three people does not know the difference between the two titles. It is unfortunately the case in Ireland that physical therapist is being used as a title by a group who are not a health care profession in the sense of having completed a physiotherapy degree course. We are internationally qualified and are associated with the Wellcome Federation of Physical Therapists. We are allied to and have reporting with the UN and so on. The Good Friday Agreement recognises both titles in the North of this country. It is important that we address this issue now because the confusion for the public represents a public safety issue. People need to get the appropriate treatment and level of expertise holistically in all systems — for respiratory, cardiovascular and neurological conditions, the treatment of children and the treatment of the vulnerable. The very least this country needs is a standard of qualification that reflects the expertise that is required for our patients in all health care settings.

We hope the committee will urge the Minister to recruit more physiotherapists for front line services because that is where we will get cost benefit. It would reduce the cost of long-term disability which results from the present inadequate access. Many physiotherapists become demoralised and de-motivated because they are seeing patients for whom they could have done something six months earlier and certainly a year earlier. That earlier intervention would have reduced their level of human suffering and disability considerably. We have a serious concern about public safety. We need to get the legal protection of both titles. Regarding the Good Friday Agreement we are hoping that reciprocity and common policies can be reflected.

I am a tremendous fan of physiotherapy, which is very important. I echo everything Ms Shanahan has said. As a GP, I am particularly concerned at the number of people I refer for physiotherapy who do not progress as rapidly as I would anticipate. I often inquire further to find that they have been attending a physical therapist. It is a major issue and one on which I support Ms Shanahan 100%. We need to protect the title and resolve the issue. We need to stop people being hoodwinked. When people see these things up on the wall they are led to believe that they are going to a physiotherapist and receiving the sort of professional care that a physiotherapist is able to give.

It is an outrageous waste of money and an extraordinary exhibition of poor management and lack of co-ordination. These are some of the brightest and best graduates. Some 560 leaving certificate points——

Ms Annette Shanahan

That was the entry requirement. It is still 555 in the University of Limerick.

They are highly motivated and have been training for how many years?

Ms Annette Shanahan

Four years.

They are then left on the heap. This is a total waste of the taxpayers' money when the need exists as Ms Shanahan has clearly demonstrated with the waiting times and waiting lists. The money has been spent. It is demoralising for our young people who strive so hard to first get the necessary leaving certificate points and then their degree. This is the manner in which we as a society treat them. I am not trying to be political here but this comes as a result of bad governance.

As a GP, I could not agree with Ms Shanahan more on the importance of early intervention. Even something as simple as a twisted ankle can reduce morbidity and time out of work by a considerable percentage. We are being penny wise but pound foolish. This shows a lack of planning and is something this committee will need to address. I do not need to ask Ms Shanahan about the role of physiotherapy because I am familiar with it and I believe it to be an integral part of primary care.

I fully support everything that Ms Shanahan and her colleagues have presented. I note that she asked for the committee's assistance with the two main issues and we should be willing to give that support. The HSE's presentation listed physiotherapists as one of the key groups of people in the primary care teams that are being rolled out. The committee should be able to make a strong case for employing the physiotherapists who have been trained. I was on the Mid-Western Health Board when the then Minister for Education and Science, Deputy Hanafin, announced the extra places and programmes. With other health boards, that health board had been pushing for more training places in order to fill these posts. Now, very sadly, 59% of 2008 graduates and 42% of 2007 graduates are not appropriately employed. There is not much we can add to the presentation except to fully support it. When publishing our final report we should be mindful of everything Ms Shanahan has said.

I welcome the delegates and thank them for the presentation. I am concerned at the mention of the three-month window. The average waiting time is 16 weeks. The reality is that almost everybody is missing the window. There are cost implications for a person being off work for so long or perhaps not getting back at all. Regarding the waiting lists, how do physiotherapists prioritise their patients? We all have evidence in our constituencies of people trying to access physiotherapy services and being left for a long period of time. What happens to those patients who miss out and slip down the list? Do they fall off the list altogether? For some is it eventually decided there is no potential benefit in having physiotherapy because they have been left for so long? The statistics presented have highlighted the benefits of early intervention, with which we can agree.

Is Ms Shanahan satisfied that the roll-out of the primary care teams is happening quickly enough? Everybody recognises that physiotherapy is an essential part of the primary care teams. Is the Irish Society of Chartered Physiotherapists being adequately consulted in that regard?

I thank the delegates for the presentation. I recognise the importance of physiotherapy and the tremendous contribution it makes to rehabilitation in order to get people back to normality. In the paper it submitted the Irish Society of Chartered Physiotherapists raised two questions on recruitment and section 95(3) of the Health and Social Care Professionals Act. I would be glad to raise those two points with the Minister.

Our brief today is the development of primary care. We have had a number of submissions already this morning, including one from the Health Service Executive. It is very positive about its desire to move forward very rapidly on the establishment of health care teams. It is fair to say that physiotherapy has been mainly a hospital-based service in this country. To an extent, while there are physiotherapists working in the community, in many parts of the country it will be a new service. We would be interested in establishing how physiotherapists will fit in as part of a team. How does the Irish Society of Chartered Physiotherapists envisage the development of physiotherapy and primary care? What recommendations does it want us to make on how physiotherapy fits into the primary care team?

I welcome the witnesses and thank them for the presentation. What level of consultation has the Irish Society of Chartered Physiotherapists had with the HSE on setting up primary care teams? Deputy O'Hanlon referred to the major problem of accessibility. If the primary care teams are rolled out in a proper manner, it should be easier for people to get physiotherapy services closer to home. A number of weeks ago I was in Monaghan General Hospital. When I walked past the physiotherapy clinic I was astonished to see a sign indicating how many people had missed their appointments. All I could think of was the number of people who would have gladly availed of appointments if they had been in a position to get them. When I inquired about it, I was told that sometimes people believe they are sorted after one or two appointments and have no need to come back. There is an accessibility issue. If the service was closer to them and they did not need to travel the 25 or 30 miles to access it, it might go some way towards sorting out the problem.

I refer to the issue of physical therapists and physiotherapists. Somebody who cannot get a physiotherapy appointment may well go to a physical therapist in the belief that they are the same. There is a level of confusion and people do not know the difference. The accessibility issue again arises. If the service were closer to them it might alleviate that confusion.

I ask Ms Shanahan to elaborate on the disconnect between the availability of employment and the number of graduates because the figures are quite startling. We have received indications from other people in the therapy areas that one of the problems is the level at which the HSE recruits people. Graduates may find that jobs at their level are not immediately available. Will our guests comment on this aspect?

Ms Annette Shanahan

I will ask Ms Gorman to comment on the matter.

Ms Mary Gorman

We are not particularly satisfied with the rate of roll-out to date. At senior and basic recruitment levels, we have a population for which we must care. In some areas the primary continuing community care, PCCC, element has not yet been developed to a significant degree. We must ensure we have a level of support and supervision for staff grades. In 2005, when the private care steering group, of which I was a member, closed down, we drafted a position paper in which it was stated we would be happy to take staff grades in an area once at least two senior physiotherapists were already in place. This does not mean certain people looking over the shoulders of others, rather that support would be available in the locality. There are areas where services have not been previously available and appointments will have to be made at more senior grade level in order to commence such services, following which staff grade appointments can be made.

In the past the service developed differently in various former health board areas. There are areas, for example, where acute and PCCC services are combined in one structure. In such circumstances, there are opportunities for staff grades to come under supervision at hospital level and for others to move to primary care. There are ways around it.

On the level of concentration and how the programme is being rolled out, local implementation groups have been set up in many areas. Physiotherapy services would be involved in these groups. The feedback I have received indicates that the standard of consultation has not reached a level with which we would be happy. Some of the direction relating to the roll-out of primary care teams is coming directly from the top, with very little consultation on actual needs regarding the competence and skill levels required to care for the population and the complex conditions that arise among its members. As a profession, we have a duty to ensure those of the appropriate grade care for people with complex conditions who present at that level. Does that make sense?

Ms Fiona McGrath

On the rolling out of primary care teams, it is extremely important that the skills mix relating to an entire area be taken into consideration. We must examine the position on the services being provided by the acute hospital in the area. We must also examine how we can utilise staff across the acute and primary care services in integrating the skills base.

When large numbers of patients are referred, unfortunately, there are going to be waiting lists. The use of such lists means that one person is prioritised over another. Such prioritisation is based on need in the context of the onset and acuteness of an episode and the seriousness of the condition with which a patient presents. The major concern for us is that those patients who are prioritised lower down the list also have genuine problems. They may only have hip pain — one of the early signs of arthritis — and lost a degree of mobility and be at risk of falling. However, we are not getting to deal with those patients who are remaining on the waiting lists and whose problems are not being addressed. What happens is that they fall at home and are admitted to accident and emergency departments with fractures. If we could deal with them, the number of such admissions would be reduced.

This is a major issue for anyone obliged to be prioritised. It would be great if the roll-out of the primary care team allowed access in order that preventive as well as rehabilitative treatment might be provided.

Mr. Ruaidhrí O’Connor

Deputy Conlon referred to people in County Monaghan not being able to access their local physiotherapy service. Naturally, they were seeking a locally available service and the only such service was provided by the Irish physical therapist in the area. I re-emphasise the dangers in that regard, particularly for patients with a history of neurological or cardiorespiratory difficulties. Only chartered physiotherapists work across the three core areas of physiotherapy. We have a burgeoning file of reports on this matter. They indicate that in some instances members of the public have been confused by people who provide services and claim to be physiotherapists. One such report was made by a medical consultant whose father who has a neurological condition was in a nursing home and who inquired before placing him there whether the home employed a physiotherapist. The consultant in question was satisfied that there was a physiotherapist in place but only realised some months later that the individual concerned was an Irish physical therapist and had received no training or skills in that area. That was a major safety concern with regard to the man's father. In the publicly funded services a physical therapist was, again, mistakenly employed. A county council published information on physical therapy and physiotherapy services. The information in question which was available to members of the public in general and the parents of people with a disability, in particular, actually related to physiotherapy services. The council had consulted a US source for physical therapy but what it obtained was a description of what would be the situation for a chartered physiotherapist. The information published did not reflect what would be the position in the case of Irish physical therapists. There are countless examples of such confusion and the potentially alarming effect it could have on public safety.

Ms Annette Shanahan

I reiterate that it is not our intention to undermine anybody's right to earn a living. Our only issues are the confusion that has been caused and patient safety. As chairperson of our professional practice, professional procedures and ethics committee, I am becoming tired of having to deal with complaints we are receiving which do not even relate to our members. The confusion must be dealt with. We do not want to return to the committee 12 months from now and be obliged to use phrases such as "if only we had been provided with protection" or "if only the registration board had been established". The confusion caused with regard to titles is a critical issue.

Ms Mary Gorman

To emphasise that point, if we are to function well at early intervention and primary care level, more direct or easy access forms part of the equation. Regardless of whether it is true, the mix of public and private services is using all the resources available. Once members of the public can source services, they must be in a position to know that they are availing of the services of a member of the chartered physiotherapy profession.

Patients not attending for appointments is a matter with which I became familiar when I visited primary care centres in Australia many years ago. One of the major difficulties was that the waiting period — six months — was so long people usually made other treatment arrangements in the interim. The fact that they did not cancel their appointments led to the creation of a double-waste scenario.

I strongly recommend to the Minister that she take legislative steps to protect the titles of "physiotherapist" and "physical therapist" in order that there will not be confusion. I do not believe anyone else present has an issue with this. The committee will certainly discuss the matter later. The representatives of the HSE who appeared before us earlier indicated and intimated that there would be no additional resources for staff. Some might say the HSE is moving the deck chairs on the Titanic, while others might state it is moving pieces around on a chessboard.

There is a shortage of physiotherapists and a reluctance to take on new recruits, which is extremely disappointing for graduates. There are many physiotherapists in private practice. There is one in place in mine. This is a source of great annoyance to me and my patients. I can refer private patients to the individual concerned, but my public-GMS patients who cannot afford it must pay. Does the Irish Society of Chartered Physiotherapists represent those in private practice to whom I refer?

Ms Annette Shanahan

Yes.

How will the individuals concerned be brought into the loop in the context of the primary care strategy?

Ms Annette Shanahan

There are over 1,000 chartered physiotherapists who work within the private and voluntary sectors. We have over 3,000 members, a substantial proportion of our membership. Many of us actually went into the private sector primarily to seek job satisfaction. We wanted to see patients quickly. We wanted to make an expeditious difference and we are supported by our colleagues in acute services and primary care settings in that regard. Many of us found great satisfaction in being accessible.

I am not here to trumpet pro bono but we have sought recognition of our expertise at GMS level. Many of us who are a long time on the road have been proponents of this argument. Significant expertise and a substantial number of premises could be utilised cost effectively. We are present to discuss two strands — sustainable resources and patient safety. We have the resources as a body of professionals and many of us could easily be contracted to assist the health services in providing the best of care. Bearing in mind that we are used to one-on-one scheduled appointments, excellent supports and electronic computerised record keeping, private practitioners have run health centres for the past 30 years. I have nine people in my practice and, therefore, the need is there. We have sought all we can and we have developed our own practices to meet that need. It is not an either-or scenario. I am firmly of the belief, as are my colleagues, that this is about patients having access to services and it does not matter who pays for it. It matters that they are delivered by an appropriately qualified professional with patient advocacy and patient needs at the centre of his or her work and not who is paying for the building.

I accept that but how will physiotherapists come in under the umbrella of the primary care strategy as it evolves?

Ms Annette Shanahan

There is no reason we cannot provide the staff and expertise. Ms Gorman has been involved in the primary care roll-out.

Ms Mary Gorman

I have contracted private services where necessary to fill gaps in service provision. As Ms McGrath said, we need to work with the expertise in the locality and whether one works in the public or private sector is not an issue. As a body, that is the way we think. It has not been greatly facilitated by the HSE but, in other instances, services have been contracted. By and large, they were only contracted to fill gaps and that is not good enough. A plan is needed to address how best to use the skills available in the locality and no physiotherapist would have an issue with that. We would love to see that implemented. That also includes the voluntary sector when it comes to disability. To date, the HSE has been inclined to work within its own confines and if we did not come forward with the idea to contract services, as I did in my area, it would not have happened. It has not been included in planning.

I thank the members of the delegation for their presentation. We have learned a great deal and, as Deputies O'Hanlon and Reilly said, the committee will do what it can to assist them with their cases. We will highlight these matters to the Minister, the Department and the HSE.

The joint committee adjourned at 1.25 p.m. until 9.45 a.m. on Thursday, 29 January 2009.
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