Beyond the Barriers

Authors

Alexandra Tobin MCSP is CSP professional adviser [or clinical audit and physiotherapy manager, East Wiltshire Health Care NHS Trust. Marlan Judd MSc MCSP is clinical audit co- ordinator at the <:amden and Islington Community Health Care NHS Trust, arid a physiotherapist.

Tobin, A and Judd, M (1999). ‘Beyond the barriers’, Physiothapy, 85, 2, 61-63.

Introduction .................................................................................................. This is the third in a series of three articles, which explore some of the barriers to carrying out effective clinical audit. The first, ‘IJnderstanding the Barriers’, was published in November 1998 (Tobin and Judd, 1998) and the second, ‘Experiencing the Barriers’ was published in January 1999 (Tobin andJudd, 1999).

In this paper, we aim to look beyond the barriers that have often prevented physiotherapists from participating in effective clinical audit, in order to focus on the new agenda for quality that is emerging in the modern NHS.

The New NHS The primary aims of the government’s ..................................................................................................

current modernisation programme for the NHS include a new drive to improve the quality of clinical care at all levels of health care provision. As part of this, concerns about the quality of health care, where variations in the standards of care between different services are found to exist, will also be addressed (DOH, 1997; DOH, 1998).

In the past clinicians have often been frustrated arid despondent when NHS trust board agendas and management team meetings have been dominated by financial issues and activity targets. Many felt that under the previous government’s market- driven system for the NHS, the quality of care had become subservient to price and quantity in a competitive ethos (Scally and Donaldson, 1998).

In the future, well managed organisations will be those in which financial control, service performance, and clinical qiiality are integrated a t every level (Scally arid Donaldson, 1998).

The introduction of clinical governance will provide a framework to enable NHS trusts to co-ordinate quality improvement and quality assurance within their clinical

Key Words 61 Audit, evidence-based practice, clinical services, quality.

by Alexandra Tohin Marian Judd

services (DOH, 1997; DOH, 1998). For the first time, all healthcare providers in the NHS will have a statutory duty to seek quality improvement through clinical governance.

Clinical audit will be an important element of this new clinical governance framework, as it is a tool which enables existing clinical practice to be monitored and improved. It is still a matter of concern, therefore, that despite the many audit enthusiasts in the physiotherapy profession who have made attempts to address efrective care issues, there are some who remain reluctant either to understand or to participate in this process. In Promoting Clinical Ejjectiveness: A flamework Jkr action in and through the NHS (NHSE, 1996), it is stated that ‘while clinical audit has had a powerful impact on those who have taken it up, many still remain uninvolved’.

What are the Issues for Therapists? In response to the current Department of Health agenda for the NHS, one of the biggest issues for individual therapists and therapy services is how to effect major cultural changes in professional attitudes, responsibilities and practices in order to address this agenda.

Therapists are known to be deeply concerned about the well-being of their patients and are generally respected for their efforts to deliver high standards of care. Patients frequently express high levels of satisfaction with therapy services. However, what. is now being asked is for individual therapists to embrace a new, systematic and evaluative approach to clinical care; to question what works best and to be prepared to make changes in clinical practices when:

Valid research evidence exists. If there is consensus about efTective care strategies from experts within professions.

62

rn Enough patients express views which indicate that changes in the delivery of care are needed.

Taking these new values on board may be a tall order for many whose beliefs about good practice are based on long experience. However, it must be understood that long experience and personal certainty about effectiveness cannot provide evidence for effectiveness without audit. New goals have now been set for the NHS and the new focus on measuring the quality of care will need to be addressed

To help us to do this, there are some general questions that the profession might consider: rn Is there evidence for the effectiveness of a

particular physiotherapy treatment, or clinical management strategy? If not, is its effectiveness supported by mainstream professional opinion?

levels of improvement as a result of the physiotherapy that they have received?

rn In order to demonstrate this, how can the effectiveness of physiotherapy be measured? Individual therapists might consider:

rn Is the treatment I provide for patients effective?

rn Does it address the patients’ preferred outcomes from physiotherapy?

H What evidence exists to demonstrate that the treatment is effective? How can I continually improve the clinical care that I offer to patients? Those who manage physiotherapy services

rn Are patients achieving their optimum

in today’s climate might consider: rn How can the principles of clinical

governance be introduced into the physiotherapy service?

rn Does the physiotherapy service provide effective care to patients?

rn Is this being demonstrated through a planned programme of clinical audit?

rn Are all the physiotherapists expected to set standards based on the latest evidence or expert opinion?

rn Do the physiotherapists take part in multi- disciplinary audits with other health care professionals?

competent?

this?

to update their clinical skills?

research?

Are all the physiotherapists clinically

rn Is an appraisal system in place to evaluate

rn Do the physiotherapists have opportunities

rn Do any physiotherapists undertake

rn Do any physiotherapists undertake literature review/journal club activities?

rn Is there an adequate budget for education and training? Physiotherapy patients might consider:

rn Has the care I have received addressed my problems and needs?

rn Have I received an acceptable level of professional service?

rn Have I been sufficiently consulted and informed about my care?

rn Have I been given enough information to enable me to make decisions about my care?

Professionalism The Rules of Professional Conduct for physiotherapists state that ‘Chartered physiotherapists shall adhere at all times to personal and professional standards which reflect credit on the profession’ (CSP, 1996).

In today’s NHS, this can be interpreted to mean that each physiotherapist has a duty to provide the best care possible for patients, while maintaining the highest standards of professionalism. Implicit within this code is the duty to maintain and update clinical knowledge and skills. As new and valid evidence for effectiveness of clinical care becomes available, an updating of know- ledge and skills must follow.

A culture of lifelong learning is one where individual physiotherapists are willing to take a pro-active approach to continuous learning throughout their professional careers.

..................................................................................................

Providing Effective Physiotherapy Services Therapists working in busy clinical settings need to consider the best use of time and resources when planning and implementing a clinical effectiveness strategy. For example, it is unlikely to be cost effective to expect every member of a team to take time to undertake literature searches. Creating an evaluative culture often requires considerable work, yet the rewards are quickly evident (Buttery et al, 1995). Physiotherapists who have undertaken clinical audit projects are generally enthusiastic about the changes in clinical practice that have resulted from audit and the benefits of this for patients and therapists.

Implementing a clinical effectiveness strategy within a service needs a clear management lead and some enthusiastic key players. It should also be linked with any

..................................................................................................

Physiotherapy February 1999/vol85/no 2

Briefing paper

organisational strategy for clinical effectiveness and should encourage therapists to take part in condition-specific multi-disciplinary audits within the wider multi-disciplinary team.

Agreement may be needed in order to spread the load, so that physiotherapy team members share the work associated with obtaining information, implementing clinical guidelines and treatment protocols, and agreeing measurable standards. This will also help to create ownership within the team.

Strong leadership from physiotherapy service managers is essential when developing and implementing a clinical effectiveness strategy. This may include: W Ensuring that opportunities for clinical

education and training for physiotherapists are available. Monitoring effectiveness of clinical care through an audit programme.

W Involving the whole physiotherapy team when patient and carer views of clinical care are being evaluated.

W Facilitating any changes in physiotherapy service provision that may be necessary. Therapists should also seek to involve

themselves in multi-professional and inter- organisational audit, in order to help bring about improvements in the effectiveness of clinical care across professional and organisational interfaces. Patients and their whole care package provide the focus for this type of audit, which may involve collaboration between health care providers across the interfaces between secondary and primary care, social services and the voluntary sector,

Finally, for physiotherapy to be truly effective, patients’ and/or carers’ views

References Buttery, Y, Walshe, K, Rumsey, M, Amess, M, Bennett, J and Coles, J (1995). hinider Audit in fi.’n,gland: A m i r r u of 2 9 pngramm.s, (’AWE Kcscarc h . Chartered Society of Physiotherapy, K&.s of Pmjks.si..ai Conduct, (SP, London.

Department of Health (1997). The New NHS: M o b , dependeuble, HMSO.

Department of Health (1998). A First Class Service, HMSO.

National Health Service Executive (1996). I%imoting Clinical Efftiuenass: A jramework for action in and through the NHS, NHSE, Bristol.

about the care that they have received must be taken into account. Physiotherapists will need to seek out reliable methods of collecting and analysing these views and will need to be prepared to act on the results of their findings, by making changes in the pattern of physiotherapy service delivery.

Conclusion The new agenda for quality that is emerging in the modern NHS has set the stage for the clinical professions to be able to make the achievement of excellence in clinical practice a priority for every individual practitioner.

Clinical audit, when carried out as part of an overall clinical effectiveness strategy, provides an effective method of measuring and demonstrating the quality of physiotherapy services.

Physiotherapists have, in the past, often found it difficult to undertake clinical audit (Robinson, 1996). Some of the most common constraints on audit for physiotherapists have been identified and reported ( Tobin and Judd, 1998, 1999) and many of these factors continue to be an issue in physiotherapy services throughout the NHS. The stage may have been set for the introduction of a new range of quality improvement measures in clinical services, but considerable work remains to be done in order to support physiotherapists through this period of cultural change.

As we look forward and begin to embrace what is by far the most ambitious quality initiative that will ever have been implemented in the NHS (Scally and Donaldson, 1998), it will be important to have learned the lessons from the past and to turn them into the successes of the future.

........................................ I..... ....................................................

Robinson, S (1996). ‘Audit in the therapy professions: Some constraints on progress’, Qualib an Health Cam, 5, 206-2 14.

ScaUy, G and Donaldson, L (1998). ‘Clinical governance and the drive for quality improvement in the new NIIS in England’, British MedimlJimrnol, 317,6145.

Tobin, A and Judd, M (1998). ‘Understanding the barriers’, Physiotherapy, 84, 11,527429.

Tobin, A and Judd, M (1999). ‘Experiencing the barriers’, Physiothmupy, 85, 1, 6-10.

Phpiothernpy February 1999/vol85/no 2