Changes in physiotherapy practice--are we doing the right thing?

Two papers in this issue of the journal confront key policy changes in New Zealand's approach to healthcare with particular emphasis on how the physiotherapy profession might best respond (Stewart and Haswell, 2007; Reid and Larmer, 2007). Both papers provide timely and useful review of these changes and propose some possible actions for physiotherapy.

However, both papers are also a reminder that whilst we may like to think that what we do is patient/person centred, it is actually very much government priority centred. Is this a bad thing? Well--not necessarily and certainly the two perspectives need not be mutually exclusive. Indeed an emphasis on wellness, preventing disease and rectifying existing inequity in access to health care are fundamental in a health system that is truly person centred. However, the reality that the patients we see, and the very services we provide are so governed by the external structures and environment, provokes a number of questions, one of which is:

Given that everything we do is driven by powerful external structures such as policy, prioritisation and funding, what should be our response?

It sometimes appears the action we (ie health professionals) are most adept at is taking a somewhat 'head in the sand' approach: awaiting changes in policy and going with the flow, thereafter complaining about the consequences of the changes we do not like or retrospectively disagree with. If the most recent changes were to be the last, then so be it--we could read the two papers in this issue and at least be more knowledgeable. However, the one thing we can be certain of is that regardless of the outcome of the next election, more changes in health policy and prioritisation lie ahead with changes continuing to impact on both health professionals and on patients.

A different response to lying low until the changes hit is demonstrated by those in the profession who seem to keep one step ahead of the field and be entrepreneurial, seeing every change as the potential for a new initiative. Whilst there is no doubt that some great initiatives can and have been made (arguably the podiatry intervention described by Reid and Larmer 2007), as a non-physiotherapist it seems that some responses fitting the entrepreneurial description have been of questionable value to either the profession or more importantly to patients. Just because a contract to deliver a certain service exists, should we provide it when there is little evidence that it helps such as in the case of activity based programmes for improving return to work in back pain (Anema et al 2007)? Should we, in the way we provide services, continue to be relatively passive in our response to the disparity in access to services for those with injury versus illness?

Of all the possible responses to policy change, one that increasingly seems warranted is to take individual and collective opportunities to engage with, question, and contribute to the way the external environment is being developed and shaped. Whilst our professional bodies are involved on our behalf, perhaps there is more we could do. This is not to say we should all be complaining to our MPs or arguing in the media about issues that concern us. Indeed, these actions (especially the latter) may even work against contributing depending on the basis and strength of our critique.

At the risk of being accused of a forced segue, engaging in and influencing policy has something in common with the call for interdisciplinary approaches and work to be done by teams in the Primary Health Care Strategy. Research increasingly indicates that knowledge exchange is at the heart of teams that actually work (Burnett et al 2005; McPherson et al, 2001; Opie, 2000; Pablos-Mendez and Shademani 2006; Zarraga and Bonache 2005). For knowledge exchange to occur, all members of the team must represent their knowledge in a way that the other members of the team (including the patient) actually get it. And, all members of the team need to develop the skills of really 'listening' to other discipline knowledge and consider its relevance deeply in order to really work together. Likewise, influencing policy about the future of health care and our professions requires we engage in knowledge exchange with those in politics and policy. As long as we expect others to understand our strongly held views in the absence of a shared language, we will influence little and fail to work together.

So what policy developments in health would you like to get higher up the agenda? Based on this piece and a recent editorial in The Australian Medical Journal (McPherson and Reid 2007) a few of my favourites are out there including: the inherent inequity in a two tiered health service; the need for improved methodology in workforce development research to explore patient outcomes as much as outputs; and the potential for physical interventions (including physiotherapy) to be enhanced by a better understanding and response to how people think, respond and behave. Of course the task now is to become more successful in exchanging knowledge about whatever issues are important to us so that we inform and influence the next wave of policy change.

REFERENCES

Anema JR, Steenstra IA, Bongers PM, de Vet HC, Knol DL, Loisel P, and van Mechelen W. (2007) Multidisciplinary rehabilitation for subacute low back pain: graded activity or workplace intervention or both? A randomized controlled trial. Spine 32 (3): p. 291-8; discussion 299-300.

Burnett SM, Williams DA, and Webster L. (2005) Knowledge support for interdisciplinary models of healthcare delivery: a study of knowledge needs and roles in managed clinical networks. Health Informatics Journal 11(2): p. 146-160.

McPherson KM, Headrick LA, and Moss F. (2001) Working and learning together: good quality care depends on it, but how can we achieve it? Quality and Safety in Healthcare 10 (Supplement 11): p. 46-53.

McPherson KM and Reid DA. (2007) New roles in health care: what are the key questions? The Medical Journal of Australia 186 (12): p. 614-5.

Opie A. Thinking teams/thinking clients: knowledge based teamwork. 2000, New York: Columbia Press.

Pablos-MendezA and Shademani R. (2006) Knowledge translation in global health. Journal of Continuing Education in the Health Professions 26(1): p. 81-6.

Reid and Larmer, 2007 The New Zealand Health Priorities: Where do New Zealand Private Practice Physiotherapists fit? New Zealand Journal of Physiotherapy, VOL PAGE

Stewart and Haswell, 2007 Primary Health Care in Aotearoa, New Zealand: Challenges and Opportunities for Physiotherapists New Zealand Journal of Physiotherapy, VOL PAGE

Zdrraga C and Bonache J. (2005) The Impact of Team Atmosphere on Knowledge Outcomes in Self-managed Teams. Organization Studies 26(5): p. 661-681.

ADDRESS FOR CORRESPONDENCE

Kathryn McPherson PhD, Division of Rehabilitation and Occupation Studies, Akoranga Drive Campus, Auckland University of Technology, AA Building, Room 263, Private Bag 92006, Auckland 1142. Phone: [phone] ext 7110, Fax: [phone]. Email: Kathryn. [e-mail]

Kathryn McPherson PhD

Professor of Rehabilitation (Laura Fergusson Chair)

Auckland University of Technology