Letters: 3 December 2014

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Take a closer look

I was disappointed that the article on the new guidelines for metastatic spinal cord compression (MSCC) failed to give a complete picture (page 13, 1 October and online 23 September).

The guidelines were the result of two years of work from a dedicated multidisciplinary team in Northern Ireland, including representatives from physiotherapy profession.

I realise a short news story cannot cover the nuances of the recommendations. In particular, the assessment process outlined in the story needs clarification.

In addition to the five points listed in the article, assessment should include many other features including a thorough examination of the four cardinal and clinical diagnostic features of MSCC.

Namely: pain; motor dysfunction; sensory dysfunction; and bladder and bowel dysfunction.

The guidelines also stress the importance of clinical vigilance and monitoring of pain, muscle power and sensation during rehabilitation. They also give clear recommendations on the management of the unstable MSCC and stable MSCC patient.

I would urge CSP members to take a closer look at the guidelines.  These are available here.Paula Finlay. clinical specialist physiotherapist in neuro-oncology and one of the lead authors of the guidelines, Belfast Health and Social Care trust.

Question of autonomy

I agree with Michael Robinson that we need to capitalise on our ‘hard-earned clinical autonomy’ (Page 6, 5 November).

But Karen Middleton’s ‘how dare they’ comment (page 9, 15 October) does accurately reflect what many of us feel as we experience how aspects of our autonomy are being eroded, where commissioners constrain the kind and/or duration of treatment they purchase.

The Standing Medical Advisory Committee advised the medical professions in 1977 that doctors should make more use of the experience of therapists as regards decisions about the kind and duration of treatment (HC(77)33).

We should be clear that the committee was saying something about the relationship between referring doctors and therapists, at that time. We should not overstate the relevance of that advice and assume that our autonomy was secured by the publication of this circular.

The Privy Council approved change of the CSP bylaw in 1978 had probably more of an impact, as it allowed physiotherapists to see patients without medical referral, outside the NHS.

The problem with saying that we ‘have clinical autonomy’ is that it is not an inherent property of the physiotherapist. The level of professional autonomy we have is dependent on the outcome of a range of power dynamics that are played out in the healthcare organisation we work in, or for.

As such, professional autonomy cannot be said to the enshrined in HC(77)33. Nor is it mentioned in the NHS Constitution (2013).

In physiotherapy, technical and economic autonomy are hardly separable. Where limits are placed on our interventions, it usually seems to affect its ‘duration’ and access to the service.

An example of the former is the cap on the number of sessions and their duration and an example of the latter is the fact that self-referral is still the exception rather than the rule, despite the evidence of its cost-efficacy.

The ‘freedom’ that Mr Robinson refers to does not seem to be commonplace or equally distributed across the NHS system in England. Edward Bakker, Sheffield Hallam University.

Ethical matters

CSP chief executive Karen Middleton’s statement regarding clinical autonomy is based on a clear understanding of what this implies and the context in which clinical autonomy operates (page 9, 15 October). But Michael Robinson’s criticism of her in the letters page appears not be (page 6, 5 November).

Clinical autonomy is definitely not ‘doing what we want’, as Mr Robinson implies. It is entirely constrained by our professional guidelines.

These clearly indicate that each patient we see is a unique individual, that we should provide that individual with the assessment, approach and interventions or treatments that they require to meet their needs and be able to justify our clinical reasoning in the light of the contemporary evidence base.

Explicit in this is that we ‘move with the times’ in as much as this applies to the clinical science and not mere political expediency.

Furthermore, as healthcare professionals we are constrained to stand up for the individual’s best interests and advocate from the perspective of the evidence. Mick Skelly

You’ve added...

In response to an online news item titled ‘Bury physios make I will if you will exercise pledge’, Deborah Bancroft said:This event marked the start of our journey to introduce healthy conversations into our everyday practice. Paul Chapman commented on an online article on an NHS digital plan:  Interesting over the last two weeks we have seen to major documents published that now provide physiotherapists with the opportunity to make a difference in the way they deliver patient care.  You can comment on articles from this issue of Frontline online. CSP members can log here and then go to the ‘current issue’ section. You’ll also find icons to recommend articles to other members, Facebook ‘like’ Frontline or tweet articles. Comments posted online may be printed in shortened form in the Talkback section of Frontline.

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