Reasoning, Responsibility and Reform in MSK Practice – Xmas special
I don’t have subscribers to my blog, so I suppose no one will be reading this blog by mistake. If you’ve entered the darker reaches of my website (that no Googlebot has ever found), you’ve done it on purpose.
My usual topics are mostly cycling related, often musculokeletal in focus, but usually written for public consumption. If you’re expecting me to big up Tadcaster, or lay the gauntlet down to Chris Froome, then look elsewhere. If you’re looking for an impassioned critique of my profession and a rallying call for us to seize the opportunities thrust our way by the rapid changing health environment that we have in Britain… then welcome to my blog!
Let me take you back 2017 years, to a manger, there was Gold, Frankenstein and Mirth, no rooms were to be had at the inn (blah blah blah). A baby was born and this baby was so pivotal that ever since then we have been counting up the days from its arrival. Let me propose to you that at the time this baby wasn’t always aware how its impact would be viewed retrospectively.
Let me transport you again, this time to the early 21st century. A new media savvy northern physio frustrated by the lack of critical thought in his profession, with an interest in philosophy that enables him to take a broader view of his profession starts a physio business. Jack Chew begets Chews Health, Chews Health begets The Physio Matters Podcast, which builds a social medial following and a reputation for critical thought and development of our profession.
This brings us up to date, where my sermon starts. Anyone within my profession specifically those that have to listen to my moaning, will know that healthcare in the UK is changing. The forces that are being applied are not coming from a position of service improvement, they are financial (e.g. first contact practitioners). There are some areas where this challenge is being met by people with a clear vision and are seizing the opportunity that change offers. Some of these people are physiotherapists. Because of the pace of change, this is an opportunity that will leave people behind. It is my worry that our profession as a whole will be left picking low hanging fruit instead of claiming the whole vineyard, or god forbid snatching the AOP.
Specifically I worry that as a profession we are poorly lead. When you compare us to the medical profession and the rise of MSK as a speciality over and above Sports Medicine, we’re still in the manger sucking our feet.
In MSK physiotherapy we have no strong leadership.
The scorecard so far:
The CSP (D) – Acting too slow, without a truly coal face view on the opportunities that are arising (e.g. first contact practitioners) and how we make our selves irreplaceable. They do not seem to reflect or represent me. Maybe their portfolio is to wide?
The MACP (C) – I love the MACP, they were the body that first poked my interest in MSK and truly encouraged a thirst for knowledge. They were never about manipulation to me. However they are at the moment not acting fast enough to move into the role, as their moniker suggests, as THE musculoskeletal association of chartered physiotherapists. I fear that they are not able at present to act fast enough.
Other CIGS (N/A) – Other Clinical interest groups, to be honest I know little about them and would be interested in an opinion. However my gut tells me that they will carry to many competing interests.
A lot like Russell Brand and his Trews, Jack Chew has had the vision to see that a very important cohort does not have a voice. Along with Connect and the Physio Matters team he arranged a meeting of minds. This was in Birmingham last week and sort to unpick this feeling of rudderless drifting that our profession has, specifically as it functions within national health provision.
Jack Chew is not the messiah, I suspect that he is a very naughty boy; however he is in a position where he has the power to move our profession forward, simply by facilitating the discussion. He has not ducked this responsibility and should be commended, but we shouldn’t look at him solely to move things forward.
Is there a reason why MSK work needs to be medical at all?
Physiotherapists should be able to lead on the provision of MSK care. However we are kidding ourselves if we think that we have the ability to role this out nationwide with our current collective skillset. When I say skillset I do not mean the ability to order scans, or bloods, or direct list for surgery. Good MSK care looks the same as good physiotherapy has always looked.
- Communication skills that enable us to meet a persons needs, enlighten them as to needs they are yet to see they have, but to engage on a human level.
- Appropriately diagnose an issue. I know that pathoanatomy is a dirty word in some physio circles, but it exists. You tell the people I see in my NHS clinics with spinal fractures or inflammatory disease, to name but a few, that all seemingly musculoskeletal presenting pain should be normalised through a pain science paradigm. Without this ability to recognise pathology we cannot:
- Use our ability to normalise this and go on to promote a healthy management strategy, or
- Act as a conduit for timely, appropriate medical management.
- Functionally relevant rehabilitation, that is engaging, well presented and focusses a client on being the person they want to be. When did professional footballers become worthy of focussed rehab, but a 50 year old weekend warrior warrants only a sheet of basic quads exercises. Our profession disappeared up its arse for a decade obsessing about deep neck flexors and transverse abdominus, lets just get back to basic principles and do them well.
We should acknowledge that these are real skills. One that our medical colleagues often lack. But without being able to reliably undertake point 2 we will always need medical backup and we will therefore always be seen as disposable. I’ve worked in MSK services for 11 years, time and again I have seen my medical colleagues bemoan the fact that we harp on about being autonomous, but then have a lack of courage in our convictions to back our clinical decision making. Looking for ratification by a doctor. While this happens we have no hope as first contact practitioners.
If I got one thing from #TheBigRs it was a rekindling of my love for Neil Langridge, after a period in the wilderness. Here is a model of an MSK clinician, who as a case study can prove that he adds value. I’m not putting him up on a pedestal so that we can all follow, like we did with Messes McKenzie and Maitland, but acknowledging that Neil will, if he reads this, be cringing. He has the humility that is needed to be a lifelong learner and not conflate confidence with competence.
Recommendations (for what they’re worth)
We are not searching for something that doesn’t exist. We simply need more Neil’s. Here is a recipe for Neil 2.0:
- As a profession foster good communication, diagnositic and rehab skills from undergrad, through to post grad and then via work based governance structures that invest in staff.
- Sell our profession for its plus points, not as we did with orthopaedic ESP’s, as cheap labour. We will never change our reputation with our medical colleagues unless we back ourselves and have confidence in our added value. Whether we like it or not, we are in competition with medics for MSK work, but they are often in positions of power making decisions about us.
- Develop a framework for change. There are no easy fixes, we shouldn’t aim for low hanging fruit. That would be such a physio thing to do; organising a fuddle while Rome burns.
I have no confidence that the CSP can rise to the challenge, I think the MACP could. I don’t think it is fair to leave this up to market forces. Private company provision of MSK is the future I suspect, but it is my view that we cannot leave the profession to fragment to a point that individual service providers meet their commissioned needs with an apprenticeship.
I do not think that this window of opportunity is going to be open long enough to form a different vehicle for change; maybe a lobby group, but this will have no real power.
We cannot lose the momentum generated by #TheBigRs. Collectively we will kick ourselves if in 5 years’ time a well organised group of MSK physicians are leading on delivering MSK services. Be they first contact practitioners or leaders of commissioned MSK services; we can do this.
Should the Musculoskeletal Association of Chartered Physiotherapists step up?
Do they want to?
How would this organisation have to change?
Just some thoughts. Thanks for reading!
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