There is Half an Elephant in the Room and it is the Shit End

By Glen O'Humeral

Let’s discuss raising standards in MSK care and specifically Physiotherapy. There are two ways of thinking about it. The most prevailing way is to raise the ceiling of practice and this is the wrong way.

Think of all the developments you have seen over your career. How many of them have looked at raising the ceiling of MSK practice? Prescribing, injecting, imaging, blood testing, first contact roles, extended scope roles, consultant roles (shall I continue…?) Can you think of any that improve AVERAGE levels of practice? 

The second and correct way of raising standards by the way is elevating average practice by pulling up the floor of poor practice. Statistically 50% of MSK therapists are below average regardless of how we as an industry wish to define clinical quality, of course using statistics means they will always be but the average, deviations and ends CAN move and as long as they improve then that's great. This means when someone accesses care they are as likely to see a below average clinician as an above average clinician. No one admits or talks about this though and it is most obvious in the private sector for blindingly clear reasons. No one is going to spend their money after going to a website and seeing ‘below average Physiotherapist’ in the bio. Everyone is specialist this, highly qualified that, level 99 other thing. 

The bell curve of quality practice is a beautiful thing because it tells us how to improve practice. Unfortunately lifting the floor of quality is a PR nightmare because first you have to admit that some clinicians are unfathomably shit. I am not even talking about safety, negligence, or those few clinicians who are doing things that are illegal. I am talking about competence in the myriad of skills required to assess and treat someone with an MSK issue (communication, reasoning, knowledge, humility, adaptability and so on). Are these assessed in any meaningful way? Have you got any idea where you sit on the sliding scale of quality in any of these measures? If you don’t know then how do the powers that be know? They don’t have cameras in all of our treatment rooms, I checked.

Look at my crude bell curve graph below. Improve the shittest clinicians and the AVERAGE skill goes up, I didn’t even move the top 2%...

A frankly comical situation we find ourselves in is with the CPD (continuing professional development) landscape. We have a market of CPD courses and opportunities that are regulated in LITERALLY no capacity. The HCPC wants us to do CPD but there is no barrier to entry as to what that is. Anyone can market a course on whatever they want and that's fine. Specific Horoscope Inspired Therapy™ can be sold tomorrow by physios to physios and if someone wants to pay to go on it then happy days. 

The CSP of course have no skin in this game, the irony of them setting a bar to entry when to be a Chartered Physiotherapist versus a non-Chartered Physiotherapist means nothing at all except that you paid your membership fee. They have a lovely get out because the HCPC is the regulator, well supposedly, depending on your opinion of its effectiveness. The only way of being struck off from the CSP is by bringing them into disrepute: otherwise you can be as clinically rubbish as you like. You can see how this is extremely beneficial, it frees them up to campaign purely on an increase in volume - more physios, more degree places etc. and when faced with any questions about the quality of that ‘more’ they can reply “HCPC are the regulator”.

Anyway, I have digressed. What is the point of this article other than an outright whinge? I want you to think about yourself, how can you ensure you are in the top 49% of everything? Have you ever needed to generate work to maintain your income or does work just get given to you and you collect your salary? If it's the latter, then are you really pushed to be at the top of competence? Really? REALLY? This isn’t punted at NHS clinicians either: there are plenty of private clinicians in the same boat with a surplus of referrals or insurance work.

I would suggest we lobby the CSP and/or HCPC but to be honest, I have lost the will and the energy for that. So look after yourself, your quality, your competence and make sure you are in the top 49%. Don't just do CPD you find interesting, truly assess where your weaknesses are. Find someone who isn't shy to tell you and then for the love of all that is holy, don’t get offended by it. See it as an opportunity. 

If every physio reads this and actually works hard at doing that, the floor will come up or as someone I know likes to say: “A rising tide lifts all boats.”