La guerra successòria del comtat d'Urgell

This section details a number of systematic reviews that have covered extended practice role in physiotherapy, but not all of them are specific to MSK medicine.

McPherson et al. (2006), following an earlier study (McPherson et al., 2004) systematically reviewed extended-scope roles in five allied health professions (physiotherapists, OTs, radiographers, paramedics, and speech and language therapists). The four reviewers had two main objectives: first, to identify the range of extended-scope roles and second, to search for evidence on the effectiveness of extended-scope practitioner services in terms of their effects on patients, other health-care professionals, and health-care services. They included literature on non-NHS health-care settings and imposed no limitations on language or year of publication. Their definition of an extended-scope practitioner encompassed any

67 activity that included role enhancement (extending skills or the role itself) or substitution (substituting one role for another). The authors used a broad search strategy to identify studies from a wide range of sources. They included published and unpublished ‘grey’ literature, and placed no limits on the type of study design considered. Their approach to the systematic review and appraisal was derived from guidelines developed by the Cochrane Collaboration (Olson, 1995; Clarke & Oxman, 2001). Out of 355 relevant papers, 22 were of a sufficiently high quality to enable data extraction to take place. Of these, 18 were from the UK, three were from the US and one was an international paper. They retained a further 333 papers because of the usefulness of the descriptive information contained within them, even though data extraction was not possible. Only five papers concerned physiotherapy and these included one randomized controlled trial (Daker-White et al., 1999), one unpublished MSc. dissertation (Hattam, 2002), three qualitative study designs (Atkins, 2003; Milligan, 2003; Dawson & Ghazi, 2004), and two surveys concerning physiotherapists and OTs (Ellis & Kersten, 2001; 2002). Interestingly, one of the qualitative studies they chose to include (Atkins, 2003) concerned physiotherapists’ experience of using injection therapy, when this has been within the scope of general physiotherapy practice since 1995. The authors concluded that extended-scope practitioners usually undertook training on an ad hoc basis but that this varied considerably across posts. They cited the image- reporting course undertaken by reporting radiographers as an exemplar of extended-scope practitioners’ training and education. This course is a prerequisite for radiographers who report X-rays and other imaging modalities (Berman et al., 1985; Hughes, Hughes, & Hamill, 1996). A more recent study examined postgraduate training for exended-scope radiographers and found wide variations in training standards, with most of it being ad hoc and rarely accredited or validated(Miller et al., 2011).

Kersten et al. (2007) published a systematic review that focused purely on extended-scope roles in physiotherapy, but it duplicated some of the information contained in the aforementioned review by McPherson et al. (2006). However, they did mention three additional studies (Hattam, 2004; McClellan et al., 2006; Pearse et al., 2006), one of which was a paper that McPherson et al. (2006)

68 referred to when it was still an unpublished MSc. dissertation (Hattam, 2002); none of these papers was evaluated, because they were all retrieved after the study’s publication date. The authors identified 152 papers that met their search inclusion and exclusion criteria. These criteria were identical to the McPherson et al. (2006) review; in other words, there had to be an example of role enhancement, role substitution, or another form of extended-scope physiotherapy practice; moreover, the studies had to include a measure of the impact of ESPs on patients, health-care professionals, and services. Papers not meeting these criteria were still included for descriptive purposes but only those meeting the criteria proceeded to quality screening, which was performed using recognized guidelines (CRD, 2007; SPH, 2011); seven studies passed these quality checks. Not surprisingly, these were the same seven studies identified in the earlier review by McPherson et al. (2006). They also arranged all 152 papers into six categories, using a system that seemed to have been determined by the authors themselves. The categories ranged from A (evidence was present, even if it was limited, supporting the ESP role) to F (largely descriptive in nature, with authors expressing concerns about ESP role). No papers included data which did not support ESPs (category C), and no papers fell into category F. The majority of studies (89%) originated in the UK (n=135) and 66% of studies (n=100) concerned MSK ESP roles. The authors concluded that there was a preponderance of support for extended-scope physiotherapy in the literature but that very little of it came from robust research evidence. They highlighted the apparent void in training and education for ESPs, and proposed that they should undertake formalized training. They also cited the image-reporting course for reporting radiographers as an exemplary training model, and a course taken by paramedics to enable them to perform thrombolysis (Pedley et al., 2003). In short, this 2007 systematic review added little new information about ESP practice.

A systematic review undertaken at the University of South Australia (Lowe & Prior, 2008) considered five clinical areas of ESP practice; namely, orthopaedics, emergency care, obstetrics, gynaecology, and developmental disability. The first part of this paper focused on the literature review and proposed five aims and eight research questions; the principal aim was to ascertain the feasibility of

69 introducing ESP roles into ACT (Australian Capital Territory) Health and DHCS (Disability, Housing and Community Services). The peer-reviewed international literature was searched for evidence on ESP practice, and both the national and the ‘grey’ literature were searched for an Australian perspective (in order to clarify relevant issues for ACT). Their definition of an ESP included working beyond the recognized scope of practice with some element of role expansion or enhancement, which also exemplified extended therapeutics, diagnostics or practice consultation. They imposed no limits on the type of study design, but limited the search to between 1998 and 2008, with the ‘grey’ literature search commencing from 2003. It was a little unclear how the initial search was performed and by whom, and the authors provided no information on their methods of data extraction beyond stating that they used a ‘custom-built’ descriptive data extraction template. A recognized system was used to rate the quality of papers (CEBM, 2010) and 36 peer-reviewed papers met their inclusion criteria. They found four systematic reviews (Bethel, 2005; McPherson et al., 2006; Humphreys et al., 2007; Kersten et al., 2007), one narrative review (Anaf & Sheppard, 2007a), and 31 primary research articles, which included two randomized controlled trials (Daker-White et al., 1999; Richardson, et al., 2005). The majority of studies came from the UK (n=33), but there were two from Australia and one from the US; the ‘grey’ literature yielded 51 studies that met the inclusion criteria but these had been limited to Australian papers. The PI contacted the research team and asked them to identify the systematic reviews. One of the reviews (Bethel, 2005) was not a formal systematic review but a critical appraisal of the relevant literature. Another paper (Humphreys et al., 2007) was a systematic review, but it concerned consultant posts in nursing and the allied health professions – and because consultant practitioners’ practice should be at a more senior level than extended-scope practitioners’ practice, one could question the inclusion of this paper in the review. In conclusion, the authors of this review reiterated the importance of medical support for ESP posts and the need to define clinical competencies. They also recommended that all stakeholders participated in the development of training programmes. A further systematic review updated this 2008 review (Stanhope et al., 2012b) and focused on the role of ESPs in orthopaedics. The authors discovered a further six studies that had been

70 published since 2008. However, their poor quality meant that the evidence base effectively remained the same.

Laurant et al. (2010) conducted a systematic review that explored the evidence for the effectiveness of ‘non-physician clinicians’ (nurses, physician assistants, pharmacists, and AHPs) who extend their roles into areas of practice that used to be the domain of doctors. They focused on non-physician clinicians acting as either ‘doctor supplements’ or ‘doctor substitutes’. The former involved providing complementary additional services, and the latter involved these clinicians performing the same services as doctors (to enable doctors to do what only doctors can do). The authors separated supplementation into three categories of role revision: delegation (intra-professional shifting of service provision from a senior to a junior grade), innovation (a new type of professional) and enhancement (extending practice skills); however, they stated that non-physician clinician extended roles often demonstrate more than one type of role revision. In this review, studies were included if they were looking at the impact of non- medical clinicians compared with usual care provided by doctors; they also had to consider the effects on a range of structural, process, and outcome indicators. In their approach to the literature search, the authors initially focused on systematic reviews published in, or after 2005; review papers were considered ‘out of date’ prior to this. They then searched for randomized controlled trials, quasi- experimental studies, and controlled observational (cohort or case-control) studies; these studies were included only if they had not already been included as level A (systematic review) evidence. The earliest study included dated back to 1961, and they specifically excluded observational studies without a control, and expert opinion pieces. Three independent reviewers were involved in the evaluation of these papers, and they discussed any disagreements together when they occurred. The authors were unable to apply statistical tests to their data due to the heterogeneous nature of the studies; instead, they summarized data descriptively. They finally included 31 studies: twenty-eight systematic reviews and three original studies. The systematic reviews and professional group associations comprised five occupational groups: nurses (n=18), physician assistants (n=5),

71 pharmacists (n=4), AHPs (n=1), and studies containing of mixture of non-physician assistants (n=3).

There appeared to be no adverse effects associated with extending the roles of non-medical clinicians, but the authors qualified this comment by saying that this could really only apply to the nursing profession; the evidence relating to the other allied health professions, including physiotherapy, was insufficient to allow any firm conclusions to be drawn. They recommended cluster randomized controlled trials (where possible) to examine the effectiveness and cost-effectivness of extended roles, and encouraged researchers to compare non-physician roles with physician roles. The sole systematic review concerning AHPs (McPherson et al., 2006) yielded little useful information about ESP physiotherapists working in ‘substitution’ roles. Many of the studies included in the review had a short-term follow-up and with overall sample sizes being small, the authors felt that this might have concealed potentially negative findings such as ‘missed’ diagnoses. Nonetheless, they still argued that within hospital orthopaedic outpatient settings, ESPs appeared to provide the same quality of care as doctors and produced similar outcomes. It is somewhat misleading to put forward an argument based on just one systematic review comprising five UK studies, only one of which was a randomized controlled trial (Daker-White et al., 1999); however, such is the state of the literature surrounding ESP practice. The authors highlighted the fact that the research evidence has not kept pace with practice and service developments. They also commented that ESPs are not able to substitute for doctors in their entirety. This seems such an obvious observation to make and yet few papers refer to this fact. Finally, the authors recommended further clarification about training and regulation of non-medical clinicians working in extended roles, and the inherent professional indemnity insurance issues involved. Doctors have been required to undergo revalidation and relicensing since 2009 (NHS Employers, 2009) and if this is introduced for physiotherapists, what will this mean for new and existing extended professional roles?

Sibbald, Shen & McBride (2004) reviewed the evidence for the effectiveness and efficiency of changing workforce skill-mix, which they grouped into four categories:

72 enhancement (role extension), substitution (substituting one worker for another), delegation, and innovation (introducing a new role). They systematically searched the literature for evidence that had used either a systematic review or a quasi- experimental design and for studies with a qualitative analysis or quantitative meta-analysis of findings. They excluded literature prior to 1990 on the basis that it would be unlikely to yield relevant studies. Two independent reviewers used an appraisal scoring system with a maximum possible score of 8/8. In the two categories relating to ESPs (enhancement and substitution), no studies relating to ESP physiotherapy were found. This is not surprising given the fact this this study predates later systematic reviews.

2.5 Summary

The literature surrounding ESP practice is generally poor and it remains a difficult subject to research due to considerable variations in the parameters of these roles. This chapter has reviewed the literature on ESP roles in the UK, Canada, Australia, and in the US. The majority of studies focused on ESPs working in orthopaedics and emergency medicine. It is difficult to make comparisons between the ESP role in the UK with that of its counterparts abroad because of the different health-care systems involved. The overall quality of research is inadequate; most studies are either observational or descriptive in nature and often concern one ESP at one site. This reflects the way ESP posts are set up, which is usually on an ad hoc basis, to meet the needs of local services. There is clearly a need for more robust research in the field of ESP practice.

The majority of ESPs work in secondary care and although ESPs may think that they are practising autonomously, the need for medical support is a prominent feature in the literature. A common theme running through many of the secondary- care-based studies is the desire to compare ESPs with doctors. The overall conclusion is that ESPs are on a par with doctors when certain activities are examined, for example accuracy in surgical prediction, managing minor MSK injuries, performing joint injections, and the appropriate use of diagnostic imaging. However, most studies use inadequate outcome measures and are poorly designed, and ESPs tend to be seeing a particular cohort of patients selected for

73 them by their medical colleagues. One has to wonder about the merits of comparing physiotherapists’ performance with that of doctors, because it is not a comparison of equals. It is surely better to accept the differences between the two, and focus on the strengths and benefits that can result from employing skill-mix more effectively. Perhaps the reason why so few studies have attempted a cost- benefit analysis is that researchers recognize that clinical effectiveness of role substitution should take precedence over financial savings.

The design of this current study was influenced by one paper in particular: a small- scale study, which engaged 21 experts in a three-round Delphi survey in order to obtain a consensus on the competencies required of extended-scope practitioners (physiotherapists and OTs) in hand therapy (Ellis, Kersten & Sibley, 2005). This literature review has revealed a significant gap in knowledge concerning the clinical competencies and training required of MSK ESPs in the UK. For ESPs in community MSK interface clinics (which act as gatekeepers for secondary-care specialist services), this is critically important, because these ESPs are unlikely to have access to the same level of specialist medical support as their colleagues in secondary care. It is apparent from the literature that ESP practice has changed over the years, which renders some of the older studies less relevant to current practice.

This current research focuses on the clinical competencies required for primary- care-based MSK ESP practice. Very few papers in the literature discussed the clinical competencies and training associated with the ESP role and those that did were rather vague and referred to experiential training. Interestingly, it was a non- UK study concerning the APP role in Canada, which seemed to define the most rigorous educational preparation (Robarts et al., 2008). Although APPs confine their practice to the management of patients undergoing hip and knee arthroplasty, the benchmark used to evaluate their competencies was a medical competency framework produced by the Royal College of Physicians and Surgeons of Canada.

74 The specific aims of this study were as follows:

1. ascertain the views of medical MSK experts on the nature of the core clinical competencies (skills, knowledge, and attitudes) required of MSK ESPs working in primary-care-based settings

2. ascertain these medical MSK experts views on methods of acquiring these clinical competencies

3. determine if a consensus on competencies could be reached by engaging these experts in a formal consensus exercise (Delphi)

The next chapter will discuss the NHS reforms and policies that have recently brought primary and community-care services into the spotlight.

75 Chapter 3

Focus on MSK Medicine in Primary Care

3.1 Introduction

The current study focuses on the MSK ESP role in primary care. This chapter highlights the prevalence of MSK conditions in the community and the importance of training and education for GPs and ESPs working in this field. It also discusses primary-care-based MSK interface clinics, which filter GP referrals to hospital- based MSK services. Many of these clinics are led by ESPs, with limited access to support from MSK medical specialists in secondary care. The primary-care clinician faces a wide variety of MSK presentations affecting the spine, and both upper and lower extremities. This requires knowledge of orthopaedic surgery, rheumatology, pain medicine, neurology, sports medicine, and non-MSK conditions that may be associated with, or masquerade as, MSK pathology. Hence, it is critically important to identify the core clinical competencies required of primary-care-based MSK ESPs.