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Hip, hip, recovery?

Hip and knee replacements have been one of the success stories of recent times, enabling people to regain mobility and live comparatively pain free. So much so that, according to the National Joint Registry, in the UK some 160,000 procedures are carried out every year.


So is it a case of hip, hip, hooray for the NHS? Well, according to a report released by the Chartered Society of Physiotherapy it is more a case of ‘could do better’. Their findings come from a major audit into hip replacement procedures which revealed that after-care is sadly more of a postcode lottery than it should be. With only 20% of health authorities maintaining continuity of care following a hip operation some patients are just not receiving the physiotherapy which they need in order to help them to make a full recovery.


This can have serious consequences. Hip fracture is the most common cause of injury related deaths in adults, costing the NHS and social care £1b per year. Any delay in starting a personal recovery and physiotherapy programme can not only hamper the chances of full recovery, it can also lead to further complications due to the lack of mobility. These can include chest infections and blood clots, both of which can prove fatal. Moreover, if muscles and ligaments are not re-trained as soon as possible following an operation the damage may be irreversible, leaving the patient wheelchair bound and relying on care services for ongoing support.


In response to the study the Chartered Society of Physiotherapy has launched a best practice care standard for hip operations. This states that all patients should receive an assessment by a physiotherapist within a day of their operation. This should be followed by at least two hours of physiotherapy in the week following hip replacement surgery with a further two hours per week until they are fully recovered.


Whilst two hours per week may not seem very much, it represents a considerable improvement on the less than an hour a week which the survey revealed some patients were receiving. And even that was better than the 80 day wait for rehabilitation which faced some patients after their operation. And we shouldn’t forget that a regular programme of physiotherapy will also help patients to stay on track with their own recovery regime; with physiotherapists being able to check that exercises are carried out as well as suggesting alternatives should the current rehabilitation regime not be as effective as it could be.


Undoubtedly the requirement for two hours treatment per patient per week will place added strain on the physiotherapy profession.  However, this will be partially offset by a reduction in ongoing requirements to treat patients who have developed life-long care needs as a result of not having appropriate treatment immediately following their operations.


Commenting on the new care standard Chartered Society of Physiotherapy Chair, Alex Mackenzie, said “Our ageing population means there are more people than ever before at risk of hip fracture and it is vital they can access high quality, timely and intensive rehabilitation.”

Treating the person not the condition

The importance of treating the patient not the condition has been brought into sharp focus by a Cambridge University study published in the British Journal of General Practice. Reviewing the health records of more than 400,000 adults, the study revealed that 30% of females and 24.4% of males were suffering from more than one health condition, otherwise known as multimorbidity. Moreover, those who reported experiencing more than one health condition accounted for 52.9% of GP consultations and 78.7% of prescriptions.


Breaking down the statistics by underlying cause, the most prevalent conditions according to the report were hypertension (18.2%), depression or anxiety (10.3%), and chronic pain (10.1%). Interestingly, those aged between eighteen and forty-four or having been identified as having lower socio-economic status were more likely to report a combination of physical and mental conditions.


Whilst the findings may not come as a huge surprise to health professionals, nevertheless they do serve to highlight the way in which individual conditions should not be treated in isolation. As the report’s authors highlight “multimorbidity has a substantial impact on various health services ranging from general practice to end-of-life care.” Moreover, gaining a better understanding of the complex relationships between conditions could help the health service in general to target resources appropriately. As Dr Duncan Edwards, one of the authors commented “It may be that we need to think about a drastic restructuring of services: no longer will people be seen in ‘single disease’ services but in new multimorbidity clinics designed for the future.”


Where does this leave health professionals in the meantime? For some, it may simply a question of heightening awareness rather than changing practices. For example, physiotherapists, osteopaths and chiropractors are well used to thinking holistically when treating muscle and ligament pain. That’s because carrying the body differently in response to an injury is very likely to lead to referred pain or contribute to additional musculoskeletal damage.


Where the challenge becomes more complex is when it crosses disciplines; for example where obesity gives rise to a range of conditions including chronic pain, hypertension, diabetes and depression. In these instances whilst the potential causal link may be understood, care may be provided by a number of health specialists. Not only does this condemn the patient to multiple doctor and hospital appointments, a delay in treating one aspect of the condition may contribute negatively to the chance of recovery in other areas.


The five-year forward review of health practices in the UK had already identified the need for treating patients holistically. This study sheds further light on the reasoning behind that review as well as calling into question the current structure of health services within this country. Treating the condition in isolation may not restore the patient to full health and could even lead to further complications. As Professor Helen Stokes-Lampard, Chairman of the Royal College of GPs, commented: “This large-scale, comprehensive research is further evidence of the increasing complexity of cases that GPs are dealing with, and the inadequacy of the standard 10-minute consultation.”


Providing specialist rehabilitation

When a traumatic event occurs we’d like to think that our health services are there for us. Particularly so if the event results in a form of trauma which requires long-term recuperative treatment. So would it surprise you to hear that in-patient specialist rehabilitation units only have the capacity to cater for 5% of the total number of individuals who are admitted each year to major trauma centres?

Those are the findings of a report commissioned by the Health Quality Improvement Partnership (HQIP) which looked into the provision of trauma care across England. As with many other health services the provision of specialist trauma care seems to be a postcode lottery with, according to district, between 1 and 8 adult trauma specialist rehabilitation beds available per 1 million people.

In bald terms, this means that across England only some 950 patients can be treated each year in specialist rehabilitation beds. The report also commented that under commissioning and insufficient staffing resulted in specialist rehabilitation units struggling to manage a complex caseload. Cost efficiency calculations were also not recorded by a quarter of the providers resulting in uncertainty about the balance between specialist treatment and long-term care in the community.

Now admittedly some of those who initially find themselves at major trauma centres may not require a high level of support but the report’s authors are calling on major trauma centres to “review the capacity and pathways for specialist rehabilitation following major trauma” in the light of the report. This should include the drawing up of local action plans together with an increase in the capacity of level Ic (cognative / behavioural) beds in order to shorten waiting times for these patients.

Trauma at all levels from major to relatively minor has an impact not only on the individual affected, but also on their family and their capacity to work. For the good of the individual as well as for the long-term health and productivity of the country it is therefore important that when an incident occurs priority is given to helping the individual to recover as swiftly as practicable. This means that all health professionals, whether they work in specialist NHS units or in private clinics have their part to play in providing rehabilitation treatments in a timely manner. Psychiatrists and counsellors, physiotherapists and mobility specialists, dentists and opticians; whatever the requirement, in helping the individual they are also helping the country.

But health professionals will only be able to give of their best when they in turn are supported by an efficient administration system. Addressing the rehabilitation needs of individuals requires concentration and a clear brain in order to draw on best practice knowledge. Health professionals won’t be able to give patients their full attention if they have worked late into the night in finding and filing notes, managing the appointment diary and dealing with the finances.

This is where backup systems such as online diaries, electronic filing of notes and card payments can make all the difference. In effect, by taking advantage of the support which is available to them, health professionals can in turn provide the best support possible to help their patients to recover. Yes, some will require the services of a specialist treatment centre; but for the rest, being able to call upon swift and timely rehabilitation services could make a significant difference to their long-term recovery.



Occupational Health – Planning The Future

Good work is good for health, good for business and good for national prosperity.”

This by-line from a report by the Council for Work and Health perfectly sums up why occupational health needs to become an integrated part of health provision in the UK. The report was drawn up in response to demographic changes allied with the need for employers to improve productivity and efficiency levels. With that in mind, the report’s authors aimed not only to create a vision for occupational health practice but also to identify the level of healthcare training required to deliver the vision into practice.

The Council for Work and Health aims to provide a coordinated voice for all of the professionals who work in the occupational health field. Formed in 2008 its projects include the provision of advice and guidance for employers as well as training for occupational health practitioners and allied health professionals.

 This latest report entitled ‘Planning the future: Implications for occupational health; delivery and training’ came up with six key recommendations which were aimed at ensuring that occupational health not only meets the needs of the working population but also provides an early intervention mechanism. These recommendations are:

  • to integrate occupational health into mainstream healthcare provision in order to provide a greater level of holistic patient care
  • the creation of government incentives to encourage investment in healthy workplaces, perhaps by removing the tax liability for occupational health and well-being interventions
  • to boost the visibility of occupational health within the workplace by providing employers with access to relevant professional help and by promoting the return on investment in occupational health
  • to develop competency frameworks within a multiagency approach in order to boost the skill levels of those working within the operational health field
  • to develop models both to facilitate workplace health planning and to predict the match between requirement and supply
  • to attract and train professionals to meet expected needs

In recent years businesses have moved away from seeing their employees as necessary costs, nowadays recognising their people as the most valuable asset which a business can have. In tandem with this, occupational health is increasingly being seen as a valuable aid to employee well-being.

Whilst some businesses may employ dedicated occupational health teams, the opportunity exists for health practitioners such as physiotherapists and osteopaths to have more flexible arrangements with business. This may include the provision of general advice, being called in on an as needed basis or providing ongoing support to members of the team who have particular health needs.

Other health professionals such as counsellors may also be called on an as required basis. For example, those drawing up business continuity, or risk management, plans are increasingly taking account of the effects of disasters on their employees’ mental well-being. Providing access to counselling can make a measurable difference in helping employees to return to ‘work as usual’ following an event.

We live in a time in which NHS resources are stretched. In business too, low productivity levels are causing concern leading to a constant demand to do more with the resources which we have. In addition, the rise in retirement age is increasingly going to require businesses to work with their employees in order to help people to continue to carry out their duties as they move towards later retirement. All these factors and more place an increasing focus on the role of occupational health professionals. As Professor John Harrison said “It could be argued that there has never been a more important time for occupational health as a key contributor to the health and wellbeing of working age people.”

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