CPN Course on Vulnerability

Recently, I engaged with the CPN regarding the topic of vulnerability with the goal of using the concept to think differently about critical aspects of Physiotherapy.

What proceeds next are the notes that were used to establish the conversation, followed by initial observations from the topics that surfaced.

Why the topic of vulnerability?

We all are feeling it, in one way or another, the sense of impending challenge, susceptibility, and even threat.

From the cost of living crisis due to the current war in Ukraine to the planetary health crisis with global warming and climate change due to the human consumption of resources.

The economic destabilisation from an ever-changing political climate through forms of sociocultural self-preservation, capitalism and right-wing othering of those that are more misfortunate than others.

The technological advancement, which is growing at pace, driving toward forms of change that may cause unforeseen circumstances out of human control such as machine learning and AI.

From the habitats we exist in, the architecture of the buildings, the furnishings, the offices, and clinics we may work within all have the capacity to endure and subsist…but change is inevitable. All entities that exist are all, in some way, vulnerable.

From a healthcare perspective, we support, care and help those that may be vulnerable.

However, we are also alert to the way in which the term vulnerability may promote stigma and marginalisation of individuals, groups, and communities.

Healthcare structures themselves are under tremendous strain even before the global pandemic, with vulnerable systems being challenged from under funding and underhand political manoeuvres oriented toward privatisation.

The term vulnerable can also be used in a vague way such that there may be a misunderstanding of who is vulnerable, why they are vulnerable, and what they are vulnerable to. This in turn can have the effect of obscuring systemic and structural causes of inequity, including the role of power for political purposes, and therefore limit opportunities for transformational change.

As a healthcare professional myself, much of my work is surrounded by language and acts that are intertwined with the concept of vulnerability.

But is vulnerability always negative—not necessarily—many know of the work of Brené Brown who describes vulnerability as ‘uncertainty, risk and emotional exposure’ and something that ‘forces us to loosen our control’ and to embrace it. To do this is to have the ‘courage to show up where you cannot control the outcome’.

Much like me, those that were involved and spoke up in the session were exposed and becoming vulnerable…

Vulnerability: A Poem by David Whyte

“Vulnerability is not a weakness, a passing indisposition, or something we can arrange to do without, vulnerability is not a choice, vulnerability is the underlying, ever present and abiding undercurrent of our natural state.

To run from vulnerability is to run from the essence of our nature, the attempt to be invulnerable is the vain attempt to become something we are not and most especially, to close off our understanding of the grief of others. More seriously, in refusing our vulnerability we refuse the help needed at every turn of our existence and immobilise the essential, tidal and conversational foundations of our identity.

To have a temporary, isolated sense of power over all events and circumstances, is a lovely illusionary privilege and perhaps the prime and most beautifully constructed conceit of being human and especially of being youthfully human, but it is a privilege that must be surrendered with that same youth, with ill health, with accident, with the loss of loved ones who do not share our untouchable powers; powers eventually and most emphatically given up, as we approach our last breath.

The only choice we have as we mature is how we inhabit our vulnerability, how we become larger and more courageous and more compassionate through our intimacy with disappearance, our choice is to inhabit vulnerability as generous citizens of loss, robustly and fully, or conversely, as misers and complainers, reluctant and fearful, always at the gates of existence, but never bravely and completely attempting to enter, never wanting to risk ourselves, never walking fully through the door.”


The popularity of the concept Vulnerability over time:

Vulnerability has been used significantly since the 1920s, with an extraordinary amount of interest growing from the 1980s.

Etymology:

Latin Latin Late Latin Modern use

Vulnus → Vulnerare → Vulnerabilis → Vulnerable

Wound → to wound, hurt/injure wounding early 17th C

What immediately becomes apparent from the Collins dictionary is that vulnerability is conceived from a human and living perspective with negative connotations.

From the Collins dictionary

Vulnerable

  1. Someone who is vulnerable is weak and without protection, with the result that they are easily hurt physically or emotionally.
  2. If a person, animal, or plant is vulnerable to a disease, they are more likely to get it than other people, animals, or plants.
  3. Vulnerable something can be easily harmed or affected by something bad.

And From Google:

1. Exposed to the possibility of being attacked or harmed, either physically or emotionally.

Initial Observations Following the Discussion on Vulnerability

The first session of the CPN course on vulnerability was a very affirming and positive experience.

The concept of vulnerability was openly discussed, and a many key points arose, some of which are below:

Conceptual vagueness: It was apparent that the concept of vulnerability was vague. This included whether it be used as a universal concept that centred on the demise, fragility, susceptibility of entities that exist or whether it was focused on humans, environments, ecosystems, objects, and relations.

Location: Associated with conceptual vagueness, the location of vulnerability appeared to be an important topic of discussion. Should the focus of vulnerability be centred on humans and potentially be reduced to physical, emotional or cognitive properties? Certainly, viewing vulnerability from a human perspective, a human centring, tended to focus on individuals rather than communities and societies. Furthermore, these dimensions of vulnerability appear to coincide with the domains of human abilities as introduced in developmental psychology, namely physical, social and intellectual abilities. One cannot but feel that focusing on humans and, individuals, does not express the concept of vulnerability in quite the way in which humans rely on their environments and other nonhuman entities that shape existence.

What are the alternatives? If we were to conceptualise vulnerability as an arrangement of complex entities that coexist and cohabitate, then we would need to draw a larger location. The boundaries of which appear permeable, multi-variant and multivalent. The qualities of vulnerability may vary in intensity, in time and in space.

Temporality: The concept of time entered the discussion. Whether this should centre on human experience, from the notion that our current experiences are existentially located from an individual’s previous experiences and events, entangled with the concerns and expectations of the future. Or whether the concept of time should be considered differently. For example, geological stratifications and tectonic plates move slowly, compress and manifest landscapes across vast time-periods in comparison to human lifecycles. From what temporal scale should the concept of vulnerability be seen?

Manifestation: How the concept of vulnerability is conceived was also discussed. Vulnerability could be seen as a concept from its etymological roots as a ‘wound’ing and as such carries negative connotations. This negative aspect of vulnerability could include fragility, frailty, weakness, susceptibility, but there was also discussion around positive aspect of vulnerability. The American Professor, researcher and author Brené Brown was brought into the discussion in how she describes vulnerability as an asset, as something that if one could draw courage could use vulnerability as are strength and a positive power. It also seems perhaps evident that for change to occur, an entity would need a capacity to be affected, thereby the need of vulnerability would need to exist for transformation to occur. Vulnerability, however, exists regardless if change manifests or not. Invulnerability appears not to exist. From early superheroes such as Superman and his fragility to kryptonite and the war hero Achilles who had his weakness at the back of his heel.

Scepticism: There was much discussion around the normative state around the concept of vulnerability and that vulnerability is used as an ‘other side’, a way in which something becomes normalised akin to homeostasis. It was felt that vulnerability was a ‘feel good’ concept that skirts around the fact of the fleetness of existence toward death and decay. Conversations included aspects of Nietzschean ideas of existential non-meaning, that life itself has no meaning, but vulnerability was used to give a sense of hope or something for people to grasp hold of. The concept of vulnerability could be seen like casting a comfort blanket on a nature of reality. The term ‘fugaciousness’ came to light, referring to an entities lack of enduring qualities, of transience, transiency, impermanence, and evanescence.

Humanistic conception: There were criticisms placed on the concept of vulnerability in that it was often reduced towards a human understanding, perspective and orientation. It, therefore, suffered with value laden qualities which could be used in unequal power dynamics and distribution. For example, who was vulnerable, what groups or individuals and for what purpose were they assigned that label? The very identity of being vulnerable and of vulnerability could be used to subjugate human and non-human entities for others gain.

Process orientation: The quality of vulnerability itself as a process was discussed in reference toward a feeling of fluctuant and a dynamic nature of vulnerability. This process orientated perspective cast a shadow on the vulnerability, being a static concept bereft of the unfolding viewpoint of existence.

Next steps: It was felt that a helpful next step was to examine an ontological basis of vulnerability, and to do so require approaching this from a certain philosophical perspective. That philosophical perspective will be from the work of Gilles Deleuze and Felix Guittari who will be introduced next time.

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Vulnerability: A key concept in Bioethics.

The concept of vulnerability is broad and covers a wide variety of fields, areas of research and analysis. This blog post discusses the concept of vulnerability in bioethics.

The dictionary definition of ‘vulnerability’ is that it is both, a noun originating from the Latin vulnus (wound), and an adjective ‘vulnerable’. The word vulnerable is used to describe something that is “susceptible to physical or emotional attack or damage”, however, when applied in different contexts the word has a variety of implications. For example, in conversations surrounding climate change, the term vulnerability can be defined as the tendency for an entity to suffer damage due to environmental causes. In economics, it can relate to a countries’ capacity to maintain financial reserves to pay its external debt.

Despite these differences, the variations in the concept of vulnerability appear to revolve around its etymology in that it correlates with the conditions of exposure or susceptibility to wounding.

An interesting paper by Cunha and Garrafa (2016) examined the concept of vulnerability from different perspectives across five regional approaches to bioethics from the United States, Europe, Latin America, Africa to Asia.

Vulnerability in the Bioethics of United States Origin

The most common perspective of bioethics from the United States focus on the relationship of vulnerability with the principle of autonomy. A vulnerable person is one who is incapable of making decisions regarding their interests. This appears to be intertwined with the moral conflicts and political associations of a history favouring the individual and one’s freedom and autonomy over values and interests of a more collective nature. Even when there have been strong debates around this topic area such as the vulnerability of racial minorities, the economically disadvantaged and the very sick and institutionalised, the debate appears to return to issues surrounding autonomy and consent. In response to this, there has been a suggestion that the development of a wide-ranging theory of vulnerability is required. This then would consider both the intrinsic vulnerability of certain groups, for example women, and the social and cultural determinants that make women even more vulnerable than others. However, this approach has not been accepted as the mainstream perspective of bioethics in the United States.

Vulnerability in the Bioethics of European Origin

Although there are similarities to the concept of vulnerability between the U.S. and Europe, it has been proposed that there are distinct differences. The influence of two European philosophers; Emmanuel Levinas and Hans Jonas have made this impact. According to Levinas, vulnerability is the foundation of subjectivity and of ethics itself, this is because of the existence of a “first person” who will depend on the non-violent encounter of the other. In this way, individuals are vulnerable in the most basic and fundamental way. According to Jonas, vulnerability is an attribute of all living things that can die. The European Bioethical community (Basic Ethical Principles in European Bioethics and Biolaw) drew up at four principles that would be fundamental regarding the topics bioethics and biolaw. These were autonomy, dignity, integrity, and vulnerability. It is argued that vulnerability should be understood as “ontologically prior” to the other principles, in so far as it expresses an attribute that precedes any other norm.

Vulnerability in the Bioethics of Latin American Origin

Within Latin America, the concept of vulnerability in bioethics evolved around the 1970s. This may be as a result of conflicts that occurred in Latin America where the United States were directly involved, thus leading the subject of bioethics to become politically and socially intertwined rather than a purely academic discipline. This shift reflected bioethics that was deeply grounded with the social and collective inequalities that were prevalent at the time, including poverty, inequality, social and environmental exploitation. The view of vulnerability expanded to encompass various forms of exclusion of population groups in relation to events or benefits that may be occurring within the worldwide process of development. Discussion centred around the adjective ‘vulnerable’ to mean ‘weaker subject or issue’ or ‘the point through which someone can be attacked, harmed or wounded’. This shaped the concept of vulnerability toward a human frailty, a lack of protection and helplessness or even abandonment.

Further, the concept of vulnerability became a topic that was spatiotemporally involved when using the words ‘potential’ or ‘actual’ capacity to be affected through the terms ‘vulnerated’ and ‘vulneration’. The concept of vulnerability could be seen as the potential of something that could be wounded, rather than actually wounded. A vulnerated state is one in which an act has taken place. Seen in another way, all living beings are susceptible to being wounded (vulnerability), but only those that have actually been wounded are vulnerated.

Latin American bioethicists brought forward political differences between vulnerability as an ontological condition and vulnerability as a contingent situation. Susceptibility, in this context, was characterised as the socially produced circumstances that threatened groups required justified protective action by the state. Social vulnerability emerged, which was taken to mean the limits of self-determination and increased exposure to risk created by a situation of social exclusion. There was a certain degree of push back when using the concept of vulnerability to characterise abstract subjects without clearly delineating the subjects themselves. In the main, this was in relation to the ‘colonial’ pattern of power that has structured the world system since the beginning of the modern era, through white, European-American, Christian, heterosexual men. It became apparent that the Latin American bioethical conception of vulnerability was strongly related to the social dimension of vulnerability, where socioeconomic differences among populations are highlighted with connections to the political and ethical control of humans.

Vulnerability in the Bioethics of African Origin

African bioethics researchers have been critical of institutionalised University centred studies in light of continued reference to Western bioethics. Among African bioethics literature there is reference to traditional medicine, proverbs, songs, mythology, folklore and religious rites. In particular, philosophical approaches to life such as Ubuntu, a tradition within African thinking that includes a set of values and thoughts which are distinct and contrast from Western approaches. The late Archbishop Desmond Tutu described Ubuntu to mean ‘I am because we are’. He went on to explain;

We believe that a person is a person through other persons. That my humanity is caught up, bound up, inextricably, with yours. When I dehumanise you, I dehumanise myself. The solitary human being is a contradiction in terms. Therefore, you seek to work for the common good because your humanity comes into its own in community, in belonging.

Beauchamp and Childress (2001) developed four principles within Western bioethics—autonomy, non-maleficence, beneficence and justice. In contrast to this, African bioethics replace justice with harmony and also replace respect for individuals for autonomy. Vulnerability, therefore, exists within communal and collective forms of humanity rather than the individual autonomous person.

Vulnerability in the Bioethics of Asian Origin

Due to Asia’s vast size and diversity in respect to culture and religion, Asia benefits from a rich and varied tradition of bioethics. For example, Buddhist and Taoist bioethics emphasise the role of compassion, empathy, hope, and wisdom. Similar to African bioethics, there exists an emphasis on the role of family, community, and religious traditions. The complex context of cultural, territorial and religious diversity of Asia makes it challenging to construct a single theoretical and normative foundation for the bioethics of that region. Vulnerability, therefore, becomes consistent with African bioethics in that it is a context dependent concept oriented towards openness towards others with a shared sense of collaborative support bound by culture and religious form of practices.

Summary

As noted, in bioethics originating from the United States, vulnerability is usually correlated with incapacity to provide consent or to exercise autonomy, whereas in European bioethics the focus is mostly on the condition of intrinsic frailty of all living beings. From the Latin American perspective, discussions are characterised by a political focus aimed at identifying the ways in which vulnerability develops and exploits communities. What is evident is that these perspectives do not contradict each other and may actually complement each other in that they focus on different instances of vulnerability. For example, the individual dimension is highlighted in American bioethics, whereas the ontological dimension is clear in European bioethics and the political dimension strongly is evident in Latin American bioethics. African and Asian bioethical perspectives shed light on a shared and community-based concept of vulnerability despite regional, geographical, spiritual and religious differences.

A universal definition for the principle of vulnerability is not clear, and efforts toward this appear unwarranted. Attempts at trying to resolve any conflicts involving the concept of vulnerability within the field of bioethics will not be achieved through negotiated geographical definitions. However, it might be beneficial to identify and address the reasons, agents, and processes that maintain the unequal distribution of wounds among different individuals and groups across the world.

References

Cunha, T., & Garrafa, V. (2016). Vulnerability: A Key Principle for Global Bioethics? Cambridge Quarterly of Healthcare Ethics, 25(2), 197-208. doi:10.1017/S096318011500050X

Beauchamp TL, Childress JF (2001) Principles of biomedical ethics. 5th. New York: Oxford University Press.

The Advanced Practice MSK standards: It starts on day one.

As the public consultation on the advanced musculoskeletal standards is launched https://skillsforhealth.org.uk/have-your-say-on-the-musculoskeletal-advanced-practice-and-governance-framework/

I wanted to offer a narrative, primarily directed at students and less experienced practitioners. The reason to do this as one of the authors of the document is to really try to encourage the views from you, as you are the Advanced Practice and Consultant practitioners of tomorrow, and I will be retired and consulting YOU for my various MSK issues. Your views are vital, and just because this looks “advanced” and “special”, the reality is this should, if it is to be useful,  be part of your career aims, goals, values from day one for anyone with an interest in MSK, and not be seen as “special” at all.

So, within the document there are capabilities built around MSK practice and these have been mapped against the multi-professional framework for advanced clinical practice in England https://www.hee.nhs.uk/sites/default/files/documents/multi-professionalframeworkforadvancedclinicalpracticeinengland.pdf . So the MSK framework looks to operationalise the integrated 4 pillars into a bespoke model that reflects your day to day practice. But I thought it might be helpful for you to offer some reflections that are more general in how this frameworks underpins the characteristics of the modern MSK practitioner, and to do this I have highlighted some more general considerations that I hope when you read them may offer some direction of travel and give you the encouragement to get involved in the consultation, as you have advanced practice skills, characteristics and abilities already, perhaps you don’t realise it. This is not about experience, how many weekend courses someone has done or the number of webinars attended. If you can learn from experience and mistakes, and reflect well, you will rapidly build the “skills” as such that you need. This of course starts on day one.

I describe myself as a MSK generalist. I have worked in primary, community and secondary care, I see multi-body parts, I work in diagnostics and offer injections and support patients through rehabilitation from the older person, sedentary, sports and young. So, I don’t have a “specialism”, and in that sense the pointers below are I think the “specialisms” of advanced practice rather than saying I am a spine, shoulder, foot specialist. Therefore, if you have a look at these reflections below, you will probably see you do this yourself in some way, shape or form, and in fact it is you who should be commenting on the frameworks just as much as the “specialists”. The characteristics that make you a great student, newly qualified practitioner are exactly the same as a great Advanced clinician: the difference is the knowing, appreciation and the evidencing of those skills and putting them into practice with the benefit of some clinical experiences –which will inevitably will come, but you should recognise it starts from day one.

Pillars of Practice
  • MSK advanced practice is about rehabilitation.

Rehabilitation of individuals and the population you serve is a vital component not something as I was once told “you just do the final bits don’t you?” – it remains as integral to every interaction we have – it is THE intervention of choice, and comes in multiple formats. The “skills” (think C) of rehabilitation such as Communication, Compassion, Clinical reasoning, Common-sense and Core skills done really well can all be worked on from day one and are advanced when used skilfully. There is nothing fancy about printing a rehabilitation plan, but to bespoke one that is tailored, progressive and goal orientated is advanced, skilful and headline stuff. Throw in the reassurance of Confidence, Competence and Capability and you have an extremely valuable clinician.

  • Advanced practice is not about requesting things.

The advanced practice in this is the reasoning behind these choices, the interpretation of the findings, the communication of those findings and the reassurance you offer with respect to the relevance. It is about the action you take with the results, which requires knowledge but really importantly responsibility for that action. Taking responsibility is a characteristic you already have, just learn to develop it, and so don’t get hung up thinking, requesting an MRI is an advanced skill, it’s not, the accountability for actions is far more reflective of the level. You can develop these from day one.

  • Advanced practice is valuable across the whole system.

In all forms of practice you can influence. Primary to tertiary, community, cross boundary. Knowing how to influence the benefits of MSK practice to a wider population, through not only classically described MSK practice but also public health, emotional well-being and activating physical inactivity are hallmarks of advanced practice. You can do this from day one, it’s a really powerful hallmark of advanced care.

  • Advanced “hands on” skills are not a hallmark of advanced practice.

Good quality handling is needed in any form of practice, respiratory, neurology, frailty, MSK. It can inform, reassure, support. There is no magic to this in MSK, and the advanced MSK clinician needs another C here – Critical thinking. Applying any intervention needs to be evidence based, judicious, person centred and designed to inform, and lead to the realising of the potential. Whether its task, movement, of part of diagnostic reasoning, the Advanced bit of any handling is Communication and Clinical reasoning. Why are you doing something, what does it mean, does it offer evidence based value? These are the advanced skills of handling, not the handling per se. Of course skilful guidance is extremely valuable, watch a clinician gain a frail patient into standing on a ward can leave you thinking “how did they do that?!” –well, the key was not only how they used handling to reassure and guide but listen to HOW they did it, the words they used, the time they utilised with the patient and the understanding of the person before any of it started. These are advanced “skills” from day one which you can use.

  • Advanced practice is not about the title or the badge: leadership key.

Advanced practice uses a range of learning styles, leading styles and harbours great emotional intelligence. The advanced practice clinician wants to get the best out of others, and gets great value in developing others over and above their own needs or reputation. There was a time when for me when “extended scope practitioner” just seemed like a title that took a lot of space on a badge. When I gained these roles the badge was not important, the leadership was the step up and not the “scope” which is not reflective of the role. Now we use the term advanced practitioner rather than ESP, and high quality leadership, was so often missed in the early days of the “extended scope/big badge” development as a lot of time was taken up knowing a lot about orthopaedic surgery and perhaps leadership took a back seat. These leadership principles can begin from day one.

So, I hope you will engage in the consultation. I hope as students and what you might perceive as “less qualified” realise that you are VERY qualified to get involved and your view massively counts. I hope you can see that although we have to have capabilities to support safe practice, much of advanced practice is about behaviours, seeing the wider picture and being broad (not special!).

As one of the authors in the primary care road map and MSK standards I want to state some important acknowledgements. These standards will not be perfect, they will and must change with feedback, the advancement of science and practice and the development of the professions must influence future iterations. A good way to demonstrate your emerging clinical and leadership behaviours is to constructively influence change, so why not get involved in this?

Thanks for reading.

Dr Neil Langridge.

Advanced Practice Standards: What can we learn from what we have missed?

Dr Neil Langridge shares his thoughts on contemporary issues as we approach PhysioUK 2021 in a focussed symposium that he is involved with on Advanced Practice in the UK.

I thought I would write a few lines regarding some reflections I have had concerning the FCP RoadMap (Primary Care Advanced Practice) (Acknowledgements Tim Noblet, Jodie Smith, Amanda Hensman-Crook, Julia Taylor, Matt Low) and the draft Advanced MSK standards across the multi-professions which I have also been involved in.

The prompts for this blog started with a short social media discussion that began with something along the lines of “what is the point of the FCP RoadMap standards? It doesn’t acknowledge experience etc, it’s a waste of time”, and secondly my observations of how a standards document can create battles which at the outset of developing the standards I was naïve about, and subsequently have learnt a lot over that time, and I hope it’s worth sharing.

Advanced practice as we know is developing very quickly. In terms of the MSK Roadmap to FCP and AP in primary care based on agreed standards and the pending advanced MSK standards have moved at a relatively rapid rate. The reason I say “relatively” is because prior to this we essentially had 25 years of slower development in this field. We had new roles, new job descriptions, variable accountability, but as a profession, no national level standards that would be considered agreed and transferable. I gained 22 years ago what was then described as an ESP role with an interview and locally agreed competencies which were signed off locally. There was no bench-marking of this, no central way of “judging” whether this process was robust, effective, fair, but as a profession we did not have anything else, and so in terms of Governance services were duty bound to produce their own. Some excellent work grew from (Syme et al 2013 APPN Resource Manual for Extended Musculoskeletal Physiotherapy Roles) this but it was not always shared, tested, or importantly required and so we all worked in silos with similar name badges, with minimal reference points between us other than implicit levels of practice that held a commonality through the term ESP, and through local needs which were non-transferable or recognised outside the organisation.

Consultant Practice emerged over 20 years ago, very little happened in terms of how to develop these individuals, how to bring them together in a common framework that would allow for the introduction of the title into the health system with the due reference to their skills and expertise, other than.. yep, the job title. How did I get my Consultant post? – through an interview, I believed at that time of my appointment (9 years ago) there was an enormous gap in how we justified these titles without any governance structure or capabilities underpinning them other than what would be locally agreed. I really experienced that when meeting medical colleagues who asked “so how do you get being a Consultant AHP?” I always felt I was scrabbling for a credible answer.

The Multi-professional advanced practice framework broke that process and settled the debate about what is advanced practice and certainly recognising it as a level 7 (masters level practice) and subsequently the Consultant Framework at Level 8 (Doctoral)was a significant line in the sand for Physiotherapy and AHPs to be able to consider aligning to this and getting houses in order to really drive the professions out of these silos into a much more aligned group with transferable standards.

When I initially moved into Primary Care in 2015, as a Vanguard pilot, the first observation I made was this is new and different, it’s not the exactly same as my physiotherapy practice, clearly based on it and influenced by my advanced orthopaedic roles, but importantly it felt different. I thought therefore that this had to be an opportunity to stop complaining about a lack of reference standards and do something about it. We thankfully had the MSK Core Capabilities framework to work with though and there could be no better time to build an agreed reference that would support clinicians, colleagues and services whilst assuring patients by offering a standard to work towards in FCP (Masters level) and advanced practice in primary care. 

We needed to assess in practice the capabilities and competencies of these clinicians at masters’ level against these frameworks and this led to the MSK RoadMap in Primary Care which was built around capability, but also had the remit to bring together career opportunities and portfolio experiences into a common approach.

I knew there were local models already occurring for governance reasons, so we thought why not join them up into a national model? Many services were “operationalising” the Core Capabilities Framework, @Paulawoods5 (Paula Deacon), @simon_ingram13 (Simon Ingram) were good examples of how this was happening.  The plan was to develop something that linked the frameworks already out there, multi-professional, MSK core capabilities and subsequently the advanced MSK standards into document so that clinicians when completing one capability could cross reference that across different pathways. This was felt to be one of the most important components; ensure that advanced MSK and FCP practice capabilities could be mapped and over-lapped where this happened so enabling a framework that could if wanted, cover both pathways. This would reduce work, offer depth and a pathway that clinicians could follow. Of course, FCP and MSK Physiotherapy are aligned in so many ways, and both needed to be on a pathway to advanced and consultant practice if clinicians so desired this.

Support was offered from HEE and with other groups such as the MACP, APPN, SOMM and what is known as the MSK partnership as the building of this occurred. At the same time there was a real drive on standards and governance from MSKR  and I met kindred spirits in these groups and Connect Health @ashjamesphysio (Ash James) who were supportive throughout.

Finally, a primary care standard was agreed, the Advanced MSK standards are now pending and the Consultant Framework will need to have doctoral level MSK capabilities attached to it as we move forward. 

As I reflect on this I also return on the statement “it’s a waste of time”. My view still remains that if so, what is the alternative? I have seen these standards create quite differing reactions from organisations who from what I see and experience had agendas that were not either clear to me, or were in opposition to what we were trying to do. This is where much I my naivety became rapidly apparent. Incorporating standards – my narrow view was, “of course we should all want that, I bet patients would want that, and for career profession, and ultimately patient safety, it’s a must”. Then out of this somewhat blinkered thinking of mine, the drivers/barriers to this began to rear their heads.

Contracts, money, banding, staffing. I assumed that standards come first and then you work the rest around that, however it soon became clear that I may have mis-understood the relationships that occur when agendas are challenged. 

We ran I into the debates on how FCP will de-stabilise services, that we will lose clinicians, that achieving standards will take too long and quotas won’t be reached, which I understood entirely, I didn’t necessarily agree with but I had already written about this problem back some years ago (circa 2001):

 ….but as we move to managing populations and integrating care, the de-stabilisation argument does not in my opinion come from the clinical concept of FCP, but the logistics and operationalisation of the model itself.

This is now where I see the gaps across advanced and FCP practice. There is no value in identifying the gaps and then not offering an alternative and so thinking what next is the key question. The health system we have is cut up into “pockets” but being brought back into “systems” once again that ultimately can provide care at scale across all pathways. 

I feel there is a disconnect between application of standards, professional development of practice and system readiness to accommodate the rapid growth. What I fear is that whilst the profession rapidly works into these new spaces is that firstly patients are not informed with regards what these roles are, they are the advocates the profession should be working under. Secondly the system destabilisation suggestion is not FCP but the method in which it is being allowed to be provided. Individual models that lack integration due to contractual obligations and/or models that don’t promote the integration as a central requirement ultimately are providing contracts for providers at the expense of the pathway, and not really supporting the whole MSK system as much as it could.

This is the time I believe for MSK services to link together, halt being driven into competing contracts, and bring the best of each service (FCP, Interface, Rehab) under good quality leadership, that provides exciting, blended roles. If we have this the barriers I experienced as I saw the Primary Care standards emerge will be managed by joined up, co-produced leadership across a system. If we want to stop the belief that we are de-stabilising MSK services then join them up, economy of scale, re-invest the savings of this model into staffing, recruitment, retentions, and training and build the workforce around the standards and not the other way round.

This then has to be topped off with an agreed career framework for all MSK clinicians working to the same standards, with the same opportunities, whether its sports rehab, therapy, ex instructors, Physiotherapists, if they map to the standards, then they can do the job. Invest across the system and it will offer greater economic development, invest at scale into blended roles, invest in quality and standards, and I believe this ensures it is not waste of timestandards actually are how you stabilise the systemand create a model of growth that patients will benefit from.

So, if we have standards, we now have to create the environment for them to flourish in for the benefit of patient care. It is my belief as advanced practice and FCP emerges that the leadership now is vital, and this must not be at the expense of awarded contracts that do insist on integrating and effecting a wider change rather than just seeing a case load. System management/leadership, blended roles, MSK roles across all professions, integrated population management pathways, contracts that allow for growth and not suppresses it are some ideas that have crossed my mind of late, what do others think?

What I have learnt in my naivety is that without a system change that is symbiotic to the development of standards then patient education, higher education, professional groups will struggle to meet so many differing demands and the full benefits of these changes may struggle to be realised.

Dr Neil Langridge, APPN President, MACP Vice Chair and Education Lead (FMACP, FCSP)

It’s been 24 Years………………………………….!

The last time prior to this crisis I did anything close to being useful on a ward was 24 years ago. 4 weeks ago I was back with a ward team. I wanted to reflect and share some thoughts as it might help a little with the conversations that are already happening around rehabilitation, silos of practice, the future, patient cohorts and Physiotherapy in general.
 
When I turned up to the ward I was assigned to, I have to say I was nervous, thinking ”I am so out of date!” However, good support, a drag out of the memory bank and some common sense and I made a start. Quite quickly, in the days following, the ward was 90% COVID-19 +ve and although this changes your thinking, it didn’t detract from the job in hand.
 
What I quickly began to see were that patients in these scenarios, the frail, fractured hips, complex multi-morbidity and COVID-19 symptoms, needed to be approached with the model of what some may consider basic function: sit and reach, turn in bed, sit to stand and reverse, standing safely, weight transference, walking with and without support. The clinical reasoning really underpinned building these “basic” life functions into a fatigue resistant, safe and successful model but, most importantly, in a bespoke way towards their own social and medical needs. What I quickly realised; the assumed “basics” are complex.
 
Using ADL (activity of daily living) equipment with grounded clinical reasoning behind such choices, understanding the home situation and the context of the patients’ lives were vital in working towards the “basic” goals. Although these “basic” functional tasks are static in someways, the way they are approached from a therapist perspective is complex, due to the fact that they really are so person/life/home/socially centred. The patients’ perception of themselves and their situation leading the narrative around what might be possible is a communication challenge, and one that had to be undertaken sensitively at all times.
I reflected this reasoning experience against my own practice. Firstly, it really emphasised the over complexity that MSK practice may make on a number of presentations that are seen within the general population. The close scrutiny of identifying muscular imbalances, “weakness”, inhibition, “dysfunction” have been challenged of late as not being a valid, reliable observation or even an entity. Although, I am sure there is a debate to be had here, what is not, in my mind, is the validity of a patient not being able to achieve life functions. So, I once again had a really good rebalance of getting to the root need of what might be a successful outcome for a patient before embarking on anything progressive.  Basic loss of function and the mechanisms around that achievement underpin the complexity of reasoning. Multiple causes, medical, social, emotional, biochemical, pathological in multiple domains and relationships lead to the observations we see. As we try to “analyse” this, much of it is beyond what perhaps is possible, but what we can do is look to resolve a persons clear lack of capacity in a simple but broad way using multiple methods as appropriate.

 

This requires looking outside of our normal MSK pathways of practice as well as utilising the grounded skills we learned as new graduates as part of our early rotations and wider experiences. One problem is that using a linear model of practice fails in the multi-morbidity model of population healthcare. As part of my work in First Contact Practice I cited system knowledge as a key element of requirement needed in primary care, and this was not only biological systems but health systems as well, including the knowledge of how the system offers care in the widest sense to serve our patients as effectively as possible.
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So, to my second point of reflection and the thorny subject of the Bio-Psychosocial approach and all its interpretations. My experience made me really think about the word social” in the context of MSK and also from the ward/community rehabilitation context. Many times early in my career, I tried to understand MSK patients’ social elements as sports, interests, work, hobbies etc. then as my knowledge and experience developed, I sought to understand the person perspective, values, beliefs based on their lives, interactions, culture, expectations and this proved valuable and much has been cited around these constructs. But in the context of ward to community rehab, I realised that the word “social” also links to the care sector, and this was an area I knew very little, if nothing about.
How the care sector operates and works, the pathways, the potential support available were all new processes that I had not taken into account at really any level other than a low level of understanding from working in primary care. This network is VITAL in the future planning for these patients, and although I was OK (just) on the wards it was in this area I was of little benefit.
Therefore, opening up the word Social in the BPS model for me now needs to include a knowledge base around health AND SOCIAL CARE. I wonder how many of my MSK colleagues can truthfully say they know the local social care network well enough to give good advice but also link into really widening the support systems that patients will need to attain the “basics”. So in this context attaining the Basics is Complex. If anything I am now consciously incompetent in this area which is a move forward from where I was previously.
 
We might be great in MSK at giving a range of progressive knee and shoulder exercises, but contextually, is this the rehab that meets the patient needs or are our heads slightly in the sand here in the current climate? Is exercise on its own really enough? If we are working much of our practice in a digital way, then let’s use this opportunity to offer the widest health and social support we can. I believe that the broad skills of our profession are ideally suited here as our community colleagues can provide huge value and support in determining the development of practice. Let’s really drive down the barriers and get integrated where we can, not just an MSK pathway in a linear way, but broadly across the health and social care sectors.
 
I know that there have been challenges where physiotherapists are accused of lacking exercise prescription skills within certain cohorts of patients. I would now start to argue that if this is so we can improve that very easily, but where we can really have a significant impact is around supporting the needs of the population suffering in this crisis. Perhaps, at this moment, we need to judge that the low level MSK aches and pains that we have seen in the past is just not a priority.
 
My third point therefore is around silos of practice. Not in MSK as such, but in truly integrated care for patients in these situations and in this crisis. Is it time to reconsider how MSK practice in the NHS is really utilised and what skills in the future are going to be important for the populations we serve? My MSK team have been amazing in redeploying (as many others have) across frailty, community services and ward support. The learning after this will be so rich, we must take this opportunity forwards into the future.
There is much learning to be had, but to start that, questions need to be posed. These will inevitably be tough questions around using resources wisely. So, is MSK an independent area of practice when it comes to rehab or should we be better at using our broad skills to approach MSK, frailty, pulmonary rehab, community enablement, social care referrals in one hit? Time to stop moving patients about and perhaps reconsider rehabilitation in its broadest sense possible? Where can really impact the NHS Long Term Plan? We have directors of Nursing and AHPs leading the professional line, we have Medical Directors as well. There is no better time to consider the need for Directors of Rehabilitation that have a focus in community, public health and rehabilitation across all domains?
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So, lastly what is expertise going to look like in MSK in the future as a result of what is happening right now? I don’t know, but my experience so far would suggest that we need to serve the population right now and in the immediate future. I am less confident that we need an in-depth knowledge of the rotator cuff, transversus abdominus, or best surgical approaches for traumatic knee injuries. In my opinion, we need expertise in multi-morbidity rehabilitation, with a focus on MSK, but integrated as part of “life function rehabilitation” that sits alongside an improved knowledge of the “social” element of care at its broadest and supportive context.
Defining MSK expertise differently from knowing all about the possible surgical options and high performance level/elite principles as opposed to knowing more about social care options may not look quite so jazzy and expert, but right now it’s a whole lot more useful to the folk that really need our help.
 
Can we ready ourselves for this? It can only make MSK practice more valuable to the population we serve if we do embrace this knowledge and perspective.
 
How we will understand this will be an iterative process, and it will require commissioners to think differently, STPs to work far more rapidly and the profession to see MSK Physiotherapy as integrated and not separate from our ward and community colleagues.
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It has been humbling to see the work, contributions and support our profession has so far offered, but perhaps there is even more to come.
 
Thanks to all!
Neil Langridge
Consultant MSK Physiotherapist