CHAPTER 19 Health profession regulation: the case of physiotherapy
This chapter uses the example of physiotherapy to describe the regulation of a health profession and the way health professionals contribute through the public and private health care system. The history of professions in Australia provides insight into conditions and regulations that influence current practices. The way that professions evolve in no small part depends on the regulatory frameworks that members create to monitor and maintain high quality professional standards and services. Professionals also create opportunities for career pathways and specialisation. Diligence and determination to achieve high standards are important determinants of professional status and achievement.
Physiotherapists in Australia provide essential health services. They play a key role in optimising the health and welfare of individuals and the community. Physiotherapists are particularly skilled in the prevention, diagnosis and therapeutic management of disorders of movement, and in designing strategies to optimise function and participation in society (APA 1999). A degree in physiotherapy prepares graduates for careers in metropolitan, rural and remote settings. Physiotherapists work independently or as part of a team of health professionals. They work in public and private hospitals, community health centres, sports medicine clinics, maternity hospitals, special schools, rehabilitation centres, aged care facilities, in private practice and industry, as well as in health promotion, education, management and research.
It is not clear when physiotherapy began in Australia. Massage and the benefits of exercise have been documented since the 1870s. Poliomyelitis and the aftermath of wars amplified the need for rehabilitation services provided by physiotherapists. Early indications of a desire to standardise service quality is evident in a Bill introduced in Victoria in 1922 that called for registration of massage therapists to be overseen by the Massage Registration Board. In the 1930s the name physiotherapist replaced ‘massage therapist’ and the APA took over from the Australian Massage Association as the coordinating body.
In the 1970s, with the federation of state bodies, the APA became a national body (Bentley 2006). Today the APA is the peak body representing the interests of Australian physiotherapists and their patients. It is a national organisation with state and territory branches and a vehicle for governance of specialty subgroups. The APA manages the Physiotherapy Research Foundation, a charitable trust established in 1988 to foster research in the physiotherapy profession. It is also a member organisation of the World Confederation of Physical Therapy.
An Act of Parliament dictates that only a graduate of an accredited physiotherapy course can use the title of physiotherapist. In 1992 there was nation-wide agreement that the undergraduate Bachelor of Physiotherapy program should be 4 years.
The past 30 years have seen the evolution of an increasingly qualified physiotherapy workforce. Masters degrees are commonplace. Physiotherapists with a PhD were virtually non-existent in the 1970s, while these days it is the standard qualification in universities and has a rapidly growing presence in both public and private physiotherapy services. This advancement has been driven by professional commitment to excellence (see below, under the heading ‘career pathways’). Yet the health system has not adapted to this growth.
The medical profession has established a clear hierarchy of professional advancement for medical practitioners within the health care system, while physiotherapists continue to operate within a relatively flat career framework. Although opportunities for promotion are possible, they are relatively few. On graduation, physiotherapists are primary care providers, responsible for direct and unsupervised provision of health care services. In contrast, medical graduates are supported by a salaried intern year on graduation and a hierarchy in professional advancement within the health care system, with a registrar to support new graduates and provide a pathway for learning, promotion and specialisation.
Education of entry-level practitioners continues to be challenging in physiotherapy and other allied health fields. Despite overwhelming evidence that the cost of educating medical and physiotherapy students is comparable, more funding is provided for medical than for physiotherapy students. This is partly because of the greater awareness of the services provided by doctors and partly because the Australian Medical Association is a powerful and effective interest group and advocate for the needs of doctors and medical students. The Australian Physiotherapy Association is increasingly active in its representation for physiotherapists and students of physiotherapy, and diligent in its efforts to raise awareness of the current discriminatory practices with Ministers for Health and Ministers for Education.
To be able to register to practise as a physiotherapist, a person must graduate from an accredited physiotherapy course. In Australia, all physiotherapy courses are conducted at universities. In 2007 in Australia there were 20 accredited courses at 14 universities. Six are graduate entry masters degrees, one is a doctorate, 11 are bachelor degrees and two are double degrees. All courses graduate an entry level practitioner. Course models vary and have evolved from subject-based, didactic delivery and instructional practical training to problem-based, integrated education curricula. Modern programs emphasise self-directed learning and ‘learning how to find the answer’ in alignment with a large and evolving body of information on best practice in health service.
Biomedical sciences, social sciences, small group skill development, and clinical education are features of all physiotherapy courses. Initiatives in physiotherapy education are reflected in case-based learning, inter-professional education (IPE), development in research skills and knowledge of the evidence base of practice, and simulated scenarios to promote clinical skill development. Similar to the medical profession, courses must not only be academically sound but must also meet the competency requirements of the Australian Physiotherapy Council (APC) and the expectations of future employers of graduates. The APC sets standards for physiotherapy courses (the Australian Standards for Physiotherapy, revised in 2006) and manages the accreditation process. Courses must demonstrate that graduates have the teaching and learning opportunities to develop the competencies defined in the standards.
On successful completion of at least a 4-year Bachelor of Physiotherapy degree, a graduate is eligible to register with the Physiotherapist’s Registration Board in their state or territory and gains primary contact practitioner status. This means that they can provide services directly to the community without a referral from a medical practitioner. Eligibility to register is subject to their program having completed the relevant accreditation. Each state and territory has its own registration board. The Physiotherapists Registration Board is a statutory body; that is, a government-appointed body set up to advise on matters relating to the practice of physiotherapy. The primary function of a registration board is to protect and promote public safety in relation to physiotherapy. Its functions are to register suitably qualified physiotherapists (thus entitling them to practise), investigate professional conduct and fitness to practise, and regulate the standards of practice in physiotherapy.
Physiotherapists are eligible to practise in all states and territories though registered with a board in one state or territory. Under mutual recognition, movement across borders only requires written notification to the Physiotherapy Registration Board in any state or territory where a physiotherapist might temporarily practise. Following the recommendations of the Productivity Commission inquiry into the health workforce, a National Registration Board managing nine professions is scheduled to commence operation in July 2008, and will provide practice portability across Australia for the registered professions (Productivity Commission 2005). Like all health professionals, APA members are bound by a Code of Conduct, and matters of concern can also be directed to the APA.
Apart from accreditation, the APC has a number of other roles, all of which are designed to promote a safe and competent physiotherapy workforce for the Australian community. The APC has responsibility for the process of assessing overseas qualified physiotherapists to enable registration to practise in Australia. It also provides advice to government agencies and works closely with Physiotherapist Registration Boards in Australia on legislative matters to promote a consistent national approach to physiotherapy registration and defensible national standards. The APC also reviews and updates the Australian Standards for Physiotherapy. As these standards are used to review university courses, changes to the standards have the effect of modifying the content of courses and ensuring they reflect current best practice.
Pause for reflection
Some health service providers complete courses that are accredited and must comply with minimal standards, while others are unregulated. How might these inconsistencies affect health services available to Australians? How could you find out if a particular profession is regulated by the application of standards? How could you find out how such standards are developed, applied and updated?
In each area of practice, physiotherapists utilise a range of strategies to promote and improve health. Treatment modalities include manual therapies such as joint mobilisation, individually tailored and group exercise, exercise in water (aquatic physiotherapy) and electrophysical agents such as heat, cold and electrical stimulation of muscle. Physiotherapists also work with patients to educate them about their condition and the best way to manage their health and prevent recurrences.
Physiotherapists have a highly specialised knowledge of anatomy, body mechanics and the health consequences of a broad range of conditions. Increasingly, physiotherapists are driving high quality research into effective methods for promoting health, such as the multicentre study of early rehabilitation following stroke (Bernhardt et al 2006), the combination of drugs and rehabilitation, such as the use of botulinum toxin A in management of cerebral palsy (Boyd & Hayes 2001) and best practice in exercise for common conditions such as arthritis (Bennell & Hinman 2005).
Traditional and core areas of practice are cardiorespiratory physiotherapy, musculoskeletal physiotherapy and neurological physiotherapy. Other areas of specialisation include gerontology, paediatrics, women’s health and occupational health. Animal physiotherapy, emergency care and health promotion programs for the aging population are three of several emerging areas of practice. Physiotherapists are also engaged in education of health care students in universities and in the public and private health care systems.
Formal specialisation is available through a process governed by the Australian College of Physiotherapists (ACP), the awarding body of the APA. An APA Sports Physiotherapist is described below to demonstrate a typical specialisation pathway. The first stage is to become a member of the Sports Physiotherapy Association (SPA), a national group of the APA. Registered physiotherapists seeking specialisation must first complete a Level 1 sports physiotherapy course conducted over 2 days (prerequisites current basic First Aid Certificate, current Resuscitation Certificate). After a minimum of 12 months of practice they are eligible to complete a 4-day Level 2 sports physiotherapy course. After a minimum of 12 additional months of practice and a total of 5 years of clinical experience, they are eligible to undertake a 7-day intensive Level 3 Sports physiotherapy course conducted at the Australian Institute for Sport (AIS). Candidates who then complete a Sports Physiotherapy Masters Degree (usually at least 1 year full time or 2 years part time), or equivalent alternative pathway, and successfully complete 2 sets of examinations conducted by SPA, may call themselves an ‘APA Sports Physiotherapist’. Once this level has been achieved, they are eligible to undertake additional learning in the areas of teaching, clinical practice, research and designated courses. Following completion they are eligible to sit the final clinical exams of the ACP to become a specialist sports physiotherapist.
Similarly demanding processes are in place for specialisation in other areas. The professional performance criteria or competency standards for a specialist title awarded by any of the 12 specialisation areas in physiotherapy are monitored and ratified by the ACP.
This specialisation process has been criticised for a number of reasons. Arguably the most important criticism is that an APA Sports Physiotherapist or specialist in another field is not remunerated appropriately, either financially or with recognised status, after they have completed the process of accreditation. Consumers, health care providers (including other physiotherapists) and medical referrers do not routinely distinguish between these highly qualified physiotherapists and a new graduate. Physiotherapy continues to evolve and the new specialisation framework implemented by the APA in 2007 is designed to address these needs.