The History of the Physiotherapy

Profession (CSP 2010), which provides an insight into the development of autonomy and, subsequently, scope of practice. The Chartered Society of Physiotherapy (CSP) was founded in the UK in 1894, under the name of the Society of Trained Masseuses. It was established as a means of regulating the practice of ‘medical rubbers’. For many years, doctors governed the profession and one of the first rules of professional conduct stated ‘no massage to be undertaken except under medical direction’ (Barclay 1994). The Society used the opportunities created by developments in medicine and technology, and the demands of war to extend its manual therapy skills, and to add exercise and movement, electrophysical modalities and other physical approaches to its repertoire during the early years of the twentieth century (Barclay 1994). This scope of practice, which was legitimised by a Royal Charter in 1920, remains the hallmark of contemporary physiotherapy

practice (CSP 2008). Physiotherapy continued to evolve and consolidate its

position during the 1930s and 1940s. This was achieved through ongoing patronage of the medical profession and recognition of physiotherapy’s contribution to society’s health and well-being. The development of the Welfare State during the 1940s created opportunities for physiotherapy

to apply and develop its practice across a growing range of medical specialisms (Barclay 1994). Physiotherapy training moved into hospital-based schools during 1948, which effectively meant that newly qualified physiotherapists were prepared for practice in National Health Service (NHS) hospitals. Over time, the NHS became the primary employer of physiotherapists.

Physiotherapy’s quest for self-regulation during the 1950s was quashed by the medics who had effectively established control of its practice through sustained involvement in the CSP’s governance structures and ongoing patronage. Following intense lobbying by physiotherapy and other healthcare professions, the Council of Professions Supplementary to Medicine (CPSM) opened a physiotherapy register in 1962 which represented a shift in the power of medicine over physiotherapy. Despite the introduction of state regulation, doctors continued to assert full responsibility for patients in their charge, arguing that ‘professional and technical staff have no right

to challenge his views; only he is equipped to decide how best to get the patients fit again’ (Barclay 1994). It took more than 80 years for the physiotherapy profession to progress from the paternalism of doctors, on

whom physiotherapists were dependent for referrals. The first breakthrough came in the early 1970s, when a report by the Remedial Professions Committee, chaired by Professor Sir Ronald Tunbridge, included a statement that, while the doctor should retain responsibility for prescribing treatment, more scope in application and duration should be given to therapists. The McMillan report (DHSS 1973) went further, by recommending that therapists

should be allowed to decide the nature and duration of treatment, although doctors would remain responsible for the patient’s welfare. This recognised that doctors who referred patients would not be skilled in the detailed application of particular techniques, and that the therapist would therefore be able to operate more effectively if given greater responsibility and freedom. Eventually, in the 1970s, a ‘Health Circular, Relationship between the Medical and Remedial Professions’ was issued (DHSS 1977). This acknowledged the therapist’s competence and responsibility for deciding the nature of the treatment to be given. It recognised the ability of the physiotherapist to determine the most appropriate intervention for a patient, based on knowledge over and above that which it would be reasonable to expect a doctor to possess. It also recognised the close relationship between therapist and patient, and the importance of the therapist interpreting and adjusting treatment according to immediate patient responses, thus securing professional autonomy. This autonomy brought responsibilities and the ongoing need for physiotherapists to demonstrate competence in decision-making, building up the trust of doctors and those paying for physiotherapy services. This was reflected in the inclusion of skills of assessment and analysis as a key component of the qualifying curriculum introduced

in 1974.

Two years after gaining professional autonomy in 1977, and supported by the shifts in physiotherapy education towards polytechnics, the CSP opened the debate on all-graduate entry – an identity traditionally associated with professions (Tidswell 1991). All-graduate entry was finally achieved in 1994 following considerable debate about how degree status would benefit patients and ensure the ongoing development of physiotherapy practice

(Tidswell 2009). In 1996 delegation of activities to healthcare practitioners,

including some medical tasks, was facilitated by the document ‘Central Consultants and Specialists Committee: Towards tomorrow – The future role of the consultant’ (Marriott 1996). The content of this report, together with the political drivers to contain healthcare service costs and maximise productivity, created new opportunities for physiotherapists to develop new skillsets to undertake tasks that were previously the domain of medicine. These ‘extended’ roles were typically found in musculoskeletal medicine: physiotherapists working alongside doctors triaging patients on the waiting list or providing ongoing medical management of people with long-term conditions. Over time, these roles shifted into other medical specialisms, such as neurology, respiratory care and women’s health – evidence of the clinical- and cost-effectiveness of this model of practice. Towards the end of the 1990s, concerns about the quality of patient care, professional power and the need to contain the spiralling medico-legal costs, led to an overhaul

of the regulatory frameworks in healthcare. Clinical governance was introduced as a system of quality control in 1997. Discussions about the need to review the regulation of professional groups like physiotherapy who worked alongside medicine, led to a change in terminology in 1999, from ‘professions supplementary to medicine’ to ‘health professions’. Legal protection of the title ‘physiotherapy’ and ‘physical therapist’ followed under the Health Professions Order (DH 2002, HCPC 2001) – an outcome that the Chartered Society had been seeking for over 30 years. Alongside protection of title came a whole raft of changes designed to strengthen and modernise the regulation of healthcare professions, including physiotherapy.

The CPSM was replaced by the Health Professions Council (HPC) in 2002 and subsequently renamed the Health and Care Professions Council (HCPC) in 2012. One of the most significant changes for registrants was the introduction of a process to audit their ongoing competence to practise and requiring engagement with continuing professional development (CPD) (HCPC 2011). Once the physiotherapy profession had acquired allgraduate

entry, physiotherapy continued its pursuit of professional traits by shifting the debate from examination of skills and techniques to attempting to identify the underpinning knowledge that makes it unique (Roberts 2001).

This change is reflected in both the Physiotherapy Framework (CSP 2011c) and the Learning and Development Principles (CSP 2011b).

In 2007 the CSP Council agreed a fresh interpretation of the Royal Charter:

… the scope of practice is defined as any activity undertaken by an individual physiotherapist that

may be situated within the four pillars of physiotherapy practice where the individual is educated, trained and competent to perform that activity. Such activities should be linked to existing or emerging occupational and/or practice frameworks acknowledged by the profession, and be supported by a body of evidence… (CSP 2008)

Most recently, the CSP Council agreed to a new Code of Professional Values and Behaviour (CSP 2011a) that brings to the fore CSP member responsibilities relating to scope of practice, including the responsibility to consult with the CSP if a member is aware that a new area of

practice challenges the boundaries of recognised scope of practice. Physiotherapy has used the opportunities created by changes in society, developments in science and technology, and transformations in the design and delivery of education and healthcare, to evolve into what the profession

is today.


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