Within year forward view (2012) states that the demand

Within the National Health Service (NHS), the
demand for urgent and emergency care services have substantially increased over
the last decade (Eatock et al, 2017). This notion has been reinforced by Barker
(2017) who found that in 2016, 23.5 million people visited emergency
departments in England, with projections predicting an increase over the coming
years. As pressure and demand continually grows on a national level, new
healthcare policies such as the NHS five year forward view (2012) have been
released and stipulate the need and means for change (Cecil et al, 2016).Furthermore,
a comprehensive assessment of demand and pressure on urgent and emergency care services
conducted by Barker (2017),  found an increased
percentage of service users spending more than 4 hours in emergency care, with
the target of 95% of all
attendees being discharged, admitted or transferred within 4 hours not having
been achieved since July 2015 in the majority of type one emergency departments
(Barker, 2017). Despite falling short in reaching several
targets, multiple attempts have been made to try and reduce the pressure and
demand on both staff and service. Examples of this includes the introduction specialist
practioners, increasing staffing through private/locum agencies and re-designing
of the departments to allow more space and facilities for patients to be seen (Mason
et al, 2007 & Lane et al, 2016). Although these changes have had a positive
impact on several trusts around the country (Bowers et al 2009), the NHS five
year forward view (2012) states that the demand for emergency care services are ‘at full stretch’, with Jones (2011)
suggesting the need for more measures to be introduced within the NHS.

When looking at the demographic of patients seen
within emergency care settings, it becomes clear that service users over 80
years of age are most likely to be seen in on a national level (Barker, 2017).
The causes of these admissions have been strongly correlated with fall related
injuries, with 20-25 year olds being seen most of the working population
(Barker, 2017). Patients who attend emergency care services are diagnosed with
dislocation, joint injury
and fractures more than any other complaint, with soft tissue inflammation,
sprain/ligamentous injury, lacerations and respiratory condition exacerbations,
taking up the top 10 most common reasons to attend urgent and emergency
services (Barker, 2017). With the occurrence rate of these
injuries increasing since 2015 (Barker,
2017), it becomes clear
that the scope of physiotherapists practice can be applied to target these injuries
and patient populations, while simultaneously reducing the pressure on trusts
and services and aiding in the delivery of the NHS business plan (2016).

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As proposed by several studies, physiotherapy plays a crucial role in assessment,
treatment and rehabilitation (de
Gruchy et al, 2015; de Zoete et al, 2017), with Leo et al (2015) highlighting the potential to apply this skill set within an
emergency care setting.  With over a
million emergency care admissions being linked to musculoskeletal causes in
2016 (Barker, 2017), it becomes clear that physiotherapists could have a
positive impact in the assessment and treatment of these acute injuries,
alongside neural, respiratory and soft tissue related injuries (Kersten et al 2007). As a result, this assignment will aim to
undertake a critical discussion on the role of physiotherapy in assisting the reshaping
of emergency care services. The approach taken in this assignment will centre
around targeting the key demographics seen in the emergency department, as well
as the role of more senior physiotherapists in assessing and treating the most
occurring injuries. Focus will also be placed on the NHS business plan (2016) and how aspects such as patient management, physiotherapeutic
interventions and a more holistic approach may potentially aid in its delivery.

When considering the 80 years old and
above patient demographic, physiotherapists may play a significant role in
avoiding admissions, length of stay and discharging in an emergency care
scenario (Barker, 2017). Methods of managing these patients has
been explored by Sach et al (2012), who found that falls in the elderly was a
critical problem in emergency care admissions. With the objective of managing
this patient group with more efficiency, Sach et al (2012) ran a feasibility
study on 157 participants within the UK, to assess whether referral to a physiotherapy
community fall prevention service was more beneficial and cost-effective when
compared to continuous emergency care visits following a fall. The study found
that over a 12-month period, patients who utilised the community services had
5.34 fewer falls and also resulted in better overall cost-effectiveness within
this key population. Logan et al (2010) came to a similar conclusion through a randomised
control trial to test the effectiveness of a community based, physiotherapy
falls prevention team in patients who called an ambulance after having a fall.
In total, 204 participants over the age of 60 were utilised in the study which
covered four trusts within the UK. Measures of falls were conducted through
noting the rate of falls over 12 months which was derived from monthly diaries.
Secondary outcome measures included the Barthel index, activities of daily
living scale, and falls efficacy scale. The results of this study improved fall
rate and outcomes in the high-risk group of older people who call an emergency
ambulance after a fall, therefore mirroring the conclusion of Sach et al

Although these studies focus on a younger
age group compared to the >80 age group, the results may still be used to
apply a community falls programme, specifically closer to type one emergency
departments which struggle the to see patients within the four-hour target and
have a much higher demand (Barker,
2017). Contrary to this, it
may also be argued that these results are not nationally applicable, due to the
differing nature of trusts and the relatively small and culturally narrow
sample sizes used when considering the volume of patients over the age of 80 in
emergency departments. While this idea isn’t based within an emergency care
setting, it strikes a balance between appropriate multidisciplinary team (MDT)
involvement and reducing patient flow to emergency departments, thus reducing
pressure on staff and resources (Evans, 2016). While this comes close to
fulfilling the NHS business plans proposition of providing care ‘closer to
home’ (NHS business plan, 2016), an additional advantage of this form of
patient management includes a reduced rate of admissions and re-admissions within
the emergency department (Evans, 2016). Despite this concept taking a reactive
approach to falls rather than a proactive approach, it can also be suggested
that it would be very well suited to a physiotherapists scope of practice and
would be easier to incorporate over a seven-day working period (Taylor &
Shields, 2014). It may also reduce pressure on emergency ambulances, further
helping achieve aspects of the NHS business plan. Furthermore, through
community interaction, physiotherapists have more contact time with patients,
enabling them to have more opportunities to integrate education based health
promotion and behaviour change compared to being seen in an emergency
department (Sherrington, 2016), providing an opportunity for more holistic
patient management and better patient flow within emergency care departments.

When looking at the drivers of change
within the NHS, the ‘Force Field Analysis’ (Lewin, 1951) shows that changing
the approach to falls in the over 80 years of age demographic will be met with
resistance, including the financial investment in setting up new physiotherapy
falls teams closer to type one emergency departments (Burnes & Cooke, 2013).
However, the obstacle of cost effectiveness has been well studied through a
systematic review by Gillespie et al (2009), who analysed the cost benefit of a
community falls team. Their results indicated a long-term cost saving when
compared to patients being seen in an emergency department setting for fall
related injuries such as pelvic fractures. This was also agreed upon by both
Sach et al (2012) and Logan et al (2010) who suggested the benefit of cost over
a long-term period. The attitude and thoughts of physiotherapy staff may also
be a barrier to change as they may not want to adopt the idea of seven day
working within the community, as it places them under more stress and pressure
compared to working within an emergency setting where seven-day working is more
established (Taylor & Shields, 2014).

Contrary to this, Davison et al (2005)
proposes a multifactorial intervention approach which involves the use of
physiotherapists in a triage and assessment capacity, as well as advisors on
health and behaviour change within the emergency care setting. Compared to a
community based intervention, this approach allows direct treatment of an
elderly patient who has suffered from a fall and enables physiotherapy based
intervention to speed up the assessment and discharge process, as well as
having the potential to meet the criteria of patient satisfaction in the five
year forward view (2012).   This approach has been investigated within
research, which highlights the skill set of physiotherapists and how they may
be implemented within an emergency care setting to help assess, manage and prevent
common musculoskeletal injuries related to falls (Anaf & Sheppard, 2007
& Fong et al, 2008). While physiotherapists currently have various roles
within emergency care (Hoskins, 2011), the ability to have more contact with
the most commonly admitted demographic would have the potential to positively
impact patient flow and reduce pressure on the multi-disciplinary team (Guengerich,
2013). An additional advantage of this approach includes, the established use
of physiotherapists in emergency care in an assessment and management capacity,
while being able to liaise with doctors, nurses and allied health professionals
in order to achieve optimal patient care and satisfaction (Sheppard, 2010).  

This was investigated in a randomised
control trial by Davison et al (2005) who similar to Sach et al (2012), utilised
146 female and male participants over the age of 65. The intervention group
were exposed to a medical
and falls history and full clinical examination were performed within an emergency
care setting. Following this assessment, appropriate management methods were
then implemented to the patients in the form of footwear, orthotics and assistive
mobility equipment. Although this assessment takes place in an emergency setting,
its results show that multifactorial
intervention is effective at reducing the fall burden in cognitively intact
patients over 65 attending emergency care, but does not lessen the proportion
of subjects still falling. Similarly, a randomised control trial conducted by
Russel et al (2010) aimed to assess a multifactorial intervention program, which
would aid in preventing re-admission due to falls in the elderly after their
initial admission to an emergency department in Australia. Intervention
included the use of an assessment, behaviour change advice and onward referral
to an occupation health team. However, results suggest that multifactorial
intervention by a physiotherapist made no difference in the outcomes of falls
and re-admission (Russel et al, 2010). This conclusion was also shared in a
randomised control trial carried out by de Vries et al (2010), who found that multifactorial
intervention within an emergency care environment made minimal difference in
the falling occurrence in elderly patients.  

When analysing the methodology behind
these studies, it may be argued that research conducted outside of the UK lacks
applicability to the NHS structure and healthcare policies, despite the
similarities in elderly fall based patient admissions in emergency care. Although
the elderly population increasing on a national level (Shaw et al, 2010), the
need for additional contemporary research is required regarding a multifactorial
approach to falls within emergency care settings. However, Chisholme et al (2012)
suggests that seeing a patient in an emergency care setting may be the best
time for a patient to accept and understand behaviour change advice, with the
patient more likely to understand the contemplation, preparation and actions
phases of change, as proposed by the trans-theoretical model (Prochaska et al,
1992).  With minimal mention of
cost-effectiveness in these studies, it may be stated that having a community
based physiotherapy falls team may be more beneficial and cost effective than
an emergency care department based physiotherapy falls team, with less strain
being placed on emergency care resources and staff. Having a community team
also avoids admission, waiting times and a reduction in a key patient
population not attending A, while better fulfilling the NHS business plan
(2016) and five year forward view (2012) ideas.

While the most commonly seen patient
demographic in emergency care has been critically discussed, the need to assess
the additional roles of a physiotherapist in emergency care is paramount. With
the number of doctors and nurses in decline within the NHS (Lacobucci, 2016)
and the field of physiotherapy constantly advancing, the need to explore the implementation
of physiotherapists with more expansive skill sets is crucial (Ruston, 2008). Extended
scope practioners (ESP’s) have begun to work more within hospital settings and
have progressed their ability to assess, treat and manage several complex conditions
(Thompson et al, 2017). With their role becoming more familiar, it may be
argued that they may also play a significant role in emergency care across
trusts (Thompson et al, 2017). This
idea is further reinforced by Barker (2017) who suggests that over three
million musculoskeletal injuries were seen nationally, with ESP
physiotherapists having the potential to aid in their assessment and treatment
through requesting x-rays, prescribing, making referrals to specialists and
performing/assisting in some minor injection and surgical procedures (Ruston,

In an effort to understand the
applicability of this idea, Taylor et al (2011) conducted a study across three
emergency departments in the UK, which investigated if direct physiotherapy
assessment and management of patients with musculoskeletal injuries reduced
length of stay without any increase in adverse effects. This involved the
inclusion of 306 adults presenting to emergency departments with peripheral
musculoskeletal injuries who were allocated to primary or secondary contact
physiotherapy. Although only one session of physiotherapy intervention was
used, outcome measures involved patient
length of stay, waiting time and treatment time. Secondary outcome measures
were imaging referrals, patient satisfaction and emergency department staff
acceptance. The results of this study showed that primary contact with physiotherapy
resulted in a reduced length of stay by 59.5 minutes and a reduced
treatment time of 34.9 minutes. More than 82% of patients strongly agreed
that they were satisfied with physiotherapy management, with 96% of emergency
department staff agreeing that primary contact physiotherapists had appropriate
skills and knowledge to provide urgent and emergency care (Taylor et al, 2011),
which also mirrors the conclusions deduced by Lau et al (2008) and Gill &
Stella (2013). To further support this proposal, a systematic review by
McClellan et al (2010) concluded that ESPs can provide a high standard of care
at an affordable cost, whilst positively influencing patient satisfaction and
having the ability to positive impact staffing shortages in emergency care.
This conclusion was also shared in studies by Stanhope (2012) and Sheppard et
al (2010), who stated that ESP physiotherapists showed positive outcomes in diagnostic
ability, waiting times and improved health outcomes, further strengthening the
need for ESP’s when managing musculoskeletal injuries within urgent and
emergency care.

When critically analysing the research
behind these results, it may be argued that Taylor et al (2011) focuses on reduced
patient contact time, small population samples and may not consider the
barriers to change from the perspective of the physiotherapist (Rosenberg &
Mosca, 2011), alongside the applicability of ESP’s in all trusts on a national
level (Kennedy et al, 2010). Despite having the ability to work closely with
several interdisciplinary teams to provide patient care, the type of care
delivered may deviate from a traditional holistic and biopsychosocial approach as
patients may be seen for their specific injury rather than aiming to understand
causes, behaviour change and prevention methods.  However, Keogh et al (2015) suggests that
physiotherapists can still have an impact in behaviour change within this
setting as ESP’s are able to offer behaviour change advice, which allows
potential progression from a pre-contemplation phase to an action phase of
change as stipulated by the established trans-theoretical model (Prochaska et
al, 1992).  When referring to relevant
healthcare policies, it may be proposed that the increased use of ESP’s over seven
day working largely benefits patient outcomes, while also lying in unison with
the aims of the five year forward view (2012) which aims to ensure that patients have access to seven day
services. In addition, ESP introduction has widely been cited as a
cost-effective method of delivering in emergency care and meets aims set by
both the NHS business plan (2016) and the five year forward view (2012), while
reducing the need for agency and locum staff.

When coming to a conclusion on how
physiotherapy can help reshape the urgent and emergency care service, it
becomes clear that there are multiple approaches which may be taken to aid in
the delivery of the NHS business plan and other healthcare policy. This
assignment has discussed how physiotherapy can be used as a means of community
based intervention and hospital based intervention for the most commonly seen
demographic in emergency care, as well as how more specialist physiotherapists
can tackle the most commonly encountered injuries within an emergency
department. Despite there being several obstacles to change, community based
intervention instead of continuous emergency care admission has shown to be
more cost effective and more efficient when managing patients over the age of
80 for falls, while also keeping in line with the delivery of the NHS business
plan and providing an excellent chance for behaviour change and health
promotion closer to home. To add to this, the inclusion of specialist ESP
physiotherapists can greatly reduce the demand on doctors and allows patients
within an emergency care department to be seen faster and more frequently,
allowing government initiatives to be met and delivery of more consistent care
throughout emergency departments in the country. Although more research may be
needed to further solidify these ideas, it may be said that culminating these
ideas may be advantageous when aiming to deliver the NHS business plan (2016)
and improve patient satisfaction in urgent and emergency care.