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Flexible Working This is the second in a series of articles which will consider issues and differing views around the current debate on flexible working. This article offers the Clinical Interest Groups’ perspective.

Introduction At a recent Clinical Interest Group Liaison Committee meeting the issue of physiotherapy working hours was raised. A number of examples were given of situations where the unavailability of physiotherapists outside normal working hours was resulting in other professions (particularly nurses such as nurse practitioners, clinical nurse specialists, rehabilitation nurses and midwives) taking on, or wishing to take on, physiotherapy treatments or the use of physiotherapy treatment modalities. This is not a new concern - it has been a problem in, for example, respiratory care fields for some time. However, CIG representatives are now aware of this happening more often in other areas. This poses a potential threat to the physiotherapy profession and the standard of physiotherapy treatment available to patients.

Why is this happening? What shouldlcan we do about it? Do physiotherapists realise that this is occurring and the longer-term implications for them?

If the demand for out-of-hours physiotherapy treatment is reasonable will it increasingly provide an opportunity for other professionals to offer this service?

CIG representatives are concerned that members may not be fully aware of this situation or of the consequences it may have for the profession.

Why Is It Happening? Traditionally, physiotherapists provide a full service between the hours of approximately 8 am and 5 pm, Monday to Friday, with on-call for emergencylrespiratory treatvents. Some units provide various levels of evening and weekend physiotherapy services for specific aspects of their work (eg out-patient services, community, respiratory work, and some types of rehabilitation). However, this is generally less comprehensive than that provided during normal working hours.

Some NHS units practise degrees of ‘flexible working’ to the benefit of both staff and service users (eg start between 7.30 and 9.30 am and finish betwen 3.30 and 6 pm).

Private practitioners, as self-employed ind;viduals, commonly work more flexible hours to suit patient preferences and so maintain their income. It has to be acknowledged that the type of working arrangements that exist in most physiotherapy NHS departments provides good working conditions for the physiotherapists, but may not be suitable for some patientslclients. However, it is possible that rigid conformity to this pattern could ultimately be detrimental to our profession’s standing and its long-term future.

It is probably neither essential nor effective for us to provide a full 24-hour service uniformly across all specialties, but by not being available when physiotherapy

treatments are required we are inviting other profess- ional groups to take over our role. This threat may be exacerbated by other professions looking to extend their scope of practice. This and other similar developments require due consideration but our. concern here is the pattern of physiotherapy service hours.

What Can We Do About It? We can react to these initiatives by: 0 Responding in a planned fashion. 0 Negotiating gradual change. 0 Refusing to be involved in any change.

However, physiotherapy services are largely funded by contract income. As purchasing patterns change, physiotherapy must alter its package of service provision to meet changing demands, but without jeopardising patient care. Failure to respond to new requirements1 needs will perhaps result in the loss of contract income and ultimately put physiotherapy jobs at risk.

Some units have increased the flexibility of their service hours in direct response to purchaserslusers’ demands and in a few cases staff preference. The ability to build-in flexible working will in part be determined by local factors such as staff availability.

Ways of Staffing Extended Services This will vary depending on the size of hospitallunit, the type/extent of services required, and staffing levels. Possible methods include:

0 Increased spanluse of flexitime. 0 Shift working. 0 Staggered days off. 0 Use of part-timelbankkasual staff for busy periods or work out of normal hours.

One or a combination of these may be suitable. It is important to note that the development of such working practices may create employment opportunities for some physiotherapists who have been unable to work in the traditional environment as well as improving the access to and effectiveness of the service to patients.

Areas for Concern/Debate 1. Are/will there be enough physiotherapists available to provide the extended services? Will contractual changes to accommodate flexible working be open for negotiation, eg progressive implementation?

Physiotherapy led skill-mix reviews could be used to identify which elements of treatment programmes can be delegated safely to other professionals (suitably trained)

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or to helpers. This may free valuable skilled physiotherapy time and make possible extended treatment hours within a fixed budget. Physiotherapists must always assess, diagnose, formulate the physiotherapy management programme, decide which elements can be delegated and to whom, and monitor outcome (see CSP Guideline 15 - ‘The Delegation of Tasks to Helpers and Other Support Workers’).

2. Are extended services justified? It is necessary to demonstrate that the extension of the service is justified. Public resources should not be squandered unnecessarily. Issues which can be considered are:

(a) Health gain Increased number of patients achieving a certain health status. Patients achieve an enhanced health status. Patients achieve a certain health status more quickly.

(b) Access Patients in work enabled to have treatment during their leisure time. Out-patient and domiciliary patients having more choice in appointment times. Children treated after school hours.

(c) Acceptability Enable more account to be taken of demonstrable patientkarer preferences.

The above issues can be related to local and national initiatives such as Health of the Nation, reduction in waiting lists, and changes following patient satisfaction surveys.

The CSP’s Clinical Interest Groups are the focus for concerns on these issues and have identified the following points: Association of Chartered Physiotherapists in Respiratory Care Questions the need for very acute services during working hours if they are not required for two-thirds of time out of normal hours. Also, how can we justify a specialist clinician if less experienced physiotherapists (or nursing staff) cope for the majority of the time - does this raise the issue of the consultant role of the physiotherapist?

Association of Chartered Physiotherapists in the Community Increase in acute rehabilitation in the community with the need to see relativeslfamilies of patients to teach or review handlinglexercise programmes.

Association of Chartered Physiotherapists in Women ‘s Health Evening ante-natal classes and the potential problem of midwives taking on electrophysical modalities.

Association of Chartered Physiotherapists Interested in Neurology The requirement to extend the rehabilitation programme to seven days a week for this group of patients was identified.

Association of Orthopaedic Chartered Physiotherapists May enhance patient throughput.

Association of Chartered Physiotherapists with a Special Interest in Elderly People Enhanced patient throughput with a seven-day service has been demonstrated.

3. How would physiotherapy staff feel about the lack of overtime pay at overtime rates? Opinions may vary - some staff welcome the extra income that additional working may bring; or the split shift or four days in seven working; some work for interest/ experience and some because they are contracted to do so.

4. How would physiotherapy staff feel about not working flxed hours? While this may be a drawback for some staff, greater flexibility may be welcomed by others (eg because of family commitments), and be to the advantage of the service.

5. What about the availability of expertise? This would depend on local arrangements but would have to be considered along with appropriate senior cover for junior grades and student supervision. Hence the need for therapy managers who can understand the nuances of suitable supervision and of case mix and work load.

Summary There is considerable potential for the development of physiotherapy services and the physiotherapy profession by increasing flexibility of working hours but its implementation would not be without difficulties. As with any major service provision process change, the need for careful planning and supported introduction is paramount. In fact it may well be a necessity to protect our existing role and to enhance patient care.

Physiotherapy, October 1994, voi80, no 10