Efficiency the more complex issue of the ratio of the effect achieved to the resources used

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-In this instance, evidence that one technique, method or approach of physiotherapy is more effective than another at enhancing the rate or extent of recovery from hemiplegia, or both, would also contribute•to greater efficiency* In this respect, resources include the physiotherapists, their handling skills and the settings in which the skills are used* While techniques of handling cause the provision of physiotherapy for hemiplegia to draw relatively lightly on capital and revenue resources; inevitably, physiotherapeutic manpower resources are used very heavily. In order for physiotherapists1 skills to be used more efficiently, a standardised physiotherapeutic

assessment might also be used to determine (A) if some patients have a greater or lesser potential than others to benefit from continued treatment, and (B) if the,- type of treatment centre influences the effectiveness of treatment*

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-2,4*2 The needs of physiotherapists

In all four of Bradshaw*s areas, the needs of physiotherapists are clearly linked to changes in their role and function during

the last twenty years*

In order to practice in the National Health Service physio­

therapists, and other health care practitioners such as occupational therapists and dieticians, are required to

register under the Professions Supplementary to Medicine Act, (1960). At the time this Act came into force, unless circum­

stances were "exceptional", rules of professional conduct required physiotherapists to treat only patients who had been referred by a registered medical or dental practitioner.

Frequently, this referral included prescription of physiotherapy on the basis of the findings of the doctor’s examination and his diagnosis* Phyisotherapists made assessments and recorded their findings at the outset and throughout treatment in order to monitor patients* progress.

During the intervening years, the relationship between physiotherapists and the medical and dental professions has changed. Research in associated areas has provided physio­

therapists with knowledge to develop new techniques of treatment and related skills, and to describe contraindications to use.

In response to the effects of the new techniques, the focus of diagnosis and treatment has gradually changedo Physiotherapists have become more orientated towards symptoms and dysfunctions presented by the individual, such as limitation of range of movement of a joint; pain and muscle weakness; or hypotonia and

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-ataxia. Consequently, they have become more concerned with evaluation of their treatments of individuals against the background of the person’s life as a whole; and detailed prescription of physiotherapy on the basis of the medical diagnosis has become inappropriate.

The changes in practice require critical assessment of the

patient, in order to establish priorities in dealing with symptoms.

and critical appraisal of physiotherapeutic techniques, in order to select the most appropriate for each individual. The 1970 Report of the Review Committee of the Chartered Society of Physiotherapy recorded that the existing referral and prescrip­1 tive practices were outmoded. This report was before the

Society’s Examination Committee when it restructured the

professional examination system.. At that time, candidates for the Society’s final examination were required to simulate treat­

ment for a particular condition or diagnosis. The new Part II (final) examination reflects changes in the practice and role of physiotherapists: it examines candidates’ ability to select and apply techniques of.: assessment appropriate to an individual patient; to analyse the findings and discuss them with the examiners; and to formulate a plan of treatment, including prescription of techniques of treatment (CSP, 1977).

Government reports appearing early in the decade also stressed physiotherapists* ability to assess patients for the purposes of planning their own treatment (DHSS, 1972; 1973). The McMillan Report (DHSS, 1973) recommended review of the administrative memorandum HM (62)18, which had required physiotherapists to work 1. Hereafter, the Chartered Society of Physiotherapy will be

referred to as CSP.

under the direction of a medical practitioner, so that the nature and duration of physiotherapy would be determined by the physiotherapist treating the patient. This prescriptive role is implicit in the replacement circular, HC(77)33. Statements of Conduct of the Council for Professions Supplementary to Medicine and the CSP’s Rules of Professional Conduct were also amended to allow physiotherapists to treat patients who have not been

referred by a doctor or a dentist if they have "direct access to the patient1s doctor"•1

Physiotherapists* acquisition of a prescriptive role can be seen as a developmental stage in the process of maturation of

physiotherapy as a profession complementary, rather than supplementary, to medicine. The progress from fulfilment of medical prescription to prescription-by-self has implications for evaluation of methods and techniques of physiotherapy. The further development of physiotherapy is clearly linked to eval­

uation of physiotherapy by physiotherapists (Partridge, 1980).

This is particularly evident in those areas, such as treatment of hemiplegia, where physiotherapists have propounded methods which contain uniquely physiotherapeutic elements.

In order to fulfil the obligations which accompany their new professional rights, physiotherapists need standardised

assessments. They have expressed this need by devising check lists and other records; but many data are recorded only in an individual physiotherapist’s memory» This ad hoc approach to 1. Statement of Conduct by the Disciplinary Committee of the Physiotherapists’ Board of the Council for Professions

Supplementary to Medicine, 1973/74; and Rule 2 of the Rules of Conduct of the CSP, approved by Privy Council, May, 1978.

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-making and recording assessments carries a professional dis­

advantage : knowledge of hemiplegia acquired through physio­

therapeutic handling of many patients remains an individual and largely temporary phenomenon (Mitchelson, Holland and Mitchell, 1977). An accurate description of responses to physiotherapeutic handling, and their places in the sequence of restoration of normal patterns of movement, is needed in order to affect the general level of skills and to facilitate the learning of students and inexperienced physiotherapists.

A standardised assessment of hemiplegic patients would:

A. facilitate both the teaching of assessment to students