Notes on the relationship between physiotherapy and the medical profession in the early days of the National Health Service
In the early days of the UK National Health Service (which came into being on 5thJuly, 1948) the influence of the medical profession in terms of the direction, prescription, education and training and supervision of physiotherapy was very powerful. Clinical, managerial and leadership autonomies embrace complex sets of relationships and the development of these autonomies together with the ongoing process of professionalisation have had a great influence on the way physiotherapy has developed and is provided today.
In 1949, the control of physiotherapy by the medical profession was clearly apparent, evidenced by the plethora of the then Ministry of Health official memoranda sent by the Minister of Health to regional Health Boards, Hospital Management Committees and Boards of Governors of teaching hospitals:
“The Minister is advised that the maximum benefit of modern physiotherapy is to be obtained under Specialist supervision in fully staffed hospital departments… physiotherapy in the NHS should be provided only under specialist prescription as part of the hospital and specialist services, responsibility should be accepted by the Regional Boards only for treatment prescribed by hospital specialists and carried out under their supervision. General practitioners (doctors), of course, can use their own equipment to administer physiotherapy treatment to patients”. (Health Ministry Circular 1949 – HMC (49)93.
It is clear from this that doctors were regarded as being capable of administering physiotherapy to patients themselves. The attitude and approach to the relationship between the medical profession and physiotherapy expressed at this time, as exemplified by this and many similar documents published at that time would be prevalent for many years to follow.
These views were reinforced in 1951 when an important and very controversial report-the “Cope Report” was published. The brief of the Cope Committee was to report on “the supply and demand, training and qualification of certain medical auxiliaries employed in the NHS, and to make recommendations”.
At the time of the Cope report, physiotherapists, along with seven other occupational groups, were known as “medical auxiliaries”. Under the overall co-ordination of Dr. Zachary Cope and two Ministry officials, 8 sub-committees, one for each of the occupational groups, met separately. There were no plenary sessions,” medical auxiliaries” from the eight occupations were kept separate from one another and were always well outnumbered by doctors and Ministry officials. The “medical auxiliary” participants were Ministry nominees and were not representatives from professional Associations, which were limited to giving evidence only”.
The Cope Report reaffirmed that physiotherapists were auxiliaries and defined the term as: “persons who assist medical practitioners (otherwise than as nurses) in the investigation and treatment of disease by virtue of some special skill acquired through a recognised course of training”. The Report emphasised the dominant role of the medical profession; “in every hospital one consultant, preferably a specialist in physical medicine, should be given the oversight of a department…to prevent unnecessary work in the physiotherapy department, treatment in all cases should be prescribed by a medical or surgical specialist (doctor) …the general direction of studies in each School should be in the hands of a medical practitioner who should, where ever possible, be a specialist in physical medicine”. (Ministry of Health, 1951).
Doctors were seen as taking the lead in the qualifying examinations for physiotherapists, it was recommended that half of the examiners should be chosen from a panel of medical practitioner examiners. The idea that the “auxiliaries” should validate their own qualifications was dismissed as “unsatisfactory”. The Report also recommended that a statutory body should be set up to undertake a review of educational standards, and to ensure that the demand for auxiliaries was matched by a well trained supply. The Statutory body envisaged would comprise a two-tier system in which “medical auxiliaries” would be in a minority on the policy making council, but would be allowed a majority on the administrative boards. Doctors would be in the majority on the Supervisory Council.
The “medical auxiliaries” (including physiotherapists) were regarded as totally subordinate to medical practitioners.
As might be expected, the publication of the Cope Report engendered much hostility from the occupational groups concerned. Although the “medical auxiliary” membership of the Cope Committee had been appointed by the Ministry of Health, nine from the total of seventeen of them signed minority reports.
In 1951 the eight occupational groups concerned held a meeting to discuss the Cope proposals and the formulation of a response. This was the first time the groups had joined together to discuss such a matter and therefore the Cope reports had the effect of uniting the professions.
The meeting agreed a critical response. While there was agreement on the need for Statutory Registration, the Cope proposals were strongly rejected.
The grounds for rejection were that:
- The proposals did not give the freedom necessary to the professions and their members if they were to give the best professional services to their patients
- The proposals would take away from the professions responsibility for much of their own government and development
- Responsibility would be transferred to a Council upon which no profession could be adequately represented and some may not be represented at all
- The professional bodies would be deprived of responsibility for the admission and training of their own students and for the standard of their qualification for membership
- The Report treated the occupational groups as a homogeneous group of professions but in reality they were heterogeneous
- The Report assumed that the needs of the NHS in respect of these professions could be met without regard to the needs of the other fields in which the professions operated.
As a result of the representations from the eight occupational groups (professions) the recommendations of the Cope Committee were abandoned despite strong pressure from the medical profession for implementation.
The Minister of Health was unable to bring a Bill to the House of Commons to legislate on the Cope Committee recommendations as there was insufficient agreement on “fundamental matters to proceed”. In view of this he recognised the credentials of the Professional Associations as qualifications for employment in the NHS as a temporary measure.
Following the abandonment of the Cope Report, the Ministry of Health re-opened discussions with the “medical auxiliaries” in 1954, and for the first time each profession was invited to nominate two delegates to discussions which would encompass the possibility of a method of State Registration.
After many years of discussion, the “Professions Supplementary to Medicine” Bill was introduced into the House of Commons in 1959 leading to the 1960 Act of Parliament which provided both for the Registration of eight professions (including physiotherapy) and a Statutory Framework that might be regarded as an indication that the professions were able to regulate themselves. “For the protection of their patients”.
At this time, the staffing structure of most physiotherapy departments was, typically, a superintendent physiotherapist, senior physiotherapist and basic grade staff. In some areas there were Group superintendents who acted as head physiotherapist for several hospitals and the whole service usually came under the direction of consultant medical staff. Physiotherapy was mostly based in general hospitals with minimal input elsewhere.
This contribution to the IPHA article touches briefly on the early position of physiotherapy within the then new National Health Service in the UK and some aspects of the politics and relationship between physiotherapy and the medical profession and the then Ministry of Health.
I would be pleased to provide references for anyone with an interest.
This contribution is the first part of a series which is intended to give a “feel” for the development of Physiotherapy on a continuum of professionalisation which lays the foundations for where we are today and possibly opens us up to some of the many questions about “where physiotherapy might be going” in the future.
