Transforming physiotherapy: act now on equity

Did you know equality and equity aren’t the same? Equality offers everyone the same opportunities, while equity takes extra steps to meet people’s needs, thus reducing barriers to access and improving their chances of having the best possible experience and health outcomes. 

Often, those who need the most support face the greatest barriers to accessing and benefiting from services, perpetuating a harmful cycle. 

Let’s take a moment to consider some striking statistics about women in the UK: on average women born in the most deprived areas of Scotland live 10 years less and experience 21.5 fewer years of good health than those in the least deprived areas (Health Foundation). 

Women with learning disabilities die an average of 23 years younger than the general population (LeDeR, 2023) and the average age of death for women experiencing homelessness in the UK is 43 years old (Crisis).

While there are many social determinants of health, factors such as the conditions in which people are born, grow, live, work, and age are beyond the control of physiotherapy services. It is within our ability to identify barriers in our service and take steps to reduce them, improving equity and creating fairer, more inclusive services accessible to everyone who can benefit from our support.

Small changes can have a significant impact for individuals and groups at risk of health inequalities. Two physiotherapy services

 from the southeast coast share how they have begun identifying and tackling health inequalities to enhance health equity.

Pramod Selkar head of specialist services for East Kent, and Kate Savage, pulmonary rehabilitation senior clinical lead physiotherapist from Kent Community Health NHS Trust, share how their quality improvement projects are driving equitable access to care. 

‘Pulmonary rehabilitation significantly improves the individual’s quality of life, reduces hospital admissions and mortality,’ says Pramod. ‘Making it accessible to all is paramount.’

Identifying population needs

Parts of Kent have high levels of socio-economic deprivation, particularly in the large coastal regions; there is a higher burden for respiratory disease within coastal communities. 

‘It is important to recognise that one provision does not fit all,’ Kate explains.

‘Equity means that all patients are able to access our service, whatever their background or socio-economic status.’

As a result, the team took steps to better understand their local population and the barriers they face to accessing healthcare. 

Empowering the team to improve data collection

Data was key to understanding population needs. The service started collecting ethnicity data in November 2021, utilising their electronic patient record system and analysed it using the Power BI system. To empower the team, they received guidance from their organisation’s health equity team to build confidence around asking questions regarding ethnicity. A flashing reminder banner was also added to the electronic patient records to remind the team to enter the data.

Using data and local insight to drive action

Improved data collection combined with patient surveys and informal staff conversations with patients highlighted key issues. 

These helped to identify and prioritise action plans to reduce barriers and improve equity.

Collaborating and combining strategies to create optimal impact

The team collaborated with their organisation’s communications team, health inequalities team and the electronic patient record team, and ensured staff had protected time to undertake the project strategies by taking a quality improvement approach.

Project strategies

• Implementing an automatic text message reminder service for appointments, one week and again 24 hours prior to the scheduled appointment. 
• Service information leaflets and education materials are now available online in multiple languages including spoken language.
• Changing the location of one clinic in a low socio-economic area to improve access via public transport following patient feedback. 

Impacts

The service successfully implemented the text reminder service in August 2022 which, combined with the other strategies significantly reduced the Did Not Attend (DNA) rate for patients in the most deprived areas. 

By reducing the DNA rate, the service is now more efficient helping to improve waits and enhance pulmonary rehabilitation accessibility. This has enabled the service to use its resources more effectively by reducing wasted DNA slots. 

Recording of ethnicity data is now embedded within the normal service practice. 

Next steps

To reduce the number of patients declining pulmonary rehabilitation after waiting for an assessment, the service is developing a video to illustrate what to expect from pulmonary rehabilitation, supporting accessibility for patients who struggle with verbal or written language. This will also support patients to understand why they have been referred to pulmonary rehabilitation. 

The service continues to monitor ethnicity data, looking for trends across DNA rates and waiting times. 

Horder Healthcare’s physiotherapy team in East Sussex supports both NHS and self-funding patients. Hannah Munn, MSK clinical quality manager, and Stephanie Oakley, a highly specialist physiotherapist and the service improvement lead, share the team’s progress in improving health equity for patients.

Getting started

Annually, the team collaborates to identify priority areas for service improvement, developing these into Physiotherapy Improvement Projects (PIPs). 

Guided by the NHS Long Term Plan (2019) and inspired by Stephanie Nixon’s CSP conference speech on the coin model, the team sought to understand their population and identify areas for equitable change, considering social deprivation and wider inequalities. 

‘It was important to us that every effort was made to tackle inequalities impacting our service users,’ Hannah says.

Team insights and local knowledge

While Horder’s populations generally don’t face high deprivation levels, local insights revealed other health determinants creating inequities. Poor public transport in rural areas disadvantages non-drivers, and post-pandemic, service hours have become more limited, reducing accessibility. 

Many patients are carers, who are twice as likely to experience poor health due to lack of information, support, financial concerns, stress, and social isolation.

Data was used to assess population needs and focus projects

While the Horder team is skilled in data collection, their challenge was analysing data to provide meaningful insights and establishing a digital solution to support this. 

In September 2021, a pan-Sussex MSK collaborative (consisting of NHS Sussex, Horder Healthcare, East Sussex Healthcare Trust, Sussex Community Trust, Sussex MSK Partnership Central and University Hospitals Sussex) secured NHS Digital funding to capture 

Patient Reported Outcome Measures (PROMs) to enable system comparison. 

Cemplicity was selected to develop a platform to collect and analyse the PROMs, going live in 2022. NHS health inequalities funding was then secured and the pan-Sussex collaborative with Cemplicity developed the platform to identify health inequalities data, with collection commencing in September 2023. 

By cross-referencing the Core20 criteria with the EQ-5D-5L PROM and health confidence scores, the Cemplicity platform flagged patients at high risk of health inequalities

This collaboration with the pan-Sussex group has provided valuable insights into population needs, enabling robust health inequality project plans and targeted services. Moving forward, the pan-Sussex collaborative intends to establish funding to ensure continued data collection with the Cemplicity platform.

Actions Taken to Improve Health Equity

Patients identified as being at higher risk of experiencing health inequalities are now signposted to care coordinators and social prescribers. Adjusted referral criteria prioritise appointments for these vulnerable patients, ensuring more equitable access to care. 

The team’s quality improvement initiatives have raised awareness of health inequalities within the organisation, fostering connections with the equality, diversity and inclusion group, leading to a review of service hours and resource redesign for improved equity. 

The team has also received training from the local charity Care for the Carers, enhancing their understanding of caregivers’ lived experiences and prompting steps towards becoming a carer-friendly organisation.

Next Steps

The Horder team plans to leverage data for further quality improvement projects, including adjusting clinic hours for better appointment access, exploring local transport options for non-drivers, enhancing website accessibility through technology and further educating staff on health inequalities.