Do you need a four-year degree to tell someone to stop smoking and do more exercise?

Figure taken from McNamara, K, Knight, A, Livingston, M, Kypri, K, Malo, J, Roberts, L, Stanley, S, Grimes, C, Bolam, B, Gooey, M, Daube, M, O’Reilly, S, Colagiuri, S, Peeters, A, Tolhurst, P, Batterham, P, Dunbar, JA & De Courten, M (2015), Targets and indicators for chronic disease prevention in Australia, Australian Health Policy Collaboration technical paper No. 2015-08, AHPC, Melbourne (p.32). Accessed 2 Dec 2015.

One of the biggest growth areas for physiotherapists in the coming years years will be the management of chronic illness.  The numbers of people now living with conditions that were once relatively rare is quite staggering, and they are becoming more complex.

A report released last week by the Australian Health Policy Collaboration (link) has once again highlighted the need for us to take a society-wide approach to managing the threats posed by conditions like heart disease, diabetes, cancer and respiratory illnesses, through a concerted effort to tackle the 'upstream' causes: alcohol consumption, sedentary behaviour, high salt intake, smoking, etc.

Obesity, diabetes, hypertension and poor mental health are now competing with more familiar chronic disorders like joint degeneration, pain, loss of function, falls, etc., and are exercising government minds, not least because they represent a seemingly bottomless pit of future health care spending.

Clearly something needs to be done.

Thus far, health funders have looked to the established health professionals to see if they can shift from specialist care to more primary and patient-centred approaches, but results have been patchy.  Some health professionals are struggling to relinquish positions of authority and power that were so important to them in the 20th century, others just don't know what to do.  All have been affected by the changing economy of (health)care though.

So far, you would have to admit that the response from physiotherapists has been woefully inadequate.  We have had a burst of interest in smoking cessation, and rushed to be spectators in the Elizabethan bear-bating parody that is obesity management, and now it seems our latest target is sedentary behaviour, or 'the new smoking.'

In truth, these approaches appear more like the unedifying spectacle of the January sales than a reasoned, well-theorized and conceptually robust approach to a genuine problem of real significance to the future of health care.

A lot of the focus is on relatively straightforward early interventions; things that are designed to improve people's lifestyles - smoking, exercise, diet and alcohol consumption.  But there has been much less focus on the management of people with complex and chronic health problems.  And so, physiotherapists have found themselves competing with personal trainers, green prescription providers, practice nurses and others for the right to tell people to stop smoking and do more exercise.

But here's the problem.  You don't need a four year degree to tell people to stop smoking and do more exercise.  You don't need to be a Doctor of Physical Therapy to tell people that they should walk 10,000 steps a day or that red wine is good, but only in moderation.  So if this isn't where the future of physiotherapy lies, where is it?

Clearly there is some virtue in having orthodox, respected health professionals telling people to live better lives.  Health professionals do, after all, still command a great deal of public respect.  But beyond this it seems a considerable waste of resource to have skilled diagnosticians with expertise in human movement and the management of multiple co-morbidities that affect people with chronic diseases, delivering green prescriptions to people who already know they don't do enough exercise.

Our role, surely, needs to concentrate on the elderly man struggling to cope with peripheral vascular disease, COPD, chronic back pain and depression; the woman with MS struggling to bring up three children, work full time and retain a meaningful sense of hope for the future; or the teenage boy with muscular dystrophy coming to terms with a compromised respiratory system, chronic fatigue, a changing body image, and acute anxiety about his premature death?

There are many people who can, and will, chastise others for smoking, drinking too much, and sitting in chairs for too long.  But let us not be those people.  Let us work in a way that does justice to our considerable skills and draws on our unique experience and position within the healthcare system.  There is a huge need for our services, but we need to  go beyond the obvious and taken-for-granted simplicity of current thinking in healthcare, to offer a more critically sound approach to future practice.  Only then will we be able to justify our place in the new economy of care.