FEATURE
PHYSIOTHERAPY AND COMMUNITY MEDICINE
Ian W Webster
School of Community Medicine — University
Community based health care should be oriented to local needs, preventive medicine and should be accessible
to all. The bias in health care provision at large central institutions produces an uneven delivery of service
dependent upon the nature of the disease.
NEW DIRECTIONS IN HEALTH CARE
Australia's interest in community-based health
services is not new or unique. Similar concepts and
words are being used to fashion the health services
in rural India as they are in the United Kingdom.
The descriptions of the health team in India could
fit the community health teams of Sydney. Socialist
and capitalist countries place value on community
care, on preventive services, on rehabilitation and
after-care,
For example, in the UK a Government White
Paper on public expenditure stated in 1971:
"It is envisaged that these proportions [of
expenditure] will gradually change in favour of
community health and welfare services as the
policy develops of providing care in the
community where this is more appropriate than
hospital care."
And in India
"The goals are now to provide comprehensive
care to the people as a whole with promotive,
preventive, and rehabilitative services. . . . it has
become necessary to shift our objectives from
providing islands of excellence for a few to the
optimal for a l l . . . "
Yet despite the policy statement of Federal
Health Ministers and State Ministers for Health, a
conviction expressed by professional leaders and
health departments; and support of the mass media
of the need for a change in direction towards
community health care — Australian initiatives
are being thwarted. We are at a stage when the
policy for community health services has to be
consolidated and developed more logically and
coherently and presented with greater force.
In these community developments there are
obstacles to be found in the separate and virtually
Ian W Webster graduated from Melbourne
University in I960 and is currently Professor
of Community Medicine at the University of
New South Wales. His current interests are
chronic disability, handicap, ageing, health
screening and, alcohol and drug dependence.
Aust. J. Physiother. 26:2, April, 1980
ofNSW
autonomous administration of hospitals, weak
local decision-making processes, and reactive
responses of hospital administrations and staff to
the potential benefits of community health services.
It is necessary to re-state some of the reasons
why community health services are necessary and
timely in Australia. There are implications for
physiotherapists as they face a future in which
resources will be limited and graduates will be in
good supply. There are no absolute measures; so
practice within and outside institutions — the
world of sick horizontal patients and the world of
well ambulant persons — will be compared.
It is not my intention to denigrate the services to
the sick in institutions, as much of this is provided
by well-meaning and kindly people but all is not
well with our health policies and hospital and
medical services need critical appraisal. Within the
constraints of existing health policy, treatment
services are as effective as they can be. There is a
strong desire to provide efficient and humane
treatment of acute illness. The challenge to relieve
suffering has brought forth a powerful response
—more hospital beds, more doctors, more hospital
personnel, better and newer equipment. Treatment
failures cannot be blamed on a lack of effort, of
interest .or of will. But the increased effort has
diminishing returns and failure lies in the
intractability of advanced disease states.
To look into the past from established disease to
its onset, and to future long term consequences
—no comparable effort by the health professions
can be observed, in prevention or supportive
health care, as is given to curative services.
Our failures in these fields can be ascribed to a lack
of effort and motivation in comparison with the
intense response to episodic illness — particularly
catastrophic illness. New directions for health care
demand a redirection of a substantial proportion
of the effort of treatment services to prevention
and supportive health care.
I have three biases in this discussion — one is to
the philosophy of outreach of health services — the
second is to fairness of access to health services and
associated resources — and the third, is a distrust
of the objectives of large organisations and the
45
 PHYSIOTHERAPY AND COMMUNITY
people who dispense power from them. T o be
honest a b o u t what is currently taking place will be
tinged with some sadness a n d disappointment at
opportunities lost. But we can be p r o u d of many
successful community health initiatives during the
past five years: for example, new training courses
for h e a l t h professionals, c o m m u n i t y geriatric
services, c o m m u n i t y health t e a m s , Aboriginal
health programmes, health screening programmes,
diabetic treatment-education programmes and
s o m e imaginative attempts at health education.
SERVICES FOR WHOM?
Hospital meetings centre on case discussions, so
let us start an examination of community health by
describing two examples of the effect of the same
disease process.
If your mother, or wife, or relative was to suffer a
stroke her treatment should depend on the degree
of brain damage and medical condition. More t h a n
likely, the treatment received will be determined by
factors unrelated to this. Does the regional hospital
r e a d i l y a c c e p t p a t i e n t s with this c o n d i t i o n ?
W h a t relationship does the local doctor have to the
regional hospital or t o local community health
services? Does the doctor have access to nursing
h o m e beds? Is there a hospital related to the local
c o m m u n i t y ? Are there nursing home beds in the
area?
Beds for the care of these patients are not
distributed equitably either through hospitals or
nursing homes. Major hospitals generally attach a
low p r i o r i t y to such p a t i e n t s a n d general
practitioners have great difficulty arranging for
their admission. All t o o frequently they receive
inadequate medical attention and rehabilitation
and are directly admitted to a nursing home.
H o w can this arise when this particular event is a
c o m m o n cause of death in women over 50 years of
age? There are variations in the geographical
incidence of stroke in Sydney and the health
service arrangements are not distributed accord-
ingly. T h e person with a stroke is not a valued
patient in the health care system.
However, should a h u s b a n d , a father, or male
relative suffer chest pain due to the same vascular
d i s e a s e b u t this t i m e affecting t h e h e a r t , a
completely different response is likely. The hospital
will eagerly accept the patient. He will be brought
to hospital in a coronary care ambulance and be
admitted to a well-equipped and well-staffed part
of t h e h o s p i t a l — t h e c o r o n a r y c a r e u n i t .
The doctors, general practitioners and hospital
specialists, clearly know what is to be done and
enjoy doing it. Every aspect of care, including
a p p r o p r i a t e discharge from hospital, will be dealt
with adequately and thoughtfully and a high level
of expenditure will be incurred.
46
MEDICINE
Coronary heart disease is the major cause of
death in persons over 50 years of age, affecting
males particularly and on average occurs approx-
imately 7—8 years earlier than stroke.
Here we have two a c u t e manifestations of
degenerative, vascular disease due to the modern
' w e s t e r n ' way of life. T h e manifestations are
different — in one case, stroke, the residual
i m p a i r m e n t is m o r e d i s a b l i n g of mental and
physical function — in the other, coronary heart
disease, medical interventions are more available
and better understood. The burden of care in one
c a s e falls o n r e h a b i l i t a t i o n p e r s o n n e l and
community based services and in the other on
intensive hospital treatment.
Diseases are accorded s t a t i c , and the health
personnel who claim expertise in these diseases are
awarded parallel status in t h e health care system.
S t r o k e a n d c o r o n a r y h e a r t disease are two
examples which illustrate the differentials which
c a u s e p a t i e n t s with c e r t a i n c o n d i t i o n s to be
considered " w o r t h y " or " u n w o r t h y " of treatment.
Patients who are old or who have unattractive
diseases — particularly if social determinants are
contributory — tend to be excluded from the
technological dynamic of the d o m i n a n t health care
institutions. This selectivity represents an unfair
allocation of resources, suggesting that the effort
of treatment for many conditions could be better
shared. A more a p p r o p r i a t e allocation could be
achieved through health services developed and
monitored on the basis of community determined
needs and priorities — the touchstone philosophy
for community health.
But what is more reflective of the need for. a new
philosophy of health care is the attitude of the
providers of services. There has been, and still is, a
noble belief in service to humanity as the ethical
basis for helping the sick; an ethic which overrides
all other attributes which separate individuals into
groups — age, religion, financial state and political
viewpoint. Regrettably, ethical standards of this
kind are often thwarted by the organisations
established to enact our health care policies.
One attitude is a deep-rooted rejection of certain
health problems as non-medical and less deserving
of assistance. This attitude runs as an undercurrent
t h r o u g h h e a l t h c a r e i n s t i t u t i o n s a n d can be
discerned from the way in which patients with
difficult problems, or who have problems not
amenable to direct intervention, are categorised
and described.
Community health services are re-defining
worthiness to include persons and diseases
previously unacceptable, except on the providers'
terms, to the health care system.
AUSL J. Physiother. 26:2, April, 1980
 WEBSTER
Definition of needs
Social policy for health care should be based on
community health needs. The response to an
individual's health needs are appropriately the
r e s p o n s i b i l i t y of trained professionals in
conjunction with the perceptions and wishes of
the individual.
Social policy for health requires a concept of
needs and an agreed process for assessment and
decision. As there is no absolute measure of health,
various proxies are used to compare group health
status. Thus health need becomes an indirect
comparative measure of disease incidence and
prevalence, subjective perceptions, health related
behaviours and biological variation. Much current
research is being directed to composite measures of
health status to provide better estimates of health
need. The motivation behind this research is the
belief that health services should be organised
according to health needs as indicated by these
measures.
Access to health care should not discriminate
between communities or individuals with
equivalent health needs. The social response to
community health need is multi-valued. What
responsibility should local communities have in
determining their own needs and in regulating
demands for services? Theoretically, through
access to health information, appreciated and
evaluated through representative participation,
local communities should hold the key to their own
health. Few local communities have exercised
power in this way. There are difficulties created
by the emotional investment in health care issues,
the lack of comprehensible health intelligence
information due to the technical nature of the data,
and a proper desire for objective decision-making
by administrators.
Community values are malefactors in disordered
health. The social, environmental and behavioural
factors can only be appreciated if these phenomena
and their effects are systematically recorded.
Leadership by health professionals is important in
recognising and monitoring community health
problems. This was successful in the control of
infectious diseases and is just as relevant to today's
health problems.
Community health services have a clear
obligation to base decisions for maintaining
existing programmes and for initiating new services
on objective health intelligence information and on
consultation with an informed community
Community differences
Most nations have social policies which recognise
community health as a national asset and that poor
health of population groups calls for special
government programmes. In Australia this
Ausu J. Physiother. 26:2, April, 1980
extends, for example, to Aborigines, recent
immigrants and refugees, the aged and war veterans
(as communities defined by personal attributes), to
rural areas, and to areas of cities.
Health services should be flexible enough to
respond to the diverse health problems of
communities and planning is an idea of good
currency. With the health intelligence information
collected by a burgeoning body of health service
researchers the response to community health
problems should be rational and appropriate.
Will this follow — given the distribution of power
within the h e a l t h system, the overriding
influence of health insurance policies and prevailing
conceptions of health care based on a dependent
population?
The first step for organised health services is to
realise that the health impairments to which they
are responding are distributed unevenly. Maps of
Sydney which contour biological impairment,
subjective health, disease and death rates, and
social indices describe 'countries within a country'
of disordered health and disability. The East is
better off than the West as the North is from the
South Superimposed is the maelstrom of the inner
city. There are communities of high risk and low
risk.
There is little evidence that private health care
can meet all the needs created by community
health differences, as the preventive and rehabili-
tative philosophies which are necessary are
incompatible with current health insurance
reimbursements.
The opportunity for Government to respond to
health-social gradients within our community
arose with the establishment of the Community
Health Programme and regionalisation of the
administration of health services.
HOSPITALS AND
HEALTH CARE INSTITUTIONS
Hospitals have been transformed into insti-
tutions where major intensive medical treatment
takes place. More and more they are places where
operative surgery is the dominant activity and
they provide medical treatment programmes with
great efficiency > Once they were places where the
destitute poor were cared for, wealthier people
cared for their sick at home. But now access is
available to all social classes for medical treatment.
Hospital programmes have certain attributes
which militate against a health promotion function:
all patients are brought to a controlled and
managed environment and put to bed; the medical
task is sub-divided and highly specialised; patients
are treated as very sick and are expected to be
dependent and compliant; there is a high utilisation
of costly personnel and technology. Further,
47
 PHYSIOTHERAPY AND COMMUNITY MEDICINE
organisational arrangements separate vertical
functions, nursing and body care, administrative,
medical-technical and housekeeping, from
horizontal responsibilities to patient and pro-
fessional colleagues. While these attributes have
benefited the organisational response to acute
episodic illness, there is a rigidity in the system and
a stereotyping of the treatment response which
makes institutional practice incompatible with
goals for community health.
The difficulties may be symbolised by the sheer
structural size and complexity of the modern
hospital. Sick patients are brought to it and the
hospital staff provide their services to the individual
who will later return to the world of the well.
Unless there is a reduction in size, with a consequent
reduction in technical complexity, the modern
hospital cannot have a health promoting function
or respond to the real medical needs of
communities. Within large organisations resources
will continue to he allocated to competitive and
prestigious units led by competent and ambitious
men of medicine.
DEPENDENCY
Very sick patients require decisions and actions
to be taken by experts, or by someone else. The
world of sickness becomes narrowed to the most
basic needs of comfort and sustenance for the
patient and it is not until sickness lifts that there is
interest in the wider world. The sick person is
concerned with recovery from a particular episode
of illness and this, too, is the goal of the carers.
Where there are many sick people to be cared for
— in hospital — the management objectives for
health care are based on sick and compliant
patients confined to bed. But the objectives of
maintenance and restoration of health are based
on the expectation of citizens to lead independent
and responsible lives.
The management objectives of community health
services — preventive — therapeutic — rehabili-
tative — are primarily based on goals of
independent and responsible living. The subject
population is generally ambulant and non-
institutional. Environmental modification, includ-
ing the work-place and school, are open as
strategies to community based services.
PROFESSIONALISM
There is a view that to be professional is to be
elitist, separate and authoritarian. To be pro-
fessional should mean: competence, performance
to a high standard and a controlling ethic.
The nascent community health services have had
difficulty developing standards for performance
and competence — they simply have not existed
for long enough and inconsistent government
48
policies have produced instability and insecurity
The community health personnel belong to weak
professions, except for nurses (and to a lesser
extent physiotherapists) and they have not
established, or do not appear to have established,
codes of practice which are well understood by
other professions and the public.
There is a belief among health personnel that to
communicate with individuals with certain
problems such as psychiatric disturbances, alcohol
and drug addictions, or with groups such as
migrants, the style of approach has to be less
formal and less respectful of traditional pro*
fessional relationships. But is this a correct
perception of community expectations?
Many patients expect a respectful relationship
based on courtesy and this entails a degree of
formality. Medical practitioners and voluntary
agencies expect this of any organisation or
individual to whom they refer patients and of any
subsequent relationship they may have with
community health staff.
Community health services need to develop a
professional approach and stance to specific health
problems such as alcohol and drug abuse,
prevention and geriatric care, and to specific
population groups.
A professional approach should include : goud
record keeping; good written and verbal communi-
cation with other agencies, individuals and
professionals; a style which is comfortable to all
who seek help (this may mean that individuals will
have to be more flexible and more value-free in
their relationships with clients, or programmes
with clearly defined target populations should
have styles appropriate to the target group); and
there should be good overall clinical supervision
and graded responsibilities for new staff.
The service unit should develop defined and agreed
processes for analysing workload and effectiveness.
COMMUNITY HEALTH RESPONSIBILITIES
AND PHILOSOPHY
The responsibility for providing health services
is given to professional personnel by the
community. For this responsibility certain
privileges and rights are extended which carry
special obligations, for example, to record activities
and data over and beyond personal work
requirements to include data about health status
and outcomes of treatment. The professional is
accountable both to the sick person and to society
for the work that is done and for continuing
evaluation of its worth.
Outreach is a central tenet of community health
services as it is no longer satisfactory to rely on
patient initiated transactions over sickness to
maintain community health, or to keep an
Aust. J. Physiother. 26:2, April 1980
 WEBSTER

individual well, or to maintain a disabled person in
his or her environment.
A further tenent, as already observed, is that
services should be responsive to need and,
comparative methods are necessary to demonstrate
inequalities between component sub-systems,
structures and groups of society.
PREVENTION
The brief which supersedes all others in
community-based health services is prevention.
Existing services remain uncommitted to this
philosophy. Pragmatic decisions have to be taken
in prevention, just as they have been for therapeutic
services. The 'here and now' action plan for
prevention involves : education about specific
health problems and behaviours; case detection
activities; early diagnosis; and surveillance of
individuals and communities.
Problems need to be picked off one at a time (or
in groups) and prevention 'packages' produced
which the lay public can identify, appreciate and be
involved in.
Initiatives in prevention and health promotion
lie especially in the sphere of responsibility of the
community health services.
DISABILITY
The long-term disabling illnesses and injuries are
common. Persons with these conditions trouble
the health service providers because their dis-
abilities are rarely amenable to change by
treatment of the underlying diseases. The manage-
ment goals for disability are directed at optimal
activity or function within bounds set by structural^
physiological or mental impairment. Rehabilita-
tion and maintenance depend on environmental
intervention, development of new capacities and
skills by the disabled person, and the provision of
aids.
Managing patients with disability requires an
acceptance of a level of disorder which can be
modified marginally, if at all. The process is time-
consummg and involves a comprehensive range of
skills not usually part of the doctor's armament-
arium. A sense of achievement with marginal
improvement is a necessary prerequisite for people

TABLE 1
DISTINGUISHING CHARACTERISTICS* OF COMMUNITY
PRACTICE COMPARED WITH HOSPITAL PRACTICE
Differences in the professional/doctor-client/patient relationship

Community practice Hospital practice

1. The patient/subject Ambulant, not as sick In bed, sick
All ages, but very young and old Determined by disease and
2. Age groups over-represented hospital policy
Both sexes, preponderance of May be determined by policy
3. Sex females
Independent to dependent Dependent to helpless
4. Dependency status
Doctor's rooms, health centre, Hospital ward
5. Environment
patient's home, nursing home or
private hospital
6. Family and social network Frequently consultation involves Family not involved as much
family and friends
7. Data base Social information an important Technical information forms a
component substantial part
8. Time of consultation ' Initiated by patient/ client Initiated usually by doctor or
hospital
9. Time base of observation Frequently part of a continuing Usually part of an acute illness
relationship and therefore ex- episode and therefore brief in the
tended in context of a lifetime context of a lifetime

* Tables 1, 2 and 3 emphasise the differences, accepting that there are common grounds for clinical and
professional health practice whether this is institutional or non-institutional.

AusL J. Physiother. 26:2, April, 1980 49

 PHYSIOTHERAPY AND COMMUNITY MEDICINE

who work in this field. The time spent on urgent
problem-solving in the busy general hospital is
inimical to good management of disabled persons.
Community health services have a special
responsibility in the sphere of management of
disability and handicap.
The style of approach and the methodology
differs between community-based and institutional
services as regards the professional relations hit)
(table 1), the way problems are identified arid
analysed (table 2) and the management goals (table
3), These tables portray the differences "m
comparing hospital and community practice.

TABLE 2

DISTINGUISHING CHARACTERISTICS* OF COMMUNITY

PRACTICE COMPARED WITH HOSPITAL PRACTICE

Problem Identification and Analysis

Community practice Hospital practice

1. Types of problems Determined by target or practice
population. Undifferentiated
presentation
2. Use of time Usually brief consultation involv-
ing one clinician, usually a
general practitioner. In a com-
munity health team referral to
other team members often takes
place. Effective use of time is
critical in primary medical care
Frequently a contact in the
context of a continuing relation-
ship
.3. D a t a base for problem History and examination is
solving problem orientated and focal
4. Techniques of analysis Problem solving is based on early
levels of the'decision-tree*. A less
definite level of disease diagnosis
is necessary
5. Complexity Less control over extraneous
variables; unravelling physical,
psychological and social factors
is a major task
6. Epidemiology Important background for
problem identification
Determined by the specialty and
hospital policy. Differentiated
presentation
Lengthy consultations, frequen-
tly involving a number of
clinicians
Usually a major episode which
occasionally leads to a continuing
relationship
History and examinationincludes
a larger routine data base e.g,
screening tests and observations
Analysis is directed towards
definitive diagnosis
More control over extraneous
variables
Because of selection and referral,
epidemiology is of less value in
defining probabilities for diag-

7. Solutions Integrative and comprehensive Reductive and specific

* See footnote to Table I.

50 ^ Amu J. Phvsiother. 26:2, April, 1980

 WEBSTER

TABLE 3
DISTINGUISHING CHARACTERISTICS OF COMMUNITY
PRACTICE COMPARED WITH HOSPITAL PRACTICE

Problem Management

Community practice Hospital practice

1. Goal Health maintenance as well as Treatment of the sick
therapeutic
2. Programmes Need for co-operative goals. More intensive and specific.
Goals need to be integrated with Clinician less directly involved in
social and environmental circum- social and environmental
stances aspects.

3. Team Shared responsibility will occur Clinician, although working in a

more often in the future team, is regarded as being in
charge

4. Referral Referral is an important decision Patients are already referred.

in patient care, Referral should Cross-referral is common
be carefully considered and
sparingly used

5. Economy Cost saving is an important High cost area. Cost control is

function as the GP acts as a point difficult because of high usage of
of access to the health system, technology and personnel
and community health centres
have low-cost technology

6. Prevention Specific responsibility of general Minimal preventive function as

practitioners and community presently organised
health personnel — early
detection, prophylaxis, health
education, well person examin-
ation

7. Rehabilitation All health professionals are Frequently rehabilitation special-

members of the Community ist and other rehabilitation
rehabilitation* team. Long term personnel become involved
support needed

8. Environment Home or community Institutional

Few technical aids and personnel Ready availability of technical

aids and personnel

9. Pharmaceutical prescribing Relatively unsupervised and Supervised by hospital staff.

compliance is a problem Compliance less of a problem
for in-patients

Prescriptions are written and D r u g p r e s c r i b i n g is highly

dispensed by private pharmacists, systematised
although other arrangements
may exist for health centres
and clinics
* See footnote to Table 1.

Aust. J. Physiother. 26:2, April, 1980 51

 PHYSIOTHERAPY AND COMMUNITY MEDICINE
RE^EXAMINATION OF THE
PROFESSIONAL ROLE
It is important at times to re-examine the
purpose of a profession. Physiotherapy is going
through a period of soul-searching in company
with most of the other health professions. So long
as this is a realistic process based on societal needs
and not a grab for more power and resources in the
health sector, then the community will be well
served.
The health field has experienced rapid changes
due to scientific and technical developments — but
professional practice has been relatively stable for
decades. Despite the upheavals about how services
should be paid for, the way doctors consult with
each other and with other disciplines, and the way
patients gain access to health services, practice has
maintained a comfortable and stable pattern for
the professions involved,
Certainly, there have been some changes; such as
the recent decision by physiotherapists to be
practitioners of first contact, and the development
of publicly financed community-based personal
health services over the past five years. The latter is
important because it offers the potential of re-
directing health care resources to appropriate
programmes for contemporary problems.
The discipline of physiotherapy
While most of those who work in the health
system have a pretty good idea of what physio-
therapists do, there is still room for a better
understanding, the people outside the system
would have difficulty describing the physio-
therapist's task. I looked in two directions for
guidance'— the New South Wales Physio-
therapists' Registration Amendment Act 1972 —
and the aims for the Bachelor of Applied Science
(Physiotherapy) Cumberland College of Health
Sciences.
The New South Wales Act states
"Physiotherapy" means the use by external
application to the human body of massage,
being manipulation of soft tissues of the human
body, passive movements, remedial exercises,
muscle re-education, electricity, heat, light,
sound, water, ultrasonic therapy apparatus, or
any proclaimed method, for the purpose of
curing or alleviating any abnormal condition of
the human body, and includes the application of
any medical or surgical appliance so far as the
application of such appliance is necessary in the
use as aforesaid of massage, passive movements,
remedial exercises, muscle re-education, electric-
ity, heat, light, sound, Water or any proclaimed
method."
52
This definition emphasises: external applications
as treatment, physical agents and methods as the
mode of treatment and any abnormal condition as
the reason for treatment.
The aims of the course at Cumberland College,
which I assume are similar to other courses, will
equip physiotherapists with skills relevant to
primary health care. These are: an orientation to
the assessment and management of impairment
and disability; a basic grounding in the structure
and function of the human body; an understanding
of socio-economic factors and affective function in
disordered health; communication with patients
and other professionals; and administrative and
organisational responsibilities. Some of these aims
are noteworthy because they do not appear in the
stated aims of medical courses. Generally they
should equip physiotherapist graduates well for
community-based practice.
However, these fields are not open to physio-
therapists alone. Doctors claim responsibilities in
some of these activities, occupational therapists
also lay claim to some of the territory, and now, in
some States, chiropractors are to be given statutory
rights to specific treatments for specified
conditions.
There are new professions claiming rights to
health care practices and seeking registration by
State Governments. Physiotherapy was one of the
early registered professions which could be clearly
recognised by the general public as having a
'caring' role. Physiotherapy was one of the
professions which provided direct services for a fee
to the general public and whose treatments carried
risks of physical injury. Registration was a way of
regulating independent practitioners for public
protection as well as providing intra-professional
and inter-professional harmony.
As new technologies and disciplines develop,
governments are now expected to exercise greater
control over the resources of the health sector. Asa
result, health administrators now face massive
manpower problems and need better surveillance
of the professional workforce. Registration will
provide an opportunity to do this. But there are
significant problems in large scale registration
which relate to exclusiveness of a profession, the
motivation towards status by the groups involved
and the less than imagined gains in standards that
registration confers. The newer "professions"
seeking registration are not well-defined in the
public mind because they have not existed for long
enough. Those that arise out of technical develop-
ments are easy to pinpoint and those based on a
scientific discipline, such as psychology, are better
understood than disciplines which arise out of
different patterns of providing human services, e.g.
Social Work and Occupational Therapy.
Aust. J. Physiother. 26:2, April, 1980
 WEBSTER
PRACTICAL IMPLICATIONS
FOR PHYSIOTHERAPY
Compared with many of these disciplines,
physiotherapy has the advantage of better role
definition and acceptance, and longer statutory
recognition. These assets should be built upon as
the health professions face contemporary and
future challenges to the appropriateness and
effectiveness of the work done by their members.
An important exercise for the physiotherapy
profession would be to define those aspects of their
daily work which are of special value, even though
in the past they have not been declared as part of
the physiotherapist's task. I think, for example, of
the time spent with patients explaining their
condition to them, offering sympathetic under-
standing and teaching them how to cope with their
disabilities, or I think of some of the preventive-
educational programmes being developed for those
with long-term impairments.
Physiotherapy, like the rest of the health
professions, will increasingly be called to account
for work done. Just as the technology of medicine
is under scrutiny, so will the technology of the
physiotherapist be re-assessed, in this reappraisal
some treatments will he discarded; this is as it
should be — many medical treatments should also
be discarded. I imagine it would be relatively easy
to find equivalents to the medical concern about
over-investigation and over-medication in physio-
therapy practice and departments.
HEALTH TASKS
The task of managing the health impairments of
ageing will increase, including the respiratory
impairment by smoking, cerebrovascular and
cardiovascular diseases, and impairments of
musculo-skeletal function — all conditions which
have a long time-base of underlying biological
change. In these circumstances physiotherapy will
be rehabilitative and supportive. Injury will
continue to provide a demand for similar services.
There is a basic difference in problem orientation
between physiotherapists and medical practi-
tioners. Medical practitioners are primarily
concerned with the diagnosis and treatment of
disease whereas physiotherapists are more involved
with assessing (and measuring) impairment and
ascertaining its disabling effect. This orientation
leads to a different approach to patient care,
particularly in the use of time and to the personal
satisfactions experienced from patient manage-
ment. Both professions, it needs to be said, have
been, orientated to the treatment of established
illness and have neglected prevention.
Aust. J. Physiother. 26:2, April 1980
Physiotherapists have special capacities based
on their orientation to human structure and
function, and their expertise in the measurement of
musculo-skeletal, neurological, respiratory and
cardio-vascular impairment. The goals of physio-
therapy treatment are best measured by gains of
functional capacity.
These qualities are valuable in supportive health
care but there are preventive activities which are
also appropriate to physiotherapy including:
screening of school children for musculo-skeletal
disorders
antenatal care
prevention of venous and respiratory compli-
cations in bedfast patients
pre-operative respiratory training
respiratory assessment of patients with
respiratory disease
respiratory training in patients with respiratory
disease
ergonomics
rehabilitation (e.g. cardiac, respiratory) as a
preventive function
population screening for respiratory and
musculo-skeletal disorders
CONCLUSION
We have reached a point where the definition of
the health care task has shifted. As part of this
redefinition health services accept problems
hitherto excluded from disease models and are
prepared to intervene at different points in the
disease matrix.
There are two reasons for this change. Firstly,
specific treatments are frequently found to be
pallative and not curative — therefore, preventive
strategies may be more appropriate. Secondly,
costs of health care have reached a point of
diminishing return.
Physiotherapists and other professional health
workers now find that there are new opportunities
for work in non-institutional settings. Health care
in this context, whether delivered by general
practitioners or therapists, has many characteristics
unfamiliar to hospital based personnel- The
differences include: the incidence of illness and
disease, the patient-therapist (doctor) relationship,
problem-solving and management goals, and
professional responsibility.
The fields of health science and human behaviour
covered in physiotherapy education programmes
equip physiotherapists for effective preventive
interventions —in the occurrence and development
of disease, in modifying the severity of disability
and reducing the over-use of secondary health
services.
53
 PHYSIOTHERAPY AND COMMUNITY MEDICINE

BIBLIOGRAPHY
Faghih, M.A, and Amini, F. "Community
Medicine and the Health Team" in Epidemiology
and Health, Holland, W.W. and Gilderdale, S.
(eds) Henry Kimpton Publishers, London.
Townsend, P. 1975 "Social Work and the Fifth
Social Service" in Sociology and Social Policy
Allen Lane (ed) Penguin Books Ltd. Middlesex.