Why it's important to be proactive in safeguarding your aquatic physiotherapy service.
Hydrotherapy pools across the NHS have come under increasing pressure in recent years. Local budget-holders have often seen them as relatively easy targets for making cost savings because of a perception that they are inefficient to run. Even when a decision hasn’t been taken to close a pool, many have suffered gradual disinvestment, effectively winding down the quality of care that is available for local patients.
Unfortunately, the unprecedented impact of Covid-19 on the NHS is likely to exacerbate the pressures on hydrotherapy pools even further. It is important to act now to demonstrate the impact that hydrotherapy has on your patients’ health and wellbeing, in order to safeguard the future of your service.
Frequently asked questions
My pool is under threat of closure/remains closed indefinitely – what can I do to change this decision?
If your pool is under threat of closure, it is important to understand the consultation process and the timelines involved so you are aware how much time you have to influence the decision.
Write to your head of therapies and your organisation’s clinical director as soon as possible to highlight the importance of aquatic physiotherapy and the negative impact on the patient population of a lack of access to aquatic physiotherapy or a hydrotherapy pool.
Wherever possible, take an integrated approach alongside other teams/departments that may be impacted by the loss of the hydrotherapy pool and who may not be aware of the proposed changes – for example, consultant teams or GPs who refer into your service or whose patients benefit from it.
How to maximise the impact of your campaign
Engage with patient organisations and charities who are affected. Collate data, gather patient testimonials and be prepared to present your case at a trust board public meeting and a clinical commissioning group (CCG) meeting, depending on who is making the decision.
(Refer to the FAQ on demonstrating impact below for further guidance on the type of data to collect and how to gather patient testimonials.)
Finding service users who are willing to speak at meetings will also be beneficial as, often, questions need to be raised by people living in the area affected by the closure.
Local councils may have an interest in the decision if they think a proper consultation has not been carried out and it may be possible to have this looked at by your council’s scrutiny committee.
Your local CSP team can support you with your case – email firstname.lastname@example.org or call 0207 306 6666 and the Enquiries Team will put you in touch with the local CSP team for your region.
As part of this process, you should ask your organisation whether they have carried out an equality impact assessment (EIA) on their decision, which should take into account the impact on staff and patients. Request to view the EIA and then check whether it has thoroughly considered how patients are going to be disadvantaged by the decision. You are entitled to challenge the EIA if key information has been omitted.
If, as part of the process, the trust are suggesting alternative hydrotherapy pools that can be utilised, then look at the impact this would have on the service and on patients both in terms of cost and travel to a different site.
It is extremely important to gather data, testimonials and case studies to illustrated quantitively and qualitatively the impact that aquatic physiotherapy and access to the hydrotherapy pool has for service users and the local community.
Look at other organisations that have gone through a similar process – for example, read campaign reports from St George’s Community Hydrotherapy Pool in Peterborough.
I have tried to change my organisation’s decision but they appear to be proceeding with closure regardless – what can I do?
You can get help from your local CSP team to start a campaign to save your service. This may entail a number of actions including:
- Acting on your behalf and in collaboration with you at trust and clinical commissioning group (CCG) meetings.
- Advocating for your service with key stakeholders in the area, including Healthwatch, the local council and the local MP.
- Issuing a press release and speaking to local media to highlight the campaign.
- Starting a public petition to generate awareness and campaign to save your service.
To contact your local CSP team, email email@example.com or call 0207 306 6666 and the Enquiries Team will put you in touch with the local CSP team for your region.
My hydrotherapy pool has not reopened because of uncertainty around how to do this safely under Covid-19 restrictions – what resources are there to support this process?
Both the Aquatic Therapy Association of Chartered Physiotherapists (ATACP) and Pool Water Treatment Advisory Group (PWTAG) have embedded enhanced hygiene and mitigating steps into their recommendations for practice to minimise the risk related to Covid-19 when providing aquatic physiotherapy in a hydrotherapy pool. These should be followed alongside national infection prevention and control (IPC) guidelines and local risk assessment.
- PWTAG code of practice
- ATACP recommendations for safe aquatic physiotherapy practice in relation to the Covid-19 pandemic
- ATACP guidance on aquatic physiotherapy practice 2021
For more advice and nation-specific information please refer to the CSP clinical guidance page about aquatic therapy during the pandemic.
How do I explain the difference between aquatic physiotherapy and exercise in a swimming pool?
'[Aquatic physiotherapy is] a physiotherapy programme utilising the properties of water, designed by a suitably qualified physiotherapist. The programme should be specific for an individual to maximise function which can be physical, physiological, or psychosocial. Treatments should be carried out by appropriately trained personnel, ideally in a purpose-built, and suitably heated hydrotherapy pool.'
Aquatic Therapy Association of Chartered Physiotherapists (ATACP) 2021
A hydrotherapy pool is warmer than a swimming pool (33-36ºC versus 29ºC) meaning that patients experience physiological benefits over and above what can be achieved in lower-temperature environments, which aids recovery and wellbeing – for example, improved circulation, improved renal function, improved respiratory function, reduced muscle spasms and spasticity, and reduced pain.
How do I explain the benefits of aquatic physiotherapy over and above land-based therapy?
The advantages of aquatic physiotherapy in a hydrotherapy environment are numerous. The key differences compared with physiotherapy on land are the physiological benefits of heat and hydrostatic pressure and the apparent weightlessness due to the patient's buoyancy in water. Among many benefits, aquatic physiotherapy can:
- Reduce muscle spasticity.
- Reduce pain and swelling/oedema.
- Enable new skills to be learned in an unencumbered environment.
- Make movements easier – carrying out exercises and activities that cannot yet be achieved on land allows for more rapid progress.
- Maintain essential skills for function and independence, such as standing, balancing and walking.
- Enhance cardiovascular response to exercise.
- Enhance fitness and wellbeing in an environment that is enjoyable and motivating for people of all ages, and with different physical and cognitive abilities.
What resources should I be gathering to demonstrate the impact that the aquatic therapy service has for patients and its value in my local health system?
There is an increasing need to evaluate and justify aquatic physiotherapy services to ensure effectiveness and financial viability. Using outcome measures to produce standardised data allows services to be scrutinised and assessed by users and outside agencies. There are disease/disorder-specific outcome measures that can be used because aquatic physiotherapy is provided to multiple specialties and co-morbidities. (See the ATACP guidance on aquatic physiotherapy practice 2021.)
Therefore, it is important for all aquatic physiotherapy services – whether under threat or not – to collect relevant and meaningful data.
When choosing what data to share with stakeholders, consider the messages that you want to convey to your audience. Answering the following questions to help you decide.
Be clear about why you are collecting the data (for what purpose will it be used) and why the selected outcome measures have been chosen, and maintain this focus when collating the data – do not allow nuance to bend the data. Write down a protocol beforehand and stick to it. A consistent dataset is much easier to use.
Know your audience and who you will be targeting. Also, consider who will be affected by the decisions that may come from the data. For example, if talking to commissioners, data that includes effects on the system – such as bed days saved, emergency department attendances saved, admissions prevented, discharges expedited and so on – may have more impact than data on health outcomes alone.
What is my question and what am I wanting to show? What data do those I am attempting to influence need to make their decisions? What drives their decisions? Does my data meet their needs?
Consider throughout how decisions will be reached and tailor the way your data is presented and formatted to have maximum impact.
Ensure that you store data appropriately, that any data you share is grouped and anonymised, and let people know you are collecting data and that you will be using it – ensure GDPR (General Data Protection Regulation) compliance.
Consider a combination of the following data collection methods that can demonstrate the impact of aquatic physiotherapy to the individual patient and the positive impact to your local health systems – such as the number of patients who can be discharged to self-management, the number of patients who were able to reduce or stop analgesics or the number of patients coming off of waiting lists for surgery etc:
- PROM (Patient Reported Outcome Measure). For example, MYMOP (Measure Yourself Medical Outcomes Profile) is applicable to any condition.
- PREM (Patient-Reported Experience Measure). For example, the Friends and Family Test (FFT).
- Condition-specific measures/ objective measures (depending on the clinical aims for each patient). Find out more on the CSP's page about outcome and experience measures.
Furthermore, consider collecting data to map the demographics of patients accessing your service so that you can demonstrate that the service has a good level of equity of access and that it is addressing the needs of a diverse range of populations in your community. This could be gathered internally from information on your electronic patient note system or can be taken at the time of booking the appointment.
If your service is under threat, collecting testimonials from patients can be key to making the impact of the hydrotherapy pool on wellbeing and quality of life clear to funders and managers. Advice from those who have had to campaign for their hydrotherapy pool to remain open is to seek consent to share patients’ personal stories (with the inclusion of photos) to give a greater impact.
For example, St George’s Community Hydrotherapy Pool in Peterborough collected patient testimonials during the campaign to save the service in 2018.
Cast the net wider to include feedback and testimonials from other stakeholders who access the hydrotherapy pool – for example, consultants or GPs whose patients benefit from aquatic physiotherapy, or groups that use the pool privately.
Where can I find further resources to demonstrate the importance and impact of aquatic physiotherapy?
All CSP members have access to the Discovery evidence and knowledge search, which brings together all the online library resources via a single interface.
Research papers that may be helpful include:
- Pattman J, Hall J and Record E (2013) 'Effectiveness of Aquatic Physiotherapy in Clinical Practice', International Journal of Aquatic Research and Education, 7, 396-406
- Marinho-Buzelli AR, Bonnyman AM and Verrier MC (2015) ‘The effects of aquatic therapy on mobility of individuals with neurological diseases: a systematic review’, Clinical Rehabilitation 2015, Vol. 29 (8) 741-51
- Waller B, Ogonowska-Slodownik A, Vitor M, Rodionova K, Lambeck J, Heinonen A and Daly D (2016) ‘The effect of aquatic exercise on physical functioning in the older adult: a systematic review with meta-analysis’Age and Ageing, 45: 594-602, DOI: 10.1093/ageing/afw102
- Becker BE (2020) ‘Aquatic Therapy in Contemporary Neurorehabilitation: An Update’, American Academy of Physical Medicine and Rehabilitation, 12, 1251-59,https://dx.doi.org/10.1002/pmrj.12435
- Geytenbeek J (2002) ‘Evidence for Effective Hydrotherapy’, Physiotherapy, 88 (9) 514-29
- Heywood S,McClelland J,Mentiplay B, Geigle P, Rahmann A and Clark R (2017) ‘Effectiveness of Aquatic Exercise in Improving Lower Limb Strength in Musculoskeletal Conditions: A Systematic Review and Meta-Analysis’,Archives of Physical Medicine and Rehabilitation, 98: 173-86
- Heywood S, McClelland J, Geigle P, Rahmann A and Clark R (2016) ‘Spatiotemporal, kinematic, force and muscle activation outcomes during gait and functional exercise in water compared to on land: A systematic review’ Gait and Posture, 48, 120-30
- Bansi J, Bloch W, Gamper U and Kesselring J (2012) ‘Training in MS: influence of two different endurance training protocols (aquatic versus overland) on cytokine and neurotrophin concentrations during three week randomized controlled trial’, Multiple Sclerosis Journal, DOI 10.1177/1352458512458605,http://msj.sagepub.com/content/early/2012/08/30/1352458512458605
- Castro-Sánchez AM, Matarán-Peñarrocha GA, Lara-Palomo I, Saavedra-Hernández M, Arroyo-Morales M and Moreno-Lorenzo C (2012) ‘Hydrotherapy for the Treatment of Pain in People with Multiple Sclerosis: A Randomized Controlled Trial’, Evidence-Based Complementary and Alternative Medicine, Article ID 473963
- Adsett JA, Mudge AM, Morris N, Kuys S and Paratz DJ (2015) ‘Aquatic exercise training and stable heart failure: A systematic review and meta-analysis’,International Journal of Cardiology, 186, 22-28
- Rees JL, Johnson ST and Boulé GN (2017) ‘Aquatic exercise for adults with type 2 diabetes: a meta-analysis’Acta Diabetologica, DOI: 10.1007/s00592-017-1023-9
- Bartels EM, Juhl CB, Christensen R, Hagen KB, Danneskiold-Samsøe B, Dagfinrud H and Lund H (2016) ‘Aquatic exercise for the treatment of knee and hip osteoarthritis’ Cochrane Database of Systematic Reviews, Issue 3. Art. No: CD005523
- McNamara RJ, McKeough ZJ, McKenzie DK and Alison JA (2013) ‘Water‐based exercise training for chronic obstructive pulmonary disease’, Cochrane Database of Systematic Reviews' Issue 12. Art. No: CD008290. DOI: 10.1002/14651858.CD008290.pub2
- Mehrholz J, Kugler J, Pohl M. (2011) ‘Water-based exercises for improving activities of daily living after stroke’ Cochrane Database of Systematic Reviews, Issue 1. Art. No: CD008186, DOI: 10.1002/14651858.CD008186.pub2
Policy and organisational information that may be useful to reference:
- National Institute for Health and Care Excellence (2017) 'Spondyloarthritis in over 16s: diagnosis and management' (NICE Guideline 65)
- NHS England (2019) 'The NHS Long Term Plan'
- Swim England offer support to leisure providers that could be relevant to aquatic physiotherapy providers – for example, resources, training, strong links to local public and private leisure pool provision and consultancy support around facilities and service sustainability. For more information, email firstname.lastname@example.org
- Public Health England (2016) 'Health matters: getting every adult active everyday'
- Public Water Treatment Advisory Group
- Sport For Confidence
Are there any other actions I can take to promote aquatic physiotherapy and our hydrotherapy pool?
There are many other ways you can promote your service, whether it is under threat or not:
- Invite your organisation’s key decision-makers (such as hospital board directors) to visit the service and meet patients and staff.
- Contact your organisation’s communications team and ask if they would be interested in doing a feature on your service and the benefits to patients.
- Use case studies of services and pools that are well-funded and supported in other parts of the country to back up your argument.
- Do your own short film of your service to promote on social media – you can feature interviews with the team, patients and some clips of patients in the water just using your smartphone. You just need to make sure that you have received the relevant permissions from the people featuring in your film clip. We have example model release forms you can use for this purpose. Just ask your local Campaigns and Regional Engagement Officer by emailing email@example.com.
Should I use the term aquatic physiotherapy rather than hydrotherapy?
Aquatic physiotherapy is the new name for hydrotherapy. The reason it has been changed is to make it easier to review the evidence because hydrotherapy is a generic term used for other treatments involving water such as colonic irrigation. This change will also bring UK practice in line with European and international terminology. You would describe aquatic physiotherapy as taking place in a hydrotherapy pool.