Under pressure

As obesity levels soar, the toll on health professionals intesifies. Graham Clews investigates

Claire Harding was working as a physio a few years ago when an extremely obese patient was referred for physiotherapy by their consultant. The trouble was, the patient was so heavy the physios could not move them. 'Eventually we had to have a special frame welded,' says Ms Harding, who is CSP health and safety rep in Liverpool. 'None of the equipment we had was strong enough. The consultant was saying to us: “Why don't  you just move them?” We said it wasn't safe and we weren't going to take responsibility for what might happen if we tried.' That incident happened some time ago, and Ms Harding says more and better specialist equipment is now more widely available. But as the UK population gets heavier, the problem of providing effective physiotherapy to obese patients is undoubtedly  getting worse. A study published by the Health and Safety Executive last year found between 1993 and 2004 there had been a 50 per cent increase in the proportion of the UK public whose body mass index was over 30, the World Health Organization definition of obese. The proportion of the population whose BMI was over 35 had doubled in that time, and the HSE concluded that if these trends continued then more than a quarter of the population (26 per cent) would be officially obese by 2010. Donna Payne, the CSP's national health and safety officer, says safety reps are concerned about a lack of access to special equipment and moving and handling support when dealing with very heavy, or bariatric, patients. The problem is NHS-wide and it can lead to desperate situations. 'One safety rep told me they did not have the equipment to move a heavy patient, so they had to call the fire brigade, and eventually it took six people,' she says. 'That's not good from the staff's point of view, or for the patient's dignity.' This sort of situation is rare, and the most effective way of preventing similar incidents is for trusts to implement policies for dealing with bariatric patients. But the HSE's report found fewer than half (42 per cent) of trusts have such a policy, and more than 35 per cent explicitly stated they did not provide specific manual handling training for staff to deal with bariatric patients. EQUIPMENT SHORTFALL   Ms Harding, who works at Knowsley primary care  trust says the problem is not just a lack of training  or equipment, but also a lack of access to the equipment. 'We have a bariatric library, which includes things like hoists and oversize commodes.' The problem is when physiotherapists need the equipment they need it immediately, but there's rarely time to travel to collect it. Stuart Alexander works in elderly rehabilitation and intermediate care for Newcastle PCT. His ward has a hoist, stand aids, strengthened walking frames, and a mobile platform, which has therapeutic properties as well as being used to move very heavy patients short distances, such as to the toilet. But this is often still not enough. Physios have to 'beg, borrow or steal' wheelchairs, he says, and beds in the ward are not always big enough for some very large patients. Bariatric patients have to be kept in one of the few rooms that are easily accessible and large enough to hold the equipment and extra staff. Anita Rush, a nurse with Berkshire community equipment services, provides training to physiotherapists and other allied health professionals working for Berkshire West PCT. She says treating a patient who weighs 30 stone can be completely different from treating someone who weighs 10 stone. 'It is about understanding the different movements bariatric people make,' she says. Ms Rush uses a bariatric model at her training sessions so AHPs can really understand what it is like to manoeuvre someone of that size. Risk assessments are also imperative, she says, and they should cover everything from the weight of the patient to their mobility and their psychological needs, as well as looking at the number of staff required to provide treatment, the equipment required and staff's accessibility to the patient. TRAINING NEEDS   CSP research and policy officer Warren Glover wrote a major report on musculoskeletal injuries among members. He surveyed more than 4,000 physiotherapists and found dealing with very heavy patients was one of the most common reasons why physios sought help while at work. The trouble was they sought help only after they had been injured. 'There tends to be a can-do attitude among physios,' he says. 'They put the patient first and their own health and safety is often secondary. Physios will seek help, but not as early as they should.' So is there a need for further advice or education for staff? Physiotherapist Pat Alexander is a freelance back care adviser and trainer, and is writing new CSP guidelines for the moving and handling of heavy patients. She believes specific training for dealing with bariatric patients should probably only be introduced at postgraduate level. 'I'm not sure undergraduates should be exposed to that,' she says. 'Perhaps we should protect inexperienced staff from the possible consequences.' Those consequences can be severe and Ms Alexander believes there is a 'real danger of serious injury' if a very heavy patient were to fall on a physio treating them. TREATMENT CHOICES   Chris McCarthy, chair of the Manipulation Association of Chartered Physiotherapists, agrees more senior physios are often better qualified to treat bariatric patients. Dr McCarthy, who is professor of rehabilitation at Warwick University, says most physiotherapists who have a postgraduate training in manual therapy will have been taught how to position themselves ergonomically when treating bariatric patients. But that doesn't apply to all physios. 'It's difficult to say, but perhaps it is not taught on undergraduate courses as much as perhaps it should be,' he says. 'When we first qualify we are safe but not particularly skilled.' For most manual therapy, the size of the practitioner compared to the size of the patient makes little difference, Dr McCarthy says, but the combination of a very heavy male patient and a very small female physio could cause concerns about patient handling and affect treatment decisions. Treatment of upper limbs and necks should not really be a problem, he says, but treatments involving working on a patient's back or lower limbs are riskier, because of the greater weights involved. That is when it is important physiotherapists know how to position themselves safely. 'One of the advantages of physiotherapy is we have a variety of techniques we can use to treat patients,' says Dr McCarthy. 'Certain treatments will be more difficult, particularly when it is difficult to palpate, and in those cases morbid obesity could preclude certain treatments. But we have a range of other treatments that can be used.' Ms Alexander says: 'We need to deal with whole systems. We must have physios, occupational therapists and dieticians working together, because it  is not only the patient's size and manoeuvrability that is a problem. They may have a number of other difficulties that will need to be addressed if they are  to be treated successfully.' FL Community pathway Judy Dalton, a physiotherapist with Rotherham PCT, is developing a community pathway for bariatric patients. 'We have already developed an assessment tool which enables us to gather information about patients who weigh over 20 stone, and who may be known to district nursing or therapy services,' she says. 'The intention is then to share this information, with patient consent, with other agencies, such as Yorkshire ambulance service, and Rotherham trust moving and handling coordinator.' To deploy the assessment tool, a short training package for district nurses, community physios and OTs has been developed, which highlights the problems experienced by very heavy people, including mobility, continence and the safe working load of any equipment provided for them. Other issues covered include the sensitivity required to undertake the assessment, and the need for the ambulance service to be briefed so they can avoid undignified handling. 'We still have some way to go in managing bariatric patients in the community: specialist equipment is usually more expensive and is a challenge for the equipment stores, and care packages usually include up to six carers for rolling the patients in bed,' Ms Dalton says. 'However, with more than 60 community professionals having an increased holistic awareness, and close communication between the different agencies, together with a pathway which will assist them with onward referral, we should be providing an improved service.' So far, there are 27 patients with a BMI of more than 50 on Rotherham PCT's patient consensual database.
Graham Clews

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