Physiotherapy rehabilitation manifesto declarations designed to assure that quality clinical delivery can flourish in a UK urban hospital facility: Results from the first decade (2014-2023)

Background: Global demand for rehabilitation is high and projected to rise, driven by an increasing prevalence of chronic conditions, population aging, and a rise in demand for quality. Patients expect quality interventions delivered by experts, managers implore more for less, while clinicians including physiotherapists strive for support for professional agency from employers. The increasing demand necessitates effective rehabilitation interventions essential to improve patient outcomes, yet marginalization and the worst forms of managerialism pose real threats to clinical excellence.Methods: In 2013, we introduced a physiotherapy rehabilitation team manifesto in response to a shift towards prioritizing transactional metrics over clinical development outputs, which we deemed a threat to the quality of care. The manifesto consisted of seven declarations to strengthen clinical governance We evaluated its impact by comparing standardized clinical output counts (e.g. abstracts, publications, grants) and Advanced Practice (AP) proxy measures as independent and dependent variables, respectively, between the pre-manifesto (2004-2013) and post-manifesto decades (2014-2023). Results: There was a significant increase in total clinical outputs in the decade post manifesto which included 101 peer-reviewed publications. AP proxy measures improved post manifesto, with significant proportional rises in post-graduate education enrollments (11(19%) pre-manifesto and 48(81%) post-manifesto), and publication first/last authorship by team members (5(45%) pre-manifesto and 61(76%) post manifesto), indicating evolving research and networking skills. We argue that semiotic mediation, where achieving outputs enhances rehabilitation quality through social discourse, combined with Kanter's structural empowerment theory, provides a framework that explains our positive outcomes. Conclusion: The manifesto fostered a supportive structure that empowers physiotherapy clinicians to contribute, innovate, and feel valued. To combat excessive managerialism and ensure a flourishing clinical workforce, we next recommend scaling the manifesto to other physiotherapy specialties and redesigning it as policy in partnership with managers.