Thank you for submitting this editorial on a relevant contemporary issue for physiotherapy educators and higher education institutions. Overall I think you have achieved your aim of stimulating a discussion around cost, using a clear framework and well considered examples. Below are some minor comments and questions which were stimulated by my reading of your article for you to consider.
The title is clear and concise. I particularly like that it is framed as a call for physiotherapy educators to engage in a dialogue that we may often avoid.
As this is an editorial your abstract is essentially your opening paragraph. It is therefore not required to set out a precis of the entire article but should draw a reader in to the article and highlight the main theme. To that end I would suggest that your opening paragraph has an explicit link to cost as currently I read it as having a broader focus on value and sustainability.
Paragraph 1. As above, I wonder if a more explicit focus on cost would help to frame the article. Could the distinction that you draw between the cost and outcome components of value in paragraph 4 be introduced here?
Paragraph 2. You make a good case that this is a neglected area of inquiry in physiotherapy. It may be outside the scope of this editorial, but I would be interested in whether there were themes from the more plentiful nursing and medical literature which are relevant to physiotherapy education, or whether there are sufficient disciplinary differences that make application across disciplines impossible.
Paragraph 3. Is there an established link between countries training to independent autonomous practitioner and increased cost of education?
Paragraph 4. Establishes your focus on cost over outcomes clearly (although as above I wonder if this would be better placed earlier). The opening statement did make me wonder if there would be any institutions happy to accept slightly worse outcomes for a significant reduction in cost? Is there any data supporting the growing demand for physiotherapists? (For example in the UK the CSP has used workforce modelling to demonstrate the need for 500 additional graduate physiotherapists a year)
Body of editorial
The types of costs are clearly explained for the reader who may not be familiar with economic terminology.
Personnel costs. To maintain your argument that better cost management would result in greater numbers of equal outputs or improved outputs rather than risking worse outcomes, is there evidence to demonstrate that a move to online learning would not risk a decrease in output quality? For example, George et al 2014 reported equivalent knowledge gains following online learning compared to classroom-based in a systematic review of studies in healthcare students.
Box 1. You make a number of good suggestions. I would possibly challenge the argument that a 2:1 model of clinical education reduces the clinical educator workload by half. But this model creates other peer learning opportunities and there may even be evidence to support 3:1 models.
Facility costs. The argument is well made that flipped classroom models may not necessarily decrease cost, but may change the nature of space requirements. I wondered whether there was a link to be made between changes in the dominant pedagogy might impact on facility costs. For example, moving from more didactic teaching methods to active learning/inquiry-based approaches may require more investment in social learning space and wifi capacity over traditional lecture theatres and audiovisual equipment.
Equipment costs. Your arguments in relation to economies of scope and the need to carefully consider the additional benefits of more costly equipment are clear.
Client-input costs. I found the two examples used to illustrate your points here really thought-provoking. Again this may be outside the scope of this editorial, but I wondered what the differences are in terms of who carries the cost burden between the different stakeholders in different countries?
I think your conclusion is clear and thought-provoking, achieving the aims of your editorial. I like the use of Box 2 to summarise your key points.
Thank you again for the opportunity to review this editorial.
Ben Ellis, Senior lecturer/MSc (Pre-registration) Physiotherapy Subject Coordinator, Oxford Brookes University