Direct access to physiotherapy in primary care: now?—and into the future?

doi:10.1016/j.physio.2004.01.005

Physiotherapy

Volume 90, Issue 2, June 2004, Pages 64-72

https://doi.org/10.1016/j.physio.2004.01.005 Get rights and content

Abstract

Background Patient direct access to physiotherapy (self-referral), is not the routine mechanism in use within the National Health Service (NHS) although more recently it has become a topic of considerable United Kingdom (UK) and international interest.

Aim To develop, implement, investigate and report on a direct access primary care based physiotherapy service.

Design of study Experimental and qualitative.

Setting A general practice in a health district of Scotland.

Method The service was introduced and compared to the existing system of open access over a 12-month period. Demographic and clinical data were collected relating to two samples.

Control year group All general practitioner (GP) referrals in the year prior to the study year.

Study year group general practitioner and direct access referrals. All patients were followed up 1-month after discharge, and the number of associated general practitioner consultations collated together with clinician views of physiotherapy generally and direct access specifically.

Results The control and study year groups were homogenous with regard to number of referrals (339 versus 340), patient age, gender, condition category and its severity. There were, however, significant differences between direct access and general practitioner referrals (22.4%, n=76; versus 77.6%, n=264). Direct access patients were more likely to have been: male, younger, suffering from conditions of a shorter duration, in paid employment with less work absence, more compliant with attendance, had fewer physiotherapy contacts, lower reporting of symptom severity at discharge and were more highly satisfied with their physiotherapy care and experienced less general practitioner consultations (P<0.001). Support for direct access was strongly expressed by service users and clinicians.

Conclusions Direct access to physiotherapy is an example of innovative primary care service provision that is feasible, acceptable to both users and providers and has major implications for general practitioner workload. Its efficacy, however, should be evaluated in a range of settings before being universally introduced.

Section snippets

Background and purpose

Recently, direct access to physiotherapy has become an issue of growing interest voiced by physiotherapists, physiotherapy managers, general practitioners, politicians and even patients and the wider public [1], [2], [3], [4], [5]. Patients can easily access physiotherapy directly within the private and sports sectors, however, in all but a minority of locations, it is not the mechanism adopted by the National Health Service (NHS). Current healthcare policy strives for innovation and improved

Aims

The aims of the present study were to:

•
Develop and introduce a direct access physiotherapy service in a primary care setting.
•
Compare direct and open access physiotherapy referrals.
•
Investigate the impact of open and direct access referrals on general practitioner workload.
•
Ascertain the views of clinicians, service users and non-users.

The purpose of this paper is to report the major findings of a primary care based direct access service and also to consider the future for direct access.

Setting

The study was conducted within a semi-urban general practice in Dundee, Scotland whose overall profile is described in Box 1. The practice had had an established and consistent on-site open access physiotherapy service since 1994 (40 referrals per 1000 practice population). Full support for the study was provided by all general practitioners, practice manager, clinical and managerial physiotherapists who were keen to investigate whether direct access should be considered as an additional mode

Results

An examination of the referral rates, demographic characteristics and presenting conditions associated with the control and study year groups established that the groups were homogenous. The referral rate to physiotherapy was similar during each year (339 versus 340). There were no significant differences between the groups in their gender distribution 41:59 (M:F) (P=0.963) age group (P=0.900) or condition category (P=0.109) with the majority of presenting conditions being musculoskeletal in

Results of the Logistic Regression Testing

The characteristics investigated related to the patients’ age band, gender, condition category, severity of presenting condition, duration of symptoms and their employment status. It would appear from the results for both patient condition category (P=0.235) and the severity of the presenting condition (P=0.077), the association with mode of access was not statistically significant. Patient gender (P=0.007), age band (P=0.021), employment status (P=0.015) and duration of symptoms (P<0.001) all

General practitioner workload

There were considerable differences between the referral groups in terms of the associated numbers of general practitioner consultations both in the period prior to and also post physiotherapy intervention (P<0.001) (Table 2).

Discussion

The findings of the present study have demonstrated that direct access to physiotherapy was feasible and acceptable at the study location. Findings that support the only other published investigation into this mode of access to date within the UK [10]. The present study identified that, contrary to popular belief, introducing a system of direct access did not result in an overall increased rate of referral to physiotherapy. The rate experienced, however (10 referrals per1000 practice

Impact on general practitioner workload

The impact of direct access to physiotherapy on general practitioner workload demonstrated within the study has major implications for service delivery within primary care. An indication of the actual size can be estimated if an average time of 10 minutes per general practitioner consultation is multiplied by the mean number of general practitioner consultations experienced by each group. This calculation identified that the time associated with each open access patient was considerably longer

Limitations

Although this study involved 679 patients, only one general practice was involved. It must also be considered that the patient profile of the participating practice, although similar to many other practices locally and throughout the UK, cannot be considered as universally representative. In addition, the waiting time for physiotherapy was not unduly long for either group due to an adequate staffing/patient ratio. The direct applicability of the findings of the present study to all practices

Conclusions

The concerns that have hindered the progression to a system of true autonomy within physiotherapy to date have primarily focused on the fear that the profession would not be able to cope with the resultant demand for their services. Based on the limited evidence provided within the present work, that previously reported and from experience in the USA, these concerns appear to be unfounded. The results suggest that direct access could improve patient access, which is in keeping with the

Back to the future

Presentations at conferences and the resultant publicity has generated considerable interest from physiotherapists, general practitioners and politicians. It is should be noted, however, that these results represent the findings in only one location whose profile cannot be described as representative of, and therefore, relevant to, all primary care settings (Box 1). It is, therefore, recommended that before further direct access physiotherapy services are introduced, the efficacy of this mode

Ethical approval

Ethical approval for the study was granted by Tayside Research of Ethics Committee and Glasgow Caledonian University.

Acknowledgements

Dr William McLaren, Department of Maths, Glasgow Caledonian University for his invaluable guidance and assistance with the statistical analyses of this work. The authors would also like to acknowledge the clinical physiotherapists, their managers and general practitioners who are currently participating in the national multi-centred trial of direct access. Their foresight in understanding and supporting the need for further evaluation of this topic is gratefully appreciated.

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Les textes récents relatifs à la création d’entités telles que les Communautés professionnelles territoriales de santé et la possibilité de se rendre directement chez son kinésithérapeute dans deux cas bien circonscrits, ont permis de tester un élargissement des possibilités de recours à l’accès direct au kinésithérapeute. Ce projet-pilote visait à vérifier si un accès direct au kinésithérapeute constituait un axe de progrès du système de santé français. Le partenariat entre deux cabinets libéraux a permis de définir strictement les cas de recours possibles, tout en garantissant au patient la liberté de choix du thérapeute, mais aussi et surtout sa sécurité au travers du protocole adopté pour cette étude. Les données récoltées ont mis en lumière que, comme dans de nombreux pays étrangers qui le pratiquent depuis longtemps, cet accès direct est un modèle vertueux, sûr, efficace, rentable et qui peut contribuer à améliorer l’accès aux soins et traitements primaires. Le succès mitigé en nombre d’adressages questionne sur le paradigme de la prescription.
5.
The recent texts concerning the creation of entities such as the Territorial Professional Communities of Health and the opportunity of going directly to one's physiotherapist in two well-defined cases, have made it possible to test a widening of the possibilities of recourse to direct access to the physiotherapist. The aim of this experiment was to verify whether direct access to a physiotherapist was a way of improving the French health system. The partnership between two private practices made it possible to strictly define the possible cases of recourse, while guaranteeing the patient's the freedom of choice of therapist, but also and above all his safety through the protocol adopted for this study. The data collected highlighted that, as in many foreign countries which have practiced it for a long time, this direct access is a virtuous, safe, effective, cost-effective model and can help improve access to primary care and treatment. The mixed success in terms of referrals raises questions about the prescription paradigm.
5.
Implementing patient direct access to musculoskeletal physiotherapy in primary care: views of patients, general practitioners, physiotherapists and clinical commissioners in England
2021, Physiotherapy (United Kingdom)
Musculoskeletal problems are the leading cause of chronic disability. Most patients in the UK seek initial care from general practitioners (GPs), who are struggling to meet demand. Patient direct access to National Health Service physiotherapy is one possible solution. The purpose of this study was to understand the experiences of patients, GPs, physiotherapists and clinical commissioners on direct access in a region in England with it commissioned.
The study was informed by Normalisation Process Theory (NTP). Data collection was via semi-structured individual face-to-face and telephone interviews with 22 patients and 20 health care professionals (HCPs). Data were analysed thematically using NPT.
Three themes emerged: understanding physiotherapy and the direct access pathway; negotiating the pathway; making the pathway viable. HCPs saw direct access as acceptable. Whilst patients found the concept of direct access, those with complex conditions continued to see their GP as first point of contact. Some GPs and patients reported a lack of clarity around the pathway, reflected in ambiguous paperwork and inconsistent promotion. Operational challenges emerged in cross-disciplinary communication and between HCPs and patients, and lack of adequate resources.
Direct access to NHS musculoskeletal physiotherapy is acceptable to patients and HCPs. There is need to ensure: effective communication between HCPs and with patients, clarity on the scope of physiotherapy and the direct access pathway, and sufficient resources to meet demand. Patient direct access can free GPs to focus on those patients with more complex health conditions who are most in need of their care.
Impact of models of care integrating direct access to physiotherapy in primary care and emergency care contexts in patients with musculoskeletal disorders: A narrative review
2020, Revue d'Epidemiologie et de Sante Publique
Les affections musculosquelettiques sont confrontées à une augmentation de leur prévalence, principalement en raison de la sédentarité. Des données probantes fortes soutiennent le recours précoce à un traitement de première ligne incluant la kinésithérapie. De nouveaux modèles innovants en soins primaires et aux urgences ont été développés et utilisent les compétences du masseur-kinésithérapeute pour la prise en charge précoce et de première ligne des patients souffrant d’affections musculosquelettiques. L’objectif de cette revue était d’identifier et de décrire les études évaluant les modèles de soins intégrant l’accès direct à la kinésithérapie en soins primaires et aux urgences pour les patients présentant une affection musculosquelettique et proposer des perspectives sur l’application de ces deux modèles en France.
Une revue de la littérature a été réalisée à partir de l’inclusion d’études provenant de quatre bases de données scientifiques, PubMed, CINAHL, Embase et PEDro. Les articles recherchés devaient traiter de l’efficacité clinique ou de l’efficience de ces modèles de soins dans un contexte de soins primaires ou d’urgence. Une méthode narrative de revue de la littérature a été utilisée. La synthèse porte sur l’analyse qualitative des études incluses.
Au total, 39 études ont été incluses dans cette revue : 19 sur l’évaluation de l’accès direct à la kinésithérapie en soins primaires et 20 sur l’évaluation de l’accès direct aux urgences. Celles-ci rapportaient que les différents modèles de soins intégrant l’accès direct en soins primaires ou aux urgences fournissaient de meilleurs résultats en termes de qualité et d’accès aux soins tout en maintenant une sécurité similaire. La méthodologie des études incluses a cependant été estimée comme de qualité hétérogène.
Les études portant sur ces nouveaux modèles de soins intégrant l’accès direct à la kinésithérapie en soins primaires et aux urgences permettent de retenir deux enseignements : ils n’ont pas vocation à remplacer le médecin et encouragent la collaboration entre professionnels de la santé afin d’améliorer l’accès pour les patients à des soins efficients. Il convient de s’intéresser désormais aux facteurs de dissémination permettant d’assurer l’efficience de ces modèles innovants dans d’autres pays, comme la France.
Musculoskeletal disorders are increasing in prevalence, principally due to sedentary behaviors. Strong evidence supports an early need for first-line treatment including physiotherapy. New and innovative models in primary and emergency care have been drawn up and put the physiotherapist's skills to work in early and first-line management of patients with musculoskeletal disorders. The objectives of this review were to identify and describe studies assessing models of care integrating direct access to physiotherapy in primary care and in emergency care for patients with musculoskeletal disorders and to provide perspectives on the application of these two models in France.
A literature review was carried out including studies extracted from four scientific databases: PubMed, CINAHL, Embase, and PEDro. The selected articles had to address the clinical effectiveness or efficiency of these models for the provision of care in primary or in emergency care. A narrative literature review method was used. The synthesis deals with the qualitative analysis of the included studies.
Thirty-nine studies were included in this review: 19 on assessment of the direct access to physiotherapy model in primary care and 20 on the direct access to physiotherapy model in emergency departments as concerns patients with musculoskeletal disorders. The studies showed that the different models incorporating direct access to physiotherapy in primary or in emergency care provided better outcomes in terms of quality and access to care while maintaning a similar degree of safety. However, the methodology of the studies included was estimated as being of heterogeneous quality.
The studies dealing with the new models for provision of care integrating direct access to physiotherapy in primary care or emergency care impart two lessons: (1) they are not designed to replace the physician; (2) collaboration between different health professionals aimed at improving patients’ access to efficient care is to be encouraged. It would be worthwhile to focus upon dissemination factors that would enhance the efficiency of these innovative models in other countries, as in France.
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To determine patient characteristics, frequency of use, type of symptoms and treatment outcomes in patients with knee or ankle symptoms, separately, for patients referred by their general practitioner (GP) and patients who self-referred.
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Dutch primary care physical therapy practices.
All patients who visited a physiotherapist with knee or ankle symptoms between 2006 and 2012.
Data were collected from the NIVEL Primary Care Database. The mode of access (self-referred or GP-referred) was determined for all patients. For analyses, descriptive statistics, unpaired t-tests, Chi-square test and logistic regression analyses were applied.
The study included 6179 patients with knee or ankle symptoms. The use of self-referral increased from 26% in 2006 to 56% in 2012, and stabilised between 2010 and 2012. Self-referred patients were younger, had a higher education level and had a shorter duration of symptoms compared with GP-referred patients. Self-referred patients had fewer treatment sessions than GP-referred patients.
Among patients with knee or ankle symptoms, younger patients, and those with a higher education level, a shorter duration of symptoms and recurrent symptoms were more likely to self-refer than other patients. Self-referred patients had fewer treatment sessions. After 2009, the frequency of self-referrals to physical therapists stabilised. Future studies should examine the effectiveness of physical therapy for patients who self-refer with acute knee and ankle symptoms.
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^☆: This work was undertaken as the subject of a Ph.D. awarded in 2002 (L.K.H.). Various aspects of this work have been previously presented at: Primary Care, 2001, Birmingham (CSP Invited Lecture), CSP Annual Congress, 2002, WCPT, Barcelona, 2003.

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Direct access to physiotherapy in primary care: now?—and into the future?☆

Abstract

Section snippets

Background and purpose

Aims

Setting

Results

Results of the Logistic Regression Testing

General practitioner workload

Discussion

Impact on general practitioner workload

Limitations

Conclusions

Back to the future

Ethical approval

Acknowledgements

Physiotherapy

Physiotherapy

Should general practitioners refer patients directly to physical therapists?

Br. J. Gen. Pract.

General practice based physiotherapy: its use and effect on referrals to hospital orthopaedics and rheumatology outpatient departments

Br. J. Gen. Pract.

Management of joint and soft tissue injuries in three general practices: value of on-site physiotherapy

Br. J. Gen. Pract.

Physiotherapy in general practice: leading the way into the twenty-first century

Physiotherapy