The benefits of early
appropriate access to Physiotherapists for patients with musculoskeletal
disorders is no longer disputed. Research evidence is overwhelming in
confirming it is both clinically and cost effective for patients to consult a
Chartered Physiotherapist with their back neck or limb complaints. Patients can
self-refer in most places in Scotland and two-thirds of Wales,
but only three of 10 CCGs in England offer that option in any form and there is
one pilot scheme in Northern Ireland.
However, with primary care
under enormous pressure and seeking new models of care that put patients in
control, the case for making physiotherapists the first point of contact for back, neck, limb problems - whether
working alongside GPs or in more traditional outpatient settings – has never
been stronger
Creating capacity
§ Giving patients the
choice to be assessed by a physiotherapist as their first point of contact
frees up GPs for other often more acute cases
§ Musculoskeletal
conditions alone account for up to 30% of consultations in GP surgeries each
year – more than 100 million appointments.
§ When other
conditions, such as frailty and women’s health, are taken into consideration,
the potential impact for the HSE and all public health services is enormous
Saving money
§ Self-referral for
an MSK problem cuts costs for the NHS by an average of £33 per patient
§ This represents a
saving of up to 25%
§ Savings also come
through fewer investigations, such as scans and x-rays, and lower levels of
prescribing
Improving patient
outcomes
In Torbay, North
Devon, introducing self-referral cut waiting times from 10 weeks to
within three days for 90% of patients with musculoskeletal complaints
§ Self-referral helps
prevent acute problems from becoming chronic and reduces long-term pain and
disability
§ It reduces the time
people are off sick from work
§ It is also shown to
reduce waiting times and improve patient satisfaction
Putting patients in control
§ Self-referral is an
important route into advice and treatment for the growing numbers of people
with at least one long-term condition
§ It enables
individuals to feel confident to more effectively manage their own condition
and live independently
§ Giving patients the
responsibility for their own referral is shown to cut did-not-attend rates and
improve adherence to treatment plans
Putting self-referral into practice
Working alongside
GPs
In West Wakefield physiotherapists are the first
point of contact for patients with musculoskeletal pain and dysfunction.
The service, which has been running since late 2014
following a successful pilot, has expanded to six GP practices in West
Wakefield and receives on average 900 referrals a month.
By upskilling reception staff to identify
appropriate patients to be seen by physiotherapists, significant GP time has
been saved.
The GP's view
Self-referral was rolled out across the Plymouth
area in February 2015 after a successful trial.
Dr Gary Lenden, a GP from Plymouth and Clinical
Lead for the Western locality of Northern, Eastern and Western Devon Clinical
Commissioning Group, said:
'Being able to self-refer makes patients feel
empowered, because they have the chance to say exactly what symptoms they are
experiencing and how it is affecting them.
'It also means people can be seen quicker, which is
more convenient for them and prevents chronic issues developing.
'Hopefully this will reduce the need for
prescriptions and expensive diagnostic tests. Allowing patients to self-refer
also reduces the overall musculoskeletal workload for GP practices, which frees
up appointment slots in busy clinics.'
The rapid access
service
Patients refering themselves by telephone in the
Torbay and Southern Devon Health and Care NHS Trust are offered an appointment
with a physiotherapist within 72 hours.
The waiting time prior to the introduction of
rapid-access/self–referral was up to 10 weeks. The service cut DNAs by at least
70% and reduced the number of follow-up appointments by more than 18%.
The drop-in clinic
Abertawe Bro Morgannwg University Health Board set
up a walk-in clinic in November 2009 for immediate, face-to-face
musculoskeletal assessment and advice.
The service runs for two hours each weekday morning
and has led to a significant reduction in the volume of follow-up appointments
and an overall patient satisfaction rating of 9.6 out of 10.
A ‘Physio Direct’ telephone service has since been
established alongside the clinic for an hour a day to provide early advice and
management for people with MSK problems.
Telephone triage
Self-referral is long–established in Scotland and
all health boards offer either a full or partial service.
Telephone triage is central to that, although many
patients can also access services electronically.
NHS Tayside trialled the Musculoskeletal Advice and
Triage Service (MATS), offering a telephone assessment by a physiotherapist to
patients diverted from the national NHS 24 helpline.
By cutting the number of face-to-face follow-up
appointments needed, the 39-week trial is estimated
to have saved the equivalent of 182 working days for the service.
to have saved the equivalent of 182 working days for the service.
It halved waiting times and achieved high patient
satisfaction levels.
Mythbusters
Won’t self-referral
lead to a surge in referrals?
No. The evidence shows that unless there was a
previously unmet need in the area, referrals do not increase significantly in
the early stages of implementation and later level off.
Indeed, self-referrers are shown to need fewer
appointments so activity levels can actually reduce.
A rise in referrals can also reduce demand in the
longer-term if patients with minor problems seek treatment sooner before they
can become chronic.
Aren’t there safety
concerns?
No. Physiotherapists complete extensive training to
identify red flags and would always refer a patient back to a GP if they had
concerns.
Low numbers of complaints about physiotherapists to
their regulator, the Health and Care Professions Council, demonstrate their
high level of professionalism.
Self-referral has also been the primary route in to
private treatment for decades, further demonstrating the safe, effective nature
of the model.
The patient voice
Patient satisfaction was recorded as high during
the Department of Health’s pilot scheme in England and feedback was positive.
'"Cost-effective in terms of my time and
commitments.'
'I was pleased at the speed with which my
self-referral was dealt with.'
'Constructive advice for self-help and management
for living with arthritis.'
'In-depth consultation in a relaxed and unhurried
way.'
'This service should continue to be offered for all
patients.'
'Most appreciative of my 'personal exercise
programme' given to me and explained.'
Recommendations for implementing
self-referral
Understand existing referral
patterns from local GPs
Establish baseline data for
activity, cost and outcomes
Reduce waiting lists in
preparation for direct access
Ensure all staff in the
pathway understand and support the self referral scheme
Identify appropriate
opportunities to signpost to self referral
Engage with development
and design with online referral systems to allow self referral
References
1. The Chartered
Society of Physiotherapy, Freedom of Information Audit, 2014
2. British Orthopaedic
Association. Getting it right first time (GIRFT): improving the Quality of
Orthopaedic Care within the National Health Service in England. London: British
Orthopaedic Association; 2015. URL: www.gettingitrightfirsttime.com/report
3. The Chartered
Society of Physiotherapy. Musculoskeletal physiotherapy: patient self-referral.
London: The Chartered Society of Physiotherapy; 2012. URL: www.nice.org.uk
4. Holdsworth L,
Webster V, McFadyen A. What are the costs to NHS Scotland of self-referral to
physiotherapy? Results of a national trial. Physiotherapy. 2007;93(1):3-11
5. Department of
Health. The musculoskeletal services framework : a joint responsibility: doing
it differently. London: Department of Health; 2006. URL: webarchive.nationalarchives.gov.uk
6. Nordeman L, Nilsson
B, Möller M, et al. Early access to physical therapy treatment for subacute low
back pain in primary health care. Clinical Journal of Pain. 2006;22(6):505-11
7. Department of
Health. Self-referral pilots to musculoskeletal physiotherapy and the
implications for improving access to other AHP services. London: Department of
Health; 2008. URLs: webarchive.nationalarchives.gov.uk
webarchive.nationalarchives.gov.uk
webarchive.nationalarchives.gov.uk
8. Torbay and Southern
Devon Health and Care NHS Trust. Information supplied to CSP
9. West Wakefield
Health and Wellbeing. Information supplied to CSP
10. NHS Tayside.
Information supplied to CSP
11. Abertawe Bro
Morgannwg University Health Board. Information supplied to CSP
12. Northern, Eastern
and Western Devon Clinical Commissioning Group. Information supplied to CSP
13. NHS London. Allied
Health Professions MSK toolkit. 2012. ‘A significant saving to patients was
experienced as they attended far fewer appointments which resulted in lower
personal cost and less inconvenience’. MSK framework Assessment/Diagnosis p.28.
URL: www.nras.org.uk
14. The Chartered
Society of Physiotherapy. What is physiotherapy? The Chartered Society of
Physiotherapy URL: www.csp.org.uk
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