The 1st Line Physiotherapy Service


A one-year project to evaluate the impact of a primary care physiotherapy MSK service. The evidence suggests up to 30% of a GP’s caseload could consist of musculoskeletal (MSK) related problems (Margham, 2010), which physiotherapists are ideally placed to manage.

average cost of the MSK physiotherapy service compared to £506.80 for the GP service
Average referral onto orthopaedic secondary care services by MSK physiotherapists, compared to 12% by GPs


The project ran from April 2014 to March 2015. Two MSK physiotherapists (band 7) were introduced as first contact MSK practitioners to provide two half-day sessions per week in the Inner City and University GP practices in Nottingham for a year. Within the service patients were assessed and offered advice, exercise prescription or referral onwards, as appropriate.  The proposal was put to the CCG who supported the evaluation from non-recurrent funds.

Several outcomes were collected:

  • health status (EQ-5D)
  • change in complaint (Global Rating of Change)
  • patient satisfaction
  • resource utilisation


The clinical service made the initial proposal internally supported by the therapy services manager and subsequently the CityCare senior management team. The proposal was then put to the CCG with clear objectives and outcomes detailed.

Critical in the delivery of the project was the strong clinical and team leadership, and the relationship between provider and commissioner.

The level of support internally, from commissioner and subsequently the practice manager in buy-in, was essential in getting our service up and running.

The project was implemented within four months of conception and agreement. All patients who called to make an appointment were offered the option of seeing the physiotherapist, as an alternative to the GP, if they had a MSK problem.

The service was limited to two half-hour sessions. If ongoing physiotherapy was needed patients were referred onwards to the community MSK physiotherapy service.

There was a risk of a limited service capacity, creating long waits for patients and communication difficulties within the GP practices involved. This was mitigated by placing a maximum allowable wait for patients referred to the service, with GP care being the fall back, and sharing electronic record systems for clear communication.

Additional notes

The 1st Line Physiotherapy Service, delivered at an Inner City practice (ICP) and the University practice (UP), proved safe, effective and efficient. The service was delivered by Band 7 MSK physiotherapists in two half-day sessions per week. Two clinical outcome measures were used: The EQ-5D-5L descriptive system and The Global Rating of Change (GROC) questionnaire, with measurements taken at assessment and at 6-months.

Improvements were demonstrated in clinical recovery, with 41% of ICP and 68% of UP patients being discharged to self-manage after the initial visit. 

350 patients returned patient satisfaction surveys and overall reported great confidence in the physiotherapists’ ability to assess and treat them.

Overall, the service achieved the following:

  • The number of patients managed by the MSK service and discharged increased
  • Follow-up appointments and investigations reduced, delivering a cost saving
  • Improvements were found in patients’ clinical recovery, with over 70% reporting continued improvement at 6 months
  • Patients reported satisfaction and confidence with the service provided by the physiotherapists (87% ICP and 73% UP) satisfaction in information provision and confidence in the practitioner
  • Patients improved in their health status over 6 months
  • The physiotherapy service was considerably more cost effective


Pilot Results

April 2014 – March 2015

The MSK results for the two practices: 555 patients were seen; n=219 ICP and n=336 UP

  • 71% (n=393) successfully managed by the MSK service (63%; n=138 ICP and 76%; n=255 UP)
  • 27% (n=152) referred into secondary care MSK Physiotherapy (35%; n=78 ICP and 22%; n=74 UP)
  • 6% (n=6) referred into secondary care: Orthopaedics (1%; n=3 ICP and <1%; n=3 UP)
  • <2% (n=9) referred back to their GP (<2%; n=4 ICP and <2%; n=5 UP).
  • Patient Satisfaction Questionnaires reported satisfaction and confidence with the service provided by the physiotherapists and an improvement in their health status
  • 3% (n=15) of cases necessitated Extended skills in requesting diagnostics (5%; n=11 ICP and 1%; n=4 UP)

Cost and savings

The physiotherapy service was considerably more cost effective, averaging £56.51 and £84.26 per patient at the Inner City and University sites compared with GP costs of £366.44 and £647.16 at the same practices.

Average number of appointments per patient

  Inner City Practice        University Practice
GP              2.22                 1.66
MSK Physiotherapy              1.22                 1.09


A comparison of referrals to secondary care (orthopaedic referrals) of the GPs pre-introduction of the MSK service (Jan – Dec 2013) and the service in its first year showed a significant reduction in referral rates.

Referral to orthopaedic secondary care

  Inner City Practice      University Practice
GP              16%              8%
MSK Physiotherapy               1%              1%


Nottingham CCG provides data to support calculation of the average cost for a secondary care referral to trauma and orthopaedics as £3,085 per patient, indicating a significant saving through the use of the MSK physiotherapy service.


The idea if efficacious- both from a safety perspective, a patient satisfaction perspective and from a clinical outcome perspective. There seem to be economic benefits. The implementation requires strong leadership, provider management and ideally an effective provider: commissioner relationship.