Hampshire MSK first point of contact
At the Arnewood Practice and Milton Medical Centre in Hampshire, any patient who presents to the signed-up GP practice with MSK pain will be referred to physiotherapy as the first point of contact.
Evidence demonstrates that self-referral into physiotherapy cuts costs by £33 per patient1 and reduces time off from work by 58%.2 The crisis experienced with the shortage of GPs led to a GP meeting with the Director of the service at Southern Trust NHS Foundation Trust, reaching agreement for a service review of musculoskeletal (MSK) primary care.
The Southern Health MSK service introduced two pilots in 2015:
- New Forest MSK practitioner – First contact seeing any MSK patient. 20 Minute appointments. Option to see either GP/Physiotherapist (PT), for advice and guidance and if required. CSI (steroid injection)/MRI&US/X-Ray/Referral on to secondary care.
- South East Hub model - Telephone triage in the morning followed by assessment by appropriate clinician (including a PT) in the afternoon.
The Advanced Practice Physiotherapists (APP) are autonomous clinicians trained to assess, diagnose, and manage MSK and other core elements of healthcare. They identify serious associated pathology through use of advanced practice and reasoning skills. They play a key role in well-being, exercise advice and promotion of prevention.
The MSK service is provided two mornings a week. It is a first contact practitioner role, but may also advise GP and vice-versa.
Our aims in establishing this MSK service were to:
- reduce onward referrals to secondary care
- improve conversion rates
- reduce unrequired investigations
- reduce onward rehabilitation referrals
- increase the number of individuals who are numbers able to self-manage
- increase number of exercise referrals
A key stakeholder in our work was Dr Nigel Watson, GP at Arnewood Practice and a Director on the south Hampshire Multispecialty Community Provider (MCP), part of Five Year Forward View. GPs across 27 practices are working with Southern Health NHS Trust in the partnerships, with the aim of moving services out of hospital and into the community. Other professionals that are part of the team include GP and practice nurses.
The employer is Southern Health NHS Foundation Trust and funding is via Vanguard, initially for a one year pilot. Patients access the service by receptionists offering those with an MSK condition, or pain that suggests MSK condition, the choice of the GP or MSK Practitioner.13 Self-referral evidence suggests people can self-identify. Each assessment/treatment has 20 minutes allocated, rather than the 10 minutes per GP appointment.
The GP and service lead provided training for the reception staff and materials to help them deliver their role. To raise awareness, the service is publicised to the local patient population by way of flyers in the practice.
Patients who saw a GP were more likely to receive prescription medication GP (41%) compared with those who saw a MSK Practitioner (8%).
An audit of both the GP and MSK Practitioner services were performed to demonstrate how many people are seen by each and what happens following their initial consultation.
In the time frame under audit:
- The GP saw 42 new patients and the MSK Practitioner 162.
- Patients who saw a GP were more likely to receive prescription medication GP (41%, n= 17) compared with those who saw a MSK Practitioner (8%, n=13).
- The majority of patients seen by the MSK Practitioner were discharged after the initial appointment with advice for self-management (74%, n=120).
|the GP||the MSK Practitioner|
|Patients discharged after the initial appointment with advice for self-management:||29 (69%)||120 (74%)|
|Prescription medication:||17 (41%)||13 (8%)|
|Referred to secondary care:||8 (18%)||42 (26%)|
Of the 162 patients seen by the MSK Practitioner:
- 38% (n= 62) were referred by a GP
- 62% (n= 102) directly booked via administration staff at each practice
In addition to the new patients, a further 35 individuals were seen by the MSK Practitioner in follow up appointments.
45 patients were referred onward; some for more than one service (X-ray, bloods etc).
Patients seen by the MSK practitioner service were invited to provide their feedback via a satisfaction survey. 25% (n= 40) patients completed this survey. All (100%, n= 40) were happy to be seen by a physiotherapist, felt the examination was thorough and were happy with the outcome of the appointment. Only one patients seen by the physiotherapist said they would have preferred to see a GP instead.
Cost and savings
Savings have been made through more effective referral of MSK patients. It is expected that we will see further savings through reduction of MSK patient passing to the GP caseload.
For the duration of the pilot, the physiotherapy service saw 162 patients.
Each session lasted 20 minutes at a cost of £2,922, as opposed to a GP cost of £3,529.
Of the 920 patients seen by GPs through the pilot period, 276 presented with MSK conditions.
It may be assumed that a steady increase of MSK patients straight to the MSK physiotherapy service will free up GP time to concentrate on medical patients.
However, calculations of current MSK throughput show that an increase to 2.9 WTE advanced physiotherapy practitioners would be required to meet the MSK requirements.
It is our view that a Band 8a is an obvious choice for this type of service as the physiotherapist definitely need to be experienced in complex assessment, with advanced practice skills to meet the need of the service.
An educational framework may be developed to support this service.
Other learning has been around:
- Greater understanding of local voluntary sector
- Enhance older person LTC management for MSK conditions
- Use of and link to falls prevention models
- Greater use of technology in self-management needs to be explored
- Physiotherapy to review and improve pathways – what we can and can’t change/improve/enhance
- Greater links to functional enablement
Top three learning points
- Holdsworth, LK, Webster, VS and McFadyen, AK, on behalf of the Scottish Physiotherapy Self-Referral Study Group What are the costs to NHS Scotland of self-referral to physiotherapy? Results of a national trial Physiotherapy - March 2007 (Vol. 93, Issue 1, Pages 3-11, DOI: 10.1016/j.physio.2006.05.005) http://www.csp.org.uk/physio-journal/93/1/what-are-costs-nhs-scotland-self-referral-physiotherapy-results-national-trial
- Black C. 2008. Working for a healthier tomorrow: Dame Carol Black’s review of the health of Britain’s working age population. TSO, London www.workingforhealth.gov.uk