Physiotherapy First; Direct Access Physiotherapy Service
In West Cheshire, 36 GP practices host a physiotherapy service providing first contact by a MSK physiotherapist for any patient with a suspected MSK condition.
The initial three month pilot saw 754 patients, discharging over 50% with advice and exercises. One third were referred on for physiotherapy intervention and only 3% were referred for specialist assessment.
The service received a 99% feedback of good or excellent and freed up the GPs while saving money.
The GP practice-based physiotherapy service provides first contact by a clinical specialist MSK physiotherapist for any patient ringing the practice with a suspected MSK condition.
Up to 30% of GP case load relates to musculoskeletal conditions.1
The service provides rapid access to assessment and advice for self-management; referral on for further physiotherapy or specialist assessment. The service uses the normal referral pathways.
The service was developed following the successful implementation of a three month pilot service at Ellesmere Port.
The service, part of the Prime Minister’s Challenge2, was set up as a three month pilot from January to March 2015 and has received extended funding to July 2016, to use clinical specialist MSK physiotherapists in order to free up GP time for other medical problems. Within one geographical area encompassing 10 GP practices, physiotherapists operated from five of the GP practices premises, using the established reception staff and IT infrastructure.
The other half of the GP practices gave the patient a contact number to ring for an appointment in a physiotherapy department at a cottage hospital.
Our aims are:
- To facilitate patients to access physiotherapy services more quickly
- To remove the need for a GP appointment
- To improve outcomes for patients by getting the right specialist to provide the right service
- To allow GPs to maximise the time that they have to see frail and elderly patients and those with complex needs
- To improve the quality of communication between GPs and physiotherapists in individual cases
- To improve patient satisfaction with the physiotherapist service in West Cheshire
The 10 GP practices of the Ellesmere Port locality that formed the initial pilot site, audited their musculoskeletal caseload over a 2 week period. This was normalised to reflect practice population size and was used to allocate appropriate staffing resources. The three month pilot was set up to ascertain patient uptake and patient experience on the proposed service.
Initial project data for the pilot across the 10 GP practices of the Ellesmere Port locality included patient uptake, capacity, clinic outcomes and access to further pathways.
Patients access the service by ringing the GP practice or the central booking number. Training was given to the receptionists as this was paramount to the success of the project. The service is being publicised to the local patient population by use posters in practices and on voicemail of some of the GP practices.
The pilot was supported by a part time administrator.
Two band 7 Clinical Specialist Physiotherapists provided 30 minute assessment/treatment sessions (although this will be reviewed with a view to 20 minutes). Currently, they do not hold Supplementary or Independent Prescribing rights as the GPs felt happy to retain that role.
Both staff involved were very experienced and had done significant Advanced practice modules in MSK care areas. There is a close link with the MSK triage service (which allows access to orthopaedics, pain services, rheumatology, investigations, podiatry etc) and MSK physiotherapy.
The lead therapist for MSK also has a role in service development.
The employer is Joint Therapy Services and the project is funded by the CCG for a further 12 month contract. The subsequent patient and GP practice surveys, produced June 2016, was extended to include a cost-benefit analysis to demonstrate financial sustainability.
The team now meets its target of seeing around 1,000 patients per month, roughly a quarter of the GP MSK caseload.
The reports support the business proposal that cost benefits would be realised by saving GP appointments and by enhancing the investigations, prescribing and orthopaedic pathways.
During the three month pilot 754 patients accessed the service:
- 72% (n= 542) of appointment slots were utilised (40% appointments utilised in hospital)
- 3% (n= 23) referred to the Adult Musculoskeletal Assessment and Management Service, either for more specialist assessment or orthopaedic referral, realising a 23% (n= 173) reduction in referrals
- 6% (n= 45) were referred for medication review
- 3% (n= 23) were referred for investigations such as radiology or blood tests realising an 18% reduction on previous referrals
52% (n=392) patients were discharged with advice
1,897 patients responded to the satisfaction survey, attending 28 locations:
- 83% (n=1,580) reported the service ‘excellent’ and what they expected
- 98% (n=1,863) reported their issues addressed and the appointments convenient.
- 86% (n=1.580) report they would have seen a GP
- 90% (n=1,652) were not planning to see their GP (a further 7% n=132 had not decided)
- 99% would be happy to use the service for another MSK problem.
Patient comments included:
‘Excellent service - very happy to receive advice and a work sheet rather than just go away with a referral and a long wait. Hope the practice keeps this option.’
‘Very good system more knowledge of the problem with instant advice. Great.’
‘Fantastic to have this facility in the surgery thank you and I hope it continues into the future.’
‘I was extremely impressed with the thoroughness of the assessment. The therapist I saw was efficient, listened and I was more than happy with the outcome. The leaflets she gave me described the symptom's I'd been getting previously and I am now hopeful the exercises I've been given will improve my condition. I left the Medical Centre feeling relieved and confident.’
Excellent physio, could not have done better - brilliant way for practice to go.’
‘GP (understandably) hadn't really got to the crux of what was causing pain, and I didn't feel reassured.
Physiotherapist immediately identified the issues and has left me feeling confident about what I need to do to try to improve it, and what happens next if it continues.
‘It was really helpful to have an assessment and advice on how to (hopefully) sort the problem out without a long wait. I can hopefully by following the exercises, sort out the problem myself without needing a further referral to Physiotherapy which is just great.’
GP practice feedback June 2016
GP satisfaction is very positive. 71 GP practice team members responded, of which 69% were GPs.
- 90% scored the benefits of the PhysioFirst service to the practice at 8/10 and above (the other 10% at 7/10).
- 95% (n= 64) stated that the service met their expectations
- 96% (n=65) reported the service saves GP time, allowing GPs to see more appropriate patients (87%, n=60).
- 97% (n=67) felt that the service improves care for MSK patients
‘Physiotherapy First helps us to keep going. We are so busy and at least we know that the musculoskeletal patients will be dealt with appropriately’
‘Having Physiotherapy First physio’s means that we do not have to use the usual diversion tactics of ordering X-rays or prescribe medication’
‘Physio first has made a big impact on our workload and greatly improved the MSK advice available to our patients. I think it has reduced our Adult Musculoskeletal Assessment & Management service referral rate and helps to 'nip things in the bud' by seeing them early rather than patients waiting months for physio. I suspect it also reduces our analgesia prescribing. Should we lose this service it would be a great loss to general practice and a backward step away from a more multidisciplinary approach.’
‘Physiotherapists have more knowledge and assessment skills in this area than the average GP. They can do a more thorough examination and give prompt useful advice to sort out the issue before full disability arises.’
‘This is clearly the way forward to reduce workload for GP's and help patients-physios are MUCH better than us at giving an accurate MSK diagnosis and then a treatment plan.’
Practice Manager comments: ‘If the service was stopped thought would have a great impact on the workload for the Doctors, currently the receptionists direct patients to the physio first scheme rather than the patient having to see the doctor first. It has been a great success at our practice.’
Cost and savings
The Band 7 physiotherapy appointments are currently 30 minutes, with a review planned to look at reducing the sessions to 20 minutes. The service is almost cost-neutral compared with GP appointments of 10 minutes, but savings over a six month period were:
Over the three month pilot 754 patients accessed the service, seeing physiotherapists rather than their GP.
- Plain x-ray referrals for spinal and knee problems have decreased by 18% across the Ellesmere Port area in the period between May15-Oct15, when compared to the same period in the previous year (value £4K over a six month period)
- Orthopaedic referrals have decreased by 22.9% from the Ellesmere Port area (value £17K over a six month period)
- 52% (n= 390) Over half of the patients were discharged with advice
- 34% (n= 256) were referred to physiotherapy
- 3% (n= 23) were referred to the Adult Musculoskeletal Assessment and Management Service, for either a more specialist assessment or to access Orthopaedics.
- 6% (n= 46) were also referred for a medication review
- 3% (n= 23) were referred for investigations such as radiology or blood tests
This initiative allowed a business proposal forecast extrapolated across Western Cheshire to report an anticipated saving in the region of £625K / year through:
- A reduction in plain X-rays
- A reduction in orthopaedic first appointments
- A reduction in GP appointments for MSK conditions
We have altered/changed the location of the service since start up. For all the practices involved in the pilot, we are now providing the service solely from their premises rather than from the central hub. Patients being seen at the central hub were a lot more likely to expect physiotherapy treatment. We found that patients in GP practices were a lot happier to walk away with advice and exercises.
If we would be starting the service again we would change the way we backfilled. We used current MSK staff which we backfilled with temp staffing etc. It had a detrimental effect on pressures within MSK.
Band 7 or 8a would be best for this type of service (8a if prescribing and ordering more complex investigations).
We increased the data collection from pilot to the year-long service to better deliver cost-benefit analysis to demonstrate financial sustainability for the CCG reports.
Top three learning points
- Department of Health (2008) The Musculoskeletal Services Framework; A joint responsibility: doing it differently. DH, London. http://webarchive.nationalarchives.gov.uk/20130107105354/http:/www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4138412.pdf
- The Prime Minister’s Challenge Fund: https://www.england.nhs.uk/wp-content/uploads/2015/10/pmcf-wv-one-eval-report.pdf