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The straight Story

Self-referral services are springing up countrywide. Catherine Blackledge tracks their progress

A message is appearing. You can see it in pharmacies, libraries, GP practices, sports centres and gyms, government offices, supermarkets and health fairs. It can even be read about in the local paper. This news is coming from many directions - Glasgow, Cornwall, Gateshead and Tamworth - to name just a few. Its meaning, though, is direct. It is: anyone in these areas can access NHS physiotherapy without seeing a GP or other health professional first for a referral. There's also good news within the message, as evidence shows enabling people to go straight to a physiotherapist improves patient care, reduces GP workload and saves money.

Self-referral schemes, just like the advertisement routes followed, differ slightly from location to location depending on local population need and staffing demands. GP referral patterns and possible waiting lists also inform the type of service offered. The majority - but by no means all - focus on musculoskeletal conditions. In some cases telephone-based triage services - often referred to as PhysioDirect - are offered. In others drop-in triage clinics are preferred, or patients are asked to fill out self-referral forms at the GP's clinic and from this a physiotherapy appointment is made.

The latter is the format used in the largest study to date of self-referral, analyses of which were published recently in the journal Physiotherapy, as reported in Frontline (1 March). Alternatively, patients can phone a service practice manager to make an appointment directly. Many of the services offering wider access to physiotherapy are still at a pilot stage. Some, though, are further along. The self-referral service led by superintendent Gill Starling at St Martin's Hospital, Bath and North East Somerset primary care trust (PCT) has just completed a six-month pilot.

During the pilot, patients phoned the service's reception staff to make an appointment. Gill explains: 'As our waiting list for routines is four weeks we did not feel we needed a triage system. On phoning the department, patients are asked a brief series of questions by the reception staff. These include: "Have you already been seen by your GP for this problem? Have you had physiotherapy for this problem previously? When did the problem start?"

'Reception staff are provided with a flow chart with specific questions that leads to three possible outcomes: the patient is given an urgent appointment, a routine appointment or they are advised: "You will need to discuss this with the physiotherapist. May I take your number and they will call you back".' Gill's team chose to advertise their self-referral service to patients via the local council newspaper delivered to every household in Bath and northeast Somerset. They also placed posters in GP surgeries. These read 'Do you need physiotherapy for aches and pains in joints and muscles?' Patients are then invited to arrange an appointment by phone on either Tuesdays or Thursdays between 10am and noon or 2pm and 4pm.

For anyone planning on starting up a similar service, Gill has two pieces of advice. She says: 'Keep all your staff aware of the proposal from the start,' and adds: 'If you have competent reception staff it is easier when asking the patients these questions.' Moving north, Janice Miller is the lead physiotherapist at Maryhill and Woodside health centre, Glasgow. The service began a self-referral pilot in March 2000. At this stage, patients came into their GP practice and filled in a self-referral card, which they handed to reception staff. Physiotherapists made a decision regarding treatment from what the patient had written down. However, following the completion of the pilot stage a decision was taken to try a different approach. Janice explains: 'It was felt a lot of patients could manage the problem with the correct advice and information... we could start right from that point of contact.'

Now patients either phone in or drop in to the triage clinic. The phone line is available Monday to Friday mornings and patients are advised to leave a message on the answer machine, if for any reason there is no answer at these times. In these cases, a physiotherapist phones them back within two working days. If a patient is unable to be seen at a drop-in clinic because it is full, they are offered the choice of a phone triage consultation or details of the next drop-in session. Janice notes: 'People are sometimes quite ignorant about what they should do... if they wake up with back pain... or they've got a twinge... they don't know what to do... They say how great just to be able to phone and find out.'

Following contact with the triage service all patients receive a follow-up letter reiterating the triage session's outcome and providing contact details if further help is needed. The service is now running in primary and secondary care throughout Glasgow. This involves 21 health centres and six hospitals and a population of 800,000. Adverts can be found in pharmacies, health centres and sports centres, as well as leaflets and posters in GP surgeries.

A recent audit of two sites shows 26 and 28 per cent of referrals are true self-referrals - where the patient does not go via the GP or other healthcare provider. Patient and GP satisfaction questionnaires show a positive response to the service. The standards for the service are now in the process of being audited across the whole of Glasgow.

Returning down south, Adam de Gruchy is an extended scope practitioner (ESP) based in Islington PCT, London. Here the physiotherapy service piloted two approaches to self-referral - face to face drop-in clinics (a 20-minute appointment assessing and advising on further management) and a telephone triage phone line. Posters and information leaflets were placed in GP practices and local gyms, and GPs were advised of the services by letters and emails.

'The drop-in clinics were hugely successful,' says Adam. 'We found 35 per cent of patients just wanted advice and exercise and only three per cent went on to secondary care or back to the GP for further investigations (several cases were suspected cauda equina syndrome). Three senior clinicians undergoing ESP training staffed it. GPs loved it.' However, he adds: 'The phone line was not very useful at all and generally patients called to try and make an appointment or find out when they could drop in... seems people like to see a face rather than hear a voice.'

Following the pilot, Islington PCT is planning to take forward the rapid access clinics but not the phone line. There will also be a few changes. As Adam notes, GPs loved the idea of self-referral. 'They wanted the service to have access to diagnostics and direct referral to secondary care so things weren't bounced back to them.' This is now being worked on, so eventually, with the appropriate training, physiotherapists can refer for blood tests, x-rays, ultrasounds and MRI scans without needing to go via the GP.

But it isn't all plain sailing. Adam and the Islington team are currently struggling with some of the aspects of how to deal with the number of people arriving at the drop-in clinics. 'Due to staffing problems we find it very stressful as we are getting a lot of verbal abuse from people,' he comments. There are three reasons for this: the clinics fill up and people have to come back another day; people arrive at the start of the clinic and the next appointment means waiting an hour; and people complain they want to book a set time. Adam notes the latter is offered but people generally have to wait about six weeks for this due to the waiting list. He mentions problems also stem from a lack of admin staff.

Adam's advice for fellow physios is to start with GP education. 'Meet with GPs face to face if possible to make sure they are clear on the purpose of the clinics and they are aware of how to use them appropriately... We are in the process of setting up a website where GPs and patients can download info, and we are getting on the GP education programme to educate on best practice of screening/managing musculoskeletal conditions.'

He adds: 'A lot of people will settle with advice and analgesics if given the correct information. Help GPs out with that and you will lower the demand on your service and then you will get more appropriate referrals. I wish we had done that first.' The message here is clear - self-referral can be a fantastic success story - as long as you are prepared and know your patient population. But remember, preparation takes time: both calculating what the expected demand will be and then monitoring the actual demand. It is also about finding the right balance between patient and staff needs. Do all of these, though, and your straight story could transform access to physiotherapy.

Be prepared

Nine months ago Frontline sent out a request via iCSP for information regarding self-referral services. We spoke to over 30 physiotherapists - these are some of the most common words of advice - from those with the experience

'Look thoroughly at the geographical area and ethnic mix of patient population to see if this type of scheme would be appropriate or whether adaptations would be required. Go on a site visit to an existing scheme and look at the day-to-day operation of telephone triage in order to take the most effective aspects back to your service environment. Maintain effective communication links, both with the GPs involved and the physio staff who will be operating the system, at all stages of planning and implementation,' Virginia Whiteley, senior I, PhysioDirect, Huddersfield Central & South Huddersfield PCTs.

'Visit a centre already using the service, get copies of the flow charts used, ensure you have excellent advice/exercise sheets at hand, ensure you allow enough admin time. The paperwork can be quite time consuming,' Sarah Wylson, superintendent physio, Chesterton Medical Centre, Cambridge, piloting PhysioDirect service and weekly drop-in advisory service.

'Start with a pilot scheme in forthcoming surgeries, have an initial contingency plan for referrals being high but expect this to fall to normal rates within a month or two and not to blanket introduce and to publicise,' Fiona Ottewell, head of physiotherapy, Gateshead Health foundation trust, piloting telephone triage and self-referral where patients phone practice manager to make an appointment.

'The more people staffing the service the better, a pool of a minimum of five physios is needed to run a five-day service taking into account annual leave etc. Staff levels need to be maintained. GPs need to be fully educated about the service so patients don't phone up just to book an appointment, or expect it to be fast tracked,' Isobel Weaver, running PhysioDirect service at West Cornwall Hospital, Penzance.

'Do the background work first before you open the lines, progress the advertising carefully. We sent laminated posters to each GP practice twice and still some have never heard of the service,' Gill Cotterill, superintendent physiotherapist, Royal Oldham Hospital, pilot project of telephone triage service.

Further information

  • See the NHS Forth Valley website:   www.nhsforthvalley.com
  • Holdsworth L, Webster V, McFadyen A and the Scottish physiotherapy self-referral group [2006] 'Self-referral to physiotherapy: deprivation and geographical setting. Is there a relationship? Results of a national trial', Physiotherapy, 92, 16-25
  • Holdsworth L, Webster V, McFadyen A and the Scottish physiotherapy self-referral group [2006] 'Are patients who refer themselves to physiotherapy different from those referred by GPs? Results of a national trial', Physiotherapy, 92, 26-33
  • Holdsworth L and Webster V [2004] 'Direct access to physiotherapy in primary care: now? - and in the future?', Physiotherapy, 90, 64-72

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