Physiotherapy in primary care transforms lives
Demand is increasing as the population is ageing, working longer and living with more long term conditions. At the same time there is a UK-wide shortage of GPs.
A greater role for physiotherapy in primary care offers an immediate solution, both as part of core teams within general practice and as providers of specialist rehabilitation in the community.
The physiotherapy workforce in the NHS, the social enterprise and voluntary sector and private practice can be utilised within primary care to yield system-wide benefits – reducing the pressure on GPs and making savings in secondary care.
Physiotherapists in primary care transform people’s lives by:
- Reversing conditions
- Improving quality of life
- Keeping people out of hospital
- Reducing disability
Physiotherapy: a profession to drive change
Physiotherapists are autonomous practitioners able to assess, diagnose, manage and discharge patients.
Trained to identify possible serious pathology in the same way as doctors, many physiotherapists are also qualified to administer injections or prescribe drugs without medical approval.
Physiotherapists are physical activity specialists and patients say that they trust the advice they give to support them to lead a healthy lifestyle.(2)
The net benefit of using these skills for the NHS is to reduce demand on health and care services. It keeps patients well and independent,empowering them to manage their own conditions. It reduces unnecessary investigations, hospital admissions and length of stay.
An expansion of physiotherapy within primary care provides an immediate solution to GP shortages and delivers the transformation of primary care needed for a sustainable health system tailored to modern population needs.
FACT ! Physiotherapists run pulmonary rehabilitation classes for COPD patients. COPD patients in these services are less likely to be admitted to hospital, spend less time in hospital and are 26 per cent less likely to be readmitted following discharge.(1)
Physiotherapy in general practice
Musculoskeletal (MSK) conditions make up to 30 per cent of a GP’s caseload. This rises to 50 per cent of a GP’s caseload for patients over 75.(5)
Yet 85 per cent of those do not need to see a GP. This means millions of appointments could be freed
up for other patients each year if patients were offered a choice of professional as their first point of contact.(6)
GPs are now choosing to bring in physiotherapists to work alongside them as the first contact practitioner for their MSK patients. The potential value and impact of extending this approach to service delivery is significant.
Physiotherapists seeing patients at an earlier stage, when they first present with a problem, enables prompt treatment. This is more effective and better value. It prevents short term problems from becoming long term conditions. If left these can often draw on expensive NHS resources and reduce individuals’ quality of life.
Physiotherapists in primary care have a safe record in identifiing serious pathologies requiring further investigation.(6)
MSK patients report high levels of satisfaction with direct access to physiotherapy. Evidence shows, they are confident in the information they receive and the support to self-manage their conditions.(6)
Physiotherapists working in GP practices have been shown to:
- Reduce referrals to secondary care orthopaedics
- Reduce unrequired investigations (x-ray, MRI etc)
- Reduce onward referrals to physiotherapy in community and secondary care
- Increase the number of patients able to self-manage effectively l Increase the number of referrals to leisure centres and other forms of physical activity prevention.
AHP Suffolk have reduced hip and knee replacement referrals by 40%. Of the patients who are referred, almost 100% required surgery.(3)
Patient self-referral allows people to access physiotherapy directly without the need to see a GP first.
Direct access through self-referral has been fully evaluated. It is recommended by NICE for England, Wales and NI and by the Scottish Government.(10,11)
Availability is currently inconsistent but patients can self-refer for a musculoskeletal condition, such as back pain, in most places in Scotland and two-thirds of Wales, but just one-third of England, and a single pilot service in Northern Ireland.(6)
It isn’t only MSK patients who would benefit from being able to self-refer. Evidence from other physiotherapy services, such as continence, also show similar positive outcomes.(12)
Where self-referral is offered to patients it:
- Cuts costs for the NHS by an average of £33 per patient, and further savings from a reduction in rates of prescribing – that’s a saving of up to 25%(8)
- Cuts waiting times for patients
- Improves health outcomes – it helps prevent acute problems from becoming chronic and reduces long term pain and disability
- Reduces the time employees have to take off work – cutting average time off by 58 per cent(9)
- Puts patients in control – it enables individuals to manage their condition and live independently.
Betsi Cadwaladr University Health Board
A pilot in Betsi Cudwaladr, north Wales, with two physiotherapists working across four GP practices.
Impact: in the first 6 months has seen 1525 patients who would normally have seen the GP. Only 23 of these required any input from the GP. A 12% reduction in secondary care referrals.(3)
Helen Griffiths a GP Practice Manager within the pilot said “It has made such a difference having the physios in the practice as it freed up a lot of appointments that would normally have been seen by the GPs. I really do think it’s a fantastic service.”(4)
South Lakeland GP practice, north-west England
A physiotherapist joined the practice team to assess, diagnose and triage MSK patients.
Impact: 168 GP appointments freed up in the first three months, translation of orthopaedic referral to operation increased to 99 per cent, number of steroid injections within the practice nearly doubled, preventing/delaying operations and generating income for the practice.(3)
“GPs within the West Wakefield Health and Wellbeing Project have developed a hypothesis that 50% of a GP’s workload could be undertaken by other staff. I want physiotherapy to form a significant part of this 50%” Dr Chris Jones, Programme Director, West Wakefield Health and Wellbeing Project (Vanguard site)
Torbay and Southern Devon
Torbay and Southern Devon Health and Care Trust in South West England provides a rapid access self-referral service for patients. Patients refer themselves by phone and are offered an appointment with a physiotherapist.
Impact: waiting time cut from 10 weeks to within 3 days for 90% of patients, ‘did not attend’ rates cut by at least 70% and number of follow up appointments cut by 18%.(7)
Dr Gary Lenden, Plymouth and Eastern and Western Devon CCG
Dr Gary Lenden, a GP from Plymouth and Eastern and Western Devon CCG on the roll-out of self-referral to physiotherapy in Plymouth in February 2015..
“Being able to self-refer makes patients feel empowered… people can be seen quicker, which is more convenient for them and prevents chronic issues from 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.”(7)
NHS Tayside, Scotland
Self-referral has allowed physiotherapists to manage MSK patients without GP intervention. Physiotherapists can request diagnostic tests, administer injection therapy, or refer onward to secondary care as required.
Impact: Reduced pressure on GPs. Improved orthopaedic referrals saves consultant time. £151,000 annual saving to NHS Tayside just from physiotherapists rather than consultants or GPs administering corticosteroid injections.(3)
Hope Street specialist service
Hope Street Specialist Service at the North East Lincolnshire Care Trust in East Midlands is a one-stop falls prevention and respiratory rehabilitation programme run by multi-disciplinary teams.
Impact: over four years the programme has seen an 8 per cent reduction in visits to A&E and 13 per cent reduction in hospital admissions for people who have fallen, saving on average one hospital admission and £2600 per patient.(4)
NHS Greater Glasgow community respiratory team
NHS Greater Glasgow Com munity Respiratory Team. A physiotherapy-led multidisciplinary team was established in 2013 to support patients with COPD, promote independence in self-management and reduce the impact of their disease. The scheme works closely with GPs, providing an alternative pathway to hospital admission.
Impact: 90% of urgent referrals seen within 1 day, 80% of these patients avoiding hospital admission and an overall reduction in hospital admissions of 19%, with an average saving of £3000 for every patient not needing to be admitted. (4)
South Kent Coast CCG
The Proactive Care, South Kent Coast CCG in the South East of England. Patients are provided a 12-week package of support t o improve the management of their condition from a multidisciplinary team including physiotherapy.
Impact: In the first year a 15% reduction in A&E attendance, a 55% reduction in non-elective admissions and a 75% reported improvement in functional quality, patient reported anxiety about their condition more than halved, and an overall savings of £225,938.(13)
FACT ! If everyone 65+ at risk of falling was referred to physiotherapy within the community 225,300 falls that currently mean patients end up in A&E would be prevented. This would save the NHS £331million every year. Every £1 spent on physiotherapy produces a £1.50 return on investment.(14)
Improving rehabilitation and prevention in primary care
Patients can make great progress with intensive rehabilitation in hospital only to see their progress reversed due to long waiting times for rehabilitation in the community, if they are able to access this at all.
Half of hip fracture patients are left with a permanent disability and only 30 percent make a full recovery, for instance. Many more could if they were to access more rehabilitation, in particular in the community.(5)
Enabling easy access to specialist multidisciplinary teams in the community can reduce the revolving door of hospital admissions for older people and those with long-term conditions.
Falls and COPD among older people are two of the main reasons older people are admitted to A&E, secondary care and need social are in the community. They are also two areas where improvements in primary care would have a major impact.
More resources for GPs:
- Seymour JM, Moore L, Jolley CJ, et al. Outpatient pulmonary rehabilitation following acute exacerbations of COPD. Thorax. 2010;65(5):423 8.
- Public Health England, Royal Society for Public Health. Healthy Conversations and
the Allied Health Professions. London: Public Health England; 2014. https://www.rsph.org.uk/en/policy-and-projects/areas-of-work/wider-publi...
- Unpublished data from the CSP s Innovative Practice Service Examples project. 2015.
- NHS Wales. Advanced MSK physiotherapists - living healthier, staying well.
- Briggs T WR. Getting it right first time (GIRFT): improving the quality of orthopaedic care within the National Health Service in England. London: British Orthopaedic Association; 2015. http://www.gettingitrightfirsttime.com/downloads/briggsreporta4_fin.pdf
- Ludvigsson ML, Enthoven P. Evaluation of physiotherapists as primary assessors of patients with musculoskeletal disorders seeking primary health care. Physiotherapy. 2012;98(2):131 7.
- The Chartered Society of Physiotherapy. Physiotherapy Works for self referral. London: The Chartered Society of Physiotherapy; 2015. http://www.csp.org.uk/professional-union/practice/your-business/evidence...
- Holdsworth LK, Webster VS, McFadyen AK. What are the costs to NHS Scotland of self referral to physiotherapy? Results of a national trial. Physiotherapy. 2007;93(1):311.
- Department of Health. Self referral pilots to musculoskeletal physiotherapy and the implications for improving access to other AHP services. London: Department of Health; 2008. http://webarchive.nationalarchives.gov.uk/20130107105354/http:/www.dh.go...
- The Chartered Society of Physiotherapy. Musculoskeletal physiotherapy: patient self referral. London: National Institute for Health and Care Excellence; 2012. http://arms.evidence.nhs.uk/resources/qipp/29492/attachment
- Scottish Government. Allied Health Professionals Musculoskeletal Pathway Minimum Standards: a framework for action 2015 2016. Edinburgh: Scottish Government; 2015. http://www.gov.scot/Resource/0047/00476937.pdf
- The Chartered Society of Physiotherapy. Project to evaluate patient self referral to women s health physiotherapy pilot sites. London: The Chartered Society of Physiotherapy; 2013. http://www.csp.org.uk/publications/project-evaluate-patient-self-referra...
- Kent Community Health NHS Trust. The Human Touch, Transforming Community Services in Kent. Service in the spot light: Pro Active Care: Long Term Conditions.Maidstone: Kent Community Health NHS Trust; 2013. http://www.kentcht.nhs.uk/EasySiteWeb/GatewayLink.aspx?alId=287493
- The Chartered Society of Physiotherapy. The falls prevention economic model.London: The Chartered Society of Physiotherapy; 2014. http://www.csp.org.uk/documents/falls-prevention-economic-model