Patients can self-refer in most places in Scotland and two-thirds of Wales, but just three in 10 CCGs in England offer that option in any form and there is one pilot scheme in Northern Ireland.
However, with primary care under enormous pressure and seeking new models of care that put patients in control, the case for making physiotherapists the first point of contact - whether working alongside GPs or in more traditional outpatient settings – has never been stronger.
- Giving patients the choice to be assessed by a physiotherapist as their first point of contact frees up GPs for other cases
- Musculoskeletal conditions alone account for upt o 30% of consultations in GP surgeries each year – more than 100 million appointments.
- When other conditions, such as frailty and women’s health, are taken into consideration, the potential impact for the NHS is enormous
- Self-referral for an MSK problem cuts costs for the NHS by an average of £33 per patient
- This represents a saving of up to 25%
- Savings also come through fewer investigations, such as scans and x-rays, and lower levels of prescribing
Improving patient outcomes
- Self-referral helps prevent acute problems from becoming chronic and reduces long-term pain and disability
- It reduces the time people are off sick from work
- It is also shown to reduce waiting times and improve patient satisfaction
Putting patients in control
- Self-referral is an important route into advice and treatment for the growing numbers of people with at least one long-term condition
- It enables individuals to feel confident to more effectively manage their own condition and live independently
- Giving patients the responsibility for their own referral is shown to cut did-not-attend rates and improve adherence to treatment plans
Putting self-referral into practice
Working alongside GPs
In West Wakefield physiotherapists are the first point of contact for patients with musculoskeletal pain and dysfunction.
The service, which has been running since late 2014 following a successful pilot, has expanded to six GP practices in West Wakefield and receives on average 900 referrals a month.
By upskilling reception staff to identify appropriate patients to be seen by physiotherapists, significant GP time has been saved.
The GP's view
Self-referral was rolled out across the Plymouth area in February 2015 after a successful trial.
Dr Gary Lenden, a GP from Plymouth and Clinical Lead for the Western locality of Northern, Eastern and Western Devon Clinical Commissioning Group, said:
'Being able to self-refer makes patients feel empowered, because they have the chance to say exactly what symptoms they are experiencing and how it is affecting them.
'It also means people can be seen quicker, which is more convenient for them and prevents chronic issues 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.'
The rapid access service
Patients refering themselves by telephone in the Torbay and Southern Devon Health and Care NHS Trust are offered an appointment with a physiotherapist within 72 hours.
The waiting time prior to the introduction of rapid-access/self–referral was up to 10 weeks. The service cut DNAs by at least 70% and reduced the number of follow-up appointments by more than 18%.
The drop-in clinic
Abertawe Bro Morgannwg University Health Board set up a walk-in clinic in November 2009 for immediate, face-to-face musculoskeletal assessment and advice.
The service runs for two hours each weekday morning and has led to a significant reduction in the volume of follow-up appointments and an overall patient satisfaction rating of 9.6 out of 10.
A ‘Physio Direct’ telephone service has since been established alongside the clinic for an hour a day to provide early advice and management for people with MSK problems.
Self-referral is long–established in Scotland and all health boards offer either a full or partial service.
Telephone triage is central to that, although many patients can also access services electronically.
NHS Tayside trialled the Musculoskeletal Advice and Triage Service (MATS), offering a telephone assessment by a physiotherapist to patients diverted from the national NHS 24 helpline.
By cutting the number of face-to-face follow-up appointments needed, the 39-week trial is estimated
to have saved the equivalent of 182 working days for the service.
It halved waiting times and achieved high patient satisfaction levels.
Won’t self-referral lead to a surge in referrals?
No. The evidence shows that unless there was a previously unmet need in the area, referrals do not increase significantly in the early stages of implementation and later level off.
Indeed, self-referrers are shown to need fewer appointments so activity levels can actually reduce.
A rise in referrals can also reduce demand in the longer-term if patients with minor problems seek treatment sooner before they can become chronic.
Aren’t there safety concerns?
No. Physiotherapists complete extensive training to identify red flags and would always refer a patient back to a GP if they had concerns.
Low numbers of complaints about physiotherapists to their regulator, the Health and Care Professions Council, demonstrate their high level of professionalism.
Self-referral has also been the primary route in to private treatment for decades, further demonstrating the safe, effective nature of the model.
The patient voice
Patient satisfaction was recorded as high during the Department of Health’s pilot scheme in England and feedback was positive.
'"Cost-effective in terms of my time and commitments.'
'I was pleased at the speed with which my self-referral was dealt with.'
'Constructive advice for self-help and management for living with arthritis.'
'In-depth consultation in a relaxed and unhurried way.'
'This service should continue to be offered for all patients.'
'Most appreciative of my 'personal exercise programme' given to me and explained.'
Recommendations for implementing self-referral
Understand existing referral patterns from local GPs
Establish baseline data for activity, cost and outcomes
Reduce waiting lists in preparation for direct access
Ensure all staff in the pathway understand and support the self referral scheme
Identify appropriate opportunities to signpost to self referral
Engage with development and design with online referral systems to allow self referral
More resources for GPs:
The CSP would like to thank the following people for their input: Rhoda Allison, Torbay & Southern
Devon Health & Care Trust, Christine Divers, Golden Jubilee National Hospital, Jacky Jones, Guys and St
Thomas’ NHS Foundation Trust, Karen Renforth, Northumbria Healthcare NHS Foundation Trust, Mary
Ross, Heart of England Foundation NHS Trust, Caroline Thomas, Torbay & Southern Devon Health & Care Trust.
- The Chartered Society of Physiotherapy, Freedom of Information Audit, 2014
- British Orthopaedic Association. Getting it right first time (GIRFT): improving the Quality of Orthopaedic Care within the National Health Service in England. London: British Orthopaedic Association; 2015. URL: www.gettingitrightfirsttime.com/report
- The Chartered Society of Physiotherapy. Musculoskeletal physiotherapy: patient self-referral. London: The Chartered Society of Physiotherapy; 2012. URL: www.nice.org.uk
- Holdsworth L, Webster V, McFadyen A. What are the costs to NHS Scotland of self-referral to physiotherapy? Results of a national trial. Physiotherapy. 2007;93(1):3-11
- Department of Health. The musculoskeletal services framework : a joint responsibility: doing it differently. London: Department of Health; 2006. URL: webarchive.nationalarchives.gov.uk
- Nordeman L, Nilsson B, Möller M, et al. Early access to physical therapy treatment for subacute low back pain in primary health care. Clinical Journal of Pain. 2006;22(6):505-11
- Department of Health. Self-referral pilots to musculoskeletal physiotherapy and the implications for improving access to other AHP services. London: Department of Health; 2008. URLs: webarchive.nationalarchives.gov.uk
- Torbay and Southern Devon Health and Care NHS Trust. Information supplied to CSP
- West Wakefield Health and Wellbeing. Information supplied to CSP
- NHS Tayside. Information supplied to CSP
- Abertawe Bro Morgannwg University Health Board. Information supplied to CSP
- Northern, Eastern and Western Devon Clinical Commissioning Group. Information supplied to CSP
- NHS London. Allied Health Professions MSK toolkit. 2012. ‘A significant saving to patients was experienced as they attended far fewer appointments which resulted in lower personal cost and less inconvenience’. MSK framework Assessment/Diagnosis p.28. URL: www.nras.org.uk
- The Chartered Society of Physiotherapy. What is physiotherapy? The Chartered Society of Physiotherapy URL: www.csp.org.uk