Theres never been a better time to start a self-referral service, Daloni Carlisle explains why.
You have read the report, seen the benefits and now you are wondering when you should introduce self referral in your NHS physiotherapy service. The answer has to be now, and here’s why. The first reason has to be for patients – more of which later. On a more practical level there are two other reasons to act now. The first is that the government has made it a priority for the NHS in England; and from next month primary care trusts will be looking to commission self-referral services. The second is that if you need help to get your service set up, then the CSP’s package of support materials, including workshops on implementation is ready now (see panel: We’re here to help). The government is clear about the benefits of self referral. As health secretary Alan Johnson said in October 2008 when he launched the Department of Health report on self referral to musculoskeletal physiotherapy: ‘GPs waste their own time managing patients with low back pain. Self referral does not increase demand. Patients access services quickly and are more likely to complete their treatment. In the long term, self referral is more cost effective.’ There’s also a push in the 2009-10 operating framework, which sets out the priorities for the NHS in England for the coming year. With the accent on access, it says: ‘New service models, including self referral to allied health professional services such as musculoskeletal physiotherapy, have improved patient outcomes and satisfaction, and reduced demand elsewhere in the system. ‘PCTs will want to consider such alternative models for other AHP and community services, where clinically appropriate, and promote their use to their local populations.’ In other words, physios’ ideas for new services should fall on fertile ground.
Then of course there are the benefits for patients. In addition to those cited above, the evidence shows self referral empowers patients to manage their own health. It lowers drug use by patients and therefore reduces the prescription bill to the NHS. People who self-refer to physios take less time off work and are 50 per cent less likely to be off work for more than a month, compared to those who use traditional GP referral. Those with low back pain go back to work five weeks quicker and have 40 per cent less recurrence. Currently 60 per cent of physiotherapy services in Scotland are self referral. The picture is less clear in the rest of the UK, with a survey by the CSP identifying 48 services. Ruth ten Hove, the CSP professional adviser who has taken the lead on self referral wants to see this rise rapidly. ‘I think this year there is a real window of opportunity for physios to push self referral forwards,’ she says. ‘With the inclusion specifically in the operating framework, it is now an imperative and I hope that will give physios improved confidence to talk with their commissioners about service redesign. I hope, by the end of 2010, all physio services will be on the way to offering some form of self referral. I know that is hugely ambitious, but I don’t think we will get another opportunity like this again.’
A crisis of confidence?
So just what is holding physiotherapists back? The CSP recognises that a lack of confidence may be part of the problem. ‘My feeling is there is a real demand for some practical support for members. Despite being given the green light to go ahead people are still reticent to get started,’ says Ms ten Hove. It is hoped that the CSP’s package of support will help address this issue. Some common myths about self referral may deter members (see panel: Debunking the myths). The most common is that self referral will increase demand, despite the evidence showing this does not happen, and waiting lists do not rise. Another myth is self referral costs more. The DH evaluation showed this is not the case. In the long term it can be more cost effective. Ms ten Hove points out that you can spend on money to establish services – for example by setting up telephone lines to take referrals – but you don’t have to. ‘It can be done within existing resources,’ she stresses.
With support to hand, what’s the best way forwards? Different self-referral models exist, each with their champions, and there are different opinions about how to ensure access and equity. The three programmes featured here all have different approaches: one offers a drop-in service and a phone triage service, another asks patients to hand in self-referral forms, while in the third patients phone up to make a booking and can be offered a drop-in session. These differences are understandable, as populations differ across the country. The key is understanding your population’s makeup and designing your service accordingly. In Greater Glasgow, self referral is up and running in more than 25 sites across primary and secondary care. Here, patients either phone in or drop in at specific times during the day. Some sites offer just phone in, others just drop in and some offer both. This, says Janice Miller, physiotherapy manager for West Glasgow community health and care partnership, depends on staffing levels, local needs and size of departments. She explains: ‘All patients are triaged by a physiotherapist, using a standardised form. From this triage we are able to obtain details of their problem and their health in general. The physio is then able to discuss if treatment is appropriate, advise them on the best way to help their problem, and transfer them to an appropriate department or service, if physiotherapy is not required.’ Patients requiring an urgent appointment are allocated this at the time of triage. Those patients placed on the waiting list are given advice and/or exercises, if appropriate, to help them manage their condition while waiting for their appointment. ‘The only doctor referrals we get now are where people cannot use the system for some reason, for example, because they do not speak English as a first language or are elderly or have a learning disability. We do also get medical referrals when there are very complex needs,’ says Ms Miller.
Pilot proves positive
Another success story comes from Sue Craven, physiotherapy manager at Darent Valley hospital in Dartford, Kent; one of the DH self-referral pilot sites. When the pilot started, only two GP practices were involved, now all are, and self referral is being rolled out across West Kent PCT. Patients fill out a self-referral form, and either post it or hand it in to the physio department. The form, which can be accessed online, in GP practices and from the physio department, works well, says Ms Craven. ‘We tested the questions carefully during the pilot and now we find we get good information. Patients take a lot of care. If forms are not filled in properly, then we ring up the patient.’ Importantly, the approach does not deter non-English speakers. ‘This area has a high percentage of non-English speakers, and the DH wanted to test out whether they would be disenfranchised by self referral. It did not happen, and referral rates from all parts of the population continued pretty much as normal.’ Gill Starling, superintendent physiotherapist at St Martin’s hospital in Bath, has been involved with self referral since 2005. Self referral operates in all three of the outpatients departments in the trust (Banes PCT), and there are physios in all the local GP surgeries, which patients can self-refer to as well. Patients ring the service and are given an appointment by reception staff. If their condition is urgent, they are seen within five working days. If not, they are offered a routine appointment (typically within five weeks). Of 1,632 referrals to Ms Starling’s department in April to October last year, 614 were self referral.
Patients more motivated
Ms Starling sees the approach as a major step forward for patients and physios. ‘Patients can be seen quicker, they can come back to the service more easily, they can book their own appointments, so we have fewer did not attends, and they love it.’ She notes that physios find it easier to discharge patients, because patients know they can ring up in the future for a follow up and/or a full assessment. ‘They [patients] are more in control and more motivated; so are more compliant. When patients are happier, physios are happier.’ Benefits affect others too, she observes. ‘The paperwork is easier for receptionists, GPs have less referral work to do and the DH is happy because of the reported long-term cost savings.’ A drop-in clinic, one morning a week, is now being trialled, where patients can come in for a short (10 minute) assessment and advice session. This is offered to patients who aren’t happy to wait five weeks for a routine appointment. This service ‘has gone down a storm with patients’.
Secrets of success
Garnering such positive results depends on making self referral work well, and over the years Ms Starling has learned a great deal about this. ‘I think the key to success is the manager,’ she says. ‘It needs to be led by a manager who finds it exciting. If your manager does not want to take it up, then it will be very difficult. I believed in it and made the staff believe in it too.’ Of course it is not just a question of belief. A good manager will be out there persuading partners such as the PCT professional executive committee and chief executive to roll it out, as well as getting the GPs on board, making sure there is thorough audit and monitoring and, yes, solving issues raised by physios. Ms Starling gives an example. ‘One of the worries our staff had was about patients not seeing a doctor first,’ she says. ‘We have addressed that with a very clear assessment form that asks about past medical history. They were concerned they might miss a fracture, so we have allowed them to order x-rays.’ She is also an advocate of constant reviews. ‘We had lots of reviews when we started and found, for example, that we were making urgent patients wait too long so we changed it.’
Face the challenges
Advocates of self referral do acknowledge there are challenges. ‘Our biggest challenge is around maintaining the advertised sessions during staff absence – sick leave, annual leave and so on,’ says Ms Miller. She adds that although the entire service was established within existing resources, sites that were historically under-resourced struggled to maintain the service. ‘We found physios were apprehensive at first, but they adapted pretty quickly,’ says Ms Craven. Positive patient experiences and constant communication helped this.
Talk to the GPS
All physios involved in self referral have plenty of tips for those wishing to emulate their success (see panel: Top ten... for self-referral satisfaction). Leading Ms Miller’s list is talking to GPs. ‘They can be very supportive and really like the benefits,’ she says. ‘Start small,’ adds Ms Craven. ‘Read all the evidence from the DH and from Scotland and talk to people who have already done it. Visit the GPs and the practices and explain the idea carefully. Keep talking to the GPs during the first stages of the project. Make sure your own organisation knows what is going on, especially the communications manager who will deal with press inquiries.’ Time and again there are consistent messages about what makes it work – from the single physio working alone in one GP practice to the physio manager at a large foundation trust now involved in a multi-PCT roll out: keep reviewing, keep auditing, keep on doing patient satisfaction surveys, keep talking to all the players from the receptionists to the physios to the GPs to the chief executive. These are precisely the messages the CSP will be sharing over the coming year as self referral is taken up more widely. As Ms ten Hove puts it: ‘I feel the combination of workshops and ongoing support might help people feel they have more opportunity and support to go ahead.’ The time is right: sow the seeds of self referral and you will be one of the lucky ones reaping the rewards for your patients, your service and your fellow physiotherapists. FL
Holdsworth L, Webster V. Patient Self-referral: A Guide for Therapists (2006), Radcliffe Publishing. Self-referral pilots to musculoskeletal physiotherapy and the implications for improving access to other AHP services www.dh.gov.uk/en/Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/DH_089516
Top 10... for self-referral satisfaction
Try these tips for self referral success:
- start small
- look at all the evidence
- use the CSP toolkit
- talk to people who have tried it
- decide what would work best in your area
- talk to the GPs before you start
- make a good clinical and business case to present to trust/PCT/practice-based commissioning boards
- keep everyone informed
- keep services under review and make changes as problems arise
- carry out audit and patient satisfaction surveys
We’re here to help
The CSP is supporting members implementing self referral in a number of ways:
The CSP is running 10 one-day workshops, one in each English region, in partnership with the NHS Institute for Innovation and Improvement. They are for clinicians and managers who want to know more about why and how to implement self referral. At each of them will be a local champion: someone with real experience able to give ongoing practical advice and support locally. Cost: £90 Details including dates and venues: can be downloaded from the CSP website.
The self-referral toolkit
The CSP self referral implementation toolkit (www.csp.org.uk/selfreferral and then follow link) includes: making the case for self referral which enables the user to assess their service against key performance indicators such as safety, timeliness, effectiveness, efficiency, equity, coordination and patient-centeredness. It also enables a dialogue between therapist and commissioner, in a language understandable to both are you ready for self referral? sets out the key steps which services need to engage with in order to implement self referral. It is in a question and answer format, and includes practical suggestions from those already engaged with self referral. There is an extensive section on how to maximise marketing and advertising opportunities data collection. This guidance is based on the experiences of those physiotherapists with expertise in data collection and the development of datasets. It includes a section on recommended baseline data, and what to collect if this data does not exist in the service. Based on the ‘vital signs’ recommended in the world class commissioning guidance, there is a standard data collection proforma for self referral. It has data fields, which include access, activity, outcomes and efficiency PowerPoint slides presentation that showcases the benefits of introducing selfreferral. This provides a basis for generating discussion with colleagues and key stakeholders patient leaflets and posters available to download from the CSP website. The leaflets can then be printed on to A4 paper or printed professionally in other formats
Debunking the myths
The evidence on self referral shows that:
- waiting lists will not rise
- it can be done within existing resources
- non-English speakers and other vulnerable service users can self refer
- men and women of all ages use the system equally
- it is safe
- physios are able to discharge patients in a timely way
- •self referral does not attract patients traditionally seen in the private sector
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