The role of the Advanced Practice Physiotherapist (APP) has been well established in our Rheumatology team for more than 10 years. However, following the semi-retirement of one of the medical consultants there has been an option to pilot Consultant-level Physiotherapy input to the Rheumatology team. This process of using allied health professionals to replace medics has been called “Practitioner Substitution” and is seen as an important part of improving care and patient outcomes whilst delivering the efficiencies the NHS needs. The aims of the pilot Consultant post were: to independently manage and streamline the pathway for the non-inflammatory / pain service in Rheumatology, to reduce wait times and to ensure a more inflammatory-heavy caseload for the remaining Rheumatology medical team.
A standard operating procedure (SOP) was written and agreed, with clear pathways for anticipated new patient assessment outcomes. The SOP also mandated the use of international recognised assessment and diagnostic processes for fibromyalgia. Referrers into the service were advised of the changes and were found to be supportive of this development. Weekly new patient slot numbers increased from 2 per week to 8 per week as the physiotherapy role changed from APP to consultant level. The pilot commenced April 2018; the first 12 months data were analysed to develop the case for a permanent post.
Since the start of the pilot the physiotherapist has seen 204 new patients who would have previously been seen by a consultant rheumatologist. Five patients have been transferred to the early inflammatory arthritis service, 4 have been referred to the endocrinology chronic fatigue service, and 5 have needed referral to the Pain Centre for more intensive, multi-disciplinary assessment and treatment. Eighty-three patients have received a new diagnosis of fibromyalgia, made using clinical judgement and the 2010 American College of Rheumatology diagnostic criteria. A similar number of patients with established fibromyalgia have had a fresh assessment, with new management plans agreed. Thirty seven patients have been discharged after initial assessment (with an updated, agreed management plan). Numbers of fibromyalgia patients in the general Rheumatology clinics have decreased, down from 10 a week to 1 or 2 per week. Patient feedback has been consistently good or very good. An unexpected benefit of this pilot has been a drop of referrals to physiotherapy due to patients accessing this input in their rheumatology new patient appointment.
Practitioner substitution offers a route to financial efficient improved patient care and outcomes. Appropriate triage has enabled a suitably trained and qualified physiotherapist to take over this cohort of non-inflammatory new patients. The SOP has allowed appropriate management of the patients and both timely handover of those needing care in other parts of the rheumatology team and referral to other specialities.
Cost and savings
Cost and savings have not been formally assessed as a part of this project. The substitution by a Consultant Physiotherapist for a role previously undertaken by a Medical Consultant must have provided savings to the rheumatology budget.
For patient benefit, staff satisfaction and financial prudence it is wise to use the right clinician in the right service. This pilot has shown that a suitably trained physiotherapist can manage a non-inflammatory rheumatology cohort of patients (replacing a medical consultant post) and appropriately identify those patients requiring management elsewhere.
Wider sharing of this project should enable others to consider advanced roles in their own services. This project also informs the future rheumatology physiotherapy competencies framework project.
Top three learning points
- Roles previously undertaken by medical staff in rheumatology can be performed by appropriately trained physiotherapists.
- Internationally accepted diagnostic criteria in combination with clinical judgement following detailed assessment do allow physiotherapists to diagnose fibromyalgia.
- Patient satisfaction and quality of care are key indicators of this projects success, the financial impact is less important.
This work was unfunded.
This work was presented at Physiotherapy UK 2019
For further information about this work please contact William J Gregory.
Wolfe F, Clauw DJ, Fitzcharles MA, et al. 2016 Revisions to the 2010/2011 fibromyalgia diagnostic criteria. Semin Arthritis Rheum. 2016;46(3):319-329. doi:10.1016/j.semarthrit.2016.08.012