Using ANGEL taxonomy to triage referrals in Ceredigion community physiotherapy


To evaluate whether service improvements could be made to our community physiotherapy service through clinical streaming of patient referrals using underlying principles complexity science to consistently deploy the most appropriate member of the physiotherapy team to meet the needs of patients and improve the effectiveness of our service.

Reduction of 33 weeks waiting list to 5
over implementation time of this project.


All community physiotherapy referrals screened by senior physiotherapists and streamed into two ´hubs´ 1. Long term conditions and 2. Rapid response/ mobility (undertaken in north and south of the county).

Patients were triaged upon information gathered by support workers and the complexity of work based upon information gathered, presenting condition and was scored numerically using the ANGEL taxonomy.

Within the RR / mobility stream, those patients presenting with low and stable angel scores and triaged to be suitable were delegated to band 4 physiotherapy support workers to undertake a medical mobility bundle. This bundle was created to ensure non-registered staff could safely undertake defined, specific core aspects of physiotherapy assessment for delegated patients within safe confines of this identified scope of practice, through the documentation and through their knowledge and skills. B4 SW were supported by a named band 6 physiotherapist to ensure clinical governance.

A reverse audit was undertaken retrospectively to analyse the ´safety net´ afforded through the angel scoring system and the appropriateness of delegated work to band 4 support workers at the first point of contact.


Reduction of 33 week waiting list to 5 weeks over the implementation time of this project. Increased in SW productivity during the time of the project.

Improvements in band 4 satisfaction in role due to consistency in their role and skill development. Through streaming our referrals and ANGEL taxonomy we were able to ensure the governance of delegated work to our band 4 physiotherapy support workers.

A reverse audit of all angel scores allowed us to review every medical mobility bundle delegated and proved that the score was directly linked to the delegation of these patients proving its efficacy as a method to support safe delegation and skill sharing between registered and non-registered professionals.

Cost and savings

Reduction of 33 week waiting list to 5 weeks over the implementation time of this project.


Complexity science can be utilised to understand and effectively stream our physiotherapy community work. Through using ANGEL to support a robust triage process we have developed an efficient and effective service model within our community teams.

During the time we undertook this service review our waiting list fell from 33 weeks to 5 weeks highlighting the importance of aligning the most appropriate member of the physiotherapy team to meet the needs of the person referred, to meet their needs quickly, efficiently and safely.

Complexity science and its application to physiotherapy has led to radical redesign of the physiotherapy service. This model is now being tested in various MDT meetings, on acute wards, a community hospital, a safe and steady falls prevention clinic, and integrated MDT acute / community triage (to support hospital flow), and across a whole physiotherapy service to re-imagine roles and even a new future profession required for a safe, sustainable and effective future workforce.

Funding acknowledgements

This work was funded by HDUHB Physiotherapy Service

Additional notes

This work was presented at Physiotherapy Uk 2018.