This guidance is relevant to musculoskeletal (MSK) first contact physiotherapists (FCPs) working within primary care, including private practitioners, who wish to request radiological investigations as part of their role.
Is requesting radiological investigations within the scope of the physiotherapy profession and the context of first contact physiotherapy?
Yes. Requesting investigations such as plain X-Rays, ultrasound or MRI scans as part of physiotherapy practice is within the scope of the physiotherapy profession. Clinicians working in triage/interface roles have been requesting imaging in this context as a Non-Medical Referrer (NMR) for a number of years.
Within the musculoskeletal context of practice, requests for diagnostic imaging form part of the comprehensive physiotherapy assessment of a patient’s presenting condition, and may be required in order to reach a differential diagnosis and/or to rule our serious medial pathology.More complex imaging, or ordering investigations outside the musculoskeletal context would need careful consideration in relation to professional scope. The CSP does not keep a list of techniques/modalities that fall within the profession’s scope of practice, instead we ask members to reflect critically on the scope and purpose of the physiotherapy management they are delivering (See Understand Scope of Practice) It is important to determine if you are working outside your professional scope as this can impact your insurance cover.
Is requesting radiological investigations within my personal scope of practice?
Yes, if you can demonstrate that you are educated, trained and competent in this aspect of practice, or where you are working as part of a formal training and/or development programme with appropriate supervision to acquire competence in this area.You must ensure you have completed any initial and ongoing locally required training in order to develop and maintain your competence in this area.
Can I be an FCP without this capability?
Yes. You can be an FCP even if you do not have the competence to request these investigations. However, you should be able to recognise the need for such investigations to be performed (See Section 3 of HEE Roadmap to Practice) and have mechanisms in place to allow you to make a referral to an appropriate practitioner to make the imaging request.
To maximise the benefits of an FCP service, it is optimal to have the same referral rights as primary care colleagues. An FCP should not expect additional referral rights to other professionals working within the primary care team.
Am I insured to order radiological investigations as an FCP?
Yes, although you must be clear who is providing your indemnity for this task. If you are fully employed within the NHS, your employer provides indemnity for your work. If you are self-employed you must ensure you have appropriate indemnity in place for your work. This may be through the CSP PLI scheme (subject to policy terms and conditions) or through the Clinical Negligence Scheme for General Practice. It is your responsibility to ensure you have the correct indemnity in place for your work.
Importantly, the CSP PLI scheme (a member benefit when CSP category B membership is maintained) only covers activities within the scope of physiotherapy practice profession (subject to the terms and conditions of the policy). Therefore, you must be clear that you are requesting investigations in the context of physiotherapy practice, which includes FCP roles.
It is important that your job description accurately reflects your role and responsibilities as an FCP and should specify if referring for radiological investigations is an expectation.
What training do I need to do?
Organisations may require Non Medical Referrers (NMRs) to undertake specific learning activities related to IRMER (The Ionising Radiation [Medical Exposure] Regulations 2017), which may include online learning or self-directed activity in order to be given referral rights for radiological imaging. You should liaise with your physiotherapy service and radiology leads to determine local requirements for learning and professional development.
In addition, IRMER regulations require employers to ensure that written protocols are in place for every type of radiological imaging practice. All healthcare professionals who request diagnostic imaging tests using ionising radiation should follow the protocols in place within their organisation to ensure safe referral for imaging (RCR iRefer: Making Best use of Clinical Radiology)
Further information about training recommendations
Examples of online training modules
- Royal College of Radiologists: iRefer
- e-learning for healthcare: Ionising Radiation (Medical Exposure) Regulations programme
What additional governance arrangements do I need to have in place?
Additional governance considerations include standard operating procedures (SOPs), NMR protocols or advanced clinical practice guidelines within the local Trust carrying out the imaging. Trust guidelines and protocols will sometimes include specific criteria on the appropriate imaging recommended for specific conditions.
You will therefore need to establish links with the local radiology department and follow the process to become registered with them as an NMR. This may require the agreement of a new pathway. If so, this shouldalso beestablished in conjunction with your senior managers and involve the GP practice or PCN where the FCP clinics are being delivered.
As with other investigations (e.g. blood tests) there will need to be robust governance to ensure results are acted upon even if the FCP is absent through planned or unplanned leave. If you are a private practitioner working as an FCP in a GP practice, you will need support from your GP lead to obtain referral rights within secondary care.
Does demand for radiological investigations increase with the implementation of FCP?
- Evaluation demonstrates an improved use of diagnostic capacity, with 3-5% cost reductions in plain X-rays and MRI scans ordered by general practice. There is an expectation that all FCP services will conduct service evaluation and it is highly recommended that FCPs audit their radiology referrals as part of this. This allows clinicians to critically review the clinical reasoning for referrals made alongside the findings of the investigation.
Can I interpret the results of radiological investigations as a FCP?
Yes. As with all areas of your practice you must be able to demonstrate that you are educated, trained and competent in this aspect of practice, or you are working as part of a formal training and/or development programme with appropriate supervision to acquire competence in this area
Interpretation of investigations requires more specialist training. In an FCP role, investigations will normally be returned to primary care with a report provided by the radiology department. This is the same process for GPs. More information can be found in the Royal College of Radiologists standards for interpretation and reporting of imaging investigations.