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Self-referral to physiotherapist pays off

Self-referral to a practice-based physiotherapist can save GP appointments, cut prescribing costs, and reduce secondary care referrals, write Beverley Haworth and Dr David Whittington

Self-referral to a practice-based physiotherapist can save GP appointments, cut prescribing costs, and reduce secondary care referrals, write Beverley Haworth and Dr David Whittington

Two GP practices in Tower Hamlets, east London, ran an 18-month pilot believed to be the first contemporary trial of self-referral for physiotherapy within a multicultural and socio-economically diverse setting. The positive results are now forming the basis of long-term plans to roll out a locality-based service.

Research carried out in Scotland showed self-referral decreases waiting times, among other benefits. At the initial stage of the Tower Hamlets pilot, outside Scotland, self-referral was available in the private and sports sectors but not widely available in the NHS.

A bid for the pilot was made in March 2004 and approved the following month. The Neighbourhood Renewal Fund (NRF), which was working with Tower Hamlets PCT to improve the health and well-being of the local population, provided funding to cover salaries, advertising, training and equipment, and the pilot was launched in September 2004.

METHOD

The service took six weeks to start up, during which several meetings were held between physiotherapists, GPs, nurses and reception staff. The service was advertised via posters, word of mouth, practice newsletters and practice staff.

In each of the 8,000-patient practices,

a physiotherapist was based to act as a first-contact practitioner for patients with musculoskeletal problems. Seven half-day clinics ran per week. Patients self-referred or were directed to the physiotherapist via telephone triage, without the need for GP consultation. An appointment was usually given the same day or within two days.

The close working proximity of the physiotherapists and GPs facilitated appropriate decision-making on complex patients. Those requiring secondary care could be referred without need for further GP consultation.

DEMOGRAPHICS

The demographic data and clinical information for both practices correlated well (see table opposite). There was a greater uptake by females, lower back pain was the most common complaint and patient age ranged between 16 and 92. Contrary to expectations that self-referral would generate more acute patients, 59% of patients had symptoms of greater than three months' duration.

A wide cross-section of cultures accessed the service, in line with local census findings. The 14 ethnic categories included white English, black British, Bangladeshi and white Turkish. Existing practice-based interpretation services were available to overcome any language barriers.

RESULTS

Initially referrals rates increased rapidly due to unmet need. Overall, the pilot provided quicker access to treatment, affording early intervention, prevention and self-management. The number of treatments needed was reduced and the need for post-treatment medication fell. The impact of physiotherapy was measured using a validated goal attainment scale for function, and Visual Analogue Scales (VAS) measuring subjective symptom severity.

A change of 20mm on VAS scores is regarded as clinically meaningful; the pilot showed average improvements in symptoms of 63mm. Eight in 10 patients achieved their agreed functional goals.

Audits of patients and GPs also showed high satisfaction with the service.

Key results for patients

• All patients seen within one week.

• An average of two-three treatments required per patient, compared with five-six in previous service.

• 87% of patients discontinued use of medication post-treatment, thereby preventing complications associated with prolonged use of NSAIDs and analgesics.

• Of the 58% of patients in paid employment, 94% did not need to take sick leave for their condition.

• No re-referral for the same problem over a 12-month period.

• 95% satisfaction rate among service users.

• 95% of patients felt they had learned how to manage their condition and when to consult a physiotherapist.

• Successful implementation in a culturally diverse population, uptake in line with local census findings.

• Increased access for a group with previously unmet need.

In the absence of the service, nearly three-quarters of patients (74%) said they would have visited their GP, 10% would have sought osteopathy, 10% would have done nothing, while 6% would have gone private.

All patients agreed they saved time booking directly with the physiotherapist, found the practice location more convenient than hospital and would use the service again. Comments received about the service include:

‘The self-referral scheme should be extended to other areas.'

‘I found the service very effective, as with sports injuries time is of the essence, and in the past I have had to wait for one to two months.'

‘Appreciation that this facility is available at my practice. I've been treated sooner than at the hospital and it helps that the therapist has access to my notes.'

Key results for service providers

• Minimum saving of 477 GP appointments per year, based on a physiotherapist working 3.5 days in a practice, consisting of the equivalent of seven GPs.

• Minimum prescription cost saving of £4,000 per quarter based on an 8,000 population practice.

• 10 fewer secondary care referrals per month, equivalent to the cost of one full-time physiotherapist per practice per year.

• Improved communication links within and between primary and secondary care providers.

• Quick, effective and appropriate implementation of integrated care pathway.

GPs very positive about impact of the service

• 95% said they were confident in the physiotherapists' ability to accurately diagnose and appropriately manage musculoskeletal conditions.

• 95% had confidence in the concept of physiotherapists acting as first contact practitioners.

• All unanimously agreed the self-referral system should continue.

GP comments about the service

‘Patients have all commented that this has been a great addition to the services offered at the practice.'

‘Seems to be working well. It will take time for the availability of self-referral to sink in, particularly in this culture where people think they need to see a doctor first about everything!'

LESSONS LEARNED

Practices wanting to set up a similar service should be aware that preparation and communication are vital throughout. There will always be risk involved with regard to demand exceeding capacity.

A set-up checklist should include

• Carry out background research on local demographics and referral rates for the area.

• Involve service users in set-up and day-to-day running.

• Make information and education available to staff and patients.

• Ensure strategic rollout of effective, accurate advertising; the pilot advertising materials were all in English but future consideration should be given to translating these into other languages for diverse populations.

• Develop effective triage forms.

• Put good care pathways in place.

• Regularly audit and review.

THE FUTURE

When the pilot finished, the PCT agreed to continue funding a physiotherapist at one practice for a further year.

A bid for a new lower back-pain clinic open to patient self-referrals from all practices in the locality was approved by the PCT last month. It will be run by the physiotherapist and four other staff in a hospital sited in the middle of the locality.

Ultimately the aim over the next five to 10 years is to roll out self-referral across Tower Hamlets in which mini-teams will run the service from community-based settings, as part of service redesign initiatives led by practice-based commissioning.

Beverley Haworth is a physiotherapist and project manager and clinical lead for self-referral in Tower Hamlets

Dr David Whittington is a GP at the Mission Practice in east London

60 second summary 60 second summary

Initiative: 18-month pilot for patient self-referral to practice-based physiotherapists in two GP practices in Tower Hamlets, east London.
Policy link: Improving access and taking care to the community (white paper Our Health, Our Care, Our Say); 18-week referral-to-treatment target
Set-up time: Six weeks
Cost of service: £67,000 2004/5; £84,000 2005/6, covering advertising, training, equipment and salaries for two
physiotherapists
Outcomes: Decreased waiting times; decreased use of NSAIDs post treatment; decreased time of patients off work; high service user satisfaction; GP time savings; decreased secondary care referrals
Savings: Minimum 477 GP appointments per year; £16,000 prescription costs per year; 10 secondary care referrals per month
Contact: Physiotherapist Beverley Haworth, project manager and clinical lead for self-referral in Tower Hamlets,

Patient characteristics

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