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The Department of Health (2008) anticipate that in 10 years time, 60% of the current healthcare workforce will still be providing NHS services. Thus supporting them through career frameworks will help to fulfil their individual potentials. In the Framework 15 document (HEE, 2014) there are five global drivers of change considered. These are demographics; technology innovation; social, political, economic and environmental; current and future service models and finally the expectations of patients and other staff. Workforce planners will utilise these factors when balancing an expected demand with an efficient demand(DoH, 2008).
The Department of Health (2008) anticipate that in 10 years time, 60% of the current healthcare workforce will still be providing NHS services. Thus supporting them through career frameworks will help to fulfil their individual potentials. In the Framework 15 document (HEE, 2014) there are five global drivers of change considered. These are demographics; technology innovation; social, political, economic and environmental; current and future service models and finally the expectations of patients and other staff. Workforce planners will utilise these factors when balancing an expected demand with an efficient demand(DoH, 2008).
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== Primary Care ==
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== Primary Care
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=== Description ===
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=== Cost Effectiveness ===
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=== Description
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=== Training/ Qualifications ===
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=== Evidence to support ===
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Primary care is defined as the first point of contact for someone seeking medical care, typically a general practitioner or a family doctor. Primary care acts to coordinate any other specialists that the patient may need (World Health Organisation/Europe 2004).
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Self-referral to physiotherapy is not covered in this wiki, as it is not considered a new or emerging role within the profession.<br>General Practitioners in the UK are suffering from an unstainable workload, which is limiting their appointment times with patients. Despite this, the government continues to push for GP surgeries to be open 7 days a week. If these plans go ahead, the strain placed on these AHPs will continue to grow. Added to the fact that the UK has an aging population, the strain on GPs and the rest NHS will not reach breaking point if drastic changes in primary health care are not made. The following is a quote from Sara Khan, a GP from Hertfordshire (Khan 2013): “patient demand has steadily risen, in many cases from an increasingly ageing population. It is to be celebrated that modern medicine is helping us live longer, but a side effect is that we develop conditions that require expensive care. My appointments with older patients are frequently longer due to multiple, complicated health needs that require careful need and attention. This inevitably eats into the time I have for appointments with other patients.”<br>This article (LINK) is one of many highlighting the current issues surrounding primary care in the UK. <br>This unstainable workload has caused great unrest among GPs, leading to the looming GP crisis. A survey of 1,004 GPs in the UK, as part of the BBC’s Inside Out programme (BBC 2015) (LINK) found that 56% said they plan to retire of leave before they turn 60. The workload, out of hours working and volume of consultations were some of the reasons for this.
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Due to a lack of government funding and the likely shortage of GP’s, the role of physiotherapists in primary care is currently being explored. The importance of the profession in the future of primary care is highlighted in a report by the Primary Care Workforce Commission (2015) (LIINK). The report endorses self referral to services and highlights the potential benefits of physiotherapists working alongside GPs, as a first point of contact for patients. Physiotherapists pride themselves for being autonomous in assessing, diagnosing, treating and discharging patients. Some advanced practitioners and extended scope practitioner physiotherapists are trained to prescribe drugs and provide injection therapy to patients (LINK).<br>
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''“GPs within the West Wakefield Health and Wellbeing Project have developed a hypothesis that 50% of a GP’s workload could be undertaken by other staff. I want physiotherapy to form a significant part of this 50%” Dr Chris Jones, Programme Director, West Wakefield Health and Wellbeing Project.<br>(Taken from CSP leaflet: physiotherapy works for primary care (CSP LEAFLET). LINK''
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<br> Rachel Newton, the CSP’s head of policy, has asked for CSP physiotherapists with experience of working in primary care to come forward and share their experiences. She told Frontline magazine “Evidence from members is essential to making the case to decision makers for the potential for physiotherapy within primary care” (CSP 2015ii). The Primary Care iCSP group link was set up for CSP members to share experiences and benefits of physiotherapy in primary care.
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<br>Question: Isn’t self referral to physiotherapy the same as seeing a physiotherapist in primary care?<br>Answer: No. As with any self referral to a health service, you will still be placed on a waiting list. Ideally waiting times for Physiotherapist working in primary care will be the same as for GPs.
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=== Cost Effectiveness
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The main proposed benefit of physiotherapists working in primary care is reducing healthcare costs. It is estimated that MSK conditions make up 30% of a GPs appointments, yet 85% of those do not need to see a GP (Ludvigsson and Enthoven 2012). If patients were offered different professionals as their first point of contact, a huge number of GP appointments would be made available. The following costs saving benefits have been suggested by a CSP leaflet: physiotherapy works for primary care (CSP LEAFLET).
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*Reduce referrals to secondary care orthopaedics
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*Reduce unrequired investigations (x-ray, MRI)
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*Reduce onward referrals to physiotherapy in community and secondary care
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*Increase the number of patients able to self-manage effectively increase the number of referrals to leisure centres and other forms of physical activity prevention
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However, there is no reference provided for these statements, therefore their relevance is questionable.
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An article in Frontline magazine (CSP 2015i) LINK describes the need for physiotherapy as a profession to adapt and expand in response to the NHS England’s Five year forward view (NHS ENGLAND 2014). This calls for a step change in the integration of services to improve primary care. The frontline article is focuses on the 5-year journey of Amanda Hensman-Crook, formally a band 8a physiotherapist. After a successful 3 month pilot working alongside GPs, she was offered a permanent post at the GP practice, under the new title of MSK practitioner. Her pilot was based on estimates that approximately one in three GP consultations are MSK related. An audit of the service since June 2015 suggests a 20% fall in referrals to secondary MSK treatment. GPs and patients were found to be very happy with the service. A downside of this innovative service is that physiotherapists in this role will have shorter appointment times with patients. According to the article, the Hampshire service offers a 20 minute consultation, which is half the typical appointment time for a secondary care MSK service. This shows that physiotherapists can be effective in working alongside GPs as a first point of contact. If physiotherapists have the required knowledge and skills, they can relieve some of the pressures on GPs in primary care. The reduction in referrals to secondary MSK treatment highlights the money saving benefits of this system. <br>
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{{#ev:youtube|IOT59BgW0oo}}<br>
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Youtube Video – NHS Wales – advanced MSK physiotherapists
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=== Training/ Qualifications
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From the literature, it appears to mainly advanced practitioner physiotherapists who are working alongside GPs in primary care. Amanda Hensman-Crook, who began working in a GP practice LINK, was a band 8a physiotherapist before she started working under the title of advanced practitioner. The following is a link to a short descriptor of advanced practitioner physiotherapists. LINK . Further training/qualifications to become an advanced practitioner physiotherapist include:
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*One year university courses, such as the MSc advanced practitioner physiotherapist course at the University of East Anglia. These courses offer further learning for qualified physiotherapists in advanced areas, such as independent and supplementary prescribing.
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*A high level of experience is required by employers. Band 5 physiotherapists will first have to specialise in one area of physiotherapy and then gain considerable experience in this area.
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Band 7 physiotherapists are expected to take up a leadership role within the team. This includes helping less qualified physiotherapists further their learning through CPD exercises. They are also expected to be comfortable managing complex cases and be experts in reviewing emerging evidence within their area of specialised knowledge.
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A barrier to progressing to advanced practitioner level is course fees for advanced physiotherapy masters courses. Fees range from £7000 for UK/EU students to £15000 for international students. <br>As working in primary care is an emerging role in physiotherapy the NHS is still piloting the idea around the UK. As a result, there is no recognised progression pathway beyond reaching an advanced practitioner level of expertise.
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=== Evidence to support
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A study by Ludvigsson and Enthoven (2012) evaluated physiotherapists as primary assessors of patients with MSK conditions. 51 patients with a MSK disorder were primarily assessed by a physiotherapist and 42 by a GP. Participants completed a patient satisfaction questionnaire. It was concluded that physiotherapists can be used as primary assessors of MSK conditions in primary care, as few patients needed additional GP assessment. The physiotherapists were found to be capable of identifying confirmed serious pathologies and patient satisfaction was higher with physiotherapists than GPs. The participants who were seen by a physiotherapist felt confident in the information they received and the support to self-manage their conditions. The main limitation of the study, acknowledged by the authors was the participants were not randomly allocated to be seen by a physiotherapist or GP, thereby researcher bias is not excluded.
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A study by Pinnington, Miller and Stanley (2004) evaluated prompt access to physiotherapy in the management of low back pain in primary care. The authors identify the issue of delays in getting access to specialised treatment in patients with low back pain. In the study, physiotherapist-led back pain clinics were established. Results were compared other published interventions from the literature. Data on pain, disability and well-being were collected at recruitment and 12 weeks later. The patients maintained diaries and GPs were interviewed before and after the study to obtain qualitative data. Comparative costings were derived from national and local sources. Results showed that more than 70% of the 614 patients seen only required a single visit and the majority of the patients were seen within 72 hours. Prompt access to physiotherapy reduced time taken off work and cost less per episode of back pain, compared with normal management. Qualitative data showed that patients valued early access to physiotherapy, particularly for reassurance. GPs also praised the service, largely due to the positive patient responses. This study shows the cost effectiveness among benefits of using physiotherapists as a first point of contact for patients with low back pain. This is more significant given low back pain is the most commonly presented MSK condition (Pinnington, Miller and Stanley 2004). A limitation is the study is from 2004, therefore the practices used by the physiotherapists is likely to be outdated. The study also does not specify the level or qualifications of the physiotherapists.
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<br>Holdsworth, Webster and McFadyen (2008) investigated physiotherapists and GPs views on self-referral and physiotherapy scope of practice. Data was gathered using a survey questionnaire, with both qualitative and quantitative questioning. They found the idea of physiotherapists working as first point of contact is strongly supported by the majority of physiotherapists and GPs. Potential benefits for patients were identified if physiotherapists adopted extended roles within a MSK setting, such as injection therapy and prescribing medications. <br>
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The following are examples of positive comments from physiotherapists and GPs extracted from Holdsworth, Webster and McFadyen (2008) <br>GP comments: <br>It makes logical sense, after all, physios are the experts when it comes to managing many musculoskeletal conditions’
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Physiotherapists’ comments:<br>‘I was rather nervous of seeing self-referring patients at the start, wasn’t sure what to expect but now feel much more confident, it's just a question of being thorough and nothing more really’
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‘I’m happy as I know that if I have any concerns, I can get the patients seen by their GP really quickly’
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‘Our GPs have been great and want us to take on more aspects of the patients’ management as they see the time it could save them and they must trust us to want us to do this’
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The Betsi Cadwaladr University Health Board (2015) in North Wales published results from a pilot study, in which advanced MSK physiotherapy practitioners are working in GP practices. LINK. It shows an additional 671 appointments were made available during the six-month pilot phase. Around one third of the appointments were MSK related which helped free-up GPs to concentrate on other patients and more complex cases. This data is from a National Health Board website, therefore can be deemed reliable.
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In summary, an expansion of physiotherapy within primary care provides an immediate solution to GP shortages and delivers the transformation of primary care needed for a sustainable health system tailored to modern population needs (CSP 2015). More clarity is needed on how to reach these roles working alongside GPs in primary care and the additional qualifications required.
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=== Challenges ===
=== Challenges ===