Self-referral to Physiotherapy: The Evidence from the UK WCPT, European Region Workshop, Berlin 2010 Lesley Holdsworth

1. Self-referral to Physiotherapy: The Evidence from the UK WCPT, European Region Workshop, Berlin 2010 Lesley Holdsworth Valerie Webster

2. UK Physiotherapy Access: Locus of Control: a logical progression? 1948 1970’s 1981 1990’s 1997 2008 Hospital Doctors GP’s Patients? GP Fundholding Professional Autonomy Hospitals Primary care Communities

3. Physiotherapy:UK Historical Perspective • 1978 Professional Autonomy • 1981 Open access (GP access) Benefits 1990’s Reduction in: • tertiary referrals • prescriptions / X-rays • waiting times • lower costs - efficient use of Physio Services

5. Since 1997, Healthcare Policies ….. • innovate • develop primary care • widen access / choice agenda • services centred around patients • develop roles to modernise healthcare and benefit patient care

6. Key Question • Is patient self referral to physiotherapy: • feasible? • appropriate? • acceptable? • safe? • Cost effective? • Is it an appropriate model for the modern day NHS?

7. ‘a system of access that allows patients to refer themselves to a healthcare provider directly without having to see or be prompted by another healthcare practitioner. This relates to telephone, electronic technology or face to face services’

8. Accountability • Responsibility • Private practice • Only partial autonomy within the NHS

9. Pilot work (1997-2000) • One Scottish practice (850 subjects) • clinical, demographic, outcome, patient, non user and clinician views • Feasible, acceptable, appropriate, safe • publicity generated interest but…..representative? Robust enough for changes to policy?

10. Multi-centred National Trial, 2003-05 • 29 Locations, HB Regions • 3010 patients, • 130 physiotherapists • range of geographical and socio-economic settings • Clinical, demographic and cost related data collated over a full year • Patient and clinician views established • 5 peer reviewed publications

11. What we found…………. • National referral rates by location and overall av. 53.5/1000 (44-69/1000) • 22% true self referral rate • No increased referral rates unless historical under provision • deprivation appears to have little influence Self Referral to Physiotherapy: Deprivation and Geographical Setting: Is there a Relationship? Results of a National Trial 2006, Physiotherapy Vol. 92:1, pp16-25

12. No association by referral group • Gender (NS) • Age group (NS) • Physiotherapist determined outcome (NS) • Patient determined outcome (NS) • Physiotherapy contacts (NS)

13. More back and neck conditions 54% vs 42.5%, 14 days duration of symptoms 14% vs. 8.5%, Work absence 19.5% vs.27.5%, Time off work 2.5 vs.6 days Seen quicker – within 2 weeks 44% vs. 35.5% Fully completed treatment 76% vs. 68.5% However self referrals…. P = sig

14. Costs: 25% differential p<0.001 • Self referrals were cheaper per episode because: • Less GP contact; 0.7 vs. 1.7 • fewer X-rays; 7.6% vs.13.6% • less prescribed NSAIDs drugs; 9.7% vs.15.6% - fewer referrals to secondary care; 1.3% vs. 3.1%

15. Self referrers, more likely to be … p<0.001.. • Supportive of self referral: 83% vs. 69% • Confident in knowing when to refer themselves • Supportive of autonomous behaviour: 58.5% vs. 52.5% • Satisfied: 79% vs 74% • Knowledgably of physiotherapy: < 23%

16. Patient & clinician views • Overall, supportive of: • being able to access directly • effectiveness of physiotherapy • not having to visit their GP • collaborative GP / physio working • locally provided services • ability to have point of access to advice and guidance • role development / extension

17. but... • A proportion (<20%) of patients still preferred to consult both • did not feel confident in recognising if or when physio was appropriate • minority of physiotherapists not entirely comfortable with assuming responsibility

18. AHP Research Award, 2005 Scottish Award for Innovation, 2005 What happened next?...... • Interest from rest of UK and worldwide in results and how to implement • English pilot sites, policy implications • International collaborations: • IPPA funded an international study of access and physiotherapy: 7 countries • PhD into user perspective of self referral: Helen Little

19. An investigation of the lived experience of accessing and attending NHS-based musculoskeletal physiotherapy services in Scotland using a Gadamerian hermeneutic approach. • Faith in the physiotherapist (90%) • Speed and ease of access (80%) • GP as ineffective in the treatment of musculoskeletal conditions (90%) vs. 62.5% GP ref’s • Self referral the barriers: lack of knowledge (75%) • Health related behaviours: GP ref’s Passive recipient of care (78%) SR’s Autonomy (90%)

20. An international multi-centred investigation of patient self referral and physiotherapy practice in privately funded health care systems: 2005-08

21. Physio Direct: Telephone System MRC RCT: University of Bristol 2008-2010 Internet Physio Other key UK initiatives

22. www.selfreferralphysioinfo.com

23. Key Messages • UK results: Self referral is safe, effective and acceptable • It requires the support of stakeholders • Challenges differ between countries • Need to build the international evidence base • Opportunities for the profession, globally

24. lesley.holdsworth@nhs.net v.webster@gcal.ac.uk