Written evidence from the Chartered Society of Physiotherapy
About the physiotherapy profession
- The Chartered Society of Physiotherapy (CSP) is the professional, educational and trade union body for the UK’s 56,000 registered physiotherapists, physiotherapy students and support workers
- Physiotherapists are autonomous, regulated practitioners, qualified to independently
assess and diagnose, and to identify and manage patient risk effectively
- Many advanced practice physiotherapists can prescribe medicines, order and interpret imaging (x-rays/ultrasound scans/ MRI) and bloods, provide injection therapy, and provide complex case management
- Physiotherapists are experts in musculoskeletal (MSK) disorders as well as rehabilitation, physical activity and self-management for people with a range of long- term conditions
- Increasingly, physiotherapists are working in primary care as General Practice physiotherapists to manage much of the GPs’ MSK caseload.
Summary of CSP evidence
- The use of first contact General Practice physiotherapists provides a cost effective and clinically proven means of improving primary care and reducing the demands on GPs. Adoption at scale would benefit patients, GPs and the taxpayer.
- NHS financial systems need to evolve to support the deployment of General Practice physiotherapists. Whole system savings need to be supported and Quality and Outcomes Framework (QOF) amended to take account of MSK conditions
- NHS England policies to support widening the general practice team need to be aligned not only to incentives for practices, but across the local health economy - enabling patients to access physiotherapy services at the earliest point, reducing the need for unnecessary, more costly, referral to secondary care
- GP physiotherapy roles are being piloted by 40% of CCGs and have been a success story; these models now need to be scaled up and made mainstream
- Some successful pilots are at risk of coming to an end when short-term pilot funding (e.g. GP Access Fund) ceases; more support is needed from NHSE to help local stakeholders to find solutions to this, so that physiotherapy, as a clinically- and cost-effective solution, is fully integrated and sustained within general practice
- The Department of Health (DoH) and Department of Work and Pensions (DWP) are currently considering the potential to allow physiotherapists to issue fit notes to improve MSK health services for patients in primary care; this needs to be introduced as soon as possible to further reduce pressures on GP capacity
- The factors that have contributed to the issues of recruitment and retention of GPs need to be considered in the workforce development and implementation on an expanded General Practice team.
- This includes developing a framework for professional development of physiotherapists in primary care and a model of implementation that supports integration across primary and secondary care and access to peer support.
1. Widening the GP team – General Practice Physiotherapists
1.1 Physiotherapists are autonomous, regulated practitioners. They have the same high safety record as GPs, and considerably lower levels of complaint. They don’t require supervision or delegation from doctors. Many physiotherapists have advanced practice skills, and can independently prescribe and carry out injection therapy. An advanced practice physiotherapist costs £54.11 per hour, a GP £130.71.(1)
1.2 MSK health problems account for more than 1 in 5 GP consultations,(2) are the most common cause of repeat appointments(3) and there are high levels of unnecessary medicine prescribing and referrals for investigations and into secondary care.
1.3 Evidence shows that physiotherapists have the most advanced expertise in MSK of all health professionals, with the exception of orthopedic consultants.(4) Physiotherapists can effectively manage 85 per cent of a GP’s MSK caseload without the patient needing to see the GP.(5)
1.4 GPs and policy makers are recognising the potential to utilise this expertise: the new role of General Practice Physiotherapist is being piloted in a number areas, including by 40 per cent of Clinical Commissioning Groups (CCGs).(6)
1.5 GP physiotherapists with advanced practice skills provide the same first point of contact service for people with MSK health issues as a GP would. This means that they assess, diagnose and, if necessary, refer for investigation (x-rays, scans etc), or refer to secondary care for ongoing physiotherapy treatment or to see a consultant. Within this role, they also participate in or lead practice clinical audits, research, musculoskeletal education and advice for the multi-disciplinary team.
1.6 GPs are supportive of GP Physiotherapy roles being introduced. Eight out of ten GPs say they have confidence in the model(7) and the Royal College of General Practice (RCGP) and British Medical Association (BMA) have jointly issued guidance on the role’s implementation with the CSP.(8)
1.7 The evidence from GP physiotherapy pilots show high patient satisfaction, increased capacity in general practice and reduced pressure on secondary care – in particular cutting waste from unnecessary orthopedic, MRI and x-ray referrals, and reducing waiting times for MSK patients who do need referrals to secondary care.
1.8 Because of the number of areas using the GP Access Fund for GP piloting physiotherapy initiatives, General Practice physiotherapy was chosen as one of six areas to focus on in a ‘deep dive’ exercise by Mott MacDonald, the independent evaluators commissioned by NHSE to evaluate use of the fund. This will be published later in 2017. Early findings show that both patients and GPs are seeing the benefit of having more rapid access to physiotherapy services within primary care.
1.9 General Practice Physiotherapy roles have focussed on MSK health. However, physiotherapists in these roles also bring a level of expertise in relation to a range of other conditions that would be of significant value in a GP setting. This includes identifying older people at risk of falling, supporting people with respiratory and heart conditions to self-manage, and providing the expertise to enable people with long-term conditions and disabilities the confidence and knowhow to exercise safely.
2. Incentivising expansion of the GP team
2.1 Experience from the NHS England new models of care vanguard sites suggests that the barriers to scaling up new models of care are generally transactional ones (i.e. relating to contracts, budgets, organisational accountability, and how risks are shared across organisations), rather than more fundamental ones.
2.2 To achieve delivery of its General Practice Forward View plan in relation to the expanded GP team, NHS England need to provide more support for commissioners, providers and clinicians to overcome the transactional barriers that exist locally.
2.3 This point is well illustrated by General Practice physiotherapy, where a number of successful pilots are struggling to secure mainstream funding to replace the GP Access Fund. It is extremely welcome that the direction of health policy is to recognize this, and take an area-based approach to planning services (e.g. the STPs). However, the reality of practice on the ground now is that silo working by budget-holders, the combination of different financial levers and incentives, and separate budgets across a patient’s pathway of care, are acting as a barrier to widening the GP practice team. Where CCGs aren’t funding GPs directly, there is evidence that they are not incentivised to look at more streamlined, and cost-effective ways of delivering MSK services across the whole pathway.
2.4 A variety of business models can successfully deliver GP physiotherapy. While we recognise that other models can work in specific circumstances, the CSP’s view is that the most sustainable model for development will be for GP physiotherapists to be part of the GP team, but employed by a local physiotherapy provider to the NHS (from any sector). This integrated approach relies on incentivising all partners through service level agreements between the providers of NHS physiotherapy services and GP federations.
2.5 Such an approach has multiple benefits: providing continuity of care; increasing efficiency; reducing waste; and improving the quality of care and patient experience. It also facilitates professional support and development for physiotherapists in general practice and avoids the risk of creating the problems that have resulted in the current problems of GP recruitment and retention. For GPs, the approach frees them up from managing contracts of employment with individual physiotherapists, and issues relating to annual leave and cover arrangements are managed by the provider (as part of their service level agreement).
2.6 Given the decision to retain the QOF system of payments for General Practice, the framework needs to be updated to better incentivise the shifts that are required to deliver the General Practice Forward View. The lack of a QOF for MSK conditions has long been an issue that has contributed to MSK care lacking visibility for policy makers. A QOF for the accurate diagnosis of MSK conditions and successful management of MSK within primary care could help incentivise GPs to contribute to GP Physiotherapy. It is also worth noting that in Wales discussions are taking place about the potential for a QOF for practices to diversify their teams. We recommend that NHSE explores this approach in England.
2.7 Incentives for practices also need to be aligned with work to ensure that buildings can be upgraded and used to support an expanded team. Recent reports in the media(9) of practices being financially penalized by having a part of their rent not covered as a result of expanding the team are extremely worrying. If this is a general problem, it must be addressed.
3. Enabling physiotherapists to issue Fit Notes to save GP time
3.1 MSK health issues are the most common reason for a person to be off sick from work(10) and the most common cause of disability(11). As well as having a social and economic impact, this creates a significant demand for GP appointments from patients in order to obtain a fit note.
3.2 As well as increasing demands on GP time, there are also inherent weaknesses in the current reliance on GPs to provide Fit Notes for MSK health issues. GPs can offer fitness for work information, but as well as having significant time pressures, are often not expert in MSK health issues. The section ‘may be fit for work subject to the following advice’ which can assist employees and employers to make necessary adjustments to work, is rarely completed by GPs.(12) Evidence also suggests that GPs feel ill-equipped to provide this advice and often patients are not confident in their GP’s ability to judge or advise on return to work.(13)
3.3 The current Health and Work Green Paper from the DoH and DWP recognises the potential for physiotherapy to improve MSK care in primary care and to reduce sickness absence.(12)
3.4 The DoH and DWP are also actively considering whether to extend those professionals who can issue fit notes to physiotherapists and other health professionals. Offering return-to-work advice is part of what physiotherapists do on a day-to-day basis. Physiotherapists routinely also include a patient’s work in their functional outcome measures and have ‘healthy conversations’ about work.
3.5 A Delphi study on the ideal fit note, with a panel consisting of GPs, employers, patient and employee groups, occupational health practitioners, allied health professionals and academics, supported this proposal.(14) A range of organisations, including the British Medical Association (BMA) and the CSP, has called for this reform to be introduced as soon as possible.(15)
4.1 The issues being considered by the Committee in relation to recruitment and retention of GP staff need also to be considered in relation to the wider team. Otherwise, there is a risk of replicating the problems historically experienced by GPs that have contributed to current challenges.
4.2 This includes developing the existing, wider workforce so that an expansion of physiotherapists in General Practice is possible and in line with the recommendations of the 2015 Roland Commission into primary care.(16)
4.3 The NHS Operational Planning Guidance 2016-2017(17) gives responsibility to Health Education England and NHS England to develop models and frameworks to support this expansion. The CSP is keen for this to be progressed and to help in this. In our view the priorities are:
- Support for shared learning and development among GP Physiotherapists, using the model developed for pharmacy
- Support for multi-professional learning and development through opening up the opportunities and support provided by Community Education Provider Networks (CEPNs) beyond GPs to physiotherapists and other members of expanded GP team and through extending use of multi-professional competence and capability frameworks
- Action to increase the numbers of physiotherapists with advanced practice skills (including independent prescribing and injection therapy) to increase the profession’s value and impact in meeting patient needs within general practice through first-contact roles.
Rob Yeldham BA (Hons.) Chart.PR MCIPR
Director of Strategy, Policy & Engagement
The Chartered Society of Physiotherapy
References
1. The Chartered society of Physiotherapy. Physiotherapy cost calculator. London: The Chartered Society of Physiotherapy; 2016.URL: http://www.csp.org.uk/professional-union/practice/evidence-base/physiotherapy-cost-calculator
2. Arthritis Research UK National Primary Care Centre. What do general practitioners see? Musculoskeletal Matters. 2009;Bulletin no. 1. URL: http://www.keele.ac.uk/media/keeleuniversity/ri/primarycare/bulletins/MusculoskeletalMatters1.pdf
3. Department of Health. Musculoskeletal services framework: a joint responsibility: doing it differently. London: Department of Health; 2006.
4. Childs JD, Whitman JM, Sizer PS, et al. A description of physical therapists' knowledge in managing musculoskeletal conditions. BMC Musculoskelet Disord. 2005;6:32.
5. Ludvigsson ML, Enthoven P. Evaluation of physiotherapists as primary assessors of patients with musculoskeletal disorders seeking primary health care. Physiotherapy. 2012;98(2):131-7.
6. The Chartered Society of Physiotherapy. Unpublished data from a freedom of information request on patient self-referral to physiotherapy & community rehabilitation services. London: The Chartered Society of Physiotherapy; 2016
7. Wallace F, Harper J, H S. Primary healthcare monitor 2016: Chartered Society of Physiotherapy. nfpSynergy: London; 2016.
8. The Chartered Society of Physiotherapy, Royal College of General Practictioners, British Medical Association. Implementing physiotherapy services in general practice: a guide for implementation and evaluation. London: The Chartered Society of Physiotherapy; 2016.
9. Matthews-King A. GP funding docked for housing community nurses and therapists. Pulse. 16h February 2017. URL: http://www.pulsetoday.co.uk/your-practice/practice-topics/premises/gp-practice-funding-docked-for-housing-community-nurses-and-pharmacists/20033853.article
10. Health and Safety Executive. Work Related Musculoskeletal Disorder Statistics (WRMSDs) in Great Britain 2014/15. London: Health and Safety Executive; 2015
11. Vos T, Barber RM, Bell B, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. The Lancet.386(9995):743-800. URL: http://dx.doi.org/10.1016/S0140-6736(15)60692-4
12. The Department of Health, The Department for Work and Pensions. Improving lives: the work, health and disability green paper. London: The Department of Health; 2016. URL: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/564676/work-and-health-green-paper-print-version.pdf
13. Aviva. The Aviva UK Health of the Workplace Report - Issue 4. Norwich: Aviva; 2010.
URL: https://www.aviva.com/media/upload/Health_of_the_Workplace_4_FINAL.pdf
14. Coole C, Nouri F, Potgieter I, et al. Recommendations to facilitate the ideal fit note: are they achievable in practice? BMC Family Practice. 2015;16(1):138. URL: http://dx.doi.org/10.1186/s12875-015-0360-4
15. British Medical Association. Annual represenatatives meeting 2016; Belfast: British Medical Association; 2016. URL: https://www.bma.org.uk/connectingdoctors/search?q=ARM%202016%20MOTION%20120
16. Rowland M, Primary Care Workforce Commission. The future of primary care : creating teams for tomorrow. London: Health Education England; 2015. URL: https://www.hee.nhs.uk/our-work/hospitals-primary-community-care/primary-community-care/primary-care-workforce-commission
17. NHS England, NHS Improvement. NHS operational planning and contracting guidance 2017-2019. Leeds: NHS England; 2016. URL: https://www.england.nhs.uk/wp-content/uploads/2016/09/NHS-operational-planning-guidance-201617-201819.pdf
For further information on this response or any aspect of the CSP’s work please contact:
Rachel Newton, Head of Policy
The Chartered Society of Physiotherapy
14 Bedford Row, London WC1R 4ED
Telephone: 020 7306 6625
Email: sorbya@csp.org.uk
Website: www.csp.org.uk
Chartered Society of Physiotherapy,
February 2017
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