Providing patients with direct access to musculoskeletal physiotherapy: the impact on general practice musculoskeletal workload and resource use. The STEMS-2 study.

(1)

Physiotherapyxxx(2020)xxx–xxx

Providing

patients

with

direct

access

to

musculoskeletal

physiotherapy:

the

impact

on

general

practice

musculoskeletal

workload

and

resource

use.

The

STEMS-2

study

Annette

Bishop

a,∗

,

Ying

Chen

a,b

,

Joanne

Protheroe

a

,

Reuben

O. Ogollah

c

,

James

Bailey

a

,

Martyn

Lewis

a,b

,

Kelvin

Jordan

a,b

,

Nadine

E. Foster

a,b a_Primary_Care_Centre_Versus_Arthritis,_Research_Institute_for_Primary_Care_&_Health_Sciences,_Keele_University,_{Staffordshire,}

UnitedKingdom

b_Keele_Clinical_Trials_Unit,_Research_Institute_for_Primary_Care_&_Health_Sciences,_Keele_University,_{Staffordshire,}_United

Kingdom

c_Nottingham_Clinical_Trials_Unit,_University_of_Nottingham,_University_Park,_Nottingham,_United_Kingdom

Abstract

Objectives Thisstudyexaminedthereal-worldimpactofpatientdirectaccesstoNHSphysiotherapy(self-referral)on(a)generalpractice consultationsformusculoskeletal(MSK)conditionsand(b)specifiedclinicalmanagementforpatientswithMSKconditions.

Designandsetting Naturalexperimentinfourgeneralpracticesandtheassociatedphysiotherapyservice.

Methods Anonymisedroutinelycollecteddatawereobtained.MSKcodedGPconsultations,recordedfitnotes,MSK-relatedprescription medication,X-raysandMRIrequests,andreferralstosecondarycareforpatientsconsultingwithMSKconditionswereidentifiedandtrends describedacrossa6-yearperiod(June2011toJune2017).Joinpointregressionanalysiswasusedto identifyanysignificantchangesin GPMSKconsultationtrendsbeforeandaftertheintroductionofself-referraltophysiotherapy.Physiotherapyservicedataexaminedaccess methodsusedbypatients(GPreferred,GPrecommendedself-referral,trueself-referral)andthenumberofphysiotherapysessions.

Results Directaccess resultedin inconsistentimpacton generalpractices.In one armofthe experiment asignificant increasein GP consultationswasobservedandinonearmwasstable.ExploratoryexaminationofclinicalmanagementshowedonlyrequestsforX-rays (arm1)andpossiblyrequestsforMRI(arm2)changedovertime.Physiotherapyservicereferralsshowedalowuptakeoftrueself-referral (10%and6%)ineacharmrespectively.

ConclusionThisisthefirststudytoexaminethereal-worldimpactofpatientdirectaccesstophysiotherapyatgeneralpracticelevel.Wefound noconsistentimpactofpatientdirectaccessonGPMSKworkload.Impactonsomeclinicalmanagementwasobservedbutnotconsistently inthedirectionsuggestedbypreviousstudies.

Keywords:Physiotherapy;Patientdirectaccess;Self-referral;Musculoskeletal;GPworkload;Routinelycollecteddata

Introduction

Inthedrivetoreduceburdenongeneralpractices,patient

directaccess(self-referral)toNHSphysiotherapyhasbeen

∗_{Corresponding}_author.

E-mailaddress:[email protected](A.Bishop).

suggestedasawayofreducingmusculoskeletal(MSK)

con-sultations with GPs. Previous data has suggested patient

direct accessreduces GPworkload by 20% bydecreasing

repeatconsultations[1].Wedefinepatientdirectaccessto

MSKphysiotherapyaswhere“patientsareabletorefer

them-selvestoaphysiotherapistwithouthavingtoseeaGPfirst,

https://doi.org/10.1016/j.physio.2020.04.006

(2)

Please cite this article in press as: Bishop A, et al. Providing patients with direct access to musculoskeletal physiother-apy: the impact on general practice musculoskeletal workload and resource use. The STEMS-2 study. Physiotherapy (2020), https://doi.org/10.1016/j.physio.2020.04.006

ARTICLE IN PRESS

PHYST-1181; No.ofPages9

2 A.Bishopetal./Physiotherapyxxx(2020)xxx–xxx

orwithoutbeingtoldtoreferthemselvesbyahealth

profes-sional”[2].

Thisstudyinvestigated self-referraltoanexisting NHS

MSKphysiotherapyservicenotageneralpractice-basedfirst

contact practitioner (FCP) service. Self-referral has been

established in many areas of the UK for many years but

has never been routinely available. Self-referral to

exist-ing MSKphysiotherapy services is onewayof increasing

accesstophysiotherapyforpatientsandmeetingthe

grow-ing demand for MSK care. Self-referral to physiotherapy

will continue alongside recentdevelopments such as

gen-eralpractice-basedFCPstoenhanceaccesstophysiotherapy.

Self-referralservicesalsomirrortheprocessthroughwhich

patientsmightaccessFCPservicesinwhatisknownas‘hub’

models,whereFCPsarenotbasedwithingeneralpractices

butinphysiotherapyservices,andsoinformationfrom

self-referralservicescaninformthedesignofsuchmodels.

Wepreviouslyconductedapilotclusterrandomized

con-trolledtrial(STEMS)infourgeneralpracticesandassociated

physiotherapyserviceinNorthWestEngland.Twopractices

wererandomizedtocontinuewithusualGP-ledcare

(con-trol)andtwo hadtheadditionof apatientdirect accessto

NHS physiotherapy pathway for adults with MSK

condi-tions(intervention).Asaresult patientsinthe intervention

practicescouldaccessphysiotherapythroughthreepossible

routes(a)‘GPreferred’wheretheGPornursepractitioner

sends a traditional written referral, (b) ‘true self-referral’

wherethe patientrefers themselves tothe service without

contact with their general practice and (c) ‘GP/nurse

rec-ommended self-referral’ where aGP or nurse practitioner

instructstheindividualtoself-refer.AsapilotRCTtheaim

oftheSTEMSwastoinvestigatethefeasibilityofafuture

mainRCT,andwe demonstratedthat thiswould be

feasi-ble.Itincludedanumberoffeasibilityoutcomesbutdidnot

includebetweengrouptestingonpatientoutcomesgivenit

wasafeasibilityandpilotRCT.ThepilotRCTprotocoland

resultshavebeenpublished[3,4].Thepatientdirectaccess

pathwaywasintroducedtotheinterventionpracticesinApril

2013.Thephysiotherapyservicecontinueddirectaccessafter

theRCTandsubsequentlyimplementeditinthetwocontrol

practicesinDecember2015.Thisprovidedanatural

experi-menttoaddresskeyknowledgegapsregardingpatientdirect

accesstophysiotherapy.Therewerethreecomponentstothis

newstudy(STEMS-2),withthefollowingaims.

Component1:ToanalyzechangeingeneralpracticeMSK

consultationsandspecifiedclinical management overtime

followingintroductionofthedirectaccesspathway.

Component2:Tofurtherassessthecost-effectivenessof

directaccess.

Component3:Toexploretheperceivedimpactofdirect

accessforpatients,GPs,physiotherapistsand

commission-ers.

InthispaperwereportComponent1withaprimaryaim

toinvestigatechangeingeneralpracticeMSKconsultations

asaresultof patientdirectaccesstophysiotherapy.A

sec-ondaryaimwastoexplorethewiderimpactofpatientdirect

accesstophysiotherapybyassessingwhethercertainclinical

managementwasaffectedbypatientdirectaccessto

physio-therapy.Theclinicalmanagementinvestigatedwasprovision

ofprescriptionmedication,fitnotes(sicknesscertification),

X-rays/scans and onward referral, which have been

sug-gested,inpreviousobservationalstudiesandthepilotRCT

mayreduceafterintroductionofpatientdirectaccess[1,2,4].

Components 2 and3 are reportedseparately [Yanget al.,

healtheconomicscompanionpaper],Igwesi-Chidobeetal.,

qualitativecompanionpaper].

Methods

Thisstudywasanaturalexperimentinthefourgeneral

practicesandtheassociatedphysiotherapyservicethattook

partintheSTEMSpilotRCT.Thegeneralpracticesinvolved

inthisstudyallusedthesameelectronicprimarycareclinical

system,EMISWeb.ClinicalrecordsinEMISWebcontain

Readcodes,whicharethemostcommonlyusedofclinical

codingstructuresinUKprimarycare[5]andwereusedto

identifypatientswithMSKconditions.

Weobtainedanonymisedpatientelectronichealthrecord

dataviathededicatedEMISHealthDataExtractionService.

AllpatientidentifiersareremovedbyEMISduringthe

extrac-tionprocedure,witheachpatientgivenauniqueID.Thedata

periodofinterestforthisstudywasJune2011(2yearsprior

tothestartoftheSTEMSRCTinJune2013)toJune2017

(18monthsafterthephysiotherapyserviceintroduceddirect

accessintothecontrolgeneralpracticesinDecember2015).

AnoverviewofthetimelineisshowninFig.1.

AnonymiseddataonMSKcodedconsultations,the

num-berofrecordedfitnotes,X-raysandMRIscans,MSK-related

prescription medications, and referrals to secondary care

for patients who consulted with MSK conditions were

identified. ConsultationsforaMSKcondition were

identi-fied by use of a Readcode list developed previouslyand

used in previous studies [3,4,6,7]. The Read code list is

available atwww.keele.ac.uk/mrr.Weadopted apragmatic

approach whichcounted all MSKrelevant requestsfor

X-rays,MRIscansandonwardreferrals,whichoccurredwithin

2weeksfollowingaconsultationforacodedMSKcondition.

Requestsclearlyforadifferentbodyregionthanthe MSK

consultationwerenotcounted.Wealsoidentified

prescrip-tionmedicationsmostcommonlyusedforMSKconditions

asusedinpreviousstudies[4,7].Thesemedicationsincluded

simpleanalgesics,NSAIDsandopioids.

Dataanalysis

TrendsinoverallconsultationsforMSKconditions,

num-ber of fit notes, prescribed medications, X-rays and MRI

scansandreferralstosecondarycarerequestedforpatients

withMSKpainweredescribedacrossthe6-yearperiod(June

2011toJune2017).Theimpactofintroducingpatientdirect

(3)

Fig.1.Overviewofthedatatimeline.

interventionpractices(PracticesAandB),asofJune2013

andincontrolpractices(PracticesCandD)asofDecember

2015.

QuarterlyprevalenceofMSKconsultations

Theobservationalperiodwasdividedintoquarterly

peri-ods.Thequartersweredefinedonaseasonalbasisfromthe

thirdquarter of 2011 (July,Augustand September)tothe

secondquarterof2017(April,MayandJune).

The numerators for calculating quarterly prevalence of

MSKconsultationwerethenumberofidentifiedMSK

con-sultations within each quarterly period. The denominator

wastheperson-timeofregisteredpopulationineachperiod.

QuarterlyprevalenceofMSKconsultation(numberper100

registeredpopulation)wascalculatedandtrendsdescribed

forthegeneralpracticesintheinterventionandcontrolarms

(andinindividualpractices)fromthethirdquarter2011to

thesecondquarter2017.

Subsequentlyjoinpointregressionwasusedtoassessany

significantchangesinquarterlygeneralpracticeMSK

con-sultationtrends[8].Joinpointanalysisallowedidentification

ofsignificantchangesinconsultationrates.Thetimepoint

forthestartofeachidentifiedchange(thejoinpoint)wasthen

comparedwiththedateswhendirectaccesstophysiotherapy

wasintroducedineachpractice.Ifnojoinpointwasidentified,

thiswouldindicatenosignificantchangeintheunderlying

trendin consultation prevalencefor MSK painduring the

observationalperiod. Permutationtestsusing MonteCarlo

methodswere used todetermine the minimum numberof

joinpoints required to provide an adequate fit to the data

[9].JoinpointanalyseswerecarriedoutusingtheJoinpoint

Regression Program (version4.6, StatisticalResearch and

ApplicationsBranch,NationalCancerInstitute,2018).

GeneralpracticeclinicalmanagementrelatedtoMSK consultation

Forthe secondaryaim, the quarterly prevalence

(num-berper100registeredpopulation)forX-raysandMRIscans

ordered, referralsinto secondarycare, fit notes issued for

patientswithMSKconditionsandprescriptionmedications

linked to MSK conditions werecalculated over time. The

numeratorsforcalculatingquarterlyprevalenceofeach

man-agement actionwere the numberof each actionidentified

withinthequarter.Thedenominatorwastheperson-timeof

registeredpopulationineachquarter. Quarterlyprevalence

of each specified clinical management was calculatedfor

intervention(AandB)andcontrol(CandD)practices.No

inferentialanalysis(joinpointregression)wasperformedon

theclinicalmanagementduetolimitedsamplesize.

Physiotherapyservicedata

Changesintheuseofdirectaccesspathwaysmaychange

over time as patients become more familiar with direct

accesstophysiotherapy.Themethodof referralduringthe

STEMS pilot RCT has been reported [4], so to explore

changesintrendsofaccessovertime,anonymiseddataon

methodofreferral(GPreferred,recommendedself-referral

andtrue self-referral) wereextracted fromthe

physiother-apy service from the start of 2015 to the end of 2017,

whichincludesthetimewhendirectaccesswasintroduced

in control practices. Physiotherapy service data were

pre-sentedusingdescriptivesummaries,includingthefrequency

overtimeofaccessmethods(GPreferred,GPrecommended

self-referral, trueself-referral) used bypatients inthe four

practicesandthemeannumberofphysiotherapysessionsper

practice.

Results

Patientcharacteristics

The characteristics of the patients who consulted for a

MSKconditionduringthedataperiodofinterest,July2011

toJune2017,intheparticipatingpracticesaresummarized

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ARTICLE IN PRESS

Table1

CharacteristicsofpatientsconsultingwithMSKconditions.

Characteristics Interventionpractices(AandB) Controlpractices(CandD) Total

Numberofpatients 6888 8652 15540

Male,n(%) 3126(45.4) 4000(46.2) 7126(45.9)

Ageat2011,mean(SD) 41.1(19.4) 43.6(20.2) 42.5(19.9)

IMDscore(quintilegroup)a

1(leastdeprived) 333(4.9) 599(7.0) 932(6.1)

2 1356(19.9) 1395(16.2) 2751(17.9)

3 1290(18.9) 1508(17.6) 2798(18.2)

4 2369(34.7) 2802(32.6) 5171(33.6)

5(mostdeprived) 1478(21.7) 2285(26.6) 3763(24.4)

SD,standarddeviation;IMD,IndexofMultipleDeprivation.

a_Scores_available_on₁₅₄₁₅_patients.

QuarterlyprevalenceofMSKconsultations

Theregisteredpopulation,thenumberofMSK

consulta-tionsandquarterlyprevalenceofMSKconsultationsineach

generalpracticeineachquarterlyperiodareshownin

Sup-plementaryTablesAtoC.The lowestprevalenceofMSK

consultations was seenin practice B,whereas the highest

wasinpracticeA(averagedprevalence,12.1per100

regis-teredpopulationinpracticeA,8.0inB,10.5inC,11.0in

D).

PrevalenceofMSKconsultationsinthetwogeneral

prac-ticesinthecontrolarm(CandD)wasrelativelystable(around

11per100registeredpopulation)andshowednojoinpoints,

whereastwosignificantchangesinprevalencewerefoundin

interventionpractices(AandB).Theintroductionofpatient

directaccess(secondquarter of2013)wasassociatedwith

thestartofanincreasingtrendofMSK consultation(from

7.6per100registeredpopulationat2013quarter1to11.9%

at2013quarter4),the prevalencethenbecamestableuntil

theendofobservation(Fig.2).

To further explorethese findings supplementary Fig. 1

showsthedatabyindividualpractice.Thisshowsthat

Prac-ticeAmainlydrovethechangeintrendofMSKconsultation

(increasedfrom10to15consultationsper100registered

pop-ulation)buttherewereincreasesinbothpractices.Thepattern

inthecontrolpracticesCandDalsodifferedwithpractice

CshowingareductioninMSKconsultationsfollowingthe

introductionofdirectaccess(Q42015).

OtherclinicalmanagementrelatedtoMSKconditions

The prevalence of each clinical management is shown

in Fig.3a–e. As the denominator for these estimateswas

the registered practice population the numbers are small

foralltheactionsapartfromprescriptionmedications.

Pat-ternsofquarterlyprevalenceofX-rayrequestsweresimilar

betweeninterventionandcontrolpracticesbeforethe

intro-duction of direct access (second quarter of 2013). After

that, the prevalence of X-ray ordering was consistently

lower in the intervention practices than control practices

(Fig.3a).PrevalenceofMRIrequestswassimilarbetween

arms throughout the period of investigation, although the

prevalenceininterventionpracticeswashigherthancontrol

followingintroductionofdirectaccessintocontrolpractices

inthefourthquarterof2015(Fig.3b).Theprevalenceoffit

noteswas initiallyslightlylower ininterventionpractices,

whereas itbecameslightlyhigherafter theintroduction of

direct access,comparedtocontrolpractices (Fig.3c). The

prevalenceofonwardreferralswassimilarininterventionand

controlpracticesatthetimeofintroductionofdirectaccess

into the intervention practices but wasthen slightlylower

thanforthecontrolpractices(Fig.3d).PrevalenceofMSK

prescriptionmedicationswasalsoinitiallylowerinthe

inter-ventionpracticesanditincreasedtoasimilarleveltocontrol

practicesaftertheintroductionofdirectaccess(Fig.3e).

Physiotherapyservicedata

ThephysiotherapyservicedataaresummarizedinTable2.

Referralsbytypeshowthelargemajority(78%)ofpatients

from intervention practices accessed physiotherapy via

GP/nurse recommended referral. Once direct access was

introducedintothecontrolpractices,thenumberofGP/nurse

recommendedreferralsgraduallyincreasedovera6-month

periodtoreachasimilarproportiontotheintervention

prac-tices,withalargereductionintraditionalreferralsoverthe

sametimeperiod.Themeannumberof physiotherapy

ses-sionsinallpracticeswassimilar(∼3sessionsperpatient).

There was a consistent proportion of ‘true self-referrals’

across the observed time period, from 6% to 15% (mean

10%) of totalreferralsininterventionpracticesand3%to

11%(mean6%)incontrolpracticesoncedirectaccesswas

available.

Discussion

STEMS-2wasanaturalexperimentinfourgeneral

prac-ticesandtheassociatedNHSphysiotherapyservicethathad

participatedintheSTEMSpilotRCT.STEMS-2assessedthe

impactofpatientdirectaccessonconsultationsforMSK

con-ditionsovertimeandexaminedtrendsofMSKconsultation

bothbeforeandbeyondthat reportedintheSTEMSRCT.

(5)

this article in press as: Bishop A, et al. Pro viding patients with direct access to musculosk eletal physiother -on general practice musculosk eletal w orkload and resource use. The STEMS-2 study . Physiotherap y (2020), g/10.1016/j.physio.2020.04.006

AR

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No. of P ages 9 A. Bishop et al. / Physiother apy xxx (2020) xxx–xxx 5 Table2

Summaryofphysiotherapyservicedatabetweentheinterventionandcontrolpractices.

Quarter Interventiongeneralpractices(AandB) Controlgeneralpractices(CandD)

GP/nurse referral n(%) GP/nurse recommended referral n(%) True self-referral n(%) Totalnumberof referrals Averagenumber ofsessionsper patient GP/nurse referral n(%) GP/nurse recommended referral n(%) True self-referral n(%) Totalnumberof referrals Averagenumber ofsessionsper patient 1q.2015 7(5.1) 117(84.8) 14(10.1) 138 3.0 133(100) 0(0) 0(0) 133 3.4 2q.2015 7(4.4) 142(89.9) 9(5.7) 158 3.1 157(100) 0(0) 0(0) 157 3.4 3q.2015 11(9.5) 94(81.0) 11(9.5) 116 3.1 120(100) 0(0) 0(0) 120 3.2 4q.2015 13(11.1) 93(79.5) 11(9.4) 117 3.0 103(100) 0(0) 0(0) 103 3.1 1q.2016 19(20.4) 66(71.0) 8(8.6) 93 3.0 107(87.7) 11(9.0) 4(3.3) 122 3.0 2q.2016 26(16.8) 117(75.5) 12(7.7) 155 3.3 90(62.1) 51(35.2) 4(2.8) 145 3.0 3q.2016 21(17.2) 92(75.4) 9(7.4) 122 2.5 43(36.1) 72(60.5) 4(3.4) 119 2.6 4q.2016 14(15.1) 72(77.4) 7(7.5) 93 2.3 33(29.7) 74(66.7) 4(3.6) 111 2.3 1q.2017 10(10.0) 74(74.0) 16(16.0) 100 2.4 45(23.9) 123(65.4) 20(10.6) 188 2.5 2q.2017 15(19.0) 52(65.8) 12(15.2) 79 2.8 10(8.1) 100(80.6) 14(11.3) 124 2.8 3q.2017 9(10.8) 64(77.1) 10(12.0) 83 2.9 13(10.9) 100(84.0) 6(5.0) 119 2.8 4q.2017 6(11.5) 39(75.0) 7(13.5) 52 3.3 4(4.7) 76(88.4) 6(7.0) 86 3.0

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Fig.2.JoinpointregressionanalysisofquarterlyprevalenceofMSKconsultationsininterventionandcontrolpracticesfromJuly2011toJune2017.

orderingof X-raysandMRIs,issuing offit notes, onward

referralratesandprovisionofprescription medicationsfor

MSKconditions.

Thisisthefirststudytoexaminetheimpactof

introduc-ingpatientdirectaccesstophysiotherapyongeneralpractice

MSK workload at apractice level byusing routinely

col-lecteddataidentifyingallcodedconsultations.The results

showthatdirectaccessdidnothaveaconsistentimpacton

MSKconsultations.Introductionofpatientdirectaccessin

theSTEMSRCTinterventionpracticesresultedina

signif-icant increase in MSK consultations. When patient direct

access to physiotherapy was subsequently introduced into

the control practices,nooverall change inMSK

consulta-tionswasobservedalthoughasignificantreductionwasseen

inoneofthetwopracticesaroundthetimeofintroduction.

PreviousworksuggeststhatpatientdirectaccessreducesGP

workloadbyreducingrepeatconsultations[1,2]andthe

rea-sonsfortheincreaseinMSKconsultationinthisstudyarenot

clear.Thelinkedinterviewstudy[Igwesi-Chidobeetal.,

qual-itative companion paper] found someparticipants thought

thatadiagnosiscanonlybeprovidedbyadoctor.This

sug-gestsapersistenceofabiomedicalmodelformanypatients

ashasbeen highlightedfor peoplewithbackpain[10].In

preparationfortheSTEMSRCTalladultsregisteredatthe

interventionpracticesweremailedinformationaboutdirect

access(n=8222),soonepossibleexplanationfortheincrease

inMSKconsultationsisthathavingreceivedtheinformation

somepatientswhowishedtoself-referconsultedtheirGPto

receive/confirmadiagnosis.

Examiningtheimpactofpatientdirectaccessonthe

clini-calmanagementwasexploratoryandalltheactionsexamined

occurredinsmallnumbersapartfromprovisionof

prescrip-tionmedication.Fromthesedata,onlyrequestsforX-raysin

theSTEMSinterventionpracticesandpossiblyrequestsfor

MRI inSTEMScontrol practiceswere impactedbydirect

access.Noclearimpactonotherclinicalmanagementwas

apparent.ThisisincontrasttotheSTEMSRCTexploratory

cost analysiswherefewerMRIs andX-rayswerereported

intheinterventionarm.HoweverbeingapilotRCTthereis

considerableuncertaintyinthereportedestimates[4].

Previ-ousstudies[1,2,11–13]havealsodescribedreducedepisode

of care costs of patients using direct access compared to

GP-referral. Thereduced costsare attributedto theuse of

fewerscansandprescriptioncostsandalsotodifferencesin

attendanceswithhealthcareprofessionals.However,these

studies tend to examine thoseaccessing self-referralwith

thosewhodonotanditisrecognizedthatthereareimportant

differencesinthecharacteristicsofself-referrerscompared

toGP-referredpatientsthatcanaffecthealthcareutilization,

suchasbeingyounger,havinganacutecondition,beingless

likelytobeabsentfromworkandhavingarecurrenceofa

(7)

Fig.3.(a–e)GPmanagementactionsrelatedtoMSKconsultationsininterventionandcontrolpractices(prevalenceper100GPpracticeregisteredpopulation) fromJuly2011toJune2017.

SincetheendoftheSTEMSpilotRCTin2013therewas

aclearreturntotheusualcultureofpatientsinitiallyseeking

carefromtheirgeneralpractice.Thephysiotherapyservice

datashowalackofuptakebypatientsof‘trueself-referral’;in

thisstudythiscomprisedonly10%ininterventionpractices

and6%incontrolpracticesof thephysiotherapycaseload.

The small proportion of ‘true self-referrals’ is in contrast

tothe STEMSpilotRCTwhere26%of thephysiotherapy

caseload came via ‘true self-referral’. This was no doubt

boostedbythepretrialmarketingofthenewdirectaccess

ser-vice,whereasfollowingtheRCTtherewasnostandardized

approachtomessagingpatientsaboutthedirectaccess

ser-vice.Introductionofdirectaccessintothecontrolpractices

hadnostandardizednorformalcommunicationstrategyto

patients about direct access,andthis nodoubt contributes

to the lower proportion of ‘true self-referrals’ from these

practices. However, a high proportion of referrals to the

physiotherapyservicefromallpracticeswere‘GP/nurse

rec-ommended’ whichindicates ashift away from traditional

referrals.

In the linked interview study [Igwesi-Chidobe et al.,

qualitativecompanionpaper]aclearlackofawarenessand

understandingofthepatientdirectaccesstophysiotherapy

pathwaywasidentified.Thishighlightstheneedforon-going

andconsistentpromotionofdirectaccesstopatientsandthe

publictoavoidareturntotheusualpracticeofpatients

ini-tiallyseekingcarefromtheirGP.Achievinglastingcultural

(8)

mul-Please cite this article in press as: Bishop A, et al. Providing patients with direct access to musculoskeletal physiother-apy: the impact on general practice musculoskeletal workload and resource use. The STEMS-2 study. Physiotherapy (2020), https://doi.org/10.1016/j.physio.2020.04.006

ARTICLE IN PRESS

tifacetedapproaches[16,17].Thisalsopartlyexplainswhy

evaluationsofpatientdirectaccess/self-referralserviceshave

generallynotseenlargeincreasesinoveralldemandfor

phys-iotherapyserviceswhen patientdirectaccess isintroduced

[1,2].IntheNetherlandswherepatientdirectaccessto

phys-iotherapywasintroducedacrossthewholehealthcaresystem

in2006,28%ofpatientsuseddirectaccesstophysiotherapy

after12months[15]risingto46%after 5years[18],

sug-gestingagradualriseinself-referralwhereimplementationis

successful.Yangetal.,[healtheconomicscompanionpaper]

suggestthatifthereisalargeshiftfromtraditionalGP-led

careto patientdirect access tophysiotherapy, demand for

physiotherapywill increasewhichwould require

appropri-ateinvestmentinphysiotherapyservices.Theresultsofthis

studysuggestthatwillnotbethe caseunlessdirectaccess

ismoresuccessfullymarketedtopatients,implementedand

sustained.

Thisstudy identifies a numberof issues around access

modelstoMSKhealthcare.Thesearerelevantbothto

self-referraltoexistingMSKservicesbutalsofornewservices

whichmaybedevelopedandimplemented.Although

gen-eralpracticebasedFCPsmayhelptoovercomesomeofthe

problemsofawarenessamongstpatientsandmaybemore

likelytobeseenasavalidalternative totheGPsincethey

arebasedinthesamebuilding,someFCPservicesarealso

establishedin‘hubs’servinganumberofgeneralpractices.

Thismaybeduetologisticsofstaffing,providingtrainingin

firstcontactrolesforlessexperiencedstafforsimplydueto

lackofsuitablespaceingeneralpractices.Raisingawareness

tobothpatientsandprofessionalsofnewmodelsofcareis

essentialforsuccessandthisneedstobeconsistentandneeds

tocontinueuntillastingchangeisachieved.

Strengthsandlimitations–Strengthsofthisstudyisthat

STEMS-2 was a natural experiment that provided a

real-worldsettingtoinvestigatetheimpactofpatientdirectaccess

tophysiotherapyforMSKconditions.Itusedroutinely

col-lecteddatatorobustlyquantifytheimpactongeneralpractice

MSKconsultationsandclinicalmanagementforpatientswith

MSK conditions. A limitation is that only four practices

wereincluded inthe natural experimentas thesepractices

hadpreviouslyparticipatedinthe STEMSpilot RCT.The

inconsistentfindingsseenacrossthepracticessuggestother

factorsinadditiontotheintroductionofpatientdirectaccess

impactonMSKconsultations.Inthistypeofstudythereare

challengesincapturingallMSKconsultationsas itiswell

recognizedthat Read codes arenot recorded for 100% of

presentingconditions[19].Althoughcodingofconsultations

andclinicalmanagementvariesacrosspractitionersour

anal-yseswereessentiallywithinpracticeandsothecodinghabits

oftheGPsinthe participatingpracticeswerenotexpected

tosystematicallyvaryacrossthecourseofthisstudy.

How-ever,somevariationwouldbeexpectedwithin-practicedue

tochange inpersonnel thoughthesenaturalchangescould

equallyoccuracrossbothinterventionandcontrolpractices.

In addition,somereferrals,investigations andprescription

medicationcouldhavebeenfornon-MSKreasonsbutthese

couldnotbeidentifiedduetotheanonymisednatureofthe

data.

Conclusion

Inthisnaturalexperimentwithfourgeneralpracticesand

associated physiotherapy service, we found no consistent

impact of patient direct access to NHS physiotherapy for

MSKconditionsonthemusculoskeletalworkloadofthe

prac-tices. Overall, changesin someclinicalmanagement were

observedbutnotconsistentlyinthedirectionsuggestedby

previous studies.Itis essentialthat patientdirectaccessis

successfully communicatedtopatients inwaysthatensure

that new services aresustained over time, sothat impacts

canbeassessed.Theinconsistentfindingsinthefourgeneral

practices inthisstudy, supportthe need fora largerstudy

with many more general practices andphysiotherapy

ser-vices. AfuturelargeclusterRCTtoprovidepractice level

robustevidenceoftheeffectivenessandcost-effectivenessof

self-referraltophysiotherapyiswarranted.

Contributionofthepaper

Thispaperaddstothecurrentliteratureby:

• Providingdataonthereal-worldimpactofpatientdirect

access to NHS physiotherapy at general practice level

usingroutinelycollecteddata.

• Contributingtotheevidencebaseformodelsofcarefor

patientswithmusculoskeletalconditions.

• Highlightingsomeofthechallengesforsustained

imple-mentation of patient direct access (self-referral) to

physiotherapy.

Acknowledgements

Wewouldliketoacknowledgethecontributionof

follow-ing:

EmilyHughes,TrialManager,KeeleClinicalTrialsUnit,

whowasthestudymanagerfortheSTEMS-2study.

SimonWathall,HealthInformaticsSpecialist,Keele

Clin-icalTrialsUnit,forhisroleinobtainingthedatafromEMIS

HealthDataExtractionService.

KatrinaHughes,ClinicalSpecialistPhysiotherapist,

Cen-tralCheshireIntegratedCarePartnershipandPhysiotherapy

ResearchFacilitator,KeeleUniversity.

The general practices and physiotherapy service who

allowedusaccesstotheiranonymiseddata.

Professor Kelvin Jordan holds an Honorary Academic

ContractwithPublicHealthEngland.

Conflictofinterest:AnnetteBishopisanassociateeditor

(9)

Ethical Approval: Research Ethics Committee (REC)

approval gained on 16th August 2017 (IRAS Project ID:

225726RECreference:17/EM/0310.

Funding: The STEMS-2 study was funded by Versus

Arthritis(grantref:21406).ProfessorNadineFosterwas

sup-portedthroughanNIHRProfessorship(NIHR-RP-001-015)

andisaNIHRSeniorInvestigator.Theviewsexpressedin

thispublicationarethoseoftheauthorsandnotnecessarily

thoseoftheNHS,theNIHRortheDepartmentofHealthand

SocialCare.

AppendixA. Supplementarydata

Supplementary data associated with this article can

be found, in the online version, at https://doi.org/10.

1016/j.physio.2020.04.006.

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