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

2. 2 UK Physiotherapy Access: Locus of Control: a logical progression? Hospital Doctors GP’s Patients? 1948 1970’s1981 1990’s 1997 2008 Professional Autonomy GP Fundholding Hospitals Primary care Communities

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

4. 4

5. 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. 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. 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. 8 Accountability Responsibility Private practice Only partial autonomy within the NHS

9. 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. 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. 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. 12 No association by referral group Gender (NS) Age group (NS) Physiotherapist determined outcome (NS) Patient determined outcome (NS) Physiotherapy contacts (NS)

13. 13 However self referrals…. P = sig 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%

14. 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. 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. 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. 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. 18 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 AHP Research Award, 2005 Scottish Award for Innovation, 2005

19. 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. 20 An international multi-centred investigation of patient self referral and physiotherapy practice in privately funded health care systems: 2005-08

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

22. 22 www.selfreferralphysioinfo.com

23. 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. 24 lesley.holdsworth@nhs.net v.webster@gcal.ac.uk