Primary National Health Service (NHS), providing the main

Primary Care (PC) is the
bedrock of the National Health Service (NHS), providing the main source of
healthcare and most first-point of contact (FPOC) healthcare such as disease
diagnosis, prevention, monitoring and management (NHS England, 2016; Hobbs et
al. 2016). PC includes services such as the General Practitioner (GP),
pharmacist, dentist and optician with approximately 90% of all NHS contacts
occurring within these areas (Hobbs et al. 2016).

The British Medical
Association (BMA) carried out a survey and found that 34% of GPs intended to
retire within the next 5 years and 17% hoped to change to part-time work (NHS
England, 2015). Unsurprisingly this then led to the lowest overall job
satisfaction for GPs, since surveys began in 1998 (Gibson et al. 2015). This is
supported by more recent data that has shown the number of GPs in practice fell
by 542 between March 2016 and 2017, with workload identified to be the principal
factor in why GPs considered leaving the profession (Department of Health
annual report, 2017)

Presently there are 11
million people in the United Kingdom (UK) over the age of 65, with 25% of the
population estimated to be above this age range by 2040 (BMA, 2017). It is one
of the marvels of modern medicine, but the ageing population is having
concurrent rises in chronic health conditions associated with old age (Goodwin
and Hendrick, 2016). In addition to this, there is a growth in patient
expectation and demand beyond that which is realistic for GPs to cope with
(Doran et al. 2016).

One of the central themes
of the NHS Business Plan 2016/17 is that of improving PC services (NHS England,
2016). In this document, it highlights the Government’s commitment to ensuring
a 7-day service and more evening appointments for GPs by 2020. The Government also
ensures a minimum of 5000 additional doctors as well as 5000 additional staff
such as mental health workers, physician associates and clinical pharmacists
(NHS England, 2016). This essay will aim to discuss how the provision of
Physiotherapists (PTs) can help support this commitment to improving PC services,
specifically within the General Practice Surgery.

 

 

Main Body

 

Musculoskeletal (MSK) conditions are a
frequent cause of appointments in PC, with 20-30% of a GP’s patient list and
40% of those going to an NHS walk-in centre doing so because of an MSK related
problem (Jordan et al. 2010; Sephton et al. 2010). Examples of common MSK
conditions include lower-back pain, adhesive capsulitis and tendinopathies to
name a few. Evidence shows
that in the UK approximately 21% of patients will consult their GP due to lower
back pain, and 35% for Osteoarthritis (Jordan et al. 2013).

 

In
2016 an estimated 137 million working days were lost due to sickness or injury
in the UK, with 22.4% of that figure due to musculoskeletal conditions (Office
for National Statistics, 2017). This equates to roughly 30.8 million working
days lost, however people who are able to self-refer to PT have been shown to
take fewer days off and are even 50% less likely to take a leave of absence for
more than a month compared to conventional GP referrals (CSP, 2017).

Physiotherapy provision could provide an economic benefit which is likely to be
even greater if reduced time off of work is taken into account, whereby
increases in work productivity may offset the increase in cost of employing PTs.

 

PTs have long been considered skilled
clinicians in dealing with such ailments, with some studies showing PTs possess
a greater diagnostic accuracy than other healthcare professionals (Moore et al.

2005). It should be noted that within this aforementioned study, the clinical
diagnostic accuracy (CDA) of Orthopaedic surgeons was greater (80.8%) than that
of PTs (74.5%), although this was not a statistically significant difference (p
> 0.5). The study did however find a sizeable difference between the CDA of
PTs and non-orthopaedic clinicians such as Nurse practitioners, A&E Doctors
and, crucially, GPs. The study found that the CDA of GPs was 42.7% for a
variety of musculoskeletal diagnoses including lumbar disc herniation, anterior
cruciate ligament sprain and shoulder labral tears.

 

The role of PTs is expanded further than just
diagnosis, treating and managing patients but also referring them onwards to
the appropriate medical professional if required. Implementing a holistic
multidisciplinary approach to therapy ensures that PTs are confident in knowing
the other clinicians at their disposal and, most importantly, when it is
appropriate to refer onwards.

 

A study which assessed the appropriateness of
referrals from GPs was carried out by Roland et al. (1991). GPs were asked to
complete questionnaires following an orthopaedic referral and found that 10.8%
of GPs thought that their referral was either probably, or definitely,
unnecessary. In fact, referrals for back pain were deemed the most
inappropriate and in 58 cases GPs highlighted the fact that if other facilities
such as Physiotherapy were directly available to them it may have prevented the
referral. Interestingly the orthopaedic consultants, to whom the referrals were
made, documented 42.7% to be either probably or definitely inappropriate. Had
physiotherapy been the FPOC for these patients, as opposed to the GP, they
would have likely been able to treat and manage the patients themselves, thus
reducing waiting times for the patient and increasing patient satisfaction (McMullan
and Netland, 2013; Waters et al. 2016).

 

It should be stressed that this study is 26
years old and therefore it is difficult to determine whether this is an issue
that is still prevalent currently in PC. The data itself may also be less than
reliable, as asking GPs to assess their own referrals seems counterintuitive.

Many will not have wanted to admit that they had unnecessarily written a
referral, while judgement of the appropriateness was entirely subjective with
no set criteria for both the GPs and consultants to follow. Additionally, many
of the GPs received their questionnaires several months after the referral was
made and therefore may have simply forgotten how appropriate the referral was.

 

MacKay et al. (2009) sought to determine
whether Physiotherapy Extended Scope Practitioners (ESPs) were able to
appropriately identify when a patient should be referred on to an orthopaedic
surgeon for a total joint replacement. The authors delved deeper and assessed
whether the PT and surgeon were in agreement on the clinical diagnosis and
studied their recommendations for conservative management of patients. The
study found that the ESPs and surgeons agreed on the appropriateness of
orthopaedic consultation in 91.8% of cases and the inter-rater agreement on
clinical recommendations for either conservative or surgical management was
85.5%. It is therefore possible to conclude that patients with hip or knee pain
can be appropriately referred for orthopaedic consultation by ESPs, therefore
these are the patients who actually need surgery as opposed to just an opinion.

Again, this further reduces waiting times for operations which will in turn
improve patient satisfaction (McMullan and Netland, 2013; Waters et al. 2016).

 

As briefly touched upon earlier, the
government has announced a commitment to ensuring a minimum of 5000 additional
healthcare professionals by 2020 in order to broaden the mix of skills and
specialists that are available to patients as well as support the work of GPs (Department
of Health, 2017). As far back as 2005 it has been suggested that patients want
more flexible access to PC services, highlighting physiotherapy as an example
(Coulter, 2005). Generally, patients are willing to be seen by healthcare
professionals other than Doctors thus providing scope to vary the skill mix and
encourage multidisciplinary team working. Conversely older people and those
with chronic ailments, who are
the most common consumers of PC, value care from professionals that they know
already (Coulter, 2005). Moreover, almost 100 PTs gained
independent prescribing rights in the UK between August 2016 and January 2017,
bringing the total to almost 500 (CSP, 2017). Through attaining this skill,
ESPs can reduce the need to refer patients back to their GP and the NHS is able
to make better use of the varying skills of their workforce to deliver a more
streamlined and efficient service.

 

Pilot studies featuring PTs in PC are seldom,
but those that have taken place have found significantly positive results. In
Wales, The Betsi Cadwaladr University Health Board started a pilot scheme in
2015 whereby advanced-MSK PTs were introduced to four GP practices. Within the
first nine months of the service, nearly 2000 appointments were made with PTs
which previously would have been seen by GPs. In turn, this has reduced the GPs
workload and seen a 16% reduction in onward referrals.

 

A similar pilot was initiated in Scotland in
August 2016 within three GP practices, with a combined total patient list of
14,000. As such PTs have provided over 1000 consultations with 94% not requiring
a further appointment (The Scottish Government, 2017). This has meant GPs are
able to utilise their time more effectively by seeing patients in greater need
of their expertise. Similarly, patients were able to self-refer themselves to
Physiotherapy providing them with more direct access to the specialist that
they require, thus improving patient satisfaction.

 

Through self-referral schemes patients are
able to be seen much quicker and evidence shows that early intervention for LBP
enables workers to return to work up to five weeks early, with a 40% reduction
in recurrence the following year (CSP, 2016). Self-referral also plays an
integral role of putting individuals in control of their own care, thus
fostering self-management and reducing the consumerist approach to healthcare
that is so widely exhibited at present (Davidson, 2016). This also works in
favour of the NHS’s proposal to “redesign and modernise the referral process”
and to “encourage patient empowerment” (NHS England, 2016 pp.30 and pp 38). Research on the cost savings of self-referral in Scotland
showed an average saving of approximately £2 million each year, considering the
costs of patient self-referral were calculated as £66.31 per
episode compared to GP referral at £88.99 (The Scottish Government, 2017).

 

Ludvigsson
and Enthoven (2012) undertook a study evaluating PTs as FPOC for patients with
MSK issues within a GP practice. The authors found that the service was safe
and 85% of patients were able to be managed solely by the PT. Patient
satisfaction was good and the majority of patients did not need to return to
see their GP in the three-months after seeing a PT. The main limitation of the
study was that the participants were not randomly allocated to be seen by the
PT or GP, therefore researcher bias cannot be excluded.

 

Further evidence of the benefits of a PT
service within a PC setting have been seen in England. In Darlington, a pilot
scheme in two GP practices (eventually increasing to four) had an ESP available
for two hours a day providing an initial triage appointment and on-going
treatment. Between December 2015 and September 2016, a total of 1147 patients
were seen for MSK issues with only 2% requiring onward referral to the GP,
meaning 1128 more GP appointments were available for other patients to access
(Goddard, 2017). 74% were managed with health-education and advice, therefore
they were able to self-manage and did not require ongoing treatment.

 

Ultimately it is the opinion of the patients
that is most crucial when implementing a new health-care strategy. In this case,
of the 70 patients who completed a questionnaire, 100% said that they would
recommend this service to family and friends as well as continue to use the
service themselves (Goddard, 2017). It is no secret that the NHS is facing a
financial challenge, as noted in the Business Plan (NHS England, 2016), as such
the government is striving for cost-effective strategies. With estimated
savings of £26,000 over 7 months in the aforementioned study, it is clear that
by improving efficiency and moderating demand, the NHS could extremely prosper
from the provision of PTs in PC.  

 

Most recently a study of a Suffolk-based GP
practice investigated the benefits of having a Senior PT (as opposed to an ESP)
as the FPOC (May, 2017). The author explained that the cost of an ESP would
have been £30.30 per hour compared to £22.75 for the Senior PT, hence their
inclusion in the study. In total 802 patients were seen by the FPOC PT, thus freeing
up the GP’s caseload significantly. Although the study was written this year and
the author implemented a novel idea of using the more financially justifiable
Senior PT, this article had many flaws. The article failed to mention over how
many months the pilot was taking place, nor did it go into any detail about the
questionnaires that were used to gauge feedback from patients and GPs. The
article in total was the length of an abstract and by no means a thoroughly
written study, with no citations or references provided. Without clear
evidence-based research it cannot be deemed a robust or valid piece of writing
(Brownson et al. 2017). It is also unclear where the author attained their
figure for the cost of employing a Senior PT as the CSP has stated that the
cost is £54.11 per hour (CSP, 2016).

 

According to the CSP (2016), a GP currently
costs £130.71 per hour, a significant sum more than a Senior PT, meaning there
is a clear financial motivation towards favouring a PT in a GP practice. It is
no illusion that the NHS is facing a serious financial challenge at present,
explaining in the 2016/2017 Business Plan that by making better use of the
skills of their workforce they will become more sustainable (NHS England, 2016).

  

 

Bowling et al. (2006) stated that 43% of
hospital doctors and GPs identified lack of time as negatively affecting their
decision making, while 41% highlighted inadequate staffing levels as having the
same affect. Patient centred healthcare is the foundation upon which the NHS
has flourished for many years but constructive, caring and efficient healthcare
cannot be delivered through a succession of short and intermittent GP
consultations interspersed with poor decision making and stress of further work
obligations (Toop, 1998). In its entirety, this goes against the core values of
the NHS and as such leads to worsening patient care, increased waiting times
with rushed services simply leading to poor patient satisfaction.

 

Mitchell (2013) highlights workforce
shortages, an ageing population and the potential to improve patient
satisfaction as forces which often initiate change in healthcare. Bullock and
Batten’s (1985) phases of planned change is one theory which could be
implemented to initiate change specifically within an organisation, such as the
NHS. The theory highlights four key stages, beginning with ‘Exploration’.

Exploration involves confirming the need for change and attaining the resources
necessary, such as the number of ESPs required to have an impact in PC.

‘Planning’ involves key decision makers such as commissioners and senior NHS
staff creating a set of actions sequenced into a plan. An example could perhaps
be the planning of a pilot scheme whereby an entire borough or town is provided
with enough ESPs that the GPs surgeries within it are staffed for at least one
day per week, for one year.

 

The third stage is aptly named ‘action’,
whereby the plan is carried out with specific feedback mechanisms executed to
allow for unexpected changes. ‘Integration’ is the final stage and involves
supporting the change with other areas of the organisation and formalising them
through policies and rewards (Cameron and Green, 2015). Policies set in place
could include formally ensuring that every GP surgery in the UK is staffed by
an ESP for at least two days per week by 2022. Financial rewards could be
provided for GP surgeries who are able to successfully implement these schemes
and illustrate reduced unnecessary referrals, with improved patient-related
outcomes.

 

 

Conclusion

 

Presently
there are approximately 5 million general practice consultations a week which
have increased not only in number (13.67%) but also in duration (13.5%) between
2007 and 2014 (Hobbs et al. 2016; NHS England, 2016). To that end, the British
Government’s commitment to ensuring 7-day access to GPs by 2020 hardly seems
feasible particularly as the BMA found that in 2016 alone more than 300 GP
practices felt they were under threat of closure due to financial strains (BMA,
2016). By sharing the burden of responsibilities, the advent of PTs in a PC setting can help relieve some
of the pressure on General Practitioners by being the FPOC (NHS England, 2016).

 

By better utilising the various
specialties in the multidisciplinary team it is possible to re-design the PC
system and ensure patients receive the best care from the most qualified
provider as quickly as possible. Parallel to this, by increasing the specialist
care available in PC, evidence suggests (Huntley et al. 2014) that in turn this
will reduce pressure on A&E and therefore unnecessary hospital admissions,
another central proposal within the NHS business plan (2016).

 

The NHS business plan also
highlights the need for new models of care with a move away from the traditional
divide between PC, community and hospitals (NHS England, 2016). A more bespoke
service is required and accomplishing this through incorporating PTs within the
Multispecialty Community Providers that are slowly appearing, could be
paramount.

 

Much of the research thus far has focused on
the role of ESPs in GP surgeries, however according to the ESP professional
network there are only 600 practicing presently (ESP Professional Network,
2017) which begs the question, is there enough to fill the 7,613 GP practices
in the UK? (BMA, 2017). Realistically if the provision of PTs in PC were to be
successful, it would require many additional PTs to gradually transition into
more advanced roles.

 

It is worth noting that at present, the
literature only supports the use of PTs in assessing MSK conditions. The
ability of PTs working in PC to assess, diagnose and treat patients with
neurological conditions for example, are yet to be evaluated. In fact, the
skills of a PT could be employed to combat various challenges within PC such as
respiratory care, falls prevention, elderly medicine, Women’s health and
chronic pain management. This is a particular area for future research to focus
on.

 

As
modern medicine has adapted, so too should health-care systems as a whole adapt
to deliver a sustainable service through improving prevention, achieving
greater efficiency and empower patients to select