Patient Self -refer ra I to Physiotherapy in General Practice - A Model for the New NHS? Summary This paper describes the changes which have occurred for GPs in access to physiotherapy services, and the benefits of GP practice based physiotherapy services. Method: An innovative study is described in which physiotherapy was made available to the public at Carnoustie Health Centre by means of a patient self-referral system. The self-referral service was evaluated over 12 months. Results: The average number of referrals each month was 23.5; only four referrals were considered by the physiotherapist to be inappropriate. The number of GP referrals made t o the existing physiotherapy service, which had been in operation for eight months when the study began, continued to increase over the 12-month study period, from 32 to 40 per month. The conditions being referred were of the same distribution as those from the GPs. Discussion: Patient self-referral has thus been shown to be feasible at a local health centre. Further studies to evaluate the benefits, such as reductions in waiting time for treatment, number of GP consultations, number of consultant referrals made by GPs, cost of prescriptions, and non-attendance at physiotherapy are indicated. It is proposed that patient self-referral within GP practice physiotherapy departments may be the model for some physiotherapy services within the new NHS. Introduction Professional Autonomy Co-operative relationships between physiotherapists and general practitioners (GPs) have resulted in provision of a number of innovative services over the last 25 years. Methods of referral and modes of access to physiotherapy have evolved considerably over this period. Reports dating from 1975 have advocated the value of GPs having direct access to physiotherapy departments rather than referring to the consultations (Norman et al, 1975; Ellman et Fe%USOn, 4 Griffin* al, 1982; Whelpton, 1997). The progression MddF (1999). from this system of referral has been the self-referral to provision of physiotherapy services within physiotherapy in general practice -A model for the primary care. Goldie (1979) suggests the new NHS?~ p~ys~ot~erapy, benefits derived from physiotherapy in 85, 1,1320. primary care are a shorter waiting time .. . . . ........ . . . ...... . ... . ............... . ..,............. . ,,,,,.............,,, . ,,,. . ....... and Key Words 13 Professional autonomy, self-referral, direct. access, open access, primary care. by Amanda Ferguson Elaine Griffin Cathy Mulcahy for treatment and an increase in GPs’ knowledge of physiotherapy skills and treatments. These benefits were also reported by a GP practice in Cheshire (Hackett et al, 1987). In order to reduce the waiting time for physiotherapy treatment this practice employed an ‘in-house’ physiotherapist for six hours a week in 1982. This service expanded very rapidly and produced a saving of &21,500 per year for the practice of 12,000 patients. Hdckett also reports that GP-based Physiotherapy services promote a reduction in the number, and hence cost of prescriptions (Hackett et al, 1993). O’Cathain et al (1995) reported that GP- based physiotherapy services can contribute to a reduction in the number of orthopaedic and rheumatology referrals. Willesden Community Hospital has found that running satellite physiotherapy clinics at GP surgeries provides increased communication between GPs and physiotherapists, with the result that physiotherapists act as a filter for consultant referrals (personal commun- ication, 1998). This closer working relationship of physiotherapists with GPs occurred within the same era that physiotherapists were granted professional autonomy in terms of deciding on appropriate treatment and on when to discharge patients from treatment (DHSS, 1977). This aspect of professional autonomy is well recognised, as is indicated by a Swedish review of physiotherapists’ conception of their professional role and autonomy (Bergman, 1990). In this review 86% of physiotherapists felt that they were in control of making their own diagnosis and prescribing treatment. Ten years after the circular from the Department of Health, the Chartered Society of Physiotherapy revised its rules of professional conduct to allow physiotherapists to see patients without a doctor’s referral (CSP, 1987). This aspect of Physiotherapy January 1999/vol85/no 1
Transcript
Patient Self -refer ra I to Physiotherapy in General Practice - A Model for the New NHS?
Summary This paper describes the changes which have occurred for GPs in access to physiotherapy services, and the benefits of GP practice based physiotherapy services.
Method: An innovative study is described in which physiotherapy was made available to the public at Carnoustie Health Centre by means of a patient self-referral system. The self-referral service was evaluated over 12 months.
Results: The average number of referrals each month was 23.5; only four referrals were considered by the physiotherapist to be inappropriate. The number of GP referrals made to the existing physiotherapy service, which had been in operation for eight months when the study began, continued to increase over the 12-month study period, from 32 to 40 per month. The conditions being referred were of the same distribution as those from the GPs.
Discussion: Patient self-referral has thus been shown to be feasible at a local health centre. Further studies to evaluate the benefits, such as reductions in waiting time for treatment, number of GP consultations, number of consultant referrals made by GPs, cost of prescriptions, and non-attendance a t physiotherapy are indicated. It is proposed that patient self-referral within GP practice physiotherapy departments may be the model for some physiotherapy services within the new NHS.
Introduction Professional Autonomy Co-operative relationships between physiotherapists and general practitioners (GPs) have resulted in provision of a number of innovative services over the last 25 years. Methods of referral and modes of access to physiotherapy have evolved considerably over this period. Reports dating from 1975 have advocated the value of GPs having direct access to physiotherapy departments rather than referring to the consultations (Norman et al, 1975; Ellman et
Fe%USOn, 4 Griffin* al, 1982; Whelpton, 1997). The progression MddF (1999). from this system of referral has been the self-referral to provision of physiotherapy services within physiotherapy in general practice - A model for the primary care. Goldie (1979) suggests the new NHS?~ p~ys~ot~erapy , benefits derived from physiotherapy in 85, 1,1320. primary care are a shorter waiting time
Key Words 13 Professional autonomy, self-referral, direct. access, open access, primary care.
by Amanda Ferguson Elaine Griffin Cathy Mulcahy
for treatment and an increase in GPs’ knowledge of physiotherapy skills and treatments.
These benefits were also reported by a GP practice in Cheshire (Hackett et al, 1987). In order to reduce the waiting time for physiotherapy treatment this practice employed an ‘in-house’ physiotherapist for six hours a week in 1982. This service expanded very rapidly and produced a saving of &21,500 per year for the practice of 12,000 patients. Hdckett also reports that GP-based Physiotherapy services promote a reduction in the number, and hence cost of prescriptions (Hackett et al, 1993). O’Cathain et al (1995) reported that GP- based physiotherapy services can contribute to a reduction in the number of orthopaedic and rheumatology referrals. Willesden Community Hospital has found that running satellite physiotherapy clinics at GP surgeries provides increased communication between GPs and physiotherapists, with the result that physiotherapists act as a filter for consultant referrals (personal commun- ication, 1998).
This closer working relationship of physiotherapists with GPs occurred within the same era that physiotherapists were granted professional autonomy in terms of deciding on appropriate treatment and on when to discharge patients from treatment (DHSS, 1977). This aspect of professional autonomy is well recognised, as is indicated by a Swedish review of physiotherapists’ conception of their professional role and autonomy (Bergman, 1990). In this review 86% of physiotherapists felt that they were in control of making their own diagnosis and prescribing treatment. Ten years after the circular from the Department of Health, the Chartered Society of Physiotherapy revised its rules of professional conduct to allow physiotherapists to see patients without a doctor’s referral (CSP, 1987). This aspect of
Physiotherapy January 1999/vol85/no 1
14
Authors Amanda Ferguson PhD MCSP worked in research at the Bioengineering Unit of Strathclyde University from 1986 to 1994, and is now in a clinical post at Carnoustie Health Centre. She was involved in the completion of this study.
Elaine Griffin MSc BSc is a lecturer at Tayside Centre for General Practice, the University of Dundee, undertaking research and development in primary care and teaching at postgraduate levels. She designed the database for this study and undertook all data analysis.
Cathy Mulcahy BPT, a clinical physiotherapist at Lawrencekirk Health Clinic, set up and ran this study for the first eight months.
This study was funded by the Primary Care Development Fund. It was presented at the Scottish Physiotherapy Workshop in Stirling, October 1996, and received the RCGP East Scotland Faculty Award for Innovation in Primary Care in September 1998.
This article was received on January 12,1998, and accepted on August 7, 1998.
Address for Correspondence Amanda Ferguson, Physiotherapy, Carnoustie Health Centre, Carnoustie, A n g u s DD7 7RB.
professional autonomy is used widely in private practice and in sports clinics, but there are no reports in the literature of patients making self-referrals to physio- therapy within the NHS.
Physiotherapists appear to feel much more restricted in their freedom to treat patients without a referral from a doctor (Bergmdn, 1990). Possible reaSons for this may be that physiotherapists are concerned that they would be inundated with referrals, and/or that GPs may be concerned that systemic conditions might go undiagnosed if patients consult physiotherdpists first.
Background to Study Carnoustie has nine GPs, organised into two fund-holding GP practices, both of which are housed in Carnoustie Health Centre (CHC). The combined patient profile for the two practices is shown in the table. There is only 1% deprivation within the population. Patient profile for the two GP practices combined (N = 11,719)
In June 1994 CHC began an ‘in-house’ physiotherapy service. Two senior I1 physio- therapists (forming one whole-time equivalent) were contracted from Angus NHS Trust to treat out-patients within the health centre. Two hours of domiciliary physiotherapy service were already being purchased privately for treatment of house- bound patients. All the GPs and hospital consultants were able to refer to these services. These services were still developing when, eight months later, patient self- referrdl to out-patient physiotherapy at CHC was made available to the public.
The GPs were keen to let the physio- therapists exercise their full role of pro- fessional autonomy, ie that the physio- therapists should decide whether self- referred patients were appropriate for physiotherapy, as well as -diagnosing, planning treatment and deciding when to discharge the patients. The GPs’ rationale was that this would enable patients to be seen more quickly, and would save GP time. If patients could be seen more quickly, the GPs anticipated that a third benefit might be
a reduction in time off work due to injuries (eg back pain). A project was conducted from February 1995 to January 1996 with the aims of establishing and evaluating the feasibility of a self-referral service. The project was run by a senior I part-time physiotherapist (0.5 wte), who was employed in addition to the existing physiotherapists.
Method Setting up the Self-referral Service The provision of the service was publicised in the local paper in January 1995, and a poster was displayed in the health centre. In order to reduce the possibility of being inundated with referrals, it was stipulated that the problem requiring treatment should only have been present in the last two months. Initially, two half-hour sessions per week were allocated during which patients could speak to the physiotherapist (in person or by telephone) to make an appointment. Theoretically ‘urgent’ patients could be seen for treatment at these times. Within eight months this system of referral was becoming unworkable, with patients telephoning to make appointments at any time, and/or expecting to be seen immediately. An alternative system was therefore introduced whereby patients completed a form with their details and information on their condition. The physiotherapist then contacted them to make an appointment.
Prevention of Misdiagnosis Protocols were written by the physiotherapist and discussed with a GP to highlight awareness of systemic conditions which might present with symptoms of a mechanical nature. These provided a check list within the subjective assessment of patients. The main symptoms identified were as follows: W Constant pain. W Pain unrelieved by changing position. W Unwanted weight loss. W Poor general health and fatigue. W Circulatory problems. W Progressive neurological changes. W Severe night pain. W Bowel and bladder disturbance.
The other factors which helped to avoid misdiagnosis were the easy availability of patients’ medical notes and informal liaison with GPs. Access to patients’ medical notes was unimpeded and notes could be viewed immediately if necessary upon request to the clerical staff. The GPs were available each
PhysiotherapyJdriuary 1999/vol %/no 1
Professiona I articles 15
morning arid afternoon during their coffee/tea break for informal liaison. This close multi-professional working relationship was possible d u e lo the physiotherapy department being located within the health centre.
Monitoring the Service Data collection was achieved by the corn- plction of a proforma on each patient at the cnd of their course of treatment. This gme:
Details of the patient. W Occupation.
Condition being treated. Effect of this on attendance a ~ : work. Treatment given. Whether referral was appropriate. Kcsult (outcome) of treatment.
W What happened to the patient at the end of treatment. The proforma categorised occupations
int.0 heavy manual, moderate manual, light manna1 and sedentary work according to the demands in terms of weight. lifted and frequency of lifting. The rationale behind 1.his was to determine whet.her heavy manual workers presented with back problems more than o ther categories of workers. T h e definitions of the cat,egories above were (respectively) 1ift.ing daily more than 1.00 lb (eg a labourer), lifting daily 30-100 lb (eg a farmer) , lifting 40 Ibs 2-3 times per week (eg a shop assistant.), and no lifting (eg an accountant).
The types of conditions were categorised into ‘soft tissue’ (comprising ‘muscular’, ‘ligamen t.ous’, ‘tendinous’), ‘degenerative’, ‘ n e u ra I ’ an d ‘ o s s e o u s ’ . ‘ D e ge n e r a t ive ’ comprised condit.ions with degeneration of. joint(s) such as arthrit is (spinal o r peripheril) or spondylosis. The category of ‘neural’ was given to conditions involving nerve root irritation (eg sciatic or brachial plexiis disorders). ‘Osseous’ referred to fractiires. The outcome of treatmerit was evalumd by the physiotherapist., and rited as ‘cured’ (ie patient. pain free with full range of movement and performing full function), ‘markedly improved’ (ie patient experiencing substantially less pain and/or subst.antia1 increase in range of movement. with only minor restriction in function), ‘slightly improved’ (ie patient experiencing a reduction in presenting symptoms but little change in function), ‘no change’ or ‘worse’. Patient feedback was sought by asking patients to complete a consumer survey questionnaire. The data were entered on to a database (Microsoft Access) which
was used in combination with a spreadsheet (Microsoft Excel) to produce the results olllput.
Consumer Survey An anonymous survey questionnaire was given or sent to each patient at the end of treatment. Patients were asked how long they had waited for treatment and to state whether they considered treatment had cured/markedly improved/slightly improved the problem, or whether it had no effect o r made the problem worse. N o definition of these categories was given, therefore the responses were purely subjective. Patients were also asked whether they felt the service should continue, and which parts of the service they found beneficial.
Results Patients Referred Between February 1995 and the end of January 1996, 282 self-referrals were made for physiotherapy, all of which were assessed by the physiotherapist. The number of patients referred each month is shown in figure 1. The average number of referrals each month was 23.5. T h e numbers of pat.ients being referred from the GPs to the existing physiotherapy service did not reduce during this period, in fact they increased from an average of 32 per month (in the previous year) to 40. The following results are based on the 236 self-referrals for whom proformas were completed by the end of the data collection period.
40
35
30
5
Feb Mar Apr May June July Aug Sept Oct Nov Dec Jan
Fig 1: Number of patient referrals in each month from February 1995 to January 1996
PhysiotherapyJdriuary 1999/vol %/no 1
16
Inappropriate Referrals Only four of the 236 self-referrals were considered to be inappropriate. These referrals were made by three patients. One of these had a chronic pain condition which was awaiting surgery and which had previously not responded to physiotherapy, another had suffered a head injury and presented with pain which appeared to be psychosomatic in origin. The other two referrals were made by one patient who had a knee injury. This patient had previously had physiotherapy and was awaiting surgery. Five patients referred themselves twice during the 12 months. These were con- sidered to be appropriate, the conditions being two patients with supraspinatus tendinitis, one sportsman with a knee injury, one patient with sacro-iliac joint dysfunction, and one patient for treatment of low back pain ante-natally and then post-natally.
Sex/ Age The sex distribution of the patients was 113 (48%) males and 123 (52%) females. The age distribution of patients is shown in figure 2. The highest number of referrals was in the 30-50 years age group.
70
60
50 P C Q, .- 40
n 0 & 30 m
+
f z 20
10
0 (20 21-30 31-40 41-50 51-60 61-70 9 0
Age (years) Fig 2: Age distribution of patients
Conditions A breakdown of the anatomical structures which predominantly caused symptoms is shown in figure 3. The majority (approx- imately two-thirds) were soft tissue, the other third were degenerative and neural. Figure 4 shows the different anatomical locations of injuries/conditions: A large proportion (33%) were back injuries. This comprised
Lower limb Back a 27% 33%
sck 17%
Fig 3: Types of injuries by percentage
Neural &16%
sseou 6%
Tendinou 6%
Ligamentous 2
Fig 4 Location of injuries by percentage
Muscular 23%
25% presenting with pain originating from the lumbo-sacral region, and 8%. from the thoracic spine. The conditions of the upper and lower limbs were primarily soft tissue injuries. Of the upper limb injuries two- thirds were sited at the shoulder; of the lower limb injuries one half were at the knee. The four most common anatomical sites were the back (33%), neck (17%), shoulder (14%) and knee (13%). These were very similar to the spread of conditions referred by the GPs during the study period. which comprised 28% back, 16% shoulder, 14% neck and 14% knee conditions. This represents the same distribution of referrals as was made by the GPs before the study.
Time Since Onset of Condition Although the criteria stipulated that the duration of symptoms should be less than two months, 72 of the patients had had symptoms for more than two months. This became apparent as the history was being taken from the patients, at which point it would have been inappropriate to dis- continue assessment, or refuse treatment. A course of treatment was therefore given to these patients, who were included in the study sample.
PhysiotherapyJdriuary 1999/vol %/no 1
Professiona I articles 17
Treatment Figure 5 shows the frequency distribution of the number of treatment sessions given for each patient. The average number of treatment sessions was six. The average number of treatments per patient for GP- referred patients during the study period was seven, and for consultant referrals nine. The reason for more treatments for consultant referrals was that many of the referrals were for rehabilitation after trauma, which required more physiotherapy than GP- and self-referred conditions.
160
140
120
g 100
g 80
260
W .- w
.c
W r)
z 20
0 c5 10 11-15 16-20 >20 Number of treatment sessions
Fig 5: Frequency distribution - number of treatment sessions
Outcome of Treatment A large majority (78%) of patients were either cured or markedly improved at the end of their physiotherapy. Of the remaining patients, a slight improvement was made in 14.5%, and only 7.5% had no change in their condition. This correlates well with the results from the consumer survey. Of the 232 patients seen, 190 were discharged having completed a course of treatment, their symptoms being either resolved or at a level where they could continue a self-care programme. Twenty-two patients were referred back to the GP as unsatisfactory progress was made with physiotherapy. Five patients were referred to other paramedics (principally the chiropodist). Fifteen patients failed to complete their course of treatment.
Consumer Survey The questionnaire was completed by 133 patients (56% return rate). This is comparable with previous rates of response to self-administered questionnaires to measure consumer satisfaction in general practice - for example Williams and Calnan
(1991) achieved 62%. The survey results showed that 28 patients (21% of total) were seen on the same day that they referred themselves. The waiting time for treatment w a s less than one week for 115 (86%) of the patients, and all patients were seen within one month of referring themselves. The outcome of physiotherapy reported from the patients’ perspective showed that 81% of patients were cured or markedly improved, 16% were slightly improved and 3% reported that treatment had no effect. No patients reported being made worse as a result of physiotherapy. All patients who responded to the survey said they would like to see the service continued. Figure 6 shows the number of patients who found each
B
I I
0 20 40 60 80 100 120 140
Number of patients
Fig 6: Numbers of patients finding service components beneficial
aspect of the service beneficial. The reasons given by the patients for preferring this system of referral were:
They did not like to take up the GPs’ time unnecessarily. They preferred to try physiotherapy before resorting to medication. They liked to seek advice from a physiotherapist directly.
Work Implications Of the 236 patients 153 (65%) were employed and 83 (35%) were unemployed.
Fig 7: Percentage of patients in each physical occupation category
Physiotherapy January 1999/vol85/no 1
18
Twenty-nine patients (12%) were off work with their condition. Figure 7 shows the proportions of patients with sedentary, light physical, moderate physical and heavy physical occupations.
Only eight patients (3%) were in the category of heavy manual workers. Of the patients preseriting with kack injuries only four had heavy rnariual jobs (involving lifting more than 100 I b daily). ‘The other patients had occupations o r pastimes involving sustained flexion, eg .joinery, gardening, car maintenance, child care; or sedentary jobs leading to poor posture, eg secrevaries, shop assistants, or sales representatives whose jobs entailed a lot of driving.
This service was used by a wide range of the population, presenting with various conditions. The spread of conditions was similar to that report.ed by another health centre physiotherapy clinic (hazer, 1982).
The large number of referrals from patients in the 30-50 years age range may be a reflection of the selection criteria, which stipulated that the condition should be present for less than two months before referral. ‘The more elderly population, with more chronic conditions, would therefore be excluded. With the exception of three, all patients used this service appropriately, arid did not take advantage of t.he system by re- referring themselves unnecessarily. The GPs at the 6ealth ccritre wanted this service to continue after the 1 2-month study period.
The success of this service at CHC niay to some extent be a function of the size of the population of Carnoustie, making the service more personal than in a large hospital, arid the nature of the referring patients, the majority of whom were prepared to take responsibility for their t.reatment. This is demonstrated by the Fact that only 6% of people failed to cornplete their course of treatment, which compares favourably with a figure o f 7% from a previous study of physiotherapy provision within a health centre (Hackett et aZ, 1987). A high level of patient responsibility is also supported by the fact that advice was considered of particular benefit, endorsing the view that the public were receptive to prophylactic and self-care programmes.
Two major advantages of working in the health centre were highlighted by the physiotherapists; these being the availability of informal liaison with the GPs, and easy
access to patients’ medical notes. It was felt that these advantages contributed to the success of open access, arid outweighed the disadvantages of lack of space.
The fact that the existing physiotherapist’s caseload was not reduced may we l l be because this service was still developing, and, as has bceri shown in another health ceritrc-, a steady rise in GP referrals can occur o v c ~ 24 months from the start of an in-house physiotherapy service (Hackett et d, 1987).
Employment A secondary airri of this project was to ofkr i IT) mediate tre a tm e 11 t , the re by hop i II g t o reduce injury time and hence time of“ work. In practice only a small percentage of the patients were off work (12%). A possible reason for this is that people may assurne their condition to be self-limiting, ant1 therefore do not seek treatment for the first few days. If improvement is not made they then need to see the GP for a sickness certificate and will then be referred through that channel. This secondary aim was therefore perhaps misconceived. The effect of early intervention of treatment on time off work would require a more detailed study.
‘The survey showed that sustained flexion and poor posture are major precipitating factors for a large proportion of back pain complaints.
Post-project Service ‘I’he evaluation of the project strongly favoured the continuation of a self-referral service. The original idea of this service ofrering patients Inore immediate treatment than those referred by the GP was however shown to be impractical, and led to a two- tier service with two waiting lists. ?’he self- referral service was therefore amalgamated within the GP-referral service. The referral forms from self-referred arid GP-referred patients were held on the same waiting list with priority given to patients off work, or in severe pain which was restricting their sleep, or experiencing severe loss of function. In order to gain this information, self-referring patients were asked to cornplete a section in the referral form asking ‘Are you off work with your condition?’ and ‘How does your condition affect your lifestyle?’ The GP- referral forms had a section where the GPs could indicate if the referral was routine/urgent/patient off work/patient post-operative. From this information the self-referred and GP-referred patients were
PhysiotherapyJanuary 1999/vol85/no 1
Professional articles 19
prioritised within the same waiting list. Treatment of these patients was provided by both senior I and senior I1 physiotherapists (1.5 wte).
T h e number of patients referred for physiotherapy via GP, open access and consultant routes in the study year 1995/96
500
450
400
350 C aJ P 300 m Q
250
ii a 200
150
100
50
0
5
0 GP referral Self referral Consultant referral
1995196 1996t97 1997198
Fig 8: Numbers of patients referred to physiotherapy 1995 to 1998, by route of referral
arid the two successive years 1996/97 and 1997/98 are shown in figure 8.
The trend is that of an overall increase in the number of referrals in each successive year. However, the average number of treatments given to each patient fell from 6.3 in 1995/96, to 5.3 in 1996/97 and 4.5 in 1997/98. A conscious decision was made to encourage a more ‘self-help’ treatment strategy, thus accommodating for the increase in numbers of patients. The waiting list therefore remained steady from the end of the project period at three to four weeks.
Implications for Future Management of .Physiotherapy Services Reports in the literature indicate that GP- based physiotherapy practice has several advantages over hospital-based physio- therapy, including savings in cost and time. I t has also been proposed that non- attendance and failure to complete treatment rates may be reduced in GP-based physiotherapy departments (Hackett et al, 1987). Physiotherapists of all grades could work at health centres and are qualified to
have full professional autonomy by virtue of being chartered physiotherapists. In order to maintain a skill mix for junior grades a system of rovation from health centre to hospital could be employed.
The data collected on the physiotherapy service a t CHC indicates that total professional autonomy in physiotherapy can work within primary care. It appears from the literature and personal communications that this study is innovative; it has however excited interest from physiotherapists in both urban and rural GP practices (personal communications), and will hopefully lead to similar studies in different types of communities, which will determine the extent to which self-referral systems can be applied within primary care as a whole.
The problem of supply and demand is evident a t CHC as i t is nationally. T h e physiotherapists have attempted to address this problem by encouraging more of a self- care approach, thus reducing the number of patient attendances. This approach has been shown to produce slightly better outcomes than hospital-based physiotherapy (Worsford et ol, 1996). At present this is successful at CHC in preventing increase in the waiting list for treatment. Other methods of reducing the work load are also currently being proposed, however, such as group sessions for back and neck pain sufferers and advice leaflets to be distributed by the GPs under instruction from the physiotherapists.
has proved successful now for Y/,years. The envisaged potential drawbacks of being inundated with referrals and/or of missing a systemic diagnosis have not been realised. The GPs respect and value the professional autonomy of physiotherapists and feel that their patients benefit from this practice,
In the new primary care led NHS, structured around local health care co- operatives (LHCCs) it is the government’s intention that the LHCCs will support teams which are formed around the practice structure, and promote the development of clinical expertise (Scottish Office, 1998). This paper highlights the potential role of physiotherapy within the new NHS from the point of view of primary care based physiotherapy services and initiatives in exercising physiotherapists’ professional autonomy.
PhysiotherapyJdnuary 1999/vol85/no 1
References Bergman, B (1990). ‘Professional role and autonomy in physiotherapy’, Scandinavian Journal of Rehabilitation Medicine, 22,7984.
Chartered Society of Physiotherapy (1987). Rules of Pmfasional Conduct, CSP, London.
Department of Health and Social Security (1 977). HC(77)33, DHSS.
EUman, R, Adams, S M, Reardon, J A and Curwen, I H (1982). ‘Making physiotherapy more accessible: Open access for general practitioners to a physiotherapy department’, Physiotherapy, 68,
Frazer, F W (1982). ‘Treatment physiotherapy’, Patient Caw, 3,1075433.
Goldie, J (1979). ‘General practice Physiotherapy’, Update, November, 1007-09.
Hackett, G I, Hudson, M F, Wylie, J B, Jackson, A D, Small, K M, Harrison, P, O’Brien, J and Harrison, P (1987). ‘Evaluation of the efficacy and acceptability to patients of a physiotherapist working in a health centre’, British Medical Journal, 294, 2426.
Hackett, G I, Bundred, P, Hutton, J I, O’Brien, J and Stanley I M (1993). ‘Management ofjoint and soft tissue injuries in three general practices:
9, 291-293.
Value of onsite physiotherapy’, British Journal of General Practice, 43, 367, 61-64.
Norman, P, Clifton, H, Williams, E and Nichols, P J (1975). ‘Access by general practitioners to physiotherapy department of a district general hospital’, British Medical Journal, 14,220-221.
O’Cathain, A, Froggett, M and Taylor, M P (1995). ‘General practice based physiotherapy: Its use and effect on referrals to hospital orthopaedics and rheumatology outpatient departments’, British Journal of General Practice, 45,
Scottish Office (1998). ‘Designed to care - Renewing the National Health Service in Scotland’, HMSO.
Whelpton, E (1997). ‘GP open access scheme’, Frontline, 3.
Williams, S J and Calnan, M (1991). ‘Key determinants of consumer satisfaction with general practice’, Family Practitioner, 8, 237-242.
Worsford, C, Langridge, J, Spaldbg, A and Mullee, MA (1996). ‘Comparison between primary care physiotherapy education/advice clinics and traditional hospital based physiotherapy treatment: A randomised trial’, British Journal of General Practice, 46,404, 165-168.
