Patient direct access to musculoskeletal physiotherapy in primary care: perceptions of patients, general practitioners, physiotherapists and clinical commissioners in England

Talk Code: 
Annette Bishop
Chinonso N. Igwesi-Chidobe, Bernadette Bartlam, Katrina Humphreys, Emily Hughes, Joanne Protheroe, John Maddison, Annette Bishop
Author institutions: 
Research Institute for Primary Care & Health Sciences, Keele University, Department of Medical Rehabilitation, College of Medicine, University of Nigeria, Family Medicine & Primary Care, Lee Kong Chian School of Medicine, Nanyang Technical University Singapore, Central Cheshire Integrated Care Partnership, The North West Coast Clinical Research Network


Musculoskeletal (MSK) conditions are the leading cause of chronic disability. Most patients in the UK seek initial care from their general practitioner (GP). However, UK primary care is struggling to meet the current demand from patients, which is set to rise as the population ages and MSK conditions increase.

Patient direct access to National Health Service (NHS) musculoskeletal physiotherapy services is one possible solution and is defined as “patients [being] able to refer themselves to a physiotherapist without having to see a GP first, or without being told to refer themselves by a health professional”.

No previous studies have investigated patient and professional views and experiences of patient direct access. This study investigated the perceived impact of patient direct access to NHS MSK physiotherapy by exploring the views/experiences of patients, general practitioners, physiotherapists and clinical commissioners in a region where direct access was rolled out following a pilot randomised trial of patient direct access.


An exploratory approach used one-to-one semi-structured interviews, conducted face-to-face or by telephone. Interviews explored patient and professional views and experiences of NHS MSK physiotherapy services, as well as organisational and commissioning barriers and facilitators to successful implementation. Interviews were transcribed verbatim and fully anonymised before analysis. Data were thematically analysed within a Normalisation Process Theory framework. Five of the co-authors, including the PPIE co-author developed the coding frame.


Patients included 16 women and 6 men, aged 36 – 86 years. Practitioners/commissioners were 9 women and 11 men with a broad range of clinical experience (2 – 34 years). Four major themes emerged:

Understanding and acceptability of physiotherapy: Many patients did not understand the roles and scope of physiotherapy. This lack of understanding around the scope of physiotherapy practice was also reflected in some accounts of the practitioners.

Understanding and awareness off direct access: GP recommended direct access patients believed they were being referred by the GP and did not understand self-referral as a concept. All groups found direct access acceptable.

Barriers for successful implementation: Challenges were identified around communication and data sharing between physiotherapists and GPs, and between primary care and specialist care which appear to mitigate against successful implementation.

Contribution of direct access to potentially enhance access to timely treatment yet with concerns expressed about generating unrealistic patient expectations.


Patient direct access to MSK physiotherapy may have the potential to promote effective and efficient patient care. Physiotherapy services need to increase public awareness about physiotherapy, its scope of practice, and access routes. GPs need to actively promote physiotherapy and its access routes with patients to increase awareness and acceptance of new methods of access. System changes are required to improve cross-disciplinary communication and facilitate successful implementation of patient direct access.

Submitted by: 
Annette Bishop
Funding acknowledgement: 
This work was funded by Versus Arthritis (grant number 21406). We acknowledge the STEMS-2 study team.