Is Patient Direct Access to NHS Physiotherapy Services Cost-Effective?

Talk Code: 
Miaoqing Yang
Miaoqing Yang1,3 (First Author), Annette Bishop2, Jon Sussex3, Martin Roland4, Sue Jowett5, Edward CF Wilson4,6
Author institutions: 
1. National Perinatal Epidemiology Unit, University of Oxford. 2. Research Institute for Primary Care and Health Sciences, Keele University. 3. RAND Europe, Cambridge. 4 Department of Public Health and Primary Care, University of Cambridge. 5. Health Economics Unit, University of Birmingham. 6 Health Economics Group, University of East Anglia.


Patient direct access to National Health Service (NHS) musculoskeletal physiotherapy services in primary care settings 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”. It has the potential to bring the MSK expertise of physiotherapists to bear at an earlier point in the patient pathway and prevent delays in access to care. Despite being endorsed by the English Department of Health and Social Care, direct access schemes have not been implemented in many places, likely due to a lack of evidence: a 2015 review of primary care services specifically recommended exploration of the cost-effectiveness of direct-access physiotherapy.


We used a discrete event simulation (DES) model to represent a hypothetical GP practice of 10,000 patients and modelled the expected costs, quality adjusted life years (QALYs) gained, waiting times and number of patients receiving physiotherapy under a direct access scheme and under status quo (no scheme) over 1 year. Costs were measured from the perspectives of the NHS and society. Model inputs were based on a pilot cluster randomised controlled trial (RCT) conducted in four general practices in Cheshire, UK, and other sources from the literature.


Direct access could increase the number of patients receiving at least one physiotherapy appointment by 63%, but without investment in extra physiotherapist capacity would increase waiting time dramatically. The increase in activity is associated with a cost of £4,999 per QALY gained.


Direct access to physiotherapy services would be cost-effective given current cost per QALY thresholds used in England. This is because physiotherapy itself is cost-effective, rather than through any savings in GP time. Direct access without an increase in supply of physiotherapists would increase waiting times and would be unlikely to be cost saving for the NHS owing to the likely increase in the use of physiotherapy services.

Submitted by: 
Ed Wilson
Funding acknowledgement: 
Study Funded by Versus Arthritis (formerly Arthritis Research UK).