What is the impact over time on GP musculoskeletal workload, of providing a patient direct access to NHS physiotherapy for adults with musculoskeletal conditions in primary care?

Talk Code: 
Annette Bishop
Annette Bishop, Ying Chen, Jo Protheroe, Reuben O Ogollah, James Bailey, Martyn Lewis, Kelvin Jordan, Nadine E Foster
Author institutions: 
1. Research Institute for Primary Care & Health Sciences, Keele University, 2. Nottingham CTU, Nottingham Health Science Partners, Queen’s Medical Centre, Nottingham.


In the drive to reduce burden on general practices, patient direct access (self-referral) to NHS physiotherapy has been suggested as a way of reducing musculoskeletal (MSK) consultations with GPs.A previous pilot cluster randomised controlled trial (STEMS) included four general practices (2 having patient direct access to NHS physiotherapy and 2 continuing usual GP-led care). On conclusion of the pilot RCT the patient direct access pathway was introduced to the practices with GP-led care allowing a natural experiment to investigate the impact of patient direct access on GP MSK workload over time. Exploratory analyses of secondary outcomes assessed whether other management actions, suggested in previous observational studies to reduce with direct access, such as prescribing of medication, work absence and x-rays and scans changed.


The 4 GP practices that participated in the pilot RCT all used the same electronic primary care clinical system, EMIS Web. Working with EMIS, we obtained extracted routinely recorded anonymised data from the registered adult population.The primary outcome was the rate per 1000 registered population of GP consultations for MSK problems across the 6-year time period investigated (June 2011 to June 2017). Quarterly GP consultation prevalence per 1,000 registered population was calculated and presented both descriptively and using trend graphs. Joinpoint regression was used to assess any changes in the quarterly GP consultation trends within the pilot trial intervention practices and separately for the control practices. Exploratory analyses described the rates per 1000 registered population for x-rays and MRI scans ordered, referrals into secondary care, sickness certificates issued for patients with MSK conditions and prescriptions for medications linked to MSK conditions.


Interim findings suggest in the four included practices no consistent impact on GP workload resulted from the introduction of patient direct access. In exploratory analyses of secondary outcomes, only referral for x-rays and into secondary care suggest patient direct access has an effect.


The introduction of patient direct access to NHS MSK physiotherapy had a variable impact on GP MSK consultations. Local factors such as the pre-existing consultation rate and possibly the previous referral to MSK physiotherapy rate need to be considered when evaluating the impact of patient direct access. Our qualitative work (presented in a separate abstract) suggests that the awareness and use of the patient direct access pathway reduced as time passed since the pilot RCT and is a factor that limits the impact on the general practice.

Submitted by: 
Annette Bishop
Funding acknowledgement: 
This work was funded by Versus Arthritis (grant number 21406). Nadine Foster a NIHR Senior Investigator. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care. We acknowledge the STEMS-2 study team and the participating general practices and physiotherapy service.