Ruth ten Hove describes how self-referral for musculoskeletal physiotherapy can result in cost savings, shorter waiting times, and benefits for patients and GPs
- Self-referral to MSK physiotherapy allows patients to refer themselves to a physiotherapy service without the need to see a GP or other healthcare professional
- A QIPP evaluation of patient self-referral for MSK physiotherapy showed several positive outcomes:
- high levels of patient satisfaction
- reduced patient absence from work
- shorter waiting times
- The introduction of patient self-referral provides savings of £25,207 per 100,000 of the population
- Provided that existing physiotherapy services are adequately resourced, the introduction of patient self-referral does not lead to an increase in demand
- Commissioners should consider including patient self-referral in service specifications for MSK conditions.
Over 200 conditions are defined as musculoskeletal (MSK), ranging from simple sprains and strains to long-term conditions, such as osteoarthritis and rheumatoid arthritis.1 Characterised by pain, loss of movement, a nd reduced function, these conditions can diminish quality of life, impact on family and social relationships, and limit a person’s capacity to work.1 An aging UK population means that the number of people living with muscular and joint pain is rising. The challenge is to seek new and innovative ways of dealing with MSK problems efficiently, effectively, and safely, in a location close to home for convenience and early care.
Patient self-referral for physiotherapy
Patient self-referral to MSK physiotherapy is a system of access that allows patients to refer themselves directly to physiotherapy, without seeing or being prompted by another healthcare professional.2
Patient self-referral to an MSK physiotherapist enables prompt treatment in the early phase of an injury or MSK problem. Musculoskeletal physiotherapists working within community outpatient settings can receive self-referrals directly from patients, and as recommended to them by GPs and other healthcare professionals. Physiotherapists can offer:3
- assessment and screening for red flags
- good knowledge of biopsychosocial models of care
- expert knowledge of exercise and rehabilitation
- a commitment to supporting self?management and promoting healthy living behaviour
- a range of treatment techniques as part of a management plan (e.g. acupuncture, manipulation) X-ray/investigation requests and referrals to specialist services, e.g. Interface4
- injections (with the ability to prescribe these independently in future).
This self-referral approach improves recovery, enabling a person to return to their ‘normal life’ as soon as possible; it also reduces the likelihood of a short-term problem becoming chronic.5 People who self-refer take fewer days off work, and are almost half as likely to be off work for longer than 1 month compared with people who have been referred using more conventional routes.2
Following a rigorous quality assurance process, patient self-referral to physiotherapy was endorsed as part of the Quality, Innovation, Productivity, and Prevention (QIPP) imperative and therefore provides a quality ‘kite mark’ for the physiotherapy services that implement it. A QIPP evaluation, Musculoskeletal physiotherapy: patient self-referral, was published by the Chartered Society of Physiotherapy in August 2012. It achieved the following scores for meeting QIPP criteria: 65% in terms of cost savings, implementability, and quality, and over 80% evidence of change.6 Two key studies were pivotal to this initiative: a national trial in Scotland7 and a pilot study in England.1
Data from the QIPP evaluation showed:1,6
- high levels of patient satisfaction among those self-referring (77% being satisfied or very satisfied with the scheme)
- waiting times in all sites falling from an average of 14.2 weeks to 8.4 weeks
- patient absence from work reducing significantly from an average of 7 days for a standard GP-referral to 4.1 days for a self-referral
- no significant differences in:
- condition severity between the referral types
- clinical outcomes between the different referral types
- aspects of geography, deprivation and ethnicity between the referral types.8
Benefits to patients and carers
Patient self-referral fits with the NHS choices agenda.9 It encourages personal responsibility for health-focused behaviour. Patients who self-refer to physiotherapy are interested in strategies for self-care and self-management, in order to prevent future MSK problems.1 Self-referral enables individuals to build confidence in the management of their own condition. This is particularly important for people living with long-term conditions. Enabling patients to self-refer to the correct services and receive individual advice and education about their condition promotes better long-term, ongoing, and safe self-management in a supported environment.
Benefits to general practice
Twelve percent of GP consultations in England relate to musculoskeletal problems,10 and so permitting patients to self-refer for physiotherapy would free up substantial GP consultation time, reducing the administrative load and time taken to complete each referral (currently assessed as about 2 weeks). This would enable GPs to concentrate on those patients with more complex medical problems.
The feedback from GPs who have direct experience of patient self-referral to physiotherapy has been extremely positive (see Box 1, below), with the vast majority wishing to retain the self-referral facility. The main reasons cited for this were:1
- savings associated with GP consultation and administrative time
- greater patient convenience
- encouragement of patient autonomy
- the potentially positive impact on waiting times.
Box 1: GP views on self-referral to musculoskeletal physiotherapy pilots2
‘They [physiotherapists] are more skilled than us in certain musculoskeletal areas and I value their diagnostic skills as well as management of the actual physiotherapy session.’
‘It has been very successful, has saved GPs considerable time, and saved patients unnecessary trips to the surgery.’
‘It gives more autonomy to the patient to have their own part in helping themselves get well.’
Impact on demand for physiotherapy
The evidence shows that, providing the physiotherapy service is already adequately resourced, introducing patient self-referral does not lead to an increase in demand. A proportion of people (about 22%) who would normally have seen their GP first, simply opt for a more direct route to solve their problem.1
The experience of services also points to patient self-referral being important in reducing waiting times. When a patient self-refers to the physiotherapy service, or is prompted by their GP to self-refer, the waiting list for physiotherapy becomes a more accurate picture of the number of patients who actually want to attend their physiotherapy appointment.
Demand for NHS physiotherapy (predominantly musculoskeletal care) is expressed per 1000 of the population, and averages 56 per 1000 (ranging from 53 [urban] to 66 [rural] per 1000).6 (These national referral rates were calculated as part of the national trial in Scotland and as such are applicable to physiotherapy services in Scotland. However, in the absence of equivalent rates in other parts of the UK, they are helpful when considering the issue.)
In 2010/11 in England, physiotherapy outpatients services managed 1.9 million adults with a first appointment, and 4.8 million follow-up attendances.6 The cost has been estimated at almost £260 million, with a mean cost of £49 for a first attendance and £35 for a follow-up appointment. The total cost per person was £133.11
Compared with traditional GP referral for MSK physiotherapy, which costs £133:7-11
- GP-suggested self-referral costs 11% less at £118
- patient self-referral costs around 25% less at £100.
Data from English pilots of the self?referral scheme indicate that referral types were as follows:1
- 41% are GP referrals
- 35.4% are GP-suggested self-referrals
- 23.6% are self-referrals.
Therefore the introduction of patient self-referral provides savings of £25,207 per 100,000 of the UK population as a result of reducing GP contact, unnecessary prescribing, and diagnostic imaging.6
Benefits to the physiotherapy service
As with any health and wellbeing service, enabling physiotherapy services to implement self-referral requires:
- a thorough understanding of the demographics of the local population and current service
- effective communication with local healthcare (especially GPs) and social care professionals
- close working relationships with local communications teams.
Introducing an innovation like self?referral enables the physiotherapy service to review all of its systems, processes, and practices. This has the effect of reinvigorating those services and enhancing the accountability of physiotherapists.
Patients who self-refer are more likely to:1
- attend appointments
- adhere to a treatment regimen
- complete their treatment
- be satisfied with their experience.
Patient self-referral therefore improves the productivity of the service, which is also very important to the general morale of the staff.
How patient self-referral works in practice
People can self-refer to their local NHS physiotherapy service (each MSK service will have explicit criteria for patient self-referral). A person wanting physiotherapy completes a self-referral form (on paper, online, or by telephone), which includes answering red-flag symptom questions that may indicate a more serious underlying health condition, requiring referral to a medical specialist. A physiotherapist assesses the form and, based on pre-determined clinical criteria, identifies whether the referral is classed as urgent, routine, or requires signposting to another service, such as the GP.2
Implementation and costs
There is often a perception among stakeholders locally that self-referral will lengthen waiting lists and cause the demand for the service to rise. However, introducing self-referral does not change the overall activity of the service (if services are not historically under?providing), so there are no additional costs incurred from implementing the system, beyond the minor printing costs required to advertise the service and produce referral forms.
Once services implement self-referral, they can be assured that, while demand may rise initially (as with any newly marketed service), it will come down to normal levels after 3 months.12
All GP commissioners and clinical commissioning groups (CCGs) should consider including patient self-referral in their MSK specification.13 Excluding patient self-referral would offer less choice of care to patients, miss an opportunity to improve patient outcomes, and be more costly to the NHS in the long term. The benefits of patient self-referral to MSK physiotherapy, and a recommendation for its inclusion in local any qualified provider (AQP) specifications, are highlighted in the national AQP guidance.14
Summary and recommendations
As well as giving people more choice and a shorter recovery time, self-referral is a more cost-effective way of receiving MSK care. Self-referral, compared with traditional medical referral, results in significant NHS and patient-related benefits. Benefits to the NHS include:1
- fewer investigations (e.g. X-ray and magnetic resonance imaging)
- less prescribing
- lower cost of medical consultation without any increase in physiotherapy contact numbers.
The inclusion of patient self-referral in commissioning specifications:
- offers more choice to patients
- improves patient outcomes and experience
- provides good value for money
- helps the physiotherapy service to achieve the QIPP agenda.
It is, therefore, strongly recommended that all GP commissioners and CCGs include patient self-referral in their MSK specification.
- CCGs should carefully review the evidence in this article and consider the feasibility of including self-referral to MSK physiotherapy in local specifications
- Caution is needed as one prerequisite of this self-referral scheme is to ensure adequate resourcing of MSK physiotherapy services prior to implementation and this is not the case in many areas
- CCGs should recognise that some cost savings (e.g. on GP time) cannot easily be realised by freeing up of financial resources as these lie in contracts set on an annual basis, in regulation (GMS contract), and administered by NHS England not CCGs (with a total sum of GP care of
- less than £100 for 1 year!)
- The studies quoted in this article, however, suggest that self-referral to physiotherapy can be a more efficient way of delivering these services, so CCGs should consider local pilots of this within set budgets as there is always the risk of supply driving demand in NHS services
- Another caution is that community physiotherapy services may become subject to a national mandatory PbR tariff next year, which makes it more difficult to set a manageable budget for such activity and could provide incentives for providers to supply more activity under Any Qualified Provider contracts than is necessary and/or affordable
- Self-referral to MSK physiotherapy services appears to have considerable merit if CCGs can ensure this does not result in increased costs to their budget.
- Department of Health. The musculoskeletal services framework—a joint responsibilty: doing it differently. London: DH, 2006. Available at: webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/
- Department of Health. Self-referral pilots to musculoskeletal physiotherapy and the implications for improving access to other AHP services. London: DH, 2008. Available at: webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/en/Publicationsandstatistics/
- Chartered Society of Physiotherapy website. What is physiotherapy? www.csp.org.uk/your-health/what-physiotherapy (accessed 24 September 2013).
- Department of Health. Health and social care information centre website. NHS business definitions: interface service. www.datadictionary.nhs.uk/data_dictionary/nhs_business_definitions/i/interface_service_de.asp?shownav=1 (accessed 24 September 2013)
- Nordeman L, Nilsson B, Möller M et al. Early access to physical therapy treatment for subacute low back pain in primary health care: a prospective randomized clinical trial. Clin J Pain 2006; 22 (6): 505–511.
- NICE website. Advanced records management system. Musculoskeletal physiotherapy: patient self-referral. Quality and productivity proven case study. Quality and productivity example. February 2011, updated August 2012. Available at: arms.evidence.nhs.uk/resources/qipp/29492/attachment
- Holdsworth L, Webster V, McFadyen A. What are the costs to NHS Scotland of self-referral to physiotherapy? Results of a national trial. Physiotherapy 2007; 93 (1): 3–11.
- Holdsworth L, Webster V, McFadyen A. Self-referral to physiotherapy: deprivation and geographical setting. Is there a relationship? Results of a national trial. Physiotherapy 2006; 92 (1): 16–25.
- Department of Health. 2013/14 Choice Framework. DH, 2013. Available at: www.nhs.uk/choiceintheNHS/Rightsandpledges/NHSConstitution/Documents/2013/choice-framework-2013-14.pdf
- Jordan K. Consultations for selected diagnoses and regional problems. Musculoskeletal matters. Arthritis Research UK National Primary Care Centre, Keele University, 2010. Available at: www.keele.ac.uk/pchs/disseminatingourresearch/newslettersandresources/bulletins/
- Department of Health. 2010–2011 reference costs publication. London: DH, 2011.Available at: www.gov.uk/government/publications/2010-11-reference-costs-publication
- Holdsworth L, Webster V. Patient self referral: a guide for therapists. Milton Keynes: Radcliffe Publishing Ltd, 2006: 73–83.
- Department of Health. The operating framework for the NHS in England 2009/10. London: DH, 2008. Available at: www.connectingforhealth.nhs.uk/systemsandservices/infogov/links/opframework20092010.pdf
- NHS supply2health website. Any qualified provider (AQP) resource centre. Extension of patient choice of any qualified provider in musculoskeletal (MSK) services for back and neck pain. www.supply2health.nhs.uk/AQPRESOURCECENTRE/Pages/AQPHome.aspx (accessed 22 July 2013). G