musculoskeletal physiotherapy: patient self-referral

Quality and Productivity: Proven Case Study

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This document can be found online at:

http://www.evidence.nhs.uk/qipp

Musculoskeletal physiotherapy: patient self-referral Provided by: Chartered Society of Physiotherapy

Publication type: Quality and productivity example

QIPP Evidence provides users with practical case studies that address the quality and

productivity challenge in health and social care. All examples submitted are evaluated by

NICE. This evaluation is based on the degree to which the initiative meets the QIPP criteria

of savings, quality, evidence and implementability; each criterion is given a score which are

then combined to give an overall score. The overall score is used to identify the best

examples, which are then shown on NHS Evidence as ‘recommended’.

Our assessment of the degree to which this particular case study meets the criteria is

represented in the evidence summary graphic below.

Evidence summary


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Details of initiative

Purpose To allow people to ‘self-refer’ to NHS (largely musculoskeletal) physiotherapy services, rather than waiting to be referred by their GP or healthcare practitioner. This speeds up access to treatment or intervention and reduces the costs associated with GP appointments and diagnostic imaging.

Description (including scope)

Prompt treatment by a physiotherapist in the early phase of an injury can improve recovery; enabling a person to return to their ‘normal life’ as soon as possible. The self-referral pilots (see Contacts and resources) have shown that people who self-refer to physiotherapy take fewer days off work, and are half as likely to be off work for longer than a month, when compared with people who have been referred using more conventional routes.

Self-referral fits with the NHS choice and personal control agenda by encouraging personal responsibility for health-focused behaviour and providing convenient, responsive services (Department of health 2006, 2008a).

The initiative means that people can refer themselves directly to their local NHS physiotherapy practice, as long as they are 16 years or over and they do not have neurological, breathing or gynaecological problems. 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 one requiring signposting to another service. Self referral is a ‘step change’ and could be included in all musculoskeletal physiotherapy services.

There is concern that introducing self-referral will increase demand for physiotherapy services beyond current capacities. However, it has been shown that provided the service is not historically under-referred to (referral rate of less than 50 per 1000), introducing self-referral does not lead to increased long term demand (Department of Health 2008b). During the first three months there may be some increase in demand as patients access the service more quickly, but levels revert to normal within this timeframe. Such observations have been seen in both studies (Holdsworth 2007, Department of Health 2008b) and from pilot services which have implemented self-referral.

See Appendix 1 for a diagrammatic representation for how the self-referral works in practice. See Contacts and resources for implementation tools for self-referral, including the self-referral form for patients on the Chartered Society for Physiotherapy website.

http://www.csp.org.uk/publications/self-referral-implementation-tools


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This is an annual review of the QIPP case study originally published in February 2011. This review provides more evidence to support costs and savings, with additional details of implementation.

Topic Staying healthy, primary care, right care and improving access.

Other information Two key studies were pivotal to this initiative: the first was a multi-centre national trial involving all regions of Scotland (Holdsworth 2007) and the other was a study conducted in England at six pilot trusts (Department of Health 2008b).

Gate 1: Savings delivered/anticipated

Amount of savings delivered/anticipated

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).

In 2010/11 in England, physiotherapy outpatients services managed 1.9 million adults with a first appointment and 4.8 million follow-up attendances. The cost has been estimated at almost £260 million, with the mean cost per first attendance of £49 and £35 for a follow-up appointment (Department of Health 2011). The total cost per person was £133.

Compared with traditional GP-referral that costs £133, an episode of GP-suggested self-referral costs 10% less at £118 and an episode of at patient self-referral costs 25% less at £100 (Holdsworth 2007, costs updated in accordance with Department of Health 2011). Data from English pilots of the self-referral scheme indicate that 41.0% of referrals come from GP-referral, 35.4% are GP-suggested self-referrals and 23.6% are self-referrals (Department of Health 2008b).

This initiative provides savings of £25,207 per 100,000 of the population as a result of reducing GP contact, unnecessary prescribing and diagnostic imaging.

The evidence shows that there is no long term increase in the overall number of physiotherapy contacts following introduction of the scheme (Department of Health 2008b).

Type of saving Self-referral, compared with traditional medical referral, results in significant NHS and patient-related cost benefits. Benefits to the NHS include reduced investigations (X-ray and MRI), prescribing and cost of medical consultation, without any increase in physiotherapy contact numbers (Department of Health 2008b). This forms the basis of the savings quoted above. Benefits to patients include reduced overall costs associated with attending medical consultations and reduced time off work.

Any costs required to Change can be achieved with minimal additional resources. This


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achieve the savings submission describes a redesign of the patient pathway that provides an alternative access route without increasing demand.

Programme budget category

Problems of the musculoskeletal system.

Details supporting Gate 1

Data from a Scottish study involving 26 general practices (Holdsworth 2007) and a study in 6 English trusts (Department of Health 2008b) supports the analysis above, which has been updated to reflect current costs.

Jordan et al (2010) found that 1 in 7 GP consultations are for musculoskeletal problems. Allowing self-referral to physiotherapy will free up substantial GP consultation time.

Gate 2: Quality outcomes

Impact on clinical quality

Should not impact on the quality of care delivered to patients. The purpose is to decrease the time-to-physiotherapy referral, rather than to change the treatment or intervention.

Impact on patient safety

Improved patient safety due to earlier treatment or intervention and potentially avoiding unnecessary exposure to ionising radiation from imaging prior to referral.

Impact on patient and carer experience

Improved patient and carer experience as delays to treatment or intervention are reduced.

Supporting evidence Data from the English study (Department of Health 2008b) showed:

High levels of patient satisfaction among those self-referring, with 77% being satisfied or very satisfied with the scheme.

Waiting times in all sites fell from an average of 14.2 weeks to 8.4 weeks, although there were contributing factors at the time such as the introduction of the 18-week patient pathway.

Patient absence from work is significantly reduced 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.

No significant differences in clinical outcomes between the different referral types.


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Gate 3: Evidence of effectiveness

Evidence base for initiative

Underpinned by accredited guidance or policy of the Department of Health or other national bodies.

Evidence of deliverable from implementation

Results from a study in six English trusts (Department of Health 2008b)

Results from a Scottish multi-centre study in 26 general practices (Holdsworth 2007)

Where implemented The following sites participated in the English pilot (Department of Health 2008b):

Barnet Hospital – Barnet and Chase Farm Hospitals NHS Trust

Bridgwater and Burnham-on-Sea Hospitals – Somerset PCT

Darent Valley Hospital – Dartford and Gravesham NHS Trust

King’s College Hospital NHS Foundation Trust

Melksham Community Hospital – Wiltshire PCT

Solihull Hospital – Heart of England NHS Foundation Trust

The Scottish multi-centre study was conducted at 26 general practices across the country (Holdsworth 2007).

Degree to which the actual benefits matched assumptions

Same as expected.

If initiative has been replicated how frequently / widely has it been replicated

In the South West region of England, where detailed scoping has taken place, over 100 services are offering this type of access for people needing musculoskeletal services.

Supporting evidence for Gate 3

No further information provided.

Gate 4: Details of implementation

Implementation details

Implementing self-referral involves:

understanding existing referral patterns from local GPs and identifying any that are currently under-referring to the service (referral rate below 50 per 1000 population). This makes it easier to ascertain if there is likely to be any long-term increase in referrals as a result of promoting the scheme. It is advisable to check any assumptions about


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referral rates with GPs.

gathering baseline data for referral rates and sources, categorisation of patients, activity and outcomes.

bringing waiting lists down to locally agreed standards if necessary and possible, before self-referral commences, as long waiting lists can discourage patients from self referral.

ensuring that all members of the team including administrative, IT and managerial roles understand the purpose of the scheme and that supporting systems are working efficiently.

ensuring that all members of the team know what they can expect in terms of a potential initial increase in referrals followed by a return to normal levels within three months, provided there is currently no under-referral to the service.

informing GPs that self-referral will be offered and explaining how it works. Evidence suggests GPs are receptive to the initiative as it is likely to reduce their workload and increase patient autonomy. A GP will need to give permission to provide any patient leaflets about the scheme in their surgery, but GP permission is not required to implement self-referral.

having a clear marketing and communications plan. At a basic level the service can be marketed through leaflets and posters in GP surgeries. Promotion can also include online media, local media and engaging with local councils and community groups.

printing patient self-referral forms and making them available in GP surgeries. It helps to keep a record of where these materials are located so they can be replenished as required.

To support implementation, the Chartered Society of Physiotherapy has:

produced implementation tools for members

undertaken a series of regional workshops

set up a network of self-referral champions (offering self-referral for more than 2 years and willing to share expertise)

set up an interactive support network

continued to work with members to develop more targeted implementation strategies (for example, local business cases, matching up of services who are offering self-referral with those who would like to develop it, to share good practice).

Time taken to implement

Implementation can be achieved in 3 months to 1 year. The Chartered Society of Physiotherapy implementation tool recommends a 3-month ‘run in’ period based on the results of the


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Scottish study (Holdsworth 2007). This is to allow services to ensure they have appropriate baseline data and also to prepare their approach and publicise the change in access to stakeholders appropriately.

Ease of implementation

Affects multiple organisations within the NHS, such as working across a health-economy. Affects GP surgeries and physiotherapists.

Level of support and commitment

Based on the evidence from Scotland and England, self-referral is well supported by GPs, physiotherapists and particularly by people wanting physiotherapy.

Barriers to implementation

Because introducing self-referral does not change the overall activity of the service (if services are not historically under providing), there is no need for any additional money for implementation beyond minor printing costs. However, there is often a perception among physiotherapists locally that waiting lists and demand for the service will rise. Once services implement self-referral, they are reassured that demand, while it may initially rise (as with any newly marketed service), will come down to normal levels after 3 months.

Risks Some of the risks were to do with physiotherapists’ own fear of practising autonomously. These concerns were eased by workshop materials (in particular, case scenario discussion). Also there is a perceived risk that people who have previously been receiving physiotherapy in the private sector could switch to NHS providers; however, no evidence of this was found during the study in England (Department of Health 2008b).

Supporting evidence for Gate 4

No further information provided.

Further evidence

Dependencies It is important to understand current referral patterns from GPs, and beneficial to get GP buy-in. Experience shows it is beneficial to engage the assistance of a senior grade physiotherapist who has experience of implementing patient-self referral, or a GP with Specialist Interest, to provide clinical support and back up as needed.


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Contacts and resources

Contacts and resources

Chartered Society of Physiotherapy self-referral guide www.csp.org.uk/selfreferral

Department of Health (2006) Our health, our care, our say: a new direction for community services. http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4127453

Department of Health (2008) NHS Next Stage Review: Our vision for primary and community care. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085937

Department of Health (2008) Self-referral pilots to musculoskeletal physiotherapy and the implications for improving access to other AHP services. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_089516

Department of Health (2011) 2010-11 reference costs publication. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_131140

Holdsworth LK, Webster VS, McFadyen AK. Are patients who refer themselves to physiotherapy different from those referred by GPs?: Results of a national trial. Physiotherapy 92: 26–33 2006.

Holdsworth LK, Webster VS, McFayden AK. What are the costs to NHS Scotland of self-referral to physiotherapy? Results of a national trial. Physiotherapy. 2007.

Jordan KP, Kadam UT, Hayward R, Porcheret M, Young C, Croft P. Annual consultation prevalence of regional musculoskeletal problems in primary care: an observational study. Bio Med Central Musculoskeletal Disorders 11:144 2010

If you require any further information please email: [email protected] and we will forward your enquiry and contact details to the provider of this case study. Please quote QIPP reference 10/0042 in your email.

ID: 10/0042rOriginally published: February 2011 Last updated: August 2012 Review due: August 2013.

http://www.csp.org.uk/selfreferral

http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4127453



http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085937






mailto:[email protected]

Quality and Productivity

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Appendix 1: Self-referral in practice

Figure 1. People requiring physiotherapy may be referred to the service in one of three ways. In doctor referral a general practitioner refers the individual to the service with a letter and the individual will be contacted by the physiotherapy service to arrange an appointment. In doctor suggested referral, the general practitioner suggests that the individual may benefit from physiotherapy and provides them with an information leaflet. The individual is then responsible for completing a self referral form and sending it to the physiotherapy service. In self referral the general practitioner is not involved in referral as the individual completes a self-referral form and sends it to the physiotherapy service. In all cases the physiotherapy service reviews the information provided to ascertain the urgency of the case before arranging an appointment with the individual or referring them to another specialist.

musculoskeletal physiotherapy: patient self-referral

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