First Contact Physiotherapy: An evaluation of clinical effectiveness and costs.

BACKGROUND: First Contact Physiotherapy Practitioners (FCPPs) are embedded within general practice, providing expert assessment, diagnosis and management plans for patients with musculoskeletal disorders (MSKDs), without the prior need for GP consultation. AIM: To determine the clinical effectiveness and costs of FCPP-led compared to GP-led models of care. DESIGN AND SETTING: Multiple site case study design. UK GP practices. METHOD: General Practice sites were recruited representing three models: 1. GP-led care; 2. FCPPs who could not prescribe/inject (Standard (St)); 3. FCPPs who could prescribe/inject (Additional Qualifications (AQ)). Patient participants from each site completed clinical outcome data at baseline, 3 and 6 months. The primary outcome was the SF-36v.2 Physical Component Score (PCS). Healthcare usage was collected for 6 months. RESULTS: N=426 adults were recruited from 46 practices across the UK. Non-inferiority analysis showed no significant difference in physical function (SF36-PCS) across all three arms at 6 months (p=0.999). At 3 months a significant difference in numbers improving was seen between arms: 54.7% GP consultees; 72.4% FCPP-St, 66.4% FCPP-AQ; (p=0.037). No safety issues were identified. Following initial consultation, a greater proportion of patients received medication (including opioids) in the GP-led arm (44.7%) compared with FCPP-St (17.5%) and FCPP-AQ (22.8%); (p<0.001). NHS costs (initial consultation and over 6 months follow up) were significantly higher in the GP-led model (median £105.50) vs FCPP-St (£41) and FCPP-AQ (£44); (p<0.001). CONCLUSION: FCPP led models provide safe, clinically effective and cost-beneficial management for patients with MSKDs in general practice and reduced opioid use in this cohort.

Benefits of realist evaluation for rapidly changing health service delivery.

Realist evaluation is a methodology that addresses the questions: 'what works, for whom, in which circumstances, and how?'. In this approach, programme theories are developed and tested against available evidence. However, when complex interventions are implemented in rapidly changing environments, there are many unpredictable forces that determine the programme's scope and architecture, as well as resultant outcome. These forces can be theorised, in real time, and included in realist evaluation outputs for current and future optimisation of programmes. Reflecting on a realist evaluation of first-contact physiotherapy in primary care (the FRONTIER Study), five important considerations are described for improving the quality of realist evaluation outputs when studying rapidly changing health service delivery. These are: (1) ensuring that initial programme theories are developed through creative thinking sessions, empirical and non-empirical literature, and stakeholder consultation; (2) testing the causal impact of formal and informal (eg, emergent) components of service delivery models; (3) contrasting initial programme theories with rival theory statements; (4) envisioning broad system impacts beyond the immediate implementation setting; and (5) incorporating rapidly evolving service developments and context changes into the theory testing process in real-time (eg, Additional Role Reimbursement Scheme, COVID-19). Through the reflections presented, the aim is to clarify the benefit of realist evaluation to assess emerging models of care and rapidly changing health service delivery.

Patient view of the advanced practitioner (AP) role in primary care: A realist-informed synthesis.

BACKGROUND: Approximately 30% of general practitioner consultations are due to musculoskeletal disorders (MSKDs). Physiotherapists are trained to assess, diagnose and treat a range of MSKDs, and could provide the first point of contact for primary care patients. There is limited evidence on whether this role is acceptable to patients; however, previous research has explored advanced practitioner (AP) roles in primary care, which could inform this new initiative. AIMS: This study used realist synthesis to explore factors that influence patient acceptability of AP roles in primary care. MATERIALS & METHODS: A realist synthesis was undertaken to identify initial programme theories regarding acceptability. Databases were searched to identify relevant literature. Identified studies were subject to inclusion and exclusion criteria, resulting in 38 studies included for synthesis. Theory-specific data extraction sheets were created and utilised. Data were analysed through identifying contexts, mechanisms and outcomes to formulate hypotheses. Hypotheses were validated through consultation with expert stakeholders. RESULTS: Eight theory areas were identified that potentially impacted on patient acceptability of the role: patient's prior experience of condition management; patient's expectations of condition management; communication; continuity of the individual practitioner; practitioner's scope of practice; accessibility; professional hierarchy and promoting the role. Nineteen hypotheses on the AP role were developed around these theory areas. DISCUSSION: Role acceptabiliy was influenced significantly by context and may change as the role develops, for instance, as waiting times change. CONCLUSION: Hypotheses will inform a subsequent realist evaluation exploring the physiotherapy AP role in primary care. Future research is needed to understand the acceptability of first contact physiotherapists delivering certain skills.

Patient acceptability of the physiotherapy first contact practitioner role in primary care: A realist informed qualitative study.

BACKGROUND: Approximately 30% of general practitioner (GP) consultations are due to musculoskeletal disorders (MSKDs). Physiotherapists are trained to assess, diagnose and treat MSKDs and provide an alternative to GP consultation for primary care patients as first contact physiotherapists (FCPs). AIM: To explore patient perceived acceptability of the FCP role using realist methods to understand what works for whom, how, why and in what circumstances. METHODS: A realist evaluation was undertaken, which involved three stages: forming the theory area framework; testing the theory framework and refining the programme theory. The theory framework was formed through realist synthesis. Realist interviews tested this framework. Data were collected from two GP practice case study sites and interviews were undertaken at each site. N = 20 participants were interviewed in total. In each practice, this constituted patients (n = 5), GPs (n = 1), FCPs (n = 2), receptionists (n = 1) and practice managers (n = 1). Interview data were analysed against preliminary hypotheses and, where appropriate, new theory areas were created. RESULTS: The evaluation highlighted that acceptability of the FCP role was influenced by 'expectations', 'accessibility' and 'promoting the role'. Whilst some findings were shared by both practices, different contexts resulted in unique practice findings. CONCLUSION: Patients were predominantly accepting of FCPs, nevertheless, there was a scope to increase acceptability through an implementation strategy that considered the contexts of the individual patient, as well as wider practice contexts.

Provision of first contact physiotherapy in primary care across the UK: a survey of the service.

BACKGROUND: First Contact Physiotherapy (FCP) is an emerging model of care whereby a specialist physiotherapist located within general practice undertakes the first patient assessment, diagnosis and management without a prior GP consultation. Despite institutional and professional body support for this model and NHS commitment to its implementation, data regarding current FCP provision are limited. OBJECTIVES: To identify current FCP service provision across the UK, including models of provision and key professional capabilities. DESIGN: Cross-sectional online survey, targeting physiotherapists and service managers involved in FCP. METHODS: Recruitment involved non-probability sampling targeting those involved in FCP service provision through emails to members of known clinical networks, snowballing and social media. The survey gathered data about respondents, FCP services and the role and scope of physiotherapists providing FCP. RESULTS: The authors received 102 responses; 32 from service managers and 70 working in FCP practice from England (n=60), Scotland (n=22), Wales (n=14), and Northern Ireland (n=2). Most practitioners were NHS band 7 or 8a (91%, n=63), with additional skills (e.g. requesting investigations, prescribing). 17% (12/70) worked 37.5hours/week; 37% (26/70) ≤10hours; most (71%, 50/70) used 20-minute appointments (range 10-30minutes); varying arrangements were reported for administration and follow-up. Services covered populations of 1200 to 600,000 (75% <100,000); access mostly involved combinations of self-booking and reception triage. Commissioning and funding arrangements varied widely; NHS sources provided 90% of services. CONCLUSIONS: This survey provides new evidence regarding variation in FCP practice across the UK, indicating that evidence-informed, context specific guidance on optimal models of provision is required.