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.

Understanding paramedic work in general practice in the UK: a rapid realist synthesis.

BACKGROUND: General practice in the UK is under substantial pressure and practices are increasingly including paramedics as part of their workforce. Little is known about how different models of paramedic working may affect successful implementation of the role, as viewed from patient, clinician and system perspectives. This realist synthesis developed theories about 'models of paramedic working in general practice' in different UK contexts to understand their impact. METHODS: The rapid realist synthesis comprised data from: (1) empirical and grey literature searches; (2) semi-structured realist interviews with system leaders involved with the implementation of the role; and (3) a stakeholder event with healthcare professionals and the public, to develop initial programme theories that can be tested in future work. Sources were analysed using a realist approach that explored the data for novel or causal insights to generate initial programme theories. RESULTS: Empirical sources (n = 32), grey sources (n = 95), transcripts from system leader interviews (n = 7) and audio summaries from the stakeholder event (n = 22 participants) were synthesised into a single narrative document. The findings confirmed the presence of a wide variety of models of paramedic working in UK general practice. The perceived success of models was influenced by the extent to which the paramedic service was mature and embedded in practice, and according to four theory areas: (1) Primary care staff understanding and acceptance of the paramedic role; (2) Paramedic induction process, including access to training, supervision and development opportunities; (3) Patient understanding and acceptance of the role; (4) Variations in paramedic employment models. CONCLUSIONS: Variability in how the paramedic role is operating and embedding into general practice across the UK affects the success of the role. These findings provide a theoretical foundation for future research to investigate various 'models of paramedic working' in different contexts.

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.

'Somebody stuck me in a bag of sand': Lived experiences of the altered and uncomfortable body after stroke.

OBJECTIVE: This study explored stroke survivors' experiences of altered body perception, whether these perceptions cause discomfort, and the need for clinical interventions to improve comfort. DESIGN: A qualitative phenomenological study. SETTING: Participants' homes. PARTICIPANTS: A purposive sample of 16 stroke survivors were recruited from community support groups. Participants (median: age 59; time post stroke >2 years), were at least six-months post-stroke, experiencing motor or sensory impairments and able to communicate verbally. INTERVENTIONS: Semi-structured, face-to-face interviews were analysed using an interpretive phenomenological approach and presented thematically. RESULTS: Four themes or experiences were identified: Participants described (1) a body that did not exist; (2) a body hindered by strange sensations and distorted perceptions; (3) an uncontrollable body; and (4) a body isolated from social and clinical support. Discomfort was apparent in a physical and psychological sense and body experiences were difficult to comprehend and communicate to healthcare staff. Participants wished for interventions to improve their comfort but were doubtful that such treatments existed. CONCLUSION: Indications are that altered body perceptions cause multifaceted physical and psychosocial discomfort for stroke survivors. Discussions with patients about their personal perceptions and experiences of the body may facilitate better understanding and management to improve comfort after stroke.

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.