A dedicated phone line can help patients to self-manage or to see a physiotherapist sooner, says Alison Moore
Most patients who need physiotherapy for musculoskeletal problems will see a GP, possibly try painkillers and anti-inflammatory treatment and may then be referred to a physiotherapist - who can take weeks to see them.
40% - Patients calling the dedicated lines in Gloucestershire who are managed through advice only
But an increasing number of primary care trusts and health boards have been experimenting with quicker access, where the GP is no longer the gatekeeper. Patients with musculoskeletal problems can call a dedicated number and speak to a physiotherapist who will offer advice, an appointment if appropriate or suggest they need to see a GP or hospital doctor.
The first services were set up around 10 years ago in Huntingdon in Cambridgeshire and Cheltenham in Gloucestershire. Many market themselves as Physio Direct, although the name is also used by some commercial services.
Between 15 and 30 per cent of GPs’ workload is musculoskeletal, so such schemes can reduce stress on primary care while improving care. By substituting a physiotherapist for the GP as gatekeeper to physiotherapy services, it also uses a lower cost healthcare worker.
In Gloucestershire the scheme has been extended over a wider area, echoing the coverage offered by the trust’s physiotherapy teams across the county. This extension has been gradual as local commissioners supported the roll-out across different areas, usually with very limited additional resources, if any. Teething problems included limited hours at some sites, leading to people being unable to get their call answered. These have now been addressed.
The hours of operation vary at the different sites but all adult patients registered with a GP in the area can phone in for advice and can then be offered a face to face appointment, if necessary.
A service review a few years ago found:
- better access to physiotherapy for patients without extending waiting times;
- a reduction in “paper” referrals from GPs: as use of the service has expanded across all sites, it has been associated with a downturn in GP referrals;
- better ratios of new to follow-up appointments than with GP referrals (which may be related to patients being seen earlier in their condition when timely intervention can aid recovery);
- lower did-not-attend rates, if patients were given face to face appointments, than with GP referrals;
- waiting times for physiotherapy treatment have been reduced.
The review also found high levels of patient satisfaction - 92 per cent would use the service again - and overwhelming support among GPs.
Around 40 per cent of patients who call in are managed through advice only, and most of the remainder need face to face appointments.
Lynda Hodges, physiotherapy team manager at Gloucestershire Hospitals Foundation Trust, which runs the service, says: “It may be that advice is all they require but it may be that we need to get them to come in, in which case we can prioritise them as appropriate.”
The service is popular with patients, with new Physio Direct contacts across the trust totalling 6,592 in 2008-09; 6,524 in 2009-10 and 5,143 from April to December last year.
One advantage is that physiotherapists often gain more information during the conversation with the patients than they would get from a referral letter. This enables them to decide the timescale in which they need to be seen.
Physiotherapists need good communication skills to man the phones.
“You have to identify quickly what is going on with the patients and whether it’s the right resource for them to use,” says Ms Hodges.
“We have redirected patients to other services quite quickly when we have picked up other things.
“You do need skills for it but they are the skills physiotherapists should have. It’s very similar to what you would ask them face to face. You can get a lot of feedback from patients by asking about how it feels bending forwards or picking things up.”
All qualified outpatient staff help to man the service. There is a period of training and supported work for new staff. There are staff rotas to cover the service, which varies in each site, but staff usually work on Physio Direct for two and a half to four hours a week.
The time taken for the call varies.
“We usually advise patients that the telephone call will last 10-15 minutes; it will then take the physio approximately another five minutes to complete paperwork, which may include a personalised home exercise programme and other relevant patient information leaflets,” says Ms Hodges.
“If the telephone line is busy when a patient calls they are asked to leave a message and contact details so that we can get back to them, so some time is spent calling patients back.”
But this still means the contact time per patient is considerably less than if they are face to face. New patients are normally allocated 45 minutes. If a Physio Direct patient does need to be seen, they are treated as a follow-up and only need a 30 minute slot.
Other access methods are available for those who are not happy using the phone service - referral from GP or self-referral through the website or visiting the department.
She is optimistic the service will thrive as GPs become more involved in commissioning. There are obvious benefits to GPs from offering patients direct access to physiotherapy - it should reduce how many patients they have to see and the number of referral letters they write.
But there is also evidence that some musculoskeletal problems can be prevented from getting worse if early intervention is available, Ms Hodges says.
Research suggests self-referral to physiotherapy can reduce the overall cost of treatment: a Scottish study found the cost of self-referrers was £95, compared with £126 for those referred by a GP. A large scale random controlled trial of Physio Direct compared with traditional treatments is expected to report later this year, covering effectiveness, cost and patient views.