Earlier this year, it was announced that physiotherapists will take over routine appointments from family doctors in a bid to cut waiting times at GP surgeries (British Medical Association, 2018). A new GP contract will see an army of 20 000 practice staff recruited in the hope that it will improve access to services. This change is likely to have a significant impact on community and district nurses and result in an overall improvement in patient care. For example, it might facilitate better communication between teams and patient-orientated management, thereby reducing hospital visits. Additionally, engaging with a third party such as Age UK will enhance the benefits and help keep workloads manageable. This article looks at what the implications of this contract could be on physiotherapy services across the UK.
It seems that most in the profession of physiotherapy have welcomed this initiative, at least in principle, because it acknowledges the vital frontline role that physiotherapists can play in general practice. Musculoskeletal (MSK) conditions are thought to make up as much as 30% of all GP appointments (Royal College of General Practitioners, 2019) and, in simple terms, by making physiotherapists the first point of contact for patients with MSK disorders, GPs could dedicate more time to people with other conditions. This would help to ease the well-documented pressures on general practice and reduce costs (Chartered Society of Physiotherapy (CSP), 2019). In addition, physiotherapists are the best clinicians to manage MSK conditions, for which a quick diagnosis is key for fast recovery. Physiotherapists are trained as frontline clinicians, so they are also able to identify any underlying medical issues that need addressing and help to manage these (NHS England, 2017).
This opinion seems to be echoed by the general public. According to a poll conducted on behalf of the CSP, almost three-quarters (73%) of responders said they would accept the offer of an appointment with a first-contact physiotherapist (FCP) if they were seeking help for a bone, joint or muscle problem. Only 9% of those surveyed said they would decline (CSP, 2019).
MSK conditions affect all aspects of daily life, limiting people's ability to do what they need or want to, and they can have a detrimental effect on a person's independence. They are a costly and growing problem whose predominance is increasing, not only due to population ageing but also due to rising levels of obesity and physical inactivity (Arthritis Research UK, 2018).
The new GP contract will also give specially trained frontline staff the chance to use their expertise to promote preventative initiatives as well as management and improvement measures. The majority of MSK disorders that are caused by overweight and an unhealthy lifestyle need one-off advice and an education session with an FCP. With the shortage of GPs and an increase in the demand for changes to primary care, there is a real need to address and help reduce this very real issue within the ageing community. The introduction of the FCP is a welcome initiative, and this preventative model of care, in line with national guidelines of frailty and falls, can be a cost effective and hugely beneficial service (Health Education England, 2018).
As more specialist services get involved with the ageing population, the issue of falls and frailty becomes increasingly evident. Figures from the Royal Society for the Prevention of Accidents show that in 2016–17, there were 316?669 fall-related hospital admissions in England for people aged 65 years—the equivalent of more than 867 every day across the country (Age UK, 2018b). According to Age UK, falls are the biggest cause of emergency hospital admissions for older people, and 4984 people aged 65 years or more died from having a fall in 2016, equating to 13 people every day (Age UK, 2018a).
It is also known, for example, that 10% of over 65-year-olds live with frailty—a process by which body systems gradually lose their reserves (muscle loss, balance, etc.)— whereby otherwise minor diseases can have an increasingly severe effect on the individual. Additionally, 44% of people over the age of 75 years live with more than one long-term condition (British Geriatrics Society, 2014).
The fact is that impaired MSK health impacts on general health and wellbeing, as reduced mobility is a risk factor for other diseases. Therefore, as we go forward, the importance of maintaining mobility and physical function and refocusing healthcare towards health promotion, prevention and rehabilitation cannot be overlooked.
A good example of this is the Grange and Lakes Integrated Care Community, which has set up ‘Bounce Back Clinics’. Physiotherapist Amanda Hensman-Crook leads the service, which looks at physiotherapy, pharmacy, nursing and third-sector involvement. The aim of this initiative is to, quite simply, provide a frontline frailty service that would benefit the local community.
Initially, a number of goals were established with the primary objective being a reduction in the number of falls and the need for unplanned GP visits, 999/111 calls, emergency department attendances and unplanned admissions. An improvement in mobility and self-care and a better understanding of and concordance with medication were also targeted, along with a reduction in social isolation. Finally, the clinic was tasked with improving the quality of life of patients by providing a wraparound service close to home and providing closer links with acute and community providers, the third sector and wider cross-organisational teams.
Specific measures were undertaken and evaluated, and the results have been very positive as a result of the physiotherapy intervention. In fact, at the 3-month follow-up, there was an astounding 97% improvement in the confidence measure among the people who visited this clinic, with no deterioration. In terms of the frailty score, 63% patients showed overall improvement, while the score stayed the same in 37% (it should be noted that the Edmonton Frail Scale is not the most sensitive scoring system). Further, 90% of the attendees showed compliance with their exercise programmes, and 100% returned to outdoor activities. The conclusions were that the Bounce Back Clinic is a popular service, is cost effective and that engagement of a multidisciplinary team has resulted in full holistic assessment of the patients.
One issue that this initiative does not address is how to provide treatment for people who are unable to travel to their GP. This could be for a number of reasons, such as being unable to walk or drive due to an injury or long-term condition, having other commitments or simply not being able to take the time off work. This is where technology can play a vital role in complementing this initiative. Technology would also be ideal for easy monitoring and follow-up.
For example, leading research has found that video consultations are as effective as face-to-face appointments (Tates et al, 2017), and the author's experience is that 3 in 4 people can be triaged, assessed and supported online without any need for physical treatment. This means that the service can be accessible to anyone with a screen and an internet connection from their home, workplace or even overseas. It is simple to use and should not be a barrier for the older generation, as evidenced by 2018 data from the Office of National Statistics, which showed that internet use in the 65–74 year age group has increased from 52% in 2011 to 80% in 2018 (Office for National Statistics, 2018).
Appointments can be booked online in real time and are generally available on the same day to swiftly help reduce suffering and concern and, in many cases, hasten the recovery time (Telehealth Network, 2018). There is no doubt that this kind of service has an important role to play in the future and will perfectly complement traditional physiotherapy.
The NHS has long been criticised for its failure to maximise the benefits of technology. However, with the appointment of Matt Hancock as Health Secretary and the announcement of his ‘tech vision’ (Department of Health and Social Care, 2018; Health Foundation, 2018)—designed to help NHS organisations to introduce innovative technologies for the benefit of staff and patients—there is the hope that this aspect will be improved. It is a powerful step change. Hopefully, the NHS delivers on its promises.