SAPC hot topic: is it a dangerous idea to make physiotherapists the gatekeepers of frontline primary care for all patients with musculoskeletal problems?

At our 42nd SAPC Annual Scientific Meeting in Nottingham, four brave souls faced a critical audience in our Dangerous Ideas Soapbox. We asked the audience to vote for the idea which they thought was creative (new), challenging (dangerous) and had the potential to make a difference. Our winner this year was Annette Bishop. She outlines her dangerous idea in our latest Hot Topic article. What do you think? Send us feedback via Twitter (@sapcacuk) or by email to office@sapc.ac.uk

Musculoskeletal conditions are common. They make a large and significant contribution to the workload of general practitioners, currently accounting for one-quarter of all consultations, and are the most common reason for patients to seek repeat consultations in primary care (Picavet and Schouten, 2003, Department of Health, 2006). The predicted rise in the overall age of the UK population over the next 20 years will result in a substantial increase in the prevalence of musculoskeletal conditions. Coupled with rising public expectations of health care, this will drive up demands on GPs. The time has come to ask if the traditional model of primary care in which the GP sits as gatekeeper is the most efficient and effective way for the NHS to provide care for patients with musculoskeletal problems. Shifting first contact care for patients with musculoskeletal conditions to physiotherapists provides a clear and effective alternative.

Physiotherapists have the right skills, expertise and interest

The primary care management of many musculoskeletal conditions is more about managing symptoms and promoting function and activity than diagnosis and medical treatment. Best evidence guidelines for the care of patients with musculoskeletal conditions recommend supporting people to stay active and at work, helping them to set and realise realistic goals regarding their condition and providing interventions such as exercise programmes, manual therapy and acupuncture (NICE, 2008; Savigny et al., 2009). Physiotherapists are specifically trained and equipped to deliver such care and there is evidence that they improve clinical outcomes for this group of patients. By contrast, many GPs – although certainly not all – have limited interest, expertise and training to deal effectively with many of these musculoskeletal conditions (Lanyon et al., 1995). Traditionally GPs receive little training in common musculoskeletal problems and can feel ill-equipped to manage patients with common musculoskeletal conditions such as back pain (Breen et al., 2007).

Although currently patients with musculoskeletal conditions requiring prescription medication or sickness certification would still need to see a GP, physiotherapists in the UK have recently been granted independent prescribing rights. Many GPs would also welcome a change in legislation allowing physiotherapists to handle sickness certification (Wynne-Jones et al., 2010).

The evidence in support of changing the GP-led model of care is growing, with direct access to physiotherapists well established in countries such as Australia, New Zealand, Canada, several US states, the Netherlands and Scotland. Published research is also demonstrating that physiotherapists can provide a front-line service that saves money, provides high levels of patient satisfaction, and improves clinical outcomes for this group of patients (Galley, 1977; Massey, 2002; Holdsworth and Webster, 2004).

Physiotherapy is a cost-effective intervention

Physiotherapists are able to deliver many of the cost-effective treatments available in primary care (Lin et al., 2011), including strong controlled trial evidence of the effectiveness of their delivery of biopsychosocial care for patients with common musculoskeletal conditions (Hill et al., 2011). Physiotherapists have been early adopters of stratified care for patients with low back pain, where patients at low risk of poor outcome receive brief advice and support to self-manage while those at higher risk are provided with courses of treatment that target the patients’ physical and psychosocial obstacles to recovery. In addition, evidence also shows that early access to physiotherapy reduces the time patients are off-sick, helps prevent acute problems becoming chronic, and reduces long-term pain and disability (Nordeman et al., 2006; Savigny et al., 2009; Addley et al., 2010).

Physiotherapy is safe

A common and important argument voiced in favour of a GP-led model of care for patients with musculoskeletal problems is that serious pathologies have to be identified and patients need to be appropriately selected and referred for urgent medical management. In patients with musculoskeletal problems, serious pathologies are rare. Using the example of back pain, <1% of primary care cases are due to serious pathology (Henschke et al., 2009). Research shows other health professionals are just as able as GPs to recognise red flag symptoms (Jette et al., 2006; Leemrijse et al., 2008; Taylor et al., 2011).

But surely patients with multiple problems need the generalist?

More people are living with multiple health conditions and multimorbidity increases with age. By the age of 65 years around 65% of the population have two or more co-existing conditions (Barnett et al., 2012). However, even when patients themselves prioritise their musculoskeletal problem, the GP tends to place a higher priority on the other health conditions. Studies confirm that patients with common musculoskeletal problems such as osteoarthritis (OA) or back pain complain that GPs ‘don't take their problem seriously’ (Alami et al., 2011).

If physiotherapists were on the frontline, then of course overall responsibility would still lie with the GP for patients with conditions such as diabetes or coronary heart disease who expect and require the attention of a doctor. But these conditions, and the commonest musculoskeletal problems such as OA and back pain, can all be considered as long-term conditions where patients need skilled confident advice and support to self-manage, notably with exercise and activity. Physiotherapists therefore have a significant contribution to make in the management of many long-term conditions, and patients presenting with other morbidities alongside musculoskeletal problems would gain additional benefits from a physiotherapy-led service.

The Royal College of General Practitioners has acknowledged that primary care is moving towards a ‘system of integrated care, where clinicians work closely together in flexible teams, formed around the needs of the patient and not driven by professional convenience or historic location’ (RCGP, 2013). Physiotherapists are well placed to contribute to making this vision a reality by taking responsibility for frontline primary care for patients with musculoskeletal problems. The accompanying drive to develop the education, practice patterns and licensure of physiotherapy to deliver the workforce to do this carries exciting potential for an effective and satisfying service for patients suffering from conditions which are the commonest cause of disability in the community and for an effective and satisfying partnership between physiotherapists and GPs and their practice teams.