Authors' objectives: First-contact physiotherapists assess and diagnose patients with musculoskeletal disorders, determining the best course of management without prior general practitioner consultation. The primary aim was to determine the clinical and cost-effectiveness of first-contact physiotherapists compared with general practitioner-led models of care. Musculoskeletal disorders (MSKDs) are the leading cause of disability in the UK. They accounted for over 23 million lost workdays annually and consume a significant amount of the health budget (approximately £5 billion per annum is spent by NHS England). Year on year, there continue to be unprecedented numbers of consultations in primary care; between 20% and 30% are related to MSKDs. Given the increasing demand for general practitioner (GP) services and current difficulties surrounding GP recruitment and retention, alternative implementable and affordable models of care are essential. One service initiative that has become prevalent is first-contact physiotherapy, whereby patients attending GP surgeries for MSKD are treated by experienced first contact physiotherapy practitioners (FCPs) on a first point of access basis, thereby providing timely specialist advice and reducing demands on GP time. Local service initiatives and a national evaluation indicate that they reduce GP appointments and requests for unnecessary investigations and improve patient satisfaction. There was no evidence to determine whether the model was more clinically efficacious or cost-effective than GP-led models of care.

Authors' results and conclusions: No statistically significant difference in the primary outcome Short Form 36 physical component score measure at 6-month primary end point between general practitioner-led, first-contact physiotherapist standard provision and first-contact physiotherapist with additional qualifications models of care. A greater number of patients who had first-contact physiotherapist standard provision (72.4%) and first-contact physiotherapist with additional qualifications (66.4%) showed an improvement at 3 months compared with general practitioner-led care (54.7%). No statistically significant differences were found between the study arms in other secondary outcome measures, including the EuroQol-5 Dimensions, five-level version. Some 6.3% of participants were lost to follow-up at 3 months; a further 1.9% were lost to follow-up after 3 months and before 6 months. Service-use analysis data were available for 348 participants (81.7%) at 6 months. Inspecting the entire 6 months of the study, a statistically significant difference in total cost was seen between the three service models, irrespective of whether inpatient costs were included or excluded from the calculation. In both instances, the general practitioner service model was found to be significantly costlier, with a median total cost of £105.50 versus £41.00 for first-contact physiotherapist standard provision and £44.00 for first-contact physiotherapists with additional qualifications. Base-case analysis used band 7 for first-contact physiotherapist groups. A sensitivity analysis was undertaken at band 8a for first-contact physiotherapists with additional qualifications; the general practitioner-led model of care remained significantly costlier. Qualitative investigation highlighted key issues to support implementation: understanding role remit, integrating and supporting staff including full information technology access and extended appointment times. First-contact physiotherapists and general practitioner models of care are equally clinically effective for people with musculoskeletal disorders. Analysis showed the general practitioner-led model of care is costlier than both the first-contact physiotherapist standard provision and first-contact physiotherapist with additional qualifications models. Implementation is supported by raising awareness of the first-contact physiotherapist role, retention of extended appointment times, and employment models that provide first-contact physiotherapists with professional support. The FCP model of care, irrespective of whether the practitioner has additional qualifications to inject and/or prescribe, demonstrates no statistically significant difference in clinical outcomes over time compared with a GP-led model of care, and no differences in safety were identified across arms; findings that patients who see the FCP recover sooner and have fewer lost days suggest a valuable societal impact. These data would suggest that FCP is a viable alternative model to GP-led models of care for MSKD. When considering costs, both the FCP(ST) and FCP(AQ) models produced lower total health costs compared with the GP-led model of care. Successful implementation of FCP is supported through widespread advertising of the role to patients; ensuring a good understanding of the role among practice staff who can advocate for the role, including reception staff who are better equipped to direct appropriate patients to FCP services; employment models that support FCP professional development and offer professional support; and ensuring that extended consultation times are retained (20 minutes) to ensure a full assessment and biopsychosocial approach to patient management.

Authors' methods: Mixed-method realist evaluation of effectiveness and costs, comprising three main phases: A United Kingdom-wide survey of first contact physiotherapists. Rapid realist review of first contact physiotherapists to determine programme theories. A mixed-method case study evaluation of 46 general practices across the United Kingdom, grouped as three service delivery models: General practitioner: general practitioner-led models of care (no first contact physiotherapists). First-contact physiotherapists standard provision: standard first-contact physiotherapist-led model of care. First-contact physiotherapists with additional qualifications: first-contact physiotherapists with additional qualifications to enable them to inject and/or prescribe. United Kingdom general practice. A total of 46 sites participated in the case study evaluation and 426 patients were recruited; 80 staff and patients were interviewed. Short Form 36 physical outcome component score and costs of treatment. Services were significantly impacted by COVID-19 treatment restrictions, and recruitment was hampered by additional pressures in primary care. A further limitation was the lack of diversity within the sample. The research was conducted in four phases: A UK-wide survey of 102 FCP services to identify key aspects of delivery models to inform phases 2 and 3. A rapid realist review to establish the initial set of realist programme theories underpinning FCP models of care, followed by a consensus exercise with key stakeholders to validate the programme theories that were tested in phase 3. Mixed-method case study evaluation of 46 general practices across the UK investigating three models of service provision. GP-led models of care (usual practice). FCP without additional qualifications [FCP standard provision (ST)] to inject and/or prescribe. FCP with additional qualifications [FCP(AQ)] to inject and/or prescribe. Data were collected from 426 adults consulting with a new (episode) MSKD. Outcome measures were recorded at baseline, 3 and 6 months (primary end point) to track changes in pain and functioning using the Short Form questionnaire-36 items physical component summary (SF-36-PCS) primary outcome measure, and were compared across the care models. Secondary outcomes included MSKD impact, mental health, patient safety, time off work/change of work practices, health-related quality of life and patient satisfaction. The scope of the economic evaluation was informed by the realist programme theories to determine the costs and cost-effectiveness given a range of associated processes, contexts and services, and data were collected using a tailored version of the Client Services Receipt Inventory for MSKDs in primary care. Realist qualitative interviews (n = 80) were conducted with practice staff, patients and other system informants (FCP educator, interface clinician and manager) to test programme theories derived in stage 2 regarding what works, for whom, how and in what circumstances, accounting for aspects of the context that have causal impact. In response to the COVID-19 pandemic, an additional work package investigating the impact of remote consultations on FCP well-being was also undertaken. A UK-wide survey was completed by 109 FCPs with 16 follow-up interviews. This study was conducted during the COVID-19 pandemic, which significantly hampered recruitment due to pressures in primary care. As such, the case study evaluation was slightly underpowered, particularly in the GP arm, as services were capitalising on national funding programmes supporting the employment of FCPs in primary care, yet this work still provides significant insight into the clinical effectiveness and costs associated with the various models of care. Furthermore, recruitment was significantly different across individual participating sites. A further limitation is the diversity within the patient sample. While practices were purposefully recruited in areas that had high ethnic diversity, the recruited sample did not reflect practice populations.

Authors' identified further research: Determining whether shifting workforce impacts physiotherapy provision and outcomes across the musculoskeletal pathway.

Project Status: Completed

URL for project: https://www.journalslibrary.nihr.ac.uk/programmes/hsdr/16/116/03

Year Published: 2024

URL for published report: https://www.journalslibrary.nihr.ac.uk/hsdr/RTKY7521

URL for additional information: English

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: England, United Kingdom

DOI: 10.3310/RTKY7521

Organisation Name: NIHR Health Services and Delivery Research programme

Contact Address: NIHR Journals Library, National Institute for Health and Care Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK

Contact Name: journals.library@nihr.ac.uk

Contact Email: journals.library@nihr.ac.uk