CSP Wales Office
1 Cathedral Road
Cardiff CF11 9SD
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Dr Dai Lloyd AM, Chair
Health Social Care and Sport Committee
Cardiff Bay
Cardiff
CF99 1NA
3rd of February 2017
Dear Chair and Committee Members
Inquiry into primary care
The Chartered Society of Physiotherapy (CSP) in Wales is pleased to be able to provide a written contribution to this inquiry.
Just over 20% of patients see their GP about a Musculoskeletal (MSK) problem each year. Evidence suggests that 85% of these cases can be dealt with effectively by a physiotherapist without any need to see the GP.[1]
The CSP has been included in the Cabinet Secretary’s Ministerial Taskforce on the Primary Care Workforce and welcomes the fact that a multi-disciplinary approach is being taken.
The CSP notes the wide range of questions posed by the committee as part of the inquiry. The profession will concentrate on providing information around the multi-disciplinary team developments in primary care.
The emerging multi-disciplinary team – how health and care professionals fit into the new cluster model and how their contribution can be measured
1. The physiotherapy profession brings a wide range of skills to primary care, supporting GPs and the wider primary care team. Traditionally physiotherapy staff have been predominantly based in hospitals, with ward- based physiotherapists and community (MSK) outpatient services in hospitals and clinics. However, this picture is changing with physiotherapists and physiotherapy support workers increasingly as key members of services outside of the hospital environment, including: community resource teams; community based rehabilitation teams (eg pulmonary rehabilitation, post hip fracture, falls prevention) reablement services and in initiatives such as joint working with the Welsh Ambulance service to keep people out of hospital.
2. Most recently physiotherapists are taking on new roles within GP teams and practices due to the knowledge and skills they bring. Physiotherapy is an active and interactive practice that works in partnership with people to maximise their ability to move and function. In a primary care setting, physiotherapy has a valuable role to play in promoting health and wellbeing (e.g. of older people at risk of falling, of children and young people who are overweight/obese); in offering treatment and advice (e.g. for acute musculoskeletal injuries or exacerbations of respiratory disease); and rehabilitation (e.g. helping someone with a long-term condition optimise their ability to live independently). Physiotherapy is therefore a resource that can increase capacity of General Practices to address the health needs of local populations in ways that add value to primary care – as the examples in Appendix 1 show.
3. The CSP provided the following contribution to the Cabinet Secretary’s Ministerial Taskforce on the Primary Care Workforce highlighting challenges faced by physiotherapy as part of the wider primary care workforce.
i) Developing new roles in General Practice. The case for physiotherapy operating in primary care is well understood in relation to the management of musculoskeletal (MSK) conditions. Already Health Boards across Wales have taken steps to develop General Practice Physiotherapist posts with a couple of Health Boards progressing faster than others. For example, Betsi Cadwaladr UHB provides physiotherapy in over 49 GP practices and has 19 physiotherapists qualified to prescribe medicines. Abertawe, Bro Morgannwg UHB offers an open access ‘walk-in’ clinic in Swansea, Neath Port Talbot and Bridgend. The North Wales experience has demonstrated reduced referrals to secondary care and a reduction in follow-up GP appointments. An audit carried out showed a 25% reduction in referrals to rheumatology, 62% to pain clinic and 40% to spinal specialists. Research from the CSP suggests that there is support for the roles with 8 out of 10 GPs having confidence in the model. [2]
The CSP hopes the inquiry will generate an impetus for Health Boards to share learning from pilots and be supported to find ways of implementing evidence of ‘what works’ in practice across Wales. Most Health Boards physiotherapy services are either currently piloting a model or have piloted physiotherapists working in General Practice. To scale up service management and funding models are the areas that need to be worked through.
ii) Self-referral/direct access for patients to physiotherapy. Part of a physiotherapy service provision within the primary care and community setting includes providing a self-referral/direct access to physiotherapy services. This is not universally available across the whole of Wales. Four out of the seven Health Boards provide it with one Health Board offering a GP self-directed ‘same day’ service. In the main, self-referral is for MSK although ABMU has begun piloting self-referral for neurological conditions in Swansea. There remains a challenge to see all the Health Boards offering self-referral/direct access across the country. Concerns about capacity within the physiotherapy services may account for one of the reasons why it is not uniformly available.
However, recent research from Keele[3] has shown that after proactive promotion of self-referral services to the 10,000 patients in the pilots GP areas there was no increase in referrals and no increase in inappropriate referrals.
iii) Community based physiotherapy. Physiotherapists are integral to and often lead community-based services such as falls prevention, reablement and community pulmonary rehabilitation. Physiotherapy in community based settings provides support across a range of speciality groups (eg, respiratory, neurological, older people and frail elderly) to maintain strength, balance, mobility and independence, supporting more people to remain active and in their own homes. One of the challenges for services is developing a greater capacity in a primary care and community based setting while there continues to be a demand on hospital-based services. Investment in primary care, in rehabilitation and integrated community based services is a prerequisite to reducing demand on hospital-based care. Although this not an easy task and will require shifting of services and moving of resources. This becomes increasingly more difficult as services face an increase in the frail elderly accessing services, winter pressures, managing complex needs and co-morbidities. The role of rehabilitation will be critical.
iv) New models – funding, management, governance. Physiotherapy, along with other therapy and allied professions can provide a wide range of services in a primary care setting. There are challenges, however, that need to be addressed:
· GPs need to be aware of the full potential these professions can bring and then need to be supported, financially, to develop a new multidisciplinary approach.
· Funding will need to come from a number of sources – use of existing General Practice funding, service level agreements with teams in secondary care, Health Board primary care funding and new funding to support development and increase overall capacity where this is needed.
· Service management and human resource considerations are required to ensure that individuals have access to support, mentorship, training and development and resources (e.g. ICT, physical space) to ensure the service maintains its capacity to deliver safe, effective, high quality care to patients and their families. Employment models, including the importance of maintaining NHS terms and conditions will also need to addressed.
v) Investment in staff to provide quality services. To make the changes that are needed it will be essential to ensure quality employment through investment in staffing and professional development. For example, this includes ensuring there is support and capacity for staff to engage in service development, research and learning and their working environment. These are integral to delivery of high quality patient care, with high quality skills in high quality facilities. Continued investment in the existing physiotherapy workforce will be needed including through:
· Increasing the number of physiotherapists able to engage in independent prescribing, injection therapy and ordering diagnostics
· Developing physiotherapists’ broader advanced practice skills
· Facilitating physiotherapists’ return to practice after a career break
· Facilitating flexible working (eg carer commitments)
Developments and investment in staff will need to be linked to an increase in student numbers.
vi) Placement and learning opportunities in primary care. We need to equip the physiotherapy workforce of the future (eg physiotherapy undergraduates and the physiotherapy/AHP support worker workforce) with behaviours, knowledge, skills and experience of primary care through their education and training. This will need to be considered by the education and service providers and will need a collaborative approach. The new Health Education Wales body set up to oversee strategic workforce planning, workforce design and education commissioning for NHS Wales will be able to promote such an approach to sustain development of the workforce in primary care for the future.
There must be a drive to increase student’ access to patient experience and practice-based learning in primary care, and already we have seen colleagues from Cardiff University working with clinical teams and services to extend practice-based learning into community/primary care settings. The CSP is launching a campaign this year to encourage the profession to access a wider range of settings to support more practice based learning opportunities for students.
vii) Widening Access and the Welsh Language. Delivering services through the medium of Welsh is a challenge (not just for physiotherapy) and support will be needed to develop the capacity, to recognise and to value the current capacity to deliver services through the medium of Welsh if that is what the patient/service wishes to use. This links to Welsh Government’s intentions to strengthen powers and extend the scope of the Welsh Language Act and their work around recruitment and retention and widening access.
4. The CSP has been working with the BMA Cymru Wales and supported by the RCGP Wales to develop guidance on setting up first contact physiotherapy practitioner posts in primary care. ‘General Practice Physiotherapy posts – a guide for implementation and evaluation’[4] provides practical guidance for physiotherapists, GPs and those involved in funding and planning musculoskeletal (MSK) services. It provides detail on funding models, implementation considerations and physiotherapist’s roles and measuring impact and benefits.
5. The CSP has also developed a cost calculator [5]– a web based tool which helps businesses understand the costs of a potential service to primary care. The cost calculator shows that if physiotherapy were available as a first contact in a practice GPs would be able to see their patients for 5 minutes longer each, increasing quality of care.
6. Measuring the benefits of physiotherapy as part of the multi-disciplinary team in primary care will have to be looked at across a range of areas. These include:
- Benefits for GPs - freeing up their time, with fewer repeat appointments and less money spent on locums
- Benefits for patients - swifter access to specialists in MSK and empowerment to self-manage
- Benefits in relation to NHS resources - less unnecessary testing and prescribing, less onward referrals to secondary care for physiotherapy treatment or consultant appointments and shorter waiting times in secondary care.
The CSP also suggests the potential benefits of reducing sickness absence and the further reduction in unnecessary GP appointments if UK government allows physiotherapists to issue ‘Fit Notes’ (currently under consideration in the Health and Work Green Paper) – something that has been called for by both the CSP and BMA UK.
Concluding comments
The CSP in Wales hopes this written submission is useful to the committee and looks forward to continuing to play an active role in the inquiry. The profession is keeping an overview of developments across Wales supporting primary care and general practice in particular. Developments to date are captured in Appendix 1.
If you require any further information from the professional body please do not hesitate to get in touch.
Yours sincerely
Philippa Ford MBE MCSP
CSP Policy & Public Affairs Manager for Wales
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In association with:
Chartered Society of Physiotherapy Welsh Board
The Welsh Physiotherapy Leaders Advisory Group
About the CSP and Physiotherapy
The Chartered Society of Physiotherapy is the professional, educational and trade union body for the UK’s 56,000 chartered physiotherapists, physiotherapy students and support workers. The CSP represents 2,300 members in Wales.