Provision of first contact physiotherapy in primary care across the UK: a survey of the service

Views and experiences of non-medical prescribing: a national survey of prescribing physiotherapists

BACKGROUND

Physiotherapy non-medical prescribing (NMP) is a contemporary development whereby physiotherapists can prescribe medications within their scope of practice. Despite institutional and professional support for its implementation, data regarding physiotherapists' views and experiences of NMP is limited.

OBJECTIVES

To explore the views and experiences of NMP for UK prescribing physiotherapists.

DESIGN

Cross-sectional study, using an anonymous, online survey.

METHODS

Recruitment involved non-probability sampling targeting UK physiotherapists with a NMP qualification. Data was gathered about the role, scope, and activity of prescribing physiotherapists via closed and open-ended questions. Descriptive statistics and inductive content analysis were undertaken.

RESULTS

Of the 552 respondents, most worked in FCP roles (122/552, 22%) and 82% (450/552) prescribed medication. NSAIDs were the most prescribed drug class (267/450, 59%). Perceived benefits were enhanced patient care, reduced burden on other prescribers, and improved medication access. Challenges included restrictions on prescribing or deprescribing controlled drugs (CDs), limited scope of practice, and inadequate CPD. Themes identified to improve physiotherapy NMP were increasing the CDs that physiotherapists can independently prescribe and deprescribe, improving CPD and supervision, and increasing awareness amongst the public and healthcare professionals.

CONCLUSIONS

This study provides novel findings of the perceived benefits, challenges, and development areas for physiotherapy prescribing. There is a need to review and potentially expand the drug formulary for physiotherapists. Improving education and supervision is crucial for the sustainable growth of physiotherapy NMP. Increasing the awareness amongst the public and healthcare professionals may enhance the acceptance of physiotherapy prescribing. CONTRIBUTION OF THE PAPER.

First contact physiotherapy: an evaluation of clinical effectiveness and costs

BACKGROUND

First contact physiotherapy practitioners (FCPPs) are embedded within general practice, providing expert assessment, diagnosis, and management plans for patients with musculoskeletal disorders (MSKDs), without the prior need for GP consultation.

AIM

To determine the clinical effectiveness and costs of FCPP models compared with GP-led models of care.

DESIGN AND SETTING

Multiple site case-study design of general practices in the UK.

METHOD

General practice sites were recruited representing the following three models: 1) GP-led care; 2) FCPPs who could not prescribe or inject (FCPPs-standard [St]); and 3) FCPPs who could prescribe and/or inject (FCPPs-additional qualifications [AQ]). Patient participants from each site completed outcome data at baseline, 3 months, and 6 months. The primary outcome was the SF-36 Physical Component Summary (PCS) score. Healthcare usage was collected for 6 months.

RESULTS

In total, 426 adults were recruited from 46 practices across the UK. Non-inferiority analysis showed no significant difference in physical function (SF-36 PCS) across all three arms at 6 months (P = 0.667). At 3 months, a significant difference in numbers improving was seen between arms: 54.7% (n = 47) GP consultees, 72.4% (n = 71) FCPP-St, and 66.4% (n = 101) FCPP-AQ (P = 0.037). No safety issues were identified. Following initial consultation, a greater proportion of patients received medication (including opioids) in the GP-led arm (44.7%, n = 42), compared with FCPP-St (18.4%, n = 21) and FCPP-AQ (24.7%, n = 40) (P<0.001). NHS costs (initial consultation and over 6-month follow-up) were significantly higher in the GP-led model (median £105.5 per patient) versus FCPP-St (£41.0 per patient) and FCPP-AQ (£44.0 per patient) (P<0.001).

CONCLUSION

FCPP-led models of care provide safe, clinically effective patient management, with cost-benefits and reduced opioid use in this cohort.

Using Twitter (X) to Mobilize Knowledge for First Contact Physiotherapists: Qualitative Study

BACKGROUND

Twitter (now X) is a digital social network commonly used by health care professionals. Little is known about whether it helps health care professionals to share, mobilize, and cocreate knowledge or reduce the time between research knowledge being created and used in clinical practice (the evidence-to-practice gap). Musculoskeletal first contact physiotherapists (FCPs) are primary care specialists who diagnose and treat people with musculoskeletal conditions without needing to see their general practitioner (family physician) first. They often work as a sole FCP in practice; hence, they are an ideal health care professional group with whom to explore knowledge mobilization using Twitter.

OBJECTIVE

We aimed to explore how Twitter is and can be used to mobilize knowledge, including research findings, to inform FCPs' clinical practice.

METHODS

Semistructured interviews of FCPs with experience of working in English primary care were conducted. FCPs were purposively sampled based on employment arrangements and Twitter use. Recruitment was accomplished via known FCP networks and Twitter, supplemented by snowball sampling. Interviews were conducted digitally and used a topic guide exploring FCP's perceptions and experiences of accessing knowledge, via Twitter, for clinical practice. Data were analyzed thematically and informed by the knowledge mobilization mindlines model. Public contributors were involved throughout.

RESULTS

In total, 19 FCPs consented to the interview (Twitter users, n=14 and female, n=9). Three themes were identified: (1) How Twitter meets the needs of FCPs, (2) Twitter and a journey of knowledge to support clinical practice, and (3) factors impeding knowledge sharing on Twitter. FCPs described needs relating to isolated working practices, time demands, and role uncertainty. Twitter provided rapid access to succinct knowledge, the opportunity to network, and peer reassurance regarding clinical cases, evidence, and policy. FCPs took a journey of knowledge exchange on Twitter, including scrolling for knowledge, filtering for credibility and adapting knowledge for in-service training and clinical practice. Participants engaged best with images and infographics. FCPs described misinformation, bias, echo chambers, unprofessionalism, hostility, privacy concerns and blurred personal boundaries as factors impeding knowledge sharing on Twitter. Consequently, many did not feel confident enough to actively participate on Twitter.

CONCLUSIONS

This study explores how Twitter is and can be used to mobilize knowledge to inform FCP clinical practice. Twitter can meet the knowledge needs of FCPs through rapid access to succinct knowledge, networking opportunities, and professional reassurance. The journey of knowledge exchange from Twitter to clinical practice can be explained by considering the mindlines model, which describes how FCPs exchange knowledge in digital and offline contexts. Findings demonstrate that Twitter can be a useful adjunct to FCP practice, although several factors impede knowledge sharing on the platform. We recommend social media training and enhanced governance guidance from professional bodies to support the use of Twitter for knowledge mobilization.

Patient experiences of referral practices and primary care physiotherapy for chronic nonspecific low back pain

BACKGROUND

Low back pain (LBP) clinical practice guidelines recommend referral for patients with persistent LBP however discordance persists between recommended care and implementation in practice. Understanding patient experiences of referral practices and physiotherapy care could be important for optimizing LBP management in primary care settings.

PURPOSE

This study explored referral experiences of people with nonspecific LBP in Australian primary care and their knowledge and experience of physiotherapy.

METHODS

An interpretive descriptive qualitative framework was used with 17 participants interviewed from community-based physiotherapy practices.

RESULTS

Four themes described the participants' experiences of referrals in primary care settings: 1) Referral practices ranged from formal to informal to non-existent; 2) Fragmented inter-and intra-professional LBP care management; 3) Patient perceived differences in the roles of physiotherapists and specialist physiotherapists; and 4) Patient nominated barriers and facilitators to optimal referral practices.

CONCLUSION

Physiotherapists support people with LBP to improve strength and function, whereas the specialist physiotherapist's role was seen as more holistic. Referral pathways that align to clinical guideline recommendations for non-surgical management and treatment remain underdeveloped. Improved referral pathways to clinicians such as physiotherapists with additional credentialed skills and competence in musculoskeletal care could improve people's experiences of care and health outcomes.

Let the records speak: an exploration of rehabilitation services offered in primary healthcare, Johannesburg metropolitan district

BACKGROUND

Primary healthcare in South Africa aims to transform the national health system by emphasising community-based care and preventive strategies. However, rehabilitation services, particularly for individuals with disabilities and chronic non-communicable diseases, are often overlooked in primary healthcare. This study aimed to investigate the provision of primary healthcare rehabilitation services in the Johannesburg Metropolitan District by exploring client sociodemographics and variations in services provided by rehabilitation professionals.

METHODS

A retrospective review of clinic rehabilitation records from 2011 to 2020 was conducted at nine provincially funded community health centres (CHCs) offering rehabilitation services. Stratified sampling facilitated record selection based on rehabilitation service type and year. A specifically designed data extraction tool captured demographics, disabilities, rehabilitation received, and referral sources. Descriptive analysis used means, standard deviations, and frequencies.

RESULTS

The findings show a diverse client population with a wide age range, with a significant proportion falling into the < 5 years and 30-49 years age groups. Neuromusculoskeletal and movement-related disabilities were most prevalent, affecting approximately two-thirds of clients. Referral sources were often undocumented, and inconsistent discharge information with no record of patient follow up, highlighted the need for improved documentation practices. Clinic visits were the primary service delivery mode, followed by limited home visits and outreach services. Occupational therapy and physiotherapy were the most used services. Speech and language therapy services were underused, and some CHCs lacked audiology services. There were variations in the number of individual and group sessions provided by the different rehabilitation services, and there were age- and disability-specific differences in service use.

CONCLUSION

This study offers insights into rehabilitation service provision in the Johannesburg Metropolitan District and enhances our understanding of rehabilitation services in primary healthcare settings. It underscores the importance of a multidisciplinary rehabilitation team to address diverse rehabilitation needs, improving documentation and discharge practices, expanding service delivery models, and reducing disparities in service use. The findings inform strategies for optimising service delivery, workforce, resource allocation, and intersectoral collaboration to ultimately enhance the quality and accessibility of integrated rehabilitation services.

"Cooperation between physicians and physios fosters trust you know": a qualitative study exploring patients' experience with first-contact physiotherapy for low back pain in French primary care

BACKGROUND

Physiotherapists working in collaboration with family physicians in French multidisciplinary primary healthcare clinics are now able to manage acute low back pain patients as first-contact practitioners in advanced practice roles. This includes medical act delegation such as making a medical diagnosis and prescribing medication. The aim of this study is to explore patients' experience and perceptions when attending a first-contact physiotherapist (FCP) in an advanced practice collaborative primary care model for acute low back pain (LBP).

METHODS

A qualitative study using semi-structured interviews was conducted. Patients that consulted a FCP for acute LBP care in new collaborative model were included. Interviews were transcribed verbatim and inductive thematic analysis was performed to generate themes related to patients' experience and perceptions.

RESULTS

Ten patients were interviewed (3 women, 7 men; mean age 36.5 ± 9.63 years). All LBP participants experienced important level of pain and disability. Four overarching themes related to patients' experience with the new FCP model were formalized: 1) "Going to see a physiotherapist who specializes in painful movements, well that makes sense to me", 2) "Physiotherapist offered to give me exercises to do at home to relieve the back pain", 3) "I went there feeling confident", 4) "The physiotherapist can do more than just send you to see more appropriate people". Participants highlighted the need to receive timely and high-quality care and were receptive with being autonomously managed by a FCP. Overall, patients' experiences with FCP model of care were positive. Participants were highly confident in the FCP's ability to perform delegated medical tasks including making a medical diagnosis and prescribing oral medication such as analgesic drugs. Patients felt that a greater expansion of FCPs' scope of practice was needed to improve the model.

CONCLUSION

Findings from this study can inform the implementation of FCP in countries where patients are not typically granted FCP by underlining that patients are favourable towards the advance practice model as such models support timely and high-quality care. Further research is needed to better determine the future advance practice physiotherapists' scope of practice in French primary and secondary care settings.

Implementation of community physiotherapy in primary care: one-year results of an on-call physiotherapy service

BACKGROUND

Primary health care systems have a key role in meeting health needs of community, including function. The aim of this paper is to describe the population involved in the Community Physiotherapist project and their health outcomes over a one-year period.

METHODS

The Community Physiotherapist is an on-call service which requires a request by general practitioners or medical specialists. Reason for prescription, waiting time for service delivery, diagnostic categories, provided intervention, number of interventions and outcomes were recorded for everyone included in the project. Possible differences in characteristics between individuals referred by medical specialists and general practitioners were also investigated.

RESULTS

From January to December 2022, 409 individuals were referred to the Community Physiotherapist pathway. Functional goals were achieved in 79.5% of interventions, without reported adverse events. In most cases physiotherapists provided counselling or caregiver training and 3.3% of individuals needed a full rehabilitation program. The groups of individuals referred by the two types of prescribers showed no significant differences, apart, as expected, from their median age.

CONCLUSIONS

The introduction of the Community Physiotherapist model within the primary care setting allows to provide appropriate, effective and safe interventions. Sharing the project among all the health professionals helped to support its appropriateness and effectiveness. Results also indicate that a new organizational model, such as the Community Physiotherapist, will take a long time to be implemented.

Patient access to first contact practitioner physiotherapists in the UK: A national survey

BACKGROUND

First Contact Practice Physiotherapists (FCPPs) offer expert care for patients with musculoskeletal (MSK) conditions in Primary Care, usually within GP practices. This is a rapidly expanding area of practice endorsed by NHS England, the Chartered Society of Physiotherapy (CSP) and the British Medical Association (BMA). Efficient and appropriate access is important for optimising FCPP practice, but there is little published information about how patients currently access FCPP appointments.

OBJECTIVE

To investigate how patients access FCPP appointments in General Practice.

DESIGN

Cross-sectional online survey of FCPPs in the UK.

METHODS

FCPPs were surveyed about patient access to appointments. The survey instrument was designed using Jisc Online Surveys, piloted, and then distributed via social media and professional groups to FCPPs nationwide. Descriptive statistics were used to analyse demographic and multiple-choice questions, and free text responses were analysed using quantitative content analysis.

RESULTS

193 participants completed the survey. Booking via GP Reception (n = 179) was reported as the most common route into an FCPP appointment, closely followed by booking after seeing another clinician for the problem (n = 172).

CONCLUSION

This research has provided clarity regarding how patients access the rapidly growing speciality of FCPP within GP practices in the UK. The role of GP Reception staff in facilitating access to FCPPs, the application of triage and the use of digital or online systems were highlighted as important elements for enabling efficient access to FCPPs by patients with MSK conditions.

A case study of the impact of a dietitian in the multi-disciplinary team within primary care: a service evaluation

BACKGROUND

Expanding the primary care workforce to alleviate general practitioner (GP) workload, improve access and improve quality of care is a current UK strategy. Evidence suggests dietitians can improve patient outcomes and make cost savings. The present study aimed to evaluate a dietitian working as an expert generalist and first contact practitioner (FCP) in a general practice multi-disciplinary team (MDT) to provide appropriate care to patients and reduce GP workload.

METHODS

A dietitian was employed for 6 months at 0.6 full-time equivalents in a group of general practices in Devon, UK. Data were collected on the referral source, patient satisfaction, health outcomes and changes in prescribing data for all patients seen by the dietitian. Focus groups and interviews provided data to understand the experience of introducing a dietitian into the team.

RESULTS

This model of service delivery showed the dietitian acting as an expert generalist, a FCP and able to educate the MDT. A range of professionals within the MDT referred patients with a wide range of diagnoses (both paediatric and adults) and the dietitian acted as a FCP for 29% of patients. Saving were made for the optimisation of medicine management.

CONCLUSIONS

The dietitian can improve patient-centred care for several patient groups; enhance learning for staff around nutrition and dietary issues; and contribute to more efficient working and cost savings around prescription of nutritional products. This was an evaluation of one service and further research is needed to understand the value dietitians can contribute and the factors supporting effective and efficient working in this context.

Advanced practice physiotherapists in Scottish primary care: Axial Spondyloarthropathy epidemiology, time to diagnosis, and referrals to rheumatology

OBJECTIVES

(1) Generate empirical knowledge of a Musculoskeletal (MSK) Advanced Practice Physiotherapist (APP) Service in Scottish Primary Care; (2) Identify the incidence and baseline time to diagnosis of Axial Spondyloarthropathy (AxSpA); (3) Identify APP Rheumatology referral fulfilment of the NICE 2017 Guidelines and Spondylarthritis Diagnosis Evaluation (SPADE) Tool; (4) Calculate APP Rheumatology referral conversion rates for AxSpA diagnosis and further investigation; (5) Contribute towards the current body of literature for informing analysis of MSK APP services within Scottish Primary Care.

METHODS

An audit and evaluation approach was undertaken over a 3-year period (May 2019-April 2022). Relevant clinical cases from the whole-service data-set were identified and analysed, using retrospective electronic healthcare record review and descriptive statistical techniques.

RESULTS

A total of 37,656 primary care MSK APP consultations took place, with N = 19 suspected AxSpA referrals made to Rheumatology. N = 6 cases of AxSpA were diagnosed by a Rheumatologist (31.6%). The mean age of individuals diagnosed with AxSpA was 39.6 ± 8.8, and 66.7% (4/6) were female. Mean time to diagnosis was 3.4 years, and incidence per-10,000 person-years was 1.6. Compliance of referrals with the NICE 2017 Guidelines and SPADE Tool Criteria was 78.9%. Of those diagnosed with AxSpA, 66.7% met both referral criterion sets.

CONCLUSION

Those referred by an MSK APP from primary care had a 5.1 year shorter time to diagnosis than the previous reported UK average of 8.5 years. APPs identified relevant AxSpA features in referring to Rheumatology, and supported effective implementation of the local secondary care pathway.

The experiences of uncertainty amongst musculoskeletal physiotherapists in first contact practitioner roles within primary care

AIM

The aim of this research was to explore the experiences of uncertainty amongst Musculoskeletal First Contact Practitioners working in primary care.

BACKGROUND

The Musculoskeletal First Contact Practitioner role involves advanced physiotherapists providing an alternative to the GP by acting as first point of contact for people presenting to primary care with musculoskeletal conditions. Limited research into the role exists but the first-contact aspect, clinical complexity and time pressures are deemed to contribute to uncertainty within the role.

METHOD

A qualitative research design was undertaken using a hermeneutic interpretative phenomenological approach. Data was collected using semi-structured interviews with subsequent thematic analysis of the data.

FINDINGS

Eight participants working as Musculoskeletal First Contact Practitioners across England were recruited using purposive sampling. Five themes were identified: (1) Role clarity within primary care, (2) Burden of responsibility, (3) Preparedness for the primary care environment, (4) 'I'm not really sure how long I am going to stay in this role', (5) Mitigating uncertainty.

CONCLUSION

This study demonstrates the multifaceted phenomenon of uncertainty amongst Musculoskeletal First Contact Practitioners. Uncertainty appeared to be influenced by the primary care environment, preparedness for the role and perceived burden of responsibility. Diagnostic uncertainty was prevalent with concerns of missing serious pathology evident. The impact of uncertainty on wellbeing was linked to possible burnout and retention issues. Consultation approaches, access to support networks and a cultural shift in tolerating uncertainty were reported to mitigate uncertainty. Further research into possible differences in experiences related to employment models appears warranted.

What is the prevalence of burnout amongst first contact physiotherapists working within primary care?

BACKGROUND

It has long been known general practitioners suffer with burnout. First contact physiotherapists (FCP's) are a new role to primary care. However, concerns have been raised around the longevity and sustainability of the role and the risk of clinician burnout.

AIMS

To assess the prevalence of burnout amongst the FCP workforce.

METHOD

A self-reporting online questionnaire was developed and captured key demographical data and burnout scores amongst FCP's between February 2022 and March 2022. The burnout assessment tool (BAT12) was used to assess clinician burnout.

RESULTS

A total of 332 responses were collected. Overall, 13% of clinicians were burnt out, and 16% at risk. The BAT12 also found 43% of the clinicians are exhausted and a further 35% are at risk of exhaustion. Non-clinical hours were significantly associated with burnout score. Clinicians who had more non-clinical time per month were the least burnt out. Increased non-clinical hours was significant in reducing burnout score.

CONCLUSIONS

This study found 13% of clinicians are suffering from burnout with a further 16% at risk. Worryingly 78% of clinicians are either exhausted or at risk of exhaustion. Non-clinical hours have a direct impact on burnout and every effort is needed by employers to increase non-clinical time. This study supports the release by the Chartered Society of Physiotherapy whereby they recommend sufficient time be allocated within job plans for appropriate supervision, training and continued professional development. Further research is needed to explore the association of non-clinical time and clinician burnout.

A proposed framework for point of care musculoskeletal ultrasound and ultrasound image-guided interventions by physiotherapists: scope of practice, education and governance

BACKGROUND

The use of point of care ultrasound (PoCUS) in the management of musculoskeletal (MSK) disorders is a diverse area of PoCUS practice. Its use by clinicians, such as physiotherapists, can occur across a wide range of roles and care pathway configurations; however, professional, educational and regulatory uncertainties can leave clinicians, managers and patients at risk.

MAIN BODY

A PoCUS framework approach (previously applied to support PoCUS consolidation and expansion) is used to frame these proposals. Central to this is the defining of (clinical and sonographic) scope of practice (ScoP). A number of indicative ScoPs are described to both (i) illustrate application of the principles and (ii) provide templates for ScoP derivations for individual services or clinicians. Image-guided MSK interventions are increasingly an aspect of MSK physiotherapy PoCUS. Given the utility of physiotherapists drawing upon their imaging to fully inform the selection (and performance) of such techniques, we present a rationale for competency in undertaking sonographic differentials as a pre-cursor to performing ultrasound image-guided MSK interventions. Alignment of ScoP with the relevant education and formal competency assessments are a cornerstone of the PoCUS framework approach; as such, key aspects of MSK PoCUS education and competency assessment are outlined. Strategies for addressing such requirements in healthcare settings where formal provision is not accessible, are also presented. Governance considerations are aligned with the regulatory environment, including those pertaining to professional guidance and insurance considerations. In addition, generic quality assurance elements are emphasised, as core aspects of high-quality service provision. Whilst the paper clarifies the situation for MSK physiotherapists using PoCUS in the UK, prompts are provided to support other professional groups working in MSK services in the United Kingdom (UK) and MSK physiotherapists/physical therapists in other countries-to facilitate their application of the principles.

CONCLUSION

Acknowledging the breadth of MSK physiotherapy PoCUS practice, this paper draws upon a framework approach to provide integrated ScoP, education/competency and governance solutions, along with mechanisms for other professions working with MSK PoCUS-and physiotherapists/physical therapists outside of the UK-to consolidate and expand their practice.

Advanced Practice Physiotherapists and the implementation of the JIGSAW-E model for the management of osteoarthritis in Scottish primary care settings: a qualitative case study

OBJECTIVE

To explore the acceptability, barriers and enablers of NICE guidelines for osteoarthritis in the Scottish primary care setting using the Joint Implementation of Guidelines for Osteoarthritis in Western Europe (JIGSAW-E) model and investigate the role of Advanced Physiotherapy Practitioners (APPs) in providing evidence-based care.

DESIGN

A qualitative case study comprised of semi-structured interviews followed by a workshop with participants.

SETTING

10 Scottish primary care practices.

PARTICIPANTS

Six general practitioners (GPs) and eight APPs were interviewed. Twenty-three practitioners attended the workshop including 22 physiotherapists and one GP.

RESULTS

While both GPs and APPs recognised the need to improve and standardise osteoarthritis care delivery, this study found that APPs were better situated to implement the evidence-based model. Barriers to implementation included lack of time for training, limited appointment time for GPs to consult and discuss medication use with patients, limitation of disease specific guidelines for patients with complex multimorbidity, and system-based barriers such as electronic data collection and high staff turnover. The key enabler was practitioners' motivation to provide optimal, standardised quality care for osteoarthritis. To increase acceptance, ownership and usability for both practitioners and patients, the JIGSAW-E model materials required adaptation to the local context.

CONCLUSION

This study provides evidence that the JIGSAW-E model is acceptable in Scottish primary care. Furthermore, the evolving roles of GPs and APPs within multidisciplinary primary care teams provides a platform to implement the JIGSAW-E model, where APPs are well placed to provide leadership and training in the delivery of evidence-based care for osteoarthritis.

Association Between Physical Functioning and Time Until a New Hospitalization in Community-Dwelling Older Adults: A Prospective Cohort Study

BACKGROUND AND PURPOSE

Physical functioning refers to the ability to independently perform activities that require physical ability, and may be an important tool for predicting a higher risk of hospitalization. The objective of this study was to verify whether aspects of physical functioning are independently associated with the risk for new hospitalization in older adults seen in primary health care.

METHODS

This prospective cohort study consisted of 473 older adults 60 years and older who had not been hospitalized in the prior year. Hospitalization records were obtained with authorization from the hospital admission. Depending on physical functioning, the probability of a new hospital admission within the next 5 years was determined based on survival analysis and the Kaplan-Meier curve. Physical functioning was evaluated using 5 easy-to-administer tests: handgrip strength using a Jamar dynamometer, functional performance using the Short Physical Performance Battery, balance using the step test, mobility using the Timed Up and Go (TUG) test, and gait speed using the 4-m walk test. The association between poor physical functioning and new hospitalization was verified using a Cox regression model, adjusted for sex, age, number of comorbidities, number of medications, and BMI. Models were implemented separately for each physical functioning test.

RESULTS

In the sample, 32% had been hospitalized at least once in 5 years. The Kaplan-Meier curve showed a decrease in the probability of nonhospitalization within the next 5 years. Cox regression analysis showed an association between hospitalization within the next 5 years and mobility on the TUG test of more than 12.4 seconds in the crude (hazard ratio [HR] = 1.33, 95% CI = 1.10-1.60) and adjusted models (HR = 1.26, 95% CI = 1.02-1.56), and balance using the step test of more than 7.5 seconds in the crude (HR = 1.27, 95% CI = 1.03-1.56) model.

CONCLUSIONS

Physical functioning tests demonstrated that poor physical performance predicts new hospitalization, and reinforced the importance of their application in physical therapy practice in primary health care settings.

First Contact Practitioners' (FCPs) and General Practitioners' Perceptions Towards FCPs Delivering Vocational Advice to Patients with Musculoskeletal Conditions: A Qualitative Investigation of the Implementation Potential of the I-SWAP Initiative

Purpose Musculoskeletal (MSK) pain is a common cause of work absence. The recent SWAP (Study of Work And Pain) randomised controlled trial (RCT) found that a brief vocational advice service for primary care patients with MSK pain led to fewer days' work absence and provided good return-on-investment. The I-SWAP (Implementation of the Study of Work And Pain) initiative aimed to deliver an implementation test-bed of the SWAP vocational advice intervention with First Contact Practitioners (FCP). This entailed adapting the SWAP vocational advice training to fit the FCP role. This qualitative investigation explored the implementation potential of FCPs delivering vocational advice for patients with MSK pain. Methods Semi-structured interviews and focus groups were conducted with 10 FCPs and 5 GPs. Data were analysed thematically and findings explored using Normalisation Process Theory (NPT). Results I-SWAP achieved a degree of 'coherence' (i.e. made sense), with both FCPs and GPs feeling FCPs were well-placed to discuss work issues with these patients. However, for many of the FCPs, addressing or modifying psychosocial and occupational barriers to return-to-work was not considered feasible within FCP consultations, and improving physical function was prioritised. Concerns were also raised that employers would not act on FCPs' recommendations regarding return-to-work. Conclusion FCPs appear well-placed to discuss work issues with MSK patients, and signpost/refer to other services; however, because they often only see patients once they are less suited to deliver other aspects of vocational advice. Future research is needed to explore how best to provide vocational advice in primary care settings.

Patient view of the advanced practitioner (AP) role in primary care: A realist-informed synthesis

BACKGROUND

Approximately 30% of general practitioner consultations are due to musculoskeletal disorders (MSKDs). Physiotherapists are trained to assess, diagnose and treat a range of MSKDs, and could provide the first point of contact for primary care patients. There is limited evidence on whether this role is acceptable to patients; however, previous research has explored advanced practitioner (AP) roles in primary care, which could inform this new initiative.

AIMS

This study used realist synthesis to explore factors that influence patient acceptability of AP roles in primary care. MATERIALS & METHODS: A realist synthesis was undertaken to identify initial programme theories regarding acceptability. Databases were searched to identify relevant literature. Identified studies were subject to inclusion and exclusion criteria, resulting in 38 studies included for synthesis. Theory-specific data extraction sheets were created and utilised. Data were analysed through identifying contexts, mechanisms and outcomes to formulate hypotheses. Hypotheses were validated through consultation with expert stakeholders.

RESULTS

Eight theory areas were identified that potentially impacted on patient acceptability of the role: patient's prior experience of condition management; patient's expectations of condition management; communication; continuity of the individual practitioner; practitioner's scope of practice; accessibility; professional hierarchy and promoting the role. Nineteen hypotheses on the AP role were developed around these theory areas.

DISCUSSION

Role acceptabiliy was influenced significantly by context and may change as the role develops, for instance, as waiting times change.

CONCLUSION

Hypotheses will inform a subsequent realist evaluation exploring the physiotherapy AP role in primary care. Future research is needed to understand the acceptability of first contact physiotherapists delivering certain skills.

Patient satisfaction with the first contact physiotherapy service: Results from the national evaluation survey

BACKGROUND

Musculoskeletal (MSK) First Contact Physiotherapists (FCPs) are diagnostic clinicians able to assess and manage undifferentiated and undiagnosed MSK presentations. The FCP role in primary care has been introduced to allow patients with MSK pain to see a FCP directly rather than wait to see a General Practitioner (GP) first, which improves capacity within primary care. A national evaluation was undertaken of the FCP model. This article reports the thematic analysis of the free-text responses of patients who participated in the national evaluation.

METHODS

An online platform collected patient-reported experience and outcomes following the FCP consultation and at 1, 2 and 3 months follow-up. Free-text responses to the Friends and Family test, reasons for consulting another health care professional (HCP) and general comments were thematically analysed and grouped according to their responses.

RESULTS

Over 13 months, 680 of 2825 registered patients (24%) completed the initial questionnaire and 54% (n = 370) completed the 3-month follow-up. During the course of the evaluation, 785 participants provided free-text responses. Themes identified from free-text responses were: communication and knowledge, clinicians' characteristics, efficiency, treatment provided, assessment skills and service provided in comparison to GP care. Complaints represented 4% (n = 26 comments) of total feedback. The main reasons for consulting other HCPs after seeing a FCP were persistent pain, delays in referrals or already attending NHS physiotherapy.

CONCLUSION

Thematic analysis of free-text responses in the national FCP evaluation provides context and detail to the positive outcomes reported by patients after consulting a FCP in primary care.