Title: First Contact Physiotherapy in Primary Care (FRONTIER): A Realist Evaluation of effectiveness and costs
Funder: Department of Health and Social Care

Abstract: Musculoskeletal Disorders (MSKDs) are the leading cause of disability in the UK. They account for 10.8m lost work days annually and consume a significant amount of the health budget (approximately £5billion per annum is spent by NHS England). In 2014 there were 340m GP consultations in England, an increase of almost 12% over five years; approximately one third related to MSKDs. Given the increasing demand for GP services, and current difficulties surrounding GP recruitment and retention, alternative implementable and affordable models of care are essential. One service initiative that is gaining commissioning attention is First Contact Physiotherapy (FCP), whereby patients attending GP surgeries for MSKD are treated by experienced physiotherapy practitioners on a first point of access basis; thereby providing timely specialist advice and reducing demands on GP time. A national search conducted by the applicants (in December 2016), found 85 locations in England and further initiatives in Wales offering FCP, but considerable variation existed in the way in which it was both implemented (e.g. staff seniority, duration of sessions, staff availability) and funded (e.g. shared between practices (federated), NHS seconded or privately employed by GP surgery). Importantly our 2016 search also revealed two key delivery models that are being implemented: (1) some locations employ traditionally qualified ‘standard’ physiotherapists (non-Extended Scope Physiotherapists (ESPs)) who deliver assessment and non-pharmacological management with or without onward referral; (2) others employ ESPs who have additional validated competencies traditionally undertaken by the medical profession, that permit them to prescribe, inject, order/interpret investigations (e.g. imaging) and list for surgery. Local audits of both FCP models generally indicate that they reduce GP appointments and requests for unnecessary investigations, improve patient satisfaction and incur cost savings, in comparison to standard GP led approaches. Further robust research is needed however to examine the diversity and complexity of FCP models across the UK and determine the impact of emerging FCP models on patient outcomes, costs and systems level impact on MSK services. This research will provide robust evidence by conducting a realist evaluation (a theory driven methodological approach, used to evaluate social programmes) of delivery models to identify how FCP works, for whom, under what circumstances, how and with what resource implications. The research will be conducted in four work-packages (WP): 1. A UK-wide survey scoping exercise to identify key aspects of service provision. This will facilitate purposive sampling of delivery models (case studies) that will be subject to further in-depth investigation. 2. A rapid realist review of identified aspects of service provision, derived from the scoping exercise, to establish the initial set of realist programme theories underpinning FCP models of care. This will be followed by a consensus exercise with key stakeholders to validate the programme theories, in terms of the resource-response mechanisms in various contexts (context-mechanism-outcome configurations). 3. In depth case study of three key delivery models (physiotherapists (non-ESP), ESP, and usual GP care), each at eight different general practices (sites), using realist evaluation to examine outcomes. Data will be collected (quantitative and qualitative) on what works, for whom, how and in what circumstances, accounting for aspects of the context that have causal impact: (e.g. privately employed or federated, practice size, deprivation), and at what cost. Realist qualitative interviews will be conducted with five stakeholder groups involved in service provision across sites: (i) clinic receptionists; (ii) GPs; (iii) physiotherapists/ESPs; (iv) patients; and (v) commissioners. Patients (n=579) attending with MSKD, will be followed for 6 months to track changes in pain and functioning using the SF36-Physical Component Summary (primary outcome measure), and compared across Standard FCP, ESP and usual GP care models. Secondary outcomes will include mental health, patient safety, time off work/change of work practices, health related quality of life and patient satisfaction, and will be collected with validated outcome measures. The scope of the economic evaluation will be informed by the realist programme theories to determine the costs and cost effectiveness given a range of associated processes, contexts, and outcomes. 4. An integrated evaluation of the outputs from the other work-packages. Focus groups with key stakeholders in years 1,2 and 3 will determine the most appropriate format and dissemination route for information gained throughout the study. We will assess any impact this has had on practice in focus groups in subsequent years (i.e. year 2 focus group will reflect on the outputs from year 1 etc). Results will be used to develop an evidence-informed commissioning pack to assist implementation decisions. Where possible we will present data relevant to outcomes based commissioning processes.

Lay abstract: Millions of people in the UK experience pain and reduced quality of life as a result of conditions or injuries that affect the bones, spine, joints and muscles – these are known as musculoskeletal disorders (MSKD), and about one third of all GP appointments are taken up by patients consulting with these problems. This is costing the NHS a lot of money and making it more difficult for all patients to get an appointment with their GP. The problem is worsened by the national shortage of GPs, and many of those who are in practice currently suggest they may reduce their hours or leave the profession entirely. We therefore need to establish better ways to manage the large numbers of people who need healthcare advice and treatment from their GP. One approach that is gaining popularity is First Contact Physiotherapy (FCP), whereby a highly skilled physiotherapist who is expert in managing MSKD works within the GP practice, and sees patients with MSKD without them having to consult a GP first. The physiotherapist can assess the patient’s condition and provide immediate advice, and in some cases prescribe drugs, order x-rays and blood tests, or inject joints. Early information on this new model suggests that it may free up GP time to see other patients, reduce unnecessary requests for further tests or consultant opinion, improve patient satisfaction and save the NHS money. There are different ways in which FCP can be provided, but we know little about what works in which circumstances. For example, in some practices physiotherapists can only assess and provide limited treatment and advice, whereas in others they can prescribe drugs, inject joints and order other investigations. These factors are likely to have a significant effect on: costs; amount of GP time saved; satisfaction; and the overall quality of the service patients are offered. We will investigate use of FCP in a variety of GP practices across the UK, to find out what works best in different situations, and why. We will conduct a UK-wide survey to establish the extent of FCP practice, and use this information to select a sample of GP practices to study in further detail. We will then review previous work on FCP to identify factors that may affect how the service works, and consult with stakeholders to ensure we fully understand the issues. We will use this information to guide how we investigate GP practices that are implementing FCP. We will focus on 16 different practices nationwide that use FCP models, and investigate how they work in practice. We will also include 8 GP practices that do not have FCP, for further comparison. We will interview healthcare staff, patients, receptionists, practice managers and commissioners to gain a better insight into what works, how and for whom. We will monitor approximately 25 patients within each GP practice to track how their pain and function changes over six months, and collect information about waiting times and satisfaction with the service they received. We will compare the type and amount of healthcare resources they use, and how quickly they are able to return to work or their usual activities. The evaluation will help us understand the benefits of the FCP model to patients and the NHS as a whole. We will work with all stakeholders throughout to ensure this information is clearly presented and distributed, and used to provide a better understanding of how FCP works/could be improved. This will assist healthcare commissioners and GP practice managers in making better decisions regarding whether and how to implement FCP in their own area.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: MUSCULOSKELETAL