Title: Musculoskeletal Outpatient Physiotherapy Delegation (MOPeD): A mixed methods study
Funder: Health Education England

Abstract: Background: There are approximately 9000 physiotherapy assistants in the UK forming 15% of the total physiotherapy workforce. Many of them work in NHS physiotherapy outpatient services treating patients with musculoskeletal conditions, the largest patient population group treated by physiotherapists. In many services they take responsibility, under professional supervision, for types of clinical work traditionally undertaken by physiotherapists such as leading exercise classes and treating individual patients. Nevertheless, their role(s) are relatively undefined and as such there is considerable variation in the duties and tasks they undertake. In some physiotherapy services they have a predominantly clinical role whereas in others they fulfil primarily an administrative role. This latter situation leads to physiotherapy assistants not being able to utilise their clinical skills, job dissatisfaction, as well as unjustified variation in care and clinical services provided to patients. Research question: The overall research question is: 'What should a 'best practice' framework of delegation incorporate and how can this be operationalised to guide utilisation of physiotherapy assistants in NHS musculoskeletal outpatient physiotherapy services?' Objectives: The specific objectives are: 1. To explore how the current use of delegation is informed by the culture within the clinical setting as well as views, attitudes about and experiences of delegation among physiotherapists, physiotherapy assistants, physiotherapy managers and patients.2. To reach consensus amongst physiotherapists, physiotherapy assistants and physiotherapy managers about what constitutes 'best practice' and what components should be included in a best practice framework of delegation in NHS musculoskeletal outpatient physiotherapy services. 3. To describe, explain and predict patients' preferences between care from physiotherapists and physiotherapy assistants. 4. To develop a best practice delegation framework which can be used and tested within NHS musculoskeletal outpatient physiotherapy services. Methods: Stage 1:A focused ethnography will be conducted in two musculoskeletal outpatient physiotherapy services where delegation is currently being used. Findings from the ethnographic study will inform the next stages.Stage 2a: A consensus study will be carried out, using Nominal Group Technique, with three separate groups of physiotherapists, physiotherapy assistants and physiotherapy managers to reach agreement about what a 'best practice' delegation framework should include. Stage 2b: A discrete choice experiment will be designed based on the data from the ethnography. It will be conducted to elicit patients' preferences about the use of delegation to physiotherapy assistants within musculoskeletal physiotherapy services. Stage 3: The results of stages 1, 2a and 2b will be triangulated to inform the development of a best practice delegation framework for future testing and use within NHS musculoskeletal outpatient physiotherapy services. Anticipated impact and dissemination: I will generate new knowledge about current delegation practice and stakeholders' views which can influence future practice Findings from this study will be disseminated in peer-reviewed journals, conference presentations, the lay press and social media The clinical and cost-effectiveness of using the best practice delegation framework will be investigated in post-doctoral research I will develop myself as a future NIHR research leader with skills and experience in qualitative research, consensus methods and attribute-based survey methods for eliciting patient preferences.

Lay abstract: Background of this research There are approximately 9,000 physiotherapy assistants in the UK. Many of them work in physiotherapy outpatient services treating patients with musculoskeletal or painful muscle and joint conditions that are more common as people age. This is the largest group of patients that NHS physiotherapy services care for. The role of physiotherapy assistants is not well defined and their duties and tasks vary from one service to another. National guidance from the Chartered Society of Physiotherapy (CSP) is not very helpful, as it leaves decision-making about the delegation of tasks to the individual physiotherapist supervising the work of the physiotherapy assistant. As a result, in some services physiotherapy assistants take responsibility, under the professional supervision of a physiotherapist, for clinical work that traditionally physiotherapists would have undertaken, such as leading patient exercise classes and treating individual patients. In other services their role is mainly administrative. We do not know what best practice is in terms of delegation of work to physiotherapy assistants. As the NHS responds to a growing and ageing patient population and higher healthcare costs, physiotherapy assistants are likely to become increasingly important members of physiotherapy teams and clarity is needed about their role. Aim The overall aim of this research is to develop a 'best practice' framework of delegation to physiotherapy assistants in NHS musculoskeletal outpatient physiotherapy services.Design and methods usedThe study will use different research designs across three stages. Stage 1: I will explore how the culture in physiotherapy services may influence how tasks are delegated to physiotherapy assistants by doing detailed observations in two NHS musculoskeletal outpatient physiotherapy services. I will also conduct interviews with physiotherapists, physiotherapy assistants, managers and patients to find out about their experiences of and attitudes about delegation. The findings will inform the design of the next stages of the study. Stage 2a:I will work with three separate groups of physiotherapists, physiotherapy assistants and physiotherapy service managers. I will use a discussion method called Nominal Group Technique to reach agreement about what a 'best practice' delegation framework should include. Stage 2b: I will also use findings from the patient interviews in stage one to design a survey to better understand patients' preferences for receiving physiotherapy treatment from physiotherapy assistants. Specifically, I will use a technique called Discrete Choice Experiment to describe, explain and predict patients' preferences between care from physiotherapists and physiotherapy assistants. Stage 3: I will bring together all findings to develop a 'best practice' framework to guide physiotherapists in delegating clinical work to physiotherapy assistants. Patient and public involvement I have worked with a group of seven patients to develop this study. They all have experience of treatment from a physiotherapist and/or physiotherapy assistant for musculoskeletal conditions. This group will continue to have an active role in contributing to all stages of the research, including giving input into: The design of materials to inform participants and the public about the study The design of the patient interviews and survey The interpretation of the results The design of the best practice model of delegation Producing the materials for sharing the results publicly and deciding where to share the resultsSharing the results The findings will be shared with the appropriate professional groups and networks within the CSP. A summary of the results will be disseminated widely on social media. I will prepare a webinar for physiotherapists and physiotherapy assistants and share it via the CSP website. I intend to present findings at local, national and/or international physiotherapy and healthcare conferences. I will submit publications in selected magazines/newspapers and articles in professional and academic journals.

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