PHYSIO DIRECT

1. PHYSIO DIRECT • JILL GAMLIN - CONSULTANT PHYSIOTHERAPIST • KATHY DUFFIELD - SENIOR I PHYSIOTHERAPIST

2. Catalysts for change……….. Personal Dissatisfaction Patient Dissatisfaction Time to Think Right Time....Right Place

3. Patient dissatisfaction • Delayed referral, patients’ problems become more chronic, more difficult to resolve, poorer outcome of treatment • Research evidence - early intervention, aids patient recovery • Current patient pathway through the system had bottlenecks and wasted patients’ time • Frustration for all those involved

4. Previous Patient Pathway Patient Hospital Consultant GP Discharge NSAID and or Analgesia Not Resolved Physiotherapy 2/52-6/52 to triage Not Resolved Physiotherapy extended scope practitioner Consultant Physiotherapist

5. Time to think • Stuck in a traffic jam, chance comment Radio 4 - GPs used as inappropriate gate keepers for the NHS • Why not let patients access physiotherapy directly if they think we can help them? • Requires a new approach to assessment and management. • NHS Direct why not Physio Direct?

6. Right environment • Line manager excited and receptive to new ideas • Dissatisfaction with the present, willingness to change • PCT management ready to facilitate and support the change process financially and with key personnel

7. Key Objectives • Improve access and capacity for physiotherapy to ensure early identification and management of problems • Empowerment of individuals to take control thus reducing chronic pain • Pathway redesign reducing GP time dealing with M/S problems, ensuring appropriate referral to secondary care

8. Process of project development • Early involvement of key players - PT team, head of primary care, IT, GPs, practice managers, patients, pharmacy, PEC • Clear vision - good communication, focus on improving patient-centred care • Open approach to problem solving, can do philosophy, negotiation • Attention to risk management, clinical governance

9. Project development • Reflective learning to capture problems and solutions and to carry learning forward • Strong leadership to find solutions rather than allowing derailment. Conviction, determination, confidence that the direction is right • Seeking advice from wherever is necessary to resolve the next problem

10. Project details • 2 GP practices involved representing 23,000 patients • 1 practice enthusiastic and innovative, the other had longstanding problems with access • Initially a 6 month project which started Nov 01 with £15,000 funding for 1 WTE senior I PT

11. How it works • Dedicated phone line open 8.30am-12.30pm Mondays to Fridays excluding BH • Computerised screening tool – patient details, different screens for problems such as LBP, neck, thoracic spine, peripheral joints • Decision made re diagnosis, advice sheets sent by post that day

12. How it works • If unable to make a sound clinical decision or problems with patient comprehension – appointment to be seen by PT • Inappropriate for PT – d/w Consultant PT re further investigations/management including ref onto other Consultants, suspected fracture – ref A&E • Same day information to GP re consultation, advice sent to patient with clear instructions to call PT Direct back if not resolving

13. How it works • Training by Pharmacy to PT to ensure safe advice re OTC medication • Prescription – faxed request to GP for prescription for patient to collect if in agreement • Agreement for PT to request sick certificate for 2 weeks without GP appointment

14. Referral Pathways Patient Physio Direct GP Orthopaedic Consultant Rheumatology Consultant Extended Scope Practitioner Consultant Physiotherapist

15. Key aspects - ‘outside the box’ • Different ethos - locus of control passes to patient • First contact by phone, computerised screening tool. Advice sent by post same day • Local agreement sick certificates and prescriptions • Consultant Physiotherapist led service from primary to secondary care

16. Outcome of new service • 70% of callers managed with telephone advice only • Easier access • DNA rate for appointments reduced 15% - < 1% • Reduced GP appointments for M/S patients • Faster access to secondary care consultants when required.

17. Audit • 100 patients selected randomly, 63 returned • Of the 63, 36 received advice + exercise sheets only, 27 advice + at least 1 appointment • Figures given are for both groups added together • 31 rated service as excellent, 20 good, 9 average, 1 below average, 1 poor, 1 no comment • Positive comments made by both groups regarding access, time saved and quality of the service

18. Patient comments • “The prompt and direct service received can be followed with confidence in the knowledge it comes from those best qualified to give it . This much needed and valued service should continue” • Some more negative comments, difficulty understanding exercises from the sheet, opening times not convenient, time taken to go through questions, already doing exercises so no help

19. Outcome • 15 resolved completely • 33 improved but not resolved • 7 not helped • 14 of the not resolved group contacted PT direct again • Some still receiving treatment • 6 went back to the GP

20. Future use of the service • 56 would use the service again, 4 would not • 57 would recommend the service to others, 4 might, 2 would not – these were in the advice only group • 1 letter of complaint related to the title of the exercise sheet, resolved with one appointment

21. GP audit results • Overall happy, one surgery felt consultations were quicker, patients don’t come back to chase PT appointment • Helps patients to be proactive • Improved communications PT and GP • Improved access for Orthopaedic opinion • Allows patients to decide whether they will pursue PT • Helps prevent chronicity

22. PT audit results • All 5 PTs commented on the speed of access, more patient control, patients don’t have to pay for the car park or leave work • Problems – communication with GPs, patients returning to GP rather than staying with the service • Access to consultant PT • Stressful coping with the additional work – as not now able to ref back to GP

23. PT audit results • “ The whole experience of PT direct has improved my assessment skills, it has however been harder work due to the higher levels of complex patients. I have also needed more time for communication with GPs.”

24. Future developments • Roll out to St Neots Nov 03, St Ives ? Jan 04, other GP surgeries ? March 04 • Extension of opening of telephone line ?8.00am – early evening, ? Saturdays • Advertising and promotion, education of users and GPs • Research funded by professional body • Interest from the StHA roll out to rest of region • Part of DOH project group - role of AHPs in moving work from secondary to primary care

25. Future Development of Physio Direct Patient Pathway (end of 2003/early 2004) Patient Discharge GP Physio Direct PCT Orthopaedic Panel Physiotherapy Extended Scope Practitioner Hospital Consultant Consultant Physiotherapist

26. The last word from the patient…….. • “ This service encouraged me to seek advice, which otherwise I would not have done. I intend to seek advice again on another problem: this I would not do if I had to visit the doctor. To the likes of me this service is invaluable.”