Primary Care Investment Funded Programme: Advanced Practice Physiotherapist (APP) Issue to be addressed As part of the normal core MSK service pathway patients present at their GP practice, then either receive brief advice and medication, and/or referral onwards to CMAT’s / direct to see a Physio. GPs have neither the specialist knowledge or time to provide the same level of care and advice as a Physio. Therefore this programme is being run in an effort to meet the following aims: Two Key Aim(s) of Programme Aim Rationale 1. Ease pressure on overloaded GPs by providing additional resource (APP) to see and treat patients with MSK conditions Patients would benefit by having direct access to seeing the most appropriate health professional for their MSK condition (physio). This would result in reduced referrals into specialist services and reduce demand on GPs 2. Shift care from secondary to primary (closer to the patients residence) If patients have greater and quicker access to specialist healthcare staff (APP), this should result in fewer onward referrals into specialist services. And in the longer-term help shift non-specialist MSK treatment/management from secondary to primary care services/locations – including staffing

Core MSK Service Care Pathway Physiotherapists are the key Expert Health Professionals 6b Lifestyle Services Private Physio Treatment given and/or buy medication Community Pharmacy 6c Clinic (Rheum, Pod/Orth, Pain, OT, Upper Limb, Orthopaedics) MIU / ED / OOH Self-treat and manage 4c MSK Clinic GPwSI ES Physio ES Podiatrist Consultant Yes 2 Self- referral to Physio Physio Apt Pain level very high (urgent) Options Further treatment required? 5 Treatment required? Patient has a MSK condition End of treatment episode Access Health Service 4b No Referral to CMATS (assess) 6d No Yes Yes 7 Apt available? (in reasonable time-frame) Call GP Reception Gp Apt Yes No No 1 4a 3 6a Physio Specialist treatment required? Yes No

New APP MSK Service Care Pathway AAPs are new additional key Expert Health Professionals 6b Lifestyle Services Private Physio Treatment given and/or buy medication Community Pharmacy 6c Clinic (Rheum, Pod/Orth, Pain, OT, Upper Limb, Orthopaedics) MIU / ED / OOH Self-treat and manage 4c MSK Clinic GPwSI ES Physio ES Podiatrist Consultant Yes 2 Self- referral to Physio Physio Apt Pain level very high (urgent) Options Further treatment required? 5 Treatment required? Patient has a MSK condition End of treatment episode Access Health Service 4b No Referral to CMATS (assess) 6d Yes Yes 7 No Apt available? (in reasonable time-frame) Call GP Reception GP Apt Yes No 8 No 1 4a Patient aware of APP service? No Yes 9 3 Patient ‘happy’ to see APP? Awareness of AAP Service AAP Service No 6a Physio Yes Specialist treatment required? 10 Other services needed ? Recep’t allocate Apt APP Apt Yes Yes No 11 No

Important Data to be collected to evaluate and evidence New AAP service (Physio) Table 1. Key for data collection (baseline (including ongoing), and new data once AAP running) NB: some data is harder to collect and analyse, but that shouldn’t prevent it being identified (and possible solutions developed to address this) Data collection number Baseline or New Data to collect Rationale (for collecting data) Currently collecting? Data source (and how it will / could be collected-evidenced) Importance of data 1 Baseline No. of patient calls requesting MSK only apt. To measure demand into the GP practice you’d want to know how many patients are ringing to get an appointment with an MSK (only) condition. No A system would need setting up either to take a snap shot of calls (say for a short period of time each day of the week) or devise some way of recording this somewhere, e.g. EMIS or develop something bespoke (Access DB) Extremely important data if you want to accurately measure demand (pre- and post APP), e.g. is there a huge unmet needed or are patients accessing the APP for minor MSK because ‘they can’? 2 No. Patients making self referrals Would expect self referral to decrease if patients’ aware they can get access locally at their GP CMATs Useful, but unless there are reasonably high numbers of self-referring patients not essential 3 No. of patients not able to get a GP apt. (for MSK condition) Measure of how ‘easy’ patients find it to get an appointment with their GP for a MSK related condition, e.g. how long are they having to wait, and are they then going to MIU/GPOOH/ED if they can’t get one? Like for data collection 1, a system would need setting up to collect this data Important to understand the exact demand within primary care (GP practice) and how long patients are having to wait to see their GP for a MSK condition

Table 1 continued. Key for data collection (baseline and ongoing, and new data once AAP running) NB: some data is harder to collect and analyse, but that shouldn’t prevent it being identified (and possible solutions developed to address this) Data collection number Baseline or New Data to collect Rationale (for collecting data) Currently collecting? Data source (and how it will / could be collected-evidenced) Importance of data 4a-c Baseline No. of apts booked Need to know how many patients are being booked in to see their GP or Physio (not APP) or turning up to MIU/ED/GPOOH, as the APP service should result in decreases Partly Combination of GP systems, CMAT and WPAS/manual? Very important to evidence the impact of the APP service. Good marker to know if meeting Aim 2. 5 No. of patients referred A key measure to capture how many patients are flowing into specialist services – as you would expect this number to decrease with the APP service CMATs Important to gauge effectiveness in decreasing patient numbers (have APP service intervened?) into specialist / secondary care. Good marker to know if meeting Aim 2. 6a-d No. of appointments, length of interventions and outcomes This is a measure of demand into all these services, which (again) you would expect to reduce upon delivery of the APP service (when the size of the APP service is sufficient that is) Clinical systems and paper records Again, important to see what the outcomes are, gauge waiting times and clinical outcomes. Good marker to know if meeting Aim 2. 7 Length of episode, and sample of patient experience Understanding the various care pathway steps, interventions and ‘waiting times’ between steps is crucial. Because if patient volumes reduce, as we’d expect with the APP service in place, there should be a concomitant enhanced treatment experience for those seeking specialist services for MSK conditions All the various clinical, administrative (including Primary Care systems) and paper systems used for data collection Very important - will the APP service improve the whole patient experience? Including actual (qualitative) patient feedback

Table 1 continued. Key for data collection (baseline and ongoing, and new data once AAP running) NB: some data is harder to collect and analyse, but that shouldn’t prevent it being identified (and possible solutions developed to address this) Data collection number Baseline or New Data to collect Rationale (for collecting data) Currently collecting? Data source (and how it will / could be collected-evidenced) Importance of data 8 Patient awareness of APP service Patient awareness of APP service will be non-existent at start, but will increase. This is an additional marker of measuring demand and the appropriateness of those accessing the service No Ideally by receptionist (who informs them) upon patient ringing in to make MSK appointment with GP, but at least recorded by APP at first appointment (form/system devising) Important to understand the local (growing or not) awareness of the types of health services available locally, and whether the ‘right’ people are accessing them 9 Linked to above data: proportion of patients agreeing to see APP instead of their GP Useful for gauging the skills of the GP receptionist (e.g. navigation/triage conversation training done and using) and for the confidence / acceptance of patients to use the APP service A system (electronic or paper) would need setting up to record the percentage of patients being successfully diverted to the APP service, instead of to the GP Very important as it provides very accurate numbers of patients being seen by the APP service – and thus ‘increasing capacity’ for GPs to see more complex patients. A direct measure of meeting Aim 1. 10 APP apts Measuring the number of APP apts, follow-up apts, and outcome (e.g. discharge or onward referral – and why) to evidence the impact on health outcomes and on up-stream care-pathway processes Partly Collected routinely by APPs, and health outcomes in notes (could potentially do an audit of a sample to get a feel for health outcome data) Very important to understand number of apts, and follow-ups, and resulting processes following the APP appointment 11 APP onward referrals One of the two key aims of the APP service is to help shift care from secondary to primary care – therefore it’s important to know how many onward referrals an APP might make versus the GP and also the appropriateness of the referral Currently unclear how easy it is to accurately identify APP versus GP referrals into CMATs (this needs further work) Again very important – see rationale. Helps to provide evidence of meeting Aim 2.

Additional measures Training package produced and delivered to help receptionists become navigators, e.g. expertly enquiring why the patient is ringing and making an APP appointment if MSK condition If possible a piece of work with a number of private Physio services locally – have they seen a reduction in people accessing their services? Prescription for MSK related conditions (APP vs. GP)

Further/future considerations for evaluation There are APP sessions in over 60 GP practices, which is a fantastic achievement. But it’s likely the APP service may be spread too thinly – thus diluting the potential benefits of the service (if you’re only seeing 3-4 patients every week – the GP won’t ‘feel’ any releasing of his/her time, and it will also take longer for patients to learn and understand the APP service). Therefore it would be wise to consider having an extended and sustained clinical presence at one GP practice (possibly as a hub for a number of GP practices) The importance and training delivered to the receptionists can’t be overstated – as they are the first line of contact with the patients (including having the potential to collect some key data to help evaluate the service). In fact the actual success or not of the APP service could be directly related to the engagement and willingness of the receptionists (and practice manager – of course leaving aside the GP/GP partners) There is a substantial amount of baseline and prospective data that could be analysed on the GP systems (mostly EMIS). However, we don’t have access to these systems and hence the expertise to retrieve and analyse the data. Therefore, receiving training and getting additional resource would be extremely beneficial (this would benefit many of the PCIF programmes, not just this one) The APP service is operating in a very complex health care system, which includes multiple clinical and administrative systems (that are not integrated), and complex models of health care delivery that is changing constantly, e.g. managed practices, Healthy Prestatyn, traditional GP practices. To effectively evaluate and realise the benefits additional dedicated resource is required – around programme management, service evaluation and improvement (including data collection, analysis and report writing)