PHYSIO DIRECT JILL GAMLIN - CONSULTANT PHYSIOTHERAPIST JILL GAMLIN - CONSULTANT PHYSIOTHERAPIST KATHY DUFFIELD - SENIOR I PHYSIOTHERAPIST KATHY DUFFIELD - SENIOR I PHYSIOTHERAPIST

Catalysts for change………..

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

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

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

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

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

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

Project development Reflective learning to capture problems and solutions and to carry learning forward 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 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 Seeking advice from wherever is necessary to resolve the next problem

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

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

How it works If unable to make a sound clinical decision or problems with patient comprehension – appointment to be seen by PT 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 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 Same day information to GP re consultation, advice sent to patient with clear instructions to call PT Direct back if not resolving

How it works Training by Pharmacy to PT to ensure safe advice re OTC medication 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 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 Agreement for PT to request sick certificate for 2 weeks without GP appointment

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

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

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

Audit 100 patients selected randomly, 63 returned 100 patients selected randomly, 63 returned Of the 63, 36 received advice + exercise sheets only, 27 advice + at least 1 appointment Of the 63, 36 received advice + exercise sheets only, 27 advice + at least 1 appointment Figures given are for both groups added together 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 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 Positive comments made by both groups regarding access, time saved and quality of the service

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 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 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

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

Future use of the service 56 would use the service again, 4 would not 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 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 1 letter of complaint related to the title of the exercise sheet, resolved with one appointment

GP audit results Overall happy, one surgery felt consultations were quicker, patients dont come back to chase PT appointment Overall happy, one surgery felt consultations were quicker, patients dont come back to chase PT appointment Helps patients to be proactive Helps patients to be proactive Improved communications PT and GP Improved communications PT and GP Improved access for Orthopaedic opinion Improved access for Orthopaedic opinion Allows patients to decide whether they will pursue PT Allows patients to decide whether they will pursue PT Helps prevent chronicity Helps prevent chronicity

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

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. 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.

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

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

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. 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.