Abstract
Background First contact physiotherapy practitioners (FCPPs) are embedded within general practice, providing expert assessment, diagnosis, and management plans for patients with musculoskeletal disorders (MSKDs), without the prior need for GP consultation.
Aim To determine the clinical effectiveness and costs of FCPP models compared with GP-led models of care.
Design and setting Multiple site case-study design of general practices in the UK.
Method General practice sites were recruited representing the following three models: 1) GP-led care; 2) FCPPs who could not prescribe or inject (FCPPs-standard [St]); and 3) FCPPs who could prescribe and/or inject (FCPPs-additional qualifications [AQ]). Patient participants from each site completed outcome data at baseline, 3 months, and 6 months. The primary outcome was the SF-36 Physical Component Summary (PCS) score. Healthcare usage was collected for 6 months.
Results In total, 426 adults were recruited from 46 practices across the UK. Non-inferiority analysis showed no significant difference in physical function (SF-36 PCS) across all three arms at 6 months (P = 0.667). At 3 months, a significant difference in numbers improving was seen between arms: 54.7% (n = 47) GP consultees, 72.4% (n = 71) FCPP-St, and 66.4% (n = 101) FCPP-AQ (P = 0.037). No safety issues were identified. Following initial consultation, a greater proportion of patients received medication (including opioids) in the GP-led arm (44.7%, n = 42), compared with FCPP-St (18.4%, n = 21) and FCPP-AQ (24.7%, n = 40) (P<0.001). NHS costs (initial consultation and over 6-month follow-up) were significantly higher in the GP-led model (median £105.5 per patient) versus FCPP-St (£41.0 per patient) and FCPP-AQ (£44.0 per patient) (P<0.001).
Conclusion FCPP-led models of care provide safe, clinically effective patient management, with cost-benefits and reduced opioid use in this cohort.
Introduction
General practice is experiencing unprecedented demand for appointments at a time when the number of fully qualified GPs is falling, part-time working is increasing, and average patient caseload is rising.1 The Additional Roles Reimbursement Scheme was introduced in 2019 with the intention of growing the capacity of the primary care workforce.2 First contact physiotherapy practitioners (FCPPs) were one of five professional roles initially identified for expedited implementation,2 in recognition of the growing demands musculoskeletal disorders (MSKDs) place on general practice, which account for up to 30% of consultations.3 FCPPs have an extended appointment time (normally 20 minutes) to assess, diagnose, and determine the most appropriate interventions and manage onward referral for patients without the prior need for GP consultation.4 Some FCPPs also have the capability to provide injection therapy, and following legislation change in 2013, licensed physiotherapists can independently prescribe, including, since 2015, some controlled drugs.5 By 2024, all adults in England consulting with a suspected MSKD should be offered a consultation with a FCPP within their local practice.6
Since its inception, local service evaluations indicate that FCPPs reduce the need for GP consultation, referral to secondary care services, and prescribed medications, while improving patient and staff satisfaction.7 The only large-scale evaluation of FCPP was conducted as part of an NHS England national pilot of the initiative and reported against pre-determined criteria including the following: re-consultation rates with the GP; improvements in patient symptoms at 3 months; provision of self-management and/or exercise advice for the condition; and impact on ability to work.8 Pre-determined criteria were largely successfully met, apart from limited information on presenteeism and the ability to work. While this evaluation provided important data on the potential of FCPP, there was no insight regarding longer-term clinical outcomes, use of healthcare resources, or differences in outcomes compared with traditional GP-led models of care.
The current study aimed to determine the impact of FCPP on clinical outcomes and healthcare resource use for 6 months post-consultation compared with GP-led models of care.
| Introducing first contact physiotherapy practitioners (FCPPs) into general practice provides access to expert skills in musculoskeletal disorders (MSKDs) and helps manage patient demand for appointments; MSKD consultations account for up to one-third of GP workload. This study found that FCPPs provide a safe, clinically effective, and cost-beneficial alternative to GP-led consultations. FCPPs also positively impact on medication use (including opioids) and patients improve quicker than those who have not initially consulted with GPs. Embedding FCPP as a standard model in general practice will provide benefits for patients and savings for the healthcare system while reducing the number of patients consulting GPs with MSKDs. |
Method
Setting and practice recruitment
General practices across the UK were invited to participate either via expressions of interest in response to a previous survey regarding FCPP provision,9 or through advertisement via Clinical Research Networks. The aim was to recruit across all four nations, from a range of urban and rural areas, and differing levels of deprivation; deprivation index was based on practice report and confirmed by nationally available data.10–13
Description of services
General practice study sites were categorised into the following three study arms, according to their existing service provision:
no FCPP service: MSKD management with GP-led consultation (‘GP’);
standard FCPP with no additional competencies for prescribing and/or injecting (‘FCPP-St’); and
FCPP with additional qualifications to prescribe and/or inject (‘FCPP-AQ’).
Participant recruitment
Patients who attended appointments for MSKDs in the study sites were given recruitment materials by the clinician or an allocated practice staff member. They were invited to contact the study team for further information, or to express their willingness to participate. Volunteers were screened for eligibility.
The inclusion criteria were as follows: 1) patients consulting with a suspected MSKD episode, defined as any acute or chronic disorder related to the spinal or peripheral musculoskeletal (MSK) system; 2) patients not consulted for the same problem in preceding 3 months; and 3) patients aged ≥18 years. The exclusion criteria were as follows: 1) receiving palliative care; and 2) non-English speaking and unwilling to provide informed consent and communicate through an interpreter.
Eligible participants provided written, informed consent. Recruitment started in December 2019, slowed in January 2020, owing to the emerging COVID-19 pandemic, and paused in March 2020. Recruitment re-started under COVID-19 restrictions in July 2020 and ended in April 2022. Final assessments were completed in October 2022.
Data collection
Information on age, gender, reason for consultation, MSK risk (using STarT MSK), education, and employment were collected by telephone at baseline (post-consultation). Participants were also asked about their consultation experience and any safety concerns (to be reported elsewhere). There were no notable differences across groups.
Questionnaires regarding Patient Reported Outcome Measures (PROMs) were posted to participants following initial consultation (baseline) and at 3 months and 6 months post-consultation. The questionnaires were self-completed and returned by post. The primary outcome measure was the change from baseline to 6 months in the SF-36 Physical Component Summary (PCS) score.14 Secondary clinical outcomes were SF-36 Mental Component Summary score; Musculoskeletal Health Questionnaire (MSK-HQ, total and physical); perceived safety of health care, using the healthcare experience in general practice survey, short form (Patient Reported Experiences and Outcomes of Safety in Primary Care; PREOS-PC Q5), on a 10-point scale: completely unsafe (0) to completely safe (10); and Roland–Morris Disability Questionnaire (for patients with low back pain). EQ-5D-5L, a generic measure of health-related quality of life, was gathered for use in the economic evaluation.15
Sample size
The total participants required per arm was 181 across 39 sites. This was based on a non-inferiority margin of 2 units in SF-36 PCS scale,14 a minimal clinically important difference of 4 points16 and standard deviation (SD) 6.5,17 a one-sided P = 0.05 non-inferior hypothesis test, with 80% power, a design effect of 1.09 for a cluster size of 14 and an intraclass correlation coefficient (ICC) of 0.0075,18 and 20% attrition. COVID-19 impacted recruitment, so figures were revisited. Actual attrition rates were used (5%) and number of sites were increased (n = 46), which required a total sample size of n = 462 (n = 154 per arm).
Data analyses
The primary outcome was the change in SF-36 PCS score from baseline to 6 months compared between arms, using a one-way analysis of variance; in case of difference, a post-hoc unpaired t-test was performed. Further comparisons were undertaken in the context of stepwise linear regression modelling, incorporating demographic and clinical data, including baseline SF-36 PCS score. Outcomes from baseline to 3 months are also reported.
Economic analysis
The base case economic analysis adopted an NHS and social care perspective. Information on service use related to the MSK condition was gathered retrospectively by telephone interview at 3 months and 6 months, using a tailored version of the Client Service Receipt Inventory (CSRI).19 This included: NHS and private healthcare services (primary, community, accident and emergency [A&E], outpatient referrals, and inpatient stays) and social care. Unit costs20,21 were applied to service use and summed (months 1–6) at the participant level, including the cost of the index consultation (see Supplementary Information S1). Group costs were inspected and compared. Owing to the skewed nature of the total costs data, stepwise logistic regression was used to model the presence or absence of additional costs over and above the cost of the initial presentation, with service model as a dummy variable and baseline demographic and clinical factors as covariates. A societal perspective was included through consideration of self-reported days off work and inability to perform usual activities, and the private perspective through out-of-pocket expenditures.
Analyses were carried out using IBM SPSS Statistics (version 27). Database access can be requested via: http://researchdata.uwe.ac.uk/703.
Results
A total of 426 participants were recruited from 46 general practices across the UK, with a range of deprivation indices and rural or urban locations. Of the 426 participants, there were 110 (25.8%) from GP-led care, 124 (29.1%) from FCPP-St, and 192 (45.1%) from FCPP-AQ. A total of 46 GP practices were involved: 13 GP-led care practices (with 1, 2, 2, 5, 6, 6, 7, 10, 11, 14, 14, 15, and 17 participants), 15 FCPP-St practices (with 1, 3, 3, 3, 4, 4, 5, 7, 7, 9, 9, 14, 15, 17, and 23 participants), and 18 FCPP-AQ practices (with 1, 1, 4, 4, 6, 8, 8, 9, 11, 12, 14, 15, 15, 16, 16, 16, 17, and 19 participants). The study completion rates in each arm for PROMs and CSRIs, along with attrition patterns, can be seen in Supplementary Table S1.
Mean age was 63 years (SD 13.2); 34.1% (n = 145) were male and 97.8% (n = 408) reported White ethnicity. There were no statistically significant differences in individual baseline demographics between arms. There was some discrepancy in practice-level deprivation across arms, with a higher representation of low deprived practices in the FCPP-St arm (Table 1). Data were returned at all three time points by 377 (88.5%) participants, including 320 (75.1%) who provided completed PROM and CSRI data. Details of attrition from the study are given in Supplementary Table S1.
Table 1. Baseline demographics: summary statistics with comparison of the three service models
Clinical data revealed no statistically significant differences between arms at baseline, except for the EQ-5D-5L (visual analogue scale [VAS]; better state of health reported in FCPP-St model) and for MSK-HQ total (a more desirable MSK status was indicated in FCPP-St model). Participants reported a range of peripheral and spinal diagnoses (up to two pain sites); given the previously reported high incidence of low back pain in primary care,18 a 24.9% (n = 106/426) prevalence was noted (Table 2).
Table 2. Baseline clinical summary for each of the three service models
Outcomes analysis
The primary outcome variable was the change in SF-36 PCS score from baseline to 6 months; in an unadjusted analysis, no statistically significant difference was found between arms (Table 3). This was confirmed under linear regression, with a final model (R2 = 0.138, n = 332) predicting change = 15.074–0.333x (SF-36 PCS score at baseline) + 2.377 (if university educated) + 2.402 (if in full-time employment). Service model along with age at baseline, gender (male: yes/no), ethnic origin (White: yes/no), whether MSKD area at baseline included back (yes/no), whether MSKD area at baseline included knee or leg or hip or foot or ankle (yes/ no), and whether the presented MSK condition had affected employment or ability to perform usual activities (yes/ no) were not significant (see Supplementary Table S2).
Table 3. Primary and secondary outcome changes from baseline to 3 months and from baseline to 6 months (positive changes indicate improvement)
However, when each of these change outcomes was simplified from the change in continuous score to an improved or worsened/stayed the same scenario, a statistically significant difference between arms was seen in two instances. At 3 months, the FCPP-St and FCPP-AQ service models delivered a statistically significant greater improvement rate for the primary outcome variable SF-36 PCS score compared with the GP-led service model (P = 0.037). At 6 months, the FCPP-St and FCPP-AQ service models delivered a statistically significant greater improvement rate for the secondary outcome MSK-HQ physical compared with the GP-led service model (P = 0.016; Table 3). No other statistically significant differences in outcomes were found between arms. No safety issues were identified.
Healthcare utilisation and costs
The initial consultation was assumed to be face-to-face with a GP, FCPP-St, or FCPP-AQ. CSRI data were available for 370/426 (86.9%) of participants at 3 months, 348 (81.7%) at 6 months (see Supplementary Table S1). Health service use after the initial consultation was low in all arms, most being within general practice; few participants reported hospital use. Key health service usage (GP and physiotherapist) and prescribing outcomes are shown in Table 4. In the 3 months following initial consultation, a greater proportion of patients received medication (including opioids) in the GP-led arm (44.7%; n = 42) compared with FCPP-St (18.4%; n = 21) and FCPP-AQ (24.7%; n = 40) (χ2 P<0.001). A full breakdown of NHS service use, including medication prescribing, at 3 months and 6 months, is shown in Supplementary Tables S3 and S4. There was scattered use of the private sector while use of over-the-counter medications was commonplace (see Supplementary Tables S5 and S6).
Table 4. Key self-reported NHS service usages associated with the presenting musculoskeletal condition, not including initial presentation, at 3 months and 6 months
Group mean total costs (health services, excluding medications) over 6-month follow-up for the three service models are shown in Table 5. Comparisons were performed both excluding and including inpatient (planned MSK surgery) events, and assuming the FCPP-St and FCPP-AQ were both working at salary level band 7; a sensitivity analysis was performed with the FCPP-AQ costed at the higher band 8a. In each comparison, there is a statistically significant difference in costs between the three models (P<0.001) with the GP model the more costly (median £105.5 per patient versus £41.0 for FCPP-St and £44.0 for FCPP-AQ in the band 7 calculation), and no statistically significant difference between the FCPP-St and FCPP-AQ. In the band 8a comparison, the FCPP-AQ was significantly more costly than the FCPP-St. Regarding days lost through inability to work or perform usual activities, the FCPP-St model showed greater reductions in days lost compared with GP-led care and FCPP-AQ, but there was no statistically significant difference between GP-led care and FCPP-AQ (Table 6). Only eight participants had absences covered by sick notes in the first 3 months and three during the second period (two of which were new).
Table 5. Total costs (£) summary statistics, months 0–6
Table 6. Changes in days lost (unable to work or perform usual activities), with comparisons of the three service models
Backwards stepwise logistic regression to model the presence or absence of additional health service costs in months 0–6 over and above the initial presentation (excluding inpatient), with re-running of the final model to include additional participants for whom data were missing only for non-significant predictors, led to the model in Supplementary Table S2 (with Nagelkerke R2 = 0.072, n = 334). The model demonstrates a significantly (2.181 times) higher likelihood of incurring additional costs after the initial consultation with a GP-led service model compared with a FCPP-St or FCPP-AQ service model. Higher scores in baseline SF-36 PCS score are also significantly associated with a lower likelihood of incurring additional cost (adjusted odds ratio of 0.966 implies that a participant with a baseline SF-36 PCS score, which is 10 points higher than another participant, is 0.96610 = 0.708 times less likely to incur additional cost). No other predictors were statistically significant.
The analysis demonstrated that neither FCPP model was inferior in relation to clinical outcome at 6-month post-consultation compared with the GP-led model, but both were significantly less costly; P<0.001. There were no significant differences in quality-of-life changes (based on EQ-5D-5L) between the models at 3 months or 6 months, so given the cost differentials, no formal cost-effectiveness analysis was undertaken (Tables 3 and 5).
Discussion
Summary
Analysis demonstrated no statistically significant difference in clinical outcomes between different service models after 6 months. However, the GP-led model of care was approximately 2.5 times costlier than the FCPP-St and FCPP-AQ models. Furthermore, at 3 months, a greater proportion of patients who consulted with FCPPs had improved, compared with those who had consulted with GPs, and time off work or unable to perform usual activities was reduced in the FCPP-St consultees.
Strengths and limitations
To the authors’ knowledge, this is the first study that has compared GP-and FCPP-led models of care for MSKDs and included data from all four UK nations. It provides a robust overview of the service innovation to support decision making, and a qualitative analysis, which was conducted concurrently, will allow further interpretation of findings.
Recruitment was severely hampered by the COVID-19 pandemic, yet this study still provides the most extensive dataset of FCPPs to date. There was uneven recruitment across study arms and sites because the drive for FCPP recruitment, resulting from the Additional Roles Reimbursement Scheme, made the identification of GP-led sites challenging; and recruitment within some individual sites was lower than anticipated. At site level, there was some variation in deprivation across arms: the FCPP-St consisted of relatively more practices with lower levels of deprivation compared with the other arms, which may explain the higher levels of quality of life (EQ-5D-5L [VAS] and MSK-HQ) reported at baseline within this arm. However, while these differences were of statistical significance, neither was of clinical significance, based on previously reported levels of minimum clinical important difference23,24 and, importantly, there was no difference in the primary outcome measure at baseline across arms. All sites that expressed an interest in participation were recruited, so this variation did not result from selective recruitment. Furthermore, at the level of individual participants, no significant differences were found between groups regarding levels of education or employment.
The sample was almost exclusively White and not representative of practice cohorts despite efforts for diverse recruitment at practice and patient level. Only 12/46 (26.1%) sites returned requested data regarding numbers invited to participate in the study, so how representative the study sample is of those eligible is unable to be reported. Much of the recruitment was undertaken under COVID-19 restrictions, which disproportionately impacted people of ethnic minority heritage, which may have influenced decision to participate, although in consultation with recruitment sites, it was identified that fewer people from ethnic minority communities consult FCPP staff. There was potential recruitment bias as not all eligible participants consented to join the study.
Comparison with existing literature
To the authors’ knowledge, this is the first study to show a comparison between GP and FCPP clinical outcomes and resource use, confirming the proposed benefits of the new model of care. While at 6 months there were no differences in patient improvement across the models studied, at 3 months a significantly greater proportion of patients who consulted with FCPPs had improved compared with GP consultees, with positive impact on ability to work or perform usual activities in FCPP-St (P = 0.005). Previous work highlighted GP propensity for pharmacological management rather than guideline-based self-management and rehabilitation strategies, which may account for these differences;25–27 indeed, a greater proportion of patients under GP-led care were prescribed medication, including opioid derivatives. The authors are unable to identify any factors in the study design that would account for this finding and believe this is a result of clinical decision making. Other work has shown that FCPPs with a licence to prescribe are still reluctant to use this intervention, instead choosing to use their capability to deprescribe where possible and intervene with non-pharmacological measures.28
From an onward resource use perspective, data showed minimal reliance on other services within each model and therefore relatively low costs. For services that were used, there was a greater number of referrals onto outpatient physiotherapy by GPs, as would be expected; other work has suggested GP overuse of magnetic resonance imaging (MRI), but this was not found.29 These data were obtained through self-report so may have been subject to recall bias. It is noted, however, that other studies report the similarities in self-report versus medical record review, and in some cases note greater accuracy with patient recall.30
A previous evaluation in England reported that GP workload was positively impacted by FCPPs. It found most patients did not consult their GP with the same problem within 3 months of seeing the FCPP.8 This concurs with the present study’s findings that only 23/276 (8.3%) of patients consulted the GP for the same problem having seen the FCPP, whereas many more (30.9%) initial GP consultees re-consulted the GP for the same problem within the study period (Table 4).
A predominant aim of introducing FCPPs is to make better use of resources in general practice. The present study shows clear cost benefits to implementing FCPP models compared with GP-led care given the extent of MSKD consultations in primary care.3
Implications for research and practice
This research supports continued implementation of FCPP in general practice as a safe, clinically effective, and cost-beneficial approach to managing people with MSKDs. Given FCPPs’ low reliance on prescription medications, it may also assist in reducing opioid prescriptions in primary care. Further research is required to understand why there appears to be disproportionate consultations from people of ethnic minority heritage to ensure appropriate access for all.
