Advanced Practitioner Physiotherapists (APP) in Primary Care – A new Era

Cathy Wynne

Robert Caine


Betsi Cadwaladr University Health Board


Project Scope

This service simplifies the Musculoskelatal (MSK) referral pathway by making Advanced Practitioner Physiotherapists (APP) the 1st point of Contact for MSK conditions in Primary Care.


The purpose of this initiative is to allow patients presenting with MSK complaints to be seen in their local GP surgery by an APP, thereby reducing the demand on the GP, relieving pressure on primary care services and releasing vital GP capacity allowing them to deal with more complex medical cases, to “do what only they can do”.


Analysis and Approach

We have identified the need for new models of care to provide a sustainable primary care workforce for the future needs of the population.


The impetus for the service change is to determine whether the APP can effectively manage this cohort of patients thereby releasing vital GP capacity.


The APP model is endorsed by the Chartered Society of Physiotherapy (CSP) to enable physiotherapists to become the first point of contact for MSK patients in primary care.


At the time of writing there was no published research to date regarding this APP model of care.


Interventions

Permanent funding has been sourced for 13.5 WTE APPs in primary care across Betsi Cadwaladr University Health Board (BCUHB), ensuring consistency across the patch and making this service accessible to patients across North Wales.


Future plans:

  • To increase the percentage of first point of contacts for MSK conditions in primary care.

  • To establish changes in referral rates from primary care to secondary care for MSK services.

  • To secure further funding to ensure each GP cluster has access to the MSK APP service.

  • To ensure successful recruitment of B5 physiotherapists to enable backfilling and release of staff.

  • Further upskill staff in the extended scope skills required for this position.

  • To continue to promote / present this new service at all available opportunities.

  • To attract external staff with the right skill set into these new primary care positions as they become available.

  • To ensure high levels of patient satisfaction by distributing patient satisfaction questionnaires.

  • Continually re-evaluate and develop robust governance framework.

  • Continued full evaluation of the service.


Outcomes

Activity: APPs saw a total of 6120 patients in primary care (January 2015 – October 2016).

First point of Contact: APPs saw 524 patients as the first point of contact (9%).

Secondary Care referrals: Aim is to show a reduction in secondary MSK care referrals - this data is not available at present.

Upskilling the workforce: This service has increased the number of physiotherapists with extended scope skills (see table above).

Cost Savings: By seeing an APP / ESP Physiotherapist as an alternative to the GP, the following cost savings have been achieved:


Patient Satisfaction Questionnaire Results (June 2016)

83 returned questionnaires highlighting the following themes:

  • Patient acceptance of this new model of care and happy to see an APP as 1st point of contact.

  • This new innovative service was viewed as excellent by the majority of patients.

  • APPs were able to manage this cohort of patients in primary care.

  • The need for this service to operate on a more frequent basis.

  • Comments received regarding the locality of the service and ease of access.


Future areas of evaluation include:

GP feedback: To receive GP feedback from all cluster groups currently running this new model of care. Early feedback demonstrates the positive impact this service is having on the community.

Practice feedback: To receive feedback from the staff working within the GP practices.

Orthopaedic Conversion rate: Ortho conversion rate (IT issues).

Continue to promote the service.


Fit with Prudent Healthcare

Principle 1: It is essential that the APPs achieve concordance with the patient, ensuring they work together as equal partners with patient “buy in “ when formulating a treatment plan. This model of care will ensure the patient is seen sooner by an APP (rather than waiting for a CMATS/ physiotherapy appointment).


This early intervention is essential to prevent chronicity of MSK disorders. There is good evidence to show that rapid access to MSK services reduces the amount of time the person is off work, prevents an acute problem becoming chronic, thereby reducing the total intervention required to achieved the desired outcome. Early intervention is more likely to get engagement from the patient in the treatment plan.


Principle 2: APPs are in an excellent position to take on the roles and responsibilities previously considered the domain of the GP, assess and manage the 30% MSK caseload, and as such improve the patient experience whilst benefiting both primary and secondary care services. By taking on this caseload, it will enable the GPs to take on the more urgent medical cases and “do only what they can do”.


Using the APPs as gatekeepers to MSK services in secondary care will ensure only the most appropriate cases go through and in the long term result in a reduction in secondary care MSK waiting times.


Principle 3: Ensure all APPs use evidence based practice and give the patient the tools/lifelong management skills to manage their condition.


Principle 4: Ensure role out across North Wales, in the GP clusters. Currently the APP model has been rolled out in 49 GP practices across North Wales with plans to expand further. These services have been set up in the same way, collecting the same data to ensure consistency and to reduce inappropriate variation.


Part of Cohort Bevan Exemplars 2015-16