Global View of Direct Access and Patient Self Referral to Physical Therapy

A Global View of Direct Access andPatient Self-Referral toPhysical Therapy:Implications for the ProfessionTracy J. Bury, Emma K. Stokes

Background. International policy advocates for direct access, but the extent towhich it exists worldwide was unknown.

Objective. The purpose of this study was to map the presence of direct access tophysical therapy services in the member organizations of the World Confederationfor Physical Therapy (WCPT) in the context of physical therapist practice and healthsystems.

Design. A 2-stage, mixed-method, descriptive study was conducted.

Methods. A purposive sample of member organizations of WCPT in Europe wasused to refine the survey instrument, followed by an online survey sent to all WCPTmember organizations. Data were analyzed using descriptive statistics, and contentanalysis was used to analyze open-ended responses to identify themes.

Results. A response rate of 68% (72/106) was achieved. Direct access to physicaltherapy was reported by 58% of the respondents, with greater prevalence in privatesettings. Organizations reported that professional (entry-level) education equippedphysical therapists for direct access in 69% of the countries. National physical therapyassociations (89%) and the public (84%) were thought to be in support of directaccess, with less support perceived from policy makers (35%) and physicians (16%).Physical therapists ability to assess, diagnose, and refer patients on to specialists wasmore prevalent in the presence of direct access.

Limitations. The findings may not be representative of the Asia Western Pacific(AWP) region, where there was a lower response rate.

Conclusions. Professional legislation, the medical profession, politicians, andpolicy makers are perceived to act as both barriers to and facilitators of direct access.Evidence for clinical effectiveness and cost-effectiveness and examples of goodpractice are seen as vital resources that could be shared internationally, and profes-sional leadership has an important role to play in facilitating change and advocacy.

T.J. Bury, MSc, GradDipPhys,World Confederation for PhysicalTherapy, Victoria Charity Centre,11 Belgrave Rd, London, SW1V1RB, United Kingdom, andDepartment of Physiotherapy,Trinity College, Dublin, Ireland.Address all correspondence to MsBury at: [email protected].

E.K. Stokes, PhD, MSc, Depart-ment of Physiotherapy, TrinityCollege, and World Confederationfor Physical Therapy.

[Bury TJ, Stokes EK. A global viewof direct access and patient self-referral to physical therapy: impli-cations for the profession. PhysTher. 2013;93:449459.]

2013 American Physical TherapyAssociation

Published Ahead of Print:November 29, 2012

Accepted: November 16, 2012Submitted: February 14, 2012

Research Report

Post a Rapid Response tothis article at:ptjournal.apta.org

April 2013 Volume 93 Number 4 Physical Therapy f 449

Attaining professional auton-omy is a high priority forphysical therapists and theirprofessional organizations.1 Sincethe mid-1990s, the position of theWorld Confederation for PhysicalTherapy (WCPT) on autonomy isthat physical therapists are able toact as first contact practitioners,and patients/clients may seek ser-vices directly without referral fromanother health care professional.2(p1)

Direct access and patient self-referralto physical therapists are manifesta-tions of professional autonomy. Ifanother profession is seen to domi-nate or control access to physicaltherapy services, it limits or weakensprofessional autonomy.1 The extentto which physical therapists haveautonomy varies within and betweenhealth systems internationally.

Of the 2 terms, direct access andpatient self-referral, the former ismore recognizable across the profes-sion globally and among other healthprofessionals, politicians, and gov-ernment officials. It is usually theterm used to refer to patients seekingthe services of a physical therapistwithout referral from a third party(usually a physician). However, insome instances, it may be used todescribe the situation where physi-cal therapists have direct access toassess and treat patients without amedical referral, for example, in anintensive care unit where physicaltherapists determine which patientscan benefit from physical therapy.This situation is distinct from patientself-referral, which implies thatpatients are able to refer themselvesto a physical therapist without hav-ing to see anyone else first, or with-out being told to refer themselves by

another health professional (this sit-uation can relate to telephone andface-to-face services, as well as thosedelivered via the Internet).3 In theliterature, the articles on directaccess refer to this latter scenarioof self-referral,417 and the term self-referral is gaining prominence.3,1826

Published literature on direct accessand self-referral has to date primarilybeen limited to articles from theUnited States, United Kingdom, Aus-tralia, and the Netherlands, with agrowing body of evidence and policysupport to support its implementa-tion and its clinical effectiveness andcost-effectiveness.1113,15,16,2024,2631

In 2009, an international policy sum-mit on advanced scope of practiceand direct access in physical ther-apy, co-hosted by WCPT, the Amer-ican Physical Therapy Association(APTA), and the Canadian Physio-therapy Association, reviewed theevidence for direct access and self-referral, along with strategies forinfluencing national health policyand implementing change.32 Theinternational policy summit identi-fied the need to understand moreabout the global implementation ofdirect access in order to informfuture health strategies and assistWCPT member organizations (MOs)in influencing national legislation. InJune 2011, the General Meeting ofWCPT agreed upon a new policystatement on direct access andpatient self-referral to physical ther-apy.33 Further policies and guide-lines from WCPT on education andprofessional regulation serve to sup-port this policy statement.3437

The aim of this study was to com-plete an international survey ofWCPTs MOs in order to develop aglobal picture of direct access tophysical therapy. Given the desire ofWCPT to assist with policy develop-ment and implementation nationally,it also was considered important tounderstand the potential barriers

and facilitators of direct access and,where relevant, to learn from theexperiences of those countrieswhere direct access was available.Due to the policy focus, the studywas placed in the context of profes-sional practice and national legisla-tion, health systems, financial mod-els, and educational requirements.

MethodParticipantsThe WCPT is a confederation ofMOs. It has 106 members, represent-ing more than 350,000 physical ther-apists worldwide. A country mayonly have one organization belong-ing to WCPT; therefore, 106 coun-tries were represented in the partic-ipant sample. The survey was opento all MOs, including new membersup for approval at the General Meet-ing in June 2011 (8 of the 106 mem-bers). Each MO has a primary con-tact registered with WCPT, who wascontacted with the survey detailsand invited to participate. Only oneresponse was permitted per organi-zation, and the named contacts wereadvised to collect any necessaryinformation and consult with othersprior to completing the survey inorder to provide a national perspec-tive on behalf of their organiza-tion. The WCPT also has a regionalstructure of 5 regions throughwhich the survey was promoted(for a list of MOs by region, visithttp://wcpt.org/regions).

Study Design and ProtocolThe study was a nonexperimentaldescriptive study utilizing both quan-titative and qualitative methods.We developed a pilot survey toolusing SurveyMonkey (Palo Alto, Cal-ifornia, available at http://www.SurveyMonkey.com). The questionswere informed by the findings ofprevious studies, discussions at theinternational policy summit, andinquiries to WCPT. English is theworking language of WCPT and in allcommunications with its members,

Available WithThis Article atptjournal.apta.org

eAppendix: Survey Instrument

A Global View of Direct Access and Patient Self-Referral to Physical Therapy

450 f Physical Therapy Volume 93 Number 4 April 2013

so the survey was produced in Eng-lish only.

A meeting of the European Region(EU) of WCPT was taking place inMay 2010 with a workshop on directaccess, providing the opportunity toexplore interpretation of the surveyquestions with a multicultural andmultilingual group (n27/40 pres-ent). The survey was presentedquestion-by-question to exploreunderstanding of the questions, iden-tify and resolve any ambiguities, clar-ify terminology, and refine content.After a full group discussion, 3smaller focus groups with indepen-dent facilitators discussed the ques-tion set in detail and providedguidance on refining the surveyinstrument.

A second iteration of the survey wassent to an international referencegroup of 11 individuals knowledge-able in the subject to provide feed-back, 2 of whom also had been at theEuropean workshop and, therefore,were privy to the discussions. Basedon this feedback and responses fromthe workshop, content validity wasestablished and the survey instru-ment was finalized (eAppendix,available at ptjournal.apta.org).

The WCPT does not have an ethicalreview committee, but the WCPTExecutive Committee gave itsapproval of the study, recognizingthat the study was developed in linewith the Declaration of Helsinki andother international guidelines.3840

The purpose of the survey and howthe data were to be used were setout in the survey invitation. Partici-pants were assured of the confiden-tiality of contact information, andrespondents were followed up toensure consent for the release ofdata and given the opportunity todecline consent on the whole sub-mission or specific questions ifcountries were to be identified inany reporting. Every effort was

made to ensure anonymity of therespondents.

Participants were invited to com-plete the survey in July 2010, and thesurvey was kept open for 12 monthsto allow for follow-up with nonre-sponders. Several reminders weresent via e-mail during this period.Survey data were exported intoExcel (Microsoft Corporation, Red-mond, Washington), which was usedfor analysis.

Data AnalysisDescriptive statistics, including fre-quencies, percentages, and chi-square analysis, were used to sum-marize quantitative data. Post hoccross-tabulations were completedusing chi-square tests to examine therelationship between legislation anddirect access and the relationshipbetween direct access and scope ofpractice; the significance level wasset at .05.

Qualitative data were categorizedand analyzed using content analysis.Both authors independently reviewedthe responses to open-ended ques-tions, coding them to develop cate-gories, and they then reviewedassessments together. Where catego-ries differed, the authors reachedagreement on labels through discus-sion and consensus. They thenreviewed the allocation of responsesagainst the categories to review anydifferences and reach consensus.

A subset of the data relating to theMOs of WCPT in the EU has beenanalyzed in the context of workforcemigration issues in the EU, whichsupports the free mobility of profes-sionals across national boundaries, asit is required of all member states ofthe EU.41

ResultsSeventy-two of the 106 MOs com-pleted the survey, a response rate of68%. The size of organizations

belonging to WCPT is wide ranging,and Table 1 gives details of partici-pants and respondents, includingresponse rates by region (range38%85%). The WCPT has had mem-bers since 1951, so some are long-standing and well established,whereas others are relatively newand still developing; the sampleincluded 8 new MOs approved in2011.

Forty MOs (40/69, 58%) reportedthat direct access and self-referralwere permitted in their countries,either occurring where it was per-mitted, by legislation, or by profes-sional practice in the absence ofnational legislation. There were vari-ations on a regional basis, as shownin Figure 1. Of the 57 MOs (n57/71) who reported that nationallegislation existed, 57% (n30/57)reported that direct access was per-mitted. Of 14 MOs who reported anabsence of legislation, 71% (n10/14) reported that there was directaccess (P.2). In 2 countries withstate or provincial legislation, avail-ability was determined on a state-by-state basis.

Of those acknowledging the permis-sion for direct access, 19 (19/40,48%) indicated that direct access wasavailable in both public and privatehealth settings, with 17 (17/40, 43%)indicating that it was present only inprivate health settings. In addition,15 MOs reported that direct accessdid occur in the private setting, eventhough it did not appear to be sup-ported by legislation or professionalpractice. Free-text explanations forthis disparity suggested it occurredand patients and physical therapiststook the risks in the absence of leg-islation, the application of legislationto the private practice was unclear,or only preventative advice wasgiven. This global variation is shownin the Appendix. Where there wasdirect access in the private setting,respondents reported that reim-



bursement for individuals with insur-ance policies was dependent on thepolicy (30/51, 59%), and 14 indi-cated that the insurance did notcover physical therapy.

Respondents reported that privatephysical therapy services might beself-funded (67/71, 94%) or fundedthrough private or voluntary insur-ance premiums (54/71, 76%), com-pulsory insurance premiums (23/71,

32%), or a public taxfunded system(23/71, 32%), none of which weremutually exclusive. In the publichealth system, services were mostfrequently funded through publictaxation (54/71, 76%), but this fund-ing often was supplemented bypatients self-funding (19/54, 35%),private or voluntary insurance premi-ums (21/54, 39%), and compulsoryinsurance premiums (19/54, 35%).

Respondents identified some limita-tions affecting direct access where itwas available, including: conditionswere mainly limited to those of amusculoskeletal nature (n1); onlyprevention and health education,not treatment (as defined by nationallegislation), were permitted (n2);some specific interventions wererestricted (eg, manipulation, wounddebridement), and electrophysicalagents were excluded (n4); a phy-

Table 1.Participants

WCPTa

Region

Participants Respondents Nonrespondents

No. ofMember

OrganizationsSurveys

CompletedResponse

Rate

Size of MemberOrganization

(Reported MemberNumbers [Medianand Range])b

Length ofMembershipin WCPT (y)

Size of MemberOrganization

(Reported MemberNumbers [Medianand Range])b

Length ofMembershipin WCPT (y)

Africa 16 11 69% 84 (153,254) 16 (460) 66 (25650) 16 (033)c

Asia WesternPacific

26 10 38% 471 (3059,586) 22.5 (060)d 515 (8021,511) 16 (044)c

Europe 40 34 85% 1,050 (6438,375) 37 (460) 290 (42974) 14 (023)d

North AmericaCaribbean

13 10 78% 45 (2452,342) 30 (460) 30 (20124) 12 (420)

South America 11 7 64% 310 (305,215) 41 (452) 128 (401,124) 4 (016)d

Total 106 72 68% 552 (1559,586) 31 (060) 200 (2021,511) 12 (044)

a WCPTWorld Confederation for Physical Therapy.b Data from 2011 reported member numbers per member organization (not the same number as practising physical therapists per country).c 1 new member organization in 2011.d 2 new member organizations in 2011.

Figure 1.Patterns of direct access globally by region of the World Confederation for Physical Therapy (WCPT). AWPAsia Western Pacific,NACNorth America Caribbean, SASouth America.



sician referral was required in publicsettings (n2); and institution-basedpolicies and commissioning deter-mined whether direct access andself-referral services were permitted,irrespective of national legislation(n3).

Both legislation and direct accessappeared to have an influence onphysical therapists scope of prac-tice. Where there was national legis-lation governing the physical ther-apy profession, physical therapistswere more likely to be able to treat(100% versus 88%, n70, P.01)and offer preventative advice (96%versus 81%, n70, P.04), but theirfreedom to refer on to other special-ties was less (35% versus 69%, n70,P.02). Where direct access waspermitted, it was seen to have a pos-itive bearing on the scope of practiceof physical therapists in terms ofassessment, diagnosis, and referral tospecialists, as shown in Table 2.

Respondents were asked to com-ment on whether physical therapyqualifying education equipped phys-ical therapists for direct access.Sixty-nine percent of the respon-dents (n45/65) said that it didequip them compared with 31%(n20/65) who said no. Not allWCPT MOs are based in countrieswith qualifying education programs.In those countries (n20) wherefurther educational measures wererequired prior to physical therapistshaving the necessary competenciesfor direct access, 60% (12/20) indi-cated that a period of supervisedpractice or continuing professionaldevelopment was required, and 35%(7/20) indicated that a masters-levelqualification was necessary. Theseoptions were not mutually exclusive.

Seventy-two percent of the respon-dents (n46/64) felt that thenational physical therapy associationwas completely supportive of directaccess, 17% (n11/64) felt there

was limited support, 6% (n4/64)were unsure, and 5% (n3) feltthere was no support. This latterfinding was explained by 2 respon-dents as a reflection of the profes-sion not being educationallyequipped for direct access. Memberorganizations perceived there to besupport for direct access frompatients, with 84% (54/64) reportingthat they thought patients were sup-portive. This finding contrasted withMOs perception of the level of sup-port from politicians and policy mak-ers, where 35% (22/63) of respon-dents felt there was support. Only16% (10/63) of the respondents feltthere was support from the medicalprofession, with 59% (37/63) report-ing that they felt the medical profes-sion did not support direct access.

Respondents were asked to ratepotential barriers to and facilitatorsof direct access and self-referral on ascale of 1 to 5, where 1 was a minorbarrier and 5 was a major barrier,and 64 responded. Recognizing thatitems may work as both barriers andfacilitators, there was some overlapin the topics across the questions.Fifty-nine respondents (n59/64,92%) identified medical support as abarrier, with 54% rating it as a strongfactor (rated 45); it also wasreported to be a facilitator by 45

respondents (70%), with 67% ratingit strongly (rated 45). Factors wereperceived to have the potential to beboth barriers and facilitators, asshown in Figure 2, with the strengthof effect being perceived to be stron-ger when acting as a facilitator.

Respondents were asked to identifywhat resources they felt would helpthem in taking forward direct accessand self-referral as a policy nation-ally, and 68% (49/72) responded. Anumber of themes emerged, whichare presented in Table 3. Generally,respondents identified more thanone resource or activity that theythought would be beneficial.

Ten MOs (n10/72, 14%) com-mented on their experience ofimplementing direct access and self-referral policies nationally. Advocacyactivities such as lobbying, cam-paigning, and advertising werereported by 5 respondents. Securingthe engagement from the medicalprofession and health service com-missioners was reported by 3respondents, and 2 referred toengagement with politicians asimportant. One respondent hadundertaken a focused knowledgetranslation initiative led by thenational professional organization.Four respondents thought that rais-

Table 2.Impact of Direct Access on Scope of Practice of Physical Therapistsa

Physical therapists are able to:

No. (%) of Respondents

P

Direct Access andSelf-ReferralPermitted(n40)

No DirectAccess andSelf-Referral

(n29)

Assess 40 (100) 24 (83) .01

Diagnose 35 (88) 9 (31) .000*

Treat (ie, interventions, advice, andevaluation of outcome)

40 (100) 27 (93) .09

Refer on to other specialties/services(eg, x-ray/ultrasound/specialist)

28 (70) 4 (14) .000*

Offer preventative advice 38 (95) 26 (90) .4

a Asterisk indicates significant at .0001 level.



Table 3.Resources Identified as Required by World Confederation for Physical Therapy (WCPT) Member Organizations to Help ProgressDirect Access

Theme DescriptionResponses

(n) Example Responses

Evidence Evidence demonstrating clinical effectivenessand cost-effectiveness of direct access

18 Evidence supporting effectiveness of direct access in other. . . countries

More evidence for the cost-effectiveness of self-referral

Knowledge translation/knowledge-to-actionresources

Requests for examples of models of goodpractice and service delivery exemplars

15 Best practice models from research outcomesInformation on the implementation and success of direct

access/self-referral

Education Improvements in the education of physicaltherapists at both entry level and post-qualifying level to equip them with thecompetencies required for direct accessand self-referral

11 If the entry-level education is improved toward diagnosticskills, then this will aid direct access

Workshops with other specialists

Legislation Review and changes to national legislationand regulatory requirements to permitdirect access and self-referral to physicaltherapists

11 Proper legislation and act/law on physiotherapy professionTo include the direct access in the law

Advocacy Initiatives aimed at securing political support 13 Awareness campaign and public relations with Ministry

Medical and other health professionalsupport

10 If the physicians can view it as a means of getting theassistance to the patient early and so reduce their workload. . . can see the benefit in terms of dollars and cents

Raising awareness and support among thepublic

9 Creation of more public awareness

Professional leadership From WCPT internationally and memberassociations nationally, in the form ofpolicy statements, guidance on education,and regulation and the collation ofevidence and best practice models

11 Professional organization agreementsPolicy statement from WCPT on direct access

Figure 2.Barriers and facilitators to direct access as reported by the World Confederation for Physical Therapy (WCPT) member organizations(MOs). PTphysical therapist.



ing educational standards of quali-fying professional (entry-level)physical therapist education andcontaining professional develop-ment had been successful. Only 1respondent noted success with leg-islation changes. A limited numberof MOs had resources on directaccess available on their websites,although they were not all openaccess and restricted to member-only areas.

Respondents were provided withthe opportunity to make any addi-tional comments at the end of thesurvey. No new themes emerged,but those associated with the suc-cessful implementation of directaccess and resources thought to benecessary were reinforced. Therewere requests for assistance inimplementing legislative change thatrecognized the autonomy of thephysical therapy profession and theinclusion of direct access (n4). Therole of national professional organi-zations and WCPT in facilitatingchange in favor of direct access andself-referral was highlighted, alongwith a desire for a network ofexperts (n4). The need for termi-nology to be clear in defining directaccess and self-referral was identifiedas important in the collation of evi-dence to ensure that true clinicaleffectiveness and cost-effectivenesscould be evaluated (n2).

DiscussionThis survey set out to develop aglobal profile of direct access andpatient self-referral for physical ther-apy to identify where it was availableand to investigate the context ofpractice, factors influencing it, andthe resources that were thought nec-essary to further advance anddevelop services. The participantswere selected to provide a nationalrather than an individual perspec-tive, representing a collective opin-ion from a professional physical ther-apy association.

Previous studies have focused onclinical effectiveness and cost-effectiveness, medical and publicacceptance, and, to a limited extent,barriers and facilitators, usually inthe context of individual practice. Asnoted by McCallum and DiAngelis,31

comparing studies on direct access isdifficult because of the way in whichdirect access to physical therapy hasbeen defined across studies and thedata collection applied.

Direct access and patient self-referralis not a new model for providingphysical therapy services. In 1976,the Australian Physiotherapy Associ-ation repealed its first ethical princi-ple, which stated that physiothera-pists would only treat patientsreferred to them by a registered med-ical practitioner.42(p217) At the time,the widespread model of physicaltherapist practice was one wherephysical therapists took directionfrom a physician. The initiative fromAustralia was taken to the meeting ofWCPT in 1978 to facilitate this movein other MOs, and a motion waspassed that the issue of primarypractitioner status be interpreted byeach country in terms of their ownstandards.42(p217) Since then, prog-ress across the MOs of WCPT hasbeen varied, and the issue is now ahigh-profile advocacy issue for many.Some have already reaped the bene-fits of advocacy initiatives and legis-lative change,42 and many morestrive to make the changes and arekeen to learn from their internationalcolleagues. Member organizationsresponding to the survey offered toshare experiences of implementingdirect access, suggested developinga network of experts, and identifiedthe need for guidance on legislativechange to support direct access andself-referral. A limited amount ofonline resources and other educa-tion material also was identified.

The findings build on what is knownat a national level in a limited num-

ber of countries,3,12,20,2224,31 provid-ing a diverse picture of direct access.It would appear that direct accessand self-referral as an objectiverequires strategic coordinatedaction. This objective is unlikely tobe achieved at an individual level andrequires leadership from profes-sional physical therapy associationsand service leaders working on anumber of strategies. Advocacy strat-egies with all stakeholders, includingphysical therapists, politicians andpolicy makers, the medical profes-sion, and service users, such as theuse of awareness campaigns usinga variety of media, tailored to differ-ent stakeholder groups, with whichsome are already engaged, are likelyto be important.4345 The role ofadvocacy strategies is supported by asmall study, which included bothmembers and nonmembers ofAPTA.31 Securing professional sup-port and empowering individualphysical therapists are likely to beachieved with leadership fromnational associations and opinionleaders. Other strategies identifiedincluded raising the standards ofphysical therapist entry-level educa-tion to equip physical therapistsfor autonomous practice and directaccess, and reviewing legislation.

The perceived barriers to and facili-tators of direct access, surroundingthe views of key stakeholders (themedical profession, policy makers,and the public), represent the viewsof physical therapists and may not bean accurate representation of thosestakeholder groups. The fact that allappear to some extent as both barri-ers and facilitators shows howimportant they are to the professionand, whether real or perceived, thatthey need to be addressed. The per-ceived influence of policy makers onthe availability of direct access, irre-spective of whether it was permittedunder legislation, was evident fromthe respondents and is consistentwith previous studies.5,6,31 In a UK



study, Holdsworth et al23 found thatboth physical therapists and generalpractitioners (family physicians)supported patient self-referral andstressed the importance of raisingawareness both within and externalto the profession. Webster et al26

found that self-referral was viewedpositively by service users, support-ing the perceptions reported in thecurrent study. These studies shouldhelp inform advocacy efforts.

AlthoughWCPT has produced guide-lines for physical therapist entry-level education, they remain aspira-tional for some members of WCPT,whereas others exceed them. Asnoted by the respondents, educationplays a vital part in equipping phys-ical therapists with the requisitecompetencies to accept patientswho self-refer. If the graduate com-petencies are not appropriate atentry level, additional measures areneeded. The role of continuing pro-fessional development in preparingphysical therapists for direct accesshas been identified in other studies,even where entry-level educationshould provide the necessarycompetencies.23,31

Legislation that recognizes physicaltherapy as an autonomous profes-sion, able to accept patients viadirect access and self-referral, is per-ceived as a significant facilitator andas a barrier when it is absent. How-ever, the results show that in manycountries where MOs reported therewas an absence of legislation, directaccess was permitted or occurred.There appears to be greater freedomfor physical therapists to refer on toother specialties or services wheredirect access exists. Certainly, if leg-islation is introduced in those coun-tries currently without it, it will beimportant to retain these profes-sional autonomy roles. As noted byKruger,42 legislative change maybring about positive change, butchallenges to implementing direct

access and self-referral remain thatare cultural (eg, the relationshipwith the medical profession) andstructural (eg, funding models). Thefindings of this study support theseobservations.

Health service funding models andreimbursement policies appear tohave an impact on the availability ofdirect access. Although some privatephysical therapy services acceptpatients via self-referral, there areinstances where insurance policieswill not provide reimbursementwithout a physician referral. This sit-uation manifests itself in the samecountries where public services sup-port self-referral without a physicianreferral. In this situation, it is likelyto require the physical therapy pro-fession to actively engage with theinsurance companies and medicalprofession to challenge the insur-ance companies policies so thatpractice reflects contemporary ser-vice delivery models available in avariety of settings.31 This strategy islikely to be more successful whenthe clinical effectiveness and cost-effectiveness business case is pre-sented. The case for direct accessand self-referral for physical therapyis supported by growing evidenceshowing that patient safety is not putat risk, that it is likely to result inreduced health service costs as aresult of less physician care, and thatquality of care is likely to beenhanced.12,20,2224,46 This evidence,along with the results of this study,should be useful in informing policydecisions and advocacy effortsregarding direct access andself-referral.

LimitationsAlthough this study achieved a highresponse rate overall, the responserate varied across the 5 regions ofWCPT. There was a much highresponse rate from Europe, whichcould be attributed to the workshopprior to data entry sensitizing

respondents to the survey, or thefact that direct access was a signifi-cant policy issue for many of theorganizations represented in theEuropean region. Ideally, it wouldhave been valuable to have carriedout the same workshop in each ofthe regions. It is unclear why therewas such a low response rate in theAsia Western Pacific region; there-fore, caution should be applied inextrapolating the findings in thatregion.

Participants were requested torespond on behalf of their MOs toprovide a national perspective, butthere is a risk that respondents mighthave replied based on personal opin-ion. The survey language was Eng-lish, and although English is the offi-cial language of WCPT, some MOsmay have had difficulty understand-ing the questions and completingthe survey and, therefore, may havefailed to complete it. However,based on the responses, there was alarge number of respondents fromcountries for whom English was notthe first language.

Despite these limitations, we believethe study provides a benchmark pro-file of direct access to physical ther-apy globally, with useful data toinform future developments.

ConclusionTo assist future research studies onthe clinical effectiveness and cost-effectiveness of physical therapydirect access services, it will beimportant to clearly define the termsdirect access and self-referral.The term patient self-referral moreaccurately reflects the practice beingdescribed, but direct access is theterm more widely understood, bothwithin the profession internationallyand with other stakeholders. Furtherclinical effectiveness and cost-effectiveness studies for different cli-ent groups (eg, patients with neuro-logical disorders or gynecologic



problems) across a variety of settingswill further strengthen the businesscase and should incorporate theviews of service users.

There appears to be a perception ofwidespread support for direct accessand patient self-referral for physicaltherapy, not just from within theprofession; however, it is not uni-versal. Professional leadership andadvocacy from national professionalorganizations and WCPT are impor-tant in facilitating change in healthpolicy and service implementation.Resources to support those coun-tries that want to develop directaccess services are needed. Theseresources may include advice onreviewing legislative changes, devel-oping education and advocacy initia-tives, drawing on the evidence ofclinical effectiveness and cost-effectiveness to support the businesscase, and the development of goodpractice case studies illustratingimplementation strategies and ser-vice delivery models.

The WCPT has developed guidelinesfor physical therapist entry-level edu-cation and for professional regula-tion and legislation,35,36 all of whichunderpin the autonomous practiceof physical therapists and the right toaccept patients via direct access, solong as they have the competenciesto do so. These guidelines are set outin the new policy on direct accessapproved by the MOs of WCPT in2011.33 In the course of this survey,lessons learned from implementa-tion experiences have been sharedand provide guidance for those start-ing out on developing and imple-menting direct access. Further workis now needed to collate theresources identified and make themas widely accessible as possible.

Both authors provided concept/idea/re-search design and contributed to writing,data collection and analysis, and project

management. Ms Bury provided study par-ticipants and institutional liaisons.

Both authors are involved with the work ofWCPT. Ms Bury is an employed member ofstaff, and Dr Stokes is currently Vice Presi-dent and sits on the Executive Committee; atthe time of the study she was the Europeanregional representative on the Committee.

The views expressed in the article are thoseof the authors and do not necessarily repre-sent the views of WCPT. The authorsacknowledge the support of all delegates tothe European Region of WCPT Workshop onDirect Access, the external reference groupfor assistance in developing the surveyinstrument, and the respondents fromWCPTs member organizations.

The preliminary findings were presented atthe 16th International Congress of the WorldConfederation for Physical Therapy; June2023, 2011; Amsterdam, the Netherlands.

DOI: 10.2522/ptj.20120060

References1 Sandstrom RW. The meanings of auton-

omy for physical therapy [erratum in: PhysTher. 2007;87:227]. Phys Ther. 2007;87:98106.

2 Policy Statement: Autonomy. London,United Kingdom: World Confederation forPhysical Therapy; 2011.

3 Self-referral Pilots to MusculoskeletalPhysiotherapy and the Implications forImproving Access to Other AHP Services.London, United Kingdom: Department ofHealth; 2008.

4 Boyce RA. Direct access physiotherapy inAustralia [letter]. Physiotherapy. 2005;91:6162.

5 Crout KL, Tweedie JH, Miller DJ. Physicaltherapists opinions and practices regard-ing direct access. Phys Ther. 1998;78:5261.

6 Domholdt E, Durchholz AG. Direct accessuse by experienced therapists in stateswith direct access. Phys Ther. 1992;72:569574.

7 Domholdt E, Lord L, LeMasters A, DurantT. Direct access: a hypothetical debate.Clinical Management. 1989;9(2):33.

8 Durant TL, Lord LJ, Domholdt E. Outpa-tient views on direct access to physicaltherapy in Indiana. Phys Ther. 1989;69:850857.

9 Flynn TW. Direct access: the time hascome for action. J Orthop Sports PhysTher. 2003;33:102103.

10 Fordham R, Hodkinson C. A Cost BenefitAnalysis of Open Access to Physiotherapyfor GPs: Discussion Paper 29. York,United Kingdom: Centre for Health Eco-nomics Health Economics Consortium,University of York; 1998.

11 Holdsworth LK, Webster VS. Direct accessto physiotherapy in primary care: now andinto the future? Physiotherapy. 2004;90:6472.

12 Leemrijse CJ, Swinkels IC, Veenhof C.Direct access to physical therapy in theNetherlands: results from the first year incommunity-based physical therapy. PhysTher. 2008;88:936946.

13 Mitchell JM, de Lissovoy G. A comparisonof resource use and cost in direct accessversus physician referral episodes of phys-ical therapy. Phys Ther. 1997;77:1018.

14 Moore J. Vision in action: direct access. PTMagazine. 2001;9(2):7779.

15 Rose SJ. Direct access: the need for aneducational component. Phys Ther. 1988;68:1329.

16 Swinkels IC, Leemrijse CJ, Veenhof C. Oneyear of direct access to physiotherapy [inDutch]. Ned Tijdschr Fysiotherapie. 2007;117:158165.

17 Tepper DE. Reimbursement victories:direct access and others. PT Magazine.2003;11(3):4245, 61.

18 Self-referral to Physiotherapy Services.London, United Kingdom: Chartered Soci-ety of Physiotherapy; 2004.

19 Ferguson A, Griffin E, Mulcahy C. Patientself-referral to physiotherapy in generalpractice: a model for the new NHS? Phys-iotherapy. 1999;85:1320.

20 Holdsworth LK, Webster VS, McFadyenAK. Are patients who refer themselvesto physiotherapy different from thosereferred by GPs: results of a national trial.Physiotherapy. 2006;92:2633.

21 Holdsworth LK, Webster VS, McFadyenAK. Self-referral to physiotherapydepri-vation and geographical settingis therea relationship: results of a national trial.Physiotherapy. 2006;92:1625.

22 Holdsworth LK, Webster VS, McFadyenAK. What are the costs to NHS Scotland ofself-referral to physiotherapy: results of anational trial. Physiotherapy. 2007;93:311.

23 Holdsworth LK, Webster VS, McFadyenAK. Physiotherapists and general practi-tioners views of self-referral and physio-therapy scope of practice: results from anational trial. Physiotherapy. 2008;94:236243.

24 Pendergast J, Kliethermes SA, FreburgerJK, Duffy PA. A comparison of health careuse for physician-referred and self-referredepisodes of outpatient physical therapy.Health Serv Res. 2012;47:633654.

25 Saporta A, Gibson BE. Ethics of self-referralfor profit: case example of a physician-owned physiotherapy clinic. PhysiotherCan. 2007;59:266271.

26 Webster VS, Holdsworth LK, McFadyen,Little H. Self-referral, access and physio-therapy, patients knowledge and atti-tudes: results of a national trial. Physio-therapy. 2008;94:141.

27 Galley P. Patient referral and the physio-therapist. Aust J Physiother. 1976;22:117120.



28 Galley P. Physiotherapists as first-contactpractitioners: new challenges and respon-sibilities in Australia. Physiotherapy. 1977;63:246248.

29 Leemrijse CJ, Swinkels IC, Pisters MF, et al.Direct access to physiotherapy: thepatients choice [in Dutch]. Ned TijdschrFysiotherapie. 2008;118:6267.

30 Massey BF Jr. 2002 APTA presidentialaddress: whats all the fuss about directaccess? Phys Ther. 2002;82:11201123.

31 McCallum CA, DiAngelis T. Direct access:factors that affect physical therapist prac-tice in the state of Ohio. Phys Ther. 2012;92:688706.

32 World Confederation for Physical Thera-py. Direct access and patient self-referralto physical therapy. Available at: http://www.wcpt.org/node/34062. AccessedDecember 22, 2011.

33 Policy Statement: Direct Access andPatient/Client Self-referral to PhysicalTherapy. London, United Kingdom: WorldConfederation for Physical Therapy; 2011.

34 Policy Statement: Education. London,United Kingdom: World Confederation forPhysical Therapy; 2011.

35 WCPT Guideline for Physical TherapistProfessional Entry Level Education. Lon-don, United Kingdom: World Confedera-tion for Physical Therapy; 2011.

36 WCPT Guideline for the Development ofa System of Legislation/Regulation/Rec-ognition of Physical Therapists. London,United Kingdom: World Confederation forPhysical Therapy; 2011.

37 Policy Statement: Description of PhysicalTherapy. London, United Kingdom: WorldConfederation for Physical Therapy; 2011.

38 1991 International Guidelines for Ethi-cal Review of Epidemiological Studies.London, United Kingdom: Council ofInternational Organizations for MedicalScience; 1991.

39 Ethical Guidelines for BiomedicalResearch Involving Human Subjects.London, United Kingdom: Council ofInternational Organizations for MedicalScience; 2008.

40 Declaration of Helsinki: Ethical Princi-ples for Medical Research InvolvingHuman Subjects. Ferney-Voltaire, France:World Medical Association; 2008.

41 Bury T, Stokes E. Direct access andpatient/client self-referral to physiothera-py: a review of contemporary practicewithin the European Union. Physiother-apy. In press.

42 Kruger J. Patient referral and the physio-therapist: three decades later. J Phys-iother. 2010;56:217218.

43 American Physical Therapy Association.Direct access in practice. Available at:http://www.apta.org/DirectAccess/. Ac-cessed January 30, 2012.

44 Efficiency and Health Human Resources:A Submission to the House of CommonsStanding Committee on Health. Ottawa,Ontario, Canada: Canadian PhysiotherapyAssociation; 2009.

45 Chartered Society of Physiotherapy. Selfreferral. Available at: http://www.csp.org.uk/topics/self-referral. Accessed January30, 2012.

46 Shoemaker MJ. Direct consumer access tophysical therapy in Michigan: challengesto policy adoption [erratum in: Phys Ther.2012;92:471]. Phys Ther. 2012;92:236250.



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Global View of Direct Access and Patient Self Referral to Physical Therapy

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