PHYSIO DIRECTPHYSIO DIRECT

• JILL GAMLIN - JILL GAMLIN - CONSULTANT CONSULTANT PHYSIOTHERAPISPHYSIOTHERAPISTT

• KATHY DUFFIELD KATHY DUFFIELD - SENIOR I - SENIOR I PHYSIOTHERAPISPHYSIOTHERAPISTT

Catalysts for change………..Catalysts for change………..

Patient dissatisfactionPatient dissatisfaction

• Delayed referral, patients’ problems Delayed referral, patients’ problems become more chronic, more difficult to become more chronic, more difficult to resolve, poorer outcome of treatmentresolve, poorer outcome of treatment

• Research evidence - early intervention, Research evidence - early intervention, aids patient recoveryaids patient recovery

• Current patient pathway through the Current patient pathway through the system had bottlenecks and wasted system had bottlenecks and wasted patients’ timepatients’ time

• Frustration for all those involvedFrustration for all those involved

Previous Patient PathwayPatient

GP

HospitalConsultant

Not ResolvedNSAID andor Analgesia

Not ResolvedPhysiotherapy 2/52-6/52

to triage

Discharge

Physiotherapy extended scopepractitioner

Consultant Physiotherapist

Time to thinkTime to think

• Stuck in a traffic jam, chance comment Stuck in a traffic jam, chance comment Radio 4 - GPs used as inappropriate gate Radio 4 - GPs used as inappropriate gate keepers for the NHSkeepers for the NHS

• Why not let patients access physiotherapy Why not let patients access physiotherapy directly if they think we can help them? directly if they think we can help them?

• Requires a new approach to assessment Requires a new approach to assessment and management.and management.

• NHS Direct why not Physio Direct?NHS Direct why not Physio Direct?

Right environmentRight environment

• Line manager excited and receptive Line manager excited and receptive to new ideasto new ideas

• Dissatisfaction with the present, Dissatisfaction with the present, willingness to changewillingness to change

• PCT management ready to facilitate PCT management ready to facilitate and support the change process and support the change process financially and with key personnelfinancially and with key personnel

Key ObjectivesKey Objectives

• Improve access and capacity for Improve access and capacity for physiotherapy to ensure early physiotherapy to ensure early identification and management of identification and management of problemsproblems

• Empowerment of individuals to take Empowerment of individuals to take control thus reducing chronic paincontrol thus reducing chronic pain

• Pathway redesign reducing GP time Pathway redesign reducing GP time dealing with M/S problems, ensuring dealing with M/S problems, ensuring appropriate referral to secondary careappropriate referral to secondary care

Process of project Process of project developmentdevelopment• Early involvement of key players - PT team, Early involvement of key players - PT team,

head of primary care, IT, GPs, practice head of primary care, IT, GPs, practice managers, patients, pharmacy, PECmanagers, patients, pharmacy, PEC

• Clear vision - good communication, focus Clear vision - good communication, focus on improving patient-centred careon improving patient-centred care

• Open approach to problem solving, Open approach to problem solving, can do can do philosophy, negotiationphilosophy, negotiation

• Attention to risk management, clinical Attention to risk management, clinical governancegovernance

Project developmentProject development

• Reflective learning to capture problems Reflective learning to capture problems and solutions and to carry learning and solutions and to carry learning forwardforward

• Strong leadership to find solutions rather Strong leadership to find solutions rather than allowing derailment. Conviction, than allowing derailment. Conviction, determination, confidence that the determination, confidence that the direction is rightdirection is right

• Seeking advice from wherever is Seeking advice from wherever is necessary to resolve the next problemnecessary to resolve the next problem

Project detailsProject details

• 2 GP practices involved representing 2 GP practices involved representing 23,000 patients23,000 patients

• 1 practice enthusiastic and 1 practice enthusiastic and innovative, the other had innovative, the other had longstanding problems with accesslongstanding problems with access

• Initially a 6 month project which Initially a 6 month project which started Nov 01 with £15,000 funding started Nov 01 with £15,000 funding for 1 WTE senior I PTfor 1 WTE senior I PT

How it worksHow it works

• Dedicated phone line open 8.30am-Dedicated phone line open 8.30am-12.30pm Mondays to Fridays 12.30pm Mondays to Fridays excluding BHexcluding BH

• Computerised screening tool – Computerised screening tool – patient details, different screens for patient details, different screens for problems such as LBP, neck, thoracic problems such as LBP, neck, thoracic spine, peripheral jointsspine, peripheral joints

• Decision made re diagnosis, advice Decision made re diagnosis, advice sheets sent by post that daysheets sent by post that day

How it worksHow it works

• If unable to make a sound clinical decision or If unable to make a sound clinical decision or problems with patient comprehension – problems with patient comprehension – appointment to be seen by PTappointment to be seen by PT

• Inappropriate for PT – d/w Consultant PT re Inappropriate for PT – d/w Consultant PT re further investigations/management including further investigations/management including ref onto other Consultants, suspected ref onto other Consultants, suspected fracture – ref A&Efracture – ref A&E

• Same day information to GP re consultation, Same day information to GP re consultation, advice sent to patient with clear instructions advice sent to patient with clear instructions to call PT Direct back if not resolvingto call PT Direct back if not resolving

How it worksHow it works

• Training by Pharmacy to PT to ensure Training by Pharmacy to PT to ensure safe advice re OTC medicationsafe advice re OTC medication

• Prescription – faxed request to GP for Prescription – faxed request to GP for prescription for patient to collect if in prescription for patient to collect if in agreementagreement

• Agreement for PT to request sick Agreement for PT to request sick certificate for 2 weeks without GP certificate for 2 weeks without GP appointmentappointment

Referral PathwaysPatient

GPOrthopaedic Consultant

Rheumatology Consultant

Physio Direct

Extended Scope Practitioner

Consultant Physiotherapist

Key aspects - ‘outside Key aspects - ‘outside the box’the box’• Different ethos - locus of control passes to Different ethos - locus of control passes to

patientpatient

• First contact by phone, computerised First contact by phone, computerised screening tool. Advice sent by post same screening tool. Advice sent by post same dayday

• Local agreement sick certificates and Local agreement sick certificates and prescriptionsprescriptions

• Consultant Physiotherapist led service Consultant Physiotherapist led service from primary to secondary care from primary to secondary care

Outcome of new serviceOutcome of new service

• 70% of callers managed with telephone 70% of callers managed with telephone advice onlyadvice only

• Easier accessEasier access

• DNA rate for appointments reduced 15% - DNA rate for appointments reduced 15% - < 1%< 1%

• Reduced GP appointments for M/S patientsReduced GP appointments for M/S patients

• Faster access to secondary care Faster access to secondary care consultants when required. consultants when required.

AuditAudit

• 100 patients selected randomly, 63 returned100 patients selected randomly, 63 returned• Of the 63, 36 received advice + exercise Of the 63, 36 received advice + exercise

sheets only, 27 advice + at least 1 sheets only, 27 advice + at least 1 appointment appointment

• Figures given are for both groups added Figures given are for both groups added together together

• 31 rated service as excellent, 20 good, 9 31 rated service as excellent, 20 good, 9 average, 1 below average, 1 poor, 1 no average, 1 below average, 1 poor, 1 no commentcomment

• Positive comments made by both groups Positive comments made by both groups regarding access, time saved and quality of regarding access, time saved and quality of the servicethe service

Patient commentsPatient comments

• ““The prompt and direct service received can The prompt and direct service received can be followed with confidence in the be followed with confidence in the knowledge it comes from those best knowledge it comes from those best qualified to give it . This much needed and qualified to give it . This much needed and valued service should continue”valued service should continue”

• Some more negative comments, difficulty Some more negative comments, difficulty understanding exercises from the sheet, understanding exercises from the sheet, opening times not convenient, time taken to opening times not convenient, time taken to go through questions, already doing go through questions, already doing exercises so no helpexercises so no help

OutcomeOutcome

• 15 resolved completely15 resolved completely

• 33 improved but not resolved33 improved but not resolved

• 7 not helped7 not helped

• 14 of the not resolved group 14 of the not resolved group contacted PT direct againcontacted PT direct again

• Some still receiving treatmentSome still receiving treatment

• 6 went back to the GP6 went back to the GP

Future use of the serviceFuture use of the service

• 56 would use the service again, 4 56 would use the service again, 4 would notwould not

• 57 would recommend the service to 57 would recommend the service to others, 4 might, 2 would not – these others, 4 might, 2 would not – these were in the advice only groupwere in the advice only group

• 1 letter of complaint related to the 1 letter of complaint related to the title of the exercise sheet, resolved title of the exercise sheet, resolved with one appointmentwith one appointment

GP audit resultsGP audit results

• Overall happy, one surgery felt Overall happy, one surgery felt consultations were quicker, patients don’t consultations were quicker, patients don’t come back to chase PT appointmentcome back to chase PT appointment

• Helps patients to be proactiveHelps patients to be proactive• Improved communications PT and GPImproved communications PT and GP• Improved access for Orthopaedic opinionImproved access for Orthopaedic opinion• Allows patients to decide whether they will Allows patients to decide whether they will

pursue PTpursue PT• Helps prevent chronicityHelps prevent chronicity

PT audit resultsPT audit results

• All 5 PTs commented on the speed of All 5 PTs commented on the speed of access, more patient control, patients access, more patient control, patients don’t have to pay for the car park or leave don’t have to pay for the car park or leave workwork

• Problems – communication with GPs, Problems – communication with GPs, patients returning to GP rather than patients returning to GP rather than staying with the servicestaying with the service

• Access to consultant PTAccess to consultant PT• Stressful coping with the additional work – Stressful coping with the additional work –

as not now able to ref back to GPas not now able to ref back to GP

PT audit resultsPT audit results

• “ “ The whole experience of PT direct The whole experience of PT direct has improved my assessment skills, has improved my assessment skills, it has however been harder work due it has however been harder work due to the higher levels of complex to the higher levels of complex patients. I have also needed more patients. I have also needed more time for communication with GPs.” time for communication with GPs.”

Future developmentsFuture developments

• Roll out to St Neots Nov 03, St Ives ? Jan 04, Roll out to St Neots Nov 03, St Ives ? Jan 04, other GP surgeries ? March 04other GP surgeries ? March 04

• Extension of opening of telephone line ?Extension of opening of telephone line ?8.00am – early evening, ? Saturdays8.00am – early evening, ? Saturdays

• Advertising and promotion, education of Advertising and promotion, education of users and GPsusers and GPs

• Research funded by professional bodyResearch funded by professional body• Interest from the StHA roll out to rest of Interest from the StHA roll out to rest of

regionregion• Part of DOH project group - role of AHPs in Part of DOH project group - role of AHPs in

moving work from secondary to primary caremoving work from secondary to primary care

Future Development of Physio Direct Patient Pathway (end of 2003/early 2004)

Patient

GPPhysio Direct

PCT Orthopaedic Panel

HospitalConsultant

Discharge

Physiotherapy Extended Scope Practitioner

Consultant Physiotherapist

The last word from the The last word from the patient……..patient……..

• “ “ This service encouraged me to This service encouraged me to seek advice, which otherwise I would seek advice, which otherwise I would not have done. I intend to seek not have done. I intend to seek advice again on another problem: advice again on another problem: this I would not do if I had to visit the this I would not do if I had to visit the doctor. To the likes of me this doctor. To the likes of me this service is invaluable.”service is invaluable.”