First point of contact physiotherapy: a realist review and evaluation

Background General Practice, the cornerstone of the National Health Service (NHS), is experiencing increased patient demand and overstretched resources. Musculoskeletal health disorders (MSDs), such as back pain and hip pain, are common conditions. Almost all patients with MSDs consult their general practitioner (GP) as a first point of contact (FPC). Evidence exists that physiotherapy is an effective intervention for most MSDs. First point of contact physiotherapy (FPCP), for patients experiencing MSDs, offers an alternative to the GP as FPC. FPCP has demonstrated clinical efficacy, patient and GP satisfaction and indications of financial benefit. Patients have been able to refer directly to a physiotherapist, without a referral from a doctor, since 1977. However, uptake of FPCP has been poor with patients continuing to default to their GP. FPCP has the potential of helping alleviate some of the pressures in general practice. This is likely to remain unrealised if patients continue to default to a GP in this way. Physiotherapy, as an occupation, has been engaged in a professional project over the course of the last century. A professional project is the processes and developments whereby a distinct occupational group seeks to legitimise its monopoly in the market and its social order. The research in this thesis conceptualised the FPCP initiative as the latest manifestation of physiotherapy’s professional project. FPCP could be seen as encroaching into traditional GP jurisdiction. The sociology of the professions literature informs us that this encroachment could incite interprofessional tension. This research explored the process whereby FPCP was implemented into the complex general practice system. The question addressed in this research was: • If FPCP constitutes a professional project what are the reactions and responses of the multiple stakeholders to this, why are their reactions constructed as such, how are they articulated, in what circumstances and how do they influence operationalisation? Methods The research employed realist methodologies; both realist review and realist evaluation. The realist approach is concerned with developing, testing and refining programme theories by exploring the interactions of contexts, mechanisms and outcomes. Four initial programme theories were developed systematically through stakeholder engagement. These theories were tested against the existing body of literature through the realist review approach. The databases searched were MEDLINE, CINAHL, EMBASE, PsychINFO via OVID Databases and Web of Science and sixteen pieces of literature retained for data extraction and review. This resulted in eight refined theories which were themselves tested by conducting eighteen individual interviews and eight focus groups with stakeholder members. The forty-one participants included physiotherapists, GPs, commissioners, administration staff and patients. A thematic analytical approach was used employing a hybrid of inductive and deductive coding to theme development which informed the qualitative analysis. The output of the research was a series of transferable guidelines that inform future service development and research. Results Synthesis of the data revealed the following findings. An overview of the theory development is presented in figures 1 and 2. 1. Understanding The public were aware of physiotherapy as an established profession. Understanding of the clinical application of physiotherapeutic interventions for MSDs was confused and generally misaligned with clinical practice. Public awareness and understanding of FPCP was negligible. The methods of marketing FPCP were shown to be ineffective. There was no evidence of any systematic planning in the design or implementation of the marketing strategies used to advertise FPCP services. There was no evidence that the effectiveness of any marketing strategies had been evaluated. 2. Signposting Signposting by administration staff was the most effective method of facilitating patient access to FPCP. This role was sometimes resisted by patients. Administration staff welcomed the signposting role despite the additional stress it could cause. Signposting provided education and ensured patients received the best care. The challenges in the signposting role could be ameliorated with adequate training, staff experience and peer support. 3. Embedding As a FPCP service embedded it became normalised in the general practice and for patients. The service became more visible to patients who became more familiar with it as a resource and patient access increased. Administrators became more confident to signpost and GPs became more confident in physiotherapist competence as FPCP embedded. 4. Professional project FPCP was a professional project set against the historically established dominance of medicine. Patients were predisposed to default to their GP as the FPC. GPs were aware of the need for their role, and general practice, to evolve in the face of increasing pressures. GPs spoke supportively of the FPCP initiative while, at the same time exhibiting a controlling role over the definition of role boundaries and professional jurisdictions. The relationship between GP and physiotherapist enhanced when they worked alongside one another. Conclusion This realist review and evaluation produced a number of key findings. Six key lessons, generated from the results, are presented that inform future service development. In summary, despite evidence of clinical efficacy, patient and GP satisfaction, FPCP has not been implemented with sufficient capacity to result in a noticeable impact. This research synthesised a number of implementation guidelines and future research opportunities