Self Referral

Julie ShepherdLead Physiotherapist

Overview of presentation

• History & evolution of local self referral scheme• Benefits• Implementation • Evaluation• The Future!

Key points regarding Self Referral

• Does not open the floodgates• Is patient centred & encourages self

management/empowerment • Enables timely access to advice/reducing chronicity• Can prevent people going off work/get them back to

work• Enhances therapists autonomy & management

strategies• Can increase capacity by reducing new to follow up

ratios• Saves GP time• Can support long term conditions

GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST

Physio Outpatient New Attendances by Source of Referral: Trustwide

0

20004000

6000

8000

1000012000

14000

2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11

Year

New

atts

Self Cons GP Other

Physiotherapy Outpatient new attendances

Source 2001/02 2002/03 2003/04 2006/07 2007/08 2008/09 2009/10 2010/11 GP 5083 9401 8827 9051 8093 8513 6998 7007

Consultant 3225 5840 4726 5522 6284 7306 8845 7647 Self 934 2210 3868 9997 11807 11850 11973 12584

Other 466 409 1358 3188 2775 3479 5508 5465 Total 9708 17860 18779 27758 28959 31148 33324 32703

% self 9.6 12.37 20.59 36.01 40.77 38.04 35.92 38.47

Local implementation milestones

• 1991 - Established in East Gloucestershire Trust, stopped with the introduction of GP Fundholding in 1995 & then re-established in 1998 with the demise of GP Fundholding & the emergence of Primary Care Groups

• 2000 – Staff self referral at Cheltenham General Hospital

• 2001 – ‘Physio Direct’ telephone access• 2010 – ‘Drop in’ clinics

Staff Self Referral

• 341 patients seen in the first year (2000)• New to follow up ratio 1: 1.4 compared to

department average of 1: 3.4• Anecdotally – patients more self motivated &

happy to self manage• Commended by a Health & Social Care Award

2001 “Improving the lives of staff” category

‘Physio Direct’

• A ‘trial’ which commenced in November 2001 with 3 GP practices (1 hour per day, Mon-Fri)

• Extended in 2002 (3.5 hours per day) to cover 6 practices in total (population of 53,000)

• Extended in 2005 to cover all GP practices within Cheltenham (from 9.00am to 4pm)

Key Objectives

• Provide telephone access to people to ensure timely advice/intervention is given

• Empower people to self manage their condition• Provide a new service within existing resources• Demonstrate that demand and capacity can be managed

in a different way• Reduce administration and save time for GPs

The Pathway

• The patient can self refer via the telephone following the process outlined on posters or in the GP newsletter.

• Alternatively if the GP feels that his/her patient requires physiotherapy, the GP tells the patient to contact Physio Direct.

• The patient phones the physiotherapy department at the designated times to speak to a Physiotherapist.

The Pathway

• Assessment by asking a series of questions, leads to one of the following outcomes for the patient:• Advice including an exercise sheet (post or e-

mail) and/or information leaflet or• An appointment to see the physiotherapist or• Referral to their GP if a medical assessment

is indicated.

How the scheme was managed

• All parties agreeing clear objectives and measures• Involvement of all staff delivering the service from the

outset• Working with PCT “Access” leads and GPs • Making changes as needed and testing to ensure added

value• Starting small and building a system based on measured

success• Evaluation and feedback to all involved

‘Red Flags’

In the first year, 3 patients were fast tracked with the following problems:

• Pathological fracture of C7• Fractured pubic ramus• Child with an avulsion fracture

Evaluation

• Questionnaire surveys were sent to participating GPs and patients who had been managed by Physio Direct and had been discharged from the service at 3 months and 14 months.

• A response rate of 92% and 64% (3 months), 87% and 58% (14 months) respectively was achieved.

Of the sample of patients surveyed:• 71% of patients reported that they felt more in control of

their symptoms • 69% of patients had not consulted elsewhere• 88% felt that the service should continue

Analysis of the activity data Nov 2001-Dec 2002:

820 patients called Physio Direct• 40% of those were managed with advice and

exercise sheets/information leaflets only• 60% of those visited the local Physiotherapy

Department for follow up intervention. Of those, 25% needed only one follow up appointment

• The average wait for routine referrals to the department remained consistent at 7 weeks

Comments from service users

• “An easy quick way to have minor problems solved”

• “Excellent way of getting quick advice. I have previously had to wait weeks for an appointment. I spoke to a friendly physio who listened and gave me unhurried time. I needed reassurance and was told I could phone again and be seen if necessary and speak to the same person”

Comments from service users

• “I was very pleased with the service given. The only piece of information I didn’t get was when to stop the exercises”

• “Most of this is not relevant to me, as the physio, hearing of my problem took me to A&E where a crack in the bone was discovered. I was impressed with the system. Many thanks to the physio concerned”

Comments from service users

• “Physio triumphed where my doctor failed to diagnose and treat”

• “The immediacy of consultation and advice was a tremendous improvement on previous referrals to physio with the traditional long wait for treatment/advice”

• “Reassurance and professional pain management helped alleviate the stress and anxiety and prevented non-useful visits to the GP”

Comments from service users

• “It took some 5 hours on the phone, over 2 weeks to at last get in touch with the Physio”

• “I feel that it is necessary for the Physio to have a diagnosis of the problem, either from the GP or Consultant”

Comments from GPs

• “Patients very happy with the service and I have had very good reports from those using it. Saves an enormous amount of time in admin and unnecessary referrals to yourselves. Thank you”

• “The scheme seems to be working well. I have had positive feedback from patients, both from those that get advice and leaflets in the post and those who get appointments”

Comments from GPs

• “Of great assistance and simpler than direct booking which wasted staff time”

• “Very helpful service P.S. good questionnaire – short brief and to the point”

• “Excellent++++”• “Greatly reduced admin, so please continue”

Current methods supporting self referral

• Telephone eg ‘Physio Direct’ & follow up consultations

• ‘Paper’ Self referral form (including pre-assessment form)

• On line referral: Re-vamped website• ‘Drop in’ clinics

Learning through implementing Self Referral

• Does not open the floodgates• Enables timely access to advice/reducing chronicity• Can prevent people going off work/get them back to work• Is patient centred & encourages self

management/empowerment • Enhances therapists autonomy & professional

responsibility• Can reduce DNA rates and new to follow up ratios• Saves GP time• Can support long term conditions• Gives confidence to take on new ways of working –

development of ‘drop in’ clinics

What you need:

• Passion for change & to take a ‘risk’• Staff involvement from the outset in planning &

implementation• Self management philosophy• GPs on side• Start small and build in ‘bite size’ chunks• Tailor it in regard to your population & feedback• Other helpful resources - Self Referral

Implementation tools: www.csp.org.uk

The future?

Increased usage of technology to communicate

with patients• e-mail• ?SKYPE• ?Twitter• ?Blogs

References• Holdsworth LK, Webster VS, McFadyen AK, et al. What are the costs to NHS Scotland of self-referral to physiotherapy? Results of a national trial.

Physiotherapy. 2007;93(1): • Department of Health. Self-referral pilots to musculoskeletal physiotherapy and the implications for improving access to other AHP services. London:

Department of Health; 2008. p 9 • Chartered Society of Physiotherapy. Proceedings of Council: byelaw amendments. Physiotherapy. 1978;64(7):218. • Department of Health. The NHS in England: The operating framework for 2009/10. London: Department of Health; 2009. • Department of Health. Self-referral pilots to musculoskeletal physiotherapy and the implications for improving access to other AHP services. London:

Department of Health; 2008. • Department of Health. Self-referral pilots to musculoskeletal physiotherapy and the implications for improving access to other AHP services. London:

Department of Health; 2008. p 15 • Department of Health. Self-referral pilots to musculoskeletal physiotherapy and the implications for improving access to other AHP services. London:

Department of Health; 2008. p 16 • Black C. Working for a healthier tomorrow. Dame Carol Black's review of the health of Britain's working age population. London: TSO; 2008. p 76 • Department of Health. Self-referral pilots to musculoskeletal physiotherapy and the implications for improving access to other AHP services. London:

Department of Health; 2008. p 18.URL: • Department of Health. The patient's charter. London: Department of Health; 1991. • Holdsworth LK, Webster VS, McFayden AK. Direct access to physiotherapy in primary care now and into the future. Physiotherapy. 2004;90(2):64-

72. • Department of Health. The NHS in England: The operating framework for 2009/10. London: Department of Health; 2009. p 16 • Department of Health. The NHS in England: The operating framework for 2009/10. London: Department of Health; 2009. p 13 • Black C. Working for a healthier tomorrow. Dame Carol Black's review of the health of Britain's working age population. London: TSO; 2008. p 76 • Darzi A. High quality care for all: NHS Next Stage Review final report. Cmd 7432. London: Department of Health; 2008. • Scottish Executive Health Department. Building on success: Future directions for allied health professions in Scotland. Edinburgh: Scottish

Executive; 2002. • NHS Scotland. Better health, better care: action plan. Edinburgh: NHS Scotland; 2007. • Scottish Executive. Co-ordinated, integrated and fit for purpose: a delivery framework for adult rehabilitation in Scotland. Edinburgh: Scottish

Executive; 2007. • Sturgeon N. Scottish parliamentary questions: written answers Tuesday 3 November 2009 Edinburgh: Scottish Parliament; 2009. • NHS Lothian. NHS Lothian at the cutting edge (press release). Edinburgh: NHS Lothian; 2009. • Welsh Assembly Government. A therapy strategy for Wales: the contribution of therapy services to transforming the delivery of health and social

care in Wales. Therapies for modernisation. Cardiff: Welsh Assembly Government; 2006. p 5 • Bookmark/Search this post with:

"If you always do what you've always done, you'll always get what you've

always got."

For further information please contact:julie.shepherd@glos.nhs.uk