1 Business Case Advanced Physiotherapy Practitioners in Primary Care 1.0 Introduction This scheme supports the sustainability of primary care and the move towards a first line prudent multi-professional model of care. Its primary aim is to relieve the pressure on the GPs by building in additional capacity thereby releasing GP time and enabling them to manage more complex cases and co-morbidity presentations. The initiative allows people presenting with musculoskeletal problems to be seen locally by an Advanced Physiotherapy Musculoskeletal Practitioner (APP) as an alternative to seeing their GP. This releases capacity for GPs and provide fast access and early management of patients with these conditions. These posts do not replace routine physiotherapy treatment; if patients require a course of rehabilitative physiotherapy they will be signposted to the nearest outpatient physiotherapy site. 2.0 Executive summary Funding originated from the pacesetter scheme to test the concept and has been supplemented by the primary care workforce monies, cluster investment and through managed practice GMS monies. The scale up of the model and the support through investment by clusters point to its perceived success in supporting primary care although the model still requires further development. By March 2018 we expect 80 practices to have access to the scheme and it is expected that approximately 40,000 appointments will have been provided by the physiotherapy model in the two years of its existence. This is activity that otherwise would have been seen by the GP. Of all the pacesetter and workforce schemes we believe this model delivers a scale which would now be difficult to withdraw from without destabilising primary care further. Furthermore new roles in primary care will take time for both the skills and culture of individuals to work within primary care to develop and a longer term view of the development of new primary care roles is advocated. Patient satisfaction within the service is high with a good level of acceptance of this new model and an ease of access and appropriateness of location being noted. The model has gained widespread national interest and is now common place within the UK. Whilst there is some good evidence regarding the impact on first contact general practice activity there is insufficient evidence at present to support a secondary hypothesis of how the new pathway might impact on referrals to secondary care MSK services such as orthopaedics, rheumatology, pain and outpatient physiotherapy services. In order to explore this further a new evaluation framework, based on the new pathway (appendix 1), to look for causal determinants has been created for use in 2018. This paper provides three recommendations: 1. That the APP model continues as a scheme to support primary care activity and sustainability.
2 2. That the existing primary care monies continues to support the scheme during 2018/19 3. Further work is done during 2018 to better understand the impact on other services in order to determine what if any, resource could be reallocated within the system. 3.0 The Advanced Physiotherapy Practitioners (APP) scheme The underlying principle of this new model of patient centred care is to deliver an excellent integrated service, close to the patient s home without unnecessary delay. This service aims to simplify the musculoskeletal (MSK) pathway by making Advanced Physiotherapy Practitioners (APP) the 1 st point of contact for MSK conditions in primary care. This scheme supports the sustainability of primary care and the move towards a first line prudent multi-professional model of care. We aim to relieve the pressure on the GPs by building in additional capacity releasing GP time thereby enabling them to manage the more complex cases and co-morbidity presentations. This new service fulfils the four principles of prudent health implemented by the Welsh Government in aiming to be part of the long term solution in providing a sustainable integrated health care service across North Wales. Following engagement with GP clusters, primary care services, secondary care services and therapy managers we have been successful in appointing 15 wte APP positions across BCUHB. This ensures good access in all localities. To provide a completely equitable service across the health board, enabling patients to access the service even in the most rural locations, we are aiming towards gaining further funding for 11 wte B7 APP. This would provide 2.0 wte B7 APP per GP cluster, totalling 26 wte APPs across BCUHB. This service has now been running since January 2015 and the diagram below demonstrates the rapid growth and expansion of the Primary Care service. This has been made possible by securing funding from a variety of sources including Pacesetter / Workforce monies, GMS funds for practices which are Health Board run and Cluster monies. These roles are essential for the continued development and roll out of this new innovative service across BCUHB. 70 60 50 40 30 Service Expansion 65 20 10 0 20 14 4 1 4 2015 2016 2017 Number of GP Practices Number of Physios
3 4.0 Strategic vision for outpatient physiotherapy and the APP service. 4.1 Current Outpatient Physiotherapy model Outpatient physiotherapy services are located across the system as shown below in figure 1. The traditional model has been for patients to be referred either from the GP or from a Consultant led service. In recent years the level of self-referrals has grown and there are now an increasing number of patients seen within the APP model. Figure 1 1. GMS funded service In this domain physiotherapy is funded directly by GMS money and directly supports the activity of the practice from which the funding originates. Example: 0.32 wte physiotherapist in the managed practice in Blaenau Ffestiniog. 2. Primary care plus- In this domain physiotherapy if funded by non GMS primary care investment money such as the pacesetter, workforce and cluster revenue streams. Here the money supports the sustainability of primary care and the primary care activity of those practices involved in the agreed schemes. Example: The use of APPs. 3. Community Services- In this domain physiotherapy is funded from the Health Board s Hospital Community Health care (HCHS) budget and supports activity from primary care, secondary care and direct access referrals in that local area. Example: Llandudno Community Hospital physiotherapy department. 4. Community in secondary care as per 3. above but reflecting that YG and WMH sites provide significant community and primary care activity at their sites, being centres of large populations in north wales. YGC activity has moved to a community site model as part of the redevelopment project.this domain is also arguably where CMATS sits with the exception of East where it is primary care led. CMATS is an orthopaedic/rheumatology referral pathway rather than physiotherapy.
4 5. Secondary care- In this domain physiotherapy is funded from the Health Board s Hospital Community Health care (HCHS) budget and supports activity from secondary care based specialities. Examples Multi-disciplinary outpatient clinics working alongside the Consultant or post day surgery activity. 4.2 Potential future model Many GPs are already seeing the benefits of drawing in the expertise of experienced physiotherapists to work alongside them as the first point of contact for their MSK patients. Physiotherapists are able to advise on self-management, and initiate further investigations and referrals, when needed. This approach to service delivery puts physiotherapy expertise at the start of the pathway, where patients can most benefit. The National Plan for primary care in Wales commits to the importance of primary care as the bedrock of a sustainable health service, and the pivotal role of GPs within a multidisciplinary primary health care team. It places an emphasis on how we can harness and target all our available resources effectively and optimise how we utilise the skills of broad range of health professionals for the benefit of our patients - within a practice-based team. Given the advances made in BCUHB with regard to APPs in primary care and the likelihood of ongoing challenges in this sector the role of physiotherapy appears to provide one validated option, amongst others, to improve the situation. Therefore the future model for physiotherapy expects the visibility and use of physiotherapists in providing first line contact within primary care to continue and to grow, whilst offering the opportunity to re-provide the provision of some secondary care activity closer to people s homes through an enlarged primary/community service. The CMATS service should become part of the APP model. Effectively bringing that service directly into primary and community care. The new service pathway is outlined in appendix 1 and the change to the location of service delivery is shown below in figure 2. Figure 2
5 The future model proposes several changes to the existing situation. 1. That individual GP practices remain free to use their GMS funding to support a practice specific model of multi-disciplinary provision. This will apply to Health Board managed practices also. BCUHB s physiotherapy service will act as a provider of such service in the managed service model. In the contractor model GP practices can fund their own physiotherapist in one of three ways. Firstly they can contract for the service, secondly they can directly employ a physiotherapist as an employee and thirdly they could invite a physiotherapist to join the practice as a partner. In all cases the service supports the activity of the practice from which the funding originates. A model to support practices in difficulty could be developed whereby APPs could deliver first contact activity with a time-limited cost sharing arrangement between the Health Board and the GMS funded practice. An extension of this model could be for clusters, or groups of practice, to invest jointly from their individual GMS allocations to support GMS activity as a method of improving cluster/group sustainability. 2. That the primary care APP model, CMAT and community physiotherapy model integrate further. This will include moving community activity away from the secondary care sites wherever possible in line with the model developed from the YGC project. The model should support both first contact general practice activity and ongoing care from primary care, secondary care and direct access referral. Funding should be sourced from both non GMS primary care investment money and the Health Board s Hospital Community Health care budget. The integration of the CMATS service should further streamline referral pathways to musculoskeletal services. 3. Estate plans within clusters should increasingly consider the number and location of appropriate physiotherapy facilities to meet their local need and support the model. This should vary from a single hub supporting the whole locality to a more dispersed model working from both GP premises and local community Hospitals. 4. The provision of outpatient physiotherapy within secondary care supports models of secondary care service provision only. 5.0 Workforce All staff working within the primary care team has a minimum of 5 years clinical experience and are either undertaking or completed MSc level study. This experience and knowledge has ensured that they are specialists in the field of musculoskeletal medicine with both advanced clinical reasoning and diagnostic skills. The development of the extended scope roles and advanced practitioner roles is vital in this current economic climate. There is evidence of many Advanced Nurse Practitioner roles within primary care but the role of the Advanced Physiotherapy Practitioner in Primary Care is just emerging. The BCUHB APP service has been showcased at many national events with case studies published on both Public Health Wales and CSP internet pages and is essentially thought of as a service to aspire to within the field of Physiotherapy.
6 For the physiotherapist to be able to treat the patient in its entirety it is essential that they have the advanced skills tool kit which includes the ability to prescribe, refer for diagnostics, undertake joint and soft tissue injections and have the ability to refer for and interpret bloods. Most of these skills are gained via level 7 education and clinical mentoring. With this level of clinical skills they have the ability to see patient as the first point of contact, screen the patient for red flags, diagnose the condition as a GP would do and give early advice / education and sign post on as necessary. These roles are typically seen within secondary care, in clinics alongside Orthopaedic/ Rhuematology / Pain Consultants, A&E and CMATS. The essential skill set which they have developed provides a flexible cohort of staff who can work across a range of clinical settings according to service pressure and priorities. Injection Therapists Non Medical referral rights Non medical Prescribing West 10 14 8 Centre 6 6 7 East 10 12 6 BCUHB 26 32 21 6.0 Evaluation 6.1 Primary Aim - Increasing capacity in primary care This service has now been running since January 2015 with a gradual build-up of capacity such that there are now approximately 14 wte Advanced Practice Physiotherapist primary care posts.the model has gained widespread national interest and is now common place within the UK. Funding originated from the pacesetter scheme to test the concept and has been supplemented by the primary care workforce monies, cluster investment and through managed practice GMS monies. The number of practices now supported is 68; access for a further 12 is anticipated by March 18. Some 36,500 appointments have been provided since the inception of APPs in primary care supporting GP capacity. On average some 40% of MSK patients these have been seen as first contact by the Physiotherapists, however in some practices the percentage is as high as 76%.We aim to improve access to APPs and further support GPs by increasing the % of patients seen as first contact by ongoing training of navigator reception staff and working with GPs to understand the reasons behind this. Some patients will always choose to see a GP on the presentation of their symptom and some GPs will choose to refer on to the practice physio if patients present with more than one issue. Using the Bevan cost calculator the traditional GP pathway was costed out in steps and compared with the new APP pathway. The pathway consisted of first presentation of MSK condition, management in primary care and the pathway into secondary care orthopaedic services.
7 Traditional GP model = 9 steps APP pathway = 5 steps The removal of 4 steps equated to a reduction in time of 98 minutes per patient on the Orthopaedic pathway, totally a cost saving of 111.00 per patient. Total 278 min 180 min 98 min 204.07 93.07 111.00 The service evaluation has found evidence in favour of the APP managing MSK patients in primary care. The evidence suggested that the majority of the GP cohort of North Wales were supportive of the role of the APP and did in fact consider it a move in the right direction, benefitting both primary care services and the patient. Further to this it was evident that GP opinion was encouragingly positive and supportive toward the service. The service evaluation has established that whilst the APP model in primary care was beneficial, it also had its limitations and areas in need of further development. The most prominent finding from the questionnaire in terms of service development was that of GP education around the role and capabilities of the APP. This was followed by the need for greater access to the service, both in terms of capacity and availability. The service evaluation highlighted several recommendations for further positive development. Firstly, the APP within each practice should form an active part within the MDT. Secondly, further work was deemed necessary on GP education around APP red flag management and the governance processes that underpin this. Thirdly, as the service develops and expands a cost effectiveness exercise should be performed to assess the financial viability of the service. And finally, a service mapping process should be performed to identify the GP surgeries most in need of the APP model of care. The service evaluation outcome was positive toward the APP managing MSK patients in primary care as an alternative to the GP. However, the role of the APP in primary care at the time of writing was in its infancy, particularly with regard to acting as a first contact practitioner. Further research over an extended period of time is therefore required to fully evaluate its success. In June 2016 a patient satisfaction survey was undertaken with 200 questionnaires given out to patients. There was a 42% response rate, equal to 83 returned responses. A thematic analysis was conducted on the open questions highlighting the following themes. Good patient acceptance of this new model of care Excellent levels of patient satisfaction The need for it to operated on a more frequent basis Ease of access and appropriateness of locality. 6.2 Secondary impact of the scheme 6.2.1 Prescribing costs. Projections of annual costs saving on prescribing analgesics are estimated as 41,000 (table 1 below) based on the premise that physiotherapists are more likely to prescribe self help and exercise programmes rather than medication. This measures though only those where a reduced medication is offered and not those who are prescribed no medication. Further work needs to be done to fully understand the implications
8 for de-prescribing and also to evaluate whether there is a reduction in the number of MSK review patients in a GP caseload as identified earlier. Table 1 Location % of pts given prescription Av. Number of prescriptions per week Cost of analgesia per week West 14% 31 713 30231.20 East 4% 6 138.00 5851.20 Centre 5% 5 115.00 4876 BCUHB 8% 42 966 40958.40 Annual cost savings ( based on APP seeing pt. as alternative to GP) 6.2.2 Demonstrate a demand reduction of referrals into secondary care MSK services Most secondary care MSK services are accessed via CMATS. Since the development of the APP service, there has been a reduction on referrals into Orthopaedics, Pain and Rheumatology services. 2014/15 pre APP 2015/16 APP 2016/17 Reduction in Ref (since Apr15) 16,351 15,313 13,483 2868 372,840 Cost Saving (based on CMATS / Ortho NP appt = 130 There has also been a slight reduction of referrals into physiotherapy services across BCUHB although the data is not validated fully yet. However caution must be given to the interpretation of all these early finding as reductions are not universal across North Wales and cannot be fully correlated with areas where the APP scheme exist. In addition the longer term picture of demand into these services, based on rolling averages and known demographic growth, suggest the perspective on resources utilisation may be more about cost avoidance, which is containing growth and expenditure, rather than releasing resource to reinvest. Unfortunately no clear evaluation framework was established at the beginning of the scheme to measure the potential secondary impacts on secondary care and physiotherapy. That framework will be used throughout 2018 to look for evidence to support or deny any opportunity for system resource movement. Given the pressures to deliver the RTT target and the therapy 14 week component wait target any plan to move resource must be sure that it does not simply create a pressure elsewhere in the system. For services such as orthopaedics, rheumatology or physiotherapy any agreement to vire money into primary care requires a level of confidence in the evidence that currently does not exist from the available data.
9 7.0 Future developments A marketing campaign is essential to expose this new service to the public and take it to the next level. It is necessary to fully explain this new model of care, how primary care is changing and the role of the navigator, needing to ask a few questions enabling sign posting of the patient to the most appropriate clinician. A review of the skill level required for the APP role, for example the need for advanced practice such as injection therapy. The vision is for the APP to be a core member of the Primary care team, taking on all the MSK workload from the GP practices. At present physiotherapists are only taking on the MSK cases but going forwards it is imperative that we look at supporting GPs further with other chronic conditions. Enhanced evaluation to get information out of the GP systems EMIS WEB / VISION. To ensure an enhanced evaluation then funding is vital to develop a search tool to retrieve valuable information from EMIS WEB/ VISION. Key areas to research - To determine the GP MSK caseload pre APP service and to look at the current GP MSK caseload to establish if there is a reduction of MSK cases being seen - To monitor prescribing rates within the MSK caseload, pre APP and currently. - To monitor review rates back to the GP for MSK conditions pre and currently, to establish any trends. - 8.0 Recommendations 1. That the APP model continues as a scheme first and foremost to support primary care activity and sustainability. 2. That the existing primary care monies continues to support the scheme during 2018/19 Thus the 7.4 wte physiotherapy posts that have been funded via pacesetter/ workforce monies continue for a further year. 3. Further work is undertaken during 2018 to better understand the impact on other services in order to determine what if any, resource could be reallocated within the system.
10 Appendix 1 New Service Care pathway
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