Family Practice Vol. 20, No. 5, 578-582
© Oxford University Press 2003
Health Services Research |
GP referral for physiotherapy to musculoskeletal conditions—a qualitative study
Physiotherapy Department, Torbay Hospital, Torquay TQ2 7AA and
a Honiton Research Practice, Marlpits Lane, Honiton EX14 2NY, UK.
Correspondence to Mark Clemence; E-mail: mclemence{at}connectfree.co.uk
Clemence ML and Seamark DA. GP referral for physiotherapy to musculoskeletal conditions— a qualitative study. Family Practice 2003; 20: 578–582.
Received 12 December 2002; Revised 25 April 2003; Accepted 19 May 2003.
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Abstract |
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Background. Little is known about the dynamics of GP referral for physiotherapy. Better understanding of this process is important because of the growing number of physiotherapy referrals by GPs.
Objectives. Our aim was to achieve insight into the experiences and views of patients, GPs and physiotherapists in relation to physiotherapy referral for musculoskeletal conditions.
Method. The study involved qualitative methodology using 22 semi-structured in-depth interviews. The interviews were recorded and transcribed verbatim. The transcripts were coded and analysed using the methods developed in grounded theory. Interviews were undertaken with GPs in primary care, Health Authority and hospital locations. Interviews with physiotherapists and patients were undertaken within community and district hospital locations.
Results. Three classifications of referral type were developed by the authors from the data, ‘appropriate referral’, ‘load-sharing referral’ and ‘dumping referral’. There are descriptions of influences on GP referral behaviour, physiotherapists’ response to appropriateness and expectations from the perspective of GPs and physiotherapists. Communication was shown as important in determining appropriate referral, but the quality of communication was variable. GPs’ past experience of physiotherapy significantly affected referral. Patients’ expectations about physiotherapy were described as variable and sometimes unrealistic.
Conclusions. The selection of appropriate referrals by GPs could be helped by improved communication and better definitions of appropriateness. Closer working between the two professions would result in the better management of problematic patients and prevent wasted resources through avoiding inappropriate referral. Written guidelines appeared to be of less use than direct contact. The concept of expectations appeared relevant to multiple aspects of physiotherapy referral.
Keywords. GPs, musculoskeletal problems, physiotherapy, referral.
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Introduction |
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Direct GP referral for National Health Service physiotherapy has existed since the 1970s.1 The majority of early studies into direct referral focus on demand, the types of conditions referred, service structure and clinical outcome.2–4 A review of studies5 showed the popularity and perceived effectiveness of GP referral for physiotherapy, but little work has been conducted on the expectations and perceptions of referral. One group used qualitative methodology to obtain data from patients, doctors and physiotherapists within the same study,6 whilst others discussed the issue of GP referral of patients with underlying psychological causes of their physical symptoms.7 The authors highlighted that GPs regularly refer this type of patient, but stated that there is a paucity of information on this aspect of physiotherapy referral. Others have argued that there is a direct association between expectation and satisfaction,8 and there is some evidence to support this association within physiotherapy.9 Carter et al.10 argued that GP referral rates were significantly affected by resource-related issues.
The study aimed to achieve insight into the experiences and views of patients, GPs and physiotherapists in relation to physiotherapy referral. Due to a lack of previous research, the question was approached using qualitative methodology. This paper focuses on influences on GP referral behaviour, physiotherapist response to appropriateness and expectations from the perspective of GPs and physiotherapists.
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Method |
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The project received LREC approval. We identified 18 respondents (six patients, six GPs and six physiotherapists) using the key informant technique. A key informant is an expert source of information and is able to provide insight into the behaviour of those around them.11 A further two physiotherapist and two GP respondents were purposely selected using theoretical sampling to develop emergent themes,12 giving a total of 22 respondents. The GP informants were selected to include three with Primary Care Group management responsibilities, GPs involved in Clinical Governance and research. The physiotherapists were selected to include those in management roles and senior clinicians with specialist skills in treating musculoskeletal conditions. Patients were selected to reflect the most common types of musculoskeletal conditions referred for physiotherapy (as indicated by a local audit of conditions referred prior to conducting the main research study), namely cervical and lumbar spine pain, shoulder pain and lower limb trauma.
Respondents were interviewed by one of the authors (MLC). Data were collected using semi-structured interviews; a list of the topics is shown in Appendix 1. The results were recorded on audiotape and transcribed verbatim by a research assistant and one of the authors (MLC). The interviews lasted up to 45 min each. The transcripts were analysed using the techniques of grounded theory.12,13 This involved identifying conceptual themes in the text which were given names [codes]. Codes expressing related concepts were grouped together into larger units termed categories. A process of analysis and revision was adopted whereby provisional coding was modified in the light of newly gathered data, which in turn informed the questioning used during interviews. Triagulation of data sources was adopted within the sampling strategy to improve the range of data obtained.14
To increase the validity of the coding framework, a number of strategies were adopted. The initial categories developed were subjected to member checking.15 This entailed passing copies of an interim report of the findings to 12 GP and physiotherapist respondents and requesting written comments. Member checking was also used to check transcription accuracy by passing copies of their interview transcripts to one GP and one physiotherapist respondent. Both methods produced high degrees of agreement with the authors. The use of member checking in this study is expanded further in the Discussion. In addition, each transcription was checked against the original tape and corrected. Further validation of the coding structure was achieved by using a person independent of the study to code a sample of the transcripts and then their coding definitions were compared with those of the authors. The final coding structure was adapted to accommodate any divergent opinions.
Within qualitative research, it is necessary to adopt a range of strategies to achieve validity.15,16 The other strategies used in this study included negative case analysis and an attitude of reflexivity. Negative case analysis involved deliberately seeking examples within the data which appeared to nullify the emerging coding framework and then using these so-called ‘negative cases’ to develop a more comprehensive analysis. Reflexivity was facilitated by keeping a research journal throughout this study, providing an audit trail.
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Results |
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Referral type
Three classifications of referral types were developed from the data by the authors: the ‘appropriate’ referral, the ‘load-sharing’ referral and the ‘dumping’ referral.
The selection of ‘appropriate’ referrals for physiotherapy centred on the GPs’ gatekeeper role, which was supported by two-way communication with physiotherapists.
"We would always value feedback, we do get valuable feedback, we have occasional meetings with our physios and they show what we’ve done and the question is ‘are our referrals appropriate?’ and the answer is always yes, so there is a feedback mechanism." (GP2)"Everything is a limited resource and I think the more appropriately we refer the more effectively your service will be used and the more satisfaction we will get . . . it’s very frustrating to refer somebody and then find out it was an inappropriate referral." (GP3)
There was an association between so-called ‘heartsink’ patients and physiotherapy referral; physiotherapy was seen as a way of relieving pressure on GPs from patients for whom they were unable to resolve their chronic musculoskeletal symptoms. This was defined as ‘load-sharing’ when it was part of a planned management strategy by the GP and considered that the patient might gain some benefit (often psychological rather that physical).
"I think that practitioners genuinely and appropriately feel that they have to deflect that, share that . . . clinical tragedy or personal tragedy with someone else, it simply becomes unbearable to deal with it any more . . . I think we refer to our partners, we get a second opinion, anybody we can lay our hands on and I think its not dumping but a plea, a metaphorical plea for assistance." (GP7)"One of the GPs . . . felt that some patients were so awful that they needed to be shared." (Physiotherapist 7)
In contrast, using physiotherapy as a means of relieving GPs’ stress in the full knowledge that a patient was unlikely to gain any benefit and associated with low expectations of outcome was defined as ‘the dump’.
"I think if you asked quite a few of them [GPs] it would be; what can I do with this patient next? Oh physiotherapy will do, so a lot of it is just another option to do with somebody whose problem you can’t really do much about or you know, the type who after a while they get better anyway, so I think we have fairly low expectations of what can be changed by physiotherapy." (GP5)"Some GPs I get the impression are sort of saying ‘look I don’t know what to do with this patient . . . I don’t really care what you do with them as long as they don’t keep consulting me’." (Physiotherapist 1)
Communication
There was an important role of communication in facilitating the selection of appropriate referrals by GPs.
"Sometimes the GPs will phone me up . . . and say I’ve got this patient with a certain condition, can physiotherapy be of help? Certainly it cuts down on unnecessary referrals." (Physiotherapist 8)
There appeared to be wide variation in the quality of communication between GPs and the physiotherapists who provided their services. Two GP respondents reported the desire for greater communication (GP1 and GP8).
"We hear secondary care talking about inappropriate referrals quite a lot but we get very little feedback about our referring processes . . . So if you do feel that we are making a lot of inappropriate referrals . . . you should tell us." (GP1)
Others reported regular discussion about the selection of referrals. Discharge letters and reports had a significant influence on future referral behaviour, but locally produced written guidelines about physiotherapy referral appeared to be less important than more direct types of communication. On-site physiotherapy services appeared to increase the opportunity for communication but did not automatically increase understanding about physiotherapy; indeed most of the GPs expressed some degree of uncertainty about the exact nature of physiotherapy interventions. In part, this was recognition of the clinical autonomy of physiotherapy. Sometimes referral behaviour was influenced by knowledge of complementary therapies, especially chiropractic and osteopathy.
"I think their contact with other professionals, like chiropractors and osteopaths that they use . . . will have an effect on their view and their expectations of what we can achieve." (Physiotherapist 6)
Experience
GPs’ past experience of physiotherapy was described as significantly affecting all eight GPs’ use of physiotherapy referral. Experience gained in clinical practice appeared to be more important that formal training.
"Certainly my generation had no training or teaching or you know, guidance if you like, as to what physios can do. If you don’t know what they can do, how can you refer to them appropriately?" (GP8)"I spent a day in a physio department when I was a trainee, but that was a number of years ago and I’m sure that things have moved on from there and you tend to acquire it [understanding] more through osmosis by the letters you get back." (GP3)
Similarly, patients expectations were influenced by previous experience of physiotherapy.
"Some people come with a preconceived idea that they will have massage and some form of manipulation and others who have been before, obviously been through the system will know the type of services that we offer." (Physiotherapist 5)
Expectations
Patients had varied expectations about physiotherapy. One GP respondent suggested dimensions within patients’ expectations of physiotherapy referral.
"I think their expectations and their knowledge are hugely variable. For some people they’re looking for something as simple as a bit of heat and massage, and others are looking for perhaps a short course of treatment, but often advice how to avoid making things worse but equally other things they can do at home to make it better." (GP4)
There often appeared to be significant uncertainty about physiotherapy before the first appointment. Some patients reported having no specific expectations at their first appointment.
"I don’t really know a lot about the physiotherapy department and everything so you sort of go with a blank canvas in your mind really because you don’t really know what’s going to happen." (Patient 3)
For others, their previous experience or knowledge of physiotherapy affected their expectations.
"I suppose I knew what to expect from it, I knew that I wouldn’t necessarily get completely better so my expectations weren’t quite so high because my shoulder still hasn’t completely righted." (Patient 1)"I’ve been here before anyhow so, you know I knew what to expect." (Patient 6)
GPs appeared to provide little information about physiotherapy or have any influence on expectations prior to initial contact. This might have in part been related to ignorance on the part of the GPs or not wanting to influence the choice of treatment by physiotherapists.
"He said I’m referring you to the physiotherapists and, and he said she will give you some exercises . . . just very, very brief." (Patient 5)"I can only tell you what I say and that is some physiotherapy might help you. I don’t commit the physiotherapist to one form of treatment or another for the reasons I’ve hinted at earlier, I don’t really understand it, its not for me to make those judgements I think, and my usual phrase on the physio referral form is this is the situation with this patient, can you help?" (GP5)
Although expectations mostly appeared related to the treatment process or outcome, expectations also existed in relation to the patients’ contribution to the treatment process.
"I was delighted when the doctor referred me because I felt I would get better quicker . . . (I could) do the correct things that I was supposed to do." (Patient 2)
GPs and physiotherapists stated that sometimes patients had unrealistic expectations associated with their perceptions of complementary health care practice.
"They think physio equals magic probably because they know about manipulation, chiropractic, they think it’s going to be a treatment modality probably I suspect rather than necessarily advice." (GP2)"I would think the expectations of the patients may be sometimes more unrealistic than what we’ve got because we’ve had the experience of seeing different and loads more people with back pain and we can make a judgement of that, a judgement which becomes easier I think the more experience you get." (Physiotherapist 3)
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Discussion |
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TopAbstractIntroductionMethodResultsDiscussionAppendix 1References |
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In view of the small sample size, specific context and methodological decisions in this study, some caution must be exercized when generalizing the findings. Qualitative research data are directly affected by the context in which they are collected,14 and are affected by the methodology of data collection and analysis. Relevance comes by the reader transferring the findings of a study to their own situation. The decision not to send the interim report to patients to assist in member checking (see Method) creates a study more strongly weighted towards the GPs’ and physiotherapists’ perspective, but the elimination of bias is not necessarily an appropriate concept in qualitative research.14
This study has been undertaken in an area where there has been little previous research, and provides new insight. GPs’ understanding and use of physiotherapy appeared varied and there was strong evidence to suggest that referral was used not only in cases of clinical need but also as a means of relieving pressure when managing difficult patients. There was widespread uncertainty about the exact nature of physiotherapy on the part of GPs and patients. Previous experience was shown to be important in affecting expectations of referral in both respondent groups.
The selection of appropriate referrals caused some difficulty amongst GPs, but was helped by good communication with physiotherapists. However, appropriate physiotherapy referral needs better definition and at present appeared to be dependent on local physiotherapy opinion rather than research or national guidelines. Written guidelines did not appear to be a substitute for direct communication, and it is doubtful that on their own they would resolve the issues associated with referral selection. The value of discharge letters was reported by one respondent (GP3), yet this means of communication has only been the subject of one paper.17
The concept of expectations appeared complex and at times difficult to define.18 Not only did respondents express expectations about the treatment process and the end result, but expectations were expressed in terms of the respondents’ own contribution to the referral process, wider societal expectations, and expectations relating to interpersonal interaction in the clinical situation. Finally, patient respondents frequently expressed areas of uncertainty where the respondent did not have clearly formed expectations.
There is a need for better communication between GPs and physiotherapists to facilitate mutual understanding of skills and problems encountered. Closer working would result in better management of problematic patients and prevent wasted resources through avoiding inappropriate referral. Written guidelines for physiotherapy referral appear to be of minimal value in isolation and it is doubtful that investing large amounts of resources in them will produce good value for money. However, there are resource implications in terms of time, clerical support and capital investment to achieve better communication. The information that GPs give to patients prior to referral could be improved and used to enhance the non-specific (placebo) effects of treatment in a way that is ethical but optimizes clinical outcome.19 Patient knowledge about physiotherapy did not appear to be affected by consultation with the GP prior to referral.
Appropriate physiotherapy referral requires better definition as a concept and to be understood as something more complex than an expression of clinical suitability. It is affected by patient-, clinician- and service-related factors. The issue of unrealistic patient expectations needs to be addressed in ways which reconcile patients’ rights with available levels of resources. Past experience significantly affects patients’ and GPs’ perceptions of a new physiotherapy referral, and this study suggests that better information and communication would help to alleviate some of the present uncertainties.
Communication between patients, GPs and physiotherapists emerged as a significant concept within this study and would benefit from further research. In particular, the effect of improved communication on expectation and outcome is a potentially fruitful area of work. Exploration of role sharing between GPs and physiotherapists in managing complex or ‘heartsink’ patients is another area which could improve patient care.
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Appendix 1 |
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TopAbstractIntroductionMethodResultsDiscussionAppendix 1References |
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Outline of concepts used in interviews
GP interviews.
- Expectations
- Patient consultation reasons/triggers
- Physiotherapy referral indications
- GP training
- Referral guidelines
- ‘Heartsink’ patients
- Organization of Primary Care Trusts
- Complementary health care
Physiotherapist interviews.
- Expectations
- Assessment and consent
- Medication and physiotherapy
- Inappropriate referral
- Complementary health care
Patient interviews.
- Expectations
- Description of ‘patient journey’ through health care
- Influences on ideas of physiotherapy
- Consent
- Complementary health care
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Acknowledgments |
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The authors would like to acknowledge the invaluable support given by Dr P Lings and Ms S Blake, and also the time given by participants. This paper was produced from research undertaken as an MPhil degree by MLC at the University of Exeter. The authors would gratefully like to acknowledge the support of NHS Executive South West (start up grant), the Somerset and North Devon Primary Care Research Network and the Chartered Society of Physiotherapy Charitable Trust.
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References |
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TopAbstractIntroductionMethodResultsDiscussionAppendix 1References |
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