Physiotherapy associations across the world are working to remove barriers to healthcare and physiotherapy so that patients can have safe and affordable—if not free—access to the physiotherapy services they need, where and when they need them.

As the APA advocates for publicly funded first contact physiotherapy in primary care in Australia, we look at overseas models and at their challenges and opportunities.

We presented the successful first contact practitioner model from the UK in these pages (see ‘Funding first contact’, InMotion May 2022 here) and are working with the UK’s Chartered Society of Physiotherapy to learn from its experience, albeit with adaptation to the Australian context.

The APA also engages regularly with our colleagues from the American Physical Therapy Association and the Canadian Physiotherapy Association.

Beyond the Anglosphere, the APA has recently met with the French Conseil National de l’Ordre des Masseurs-Kinésithérapeutes to discuss its recent success with direct access physiotherapy. 

The term ‘direct access physiotherapy’ is the one used in France. In our advocacy, the APA prefers ‘publicly funded first contact physiotherapy in primary care’.

The Conseil National de l’Ordre des Masseurs-Kinésithérapeutes’ core missions are similar to Ahpra’s—the registration of physiotherapists, the implementation of a code of conduct and compliance and regulation.

The Conseil also has a mission of advocacy for the physiotherapy profession and the health sector as a whole.

There are about 103,000 registered physiotherapists in France for a population of almost 68 million.

Despite significantly different healthcare systems and differences in geography and demographics, the challenges in France are similar to those we see in Australia.

The healthcare system has not been able to keep up with demographic trends (an ageing population), shifts in health needs (an increasing prevalence of chronic conditions) and challenges due to the medico-centric model (a decline in the availability of medical services).

A notable difference in access to physiotherapy is that until very recently in France, it was impossible to receive treatment from a physiotherapist without seeing a GP first—at all, not even if the patient was willing to pay out of pocket.

Similar to seeing a medical specialist, a referral from a GP was always required for treatment.

Without a referral, French physiotherapists were only allowed to perform wellbeing, preventive or aesthetic massages or physiotherapy check-ups.

Since 2016, they could also intervene in case of emergency if no medical doctor was available.

Things started to change in 2019.

In order to reduce the number of presentations in emergency departments, physiotherapists working in multidisciplinary clinics (that include a GP) were allowed to see and treat patients presenting with acute lower back pain or with sprained ankles, without the need for a GP visit first.

There are a number of inclusion and exclusion criteria including the patient’s age, the physiotherapist’s access to the patient’s medical records and a few clinical yellow and red flags.

Then, in 2021, legislation was tabled in the French Parliament to pave the way for the formal introduction of direct access physiotherapy.

After almost two years of work by a joint parliamentary commission to agree on the terms, the bill was approved by both chambers on Tuesday, 9 and Wednesday, 10 May 2023.

French physiotherapists who work in primary care in a multidisciplinary coordinated care setting that includes a GP (the law lists explicitly the types of settings that are eligible) can see and treat patients without a GP referral:

•    with a limit of eight sessions per patient when no medical diagnosis has been made
•    with a full initial assessment report and progress reports sent to the patient’s GP and uploaded to the patient’s shared medical records.

The law also introduces the formal trial of direct access physiotherapy for physiotherapists who work in a multidisciplinary team with practitioners operating from different locations with a formal and contractual relationship for the coordination of care.

The trial will be rolled out for five years in six départements. (Départements do not have an equivalent in Australia. It is the jurisdiction sitting between the city council and the region. There are 96 of them in metropolitan France and five more overseas. Primary healthcare and social services and policies are usually designed and implemented at that level of government.)

At the time of writing, direct access physiotherapy sessions are not yet eligible for Medicare-like rebates, but this is expected to be introduced soon.

How did they get there?

The Conseil de l’Ordre had been advocating for many years for direct access physiotherapy but had met opposition from GP-representative organisations.

A number of factors have contributed to make the case for the inevitability of implementing direct access physiotherapy.

As mentioned earlier, the French healthcare system is under pressure.

Hospital care and emergency departments are described as being in crisis, access to GPs is declining and waiting times are increasing—the supply just does not meet demand.

Six million French people are not enrolled with a GP for lack of GPs being available.

Mandatory GP enrolment was introduced in France in 2004–06 and today about 10 per cent of the population cannot comply with this rule.

Those not enrolled with a GP are penalised as they do not have access to the highest Medicare-equivalent rebates.

The Conseil de l’Ordre’s relentless advocacy and stakeholder engagement included lobbying of the government, patient-facing education campaigns and working with GPs and other health professional representatives.

The Conseil de l’Ordre also translated the UK National Health Service’s 2020 Serious Pathology Guide for Clinicians in Primary Care (click here) to address GPs’ concerns that physiotherapists might miss a serious or critical condition when treating a patient.

A younger generation of GPs seems more willing to work collaboratively with other health professionals.

This trend is reflected in the positioning of their representative organisations, leading the representatives of physiotherapy, general practice, dentistry, nursing, podiatry, pharmacy and midwifery to publish a joint position and recommendations to improve access to healthcare in France.

There was also a favourable policy window during the pandemic.

The Minister for Solidarity and Health at the time, Olivier Véran, supported the idea of trialling direct access physiotherapy and pushed to introduce the legislation that would allow it.

A number of members of parliament also supported direct access physiotherapy by introducing the equivalent of private members’ bills.

As in the UK, we see that direct access physiotherapy in primary care is introduced in response to a clear need identified in the health sector, relentless advocacy, collaboration with GP representatives and political will.

Unfortunately, it also appears that things need to get worse before they get better.

This is our call to the Australian Government: things should not need to get worse before they get better.

The APA is ready—right now—to work with the government to develop a model of publicly funded first contact physiotherapy suitable for Australia’s primary care.