Funding first contact
APA General Manager, Policy and Government Relations Simon Tatz explains what publicly funded first contact physiotherapy can do for Australian healthcare.
A call for publicly funded first contact physiotherapy (FCP) is a critical part of our 2022 election campaign and our ongoing advocacy for a stronger role for physiotherapy in the health system.
Physiotherapists are already first contact practitioners but the lack of publicly funded (Medicare) access to FCP in primary care means that Australians are missing out on better and faster access to diagnosis and treatment of musculoskeletal pain and conditions.
Around 15 years ago, long waiting lists for GP appointments began to create serious problems in the United Kingdom’s health system.
With one in five GP appointments deemed ‘unnecessary’—many consultations were referrals for orthopaedic consultations or were for musculoskeletal issues that GPs couldn’t address—UK healthcare reached a tipping point.
As GP capacity was stretched and workloads increased, along with ‘competition’ from clinical pharmacists, a slow shift in thinking took place.
The solutions that emerged were based on the work of advanced practice physiotherapists, evidence from physiotherapists working in triage models and recognition of the increase in self-referrals.
The UK government, hungry for answers, opened the policy ‘window’ to the development of FCP services to ensure that, where appropriate, patients with musculoskeletal conditions are seen by the right person in a primary care setting and receive appropriate care in a timely manner.
The model positioned physiotherapists at the start of the musculoskeletal pathway and improved the patient experience and outcomes.
FCP was never about parachuting a physiotherapist into a GP practice.
It was based on a push for a multidisciplinary model of care that increased the role of physiotherapists in diagnoses and the assessment of patients.
It became the foundation of a system-wide change that streamlined care pathways.
The UK modelling showed that physiotherapists would take about half of the GP musculoskeletal workload, with a target (not yet reached) of one first contact practitioner per 10,000 population.
GPs would upskill by working alongside physiotherapists and patients would benefit from reduced waiting times and opioid prescriptions.
What made this massive transformation happen is complex, but, in short, the UK government funded it.
After three years of model development, the government set up more than 40 trial sites to produce the evidence and evaluation needed for a rollout across the health system.
Most importantly, it was backed by the British Medical Association.
The British Medical Association, seeking solutions to its own workforce issues and increasing waiting lists, saw the benefits of collaborating with the physiotherapy profession on an FCP framework and implementation.
Another significant driver was a 2016 UK parliamentary inquiry into primary care.
Reading the presentations and findings is like time travelling into what we hope will be Australia’s future.
The report saw value in multidisciplinary teams using their skills to meet the needs of patients much earlier in their journeys and in allowing GPs to concentrate on the aspects of care that only they can provide.
It also saw ‘clear benefits’ for patients in basic reforms such as enabling self-referral to physiotherapists.
Many years were spent addressing advanced-level practice, governance and the standards for physiotherapists working under the FCP model.
There was a need to educate physiotherapists about the model and its benefits; such a major reform did encounter fragmentation and gaps in professional standards and pathways that took time to get right.
Today, the UK’s National Health Service offers FCP provided by registered, qualified, autonomous clinical practitioners who are able to assess, diagnose, treat and discharge a person without a medical referral—where appropriate.
Although FCP now takes a significant proportion of the musculoskeletal workload from GPs, doctors continue to see a proportion of musculoskeletal patients, with first contact practitioners providing advice and expertise to the whole GP team.
It took over three years to move from trials of FCP to ‘launch’ and a lot of work had to be done to explain to the public what physiotherapists do and how FCP works within the GP clinical setting.
The APA is advocating for trials of the FCP model in Australia.
However, there is a long journey full of obstacles—the steeplechase of health reform—before we will approach the UK’s success.
In the UK, along with upskilling physiotherapists and GPs, the lack of patient awareness and understanding required investment in health education for the community.
We have received tremendous help from our UK colleagues in learning about how they implemented FCP and about the internal and external issues they addressed.
But we have other, perhaps more mountainous, obstacles in Australia.
The Medicare fee-for-service model is not (yet) flexible enough to accommodate highly skilled private practice physiotherapists working within GP clinics.
In the UK, referral pathways are negotiated locally, with an emphasis on self-management and supporting clinics to personalise healthcare and services.
Significantly, in the UK, FCP is supported by the powerful British Medical Association.
We are currently liaising with various Australian medical associations as it is so important to have them working with us on this.
The APA has called on governments to fund a pilot to trial the FCP model in Australia.
Physiotherapy is essential care for the close to 7 million Australians who live with musculoskeletal conditions.
This progress won’t be easy to achieve.
It must be driven and funded by governments willing to overhaul the health system.
Establishing priority pathways through publicly funded FCP will provide better and faster access to diagnosis, treatment and care of musculoskeletal pain and conditions.
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