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Direct access to physiotherapy

Patients with musculoskeletal conditions causing pain do not currently have direct access to physiotherapy on the NHS, but perhaps they should. A new pilot trial at Keele University in the UK has found that patients who can arrange to see physiotherapists without going through their GP (the current situation) reported benefits without overwhelming the service.

The study, Stepping up the Evidence for Musculoskeletal Services (STEMS), is the first randomised clinical trial to be conducted into direct patient access to physiotherapy, and was funded by the Chartered Society of Physiotherapy Charitable Trust.

Dr Annette Bishop, NIHR Research Fellow of Musculoskeletal Intervention Studies at Keele University, who led the study, said: “This research is the first randomised study anywhere in the world of direct patient access to physiotherapy. It fits with national calls to investigate new models of care to better meet demand for health services for patients with pain conditions.”

The current picture

The study has been conducted within a national climate of record demand from patients for primary health care in the UK. As well as an increase in the number of patient consultations, there has been a shift towards more complex and older patient populations, and challenges in the recruitment and retention of general practitioners.

Furthermore, patients with musculoskeletal pain problems account for at least 17 per cent of GP consultations and the recent Global Burden of Disease Study predicts that this will increase.

With this in mind, there have been calls by the Primary Care Workforce Commission, House of Commons Health Select Committee and the General Practice Forward View to investigate the impact of expanding the primary care workforce.

The senior researcher on the STEMS study, NIHR Professor Nadine Foster explains:

“One potential solution to meet this record demand would be to allow patients with musculoskeletal pain conditions to directly access physiotherapy services without a referral from their GP. Research to date is limited to observational research only but despite reported benefits, widespread availability of direct patient access to NHS physiotherapy has not occurred.”

“The STEMS pilot trial was undertaken to investigate the feasibility of a future large trial to compare the clinical and cost-effectiveness of the addition of direct patient access to physiotherapy versus continuing with usual GP-led care alone for adults with aches and pains.”


The STEMS trial demonstrated that despite actively marketing the new direct access pathway, the physiotherapy service did not experience an unmanageable increase in demand, nor did the level of inappropriate patient referrals change

The pilot has also shown that a full randomised control trial is feasible. GP practices, physiotherapy services and patients were willing to participate, showing that patient direct access to physiotherapy can be introduced into existing physiotherapy services.

Dr Annette Bishop comments:

“The STEMS pilot trial showed that introducing direct access into an existing physiotherapy service did not overwhelm the service and no concerns about safety were identified.

For more information about the STEMS trial, see the STEMS webpages

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