Skip to main content Accessibility help
Hostname: page-component-55597f9d44-l69ms Total loading time: 0.329 Render date: 2022-08-13T05:52:49.980Z Has data issue: true Feature Flags: { "shouldUseShareProductTool": true, "shouldUseHypothesis": true, "isUnsiloEnabled": true, "useRatesEcommerce": false, "useNewApi": true } hasContentIssue true

SAPC hot topic: is it a dangerous idea to make physiotherapists the gatekeepers of frontline primary care for all patients with musculoskeletal problems?

Published online by Cambridge University Press:  28 August 2013

Annette Bishop*
NIHR Research Fellow, Research Institute Primary Care Sciences, Keele University, Staffordshire, UK
Nadine E. Foster
NIHR Professor of Musculoskeletal Health in Primary Care, Research Institute Primary Care Sciences, Keele University, Staffordshire, UK
Peter Croft
Professor of Primary Care Epidemiology, Research Institute Primary Care Sciences, Keele University, Staffordshire, UK
Correspondence to: Annette Bishop, NIHR Research Fellow, Arthritis Research UK Primary Care Centre, Research Institute Primary Care Sciences, Keele University, Staffordshire ST5 5BG, UK. Email:
Rights & Permissions[Opens in a new window]


Copyright © Cambridge University Press 2013 

At our 42nd SAPC Annual Scientific Meeting in Nottingham, four brave souls faced a critical audience in our Dangerous Ideas Soapbox. We asked the audience to vote for the idea which they thought was creative (new), challenging (dangerous) and had the potential to make a difference. Our winner this year was Annette Bishop. She outlines her dangerous idea in our latest Hot Topic article. What do you think? Send us feedback via Twitter (@sapcacuk) or by email to

Musculoskeletal conditions are common. They make a large and significant contribution to the workload of general practitioners, currently accounting for one-quarter of all consultations, and are the most common reason for patients to seek repeat consultations in primary care (Picavet and Schouten, Reference Picavet and Schouten2003, Department of Health, 2006). The predicted rise in the overall age of the UK population over the next 20 years will result in a substantial increase in the prevalence of musculoskeletal conditions. Coupled with rising public expectations of health care, this will drive up demands on GPs. The time has come to ask if the traditional model of primary care in which the GP sits as gatekeeper is the most efficient and effective way for the NHS to provide care for patients with musculoskeletal problems. Shifting first contact care for patients with musculoskeletal conditions to physiotherapists provides a clear and effective alternative.

Physiotherapists have the right skills, expertise and interest

The primary care management of many musculoskeletal conditions is more about managing symptoms and promoting function and activity than diagnosis and medical treatment. Best evidence guidelines for the care of patients with musculoskeletal conditions recommend supporting people to stay active and at work, helping them to set and realise realistic goals regarding their condition and providing interventions such as exercise programmes, manual therapy and acupuncture (NICE, 2008; Savigny et al., Reference Savigny, Watson and Underwood2009). Physiotherapists are specifically trained and equipped to deliver such care and there is evidence that they improve clinical outcomes for this group of patients. By contrast, many GPs – although certainly not all – have limited interest, expertise and training to deal effectively with many of these musculoskeletal conditions (Lanyon et al., Reference Lanyon, Pope and Croft1995). Traditionally GPs receive little training in common musculoskeletal problems and can feel ill-equipped to manage patients with common musculoskeletal conditions such as back pain (Breen et al., Reference Breen, Austin, Campion-Smith, Carr and Mann2007).

Although currently patients with musculoskeletal conditions requiring prescription medication or sickness certification would still need to see a GP, physiotherapists in the UK have recently been granted independent prescribing rights. Many GPs would also welcome a change in legislation allowing physiotherapists to handle sickness certification (Wynne-Jones et al., Reference Wynne-Jones, Mallen, Main and Dunn2010).

The evidence in support of changing the GP-led model of care is growing, with direct access to physiotherapists well established in countries such as Australia, New Zealand, Canada, several US states, the Netherlands and Scotland. Published research is also demonstrating that physiotherapists can provide a front-line service that saves money, provides high levels of patient satisfaction, and improves clinical outcomes for this group of patients (Galley, Reference Galley1977; Massey, Reference Massey2002; Holdsworth and Webster, Reference Holdsworth and Webster2004).

Physiotherapy is a cost-effective intervention

Physiotherapists are able to deliver many of the cost-effective treatments available in primary care (Lin et al., Reference Lin, Haas, Maher, Machado and van Tulder2011), including strong controlled trial evidence of the effectiveness of their delivery of biopsychosocial care for patients with common musculoskeletal conditions (Hill et al., Reference Hill, Whitehurst, Lewis, Bryan, Dunn, Foster, Konstantinou, Main, Mason, Somerville, Sowden, Vohora and Hay2011). Physiotherapists have been early adopters of stratified care for patients with low back pain, where patients at low risk of poor outcome receive brief advice and support to self-manage while those at higher risk are provided with courses of treatment that target the patients’ physical and psychosocial obstacles to recovery. In addition, evidence also shows that early access to physiotherapy reduces the time patients are off-sick, helps prevent acute problems becoming chronic, and reduces long-term pain and disability (Nordeman et al., Reference Nordeman, Nilsson, Moller and Gunnarsson2006; Savigny et al., Reference Savigny, Watson and Underwood2009; Addley et al., Reference Addley, Burke and McQuillan2010).

Physiotherapy is safe

A common and important argument voiced in favour of a GP-led model of care for patients with musculoskeletal problems is that serious pathologies have to be identified and patients need to be appropriately selected and referred for urgent medical management. In patients with musculoskeletal problems, serious pathologies are rare. Using the example of back pain, <1% of primary care cases are due to serious pathology (Henschke et al., Reference Henschke, Maher, Refshauge, Herbert, Cumming, Bleasel, York, Das and McAuley2009). Research shows other health professionals are just as able as GPs to recognise red flag symptoms (Jette et al., Reference Jette, Ardleigh, Chandler and McShea2006; Leemrijse et al., Reference Leemrijse, Swinkels and Veenhof2008; Taylor et al., Reference Taylor, Norman, Roddy, Tang, Pagram and Hearn2011).

But surely patients with multiple problems need the generalist?

More people are living with multiple health conditions and multimorbidity increases with age. By the age of 65 years around 65% of the population have two or more co-existing conditions (Barnett et al., Reference Barnett, Mercer, Norbury, Watt, Wyke and Guthrie2012). However, even when patients themselves prioritise their musculoskeletal problem, the GP tends to place a higher priority on the other health conditions. Studies confirm that patients with common musculoskeletal problems such as osteoarthritis (OA) or back pain complain that GPs ‘don't take their problem seriously’ (Alami et al., Reference Alami, Boutron, Desjeux, Hirschhorn, Meric, Rannou and Poiraudeau2011).

If physiotherapists were on the frontline, then of course overall responsibility would still lie with the GP for patients with conditions such as diabetes or coronary heart disease who expect and require the attention of a doctor. But these conditions, and the commonest musculoskeletal problems such as OA and back pain, can all be considered as long-term conditions where patients need skilled confident advice and support to self-manage, notably with exercise and activity. Physiotherapists therefore have a significant contribution to make in the management of many long-term conditions, and patients presenting with other morbidities alongside musculoskeletal problems would gain additional benefits from a physiotherapy-led service.

The Royal College of General Practitioners has acknowledged that primary care is moving towards a ‘system of integrated care, where clinicians work closely together in flexible teams, formed around the needs of the patient and not driven by professional convenience or historic location’ (RCGP, 2013). Physiotherapists are well placed to contribute to making this vision a reality by taking responsibility for frontline primary care for patients with musculoskeletal problems. The accompanying drive to develop the education, practice patterns and licensure of physiotherapy to deliver the workforce to do this carries exciting potential for an effective and satisfying service for patients suffering from conditions which are the commonest cause of disability in the community and for an effective and satisfying partnership between physiotherapists and GPs and their practice teams.


Annette Bishop and Nadine Foster are funded by a NIHR Research Professorship Award to Professor Nadine Foster.


Addley, K., Burke, C.McQuillan, P. 2010: Impact of a direct access occupational physiotherapy treatment service. Occupational Medicine 60, 651653.CrossRefGoogle ScholarPubMed
Alami, S., Boutron, I., Desjeux, D., Hirschhorn, M., Meric, G., Rannou, F.Poiraudeau, S. 2011: Patients’ and practitioners’ views of knee osteoarthritis and its management: a qualitative study. PLoS One 6, e19634.CrossRefGoogle Scholar
Barnett, K., Mercer, S.W., Norbury, M., Watt, G., Wyke, S.Guthrie, B. 2012: Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet 380, 3743.CrossRefGoogle ScholarPubMed
Breen, A., Austin, H., Campion-Smith, C., Carr, E.Mann, E. 2007: ‘You feel so hopeless’: a qualitative study of GP management of acute back pain. European Journal of Pain 11, 2129.CrossRefGoogle Scholar
Department of Health. 2006: The musculoskeletal services framework: a joint responsibility: doing it differently. London: DoH. Retrieved 1 July 2013 from Scholar
Galley, P. 1977: Physiotherapists as first contact practitioners: new challenges and responsibilities in Australia. Physiotherapy 63, 246248.Google ScholarPubMed
Henschke, N., Maher, C.G., Refshauge, K.M., Herbert, R.D., Cumming, R.G., Bleasel, J., York, J., Das, A.McAuley, J.H. 2009: Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain. Arthritis and Rheumatism 60, 30723080.CrossRefGoogle ScholarPubMed
Hill, J.C., Whitehurst, D.G., Lewis, M., Bryan, S., Dunn, K.M., Foster, N.E., Konstantinou, K., Main, C.J., Mason, E., Somerville, S., Sowden, G., Vohora, K.Hay, E.M. 2011: Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet 378, 15601571.CrossRefGoogle ScholarPubMed
Holdsworth, L.K.Webster, V.S. 2004: Direct access to physiotherapy in primary care: now and into the future? Physiotherapy 90, 6472.CrossRefGoogle Scholar
Jette, D.U., Ardleigh, K., Chandler, K.McShea, L. 2006: Decision-making ability of physical therapists: physical therapy intervention or medical referral. Physical Therapy 86, 16191629.CrossRefGoogle ScholarPubMed
Lanyon, P., Pope, D.Croft, P. 1995: Rheumatology education and management skills in general practice: a national study of trainees. Annals of Rheumatic Diseases 54, 735739.CrossRefGoogle ScholarPubMed
Leemrijse, C.J., Swinkels, I.C.S.Veenhof, C. 2008: Direct access to physical therapy in the Netherlands: results from the first year in community-based physical therapy. Physical Therapy 88, 936946.CrossRefGoogle ScholarPubMed
Lin, C.W., Haas, M., Maher, C.G., Machado, L.A.van Tulder, M.W. 2011: Cost-effectiveness of general practice care for low back pain: a systematic review. European Spine Journal 20, 10121023.CrossRefGoogle ScholarPubMed
Massey, B.F. 2002: American physical therapy association presidential address: what's all the fuss about direct access? Physical Therapy 82, 11201123.Google Scholar
NICE. 2008: Osteoarthritis. The care and management of osteoarthritis in adults. Manchester: National Institute for Health and Clinical Excellence.Google Scholar
Nordeman, L., Nilsson, B., Moller, M.Gunnarsson, R. 2006: Early access to physical therapy treatment for subacute low back pain in primary health care: a prospective randomized clinical trial. Clinical Journal of Pain 22, 505511.CrossRefGoogle ScholarPubMed
Picavet, H.S.Schouten, J.S. 2003: Musculoskeletal pain in the Netherlands: prevalences, consequences and risk groups, the DMC3-study. Pain 102, 167178.CrossRefGoogle Scholar
RCGP. 2013: The 2022 GP: a vision for general practice in the future NHS. London: Royal College of General Practitioners.Google Scholar
Savigny, P., Watson, P.Underwood, M. 2009: Early management of persistent non-specific low back pain: summary of NICE guidance. British Medical Journal 338, b1805.CrossRefGoogle ScholarPubMed
Taylor, N.F., Norman, E., Roddy, L., Tang, C., Pagram, A.Hearn, K. 2011: Primary contact physiotherapy in emergency departments can reduce length of stay for patients with peripheral musculoskeletal injuries compared with secondary contact physiotherapy: a prospective non-randomised controlled trial. Physiotherapy 97, 107114.CrossRefGoogle ScholarPubMed
Wynne-Jones, G., Mallen, C.D., Main, C.J.Dunn, K.M. 2010: What do GPs feel about sickness certification? A systematic search and narrative review. Scandinavian Journal of Primary Health Care 28, 6775.CrossRefGoogle ScholarPubMed
You have Access
Cited by

Save article to Kindle

To save this article to your Kindle, first ensure is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the or variations. ‘’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

SAPC hot topic: is it a dangerous idea to make physiotherapists the gatekeepers of frontline primary care for all patients with musculoskeletal problems?
Available formats

Save article to Dropbox

To save this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you used this feature, you will be asked to authorise Cambridge Core to connect with your Dropbox account. Find out more about saving content to Dropbox.

SAPC hot topic: is it a dangerous idea to make physiotherapists the gatekeepers of frontline primary care for all patients with musculoskeletal problems?
Available formats

Save article to Google Drive

To save this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you used this feature, you will be asked to authorise Cambridge Core to connect with your Google Drive account. Find out more about saving content to Google Drive.

SAPC hot topic: is it a dangerous idea to make physiotherapists the gatekeepers of frontline primary care for all patients with musculoskeletal problems?
Available formats

Reply to: Submit a response

Please enter your response.

Your details

Please enter a valid email address.

Conflicting interests

Do you have any conflicting interests? *