Self-referral/direct access to physical therapy

• What is self-referral?
• Useful resources

What is self-referral/direct access?

Self referral/direct access means that patients are able to refer themselves to a physical therapist without having to see anyone else first, or without being told to refer themselves by another health professional. This can relate to telephone and face-to-face services, as well as those delivered via new media such as over the internet.

Reference: Department of Health (2008) Self-referral pilots to musculoskeletal physiotherapy and the implications for improving access to other AHP services. Department of Health; London, UK.

Why self-referral is considered a valuable term:

• It is thought to be clearly understood by the patient/client.
• It clearly defines the source of referral.
• It defines a group of patients/clients which in turn allows for analysis and comparisons across sources of referrals eg patients/clients who referred themselves versus general practitioner/family physician referral to physical therapy. With clear comparisons evidence can be produced to support self-referral as being clinically and cost effective.

Direct access is the term that is more familiar across the profession globally and among other health professionals and government officials. There is concern that not all patients/clients understand the term referral or what it implies. Direct access does not refer to access between health professionals eg a physician has direct access to physical therapists. 

Both terms are still appropriate to use.

Direct access is the term used in WCPT's existing policy statements. WCPT's Declaration of Principle on Autonomy has clearly stated since 1995 that "Patients/clients should have direct access to physical therapist services." However, self-referral/direct access is not a given in all of WCPT’s member organisations’ countries. Appropriate legislative and regulatory policies need to be in place to recognise and permit practice without a medical referral, as well as required levels of pre-qualifying physical therapy education. WCPT will be reviewing its policy statement in relation to direct access given discussions on self-referral/direct access.

Self-referral/direct access to physical therapy is clinically and cost effective and results in satisfied patients/clients.

Some key facts:
 

• Self-referral/direct access puts patients/clients in control of their care
• Patients/clients who refer themselves to physical therapy:
  • are more proactive
  • are more autonomous in making health decisions
  • take less time off work
  • return to work sooner
  • are more likely complete a course of treatment
  • are more interested in self management
  • more satisfied with their care
• Self-referral/direct access saves money through:
  • reducing costs of seeing other health professionals eg general practitioners/family physicians
  • less prescribing
  • less investigations
  • less secondary care
  • reducing costs to society eg through time off work
  • less administration costs
• Self-referral/direct access does not lead to increased demands for services if they are adequately resourced
• Self-referral/direct access is not just appropriate for musculoskeletal services but across areas of practice
• Research to date has focused on musculoskeletal patients

Resources here can help physical therapists work strategically to develop self-referral/direct access services and, where required, open discussions with government health departments, regulatory bodies, health professionals and others to bring about the necessary changes to support the implementation of self-referral/direct access services.

The Advanced Scope of Practice and Direct Access in Physical Therapy Policy Summit of 2009 looked in detail at the evidence for self-referral/direct access and strategies for influencing policy and implementing change from across the globe. The presentations provide summaries of the evidence and perspectives from different WCPT member organisations.

Useful Resources

• Resources from WCPT member organisations
• Evidence for effectiveness of self-referral
• Other resources

Resources from WCPT member organisations

American Physical Therapy Association (APTA)

• Direct access overview
• Direct access legislation

Chartered Society of Physiotherapy (CSP) UK

• Self-referral home page
• Information for policy makers
• Information for practitioners/managers, including tool kit resources for developing self referral service, publications and PowerPoint show
• Self-referral implementation tools
• Self-referral to physiotherapy services information paper (2004)

Evidence for the effectiveness of self-referral

These references provide evidence of the clinical and cost effectiveness of self-referral/direct access physical therapy services:

• Department of Health. (2008) Self-referral pilots to musculoskeletal physiotherapy and the implications for improving access to other AHP services. Department of Health; London, UK.
• Holdsworth LK, Webster, VS and McFadyen, AK. "Self-referral to physiotherapy: deprivation and geographical setting: is there a relationship? Results of a national trial." Physiotherapy 2006; 92(1): 16-25.
• Holdsworth LK, Webster, VS and McFadyen, AK. "Are patients who refer themselves to physiotherapy different from those referred by GPs? Results of a national trial." Physiotherapy 2006; 92(1): 26-33.
• Holdsworth LK, Webster, VS and McFadyen, AK. "What are the costs to NHS Scotland of self-referral to physiotherapy? Results of a national trial." Physiotherapy 2007; 93(1): 3-11.
• Holdsworth LK, Webster, VS and McFadyen, AK. "Physiotherapists' and general practitioners' views of self-referral and physiotherapy scope of practice: results from a national trial." Physiotherapy 2008; 94(3): 236-243.
• Leemrijse CJ, Swinkels, ICS and Veenhof, C. "Direct Access to Physical Therapy in the Netherlands: Results From the First Year in Community-Based Physical Therapy." Physical Therapy 2008; 88(8): 936-946.
• Mitchell JM and de Lissovoy, G. "A comparison of resource use and cost in direct access versus physician referral episodes of physical therapy." Physical Therapy 1997; 77(11): 10-18. 
• Nova Scotia Physiotherapy Advisory Group. (2007) Integrating Physiotherapy into the Primary Health Care Model in Nova Scotia: an Economic Solution.
• Swinkels ICS, Leemrijse, CJ and Veenhof, C. "One year of direct access to physiotherapy [Dutch]." Nederlands Tijdschrift Voor Fysiotherapie 2007; 117(5): 158-165.
• Turner D. "An exploratory study of physiotherapy telephone assessment... Including commentary by Foster NE." International Journal of Therapy & Rehabilitation 2009; 16(2): 97-105.
• Webster VS,Holdsworth, LK,McFadyen, et al. "Self-referral, access and physiotherapy: patients' knowledge and attitudes. Results of a national trial." Physiotherapy 2008; 94(2): 141.

Other resources

• Reference List: collection of references including historical perspectives.
• Book: Holdsworth LK & Webster VS. (2006) Patient Self Referral: a guide for therapists.  Radcliffe publishing, Oxford, UK.
• Website: Self Referral Information