Official Report: Minutes of Evidence

The Chairperson (Ms Maeve McLaughlin): Folks, you are very welcome. Apologies for keeping you for so long; it was a long first session. You are very welcome to the meeting. Natalie Beswetherick — did I pronounce that correctly?

Ms Natalie Beswetherick (Chartered Society of Physiotherapy): Almost 100%.

The Chairperson (Ms Maeve McLaughlin): What is the correct pronunciation?

Ms Beswetherick: Just as it sounds: Beswetherick. It is Cornish.

The Chairperson (Ms Maeve McLaughlin): OK. Thank you very much. Natalie is the director of practice and development at the Chartered Society of Physiotherapy (CSP); Tom Sullivan is the public affairs and policy manager. You are both very welcome. I invite you to make some opening comments, and we will then open it up for members' questions or comments.

Mr Tom Sullivan (Chartered Society of Physiotherapy): Thank you very much, Chair. I thank you and the Committee for inviting us to provide some insight into self-referral to physiotherapy in Northern Ireland. The Chartered Society of Physiotherapy is a professional, educational and trade union body that represents 53,000 members across the UK. It believes that the introduction of self-referral could address some of the challenges faced by the health service in Northern Ireland.

It is clear that the demand on our health and social care system is increasing, not least because of the increasing number of frail and older people with chronic conditions who require more attention. Our members are working incredibly hard in very difficult circumstances to deal with, and meet, the needs of vulnerable people. We believe that the introduction of self-referral, as has happened in other parts of the UK, can go some way to addressing the pressures on the system. Self-referral aligns itself perfectly with the aims and objectives of Transforming Your Care, which is essentially about patients being able to access the right services at the right time in the right location.

Indeed, when Pamela McCreedy, director of Transforming Your Care, announced the self-referral pilot last March, she said:

It is disappointing, therefore, that in our last year of this, despite explicit provision in the commissioning plan, we still do not have a pilot for self-referral.

I will end on that note, Chair, because I think that it is probably best if I hand over to Natalie. As director of practice and development for the CSP, Natalie has over 30 years' clinical and management experience in physiotherapy and, indeed, was responsible for introducing self-referral to the Gloucester foundation trust. It is probably best if Natalie gives you some of her personal testimony of how that operated and how it was introduced there. Then we will have questions and answers.

Ms Beswetherick: Thank you very much for the kind invitation. I am pleased to be at Stormont again. I am pleased to recognise Paula Bradley, who hosted a CSP event a couple of years ago that I attended. It is great to be here again.

I want to go through my personal experience as a lead of physiotherapy services in Gloucestershire when we introduced self-referrals for people with musculoskeletal (MSK) conditions. The population of Gloucestershire is about 600,000, and the area comprises urban, semi-rural and rural locations. I took an incremental approach, and, from the start, there was very strong GP involvement in the planning.

The first question that I will answer is this: why did we do it? We knew from the evidence base, even at that time, that people who had early physiotherapy intervention for a bad back, a bad neck or a pulled muscle returned to their normal activities or to work much more expediently. They also required fewer resources.

How did we sell it to GPs? I went out, with my colleagues, to visit all the GP practices that we were going to work with, and we shared with them the evidence base about what physiotherapy could do and the demonstrable effect of early intervention. We also said to them, "This will save you time, and this will save you administrative time, because if patients can refer directly, rather than having to see you, it means that you can take those slots for maybe the more elderly or complex patients who need to see the GP".

GPs were pleased to be involved in a pilot. We started very small; we started with three GP practices in one location in Cheltenham in Gloucestershire. We had taken baseline data, previously. We looked at it at three months and then at six months, and when we were sure that we were seeing the effects that we expected to see, we grew by opening it up to further GP practices. It took us over two years to cover the whole population of Gloucestershire, but my experience is that that incremental approach is useful. It allows you time. If you need to tweak something, which can happen, even with the best planning in the world, you get time to do it. If things unexpectedly turn up, you can attend to them.

What was the result? Our waiting times had been about six to eight weeks, and, in some areas, higher. They all came down. In some areas, they came down as low as two weeks, but the average was four to six weeks, at their maximum, for routine or non-urgent referrals. The other big changes to data relate to a funny term, the "DNA" rates. DNA (did not attends) are those who did not turn up. Every one of those is a waste of resource. Our rates of people not turning up had been about 6% to 8%, but they went down to 2%.

Interestingly, by the time we were looking at doing an evaluation at one year, we realised that we were seeing more patients with the same number of staff. That is because each patient required less intervention than had been the case previously and we were maximising every "clinic slot", for want of a better term, as we had far fewer people not turning up. As part of the evaluation, we also undertook GP satisfaction and patient surveys, post treatment. The responses were incredibly positive. GPs loved the fact that they had less administration to do, with fewer people to refer on; they appreciated that patients were being seen by the right person at the right time. They also reported to us that, if patients came back for something else, they said what a great experience they had had.

Most patients felt more in control of their symptoms and able to manage their condition much more effectively because they had been advised on some self-management. The type of quotations that we had were very similar to this that I take now from a recent news piece from a general practitioner in Plymouth in the south-west of England. This person works for one of the commissioning groups, the Northern, Eastern and Western Devon Clinical Commissioning Group. On a news piece in the last few weeks, this person said:

There is only one concern that people always raise when they are considering self-referral: will it not just increase demand? That did not happen. People have always asked whether self-referral would open the floodgates. My experience is that, if you do incremental change, bit by bit, you do not see an increase in demand. If you see any change, it would be because your baseline resources had not been adequate in the first place.

My conclusion is as follows. My physiotherapist colleagues in Northern Ireland have done a massive amount on the musculoskeletal pathway, and they have worked hard to improve your constituents' access to their services. Physiotherapists now prescribe independently; in Northern Ireland, at least nine physiotherapists can independently prescribe, and there are physiotherapists in each trust who can inject if required. The services across Northern Ireland are more than ready, I believe, to pilot self-referral.

The other important thing for the Health Committee is that self-referral empowers people to help to manage their own conditions. That is absolutely in line with the Donaldson review, which, I read recently, reported for Northern Ireland. From my experience, I truly believe that self-referral is a no-brainer. I am happy to take questions.

The Chairperson (Ms Maeve McLaughlin): Thank you; that was very useful. I note that you say that incremental change is appropriate on these issues. You indicate that waiting times had come down. In your experience of the programmes, was a cost analysis done? I know that this is not about savings as such, but was there an analysis of the savings to be had from keeping people off lists and out of emergency departments?

Ms Beswetherick: It would certainly not affect people turning up to an emergency department, because most people's musculoskeletal conditions — acute back pain, a pulled shoulder, a bad knee after twisting too much playing golf or whatever it is — are not normally conditions that would take somebody to the emergency department.

The research done on self-referral in Scotland, England, the Netherlands and the USA all demonstrate savings. In England, the self-referral model has been fully examined by the quality, innovation, productivity and prevention (QIPP) programme, which is part of NHS evidence, and has been found to be extremely cost-effective. The research has shown that there are savings to be made in decreased GP appointments, decreased use of diagnostics and decreased use of prescriptions. In addition to that, maybe not for health but certainly for work and pensions departments, people who self-refer are much less likely to go off work, or they will return to work faster, so there is a gain for society in terms of people being at work.

I have also evaluated self-referral in the hospital I worked in. Staff self-referring to physiotherapy led to a substantial reduction in days lost from work. We costed that up for each day lost, and there was a massive saving in terms of decreased locum use within a hospital environment, for example. That was significant. There is strong evidence supporting the idea that it is a cost-effective way forward.

The Chairperson (Ms Maeve McLaughlin): In relation to our situation here, it is also a clear policy fit in relation to prevention and in moving the focus from acute, but I am specifically interested in the pilot, the impact of that and your view — it is more a question for the Department — on why a decision was taken, or what rationale was provided, to pull it.

Mr Sullivan: The Department of Health decided to defer it on the basis of pressures on waiting time targets at present. In my view, this is not a rational or logical reason for not proceeding. The reason we decided to go with a self-referral pilot in the first instance was to offer a means by which you could gather and analyse the information that would be required before there was a further roll-out across Northern Ireland. In my view, it does not make any logical sense not to proceed with the pilot. The whole point of the pilot, in the first instance, was to gather that information, analyse it and then look at what potential obstacles or barriers there might be to rolling it out and how to overcome those.

It is important, as Natalie said when she introduced it in Gloucester, that we take an incremental approach. It was not about a revolution overnight. It was about incrementally doing it by degrees, looking at the demographics in each locality and seeing how it would apply differently in those localities. From our point of view, it does not make sense not to go with the pilot.

The Chairperson (Ms Maeve McLaughlin): Has there been any further follow-up from the Department on that, given that we are going to be discussing it with them in the next session?

These sound systems are awful today.

Mr Sullivan: I understand some of their concerns that there is a perception that there would be a huge spike in demand, and that waiting time targets for outpatient appointments in some areas are quite challenging at the moment; so maybe there is a certain degree of caution about introducing self-referral, there being a huge spike in numbers and that being reflected badly within Northern Ireland. But perhaps there is also some concern that, if we introduce self-referral across Northern Ireland, we will need to demonstrate that it works in order to make the argument for rolling it out across all the other trusts.

The Chairperson (Ms Maeve McLaughlin): Apologies about the noise. It is just busy MLAs and their phones going. I remind MLAs to double-check please. A number of members indicated that they wanted to speak. Kieran first.

Mr McCarthy: Thank you very much for your presentation. You mentioned the word "no-brainer". When you were doing your presentation, I was thinking "common sense". Do you agree that there seems to be a lack of common sense in those who are making the decisions? I remember that the former Minister was here, and he was quite enthusiastic about the introduction of self-referral. Suddenly, it is not happening. I am looking at the report, which states that England has 46%, Scotland has 50%, Wales has 62%, and Northern Ireland has 0%. Surely, somebody must be hugely embarrassed when they look at that and see that we are, once again, lagging behind. Tom said that it was initially for a pilot operation, and we have not even started it. Where do we go from here?

Mr Sullivan: I think that some of the issues that have come to the fore recently, in some of the recommendations of the Donaldson review, reflect the lack of movement there has been in Transforming Your Care, and obviously there is a recommendation that there should be renewed impetus and a timetabled programme for moving forward on Transforming Your Care. I think it lost its impetus somewhere along the way, for whatever reason, and I am not sure exactly why. Nevertheless, somewhere along the way, self-referral perhaps got lost in that. I also think that it reflects where physiotherapists and other allied health professionals sit within the structures and that, sometimes, our voices would not be as strong as those of some of the other professions. Therefore, when conversations are being had at that higher strategic level, then perhaps at times we are not included and, therefore, either by default or by design, our issues are not as prominent as they should be.

Mr McCarthy: We are on a journey with Transforming Your Care, and here is a perfect example of where those in authority are falling down on their own programme. The Minister was certainly very excited about this. Is there someone somewhere, other than the Minister, pulling the strings against what we are trying to do?

Mr Sullivan: I do not know about that. Obviously, that was highlighted in the Donaldson review, in terms of who is in charge, but I do not think it is down to individuals per se; I think there are systemic reasons for that. I do not want to say that it is down to any individual. The system is conditioned to react and behave in the way it does, and I think you need to change how the system currently operates in terms of policy. There is a tendency, as Donaldson noted, for the system to operate according to departmental silos without any consideration of the wider strategic intent and that perhaps we need to change the system to make it better in order to incorporate or integrate the views of all of the professions to come up with solutions.

The Chairperson (Ms Maeve McLaughlin): I think, as well, Kieran, there would be a line of questioning to the Department, which is in next, around the rationale for its decisions.

Again, I apologise for the interference; I do not know what is causing it.

Mrs Dobson: Thank you for your briefing. I have an observation to start with. We all know how much pressure GPs are under. Increasingly, constituents come to me — and I am sure it is the same for other members — and say how difficult it is to get an appointment with their GP and the added pressure that has if they feel that they have to go to ED, and there is a 20% shortage of GPs at the moment. Natalie, your final comment was very apt in that self-referral is a no-brainer. I agree with Kieran on that. Given that 25% of GP visits are muscular related, surely it is a no-brainer. A system of self-referral would obviously relieve that pressure. I read through some of the details of this, and it is nothing new. Back in 2008, if I am right, the argument won the day when Alan Johnson endorsed a national roll-out service of self-referral to therapy sessions. Why has it taken so long for Northern Ireland to catch up? Can you understand the rationale behind that? It seems to be a no-brainer given the pressures that GPs are under.

Ms Beswetherick: I want to reassert that the evidence base is very strong and has got stronger over the years with other countries and, notably, from the USA, which has an insurance-based system, and has demonstrated the cost-effectiveness of self-referral. Initially, some of the UK research was not considered strong enough, and there was not consistency from countries that had tried it outside the UK, but now that we have very strong evidence that reinforces it, that adds to the weight of the evidence that we have had from Scotland and England, which has been helped by the evidence from the USA and the Netherlands in that regard.

Some people feel worried sometimes about whether physiotherapists can manage musculoskeletal conditions. Practice in this particular area is their bread and butter. They are well versed in assessment and diagnosis. They understand red-flag zones, which are the types of conditions that are warning signals for something quite serious. They are all trained to look at those. When you bring in a new system, self-referral is just a new referral system. It is important that we get all that planning right from the beginning. That can take time. It is my understanding that planning has been significant and fully supported right across Northern Ireland, with maximum involvement of physiotherapists and others to ensure that any risk is fully mitigated. All the evidence now is saying that the time is right; the time is now.

Mrs Dobson: Tom touched on waiting times, which are deeply worrying for patients. I note that the Minister called it a "challenge". I can only imagine what patients might call it. Surely there is so much greater costs and pressures on our health service if patients go without physio, such as muscle weakening and inability to regain strength. So, I feel that we should be pressing ahead rather than stopping the project.

I was not here in the previous mandate, but Kieran earlier touched on the fact that the Minister's predecessor planned to roll out the service across Northern Ireland by March 2015. We know that that has not been achieved. What is your best guess as to when this could be brought in by?

Mr Sullivan: We need to have the pilot first and take that forward. Any prediction of how we would roll it out across Northern Ireland would be based on that analysis. That is why it does not make sense not to have a pilot.

Mrs Dobson: The absence of a pilot is pushing it further away.

Mr Sullivan: Of course it is. It is impossible for me to say precisely when it could be done. In an ideal world, I would like to see it done tomorrow. However, we are realistic and practical and recognise that there are other pressures on the service, that we are going to have to deal with it incrementally, but that the pilot is the way to do that. We need to move forward in the first instance on the pilot, get it out of the way, use the analysis and move forward from that point sooner rather than later.

The Chairperson (Ms Maeve McLaughlin): I will adjourn for a minute to try to work out what is going on with the sound system.

The Chairperson (Ms Maeve McLaughlin): We will open up the meeting again.

Mr McKinney: I am impressed by the process outlined in your presentation. It is money-saving etc. Given that it is such a no-brainer, what are the blockages? Maybe that is unfair on you given that the Department is coming in afterwards, but are there any medical blockages? For example, while something might present itself as musculoskeletal, it could be hiding a cancer. Are there any GP or medical worries that mean that they want to step through those analysis processes first? Given that this is such an obvious answer that is presenting savings, consistent with TYC, shortening waiting queues etc, why is it not happening? Are there any other reasons out there that we are being blindsided by that could lead to this not being adopted as swiftly as it is in other areas?

Ms Beswetherick: To my knowledge, there is no medical reason why this should not be pursued. The planning and processes that the people involved have undertaken would ensure that the referral mechanisms and assessment processes would fully cover, and have a full pathway through which you could determine, a diagnosis. You would identify any of these red flags, which indicate a cancer or something serious going on. Physiotherapists do that as part of their standard assessment. To my knowledge, there is no indication that that is a blockage.

Mr McKinney: Could there be any financial arguments that the Department is looking at?

Mr Sullivan: As I already mentioned, Fearghal, there could be some issues around capacity and demand and the workforce being able to meet the perception of the initial spike or stampede that you might get from people self-referring. However, again, that has not been the experience. It is more perception than reality. There are issues around workforce. Physiotherapy, like other professions, has been affected in recent years by vacancy freezes and recruitment difficulties given the financial constraints. That has to be a consideration in the reticence to move forward on this. However, it is a pilot, and all those factors would be taken into account.

As far as I am aware, there is no impediment from the other professions to doing it. GPs would actually welcome some of the pressure being taken off them in that regard. As we know, not a day goes by in Northern Ireland when we do not hear that GPs are at capacity when meeting demand, particularly for frail and older people, and given the increase in the number of chronic conditions. The overall system is under pressure, as we know. However, we believe that there is a potential that, if you combine self-referral and newly acquired independent prescribing rights for physiotherapists, this could be a real source of benefit to general practitioners as well. However, to answer your question: no, I am not aware of any ideological impediment to self-referral for physiotherapy.

Mr McKinney: To what extent do people go privately to physiotherapists? Is that something that the Department would want to drive people towards?

Mr Sullivan: Those who can afford to do so, go immediately.

Mr McKinney: I am not advocating that as an approach. You know the SDLP's policies on these things being free at the point of care.

Mr Sullivan: As an organisation, we are fundamentally committed to the health service being free at the point of entry, funded out of general taxation, and accessible to all on the basis of need. Natalie, I do not know what your experience was in Gloucester of people going privately.

Ms Beswetherick: My experience was as you have said, Tom. Patients who could afford to do so, and chose to see a private practitioner, did so, and self-referral did not make any difference to the population who took that choice anyway. Self-referral is there to improve access for people who cannot afford to see a private practitioner. What you want to do for your constituents is to actually improve access in a much more timely fashion, which will have those added benefits further down the line of getting back to work and normal activities, using less medication etc. It still all stacks up. I cannot add anything more, but it did not make any difference to the private practitioners in the area at all. It did not reduce their work.

Mr McKinney: My final point is that, strangely, a pilot could prove more expensive per head because the scale of demand is smaller. Is that something that could impact?

Mr Sullivan: I think there could be more discussion around how we take the pilot forward. I think there is room for negotiation and discussion around how the pilot proceeds. Again, that should not take months. Everything was ready to go in April 2014, and we are in the same state of readiness. Maybe we need to look at whether you do it across the whole trust or with a number of practices and build it up from there.

Mr McKinney: I know I said "finally", but, finally finally, is there any breakdown in communication. What is the state of play with how you guys are communicating with each other around this?

Mr Sullivan: There has always been a good relationship in terms of the communication we have with Michelle and her colleagues at the Public Health Agency in relation to the project board, which was put together by a combination of our physio lead in the south and east, GP involvement, user involvement from an Arthritis Care representative, and involvement from the Public Health Agency.

Ms P Bradley: Thank you, Natalie and Tom. Most of the questions have been asked, so I will not bore everybody by asking the same ones over again. I want to make a couple of comments. You are both aware of my support for this from the first I heard about it. You both know that I worked as part of a multidisciplinary team, where some of the most professional people I ever worked with were our physiotherapists. I think that a lot of people get hung up on what they see as a physiotherapist. That is how I used to visualise a physiotherapist until I worked as part of that team and saw the intricate work they did in managing long-term conditions and long-term diseases that take precedence on a hospital site in dealing with the likes of chronic obstructive pulmonary disease (COPD) and various long-term conditions that they work with every day.

We have self-referral for other conditions and other needs, and I cannot believe that we are even discussing this. I cannot believe that this was not done a long time ago. As we all know, self-referral is nothing new in the health service. It has been going on from time immemorial. We have the likes of speech and language therapy that has always had self-referral. The likes of social work has self-referral, so why are we sitting at this stage? Why did it ever come into being that this was not the best idea and a great idea to alleviate pressures on our health service and capture an audience that is not being captured in other areas of the health service and getting them involved in early intervention and prevention? In the long term, this is far better for our economy and for our society. When I sit and read this and read the letter that we received, I think that this is nothing new. Self-referral is nothing new. Why are we even having to debate this?

Mr Sullivan: I do not have all the answers to that, Paula, but I agree entirely that it is an obvious solution, in many ways, to a lot of the challenges here. In the past, Northern Ireland has been playing catch-up with a lot of innovations that have happened elsewhere, and there are probably historical and structural reasons for that. Again, I cannot give you a definitive answer as to why it has not proceeded at this point other than to say that I think that, with the Donaldson review, the commissioning plan produced recently and the involvement of allied health professionals outlined in the commissioning plan, there is perhaps a renewed impetus in moving forward and better utilising the skills of physiotherapists and others.

You are absolutely right that there is a lack of understanding amongst the wider public and others, even amongst other health professionals, about the range of input that physiotherapists can have, whether that is in neurology, paediatrics, COPD etc.

Ms P Bradley: It is even about feeding regimes — things that people would never think that a physiotherapist is involved with. If we had this other end dealt with through self-referral, it would free up services so that the physios could carry on with the professional jobs that they have.

Mr Sullivan: Absolutely, Paula. It comes back to what I said, which is that, in the past and at times currently, we have perhaps not been involved in those conversations at a strategic level in the way that we should have been.

The Chairperson (Ms Maeve McLaughlin): OK. Thank you both. I assume that you heard the support from all members today. The fact that the scheme is a policy fit with Transforming Your Care is not rocket science. There is energy and appetite in this room to make it happen. I hope that you will have the time to listen in the next session about how those decisions were reached. We will continue to have the conversation.

Mr Sullivan: Thank you, Chairperson. I thank the Committee for its time.