Nicola Walsh

BACKGROUND Low back pain (LBP) affects many people in the UK, restricting their daily activities and accounting for 5% of GP appointments. Many digital tools exist to support people with low back pain to self-manage their symptoms, however, there is limited evidence on how they work for patients and healthcare professionals, and how consistently they deliver high-quality care. getUBetter is a digital health app that is used by the NHS to support people with low back pain. It helps people to effectively self-manage, use less healthcare resources and return to work. It aims to support them through their recovery journey day-by-day providing them with knowledge, skills, and confidence to self-manage through advice, guidance, exercises, and referral to treatment and local services when needed. OBJECTIVE To generate real-world evidence on the clinical and cost-effectiveness of implementing getUBetter into LBP clinical pathways, explore current implementation issues, develop training resources and guidance to enable national adoption, and transferable learning to support broader digital adoption across the NHS. METHODS The project is made up of 3 parts: 1) Patients with LBP, in various GP practices across one integrated care system (ICS) footprint in southwest England who use the app and those who don’t use it will be recruited into the study. Patients will complete a survey four times over a 12-month period, reporting their use of getUBetter and changes in their symptoms. We will also analyse healthcare data (e.g. number of GP appointments) from the local NHS system to assess the impact of using getUBetter at a system level. 2) Patients who use getUBetter and healthcare professionals who offer it will be interviewed to understand their experiences and the factors that influence their decision to use it or stop using it. 3) Findings will be used to develop guidelines and training resources to support patients, healthcare professionals, local healthcare systems and national services when embedding and using getUBetter, and other digital health tools for the self-management of low back pain and other muscle and joint conditions. RESULTS The study commented in November 2024, and all work packages are in progress. CONCLUSIONS getUBetter will use study findings to strengthen their processes to help patients, clinicians, and the health service. This project will create knowledge regarding how technology can support Integrated Care Systems (ICSs) to deliver care across a whole care pathway. Outputs will contribute to NHS understanding of how digital technologies can be used in the real-world and optimally to implement and promote adoption.

Background: The Additional Roles Reimbursement Scheme (ARRS), introduced by NHS England in 2019, aimed to expand the workforce, promote multidisciplinary team-based care, and improve patient outcomes. Aim: To examine changes in consultation rates and outcomes in relation to ARRS implementation, and compare outcomes across primary care roles. Design and setting: Longitudinal cohort study using the Clinical Practice Research Datalink (CPRD) AURUM, analysing 12 170 079 consultations (2015–2021) from 600 000 randomly sampled patients at 400 English practices. Method: Joinpoint regression modelled trends in age- and sex-standardised consultation rates, further consultations within 1–14 days, prescribing, and referrals. Multilevel regression compared outcomes between diagnostic-capable roles and GPs. Results: Most consultations remained GP- or nurse-led, but rates with direct patient care (DPC)-ARRS-eligible roles increased, particularly for pharmacists, physiotherapists, and nursing associates. For paramedics and mental health practitioners, growth preceded formal ARRS inclusion, suggesting the scheme accelerated rather than initiated expansion. Most DPC-ARRS-eligible roles were consulted more frequently in less deprived areas, except physiotherapists. Compared with GPs, most DPC-ARRS-eligible roles delivered more consultations face to face (except pharmacists), had lower prescribing (except advanced nurse practitioners) and referral rates, and higher further consultation rates with a diagnostic-capable clinician within 1–14 days (except pharmacists). However, all DPC-ARRS-eligible roles had lower odds of a further consultation specifically with a GP. Conclusion: ARRS has supported and accelerated the diversification of the primary care skill mix. Patterns of consultation activity suggest an expansion of overall primary care capacity with some redistribution of workload across the multidisciplinary team, rather than a direct reduction in GP workload.

Background: The Additional Roles Reimbursement Scheme (ARRS) launched in England in 2019 to expand the multidisciplinary primary care workforce, but its impact on workload since implementation is unclear. Aim: To examine changes in workload complexity associated with ARRS implementation. Design and setting: A longitudinal cohort study was conducted, which used the Clinical Practice Research Datalink (CPRD) Aurum. In total, 3 530 628 consultations were analysed involving GPs, nurses, or direct patient care (DPC)-ARRS roles for 420 986 patients from 369 English practices in 2018 and 2021. Method: Multilevel logistic regression assessed associations between 17 patient and consultation complexity factors and being seen by a DPC-ARRS role, adjusting for year, age, sex, region, deprivation, and consultation mode. Results: Complex consultations with DPC-ARRS-eligible roles increased from 15.8% in 2018 to 18.8% in 2021. Diagnostically capable ARRS roles were more likely than GPs to conduct the first consultation after diabetes diagnosis (odds ratio [OR] 1.4, 95% confidence interval [CI] = 1.3 to 1.5) and consultations with ≥2 preventive tasks (OR 5.6, 95% CI = 5.5 to 5.8), but less likely to manage chronic pain (OR 0.8, 95% CI = 0.7 to 0.9), dementia (OR 0.4, 95% CI = 0.3 to 0.4), mental illness (OR 0.4, 95% CI = 0.3 to 0.5), learning disabilities (OR 0.3, 95% CI = 0.3 to 0.4), consultations with ≥3 medicines prescribed (OR 0.6, 95% CI = 0.5 to 0.6), consultations resulted in emergency admission (OR 0.7, 95% CI = 0.6 to 0.8), and consultations with ≥2 diagnoses coded (OR 0.5, 95% CI = 0.5 to 0.5). Patients with interpreter needs (OR 1.2, 95% CI = 1.1 to 1.3), experiencing recent homelessness (OR 1.4, 95% CI = 1.1 to 1.7), or ≥3 long-term conditions (OR 1.1, 95% CI = 1.1 to 1.1) were more likely to be seen by diagnostic ARRS staff. Conclusion: Following ARRS implementation, primary care activity was delivered by a broader workforce managing increasingly complex care. Further research should assess the safety, quality, and system impacts of ARRS roles.

First Contact Physiotherapy Practitioners (FCPPs) are working across the UK to deliver musculoskeletal services to patients within general practice. Little is known about the impact of the model and how variation in delivery may lead to different experiences and outcomes of the service amongst patients and general practice staff. This study explored staff and patient experiences of First Contact Physiotherapy in general practice to determine what works, for whom, under what circumstances, and how. Qualitative interviews were conducted in general practice sites across Great Britain. Interviews were based on initial programme theories identified in an earlier realist review and consensus event. We conducted 80 remote interviews with practice staff and patients, and a further 3 interviews with respondents with other roles related to First Contact Physiotherapy provision. All interviews were analysed using a realist approach. Seven overarching theory areas were identified: 1. Awareness of FCPPs; 2. Communication and integration into practice; 3. FCPP approach in primary care; 4. FCPP additional qualifications; 5. Practice workload; 6. FCPP personal development; and 7. Employment models of FCPP. Three key areas were identified as integral to successful service delivery and implementation: FCPP integration; skillset and impact on resource use; and employment model. Findings from this study strengthen the evidence by providing a robust piece of empirical work about the key issues and contexts impacting successful implementation of the FCPP role into general practice, which will aid decision makers when developing First Contact Physiotherapy services.

Background: Complex Regional Pain Syndrome (CRPS) is a distressing pain condition that can lead to significant burdens for individuals and society. A small number of specialist CRPS-practice services exist, but access is limited; most patients are managed in local hospitals or community settings. In a series of phases, we sought to understand the needs and perspectives of therapy practitioners across the care pathway in England and to identify recommendations to improve therapy-led management of CRPS. Methods: In phase 1, we disseminated an e-survey to physiotherapists, occupational therapists and hand therapists across a range of settings. Phase 2 comprised semi-structured interviews with therapists and patients. Online stakeholder events (phase 3) were convened to review findings and prioritise suggestions to enhance CRPS care. Results: Seventy-seven therapists responded to the e-survey and 31 semi-structured interviews were conducted (n = 10 patients, n = 9 therapists from specialist CRPS-practice services, n = 12 therapists from other settings). N = 11 therapists and n = 5 patients participated in the stakeholder events. Findings indicated pathways of care are complex, but similarities exist in therapy approaches across settings, albeit with longer, more frequent appointments in specialist CRPS-practice services. Recommendations to improve CRPS management included: additional education provision for therapists (including better access to CRPS ‘experts’), CRPS education for other clinicians, streamlining of patient pathways, and improving patient information. Conclusions: This work highlights opportunities to improve therapy-led care for people living with CRPS. Findings will be valuable in informing UK clinical guidelines and strengthening initiatives to enhance support for therapists.

Background: General practice services are under pressure due increased demand. Alongside substantial national recruitment challenges, there exists a shortage of general practitioners to meet current need. Resultingly, allied healthcare professionals, including paramedics, are being utilised in general practice. Aim: To determine the models of paramedics in general practice settings; the mechanisms that underpin effective paramedics in general practice; and the impact of paramedics in general practice on safety, costs and clinical and patient-reported outcomes and experience. Design: A mixed-methods realist evaluation comprised a rapid realist review followed by an evaluation of paramedics in general practice in general practice case study sites. Patient and public involvement and input was integral, ensuring validity from a patient and carer perspective. Setting: General practices in England. Participants: A total of 34 general practices participated as case study sites, of which 25 were ‘paramedics in general practice’ sites. Data from qualitative realist interviews (n = 69), quantitative questionnaires (n = 489) and electronic records (n = 22,509 consultations) were collected. Interventions: Paramedics in general practice models were classified according to: (1) level of integration of the paramedic to the general practice team; and (2) complexity of patients seen by paramedics. Main outcome measures: Qualitative interviews investigated initial programme theories with staff and patient participants. Patient participant questionnaires utilised validated measures: the Patient-Reported Experiences and Outcomes of Safety in Primary Care (safety); EuroQol-5 Dimensions, five-level version (health-related quality of life); Primary Care Outcomes Questionnaire; the Modular Resource Use Measure (health and care resource utilisation). Electronic health records provided data on primary care use. Review methods: A rapid realist review of the published and grey literature, supplemented with direct enquiry with system leaders and key stakeholders. Results: The rapid realist review highlighted significant variation in paramedics’ roles in general practice. Qualitative interviews identified domains related to access, safety, workforce reconfiguration, infrastructure, patient experience, and outcomes. Lower Patient-Reported Experiences and Outcomes of Safety in Primary Care practice activation scores were found at paramedics in general practice sites (perceived less engaged in promoting safety), in particular those with medium and low levels of paramedics in general practice integration and complexity. There was a small statistically significant difference in the Primary Care Outcomes Questionnaire ‘Confidence in Health Plan’ by paramedics in general practice complexity, such that confidence had deteriorated slightly more in the high-complexity group compared to non-paramedics in general practice. Paramedics in general practice sites had lower scores at initial visit and 30 days for the Primary Care Outcomes Questionnaire ‘Confidence in Health Provision’. We found little evidence that paramedics in general practice care led to substantial spillover effects via increased reconsultations, prescriptions, secondary care referrals or unplanned hospital admission costs. Limitations: The study faced challenges in recruitment. Self-selected participating sites may not be representative of all general practitioners in England, and categorising paramedics in general practice models for analysis was more complex than anticipated. The comparison of costs and outcomes between paramedics in general practice and non-paramedics in general practice sites was based on an observational study design. Conclusions: Paramedics in general practice care improves access to general practice. Safety and acceptability require resources for induction, supervision, training and education. Paramedics in general practice integration affects staff satisfaction and role longevity. Paramedics in general practice allows paramedics to develop and evolve. Future work: Larger studies utilising different study designs with longer follow-up are needed to fully understand the impact of paramedics in general practice on clinical outcomes and episode of care costs. Study registration: This study is registered as ISRCTN56909665 https://doi.org/10.1186/ISRCTN56909665. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR132736) and is published in full in Health and Social Care Delivery Research; Vol. 13, No. 6. See the NIHR Funding and Awards website for further award information.

Background: First-contact physiotherapists assess and diagnose patients with musculoskeletal disorders, determining the best course of management without prior general practitioner consultation. Objectives: The primary aim was to determine the clinical and cost-effectiveness of first-contact physiotherapists compared with general practitioner-led models of care. Design: Mixed-method realist evaluation of effectiveness and costs, comprising three main phases: A United Kingdom-wide survey of first contact physiotherapists. Rapid realist review of first contact physiotherapists to determine programme theories. A mixed-method case study evaluation of 46 general practices across the United Kingdom, grouped as three service delivery models: General practitioner: general practitioner-led models of care (no first contact physiotherapists). First-contact physiotherapists standard provision: standard first-contact physiotherapist-led model of care. First-contact physiotherapists with additional qualifications: first-contact physiotherapists with additional qualifications to enable them to inject and/or prescribe. Setting: United Kingdom general practice. Participants: A total of 46 sites participated in the case study evaluation and 426 patients were recruited; 80 staff and patients were interviewed. Main outcome measures: Short Form 36 physical outcome component score and costs of treatment. Results: No statistically significant difference in the primary outcome Short Form 36 physical component score measure at 6-month primary end point between general practitioner-led, first-contact physiotherapist standard provision and first-contact physiotherapist with additional qualifications models of care. A greater number of patients who had first-contact physiotherapist standard provision (72.4%) and first-contact physiotherapist with additional qualifications (66.4%) showed an improvement at 3 months compared with general practitioner-led care (54.7%). No statistically significant differences were found between the study arms in other secondary outcome measures, including the EuroQol-5 Dimensions, five-level version. Some 6.3% of participants were lost to follow-up at 3 months; a further 1.9% were lost to follow-up after 3 months and before 6 months. Service-use analysis data were available for 348 participants (81.7%) at 6 months. Inspecting the entire 6 months of the study, a statistically significant difference in total cost was seen between the three service models, irrespective of whether inpatient costs were included or excluded from the calculation. In both instances, the general practitioner service model was found to be significantly costlier, with a median total cost of £105.50 versus £41.00 for first-contact physiotherapist standard provision and £44.00 for first-contact physiotherapists with additional qualifications. Base-case analysis used band 7 for first-contact physiotherapist groups. A sensitivity analysis was undertaken at band 8a for first-contact physiotherapists with additional qualifications; the general practitioner-led model of care remained significantly costlier. Qualitative investigation highlighted key issues to support implementation: understanding role remit, integrating and supporting staff including full information technology access and extended appointment times. Limitations: Services were significantly impacted by COVID-19 treatment restrictions, and recruitment was hampered by additional pressures in primary care. A further limitation was the lack of diversity within the sample. Conclusions: First-contact physiotherapists and general practitioner models of care are equally clinically effective for people with musculoskeletal disorders. Analysis showed the general practitioner-led model of care is costlier than both the first-contact physiotherapist standard provision and first-contact physiotherapist with additional qualifications models. Implementation is supported by raising awareness of the first-contact physiotherapist role, retention of extended appointment times, and employment models that provide first-contact physiotherapists with professional support. Future research: Determining whether shifting workforce impacts physiotherapy provision and outcomes across the musculoskeletal pathway. Study registration: The study is registered as Research Registry UIN researchregistry5033. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 16/116/03) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 49. See the NIHR Funding and Awards website for further award information.