Rachel Thomas

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.

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: 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.

Background: Musculoskeletal disorders (MSKDs) are a significant reason for general practice consultations in the United Kingdom. Current models of care include consultation with a General Practitioner (GP) or a First Contact Physiotherapy Practitioner (FCPP). Evidence suggests that FCPP led care is safe, yet it is unknown whether patients share this belief.Purpose: To explore patients' perspectives of general practice consultation for MSKDs, including views on safety, satisfaction and recommendations for future practice.Methods: A secondary data analysis utilising qualitative data from the Patient Reported Experiences and Outcomes of Safety in Primary Care (PREOS‐PC) questionnaire completed by 426 general practice patients who consulted with a MSKD between December 2019 and October 2022. Responses to the question ‘What changes, if any, would you suggest to your GP surgery to make sure that health care is provided safely?’ were analysed using content analysis.Results: 606 responses across three timepoints were analysed. Two themes and six subthemes were identified; views on safety and satisfaction (inherent trust in the system, provision of face‐to‐face appointments, prompt access to care, person‐centred care) and recommendations for future practice (appointment system: prompt access to face‐to‐face appointments, delivery of care: co‐ordinated and collaborative person‐centred care).Conclusions: Patients commented that FCPP consultations provided quick and accurate diagnoses and targeted advice. Recommendations for future practice included prompt access to face‐to‐face appointments, phone calls to be answered more quickly, improved communication for test results and follow ups, patients to feel listened to with a more individualised approach, and better continuity of care.

Background: First contact physiotherapy practitioners (FCPPs) are embedded within general practice, providing expert assessment, diagnosis, and management plans for patients with musculoskeletal disorders (MSKDs), without the prior need for GP consultation.Aim: To determine the clinical effectiveness and costs of FCPP models compared with GP-led models of care.Design and setting: Multiple site case-study design of general practices in the UK.Method: General practice sites were recruited representing the following three models: 1) GP-led care; 2) FCPPs who could not prescribe or inject (FCPPs-standard [St]); and 3) FCPPs who could prescribe and/or inject (FCPPs-additional qualifications [AQ]). Patient participants from each site completed outcome data at baseline, 3 months, and 6 months. The primary outcome was the SF-36 Physical Component Summary (PCS) score. Healthcare usage was collected for 6 months.Results: In total, 426 adults were recruited from 46 practices across the UK. Non-inferiority analysis showed no significant difference in physical function (SF-36 PCS) across all three arms at 6 months (P= 0.667). At 3 months, a significant difference in numbers improving was seen between arms: 54.7% (n= 47) GP consultees, 72.4% (n= 71) FCPP-St, and 66.4% (n= 101) FCPP-AQ (P= 0.037). No safety issues were identified. Following initial consultation, a greater proportion of patients received medication (including opioids) in the GP-led arm (44.7%,n= 42), compared with FCPP-St (18.4%,n= 21) and FCPP-AQ (24.7%,n= 40) (PP<0.001).Conclusion: FCPP-led models of care provide safe, clinically effective patient management, with cost-benefits and reduced opioid use in this cohort.

Introduction: Managing symptoms, resisting functional decline and maintaining health and independence are key motivators for people with Rheumatoid Arthritis (RA) who successfully engage with physical activity (PA). To inform PA support for people with RA the aim was to determine whether the broader RA population share similar beliefs and strategies regarding PA to those who report successful engagement.Methods: A modified two‐stage Delphi approach. 200 patients from four National Health Service rheumatology departments received a postal questionnaire containing statements relating to engagement with PA derived from prior interview data from physically active individuals with RA. Statements rated as agree or strongly agree by >50% of respondents were retained and the same respondents asked to rate and prioritize potential PA intervention components.Ethical approval: Oxford C Research Ethics Committee (ref 13/SC/0418).Results: Questionnaire one received 49 responses (11 males, 37 females, 1 unknown), mean age 65 years (range 29–82). Low levels of PA were reported by 60% of respondents. Questionnaire two responses (n = 36) indicated that a PA intervention should include information about prevention of RA symptoms worsening and benefits of PA for joints; help participants to achieve improved pain management and a feeling of being in control of their RA. For PA maintenance it was important that medication controlled symptoms, and PA instructors understood RA to ensure safety.Conclusions: A key factor to consider when designing a PA intervention for people with RA is that education from a knowledgeable instructor should underpin programme delivery alongside effective medication. Programmes may need tailoring based on demographics; this should be explored in future studies.