Demonstrating clinical quality and cost effectiveness: can extended scope physiotherapists rise to the challenge?

In the UK many musculoskeletal departments are staffed by specialist physiotherapists (called ‘extended scope physiotherapists’, ESPs). They are defined as clinical physiotherapists, who having worked at an advanced level take further training in tasks or roles which are recognized as being beyond the normal scope of practice for that physiotherapist, such as requesting X-rays and making referrals to specialists.

Several aspects of the role of the ESP are explored in this issue of the journal which gives the opportunity for ESPs and those in leadership roles to consider the shape and structure of ESP services as we move further towards National Health Service re-organization in the UK and the possible shift in activity from secondary care to community type services.

Whether ESPs work in primary or secondary care, their survival depends on their ability to demonstrate their worth, quality, and efficiency. A number of studies have shown that patients are highly satisfied by the services offered by ESPs^1–3 and that they are effective where comparing the level of diagnostic agreement between consultants and ESPs, particularly in orthopaedics.^4,5 However apart from diagnostic correlation there remain questions as to whether ESPs have shown themselves to be efficient and perhaps more importantly value for money. Maddison et al.,⁶ demonstrated one aspect of efficiency which was that interface services [staffed by ESPs and general practitioners (GPs) with special interest] were able to retain high numbers of patients in primary care and reduce referrals to musculoskeletal departments in hospital. However the cost of these services and the effectiveness in terms of clinical outcome measures were not clearly identified. Reflection on the lack of published cost effectiveness data suggests the possibility that ESP services are expensive or non-competitive. One study undertaken several years ago by Daker-White et al.,² did find that ESPs were cost effective when comparing them to sub-consultant surgical staff, but it is interesting to note that there has been little published since this time. Maybe in this time of austerity ESPs should make efforts to robustly analyse and publish their costs in the health economics arena?

Demonstrating the clinical quality and worth of ESP services on a collective level is also difficult when there is wide variation in ESP roles and services. Validated, reliable, and relevant outcome measures to demonstrate the value of ESP activity are difficult to find. When considering the variance in roles and service models, the comparison of the ‘triage’ versus the ‘see and treat’ model demonstrates this point. For example, there are inherent difficulties in measuring outcomes in services which mainly provide one off appointments, like those common in triage services. It is not likely that quality of life indicators would show improvements within these patient groups. The surgical conversion rate^7,8 is a commonly used measure of ESP efficiency, particularly useful for those who only see the patient once such as those in a triage or assessment clinic roles. However the conversion rate does have limitations in that it may be dependent on or influenced by a range of economic, political, and personal factors such as commissioning barriers, waiting lists, and the personal preferences of clinical staff. Thus standardized comparisons of efficiency using this measurement alone may be difficult to make.

In an effort to demonstrate the value of services provided by ESPs, it is important to consider whether more complex outcome measures which include gathering information from several parts of the health economy, across both primary and secondary care may be needed. For example, measurement of patients along a clinical pathway from ESP assessment to post-surgical assessment such as the model audited by Gardiner and Turner⁹ may be useful. Measurements of conservative management following referral to other services such as functional outcomes after physiotherapy or podiatry may demonstrate ESPs' ability to refer appropriate patients to physiotherapy. Measurement of the number of re-referrals made by GPs to other services within allied care pathways such as the number of re-referrals to pain clinic, radiology, or orthopaedics may also be options which allow aspects of the ESP role to be evaluated.

It may be the right time to define the different models of ESP working more clearly and relate these models to the service outcomes required. Hopefully this would enable commissioners to identify the type of ESP roles they need to meet the requirements of the currently changing landscape. Minimum training standards would enable those commissioning and providing services to be clearer about the competency of ESPs working within areas such as interface services where consultant support is absent. Clearly defining the role of ESPs and ESP services would also provide direction for the development of relevant outcome measures and may enable ESPs to demonstrate their value more clearly.