Last month, the research roundup provided you with an overview of articles looking at pharmacist prescribing practices (Robertson, 2022). This month, three articles are reviewed that relate to physiotherapist prescribers. The first paper looks at physiotherapy prescribers in a musculoskeletal area of practice for advanced physiotherapy practitioners. The second paper looks at independent prescribers in primary care including nurses, pharmacists and physiotherapy prescribers. Finally, the third article looks at advanced physiotherapy practitioners in an urgent care area setting.
Physiotherapists musculoskeletal science and practice clinics
The aim of this piece of research, published in the Journal of Musculoskeletal Science and Practice (advanced online ahead of October 2022 publication) was to establish how musculoskeletal advanced practice and consultant physiotherapists in England are using their independent non-medical prescribing skills to inform the evaluation of services and the impact of research on independent prescribing (Noblet et al, 2022).
The study was conducted using a multi-site, prospective design and was observational in nature, including seven advanced practice musculoskeletal physiotherapist independent prescribers in England from October 2019 to March 2020. Each participant collected anonymised data around their independent prescribing activity and use of their prescribing skills and knowledge. The activities of interest included prescribing with FP10 prescriptions, recommendation of over-the-counter medications, medicines management and optimisation, deprescribing, liaising with colleagues to inform prescribing decisions, making recommendations or referring the patient to another prescriber to prescribe the medicine, such as a GP. The settings were varied and included: first contact practice, primary care, community triage, secondary care orthopaedics, secondary care rheumatology and private practice. Quantitative data were analysed descriptively with qualitative data analysed/synthesised via thematic analysis. In total, the data collected covered 2470 patients.
The researchers found the predominant activities were prescribing for pain and inflammation, which accounted for 51.3% and 39.6% respectively. This prescribing was mostly in the first 206 weeks following diagnosis and onset of the presenting complaint. Other activities recorded were medicines optimisation (18.1%) and over-the-counter recommendation (15.5%). Deprescribing only accounted for 10.8% of activity. It was found that in over 90% of the episodes, independent prescribing was used over the supplementary prescribing process. Prescribing covered a wide range of musculoskeletal regions with spinal issues making up a significant proportion of patient episodes. Medication prescribed was typically analgesic or antiinflammatory in nature, including opioids and non-steroidal drugs.
Qualitative data were synthesised into four themes: multimodal physiotherapeutic approach, joint decision making and patient choice, working with complexity and legal and regulatory restriction.
The authors concluded that physiotherapist independent prescribing was used within all health sectors in conjunction with advanced skills in musculoskeletal physiotherapy as part of a multimodal physiotherapeutic approach. Prescribing activity was dictated by clinicians' clinical reasoning and use of joint decision-making.
Physiotherapists in primary care
This article published in the BMJ Open Access online journal is a systematic review of literature that explores the barriers and facilitators to implementing independent prescribing by non-medical practitioners, including physiotherapists in the primary care arena (Edwards et al, 2022). The review aimed to explore stakeholders' views and identify perceived barriers and facilitators to inform workforce transformation in the UK. The authors employed a robust methodological approach to the review of qualitative studies with strict inclusion and exclusion criteria over multiple databases.
The search was limited to publications between January 2010 and September 2021. Appropriate quality appraisal tools were used resulting in 23 articles being included. Data were extracted and coded before a two-person review and inductive thematic analysis were applied. The articles all addressed nurse, pharmacist and physiotherapist independent prescribing.
Synthesis identified barriers and facilitators in four key stages of implementation: (1) ‘preparation’, (2) ‘training’, (3) ‘transition’ and 4) ‘sustainment’. Enhancement, substitution and role-specific implementation models reflected three main ways that the independent prescriber role was used in primary care. The preparation theme identified barriers and facilitators in the planning stage of non-medical prescribing implementation in primary care. These related to service need, organisational readiness, consistent leadership and an interprofessional environment. It was important to identify shortfalls in care provision and the need for autonomous practitioners with prescribing rights to fill service gaps.
The training theme identified areas around the selection of the right practitioners to enter prescribing training and also the support and governance during the training period. These were related to academic demands, supported study time and the use of buddying schemes.
The transition theme highlighted reports of poor transition support, with some practitioners feeling isolated and in need of structured and informal supervision at the point of transition. Finally, sustainment highlighted subthemes of service delivery and supported role development relating to how non-medical prescribing was used and maximised in primary care.
The authors concluded that although the number of independent prescribers continues to grow, numerous barriers to implementation persist. A more coordinated and targeted approach is key to overcoming barriers identified in the four stages of implementation and would help ensure that non-medical prescribing is recognised as an effective approach to help alleviate workforce shortfalls in the UK, and around the world.
Physiotherapists in urgent treatment centres
This pilot study, published in the Journal of Physiotherapy in June 2022 aimed to quantify the proportional presentations of patients attending the emergency department who were suitable for management by advanced physiotherapy practitioners (McDonough et al, 2022). A secondary aim was to analyse patient care delivered by these advanced physiotherapy practitioners in comparison to other members of the multidisciplinary team. The study was carried out as a retrospective service evaluation at an urgent treatment centre within a busy major trauma unit of an acute NHS university teaching hospital in England. The study period covered 3 months and attendances between the hours of 08:00 and 20:00. This led to the inclusion of 3927 patients triaged. Data were collected to assess the number of patients seen by all multidisciplinary cohort members. This was to assess presentation patterns and compare workload delivery. The staffing was by emergency nurse practitioners, general practitioners and advanced physiotherapy practitioners. This data collection was retrospective and included numbers of patients seen, range of conditions, re-attendances, discharge destination, time to treat and investigations ordered. Analysis was performed by professional groups and compared between professions.
In the 3-month period, emergency nurse practitioners saw 1391 patients, general practitioners 1169 patients and advanced physiotherapy practitioners saw 598 patients. Figures were then adjusted to account for shift hours covered by each profession. The pilot found that the advanced physiotherapy practitioners could assess and treat a wide range of conditions within the urgent treatment centre and saw 30% of the caseload, organised similar numbers of investigations to general practitioners and had fewer 30-day re-attendances. The range of presenting conditions was mapped to profession seen and showed appropriate triage to healthcare professional with physiotherapists seeing mostly back pain, neck pain and limb injury presentations. Limb problems accounted for 43% of the total attendance in the urgent treatment centre. In addition, these patients when seen by a physiotherapist, spent on average 15 minutes less in the department, compared with other professions. The authors concluded that advanced physiotherapy practitioners can assess, treat, discharge and appropriately refer similar numbers of patients as multidisciplinary colleagues. They suggested that this makes them cost-effective within an urgent treatment centre environment, but do state that further study is needed to confirm this.
These articles demonstrate the clear value and benefit to patient care of having prescribing physiotherapists in many areas of clinical practice. While still relatively small in comparison to pharmacist and nurse prescribers, the number of independent physiotherapy prescribers continues to grow, with 1630 independent prescribers being annotated as of 2020 (Health and Care Professions Council, 2020) with their scope of practice focused around respiratory and musculoskeletal care. Advanced physiotherapy practitioners make up a significant proportion of physiotherapist prescribers.