Are we (the UK health system) failing patient’s?
Why do GP’s not refer to physio more?
My fiancé came home yesterday and said
“Mrs X from work has hurt her shoulder. She’s been told its a rotator cuff problem and to look up the exercises on the internet. I asked her if she’d been referred or even recommended for physio and she said no” he explained.
Now assuming there have been no Chinese whispers and the information is correct then this is extremely worrying and unfortunately something that I’m hearing more and more often. I understand that there are pressures within the NHS but if we look at this from a purely non financial view point. What would the best GP, the best healthcare system in the world do? In fact even if we look at it from a financial view point ( I’ll explain later) it still is the right thing to do.
A Physio’s Education
Within every physio’s education there is an investment of at least £9, 000 (if they trained over 7 years ago -£27,000 if they are training now). Then usually post graduate education of diploma level or MSC (£12, 000) and this doesn’t even include the course, clinical discussions undertaken and research analysis which will continue throughout a physio’s career.
I value my education and years of experience to help patients reach their goals quicker than them having to guess. One of the common exercises found on the internet for rotator cuff dysfunction is prone lying, shoulder abducted to 90 degrees with combined external rotation. With this particular exercise it is extremely important that you are getting the correct muscle activation with the humeral head centralised and to avoid the humeral head translating cranially.
The risk of incorrect exercise
If the GP had not recognised irritation of the bursa or bicep tendon ( which is common in rotator cuff dysfunction) then this exercise may aggravate the patients symptoms. Of course the testing for shoulders is not very accurate for isolating individual structures even within physiotherapy however with good exercise based therapy you can see incredible results. Many of my patients I will discharge within 4-6 sessions which is extremely cost effective when you think of the economic burden of people being off work or effect on their lives ( difficulty taking care of family, doing the things they love).
I also feel that follow up is very important to see the response to exercise, to ensure the patient is doing exercises correctly and so that the exercises are pitched at the right level of difficulty. One might stop the exercises rather than adjust if pain worsens ( after trying internet self prescribed exercises) because they do not understands the biomechanics and what we are trying to achieve. This isn’t delivering the best available care to the patient.
So this is my question.. Why do GP’s not recommend physio more?
A recent study showed that the life time prevalence for shoulder was 66.7%. This means a lot of people are going to experience shoulder pain at some point in their life. Across the globe Australia, Canada and the USA have demonstrated that there is large reliance on investigations such as Xray, bloods and ultrasound to make the diagnosis. Unfortunately we know that often asymptomatic patients ( i.e. those with no pain) will often have findings on investigations so sometimes, even if there is pathology seen/indicated on the investigation, this may not be the cause of their pain ( Judge et al, 2014).
56-83% of GP’s that answered the study said they were confident in their diagnosis. This was from a 14.7% response rate. 7 in 10 cases were supposedly referred to physiotherapy however due to the low response rate of the survey this could be influenced by non-response bias. What are the other 84.3% of GP’s doing? The people who answered the survey may be more interested in shoulders or feel more comfortable with the questions which may affect the validity of the results for the the whole population group ( which was only 5000 anyway).
This response rate probably reflects the pressures on GP’s time and I don’t understand why they don’t have protected time for helping in research which is SO important in moving the healthcare profession forward. Please read the book on Black Box Thinking by Matthew Syed which is a fantastic read on how we could make changes to improve healthcare in the Uk and across the world.
How much do investigations cost the NHS?
When trying to write this blog it was incredibly hard to find information on how much each of these investigations cost the NHS. This may be because the costs are different at each hospital but I did managed to find private fees at Torbay. We need complete transparency to help our NHS improve and for ideas and innovation to help save money and improve efficiency (as within any large business!).
My understanding of this table is that the radiologists fee is £68 and the cost of producing/ordering/analysis is £45. That seems an awful lot for an one joint Xray! However this site quotes it as being £27 perhaps they are looking at an average?
When you look further into the study and read the vignette (example) based questions Gp’s were asked to select from a list of DIAGNOSES.
They were given a 1-7 likert scale reflecting their confidence with their diagnosis ( ranging from definitely yes to definitely not). They were asked if their would request INVESTIGATIONS and then to state a reason why from the following list: to confirm diagnosis, toe exclude other diagnosis, to guide treatment options, to decide on specialist referral or a free text option.
What treatments would GP’s recommend?
GP’s were then asked to indicate what treatment they would recommend and asked to select from a list which included non steroidal anti inflammatories, corticosteroid injection ( guided or not), physiotherapy on a free text option. They were then asked if they would refer them for a specialist opinion such as the mSK service/ rheumatology or orthopaedics.
Of the 5000 initial surveys sent 2500 were web based questionnaires and the other 2500 were postal questionnaire. They were randomly selected and equally divided across the 4 countries of the UK.
Only 7.4% of the email questionnaires were completed (182 GP’s)!
There was 22% response for the postal questionnaires (542 GP’s).
Some questionnaires had to be discarded which meant actually 714 were valid and analysed in total.
Potential problems that may have affected the study
We have to remember as human beings we also don’t like to heavily commit to a firm diagnosis in case we are wrong. This may affect the likert scale but if we are unsure this may also increase the chances requesting investigations which ultimately may not change management when you could have had the problem resolved by a physio in the mean time!
The GP’s who answered had a mean duration of clinical practice of 17.5 years and most worked in urban or semi rural areas.
6% had a special interest in MSK medicine
37% had post graduate education on shoulder pain
There was some missing data that range between 1% and 29%
The question with the most amount of missing data appeared to be the destination of referrals to specialist care for rotator cuff tendinopathy (29%) or Adhesive capsulitis AKA frozen shoulder (13%)
56% of GP’s felt confident yes, that this question was a rotator cuff tendinopathy problem, 13% felt confident it was OA, 9% felt confident is was ACJ and 10% felt confident it was adhesive capsulitis.
Lets look at the numbers
Thats 145 GP’s ( of which only 714 out of 5000 responded – lets not even consider non response bias for a minute) who may be misdiagnosing the patient. The patient then starts non specific exercises for whatever diagnosis has been given and potentially gets no follow by a specialist who see’s shoulders regularly and for more time than the average GP does.
If a third of MSK problems that are seen in primary care are shoulders then we will be failing patients. We need to do better.
Don’t get me wrong diagnosis of shoulders can be very difficult and GP’s have to have knowledge in so many different areas and an extremely difficult job. But I find it hard to understand why more referrals aren’t being made to those who have spent their education just focusing on this particular area (MSK).
Lets look in more detail at the rotator cuff tendinopathy vignette.
42% of GP’s did not select any investigations ( HOORAY!). I would be interested to see how many physio would? I suspect non in the absence of red flags on the initial consultation..
Out of the remaining Gp’s.
242 (60%) selected plain radiographs
172 ( 42%) selected blood tests
154 (38%) USS
1 in 5 GP’s who were confident they had the correct diagnosis ordered X-rays to confirm the correct diagnosis! The problems is a) you don’t need an Xray because it doesn’t change management unless you suspect there is sinister pathology and need to rule out an alternative diagnosis. There is so much evidence that shows that many people have findings on investigations that are not clinically significant (Judge et al, 2014)
I feel extremely passionate about this because in 2017, with the internet and fantastic technology this information should be disseminated so much more effectively. Every GP surgery should be helping GP’s get easy access to evidence because it would save so much money in unnecessary investigations. Now I understand that pressures are difficult within the NHS but why people are waiting on the NHS list why not utilise the private support networks so that people people can get quick access to an expert?
The GP Wins and the patient wins.: Less visits taking up of the Gp’s valuable time. Less money spent on investigations. Happy patient with less pain in a shorter period of time.
Just consider a referral to a physio. Yes, you may have to part with some of your hard earned cash in exchange for the expert education and experience of a physio who’s been doing it for 8 years. Yes, you may have to put in some effort and follow the guidelines given to you to support you in your recovery. But how bad do you want to resolve your pain? How much value do you put on your health and being able to do the things you love?
People don’t bat an eyelid when they buy new jeans for £60 or £100 a month for a new car or £50 for a meal out. Invest in your health. Get back to the things that you love by speaking to an expert and following their program to hep you achieve your goals.
Judge A , Murphy RJ , Maxwell R , et al . Temporal trends and geographical variation in the use of subacromial decompression and rotator cuff repair of the shoulder in England. Bone Joint J 2014;96-B:70–4.doi:10.1302/0301-620X.96B1.32556 CrossRefPubMedGoogle Scholar
Artus M, van der Windt DA, Afolabi EK, et alManagement of shoulder pain by UK general practitioners (GPs): a national surveyBMJ Open 2017;7:e015711. doi: 10.1136/bmjopen-2016-015711