Physiotherapists and patients positive about direct access

Even though people no longer need a referral to see a physiotherapist in the Netherlands, there has not been a sharp increase in the use of physiotherapy. Physiotherapists and patients are satisfied, and general practitioners (GPs) haven’t noticed any changes to their workload. This is contained in an article by researchers from the Netherlands Institute for Health Services Research (NIVEL). Their findings were published in the academic journal Physical Therapy.

In 2006, the Dutch Ministry of Public Health, Welfare, and Sport (VWS) introduced free access to physiotherapy. Everyone can now see a physiotherapist without a referral. This was expected to result in greater recognition of physiotherapists as fully qualified practitioners in their own right, and also give patients more freedom of choice and lighten the workload of GPs to some extent. No major effect on GPs’ workload had been expected because only a small proportion of patients go to their GP with complaints that can be alleviated by physiotherapy. However, there had been the fear that direct access would lead to many more physiotherapy treatments. NIVEL researcher Ilse Swinkels: “This fear turned out to be unfounded. Although we did see more patients, this rise can also be explained by the increase in the number of older people and people with chronic diseases. In addition, people who come without a referral have fewer treatments, and not everyone ends up receiving treatment.”
Back, shoulder, and neck
Data from the NIVEL Primary Care Database shows that, between 2004 and 2009, the number of back, shoulder, and neck complaints dropped slightly, while the number of knee complaints rose. In 2004, 17% of all Dutch people visited a physiotherapist; in 2009 this was 21%. The number of people who went to the physiotherapist without a referral went from 28% in 2006 to 44% in 2010 and 47% in 2012. Patients with no referral have an average of three fewer treatments than people who are referred by their GP. Ilse Swinkels: “This could be because they seek treatment sooner. Research has shown that this leads to a quicker recovery. At the same time, it’s also possible that their complaints are less serious, but this has not been studied.”
Direct access means that a physiotherapist can examine patients without the requirement of a physical referral. When patients come without a referral, they undergo a ten-minute screening process during which the physiotherapist considers whether he or she can treat the complaints or whether there are any indications that a doctor should see the patient first. For example, if a patient has suddenly lost a lot of weight, a physiotherapist will always refer him or her to their GP. If the physiotherapist decides to treat the patient, the next visit will include a more extensive examination, and then treatment will begin.
“More and more, patients are going to see physiotherapists without first being referred by their GP – it’s easy, and takes less time,” says Swinkels. “Physiotherapists are happy with this – they have more autonomy, but on the other hand, also more paperwork. They have to write a report for the GP after the first examination and also at the end of the treatment, with the patient’s permission. For patients with a referral, a report has to be written only at the end of treatment. Also, more information has to be recorded. Although direct access does result in more paperwork for physiotherapists, they seem to feel this is outweighed by the recognition they receive as fully qualified practitioners in their own right, and the advantages they believe this offers their patients.” 

Ministry of Health, Welfare and Sport