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Manipulation Services for NHS Patients:
Precedents and Future Models for Provision
Executive Summary
Provision and delivery of care for sufferers of musculoskeletal disorders has recently come into sharp focus, largely due to the epidemiology and socio-economic costs of low back pain. Other contributors have been legislative reforms within the UK National Health Service (NHS), changes in government policy and the recent statutory self-regulation of chiropractors and osteopaths (who generally work outside the NHS).
This study examined past and current levels of provision of musculoskeletal services by practitioners qualified in manipulation for NHS patients immediately prior to the end of fundholding. It also elicited practitioner views on optimal models for future arrangements, as perceived for themselves and for their patients. Dividing the sample into practitioner and patient ‘interest' groups allowed this. The results provide an informed basis on which to plan future NHS services.
A total of 3,840 questionnaires were distributed to all chiropractors (n=1,042) and osteopaths (n=2,393) on their professional registers and to all members of the Manipulation Association of Chartered Physiotherapists (n=408). An overall response rate of 62% was achieved.
Approximately one-third of the chiropractors and half the osteopaths and physiotherapists had more than ten years experience of treating musculoskeletal disorders. However, in the case of the latter, this did not relate specifically to manipulation.
Fifty-eight percent of chiropractors and two-thirds of the osteopaths worked in multiple localities (eg. town, city, rural, etc), compared to a little under half of the physiotherapists.
The majority of chiropractors (84%) and osteopaths (76%) were in private practice, approximately double (42%) the number of manipulation physiotherapists.
Proportionally more osteopaths (17%) than chiropractors (10%) were sited in GP practices. Only 2% of the physiotherapists were based in either private or NHS GP practices.
Nearly all physiotherapists had previously provided services to NHS patients suffering musculoskeletal complaints. The same was true of approximately one-third of the chiropractors and osteopaths.
None of the five manipulation physiotherapists who had not previously treated NHS patients with musculoskeletal disorders expressed a desire to do so in the future. Approximately one-quarter of the chiropractors and one-fifth of the osteopaths who had not provided NHS services before were very keen to do so given acceptable terms and conditions. Chiropractors in the practitioner interest group indicated a significantly (p=0.05) stronger desire to provide these services than the same group within osteopathy.
Prior & Current Provision
Manipulation Physiotherapy
Sixty percent of the manipulation physiotherapists had current NHS arrangements and 78% of these had held prior arrangements.
Of those who reported having prior and current arrangements, markedly fewer manipulation physiotherapists were currently providing full-time services for NHS patients (39% compared to 76% previously).
There appeared to be a downward trend in the number of therapists working in NHS hospital trusts, while the number who secured working arrangements with GP fundholders had risen from approximately one-fifth to a little under one half.
Of the manipulation physiotherapists currently providing services for NHS patients, two-fifths were providing these services on a full-time basis. Nearly two-thirds of those receiving GP referrals were employed in a NHS hospital trust. Only 12% were working in NHS primary care centres. The most commonly held contract was the block contract. On a scale of 1(very unsatisfied) to 7(very satisfied) the mean satisfaction rating for this group was 4.9 (SD1.4).
Chiropractic & Osteopathy
Nineteen percent of the osteopaths and 18% of the chiropractors were providing musculoskeletal services for NHS patients at the time of the study. Less than 10% in either profession were doing so on a full-time basis.
Over half the osteopaths with current NHS arrangements had previously provided such services. Two-thirds of the chiropractors currently providing services for NHS patients had also done so previously.
Cost-per-case contractual arrangements with fundholders were the most common method of GP referral to these services.
Thirteen percent of the chiropractors and 10% of the osteopaths reported arrangements for consultant referral.
The most common contractual arrangement among both professions was the cost per case.
In general, the chiropractors were more satisfied with arrangements than were the osteopaths, although there was no significant difference in mean scores.
Future Provision
of respondents in all three professions indicated interest in providing or continuing to provide services for NHS patients.
Patient Mix: The majority of all groups expressed a desire to see mainly private but some NHS patients. However, approximately one-quarter of the manipulation physiotherapists reported a preference to see mostly NHS patients. Approximately one-fifth (16%) of the manipulation physiotherapists wanted to provide services for NHS patients only.
Duration & Area of Complaint: The majority of respondents wanted to see complaints of all duration, believing this to be in the best interests of patients. Similarly, the preference was to offer services for all areas of complaint.
Ideal Setting: The preference of all chiropractors and osteopaths was to remain in private practice premises. Approximately half the physiotherapists also believed this to be optimal for both practitioners and patients. With regard to private practice, the second choice of most practitioners across all groups was to be sited in private GP/health centre premises or to operate a clinic from home. In terms of NHS settings, working in a NHS GP practice or health centre was most strongly supported by the osteopaths. Although this was also the choice of the chiropractors, they showed considerably less support for it, while the manipulation physiotherapists in both practitioner and patient groups favoured working in NHS Trust Hospital outpatient departments.
Access: There was overwhelming support (90-95%) for the GP to act as gatekeeper to musculoskeletal services for NHS patients. However, nearly two-thirds of the chiropractors, approximately half the osteopaths and 41% of the physiotherapists thought that NHS patients should also be able to self-refer.
Multidisciplinary Practice: Over half the osteopaths and physiotherapists thought it desirable to share premises with general practitioners, compared to 40% of the chiropractors.
Hours Per Week & Employment Status: The preference (mode) for all groups was to provide services for NHS patients up to a maximum of 15 hours per week. Neither the chiropractors nor osteopaths believed it to be in the interests of patients to provide services under the NHS for more than 20 hours per week. Sixteen percent of the physiotherapists believed the provision of full-time services to be optimal from a patient perspective. Ninety-two percent of the chiropractors considered being self-employed and contracted by the NHS to be best for both practitioners and patients, as did 85% of the osteopaths. Half the physiotherapists concurred, although one-quarter favoured full-time employment in the NHS as the ideal arrangement for patients.
Preferred Contractual Arrangements and Reimbursement: Cost per case was the contract of choice for both practitioner and patient interest groups among the chiropractors and osteopaths. The physiotherapists also concurred with this in terms of their own interests. However, those who were asked to respond in terms of patient interests favoured the block contract. From a practitioner's viewpoint, the chiropractors favoured (46%) an arrangement whereby the patient paid the fee and then sought reimbursement from the NHS. For patients, they thought it would be better to invoice the purchaser. This latter arrangement was also the choice of the osteopaths in both groups. The majority of the manipulation physiotherapists, however, wanted to be salaried. Payment on a sessional basis was preferred by approximately half the chiropractors and physiotherapists and by two-thirds of the osteopaths. |
