RESEARCH ARTICLE

General Practitioners’ Views About an Orthopaedic Clinical Assessment Service Damon Burn1*, Stephen May2 & Lindsay Edwards3 1

Trauma Orthopaedic and Musculoskeletal Services, Walsall Healthcare NHS Trust, Walsall, UK

2

Faculty of Health and Wellbeing, Sheffield Hallam University, Sheffield, UK

3

ATOS Healthcare, Nottingham, UK

Abstract Background. General practitioners’ (GP) views about orthopaedic clinical assessment services (OCAS) managed by physiotherapists in the NHS have seldom been sought, yet GPs are likely to be key referrers to such a service. Aim. This study aims to review GP views about an OCAS and how they believed the service could be improved. Design of the Study. Fifteen consenting GPs were interviewed utilizing semi-structured interviews and a standardized topic guide. Method. Interviews were recorded, transcribed and analysed for emergent themes. Interviews were analysed sequentially by date performed until saturation. Themes were discussed, and disagreements evaluated until agreement was found between the two main authors. The third author then analysed randomly selected interview transcripts and found no additional themes. Results. The study found GPs refer to specialist services, including this OCAS, because of wait times, locality, patient experience, GP experience and knowledge of available services. No GP identified they knew all possible orthopaedic referral routes. Conclusion. GPs saw OCAS as another referral choice for patients suffering orthopaedic pathologies. GPs identified some difficulty in understanding the different services including the various professional roles involved. To assist with their understanding, they described requesting advertising of the different services and the clinicians involved or streamlining of services by provider services. Further detailed research addressing the limitations in this research design is indicated to investigate GP’s thoughts and behaviours in relation to referral patterns especially as GPs in the UK took on commissioning for services from April 2013. Copyright © 2014 John Wiley & Sons, Ltd. Received 11 September 2013; Revised 3 December 2013; Accepted 13 February 2014 Keywords interdisciplinary; multi-disciplinary; orthopaedics; physiotherapy *Correspondence Damon Burn, Trauma Orthopaedic and Musculoskeletal Services, Walsall Healthcare NHS Trust, Walsall, WS108SY, UK. Email: [email protected]

Published online 4 April 2014 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/pri.1581

Introduction Musculoskeletal physiotherapists were first used to manage orthopaedic demand as far back as the 1980s, but over the last 12 years, there has been a dramatic increase especially in the UK and also in Australia and Canada (Byles and Ling, 1989; Daker-White et al., 1999; DoH, 2000; Oldmeadow et al., 2007; MacKay et al., 2009). 176

The drivers for this increase include high cost burden of musculoskeletal care in secondary care, long wait times to see orthopaedic surgeons, increasing prevalence of chronic musculoskeletal problems, high numbers of referrals reaching orthopaedic surgeons without need for surgical intervention, reduction in working hours of junior doctors and transference of Physiother. Res. Int. 19 (2014) 176–185 © 2014 John Wiley & Sons, Ltd.

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care from secondary to primary care (Durrell, 1996; Rashid et al., 1996; Hattam and Smeatham, 1999; DoH, 2000; Hattam, 2004; Speed and Crisp, 2005; DoH, 2006; Oldmeadow et al., 2007; Akbari et al.., 2009; MacKay et al., 2009). The main aim for the posts has been to decrease the number of patients with orthopaedic conditions that are not amendable to surgery being referred to orthopaedic surgeons unnecessarily. Using physiotherapists is only one way of improving appropriateness. Other effective strategies include orthopaedic consultant involvement in general practitioner (GP) educational sessions, attachment of physiotherapists to GP practices, joint consultations with GPs and orthopaedic consultants and use of referral criteria with dissemination of guidelines (Vierhout and Knottnerus, 1995; Akbari et al., 2009). Ineffective strategies include passive dissemination of guidelines, feedback on referral rates and discussion with medical advisors (Vierhout and Knottnerus, 1995; Akbari et al., 2009). By using physiotherapists, services may be able to improve referral effectiveness without changing routine medical practice. This may be why there has been a large increase over the last 12 years as medical practice can be difficult to change (Freeman and Sweeney, 2001; Armstrong, 2002; Imison and Naylor, 2010). Physiotherapists have performed these roles differently depending on the local or national requirements, and legislation. In the UK and Canada, many of these roles have involved extension of practice, substituting roles normally performed by doctors. These extra responsibilities have included ordering diagnostics (i.e. X-rays, magnetic resonance imaging and Dexa scans), performing articular or peri-articular injections of drugs including corticosteroids, listing for surgery and triaging referrals via either paper or face-to-face assessments (Woodhouse, 2006; Kersten et al., 2007). These extra roles have usually been agreed locally through medical directives, and hence, there is generally no recognized credentialing in the UK or elsewhere for these positions (Woodhouse, 2006; Kersten et al., 2007). Names for these roles include extended scope practitioner (ESP), which will be utilized for the rest of the paper, orthopaedic practitioner, extended class physiotherapist and advanced physiotherapist (Woodhouse, 2006; Kersten et al., 2007). Legislation has followed for some of these roles to be performed independently such as independent prescribing in the UK (DoH, 2012). Australian services have been slightly different. Triage services have been set up to take on the role Physiother. Res. Int. 19 (2014) 176–185 © 2014 John Wiley & Sons, Ltd.

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of streamlining processes rather than substituted roles (Schoch, 2012; Stanhope et al., 2012). There is debate in Australian literature as to whether extra responsibilities are part of advanced practice or an extension of practice and therefore out of the Australian legal framework (Crane and Delaney, 2013). Other possible reasons for non-extension of practice include different payment mechanisms for healthcare (i.e. public health is not reimbursed for physiotherapists ordering diagnostics), a shortage of physiotherapists or lack of medical acceptance for substitution of roles (McPherson and Reid, 2007; Kilner and Sheppard, 2010; Flannery and Waterford, 2012). Acceptance by the medical fraternity of changing roles in relation to ESP positions has rarely been studied. One study indicated that utilization of ESPs depends entirely on consultant and medical fraternity acceptance (Dawson and Ghazi, 2004). In contrast, another larger study demonstrated GP’s high level of comfort and confidence with ESPs and physiotherapists managing patients with orthopaedic conditions (Holdsworth et al., 2008). In 2005, it was identified in Walsall (UK) that there were long wait times for patients being referred with orthopaedic conditions to secondary care orthopaedics (Manor Hospital). Walsall has a population of 250,000, with high levels of cultural diversity and deprivation. An orthopaedic clinical assessment service (OCAS) was commissioned to address this issue, staffed by ESP physiotherapists. The service was designed as a signposting service to direct patients to appropriate care with the following aims:

• • • •

triaging patients appropriate for conservative therapy to the most appropriate service; treat patients when appropriate with advanced skills including injections; utilizing diagnostics as indicated (originally X-rays, but later magnetic resonance imaging); and referral onto orthopaedic services when indicated.

OCAS was set up as another option for GPs to refer patients in addition to the five other options: orthopaedic secondary care, musculoskeletal physiotherapy, biomechanical podiatry, podiatric surgery and a minor surgery service, which included joint injections and carpal tunnel operations. It was envisaged that patients with simpler orthopaedic conditions would continue to be referred to musculoskeletal physiotherapy and biomechanical podiatry as these services do not have access to diagnostics and are not able to refer to secondary care. 177

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At the time, approximately 600 patients a month were referred to orthopaedic secondary care. After 2–3 years, the service did not appear to be impacting on referral numbers, despite OCAS seeing approximately 100–120 patients a month. An unpublished small study interviewing six incentivized GPs was conducted to investigate further (Lane, 2008). It concluded GPs

• • • • • •

did not understand what OCAS actually did; felt the referral process was complicated; felt they did not get enough feedback from the service; felt that the service was imposed on them without consultation; felt the service impacted directly on their autonomy and gatekeeper role; and described being unhappy with musculoskeletal physiotherapy.

It is difficult to draw conclusions from the study because of the small number of incentivized participants. Following this study, Coyle and Carpenter (2011) conducted a qualitative study to explore the experience of patients who had attended OCAS. They made the following recommendations:

• •

a need to educate referrers and commissioners about the role and practice of ESPs and further research was required to explore knowledge and attitudes of GPs about the ESP roles.

The aims of the study were to build on these previous studies by investigating GP’s views and attitudes towards OCAS and to explore understanding of the service and its staff compared with other services, and how they believed the service and other services could be improved for more seamless care of patients.

Methods Study design The study was conducted using semi-structured interviews. Interviews were performed for a few reasons. Firstly, the aim was to build on a previous study that interviewed GPs in Walsall, and as such, it was felt a similar methodology should be chosen. Secondly, previous experience in Walsall of sending questionnaires in relation to musculoskeletal services unfortunately gained not only a poor response rate but also responses lacking depth for interpretation. This is despite there being 180 GPs in Walsall. It was felt that more in-depth 178

answers would be given on behaviours and experience of GPs by performing interviews. Ethical approval was gained from NHS Walsall Local Research Ethics committee and through Sheffield Hallam University Health and Wellbeing Ethics Committee.

Topic guide The topic guide was agreed between the researcher, the Service Improvement Department of Walsall Community Health and Sheffield Hallam University (Table 1). The questions were open ended in nature to allow the volunteer to elaborate in more detail on experiences if required. If a volunteer was uncertain of a question, the researcher was able to clarify and expand further to help elicit a response.

Sample The sample was recruited from the current 180 GPs, in 68 practices, listed with the NHS Walsall. All Walsall GPs were invited to participate by post and email. Those willing to participate were asked to respond within 3 weeks. As only four GPs responded to the first request, non-responding GPs were emailed personally again to request participation. Eleven further GPs responded to make a total of 15 interviews, from 14 different practices. The respondent GPs came from across the borough with equal representation geographically across the four regions of Walsall.

Interviews The interviews were conducted at the GP’s own practice by the main researcher (D. B.). Interviews were tape recorded. Each interview took approximately 45 minutes. Interviews were later transcribed by the researcher. To improve rigour, a written transcript was sent back to the volunteer to confirm the written content. If the GP felt what was transcribed was not what was intended to be said, they were able to write back to the researcher and update the transcript. Informed consent was gained by signing a consent form before the interview following reading an information sheet.

Data analysis process Data were analysed by identifying emergent themes as follows (Smith et al., 1999; Robson, 2002; Green and Thorogood, 2004): Physiother. Res. Int. 19 (2014) 176–185 © 2014 John Wiley & Sons, Ltd.

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Table 1. Topic guide

• Please describe the following • How many years have you been a GP? • How much MSK experience do you feel you have? • Describe approximate percentage of MSK patients seen in practice? • Gender? • Describe the mix of patients currently seen in your practice in terms of ethnic and socioeconomic background

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• •

As a final check, another researcher (L. E.), blind to the previous thematic analysis, reviewed two randomly selected transcripts. The themes identified by this researcher were the same as those already identified. It was agreed a priori that themes had to be identified in more than half of the interviews analysed to become an identified theme.

• How do you decide whether to refer a patient to the following or to self manage a musculoskeletal patient? • OCAS • Orthopaedics • Musculoskeletal physiotherapy• Podiatric surgery • Biomechanical podiatry • Minor surgery • What function do you believe the orthopaedic clinical assessment service performs? • Would you like Walsall Community Health to give you more referral choices or decrease the referral choices? • How do you explain to patients you are referring them to the orthopaedic clinical assessment service? • What are the patient responses/expectations when told they will be referred to an OCAS? • What feedback would you have for how the service currently performs either from patients or yourself? • What information is important to you following a patient’s visit to a service? • Can you give examples on how to improve the service? • What would help you to refer into the service? • How does having an OCAS make you feel about clinical decision making processes?

• • • • •



Familiarization with the first three transcripts and summary of data into themes independently by both researchers. Establish connections between themes and decide on themes and sub-themes. Code transcripts according to these themes. Define themes. For the first three transcripts, reviewer one (D. B.) identified seven key themes, and reviewer two (S. M.) identified eight. Three themes were identical, and four were identical apart from thematic heading. After discussion, reviewers agreed headings for these four themes. S. M. identified two remaining separate themes (dissatisfaction with OCAS and service inequality), whereas D. B. had classed service inequality as a sub-theme of dissatisfaction with OCAS. This was discussed and agreed to be one theme. Analysis continued until saturation was reached, the point where no new themes were discovered in the last three sequential interviews. Theoretical saturation is a concept that emerged from those who developed grounded theory research; the idea is that ‘unless you strive for this saturation, your theory will be conceptually inadequate’ (Strauss and Corbin, 1990, p. 188).

Physiother. Res. Int. 19 (2014) 176–185 © 2014 John Wiley & Sons, Ltd.

Results Themes are defined under the theme headings, with verbatim quotes below numbered according to participant number. Theme 1: Reasons for referral This theme describes the explanations GPs gave of reasons they would refer patients to the six possible orthopaedic routes. Reasons varied depending on GP’s knowledge and experience of services. ‘It is quicker, it is here, and it is local. So they can come and see you here (OCAS) and get an opinion and possible treatment here, without going to the Manor (hospital).’ (2) GPs also preferred patients to be managed completely by a service, with some indicating frustration when patients returned and required further referrals. ‘Bouncing patients backwards and forwards doesn’t work.’ (3) Theme 2: Referral choices This theme describes how GPs decided to refer to available services. The theme closely correlates with two other themes: reason for referral and function of OCAS. Again, referral choices were dependent on GP’s knowledge of available services. ‘In regard to biomechanical podiatry I have never heard of them to be honest.’ (8) ‘Obviously we are in the age where we are trying to reduce referrals to hospital, particularly outpatients. I think OCAS has stepped into that gap.’ (1) GPs preferred services where patients have had positive experiences. If a negative experience occurred with a new service, it affected whether they referred again. 179

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‘I found it very confusing when I used OCAS. I get referrals back saying this referral needs to be fast tracked can I give it to you? Then I sit here thinking, I have this patient running around in circles. What am I doing sending to OCAS? I am not going to send them again.’ (3) Some GPs were aware of cost implications of referring to certain services and how their practice compares to others. ‘The pressure is on us, we have been highlighted as over referrers, so basically most orthopaedic problems are going to come your way (OCAS).’ (7) Two GPs after identifying that they did know at least one of the available services suggested a single point of entry to decrease inappropriate referrals. ‘It might be easier to have a single point of referral and then you guys decide which service is more suited.’ (13) Theme 3: Referral pathway or process This theme outlines when GPs discussed either guidelines for entry into particular services or a specific pathway between services. GPs identified they did not know of guidelines or pathways for referral into the identified services and felt that these would be useful. ‘If there is more clarity in terms of the types of problems to which pathway they need to be referred to.’(6) ‘I think we need to decide a local pathway for joint injections.’ (10) Theme 4: Function of OCAS This theme outlines GP’s views on what service OCAS performs and how it fits in with other identified services. The GPs believed OCAS was a triage service to decrease inappropriate orthopaedic referrals. ‘It is a sort of triage, so that you can refer for second opinion as my knowledge of orthopaedics is quite little.’ (2) ‘It is a kind of demand management facility. A kind of triage.’ (10) 180

Two of the GPs compared how the local OCAS compared with services in the surrounding areas and nationally. ‘I know of colleagues in other areas, who have objected when it is the only way of getting patients to orthopaedics. Because if you are seeing someone who very certainly needs an orthopaedic or a neurosurgery review, then you don’t want to delay them.’ (9) One GP (11) had never heard of OCAS and was unable to identify its function. Theme 5: Information to patients This theme describes what information patients were provided with before coming to their appointment. GPs that utilized OCAS described the clinicians as physiotherapists with extra training who could see the patient more conveniently because of locality and lower wait times. ‘I explain that they are often seen in the community. And I explain they will often be seen a lot quicker than if they were waiting for an orthopaedic appointment.’ (1) ‘We explain to them that the problem they have, the physiotherapist I am sending you to has special training in orthopaedics.’ (4) Theme 6: Patient responses and expectations This theme describes how patients responded to their GP advising them of referral to OCAS and also if they described their OCAS experience to their GP. The responses can be divided into positive and negative. On the positive side, ‘The patients are fine, as long as I say it to them. The majority will do what I say, which is kind of paternalistic.’ (7) One negative comment was noted from a GP from patients. ‘There have been a couple of patients who have not got on with the practitioner. I presume this is a personality thing.’ (3) Theme 7: Satisfaction with OCAS This theme outlines GP’s positive thoughts of OCAS. This theme detailed positive statements from GPs Physiother. Res. Int. 19 (2014) 176–185 © 2014 John Wiley & Sons, Ltd.

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who thought highly of the service. They felt the service decreased their orthopaedic referral rates, produced lower waiting times and led to high patient satisfaction rates. ‘I personally, am quite happy for all orthopaedic type issues, musculoskeletal type issues, once traditional physiotherapy has not helped, I am happy for them to go through OCAS. Mainly because the patient’s actually appreciate the service.’ (1) Theme 8: Dissatisfaction with OCAS This theme outlines GP’s description if they were unhappy with OCAS and their reasons. Dissatisfaction was around three sub-themes — dissatisfaction with OCAS, dissatisfaction with musculoskeletal physiotherapy in general and dissatisfaction based on comments from other GPs. Dissatisfaction with OCAS was due to inequality of service delivery, confusion with referral forms, poor patient experience and variable waiting times. ‘They would like a joint injection service here, if they could.’ (2) ‘I think to a certain extent, something that is crazy, the multitude of referral forms that we have to deal with for each of the services.’ (3) ‘The last time I checked it on Choose and Book, the waiting list was, I can’t remember, a few months.’ (6) Confusion among some GPs as to how OCAS was different from physiotherapy led to complaints about physiotherapy. ‘I think you would get a better end result if patients are held onto longer in physiotherapy.’ (7) ‘We did have at one time a service for RTA’s and whiplash. Where you could book and get them in quickly.’ (2) Comments from other GPs impacted on referring. Some GPs described not knowing the service well, indicating there may be a problem with information to GPs. ‘Feedback I got from colleagues was quite often that OCAS did not sort out the problem and you had to refer them on anyway.’ (12) Physiother. Res. Int. 19 (2014) 176–185 © 2014 John Wiley & Sons, Ltd.

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Discussion The GPs interviewed understood when patients require further treatment and acknowledge services need to exist to help with patient care and flow and to improve efficiency of referrals. For example, ‘…we are in the age where we are trying to reduce referrals to hospital, particularly outpatients. I think OCAS has stepped into that gap.’ (1) However, quite surprisingly, none of the GPs interviewed demonstrated knowledge of all six possible referral routes, and there was some confusion between different services. This lack of clarity of where to refer patients with orthopaedic conditions was also found by Speed and Crisp (2005) when they investigated referrals to secondary care orthopaedics and rheumatology. GPs referred to specific services from personal experience of contact with staff, patient-reported experience, wait times and knowledge of services. Non-clinical factors may therefore affect referral patterns, and this needs to be taken in context with referral management strategies (Foot et al., 2010). GPs identified a need for better advertising of services or integration, as it is difficult for them to understand differences between professional roles and services. For example, ‘It might be easier to have a single point of referral and then you guys decide which service is more suited.’ (13)

This lack of knowledge of professional roles is also found in other settings (McKenna et al., 1999; Walshe et al., 2008). Provider services may need to investigate new ways of promotion including knowledge of professional roles, instead of passive dissemination, which has been found to be ineffective in changing GP’s referral patterns (Akbari et al., 2009). This is despite some of GP’s requesting referral guidelines (West et al., 2007; Akbari et al., 2009). Literature into medical prescribing has found that GP’s willingness to prescribe new medication is dependent on the amount of new information provided by drug representatives (Jones et al., 2001; Mason, 2008). Maybe clinicians in OCAS need to meet GPs to explain the benefits of the service and revisit the same way that drug representatives do. As care moves from secondary to primary care, services may need to be redesigned to make best use of resources and differing professionals (Ferguson and 181

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Cook, 2010). There may be a need to centralize referral routes, to decrease duplication and cost and to better integrate services (Speed and Crisp, 2005). It was of interest to note that some GPs knew about other triage services in surrounding areas or nationally and how they functioned. One GP noted that he did not mind if all orthopaedic referrals went through a triage: ‘I think the main issue there is that in certain parts of the country, OCAS is basically for all referrals. I personally, am quite happy for all orthopaedic type issues… for them to go through OCAS’ (1) Another GP talked about how surrounding triage services impacted on GP’s ability to manage patients. ‘I know of colleagues in other areas, who have objected when it is the only way of getting patients to orthopaedics. Because if you are seeing someone who very certainly needs an orthopaedic or a neurosurgery review, then you don’t want to delay them.’ (9) This discussion can be seen in a wider context. GPs have been noted in some situations not to implement evidence and see patient–practitioner relationship as paramount (Cranney et al., 2001; Freeman and Sweeney, 2001; Lugtenberg et al., 2009). A compulsory triage service would take away autonomy to help patients as the decision is made elsewhere. Conversely, non-compulsory triage services have been found not to impact on referral numbers to orthopaedics as they open up supplementary capacity to refer patients rather than substituting for it (Webb, 2009; Imison and Naylor, 2010). GPs that utilized OCAS were satisfied with reduced referral numbers to orthopaedics, reduced wait times and patient satisfaction. Others were dissatisfied with regard to location of services, inequality of service provision in relation to injections as a treatment option as this was only available in half the localities (due to only one clinician having attained the qualification), referral pathways in general and local musculoskeletal physiotherapy, which some GPs thought was part of OCAS. Apart from an unpublished study also investigating GP’s views of OCAS in the Walsall area, no other research literature was identified investigating GP’s thoughts about ESP musculoskeletal services (Lane, 2008). Imison and Naylor (2010) interviewed 24 GPs plus 17 triage clinicians, which included unknown number of GPs, about 182

referral management centres and triage services generally but not specifically orthopaedics. They found that the majority of GPs and also consultants felt that referral management was detrimental to consultant/GP relationship. Triage GPs unsurprisingly were complimentary of triage services and could see benefits for patients particularly in relation to improving quality of referrals to secondary care and improved relationships personally with local consultants. Some literature suggests that there is an ambivalent attitude to ESP roles, with some GPs being against the extension of roles, but others being comfortable with it (Dawson and Ghazi, 2004; Pulse, 2006; Holdsworth et al., 2008; Pulse, 2008). Holdsworth et al. (2008) surveyed 70 GPs with 67 (96%) expressing high levels of comfort and confidence in physiotherapists acting as first point of contact practitioners. It could be that GP’s views of these roles maybe similar to previously discussed consultant views, with acceptance and utilization depending on how much the role helps the doctor involved (Dawson and Ghazi, 2004). Patient experience of OCAS appears to have a major influence on GP’s referring patterns. Rosin et al. (2007) conducted focus groups with 30 GPs in six different parts of the UK investigating variation of GP referral patterns and reasons for variation. Results suggested that GPs often distrust published data sources believing many of the figures have been manipulated for political gain. They often used softer informal information from various sources including patient feedback of hospital visits. In the current study, similar themes were also found with positive and negative comments from patients affecting GP referral patterns. For example, ‘I found it very confusing when I used OCAS. I get referrals back saying this referral needs to be fast tracked can I give it to you? Then I sit here thinking, I have this patient running around in circles. What am I doing sending to OCAS? I am not going to send them again.’ (3) These ‘soft’ factors may need to be investigated in more detail when setting up triage services to gain more acceptance from local GPs and long-term success of a service.

Limitations of the study As GPs were volunteers, they self-selected to participate. It may be that GPs who wanted to give a positive Physiother. Res. Int. 19 (2014) 176–185 © 2014 John Wiley & Sons, Ltd.

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or negative perspective of OCAS volunteered, or it could be that they may have been interested in updating local knowledge of services and felt this might be a way of doing this. Research has suggested that GP’s drive to participate in research could be to update their clinical skills and knowledge and to reflect on practice more than anything else (Coar and Sim, 2006; Gunn et al., 2008). Possibly, some of the GPs by participating felt they may be able to influence how the service works and how it may integrate with other services to the benefit of their own patients (Coar and Sim, 2006; Gunn et al., 2008). The study may have therefore interviewed proactive GPs who are interested in change occurring, which may not be representative of all Walsall GPs. As the main researcher was a practising clinician in OCAS, it is likely that bias has affected both recruitment and results. The topic guide agreed may have reflected intended bias towards OCAS from the outset (Hoddinott and Pill, 1997). Participating GPs may have also participated or not participated knowing who was performing the research. However, participants were spread across the whole borough, and only two were previously known to the primary researcher. It also has to be recognized that this represented only 8% of GPs in Walsall. It is therefore unlikely that the results of this study are transferable to other GPs in Walsall or elsewhere. GP responses could also depend on whether the GP viewed the researcher as a peer or expert/judge (Chew-Graham et al., 2002; Coar and Sim, 2006). If seen as a peer, GPs may have felt more at ease with revealing sensitive information. For example, one GP stated, ‘The pressure is on us, we have been highlighted as over referrers, so basically most orthopaedic problems are going to come your way.’ (7) This is clearly a major limitation of the study, and alternative methods of recruitment and data collection might have been used, such as using a stratified approach or using a survey rather than the more time-consuming qualitative method. Previous research though has highlighted the difficulty of recruiting GPs to participate in survey research with lower rates on participation compared with other professionals (Kainer et al., 1998; Salmon et al, 2007; Kent et al., 2009). It may just be that this group is a difficult group of clinicians to recruit into any study. Physiother. Res. Int. 19 (2014) 176–185 © 2014 John Wiley & Sons, Ltd.

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Conclusion GPs saw OCAS as another referral choice for patients suffering orthopaedic pathologies. GPs identified some difficulty in understanding different services including various professional roles involved, which is not surprising considering the large increase in role extension in various professions including physiotherapy. To assist with understanding of services and roles, some GPs requested advertising by clinicians involved. Others thought that streamlining of processes to have a single point of access for patients with orthopaedic conditions was another way forward. Conclusions need to be taken in context because of the small numbers of GPs involved from only one town in the UK. Further research is indicated to investigate GP’s thoughts and behaviours in relation to referral patterns especially as GPs in the UK took on commissioning for services from April 2013. This may take on the form of interviewing with larger number of GPs or in a questionnaire form to gain higher response rates to address shortcomings in the study design of this research.

Conflicts of interest The authors declare no conflict of interest.

Ethical approval Ethical approval was gained from NHS Walsall Local Research Ethics committee and through Sheffield Hallam University Health and Wellbeing Ethics Committee.

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GP Views of Orthopaedic Assessment Service

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General practitioners' views about an orthopaedic clinical assessment service.

General practitioners' (GP) views about orthopaedic clinical assessment services (OCAS) managed by physiotherapists in the NHS have seldom been sought...
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