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Lincolnshire Knowledge and Resource Service
This search summary contains the results of a literature search
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Alison Price
Janet Badcock
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janet.badcock@lpct.nhs.uk
Librarians, Lincolnshire Knowledge and Resource Service

Lincolnshire Knowledge and Resource Service
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Lincolnshire Knowledge & Resource Service
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Literature Search Results
Search request date: 21 st December 2009
Search completion date: 7 th January 2010
Search completed by:
Alison Price
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What differences are Extended Scope Physiotherapists making to services, Trusts,
patients and referrals?

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Research
2005-2009
Title: Orthopaedic physiotherapy practitioners: surgical and radiological referral
rates.
Clinical Governance: An International Journal, 01 March 2009, vol./is. 14/1(15-19),
Author(s): Rabey M, Morgans S, Barrett C
Abstract: Purpose-The purpose of this paper is to discuss the scepticism that persists
among medics regarding appropriateness of some aspects of services provided by
extended scope physiotherapists (ESPs). This paper aims to highlight the extent and
appropriateness of surgical and radiological referrals by ESPs working in an adult
orthopaedic service., Design/methodology/approach-The patient pathway following ESP
assessment was audited over 31 months. Parameters explored included ESP referral
rates to orthopaedic consultants; the percentage of patients where the entire episode of
care was managed by the ESP; whether orthopaedic referrals were appropriate in terms
of surgical interventions; and numbers of radiology referrals specifically for knee or
lumbar complaints., Findings-Of the patients, 79 per cent had their entire episode of care
managed by ESPs. Of the patients, 9 per cent were referred on for a surgical opinion (of
which 42 per cent knees, 20 per cent lumbar). 13 per cent were referred for x-rays, 10
per cent for magnetic resonance imaging. Of the patients referred on for surgical opinion
surgical intervention was appropriate in 89 per cent of cases., Research
limitations/implications-Data from an ESP service with broad guiding protocols in a
specific hospital are not readily extrapolated to ESPs elsewhere. Appropriateness of
onwards referrals was based on the opinions of consultants to whom patients were
referred. The potential benefit of a second opinion even if surgery is not offered is not
taken into account by this model., Practical implications-These audits reinforce the
impact ESPs have on efficiency within orthopaedics. They document referral rates for x-
rays and magnetic resonance imaging by ESPs for lumbar and knee complaints that
may benefit units proposing new ESP services., Originality/value-This paper reinforces
published data on ESP management of the entire episode of care of the majority of
referrals to orthopaedics, and on the highly appropriate nature of onwards referrals.
Documented for possibly the first time, data regarding investigations for lumbar and knee
disorders highlight low referral rates.
Title: A 6-month evaluation of a clinical specialist physiotherapist's role in a
fracture clinic.
Citation: Physiotherapy Ireland, 01 June 2009, vol./is. 30/1(8-15),
Author(s): Moloney A, Dolan M, Shinnick L, Murphy M, Wallace L
Abstract: Implementation of the European Working Time Directive (EWTD) has not yet
been achieved for t Non-Consultant Hospital Doctors (NCHDs) in Ireland. Extended
scope physiotherapy practice in UK fracture clinics has had success in addressing this
issue. Clinical specialisation of a physiotherapist replacing NCHDs in fracture clinic has
not yet been trialled in Ireland. This pilot project evaluated the role of an experienced,
specially-trained physiotherapist reviewing patients with uncomplicated fractures in a
clinic setting for 6 months. One physiotherapist received additional training over a 2-
month period. A caseload of 403 patients with uncomplicated fractures and soft tissue
injuries were reviewed by the Clinical Specialist Physiotherapist (CSp) in fracture clinic.
Patient and doctor satisfaction ratings and patient caseload and waiting times were
collected over a 4-month treatment period. Working hours of NCHDs were also
recorded. There was a steady increase in patient caseload per week for the CSp in

fracture clinic. The discharge rate was 54%. Specialist Registrar hours reduced from 71
hours to 64 hours per week. Feedback from patients and the orthopaedic team was that
the CSp was a desirable addition to fracture clinic. With sufficient training and initial
supervision, it has been demonstrated that physiotherapists could take on the role of
NCHDs in fracture clinic, and this results in an improved and more efficient service. The
recommendation was to establish a CSp post in the fracture clinic in Cork University
Hospital. The Irish Society of Chartered Physiotherapy (ISCP) and the Chartered Society
of Physiotherapy (CSP) recognise the potential for physiotherapists to extend their roles.
This report supports these roles and wishes to encourage such discussion.
Title: Extended scope practitioners and clinical specialists: A place in rural
health? Author(s): Ruston S.A.
Australian Journal of Rural Health, June 2008, vol./is. 16/3(120-123),
Abstract: This review identifies two models of allied health advanced practitioner practice
that are currently in place in the National Health Service in the United Kingdom (UK). A
review of the background to advanced practitioner status is given for UK allied health
professionals and comments made on the outcomes of the UK roles. Description of the
work of Clinical Specialist and Extended Scope Practitioner is given. Alignment with
senior physiotherapy staff roles in Australia is commented upon. Some barriers or
impediments to implementation of such a system in Australia are discussed with respect
to registration, funding and support. The feasibility of such advanced practice roles for
physiotherapy is discussed while benefits and cautions are identified. The potential for
such a model of health service to be used in Australia, particularly in rural and remote
areas, is identified for debate.
Experienced physiotherapists as gatekeepers to hospital orthopaedic outpatient
care
Leonie B Oldmeadow, Harvinda S Bedi, Hugh T Burch, Jenni S Smith, Edmund S Leahy
MJA 2007; 186 (12): 625-628
Objective: To investigate the impact, quality and acceptability of a musculoskeletal
screening clinic provided by physiotherapists for patients referred to the outpatient
orthopaedic department at a major metropolitan hospital.
Design, setting and participants: Prospective observational trial undertaken between 29
November 2005 and 6 June 2006 at the Northern Hospital (a tertiary teaching hospital in
outer Melbourne) of 52 patients with non-urgent musculoskeletal conditions who were
assessed by one of two physiotherapists with postgraduate qualifications and
subsequently by an orthopaedic surgeon.
Main outcome measures: Proportion of new patients referred who could have been
managed without needing to see a surgeon; level of agreement between
physiotherapists and orthopaedic surgeon on diagnoses and management decisions;
and levels of satisfaction of patients, referring general practitioners and the orthopaedic
surgeon with the physiotherapist-led screening initiative.
Results: 45 of 52 selected patients (31 women and 21 men; mean age, 53.3 years)
attended their appointment with the physiotherapist; of these, 38 also attended a later
appointment with the orthopaedic surgeon. Seven of the 38 patients were listed for
surgery, and seven others needed management by the surgeon (injection for three,
imaging for four). Almost two-thirds (63%) were appropriate for non-surgical
management. The physiotherapists identified the same patient management plans as
the surgeon for 74% of the group. Patients and doctors reported high levels of
satisfaction with the physiotherapist-led service.

Conclusions: Nearly two-thirds of patients with non-urgent musculoskeletal conditions
referred by their GPs to one public outpatient orthopaedic department did not need to
see a surgeon at the time of referral, and were appropriately assessed and managed by
experienced, qualified physiotherapists.
http://www.mja.com.au/public/issues/186_12_180607/old10986_fm.html
Title: Physiotherapy extended scope of practice - who is doing what and why?
Citation: Physiotherapy, December 2007, vol./is. 93/4(235-242), 0031-9406
Author(s): Kersten P., McPherson K., Lattimer V., George S., Breton A., Ellis B.
Abstract: Objectives: To explore the range, drivers and perspectives of extended or
enhanced practitioner roles within physiotherapy. Data sources: Nineteen electronic
databases, hand searches, bibliography scanning and personal contact were used to
identify published and unpublished resources. Review methods: A systematic review
using an expanded approach. Resources were included if they discussed extended
scope of practice (intervention) in physiotherapy (profession) and outcome (for patients,
other health professionals, and health services delivery) irrespective of patient group,
language, year of publication (up to 2005), study design, or health care systems
evaluated. All resources were screened against formal inclusion criteria for relevance.
Information from relevant resources was extracted and details were entered into an
Access database. Results: One hundred and fifty-two physiotherapy-related resources
were identified, including seven which met appropriate quality standards (using
Cochrane methodology). A meta-analysis was not performed due to the paucity of
randomised controlled trials. Conclusions: Drivers for the roles in the 152 resources
mainly included local or national service demands (34%). Most extended scope of
practice roles reported included a form of non-invasive assessment (47%) or noninvasive
treatment (37%) of patients that was more traditionally carried out by medical
colleagues. None of the resources including data was (a) unsupportive of extended
scope of practice or (b) mainly expressing concerns. This review has demonstrated
overwhelming support for extended scope of practice; the vast majority of resources
were supportive despite being largely descriptive or discursive in nature (76%). There is
an urgent need for robust research in order to evaluate the expansion of extended scope
of practice roles, underpin further development of those roles, and strengthen the
evidence base of extended scope of practice in physiotherapy. copyright 2007 Chartered
Title: Effect of an extended scope physiotherapy service on patient satisfaction
and the outcome of soft tissue injuries in an adult emergency department.
Citation: Emergency Medicine Journal, 01 May 2006, vol./is. 23/5(384-387), 14720205
Author(s): McClellan CM, Greenwood R, Benger JR
Abstract: OBJECTIVES: To evaluate the effect of introducing an extended scope
physiotherapy (ESP) service on patient satisfaction, and to measure the functional
outcome of patients with soft tissue injuries attending an adult emergency department
(ED), comparing management by ESPs, emergency nurse practitioners (ENPs), and all
grades of ED doctor. METHODS: The ESP service operated on four days out of every
seven in a week in an urban adult ED. A satisfaction questionnaire was sent to all
patients with a peripheral soft tissue injury and fractures (not related to the ankle) within
one week of attending the ED. Patients with a unilateral soft tissue ankle injury were sent
the acute Short Form 36 (SF-36) functional outcome questionnaire, with additional visual
analogue scales for pain, at 4 and 16 weeks after their ED attendance. Waiting times
and time spent with individual practitioners was also measured. RESULTS: The ESP
service achieved patient satisfaction that was superior to either ENPs or doctors. Overall
55% of patients seen by the ESP service strongly agreed that they were satisfied with

the treatment they received, compared with 39% for ENPs and 36% for doctors (p =
0.048). Assessment of long-term outcome from ankle injury was undermined by poor
questionnaire return rates. There was a trend towards improved outcomes at four weeks
in those patients treated by an ESP, but this did not achieve statistical significance.
CONCLUSION: Adding an ESP service to the interdisciplinary team achieves higher
levels of patient satisfaction than for either doctors or ENPs. Further outcomes research,
conducted in a wider range of emergency departments and integrated with an economic
analysis, is recommended.
Title: The extended scope physiotherapist in orthopaedic out-patients - An audit
Citation: Annals of the Royal College of Surgeons of England, November 2006, vol./is.
88/7(653-655), 0035-8843
Author(s): Pearse E.O., Maclean A., Ricketts D.M.
Abstract: Introduction: We undertook an audit of the activity of the extended scope
physiotherapists (ESPs) in our unit. We assessed their activity against three benchmark
data: (i) independent assessment and management by the ESP of 85% of patients seen
by them; (ii) no patient to be re-referred to a surgeon with the same problem; and (iii)
patient satisfaction rate of 89%. Patients and methods: All new referrals seen by the
ESPs over the 6-month period between July 2002 and December 2002 were included in
the audit. Patient medical records were reviewed retrospectively. Patients were
contacted by telephone 12 months after their initial clinic appointment to obtain patient
satisfaction scores. Results: In the 6-month period, 150 patients (75 male, 75 female)
were seen. Their median age was 43.5 years (range, 17-85 years). Their main
complaints related to the spine (42%), knee (33%), shoulder (18%), or other site (7%).
The ESPs saw and managed 82/150 patients (55%) independently. Consultant review
was required for 81% of shoulder cases, 34% of knee cases and 11% of back cases.
GPs re-referred 4/150 patients (3%). We successfully contacted 126 patients by
telephone: 97 (77%) were satisfied with their management by ESPs. Of patients who
were dissatisfied, 76% did not see a consultant at any stage in their management.
Conclusions: ESPs fulfilled a useful role in our orthopaedic out-patient clinic particularly
in the back clinic. The percentage of independently managed patients was much lower
than the figure quoted in the literature. We suspect that the published literature does not
reflect modern referral patterns and recommend that time for review of new patients
seen by ESPs should be factored into consultant's clinic time. Patients' expectations
may be a barrier to achieving greater levels of patient satisfaction.
Title: A systematic review of evidence about extended roles for allied health
professionals
Citation: Journal of Health Services Research and Policy, October 2006, vol./is.
11/4(240-247), 1355-8196
Author(s): McPherson K., Kersten P., George S., Lattimer V., Breton A., Ellis B., Kaur D.,
Abstract: Objective: Extending the role of allied health professionals has been promoted
as a key component of developing a flexible health workforce. This review aimed to
synthesize the evidence about the impact of these roles. Methods: A systematic review
of extended scope of practice in five groups: paramedics, physiotherapists, occupational
therapists, radiographers, and speech and language therapists. The nature and effect of
these roles on patients, health professionals and health services were examined. An
inclusive approach to searching was used to maximize potential sources of interest
including multiple databases, 'grey' literature and subject area experts. An expanded
Gochrane Collaboration method was used in view of the anticipated lack of randomized
controlled trials and heterogeneity of designs. Papers were only excluded after the

search stage for lack of relevance. Results: A total of 355 papers was identified as
meeting relevance criteria and 21 studies progressed to full review and data extraction.
The primary reason for exclusion from data extraction was that the study included
neither qualitative nor quantitative data or because methodological flaws compromised
data quality. It was not possible to evaluate any pooled effects as patient health
outcomes were rarely considered. Conclusions: A range of extended practice roles for
allied health professionals have been promoted and are being undertaken, but their
health outcomes have rarely been evaluated. There is also little evidence as to how best
to introduce such roles, or how best to educate, support and mentor these practitioners.
copyright The Royal Society of Medicine Press Ltd 2006.
2000-2004
Title: Improved access and targeting of musculoskeletal services in northwest
Wales: targeted early access to musculoskeletal services (T.E.A.M.S.) programme.
Citation: BMJ, 2004, vol./is. 329/7478(1325-1327), 0959-8138
Author(s): Maddison, Peter, et-al
Abstract: PROBLEM: The hospital based musculoskeletal service in northwest Wales
was unable to cope with the demand for referrals from general practitioners. Waiting
times were long, duplicate referrals to other departments were common, and general
practitioners were reluctant to refer patients with common problems because of the
perceived lack of service. Many referrals were made to the inappropriate specialty,
especially orthopaedics. At least part of this problem was due to a lack of coordination
between the four hospital departments providing musculoskeletal services and the
emphasis on district general hospital based rather than community provision. DESIGN:
Review over 18 months of impact of the targeted early access to musculoskeletal
services (T.E.A.M.S.) programme on accessibility to musculoskeletal services.
SETTING: Northwest Wales. KEY MEASURES FOR IMPROVEMENT: Number of
patients referred and seen with musculoskeletal problems, waiting times, number of
duplicate referrals, and surgery conversion rates in orthopaedic clinics. STRATEGIES
FOR CHANGE: Establishing with central clinical triage a common pathway for all
musculoskeletal referrals so that patients attend the appropriate department. A back
pain pathway led by extended scope physiotherapists was developed, and general
practitioners with special interests and extended scope physiotherapists were trained to
provide services for patients with uncomplicated musculoskeletal problems in the
community. EFFECTS OF CHANGE: Over 18 months the number of referrals more than
doubled. Despite this, waiting times for musculoskeletal services fell; this was noticeable
for rheumatology and pain management. Duplicate referrals were abolished. Surgery
conversion rates did not, however, change. Questionnaires from the clinics showed a
high level of patient satisfaction. LESSONS LEARNT: Integration of hospital services
that traditionally have worked in isolation can result in greatly improved access to
musculoskeletal services. Community based multidisciplinary clinics run by specially
trained general practitioners with special interests and extended scope physiotherapists
are an effective way of managing patients with uncomplicated musculoskeletal problems
and have been well received by patients and general practitioners. The huge unmet
burden of need was reflected by the great increase in musculoskeletal referrals. Other
approaches are needed to meet this, including better education of general practitioners
and methods for identifying and modifying psychosocial risk factors for chronic pain at an
early stage. 1 fig. 2 tables 5 refs. [Abstract]

Title: The effectiveness of orthopaedic triage by extended scope physiotherapists.
Citation: Clinical Governance: An International Journal, 01 December 2004, vol./is.
9/4(244-252), 14777274
Author(s): Hattam P
Abstract: Improving the management of the orthopaedic patient has long been a top
priority in healthcare provision in the UK. For the past two decades, successive
governments have funded a plethora of "waiting list initiatives" in order to reduce waiting
times for both in and outpatients. In recent years, extended scope physiotherapists
(ESPs) have become increasingly involved in making clinical management decisions for
all orthopaedic patients - a process known as "triaging". Their effectiveness in this
triaging role remains largely untested despite having far reaching implications in terms of
service delivery, professional recognition and patient satisfaction. The study is crosssectional
in design using a survey to retrieve archival outcome data from hospital case
notes of patients referred by ESPs for consultant management. The time-framed sample
yielded 170 subjects with a wide range of disorders distributed across all anatomical
regions. The data was categorised so that effectiveness could be measured by judging
the specificity and appropriateness of referral. Results and the possibility of developing
the ESP role to include access to additional investigations and surgical listing are
discussed.
Title: Collaborative working.
Citation: Emergency Nurse, July 2004, vol./is. 12/4(16-8), 1354-5752
Author(s): Smith, M, Buckley, S
Abstract: The role of A&E extended scope physiotherapy practitioner, suitably trained
and qualified senior physiotherapists who are allowed to treat patients autonomously,
freeing doctors' time. Examples of physiotherapy practitoner schemes are discussed
including a pilot scheme at Epsom General Hospital. 8 refs.
Title: The experience of physiotherapy extended scope practitioners in
orthopaedic outpatient clinics
Citation: Physiotherapy, December 2004, vol./is. 90/4(210-216), 0031-9406
Author(s): Dawson L.J., Ghazi F.
Abstract: Objectives Over the last decade there has been an increase in the number of
physiotherapists working with an extended scope of practice in the orthopaedic
outpatient clinic. There has been a growing feeling within the profession and the
literature that these posts are more difficult than first perceived. The purpose of this
qualitative study was to look at physiotherapists working in this setting and discover what
has been their experience of the role and what recommendations they would make for
future practitioners. Design Qualitative, case study approach. Setting Scottish National
Health Service. Participants Four physiotherapists working as extended scope
practitioners. Measures Data was collected using tape-recorded semi-structured
interviews and investigated five main areas: training, responsibilities, support,
satisfaction and recommendations. Results The results suggested that success and
satisfaction in post is dependent on the relationship with the consultant and the medical
team; most extended scope practitioners experienced similar difficulties and had the
same outstanding training needs. Conclusions The overall impression from the findings
was that although the job can be stressful it is also very satisfying. By ensuring a good
relationship with the medical team, providing adequate ongoing training and support,
many of the difficulties encountered by the participants could be minimised. copyright
2004 Chartered Society of Physiotherapy.

Physiotherapists working as extended scope practitioners
James Milligan
International Journal of Therapy and Rehabilitation 10(1): 6 - 11 (Jan 2003)
This qualitative study investigates how orthopaedic specialist registrars perceive the role
of the physiotherapist working as an extended scope practitioner. The study uses indepth
interviews in a ‘grounded theory’ approach to generate data and analysis.
Respondents provided viewpoints relating to impressions of ability, supervision and risk
of litigation. Results indicate that staff promote the role.
Title: Effectiveness of secondary referral by extended scope physiotherapists.
Citation: Physiotherapy, 01 May 2003, vol./is. 89/5(324-324), 00319406
Author(s): Hattam P
Publication Type: journal article
Title: Assessment of diagnosis of knee injuries: The value of an experienced
physiotherapist
Citation: Physiotherapy, July 2003, vol./is. 89/7(417-422), 0031-9406
Author(s): Dickens V., Fazal A., Gent H., Rees A.
Abstract: A range of titles now reflects emerging roles in physiotherapy: clinical
specialists, extended scope practitioners, and more recently consultant therapists. While
each role is essentially different, what people in these roles have in common is
experience. There is a move to cut down patient waiting times both for operations and
for orthopaedic consultant outpatient appointments. An experienced physiotherapist with
additional skills would help achieve a reduction in patient waiting times, being able to
triage patients for either conservative treatment or a consultant appointment. This study
investigates physiotherapists' diagnostic accuracy of acute knee injuries and answers
the question: 'Can a physiotherapist manage the diagnosis of patients presenting with an
acute knee injury safely and effectively?' This is a prospective study investigating the
agreement between physiotherapists' clinical diagnoses and arthroscopic diagnosis of
the knee. Fifty consecutive new patients referred to one consultant's acute knee clinic
were recruited into the study. Assessment was by a consultant knee surgeon and two
experienced physiotherapists in random order. An initial diagnosis was then made. This
was compared to final diagnosis, which was mainly based on arthroscopic findings and
special investigations. The results show that experienced physiotherapists are able to
diagnose acute knee injuries with a high rate of accuracy, sensitivity and specificity.
Title: Management of soft tissue knee injuries in an accident and emergency
department: The effect of the introduction of a physiotherapy practitioner
Citation: Emergency Medicine Journal, January 2003, vol./is. 20/1(37-39), 1351-0622
Author(s): Jibuike O.O., Paul-Taylor G., Maulvi S., Richmond P., Fairclough J.
Abstract: Objective: To assess the effect of the introduction of a physiotherapist with an
extended scope of practice in the management of acute soft tissue knee injuries in an
accident and emergency (A&E) department. Methods: The A&E department established
an Acute Knee Screening Service (AKSS) in 1998. An experienced physiotherapist was
appointed to run the AKSS after additional training. Local guidelines and protocols were
developed in conjunction with trauma knee surgeons, radiologists, physiotherapists, and
A&E doctors. This study describes 100 consecutive patients managed by the AKSS over
a three month period and comparisons are made over a similar period before the
introduction of the AKSS. Results: The initial diagnosis of patients with acute knee
injuries referred to the service showed meniscal injuries (38%), cruciate ligament injuries

(18%), fractures (2%), patellofemoral joint injuries (10%), and others (32%). Ninety five
per cent of patients referred to AKSS were seen within one week. Medical time was
saved in both A&E and trauma clinic. Fifty nine per cent of patients were treated and
discharged from the service without further medical review. Thirty nine per cent (39)
were referred to trauma clinic and of these 44% (17) had MRI scans performed as
requested by the physiotherapist. Eighty eight per cent (15) of these scans showed
significant abnormality: (nine, anterior cruciate ligament tears, one, posterior cruciate
ligament tears, and nine meniscal tears). Conclusions: A physiotherapy practitioner
working with an extended role is a valuable addition to an A&E department. The AKSS
improves the quality of care of acute knee injuries, saves medical time, and fosters
cooperation across services within the NHS.
Title: Accuracy of clinical diagnosis of internal derangement of the knee by
extended scope physiotherapists and orthopaedic doctors: retrospective audit.
Citation: Physiotherapy, 01 March 2002, vol./is. 88/3(153-157), 00319406
Author(s): Gardiner J, Turner P
Abstract: Extended scope physiotherapists (ESPs) were introduced into orthopaedic
outpatient clinics in Stockport in 1995 in an attempt to reduce junior doctors' hours. The
role of an ESP is diverse and can vary greatly depending on the specialty of the
consultant with whom the ESP works. This retrospective audit acknowledges the use of
ESPs in orthopaedic outpatient clinics and compares the accuracy of clinical diagnosis
of internal derangement of the knee (IDK) by the ESPs with their medical counterparts,
including consultant and sub-consultant doctors and surgeons., All subjects who
underwent knee arthroscopy under one consultant over a five-month period in 1998
were included. The clinical diagnosis was noted and compared to the arthroscopic
diagnosis. The results of those seen by the ESPs and the orthopaedic surgeons or
doctors were compared; 52% of listings by the ESPs were in agreement with
arthroscopic findings compared with 37% from the doctors. Arthroscopies were deemed
of therapeutic value in 79% of those recorded by doctors and 100% of those listed by
ESPs., The overall accuracy of the orthopaedic team was also analysed against pre-set
standards set by the consultant. In all 83% were found to have gained therapeutic
benefit from the arthroscopic procedure. In this audit sample the ESP showed a greater
agreement between clinical diagnosis and arthroscopic diagnosis than her medical
counterparts. The overall standards fell below those pre-set but were notably higher than
in other similar studies.
Title: Reducing waiting times: physiotherapy shoulder assessment clinic.
Citation: British Journal of Therapy & Rehabilitation, 01 February 2001, vol./is.
8/2(57-59), 13548581
Author(s): Harrison J, Rangan A, Shetty A, Robinson C
Abstract: Orthopaedic outpatient waiting lists remain long. Many patients are referred
with conditions not requiring surgery. During the first year of a specialist shoulder
assessment clinic run by an extended scope physiotherapy practitioner in a district
general hospital, 130 patients were assessed with an average waiting time of 58 days
and 50% of patients were treated by physiotherapy alone.

Title: Extended scope physiotherapy: the way towards consultant
physiotherapists?
Citation: Physiotherapy (London), 2001, vol./is. 87/1(2-3), 0031-9406
Author(s): Wagstaff S, Gardiner J
Abstract: In light of Agenda for Change (NHSE, 1999) and the Government proposals for
the NHS (DoH, 1997) it is time that we as physiotherapists took charge of our own
destinies. For a long time we have complained of a ceiling to career advancement within
clinical fields and now we are being given an opportunity to recognise our more recent
initiatives and developments. Extended scope physiotherapy roles have been in place in
various hospitals throughout the UK for several years and are ever growing. There is a
well-supported CSP Occupational Interest Group, Chartered Physiotherapists Working
as Extended Scope Practitioners, which is helpful both to members and to the
furtherment of our profession. It has helped raise the profile of both extended scope
practitioners and physiotherapy as a whole. It is important that we take the right steps
now to ensure that we maintain this profile and formulate a national framework for
progression.
1990s
Title: Evaluation of an orthopaedic screening service in primary care
Citation: British Journal of Clinical Governance, 1999, vol./is. 4/2(45-49), 1466-4100
Author(s): Hattam P., Smeatham A.
Abstract: Historically, provision of orthopaedic services has been hospital based with
GPs referring patients for specialist opinion. Growing demands on the service have led
to new initiatives to reduce waiting times. One such initiative has been the introduction of
orthopaedic assistants, usually physiotherapists, working with an extended scope of
practice who see patients after referral to secondary care and determine the patients ongoing
management. Studies to date have examined the effect of an orthopaedic
assistant working alongside a consultant in the hospital environment. This study
describes the impact on the management of the orthopaedic caseload in one general
practice resulting from 'screening' prior to referral to secondary care by a physiotherapist
with an extended scope of practice. It demonstrates the successful management of the
majority of patients within primary care.

Reports
Extended Roles for Allied Health Professionals in the NHS
Report for the National Co-ordinating Centre for NHS Service Delivery and Organisation
R & D (NCCSDO)
February 2004
EXTRACT RELATING TO PHYSIOTHERAPISTS
3.2.6 Physiotherapy
Although there were many sources of information about ESP in physiotherapy, the
majority with data were audits that did not attempt to follow rigorous methodological
requirements for establishing effectiveness or efficacy. One RCT is noted below that has
some methodological flaws. However, even with those flaws, it highlights findings that
are arguably robust and focused on patient outcomes. A randomised controlled trial.
Shifting boundaries of doctors and physiotherapists in orthopaedic outpatient
departments (Daker-White et al., 1999; ref 119) Physiotherapists were compared with
sub-consultant surgical staff.
• 481 patients were randomised to see either a physiotherapist or sub-consultant
surgical staff in an orthopaedic outpatients clinic.
• Primary patient-centred measures included pain, functional disability and perceived
handicap at follow up. Secondary measures included health status, psychological status,
healthrelated quality of life, self efficacy and satisfaction with care.
• Patients seen by ESP physiotherapists had higher satisfaction than patients seen by
sub-consultant surgeons.
• ESP physiotherapists generated lower initial direct hospital costs, as they were less
likely to order radiographs and refer patients for orthopaedic surgery.
• The study concluded that orthopaedic physiotherapy specialists were as effective as
post-Fellowship junior staff and clinical assistant orthopaedic surgeons in the initial
assessment and management of new referrals to outpatient orthopaedic departments,
and generated lower initial direct hospital costs.
• Some limitations of the study must be considered as the inclusion criteria differed for
the two hospitals (patients thought likely to require surgery were included at one
hospital, excluded at the other), there was no blinding and follow up was very short
(5 months).
Three other studies in physiotherapy (and the two studies that included a focus on
occupational therapy) comprised surveys exploring reasons for implementation of the
ESP service, views of doctors working with ESPs, appropriateness of the ESP referrals
to consultants and use of skills. These surveys showed that therapists had expanded
their roles to increase their professional autonomy and skills (Hattam, 2002, ref 342; Ellis
and Kersten, 2001, ref 337; Atkins, 2003, ref 329), although service demands were more
frequently reported by medics as drivers for the development of these innovative roles
(Ellis and Kersten, 2002, ref 331). Although the ESP services appeared to decrease
waiting times (Hattam 2002) it was also reported that these could be would soon be filled
up with other patients, as noted in two of the studies (Ellis and Kersten, 2002; Milligan,
2003, ref 330). In addition, therapists and medics reported concerns in terms of
litigation, lack of confidence and fear of adverse reactions when using injection skills,
variations in training and the notion that the ESP service is ‘only as good as the therapist
employed’ (Atkins, 2003; Milligan, 2003; Ellis and Kersten, 2002). None of these surveys
sought patients’ views directly.

A qualitative master’s dissertation concerning ESP therapist experiences in orthopaedics
was located (Dawson, 2002, ref 399). This work is pending publication but in summary
the key findings were that success and satisfaction in the post is dependent on the
relationship with the consultant and the medical team and that most extended
scope practitioners experienced similar difficulties and had similar outstanding training
needs. Findings suggest that although the job can be very stressful it is also very
satisfying. Whereas this was a small case-study design with four physiotherapists, it was
methodologically robust and indicates some of the key issues that warrant further
exploration in research.
Conclusions
The review has found that despite the introduction of extended scope roles across all of
the professional groupings considered, evidence about the impact of these new roles is
limited. To date, the main focus on outcome has been largely concerned with
imperatives such as reduced demand on medical colleagues and reduced waiting lists.
Evidence from the studies considered in this review has suggested that AHP-ESP
interventions can indeed contribute to improved ease and speed of access to specialist
services that can be provided. An increasing number of studies, particularly in
radiography and paramedic practice, have suggested that improved access to specialist
interventions does lead to improved patient outcomes (such as reduced call-to-needle
times in thrombolysis).
However, we would suggest that an increased focus on health outcomes for patients is
required. Despite being identified as important by practitioners and researchers, such
outcomes have been evaluated infrequently to date. In addition, consideration of less
immediately obvious NHS outcomes (such as the impact on routine services having lost
experienced AHPs to ESP roles) is required. With the introduction of The Ten Key Roles
for AHPs and the increased activity of the CWP, it appears both timely and opportune
that there is a higher profile to focused evaluation and strengthened evidence of AHP-
ESP practice. Such evaluation is vital if we are to concentrate our efforts and
expenditure in a way that is most beneficial for our patients. The Agenda for Change
(National Health Service Modernisation Agency, 2004) brings with it an increased focus
on role development and we would suggest that specific and robust investigation is
required urgently if we are to ensure evidence-based policy around ESP.
It is perhaps salutary to note the words of George Silver, Deputy Assistant Secretary for
Health and Scientific Affairs in the 1960s, who when invited to consider the issues of
workforce and manpower shortage in the USA said:
it appals me that scientific workers, accustomed to the most rigorous application of
statistical and epidemiological principles in their particular craft, toss these tools aside
and adopt the rapt principles of faith and dogma in their place…. The manpower
shortage in the health field is a social event that has an historic basis and a
contemporary series of causes … without understanding and accepting these facts,
nothing can be done about dealing with the shortage…. Silver (1966)
Whereas ESP may provide part of the solution to current workforce pressures, Silver’s
words provide food for thought concerning how we are confronting those challenges.
Partnership between health-care practitioners, academics, funders and policy-makers in
the application of appropriate qualitative and quantitative evaluation is essential if we
are to develop roles that most benefit patients and the NHS.

5.2 Specific implications and recommendations
• Evidence suggests that AHPs are able to perform a range of advanced practices that
have been undertaken traditionally by medical practitioners.
• Pragmatic local evaluations should be incorporated when introducing role
development.
• Despite the contribution of local evaluations, robust trials comparing ESP interventions
and ‘routine’ management are required urgently.
• Further evidence about the impact of ESP on patient outcomes (such as health,
reduced disability, improved quality of life) is required.
• Cost-effectiveness trials considering comprehensive costings, including hidden costs,
are required.
• A consensus regarding a common language for ESP would be advantageous.
• Further investigation of ESP views about barriers to extending practice should be
sought.
• Further investigation on how best to prepare and support those in ESP roles is
required.
• Further development of AHP awareness and skills of research and the evaluation of
treatments or interventions is required.
• Moves towards more co-ordinated training and education of ESP AHPs should be
investigated with a view to standardisation of high-quality care while allowing for local
differences in service requirements.
FULL TEXT AT: http://www.sdo.nihr.ac.uk/files/project/31-final-report.pdf

Physiotherapy Extended Scope of Practice Project
A sixteen-week project commenced in February 2008 which aimed to scope the
feasibility of introducing extended scope of practice for physiotherapy within ACT Health
and Department Disability, Housing & Community Services (DHCS), Therapy ACT.
Executive Summary
This two part project aimed to obtain local, national and international information on the
feasibility of Extended Scope Practice – Physiotherapy. The first part consisted of a
literature review of national and international research and the second part of local focus
groups to assess the current practice environment of physiotherapists in ACT Health and
Disability, Housing and Community Services (DHCS).
The outcome of the Physiotherapy Extended Scope Practice: Phase 1 has highlighted
five clinical areas that the project reference group considers warrant further
investigation. Common themes in these areas were extension of diagnostics, extension
of practice consultation and extension of therapeutics. It is reasonable to assume that
these Extended Scope of Practice physiotherapy roles could make a significant positive
impact on patient access and quality of care, as well as workforce flexibility and capacity
within ACT Health and DHCS.
There were many common themes on the suggested impact of Extended Scope Practice
physiotherapy roles on patient care, including a reduction in patient waiting times, a
decrease in the length and number of “stops” in the patient journey and timely access to
appropriate treatment and investigations.
A comparison of the roles identified locally, with those roles identified in the literature,
was undertaken to assess whether they had been effective. Where these roles were
recognised as effective, the strategies identified as helping successful implementation
were described.
Five clinical areas for Extended Scope Practice roles were considered:
i. Orthopaedics
The focus groups identified that services could be improved by establishing an Extended
Scope Practice physiotherapy clinic which provides assessment to clients from the
orthopaedic surgical waiting list. The literature supports this observation. ESP tasks may
include ordering of diagnostic tests, limited prescribing, extended practice consultation
and prescription and administration of corticosteroid injections.
Extended Scope Practice physiotherapy roles that target surgical waiting lists can
reduce the transfer rate to surgery and have a positive impact upon patient waiting
times. They can also reduce the burden on the medical profession and lead to higher
levels of patient satisfaction.
ii. Emergency Department
ACT Health has a physiotherapy role as the primary contact for acute musculoskeletal
injuries within its emergency department. Enhancement of this role was identified around
autonomous management of simple fractures and wounds, independent interpretation of
X-rays and limited prescribing rights. The literature supports this as a strategy to reduce
patient waiting times/ cubicle occupancy time, reduce the burden on medical staff and
improve clinical management.
iii. Obstetrics
ACT Health has a physiotherapy role within the Obstetric Anal Sphincter Injuries clinic.
The focus groups identified a potential to formalise and extend this role to include limited
pharmaceutical prescribing, extended diagnostics and independent wound management.

iv. Gynaecology
The focus groups identified that services could be improved by establishing an Extended
Scope Practice physiotherapy clinic which provides assessment to clients from the
Gynaecology waiting list to reduce improve surgical waiting times. ESP tasks may
include ordering of diagnostic tests and extended practice consultation/referral to
Medical Specialists. The literature in the area of Obstetrics and Gynaecology is silent,
however, benefits are likely to be similar to those in an orthopaedic setting; including
reduced waiting times, improved clinical management, reduced burden on medical
personnel and increased patient satisfaction.
v. Developmental delay/disability
Focus groups identified two potential Extended Scope Practice physiotherapy roles for
future investigation within Therapy ACT; a hip surveillance clinic for this client group with
hip dysplasia and a Botulinum Toxin injection clinic. Successful implementation of these
roles would require engagement from the medical Paediatric Orthopaedic speciality,
which is currently in a period of transition. There is a limited amount of literature in the
paediatric arena, however what is available is supportive of initiatives in this field.
An additional area warranting future consideration is Botulinum Toxin injection clinics
that encompass both adult and paediatric client groups, providing a service for clients
with acute and chronic neurological conditions.
Implementation Strategies
The literature highlighted that there are several key components required for successful
implementation of an Extended Scope Practice physiotherapy role:
· Supportive inter-professional partnerships between health team members
· Appropriate training (both formal and informal)
· Proactive risk management and suitable planning to minimise risks and ensure legal
coverage.
· Removal of legislation/regulation obstacles
· Maintaining high standards of safe care
· Ongoing education to ensure competency which includes trans-disciplinary learning
models to maximise efficiencies and partnerships
· Measurable key performance indicators around organisational, stakeholder and clinical
outcomes, to include evaluation of effectiveness
· Demonstrating cost-effectiveness and productivity gain
Recommendations:
1. Undertake a Delphi study to ensure all stakeholders are involved in the planning of a
trial phase in the identified Extended Scope Practice areas
2. Project Reference Group to work with the workforce policy and planning unit to
overcome barriers, including legislation
3. Project Reference Group to define educational/competency requirements for
extended scope practice using Delphi study results
4. Establish a physiotherapy clinic assessing patients on the orthopaedic surgical waiting
list with a view to trialing an extended role once it has been established
5. Extend the role within Obstetrics
6. Extend the role within the Emergency Department
7. Establish a physiotherapy role assessing patients on the Gynaecology waiting list
8. Review the environment in the ACT around Therapy ACT, rehabilitation and
paediatrics in 12 months to identify whether a trial could be progressed
FULL REPORT DOWNLOADABLE FROM THE PAGE BELOW;
http://www.health.act.gov.au/c/health?a=sp&pid=1209682399

Elective Project : Review of Extended Scope Roles in Professions Allied to
Medicine
Author: Peter Carr
1. Introduction
Innovations in Care Programme
The NHS Plan ‘Improving Health in Wales’ sets out the vision for the future development
of the NHS in Wales where every part is forward thinking, innovative and modern. It is
recognised that along with investment in services there also needs to be a fresh look at
how we do things and to start to do things differently.
The Innovations in Care Programme was set up within the National Assembly for Wales
in Autumn 2000 to identify and develop this necessary change through working to
improve access to services for patients and to improve the quality of service. A key part
of that work involves identifying and disseminating areas of good practice across Wales.
Aims of the review
This paper is intended to provide some clarity to the definition of extended scope
practice and the issues relevant to such developments, bringing together some of the
current analysis and presenting it in a context of recognised and evaluated models of
good practice. The review will examine the benefits and opportunities evident with the
development of such roles and highlight the key lessons that maybe useful to all PAMs
and the NHS.
Outline of the review
The review will first explore the definition of extended scope practice, the evolution of
such roles and the existing evidence base. The review will include a discussion of the
key themes emerging from the analysis of case studies, with recommendations for the
future development of extended scope roles. The case studies, with analysis of their
benefits, are presented in the appendix. The case studies are all extended scope
physiotherapy schemes in the field of Orthopaedics. Three of the schemes received
funding from the Innovations in Care Programme; the analysis of these schemes,
included in this review, is taken from recent evaluations, commissioned by the
Innovations in Care Programme at the end of the initial twelve funding month period. The
fourth scheme is an English scheme that has achieved Beacons status and has been
running since 1998.
The case studies presented in this review define extended scope practice as that which
is delegated to them by the relevant Consultant; this delegation also seems to act as the
approval and validation for the practice. The discussion above suggests that normal
clinical practice is fluid, constantly changing and expanding to encompass new and
innovative ways of working. “Extended scope practice” could be defined as practice,
that whilst recognized and validated, exists at the very periphery of professional
boundaries, often unconventional and challenging. It would be wrong to consider
extended scope practice as existing outside the boundaries of control and regulation, yet
it is often such misconceptions that give rise to concern from professional bodies, other
professions, employers and unions; some of these concerns will be considered below.

The Evidence Base
There have been a number of studies conducted in the field of Physiotherapy,
specifically comparing traditional doctor / surgeon led clinics with ESP led clinics and
tend to be focussed around the muscoloskeletal field. Many of these studies have
explored issues relating to patient satisfaction, patient information, access to care
(waiting times), cost, effective management and workforce deployment. In all of these
studies the introduction of ESP Physiotherapy was seen to have had either improved or
equivalent outcomes.
In terms of costs related to ESP, there appears to be very little analysis. However,
research by Daker-White et al (1999) shows that the ESP service incurred lower hospital
costs: physiotherapists were less likely to request X- rays and less likely to refer patients
for orthopaedic surgery than were the sub-consultant surgeons. (The Chartered Society
of Physiotherapy, 2000)
Key Themes emerging from the case study analysis with recommendations
1. Clinical Outcomes
In terms of clinical outcomes, the benefits of developing ESP are evident from the case
studies: It appears that because of the more timely intervention by ESPs, patients with
acute conditions are avoiding chronicity and consequently negating the need for surgery
at a later date; many of these patients are able to benefit from conservative treatment.
Recommendation: It crucial that ESP developments put in place mechanisms for robust
evaluation and audit from the beginning not only to demonstrate clinical effectiveness
but also to support the dissemination and development of the new practice.
2. Primary care
To date the majority of extended scope practice has occurred within secondary care, yet
there is enormous scope to develop such practice in primary care. Many of the ESP
schemes are now receiving referrals direct from primary care for conditions previously
referred to Consultants; this can be partly attributed to the increased awareness and
acceptance of ESP amongst GPs
Recommendations: There is a need to encourage the development of ESP roles in
primary care by disseminating the benefits to GPs and to the commissioners of services.
There needs to be a greater integration and collaboration between professional in
primary and acute care, including developing more streamlined referral mechanisms and
even moving some services out of hospitals and into primary care premises in order to
improve accessibility of care.
3. Patient satisfaction
Patients seeing ESPs for assessment and treatment are fully informed and given the
option to refuse the referral. Information about the ESP is usually provided to the patient
in advance when the appointment is made, also the referring GP would be informed. The
experiences reported by the case studies suggest that patients were generally happy to
see an ESP instead of a doctor, reporting high levels of patient satisfaction with only a
very small number of exceptions.
Recommendation: It is important that all new developments in clinical practice are
monitored in terms of patient satisfaction, but more importantly that this data is then fed
back into the service and used to assist in the design and development of services to
ensure they are patient focused.

4. Training / CPD
Most training for professionals undertaking extended scope practice is provided “inhouse”.
Quite often, as with the case studies, training and mentorship has been provided
by professional peers performing similar roles and by those individuals delegating the
tasks i.e. the doctors. Some PAMs are now developing MSc level courses aimed at
providing more generic, standardised and transferable training for extended scope
practice.
Recommendation: Need to ensure that adequate, protected time for CPD is incorporated
into ESP roles. There also needs to be a more standardised and systematic approach to
training for ESP ensuring consistency and transferability.
5. Funding
The funding of ESP developments is often via short term allocation of monies. The
Welsh case studies presented in this paper were developed using short term, pumpprime
funding provided by the Innovations in Care Programme, with the expectation that
the relevant Trusts continued to support the development if successful. Similarly the
English case study was initially funded using dedicated waiting list initiative money. The
experiences of those involved in the case studies highlight specific difficulties associated
with short term funding, mainly the sense of vulnerability and uncertainty amongst staff
regarding the continuation of their work. Evidence from the case studies suggests that
often the funding provided at the start of the schemes was insufficient to cover the total
costs incurred, i.e. the funding tended to cover only the direct costs of employment and
education, but often was insufficient to meet the necessary costs of administration, audit
and the costs of the meeting increased referrals to the generic service.
Recommendations: Whilst short term funding has proven useful in “kick starting” new
initiatives there is clearly a need for organisations to commit to long term, permanent
and sustained funding for those developments which go on to demonstrate benefits to
patient care and efficiency. It is crucial that this commitment is given at the start of
developments to enable effective planning and progression of services. It is also
important that the planning of such initiatives incorporates adequate consideration to the
wider financial implications especially the inevitable impact elsewhere in the service.
6. Recruitment and retention
The career structure in PAMs is generally quite flat, with opportunity to develop more
specialist roles at Senior I and Senior II grades; further promotional opportunity were
previously only into a management grade. The development of extended scope roles
offers additional opportunity for career development and promotion whilst remaining in
the clinical field. As a consequence, the development of ESP roles has assisted in the
retention of highly skilled staff and this is supported by the experiences of those involved
in the case studies. ESP also offers opportunity for part-time working because the
development of the roles tends to be on relatively small scale, not always requiring full
time commitment; some of the case studies demonstrate this with clinicians working
part-time and even job sharing the ESP role. It was also reported by the case studies
that recruitment of staff in to those departments had also improved since developing the
ESP roles, particularly in recruiting Senior 1 grades. Anecdotal evidence from the case
studies suggest that potential employees generally perceive those departments that had
developed ESP roles as being more progressive.
Recommendations: Many ESP initiatives were developed around one individual making
the service vulnerable in the future. The development of ESP needs to ensure adequate
succession planning within the relevant departments. It is also important that
organisations maintain a flexible approach to working arrangements, supporting part-

time working and job share arrangements to enable all staff equal opportunity in
developing ESP roles.
7. Job descriptions
PAMs are covered, by their professional indemnity insurance, for activities within the
normal scope of practice. Where a practitioner is contracted by their employer to conduct
activities that fall outside the recognised scope of practice, then (as with normal
activities), the employer stands vicariously liable.
Recommendation: It is important that the remit of the extended scope role is clearly and
explicitly defined in job descriptions and the training requirements and qualifications
identified. It is also important to ensure that staff undertaking ESP roles receive the
appropriate grading and remuneration to reflect their additional responsibility.
8. Impact on other parts of the system
Inter-professional tensions:
With a shift in the scope of practice, professionals taking on new roles or duties will
inevitably be shedding other roles. This shift in roles can become inflationary, and
questions often arise such as “who will do the dirty work?" The shifts in job scope will
inevitable ripple backward from profession to profession. This is particularly problematic
when duties are passed to other disciplines i.e. in the case of social services taking
responsibility for more basic personal care, previously performed by clinicians. By
shifting responsibilities, there is a potential risk of passing some responsibilities to
less qualified staff.
Recommendations: In developing ESP there will be a requirement for careful negotiation
when agreeing and assigning professional responsibilities. Extended scope roles need
to be considered not just in the context of the boundaries they are breaching, but also in
the context of shrinking boundaries with consideration and planning of how the vacuum
is filled and how training needs are identified and met.
Intra-professional tensions:
Tensions can potentially arise within departments as the more “generic” work is seen to
be neglected in favour of the more “specialised”, a problem exacerbated when staff are
promoted from the generic service into extended scope roles with the subsequent
difficulties in back filling posts. However in the case studies presented in this paper, the
ESP posts tend to have been developed as dual roles, with clinicians balancing a
specialist, extended case load with a generic one. The development of dual roles in the
case studies appear to have eased the pressure on the generic service but also enabled
the retention of clinical specialists within that service.
Recommendation: When planning and developing ESP there is a need to be sufficient
resources available to ensure the continuation of the generic services.
Whole system impact:
Many of the ESP initiatives have been developed in response to long waiting times,
particularly out-patients, however a common impact of such developments is that
pressure is shifted elsewhere in the system, for example the inpatient surgical waiting
lists may increase as Consultants see more appropriate outpatient referrals. There may
also be a shift of patients from the medical waiting list onto the generic list of the relevant
PAMs service. Such impact was demonstrated by the case studies, and supported in the
document “Chartered Physiotherapists working as extended scope practitioners:
information paper”, (The Chartered Society of Physiotherapy, 2000). The effect of ESP
developments are however generally viewed as positive by the staff involved; surgeons

are able to reorganise their schedule, to spend more time operating and less time in
routine clinics. Similarly the PAMs services are able to develop and enhance their skills
by receiving more diverse and challenging referrals.
Recommendation:
ESP developments need to incorporate contingency planning and even may need to reevaluate
the application of resources across the whole system.
9. Relationships
Good working relationships appear to be crucial to the success of the extended scope
development. In the case studies there appeared to have been an existing relationship
between the practitioner undertaking the extended scope role and the consultant who
has delegated the work. With the all the case studies a high level of acceptance
amongst the relevant Consultants for the ESP role was evident.
Recommendations:
The extended scope role requires good inter-professional communication and
consultation with all of the healthcare team e.g. clerical staff, nurses, doctors and
diagnostic departments. It is also essential that GPs be consulted regarding any
changes to the assessment and management of the patients they refer. Management
support was also sited by those involved in the case studies as being crucial to their
success; particularly important was the ability to influence management decisions; this
will need to be encouraged.
10. Stress / job satisfaction
In a survey conducted by Weatherley & Hourigan (1998) of Physiotherapists in ESP
roles, three-quarters of respondents reported stress. The survey highlighted the need for
greater inter-professional collaboration, better clarification of roles and the development
of national guidelines of good practice. In addition the report “Exploring new roles in
practice (ENRIP report)”, (Sheffield University et al, 1999) states that 76% of ESP’s
surveyed are working beyond their contracted hours. (The Chartered Society of
Physiotherapy, 2000). Those staff involved in the case studies did report stress in terms
of feeling vulnerable in a new situation and often feeling isolated from their other
colleagues, this appeared to be less of a concern as the scheme progressed. Concern
regarding increased stress associated with extended scope practice needs to be
considered in the context of an increased level of job satisfaction reported by
professionals in such roles, this was particularly evident in the case studies presented.
This is also supported by the ENRIP report, (1999) in which 89% of extended scope
practitioners reported job satisfaction. (The Chartered Society of Physiotherapy, 2000)
Recommendation: It is important that staff undertaking ESP roles receive adequate
supervision and peer support and that responsibilities are appropriately delegated to
ensure staff have manageable remits.
Conclusions
Extended scope practice exists at the periphery of ever shifting professional boundaries,
very often representing a pioneering and innovative approach to patient care. The role
has developed slowly, responding to local needs and taking advantage of local
opportunities. The developments have tended to be driven by individual clinicians and
have largely depended on support of colleagues, e.g. other clinicians and management.
Extended scope practice is typically characterised by an increased level of autonomy for
clinicians and greater job satisfaction. Clear benefits have been demonstrated: reducing
waiting times for treatment, the prevention of chronicity with the avoidance of surgery,
and a high level of patient satisfaction. Whilst extended scope practice is well developed

within physiotherapy and Dietetics, there is actually very little evidence of development
of extended scope roles in other PAMs. This review demonstrates that there are huge
opportunities and benefits to be gained by all professions and by the NHS.
The case studies of extended scope practice presented in this review represent
valuable, transferable templates of good practice, with clear lessons that can be adopted
and adapted by all PAMs for application throughout the NHS.
Summary of Recommendations
• Need to implement robust evaluation and audit for ESP developments
• Encourage the use and dissemination of outcomes from patient satisfaction audits to
develop more patent focused services
• Ensure adequate CPD is incorporated into ESP roles
• Develop standardised training programmes for ESP roles
• Need commitment from Trusts to provide long term, sustained funding for continuation
of successful ESP developments
• Incorporate whole-system planning in the development of ESP schemes especially
regarding the allocation of resources.
• Ensure adequate succession planning for departments developing ESP roles
• Support flexible working arrangements for staff undertaking ESP roles
• Ensure ESP roles are explicitly defined in individuals job descriptions
• Provide appropriate grading and remuneration in recognition of the additional
responsibility associated with ESP roles
• Ensure comprehensive multi-agency / professional engagement and agreement when
negotiating new professional boundaries and responsibilities and ensure identification of
training requirements for all relevant staff
• Ensure adequate management support and engagement within the organisation
throughout the process of ESP development
Ensure adequate supervision and peer support for staff undertaking ESP roles
• Encourage the development of ESP roles in primary care by disseminating the benefits
to GPs and to the commissioners of services. Also improve referral mechanisms and
consider potential relocation of services into primary care settings.
References
The British Dietetic Association (1999) The Extended Role of the Dietition,
Briefing Paper No. 8
Daker-White. G, Carr. AJ, Harvey. I, Woolhead. G, Bannister. G, Nelson. I,
Kammerling. M (1999) A randomised control trial. Shifting boundaries of
doctors and physiotherapists in orthopaedic outpatient departments. Journal
of Epidemiology and Community health 53, 643-650. in The Chartered
Society of Physiotherapy (2000) Chartered Physiotherapists working as
extended scope practitioners: information paper No. PA29, Professional
Affairs Department
Ford. P (2002) Extended Role Practitioners: the role of professional bodies.
The Chartered Society of Physiotherapy
Hourigan. PG (1999) Consultant Survey. Horizon, July 1999 in The
Chartered Society of Physiotherapy (2000) Chartered Physiotherapists
working as extended scope practitioners: information paper No. PA29,
Professional Affairs Department
McClelland.S (2002) Evaluations of first round of funded schemes.
Innovations in Care. Welsh Assembly Government
Owen, G (1998) Recent Developments in Physiotherapy in the UK.

Rehabilitation International, Fall 1998, pp33-34 & 38
Sheffield University, University of Bristol School of Policy Studies,
Kings Fund (1999) Exploring new roles in practice: implications of
developments within the team. Sheffield University In The Chartered
Society of Physiotherapy (2000) Chartered Physiotherapists working as
extended scope practitioners: information paper No. PA29, Professional
Affairs Department
Weatherley. CR, Hourigan PG (1998) Triage of back pain by
physiotherapists in orthopaedic clinics. Journal of Royal Society of Medicine
91 (July 1998) 377-379 In Ford. P (2002) Extended Role Practitioners: the
role of professional bodies. The Chartered Society of Physiotherapy
Appendix 1
Case study analysis
Innovations in Care funded schemes:
The following analysis is taken from “Evaluations of First Round of Funded
Schemes”, written by Professor Siobhan McClelland, 2002, for the
Innovations in Care Programme. The evaluations involved interviews
undertaken by Siobhan McClelland, Centre for Health Leadership Wales with
Meryl Davies and Peter Carr from Innovations in Care.
Scheme 1: Extended Scope Practitioner Physiotherapist, North West Wales NHS
Trust
Lead Clinician: Carys Norgain, Therapy Co-ordinator,
Ysbyty Gwynedd
Date of Commencement:
May 2001
Description of Scheme:
Aim: To improve patient care through an Extended Scope Physiotherapist, based in
Orthopaedic Out-patients clinics, where waiting lists can be long and many referrals are
for conditions that do not respond to surgery.
The ESP service provides:
• Assessment, clinical diagnosis and management of neuromuscular disorders
• Requests for investigations such as x-rays, scans and blood tests
• Appropriate management of patients through the results of the investigations to assist
clinical diagnosis
• A referral process on to other health care professionals
• Soft tissue and intra articular injections
• Protocols and guidelines for referral
The ESPs work in the orthopaedic clinic with medical colleagues. Patients usually
receive 3/4 of an hour appointment and are given the option to see the consultant if they
prefer. 50% of the ESP time is spent in clinic and 50% dealing with back referrals in
physiotherapy outpatients.
Objectives of Scheme:
• To reduce orthopaedic waiting times
• Reduce inappropriate referrals
• Reduce chronicity and improve quality of life for patients
• Develop the evidence base for physiotherapy

Why was the Scheme Developed?
The scheme aimed to triage lower back pain patients from the orthopaedic waiting list.
These patients often waited for long periods for a specialist surgical opinion. In waiting
for long periods CSAG notes that chronicity develops and the success of rehabilitating
these patients is reduced. As many patients that were waiting to see the consultant
would then be referred to physiotherapy there was a real danger of transferring patients
from one waiting list to another. Physiotherapists were also aware of many inappropriate
referrals to physiotherapy and these were often patients who had received extensive
physiotherapy in the past. ESPs had been developed elsewhere and informal
discussions were held to consider developing this and to develop a bid for funding. It
was decided to focus on one aspect of the orthopaedic waiting list - those patients who
could not be surgically dealt with.
Recognised benefits of the scheme
• Freed up consultant time and more efficient use of physiotherapy department
• Fewer inappropriate X-ray referrals
• Waiting time reduced from 11months to 3 weeks
• 90% of patients seen were discharged after the first appointment
• Developed working relationships between physiotherapists and Consultants
• Developed the role of the ESP
Transferability
It was felt that the scheme was very transferable and that in fact it had seen transferred
from models in England. However, it was felt that relationships were important in making
the scheme work and that staff had to be open to change and new ways of working. It
was also felt important that baseline data should be established prior to the
commencement of the scheme in order to demonstrate clinical effectiveness.
Sustainability
Future funding has been secured. It is hoped that funding can be found to establish an
extended ESP in the community.
Change
It was felt important that the medical back up was available to ESPs. It was felt valuable
that scheme was being transferred that had been trialled elsewhere and that it was
easier not to 'blaze a trail'. The support of consultants was cited as key in making the
scheme happen. It was hoped that the scheme would develop into the community and
to increase the number of clinics to include peripheral hospitals within the Trust.
It was intended that CPD would be reviewed and further training and research accessed.

Scheme 2: Reducing Waiting Times Through a Physiotherapy Led
Orthopaedic Initiative, Powys NHS Trust
Lead Clinician: Marilyn Jarvis (Superintendent Physiotherapist)
War Memorial Hospital, Llandrindod Wells
Date of Commencement:
February 2001
Description of Scheme:
The scheme introduced a Physiotherapy Led Assessment Clinic, which runs alongside
the existing Consultant Led Outpatient Orthopaedic Clinic. The aim is to reduce the
waiting time for those patients whose referral suggests that this would be the most
appropriate initial intervention.
• The Orthopaedic consultant reviews new referrals and waiting list to identify
appropriate patients to be seen by the physiotherapist
• All patients identified as suitable for the clinic receive a letter with clinic details
• The clinic sessions run concurrently with existing monthly Trauma and Orthopaedic
clinic. Any patients seen by the ESP who subsequently needed to see the consultant
placed back on the waiting list in the place they would have been had they not seen the
ESP.
Objectives of Scheme:
• To reduce waiting lists/waiting times
• To provide appropriate treatment
Why was the Scheme Developed?
It was established that there were a lot of patients who were seeing the consultant who
didn't need or didn't want surgery. They looked at the different types of patients for
whom physiotherapy assessment and treatment would be more appropriate. Patients
were identified who already had had physio and were chronic with 3-4 episodes.
When the idea was first conceived there was a full complement of physios. However
once the funding was agreed there was 1 WTE vacancy. At May 2000 Trauma and
Orthopaedic waiting lists were going up. It was felt that this could be dealt with by having
more consultant capacity and it was felt that physiotherapy could assist with this. There
had been a lot of publicity about ESPs and so a business case was put together. The
consultant was approached and he also had been thinking about a similar development.
A proposal was put together so it was already on the books when IiC monies became
available. The scheme in Aintree (presented as a case study below) was used on the
basis of the proposal. The proposal was taken to management meetings for agreement
with GPs (given the community nature of the hospital). There was a little bit of dissent
but having the Aintree scheme to draw upon assisted with overcoming this and had
identified protocols.
The Aintree scheme and protocol was adapted for use in Powys and finally accepted by
the stakeholders.

Recognised benefits of the scheme
• Consultant time in the clinic freed up
• Average waiting time of 6 months to see the consultant reduced to 3 months
• 97% patient satisfaction rate
• Joint working between physiotherapy, GPs, Consultant and other staff
• The development of the extended scope role
Transferability
It was felt that transferability would depend on the circumstances. This scheme is not
quite as autonomous as an ESP and it is felt that what was required of this initiative was
not beyond the competence of a Senior I. It was felt important that the practitioner felt
comfortable with what she or he was having to do. There were other areas where there
are links between the consultant and physiotherapy where a similar scheme could
operate such as rheumatology and incontinence.
Sustainability
This is initially a 12 month project. A project team is working on costings to continue this.
It will need to be funded from existing resources and a business plan is being put
together to develop the service. Other sources of funding are being explored. A
presentation is being given to the Dyfed Powys orthopaedic network and Brecon are
possibly interested in something similar. Would like more development in reading x-rays
and in getting a wider view of the whole assessment process.
Change
The scheme was facilitated by the personalities involved, enthusiasm, commitment and
support from locality managers from the outset. The lead clinician was key in wanting it
to work as was the support of the consultant. The team are looking at expanding into
back pain. Also looking at developing pre joint replacement groups in order to improve
outcomes (in conjunction with Occupational Therapy).

Scheme 3: Physiotherapy Extended Scope Practitioners in Orthopaedics
Lead Clinician: Julie Convery ESP PoWH and Joanne Williams, ESP
Neath General Hospital
Date of Commencement:
March 2001
Description of Scheme:
The Physiotherapy Extended Scope Practitioner undertakes the ongoing care of
patients, which involves elements that fall outside the traditional physiotherapy scope of
practice. The aim is to improve the quality of physiotherapy care provided for patients
whilst reducing orthopaedic waiting times.
The Trust established two ESP posts in Neath General Hospital and Princess of Wales
Hospital. The ESP Physiotherapist:
• Reviews the Orthopaedic Waiting List and assesses all referrals to select suitability for
ESP examination
• Informs the patient of referral to ESP offering the option to refuse this service
• Assessment of individual patients and provide appropriate management which may
include advice, referral to other professionals, further investigation, provision of
aids/appliances, further treatment and discharge
• The ESP role also includes education and training of Consultant GP and Physiotherapy
staff
5 ESP clinics are held in the Bridgend locality and 4 in the Neath/Port Talbot locality on a
weekly basis each seeing approximately 16 patients per week. The non-surgical target
patients on the orthopaedic waiting list once seen by the consultant, would be referred to
the ESP. Currently in Neath 2 surgeons lists are accessed with one allowing a range of
referrals and the other only spinal cases. It is hoped that this can be progressed through
orthopaedic audit meetings. In Bridgend training of junior doctors and medical students
started at the very beginning of the project.
The ESP role is split between treating patients, mentoring, in-service training and
establishing evidence-based practice. Getting out to GP practices has been an important
component of the scheme although this education of GPs was perceived to have
'opened the floodgates' with GPs wanting direct access to the scheme.
Objectives of Scheme:
• To enable faster access to clinically appropriate services, i.e., non surgical cases not
held on orthopaedic list
• Releasing Consultant time to focus on surgical cases
• More effective use of NHS resources
• Improved quality of service and care such as prevention of secondary, more chronic
problems from acute conditions
Why was the Scheme Developed?
The physio profession have been looking at this for a long time. There is a reported
glass ceiling at Senior I where clinicians either have to enter a management route or
stop. ESPs are drivers for change within the profession. They starting bidding for such a
post 5 years ago and every year since to the Health Authority through the service
development round. When the IiC money became available the environment was right.
There was pressure on orthopaedic waiting lists but they wanted to raise the profile of
physiotherapy as well. Physios wanted to take this role on and it was a way of retaining
very senior staff. There is a high level of attrition from the profession generally.

The orthopaedic surgeons didn't drive the change but were very supportive. Clinical
influence was seen as key in changing mindsets. The average wait to see an
orthopaedic consultant was 22 weeks. It was felt that patients could be more
appropriately filtered.
Recognised benefits of the scheme
• Releases Consultant time
• Consultant waiting list in Neath reduced from 9 months to 6 months; waiting list in
Bridgend reduced to 3 months
• 100% of patients felt confident in their ESP
• Enhanced working relationships with GPs resulting in improved appropriate referrals
• Extended and developed the role of the physiotherapists involved.
Transferability
As a blueprint it was felt to be very transferable but would need to be adapted to local
circumstances and sensitivities amongst stakeholders.
Sustainability
The vision is to have a network for sharing good practice e.g. an ESP special
interest group. Permanent funding is to be provided from the LHGS.
However it is important to evaluate the impact of this service on the core
physiotherapy service.
Change
It was felt that the ESP role has been used to 'hold a mirror up to the service'.
It was felt important that resources were used effectively and they would have
tried whatever means possible to achieve this. Resistance has been
experienced but have tried to overcome this by talking to everybody and
understanding that it can take a long time to be accepted. They would like to
develop the consultant therapist role in the future and also to develop the role
both within the orthopaedic clinic and in A&E. Working within primary care
also emerged as a future area for development. It was felt that the area of
orthotics needed development particularly in the form of a podiatry joint clinic.
It was also intended looking to develop in gaining training for steroid
injections.
It was felt that the scheme worked due to experienced clinicians having
confidence to work with patients and consultants and having the strength of
character to establish effective clinical practice and management of
resources.

English waiting list initiative funded scheme
The following analysis was derived from information taken from the "Service Information
Pack", written by Arlene Allan of Aintree Hospital NHS Trust, Physiotherapy department
and from a personal interview undertaken by Meryl Davies and Peter Carr from the
Innovations in Care Programme.
Scheme 4: Physiotherapy Lead
Orthopaedic Waiting list Initiative. Aintree Hospitals NHS Trust
Lead Manager: Mrs Arlene Allan, Physiotherapy Service Manager
Date of Commencement:
April 1998
Description of Scheme:
The scheme's original target in 1998 was to provide specialist physiotherapy
assessment and follow up for 400 patients, which was soon extended to allow the
management of 1200 patients within the financial year. The waiting lists originally
targeted were those of 2 named Orthopaedic Consultants, later extended to include 4
Consultants. Patients who had been referred to the Consultant but who could be
appropriately managed by physiotherapists were offered an appointment by a senior
physiotherapist providing they or their GP had no objection. A full report of the
assessment and treatment outcome is also sent to the referring GP, including a
discharge letter for those patients that failed to attend their appointment. The
physiotherapists involved in the scheme were all of a senior grade and had previously
undergone post-graduate training the musculoskeletal specialty. The standards followed
were those for the assessment of musculoskeletal dysfunction as prepared jointly by the
Association of Orthopaedic Physiotherapists and the Manipulative Association of
Chartered Physiotherapists. The physiotherapist involved are not currently requesting
their own investigations or diagnostics. A full time clerical officer was recruited to provide
the necessary support.
Objectives of Scheme:
To reduce the Orthopaedic Consultant out-patient waiting list by introducing
physiotherapy lead clinics for those patients whose referral suggests that physiotherapy
assessment / treatment is the most appropriate initial intervention.
Why was the Scheme Developed?
As part of the Trust’s commitment to promote innovation, the Physiotherapy service at
Aintree Hospitals developed an initiative in April 1998 with the objective of reducing
waiting lists.
Recognised benefits of the scheme
° Ensured the most appropriate referral route for patients
° Enabled flexible working and retention of highly skilled clinicians
° Significant reduction of the Orthopaedic Consultant outpatient waiting list
° Achieved Beacons status in the first year of the initiative

Transferability
This ESP model has, since achieving Beacons Status, successfully provided the
template for similar developments. Those involved in the scheme continue to take part in
various dissemination activities e.g. presentations, open days, visits etc.
Sustainability
Further waiting list monies were released to continue the scheme in 1999/2000 and
consolidated funding has now been agreed. Although the development has seen an
increase in the inpatient waiting list for Orthopaedics, due to the Consultants now
assessing a higher proportion of patients requiring surgery, this appears to have been
managed by the consultants reorganising their time to spend more sessions in Theatre.
New referral protocols are being developed with the local PCGs, so that appropriate
patients can receive an immediate appointment without first gaining the GP approval.
The Physiotherapy department has ensured succession planning for training of ESP
physiotherapists so that the development can continue and expand. Several of the
department's staff are undertaking relevant MSc qualifications. The majority of the ESP
Physiotherapists undertake a "dual role" balancing the more specialist ESP work with a
generic caseload. The ESP scheme is now incorporated into the Trust's partial booking
system. There was concern that those clinicians working as ESPs would be excluded
from applying for the new Allied Health Professional Consultant posts because of the
reliance on part-time working and the limited opportunity in their current roles to
incorporate research.
Change
The physiotherapists involved in the scheme have enjoyed a high level of autonomy,
with full support from the relevant consultants regarding referral decisions. It appears
that the good working relationships between the Physiotherapists and Consultants
involved in the scheme were relevant to its success.
The importance of having Beacons status was emphasised in that it assisted in raising
the profile of the scheme, boosted the morale of staff and in enabling an easier access
to recurrent funding.

Conference Proceedings
Journal of Bone and Joint Surgery - British Volume, Vol 91-B, Issue SUPP_III, 502.
Combined Services Orthopaedic Society
London, England: 9 May 2008
SHOULD EXTENDED SCOPE PHYSIOTHERAPISTS PLACE PATIENTS DIRECTLY
ON ARTHROSCOPY LISTS?
C. Meyer; S. Kakati; A. Kotecha; and T. Crichlow
To determine if extended scope physiotherapists perform to the same standards as their
orthopaedic colleagues with regards to diagnosing knee pathology and making
appropriate referrals for arthroscopy.
Data was collected prospectively from Aug 2005. Patients were seen in a consultant led
orthopaedic clinic by an Extended Scope Physiotherapist (ESP), a registrar or the
consultant. All patients placed onto the waiting list for knee arthroscopy were considered
for the study. The outpatient diagnosis and demographic data were recorded and
compared against the arthroscopy findings. A single consultant surgeon performed the
arthroscopies.
300 patients were included in the study (100 in each group). Each group was similar in
terms of presenting complaint and demographics. There was no significant difference
between the ESP’s and registrars in their ability to diagnose intraarticular pathology (CHI
squared test: X 2.031, df 1, p=0.15). When only cruciate and meniscal pathology were
considered there was also no significant difference between the ESP’s and the registrars
(Fishers test p=0.12 and p=0.22 respectively, 2-tail test) The ESPs performed
particularly well in their ability to diagnose cruciate injuries (sensitivity 100%, specificity
100% and PPV 100%). Both ESPs and registrars had high sensitivity but low specificity
with regards to diagnosing meniscal pathology suggesting a low threshold for a positive
diagnosis and a poor ability to correctly diagnose those patients who did not have a
meniscal injury. Of the 300 patients only 9 unnecessary arthroscopies were requested.
None were requested by the ESPs.
Extended scope physiotherapists perform a useful role in orthopaedic outpatients. They
perform as well as orthopaedic registrars with regards to making the correct diagnosis
and the selection of patients for arthroscopy.
http://proceedings.jbjs.org.uk/cgi/content/abstract/91-B/SUPP_III/502-a

CSP Congress 2009
The Role of the Extended Scope Practitioner in Knee Joint Replacement Follow up
Special interest report
Purpose
The annual growth of hip and knee arthroplasty is resulting in an increasing number of
follow outpatient appointments, causing congestion in consultant led clinics. This study
reports on the role of an extended scope practitioner in an arthroplasty review clinic.
Relevance
This study relates to the development of advanced practice skills to meet the needs of a
physiotherapist working in a specific area of interest.
Description
The physiotherapist working in an extended scope role, reviewing total knee
arthroplasty, undertook a Negotiated Work Based Learning module to develop advanced
practice skills in plain film image interpretation at the School of Health Sciences,
University of Liverpool. The course enabled the physiotherapist to provide evidence of
competency of image interpretation and to develop a protocol, using the Knee Society
Scoring System (Ewald, 1999), with clear guidelines for patient management.
Evaluation
Following successful completion of the course an audit was undertaken to look at the
outcome regarding the management of the patients reviewed by the physiotherapist
during a twelve month period. Of the 508 total knee replacements which were reviewed
37 (7%) were book in for further review by the consultant. The plain film images of a
further 24 patients (4.7%) were discussed but did not result in a consultant review. All
the other patients (85%) were booked in for routine bi annual review by the
physiotherapist.
Conclusions
The 434 (85%) patients who were booked in for biannual review and who did not require
a consultant review appointment suggest that an extended scope physiotherapist can
effectively follow up total knee arthroplasty provided the appropriate practice skills have
been developed and the physiotherapist has effective communication with the surgeon.
Implications
Extended scope physiotherapists who have developed the appropriate practice skills can
follow-up arthroplasty patients, thereby reducing congestion in outpatient clinics and
allowing the surgeons to concentrate on more complex cases. Physiotherapists working
in such roles may be able to undertake arthroplasty follow up in different settings
provided the appropriate facilities and resources are available.
http://www.cspcongress.co.uk/role-extended-scope-practitioner-knee-joint-replacement-follow

Britspine
Belfast, Northern Ireland: 30 April–2 May 2008
Chairman: Mr Eddie Cooke
EXTENDED SCOPE PHYSIOTHERAPISTS: HOW OFTEN DOES THEIR CLINICAL
DIAGNOSIS AGREE WITH THE MRI SCAN?
NewsomeRJ ; ReddingtonM ; BreakwellLM ; ChivertonN ; and ColeAA
Sheffield Spinal Service, Northern General Hospital, Sheffield
Objective: To determine whether extended scope physiotherapists (ESP’s) in spinal
clinics are able to accurately assess and diagnose patient pathology as verified by MRI
findings.
Methods: This is a prospective study of 318 new spinal outpatients assessed and
examined by one of two spinal ESP’s. 76 patients (24%) were referred for an MRI scan.
At the time of request for MRI scan the likelihood of specific spinal pathology correlating
with the MRI scan was noted on a four point scale dividing the patients into 4 groups:
Group 4 = Very high suspicion of pathology (n=41)
Group 3 = Moderate suspicion of pathology (n=21)
Group 2 = Some suspicion of pathology (n=10)
Group 1 = Pathology unlikely but scan indicated eg thoracic pain (n=4).
Results: Of the 76 patients referred for an MRI scan, 54 (71%) had an MRI scan result
that would correlate with the clinical picture. Looking at the percentage of scans
correlating with the clinical picture for each of the 4 groups:
Group 4: 88%
Group 3: 67%
Group 2: 40%
Group 1: 0%
Conclusion: Dividing the patients into groups by clinical suspicion is essential for
evaluating a clinician’s ability in spinal assessment. Further evaluation of Consultants,
Fellows and Specialist Registrars is on going. This type of study could form a basis for
competency measures for staff development and training if they are undertaking
extended roles.
http://proceedings.jbjs.org.uk/cgi/content/abstract/91-B/SUPP_III/489-a

An Evaluation of Physiotherapy Extended Scope Practitioner (ESP) use
of MRI in Patients Presenting with Low Back Pain; a two-centre study.
Dominic Inman, Philip Hope, Aice Leaver, Dominic Gage, Pieter De vos miering
Background
Growing demands upon orthopaedic services in the United Kingdom have resulted in
increasing waiting times for orthopaedic consultations. The increasing pressure of new
government targets have led to role delegation within the NHS. MRI is a limited resource
that requires judicious and validated use. We evaluate use of MRI in the assessment of
patients presenting with back pain by Physiotherapy Extended Role Practitioners (ESPs)
working in a secondary care referral centre, against the standard as that practiced by
orthopaedic surgeons in a separate secondary care referral centre without a dedicated
operative spinal service.
Methodology
A retrospective review of 202 lumbar MRI scans requested by ESPs was compared with
a retrospective review of 145 lumbar MRI scans requested by orthopaedic surgeons. In
both cases cross-site tertiary referral was required if surgery was to be considered.
Presenting symptoms and signs, abnormalities detected on the MRI scans and
subsequent management were recorded with rate of operative intervention per scan
used as a measure of appropriate MRI usage. Simple descriptive analysis was
undertaken.
Results
Qualitatively, there was less clinical information upon surgical MRI request forms, with a
higher rate of neurological signs reported by ESPs (64% versus 42%).
Despite reported differences in patient presentation the abnormal scan rate was
comparable (ESPs 88%, orthopaedics 92%).
The tertiary referral rate was also comparable (ESPs 45%, orthopaedics 42%).
The numbers of patients that were listed for operative intervention in the tertiary referral
centre were 19% and 26% respectively for ESPs and orthopaedic surgeons.
Discussion
This study shows that physiotherapy ESP use of MRI in the investigation of patients
presenting with back pain is comparable to orthopaedic surgeons in a centre without a
dedicated spinal service. With adequate training and knowledge of red/ yellow flag signs
applicable to assessment of spinal problems we support the role of physiotherapy ESPs
in the assessment of patients with spine related problems.
http://www.efort.org/cdrom2008/P837.pdf

Case Studies
Improving Patient Flow in the NHS
Case studies on reducing delays
Lincolnshire Hip and Knee Pathway – Review of Whole Pathway to Achieve 18 Weeks
What they did to improve service
A day long solutions workshop was held, bringing together people from across the
pathway to discuss each of the clusters of issues in turn. A range of creative techniques
from the No Delays Achiever toolbox was used to help think beyond the usual answers,
which resulted in over 60 ideas. These were graded according to selected criteria, and
discussed further to create priorities and action plans. The actions for change covered
four areas.
1. Develop more patient-centred care, where the patient is informed and plays an active
role in treatment and rehabilitation.
2. Improve discharge planning to create a ‘pull’ process to reduce blockages
downstream.
3. Create a fast, efficient referral system with patients on the right pathway, and being
treated in the community as an option in some cases.
4. Improve communication systems within each organisation, between the organisations
and externally.
What is it like now?
The first steps to encouraging patients to take on a more active role during treatment
and rehabilitation have already been put in place. A review is currently taking place of all
information provided to patients. They will now be provided with a diary to help them
understand what to expect at each stage of their journey. They will be informed of their
‘to come in’ (TCI) date at first appointment and can plan accordingly.
A multi-disciplinary hip and knee team is being set up to manage the patient journey
from the first appointment, to put in place an early plan for discharge and to manage
patients’ expectations.
Work was already underway to set up a musculoskeletal (MSK) service as a first option
for many patients. This is being complemented by reviewing and potentially
increasing the provision of extended scope physiotherapists and GPs with
specialist interest in orthopaedics, which will reduce the number of referrals to
secondary care. In addition, work is being undertaken with GPs to ensure that patients
are fit, willing and able for surgery before being referred further, and that all the
necessary tests and minimum data sets have been supplied when the patient attends
the first outpatient appointment.
http://kingsfundlibrary.co.uk/iandi/No%20Delays%20Achiever%20Case%20Studies%20FINAL.pdf

DH Musculoskeletal Services Framework
Case study
Physiotherapy and GP musculoskeletal interface service
– Somerset Coast Primary Care Trust
The Somerset Coast PCT Musculoskeletal Interface Service (MSIS) is a collaborative
service between primary and secondary care. Extended scope physiotherapists,
GPwSIs, consultants in pain management, clinical nurse practitioners, clerical support
staff and a development lead work together to improve the quality of service for patients.
A bio psychosocial model of care is used. It was awarded Beacon Site status in 2000
and was runner up in the NHS Modernisation Award for Access in 2001.
Outcomes:
• The waiting time for an outpatient appointment is 4-6 weeks
• MRIs are performed within 2 weeks of request and patients reviewed with the results
within 4-6 weeks of request.
• 63% of all GP musculoskeletal referrals are now referred to the MSIS.
• 37% of all patients were given advice and discharged following the first appointment in
the service.
• 20% of the patients seen were referred for a surgical opinion. 75-80% of these patients
are listed for surgery.
• The approximate cost saving of using this service is £700 per patient. This takes into
account the lower conversion rate to surgery than the local orthopaedic department and
the savings made by utilising the ISTC.
• Patient satisfaction audits have been carried out and have shown that patients are very
satisfied with the clinicians they saw and the service in general.
http://kingsfundlibrary.co.uk/iandi/No%20Delays%20Achiever%20Case%20Studies%20FINAL.pdf
Health Services Management Centre
Making the Shift: A Review of NHS Experience
July 2006
Helen Parker
Nottingham Traumatic Brain Injury Team have established a chronic back pain service
using extended scope physiotherapists as part of a team delivered from leisure centres
across Nottingham. This has reduced significantly the referrals to the spinal orthopaedic
consultants, reduced the DNA rate and increased patient compliance. A measure of its
success has been demonstrated by the ability to close a service in one leisure centre as
patients improved and transfer it to another area of greater need.
http://www.hsmc.bham.ac.uk/publications/pdfs/Making_the_Shift_01.pdf
Worthing Hospital ESPs

In 2002, Worthing Hospital became one of the first in the UK to offer a dedicated
physiotherapy service to patients in A&E.
In 2007, there are now three Extended Scope Practitioners (ESP) working in the
department and seeing on average more than 250 patients every month.
The service was developed following the identification of several areas of A&E in which
physiotherapists could have a positive impact.
It was anticipated a dedicated physiotherapy service could
• offer more consistent treatment to sufferers of back pain and musculoskeletal
conditions,
• train and advise nursing and medical staff, and
• relieve some of the strain on the hospital's urgent appointment systems by cutting
routine referrals to outpatients of more minor problems.
A pilot study of minor injury treatment conducted in September 2006 proved the ESP
involvement had a positive impact on the patient journey, leading to high throughput,
reduced waiting times and high levels of patient satisfaction.
www.worthinghospital.nhs.uk/Wards_and_services/services/accident_emergency/esp/
Guidelines
Chartered Society for Physiotherapists
Physiotherapy Consultant (NHS): Role, Attributes and Guidance for Establishing
Posts
June 2002
http://www.csp.org.uk/uploads/documents/csp_physioprac_pa56.pdf
Expert Opinion – NHS Evidence
Is the extended scope practitioner the right person to undertake follow-up after
joint arthroplasty?
This editorial was written for the 2007 National Knowledge Week on Osteoarthritis. The
following member of the Expert Panel contributed to this section: Sr Rosalyn Jackson
The term extended scope practitioners (ESP) usually refers to physiotherapists who
have had further training and education in reviewing patients that were traditionally seen
by a doctor. However, there are some occupational therapists who undertake this role as
well as Arthroplasty practitioners and many orthopaedic clinical nurse specialists working
in this role.
What are the advantages in seeing an ESP?
Patients usually have longer appointment times with an ESP, usually fifteen minutes
(Jackson, 2003). This allows time to answer the patient’s questions e.g. whether they
are allowed to drive, sleep on their side, swim and so on. Typically a follow-up
appointment with a doctor is only five minutes. Additional clinic time allows the ESP to
use a holistic approach to glean further information about any problems post-discharge,
which may influence the patient’s future care and outcome. The ESP is more likely to
remind the patient about the precautions to be maintained following hip replacement or

esurfacing, i.e. avoiding low chairs, not to cross their legs and avoid flexing the hip
beyond 90º (Jackson, 2003).
Patients are happy to see either an ESP or an Advanced Health Practitioner and 94%
are very satisfied or satisfied with the service (Carter, Finley & Parkinson 2002). This
audit showed that it was cheaper than running a Consultant clinic and that it was an
effective way of improving patient care and audit within the department. A randomised
controlled trial demonstrated similar findings (Daker-White et al 1999) with patients
seeing either a doctor or a physiotherapist. Greater satisfaction was expressed by
patients seeing the physiotherapist. Patients know whom to contact if they develop a
problem or need advice and are usually seen sooner in a nurse-led service.
Freeing up Consultant time allows scope for more new or complex patients to be seen,
helping Trusts meet Government targets for first appointment and other initiatives.
What are the disadvantages in seeing an ESP?
Patients with problems may need a further clinic appointment if the ESP clinic is not run
concurrently with the consultant clinic. Even if such clinics are run concurrently, there is
no guarantee that a further appointment will not be required. Patients who require
further treatment e.g. injection of trochanteric bursitis, may need referring to a doctor if
the ESP is unable to give such injections. There needs to be a clearly defined pathway
for patients requiring further intervention such as manipulation of a stiff Total Knee
Replacement.
Patients’ expectations need to be managed so that they are aware of their follow-up
arrangements and informed whom they are going to see. Providing shared care between
different professions is a good way forward.
Clinical supervision and peer review are important components in developing the ESP
and maintaining competency as well as developing the role further. The ESP needs a
robust training package to demonstrate competency in this extended role, which takes
time to complete. This will impinge upon clinics whilst the ESP is developing
competencies and being supervised in patient review.
What are the other issues to consider?
Clinics need to be set up on the patient administration system and rooms allocated in the
outpatient department. Case-notes have to be retrieved and prepared. Provision of
secretarial support is required to type the clinic note and send a letter to the patient’s
General Practitioner.
Conclusion
I believe that Extended Scope Practitioners are the right people to review patients after
joint replacement surgery providing that they are integrated within the Orthopaedic team
and sufficient support is available for the role.

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