In association with

  • Bristol, North Somerset and South Gloucestershire Integrated Care Board
  • West of England Academic Health Science NetworkWest
  • National Institute for Health Research

Case study: Direct Access to Physiotherapy

This case study follows the 5-step process for accessing and using evidence in response to a request from commissioners to support the work of the Musculoskeletal (MSK) programme.



Using PICO, the scope of the evidence search was defined as:

Population: Adult patients with musculoskeletal disorders (MSKD)

Intervention: Self-referral to physiotherapy (PT) / PhysioDirect/ direct access (DA) to PT

Comparison: Physician referral

Outcomes: Effectiveness, cost-effectiveness.



A Clinical Effectiveness Programme Officer was asked to conduct the search and report findings.

The following search questions were addressed:

“What recent evidence is available regarding the delivery models and effectiveness of direct access (including models such as PhysioDirect) to physiotherapy?”

The search strategy involved searching the following databases and websites:

  • Cochrane Library
  • NICE Evidence

The following search strategy was used:

((“physio direct” OR “physiodirect”) OR (“self referral” OR “self-referral”) OR (“direct access”)) AND physiotherap*



A range of study types were reviewed including systematic reviews (SRs), randomised controlled trials (RCTs) and mixed-methods studies. Appraisal was conducted according to the strengths and limitations of each piece of evidence, including issues concerning sample sizes, potential for bias, and different approaches to direct access.



Findings were reported in an evidence review.  Key points of this review included:

  • Overall, the quality of the evidence-base is low and variable
  • There is conflicting evidence about the clinical effectiveness of DA to PT over physician-referral
  • Without sufficient investment in the physiotherapy workforce, DA is unlikely to be cost saving and waiting lists are likely to be severely increased
  • There is some evidence of system benefits
  • There is a risk that, unless DA services are accompanied with a concerted effort to overcome disparities in access, they have the potential to exacerbate health inequalities
  • DA is generally acceptable as a concept to both patients and HCPs in regions where there is a commissioned service
  • Patient awareness and understanding of DA to PT is generally poor.

Share & Manage

The findings of the review were consolidated into two documents, a full evidence review and a briefing version with the headline findings. This was done to enable greater accessibility of the evidence to stakeholders and commissioners who may be limited on time. To promote sharing of learning, this review was uploaded to AHSN’s Evidence Repository on the Futures NHS platform.

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