Advanced Practice Physiotherapy in Primary Care

So, you have decided to up the game with your running but now you have definitely done something to your right knee, or that old back injury has flared up again and you can barely sit at your computer for more than 5 minutes never mind a whole days work. You need to see someone…but how long will that take? Imagine though being able to just call your primary care practice and instead of having to wait to see a GP for a 10-minute appointment you are given a 20-minute slot with a physiotherapist, during which time you will have an expert assessment, options on best management discussed and then appropriate referral made if needed. This could be onward referral for radiology, neurosurgery, orthopaedics, specialist clinics or physiotherapy intervention.

Since March 2018, this is exactly the type of approach that Midlothian Health and Social Care Partnership have embarked upon within GP surgeries, embedding Advanced Physiotherapy Practitioners (APPs) into the regular GP appointments system to absorb the musculoskeletal workload from the GPs (estimated to be at around 20-30%). Any person calling up for a GP appointment complaining of any aches and pains are allocated to see a physiotherapist without having to see a GP first.

Most people need no further input; grateful for the reassurance, advice and support, they are happy to self-manage their condition independently. However, a duty doctor is usually on hand to discuss any tricky cases if needed.

Over the first year 3669 appointments have been made with the APPs, redirecting approximately 731 hours of GP time. 90% of the consultations have been managed in primary care with no further onward referral and there has been a significant reduction in core physiotherapy waiting times due to more appropriate referrals.

This innovation is being replicated across the UK in GP practices at a fast rate under the new GMC contracts in an attempt to assist with the GP crisis. The British Medical Association and Chartered Society of Physiotherapy are fully on board and actively promoting this new model of work. It all sounds great, which it is… but of course, it needs to be done with appropriate support for practitioners, research and guidance. This is being developed in England but there are no significant documents yet available in Scotland.


Clinicians are being asked to perform new, challenging and pioneering roles, occasionally pushing the boundaries of their profession, grappling with clinical governance issues and often under a variety of pressures from patients, GPs, managers and administration staff who control the diaries. Formal, consistent advanced practice educational programmes/masters modules for AHP’s are not yet standardised or widespread, as is experiential or work based learning; and all of this is mirrored in clinical practice dependant on your work location.

So with new and challenging practices, professional paradigms have to merge and clinical governance systems need to be robust to ensure safe and efficient practice. APPs need to be of sufficient clinical standard and expertise to perform well and need to be well supported.

If this seems overwhelming, don’t be disheartened. What we know anecdotally, and with some early data, is that this new system is very well received by clinicians, patients and GPs alike. Despite some of the challenges with education, clinical governance and recruitment processes APPs are doing a great job.

So how can this be recognised? The issues, the challenges, the opportunities? How can we do this better?

Enter my opportunity to participate in a NES Career Fellowship to explore some of these questions.

It has given me the space and time to take stock, understand the drivers, evaluate the systems, consider the processes, listen to staff and begin to merge it together. Discuss with other like-minded clinicians in a confidential, non-judgemental supportive learning environment (thank you for action learning sets) listen to other leaders in our field who provide the MUCH bigger picture. Supply us with the confidence in our own abilities to pursue, take ownership and provide a positive contribution to our profession.

So what have I learned so far?

  • The NHS in Scotland is full of hard working, interesting, motivated, altruistic people with incredible skills and talents – we need to share this more.
  • Twitter is a fabulous platform; I need to stop being a lurker (comfort zone well and truly challenged Debbie Provan)
  • Try to understand who holds the power and who wants ownership before trying to change things (wise words from June Wylie).
  • Appreciate that complexity is not always a personal issue (detangled the politics – Claire Ross)
  • Be cognisant of bias (thank you Daniel Kahneman – Thinking, fast and slow)
  • It’s ok to be a positive disrupter (thank you Lesley Holdsworth) and finally
  • Focus on what’s strong, not wrong (well said Graeme Paxton).

My fellowship work focusing on APPs in primary care has grown arms and legs, has even morphed into the beginnings of a clinical doctorate, I have met loads of interesting people and importantly the good work that goes on day to day is being evaluated and promoted beyond my treatment room to improve the quality work in the NHS.

Judith BalfourJudith Balfour



  1. Hi
    Is there any way we can fix this a Health board level so that blogs are not blocked and then you need to mess around to read them?


    Catriona McMaster
    Dietetic Clinical Team Lead Rehabilitation

    0141 451 6246 D/D 86246

    Greater Glasgow & Clyde Adult Acute Dietetic Service
    Zone 2/1, 2nd floor
    Office Block Building
    Queen Elizabeth University Hospital
    G51 4TF

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