Direct Access Patient Self referral within the ER-WCPT (September 2011)

Introduction - Direct access - patient self-referral

The terms direct access and patient self-referral refer to the circumstances where physical therapy services are available to patients/clients without the requirement of a third-party referral. In Europe, the most common manifestation of this concept of the delivery of physical therapy services is where the patient/client self-refers to the physical therapist as an out-patient or in a primary care setting. The drivers for making physical therapy services available to patients/clients without the requirement of a third-party referral are diverse. Demographic changes throughout the world will result in larger numbers of users of health services and these users are more informed about the choices available to them and have increasingly high health service expectations. Financial constraints require the use of models of services and interventions that can demonstrate both clinical and cost effectiveness. Some health policies throughout the world articulate the need for patients/clients to be able to refer directly to the health care profession of choice. As the desire to move the delivery of health care into the primary care setting results in changes in the structure of health care services, the removal of barriers to self-referral to a physical therapy service provides a number of key advantages for patients/clients including more consumer choice. Moreover, patient-self referral may result in increased autonomy and responsibility in the prevention and management of lifestyle related impairments and limitations in activity and participation as well as in chronic disease management.


The focus of research, to date, has been on patient/client self-referral in primary care settings e.g. patients attending for physical therapy in the community or as out-patients. Many of the developments have been in the area of musculoskeletal physical therapy services.  Two significant concerns have been raised about direct access and patient/client self-referral. The first is that it may not be safe and that users of physical therapy services may be placed at risk without a physician referral. The second is that the introduction of direct access to physical therapy services without the requirement for a referral from a physician would result in significant increases in the users of the physical therapy services.


Two large studies in Europe (Netherlands, UK) have demonstrated that the introduction of patient self-referral did not result in an increase in referral rates from historic rates if the service is adequately funded at the outset (UK study). Moreover, self-referral is safe and acceptable to patients/clients. However, even though direct access to physical therapy services may be available, some users will continue to prefer to obtain a third party referral. From a clinical perspective, the studies report that a greater proportion of those who self-referred fully completed treatment and reached goals than those who did not self-refer; patients/clients with neck and back complaints were more likely to self-refer and they frequently had a shorter duration of symptoms than those patients who sought a referral from a third-party.

A global survey – the European context

In October 2009, the World Confederation for Physical Therapy co-hosted, with the American Physical Therapy Association and the Canadian Physiotherapy Association, an international summit on two key topics for the profession of physiotherapy worldwide: direct access/patient self-referral and advanced scope of practice. Three key questions emerged from the summit about direct access/self-referral, namely,

1.    How do we raise/maintain worldwide standards?

2.    How do we identify/eliminate barriers to patient self-referral/direct access?

3.    How do we best inform/convince internal and external stakeholders?

Fundamental to answering these questions is information from member organizations of the World Confederation for Physical Therapy (WCPT). A workshop was hosted by the European Region of WCPT to exchange information about direct access/patient self-referral. During this workshop, all delegates who attended considered the first iteration of a global survey instrument. The purpose of this review was to seek a common understanding of the terms and concepts to be used in the final survey instrument. In addition, how the questions would be framed was explored. Terminology was debated and clarity sought and received. Thereafter an international reference group reviewed a further iteration of the survey. In August 2010, all WCPT member organisations were invited to complete the online survey; the survey closed in August 2011.

Updated results of the survey will be published soon.