Table 4 Typical quotes of direct and indirect stakeholders per topic

Decrease waiting lists

This does not currently play in my region.

When an ESP is used and prevents a patient from unnecessarily going to the orthopedist and therefore occupying the consultation hour, I think the waiting lists will be shortened.

Increase healthcare supply for patients

Patients often do not know what the best care is by the forest of healthcare providers. More care provision does not lead to better care.

I wonder if you will increase the healthcare supply. I do not think you can shed the healthcare supply, but you are trying to send insured patients directly to the right place where they can receive care.

Decrease healthcare costs

The biggest challenge of care will be that we have to do more and more for less and less money (and ensure sufficient staff working in the healthcare sector).

I certainly think that it can lead to a reduction in healthcare costs, because I am convinced that some of the patients who are referred to the second line do not actually have to be there. If you can get that percentage of people out of the front, then you reduce those healthcare costs

Tackle increased health demand

Particularly in the elderly, there is a lot to be gained (therapeutic and preventive) with low-threshold access to good movement care and advice.

I think there is a place for it. It is also being said that the second-line care will disappear. Hospitals in the current form are going to disappear. This is increasingly going to the periphery. And that is precisely where that super specialist who is needed in practice and the community. You will need more of that.

Relieve General Practitioners

That may be a welcome side effect, but should not be a reason to (yet) introduce a new profession. Complaints of the musculoskeletal system are not a big burden for most GPs, and there are also many abnormalities (rheumatic, paraneoplastic and otherwise) that do not belong primarily to the physiotherapist.

I certainly see that. You also hear that the GPs are too busy. Because they are the gatekeeper, they obviously need to know something. What we hear is that there are also quite a few people with musculoskeletal complaints. We think that the physio has much more knowledge of it. So yes, if they are already taken away from the GP, then you are sure to relieve the GPs.

Increase professional autonomy of physiotherapists

Especially nice for the physiotherapist, but that is in itself insufficient reason and should not be a primary goal. We must not introduce a new medical profession “because we want it so badly”

I do not think it is an important goal, but it is a result that occurs when you have that function. But then it must be guaranteed. It cannot be the case that every physiotherapist suddenly has such a forward position. So you will demonstrably have to have knowledge and skills.

Improve healthcare effectiveness

You can never be opposed to that, right?

It is an important point to put physiotherapy on the map as the professional in movement care who knows what it is about. That it will show added value in the context of sensible efficient care

Improve patient satisfaction

If the physio does what a patient would want immediately, perhaps, but more patient satisfaction? There remains a group that wants to have the doctor’s opinion.

I think that patients might ultimately be more satisfied with care in general. That less sending from the box to the wall and just to one person who understands business. But we do not have to do anything about patient satisfaction with physiotherapy, because on average it is very high. So we do not have to do much about that, but maybe in general healthcare.

Offer physiotherapists career perspective

That would be a good side effect, but it would not be a primary goal.

I certainly think so. It offers new challenges, new possibilities. You will profile yourself even more as a specialist. You can put yourself down well, so it does offer perspective. Maybe not financially, but in professionalism. I think it is a bycatch.

Tasks

Physiotherapist

General Practitioners

Patients

Indirect stakeholder

Triaging

Yes, very suitable as ESP I would say. Perhaps the most important task.

As far as I am concerned, estimations and differential diagnostics in the musculoskeletal area could be useful.

I think that a physiotherapist has more knowledge of the musculoskeletal system and a GP has more general knowledge. I think it is good to take over.

Yes I think that’s fine, as long as it falls within the domain of the physiotherapist.

Prescribing paracetamol and NSAID’s

Yes, that you can do so with additional knowledge. If we indeed know when you can or cannot prescribe it. That you cannot do it in combination with other medication. Anyway, if that is in the training that makes you ESP, I can imagine it is one of the tasks.

I find the assessment of which medication goes quite far if you cannot properly interpret comorbidity

Paracetamol, yes. Anti-inflammatory drugs I find tricky. I would like to have a second opinion from a doctor then.

Yes, both are basically over the counter medicine. So whether you say that, or whether the neighbor says it, or if someone thinks that he is going to swallow painkillers. That is not really an extra task. These are freely available products in the Netherlands. That is their own responsibility. You can advise that. But if you want to prescribe it as an advice for pain management, if you are aware of the effect and dosage, I do not think that’s a problem.

Ordering and/or interpreting diagnostic imaging

Personally, I’m mainly for requesting it. For example, the simple ankle complaint that we get as a physio. If the Ottawa Ankle rules are positive, you first have to refer the patient via the GP. I think that task can easily be done by a physiotherapist

I would rather expect an explosion in the cost of applied treatments if this is given in the hands of an ESP or an explosion in consultation time (multidisciplinary consultations)

Well that diagnostic imaging, that seems excellent to me. I think that as a physiotherapist you are very much helped if there is an image known, or a scan or something.

I think it fits very well within the scope of ESP. To bet on that. You can decide with a relatively limited amount of extra training.

Direct access

Yes, direct access. But that is more a matter of definition. I think we already do that.

X

Yes, as you said: That is already here. And I only like it as a patient that I can come and that I do not have to go to the doctor first.

Yes, fine for me. Then you also see that it does not deliver any calamities. Because actually it is already a form of triage, the screening of red flags.

Giving injections.

Yes, I think so. I think you should do that in the same way as a GP or orthopedist. You have to make a good diagnosis, take the right considerations for why you use it. Then it must be possible. But then I would also limit it to the shoulder and knee, because they are the easiest, and stay away from the other joints.

I would rather expect an explosion in the cost of applied treatments if this is given in the hands of an ESP or an explosion in consultation time (multidisciplinary consultations)

If an ESP proposes to give me an injection, I would first like to check with the doctor. I personally believe that people have to do what they are good at. And if that is what they are trained for and good at and the doctor does that once in a blue moon. Then I would certainly let that be done by the ESP.

You get so much on your neck, and why? What are you going to inject? And why do not you leave that to the professionals who are now trained for it?

Referring to specialists

You get more and more people through the direct access and then you need to send them first through the GP so they then end up in the second line. With which you take the patient away from the GP, less work pressure for the GP.

X

Yes, I think it’s fine. I do not know what the second line thinks about it? But I think it must be possible. Well, I think they should consider when they should refer. Because I think you have to prevent the specialists from saying: “Stop, we are going mad, all these physio’s that just refer. I’m already so busy.

Yes, selecting which patients go to the second line and which do not. It is on the one hand the possibility to refer, and an important task is also to limit it and prevent it from being referred.

Requesting and/or taking blood tests

But I also think that vitamin B, all kinds of other vitamins, a piece of fatigue. I would be very happy if I did not have to ask the GP every time

To do this really well and safely, extensive physiological knowledge is needed.

I do not quickly see an application for that. Perhaps I am too pragmatic, but then I would say: There are better posts for it. They are hygienic and they are all on temperature. In the context of efficiency, the hospitals do no different and are professional in it and I would say: let them continue to do it.

I think blood tests go pretty far. Sure, everything is possible, but I think it’s going pretty far.

Work capacity testing

That is a very difficult one. The GP is not able to do that either. This is often only a company doctor who can actually and legally establish this. So I have my doubts about that.

There is a great need for this, and the current GP and physio cannot judge this.

I also find this a difficult one and I wonder if patients will accept it instead of a company doctor. That is a very sensitive subject, whether people are allowed to work or what kind of work or what percentage. I don’t know if patients would accept that from someone who isn’t a doctor. I think they can do it, but only in an advising role

Yes, I find an interesting one. I think that there are opportunities. That an occupational physiotherapist may be more useful to a labor physician.

Requesting laboratory tests

But I also think that vitamin B, all kinds of other vitamins, a piece of fatigue. I would be very happy if I did not have to ask the GP every time.

To do this really well and safely, extensive physiological knowledge is needed.

Well, that also depends a bit on whether the ESP has enough know-how to make that assessment.

I do not see that at all so that an ESP should do that. I think that if there is any doubt about it, he has to go to the doctor.

Giving a medical diagnosis

Yes, if you can have additional research done and you get these things inside, then you could certainly make a medical diagnosis.

X

Yes, I also find a difficult one because you are not a medical doctor. I do not think so. I also think of an advisory role again, but do not really make a diagnosis.

No that is not possible. In the end you can never, according to me, make a medical diagnosis as long as you do not yet have the status of a medical practitioner.

Listing patients for hip or knee replacement

You can of course refer. If you have someone with obvious osteoarthritis of the knee and that is limiting their function and so on, then you can say: well, it is an idea to think about a new knee, I will send you to the orthopedist. Putting it actually on the operation list seems complicated to me. The person can use certain medication that must first be stopped for a while. The orthopedist wil probably say: I want to see that patient first before I use a knife.

Assessing whether and which surgery is required is the domain of the operator. Is it better to apply a valving osteotomy or hemiprosthesis, and which surgical technique? The operator must take into account additional issues such as urgency. All things that only the surgeon can judge.

Well, but it seems to me that the specialist would like to know what kind of patient he gets on the table and that he does not just get people from his or her hospital in all sorts of places. I do not know how that goes with responsibilities and things like that.

Yes, I think this goes pretty far too. If you are going to do that, then you do not need orthopedics. The question is whether you should want that. When you need orthopedics, they have to give that judgment. And then the orthopedic surgeon will operate. You can say: I refer to the second line.

Roles

Physiotherapist

General Practitioners

Patients

Indirect stakeholder

Working in a multi-disciplinary team

For sure. I think that we sometimes have to be a little more multi-disciplinary and also thrive very well, because other care providers depend on other care and vice versa we also depend on their care. If we were to make better use of it, the quality of the total package would be better.

In collaboration with the GP and especially specialists ideal

It seems to me, it is never wrong to have some other disciplines in a team, if you work in a health center, that you still have someone to discuss the situation.

Yes, that is perfect. If you are talking about: Someone comes in with musculoskeletal complaints and they report to a central desk. As far as I am concerned, it will not go to the GP but to the ESP who can properly assess this. You have to see it like that.

Working as a consultant

Not so much to really start a whole treatment process with the patient, but to look at it: okay, this patient is suitable for this type of physio and then goes there, or just goes there. But that you coordinate or determine that as a GP role, but no more than that.

X

Yes, it seems to me a task in itself. Provided sufficient work experience as a physiotherapist. You know what you’re talking about, I think. Seems fine

I think that is a very good one. Because I think that’s what the doctor is missing. You will be very happy with this if you do as ESP.

Having an educational role

I think that someone must have certain qualities, but in the end I have also become a teacher here. But that does not mean that every master must be able to do that.

I do not see why an ESP would be pre-eminently qualified as a teacher

Yes, but I would say: stay in practice. Because everything changes quickly, so stay up to date. Then it seems right to me to teach your colleagues.

I do not see it that way, no. In my opinion, this should not necessarily be a role for ESP. A physio can also like to do that. An ESP could do that too, but in my opinion that does not have to be a role for an ESP.

An ESP role separated from a physiotherapist role

Difficult. You will probably also work in primary care as a physiotherapist. Only it is not the intention that you as ESP will fill your own agenda or that of your colleagues. My advice will then still be to separate as good as possible.

X

That seems to me very difficult for the person concerned. To just be a physio in one moment. You always take it with you.

Yes, that depends on how technically it is regulated. If it’s a new profession, or. And otherwise you stay in the basic physiotherapist, so you can put your skills and knowledge in different places. But I do not care if you are ESP in the general practice or the physiotherapy practice.

A leadership role

Yes, especially musculoskeletal complaints. Very good though! The GP is in charge of patients with co-morbidities. This is how the care is now also organized. Maybe sometime in the future an ESP, but now it is clear the GP.

I do not think it’s useful in a medical team.

No, when I look at my own work, you have people who grow into a manager. And sometimes you do not do any work at all that you’re used to do, but you know the ropes. So yes, but you need different qualities and not every ESP could do it.

The role of case manager could well lie with the ESP in the primary care practice. Up to a certain level. Up to and including the movement-related aspect.

A role as a doctor of physiotherapy

I have a little trouble with physio-doctor. I think a doctor does a bit more than the points we just went through. So if you put yourself down as a doctor, then I wonder if that does not give a wrong picture.

X

Then they should have started studying medicine hahaha. Yes, I do not know. I also do not know how that is with such an oath and so. Of course you also have to deal with that.

I do not think so. I do not see that for me. Then you also have to get a lot of medical training. And then you go more towards the GP and the orthopedic surgeon. I do not see the added value of why someone should do that.

Working in labor related care

I do not think you should see this as an ESP role.

If independent of the own patient

I think that moving, how you sit, how you deal with stress. I also think that physical therapy can play a positive role.

Yes, you mentioned a few and I think: In principle an ESP could function here, all per specialism. Only then must he be trained more specifically.

Working in primary care arthritis care

Yes is part of it, but not as a specific role I think.

It has a more chronic and specialized character. I see ESP more as a quick and generalist, I would rather find guidance in rheumatism fit with a regular (specialized or not) physio

Yes, I’m pretty open to that. Because otherwise you have to go through a whole circle before you get help. Those roads are much shorter.

Yes, I think you should rather see it as a leading role and consultant. That the person then indeed, depending on the specialist setting, that you can refer the person to the right physiotherapists or first-line practices or health centers.

Specialized in hand therapy

Hand therapy already exists. I wonder what specifically for ESP is then.

X

Yes, I think it is possible. As I see it: the ESPs can simply specialize in certain areas and they only become more expert. So I would applaud that, I think.

Yes, I find it difficult. I am not so familiar with hand therapy myself, so now I do not know what the level of the hand therapist is. But it is true that there are some good things about it and there will also be a lot of demand for it. So that as a super specialist can also find a place.