First-of-its-kind trial at Keele University shows promising results

Posted on 13 March 2017

A pilot trial at Keele University has investigated the feasibility of giving patients direct access to physiotherapy services, with initial findings indicating that it could offer benefits to patients, GP practices and physiotherapists.

The study, Stepping up the Evidence for Musculoskeletal Services (STEMS), is the first randomised clinical trial to be conducted into direct patient access to physiotherapy, and was funded by the Chartered Society of Physiotherapy Charitable Trust.

Dr Annette Bishop, NIHR Research Fellow of Musculoskeletal Intervention Studies at Keele University, who led the study, comments:

“This research is the first randomised study anywhere in the world of direct patient access to physiotherapy. It fits with national calls to investigate new models of care to better meet demand for health services for patients with pain conditions.”

Record demand

The study has been conducted within a national climate of record demand from patients for primary health care in the UK. As well as an increase in the number of patient consultations, there has been a shift towards more complex and older patient populations, and challenges in the recruitment and retention of general practitioners.

Furthermore, patients with musculoskeletal pain problems account for at least 17 per cent of GP consultations and the recent Global Burden of Disease Study predicts that this will increase.

With this in mind, there have been calls by the Primary Care Workforce Commission, House of Commons Health Select Committee and the General Practice Forward View to investigate the impact of expanding the primary care workforce.

The senior researcher on the STEMS study, NIHR Professor Nadine Foster explains:

“One potential solution to meet this record demand would be to allow patients with musculoskeletal pain conditions to directly access physiotherapy services without a referral from their GP. Research to date is limited to observational research only but despite reported benefits, widespread availability of direct patient access to NHS physiotherapy has not occurred.”

“The STEMS pilot trial was undertaken to investigate the feasibility of a future large trial to compare the clinical and cost-effectiveness of the addition of direct patient access to physiotherapy versus continuing with usual GP-led care alone for adults with aches and pains.”


The STEMS trial demonstrated that despite actively marketing the new direct access pathway, the physiotherapy service did not experience an unmanageable increase in demand, nor did the level of inappropriate patient referrals change

The pilot has also shown that a full randomised control trial is feasible. GP practices, physiotherapy services and patients were willing to participate, showing that patient direct access to physiotherapy can be introduced into existing physiotherapy services.

Dr Annette Bishop comments:

“The STEMS pilot trial showed that introducing direct access into an existing physiotherapy service did not overwhelm the service and no concerns about safety were identified.

Professor Foster concludes:

“This successful pilot trial highlights the excellent partnership that exists between the academic team at Keele University and the NHS physiotherapy service in Central Cheshire Integrated Care Partnership. It has shown that a full trial is feasible.”

For more information about the STEMS trial, see the STEMS webpages

The study has been published this week on the BMJ Open journal

A further research study funded by Arthritis Research UK and the Chartered Society of Physiotherapy Charitable Trust is now exploring the longer term impact of direct access to physiotherapy for the general practices, physiotherapy services and patients who took part in the STEMS pilot trial. A full randomised controlled trial of this type of new service is now needed to provide definitive data on clinical and cost effectiveness.