Identifying goals, roles and tasks of extended scope physiotherapy in Dutch primary care- an exploratory, qualitative multi-step study
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Bastiaens et al. BMC Health Services Research (2021) 21:19
https://doi.org/10.1186/s12913-020-05986-w
RESEARCH ARTICLE Open Access
Identifying goals, roles and tasks of
extended scope physiotherapy in Dutch
primary care- an exploratory, qualitative
multi-step study
Ferdinand Bastiaens1,2* , Di-Janne Barten1,2 and Cindy Veenhof1,2,3
Abstract
Background: Rising healthcare costs, an increasing general practitioner shortage and an aging population have
made healthcare organization transformation a priority. To meet these challenges, traditional roles of non-medical
members have been reconsidered. Within the domain of physiotherapy, there has been significant interest in
Extended Scope Physiotherapy (ESP). Although studies have focused on the perceptions of different stakeholders in
relation to ESP, there is a large variety in the interpretation of ESP. Aim: To identify a paradigm of ESP incorporating
goals, roles and tasks, to provide a consistent approach for the implementation of ESP in primary care.
Methods: An exploratory, qualitative multi-step design was used containing a scoping review, focus groups and
semi-structured interviews. The study population consisted of patients, physiotherapists, general practitioners and
indirect stakeholders such as lecturers, health insurers and policymakers related to primary care physiotherapy. The
main topics discussed in the focus groups and semi-structured interviews were the goals, skills and roles affiliated
with ESP. The ‘framework’ method, developed by Ritchie & Spencer, was used as analytical approach to refine the
framework.
Results: Two focus groups and twelve semi-structured interviews were conducted to explore stakeholder
perspectives on ESP in Dutch primary care. A total of 11 physiotherapists, six general practitioners, five patients and
four indirect stakeholders participated in the study. There was a lot of support for ‘decreasing healthcare costs’,
‘tackling increased health demand’ and ‘improving healthcare effectiveness’ as main goals of ESP. The most
agreement was reached on ‘triaging’, ‘referring to specialists’ and ‘ordering diagnostic imaging’ as tasks fitting for
ESP. Most stakeholders also supported ‘working in a multidisciplinary team’, ‘working as a consultant’ and ‘an ESP
role separated from a physiotherapist role’ as roles of ESP.
(Continued on next page)
* Correspondence: fer.bastiaens@gmail.com
1
Physical Therapy Sciences, Program in Clinical Health Sciences, University
Medical Center Utrecht, Utrecht, The Netherlands
2
Research Group Innovation of Human Movement Care, University of
Applied Sciences Utrecht, Utrecht, Netherlands
Full list of author information is available at the end of the article
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Bastiaens et al. BMC Health Services Research (2021) 21:19 Page 2 of 24 (Continued from previous page) Conclusions: Based on the scoping review, focus groups and interviews with direct and indirect stakeholders, it appears that there is sufficient support for ESP in the Netherlands. This study provides a clear presentation of how ESP can be conceptualized in primary care. A pilot focused on determining the feasibility of ESP in Dutch primary care will be the next step. Keywords: Physical therapy modalities, Extended scope, Multi-step design, Primary health care Background ESP could be conceptualized specifically in primary care High-quality primary healthcare is an important priority is currently lacking. for Western societies. This ambition is threatened from This representation is necessary, because the con- two sides. On the one hand, the demand for healthcare text of a primary care setting is substantially differ- in a primary care setting has increased due to an aging ent from the context of secondary care in which ESP population and an increase in the number of chronically can be implemented. For example, external stake- ill patients [1]. On the other hand, general practitioners holders play an important role in primary care. In- (GPs) in primary care face increasing workloads while creased collaboration, development opportunities and the average of weekly work hours remains the same. a shared understanding between stakeholders are re- Both developments put pressure on sustaining the qual- quired for the extended scope role to flourish [16]. ity of primary healthcare and have made primary care Currently, there is insufficient insight into perceived organization transformation a priority in several coun- legitimacy from relevant stakeholder groups in pri- tries [1–4]. mary care, which is based on the value of, the confi- One of the ways these challenges in (primary) dence in and the boundaries of the extended scope healthcare have been met, is to reconsider the roles role [17]. of non-medical members of the healthcare team and The three most important stakeholder groups re- substitute tasks traditionally carried out by physicians garding ESP in primary care are patients, physiothera- [5]. By these new ‘Extended Scope’ roles, healthcare pists and GPs. Several studies have already been providers aim to increase patient satisfaction and im- performed regarding patient perceptions on ESP. A prove access to care with comparable or better quality qualitative study concerning patient perceptions of and efficacy at lower healthcare costs [6, 7]. With re- the ESP role showed themes that were important re- spect to the domain of physiotherapy, there has been garding the quality of service: provision of informa- significant interest in Extended Scope Physiotherapy tion, professional skills, interpersonal skills, outcome, (ESP) over the last 20 years within healthcare systems and patient care pathway [13]. A survey which fo- of the United Kingdom, Canada and Australia [7–11]. cused on ESP in primary care showed that patients Especially in settings providing services to patients supported the intended new roles of the ESPs regard- with musculoskeletal disorders, physiotherapists have ing the treatments of patients with musculoskeletal emerged as key providers in such new redistributed disorders [14]. roles. For example, initiatives for the treatment of pa- A qualitative study on the perspectives of physio- tients with common musculoskeletal disorders have therapists on working as an ESP in an orthopaedic been implemented in emergency departments, outpatient clinic concluded that the physiotherapists orthopaedic clinics and the primary care setting [12– experienced that, although the job can be stressful, it 14]. Research suggests that extended scope physio- is also very satisfying [18]. Furthermore, a survey of therapists achieve similar or better results in muscu- physiotherapists and physiotherapy employers on clin- loskeletal complaints regarding diagnostic accuracy, ical specialization and extended scope showed partici- effectiveness of care, care utilization and cost of care pants are supportive of the roles of the clinical compared to GPs [15]. specialists and advanced practitioners within the pro- Although ESP has widely been reported in literature, fession [19]. To our knowledge, no studies focused on there is a large variety in the interpretation of ESP be- GP perspectives on ESP yet. tween the countries and settings in which ESP is imple- Although several studies have focused on the per- mented. Remarkably, most of these studies focus on ESP ceptions of different stakeholder groups in relation to in hospital based settings. A clear representation of how ESP, no clear interpretation of ESP in primary care
Bastiaens et al. BMC Health Services Research (2021) 21:19 Page 3 of 24
exists. This is either due to perceptions of stakeholder could be used as a foundation to explore Dutch
groups being focused on ESP in hospital based stakeholder perspectives on ESP. The following
settings or perceptions of stakeholder groups being research question was formulated for the scoping
absent. review: “What characteristics or aspects are featured
Therefore, we aim to identify a stakeholder sup- in the paradigm of Extended Scope Physiotherapy in
ported paradigm of ESP, incorporating goals, roles primary care?”
and tasks, to provide a consistent approach for the
implementation of ESP in primary care through col-
laboration with patients, physiotherapists, GPs and Identifying relevant studies
other stakeholders in primary care. In order to make A search strategy was set up with the aid of an
this paradigm applicable to clinical practice in pri- information specialist and consisted of keywords and
mary care, it is best to be captured in a framework subject headings. Four databases were used to
format. systematically search articles (Medline, Embase,
Cinahl and Sportdiscus) relevant to the topic of ESP.
Methods The search string was built upon a combination of
Design the professions (e.g. physiotherapy), domain (e.g. ex-
An exploratory, qualitative multi-step design was used, tended scope), and outcomes (e.g. decision making).
based on the iterative process used by Harding et al. and The complete search string can be found in Appen-
Bravo et al. in order to complete the ESP framework [20, dix 1. The search was conducted in 2017 and
21]. The iterative process of the multi-step design is il- updated in July 2019. Studies found through the
lustrated in Fig. 1. This multi-step approach includes a search results were imported and managed in Rayyan
scoping review, focus groups and the drafting of a final QCRI [24].
framework.
Scoping literature review on ESP Study selection
The first phase is to conduct a scoping review in Studies containing a definition of, or criteria for ESP
order to develop an initial framework of ESP in in a primary care setting were included. Since the
primary care. This scoping review follows the scoping scope of physiotherapy differs between countries,
review model portrayed in Arksey and O’Malley and studies describing a scope-extending feature in the
the proposed recommendations found in Levac et al. originating country were included as well. There was
[22, 23] and consists of the following steps: no limitation regarding design or year of publication
when selecting the articles. Articles that used defini-
Identifying the research question tions adopted from other studies were excluded. Arti-
The aim of the scoping review was to identify an cles written in a language different from English or
initial framework of ESP in primary care, which Dutch were excluded as well.
Fig. 1 Iterative process of developing the framework of Extended Scope Physiotherapy in Dutch primary careBastiaens et al. BMC Health Services Research (2021) 21:19 Page 4 of 24
Study selection was performed by subsequent steps. nationwide. Patients were contacted via physiothera-
First, all imported studies were scanned for dupli- pists working in primary care practices in and around
cates. To determine eligibility, the studies were subse- Utrecht.
quently scanned on title and abstract. This was Subsequently, perspectives of several indirect stake-
followed by checking for full text availability and the holders regarding ESP, like policymakers, financiers
screening of full text articles. The selection process and lecturers on the domain of primary care, were
was conducted by the first author (FB). gathered. Healthcare departments of several insur-
ance companies were approached as financial stake-
Charting the data holders. Lecturers from both General Practice and
To provide an overview of the included studies, the fol- Physiotherapy programs were contacted as educa-
lowing data were extracted using a standardized extrac- tional stakeholders, respectively related to the Uni-
tion form: first author; year of publication; study design; versity Medical Center Utrecht and the Utrecht
ESP description, definition and/or criteria. University of Applied Sciences. Professional associa-
tions from both GPs and physiotherapists were con-
Collating, summarizing, and reporting results tacted as well. Policymakers that we contacted were
The analytical approach used to create the initial the Ministry of Health, Welfare and Sport, a physio-
framework of ESP in Dutch primary care was the therapy accreditor organization and the Dutch Ex-
‘framework’ method developed by Ritchie & Spencer tended Scope Society.
[25]. The first step was familiarization of the col- Participants were included if they were ≥ 18 years
lected data by gathering ESP descriptions, definitions and able to speak the Dutch language. In addition,
and criteria from the included studies. Secondly, all physiotherapists and GPs had to be involved with
key themes were identified in order to further de- the primary care setting during their participation of
velop the framework. Thirdly, data were indexed in the study. Patients had to have experience with the
textual form by coding the relevant information from treatment of musculoskeletal complaints in the pri-
the studies. Fourthly, data were classified according mary care setting. No exclusion criteria were used
to the relevant part of the thematic framework. Fi- in this study. In order to get a clear view of the dif-
nally, the identified themes were mapped using ta- ferent perspectives of the stakeholder groups, homo-
bles and diagrams. This initial framework was geneity was preferred in the forming of the groups
visualized by creating a mind map consisting of the [26].
codes and identified themes which were present
among multiple studies.
Procedure
Physiotherapists and GPs were invited to participate into
Exploring stakeholder perspectives
separate focus groups. With respect to feasibility, GPs
The initial framework was further discussed on clin-
were invited to take part in an online focus group by
ical relevance for primary care by a range of direct
way of FocusgroupIT (www.focusgroupit.com) instead of
and indirect stakeholders of ESP in Dutch primary
a face-to-face focus group. The aimed number of partici-
care. The stakeholder perspectives were analyzed in
pants for the focus groups was between 6 and 12 per-
order to index the data and to identify themes. These
sons per group [27]. The primary researcher (FB) led the
themes were then used to adjust the initial framework
focus group discussions.
in order to make the paradigm fitting for Dutch pri-
The views of patients and indirect stakeholders on
mary care.
ESP were gathered by semi-structured interviews.
Those interviews were held at a location of their
Participants
choice or by telephone. Voice recording was used
Physiotherapists working in primary care settings
during both the focus group sessions and the semi-
were approached to participate in this study. They
structured interviews.
were invited via general newsletters, social media
posts and personal invitations based on work-related
connections. In addition, recruitment focused on lec- Data collection
turers and internship supervisors from the Physiother- Prior to the focus groups and semi-structured inter-
apy Bachelor of the University of applied Sciences views, ‘age’, ‘sex’ and ‘familiarity with ESP’ of the partici-
Utrecht, as well as Master students and alumni of pants were noted. Additionally, ‘work experience’ and
Physiotherapy Science, Program in Clinical Health ‘postgraduate degree’ was gathered from physiotherapists
Sciences, Utrecht University. The recruitment strategy and GP’s. ‘Level of education’ and ‘type of health prob-
of GPs initially focused on primary care settings lem’ was collected from patients and ‘professionalBastiaens et al. BMC Health Services Research (2021) 21:19 Page 5 of 24
discipline/area of specialisation’ was noted in indirect obtained from all participants prior to participation in
stakeholders. the study.
An interview guide was developed based on the
initial framework. Major topics reflected the broader Results
themes found in the scoping review. Within these Literature review
topics, sample questions were formulated, specifically Study selection & data chart
focussing on subcomponents of the themes. The In total, 1896 unique entries were identified through
interview guide developed for patients was limited to the literature search of the databases. After screening
topics related to patient-experienced features of ESP. the title and abstract for inclusion, 270 studies were
The full topic list is presented in Appendix 2. Prior selected for full text screening. One study was added
to the interview, participants were given an explan- through a search of the articles reference list. In
ation about ESP in the information letter. If neces- total, 140 studies were included in this scoping re-
sary, the themes and their sub-components were view on identifying characteristics or aspects con-
explained during the interview. In order to get the cerned with ESP in primary care (Fig. 2). Included
participants’ full perspective on ESP, they were asked articles were qualitative, quantitative or descriptive
on their view of every single theme (e.g. every goal, in nature and contained experimental designs, litera-
task and role) in the initial framework. ture reviews, convention abstracts. A complete over-
view of the included studies can be found in
Appendix 3.
Data analysis
Once again, the analytical approach by Ritchie & Initial framework
Spencer was used to refine the initial framework of Based on the included studies by the scoping review,
ESP in Dutch primary care [25]. The method involves an initial framework was created containing goals,
the initial framework as a working analytical frame- roles and tasks associated with ESP in primary care
work that is used to index the data, whilst remaining (Fig. 3). Themes encompassing desired results for im-
sufficiently flexible to allow the incorporation of add- proving existing structures or tackling problems were
itional themes. The process of familiarization of the linked to Goals of ESP. Themes describing concrete
collected data, identification of themes and indexing activities were linked to Tasks of ESP, whereas
of the data in by coding was used on the transcripts. broader conditions related to job position or behavior
The classification and mapping of the data served to were linked to Roles of ESP. Goals of ESP found in
refine the mind map of the initial framework. This the literature focused on tackling major trends in
process is in accordance with approaches to establish healthcare (e.g. decreasing healthcare costs, improving
rigor in qualitative research, particularly in establish- healthcare effectiveness or decreasing waiting lists)
ing credibility, which represents means of granted [29–31]. Furthermore, goals specified one or more
value to qualitative findings [28]. groups that ought to benefit from ESP, such as in-
creasing autonomy for physiotherapists, relieving GP’s
Drawing final framework or increasing patient’s access to care [14, 32, 33]. De-
The final framework of ESP was drafted by the re- scribed tasks of ESP varied both by country and by
searchers, capturing the themes adopted by direct and time period. A total of 31 and 20 articles described
indirect stakeholders. NVivo software was used to aid triaging and referring to specialists as ESP tasks re-
the analysis and generation of additional themes. Ana- spectively [34, 35]. Articles focused on prescribing
lyses were performed by the primary researcher (FB) NSAIDs or ordering diagnostic imaging were numer-
and a member check was performed by another re- ous as well, with 28 and 31 descriptions respectively
searcher (JB). [36, 37]. Descriptions of ESP-roles sometimes focused
on a specific setting, such as hand therapy or arthritis
care [38, 39]. More general descriptions, such as con-
Ethical considerations sultants or part of a multidisciplinary team were also
Ethics approval was received from the Medical Ethics found in the literature [40, 41].
Committee of the University Medical Center Utrecht
(18–137/C). Participants received the participant in- Stakeholder perspectives
formation letter and an informed consent form by e- Participants
mail from the primary researcher prior to their par- Two focus groups and twelve semi-structured interviews
ticipation. A reminder was sent a few days before the were conducted to explore stakeholders perspectives on
start of the study. Written informed consent was ESP in Dutch primary care. One focus group containedBastiaens et al. BMC Health Services Research (2021) 21:19 Page 6 of 24
Fig. 2 Study selection flow chart
nine physiotherapists (6 males, median age: 29 years, fa- Goals of ESP In general, participants experienced diffi-
miliarity with ESP: n = 3) and one online focus group culties in envisioning clear goals for ESP. Nevertheless,
contained six GPs (5 males, median age: 40 years, famil- there was a noticeable difference in the support of the
iarity with ESP: n = 0). Two physiotherapists (2 males, different potential goals as extracted by the scoping
median age: 44 years, familiarity with ESP: n = 1) were review.
interviewed additionally to enlarge the chance of satur- Regardless the different stakeholders, there was a
ation. Furthermore, five patients (2 males, median age: lot of support for ‘decreasing healthcare costs’, ‘tack-
53 years, familiarity with ESP: n = 0) and four indirect ling increased health demand’ and ‘improving health-
stakeholders (Policy officer, Lecturer, Healthcare buyer, care effectiveness’ as important goals. A majority
Chairman professional organization, 4 males, median also supported ‘relieving GPs’. However, some partic-
age: 37 years, familiarity with ESP: n = 3) were ipants questioned whether the addition of ESP would
interviewed. have that effect. By way of illustration, a physiother-
apist mentioned: “So, what we are already doing a
Perspectives on extended scope physiotherapy bit is to take out that musculoskeletal group in par-
The initial framework presented in Fig. 2 was the start- ticular. A nurse practitioner also tackles the easier
ing point for discussions with stakeholders in focus conditions. But the result is that the GP, who hoped
groups and interviews. Their perspectives regarding the for a milder consultation, actually saw an increase
goals, tasks and goals of ESP are summarized below. An in the consultation hour.” (physiotherapist, age range
extended summary of examples illustrating contributions 40–49 years).
of the stakeholders in narrative form are presented in Moreover, most participants viewed ‘improving pa-
Appendix 4. tient satisfaction’, ‘increasing professional autonomy ofBastiaens et al. BMC Health Services Research (2021) 21:19 Page 7 of 24
Fig. 3 Initial framework Extended Scope Physiotherapy (ESP) in Dutch primary care
physiotherapists’ and ‘offering physiotherapists career musculoskeletal area could be useful.” (GP, age range
perspective’ as potential positive effects rather than 30–39 years).
goals. Little support was given to ‘decreasing waiting GPs were divided on ‘requesting diagnostic imaging’,
lists’ and ‘increasing healthcare supply’ for patients, but there was agreement in favor of the task among
because the goals were deemed irrelevant to the the other stakeholders. In contrast, only little support
Dutch healthcare system. was shown for ‘interpreting diagnostic imaging’. While
‘direct access’ and ‘work capacity testing’ were sup-
ported, most stakeholders did not see it as tasks spe-
Tasks of extended scope physiotherapists Physiother- cifically related to ESP. ‘Listing patients for hip or
apists tended to be more willing to assign tasks to knee replacement’ was not supported by GPs, patients
ESP than GPs. However, most agreement was and indirect stakeholders, illustrated by the participat-
reached on ‘triaging’ and ‘referring to specialists’ as ing lecturer: “Yes, I think this goes pretty far too. If
tasks fitting for ESP. This agreement is illustrated by you are going to do that, then you do not need ortho-
a GP who indicated: “As far as I am concerned, esti- pedics. The question is whether you should want that.
mations and differential diagnostics in the When you need orthopedics, they have to give thatBastiaens et al. BMC Health Services Research (2021) 21:19 Page 8 of 24
judgment. And then the orthopedic surgeon will pro- personal perspective. Another theme that arose was
vide surgical care. You can say: I refer to the second- ‘ESP structured as a specialist or as a generalist’.
ary care.”(Lecturer, age range 30–39 years). Some participants showed interest in an ESP frame-
The stakeholders expressed mixed reactions on ‘giv- work aimed at enhancing physiotherapeutic specialists
ing a medical diagnosis’, ‘requesting laboratory tests’ in certain niches, where other participants focused
and ‘giving injections’. Reactions on ‘requesting blood more on ESP as a generalist aimed at triaging and
tests’ were mixed as well, although the stakeholders diagnosing patients with musculoskeletal complaints
generally did not support the ‘taking of blood tests’. in general practice. The participating policy officer
When ‘prescribing’ was discussed, the majority of the viewed it as such: “I really see an ESP as a kind of
stakeholders was in favor of prescribing paracetamol, super specialist. So the moment you really start work-
but the prescription of NSAIDs received less support. ing in a part of your domain, then I think you need a
A patient noted: “Paracetamol, yes. Anti-inflammatory good basis for that. So also be able to apply those
drugs I think it is tricky. I would like to have a second extra skills to be able to develop well in that area.”(-
opinion from a doctor then.”(Patient, age range 50–59 Policy officer, age range 30–39 years). While both roles
years). do not have be mutually exclusive in ESP, some par-
ticipants showed concerns of ESP being set up too
Roles of extended scope physiotherapists There was widely.
large agreement among stakeholders regarding the po-
tential roles in ESP. Most stakeholders supported Drafting the final framework
‘working in a multidisciplinary team’, ‘working as a Based on the identified stakeholder perspectives in
consultant’ and ‘an ESP role separated from a physio- the Netherlands, the initial, literature-based frame-
therapist role’. A GP stated: “Ideally, in collaboration work was adjusted in order to fit the framework to
with the GP and especially specialists. “(GP, age range primary care. The goals ‘improving patient satisfac-
40–49 years). tion’, ‘decreasing waiting lists’ and ‘increasing health-
Additionally, the majority of the stakeholders op- care supply’ were removed from the framework,
posed having ‘an educational role’, ‘a leadership role’ whereas ‘increasing professional autonomy of physio-
and ‘a role as doctor of physiotherapy’. An example therapists’ and ‘offering physiotherapists career
illustrating a patient’s views on the leadership role: perspective’ were replaced by ‘the profiling of Physio-
“No, when I look at my own work, you have people therapy’. The tasks ‘direct access’, ‘work capacity
who grow into a [leadership role]. And sometimes you testing’, ‘giving a medical diagnosis’, ‘requesting la-
do not do any work at all that you’re used to do, but boratory tests’ and ‘requesting and/or taking blood
you know the ropes. So yes, but you need different tests’ were removed entirely and ‘ordering and/or
qualities and not every ESP could do it.”(Patient, age interpreting diagnostic imaging’ was reduced to ‘or-
range 40–49 years). dering diagnostic imaging’. Furthermore ‘prescribing
The roles ‘working in labor related care’, ‘working in paracetamol and NSAID’s’ and ‘giving injections’ were
primary care arthritis care’ and ‘specialized in hand ther- labeled as tasks for ESP which were optional with ex-
apy’ were mostly viewed as optional specializations in- tensive training. In the section ‘Roles ESP’, the themes
stead of key aspects of ESP. ‘working in labor related care’, ‘working in primary
care arthritis care’ and ‘specialized in hand therapy’
Additional themes Additional themes also arose were replaced with ‘deliver ESP in physiotherapeutic
from the data. ‘Sufficient work experience’ was noted niches’, which was labeled as optional. The roles ‘an
by all stakeholders as a requirement for ESP. A educational role’, ‘a leadership role’ and ‘a role as
physiotherapist mentioned: “I wonder, when you look doctor of physiotherapy’ were removed. The final
at setting it up and dividing it in the neighborhood, framework is illustrated in Fig. 4.
if a GP is waiting for a 26-year-old ESP that takes
over many of its tasks. I think that a lot of experi- Discussion
ence and age makes sense.”(Physiotherapist, age range The purpose of this study was to identify a stake-
20–29 years). holder supported paradigm of ESP, incorporating
Physiotherapists also indicated the ‘profiling of their goals, roles and tasks, to provide a consistent ap-
profession’ as an important goal related to ESP. This proach for the implementation of ESP in primary
goal focuses more on the overarching physiotherapeu- care. Looking at the identified paradigm, the main
tic profession in the Netherlands, whereas the already goals of ESP are to decrease healthcare costs, to
mentioned goal of offering physiotherapists’ career tackle increased health demand and improve health-
perspective focuses particularly on a therapists’ care effectiveness. The roles in which an ESP actsBastiaens et al. BMC Health Services Research (2021) 21:19 Page 9 of 24 Fig. 4 Final framework Extended Scope Physiotherapy in Dutch Primary care are more generic in nature, focusing on consulting multidisciplinary team reflects a positive view of and/or participating in a multidisciplinary team. The interdisciplinary learning. Looking at the implemen- main task of an ESP will be triaging and, if neces- tation of extended scope, previously identified key sary, referring to specialists and ordering diagnostic themes consisted for example of proactively address- imaging. Additional themes in the paradigm are the ing barriers; legislative issues; developing, accredit- possibility for ESP in physiotherapeutic niches and ing and delivering a curriculum supporting requirements for becoming an ESP, such as a min- physiotherapists to work outside of the usual scope imal amount of work experience and additional [43]. These themes have not been studied in our education. study, due to the lack of an established form of Several studies previously examined extended ESP. However, these are important points that need scope through the perspectives of different stake- to be taken into account in expanded research on holders. Wiles et al. studied the perceptions of dif- the paradigm of ESP. ferent key stakeholders on the ESP role in Australia Looking at contemporary reforms of the Dutch pri- [42]. They found agreement on the value of ESP in mary care, the identified paradigm provides clinical improving the efficacy and efficiency of health ser- relevance on the potential role of ESP. The Dutch vice delivery, achieving positive patient outcomes government aims at substitution from secondary care and offering opportunities for interdisciplinary to primary care [44, 45]. With the increased pressure learning among colleagues. This largely corresponds on GPs, more supporting healthcare providers are with the findings in our study related to the goals needed to relieve the GPs and, simultaneously, to of ESP in primary care. Although it was not stated maintain quality of care. Therefore, substitution is as a goal of ESP, the identified support for ESP in a seen as a driving force to innovations in healthcare
Bastiaens et al. BMC Health Services Research (2021) 21:19 Page 10 of 24
professions [46]. Substitution can also add to reducing version of ESP in primary care. The identified para-
healthcare costs, with ESP improving diagnostic ac- digm generally aligns with countries which have
curacy and decreasing unnecessary referrals to spe- already implemented ESP in primary care. Therefore,
cialists. Furthermore, the ESP goal to improve this paradigm ought to be useful for countries with
healthcare effectiveness fits in the restructuring model a similar primary care setting that are interested in
of Kaljouw and Van Vliet (2015), regarding personal- implementing ESP as well.
ized care [45]. This model sets up an expansion of
tasks, focusing on improving one’s function instead of
improving the illness. Recommendations
The framework provides a realistic and advantageous
Strengths and limitations model for the development of ESP in primary care
One of the strengths of this study was the iterative in the Netherlands. There seems to be sufficient sup-
design. This design enabled drafting the framework in port regarding the paradigm of ESP in view of sev-
a thorough manner. The literature review provided a eral direct and indirect stakeholders in primary care.
broad foundation in which the majority of final Therefore, it would appear that the time has come
themes were present. In addition, the diverse groups to study ESP more thoroughly by determining its’
of stakeholders provided a broad spectrum of per- feasibility by way of an observational pilot study. In
spectives on ESP applicable to the setting of primary consistence with the identified goals, tasks and roles
healthcare. Furthermore, discussions with stakeholders of ESP, diagnostic accuracy and patient and GP sat-
have helped to create support for ESP in primary isfaction should be used as outcome measures in this
care. Additionally, due to the systematic interview trial. Furthermore, emphasis should be put on re-
style and the explanations of how the tasks, roles and quirements and preconditions for physiotherapists
goals worked out in practice, participants received a who can be eligible for ESP. More research is also
clear understanding during the interview. This pro- recommended on the perspectives of healthcare pro-
vided a beneficial contribution to the cohesiveness of viders related to primary care, like general practice
the final framework. based nurse specialists, district nurses and specialists
Some limitations should be mentioned as well. For in secondary care, such as neurologists, orthopedic
example, the recruitment of GPs appeared to be surgeons and rheumatologists. Looking at the estab-
more difficult than expected. Their busy schedule lished paradigm, these healthcare providers will most
might have played a role, or their interest in the likely be influenced in their work by the introduc-
topic of ESP. Moreover, the barrier to assemble in tion of ESP and therefore can be counted as direct
one location at the same time withheld participants stakeholders. Another priority in further research is
as well. This was partly tackled by setting up the on- studying interactive discussions between stakeholder
line focus group for the GPs and taking individual groups in order to identify a more conscientious
interviews. However, a sample bias still occurred. paradigm of ESP in primary care.
Polled participants who were less invested in ESP,
were more eager to refuse participation. The small
sample size has likely led to bias, although it is not Conclusion
clear in which way this bias runs. Moreover, general This study aimed to identify a paradigm for ESP that
support for ESP has only been investigated to a lim- fits to Dutch primary care based on both literature
ited extent due to the lack of interaction between and stakeholder perspectives. Based on the scoping
the stakeholder groups. Although it is a strength of review, focus groups and semi-structured interviews
this study to give each stakeholder group room for with various direct and indirect stakeholders, it ap-
their own perspective, discussions among stake- pears that there is sufficient support for ESP in the
holders could have provided a more fleshed out Netherlands. The main goals of ESP are to decrease
paradigm. Furthermore, the recruitment strategy healthcare costs, to tackle increased healthcare de-
mainly focused on participants in the city of Utrecht mand and to improve healthcare effectiveness. The
and its metropolitan area, which is predominantly roles in which an ESP acts are more generic in na-
urban. Stakeholder perspectives from rural areas ture, focusing on consulting and/or working in a
might provide benefits to the paradigm in future multidisciplinary team. The main task of an ESP is
studies. Looking at the international validity of the triaging and, if necessary, referring to specialists and
paradigm, countries with lower levels of urban dens- ordering diagnostic imaging. An observational pilot
ity will likely benefit from taking into account a fac- study focusing on determining the feasibility of ESP
tor such as ‘access to care’ when developing their in Dutch primary care will be the next step.Bastiaens et al. BMC Health Services Research (2021) 21:19 Page 11 of 24
Appendix
Table 1 Search string scoping review Table 1 Search string scoping review (Continued)
Population: Population:
MeSH (Pubmed) Title / abstract Roles exten*
Physical therapists (mesh from 2012) Physical therap* scope of practice
Physical therapy modalities (mesh until 2012) Physiotherap* new role*
Musculoskeletal manipulations Manual therap*
Outcome:
Emtree (Embase)
MeSH Title / abstract
Physiotherapist
Decision making Outcome
Physiotherapy
Patient satisfaction Clinical reasoning
Manipulative medicine
Clinical decision making (mesh from 2016) Patient experience*
Heading (Cinahl, SPORTDiscus)
Education Patient preference*
Physical therapists
Emtree Substitution
Physical therapy
Decision making Diagnostic*
Manual therapy
Patient satisfaction Operational*
Intervention: Clinical decision making Organis*
MeSH/Emtree Title / abstract Education Organiz*
n/a advance practi* Health care organization
Heading Advanced practi* Heading
Scope of practice Advance scope* N/a
Advanced scope* The asterisk sign was used for truncation during the search
consultant physio*
Enhanced practice*
enhance practice*
Enhancing practice*
enhance scope*
Enhanced scope*
enhancing scope*
Expand practice*
Expanded practice*
Expanding practice*
Expand scope*
Expanded scope*
Expanding scope*
Extending scope*
extended scope*
extended practice*
Extending practice*
role expan*
role enhan*
role exten*
Roles expan*
Roles enhan*Bastiaens et al. BMC Health Services Research (2021) 21:19 Page 12 of 24
Table 2 Topic list focus groups
Topic Sample questions (optional)
Goals ESP What do you see as the goal of an ESP?
Tasks ESP Can you give examples of tasks you think an ESP can perform?
Do you think there are tasks that an ESP cannot perform?
Rolls ESP Looking at the roles, which ones would you see being fulfilled by the ESP?
Which roles do not fit with the ESP?
Can you tell whether this changes the collaboration with others?
Supporting conditions Which things does the ESP need to do its job well?
Can you tell what would change in the ESP’s collaboration with others?
Education ESP Can you tell what should be covered in the study program?
What do you think about admission requirements for the study program? Can you think of examples?
Confidence ESP 1. Would you go to an ESP yourself with a complaint? Why?
What would you consider when choosing an ESP or another practitioner?Table 3 Overview of the included studies in the scoping review
Author Country Design Goals Tasks Roles Additional features
(Year)
Factors General Patients GPs Physio- Other General Medicinal Diagnostics Work- Other General Disciplinary Sector Other
healthcare therapists treatment related roles specific specific
Aiken (2008) Canada inter-rater X X Study was not performed in, but
[28] reliability study is applicable to primary care
Akehurst UK Pilot X X X X X X
(2019)
Allan (2017) UK Pilot X X X
Ambury Canada Pilot X
(2010)
Atkins (2003) UK Qualitative design X X
Bailey (2015) USA Clinical X X
commentary
Bastiaens et al. BMC Health Services Research
Belot (2017) Canada Survey among X
physiotherapists
Bennet UK Pilot X X X X X X
(2017)
Beswetherick UK Literature review, X X X X
(2015) qualitative study
(2021) 21:19
Boucaut Australia Exploratory study X X
(2013)
Boyles (2011) USA Clinical X X X
[29] commentary
Braund New Survey X
(2011) Zealand
Brody (2009) USA Review X X
Brown- USA Exploratory study X Post-baccalaureate level.
Benedict
(2008)
Bubanja USA Exploratory study X
(2019)
Burn (2014) UK Pilot X
Bury (2013) WCPT Mixed method, X
(global) Exploratory study
Caine (2016) UK Exploratory study X X X X X
Candy (2011) UK Exploratory study X X
Candy (2015) UK Exploratory study X X X X
Chong (2015) Canada Survey X
[31]
Connoly USA Opinion piece X X
(2006)
Crowell USA Exploratory study X X X
(2016)
Dascanio UK Clinical X X
(2015) commentary
Page 13 of 24Table 3 Overview of the included studies in the scoping review (Continued)
Author Country Design Goals Tasks Roles Additional features
(Year)
Factors General Patients GPs Physio- Other General Medicinal Diagnostics Work- Other General Disciplinary Sector Other
healthcare therapists treatment related roles specific specific
De Sa (2014) Portugal Systematic review X pediatric primary care
Delany (2019) Australia Qualitative design Ethical considerations
Desjardins Canada Survey X X X X X X
(2016) [14]
Downie UK Exploratory study X X X X X
(2019)
Eaton (2017) UK News article X Master’s degree level
Ellis (2005) UK Delphi study X X
Ellis, R (2018) New Exploratory study X
Zealand
Bastiaens et al. BMC Health Services Research
Fennely Ireland Systematic review X X X X X X X
(2018)
Ferguson UK Exploratory study X X X X
(2011)
Fish (2019) UK Pilot X X
(2021) 21:19
Froment WCPT Survey X X X X X X
(2019) (global)
Gaskell (2010) UK Exploratory study X X X X X
Gazsi (2010) USA Exploratory study X
Gosling UK Clinical X Master’s degree level
(1999) commentary
Gosling UK Exploratory study X X X
(2019)
Grbin (2013) New Exploratory study X
Zealand
Green (2008) UK Exploratory study X X X
Greenhalgh UK Clinimetric study X X
(2016)
griffiths 1 UK Survey X X X
(2012)
griffiths 2 UK Exploratory study X X X X
(2012)
Grimmer Australia Literature review X X X X X X X X X X X
(2017)
Hattam UK Exploratory study X X
(1999) [33]
Hawke (2017) USA Exploratory study X X X Satellite clinic
[30]
Hensher UK Review X X X
(1997)
Hensman- UK Pilot X X X X X X X
Crook (2017)
Page 14 of 24Table 3 Overview of the included studies in the scoping review (Continued)
Author Country Design Goals Tasks Roles Additional features
(Year)
Factors General Patients GPs Physio- Other General Medicinal Diagnostics Work- Other General Disciplinary Sector Other
healthcare therapists treatment related roles specific specific
Higginson UK Exploratory study X X X X Telephone-based
(2017)
Hill (2016) UK Clinical trail X X X
Hing (2012) New Clinical X
Zealand commentary
Holdsworth UK Survey X X X X X X X Casemanager Role
(2008)
Huijbregts USA Clinical X X
(2007) commentary
Humprey’s UK Diary/feasibility X X X
Bastiaens et al. BMC Health Services Research
(2010) study
Igwesi- UK Qualitative study X X
Chidobe
(2019)
Innes (2015) UK Clinical X X X X
commentary
(2021) 21:19
Jadon (2009) UK Exploratory study X X X X
Johnson UK Exploratory study/ X X
(2011) pilot
Johnston Australia Clinical X X X X X
(2016) commentary
Jones (2015) UK Qualitative study X X X X X Research, training and peer
[16] support
Kamimura USA Clinical X X X X X
(2007) commentary
Kennedy Canada Survey X X X
(2011)
Kerridge- UK Exploratory study X X
Weeks (2017)
Kersten UK Systematic review X X X
(2007) [7]
Langridge UK Qualitative study X X
(2015)
Langridge UK Qualitative study X X X X X X X
(2019) [40]
Lee (2019) UK Exploratory study X X
Lehman USA Clinical X Nutritional advice
(2017) commentary
Lineker Canada Exploratory study X X X X Recommend Splints
(2011) [34]
Lundon Canada Exploratory study X X X X
(2008)
Lundon Canada Exploratory study X X X X X
Page 15 of 24
(2011) [38]Table 3 Overview of the included studies in the scoping review (Continued)
Author Country Design Goals Tasks Roles Additional features
(Year)
Factors General Patients GPs Physio- Other General Medicinal Diagnostics Work- Other General Disciplinary Sector Other
healthcare therapists treatment related roles specific specific
Lundon Canada Mixed method, X X
(2013) (1) Exploratory study
Lundon Canada Mixed method, X X X X X
(2013) (2) exploratory study
O Mir (2018) Ireland Literature review X X Pediatric care
(1)
O Mir (2018) Ireland Exploratory study X X X X X Pediatric care
(2)
Mabry (2019) USA Exploratory study X X X X X
Maiorana Australia Exploratory study X
Bastiaens et al. BMC Health Services Research
(2019)
Marks (2017) Australia Systematic review X X X X
Martini (2017) UK Pilot X X X
May (2017) UK Pilot X X X X
Mccloy USA Clinical X Nutrition, mental health,
(2001) commentary stress management
(2021) 21:19
Mcilroy UK Survey X X
(2019)
Mcneily UK Exploratory study X X
(2012)
Monteith UK Exploratory study X X X X X X X
(2019)
Morley (2019) UK Exploratory study X X X X X
Morris (2014) Australia Systematic review X X
Morris (2017) UK Qualitative design X X X
Morris (2019) UK Mixed method X X
Mullan (2016) UK Qualitative X X
Murphy Ireland Clinical trail X X X
(2011)
Myers (2019) USA Root cause X Extensive education
analysis
Noblet (2018) Australia Survey (protocol) X X X X
Norris (2002) USA Year end report X X
O’Mahony Ireland Qualitative study X X X X X
(2015)
Oakley (2015) UK Systematic lit. X X X
Review
Oriel (2003) USA Survey X X school-based physiotherapy
Palma (2017) UK Mixed method, X X
Exploratory study
Parfitt (2012) UK Retrospective X X
Page 16 of 24Table 3 Overview of the included studies in the scoping review (Continued)
Author Country Design Goals Tasks Roles Additional features
(Year)
Factors General Patients GPs Physio- Other General Medicinal Diagnostics Work- Other General Disciplinary Sector Other
healthcare therapists treatment related roles specific specific
review
Prescott UK Exploratory study X Master modules
(2011)
Quicke (2019) UK Pilot X X X
Raymer Australia Survey X
(2011)
Razmjou Canada Prospective study X X X X
(2017) [36]
Rose (2009) UK Audit X X X X
[37]
Bastiaens et al. BMC Health Services Research
Ross (2019) UK Pilot X X X X X X
Rushton Australia Review article X X X X X X X
(2008)
Salmon UK Mixed method X X X
(2017) pilot
Samsson Sweden Randomized X X X X X X
(2021) 21:19
(2016) controlled trail
Sedgeley UK Consensus study Postgraduate education
(2016)
Sephton UK Prospective X X X
(2010) cohort
Shakinovski UK Cross-sectional X X
(2011)
Shoemaker USA Exploratory study X X
(2012)
Soever (2011) Canada Pilot X X X X
Stamm EULAR Survey X X X
(2011) (Europa)
Stanhope Australia Systematic review X X X X
(2012)
Stenner UK Systematic review X X
(2018)
Stevenson UK Clinical X X X X X
(2003) commentary
Stevenson UK Clinical X X X
(2011) commentary
Stevenson UK Qualitative study X X X
(2011) (2)
Stigmar Sweden Qualitative study X X X
(2014)
Stigmar Sweden Survey X X Insurance medicine education
(2015)
Stokes (2007) UK Clinical X X
Page 17 of 24Table 3 Overview of the included studies in the scoping review (Continued)
Author Country Design Goals Tasks Roles Additional features
(Year)
Factors General Patients GPs Physio- Other General Medicinal Diagnostics Work- Other General Disciplinary Sector Other
healthcare therapists treatment related roles specific specific
commentary
Suckley UK Delphi study X X
(2012)
Thomas USA Survey X X
(2003)
Thompson, UK Case report X
A. (2017)
Thompson, J. UK Systematic review X X X
(2017)
Thomson UK Audit X X X
Bastiaens et al. BMC Health Services Research
(2017)
Unger (2005) South Survey X X Describes situations in other
Africa countries
Unger (2006) South Survey X Describes situations in other
Africa countries
Vassilevskaja UK prospective X X X
(2021) 21:19
(2019) analysis
Vits (2010) UK Clinical X X X
commentary
Vliet Vlieland The Clinical X X Describes situations in other
(2015) Nether- commentary countries
lands
Walker (1999) USA Survey X X
Wang (2007) Taiwan Pharmaco-logical X Electrotherapy
trail
Warmington Canada Cross-sectional X X X X X X
(2011) evaluation
Warmington Canada Qualitative study X X X X
(2015)
Welsh (2014) UK Qualitative study X X
White (2019) UK Delphi study X
[35]
Whittaker Canada Clinical X
(2019) commentary
Yardley Canada Survey X X X X X
(2008) [19]
Page 18 of 24Bastiaens et al. BMC Health Services Research (2021) 21:19 Page 19 of 24
Table 4 Typical quotes of direct and indirect stakeholders per topic
Goals Physiotherapist General Practitioners Indirect stakeholder
Decrease No, I do not see that as a goal. Due to the emergence of This does not currently play in When an ESP is used and
waiting lists independent treatment centers and the current healthcare my region. prevents a patient from
system, you actually see that there are no or hardly any waiting unnecessarily going to the
lists. orthopedist and therefore
occupying the consultation
hour, I think the waiting lists
will be shortened.
Increase But what [physiotherapist] just rightly points out is that the Patients often do not know I wonder if you will increase
healthcare supply is shifting. It does not change, so in principle it is not a what the best care is by the the healthcare supply. I do not
supply for larger supply. Instead of going to the doctor, you now go to forest of healthcare providers. think you can shed the
patients the ESP, which basically performs the same tasks. More care provision does not healthcare supply, but you are
lead to better care. trying to send insured patients
directly to the right place
where they can receive care.
Decrease Yes, we are of course cheaper than the GP. So that certainly The biggest challenge of care I certainly think that it can lead
healthcare costs applies to this. I do not know if a different rate applies. If there will be that we have to do to a reduction in healthcare
are other training requirements, there may also be a higher rate more and more for less and costs, because I am convinced
than a physiotherapist You should see it as a specialism. less money (and ensure that some of the patients who
sufficient staff working in the are referred to the second line
healthcare sector). 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 Yes, we have a lot to do with this. And we often look at Particularly in the elderly, there I think there is a place for it. It
health demand patients differently than the GP. In that sense, I think that the is a lot to be gained is also being said that the
quality is only better if we also look at it. We also have a lot of (therapeutic and preventive) second-line care will disappear.
experience with the elderly, so we can also help them a lot. with low-threshold access to Hospitals in the current form
good movement care and are going to disappear. This is
advice. increasingly going to the per-
iphery. And that is precisely
where that super specialist
who is needed in practice and
the community. You will need
more of that.
Relieve General So what we are already doing a bit is to take out that That may be a welcome side I certainly see that. You also
Practitioners musculoskeletal group in particular. A nurse practitioner also effect, but should not be a hear that the GPs are too busy.
tackles the easier conditions. With the result that the GP, who reason to (yet) introduce a new Because they are the
hoped for a milder consultation, but what you actually see is an profession. Complaints of the gatekeeper, they obviously
increase in the consultation hour musculoskeletal system are not need to know something.
a big burden for most GPs, and What we hear is that there are
there are also many also quite a few people with
abnormalities (rheumatic, musculoskeletal complaints. We
paraneoplastic and otherwise) think that the physio has much
that do not belong primarily to more knowledge of it. So yes, if
the physiotherapist. they are already taken away
from the GP, then you are sure
to relieve the GPs.
Increase I thought more with professional autonomy that you have Especially nice for the I do not think it is an
professional more handles as a physio to do more things. But that you will physiotherapist, but that is in important goal, but it is a result
autonomy of get more opportunities for the patient outside of exercise itself insufficient reason and that occurs when you have
physiotherapists therapy, mobilization, etc. That it is something that is more for should not be a primary goal. that function. But then it must
yourself. That is indeed possible, it could make it more We must not introduce a new be guaranteed. It cannot be
attractive. medical profession “because the case that every
we want it so badly” physiotherapist suddenly has
such a forward position. So you
will demonstrably have to have
knowledge and skills.
Improve I think that there should be a kind of shift and that this is just a You can never be opposed to It is an important point to put
healthcare nice step for a person who really sends the whole team or a that, right? physiotherapy on the map as
effectiveness neighborhood or a village and ensures that the care is more the professional in movement
effective. care who knows what it is
about. That it will show added
value in the context of sensible
efficient careBastiaens et al. BMC Health Services Research (2021) 21:19 Page 20 of 24
Table 4 Typical quotes of direct and indirect stakeholders per topic (Continued)
Goals Physiotherapist General Practitioners Indirect stakeholder
Improve patient In my experience we do it very well with the patients, high If the physio does what a I think that patients might
satisfaction marks. While the care is not always good, or equally efficient. patient would want ultimately be more satisfied
So I would like to place an exclamation mark at patient immediately, perhaps, but with care in general. That less
satisfaction in the sense of: Let’s focus on that carefully before more patient satisfaction? sending from the box to the
we get a very satisfied patient and deliver something half- There remains a group that wall and just to one person
baked. wants to have the doctor’s who understands business. But
opinion. 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 I graduated 3 years ago and from the group I graduated a That would be a good side I certainly think so. It offers
physiotherapists number of them have already stopped because they no longer effect, but it would not be a new challenges, new
career find it attractive. They started working in other places, in other primary goal. possibilities. You will profile
perspective branches. How can we keep those people in the end? 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 As far as I am concerned, I think that a physiotherapist Yes I think that’s fine, as long
would say. Perhaps the most estimations and differential has more knowledge of the as it falls within the domain of
important task. diagnostics in the musculoskeletal system and a the physiotherapist.
musculoskeletal area could be GP has more general
useful. knowledge. I think it is good to
take over.
Prescribing Yes, that you can do so with I find the assessment of which Paracetamol, yes. Anti- Yes, both are basically over the
paracetamol additional knowledge. If we medication goes quite far if inflammatory drugs I find tricky. counter medicine. So whether
and NSAID’s indeed know when you can or you cannot properly interpret I would like to have a second you say that, or whether the
cannot prescribe it. That you comorbidity opinion from a doctor then. neighbor says it, or if someone
cannot do it in combination thinks that he is going to
with other medication. Anyway, swallow painkillers. That is not
if that is in the training that really an extra task. These are
makes you ESP, I can imagine it freely available products in the
is one of the tasks. 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 Personally, I’m mainly for I would rather expect an Well that diagnostic imaging, I think it fits very well within
interpreting requesting it. For example, the explosion in the cost of that seems excellent to me. I the scope of ESP. To bet on
diagnostic simple ankle complaint that we applied treatments if this is think that as a physiotherapist that. You can decide with a
imaging get as a physio. If the Ottawa given in the hands of an ESP you are very much helped if relatively limited amount of
Ankle rules are positive, you or an explosion in there is an image known, or a extra training.
first have to refer the patient consultation time scan or something.
via the GP. I think that task can (multidisciplinary
easily be done by a consultations)
physiotherapist
Direct access Yes, direct access. But that is X Yes, as you said: That is already Yes, fine for me. Then you also
more a matter of definition. I here. And I only like it as a see that it does not deliver any
think we already do that. patient that I can come and calamities. Because actually it is
that I do not have to go to the already a form of triage, the
doctor first. screening of red flags.
Giving Yes, I think so. I think you I would rather expect an If an ESP proposes to give me You get so much on your neck,
injections. should do that in the same explosion in the cost of an injection, I would first like to and why? What are you going
way as a GP or orthopedist. applied treatments if this is check with the doctor. I to inject? And why do not you
You have to make a good given in the hands of an ESP personally believe that people leave that to the professionalsYou can also read
