This guidance is endorsed by the Chartered Society of Physiotherapy.

1. Introduction

A remote consultation is a real-time appointment that takes place between an individual and their clinician over the telephone or using video, as opposed to face to face. They are an effective way to undertake a musculoskeletal (MSK) physiotherapy consultation and should be considered as part of a blended approach to service delivery.

This guide supports adult MSK physiotherapy services – delivered by providers across primary community and/or secondary care – to implement evidence informed remote consultations. For first contact practitioner (FCP) services in primary care, community triage services and services offering self-referral, which largely see undifferentiated and undiagnosed presentations, remote consultations can also be of value for some patients (see Appendix). It supplements the general guidance on implementing video consultations on the NHS England website and in the guide on video consultation produced in partnership with the University of Oxford.

This guide was developed by the Outpatient Recovery and Transformation programme (OPRT) and BestMSKHealth Collaborative with the involvement of key stakeholders, including patients, clinicians, implementation managers, an MSK subject matter expert from the Health Education England National Workforce Transformation team, relevant professional bodies such as the Chartered Society of Physiotherapy and organisations that represent the views and interests of people with lived experience, including Arthritis and Musculoskeletal Alliance (ARMA), Versus Arthritis and the NHS England’s national lived experience group.

2. Why use remote consultations in MSK physiotherapy services?

In the UK an estimated 20.3 million people are affected by MSK conditions, accounting for 21% of years of life lived with disability and the demand is increasing as the population ages. MSK conditions now account for up to 30% of general practice consultations in England and around 70% of community MSK services are currently reporting backlogs because of the COVID-19 pandemic (FutureNHS, Community Health Services data – log in required).

The pandemic prompted new and innovative ways of working to ensure patients needing care could get it in the safest way possible, with remote consultation being one example. Although remote consultation has been well used for some time in MSK physiotherapy, recovery has necessitated faster adoption (Enock L et al 2014, Grona SL et al 2018, Shaw S et al 2018 and Marques A et al 2022). This is showing benefit for services and patients alongside face-to-face consultations for those patients who are unsuited to remote consultation or express a clear preference for face to face.

The 2023/24 priorities and operational planning guidance and delivery plan for tackling the COVID-19 backlog of elective care ask systems to use digital enablement where possible to optimise capacity and reduce the need for unnecessary face-to-face attendances. This also helps the NHS reduce its carbon footprint.

A well-delivered blended approach to the use of remote consultations can widen access to services, helping to address health inequalities by providing personalised care that gives patients more choice in and control over their healthcare decisions.

Specifically, offering patients the option to have a remote consultation can:

• save them time and money, and reduce the disruption to their day, as they will not need to travel to an appointment
• enable them to have more control over and flexibility in the choice of consultation that is most convenient to them
• reduce the stress that can be associated with attending a face-to-face appointment
• enable family members or carers to join a consultation without the need to be in the same physical place
• make some people feel more motivated and supported to take a greater role in their self-management using remote consultations, eg using video consultations to demonstrate home exercises (De Baets L et al 2021 and Boissy P et al 2016)
• make it easier for individuals with disabilities to engage with healthcare services.

For MSK physiotherapy services and staff a blended remote consultation model can:

• speed up access to physiotherapy in some cases, eg telephone triage services (outside primary care) (Taylor S et al 2002, Joseph C et al 2014 and Salisbury C et al 2013)
• enrich the consultation as some people may feel more comfortable in their own home rather than a clinical environment and as a result open up and share more information
• enable more flexible working from home/non-clinical base where appropriate, allowing more quality time with individuals as well as an improved work–life balance
• reduce travelling time for physiotherapists seeing people in their own homes
• support workforce deployment and recruitment from a wider talent pool
• enable collaborative working, with different specialists co-operating remotely to deliver joined-up care.

3. Selection of patients for remote consultations in MSK physiotherapy services

There is no ‘one size fits all’ model for delivering good practice remote consultation for MSK physiotherapy services. An evidence-informed blended model that has been co-produced with people with lived and learned experience is the best approach (Thiyagarajan A et al 2020 and Greenhalgh T et al 2020).

Although remote consultation may not be appropriate for all patients many studies report positive experiences for the use of telephone and video consultation by both clinicians and patients (Marques A et al 2022, Thiyagarajan A et al 2020, McKinstry B et al 2009, Donaghy E et al 2019, Gilbert AW et al 2018, Cliffe S et al 2021, Björndell C et al 2021 and Cook E et al 2022).

However, much of the available evidence for video consultation is based on patient cohorts with chronic and stable conditions; they may not wholly reflect the urgent and more complex patients seen in many MSK physiotherapy services (Greenhalgh T et al 2020, Carnes D et al 2017 and Lawford BJ et al 2017).

The decision on whether a physiotherapy appointment will take place in person or using video or telephone consultation should be clinically led and based on individual care needs and preferences. It should be part of a shared decision-making discussion that equips the person with the skills, knowledge and confidence to make an informed decision on which they prefer. This process should ideally be repeated for each subsequent appointment as the person’s preference may vary from appointment to appointment, depending on their needs at the time.

In general, MSK physiotherapy remote consultation is suitable for people who do not require an in-person physical examination or those with less complex or sensitive problems (Donaghy E et al 2019, Hammersley V et al 2019, Greenhalgh T et al 2018 and Hohenschurz-Schmidt D et al 2020). It may be particularly appropriate for follow-up appointments, receiving test results or to discuss a recurrence of a condition (McKinstry B et al 2009). For patients who may require diagnostics, the suitability of remote consultation should be carefully considered, as there is some evidence that examination via remote consultation may lead to imaging being over requested, especially for more complex cases and where there is diagnostic uncertainty (Jacobs JWM et al 2015 and Dunn EV et al 1977).

Also, if the appointment involves reviewing diagnostic results and the person potentially receiving bad news, they should be asked ahead how they would prefer to receive such information. There needs to be the flexibility to move individuals quickly from telephone or video to face to face should the need arise.

Choosing how to consult with your secondary care patients: a practical guide, developed in partnership with the University of Oxford, provides practical guidance on what to consider when deciding the appointment type with an individual. It is also a relevant resource for use in primary and community care settings. Evaluation of previous remote practice may enable early individualised risk assessment for people with certain MSK conditions who are more likely to require face-to-face appointments, with digital screening tools being a way to support this good practice.

What people need to know in preparation for their consultations should also be considered. Video consulting in the NHS provides guidance and resources for NHS patients and clinicians using online consultations.

As many MSK physiotherapy services will now be looking at long-term, sustainable deployment of remote options as part of their blended service approach, the wider factors impacting on patient selection need to be thoroughly understood and considered. Profiling local patients to determine who would benefit and what reasonable adjustments some may need so as not to be excluded is good practice in tailoring a personalised blended model to meet the needs of the local population. The recent National evaluation of remote physiotherapy services highlights some factors and recommendations to consider, along with all other health inequalities in MSK (Arthritis and Musculoskeletal Alliance (ARMA) 2021, MSK heath inequalities: report of roundtable).

MSK specialty conditions that may be considered suitable for remote consultation

Suitable for telephone consultation:

• acute injuries that are relatively easy to treat, eg discreet episode of back/radicular/neck pain
• triaging
• subjective assessments
• delivering advice, education and supported self-management
• follow-up for monitoring and simple interventions
• signposting people to other support
• simple presentations, eg carpal tunnel syndrome, simple mechanical back pain
• clear evidence of a diagnosis in the referral letter, eg mild initial presentation of knee/hip osteoarthritis
• chronic pain patients (referred via pain clinic)
• referral letter asks for physiotherapy rehabilitation.

Suitable for video consultation: 

• acute injuries that are relatively easy to treat, eg discreet episode of back/radicular/neck pain
• triaging
• subjective assessments
• delivering advice, education and supported self-management
• follow-up for monitoring and simple interventions
• signposting people to other support
• simple presentations, eg carpal tunnel syndrome, simple mechanical back pain
• clear evidence of a diagnosis in the referral letter, eg mild initial presentation of knee/hip osteoarthritis
• chronic pain patients (referred via pain clinic)
• referral letter asks for physiotherapy rehabilitation
• patient suitable for class (virtual or face to face).

MSK specialty conditions that may not be appropriate or may be more challenging for remote consultation

• spinal referrals with recent imaging for the same problem
• objective assessments
• atypical MSK features/pattern
• undifferentiated and undiagnosed/diagnostic uncertainty or uncertainty about management
• physical assessments (high quality physical assessment supports optimal management and treatment planning), eg sub-acromial pain syndrome, patella-femoral pain
• manual treatments, eg trigger digit
• more complex, dynamic rehabilitation
• complex conditions, eg entrapment neuropathy
• patients with balance impairment
• patients with significant mobility problems
• patients with a history of re-consultations/multiple consultations for the same problem
• referral requests for injection/epidural or investigations/consideration of invasive procedures
• evidence the patient is not improving with first-line conservative management, including physiotherapy/osteopathy/chiropractic, and is unable to manage their symptoms
• evidence of co-morbidity that could affect diagnosis, eg significant mental ill-health
• patients with communication needs that may require additional support, eg remote British Sign Language interpreters.

4. Designing a remote consultation model for MSK physiotherapy services

MSK physiotherapy examination traditionally uses face-to-face and physical examination. People will often expect a ‘hands on’ assessment and regard a face-to-face consultation as the ‘gold standard’ (Donaghy E et al 2019 and Atherton H et al 2018). Many physiotherapists may find changing practice challenging and be biased towards physical assessment and management techniques, despite a limited evidence base for many of these.

The use of remote consultation should not replace face-to-face consultation but complement and enhance service delivery. This has already been shown for telephone consultations in certain aspects of MSK physiotherapy delivery, eg single point of access assessment and triage service models that enable and enhance the triage process to rapidly identify onward management needs (Shaw S et al 2018). Offering a blended approach of face-to-face, telephone and video consultations based on what individuals want should be central to the delivery of good quality MSK physiotherapy services, rather than offering a ‘telephone first’ approach or preselecting patients for video or face to face. The use of digital appointment decision support tools to enable people to choose the right appointment type for them can support this good practice.

Remote consultations can take longer than a face-to-face appointment; in its report, the Chartered Society of Physiotherapy identifies some assessments that take 30–45 minutes face to face but an hour remotely. Although we expect the time needed to complete a remote consultation and the effectiveness of a remote assessment to improve as skills and confidence develop, services may choose to keep remote appointments longer than face-to-face appointments, especially if the time is fully used to the benefit of patients.

The full and sustainable operationalisation of best practice remote consultations, tailored to meet the needs of those using and delivering the service, requires careful planning. The clinical capacity required to meet the demand for remote consultation and other factors, such as estates, base working and wellbeing, will need to be agreed. Using the Plan, Do, Study, Act improvement cycle may help.

To deliver a best practice blended service that fully embeds personalised care and shared decision-making, widens service access and choice, and reduces inequalities in access and outcomes will require innovation, learning from research and sharing of good practice (Shaw S et al 2018). The Chartered Society of Physiotherapy’s National evaluation of remote physiotherapy services and case studies support the design of flexible models of care.

Services should be co-produced and co-designed with patients, carers and people with lived experience, to ensure they meet the needs of the population using them. While some people will embrace change readily, others may need extra support to do so (Greenhalgh T et al 2018).

5. Implementing remote consultations

When implementing best practice remote consultations in MSK physiotherapy, it may be best to start with simple MSK presentations and use available resources to support a best practice approach.

Clinical safety and managing risk

The MSK physiotherapy clinical team should have overall responsibility for developing:

• clinical guidance (to include contingencies if things do not go to plan)
• risk stratification protocols and/or
• a standard operating procedure (SOP) for the implementation and use of remote consultation in their blended service model

to ensure a clinically safe approach is taken. This SOP template can be adapted.

The local NHS provider should manage clinical risk with respect to the video consultation technology deployed in accordance with NHS Digital Standard DCB0160.

Risks and mitigations for telephone consultations in MSK physiotherapy:

• Telephone consultation may support the initial management of acute illness by effectively enabling urgent triage (Campbell JL et al 2014).
• However, the clinical decision-making required to screen for red flags and serious pathology may be more difficult remotely as at first presentation it may not be clear which diagnostic category a patient falls into (Greenhalgh S et al 2020).

Risks and mitigations for telephone and video consultations in MSK physiotherapy

• Services report that some clinicians may doubt their clinical reasoning skills when undertaking a remote consultation because they cannot obtain all the information they need from a remote assessment to make a diagnosis and plan treatment. This may lead to higher follow-up rates overall.

• Clinicians often use their ‘gut instinct’ and ‘sixth sense’ that something may not be right to support clinical decision-making (Friedemann Smith C et al 2020 and Greenhalgh et al 2021). Some clinicians may doubt their own clinical reasoning and decision-making skills when undertaking remote consultation because they cannot pick up non-verbal/body language cues, and some patients may be concerned that without a hands-on examination things will be missed (McKinstry B et al 2009, Donaghy E et al 2019, O’Connor S et al 2016, Dekker A-B et al 2020, Greenhalgh T et al 2016 and Roberts LC et al 2021). Remote consultation can also mean a more pre-planned consultation format, giving patients less opportunity to raise issues spontaneously.

• Although remote consultation can widen access to services, especially for people who may find it difficult to access a face-to-face appointment due to physical or mental ill-health, it will introduce inequality for those without access to digital technology (Greenhalgh T et al 2016, Erwin J et al 2020, Parker RF et al 2021 and Knights F et al 2021).

• Some staff may be resistant to working remotely with people, making it challenging for services offering only remote consultations to recruit and retain staff. Some clinicians may be concerned they will lose physical handling skills if they only work remotely with people.

• Concerns may be raised about how to address a safety issue while undertaking a remote consultation (Gilbert AW et al 2021).

Overcoming barriers to adopting remote consultations in MSK physiotherapy

• Reduced opportunity for physical examination/modification of MSK examination.
  
  There may be variation in how examination is conducted remotely. Research is limited into how MSK examination should be modified when using video consultation within primary and community physiotherapy settings (Murray T et al 2021).

• Clinician and patient preference/technical difficulties
  
  Although many clinicians and patients may have embraced the rapid introduction of remote consultations, those for whom it is new and unfamiliar may be unwilling to engage and embrace digital advances (Oxford Precision Psychiatry Lab, Digital technologies and telepsychiatry and Foster NE et al 2011).
  
  The introduction of new communication technology and remote consultation has changed the ‘work’ of being a patient. This change can influence engagement preference, experience and outcomes (Gilbert AW et al 2020).
  
  Unfamiliarity may also mean clinicians and patients find it harder to build a rapport, and as a result some patients may feel they have not received an adequate consultation and some clinicians may feel they have not provided one (McKinstry B et al 2009 and Atherton H et al 2018).
  
  Patient demographic variables and other factors may also determine a patient’s preference to engage with remote consultations (Dekker A-B et al 2020, Gilbert AW et al 2022 and Gilbert AW et al 2021).
  
  Some people may not have the technical knowledge and capabilities required and will need to be supported to access remote consultations (Marques A et al 2022). Patients without access to the equipment required for remote consultation will need to be provided with it to prevent inequitable access to services. Considerable support may need to be provided to ensure all patients have the skills, knowledge and confidence to use the equipment, as well as for any troubleshooting difficulties.

• Time constraints
  
  MSK physiotherapy service models allocate varying times for appointments. Remote consultations may take longer than face-to-face consultations due to technical difficulties and unfamiliarity for both the clinician and patient, as well as the complexity of undertaking a virtual MSK examination (Shaw S et al 2018, Donaghy E et al 2019 and Seuren L et al 2021).

• Patient and clinician reassurance and trust
  
  If a patient feels alienated, this can damage their therapeutic relationship with clinicians. A person’s willingness to participate in remote consultation and engage with treatment may be determined by their level of trust in and relationship with their clinician (O’Connor S et al 2016 and Seuren L et al 2021 and Hesse BW et al 2005).
  
  Some patients may need to be reassured that they can still have a carer or relative present when their consultation takes place remotely.

• Privacy and confidentiality
  
  Privacy and confidentiality may be a concern where family members are present during consultations or contributing to the consultation inappropriately, or when patients can see other staff in the background (Shaw S et al 2018, Donaghy E et al 2019 and Dekker A-B et al 2020).
  
  Although these scenarios can also be a concern during a face-to-face or telephone consultation, they may be more difficult to raise or control during a video consultation.

• Clinical safety
  
  There may be concern around how to supervise students using remote consultation to ensure safe practice (Gilbert AW et al 2021).

• Security
  
  Security may be a concern to some users of remote consultation.
  
  General themes can include host platform security of patient data, the recording and sharing of consultations by patients, and compliance with data laws such as General Data Protection Requirements (Marques A et al 2022 and Gilbert AW et al 2021).

• Consent/legal/regulatory challenges
  
  Clinicians who are home working may need to check their home insurance covers conducting clinical consultations from home (Gilbert AW et al 2021).
  
  Clinicians could face negligence claims if they are less effective or miss something when delivering a remote consultation (Leone E et al 2021).

The National evaluation of remote physiotherapy services provides additional information.

Safeguarding

For any safeguarding concerns, healthcare professionals should refer to local safeguarding policies for adults and/or children.

Some physiotherapists may be deterred from using video consultation because they do not want to see what could be happening in the background in patients’ homes, cannot offer chaperones for these consultations or patients may be inappropriately dressed (Gilbert AW et al 2021).

Although these are not safeguarding concerns exclusive to digital consultation, and can provide an opportunity to observe and then escalate a concern, the proximity of other people during remote consultations can heighten anxiety for staff.

How to identify and address safeguarding issues while undertaking a remote consultation should be agreed, and safeguarding and escalation plans for remote services should be in place, as well as a SOP to guide clinicians in the event of a safeguarding issue. Asking sensitising questions may help clinicians identify safeguarding or domestic abuse issues.

Personalised care

Remote consultation enables physiotherapy services to personalise care; that is, base care on ‘what matters’ to each individual. By co-designing services with people with lived experience and all stakeholders involved in the MSK physiotherapy pathway, all needs can be embedded in service redesign.

Deciding who will benefit most from remote consultation and who will not can be facilitated with quality shared decision-making conversations between individuals and clinicians, supported by in-consultation decision support aids. People’s values, beliefs and preferences about the risks, benefits and consequences of the different care management options should be central to these collaborative conversations. Measurement of a person’s knowledge, skills and confidence in their ability to self-manage will help tailor discussions appropriately.

Individuals need to understand the health information they are given and that they can decline using remote consultation in favour of a face-to-face appointment, without this decision affecting their ongoing care.

The following tools and resources support shared decision-making engagement and health literacy:

• NICE Shared decision making implementation guidance
• General Medical Council: Decision making and consent
• Personalised Care Institute training on shared decision making
• NHS England » Decision support tools
• ChoosingWisely UK: BRAN – Make the most of your appointment
• Institute for Healthcare Improvement: Ask Me 3: Good questions for your good health
• Assessment of the readability of materials (SMOG formula)

Health inequalities

Remote consultation may not be right for everyone but it needs to be accessible to everyone who can benefit from it, and people must not be excluded because assumptions are made about their abilities and comfort using digital technology. If remote consultation is offered as the only option and not as part of a blended model, there are risks that the full benefits may not be realised, and health inequalities and digital exclusion may be exacerbated. In designing a blended remote consultation physiotherapy service, careful consideration should be given to how remote consultation may need to be adapted to work for vulnerable groups and others who could face inequality in access.

The following principles support an equitable approach to redesign:

• understand all groups who are accessing the service, and among these which are most at risk of health inequalities
• use a population health management approach to understand variation in access, experience and outcomes
• co-produce the service with people with lived experience and other key stakeholders
• co-produce public communication based on literacy levels as part of the redesign.

Important considerations are that MSK conditions are more common among women than men, and while they can affect people of all ages, increase in prevalence with age (Versus Arthritis: The State of Musculoskeletal Health 2021). Older people may be less likely to own a mobile device, and older women in particular may lack the confidence or digital skills to undertake remote consultation (Ipsos Mori 2020, The Health Foundation COVID-19 Survey, National Statistics, Internet – Taking Part Survey 2019/20 and Office for National Statistics, Internet users, UK: 2018). They may require more support than others to do so.

MSK conditions may also be more common in some ethnic groups due to associated risk factors such as physical inactivity, vitamin D deficiency, working in manual occupations and other pre-existing long-term conditions, eg diabetes (Jeraj S et al 2020). In England, people from Gypsy or Irish Traveller, White Irish, White British or Black Caribbean groups are most likely to report a long-term MSK condition (Public Health England, Musculoskeletal conditions). There is some evidence that certain ethnic groups are less likely to use technology to manage their health. Indian and White ethnic groups fall slightly below the UK national average for internet use, while Chinese groups are significantly above average (GOV.UK Internet use, ethnicity facts and figures). Also, minority ethnic groups are more likely to live in multigenerational households, some of which may be overcrowded [58], and they may find it more difficult to protect their privacy during a remote consultation (GOV.UK Housing, household transmission and ethnicity).

MSK conditions are also more common in areas of greater poverty. As digital exclusion is associated with social and economic deprivation, understanding the digital enablement needs of these groups is an essential part of any service redesign (Vida Estacio E et al 2017 and Mitchell UA et al 2019).

There is also some evidence that those with higher levels of education and greater accessibility to a suitable space are more willing to partake in video consultations (Dekker A-B et al 2020).

Other factors to consider are the different cultural attitudes and behaviours to pain and illness, as well as language barriers and the poor availability of interpreting and translation services (Adebajo A et al 2018).

Systems and providers must examine the impact that using remote consultations may have on people with MSK conditions by completing a equality and health inequalities impact assessment (EHIA), and identify effective interventions to address potential inequalities. They should listen to and co-design services with people with lived experience and patient groups to do so.

Prescribing

The guidance High level principles for good practice in remote consultations and prescribing is for all healthcare professionals who prescribe remotely from the patient.

Group classes

Exercise is an essential component of MSK physiotherapy rehabilitation. Supporting patients to exercise appropriately and safely can be achieved remotely through group classes, eg for those with joint pain, osteoarthritis of the knee, upper or lower limb or pain classes (eg virtual exercise classes run by Homerton Healthcare NHS Foundation Trust) or digitally through exercise apps. High level rehabilitation, however, may be better face to face. Those who do not have access to technology or who are unable to attend face-to-face groups should not be excluded from receiving similar rehabilitation support.

6. Evaluating remote consultations in MSK physiotherapy

Services should develop and track specialty-specific metrics and measures to understand how remote consultations are affecting outcomes. Practice can also be audited to evaluate any changes in practice stemming from use of remote consultations, eg possible increases in referrals for investigations.

A range of evaluations completed by NHS England teams, providers, systems and external stakeholders provide valuable learning and support the case for change. The Chartered Society of Physiotherapy has also published evaluation resources.

We recommend qualitative feedback is sought to understand users’ experiences. Collection of patient feedback is best at the end of a remote consultation, by directing patients to a questionnaire or sending this via email or SMS to complete. Questions should ask about ease of use and access to the remote consultation service, views on the effectiveness of and satisfaction with the consultation, demographics and the likelihood of accepting another remote consultation.

Feedback, including on demographics where possible, should also be sought from people who decline remote consultations. This will help reveal the key barriers to people accepting remote consultations.

Collecting feedback from healthcare professionals is also important; including about ease of use, accessibility, convenience, time taken to deliver the consultation compared with a face-to-face consultation, and whether they would offer the patient another remote consultation.

7. Useful resources for remote consultations in MSK physiotherapy

Further implementation resources, including a range of patient and clinical guides and frequently asked questions are available on the Video consultations for NHS secondary care providers FutureNHS page or NHS England website.

The following resources can also support the delivery and sustainability of good quality, personalised, blended digital models:

• Video consultations in secondary care: a report by Edge Health for NHS England.
• Innovation Agency NWC – Report into remote consultations published: a wide-ranging report, commissioned by NHS England North West, into the use of remote consultations for outpatients.
• Principles for supporting high quality consultations by video in general practice during COVID-19 – key principles for safely assessing patients using a video consultation.
• Key principles for intimate clinical assessments undertaken remotely in response to COVID-19 – how to safely manage the receipt, storage and use of intimate images taken by patients for clinical purposes.
• COVID-19: guide for rapid implementation of remote consultations – Chartered Society of Physiotherapy practical advice for physiotherapists and support workers on how to implement remote physiotherapy delivery rapidly and efficiently.
• Remote consultations during the COVID-19 pandemic – top tips from Chartered Society of Physiotherapy members.
• Guide for optimising virtual appointments in MSK physiotherapy­ – a guide to support clinicians in optimising a virtual MSK appointment, St George’s University Hospitals NHS Foundation Trust.
• Telerehab resources for practitioners: A best practice guide to telerehabilitation – a Plymouth University best practice guide.
• Maintaining safe services: supporting you to make safe decisions about patient contact – Chartered Society of Physiotherapy guidance.
• Using video conferencing and consultation tools – guidance on video can be used safely from an information governance perspective.
• Remote versus face-to-face: which to use and when? – support for clinicians when choosing a consultation modality
• Remote consultations | The Chartered Society of Physiotherapy (csp.org.uk): resources to help implement and evaluate remote physiotherapy services.

Specialty case studies

• Courtesy of Christina Sothinathan, Clinical Transformation Fellow, NHS England -London Region and Health Education England & Clinical Lead and Advanced Practice Physiotherapist: Optimising Virtual Consultations in MSK Physiotherapy: King’s College Hospital NHS Foundation Trust Video Consultation Case Study – BestMSK Health Collaborative – FutureNHS Collaboration Platform
• Courtesy of Luke Tandy, Clinical Manager and Advanced Practice Physiotherapist, Provide MSK Physiotherapy Service: Blended digitally enabled delivery model in a community MSK physiotherapy service: Provide Remote Consultation Case Study – BestMSKHealth Collaborative – FutureNHS Collaboration Platform
• NHS England » Video consultations in North Tyneside Integrated Musculoskeletal Service (NTIMS)
• Digital physiotherapy case studies | The Chartered Society of Physiotherapy (csp.org.uk)

Appendix: Best practice remote consultation for first contact practitioners

A MSK first contact practitioner (FCP) is a diagnostic clinician in primary care working at master’s level with those with undiagnosed and undifferentiated diagnoses, managing complexity and uncertainty at the first point of contact (Health Education England, Roadmap FAQs).

The requirements to be recognised as an MSK FCP are a minimum five years of post-registration experience, with a minimum of three of those five years specialising in MSK conditions, and to have completed the MSK roadmap to practice training requirements as per the FCP Care Quality Commission mythbuster.

As diagnostic clinicians, MSK FCPs see patients presenting with symptoms such as pain, stiffness, pins and needles, numbness or poor mobility, rather than a diagnosed MSK condition. The presenting symptoms could include those pointing to serious pathology, early rheumatological presentations, complex co-morbidity and non-MSK conditions such as visceral, vascular and neurological masquerades (Finucane LM et al 2022 and Sloan M et al 2022).

Use of diagnostics and overprescribing of pain medications in primary care increased during the COVID-19 pandemic in the absence of face-to-face consultation. Appropriate selection of patients for remote consultation can help prevent this overuse (Diagnostics: recovery and renewal 2020, Department of Health and Social Care, National overprescribing review report 2021, Traeger A et al 2017 and Burton C et al 2021).

When remote consultations may be appropriate in FCP services

• For patients who do not require a physical examination to confirm a diagnosis and develop an effective treatment plan (Hammersley V et al 2019 and Donaghy E et al 2019).
• For follow-up appointments, patients receiving test results or to discuss a recurrence of a condition (McKinstry B et al 2009).

For undiagnosed and undifferentiated conditions face-to-face consultation is recommended as best practice.

When a face-to-face examination may be necessary in FCP services

For MSK FCPs to work safely and effectively to establish a diagnosis for a pain presentation and for emergency and urgent conditions, a face-to-face examination is highly recommended to:

• rule out multiple differentials and complexity from other existing co-morbidity
• ensure appropriate referral for diagnostics (bloods and radiology) and any referral into community and secondary care if required (Sahni M et al 2021).
• rule out serious pathology
• help an individual self-manage without being prescribed analgesia.

Personalised care

MSK FCPs provide a personalised approach to care, with shared decision-making and supported self-management at the centre of each consultation.

A holistic assessment that looks at more than just the individual’s MSK condition and requires engagement across the whole system, including the voluntary sector, needs to be undertaken in primary care.

Biopsychosocial and economic factors, with a focus on safeguarding, need to be considered, using priority setting and negotiation to arrive at a shared goal and an optimal plan (Dixon S et al 2022 and Wade VA et al 2012).

A patient’s accessibility and ability to engage in a remote consultation need to be considered to prevent inequality and disadvantage.

Advanced communication skills are needed to pick up patient cues to ensure the best outcome (Mann C et al 2021). These are often difficult to pick up remotely and this is why being able to offer a blended approach to remote and face-to-face consultations is recommended for FCPs.

Publications reference number: PR1095