Research Report

A Global View of Direct Access and

Patient Self-Referral to
Physical Therapy:
Implications for the Profession
Tracy J. Bury, Emma K. Stokes

Background. International policy advocates for direct access, but the extent to
which it exists worldwide was unknown.

Objective. The purpose of this study was to map the presence of direct access to
physical therapy services in the member organizations of the World Confederation
for Physical Therapy (WCPT) in the context of physical therapist practice and health
systems.

Design. A 2-stage, mixed-method, descriptive study was conducted.

Methods. A purposive sample of member organizations of WCPT in Europe was
used to refine the survey instrument, followed by an online survey sent to all WCPT
member organizations. Data were analyzed using descriptive statistics, and content
analysis was used to analyze open-ended responses to identify themes.

Results. A response rate of 68% (72/106) was achieved. Direct access to physical
therapy was reported by 58% of the respondents, with greater prevalence in private
settings. Organizations reported that professional (entry-level) education equipped
physical therapists for direct access in 69% of the countries. National physical therapy
associations (89%) and the public (84%) were thought to be in support of direct
access, with less support perceived from policy makers (35%) and physicians (16%).
Physical therapists ability to assess, diagnose, and refer patients on to specialists was
more prevalent in the presence of direct access.

T.J. Bury, MSc, GradDipPhys,

World Confederation for Physical
Therapy, Victoria Charity Centre,
11 Belgrave Rd, London, SW1V
1RB, United Kingdom, and
Department of Physiotherapy,
Trinity College, Dublin, Ireland.
Address all correspondence to Ms
Bury at: tbury@wcpt.org.
E.K. Stokes, PhD, MSc, Department of Physiotherapy, Trinity
College, and World Confederation
for Physical Therapy.
[Bury TJ, Stokes EK. A global view
of direct access and patient selfreferral to physical therapy: implications for the profession. Phys
Ther. 2013;93:449 459.]
2013 American Physical Therapy
Association
Published Ahead of Print:
November 29, 2012
Accepted: November 16, 2012
Submitted: February 14, 2012

Limitations. The findings may not be representative of the Asia Western Pacific
(AWP) region, where there was a lower response rate.

Conclusions. Professional legislation, the medical profession, politicians, and

policy makers are perceived to act as both barriers to and facilitators of direct access.
Evidence for clinical effectiveness and cost-effectiveness and examples of good
practice are seen as vital resources that could be shared internationally, and professional leadership has an important role to play in facilitating change and advocacy.

Post a Rapid Response to

this article at:
ptjournal.apta.org
April 2013

Volume 93

Number 4

Physical Therapy f

449

A Global View of Direct Access and Patient Self-Referral to Physical Therapy

ttaining professional autonomy is a high priority for

physical therapists and their
professional organizations.1 Since
the mid-1990s, the position of the
World Confederation for Physical
Therapy (WCPT) on autonomy is
that physical therapists are able to
act as first contact practitioners,
and patients/clients may seek services directly without referral from
another health care professional.2(p1)
Direct access and patient self-referral
to physical therapists are manifestations of professional autonomy. If
another profession is seen to dominate or control access to physical
therapy services, it limits or weakens
professional autonomy.1 The extent
to which physical therapists have
autonomy varies within and between
health systems internationally.
Of the 2 terms, direct access and
patient self-referral, the former is
more recognizable across the profession globally and among other health
professionals, politicians, and government officials. It is usually the
term used to refer to patients seeking
the services of a physical therapist
without referral from a third party
(usually a physician). However, in
some instances, it may be used to
describe the situation where physical therapists have direct access to
assess and treat patients without a
medical referral, for example, in an
intensive care unit where physical
therapists determine which patients
can benefit from physical therapy.
This situation is distinct from patient
self-referral, which implies that
patients are able to refer themselves
to a physical therapist without having to see anyone else first, or without being told to refer themselves by
Available With
This Article at
ptjournal.apta.org
eAppendix: Survey Instrument

450

Physical Therapy

Volume 93

another health professional (this situation can relate to telephone and

face-to-face services, as well as those
delivered via the Internet).3 In the
literature, the articles on direct
access refer to this latter scenario
of self-referral,4 17 and the term selfreferral is gaining prominence.3,18 26
Published literature on direct access
and self-referral has to date primarily
been limited to articles from the
United States, United Kingdom, Australia, and the Netherlands, with a
growing body of evidence and policy
support to support its implementation and its clinical effectiveness and
cost-effectiveness.1113,15,16,20 24,26 31
In 2009, an international policy summit on advanced scope of practice
and direct access in physical therapy, co-hosted by WCPT, the American Physical Therapy Association
(APTA), and the Canadian Physiotherapy Association, reviewed the
evidence for direct access and selfreferral, along with strategies for
influencing national health policy
and implementing change.32 The
international policy summit identified the need to understand more
about the global implementation of
direct access in order to inform
future health strategies and assist
WCPT member organizations (MOs)
in influencing national legislation. In
June 2011, the General Meeting of
WCPT agreed upon a new policy
statement on direct access and
patient self-referral to physical therapy.33 Further policies and guidelines from WCPT on education and
professional regulation serve to support this policy statement.34 37
The aim of this study was to complete an international survey of
WCPTs MOs in order to develop a
global picture of direct access to
physical therapy. Given the desire of
WCPT to assist with policy development and implementation nationally,
it also was considered important to
understand the potential barriers

Number 4

and facilitators of direct access and,

where relevant, to learn from the
experiences of those countries
where direct access was available.
Due to the policy focus, the study
was placed in the context of professional practice and national legislation, health systems, financial models, and educational requirements.

Method
Participants
The WCPT is a confederation of
MOs. It has 106 members, representing more than 350,000 physical therapists worldwide. A country may
only have one organization belonging to WCPT; therefore, 106 countries were represented in the participant sample. The survey was open
to all MOs, including new members
up for approval at the General Meeting in June 2011 (8 of the 106 members). Each MO has a primary contact registered with WCPT, who was
contacted with the survey details
and invited to participate. Only one
response was permitted per organization, and the named contacts were
advised to collect any necessary
information and consult with others
prior to completing the survey in
order to provide a national perspective on behalf of their organization. The WCPT also has a regional
structure of 5 regions through
which the survey was promoted
(for a list of MOs by region, visit
http://wcpt.org/regions).
Study Design and Protocol
The study was a nonexperimental
descriptive study utilizing both quantitative and qualitative methods.
We developed a pilot survey tool
using SurveyMonkey (Palo Alto, California, available at http://www.
SurveyMonkey.com). The questions
were informed by the findings of
previous studies, discussions at the
international policy summit, and
inquiries to WCPT. English is the
working language of WCPT and in all
communications with its members,
April 2013

A Global View of Direct Access and Patient Self-Referral to Physical Therapy

so the survey was produced in English only.

made to ensure anonymity of the

respondents.

A meeting of the European Region

(EU) of WCPT was taking place in
May 2010 with a workshop on direct
access, providing the opportunity to
explore interpretation of the survey
questions with a multicultural and
multilingual group (n27/40 present). The survey was presented
question-by-question to explore
understanding of the questions, identify and resolve any ambiguities, clarify terminology, and refine content.
After a full group discussion, 3
smaller focus groups with independent facilitators discussed the question set in detail and provided
guidance on refining the survey
instrument.

Participants were invited to complete the survey in July 2010, and the
survey was kept open for 12 months
to allow for follow-up with nonresponders. Several reminders were
sent via e-mail during this period.
Survey data were exported into
Excel (Microsoft Corporation, Redmond, Washington), which was used
for analysis.

A second iteration of the survey was

sent to an international reference
group of 11 individuals knowledgeable in the subject to provide feedback, 2 of whom also had been at the
European workshop and, therefore,
were privy to the discussions. Based
on this feedback and responses from
the workshop, content validity was
established and the survey instrument was finalized (eAppendix,
available at ptjournal.apta.org).
The WCPT does not have an ethical
review committee, but the WCPT
Executive Committee gave its
approval of the study, recognizing
that the study was developed in line
with the Declaration of Helsinki and
other international guidelines.38 40
The purpose of the survey and how
the data were to be used were set
out in the survey invitation. Participants were assured of the confidentiality of contact information, and
respondents were followed up to
ensure consent for the release of
data and given the opportunity to
decline consent on the whole submission or specific questions if
countries were to be identified in
any reporting. Every effort was
April 2013

Data Analysis
Descriptive statistics, including frequencies, percentages, and chisquare analysis, were used to summarize quantitative data. Post hoc
cross-tabulations were completed
using chi-square tests to examine the
relationship between legislation and
direct access and the relationship
between direct access and scope of
practice; the significance level was
set at .05.
Qualitative data were categorized
and analyzed using content analysis.
Both authors independently reviewed
the responses to open-ended questions, coding them to develop categories, and they then reviewed
assessments together. Where categories differed, the authors reached
agreement on labels through discussion and consensus. They then
reviewed the allocation of responses
against the categories to review any
differences and reach consensus.
A subset of the data relating to the
MOs of WCPT in the EU has been
analyzed in the context of workforce
migration issues in the EU, which
supports the free mobility of professionals across national boundaries, as
it is required of all member states of
the EU.41

Results
Seventy-two of the 106 MOs completed the survey, a response rate of
68%. The size of organizations

belonging to WCPT is wide ranging,

and Table 1 gives details of participants and respondents, including
response rates by region (range
38% 85%). The WCPT has had members since 1951, so some are longstanding and well established,
whereas others are relatively new
and still developing; the sample
included 8 new MOs approved in
2011.
Forty MOs (40/69, 58%) reported
that direct access and self-referral
were permitted in their countries,
either occurring where it was permitted, by legislation, or by professional practice in the absence of
national legislation. There were variations on a regional basis, as shown
in Figure 1. Of the 57 MOs (n57/
71) who reported that national
legislation existed, 57% (n30/57)
reported that direct access was permitted. Of 14 MOs who reported an
absence of legislation, 71% (n10/
14) reported that there was direct
access (P.2). In 2 countries with
state or provincial legislation, availability was determined on a state-bystate basis.
Of those acknowledging the permission for direct access, 19 (19/40,
48%) indicated that direct access was
available in both public and private
health settings, with 17 (17/40, 43%)
indicating that it was present only in
private health settings. In addition,
15 MOs reported that direct access
did occur in the private setting, even
though it did not appear to be supported by legislation or professional
practice. Free-text explanations for
this disparity suggested it occurred
and patients and physical therapists
took the risks in the absence of legislation, the application of legislation
to the private practice was unclear,
or only preventative advice was
given. This global variation is shown
in the Appendix. Where there was
direct access in the private setting,
respondents reported that reim-

Volume 93

Number 4

Physical Therapy f

451

A Global View of Direct Access and Patient Self-Referral to Physical Therapy

Table 1.
Participants
Participants

WCPTa
Region
Africa

Respondents

No. of
Member
Organizations

Surveys
Completed

Response
Rate

16

11

69%

Size of Member
Organization
(Reported Member
Numbers [Median
and Range])b
84 (153,254)

Length of
Membership
in WCPT (y)
16 (460)

Size of Member
Organization
(Reported Member
Numbers [Median
and Range])b

Length of
Membership
in WCPT (y)

66 (25650)

16 (044)c

37 (460)

290 (42974)

14 (023)d

30 (460)

30 (20124)

12 (420)

310 (305,215)

41 (452)

128 (401,124)

552 (1559,586)

31 (060)

200 (2021,511)

26

10

38%

471 (3059,586)

Europe

40

34

85%

1,050 (6438,375)

North America
Caribbean

13

10

78%

45 (2452,342)

South America

11

64%

106

72

68%

22.5 (060)

16 (033)c

515 (8021,511)

Asia Western
Pacific

Total

Nonrespondents

4 (016)d
12 (044)

WCPTWorld Confederation for Physical Therapy.

Data from 2011 reported member numbers per member organization (not the same number as practising physical therapists per country).
1 new member organization in 2011.
d
2 new member organizations in 2011.
b
c

bursement for individuals with insurance policies was dependent on the

policy (30/51, 59%), and 14 indicated that the insurance did not
cover physical therapy.
Respondents reported that private
physical therapy services might be
self-funded (67/71, 94%) or funded
through private or voluntary insurance premiums (54/71, 76%), compulsory insurance premiums (23/71,

32%), or a public taxfunded system

(23/71, 32%), none of which were
mutually exclusive. In the public
health system, services were most
frequently funded through public
taxation (54/71, 76%), but this funding often was supplemented by
patients self-funding (19/54, 35%),
private or voluntary insurance premiums (21/54, 39%), and compulsory
insurance premiums (19/54, 35%).

Respondents identified some limitations affecting direct access where it

was available, including: conditions
were mainly limited to those of a
musculoskeletal nature (n1); only
prevention and health education,
not treatment (as defined by national
legislation), were permitted (n2);
some specific interventions were
restricted (eg, manipulation, wound
debridement), and electrophysical
agents were excluded (n4); a phy-

Figure 1.
Patterns of direct access globally by region of the World Confederation for Physical Therapy (WCPT). AWPAsia Western Pacific,
NACNorth America Caribbean, SASouth America.

452

Physical Therapy

Volume 93

Number 4

April 2013

A Global View of Direct Access and Patient Self-Referral to Physical Therapy

sician referral was required in public
settings (n2); and institution-based
policies and commissioning determined whether direct access and
self-referral services were permitted,
irrespective of national legislation
(n3).
Both legislation and direct access
appeared to have an influence on
physical therapists scope of practice. Where there was national legislation governing the physical therapy profession, physical therapists
were more likely to be able to treat
(100% versus 88%, n70, P.01)
and offer preventative advice (96%
versus 81%, n70, P.04), but their
freedom to refer on to other specialties was less (35% versus 69%, n70,
P.02). Where direct access was
permitted, it was seen to have a positive bearing on the scope of practice
of physical therapists in terms of
assessment, diagnosis, and referral to
specialists, as shown in Table 2.
Respondents were asked to comment on whether physical therapy
qualifying education equipped physical therapists for direct access.
Sixty-nine percent of the respondents (n45/65) said that it did
equip them compared with 31%
(n20/65) who said no. Not all
WCPT MOs are based in countries
with qualifying education programs.
In those countries (n20) where
further educational measures were
required prior to physical therapists
having the necessary competencies
for direct access, 60% (12/20) indicated that a period of supervised
practice or continuing professional
development was required, and 35%
(7/20) indicated that a masters-level
qualification was necessary. These
options were not mutually exclusive.
Seventy-two percent of the respondents (n46/64) felt that the
national physical therapy association
was completely supportive of direct
access, 17% (n11/64) felt there
April 2013

Table 2.
Impact of Direct Access on Scope of Practice of Physical Therapistsa
No. (%) of Respondents
Direct Access and
Self-Referral
Permitted
(n40)

No Direct
Access and
Self-Referral
(n29)

Assess

40 (100)

24 (83)

.01

Physical therapists are able to:

Diagnose

35 (88)

9 (31)

.000*

Treat (ie, interventions, advice, and

evaluation of outcome)

40 (100)

27 (93)

.09

Refer on to other specialties/services

(eg, x-ray/ultrasound/specialist)

28 (70)

4 (14)

.000*

Offer preventative advice

38 (95)

26 (90)

.4

Asterisk indicates significant at .0001 level.

was limited support, 6% (n4/64)

were unsure, and 5% (n3) felt
there was no support. This latter
finding was explained by 2 respondents as a reflection of the profession not being educationally
equipped for direct access. Member
organizations perceived there to be
support for direct access from
patients, with 84% (54/64) reporting
that they thought patients were supportive. This finding contrasted with
MOs perception of the level of support from politicians and policy makers, where 35% (22/63) of respondents felt there was support. Only
16% (10/63) of the respondents felt
there was support from the medical
profession, with 59% (37/63) reporting that they felt the medical profession did not support direct access.
Respondents were asked to rate
potential barriers to and facilitators
of direct access and self-referral on a
scale of 1 to 5, where 1 was a minor
barrier and 5 was a major barrier,
and 64 responded. Recognizing that
items may work as both barriers and
facilitators, there was some overlap
in the topics across the questions.
Fifty-nine respondents (n59/64,
92%) identified medical support as a
barrier, with 54% rating it as a strong
factor (rated 4 5); it also was
reported to be a facilitator by 45

respondents (70%), with 67% rating

it strongly (rated 4 5). Factors were
perceived to have the potential to be
both barriers and facilitators, as
shown in Figure 2, with the strength
of effect being perceived to be stronger when acting as a facilitator.
Respondents were asked to identify
what resources they felt would help
them in taking forward direct access
and self-referral as a policy nationally, and 68% (49/72) responded. A
number of themes emerged, which
are presented in Table 3. Generally,
respondents identified more than
one resource or activity that they
thought would be beneficial.
Ten MOs (n10/72, 14%) commented on their experience of
implementing direct access and selfreferral policies nationally. Advocacy
activities such as lobbying, campaigning, and advertising were
reported by 5 respondents. Securing
the engagement from the medical
profession and health service commissioners was reported by 3
respondents, and 2 referred to
engagement with politicians as
important. One respondent had
undertaken a focused knowledge
translation initiative led by the
national professional organization.
Four respondents thought that rais-

Volume 93

Number 4

Physical Therapy f

453

A Global View of Direct Access and Patient Self-Referral to Physical Therapy

Figure 2.
Barriers and facilitators to direct access as reported by the World Confederation for Physical Therapy (WCPT) member organizations
(MOs). PTphysical therapist.

Table 3.
Resources Identified as Required by World Confederation for Physical Therapy (WCPT) Member Organizations to Help Progress
Direct Access
Theme

Description

Responses
(n)

Example Responses

Evidence

Evidence demonstrating clinical effectiveness

and cost-effectiveness of direct access

18

Evidence supporting effectiveness of direct access in other

. . . countries
More evidence for the cost-effectiveness of self-referral

Knowledge translation/
knowledge-to-action
resources

Requests for examples of models of good

practice and service delivery exemplars

15

Best practice models from research outcomes

Information on the implementation and success of direct
access/self-referral

Education

Improvements in the education of physical

therapists at both entry level and postqualifying level to equip them with the
competencies required for direct access
and self-referral

11

If the entry-level education is improved toward diagnostic

skills, then this will aid direct access
Workshops with other specialists

Legislation

Review and changes to national legislation

and regulatory requirements to permit
direct access and self-referral to physical
therapists

11

Proper legislation and act/law on physiotherapy profession

To include the direct access in the law

Advocacy

Initiatives aimed at securing political support

13

Awareness campaign and public relations with Ministry

Medical and other health professional

support

10

If the physicians can view it as a means of getting the

assistance to the patient early and so reduce their workload
. . . can see the benefit in terms of dollars and cents

Raising awareness and support among the

public
Professional leadership

454

From WCPT internationally and member

associations nationally, in the form of
policy statements, guidance on education,
and regulation and the collation of
evidence and best practice models

Physical Therapy

Volume 93

Number 4

9
11

Creation of more public awareness

Professional organization agreements
Policy statement from WCPT on direct access

April 2013

A Global View of Direct Access and Patient Self-Referral to Physical Therapy

ing educational standards of qualifying
professional
(entry-level)
physical therapist education and
containing professional development had been successful. Only 1
respondent noted success with legislation changes. A limited number
of MOs had resources on direct
access available on their websites,
although they were not all open
access and restricted to memberonly areas.

Previous studies have focused on

clinical effectiveness and costeffectiveness, medical and public
acceptance, and, to a limited extent,
barriers and facilitators, usually in
the context of individual practice. As
noted by McCallum and DiAngelis,31
comparing studies on direct access is
difficult because of the way in which
direct access to physical therapy has
been defined across studies and the
data collection applied.

Respondents were provided with

the opportunity to make any additional comments at the end of the
survey. No new themes emerged,
but those associated with the successful implementation of direct
access and resources thought to be
necessary were reinforced. There
were requests for assistance in
implementing legislative change that
recognized the autonomy of the
physical therapy profession and the
inclusion of direct access (n4). The
role of national professional organizations and WCPT in facilitating
change in favor of direct access and
self-referral was highlighted, along
with a desire for a network of
experts (n4). The need for terminology to be clear in defining direct
access and self-referral was identified
as important in the collation of evidence to ensure that true clinical
effectiveness and cost-effectiveness
could be evaluated (n2).

Direct access and patient self-referral

is not a new model for providing
physical therapy services. In 1976,
the Australian Physiotherapy Association repealed its first ethical principle, which stated that physiotherapists would only treat patients
referred to them by a registered medical practitioner.42(p217) At the time,
the widespread model of physical
therapist practice was one where
physical therapists took direction
from a physician. The initiative from
Australia was taken to the meeting of
WCPT in 1978 to facilitate this move
in other MOs, and a motion was
passed that the issue of primary
practitioner status be interpreted by
each country in terms of their own
standards.42(p217) Since then, progress across the MOs of WCPT has
been varied, and the issue is now a
high-profile advocacy issue for many.
Some have already reaped the benefits of advocacy initiatives and legislative change,42 and many more
strive to make the changes and are
keen to learn from their international
colleagues. Member organizations
responding to the survey offered to
share experiences of implementing
direct access, suggested developing
a network of experts, and identified
the need for guidance on legislative
change to support direct access and
self-referral. A limited amount of
online resources and other education material also was identified.

Discussion
This survey set out to develop a
global profile of direct access and
patient self-referral for physical therapy to identify where it was available
and to investigate the context of
practice, factors influencing it, and
the resources that were thought necessary to further advance and
develop services. The participants
were selected to provide a national
rather than an individual perspective, representing a collective opinion from a professional physical therapy association.
April 2013

The findings build on what is known

at a national level in a limited num-

ber of countries,3,12,20,2224,31 providing a diverse picture of direct access.

It would appear that direct access
and self-referral as an objective
requires
strategic
coordinated
action. This objective is unlikely to
be achieved at an individual level and
requires leadership from professional physical therapy associations
and service leaders working on a
number of strategies. Advocacy strategies with all stakeholders, including
physical therapists, politicians and
policy makers, the medical profession, and service users, such as the
use of awareness campaigns using
a variety of media, tailored to different stakeholder groups, with which
some are already engaged, are likely
to be important.43 45 The role of
advocacy strategies is supported by a
small study, which included both
members and nonmembers of
APTA.31 Securing professional support and empowering individual
physical therapists are likely to be
achieved with leadership from
national associations and opinion
leaders. Other strategies identified
included raising the standards of
physical therapist entry-level education to equip physical therapists
for autonomous practice and direct
access, and reviewing legislation.
The perceived barriers to and facilitators of direct access, surrounding
the views of key stakeholders (the
medical profession, policy makers,
and the public), represent the views
of physical therapists and may not be
an accurate representation of those
stakeholder groups. The fact that all
appear to some extent as both barriers and facilitators shows how
important they are to the profession
and, whether real or perceived, that
they need to be addressed. The perceived influence of policy makers on
the availability of direct access, irrespective of whether it was permitted
under legislation, was evident from
the respondents and is consistent
with previous studies.5,6,31 In a UK

Volume 93

Number 4

Physical Therapy f

455

A Global View of Direct Access and Patient Self-Referral to Physical Therapy

study, Holdsworth et al23 found that
both physical therapists and general
practitioners (family physicians)
supported patient self-referral and
stressed the importance of raising
awareness both within and external
to the profession. Webster et al26
found that self-referral was viewed
positively by service users, supporting the perceptions reported in the
current study. These studies should
help inform advocacy efforts.
Although WCPT has produced guidelines for physical therapist entrylevel education, they remain aspirational for some members of WCPT,
whereas others exceed them. As
noted by the respondents, education
plays a vital part in equipping physical therapists with the requisite
competencies to accept patients
who self-refer. If the graduate competencies are not appropriate at
entry level, additional measures are
needed. The role of continuing professional development in preparing
physical therapists for direct access
has been identified in other studies,
even where entry-level education
should provide the necessary
competencies.23,31
Legislation that recognizes physical
therapy as an autonomous profession, able to accept patients via
direct access and self-referral, is perceived as a significant facilitator and
as a barrier when it is absent. However, the results show that in many
countries where MOs reported there
was an absence of legislation, direct
access was permitted or occurred.
There appears to be greater freedom
for physical therapists to refer on to
other specialties or services where
direct access exists. Certainly, if legislation is introduced in those countries currently without it, it will be
important to retain these professional autonomy roles. As noted by
Kruger,42 legislative change may
bring about positive change, but
challenges to implementing direct
456

Physical Therapy

Volume 93

access and self-referral remain that

are cultural (eg, the relationship
with the medical profession) and
structural (eg, funding models). The
findings of this study support these
observations.
Health service funding models and
reimbursement policies appear to
have an impact on the availability of
direct access. Although some private
physical therapy services accept
patients via self-referral, there are
instances where insurance policies
will not provide reimbursement
without a physician referral. This situation manifests itself in the same
countries where public services support self-referral without a physician
referral. In this situation, it is likely
to require the physical therapy profession to actively engage with the
insurance companies and medical
profession to challenge the insurance companies policies so that
practice reflects contemporary service delivery models available in a
variety of settings.31 This strategy is
likely to be more successful when
the clinical effectiveness and costeffectiveness business case is presented. The case for direct access
and self-referral for physical therapy
is supported by growing evidence
showing that patient safety is not put
at risk, that it is likely to result in
reduced health service costs as a
result of less physician care, and that
quality of care is likely to be
enhanced.12,20,2224,46 This evidence,
along with the results of this study,
should be useful in informing policy
decisions and advocacy efforts
regarding
direct
access
and
self-referral.
Limitations
Although this study achieved a high
response rate overall, the response
rate varied across the 5 regions of
WCPT. There was a much high
response rate from Europe, which
could be attributed to the workshop
prior to data entry sensitizing

Number 4

respondents to the survey, or the

fact that direct access was a significant policy issue for many of the
organizations represented in the
European region. Ideally, it would
have been valuable to have carried
out the same workshop in each of
the regions. It is unclear why there
was such a low response rate in the
Asia Western Pacific region; therefore, caution should be applied in
extrapolating the findings in that
region.
Participants were requested to
respond on behalf of their MOs to
provide a national perspective, but
there is a risk that respondents might
have replied based on personal opinion. The survey language was English, and although English is the official language of WCPT, some MOs
may have had difficulty understanding the questions and completing
the survey and, therefore, may have
failed to complete it. However,
based on the responses, there was a
large number of respondents from
countries for whom English was not
the first language.
Despite these limitations, we believe
the study provides a benchmark profile of direct access to physical therapy globally, with useful data to
inform future developments.

Conclusion
To assist future research studies on
the clinical effectiveness and costeffectiveness of physical therapy
direct access services, it will be
important to clearly define the terms
direct access and self-referral.
The term patient self-referral more
accurately reflects the practice being
described, but direct access is the
term more widely understood, both
within the profession internationally
and with other stakeholders. Further
clinical effectiveness and costeffectiveness studies for different client groups (eg, patients with neurological disorders or gynecologic
April 2013

A Global View of Direct Access and Patient Self-Referral to Physical Therapy

problems) across a variety of settings
will further strengthen the business
case and should incorporate the
views of service users.
There appears to be a perception of
widespread support for direct access
and patient self-referral for physical
therapy, not just from within the
profession; however, it is not universal. Professional leadership and
advocacy from national professional
organizations and WCPT are important in facilitating change in health
policy and service implementation.
Resources to support those countries that want to develop direct
access services are needed. These
resources may include advice on
reviewing legislative changes, developing education and advocacy initiatives, drawing on the evidence of
clinical effectiveness and costeffectiveness to support the business
case, and the development of good
practice case studies illustrating
implementation strategies and service delivery models.
The WCPT has developed guidelines
for physical therapist entry-level education and for professional regulation and legislation,35,36 all of which
underpin the autonomous practice
of physical therapists and the right to
accept patients via direct access, so
long as they have the competencies
to do so. These guidelines are set out
in the new policy on direct access
approved by the MOs of WCPT in
2011.33 In the course of this survey,
lessons learned from implementation experiences have been shared
and provide guidance for those starting out on developing and implementing direct access. Further work
is now needed to collate the
resources identified and make them
as widely accessible as possible.
Both authors provided concept/idea/research design and contributed to writing,
data collection and analysis, and project

April 2013

management. Ms Bury provided study participants and institutional liaisons.

Both authors are involved with the work of
WCPT. Ms Bury is an employed member of
staff, and Dr Stokes is currently Vice President and sits on the Executive Committee; at
the time of the study she was the European
regional representative on the Committee.
The views expressed in the article are those
of the authors and do not necessarily represent the views of WCPT. The authors
acknowledge the support of all delegates to
the European Region of WCPT Workshop on
Direct Access, the external reference group
for assistance in developing the survey
instrument, and the respondents from
WCPTs member organizations.
The preliminary findings were presented at
the 16th International Congress of the World
Confederation for Physical Therapy; June
20 23, 2011; Amsterdam, the Netherlands.
DOI: 10.2522/ptj.20120060

References
1 Sandstrom RW. The meanings of autonomy for physical therapy [erratum in: Phys
Ther. 2007;87:227]. Phys Ther. 2007;87:
98 106.
2 Policy Statement: Autonomy. London,
United Kingdom: World Confederation for
Physical Therapy; 2011.
3 Self-referral Pilots to Musculoskeletal
Physiotherapy and the Implications for
Improving Access to Other AHP Services.
London, United Kingdom: Department of
Health; 2008.
4 Boyce RA. Direct access physiotherapy in
Australia [letter]. Physiotherapy. 2005;91:
61 62.
5 Crout KL, Tweedie JH, Miller DJ. Physical
therapists opinions and practices regarding direct access. Phys Ther. 1998;78:52
61.
6 Domholdt E, Durchholz AG. Direct access
use by experienced therapists in states
with direct access. Phys Ther. 1992;72:
569 574.
7 Domholdt E, Lord L, LeMasters A, Durant
T. Direct access: a hypothetical debate.
Clinical Management. 1989;9(2):33.
8 Durant TL, Lord LJ, Domholdt E. Outpatient views on direct access to physical
therapy in Indiana. Phys Ther. 1989;69:
850 857.
9 Flynn TW. Direct access: the time has
come for action. J Orthop Sports Phys
Ther. 2003;33:102103.
10 Fordham R, Hodkinson C. A Cost Benefit
Analysis of Open Access to Physiotherapy
for GPs: Discussion Paper 29. York,
United Kingdom: Centre for Health Economics Health Economics Consortium,
University of York; 1998.

11 Holdsworth LK, Webster VS. Direct access

to physiotherapy in primary care: now and
into the future? Physiotherapy. 2004;90:
64 72.
12 Leemrijse CJ, Swinkels IC, Veenhof C.
Direct access to physical therapy in the
Netherlands: results from the first year in
community-based physical therapy. Phys
Ther. 2008;88:936 946.
13 Mitchell JM, de Lissovoy G. A comparison
of resource use and cost in direct access
versus physician referral episodes of physical therapy. Phys Ther. 1997;77:10 18.
14 Moore J. Vision in action: direct access. PT
Magazine. 2001;9(2):7779.
15 Rose SJ. Direct access: the need for an
educational component. Phys Ther. 1988;
68:1329.
16 Swinkels IC, Leemrijse CJ, Veenhof C. One
year of direct access to physiotherapy [in
Dutch]. Ned Tijdschr Fysiotherapie. 2007;
117:158 165.
17 Tepper DE. Reimbursement victories:
direct access and others. PT Magazine.
2003;11(3):42 45, 61.
18 Self-referral to Physiotherapy Services.
London, United Kingdom: Chartered Society of Physiotherapy; 2004.
19 Ferguson A, Griffin E, Mulcahy C. Patient
self-referral to physiotherapy in general
practice: a model for the new NHS? Physiotherapy. 1999;85:1320.
20 Holdsworth LK, Webster VS, McFadyen
AK. Are patients who refer themselves
to physiotherapy different from those
referred by GPs: results of a national trial.
Physiotherapy. 2006;92:26 33.
21 Holdsworth LK, Webster VS, McFadyen
AK. Self-referral to physiotherapy deprivation and geographical settingis there
a relationship: results of a national trial.
Physiotherapy. 2006;92:16 25.
22 Holdsworth LK, Webster VS, McFadyen
AK. What are the costs to NHS Scotland of
self-referral to physiotherapy: results of a
national trial. Physiotherapy. 2007;93:311.
23 Holdsworth LK, Webster VS, McFadyen
AK. Physiotherapists and general practitioners views of self-referral and physiotherapy scope of practice: results from a
national trial. Physiotherapy. 2008;94:
236 243.
24 Pendergast J, Kliethermes SA, Freburger
JK, Duffy PA. A comparison of health care
use for physician-referred and self-referred
episodes of outpatient physical therapy.
Health Serv Res. 2012;47:633 654.
25 Saporta A, Gibson BE. Ethics of self-referral
for profit: case example of a physicianowned physiotherapy clinic. Physiother
Can. 2007;59:266 271.
26 Webster VS, Holdsworth LK, McFadyen,
Little H. Self-referral, access and physiotherapy, patients knowledge and attitudes: results of a national trial. Physiotherapy. 2008;94:141.
27 Galley P. Patient referral and the physiotherapist. Aust J Physiother. 1976;22:117
120.

Volume 93

Number 4

Physical Therapy f

457

A Global View of Direct Access and Patient Self-Referral to Physical Therapy

28 Galley P. Physiotherapists as first-contact
practitioners: new challenges and responsibilities in Australia. Physiotherapy. 1977;
63:246 248.
29 Leemrijse CJ, Swinkels IC, Pisters MF, et al.
Direct access to physiotherapy: the
patients choice [in Dutch]. Ned Tijdschr
Fysiotherapie. 2008;118:62 67.
30 Massey BF Jr. 2002 APTA presidential
address: whats all the fuss about direct
access? Phys Ther. 2002;82:1120 1123.
31 McCallum CA, DiAngelis T. Direct access:
factors that affect physical therapist practice in the state of Ohio. Phys Ther. 2012;
92:688 706.
32 World Confederation for Physical Therapy. Direct access and patient self-referral
to physical therapy. Available at: http://
www.wcpt.org/node/34062.
Accessed
December 22, 2011.
33 Policy Statement: Direct Access and
Patient/Client Self-referral to Physical
Therapy. London, United Kingdom: World
Confederation for Physical Therapy; 2011.
34 Policy Statement: Education. London,
United Kingdom: World Confederation for
Physical Therapy; 2011.

458

Physical Therapy

Volume 93

35 WCPT Guideline for Physical Therapist

Professional Entry Level Education. London, United Kingdom: World Confederation for Physical Therapy; 2011.
36 WCPT Guideline for the Development of
a System of Legislation/Regulation/Recognition of Physical Therapists. London,
United Kingdom: World Confederation for
Physical Therapy; 2011.
37 Policy Statement: Description of Physical
Therapy. London, United Kingdom: World
Confederation for Physical Therapy; 2011.
38 1991 International Guidelines for Ethical Review of Epidemiological Studies.
London, United Kingdom: Council of
International Organizations for Medical
Science; 1991.
39 Ethical Guidelines for Biomedical
Research Involving Human Subjects.
London, United Kingdom: Council of
International Organizations for Medical
Science; 2008.
40 Declaration of Helsinki: Ethical Principles for Medical Research Involving
Human Subjects. Ferney-Voltaire, France:
World Medical Association; 2008.

Number 4

41 Bury T, Stokes E. Direct access and

patient/client self-referral to physiotherapy: a review of contemporary practice
within the European Union. Physiotherapy. In press.
42 Kruger J. Patient referral and the physiotherapist: three decades later. J Physiother. 2010;56:217218.
43 American Physical Therapy Association.
Direct access in practice. Available at:
http://www.apta.org/DirectAccess/. Accessed January 30, 2012.
44 Efficiency and Health Human Resources:
A Submission to the House of Commons
Standing Committee on Health. Ottawa,
Ontario, Canada: Canadian Physiotherapy
Association; 2009.
45 Chartered Society of Physiotherapy. Self
referral. Available at: http://www.csp.org.
uk/topics/self-referral. Accessed January
30, 2012.
46 Shoemaker MJ. Direct consumer access to
physical therapy in Michigan: challenges
to policy adoption [erratum in: Phys Ther.
2012;92:471]. Phys Ther. 2012;92:236 250.

April 2013

April 2013

Those countries not colored either did not respond to the survey or do not have a World Confederation for Physical Therapy (WCPT) member organization.

Global Map of Direct Access and Self-Referrala

Appendix.

A Global View of Direct Access and Patient Self-Referral to Physical Therapy

Volume 93

Number 4

Physical Therapy f

459