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

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 A Global View of Direct Access and Patient
Self-Referral to Physical Therapy: Implications for
the Profession
Tracy J. Bury and Emma K. Stokes
PHYS THER. 2013; 93:449-459.
Originally published online November 29, 2012
doi: 10.2522/ptj.20120060

The online version of this article, along with updated information and services, can be
found online at: http://ptjournal.apta.org/content/93/4/449

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20060.DC1.html
Collections This article, along with others on similar topics, appears
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 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
T.J. Bury, MSc, GradDipPhys,
World Confederation for Physical
Background. International policy advocates for direct access, but the extent to Therapy, Victoria Charity Centre,
which it exists worldwide was unknown. 11 Belgrave Rd, London, SW1V
1RB, United Kingdom, and
Objective. The purpose of this study was to map the presence of direct access to Department of Physiotherapy,
physical therapy services in the member organizations of the World Confederation Trinity College, Dublin, Ireland.
Address all correspondence to Ms
for Physical Therapy (WCPT) in the context of physical therapist practice and health
Bury at: tbury@wcpt.org.
systems.
E.K. Stokes, PhD, MSc, Depart-
ment of Physiotherapy, Trinity
Design. A 2-stage, mixed-method, descriptive study was conducted. College, and World Confederation
for Physical Therapy.
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 [Bury TJ, Stokes EK. A global view
of direct access and patient self-
member organizations. Data were analyzed using descriptive statistics, and content referral to physical therapy: impli-
analysis was used to analyze open-ended responses to identify themes. cations for the profession. Phys
Ther. 2013;93:449 – 459.]
Results. A response rate of 68% (72/106) was achieved. Direct access to physical © 2013 American Physical Therapy
therapy was reported by 58% of the respondents, with greater prevalence in private Association
settings. Organizations reported that professional (entry-level) education equipped
Published Ahead of Print:
physical therapists for direct access in 69% of the countries. National physical therapy November 29, 2012
associations (89%) and the public (84%) were thought to be in support of direct Accepted: November 16, 2012
access, with less support perceived from policy makers (35%) and physicians (16%). Submitted: February 14, 2012
Physical therapists’ ability to assess, diagnose, and refer patients on to specialists was
more prevalent in the presence of direct access.

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 profes-
sional 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

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A Global View of Direct Access and Patient Self-Referral to Physical Therapy
A
ttaining professional auton-
omy 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 ser-
vices directly without referral from
another health care professional.”2(p1)
Direct access and patient self-referral
to physical therapists are manifesta-
tions of professional autonomy. If
another profession is seen to domi-
nate 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 profes-
sion globally and among other health
professionals, politicians, and gov-
ernment 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 physi-
cal 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 hav-
ing to see anyone else first, or with-
out being told to refer themselves by
Available With
This Article at
ptjournal.apta.org
• eAppendix: Survey Instrument
450 f Physical Therapy Volume 93 Number 4
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another health professional (this sit-
uation 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 “self-
referral” 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, Aus-
tralia, and the Netherlands, with a
growing body of evidence and policy
support to support its implementa-
tion and its clinical effectiveness and
cost-effectiveness.11–13,15,16,20 –24,26 –31
In 2009, an international policy sum-
mit on advanced scope of practice
and direct access in physical ther-
apy, co-hosted by WCPT, the Amer-
ican Physical Therapy Association
(APTA), and the Canadian Physio-
therapy Association, reviewed the
evidence for direct access and self-
referral, along with strategies for
influencing national health policy
and implementing change.32 The
international policy summit identi-
fied 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 ther-
apy.33 Further policies and guide-
lines from WCPT on education and
professional regulation serve to sup-
port this policy statement.34 –37
The aim of this study was to com-
plete an international survey of
WCPT’s MOs in order to develop a
global picture of direct access to
physical therapy. Given the desire of
WCPT to assist with policy develop-
ment and implementation nationally,
it also was considered important to
understand the potential barriers
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 profes-
sional practice and national legisla-
tion, health systems, financial mod-
els, and educational requirements.
Method
Participants
The WCPT is a confederation of
MOs. It has 106 members, represent-
ing more than 350,000 physical ther-
apists worldwide. A country may
only have one organization belong-
ing to WCPT; therefore, 106 coun-
tries were represented in the partic-
ipant sample. The survey was open
to all MOs, including new members
up for approval at the General Meet-
ing in June 2011 (8 of the 106 mem-
bers). Each MO has a primary con-
tact registered with WCPT, who was
contacted with the survey details
and invited to participate. Only one
response was permitted per organi-
zation, 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 perspec-
tive on behalf of their organiza-
tion. 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 quan-
titative and qualitative methods.
We developed a pilot survey tool
using SurveyMonkey (Palo Alto, Cal-
ifornia, 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 Eng-
lish only.
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 (n⫽27/40 pres-
ent). The survey was presented
question-by-question to explore
understanding of the questions, iden-
tify and resolve any ambiguities, clar-
ify terminology, and refine content.
After a full group discussion, 3
smaller focus groups with indepen-
dent facilitators discussed the ques-
tion set in detail and provided
guidance on refining the survey
instrument.
A second iteration of the survey was
sent to an international reference
group of 11 individuals knowledge-
able in the subject to provide feed-
back, 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 instru-
ment 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. Partici-
pants were assured of the confiden-
tiality 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 sub-
mission or specific questions if
countries were to be identified in
any reporting. Every effort was
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made to ensure anonymity of the
respondents.
Participants were invited to com-
plete the survey in July 2010, and the
survey was kept open for 12 months
to allow for follow-up with nonre-
sponders. Several reminders were
sent via e-mail during this period.
Survey data were exported into
Excel (Microsoft Corporation, Red-
mond, Washington), which was used
for analysis.
Data Analysis
Descriptive statistics, including fre-
quencies, percentages, and chi-
square analysis, were used to sum-
marize 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 ques-
tions, coding them to develop cate-
gories, and they then reviewed
assessments together. Where catego-
ries differed, the authors reached
agreement on labels through discus-
sion 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 profes-
sionals across national boundaries, as
it is required of all member states of
the EU.41
Results
Seventy-two of the 106 MOs com-
pleted the survey, a response rate of
68%. The size of organizations
Volume 93 Number 4
belonging to WCPT is wide ranging,
and Table 1 gives details of partici-
pants and respondents, including
response rates by region (range⫽
38%– 85%). The WCPT has had mem-
bers since 1951, so some are long-
standing 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 per-
mitted, by legislation, or by profes-
sional practice in the absence of
national legislation. There were vari-
ations on a regional basis, as shown
in Figure 1. Of the 57 MOs (n⫽57/
71) who reported that national
legislation existed, 57% (n⫽30/57)
reported that direct access was per-
mitted. Of 14 MOs who reported an
absence of legislation, 71% (n⫽10/
14) reported that there was direct
access (P⫽.2). In 2 countries with
state or provincial legislation, avail-
ability was determined on a state-by-
state basis.
Of those acknowledging the permis-
sion 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 sup-
ported 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 leg-
islation, 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-
Physical Therapy f 451
A Global View of Direct Access and Patient Self-Referral to Physical Therapy

Table 1.
Participants
Participants Respondents Nonrespondents
Size of Member Size of Member
Organization Organization
No. of (Reported Member Length of (Reported Member Length of
WCPTa Member Surveys Response Numbers [Median Membership Numbers [Median Membership
Region Organizations Completed Rate and Range])b in WCPT (y) and Range])b in WCPT (y)

Africa 16 11 69% 84 (15–3,254) 16 (4–60) 66 (25–650) 16 (0–33)c

d
Asia Western 26 10 38% 471 (30–59,586) 22.5 (0–60) 515 (80–21,511) 16 (0–44)c
Pacific

Europe 40 34 85% 1,050 (64–38,375) 37 (4–60) 290 (42–974) 14 (0–23)d

North America 13 10 78% 45 (24–52,342) 30 (4–60) 30 (20–124) 12 (4–20)

Caribbean

South America 11 7 64% 310 (30–5,215) 41 (4–52) 128 (40–1,124) 4 (0–16)d

Total 106 72 68% 552 (15–59,586) 31 (0–60) 200 (20–21,511) 12 (0–44)

a
WCPT⫽World Confederation for Physical Therapy.
b
Data from 2011 reported member numbers per member organization (not the same number as practising physical therapists per country).
c
1 new member organization in 2011.
d
2 new member organizations in 2011.

bursement for individuals with insur-
ance policies was dependent on the
policy (30/51, 59%), and 14 indi-
cated 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 insur-
ance premiums (54/71, 76%), com-
pulsory insurance premiums (23/71,
32%), or a public tax–funded 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 fund-
ing often was supplemented by
patients self-funding (19/54, 35%),
private or voluntary insurance premi-
ums (21/54, 39%), and compulsory
insurance premiums (19/54, 35%).
Respondents identified some limita-
tions affecting direct access where it
was available, including: conditions
were mainly limited to those of a
musculoskeletal nature (n⫽1); only
prevention and health education,
not treatment (as defined by national
legislation), were permitted (n⫽2);
some specific interventions were
restricted (eg, manipulation, wound
debridement), and electrophysical
agents were excluded (n⫽4); a phy-

Figure 1.
Patterns of direct access globally by region of the World Confederation for Physical Therapy (WCPT). AWP⫽Asia Western Pacific,
NAC⫽North America Caribbean, SA⫽South America.

452 f Physical Therapy Volume 93 Number 4 April 2013

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 A Global View of Direct Access and Patient Self-Referral to Physical Therapy
sician referral was required in public
settings (n⫽2); and institution-based
policies and commissioning deter-
mined whether direct access and
self-referral services were permitted,
irrespective of national legislation
(n⫽3).
Both legislation and direct access
appeared to have an influence on
physical therapists’ scope of prac-
tice. Where there was national legis-
lation governing the physical ther-
apy profession, physical therapists
were more likely to be able to treat
(100% versus 88%, n⫽70, P⫽.01)
and offer preventative advice (96%
versus 81%, n⫽70, P⫽.04), but their
freedom to refer on to other special-
ties was less (35% versus 69%, n⫽70,
P⫽.02). Where direct access was
permitted, it was seen to have a pos-
itive 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 com-
ment on whether physical therapy
qualifying education equipped phys-
ical therapists for direct access.
Sixty-nine percent of the respon-
dents (n⫽45/65) said that it did
equip them compared with 31%
(n⫽20/65) who said no. Not all
WCPT MOs are based in countries
with qualifying education programs.
In those countries (n⫽20) where
further educational measures were
required prior to physical therapists
having the necessary competencies
for direct access, 60% (12/20) indi-
cated that a period of supervised
practice or continuing professional
development was required, and 35%
(7/20) indicated that a master’s-level
qualification was necessary. These
options were not mutually exclusive.
Seventy-two percent of the respon-
dents (n⫽46/64) felt that the
national physical therapy association
was completely supportive of direct
access, 17% (n⫽11/64) felt there
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Table 2.
Impact of Direct Access on Scope of Practice of Physical Therapistsa
Direct Access and
Self-Referral
Physical therapists are able to:
Assess
Diagnose
Treat (ie, interventions, advice, and
evaluation of outcome)
Refer on to other specialties/services
(eg, x-ray/ultrasound/specialist)
Offer preventative advice
a
Asterisk indicates significant at .0001 level.
was limited support, 6% (n⫽4/64)
were unsure, and 5% (n⫽3) felt
there was no support. This latter
finding was explained by 2 respon-
dents as a reflection of the profes-
sion 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 sup-
portive. This finding contrasted with
MOs’ perception of the level of sup-
port from politicians and policy mak-
ers, where 35% (22/63) of respon-
dents felt there was support. Only
16% (10/63) of the respondents felt
there was support from the medical
profession, with 59% (37/63) report-
ing that they felt the medical profes-
sion 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 (n⫽59/64,
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
Volume 93 Number 4
No. (%) of Respondents
No Direct
Access and
Permitted Self-Referral
(nⴝ40) (nⴝ29) P
40 (100) 24 (83) .01
35 (88) 9 (31) ⱕ.000*
40 (100) 27 (93) .09
28 (70) 4 (14) ⱕ.000*
38 (95) 26 (90) .4
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 stron-
ger 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 nation-
ally, 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 (n⫽10/72, 14%) com-
mented on their experience of
implementing direct access and self-
referral policies nationally. Advocacy
activities such as lobbying, cam-
paigning, and advertising were
reported by 5 respondents. Securing
the engagement from the medical
profession and health service com-
missioners 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-
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). PT⫽physical therapist.

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

Evidence Evidence demonstrating clinical effectiveness 18 “Evidence supporting effectiveness of direct access in other
and cost-effectiveness of direct access . . . countries”
“More evidence for the cost-effectiveness of self-referral”

Knowledge translation/ Requests for examples of models of good 15 “Best practice models from research outcomes”
knowledge-to-action practice and service delivery exemplars “Information on the implementation and success of direct
resources access/self-referral”

Education Improvements in the education of physical 11 “If the entry-level education is improved toward diagnostic
therapists at both entry level and post- skills, then this will aid direct access”
qualifying level to equip them with the “Workshops with other specialists”
competencies required for direct access
and self-referral
Legislation Review and changes to national legislation 11 “Proper legislation and act/law on physiotherapy profession”
and regulatory requirements to permit “To include the ‘direct access’ in the law”
direct access and self-referral to physical
therapists

Advocacy Initiatives aimed at securing political support 13 “Awareness campaign and public relations with Ministry”

Medical and other health professional 10 “If the physicians can view it as a means of getting the
support 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 9 “Creation of more public awareness”
public

Professional leadership From WCPT internationally and member 11 “Professional organization agreements”
associations nationally, in the form of “Policy statement from WCPT on direct access”
policy statements, guidance on education,
and regulation and the collation of
evidence and best practice models

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 A Global View of Direct Access and Patient Self-Referral to Physical Therapy
ing educational standards of quali-
fying professional (entry-level)
physical therapist education and
containing professional develop-
ment had been successful. Only 1
respondent noted success with leg-
islation 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 member-
only areas.
Respondents were provided with
the opportunity to make any addi-
tional comments at the end of the
survey. No new themes emerged,
but those associated with the suc-
cessful 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 (n⫽4). The
role of national professional organi-
zations and WCPT in facilitating
change in favor of direct access and
self-referral was highlighted, along
with a desire for a network of
experts (n⫽4). The need for termi-
nology to be clear in defining direct
access and self-referral was identified
as important in the collation of evi-
dence to ensure that true clinical
effectiveness and cost-effectiveness
could be evaluated (n⫽2).
Discussion
This survey set out to develop a
global profile of direct access and
patient self-referral for physical ther-
apy to identify where it was available
and to investigate the context of
practice, factors influencing it, and
the resources that were thought nec-
essary to further advance and
develop services. The participants
were selected to provide a national
rather than an individual perspec-
tive, representing a collective opin-
ion from a professional physical ther-
apy association.
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Previous studies have focused on
clinical effectiveness and cost-
effectiveness, 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.
Direct access and patient self-referral
is not a new model for providing
physical therapy services. In 1976,
the Australian Physiotherapy Associ-
ation repealed its first ethical princi-
ple, which stated that “physiothera-
pists would only treat patients
referred to them by a registered med-
ical 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, prog-
ress 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 bene-
fits of advocacy initiatives and legis-
lative 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 educa-
tion material also was identified.
The findings build on what is known
at a national level in a limited num-
Volume 93 Number 4
ber of countries,3,12,20,22–24,31 provid-
ing 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 profes-
sional physical therapy associations
and service leaders working on a
number of strategies. Advocacy strat-
egies with all stakeholders, including
physical therapists, politicians and
policy makers, the medical profes-
sion, and service users, such as the
use of awareness campaigns using
a variety of media, tailored to differ-
ent 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 sup-
port 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 educa-
tion to equip physical therapists
for autonomous practice and direct
access, and reviewing legislation.
The perceived barriers to and facili-
tators 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 barri-
ers and facilitators shows how
important they are to the profession
and, whether real or perceived, that
they need to be addressed. The per-
ceived influence of policy makers on
the availability of direct access, irre-
spective of whether it was permitted
under legislation, was evident from
the respondents and is consistent
with previous studies.5,6,31 In a UK
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, support-
ing the perceptions reported in the
current study. These studies should
help inform advocacy efforts.
Although WCPT has produced guide-
lines for physical therapist entry-
level education, they remain aspira-
tional for some members of WCPT,
whereas others exceed them. As
noted by the respondents, education
plays a vital part in equipping phys-
ical therapists with the requisite
competencies to accept patients
who self-refer. If the graduate com-
petencies are not appropriate at
entry level, additional measures are
needed. The role of continuing pro-
fessional 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 profes-
sion, able to accept patients via
direct access and self-referral, is per-
ceived as a significant facilitator and
as a barrier when it is absent. How-
ever, 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 leg-
islation is introduced in those coun-
tries currently without it, it will be
important to retain these profes-
sional autonomy roles. As noted by
Kruger,42 legislative change may
bring about positive change, but
challenges to implementing direct
456 f Physical Therapy Volume 93 Number 4
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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 sit-
uation manifests itself in the same
countries where public services sup-
port self-referral without a physician
referral. In this situation, it is likely
to require the physical therapy pro-
fession to actively engage with the
insurance companies and medical
profession to challenge the insur-
ance companies’ policies so that
practice reflects contemporary ser-
vice delivery models available in a
variety of settings.31 This strategy is
likely to be more successful when
the clinical effectiveness and cost-
effectiveness business case is pre-
sented. 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.12,20,22–24,46 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
respondents to the survey, or the
fact that direct access was a signifi-
cant 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; there-
fore, 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 opin-
ion. The survey language was Eng-
lish, and although English is the offi-
cial language of WCPT, some MOs
may have had difficulty understand-
ing 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 pro-
file of direct access to physical ther-
apy globally, with useful data to
inform future developments.
Conclusion
To assist future research studies on
the clinical effectiveness and cost-
effectiveness 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 cost-
effectiveness studies for different cli-
ent groups (eg, patients with neuro-
logical 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 uni-
versal. Professional leadership and
advocacy from national professional
organizations and WCPT are impor-
tant in facilitating change in health
policy and service implementation.
Resources to support those coun-
tries that want to develop direct
access services are needed. These
resources may include advice on
reviewing legislative changes, devel-
oping education and advocacy initia-
tives, drawing on the evidence of
clinical effectiveness and cost-
effectiveness to support the business
case, and the development of good
practice case studies illustrating
implementation strategies and ser-
vice delivery models.
The WCPT has developed guidelines
for physical therapist entry-level edu-
cation and for professional regula-
tion 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 implementa-
tion experiences have been shared
and provide guidance for those start-
ing out on developing and imple-
menting 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/re-
search design and contributed to writing,
data collection and analysis, and project
April 2013
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management. Ms Bury provided study par-
ticipants 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 Presi-
dent 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 repre-
sent 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
WCPT’s 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
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 April 2013
Appendix.
Global Map of Direct Access and Self-Referrala

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Volume 93 Number 4
a
Those countries not colored either did not respond to the survey or do not have a World Confederation for Physical Therapy (WCPT) member organization.

Physical Therapy f
459
A Global View of Direct Access and Patient Self-Referral to Physical Therapy
 A Global View of Direct Access and Patient
Self-Referral to Physical Therapy: Implications for
the Profession
Tracy J. Bury and Emma K. Stokes
PHYS THER. 2013; 93:449-459.
Originally published online November 29, 2012
doi: 10.2522/ptj.20120060

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