Family Medicine and Community Health · Published 2026-04-01 · DOI 10.1136/fmch-2026-004078
Objective To characterise the organisational role configurations of physiotherapists in direct access (DA) models and describe how general practitioner (GP) gatekeeping for musculoskeletal (MSK) conditions is redistributed across health systems.Design Secondary qualitative content analysis of organisational descriptions reported in published DA/first-contact physiotherapy (FCP) studies, using a structured extraction matrix and Enhancing Transparency in Reporting the synthesis of Qualitative research (ENTREQ) reporting standards. Configuration dimensions were informed ex ante by gatekeeping and task-shifting frameworks; configurations themselves were identified inductively. A dimension of operationalised treatment authority was derived during revision from existing extraction-matrix fields.Setting Primary care settings across high-income health systems, including Beveridge-type (UK, Sweden), Bismarck-type (Netherlands, France) and pluralistic systems (USA), identified through a companion systematic review prospectively registered on the Open Science Framework (osf.io/897ub).Participants 19 empirical DA/FCP primary studies were eligible for the source review; 14 contained sufficient organisational detail for configuration mapping.Results Four configurations were empirically observed and a fifth was theoretically anticipated but not found. Autonomous first-contact MSK clinician models predominated (12 of 14 studies, predominantly Beveridge-type systems) and differentiated into two subconfigurations on the basis of operationalised treatment authority: front-end assessment and signposting (type 3a, 4 studies, including the National Health Service FCP programme) and full-episode autonomous management (type 3b, 8 studies). Protocol-governed triage with mandatory post hoc medical validation (type 2) and advanced practice with extended scope (type 4) were each observed as illustrative variants supported by a single study. DA redistributed rather than abolished gatekeeping.Conclusions In well-documented implementations, DA physiotherapy is most commonly configured as a first-contact model that redistributes GP gatekeeping for MSK conditions. This exploratory typology provides a framework for hypothesis generation and future primary research, particularly in under-represented Bismarck-type health systems.
Abstract from DOAJ. Public domain (CC0 1.0).
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