Taking responsibility for the early assessment and treatment of patients with musculoskeletal pain: a review and critical analysis

Musculoskeletal pain is common across all populations and costly in terms of impact on the individual and, more generally, on society. In most health-care systems, the first person to see the patient with a musculoskeletal problem such as back pain is the general practitioner, and access to other professionals such as physiotherapists, chiropractors, or osteopaths is still either largely controlled by a traditional medical model of referral or left to self-referral by the patient. In this paper, we examine the arguments for the general practitioner-led model and consider the arguments, and underpinning evidence, for reconsidering who should take responsibility for the early assessment and treatment of patients with musculoskeletal problems.


Introduction
Musculoskeletal pain is common across all populations and costly in terms of impact on the individual and, more generally, on society. Musculoskeletal disorders have consis tently been among the most commonly reported work-related illnesses since recording began. In the UK, an estimated 9.3 million working days were lost through these disorders in 2008-2009 [1]. In Denmark, one quarter of all health-related disability pensions are assigned because of musculoskeletal disorders, and a Dane can look forward to, on average, seven years with poorer quality of life because of musculoskeletal-related pain and disability [2].
Th e most common musculoskeletal pain problems are low back pain, shoulder pain, neck pain, and knee pain, followed by widespread pain [3]. Given projected increases in the numbers and proportions of older people in the population, the impact of these problems and the demand for musculoskeletal medicine are set to rise [4]. Patients with musculoskeletal problems require access to eff ective and timely advice, assessment, and treatment services that enable them to fulfi ll their optimum health potential and remain independent.
Studies have shown that approximately 30% to 40% of individuals with musculoskeletal complaints will consult their general practitioner (GP) about the pain [3]. Others have confi rmed the burden, in general practice, of common musculoskeletal pain, suggesting that it is the second leading reason for consultation, accounting for up to 30% of GP consultations [4]. For example, low back pain leads to approximately 7 million GP consultations per year in the UK [5] and is the second leading symptomatic cause for physician visits in the US, and, in Denmark, a family doctor sees, on average, at least one back pain patient per workday [6]. In most health-care systems, the fi rst person to see the patient with a musculoskeletal problem such as back pain is the GP, and access to other professionals such as physiotherapists is still controlled largely by a traditional medical model of referral. For example, 23% (1.6 million) of the total annual low back pain consultations in general practice in the UK result in onward referral [7], and 6.7 million musculoskeletal patients are referred each year to physiotherapy [8]. However, many patients seek care directly from health-care professionals other than their family doctor [6,9]; for example, at least one third of back pain patients in Denmark now choose to see a chiropractor as their entry into the health-care system [6], and 7.7 million adults in the US visited a chiropractor in the year 2000 [10]. Th ere is evidence that this trend is increasing; from 2000 to 2003, there was a 57% increase in US adults visiting a chiropractor [10], and from 2006 to 2010, the proportion of patients self-referring to physiotherapists in Th e Netherlands rose from 22% to 43% [11]. Th is raises the question of whether the current GP-led primary-care model for patients with musculo skeletal disorders and back pain is the best approach. Alternative options include transferring fi rst-contact care to other professional groups (such as chiropractors, physio therapists, and osteopaths) whose clinical interests and expertise more clearly focus on musculoskeletal problems, increasing and improving the training path ways of GPs or other medical doctors with musculo skeletal special interests or introducing clearer multi disci plinary care models in which a variety of professionals work together to share the responsibility for the early assessment and management of patients with musculo skeletal problems. In this paper, we examine the argu ments for the GP-led model and consider the arguments, and underpinning evidence, for reconsidering who should take responsibility for the early assessment and treatment of patients with musculoskeletal problems.

Identifying serious pathology
One of the most common arguments for the GP-led model of primary care for musculoskeletal pain problems centers on the importance of the GP in identifying serious pathology or so-called 'red fl ag' indicators of possible serious pathology [12] and ensuring urgent referral for those cases. Patients and GPs may be concerned about changing the model of care for musculoskeletal problems given the argument that the doctor is best placed to identify serious causes of musculoskeletal pain such as tumor, fracture, or infection by paying close attention to these red fl ags -clinical signs that supposedly indicate serious pathology requiring further diagnostic investigations or immediate medical attention. Fears about missed pathology have led some to question whether other health professionals, such as physio therapists, have suffi cient knowledge of diagnostic strategies [13,14]. Understandably, many patients are concerned that their musculoskeletal problem may signify a serious or progressive disease that, if treated early, can be cured. Research, however, suggests that serious disease is rarely the case in common musculoskeletal presentations. For example, in the most common musculoskeletal presentation, low back pain, the frequency of diagnoses of serious pathology is very low in patients presenting in primary care. An inception cohort of 1,172 consecutive patients receiving primary care for acute low back pain in Sydney, Australia, demonstrated a very low prevalence of serious pathology, namely 11 cases (0.9%), eight of which were vertebral fracture [15]. However, most patients in the Australian series (80.4%) had at least one red fl ag, indicating that, when used in isolation, they have little diagnostic value in the primary-care setting [16]. Evidence suggests that concentration on diff erential diagnosis and red fl ags may even divert the GP from evidence-based practice and contribute to unnecessary investigations, over-medicalization, and increased disability and costs [17]. Th ere is evidence that some relatively uncommon musculo skeletal conditions (notably rheumatoid arthritis, gout, and polymyalgia) benefi t from early diagnosis and treatment, but there is also evidence of substantial variation in the quality of early GP diagnosis and treatment (for example, [18,19]) and this variation may be related to lack of evidence about diagnostic utility of early symptoms and signs. It seems reasonable to ask for evidence about the eff ectiveness of musculo skeletal therapists in referring patients who may have such early conditions before assuming that doctors do it better and that all musculoskeletal patients must there fore be seen fi rst by a GP. Some red fl ags (such as weight loss) are common between musculoskeletal conditions and some are condition-or site-specifi c, highlighting the need for primary-care professionals to have adequate training in diff erential diagnosis and in spotting unusual presen tations of patients. Th ere is no evidence that GPs are better than other well-trained health-care profes sionals at spotting these rare cases. Rather, the evidence to date suggests that there is no diff erence in the accuracy of diagnoses reached by GPs and other professionals for musculoskeletal disorders [20]. Th is contrasts with GP management of conditions such as angina or diabetes, in which toolboxes of diagnostic and practical management skills have been acquired throughout training and in which GP interventions clearly make a diff erence.

Complexity and multimorbidity
A second argument focuses on the GP's role in the care of patients with multiple chronic conditions or multimorbidity in primary care. Multimorbidity is common in the population (58%) and in people with back pain [21]; indeed, most consultations in primary care involve people with multimorbidity (78%) [22]. Th ese patients are likely to be more complex to assess and treat and are likely to proceed to poorer clinical outcomes over time. For example, the combination of chronic musculoskeletal pain and depression is associated with clinical outcomes that are worse than those of either condition alone [23]. Some argue that musculoskeletal practitioners such as physiotherapists or chiropractors do not have the breadth of knowledge across common multimorbidities to identify and manage these patients well. It is certainly true that the patient requiring medical management of a range of chronic conditions such as diabetes or coronary heart disease, both of which occur more frequently in persons with chronic musculoskeletal pain, expects and requires the attention of a medical practitioner. However, it is also true that, ironically for the patient who has multiple health problems and who places priority on their musculoskeletal problem, there is evidence that the GP will tend to place priority on the other health conditions rather than the musculoskeletal problem [24]. Furthermore, many of the general principles of long-term manage ment of chronic health problems, such as education, support for self-care, and enhancing the individual's functional ability and quality of life despite disability, represent central tenets of physiotherapy, for example, and apply outside the fi eld of musculoskeletal pain as well [25].

The general practitioner as patient advocate in systems with gate-keeping services
For up to 100 years in many countries such as the UK, Denmark, Norway, and Sweden [26], the GP has had a pivotal role in the referral of patients to medical specialists and many other health-care professionals. Th e core values of general practice include comprehensiveness of care, a focus on the person with the disease and their psycho social context, continuity of care, and the doctorpatient relationship over time, and these encourage the GP to take responsibility for the whole patient, irrespective of the specifi c health problem [27]. It has been argued that most patients in such 'gate-keeping' systems of health care value having one point of initial contact with a health professional they know and trust when experi encing signifi cant heal th concerns and that, if allowed to choose their primary care through direct access to specialists, patients often do not go to the right specialist, because they do not have the ability or confi dence to select appropriate care [28]. Although the primary reason for introducing this principle of referral, or the 'gate-keeping role' , was the protec tion of the income of GPs [26], some believe that it has proved to be a sensible and important way of regulat ing and coordinating primary and secondary health care [26], ensuring the cost-eff ectiveness of health services such as the National Health Service (NHS) in the UK [29] and the cost-eff ective delivery of health services more broadly [30]. Th e move to 'single issue' services such as those for diabetes, depression, or musculoskeletal condi tions can be thought of as representing a 'cherry picking' approach to health care [27] that may not, in the longer term, lead to improvements in population health and risk diversifi cation but rather risks increased diversifi cation and fragmentation of primary care.

General practitioners with special interest in musculoskeletal medicine
Concerns about the long waiting times for consultant appointments following GP referral and claims that many referrals by GPs to specialists were inappropriate or unnecessary fuelled the call for, and development of, GPs with special interests (GPSIs). Th e emergence of GPSIs in some countries such as the UK and Denmark off ers the potential for more care to be provided closer to home [31] and for referrals to hospital consultants to be reduced. In 2004, there were approximately 1,300 GPSIs in the UK across a wide range of health conditions; by 2011, there were in the region of 3,000 to 4,500 GPSIs. Each of the 152 Primary Care Trusts in England, for example, has approximately 20 to 30 GPSIs across clinical fi elds such as dermatology and gynecology and, less commonly, rheumatology, pain, and musculoskeletal. Th ere is great variation across the UK in terms of the GPSI role, job specifi cation, qualifi cations, and governance arrangements. Any one Primary Care Trust may have only two or three GPSIs in musculoskeletal pain, and, although GPSIs clearly have the potential to enhance the primary-care management of patients with musculoskeletal conditions, their small numbers relative to patient demand means that GPSIs alone cannot provide a comprehensive solution in the UK. Similarly, in Denmark, the Society for Musculoskeletal Medicine lists fewer than 100 out of a total of around 3,500 GPs who are certifi ed in musculoskeletal medicine.

Arguments for considering other models of fi rst-contact care for musculoskeletal patients
Although there are clearly multiple arguments in support of retaining the GP-led model of primary care for patients with musculoskeletal pain, there are increasingly compelling arguments for rethinking who should take responsibility for fi rst-contact musculoskeletal care. First supported by a study in the British Medical Journal over 20 years ago [32] is the drive for professionals other than the GP to act as fi rst port-of-call for musculoskeletal problems. Such 'primary-care musculoskeletal specialists' could provide extended and consistent evidence-based management and hence optimize the opportunity for better clinical outcomes from current episodes of pain as well as better promote secondary prevention. Th e GP could then become involved in the care of the minority of patients with complex health problems or in the minority of patients needing a more extensive investigation. Th e arguments in favor of reconsidering the model of fi rstcontact care for patients with musculoskeletal problems include advantages to patients, to musculoskeletal therapists such as physiotherapists and chiropractors, and to GPs themselves.

The potential for improved patient care
One challenge for GPs is that the management of many musculoskeletal conditions in primary care is about symptoms and function, movement and rehabilitation, activity, and positive attitudes rather than the traditional medical model of diagnosis and medical treatment. Previous studies confi rm that patients with common musculoskeletal conditions such as osteoarthritis or back pain report GPs 'not taking their complaint seriously' [33] and therefore patients are left with the message that 'there is nothing to be done' . It seems sensible, therefore, to consider whether professional groups who actively embrace evidence-based care of patients with these conditions and who are actively engaged in leading training and research in these fi elds should be 'keeping the gate' for people who seek care for musculoskeletal problems.
Current GP care for musculoskeletal conditions is variable, consisting mostly of medication, brief advice [17,34], and relatively poor information about prognosis [35]. A recent Australian survey showed that usual care for patients with back pain does not, on average, match care endorsed by international, evidence-based guidelines [17] and that GPs favor expensive management strategies, including medication and imag ing, over simpler and universally recommended treat ments. Pathways of care for patients presenting with musculoskeletal pain are often chaotic [36], and GPs manage patients themselves or refer them to any one or more of several providers and agencies, ranging from interface services, telephone triage services, physio therapy services, complementary and alternative medicine (CAM) practitioners, podiatry services, and pain management services to traditional hospital orthopedic and rheuma tology services. Furthermore, there is evidence that many GPs lack an understanding of what musculoskeletal professionals such as physiotherapists or chiropractors can off er their patients [37] or the value of treat ments (such as exercise) off ered by these profes sionals [38]. Clinical guidelines for the management of common musculoskeletal problems such as back pain [5] and joint pain attributed to osteoarthritis [39,40] recommend pharmaco logical treatments, physical treatments such as exercise, and (for those not responding well to these treatment options) considerations of psychological treat ments or surgery or both. At present, patient care is fragmented, GPs mostly off er advice and medication, and onward referral to other professional groups determines access to additional treatments. Recent initiatives to widen medica tion-prescribing rights to allied health professionals, including physiotherapists [41], and evi dence that such professionals can be up-skilled to deliver clinically eff ective and psychologically informed inter ven tions using princi ples of cognitive-behavioral therapy [42,43] high light the possibilities, and benefi ts, of greater engagement of these professionals in the provision of best primary care. Th ese developments may relieve a currently unnecessary burden on GPs who are asked simply to write a pres crip tion for pain medication recommended by the physio therapist.
In addition, there is evidence that early intervention in general, and early treatment by physiotherapists in particular, for common musculo skeletal problems such as low back pain can reduce the amount of time people are off sick and can help to prevent acute problems from becoming chronic [5,[44][45][46]. Although early intensive treatment is not always benefi cial for recovery in musculoskeletal injuries [47], services that ensure timely access to care for musculo skeletal pain contribute importantly to patient experience and satisfaction [48]. Furthermore, there is evidence that patients going directly to see musculoskeletal prac titioners such as physiotherapists are not at risk of having their serious medical conditions overlooked [49] and that experienced physiotherapists have the same level of knowledge as orthopedic specialists [50,51], demonstrat ing good clinical diagnostic accuracy [52] and manage ment decisions [53]. Th ere is also evidence to suggest that models of care led by musculoskeletal professionals such as physiotherapists lead to fewer prescriptions and investigations, decreased need for expensive and invasive treatments [54,55], and fewer consultations back in the health-care system [56].
Th e best evidence from clinical trials indicates that primary-care treatments can achieve modest but defi nite improvements for patients with back pain. Encouraging people to stay active and at work, helping patients adjust their beliefs and expectations to realistic but achievable goals, and off ering simple analgesia and a range of interventions such as exercise, manual therapy, and acupuncture as well as support for rehabilitation to the workplace should result in less suff ering, disability, and missed work. Th ese core treatments are consistently recom mended in national and international guidelines [5,57] and are those that musculoskeletal practitioners such as physio therapists, chiropractors, and osteopaths are specifi cally equipped to deliver. Many high-quality trials of diff erent interventions test treatments versus a control group of usual primary care initiated by the GP; in most of these trials, the treatments are shown to be superior to such usual primary care [58], although the size of the average diff erences between groups is generally small to moderate. Cost-eff ectiveness data from randomized clinical trials indicate that primary care for patients with low back pain is not cost-eff ective unless it also involves one or more added components such as exercise, spinal manipulation, or behavioral counseling [59].
Clearly, it is important that the overall eff ectiveness and potential challenges of a front-line service run by primary-care musculoskeletal specialists be evaluated critically and that appropriate training, education, and development of practitioners to provide such a service be supported and maintained. Ferguson and colleagues [60] have high lighted the need for ongoing education of physiothera pists in the systematic recording of red fl ags. Th e evidence for specifi c interventions off ered by musculo skeletal practitioners such as exercise and manual therapy varies from trial to trial; although the results of these trials may be attributed, at least in part, to the heterogeneous populations of patients recruited [58], the varying eff ectiveness of practitioners and their interven tions needs to be considered also. Th e performance of such practitioners needs to be critically reviewed; there is evidence that many physiotherapists in the US, for example, may not be delivering guideline-based care [61] and that their counterparts in the UK may be working, as do many GPs, within more of a traditional biomedical model rather than an active behavioral model of rehabilitation [34]. However, our view is that the evidence to date provides good reason to suppose that a model in which front-line primary care is provided by a range of musculoskeletal professionals such as physiotherapists and chiropractors and in which GPs serve as a route of second-line referral will be just as safe and eff ective as the current GP-led model and provides suffi cient reason to suppose that it could provide more appropriate, effi cient, and eff ective care for most primary-care consulters with musculoskeletal problems. Th ese suppositions, of course, need to be tested to estimate the costs and benefi ts of making a switch from the current model; the evidence to date supports the rationale for large-scale prospective evalua tions of such service development and change, and pilot studies have shown that musculoskeletal practitioners such as chiropractors can, and are ready to, be included in national quality development systems [62].

Meeting patient demand through improved choice for patients
Greater freedom of choice in addition to improved and faster access to musculoskeletal care are further advantages for patients off ered an open service to musculoskeletal practitioners [13,63]. Th is is important because the expected increased burden of musculoskeletal pain over the next 50 years means that current models of care need to be re-evaluated in order to provide musculoskeletal services that meet rising patient demand. Musculoskeletal pain has not yet been a national healthcare priority in most countries, but, given the aging population, the burden to society will continue to rise in the future [64].
Previous changes to musculoskeletal services have already devolved much care from hospital and specialist centers to primary care (for example, in the UK through the introduction of Clinical Assessment and Treatment (CAT) services [4] at the interface between primary and secondary care). Many of these CAT services employ health profes sionals such as physiotherapists to carry out initial patient triage and place the patient in the most appro priate pathway of care [65,66]. In Sweden, many orthopedic departments now use physiotherapists as front-line diagnosticians in triaging patients with osteoarthritis. In both countries, this has resulted in dramatic reductions in waiting lists for patients waiting to see rheumatologists [65] and surgeons [67] as well as good patient outcomes over time [66]. Patient choice suggests that this could be achieved in primary care. In Denmark, at least one third of patients with back pain now choose to see a chiropractor as their entry into the health-care system [6]; in the US, more than half of people who had suff ered from back or neck pain during the past year had consulted an alternative health-care practitioner, most commonly a chiropractor or massage therapist, whereas only one third had been seen by a conventional provider [9].
Th ere is growing evidence in favor of changing the GPled model of care. Self-referral to physiotherapists is well established in countries such as Australia, New Zealand, Canada, most states of the US, Th e Netherlands, and Scotland and in some services in England [68][69][70]. Th e Netherlands has operated direct access to physiotherapists since 2006, and an evaluation shows that this is particularly popular with younger patients, those with higher levels of education, those with the most common musculoskeletal complaints of back and neck pain, and those with recurrent pain problems [13]. In addition, data show increasing proportions of patients choosing to directly access physiotherapists, from 22% in the year of introduction of self-referral to 43% over the course of a 4-year period [11]. Direct access and freedom of choice about fi rst-contact care for musculoskeletal problems thus clearly satisfy a need among patients. Evaluations of self-referral to physiotherapy have shown high patient satisfaction and have shown that GPs and physiotherapists strongly support having physio therapists work at the fi rst point of contact [13,71] for musculoskeletal problems. It also appears, from non-randomized studies, that self-referral to physiotherapy can be cost-eff ective [55]. Data on self-referral to physiotherapy in Scotland indicated that the average cost of an episode of care was £66.31 compared with £88.99 for a GP referral, suggesting an estimated cost benefi t to NHS Scotland of £2 million per year [55]. Recent self-referral pilots across six Primary Care Trusts in England highlighted a reduction in the number of associated NHS costs, particularly for investigations and prescribing, and 75% of patients who self-referred did not require a prescription for medicines. Self-referral to physiotherapy did not lead to an increase in demand for services and led to reduced work absence among patients [72]. Evalu ations of the introduction of self-referral to physiotherapy in Th e Netherlands showed that self-referring patients were treated in fewer treatment sessions (average of 2.3 fewer treatment sessions) and that overall there was no increase in the number of patients visiting a physio thera pist in comparison with the year before the introduction of self-referral [13]. In regard to chiropractors, patients have traditionally self-referred to chiropractors, and recent evidence suggests that chiropractors in the UK already view themselves as primary-contact practitioners within the musculo skeletal fi eld [73]. Patient satisfaction for chiropractic treatment is high [74], and there is evidence that back pain patients treated by chiropractors incur lower costs (due mostly to less advanced imaging) than patients treated by GPs [75]. Th ere is, however, also evidence suggesting that the characteristics of patients seeking care may not be comparable to those of patients seeking care from GPs [6,54,71].

Increased professional responsibility for allied health professionals
In many countries, health-care professionals such as physiotherapists, chiropractors, osteopaths, and exercise therapists are in important positions to provide support for active self-management and positive treatment options -especially interventions related to exercise and prevention of future episodes -for patients with musculo skeletal conditions. Furthermore, there is emerging evidence that prevention and treatment of musculoskeletal prob lems in the aging population can be tied to preven tion and treatment of other public health problems through the promotion of an active lifestyle and targeted exercise [76], an area in which primary-care performance is suboptimal [77].
Alternative models of care led by other health professionals are already well established in private practice and in many health services, including those in Australia, Denmark, and Th e Netherlands and some in the UK. Such services provide the opportunity for increased professional responsibility and challenge for musculoskeletal practitioners as they make their own decisions autonomously and in direct partnership with their patients. Th ese professionals are interested and well educated in the diagnosis and management of musculoskeletal conditions and their care is associated with better clinical outcomes [45] and greater patient satisfaction [6,74,78] and cost-eff ectiveness [55,75,79] in comparison with GP care alone [59]. If patients fi rst see these musculoskeletal practitioners, the majority are unlikely to require the input of GPs or secondary-care specialists [45] and those who do may be more likely to benefi t from those consultations.
It is important to note again the lack of randomized controlled trials to assess the eff ectiveness of these new models of care. Th ere are clear parallels with other services, however. Examples include oral health and dentistry and eye health and optometry, which provide well-established models of fi rst-contact care for patients and from which patients with suspected serious or other pathology are then referred to their GP. Dentists are even licensed to perform surgery and have limited prescription rights. Th e potential benefi ts for musculoskeletal practitioners such as physiotherapists and chiropractors are considerable, but further evidence, preferably in the form of controlled clinical trial evidence about clinical and cost outcomes, is needed.

Reducing the workload of general practitioners
Changing the care pathways for patients with common musculoskeletal problems is expected to be met with resistance at the organizational level but is likely to be a relief to many GPs [80]. Direct access to musculoskeletal specialists may reduce the workload of GPs. For example, in the year of introduction of direct access to physiotherapy in Th e Netherlands, more than one fi fth of all patients seen by physical therapists came via direct access and these were not a new group of patients [13] but were those with recurrent musculoskeletal problems who normally would have consulted their GP.
Traditionally, GPs receive little training in common musculoskeletal problems in undergraduate medical school, during medical internship, and in post-graduate education [81] and often have limited knowledge about the suite of non-pharmacological treatments available to patients. Surveys and interviews indicate a lack of confidence in examining and providing treatment to patients with back pain, and many GPs feel ill equipped, either relying on pharmacological management or subsequently referring patients to doctors with special qualifi cations or to physiotherapists, chiropractors, or osteopaths [6,17,80]. Th is limited knowledge base con trasts starkly with that of musculoskeletal professionals such as physiotherapists, chiropractors, and osteopaths. Research and academic developments in the fi eld of musculoskeletal pain are led by a range of health professionals, from physiotherapists and chiropractors to rheumatologists and psychologists, and musculoskeletal pain is a relatively neglected academic area for general practice despite its substantial impact on the workload of GPs. Th is means that much of the knowledge being generated about the assessment and management of musculoskeletal pain is seen as core business by those within physiotherapy and other musculoskeletal profes sional groups but rather less by the professional group (GPs) that most often provides front-line care for these patients.

The future of front-line care for musculoskeletal patients
At present, one can rightfully question whether physiotherapists, chiropractors, or osteopaths are capable of completely fi lling the role of primary-care provider for common musculoskeletal conditions and the extent to which their range of treatments have yet to establish a clear evidence base. Furthermore, important issues of improvements in basic training of these professions need to be addressed, and professional development and postgraduate education are required in varying degrees.
However, the important challenge is to develop a coherent health-care system that eff ectively deals with the prevention, treatment, and rehabilitation of musculoskeletal disorders and that involves all available resources and professions. Th us, the question we raise here is a practical one -whether to continue to organize primary care for musculoskeletal problems around GPs or to more clearly support physiotherapists, chiropractors, and osteopaths to increasingly move into fi rst-contact care roles. We suggest that debate, evaluation, evidence, and gradual change rather than radical transformation are needed. One potentially fruitful path could be to integrate education of these professions with each other and also with the education of medical doctors so that professional barriers and suspicions could be broken down, a common language developed, and new and innovative strategies for practice created. Such integration of education has been ongoing for almost 20 years at one Faculty of Health Sciences in Denmark, where education of chiropractors is completely integrated in the education of medical doctors. Recently, government commissions in Norway and Sweden recommended that similar educational approaches be implemented and that they also include physiotherapy. Th is type of model ensures that musculoskeletal practitioners have a high level of diagnostic skills both inside and, importantly, outside of the musculoskeletal fi eld [82].
Important questions of effi cacy and cost-eff ectiveness of interventions off ered by any professional group caring for patients with musculoskeletal pain remain to be researched and resolved, and there is evidence that a substantial proportion of patients can be managed eff ectively with minimal but nevertheless active inter vention [5,43]. Non-medical professions are well accepted as primary-care providers of oral and dental health, visual health, and many aspects of mental health, and clinicians such as nurses and pharmacists have been shown to improve both quality and cost-eff ectiveness in the management of many conditions. We think it is time to debate and re-think the way front-line musculoskeletal care is delivered in our health services. Th e models we have reviewed and suggested need to incorporate and clarify the role of the GP, including providing appropriate medical care for those patients who are referred to them with potentially serious pathology, uncommon conditions requiring the care of a medical doctor, or complex medical care needs.

Conclusions
Th ere are clear arguments for and against challenging the current GP-led primary-care model for patients with musculoskeletal pain. In our opinion, the projection of societal burden related to musculoskeletal conditions and recent research evidence about best care for these patients add considerable weight to the argument for working toward changing the current model. We propose that it is time to have this debate with openness, dialogue, and curiosity and to set aside professional tensions and traditional hierarchies. Although such tensions are under standable, focusing on them draws attention away from the primary goal, namely to improve the care of patients with musculoskeletal problems. Any change in care pathways will, of course, need to be closely examined in terms of patient experience, safety, and clinical and cost-eff ectiveness.

Abbreviations
CAT, Clinical Assessment and Treatment; GP, general practitioner; GPSI, general practitioner with special interests; NHS, National Health Service.

Competing interests
NEF is a physiotherapist who leads a program of primary-care intervention research focused on musculoskeletal pain. JH practiced as a chiropractor for 12 years before becoming a full-time academic. He currently leads a multidisciplinary research program in musculoskeletal health with a focus on spine pain at the University of Southern Denmark. PRC practiced as a family doctor for several years and continues to contribute to general practice education and research; he is a full-time researcher, working closely with GPs, rheumatologists, and therapists from a range of musculoskeletal disciplines.

Authors' information
NEF is a physiotherapist who leads a portfolio of intervention research for patients with common musculoskeletal pain problems in primary care. JH is a chiropractor who leads a comprehensive research program in musculoskeletal health at the University of Southern Denmark. PRC is a GP by background and epidemiologist by current practice.