Clinical director and GP partner Dr Joe Robson shares his experience of working alongside FCP Podiatrist Richard Keating, now a year into the role
Northamptonshire Rural PCN is a group of five GP practices all based within a rural setting.
The network serves just over 50,000 patients, with a population skewed towards an older demographic, but that also includes a significant number of commuters. Patients can experience some difficulty accessing specialist services, which are often located in urban centres.
Our PCN team currently comprises a core team of two social prescribers, three care coordinators, nine pharmacists, one pharmacy technician , two physiotherapists and, of course, a podiatrist.
The PCN recognised that a significant percentage of both chronic and on-the-day demand related to musculoskeletal (MSK) conditions. We felt we could manage this more effectively and efficiently by developing a primary care MSK team. Our concept was an expansion of the First Contact Practitioner model, with patients navigated to either physiotherapists or podiatrists, as appropriate. Further support was provided by GPs at each practice, three of which have an interest in MSK medicine.
By coordinating clinics in this way, we hoped it would allow patients faster access to both diagnosis, and also comprehensive and timely management advice.
Ultimately, it’s about streamlining and improving the patient journey, removing barriers and improving equality of access to specialist services for our rural patients. However, we also wanted to enhance the areas of expertise within our teams so we could reduce demand on GP appointments and free up clinicians’ time.
Since podiatrists are experts in all aspects of foot and lower limb function and health, they can have quite wide-ranging subspecialties from MSK to high risk foot management. So, it was important to ensure we recruited a podiatrist with the skills that matched our vision for our service. The podiatrist we were looking to recruit needed to have a strong background in MSK medicine as we already have very specific pathways for high risk foot services in our area. The desired skillset is something that will vary geographically between PCNs, as needs differ.
Key requirements for the role are:
The job was salary mapped between Band 7 and Band 8 on the Agenda for Change pay scale and posted on the NHS jobs website.
Our FCP podiatrist Richard has been in post for 12 months now. Since all the practices are in rural settings a central hub model does not suit our needs. Instead, Richard spends one day a week at each practice. Receptionists can book patients directly into his diary, either as a first contact or secondary contact when a GP or other clinical staff member feels the patient might benefit from his input. Each appointment is around 20 minutes long and the podiatrist sees, on average, 17 patients a day.
Soon after hiring for the role, we drew up criteria setting out which patients were suitable to be seen by Richard. This identifies problems that may need a referral to secondary care and filters out cases for routine care, such as toenail cutting, which we will signpost to the private sector. In general, the podiatrist will see any foot or ankle problem for assessment.
We have found there are benefits to using the skills of an FCP podiatrist skills in a more generic fashion. A recent audit has shown that roughly 30% of cases signposted to the FCP podiatrist by other clinicians were dermatology-based complaints, while around 1% of patients are offered nail surgery.
Richard will assess and offer appropriate treatments, including advice on footwear, exercise and off the shelf insoles. In addition, where appropriate he can request investigations, including bloods and imaging, act upon the imaging reports and refer the patient to secondary care providers for further treatment, if needed.
Treatments that can be provided under the primary care contract, such as toenail surgery and steroid injections, can also be administered.
Our podiatrist works mostly autonomously. However he is subject to supervision, as required under the HEE’s FCP Roadmap to Practice, and these are duties that involve GPs. A designated GP at PCN-level spends one to two hours a week with Richard to help him complete the Roadmap. Other nominated GPs work with Richard day-to-day, giving him a debrief at the end of each clinical session on cases outside his scope of practice until he is ‘signed off’ as having demonstrated competency. There are also other commitments such as completing a consultation observation tool (COT) once a month and clinical examination and procedural skills (CEP) sign off. Supporting the role does require investment of time but the benefits of this post outweigh these extra demands.
Audit is a required component of the Roadmap and we hope to have hard data in the near future that shows the impact of the role . In the meantime, patients have responded very positively to having direct access to a podiatrist.
Feedback from primary care colleagues has also been favourable. They report feeling under less strain, no longer having to deal with common conditions like plantar fasciitis, which frees them up to focus on problems that require their specific skills.
Colleagues have also found taking a more team-oriented approach has benefited their learning. One colleague recently reported having a greater appreciation for the different types of heel pain outside of plantar fasciitis, for example.
Richard has developed a good working relationship with local orthopaedic and podiatric surgery departments, who have said hey are happy with the increased conservative care patients are receiving prior to their referral.
Richard is in the process of completing his independent prescriber course and will also be applying for his advanced practice qualification through the Roadmap to Practice this year. A future goal is to continue to strengthen our links with secondary care and consultant colleagues, so we can deliver more services into the community. Increased upskilling could, in theory, lead to a greater range of treatment being provided across primary care, which would have obvious benefits.
Dr Joe Robson is clinical director at Northamptonshire Rural PCN and a GP partner at Greens Norton and Weedon Medical Practice. Richard Keating is an FCP podiatrist at Northamptonshire Rural PCN
Royal College of Podiatry – Podiatrists as First Contact Practitioners
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