Workforce/HR/Employment law Primary Care Networks

How PCNs can get the most from first contact physiotherapists

GP Dr Maggie Walker and MSK physiotherapist Jehan Yehia describe their local model for employing first contact physios and measures taken to ensure the role has maximum impact in primary care

The development of roles that support GPs is growing as rising workload has been matched by increasing patient concerns about convenient access. Hiring physiotherapists as part of the Additional Roles Reimbursement Scheme (ARRS) can be an effective solution in easing primary care workload and changing the workforce’s make-up.

Why did your PCNs employ first contact physiotherapists (FCPs)?

When ARRs funding came into play, all five PCNs in Kingston upon Thames, South West London were keen to have physiotherapists on board. Physiotherapy is a role familiar to GPs and as specialists in musculoskeletal (MSK), it was easy to see how they could benefit primary care to help with MSK conditions, reduce community referrals and improve patient outcomes.

Locally, there were also long waiting lists for outpatient physiotherapy and it was hoped that offering this service within primary care would help patients receive more timely care.

What did you hope to achieve by adding this new role?

Since it’s estimated that MSK conditions make up 30% of GP appointments, one of the main aims was to ease pressure on GPs by reallocating appointments for patients with MSK conditions to first contact practitioners. FCPs are diagnostic clinicians who work independently and can give expert advice, manage complexity and refer to specialist services.

Having MSK experts integrated into primary care allows patients to have quick and local access to expert MSK assessment, diagnosis, treatment, and advice.

What did the hiring process look like and what were the key requirements of the post?

There are a number of recruitment models PCNs can follow, each with benefits and challenges. The main consideration for any model is that governance and supervision arrangements are well thought through.

Our model was based on PCNs recruiting the FCPs but with support provided from Kingston Training Hub (KTH), which is funded by HEE and supports education and training within primary care.

Each PCN has one full-time equivalent FCP working at Band 7 to 8a on the Agenda for Change scale . Each practitioner provides a service for between three and six GP practices, with their time divided according to the size of patient population at each practice.

In our experience, one FCP working across two to three sites is manageable, but anything more becomes quite challenging. This is mainly due to differences in how each practice works and the number of lines of communication.

As set out by the Network Contract DES21/22, PCNs employing a first contact physiotherapist under the ARRS must ensure they have these qualifications :

an undergraduate degree in physiotherapy
a Master’s Level qualification or the equivalent specialist knowledge, skills and experience
able to work at Level 7 capability in MSK related areas of practice or equivalent (such as advanced assessment diagnosis and treatment)
able to operate at an advanced level of practice
be registered with the Health and Care Professional Council.

It’s important that GPs find candidates working at the correct level – an under qualified practitioner could risk patient safety. PCNs should hire practitioners working at between Band 7 and 8a. The full range of their capabilities can be seen at Health Education England’s First Contact Practitioners and Advanced Practitioners in Primary Care: (Musculoskeletal) A Roadmap to Practice.

KTH created a Governance FCP Lead role to support GPs with the logistics of employing FCPs. Having this post in place to focus on governance and quality assurance means that GP time can be used elsewhere. A standard operating procedure was also created for recruitment, induction, governance and supervision, including CPD supervision.

Our approach means our FCPs are working as part of a GP practice and have an allocated GP supervisor/mentor as well as an FCP supervisor, so the work-based assessment and supervision responsibilities are shared. The GP mentor oversees non-MSK and primary care development. We believe it’s important that MSK practitioners can learn from their GP colleagues because it ensures the FCP post develops as an integrated primary care role (as opposed to them being an MSK practitioner located in a GP practice but working separately).

For GPs, major challenges are finding the time for supervision and understanding the scope of the role. However, these are both vital if practices and PCNs are to get the most out of this new resource. Any time invested into supervising an FCP is rewarded by improvements in patient safety and outcomes, and also in the retention of practitioners since they are supported in achieving Advanced Practitioner status. In addition, improved understanding of FCPs leads to more integrated working.

What does the FCPs’ working week look like and what do they do for the PCN?

Each of our PCNs has an average population of 41,800. An FCP provides the equivalent of 10 hours for every 6,000 patients. FCPs have 80% of their time allocated to clinical work and 20% to non-clinical work, and complete a 2.5-hour CPD session every month. They will have a mix of face-to-face appointments and telephone follow-ups. Appointment times are usually 20 to 30 minutes.

Every FCP is mentored by a GP supervisor and meets once a week with an MSK supervisor who has completed the HEE supervisor training.

FCPs can take on any patient presenting with an MSK condition, acting as the first contact without the need for a GP referral. They can diagnose, screen, identify red flags and also refer any non-MSK issues back to the GP. When FCPs have provided evidence for competency, they can order imaging, blood tests, refer to orthopaedics, rheumatology and neurosurgery. They can also upskill by completing a non-medical prescribing module, so they can undertake non-medical prescribing. In addition, FCPs can help with long-term conditions such as osteoporosis screening and management. Most of our FCPs have undertaken health coaching to help with the management of long-term conditions and obesity, and for supporting the management of frail patients in primary care.

What support does the role require?

It is important to have a supervision programme in place with a named GP supervisor who can provide debriefing sessions soon after the FCP starts in their role. GPs wanting to become a practice supervisor will need to attend a two-day course (GP trainers only need complete a two-hour top up session).

You will get more out of the FCP role if it is integrated effectively into the wider team. This involves providing a full induction, especially important for those FCPs who haven’t worked in a primary care setting before. The Chartered Society of Physiotherapy provides a useful checklist for carrying FCP staff inductions.

Also ensure practitioners are clear who their ‘go-to’ person is for general or clinical queries. Good communication is key.

How have FCPs successfully helped practices so far?

Data from a 2021 audit of 40 patients at one practice, Canbury Medical Centre, showed that the FCP service potentially reduced the need for 270 face-to-face consultations with a GP.

Other outcomes over a three-month period were:

82% of the patients were seen once and did not present again for the same problem.
15% were referred on to an MSK service.
12% were referred back to the GP for other management.
12% were referred to a community physio.
16% were given an onward referral.
41% received social prescribing.

How might the role develop in future?

The FCP role is new role and is still developing and evolving. With the right development and support, they could be instrumental in delivering patient-centred care of MSK and long-term conditions in Primary Care.

Dr Maggie Walker is a GP and clinical director at Canbury Churchill Orchard Berrylands PCN. Jehan Yehia is an MSK Physiotherapist, FCP Lead and Governance Lead in Kingston and FCP at Canbury Medical Centre. She is working at Advanced Practice Level.