The role of Advanced Practitioner Physiotherapists (APPs) working as First Contact Practitioners (FCPs) within GP practices was first piloted in NHSScotland in 2015.
The new 2018 GP contract (1) aimed, amongst other factors, to allow GPs to deliver the job they trained to do and to improve patient care. It recognised their role as expert generalists. Section 4 of the new contract looks specifically at “Manageable Workload” and advocated the need for Health and Social Care Partnerships (HSCPs) to embed APPs who specialised in musculoskeletal health into GP practices.
Thus, the integration of FCPs is gaining momentum.
As already mentioned, the need for the development of these roles has been advocated in the new GP contract. This was a historic collaboration between the British Medical Association (BMA) and the Scottish Government. Whilst need and wishes are important, it is paramount this is supported by both published data and internal audits of service outcomes. In July 2019 the first published peer reviewed paper evidencing the benefits of this service within Scotland was made available (2)
It is interesting to compare how we fare at NHS Ayrshire and Arran. We first commenced our pilot in January 2017, starting to collect data as of February 2017, using 3 whole time equivalent (WTE) FCPs across various GP practices. Whilst we have no formal published data, key points of our internal audit at the one year stage (presented at national level) are highlighted in the below graph:
Further key points are:
- 72% were seen as a first point of contact
- A direct saving of approximately 13,614 GP appointments
- Using a validated questionnaire, patient satisfaction rate with FCPs was almost identical to that of GPs.
Whilst it is difficult to directly compare data between our audit and published research given different measured variables, there is a clear theme of reducing the workload of our medical colleagues, empowering patients to self-manage, and maintaining high levels of patient satisfaction.
As I am reviewing what I have already written, I realise I am at risk of boring any readers with a stats overload. Therefore I will avoid disclosing any further positive stats findings from our audit (but trust that there are plenty)!
Moving Forwards in NHS Ayrshire and Arran:
Currently, we have expanded our service to employ 12 full-time equivalent FCPs. Each clinician has demonstrated the appropriate skill set as so that they can work to level 7 on the career framework for health (3) and also the threshold level of learning expected for APPs which is level 11 (Masters) on the Scottish Credit and Qualifications Framework (4)
To minimise “post-code” service provision, our service leads have ensured we are evenly spread and work within GP clusters. This means that each FCP is working in 1 or more GP practices. Furthermore, since the collation of our 1 year audit data, two of our FCPs have undergone independent prescribing training and we anticipate that eventually all of our clinicians will be able to provide this service. It would stand to reason that this will help improve the service further.
With regards to my own specific role, I work a compressed week Monday-Thursday, 8am-6pm 3 days per week and 8am-5.30pm the other. I cover 3 practices in total- practice A, B, and C. Monday is split between practice A and B with a morning clinic for A and the afternoon for B. For this afternoon clinic we are piloting using a “hosted-model” whereby I see practice B’s patients embedded A’s facilities.
Tuesday I provide a full clinic for practice A; Wednesday I provide a full clinic for practice B. Thursday I currently utilise my 3.25 hours of protected CPD time and run a normal physiotherapy diary embedded within secondary care MSK services. Being new to both the role and trust, the utilisation of protected time has been pivotal to skill development. This MSK day and CPD time are liable to evolve in future months with potential plans including linking in with another session for practice C or creating working links with orthopaedic/emergency services.
I work in an area with a generally poor socio-economic demographic and with high levels of smoking/obesity/diabetes/alcohol consumption. To an extent this comes with an increased relative risk of encountering MSK masqueraders. In the short time I have been in the role, I have been the first contact for the following presentations less likely to be seen within traditional MSK physiotherapy roles:
- 2 missed ankle/foot fractures (previously seen at A+E departments)
- Several cases of gout (upper and lower limb)
- At least 2 cases of polymyalgia rhuematica
- One motor neurone disease
- One suspected cancer
- One suspected cauda equina syndrome (awaiting urgent MRI)
From my own perspective, it is exciting to be involved the clinical delivery of such a new service. This role has enticed me to move back into the NHS after a period of time working externally. There are of course challenges with any new service, not least of which is the creation/learning of new pathways and protocols. Also, each GP practice does it “their own way”- which is not to say that is the wrong or indeed the right way! Each GP practice is also finding its feet, as they are not only integrating physiotherapists, but commonly pharmacists and community mental health practitioners. It will take us all a while to find the best way of working together. This is why I feel it is great we are having regular FCP team meetings which allow for shared learning opportunities. We can then take the things that are working from each practice and try to integrate it into our own, as well as learning from our mistakes. It seems to be the general consensus of those currently in post, that the service will evolve with time and look somewhat different (hopefully even better) than what it does now. What is great is that each GP (and indeed other healthcare professionals) seems to be embracing these changes.
Cheers for reading.
Ryan MacLeod, Advanced Practitioner Physiotherapist,NHS Ayrshire and Arran