First contact – how ‘first contact practitioners’ are changing musculoskeletal care

NHS England’s “first contact practitioner” pilot schemes are testing whether directing patients with musculoskeletal conditions to specialist physiotherapists rather than to a GP can ease the workload on primary care, streamline care and improve recovery. Georgina Pike outlines how one pilot is working and how, in time, such models might complement occupational health.

The NHS, as we all know, is facing a staffing crisis. A dwindling healthcare workforce is struggling to manage the rapidly increasing burden of an ageing population, many with chronic co-morbidities.

Many healthcare professionals are reaching burnout and service outcomes are worsening. With the deficit between supply and demand increasing each year, waiting times to be seen by a health professional are only set to get longer, with some people already unable to get an appointment with their GP for up to six weeks.

About the author

Georgina Pike is a freelance writer who works with Surrey Physio

For those with musculoskeletal (MSK) complaints, for example back pain, waiting six weeks to be referred to see a physiotherapist (which may subsequently take another six weeks) is a painful process, quite literally. It means increasing time spent with their disability (and potentially time off work if they are of working age), in turn decreasing quality of life which, again in turn, can lead to mental and emotional health problems and make eventually returning to work that much harder.

The cost of this, is not just in terms of the physical and emotional toll on the individual patient. MSK-related workplace absence is already high, incurring significant financial costs to businesses. Lower back pain is a leading cause of occupational disability, which means – as occupational health professionals know only too well – that managing the burden of MSK health is much more than just an individual or public health issue.

The demand/access/capacity pressures facing both occupational health specifically and the NHS more widely (especially primary care) are a problem that necessitates large-scale system change and imaginative thinking.

For occupational health, as has been discussed in Occupational Health & Wellbeing over the past few months, it is likely to mean more collaborative, multi-disciplinary and inter-disciplinary working, as well as looking for creative solutions to OH’s own capacity and workforce issues.

How to extend and improve access to occupational and workplace health and support was of course also at the heart of the government’s Health is everyone’s business: proposals to reduce ill health-related job loss workplace health consultation.

Workplace support through primary care

Unlocking and improving access to primary care is key as, after all, primary care is still the healthcare “gatekeeper”; the first port of call for most patients for their healthcare needs, irrespective of whether they have access to more specialised occupational health support through their employer.

This is where a pilot programme being run by Surrey Physio (www.surreyphysio.co.uk) a group of specialist MSK clinics based in Croydon, Sutton and north east Hampshire is potentially breaking new ground.

The “first contact practitioner” (FCP) pilot involves shifting from just treating one-off episodes of illness via a GP to encouraging preventative and rehabilitative measures, as well as enabling access to specialist assessment on first contact with primary care.

The FCP is a musculoskeletal specialist who assesses those with physical complaints and either offers rehabilitative guidance or refers on to the appropriate secondary service. NHS England has outlined ambitions to have an FCP operating out of all GP surgeries by April 2024, and so FCPs may well yet become a familiar sight within primary care.

But how does this approach work? What does the pilot service look like, what are the potential challenges of implementation and, crucially of course, what are the implications here for occupational health?

Specifications for first contact practitioner interventions

Surrey Physio offers a range of MSK-based treatments, including physiotherapy, osteopathy and sports massage. It is a primary “any qualified provider” (AQP) for NHS community services and has been piloting an FCP service for more than a year.

As with getting any new initiative off the ground, there has been both an element of trial and error and a need for ongoing education and communication, as Surrey Physio chief executive Tim Allardyce explains; “The initial start-up can be tricky; we’re breaking new ground. Lots of people don’t even know what an FCP is yet, let alone how to implement an FCP service into routine practice. Everyone has lots of questions.”

Specification for high-impact FCP interventions was published last year by NHS England along with guidance from the Chartered Society of Physiotherapy (CPS). However, for most areas, the practical details are yet to be ironed out. Understanding funding, establishing lines of accountability and ensuring quality control are some of the unanswered challenges faced by those tasked with implementation.

The FCP service run by Surrey Physio consists of weekly four-hour clinics that take place on site in each GP surgery.

Reception staff and GPs can refer patients with MSK complaints to see an advanced-level physiotherapist for expert assessment and diagnosis. FCPs may make referrals to secondary specialist services, for example orthopaedics or community physiotherapy. Where appropriate, they aim to offer lifestyle advice and rehabilitative guidance, for example exercises that patients can do from home.

“The most important thing is for an FCP to be well-integrated within the multi-disciplinary team,” emphasises Ben Coffey, consultant physiotherapist and clinical lead for Surrey Physio’s FCP service.

“Building strong working relationships within the GP practice as well as with local secondary services is essential for ensuring continuity of care,” he adds.

FCPs are trained to be able to identify “red flag” symptoms that may indicate a serious underlying medical condition, however, regularly consulting with other professionals is, naturally, also a key part of FCP best practice. Practice staff are invited to seek expert support whenever needed. The FCP also attends weekly team meetings and presents training for continuing professional development.

Learning points from the FCP model

There is much to learn and work through under this new model. For example, one learning point arising from the pilot process is the challenge physiotherapists can face in terms of getting used to much shorter assessment times.

Whereas it is often standard in community treatment services to offer a 30-minute assessment, an FCP must assess, diagnose and make a treatment decision within a 20-minute time-slot.

“It is essential that our FCPs have reached a particular competence and received specialist training before they take on the role,” says Ben Coffey. “In addition, there is significant scope for isolation, as physiotherapists are keen to be around other physiotherapists, especially for continuing professional development. An FCP will need to perform a physical assessment, make a referral or offer a prescription of exercises/steroid injection, all within a very limited timeframe. There is little room for error.”

One solution Surrey Physio has come up with is “Rehab Me”, an innovative prescription software that allows each FCP to quickly and easily recommend exercises or lifestyle guidance supported by an online platform.

This not only reduces time and cuts down on paper printing, it helps to empower patients to self-manage their MSK complaints. This is because, while Rehab Me is prescribed by the MSK specialist, patients are also given a log-in that allows them to access a bespoke exercise programme from home.

There is an option to regularly self-monitor outcomes, for example severity of pain, as well as links to community programmes, volunteer opportunities and charitable organisations.

The software can even send an alert to the patient when they need to move on to the next exercise in their programme or book a review appointment.

“Rehab Me plays a vital role in enabling much needed system change,” says Allardyce. “Encouraging people to self-manage their musculoskeletal health, make lifestyle changes and get involved in community activity are all really important for improving outcomes and reducing the burden on NHS services.”

Allardyce and his team were recently awarded a grant by The Osteopathic Foundation, a charitable trust set up to advance osteopathic practice, to fund a further pilot assessing whether osteopaths can also perform the FCP role.

As allied healthcare practitioners, and with a suspected shortage of band 7 and band 8a physiotherapists, the hope is that osteopaths could potentially fill at least some of the workforce/capacity gap in this context.

“Osteopaths have a minimum of four years of musculoskeletal training but have generally been under-utilised thus far in the NHS,” says Allardyce. “I would like to see osteopathy becoming more integrated into primary care as a trusted and skilled profession.” This pilot is due to start from this month (January 2020) and should take around four months before any results become clear.

Ramifications for occupational health

Finally, occupational/workplace factors such as repetitive strain and job-related stress are of course significant factors in the onset and recovery of MSK complaints.

It is therefore hoped that FCPs could, in time, play an important role in supporting or managing occupational ill health within the primary care setting; complementing and working with employer-funded OH provision.

Offering specialist assessment via a GP could help to reduce workplace absenteeism by providing the right support in the early stages of absence. This form of early, primary care (yet also specialist) based intervention could help to prevent a condition worsening, as well as the development of subsequent health complaints, for example, depression, which could become chronic. This, in turn, could facilitate quicker return to work. The full impact of the FCP role is, however, yet to be seen.

To conclude, the introduction of FCPs into primary care has great promise to improve MSK health on a national scale. As most pilots, however, are still in their infancy, full outcomes are yet to be reported.

The largest scale published evaluation to date, uses the first two years of data and describes a significant reduction in onward referrals to secondary orthopaedics, as well as positive patient satisfaction.

It is important, however, to emphasise these findings are limited and further study is needed to generalise the results. The specific impact FCPs will have on the level of public and occupational health also requires further investigation.

Although the results look optimistic, it is important to consider that there are still potential challenges yet to be unearthed. With limited research exploring economic sustainability, organisational factors or patient preferences, it is uncertain how the FCP role will develop over time.

Any system change takes time and therefore it may be a while before good MSK practice is fully incorporated into public awareness. But if pilots such as FCPs can reduce the impact of MSK on society, on individuals and on UK plc, that can only be a good thing. If these sorts of creative approaches can also be made to complement and widen access to occupational health provision, that will be a bonus.

Supporting the implementation of FCPs may require health education and a willingness to adjust our expectations. Although it may be early days yet, the hope is very much that things are headed in the right direction.

  • Occupational health practitioners who wish to find out more about Surrey Physio’s FCP pilot can email Tim Allardyce on tim.allardyce@nhs.net

References
Lacobucci, G (2019). “Ongoing GP shortage puts NHS long term plan at risk, warn experts”. BMJ (Clinical research ed.) 364: l686.

Carroll C, Rick J, Pilgrim H, Cameron J, Hillage J (2010). “Workplace involvement improves return to work rates among employees with back pain on long-term sick leave: a systematic review of the effectiveness and cost-effectiveness of interventions”. Disability Rehabilitation. 32(8):607-21.

“Elective Care High Impact Interventions: First Contact Practitioner for MSK Services”. Leeds. NHS Improvement, NHS England (2019).

Downie, F, McRitchie, C, Monteith, W and Turner, H (2019). “Physiotherapist as an alternative to a GP for musculoskeletal conditions: a 2-year service evaluation of UK primary care data”. The British journal of general practice: the journal of the Royal College of General Practitioners. 69 (682): e314-e320.

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