How to… get the most from first-contact physiotherapists

GP Dr Maggie Walker and physiotherapist Jehan Yehia describe their local model for employing first-contact physios and how they ensure the role has maximum impact in primary care

When the additional roles reimbursement scheme (ARRS) funding came into play in 2020, all five PCNs in Kingston upon Thames, south-west London, were keen to have physiotherapists to help with musculoskeletal conditions, reduce community referrals and improve patient outcomes. Locally, there were long waiting lists for outpatient physiotherapy and it was hoped that this service would help patients receive more timely care. 

Since it’s estimated that musculoskeletal conditions make up 30% of GP appointments, one of the main aims was to ease pressure by allocating appointments for patients with musculoskeletal conditions to first-contact physiotherapists (FCPs).

What did the hiring process look like and what were the key requirements of the role?
Our model was based on the PCNs recruiting the FCP roles, with support from Kingston Training Hub (KTH), which is funded by Health Education England (HEE). Each PCN has one full-time equivalent FCP working at band 7 to 8a on the Agenda for Change scale. Each FCP offers services for between three and six GP practices.

In our experience, one FCP working in two to three sites is manageable, but anything more becomes challenging, because of differences in how each practice works and lines of communication. 

As set out by the Network Contract DES, PCNs employing an FCP 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.
• Level 7 capability in musculoskeletal areas of practice or equivalent (such as advanced assessment diagnosis and treatment).
• Ability to operate at an advanced level of practice.
• Registration with the Health and Care Professional Council.

KTH created a governance FCP lead role to help GPs with the logistics of employing FCPs. Our FCPs are working as part of a GP practice and have an allocated GP supervisor and mentor as well as an FCP supervisor, so work-based assessment and supervision responsibilities are shared. The GP mentor oversees non-musculoskeletal and primary care development, ensuring the FCP post develops as an integrated primary care role, not as a musculoskeletal practitioner located in a 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. Time invested in supervising an FCP is rewarded by improvements in patient safety and outcomes, and also in the retention of practitioners as they are supported in achieving advanced practitioner status. In addition, improved understanding of FCPs leads to integrated working. 

What is the FCPs working week?
Each of our PCNs has an average population of 41,800. An FCP provides the equivalent of 10 hours for every 6,000 patients. The 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. FCPs have a mix of face-to-face appointments and telephone follow-ups. Appointment times are usually 20 to 30 minutes. 

FCPs can take on any patient presenting with a musculoskeletal condition, without the need for a GP referral. They can diagnose, screen, identify red flags and also refer any non-musculoskeletal issues 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, completing a non-medical prescribing module. 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 management of long-term conditions and obesity, and to support the management of frail patients. 

What support does the role require?
It is important to have a named GP supervisor for debriefing sessions soon after the FCP starts in their role. You will get more out of the FCP role if it is integrated into the wider team with a full induction, especially for FCPs who haven’t worked in primary care before. The Chartered Society of Physiotherapy provides a checklist for FCP staff inductions.

How have FCPs helped practices so far?
Data from a 2019 audit of 40 patients at one practice, Canbury Medical Centre in Kingston upon Thames, Surrey, showed that the FCP service potentially saved 270 face-to-face consultations with a GP.

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 to a musculoskeletal service.
• 12% were referred to the GP for other management.
• 12% were referred to a community physiotherapist.
• 16% were given an onward referral.
• 41% received social prescribing.

Dr Maggie Walker is a GP and clinical director at Churchill Canbury Orchard Berrylands PCN in Kingston upon Thames, Surrey.
Jehan Yehia is a musculoskeletal physiotherapist, FCP lead and governance lead in Kingston upon Thames, south-west London, and FCP at Canbury Medical Centre in Kingston upon Thames, Surrey

To find out more about first-contact physios, see the HEE website. To find out about practice supervisor training, contact your local training hub