How to work with a podiatrist

Clinical director and GP partner Dr Joe Robson shares his experience of working alongside
first contact practitioner podiatrist Richard Keating, now a year into the role 

Northamptonshire Rural PCN is a group of five practices in a rural setting. The network serves just over 50,000 patients, who can experience difficulties accessing specialist services that are located in urban centres.

Why did we recruit a podiatrist?
The PCN recognised that a significant percentage of demand related to musculoskeletal (MSK) conditions. We felt we could manage this more effectively by developing a primary care MSK team. Our concept was an expansion of the first contact practitioner (FCP) model, with patients directed to physiotherapists or podiatrists as appropriate. 

We hoped this would allow patients faster access to diagnosis, and also comprehensive and timely management advice. Ultimately, it’s about streamlining and improving the patient journey. However, we also wanted to enhance the areas of expertise in our teams so we could reduce demand on GP appointments.   

What did the hiring process look like?
Since podiatrists are experts in all aspects of foot and lower limb function and health, they can have 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. We were looking to recruit a podiatrist with a strong background in MSK medicine as we already have pathways for high-risk foot services in our area. 

Key requirements for the role are:

• A BSc or equivalent in podiatric medicine.
• Registration with the healthcare and professions council.
• Evidence of being able to work at master’s degree level in the practice, or willingness to undertake this on appointment.
• Experience of operating at an advanced level of practice.

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.

What does the podiatrist do for the PCN?
Our FCP podiatrist, Richard, has been in post for 12 months now. He 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. Each appointment is around 20 minutes long and the podiatrist sees, on average, 17 patients a day.

Soon after hiring Richard, we drew up criteria setting out which patients were suitable to be seen by him. In general, the podiatrist will see any foot or ankle problem for assessment.

We have found there are also benefits to using the skills of an FCP podiatrist 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, and around 1% of patients are offered nail surgery.

Richard will assess and offer treatments, including advice on footwear, exercise and off-the-shelf insoles. In addition, he can request investigations, including bloods and imaging, act on 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.

What support does the role require?
Our podiatrist works mostly autonomously. However he is subject to supervision, as required under the Health Education England (HEE) 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 competence. 

How has the podiatrist helped practices so far?
Audit is a required component of the roadmap and we hope to have hard data in the near future that show the impact the role has had. In the meantime, the patients have responded positively to this direct access to a podiatrist.

Primary care colleagues also report that they feel under less strain. They no longer have to deal with common conditions like plantar fasciitis, which frees them up to focus on problems that require their specific skills. 

In addition, colleagues have also found that taking a more team-oriented approach has benefited their learning. 

Richard has developed a good working relationship with local orthopaedic and podiatric surgery departments, which have reported they are happy with the conservative care patients receive prior to their referral.

Dr Joe Robson is CD at Northamptonshire Rural PCN and a GP partner at Greens Norton and Weedon Medical Practice, Towcester, Northhamptonshire
Richard Keating is an FCP podiatrist at Northamptonshire Rural PCN