Successful and sustainable implementation of First Contact Physiotherapy (FCP) within Primary Care Networks
Webinar Blog and Q&A summary – 16 Sept 12.30-13.45
Connect Health “Change” brings you the second in a series of webinars to make and embed transformation in healthcare. Aimed at system leaders and clinicians across the NHS, the webinars provide practical solutions to the challenging issues we are all grappling with.
Today, we discussed the successful and sustainable implementation of FCP within primary care networks. With over 200 people signed up to take part, the intense session had over 90 questions, stimulating a great deal of quality debate.
- “Superb, well organised, good tech, well chaired, good range of speakers and topics.”
- “Pithy presentations delivered well and high value information, high quality questions and engagement.”
- “One of the most stimulating sessions of this type I have seen as evidenced by the quantity and diversity of questions.”
Background to FCP
FCP (First Contact Physiotherapy) has been championed within the NHS Long Term Plan and is considered essential to enable successful delivery. With ICS leaders committing to the phased roll out of FCP, alongside the potential possessed by FCP services to support COVID recovery, FCP implementation is moving at pace. This webinar will explore FCP from multiple perspectives to aid the successful and sustainable implementation of FCP within Primary Care Networks, including whether implementing FCP in your locality is the best use of resources.
Our Chair Andrew Cuff, Consultant Physiotherapist & Clinical Lead, Connect Health goes on to discuss why we wanted to develop this FCP webinar.
The inspiration behind focusing on this topic is two-fold
In a pre-COVID world FCP had been a hot topic for a number of years, gathering momentum throughout 2019 with increasing speed developing in early 2020. Conversations were happening with PCNs as they looked to utilise their additional role reimbursement and pilots were coming to an end. Like many things, COVID put a stop to this.
As we entered into Phase 2 recovery around July, we were starting to see that momentum around FCP implementation was picking up again. Part of the driver around this was due to the timeline associated with the DES for FCP within PCNs and partly due to the potential for FCP playing a role in supporting COVID recovery and elective backlog. With Connect Health being a national provider, it was clear that there were lots of conversations ongoing, with similar discussions, challenges and questions. To this end, we thought exploring some of these questions and challenges to and with a wider audience would be of value and brings us here to where we are today.
We had a fantastic panel of speakers that provided a 360-degree view of FCP with representation from the CSP, HEE, a GP commissioner, an ICS leader and an existing MSK pathway provider.
Watch the Webinar in Full
Amanda Hensman-Crook, Consultant MSK physiotherapist, National Health Education England AHP clinical fellow, discussed First Contact and Advanced Practitioners in primary care – a roadmap to practice.
Question 1: Why 3 years as opposed to competencies? Further reasoning regarding the min 3 years would be appreciated. Potentially restrictive to workforce development? what evidence do you have that less than 3 years cannot be safe and effective?
Answer: 5 years would be better, but we needed to set a minimum. Those who do the training pathway at 3 years will rattle through it some may take 10 years to sign off. It is a way of identifying talent in a way, but safeguards against those who require more support to get to the relevant level of practice.
It is about patient safety, the role requires being able to work with undifferentiated undiagnosed conditions in a diagnostic role. To be able to do this, you need to be able to carry out complex clinical reasoning and this can only be learned over time. When you come out of university you are a novice practitioner ie medically dependant, again this only changes to full autonomy with time. Breadth and depth of knowledge is essential for this role, not just with MSK but in MSK who may appear as visceral masquerades for example. This is not a core physiotherapy role.
Many litigation cases in the system!
Question 2: I think this means stage 1 could be a FCP module not sure if completing one level 7 FCP would give you all the clinical skills needed?
Answer: Stages 1 and 2 both sit within the FCP module. Stage 1 is academic knowledge to level 7 masters and stage 2 is application of that knowledge to practice.
Question 3: If you have been an ESP and done the e-learning primary care module, plus irmer etc. where do you stand?
Answer: All in posts (including myself) will have to do retrospective portfolio to FCP as guided CPD. This is because there has never been a standard of practice in primary care before so now there is, it needs to be honoured backward as well as forwards.
Question 4: So if you are working at APP level for many years and at level 7 then can apply for FCP post?
Answer: Yes but you will still need to sign off against the FCP portfolio route. Being an APP in community/2ndry care, does not equip you for the primary care environment.
Question 5: What about people with other exposure like those from sport, who have acute differential skills, used to ordering and interpreting imaging?
Answer: The knowledge skills and attributes document that you will need to evidence with triangulated evidence is more than diagnostic skills, it is about personalised care, neurology, social care, mental health, frailty, long term conditions etc too. No reason why any MSK practitioner can’t do this but will have to sign off against all domains before starting stage 2 then recognition as an FCP.
Question 6: There have been a large number of people entering these roles prior to these frameworks being set up, including Band 5-6s and employed directly. Where do they stand?
Answer: They will all have to retrospectively verify against the portfolio route – we have created a standard of practice for primary care for patient safety. CQC has been a driver for this as they have to deal with many issues with these lower bands coming into primary care. It is a different environment and for lower bandings to be employed require high levels of supervision and currently the infrastructure is not in place to support this. Going back to my point that FCP is a diagnostic clinician working with undifferentiated, undiagnosed conditions from the desk who is working at the top of their scope of practice.
I would suggest that band 5s in particular and band 6s do not fit the criteria to be able to have the skills to be able to do this bearing in mind that you are dealing with complexity/ complex co morbidity and polypharmacy. A clinician MUST be able to rule out red flags, know when symptoms are non MSK pain, detect early serious pathology eg cancers and early rheumatological conditions. That requires a lot of years of training. It’s not about the ability to academically learn to level 7 alone it must be applied to practice to and that takes time.
Question 7: How do we differentiate between FCP and ACP (ESP) roles, in particular in primary care services where the triage services are embedded. How can we equate the Bandings?
Answer: Band 7 work at level 7 in the clinical pillar, band 8’s are ACPs ie they have either done an ACP masters or the portfolio route to ACP where you are verified to level 7 across ALL 4 pillars of practice with triangulated evidence.
Question 8: When is the 2 day course being released? e-learning one?? Have the FCP development frameworks been released/published yet?
Answer: They have been signed off and will be landed 1st week in October.
Question 9: Thanks Amanda re FCP stage 2 sign off in practice – is HEE offering training for this?
Answer: Yes 2 day supervision course is coming out via the training hubs/primary care schools to train existing APs to sign off, also consultant practitioners and GP/GP trainers.
Question 10: Is there national guidance on audit strategies and how do we centralise this data to make if effective nationally? where could we find this guidance?
Answer: there is a standardised national data template. There will be a centralised system coming shortly using SNOMED data collection from GP computer systems.
Question 11: Is the FCP approach going to work long term or is it a false dawn?
Answer: it will work long term. The pathways are being embedded from undergraduate level and there is a need in the system as 30% of GP referrals are MSK on average and through national evaluation the +ve benefits to the system are huge so great cross system benefits.
Question 12: How do you deal with issues of capacity for triage? What is the timeframe you consider safe to leave untriaged patient on waiting for assessment?
Answer: Triage is a tricky word. Triage is just sorting out – the receptionist triages FCP. FCP do consultation, management and triage, it’s a different thing.
Question 13: The FCP model will work, but I feel that the job is much different if you’re an APP in an FCP role than a advanced physiotherapist.
Answer: An FCP who is working as an advanced physio ie band 8a needs extra training to an APP in secondary/community care as there is a need for a higher level of governance due to working with undifferentiated undiagnosed conditions and working with complex comorbidity and managing frailty/LTC and the whole person not just the MSK.
Question 14: You said that APPs will have to sign of the portfolio. How is this done? Is this a tick mark box against the qualifications one has?
Answer: it is not a tick box exercise; it requires triangulated evidence against each domain verified by a clinical supervisor.
Bradford are gold standard as are Plymouth, both have worked with HEE to incorporate the knowledge skills and attributes framework within their courses – all other HEIs have had COMMs that this needs to happen for their students to be recognised by HEE centre of advancing practice and be put on the FCP directory.
Larry Koyama, Head of FCP Implementation, Chartered Society of Physiotherapy updated us on the CSP’s approach and learning for sustainable implementation of FCP.
Question 1: You talked about collaboration and integration – with which stakeholders in local systems is this with?
Answer: Understanding the local system is critical. Key stakeholders include PCN leads, planned care and primary care commissioning colleagues as well as providers of MSK services within the PCN and/or STP footprint.
Question 2: Have PCNs been approached by the CSP to introduce the role of FRCP and the perceived benefits? Conversations seem to be driven by local MSK providers rather than the CSP – have seen no evidence of CSP activity in this regard to date.
Answer: Yes – this has happened and continues to happen. Effective and sustainable implementation is a strategic priority for the CSP. The CSP have been instrumental in having conversation and communications to all stakeholders including PCNs.
Through our National Influencing workstream there is close collaboration with organisations and bodies such as the BMA, RCGP, NHS Confed as well NHSE/I, helping us to influence PCNs as well as being able to understand the challenges of PCNs and key decision makers, an example of this targeted communication with PCNs includes the launch of the Phase 3 National Evaluation Report via a joint webinar with NHSE/I.
Through our local influencing workstream, a regional approach is taken to support and enable systems to work effectively together in the aim of effective and sustainable implementation. In addition we are also able to support members with resources that enables them to have effectively influence when approaching PCNs directly.
Question 3: Is there a timeline for publication of data from the Keele/Nottingham University evaluation? Beyond pilot data, we have very little unbiased data to support.
Answer: Launch of Phase 3 Evaluation Report in partnership with NHSE/I on 30th September. Specific publication date shortly after.
Dr Jon Tose, GP, formerly Clinical Director, NHS South Tyneside CCG, will describe his experience of introducing FCP to a PCN – a GP’s view
Question 1: With some waiting times being 24 – 26 weeks to see MSK/MCATS or community, GPs are currently using the new FCP service as a remote Physio service as the GPs are aware of the above waiting times. Other than education how can we provide a solution this?
Answer: It really is down to education. FCPs need to be clear what their job role is. They are diagnostic clinicians not core physiotherapists.
Really useful insight from a Clinical Director perspective. Key messages are to sell it to GP’s that this will reduce their MSK caseload and is NOT just more physio. We need to market this to practice managers, reception team and patients!
I agree with Jon that training with the practice especially care navigators or reception staff ensure that it works well. I am the FCP Lead and I provide training for practice staff.
Catherine Thompson, Programme Director Improving Planned Care, West Yorkshire and Harrogate Health and Care Partnership will talk about local success in improving FCP provision in MSK and the wider pathway.
Question 1: When will you be at 100% coverage across your ICS in terms of FCP roles?
Answer: I’m not sure that we will. We have one group of PCNs who at the moment don’t have a plan to have FCPs and who have chosen to use the funding for other roles. We might get to 90% by the end of next year though.
Question 2: Catherine, what is the optimum employment model; MSK service, practice or other?
Answer: I don’t think it is possible to say. They all have their strengths and weaknesses. The determining factor is what will work in the local system, to make sure that the FCP service is integrated into the existing MSK service pathways, and to make sure that there is adequate clinical and peer support for the FCPs regardless of where they are employed.
Question 3: How can we ensure FCP are embedded in the MSK pathway when FCPs can be employed directly by GP practices / PCN as well as NHS MSK services?
Answer: By educating the PCNs and by encouraging physios working directly employed by the practice to engage with the local MSK pathway and to join up with other FCPs creating networks.
Danielle Chulan, Deputy Director NHS Services, Connect Health describes the DES implications for PCNs – what can be accessed and what this means for FCP implementation.
Question 1: Some providers are providing the governance and management at their own cost. Some are not providing them. Who should pay?
Answer: I think this is the wicked problem being alluded to, is it sustainable for a provider to continue to cover this at a loss and what is compromised to achieve this, this is not scalable, manageable in a small pilot only IMO.
There is something coming out from NHSE re independent providers to safeguard ‘gazumping’ and to ensure there is engagement across the MSK pathway and to support the providers with implementation
Question 2: What’s wrong with using a private provider? Seems to be a lot of negativity about this.
Answer: It’s more to do with integration within the current MSK system. Although recognise that in some areas there isn’t an integrated MSK model (AQP commissioned pathways). It really needs to be linked to the individual landscape.
I don’t think there’s anything wrong. The key thing is to make sure it links into/ integrates with the rest of the MSK pathway.
Question 3: What do the panel see as they key areas FCP’s should be trying to achieve?
Answer: Gold standard practice for the benefit of our patients which includes educating others to raise the standard of the quality of the MSK pathway. I think that the most important thing is local services embracing FCPs into their MSK pathways, cross boundary working essential. This supports the Long Term Plan and the People Plan. It’s time to break down the barriers and work together to make gold standard MSK care for our patients.
One piece of advice with regards to what is crucial for successful and sustainable implementation of FCP
- Remember it’s the patient that is at the centre of this
- Understand your stakeholders
- Start small, evaluate, learn fast and be prepared to change
- It’s about change, keep talking, remember to see things from another’s perspective. You’ll find a position that works for everyone in the end
- Keep making sure that the patient is at the heart and make sure the patient’s journey isn’t compromised. Don’t let the finances dictate
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